Case study E: PIH Chapter 1: Nomads and Nationali
Case study E: PIH Chapter 1: “Nomads and Nationalists in the Eritrean Sahel,” by Assefaw Tekeste Ghebrekidan
9.1 9.2 ppt health care
6.2 medical humanitaianism
Exam Study Guide Topics
Understand the 10 essential services of a healthcare system
Understand the different parts of the WHO’s Health Systems Framework, including the “building blocks” and the relationship to other parts of the diagram.
Know the 3 levels of health care, and be able to identify the level given an example.
Understand the main ways that healthcare systems are organized according to financing and delivery. Given an example, be able to identify whether that is public or private (e.g. know some examples of each)
Understand the common terms used to discuss health systems, including “public,” “private,” “co-payments,” “co-insurance,” “premiums,” etc.
Know the 4 types of health care systems including:
The country known for developing it
How it is financed
Whether there is insurance. If there is insurance, describe how it works.
Impact on citizens: cost of treatment, whether everyone is insured (“Universal coverage”)
If given a description of a health care system, be able to state which of the four types of health care systems it is most like and why.
Understand the components of the US system and how it is related to the 4 “models”
Describe the political and ideological value placed on health that is associated with different types of health systems
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Bigger questions to keep in mind as you listen and read about health systems in Unit 9
To what extent do different health systems value the “right to health”?
What is the role in various health systems of individuals, as well as the public, private and nongovernmental sectors?
What is the extent to which different actors in the system are engaged in the financing and provision of health services?
How are different health systems organized and managed?
What are the key issues constraining the effectiveness and efficiency of health systems in different settings?
How can those constraints best be addressed?
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What is a health system?
WHO definition: “All actors, institutions, and resources that undertake health actions – where a health action is one where the primary intent is to improve health.”
Similarly, “a health system in the combination of resources, organization and management that culminate in the delivery of health services to the population”
Resources: drugs, medical technologies, first aid equipment, vaccines, funding, etc.
Institutions: Clinics, hospitals, pharmacies, laboratories, agencies that set standards, fundraising institutions, etc.
Actors: Doctors, nurses, community health workers, lab technicians, pharmaceutical industry workers, health researchers, etc.
Agencies (planning, regulating)
Money
People hwo provide preventative health services
“ “ “ clinical sercies
“ “ “ specilized inputs like education, drug manufacturing, research on medical devices…
From skolnik.
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The 10 Essential Public Health Services
Monitor health status to identify and solve community health problems
Diagnose and investigate health problems and health hazards in the community
Inform, educate, and empower people about health issues
Mobilize community partnerships to identify and solve health problems
Develop policies and plans that support individual and community health efforts
Enforce laws and regulations that protect health and ensure safety
Link people to needed personal health services and assure the provision of health care when otherwise unavailable
Assure a competent public and personal health care workforce
Evaluate effectiveness, accessibility, and quality of personal and population-based health services
Research for new insights and innovative solutions to health problems
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The three Levels of Care
Primary Care
First point of contact for a patient, and ongoing care over time
Primary care physician – often acts as a gatekeeper to access other levels in cases of non-emergency. Referral (to hospital) only when problems are too uncommon to maintain competence. Coordinates care when people receive services at other levels.
Secondary Care: all of the above, plus…
Specialist physicians
E.g. General hospitals
Tertiary Care: all of the above, plus…
Specialized consultative care, usu. in hospitals, on referral
Wide range of physicians (but they are specialists)
Can address a wide range of health problems
High-level diagnostics, surgeries and treatments
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Health Care Systems are Complicated!
And yes, lots of people already knew that.
Levels of care:
Primary
Secondary
Tertiary
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Classifying healthcare systems
| Delivery | |||
| Public | Private | ||
| Financing | Public | National Health Service (NHS) | National Health Insurance models |
| Private | None | Out-of-Pocket |
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Four Basic Models of Health Care Systems
British System (The Beveridge Model, aka, National Health Service)
German System (The Bismark Model)
Canadian System (The National Health Insurance Model)
Out-of-pocket System
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Beveridge Model, aka, National Health Service (NHS)
Often called “British System”
There is no insurance in this system!
