2. Health Systems 101: Reviewing the basics and agreeing On the semantics July 28 - 30, 2015 Belize REYNALDO HOLDER Health Services and Access Unit Department of Health Systems and Services

3. Outline WHO definition of Health Systems and their functions Segmentation & Fragmentation: major systemic challenges Model of Care and Organizational Model Definitions (Understanding the importance of semantics)

4. BABEL’s TOWER

5. OBJECTIVES Improving people’s health and well being; Responding to people’s expectations; Providing protection against the costs of ill-health. Improving people’s health and well being; Responding to people’s expectations; Providing protection against the costs of ill-health. Health systems : all the institutions, people and actions whose primary purpose is to improve health. WHO, 2000

7. HEALTH SYSTEM ≠ HEALTH SERVICES Healthcare provision or delivery of care is only one of the health systems functions. Health Services are the set of institutions and programs that provide: Direct care to health and disease needs of individuals; and Public Health Services for the protection of collective health, (i.e. the health of communities).

8. Major Systemic Challenges FRAGMENTATION SEGMENTATION

9. Major Systemic Challenges SEGMENTATION : The coexistence of subsystems with different modalities of financing, affiliation and healthcare delivery, each of them specializing in different strata of the population according to their type of employment, income level, ability to pay, and social status. PAHO, 2011 SEGMENTATION INEQUITY

10. Major Systemic Challenges …of Health Services relates to the coexistence of several units or facilities that are not integrated into a single network and or services at different levels of care that are not coordinated among themselves; …of Care defines healthcare delivery that does not cover the entire range of promotion, prevention, care, rehabilitation and palliative care services and or services that do not continue over time. PAHO, 2011 FRAGMENTATION Poor Performance Barriers to access Poor Quality Irrational/inefficient use High Cost Low Satisfaction

11. Major Systemic Challenges  Fragmentation of care: New model of care  Fragmentation of services: New ways of organizing and managing healthcare delivery services = IHSDNs PAHO, 2015 Addressing Fragmentation Poor Performance Barriers to access Poor Quality Irrational/inefficient use High Cost Low Satisfaction

12. Universal Coverage Sufficient organizational mechanisms and financing to cover the entire population. Universal coverage in itself is not sufficient to ensure health, well-being, and equity in health. Universal Access Absence of geographical, economic, sociocultural, organizational, or gender barriers that prevent all people from making equitable use of comprehensive health services. Universal Access to Health and Universal Health Coverage

13. Four simultaneous and Interdependent Strategic Lines

14. SL1: Expanding equitable access to comprehensive, quality, people and community centered health services New models of care, new models of organization and new ways and capacities for managing healthcare delivery services; Comprehensive and progressively expanded health services; Increase investment in the first level of care; Improve and increase the response capacity of the first level of care in IHSDNs; Identify the unmet and differentiated health needs of the population, as well as the specific needs of groups in situation of vulnerability; Improve human resource capacity in the first level of care (employment, multidisciplinary, new profiles): Essential Medicines and technologies; Empowerment of people and communities

15. SL1: Expanding equitable access to comprehensive, quality, people and community centered health services New models of care, new models of organization and new ways and capacities for managing healthcare delivery services; Comprehensive and progressively expanded health services; Increase investment in the first level of care; Improve and increase the response capacity of the first level of care in IHSDNs; Identify the unmet and differentiated health needs of the population, as well as the specific needs of groups in situation of vulnerability; Improve human resource capacity in the first level of care (employment, multidisciplinary, new profiles): Essential Medicines and technologies; Empowerment of people and communities

16. Universal access to comprehensive, quality and progressively expanded health services The model of care should be coherent with the strategic vision for health and wellbeing. The re-definition of the model of care constitutes a core decision moment in moving towards Universal Access to Health and Universal Health Coverage. The new model of care will require new organizational arrangements in order to be effective, efficient and quality oriented.

