KEYSTONE HPSR Initiative // Module 1: Introducing Health Systems & Health Policy // Slideshow 2 Health Systems and Health Policy Frameworks - 1 This is the second slideshow of Module 1: Introducing Health Systems & Health Policy, of the KEYSTONE Teaching and Learning Resources for Health Policy and Systems Research To access video sessions and slides for all modules copy and past the following link in your browser: http://bit.ly/25vVVp1 Module 1: Introducing Health Systems & Health Policy This module introduces students to the KEYSTONE initiative, the objectives and design of the inaugural course, and the field of Health Policy and Systems Research. Common frameworks used to understand health systems and health policy are delineated, including the WHO building blocks framework, health systems hardware and software, systems thinking, social construction, and people-centred health systems. There are 5 slideshows in this module. Module 1: Introducing Health Systems & Health Policy -Module 1 Slideshow 1: KEYSTONE Course: Getting Oriented -Module 1 Slideshow 2: Health Systems and Health Policy Frameworks - 1 -Module 1 Slideshow 3: Health Systems and Health Policy Frameworks - 2 -Module 1 Slideshow 4: Health Systems and Health Policy: Wrap Up -Module 1 Slideshow 5: Epistemological self-diagnosis The other modules in this series are: Module 2: Social justice, equity & gender Module 3: System complexity Module 4: Health Policy & Systems Research frameworks Module 5: Economic analysis Module 6: Policy analysis Module 7: Realist evaluation Module 8: Systems thinking Module 9: Ethnography Module 10: Implementation research Module 11: Participatory action research Module 12: Knowledge translation Module 13: Research Plan Writing KEYSTONE is a collective initiative of several Indian health policy and systems research (HPSR) organizations to strengthen national capacity in HPSR towards addressing critical needs of health systems and policy development. KEYSTONE is convened by the Public Health Foundation of India in its role as Nodal Institute of the Alliance for Health Policy and Systems Research (AHPSR). The inaugural KEYSTONE short course was conducted in New Delhi from 23 February – 5 March 2015. In the process of delivering the inaugural course, a suite of teaching and learning materials were developed under Creative Commons license, and are being made available as open access resources. The KEYSTONE teaching and learning resources include 38 videos and 32 slide presentations organized into 13 modules. These materials cover foundational concepts, common approaches used in HPSR, and guidance for preparing a research plan. These resources were created and are made available through support and funding from the Alliance for Health Policy & Systems Research (AHPSR), WHO for the KEYSTONE initiative.

1. https://twitter.com/KeystoneHPSR
Building the HPSR CommunityBuilding HPSR Capacity
KEYSTONE
Inaugural KEYSTONE Course on Health Policy and Systems Research 2015
Health System and Health Policy Frameworks- 1

2. KEYSTONE
Health Systems and Health
Policy Frameworks - 1
Kabir Sheikh
23 February 2015

3. KEYSTONE
• DEFINITIONS
• HEALTH SYSTEM FRAMEWORKS
• HEALTH POLICY FRAMEWORKS

4. KEYSTONE
DEFINITIONS

5. KEYSTONE
What is a health system?
• A health system is the sum total of all the organizations,
institutions and resources whose primary purpose is to
improve health
• A well functioning health system responds to a population’s
needs and expectations by:
– improving the health status of individuals, families and communities
– defending the population against what threatens its health
– protecting people against the financial consequences of ill-health
– providing equitable access to people-centred care
www.who.int

6. KEYSTONE
What is Policy?
“Whatever governments choose to do
or not to do” Dye 1984
“… the manner in which problems get
conceptualized and brought to
government; institutions
formulate alternatives and select
solutions; and solutions get
implemented, evaluated and
revised” Sabatier 1999
“Decisions (in the public and private
sector)… taken by those with
responsibility for a given area, e.g.
health, education, environment or
trade” Buse et al. 2005
Decisions with a Purpose

7. KEYSTONE
HEALTH SYSTEM FRAMEWORKS

8. KEYSTONE
1. SYSTEM FUNCTIONS
 Systems defined on basis of their
utility, problems mainly relate to
efficiency
 Decisions are concentrated, flow
in one direction
 Policy content not problematized
E.g. WHO ‘building blocks’
International
National
Subnational
Local
ARENA
Systems
Human Resources, Finance,
Medicines & technology,
Organizational structure,
Service infrastructure,
Information systems
Outputs
Outcomes

9. KEYSTONE

10. KEYSTONE
Three key goals (WHO – WHR 2000)
1) Improvement in health : ‘health status of the entire
population ..over people’s whole life cycle, taking
account of both premature mortality and disability.’
2) Responsiveness: ‘how the system performs relative to
non-health aspects, meeting a population’s expectations
of how it should be treated by providers of prevention,
care or non-personal services’
– Respect for persons: confidentiality, autonomy
– Client orientation: prompt attention, amenities, choice
3. Health System Goals

11. KEYSTONE
3) Fair financing : ‘the risks each household faces due to the
costs of the health system are distributed according to
ability to pay rather than to the risk of illness: a fairly
financed system ensures financial protection for
everyone..’
– Unexpected costs: reduce out of pocket payment (OOP)
– Contribution to total costs: richer households contribute
proportionally more than poorer households (progressive)
4) Now combined as ‘universal health coverage’: “access to
key promotive, preventive, curative and rehabilitative
health interventions for all at an affordable cost”. (WHA
2005 58.33)
3. Health System Goals

