Health Care Systems
Introduction[edit | edit source]
According to the World Health Organisation a health system consists of all organisations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct activities that improve health. A health system is, therefore, more than the pyramid of publicly owned facilities that deliver personal health services but include the institutions, people and resources involved in delivering health care to individuals for example;
- A mother caring for a sick child at home;
- A child receiving rehabilitation services within the school setting;
- An individual access vocational rehabilitation services within the work place;
- Private providers, behaviour change programmes, such as vector-control campaigns.
- Health insurance organisations, occupational health and safety legislation which includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well-known determinant of better health.
Rehabilitation is an essential health service, alongside prevention, promotion, treatment and palliation.  In a comprehensive health system, rehabilitation is one of the key services at both the community- and hospital level. The integration of rehabilitation in health systems (across the continuum of care, at all stages of life, and for a range of health conditions) is expected to result in improved coordination with medical and other health services, accountability, quality assurance and sustainability.(6) In the medium- and long-term, this integrated approach will result in strengthened delivery of rehabilitation services, better workforce allocation, and adequate financing.
However, there is evidence that rehabilitation is not yet effectively integrated into many health systems globally. In many countries, individuals do not have access to the rehabilitation services they need. The best way to ensure that rehabilitation services reach all those who need them is by integrating rehabilitation across all levels of the health system, as part of universal health coverage.
A well-functioning health system working in harmony is built on having trained and motivated health workers, a well-maintained infrastructure, and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans and evidence-based policies. Health Care Systems differ from nation to nation depending upon the level of economic development and the political system in place. Health care is a priority and source of concern worldwide. Every country irrespective of its private, public or mixed health care system faces challenges with regard to quality, delivery and cost of services. 
As with other social institutional structures, there are a wide variety of health systems around the world and tend to reflect the history, culture, and economics of the states in which they evolve. Nations design and develop health systems in accordance with their needs and resources, although there are common elements present in virtually all health systems for example public health measures like vaccination. In some countries, health system planning is distributed within a competitive market of private health care providers, while in others, there is a concerted effort among governments, trade unions, charities, religious organisations, or other co-ordinated bodies to deliver planned public health care services targeted to the populations they serve. 
Health care is conventionally regarded as an important determinant in promoting the general physical, mental and social well-being of people around the world and can contribute to a significant part of a country's economy, development and industrialisation when efficient. An example of this was the declaration by the World Health Organization (WHO) of worldwide eradication of smallpox eradication in 1980, the first disease in human history to be completely eliminated by deliberate health care interventions. Recognising the value of rehabilitation and its impact on individuals, families, and communities, the allocation of resources to rehabilitation services should be seen as an investment, rather than a cost. 
Health System Models[edit | edit source]
While globally each country has some variation in their health care systems, overall they tend to follow general patterns with four main models forming the basis for most health care systems globally;
The Beveridge Model[edit | edit source]
The Beveridge Model of Health Care, named for William Beveridge, the social reformer who designed Britain’s original National Health Service. Like other public services such as the police or education systems, this model of health care is both provided and financed by the government through tax payments. In this system, healthcare facilities can be owned by the Government, but may also be privately owned with Government funding, with the majority of health staff in this model composed of government employees. These systems tend to have low costs per capita, because the government, as the sole payer, controls what healthcare providers can do and what they can charge with benefits generally standardised across the country.
Health as a human right, is a central tenant of this model, with universal health coverage and equal access to care guaranteed by the government. The primary criticism of this system is the tendency toward long waiting lists with everyone guaranteed access to health services, often leading to over-utilisation and the risk of increasing costs.
Countries using the Beveridge Model or variations on it include Great Britain, where the Beveridge Model was developed, Spain, most of Scandinavia and New Zealand. Hong Kong has its own Beveridge style health care system, which remained in place after the Chinese took over that former British Colony in 1997, while Cuba represents the extreme application of the Beveridge approach with total government control over the healthcare system. 
The Bismarck Model[edit | edit source]
The Bismark Model of Health Care also referred to as a "Social Health Insurance Model" was named for the 19th Century Prussian Chancellor, Otto von Bismarck, who developed a welfare state with compulsory insurance for all working individuals as part of the unification of Germany in 1883. It is a health insurance plan that in principle must include all citizens, and is non-profit in nature, although in practice tends to be available only to the working population with the allocation of resources to those who contribute financially, so as such does not provide universal health coverage. It is predominantly funded jointly by employers and employees through payroll deductions.
