The Role Of Health Systems In Health. Episode 2, Transforming Health Systems

What is the health system relationship to health and how do we know how is it doing? Welcome to the Health Systems Transformation channel, dedicated to promoting health systems strengthening globally. In this episode, we will expand on the health systems objective, specifically on what is the role of health systems in health. I am Cristian Baeza. Join me on this journey on how to improve health systems around the world for better health and life of people. Subscribe. Welcome and see you in a moment. Welcome back. Let's begin our in-depth discussion of health systems objectives with a review of the role of health systems in ensuring good health. As a reminder, when analyzing health systems, we need to examine two key dimensions of it, the health system objectives and the health system itself, which is functions and components. Societies expect health systems to achieve at least four objectives simultaneously, good health outcomes, financial protection for all, responding to the legitimate expectations of citizens regarding the health system, and system sustainability and its contribution to country development. A well-functioning health system achieves its objectives through ensuring access to quality, effective, affordable, timely, necessary health care and population health services and interventions. We will discuss these intermediary goals as we discuss the health systems functions in later episodes. Health system services include the population and public health services and interventions, such as the response to COVID-19 pandemic, as well as health care services such as hospital and primary health care. The health system also achieves its goals through its dialogue and influencing policies in other sectors that have substantial impact on the health of the population. Let's now examine the health objectives of the health system. Health is the defining objective of health systems. The World Health Organization defines health as a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity. This definition has remained the same since 1946 when adopted by WHO. This is a comprehensive and expansive definition which emphasizes the importance of country leadership in health, but makes it sometimes complex to use in practice. As we know by now, a health system promotes, maintains, and restores good health, including attending the needs of people with disabilities. If an activity or policy in a country does not have a health primary objective, then it is not part of the health system. However, many of them are critical for health and the health system must be able to engage with other sectors to support and facilitate their role in health. It is essential to continuously monitor the health status of a country and the contribution to health by the health system to be able to improve the health conditions of people and populations. Paradoxically, we tend to measure the health system performance in health by the absence of it. To measure and monitor health status, we use a number of metrics. Historically, they include mortality, which is the number of people dying as a proportion of the general or specific populations. Morbidity, which includes the number of people who are sick or become sick in a period of time. Or disabilities, the short and long-term effects of congenital conditions or diseases on people's functional capacity in society. More recently, in the last 30 years, these metrics also include aggregated or summary metrics, such as the disability-adjusted years of life or DALY. DALY estimates the number of years of life lost due to both mortality and disability combined. The use of DALYs has allowed for development of burden of disease, which has become a widespread, accepted, and very helpful way to get a summary view of the health status of the population of a country or community, as well as the impact of specific diseases and risk factors in the overall health status of that community. Here, a 3-map visualization of burden of disease from the Global Burden of Disease Compare Tool of the Institute of Health Metrics and Evaluation, showing at a glance a visual comparison of Germany's and DRC's burden of disease. This is a very effective way of showing at a glance how DRC's population health are driven by communicable diseases and maternal and child health challenges, while Germany's are driven by non-communicable diseases and chronic diseases, an insight critical for health systems planning and management. Finally, life expectancy, or the average number of years that a person can expect to live at birth in a specific population, and more recently, healthy life expectancy, a measure of life expectancy adjusted by disability. Here are a number of sources of data I use the most in my work, the United Nations systems including WHO, UNICEF, UNFPA, and the World Bank, the United States and European CDCs, and IHME, which has become one of the gold standards in global health data and burden of disease. We will be using these metrics a lot to get insights about what is working and what is not in health systems. It is important to familiarize yourself with them, especially with the meaning and implications of using composite measures, such as DALYs or using burden of disease. When examining the potential impact or performance of a health system on health, we care about two dimensions, the level and the distribution of health or disease among the population. The level refers to the average of the metric in a given general or specific population. The distribution refers to what are the differences within that population. Let's look at a country example, neonatal mortality