Health care system. Definition. Model
The health care system is a set of all organizations, institutions and resources, the main purpose of which is to strengthen, maintain or restore health. The model of the health care system is determined by the goals, principles and relationships of the elements of the system, as well as the social system, political and socio-economic situation, traditions, culture, history, religion, other factors and the system of special compensators, characteristic of each individual country.
Health care functions include directive leadership, resource formation, financing, and service delivery. The goals of health care include preservation and strengthening of health, sensitivity (response to non-medical expectations of the population), fair financial contribution.
All health care systems can be conventionally divided into 3 groups by typology:
1. With mainly state funding. They operate in the CIS countries, Scandinavian countries, Great Britain. They work efficiently under the condition of sufficient funds in the state.
2. On the basis of insurance medicine. In such systems, there is targeted collection of funds, formation of funds and provision of guaranteed services through insurance policies. The model of insurance medicine works in various financial conditions, exists in most countries, covers approximately 70–90% of the population. At the same time, people are responsible for their health and choose one or another medical facility.
3. Mainly private healthcare system. Effectively works only for wealthy population groups. A typical example is the USA, where medical care is available for wealthy sections of the population, a large part of the population does not have health insurance, and in this connection there are many problems. For this, the state leadership is currently proposing to introduce basic health insurance, but so far it has not been possible to do so. The main directions of reforming the country’s medical sphere are increasing the coverage of the population with medical insurance, increasing the availability of medical care.
Global health care problems in the 3rd millennium
The end of the 20th century. was marked by a change in the health paradigm, an epidemiological transition from an infectious to a predominantly non-infectious type of pathology, an increase in the burden of diseases and the need for collective and individual health care services. The era of cheap healthcare is over. In the 70s of the XX century. Ukrainian SSR was among the top five in terms of health indicators in Europe. At that time, health care costs in comparative prices were $135. US per inhabitant, while in the US itself these costs amounted to 160 dollars. per inhabitant
The main achievements in the field of health care in the 3rd millennium include an increase in the average life expectancy, the overcoming of many infectious diseases, the development of preventive technologies, the emergence of genetic medicine, the creation of new generations of drugs, an increase in GDP for health care, the development of modern medical technologies, high professionalism of the medical staff, improvement of the standard of living in general.
These are certainly positive achievements. But at the same time, new challenges are emerging in society: the rapid aging of the population, the epidemic of chronic non-infectious diseases, the increase in the prevalence of risk factors, the increase in the aggressiveness of environmental factors, the development of resistance of microorganisms, financing problems in conditions of limited resources, the rapid spread of diseases due to the high mobility of the population, increasing requirements for the availability and quality of medical care, increasing the cost of health-forming services.
The average life expectancy (LEO) has increased significantly over the past 100 years. So, in 1900 it was 35 years on average, in 2000 — 65.4, in 2010 — 67.7, in 2050 — it is planned to be 75 years. But in some countries, the life expectancy at birth has already reached 82 years. The world is witnessing a significant increase in the number of people over the age of 65. In 1990, their share was 6.7%, and now it is 17% in EU countries. That is, there is a significant aging of the population, which forces us to spend more money on health care, as the number of requests for medical help increases several times.
The problem of inequality in access to medical care is also extremely relevant.
The modern world is experiencing a real epidemic of chronic non-communicable diseases associated with an unhealthy lifestyle, unbalanced nutrition, low physical activity, etc.
Mortality from diseases of 7 groups — cardiovascular, oncological, chronic respiratory, diabetes, HIV/AIDS, tuberculosis and malaria — accounts for 60% of the overall mortality structure. Leading risk factors for the global burden of disease in the WHO European Region: high blood pressure (12.8%), tobacco smoking (12.3%), alcohol abuse (10.1%), high cholesterol (8.7%), overweight body (7.8%), insufficient consumption of vegetables and fruits (4.4%), sedentary lifestyle (3.5%). Today, 55 million people in Europe are obese.