Generally, it is a mixed model health system that incorporates a mix of private and public providers and allows more flexible spending on healthcare. Providers and hospitals are generally private, while insurers are generally public. Some countries like France or Korea have a single insurer, while other countries like Germany have multiple competing insurers although pricing is controlled by the government as is also seen with the Beveridge Model.  This model is found in Germany, France, Belgium, the Netherlands, Japan, and Switzerland.
A significant drop in mortality was shown in Germany with the introduction of the original Bismarck system , thought to be due predominantly to the prevention of communicable disease. As a whole Bismark Models of Health Care generally have significantly higher accessibility, lower waiting times and often higher quality and more consumer-oriented healthcare, thought to be as a result of competition between healthcare providers. The primary criticism of the Bismarck model is how to provide care for those who are unable to work or can't afford contributions, including ageing populations and the imbalance between retirees and employees.
The National Health Insurance Model[edit | edit source]
This system combines elements of both the Beveridge and Bismarck Models of Healthcare. Generally, funding comes from a government run insurance program that every citizen pays into, as we see in the Beveridge Model, but it predominantly uses private sector providers. This model provides universal insurance that doesn't make a profit or deny claims and as such with no requirement for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than For-Profit or Private Insurance Models.
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, which is the primary criticism of these models. The potential for long waiting lists and delays in treatment can be considered a serious health policy issue. This model is found in Canada, Taiwan and South Korea, and the Medicare Model in the United States of America are based on this model.
The Private Model[edit | edit source]
Disparities in health care due to socioeconomic status and ethnicity are found in all countries. Currently, there are a limited number of countries globally that have established national health care systems, with the majority of countries providing ad hoc national medical care, which is provided on a private or pay for treatment basis. This typically means that those with access to money get access to health care, while those that do not have money do not have health care access. In many isolated or rural regions of the world, hundreds of millions of people can go their whole lives without ever accessing health care services. In this type of model Healthcare is still driven by income. This model of healthcare is found predominantly in isolated communities and is particularly seen in rural areas in India, China, Africa, South America, and among uninsured or underinsured populations within the United States of America.
Components of Health Systems[edit | edit source]
A health system consists of all the organisations, institutions, resources and people whose primary purpose is to improve health. The key components of a well-functioning health system should include: 
Leadership and Governance[edit | edit source]
Leadership and governance involve assurance that strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system design and accountability.
- Laws, policies, plans and strategies that address rehabilitation.
- Governance structures, regulatory mechanisms and accountability processes that address rehabilitation.
- Planning, collaboration and coordination processes for rehabilitation. 
Financing[edit | edit source]
Raises adequate funds for health, in ways that ensure people can use needed services and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient.
- Health expenditure for rehabilitation.
- Health financing and payment structures that include rehabilitation.
Health Workforce[edit | edit source]
A health workforce works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed, they are competent, responsive and productive).
- Health workforce that can deliver rehabilitation interventions - including rehabilitation medicine, rehabilitation-therapy personnel, and rehabilitation nursing.
Healthcare Products - Essential Medicine and Technology[edit | edit source]
Equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.
- Medicines and technology commonly used by people accessing rehabilitation, particularly assistive products.
Healthcare Infrastructure - Service Delivery[edit | edit source]
Service delivery can be defined as the way inputs are combined to allow the delivery of a series of interventions or health actions.
- Health services that deliver rehabilitation interventions, including in specialised rehabilitation hospitals, centres, wards and units; in tertiary and secondary hospitals and clinics; in primary health care facilities and in community settings.
Health Information Systems[edit | edit source]
Ensure the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.
- Data relevant to rehabilitation in the health information systems, such as population functioning data, rehabilitation availability and use data, and rehabilitation outcomes data.
- Research relevant to rehabilitation policy and programmes.
Rehabilitation in Health Systems[edit | edit source]
While we recognise that rehabilitation, in conjunction with other health services, is delivered in the context of a specific health condition, integrated into the health system is currently not effective in many areas of the world. It has been suggested that this is a result of the poor designation of responsibility for the integration of rehabilitation into the health systems. In some countries rehabilitation is more commonly associated with disability, so is often governed by and administered by social welfare services, while in other countries rehabilitation governance is shared between the ministries of health and of social welfare.