in the United States in 2017. In 2017, on average, 3.4 newborns died within the first 28 days of life out of 1,000 live births. However, national neonatal mortality is the average of the whole country. Within it, there are very significant differences. Native Americans, Hawaiian and Pacific Islanders, and African Americans have much higher neonatal mortality than Latino Americans and non-Latino whites. In fact, Native Americans have three times higher neonatal mortality than Latino Americans. In monitoring and assessing performance of health systems, we need to look at both. The level, as it gives us an overall view of what's happening in the country and in the health system. But we also need to carefully look at distribution across the population. This is critical as reducing inequality is a core value in transforming health system. Certainly a value that drives my work and experience that I share with you in this channel. It is also critical because it gives us a clear signal of where the system is working well or not working at all for the population. What explains the substantial inequality in neonatal mortality in the United States in 2017 as seen in the example? Is it the lack of access to health care provision due to shortages in human resources? Or due to the way health care providers are being paid by the purchasers reducing their productivity? Is it that neonatal services are not sufficiently included in their benefit packages? Or is it that the families are not demanding the services due to the system not being able to stimulate demand for neonatal services? Or because families cannot afford them as they are not covered under a risk pooling or insurance scheme? Or even is it that the system is failing to respond to the expectations of mothers and families by not adapting to their cultural practices and needs? This is what we do in health systems transformations. We let the health data and evidence talk to us to identify system failures and find ways to change the system to improve access to health services and health. Examining both levels and distributions on neonatal mortality in this case is essential for both equity and effectiveness of the system. It is also possible and very likely that these differences in neonatal mortality in the United States are also explained by other determinants of health beyond the health system. Indeed, health systems are important contributors to good health but they are far from being the only and sometimes the most important driver of health. Health is created by us and our households managing the contributions of many systems and inputs including education, clean air, food, inclusion in society, water and sanitation, energy and many more. Households use their income to purchase many essential goods and services. We purchase for example food and we use our formal and informal education as well as clean water and clean energy to cook nutritious foods. Let's look at the evidence in one example. Infant mortality is much higher for children whose mothers had no formal education as compared to those with secondary or more as shown in this graph adapted from the report of the commission on social determinants of health. This was the case in Colombia where infant mortality for those with mothers with no education is more than double than those of children with educated mothers. This is also the case in many countries. So then do health systems matter for health at all? You bet they do in at least three critical contributions. These three critical contributions include population and public health services, health care and its leadership in the dialogue with all sectors for better health. The relative importance of each of them is substantially dependent on the status of a country's socioeconomic development and its demographic and epidemiological profile. In the 20th century we witnessed amazing progress in health. Much of it due to economic development and other sectors of the economy but at least 40 to 50 percent or more of it was due to advances in these three dimensions of health system contributions to health. To further explore the relationship of health with health systems and other sectors of the economy I recommend reviewing four seminal global reports. The World Bank World Development Report 1993, the World Health Organization World Health Report 1999, the World Health Report 2000 and the report of the Commission on Social Determinants of Health. Much has been written in recent years about these topics but these are the pioneer global reports in the field of health, health systems and development and social determinants of health. The case is then clear for the contribution of the health system and all sectors of the economy to health. The reverse is also true. Health systems and health provide a critical contribution to the economy. A healthy productive population and the right decisions on how to fund the health system substantially help economic growth. In the more than 25 years I have worked on health systems globally I can't count the very many discussions about the contribution of health systems and health to the economy I have had around the world. The devastating impact of the COVID-19 pandemic and of dysfunctional health systems has sadly settled the case. There is a clear and strong interdependence between health and the economy. Thank you for joining me for this episode. In the next episode we will continue analyzing health systems objectives. Next time we will focus on financial protection or how health systems must be able to protect people from the financial effects of ill health. Thank you for joining us. Subscribe and see you next time in Transforming Health Systems.