17. Universal access to comprehensive, quality and progressively expanded health services The model of care must be strategically defined in order to optimize health outcomes. The model for organization and management of healthcare services must be addressed from a systems perspective. And…lets not forget the determinants of health… Universality Ethics Comprehensiveness Feasibility Evidence-based Progressivity Social Validation

18. “Because it really does not make much sense to provide excellent care in clinics and hospitals, if people are to return to the conditions that made them ill in the first place”

19. Model of Care A logical framework that defines what services will be provided to address the health needs, demands and expectations of the population. Organizational Model The structural organization and resources required for delivering of services in response to those needs, demands and expectations.

20. Model of Care vs. Organizational Model

21. Transitioning Models of Care Bio-Medical ModelPHC – Based System VALUES Health as a privilege, a commodity, or act of compassion Health as a Human Right, Equity, Solidarity FOCUSPatientsPeople, Families, Communities GOVERNANCEDoctor - Patient Multiple involvement NHA/MoH leadership FINANCING Payment to providers (fee- for-service) Profit oriented Universal Health Coverage Social Protection in Health PROVISION OF SERVICES Acute, Episodic, Curative care Comprehensive Health and Social Services DEVELOPMENT OF RESOURCES Physicians, Nurses and other professions akin to curative care Technology as a business tool Wide range of professions and competencies Appropriate and equitable use of technology SYSTEM’S APPROACHLinearComplex Adaptive System

22. Bio-Medical Model of Care

23. The patient “vanishes” The patient “shows up” The patient is “treated” The patient is discharged The bio-medical model of care and the radar phenomenon

24. People-Centered Model of Care: Distinctive Elements 1.People centered 2.Integrated 3.Comprehensive 4.Continuous 5.Life Course approach

25. Organizational Model The structural organization and resources required for delivering of services in response to those needs, demands and expectations.

26. MOH Social Security Private Practice Other Providers Private Non-profit (NGOs) Local Govs Universities HIV-AIDS Malaria & Others Maternal-Child Health Traditional Medicine Fragmentation of Healthcare Delivery and Care

27. Health Services: What pushes the need to change? Changes in Demand Changes in Offer Social Changes Demographics Epidemiology People’s Expectations Health Services Knowledge and Technology Work Force Issues Financial pressure Globalization Reforms of the State Adapted form Mc Kee, M.; Healy, J. 2002 Sectorial Reforms

28. Integrated Health Services Delivery Networks Defined as “a network of organizations that provides, or makes arrangements to provide, equitable, comprehensive, integrated, and continuous health services to a defined population and is willing to be held accountable for its clinical and economic outcomes and the health status of the population served.” (PAHO, adapted from Shortell et al)

30. Integrated Health Services Delivery Networks

31. Organizational Attributes of the Model of Care in IHSDNs People and community centered – planning and delivery based on needs; Responsibility for an assigned population in a specific territory; A network of facilities – determined by people’s needs and system’s response capacity; Multidisciplinary teams at the First Level of Care; Delivery of ambulatory specialized services at the most appropriate location, preferably in non-hospital settings; Mechanism to coordinate care throughout the continuum.

32. THE IMPORTANCE OF SEMANTICS MORE DEFINITIONS:

33. BABEL’s TOWER

34. PRIMARY HEALTH CARE vs. Primary Care vs. First Level of Care A PHC-Based Health System is an overarching approach to the organization and operation os health systems that makes the right to the highest level of health its main goal while maximizing equity and solidarity. PAHO 2011 PHC as a strategic approach to the development, organization, management and financing of health systems.

35. We utilize First Level of Care to refer to the base level of organization of the health services and to avoid confusion with the term primary care. (PAHO, 2007) PRIMARY HEALTH CARE vs. Primary Care vs. First Level of Care

36. Major Systemic Challenges …of Health Services relates to the coexistence of several units or facilities that are not integrated into a single network and or services at different levels of care that are not coordinated among themselves; …of Care defines healthcare delivery that does not cover the entire range of promotion, prevention, care, rehabilitation and palliative care services and or services that do not continue over time. PAHO, 2011 FRAGMENTATION Poor Performance Barriers to access Poor Quality Irrational/inefficient use High Cost Low Satisfaction

37. Integrated Care and Integrated Services Integration is the combination of processes, methods and tools that facilitate integrated care. Integrated care results when the culmination of these processes directly benefits communities, patients or service users.. Integrated services are the organizational structures and resources involved in facilitating integration processes. Nick Goodwin, 2014

38. Integrated Care Integrated care is an approach for people and communities that seeks to identify and resolve gaps in care, or poor care co-ordination, that leads to adverse impacts on care experiences and care outcomes. Integrated care should not be solely regarded as a response to managing medical problems, the principles extend to the wider definition of promoting health and wellbeing. Integrated care is most effective when it is population- based and takes into account the holistic needs of patients. Disease-based approaches ultimately lead to new silos of care. Nick Goodwin, 2014.