Comprehensive health services available to everyone, regardless of ability to pay
Coverage is universal; Health care is viewed as a state-supported service
Covers wide range of preventative and therapeutic services, mental health care, physical therapy, some palliative care, dental and eye care
Health care is provided and financed primarily by the government
“Single-payer system” means the government is the single payer
Countries that use the Beveridge model: Great Britain, Spain, New Zealand, Cuba, most of Scandinavia, Hong Kong
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The Beveridge Model as it works in the UK today
Mostly public financing
75% general taxation
25% payroll tax
Minimal private funding
Copayments for outpatient (non-hospital) prescription drugs, dentistry services
11% of population also buys private voluntary health insurance
To get faster and more convenient care
For elective surgery at private hospitals
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The Beveridge Model as it works in the UK today
Patients never get a bill from the doctor
Have some copays, but minimal
Out-of-pocket spending was 9% of total health care spending in the UK in 2012 (OECD, 2014a)
Some health care workers are public, some are private
Government pays private doctors set fees for services
All healthcare workers directly bill the government; patients don’t get bills
Single-payer system
Government decides what doctors can do
Government decides what doctors can charge
Tight government control keeps overall costs (e.g. cost per capita) low because government decides
Limits choice on what services people can get
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Variation on the NHS in Cuba
Cuba: whole system is government-operated
all clinics, hospitals, services staff
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Key components of the UK/Beveridge system (review)
The country known for developing it?
How it is funded?
If there is insurance, describe how it works
Impact on citizens: cost of treatment, whether everyone is insured?
Which part of the U.S. system is most similar to this?
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The Bismark Model (German system)
First universal system of health insurance, developed 1880s
Mandatory insurance, provided by “sickness funds”, covers 90% of population; rest have private insurance
Government regulates but does not provide health services directly
Financed by both employers’ tax, and employees through payroll deductions
Countries that use the Bismark Model: Germany, France, Belgium, the Netherlands, Japan, Switzerland and many Latin America countries
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The Bismark Model in Germany today
Insurance plans — “sickness funds”
Have to cover everyone
Must be not-for-profit (different from US system)
Participation is mandatory (like the “individual mandate” in the US Affordable Care Act)
Employers and employees split the cost of care equally (similar to employer-based insurance for the US)
The self-employed buy private insurance
Disabled and unemployed are also covered through various schemes
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The Bismark Model in Germany today
240 sickness funds, tightly regulated by government
Multi-payer system, but tightly regulated by government to control costs
Must accept everyone, and must provide certain services mandated by the government
Can only compete by providing additional services
Health care providers and institutions are private
Payment is negotiated between the sickness funds and providers
Patients can choose their providers
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The National Health Insurance Model: Canada
Universal coverage
Single-payer: National government-run insurance program
No profit
No need to market the plan to sell it to everyone
No financial motive to deny claims
Cheaper and simpler than private for-profit insurance (like US)
Single-payer (the government) (like Beverage)
Providers are private (like Bismark)
Countries with National Health Insurance Model: Canada, South Korea, Taiwan
This is Canada’s system
This system has elements of both Beveridge and Bismarck:
It uses private-sector providers (like Bismark) but payment comes from a government-run insurance program that every citizen pays into (like Beverage).
Canadian system – also an insurance model: government pays the providers directly through insurance,
Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance.
The single payer tends to have considerable market power to negotiate for lower prices; Canada’s system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated.
