BUILDING

INTEGRATED HEALTH SERVICE DELIVERY NETWORKS

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
 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)
BABEL’s TOWER
 Health systems: all the institutions,
people and actions whose primary
purpose is to improve health. WHO, 2000
OBJECTIVES

• 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
 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).
Major Systemic Challenges

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

Addressing Fragmentation Poor Performance

Fragmentation of care:
Barriers to access
New model of care
Fragmentation of Poor Quality

services: Irrational/inefficient use

 New ways of organizing and
managing healthcare High Cost
delivery services = IHSDNs
PAHO, 2015 Low Satisfaction
 Universal Access to Health and
Universal Health Coverage
Absence of geographical, economic, sociocultural,
organizational, or gender barriers that prevent all
Universal Access people from making equitable use of
comprehensive health services.

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.
Four simultaneous and Interdependent
Strategic Lines
 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
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
 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.
 Universal access to comprehensive, quality and
progressively expanded health services

• The model of care must

be strategically defined in Universality
order to optimize health Progressivity

outcomes.
• The model for
organization and Comprehensiveness Feasibility
Social
Validation

management of
healthcare services must
be addressed from a
Ethics
systems perspective. Evidence-based

• And…lets not forget the

determinants of health…
“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”
 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.
Model of Care vs. Organizational Model
 Transitioning Models of Care
Bio-Medical Model PHC – Based System
Health as a privilege, a
Health as a Human Right, Equity,
VALUES commodity, or act of
Solidarity
compassion

FOCUS Patients People, Families, Communities

Multiple involvement
GOVERNANCE Doctor - Patient
NHA/MoH leadership

Payment to providers (fee-

Universal Health Coverage
FINANCING for-service)
Social Protection in Health
Profit oriented

PROVISION OF Acute, Episodic, Curative Comprehensive Health and

SERVICES care Social Services

Physicians, Nurses and

Wide range of professions and
other professions akin to
DEVELOPMENT OF competencies
curative care
RESOURCES Appropriate and equitable use of
Technology as a business
technology
tool

SYSTEM’S APPROACH Linear Complex Adaptive System

 Bio-Medical Model of Care

 Centered on acute episodic care,

 Supply driven and organized by levels that fragment care
 Hospital-based and dependent on costly technologies and
specialist care,
 Provision of curative services through fragmented process
of care,
 Lack of continuity, poor quality and safety,
 Inefficient referral systems,
 Generates of exclusion and dissatisfaction.
The bio-medical model of care and the radar
phenomenon

The patient “shows up”

The patient is “treated”

The patient is discharged

The patient “vanishes”

People-Centered Model of Care:
Distinctive Elements

1. People centered
2. Integrated
3. Comprehensive
4. Continuous
5. Life Course approach
 Organizational Model
The structural organization and resources
required for delivering of services in response to
those needs, demands and expectations.
Fragmentation of Healthcare Delivery and Care

Maternal-Child Health
Universities

HIV-AIDS
Social Other

Malaria & Others

Security Providers

MOH

Private Practice

Traditional
Medicine Private Non-profit
(NGOs)
Local Govs
Health Services: What pushes the need to change?

Changes in Changes in Social Changes

Demand Offer
Demographics Knowledge and Globalization
Technology
Epidemiology Reforms of the State
Work Force Issues
People’s
Expectations Financial pressure Sectorial Reforms

Health
Services
Adapted form Mc Kee, M.; Healy, J. 2002
 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)
Integrated Health Services Delivery Networks
 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.
MORE DEFINITIONS:
THE IMPORTANCE OF SEMANTICS
BABEL’s TOWER
 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.
 PRIMARY HEALTH CARE vs.
Primary Care vs. First Level of Care

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

Integration is the combination of processes, methods and tools

that facilitate integrated care.

• Integrated services are the • Integrated care results when

organizational structures the culmination of these
and resources involved in processes directly benefits
facilitating integration communities, patients or
processes. service users.

Nick Goodwin, 2014

.
 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.
 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.
The Life Course vs Life Cicle
 DISEASE
HEALTH

Adapted from Denis Roy

HEALTH DISEASE SOCIAL CARE

 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).
 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.)
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”
 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.
Gatekeeper vs. First Point of Access
 Hospitals
• Pending assignment: What is and what is not a
hospital?
 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)
 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.
 KEY MESSAGE

• 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 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
Thank you!

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