🛟Public Health Policy and Administration Unit 11 – Health Systems and Care Delivery

Key Concepts and Definitions

• Health system encompasses all organizations, institutions, and resources devoted to producing health actions
• Health care delivery involves providing preventive, curative, and palliative interventions through health care services
• Universal health coverage ensures all individuals have access to needed health services without financial hardship
• Primary care serves as the first point of contact for patients and provides comprehensive, coordinated care
• Secondary care refers to specialized medical services typically provided by hospitals or specialists
• Tertiary care involves highly specialized medical treatment for complex conditions (cancer, cardiovascular surgery)
• Health financing mechanisms include government funding, social health insurance, private health insurance, and out-of-pocket payments
• Health policy consists of decisions, plans, and actions undertaken to achieve specific health care goals within a society

Historical Context of Health Systems

• Early health systems focused on treating acute illnesses and injuries rather than preventive care
• The Flexner Report (1910) led to reforms in medical education and the closure of many substandard medical schools in the United States
• The World Health Organization (WHO) was established in 1948 to promote international cooperation for improved health conditions
• The Declaration of Alma-Ata (1978) emphasized the importance of primary health care and health as a fundamental human right
• The Affordable Care Act (2010) expanded health insurance coverage and introduced reforms to the U.S. health care system
  • Provisions included individual mandates, subsidies for low-income individuals, and the expansion of Medicaid
• The COVID-19 pandemic (2020-present) exposed weaknesses in health systems worldwide and highlighted the need for preparedness and resilience

Types of Health Care Systems

• Beveridge Model features government-funded and operated health care services (United Kingdom, Spain)
  • Financed through taxes and ensures universal coverage for all citizens
• Bismarck Model relies on compulsory social health insurance funded by employers and employees (Germany, France)
  • Multiple non-profit insurers compete for members while the government closely regulates the system
• National Health Insurance Model combines elements of the Beveridge and Bismarck models (Canada, Taiwan)
  • Government is the sole payer for health services, but delivery remains largely in private hands
• Out-of-Pocket Model lacks a robust public health system, and individuals pay for services directly (many developing countries)
• Mixed Model incorporates aspects of different health care systems (United States, Australia)
  • Often includes a combination of public and private financing and delivery mechanisms

Health Care Delivery Models

• Fee-for-service model reimburses providers for each service rendered, which can incentivize overutilization
• Capitation model pays providers a fixed amount per enrolled patient, encouraging cost containment and preventive care
• Pay-for-performance model rewards providers for meeting predetermined quality and efficiency metrics
• Accountable care organizations (ACOs) are groups of providers that coordinate care and share financial risk for a defined patient population
• Patient-centered medical homes (PCMHs) provide comprehensive, team-based primary care with a focus on care coordination and quality improvement
• Telemedicine involves the use of telecommunications technology to deliver health care services remotely (video consultations, remote monitoring)

Financing and Economics of Health Care

• Government financing sources include general taxation, earmarked taxes, and deficit financing
• Social health insurance is typically funded through payroll taxes and managed by quasi-governmental organizations
• Private health insurance can be purchased by individuals or provided by employers as a benefit
• Out-of-pocket payments include deductibles, copayments, and direct payments for services not covered by insurance
• Health care expenditures have been rising due to factors such as population aging, technological advancements, and increased prevalence of chronic diseases
• Cost containment strategies include price regulation, utilization management, and promoting generic drug use
• Value-based purchasing aims to align provider reimbursement with the quality and efficiency of care delivered

Policy and Regulation in Health Systems

• Health policy goals often include improving access, quality, and affordability of care
• Government agencies (Centers for Medicare & Medicaid Services) oversee health care regulation and payment in the United States
• Professional organizations (American Medical Association) play a role in shaping health policy through advocacy and guidelines
• Licensing and accreditation ensure that health care providers and facilities meet minimum quality standards
• Health technology assessment evaluates the clinical and cost-effectiveness of new interventions to inform coverage decisions
• Antitrust laws prevent anticompetitive practices and promote competition in health care markets
• Privacy regulations (Health Insurance Portability and Accountability Act) protect the confidentiality of patient health information

Challenges and Current Issues

• Health disparities persist across socioeconomic, racial, and ethnic groups, highlighting the need for health equity initiatives
• Rising health care costs strain government budgets, employers, and individuals
• Workforce shortages, particularly in primary care and rural areas, can limit access to care
• Fragmentation of care delivery can lead to duplication of services, medical errors, and suboptimal outcomes
• Antimicrobial resistance poses a growing threat to public health and requires judicious use of antibiotics
• Mental health and substance use disorders are prevalent and often undertreated, requiring integrated care approaches
• Health information technology adoption has been slow, hindering efforts to improve care coordination and quality

Future Trends and Innovations

• Precision medicine tailors treatment based on an individual's genetic, environmental, and lifestyle factors
• Artificial intelligence and machine learning can support clinical decision-making and streamline administrative tasks
• Wearable devices and remote monitoring enable continuous, real-time tracking of health data
• 3D printing can create personalized medical devices and implants
• Regenerative medicine, including stem cell therapies, holds promise for treating chronic diseases and injuries
• Value-based care models will continue to evolve, emphasizing quality, outcomes, and cost-effectiveness
• Social determinants of health will receive increased attention, with interventions targeting upstream factors (housing, education, employment)
• Global health collaboration will be essential to address transnational health threats and promote health equity