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National Health Insurance Model in Canada today
Funded by taxation at the federal and provincial levels
Both personal and corporate income taxes
And some from sales tax, lottery in some provinces
Keeps costs low by limiting services and long waits for treatment
Pharmaceutical costs are so low that many Americans drive to Canada to buy medications
Although some in Canada still think they are too high
And pharmaceuticals are an out-of-pocket expense
Health care providers are largely public
National Health Insurance Model in Canada today
Covers preventive care, medical care from primary care physicians, hospitals, dental surgery and more
Some provinces require premiums for some services
But, health services cannot be denied due to financial inability to pay
Some people buy supplemental private insurance through their employer for non-covered health services
Dental services, eye care, prescription medicines
Federal system but each province gets a lot of autonomy
Differential care by province
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The Out-of-pocket Model
The out-of-pocket model is one in which any medical care is paid for entirely by the patient
This may mean seeing a non-traditional healers
Or it may mean paying with money, food, services
Or it may mean being sick and dying young
It most likely means little to no preventative care
Many low and middle income countries have no established health care system
In many places, the rich get medical care, but not the poor
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Out-of-pocket expenses vs. Out-of-pocket model
Most of the systems described here have some form of ‘out-of-pocket’ spending
British system: Copayments for drugs
Canadian system: Private health insurance to decrease wait times, and uncovered services
That is not the same as an ‘out-of-pocket’ model of health service
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Is there insurance?
Who runs the insurance system?
Yes
No
Canadian System
German System
Public/Government
Private
companies
Who pays at point of service? (Who gets the doctor’s bill?)
British System
Out of pocket System
The government
The patient
Distinguishing between the models based on insurance
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Distinguishing the models based on delivery and financing
| Delivery | |||
| Public | Private | ||
| Financing | Public | National Health Service (UK, Cuba, Spain) | National Health Insurance (Canada, South Korea, Thailand, New Zealand) |
| Private | None | Out-of-Pocket (most countries until the 19th or 20th c.) |
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Pluralistic Models
Combination of private, public, and not-for-profit sectors playing important roles in health care services
Health care is not considered a human right, but rather a personal good that is commodified
Countries that have ‘pluralistic’ models health systems
India
Nigeria
United States
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The US system is pluralistic
“Health care in the United States is currently a unique hybrid, multiple-payer system, but with elements of single payer (i.e., Medicare, although beneficiaries also contribute through premiums), publicly subsidized private payers (e.g., employer-sponsored health insurance), socialized medicine (e.g., Department of Veterans Affairs, in which government is both the payer and the employer), and self-pay (i.e., out of pocket).”
Donnelly, Peter D., Paul C. Erwin, Daniel M. Fox, and Colleen Grogan. 2019. “Single-Payer, Multiple-Payer, and State-Based Financing of Health Care: Introduction to the Special Section.” American Journal of Public Health 109 (11): 1482–83. https://doi.org/10.2105/AJPH.2019.305353.
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Which parts of the US health system are like these health models?
German system – employer-provided insurance
Difference being that in Germany, these are all non-profit insurance organizations, whereas most insurance plans in the US are for profit
Canadian system – Medicare and Medicaid
Government-run insurance plans that pay private doctors for certain sets of treatments
British system – Veteran’s health plans
Government run hospital system, public health providers
Out-of-pocket system – population with no health insurance
They can get care if they can pay for it
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| Health system: | 1. Private | 2. Pluralistic | 3. National Health Insurance | 4. National Health Service (NHS) | 5. Socialized Health Service |
| Prototype: | Most countries until the 19th or 20th century | United States, Peru, Nigeria, India | Canada, Germany, France, Belgium, Netherlands, Taiwan, Japan, Costa Rica, Latin American countries | United Kingdom, Italy, Sweden | Cuba, Soviet Union |
| Political and ideological values: | Health care as an item of personal consumption | Health care as primarily a consumer good | Health care as an insured, guaranteed service | Health care as a state-supported service | Health case as a right and a state-provided public service |
| Position of the physician: | Solo entrepreneur | Solo entrepreneur and member of practitioner group | Private solo or group practice and/or employed by hospitals | Private solo or group practice and/or employed by hospitals | State employee |
| Ownership of facilities: | Private | Private, not-for-profit, and public | Not-for-profit and public, some private | Mostly public | Entirely public |
| Source of financing: | Private out-of-pocket payments | Mix of private out-of-pocket and public | Primarily public single-payer | Public monopsony (only 1 buyer) | Public monopsony (only 1 buyer) |
| Administration and regulation | Market | Market, some government | Government, some market | Government | Government |
Adapted from: Birn, A, Y, Pillay, and T. H. Holtz. 2017. Textbook of Global Health. Oxford University Press. Page 481.