39. Comprehensive Care Services and interventions that span the spectrum of promotive, preventive, curative, rehabilitative, palliative and social care in both levels of services (First Level and Specialized care), and are coherent with person’s life course; Integration of Public Health and healthcare delivery services.

40. The Life Course vs Life Cicle

41. HEALTH DISEASE DETERMINANTS PROMOTION RISK FACTORS PREVENTION & HEALTH EDUCATION PRECLÍNICAL STAGE SPECIFIC PREVENTION CLÍNICAL STAGE COMPLICATIONS DISABILITY DIAGNOSIS & TREATMENT REHABILITATION PALLIATIVE CARE HEALTH DISEASE SOCIAL CARE Adapted from Denis Roy

42. Continuity of Care Continuity of Care: is the degree to which a series of discrete events in health care are experienced by persons as coherent and interconnected and addresses their health needs and preferences. (User perspective).

43. Continuity of Care Coordination mechanisms for: Sharing essential information for healthcare delivery Integrating care across levels and institutional boundaries Regulate access to different points of care in the network INSTRUMENTS: Evidence Base Medicine (clinical guidelines and protocols) Electronic health records Referral mechanisms Innovations in service delivery modalities (home care, day- surgery, specialty clinics in support of the First Level of Care, Telemedicine, etc.)

44. Who are healthcare managers? Operational Definitions Health Manager: “all persons in the health system who manage resources and in so doing are responsible for making decisions that influence health outcomes” Healthcare or Health Services Manager: “are those responsible for the delivery of healthcare services (meso and micro) in networks and health facilities”

45. Strengthening the management of healthcare delivery services Health services, particularly hospitals, are the most complex organizations to manage. (Drucker) Majority of hospital managers are Physicians. Medical training institutions do not normally include management as a subject. Health systems normally suffer from: – Lack of managers with the appropriate competencies – Insufficient numbers of experienced managers – Poor functional management support systems – Lack of enabling working environments.

46. Gatekeeper vs. First Point of Access

47. Hospitals Pending assignment: What is and what is not a hospital?

48. Health Systems Reforms XX and XXI Centuries Up to the 1920s: Sanitary Campaigns 1920-1940: Social Security systems (Bismarck model) 1950-1970s” “Welfare State systems” (Beveridge model) 1970-80s: Primary Health Care (Health for All – Alma Ata) 1990s: Cost-containment and efficiency driven (International Financial Institutions) 2000 to date: Renewal of PHC – People centered care – Integrated Healthcare delivery – Social Protection in Health – Universal Access to Health and Universal Health Coverage (Universal Health)

49. Health System Reform Criteria and Principles Common goal : “the improvement of the health conditions of the populations”. To promote equity in health conditions, access and coverage of services and financing of services; To improve quality of care from the technical standpoint and the user’s perspective; To increase the efficiency of health financing, and allocation and management of resources; To ensure sustainability To promote social participation in planning, management, delivery and evaluation of health services.

50. There is no single best practice for HSR, but in order to contribute to improvements in population health, reforms should be congruent with citizens’ values; contain mechanisms to protect the poor; and strengthen the capacity of national and local stakeholders to plan, administrate, regulate, evaluate, and innovate. KEY MESSAGE

51. Key Take Away Ideas Semantics matter: strive to use the right terminology There is a difference between integration of services and integrated care. Integrated service delivery is a key strategy for the attainment of Universal Access to Health and Universal Health Coverage (Universal Health) Integrated care and Integrated Health Services implementation tends to be more successful where there is a commitment to the values and principles of Primary Health Care

52. Custome Slide 51 Thank you!