Abstract

The health system should improve the quality of life and create conditions for economic growth through the preservation and improvement of the health of each individual and the entire population. Respecting the fact that health is influenced by a large number of factors outside the health system, the health system should strengthen its capacity to cooperate with other sectors and improve its own capacity to transform in order to respond to new health challenges and population needs. The health care system should implement measures to protect and improve health and treat and rehabilitate patients in an effective and rational way, and it should always be guided by scientifically based knowledge. The system will give patients a central and active role, and will be based on high ethical and moral standards.

1. Introduction

The first step towards health frameworks reinforcing is to understand that a health framework is a dynamo of intelligence and synergies between the building blocks, specifically, governance and administration, health financing, drugs and technologies, health information, health workforce, and service delivery. Successful governance and administration are the foundation and vital entry points for discussions of health policy, design, implementation, and for raising performance in healthcare delivery. Human resources for health are an important building block of a health system, and they are central towards the achievement of better health outcomes.

In recent times, disease-focused multi-billion-dollar health initiatives have emerged in the landscape of public health, and governments of many low- and middle-income countries have increased their spending on health. However, in the absence of systematic evidence, there is ongoing debate about the merits of the global aid architecture and aid effectiveness in health. It is argued that technical assistance is often tied to and driven by donors and is not appropriate for the local context of low- and middle-income countries. Recognizing the reality of limited resources and the flat-lining of international donor funding, it is important for low- and middle-income countries to be efficient by meeting priority health needs or following the approach of defining and providing a context-specific minimum service package or essential health package (EHP) of high quality.

2. Public Health

The history of community and public health dates to antiquity. For much of that history, community and public health issues were addressed only on an emergency basis. For example, if a community faced a drought or an epidemic, a town meeting would be called to deal with the issue. It has only been in the last 100 years or so that communities have taken explicit actions to deal aggressively with health issues on a continuous basis.

Today’s communities differ from those of the past in several important ways. Although people are better educated, more mobile, and more free than in the past, communities are less self-sufficient and are more dependent on state and government funding for support. Modern communities are also too large and complex to respond effectively to sudden health emergencies or to make long-term advancements in community and public health without community organization and careful planning. Better community organizing and careful long-term planning are essential to ensure that a community makes the best use of its resources for health, both in times of crisis and over the long term.

The capacity of today’s communities to respond effectively to their own issues is hindered by the following characteristics:

1. Highly developed and centralized resources in our national institutions and organizations.
2. Continuing concentration of wealth and population in the largest metropolitan areas.
3. Rapid movement of information, resources, and people made possible by advanced communication and transportation technologies that eliminate the need for local offices where resources were once housed.
4. The globalization of health.
5. Limited horizontal connections between/among organizations.
6. A system of top-down funding (an approach where money is transmitted from either the federal or state government to the local level) for many community programs.

3. Oral Health

The way each nation funds health care plays a part in the sort of oral health care given and how it is delivered. Financing can come from common government revenues, insurance, or direct payment by individuals receiving care. Most countries have a combination of financial support. When supported by government funds, treatment can be limited to specific types of treatment and/or specific treatments for specific populations.

Population age, location, and oral health status have an impact on the design of an oral health care system. For instance, whether the country has more elderly or more children might determine the location of care. Elderly care might be more effective if provided in a nursing home, whereas many countries provide care for children in school clinics. If a large portion of the population lives in rural areas, it may be necessary to provide care from mobile clinics or use alternative providers. If children in a particular country have a high caries rate and financial resources are limited, the focus of the system might primarily be on restoring the teeth, while if the caries rate was lower, the focus might be on prevention.

Health policy of each country is defined by lawmakers using data on oral health needs of their specific population. The policy reflects the health values and beliefs of the culture. Goals and objectives for actions are identified and are facilitated or restricted by available financial support.

Oral health care providers and the educational systems vary in each country. For example, the education of a dentist ranges from a 2-year postsecondary training to a 4-year postuniversity degree. There are over 40 countries where dental hygienists practice and 50 countries where dental therapists practice. Dental assistants or dental nurses are employed in most countries. Their education varies from university education to on-the-job training.

The combination of all of these factors impacts oral health care systems and makes comparisons between oral health systems and outcomes in different countries difficult. However, with the blossoming of technology, it is becoming easier to share information and compare the effectiveness of different systems.