Health care systems are faced today with such problems as the increase in the population and the growing need for medical care, the lengthening of the average life expectancy, which leads to an increase in the prevalence of chronic pathology. On the other hand, an increase in GDP per capita leads to an increase in requirements for the quality of medical care, the introduction of new medical technologies, which ultimately leads to an increase in the cost of services. All of the above explains the growth of health care costs per inhabitant and the increase in the need for financial resources in the conditions of their limited number.
The high cost of health care services, the impossibility of predicting the time of need for them and their postponement, the need to pay at the time of receiving the service, which can lead to the refusal of the service, poses a threat of impoverishment of the population, necessitates the need for financial protection and risk distribution.
Every year, 150 million people in the world bear catastrophic financial costs related to health care, and 100 million people find themselves below the poverty line. The problem of direct payments in health care is very big. In 33 countries of the world with the lowest incomes, the level of direct payments is up to 50%. In the countries of the WHO European Region, direct payments account for an average of 29% of total health care costs. It is believed that the probability of financial disaster and impoverishment is reduced to an insignificant level with a share of direct payments of 15-20%. The main problem of all health care systems is that the growth of health care costs is significantly ahead of the growth rate of GDP. WHO estimates that 20–40% of the financial resources for health care in the world are spent inefficiently.
Our analysis allows us to formulate a modern health care financing formula, which provides for coverage of at least 70% of costs from public funds, less than 5% from private health insurance, and no more than 15-20% from direct payments.
The consequences of intensive use of ecological systems, namely: significant environmental pollution, degradation, manifestations of climate change, have a negative impact on health, which, in turn, leads to the growth of ecologically dependent pathology, significant medical and socio-economic losses for society.
Today, 60 million specialists work in the field of health care in the world, including 8.7 million doctors, 16.7 million nursing and midwifery personnel, 1.2 million dental and 2.1 million pharmaceutical personnel, etc.
The shortage of medical personnel reached 4.3 million specialists, including 2.4 million doctors. The uneven distribution by region is noted: American region of WHO — 24.8 per 1000 population, European — 18.9, Southeast Asia — 4.3, African — 2.3. The level of migration of medical personnel is high. The annual migration of doctors in the countries of the European region is 5%; in the countries of the Organization for Economic Cooperation and Development — 20%, in the countries of the Persian Gulf — 50%. All this leads to low availability of medical care. 1.3 billion people in the world do not have access to the most basic medical services, the share of births accepted by qualified medical workers varies from 10% to 100% in different countries.
First aid and prevention
The main principle of providing medical care is the priority of primary health care (PHC), because 75% of people turn to primary care. Primary care is an integral part of the national health care system, which performs its main function (Alma-Athens Declaration on Primary Care). In the words of Margaret Chen: “The development of primary health care is a key element in achieving acceptable levels of health for all people in this world.”
The attitude towards prevention as the most effective way to preserve health is still not serious enough. In Ukraine, only 2% of healthcare costs are allocated to prevention. At the same time, it is known that prevention has great health potential. Prevention at the level of the entire population is the most sustainable strategy in the long term, is a means of solving problems associated with a number of socially significant and socially dangerous diseases and their common risk factors.
The strategic goals of the functioning of all health care systems are the availability and quality of medical services. However, a significant part of the population faces problems of access to health care services. It is known that women from the poorest 20% of the population are 20 times less likely to receive the help of a qualified medical professional during childbirth than from wealthy ones.
The share of births attended by qualified medical personnel in developing countries is only 65%. The share of women who received at least one qualified consultation during pregnancy in developing countries is 80%.
11% of people in the world experience serious financial obstacles in accessing health care, 5% experience poverty due to paying for health care. Transportation costs make up 10% of citizens’ expenses for medical care.
The quality of services plays an important role in health care. The quality of medical care is influenced by adequacy, availability, continuity and continuity, effectiveness, efficiency, safety, timeliness, satisfaction of needs and expectations, stability of the process and result, constant improvement and improvement. In different health care systems and in different countries, a lot of attention is paid to quality control of medical care. However, there are also problems of low quality of services and errors in the provision of medical care. For example, 44,000-98,000 patients die annually in the USA due to insufficient quality and errors, in Europe 10,000 complaints are submitted to arbitration courts every year, 52% of which are complaints about medical errors, 15 million people suffer annually. In EU countries, every 10th case of treatment harms patients. For most countries, improving the quality of medical care is one of the main tasks in the process of improving health care systems.