12. KEYSTONE
Links between functions & goals
WHO – WHR 2000

13. KEYSTONE
Systems ‘Software’
Ideas and interests, Values
and norms
Relationships and power,
Systems ‘Hardware’
Human Resources, Finance,
Medicines & technology,
Organizational structure,
Service infrastructure,
Information systems
International
National
Subnational
Local
ARENA
2. COMPLEX SYSTEMS
 Decisions are diffused
through the system, focus on
non-linear relationships
 ‘Software’ critical to health
systems performance
 Problems (and solutions) are
related to (understanding)
complexity
See Frenk 1994, de Savigny and Adam
2009

14. KEYSTONE
A health system
Health
• Beyond sickness
– mental & physical health
– social wellbeing
• Beyond the individual
– actors/agents promoting
health & wellbeing
– domestic/national AND
international factors
impacting on health and HS
agents
A complex adaptive system
• A set of interacting elements
• More than the sum of the
parts
• Acts in ways that are not fully
predictable e.g. feedback
loops
• Influenced by history
• Self-organising
• Resistant to change

15. KEYSTONE
ANTWERP MODEL: Van Olmen et al. 2010

16. KEYSTONE
COLLECTIVE
MEDIATOR
HEALTH CARE
PROVIDERS
ORGANISATION
POPULATION
ORGANISATION
RESOURCE
GENERATORS
OTHER
SECTORS
Basis for
eligibility
Degree of
control
Degree of
control
Degree of
control
Taxes, Demands
for services
Services with health
effects
Subsidies,
Information,
Ideologies
Potential personnel,
money, data
Schemes for
interpreting human
experience
Human resources,
Payment mechanisms,
Scientific information,
Technology
Formal health services
Community participation
Frenk, 1994
Competition for
responsibilities and
resources

17. KEYSTONE
Systems ‘Software’
Ideas and interests, Values
and norms Relationships
and power,
Systems ‘Hardware’
Human Resources, Finance,
Medicines & technology,
Organizational structure,
Service infrastructure,
Information systems
International
National
Subnational
Local
ARENA
3. SOCIAL
CONSTRUCTION
 Policy and systems are shaped
by particular politics, culture,
discourse (and not others)
 Policy (and systems) can be
problematized
 Suggests solutions within and
beyond health systems
(Sheikh et al. 2011)

18. KEYSTONE
People Centred Health Systems
1. Putting people’s voices and needs first
2. People-centredness in service delivery
3. Relationships matter: health systems as social institutions
4. Values drive people-centred health systems

19. KEYSTONE
1. PUTTING PEOPLE’S
VOICES & NEEDS FIRST
How can people’s voices influence
shaping the health systems to
serve public interest?
• Back to PHC approach:
equality, rights, health as
socio-economic issue
• Confronting disproportionate
power balances
• Participation  Participatory
governance
2. PEOPLE-CENTREDNESS
IN SERVICE DELIVERY
Putting people first in terms of how
services are designed and delivered,
not merely orienting services on
basis of diseases, or for
convenience of clinicians
• Quality and safety of care
• “Longitudinality”, closeness to
communities, responsiveness to
users’ views, requirements
• Capacity building as enhancing
capabilities for responsiveness

20. KEYSTONE
3. HEALTH SYSTEMS AS
SOCIAL INSTITUTIONS
Health systems actors –
administrators, providers, users,
researchers – are linked through
relationships
• Systems thrive on trust,
dialogue between actors,
• System change goes beyond
altering rules & resources, to
managing relationships
effectively
4. VALUES DRIVE PEOPLE-
CENTREDNESS
Decision-making should be
informed by people-centred values:
justice, respect, inclusiveness
• Values define system culture
and influence perfomance
• Procedural justice complements
distributional justice, in a
people-centred system

21. KEYSTONE
HEALTH POLICY FRAMEWORKS

22. KEYSTONE
The Health Policy “Triangle”
CONTENT
ACTORS
•as individuals
•as members of groups
PROCESSCONTEXT
(Walt and Gilson 1994)

23. KEYSTONE
Stages of Policy
POLICY
PROCESSES
Agenda setting
Policy-making
Implementation

24. KEYSTONE
Types of Policies
• Distributive / redistributive: concerned with the distribution
of new resources or with changing the distribution of existing
resources
• Regulatory: concerned with the control of individual and
organization activities
• Constituent: concerned with setting up and re-organizing
institutions
From Lowi (1972)

25. KEYSTONE
Top-down and Bottom-up policy
Top Down
• Policy-making and implementation
are distinct
• Focus on execution of policy-
makers’ intentions
• Starts with a statement of intent
• Implementation with clear lines of
authority and enforcement of
norms
Bottom Up
• No clear separation between
policymaking, implementation
• Subordinate actors (e.g. service
providers) also seen as decision-
makers
• Starts with a statement of
behavior in the ‘field’
• Implementation seen as
relationships between actors

26. KEYSTONE
Policy Actors
Governments
Lawmakers Executive Judiciary
Ministries and
bureaucracy
Institutions, firms and organizations
Technical and professional bodies
Donor agencies
Civil society and interest groups
‘Networks’
‘Street level bureaucrats’
Laity / electorate
Multilateral / bilateral organizations
NON-STATE
STATE

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