The World Health Organisation Rehabilitation in Health Systems provides evidence-based, expert-informed recommendations and good practice statements to support health systems and stakeholders in strengthening and extending high-quality rehabilitation services so that they can better respond to the needs of populations and integrate rehabilitation services effectively. 
Rehabilitation Services should be Integrated Into Health Systems[edit | edit source]
Quality of Evidence: Very Low
While rehabilitation for a health condition is usually provided in conjunction with other health services, it is currently not effectively integrated into health systems in many parts of the world. This has been attributed partly to how and by whom rehabilitation is governed . Clear designation of responsibility for rehabilitation is necessary for its effective integration into health systems. In most situations, the ministry of health will be the most appropriate agency for governing rehabilitation, with strong links to other relevant sectors, such as social welfare, education and labour.
Rehabilitation Services should be Integrated Into and Between Primary, Secondary and Tertiary Levels of Health Systems[edit | edit source]
Quality of Evidence: Very Low
The underdevelopment of rehabilitation in many countries and pervasive misconceptions of rehabilitation as a luxury adjunct to essential care or only for people with significant disability have often resulted in services only at selected levels of health systems. Rehabilitation is, however, required at all levels, for the identification of needs and for an effective continuum of care throughout a person’s recovery. Standardised referral pathways and other coordination mechanisms between levels help to ensure a good transition of care for optimal outcomes.
A Multi-disciplinary Rehabilitation Workforce Should be Available[edit | edit source]
Quality of Evidence: High
A multi-disciplinary workforce in a health system ensures that the range of rehabilitation needs for different domains of functioning can be met. While multi-disciplinary rehabilitation is not always necessary, it has been shown to be effective in the management of many conditions, especially those that are chronic, complex or severe  (8–10). As different rehabilitation disciplines require specific skills, a multi-disciplinary workforce can significantly improve the quality of care.
Both Community and Hospital Rehabilitation Services Should be Available[edit | edit source]
Quality of Evidence: Moderate
Rehabilitation in both hospital and community settings is necessary to ensure timely intervention and access to services. Rehabilitation in hospital settings enables early intervention, which can speed recovery, optimise outcomes and facilitate smooth, timely discharge . Many people require rehabilitation well beyond discharge from hospital, while other users may require services solely in the community. People with developmental, sensory or cognitive impairment, for example, may benefit from long-term interventions that are often best delivered at home, school or in the workplace.
Hospitals Should include Specialised Rehabilitation Units for Inpatients with Complex Needs[edit | edit source]
Quality of Evidence: Very High
Specialised rehabilitation wards provide intensive, highly specialised interventions for restoring functioning to people with complex rehabilitation needs. In a number of instances, the results are superior to those of rehabilitation provided in general wards, such as in the context of lower-limb amputation, spinal cord injury and stroke and in the care of older people.
Where Health Insurance Exists or Is To Become Available, It Should Cover Rehabilitation Services[edit | edit source]
Quality of Evidence: Very Low
Health insurance is a common mechanism for decreasing financial barriers to health services, yet the inclusion of rehabilitation in insurance coverage is variable, and, in many parts of the world, health insurance protects only a minority of the population (17). When health insurance includes rehabilitation, access to and use of rehabilitation services is increased. This mechanism should therefore be part of broader initiatives to improve the affordability of rehabilitation services.
Financial Resources Should be Allocated to Rehabilitation Services to Implement and Sustain the Recommendations on Service Delivery[edit | edit source]
Quality of Evidence: Very Low
How health systems allocate financial resources significantly affects service delivery, yet many countries do not allocate specific budgets for rehabilitation services. Allocation of resources for rehabilitation can increase both the availability and the quality of rehabilitation services and minimise out-of-pocket expenses, which is a significant barrier to service utilisation.
Financing and Procurement Policies Should Ensure that Assistive Products are Available to Everyone who Needs Them with Adequate Training Provided to Users.[edit | edit source]
Assistive products play an important role in improving functioning and increasing independence and participation; however, accessing such products can be difficult, particularly in some low- and middle-income countries. It is important not only to increase access to and the affordability of assistive products but also to train users in effective, safe use and maintenance of the products over time, when necessary. Rehabilitation professionals can ensure that the assistive products that people receive are suitable for them and their environment and are adapted as the needs of the users evolve.