In response to new challenges and threats, the countries of the WHO European Region have developed and adopted the Health 2020 European Policy Framework as a strategic platform based on values, focused on specific actions, with the possibility of adaptation to specific realities.
The new European policy outlines modern strategies and ways of solving existing health care problems.
This document requires a critical review of existing health care management mechanisms, improvement of health care policy, development of public health structures, priority of providing medical care, impact on leading risk factors: high blood pressure, tobacco smoking, alcohol abuse, high cholesterol content in the blood, obesity, insufficient physical activity, unsafe sex.
The main values of the new European policy: recognition of the right of every person to health, solidarity, justice, sustainability, universal accessibility, quality, the right to participate in decision-making, protection of human dignity, autonomy, non-discrimination, transparency, accountability.
In the statement of the Council of the EU regarding the general values and principles of health care systems, the following are declared: full coverage of the population by medical care, solidarity in financing, equality of access, high quality of medical care.
Speaking at the high-level meeting of the UN General Assembly on the prevention and control of non-communicable diseases on June 20, 2012, the President of Ukraine, Viktor Yanukovych, noted that the development of the WHO “European Health Protection Policy 2020” was the impetus for the creation of the Ukrainian program “Health i-2020: the Ukrainian dimension”. For the first time in Ukraine, this document envisages the orientation of the health care service to prevention, based on the WHO principle “Health is in all policies”, and the adoption of a healthy lifestyle.
During the meeting between the Deputy Prime Minister of Ukraine and the Minister of Health of Ukraine, Raisa Bogatyreva, with the Regional Director of the WHO Europe, Zhuzhana Yakab, on June 28, 2012, it was noted that today in the country, more attention is paid to health care than ever before. when, it is the first priority of the humanitarian policy of the state.
The development of the national strategy for the development of health care is regulated by the order of the Ministry of Health of Ukraine dated December 26, 2011 No. 964 “On the measures of the Ministry of Health of Ukraine regarding the development of the national program “Health-2020: Ukrainian dimension”. By the way, the coordination council and the working group of the Ministry of Health of Ukraine on the formation of the new program included leading specialists of the National Medical University named after O.O. Bogomolets, who actively worked on its creation. Approaches to the scientific substantiation of the document included: analysis of the health and health care situation, identification of priority problems, determination of key development strategies in accordance with the main directions of state policy, consideration of international recommendations and experience of other countries, determination of the principles of building the program, involvement of leading scientists schools, work with the main freelance specialists of the Ministry of Health of Ukraine, examination of materials, establishment of indicators of success, carrying out predictive calculations.
The principles of substantiation and development of the program were: compliance with the main directions of state policy in health care, taking into account the recommendations of international and regional health care organizations, using the positive experience of various countries, consistency in the development of program documents, scientific validity based on modern health problems and health care, reduction of systemic risks, preventive orientation, interdisciplinary approach, inclusion in the program of measures related to health care from other state programs, devoting individual years to solving one of the most important problems.
During the work on the draft program, international recommendations were taken into account and an analysis of strategic and programmatic documents in health care at the international and European level was carried out, including: Political declaration of the UN General Assembly on the prevention and control of non-communicable and infectious diseases (2011), new European health policy “Health 2020”, Tallinn Charter: Health Care Systems for Health and Well-Being (2008), Moscow Declaration of the First Global Ministerial Conference on Healthy Lifestyles and Combating Noncommunicable Diseases (2011 ), resolutions 64/11, 6512 of the UNFCCC, WHO Framework Convention on Tobacco Control, Action Plan for the Implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases for 2012–2016, Global Strategy in the Field of Nutrition, Physical Activity and Health ( 2004), European action plan to reduce the harmful use of alcohol for 2012–2020.