The spectrum of health systems
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Part III of your country papers: Health System
Organization: Is it a coordinated system run by the Ministry or Department of Health or is it more fragmented and relies primarily on market forces or NGOs? Is there a linked system of primary care, hospital care, and tertiary care?
Financing: This will vary widely by country, but some guiding questions: Is the system publicly funded, privately funded, supported by foreign donors, or a mix? If it is a mix, which kind of financing is dominant? Is the funding level sufficient to meet the needs of the population? If it has public funding, is it from taxes (if so, what kind of taxes?) or insurance premiums? What percent of healthcare costs are paid by the government (versus individuals)?
Coverage: Is there insurance? How does insurance work (who pays for it, what % of people are insured)? What costs are incurred by citizens (insurance premiums/cost of care)? Any recent significant changes in the system?
Key sector issues… next lecture.
Describe the overall health system (including organization, financing, coverage and model). After you’ve given an overview, then you’ll analyze the key sector issues. You’ll need to be concise as you will only have about a paragraph or less for each of the key sector issues.
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Exam Study Guide Topics
Know what each of the 7 health sector issues means, plus:
A specific example
A strategy to address issues related to that Key Sector Issue
Use this understanding to do research for part III of your country papers
Before next slide: what would a demographic change be? Epidemiologic change?
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| Definition | Examples | Strategies to address concerns |
| Changes in the population or changes in the patterns of disease. A health system needs to be able to respond to these. | Longer life expectancy or immigration, the increase in non-communicable diseases or the emergence of a new disease like HIV or Zika. A health system needs to be able to respond to these issues. | If non-communicable disease are on the rise, then need initiatives to address lack of physical activity, cigarette usage, etc. If HIV is on rise, need effective treatment and prevention. If population is aging, need to address NCDs such as CVD, dementia, and if the country can financially support aging population. |
1. Demographic & Epidemiologic Change
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| Definition | Examples | Strategies to address concerns |
| Quality of governance—is it open/transparent? Clear rules/ regulations? Are rules enforced? | Staff hired because of connections rather than skill. New staff may have to pay off hiring managers. Staff high absenteeism without losing job. Buying products without best prices because of corruption. Staff getting kickbacks. This happens because of lack of governance—not just individual choice. | Nat’l anticorruption campaigns with strong political will. Reforming supply procurement systems & making transparent. Auditing health system & enforcing penalties. |
2. Stewardship and governance
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| Definition | Examples | Strategies to address concerns |
| Issues related to health system staff members (includes having sufficient staff, well-trained staff, distributed throughout country where needed, salaries to keep people, high quality work conditions, not losing top skilled workers to other countries/settings). | Shortages of docs, nurses, lab techs, unqualified managers. Deficient skills due to poor training. More staff in cities; more shortages rural areas. Public sector salaries < private sector. Lack financial incentive to do quality work. Poor working conditions prompt them to leave country. | Countries & their dev’ment partners more support for education, training, plans for retention. Wealthy countries more shared global responsibility so workers won’t leave resource poor areas. |
3. Human Resources
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Human Resources Sector issue example
2003 survey of over 1400 public health centers across India
Surveyors verified the attendance of providers during unannounced visits
nearly 40% of doctors and medical service providers are absent from work on a typical day.
the absence problem is quite widely distributed and not concentrated among a few doctors.
“Doctors posted at remote facilities and at facilities with poor infrastructure and equipment were absent at significantly higher rates, as were those with longer commutes.”