Conclusion[edit | edit source]
Inadequate healthcare is prevalent globally in all countries, and no country has a perfect healthcare system. Health is a basic human right, and improvements in healthcare should be a goal of every country.  Healthcare systems present in different countries are strongly influenced by the norms and values prevalent with the respective societies, and often reflect deeply rooted social and cultural expectations and norms. Although these fundamental values are generated outside the formal structure of the healthcare system, they often define its overall character.  The concerns faced by each country when attempting to construct a system for health care delivery can be very different based on their needs impacted by a wide variety of factors including economics, climate, population size etc. No health care system is completely alike, and none are completely free of problems and as such a method that works for one country will not be completely transferrable to another due to different health concerns, priorities, and mindsets.
Health is a basic human right, and care that improves the lives of all citizens will improve a country as a whole. As such improvements in healthcare and a sustainable healthcare system will provide quality care to all citizens. should be a primary goal of every country.
Resources[edit | edit source]
World Health Organisation Resources[edit | edit source]
- Health Systems Overview
- Health Systems Governance
- Rehabilitation in Health Systems
- Rehabilitation in Health Systems: Guide for Action
Health System Models[edit | edit source]
- Health Care Systems - Four Basic Models.pdf
- Healthcare Systems Around the World.pdf
- Transforming Health - Shifting from Reactive to Proactive and Predictive Care
References [edit | edit source]
- World Health Organization. World Report on Disability 2011. Geneva: World Health Organization, 2011. Rehabilitation.
- Rehabilitation in health systems: guide for action. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.
- Cieza, Alarcos. Healthcare Systems Around the World. Global Health An Online Journal for the Digital Age. 2019
- World Health Encyclopedia. Medicine - Health System. Available from: https://www.newworldencyclopedia.org/entry/Health_care (accessed on 30 June 2021)
- McCANE D. Health Care Systems-Four Basic Models. Physicians For A National Health Program (PNHP). 2010;6.
- Physicians for a National Health Program. Health Care Systems Four Basic Models. Available from: https://members.physio-pedia.com/wp-content/uploads/2019/02/Health-Care-Systems-Four-Basic-Models-18502.pdf (Accessed 26 June 2021)
- Wallace, Lorraine S. A view of health care around the world. Annals of family medicine vol. 11,1 (2013): 84. doi:10.1370/afm.1484
- VoxEU. Bismark's Health Insurance and Its Impact on Mortality. Available from: https://voxeu.org/article/bismarck-s-health-insurance-and-its-impact-mortality (accessed 2 May 2021).
- World Health Organization. Health Systems.Available from: http://www.who.int/healthsystems/en/ (Accessed 20/06/2021)
- Global Health with Greg Martin. Health Systems Available from: https://youtu.be/ECkeJQd2IdY[last accessed 30/07/21]
- World Health Organisation. World Report on Disability. Geneva: World Health Organization and The World Bank; 2011.
- Rehabilitation in Health Systems. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
- World Health Organisation. Disability and Rehabilitation Status: review of disability issues and rehabilitation services in 29 African countries. Geneva: World Health Organization; 2004.
- Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014;9:CD000963.
- Handoll HH, Cameron ID, Mak JC, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev 2009:CD007125.
- Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013;9:CD000197.
- Li Y, Reinhardt JD, Gosney JE, Zhang X, Hu X, Chen S, et al. Evaluation of functional outcomes of physical rehabilitation and medical complications in spinal cord injury victims of the Sichuan earthquake. J Rehabil Med 2012;44:534–40.
- Siegert RJ, Jackson DM, Playford ED, Fleminger S, Turner-Stokes L. A longitudinal, multicentre, cohort study of community rehabilitation service delivery in long-term neurological conditions. BMJ Open 2014;4:e004231.
- Kurichi JE, Small DS, Bates BE, Prvu-Bettger JA, Kwong PL, Vogel WB, et al. Possible incremental benefits of specialised rehabilitation bed units among veterans after lower extremity amputation. Med Care 2009;47:457–65.
- Smith M. Ecacy of specialist versus non-specialist management of spinal cord injury within the UK. Spinal Cord 2002;40:10–6.
- Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010;340:c1718.
- Global survey of government actions on the implementation of the standard rules of the equalisation of opportunities for persons with disabilities. Amman: South-North Centre for Dialogue and Development, Oce of the United Nations Special Rapporteur on Disabilities; 2006.
- Community-based rehabilitation: CBR Guidelines. Geneva: World Health Organization; 2010.
- Lameire N, Joffe P, Wiedemann M. Healthcare Systems - An International Review: An overview. Nephrology Dialysis Transplantation. 1999 Dec 1;14(suppl_6):3-9.