Progress towards them depends on how systems carry out four vital functions: provision of health care services , resource generation, financing, and stewardship. Often health system has been defined with a reductionist perspective, for example reducing it to healthcare system. In many publications, for example, both expressions are used interchangeably. Some authors  have developed arguments to expand the concept of health systems, indicating additional dimensions that should be considered:. The World Health Organization defines health systems as follows:.
A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services.
It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health. Healthcare providers are institutions or individuals providing healthcare services.
Individuals including health professionals and allied health professions can be self-employed or working as an employee in a hospital , clinic , or other health care institution, whether government operated, private for-profit, or private not-for-profit e. They may also work outside of direct patient care such as in a government health department or other agency, medical laboratory , or health training institution. Examples of health workers are doctors , nurses , midwives , dietitians , paramedics , dentists , medical laboratory technologists , therapists , psychologists , pharmacists , chiropractors , optometrists , community health workers , traditional medicine practitioners, and others.
There are generally five primary methods of funding health systems: . Most countries' systems feature a mix of all five models. One study  based on data from the OECD concluded that all types of health care finance "are compatible with" an efficient health system. The study also found no relationship between financing and cost control. The term health insurance is generally used to describe a form of insurance that pays for medical expenses.
It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a social insurance program, or from private insurance companies. It may be obtained on a group basis e. In each case premiums or taxes protect the insured from high or unexpected health care expenses. By estimating the overall cost of health care expenses, a routine finance structure such as a monthly premium or annual tax can be developed, ensuring that money is available to pay for the health care benefits specified in the insurance agreement.
The benefit is typically administered by a government agency, a non-profit health fund or a corporation operating seeking to make a profit. Many forms of commercial health insurance control their costs by restricting the benefits that are paid by through deductibles , co-payments , coinsurance , policy exclusions, and total coverage limits and will severely restrict or refuse coverage of pre-existing conditions.
Many government schemes also have co-payment schemes but exclusions are rare because of political pressure. The larger insurance schemes may also negotiate fees with providers. Many forms of social insurance schemes control their costs by using the bargaining power of their community they represent to control costs in the health care delivery system.
For example, by negotiating drug prices directly with pharmaceutical companies negotiating standard fees with the medical profession, or reducing unnecessary health care costs. Social schemes sometimes feature contributions related to earnings as part of a scheme to deliver universal health care , which may or may not also involve the use of commercial and non-commercial insurers. Essentially the more wealthy pay proportionately more into the scheme to cover the needs of the relatively poor who therefore contribute proportionately less.
There are usually caps on the contributions of the wealthy and minimum payments that must be made by the insured often in the form of a minimum contribution, similar to a deductible in commercial insurance models. In addition to these traditional health care financing methods, some lower income countries and development partners are also implementing non-traditional or innovative financing mechanisms for scaling up delivery and sustainability of health care,  such as micro-contributions, public-private partnerships , and market-based financial transaction taxes.
There has been growing interest in blending elements of these systems. Fee-for-service arrangements pay general practitioners GPs based on the service. There are two ways to set fee levels: . In capitation payment systems , GPs are paid for each patient on their "list", usually with adjustments for factors such as age and gender. Capitation payments have become more frequent in "managed care" environments in the United States. According to OECD, "Capitation systems allow funders to control the overall level of primary health expenditures, and the allocation of funding among GPs is determined by patient registrations.
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However, under this approach, GPs may register too many patients and under-serve them, select the better risks and refer on patients who could have been treated by the GP directly. Freedom of consumer choice over doctors, coupled with the principle of "money following the patient" may moderate some of these risks.
Aside from selection, these problems are likely to be less marked than under salary-type arrangements. In recent years, providers have been switching from fee-for-service payment models to a value-based care payment system, where they are compensated for providing value to patients. In this system, providers are given incentives to close gaps in care and provide better quality care for patients. Sound information plays an increasingly critical role in the delivery of modern health care and efficiency of health systems. Necessary tools for proper health information coding and management include clinical guidelines , formal medical terminologies , and computers and other information and communication technologies.
The kinds of health data processed may include patients' medical records , hospital administration and clinical functions , and human resources information. The use of health information lies at the root of evidence-based policy and evidence-based management in health care. Increasingly, information and communication technologies are being utilised to improve health systems in developing countries through: the standardisation of health information; computer-aided diagnosis and treatment monitoring; informing population groups on health and treatment.
The management of any health system is typically directed through a set of policies and plans adopted by government, private sector business and other groups in areas such as personal healthcare delivery and financing, pharmaceuticals , health human resources , and public health.
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Public health is concerned with threats to the overall health of a community based on population health analysis. The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents for instance, in the case of a pandemic. Public health is typically divided into epidemiology , biostatistics and health services.
Environmental , social, behavioral , and occupational health are also important subfields. Today, most governments recognize the importance of public health programs in reducing the incidence of disease, disability, the effects of ageing and health inequities , although public health generally receives significantly less government funding compared with medicine. For example, most countries have a vaccination policy , supporting public health programs in providing vaccinations to promote health.
Vaccinations are voluntary in some countries and mandatory in some countries. Some governments pay all or part of the costs for vaccines in a national vaccination schedule.
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The rapid emergence of many chronic diseases , which require costly long-term care and treatment , is making many health managers and policy makers re-examine their healthcare delivery practices. Its incidence is increasing rapidly, and it is estimated that by the year , this number will double. A controversial aspect of public health is the control of tobacco smoking , linked to cancer and other chronic illnesses. Antibiotic resistance is another major concern, leading to the reemergence of diseases such as tuberculosis.
The World Health Organization , for its World Health Day campaign, is calling for intensified global commitment to safeguard antibiotics and other antimicrobial medicines for future generations. Since , more and more initiatives have been taken at the international and national levels in order to strengthen national health systems as the core components of the global health system. Having this scope in mind, it is essential to have a clear, and unrestricted, vision of national health systems that might generate further progresses in global health.
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The elaboration and the selection of performance indicators are indeed both highly dependent on the conceptual framework adopted for the evaluation of the health systems performances. An increasing number of tools and guidelines are being published by international agencies and development partners to assist health system decision-makers to monitor and assess health systems strengthening  including human resources development  using standard definitions, indicators and measures.
In response to a series of papers published in by members of the World Health Organization's Task Force on Developing Health Systems Guidance, researchers from the Future Health Systems consortium argue that there is insufficient focus on the 'policy implementation gap'. Recognizing the diversity of stakeholders and complexity of health systems is crucial to ensure that evidence-based guidelines are tested with requisite humility and without a rigid adherence to models dominated by a limited number of disciplines. Although many deliver improved healthcare a large proportion fail to sustain.
Numerous tools and frameworks have been created to respond to this challenge and increase improvement longevity. One tool highlighted the need for these tools to respond to user preferences and settings to optimize impact. Health Policy and Systems Research HPSR is an emerging multidisciplinary field that challenges 'disciplinary capture' by dominant health research traditions, arguing that these traditions generate premature and inappropriately narrow definitions that impede rather than enhance health systems strengthening. In using this approach, HPSR offers insight into health systems by generating a complex understanding of context in order to enhance health policy learning.
These include:. Which effects will dominate in the long run? An informed and up-to-date analysis of this subject, this is an essential text for all those studying, both at undergraduate and postgraduate level, performance management in the public sector. Managing Performance in the Public Sector. These include: more examples and cases, from a variety of different sectors, including, hospitals, courts, school and universities a whole new chapter on the dynamics of performance management; answering the questions - how do PM systems evolve?