Muralidharan, Karthik, Nazmul Chaudhury, Jeffrey Hammer, Michael Kremer, and Halsey Rogers. 2011. “Is There a Doctor in the House? Medical Worker Absence in India”. (working paper, Harvard University)
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| Definition | Examples | Strategies to address concerns |
| Safe, effective, patient-centered, timely, efficient, equitable | Not using evidence-based guidelines. Don’t know correct diagnosis or treatment for a disease. Inappropriate use of antibiotics, fluids, feeding, oxygen. [Note: High quality can be achieved in low-resource settings.] | Need assessments to identify quality gaps. Better oversight & training. Use clear guidelines & algorithms. Link payments to NGOs with performance. |
4. Quality of care
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| Definition | Examples | Strategies to address concerns |
| How to fund sufficiently, how to find funding to cover more or to keep covering what system is supposed to cover with changing costs (new tech, drugs, aging pop increase costs) | New technologies drive up cost of care, how to fund to reduce wait times, govt not funding health system enough to ensure decent care regardless of ability to pay. | Shift some $ from another part of economy to health. Shift to most cost effective interventions. Gather data, monitor outcomes. Increase efficiency. |
5. Financing of Health System
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| Definition | Examples | Strategies to address concerns |
| Financing the system without denying healthcare coverage to poor & without making people go bankrupt. Goal: universal coverage for basic package of health services | In India spending $ on health is a primary reason why families fall below poverty line & cause of family selling assets. People use less health care (ie hospital deliveries of babies) when charged. | Raising $ for health, improving efficiency, less out-of-pocket. Providing universal health ins. Targeting free basic package of services to those most in need |
6. Financial Protection & the Provision of Universal Coverage
More example of solutions: Allocate more proportionately to basic packages to people & places with most need. Subsidize care for poor. govts encourage NGOs to provide services to poor.
Before next slide: what’s access and equity?
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| Definition | Examples | Strategies to address concerns |
| Any disparities by sex, age, ethnicity, income, education, location? | Lack of coverage in areas where poor, rural & minorities live. Fewer trained people, equipment & drugs in those areas. Services like vaccines more available in urban areas & areas with higher income & educ. Richer people get the more expensive services. | Govts need to gather data and use it to look at where inequalities exist. Then target services there. Best if paired with improved water, sanitation, nutrition, hygiene, health behaviors (via increased knowledge) |
7. Access and Equity
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Part III of your country papers: Health System
Organization, financing, coverage – previous lecture.
Key Sector Issues: Analyze the ability of your country’s health system to tackle its health issues by researching and describing each of the following issues discussed in class (a few sentences for each issue, or a short paragraph on each, is sufficient):
demographic and epidemiologic changes
health workforce concerns (human resources)
access and equity
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Case Study Reflection Guidelines
Assignment Overview
After reading the assigned text, compose a 400-500 word reflection and submit it to the Canvas discussion board.
Content and Grading
In your reflections, address the following 3 questions.
1. What are the author's main messages/arguments? What is the main takeaway of this case study? What is the essential background information that we need to understand it? (2.5 points)
3. Share your personal reaction or stance on the issues developed in the case study. Has it changed your opinion on the topic? Does it relate to your own personal experiences? Does it connect to things you have studied in other courses, or articles you've been reading in the news lately? (2.5 points)
4. Proper citations (1 point)
Citations
You must include proper academic citation in your case study reflections. This is a good habit to get into generally. Visit this page for the general course citation guidelines.
· When referring to required course material, use a shortened version of the APA's author-date, in-text parenthetical citation system, e.g. (Marmot 2010). You can abbreviate our course textbooks to RGH and PIH, or use the case study author's last name. Be sure to spell the author's name correctly! Lectures can be cited by the number, e.g. (Ryan lecture 4.2). Videos can be cited by the primary speaker or a shortened version of the title, e.g. (Bad Sugar) or (Rosling).
· When referring to outside articles or sources, use the APA's author-date, in-text parenthetical citation system, e.g., (Washington Post 2021) and include a hyperlink or full citation to your original source at the end of your submission. Connecting the case studies to outside sources is always welcome, but be sure you are also
· You do not need to write a full bibliography for case study reflections.
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Nomads and Nationalists in the Eritrean Sahel
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