4. Population

Epidemiology and public health policy depend on the concept of population. Traditionally, health systems have been designed around a population of people with health problems, those who contact the service. Public health experts, however, have responsibility for the entire population, including those who are at risk of health problems and have early stages of disease. This can be seen as the submerged part of the disease 'iceberg'. Individuals with symptomatic disease can be further subdivided into those with symptoms not seeking medical help, symptomatic but self-treating, and those who are symptomatic but accessing informal care. Even among the symptomatic, only some individuals seek formal health care. Beneath the surface, there are a large number who may have latent, pre-symptomatic, undiscovered disease. However, not all people without symptoms can be described as in perfect health. Many people may have risk factors that make them more prone to various diseases: for example, smoking, sedentary lifestyle, and obesity, which put them at increased risk of coronary heart disease.

Firstly, we need to clearly define the population we are interested in. This might vary in size from an entire country to a small community. It may also be restricted by the disease in question, e.g. to those suffering from coronary heart disease. When the population is defined we can then consider how the pattern of disease changes. This will allow us to plan services based on the pattern of disease in the population as a whole and not just among users of the service. Secondly, we can then provide adjusted services to sub-groups of the population who differ in terms of their needs and are not making effective use of existing services (e.g. poor, non-native-language-speaking). Thirdly, by using knowledge of population trends and health status we anticipate the need for future services.

Populations may be stable or dynamic. A stable population is known as a cohort (a group of people with common characteristics). The population is defined at the start of the follow-up period and continuously decreases in size as its members cease to be at risk of becoming a case (e.g. they die). In contrast, a dynamic population is one in which there is turnover of participation while it is being observed. People enter and leave the population at different times.

5. Workplace

Public health is concerned with the protection of the entire community from illness and the prevention of disease. This discipline certainly includes the millions of people who go to work in small and large businesses. As we have discussed, the safety of workers in the workplace presents a unique set of challenges for public health organizations due to some employers' resistance and the costs associated with the development of workplace prevention programs.

Public health agencies, however, have the necessary skills to offer to the workplace. They can provide educational solutions to the issues causing morbidity and mortality in the workplace as well as in the community by offering programs and services that enable employers to discourage workers from engaging in high-risk health behaviors such as tobacco use, poor diet, obesity, and physical inactivity. Workers who engage in these behaviors are likely to do so both at work and at home. Reducing these high-risk health behaviors at home will require strategies similar to those used to reduce workplace injuries and environmental disease.

People need the expertise of public health organizations to live a healthier life both in the community and in the workplace. In fact, there is an important role for public health in shaping a vision of better health for everyone by eliminating the causes of poor health. In other words, setting realistic goals for preventing disease and injury in the community and the workplace.

6. Functioning

Justice requires that normal functioning be protected in a population and that the health that results be distributed equitably. This is ideally achieved if there is a fair distribution of the social determinants of health (including basic freedoms, education, effective political participation, control over life and work, income, and wealth) as well as an equitable public health and medical system. Such a system would emphasize health risk reduction, the fair distribution of risks, and appropriate forms of medical prevention and treatment for chronic and acute health conditions. The relatively predictable prevalence of standard public health and medical needs means that, on a population basis, there is little uncertainty plaguing health planning. At the same time, different health needs compete for scarce resources. As important as health is, it is not the only important good that must be protected or provided, and so resources for health compete with other important social needs and goals. This means the issue of priority setting for resource allocation is unavoidable in public health planning, even when issues of uncertainty around population needs are not significant.

Natural disasters, including pandemics, as well as forms of biological, chemical, and radiological terrorism, add significant uncertainty to planning for public health emergencies. The dramatic risk posed by worst-case scenarios for disasters, such as a pandemic on the scale of the 1918 flu pandemic, may lead some to think that emergency preparedness is not on a continuum with standard planning for meeting health needs and that the scale of such risks requires thinking about health needs in an entirely new way. That is a mistake for two fundamental reasons. First, the best preparation for major emergencies is a properly functioning public health system that makes appropriate allocation of resources for both emergencies and routine needs. Second, the considerations involved in thinking about appropriate resource allocation across the spectrum of emergency and routine health needs raise common issues that require common solutions. Emergency preparedness "exceptionalism" would be a self-defeating strategy.

One of the regulatory implications of the argument that emergency preparedness requires strong public health system building is that countries with global health budgets are better positioned to think about appropriate resource allocation than are countries with fragmented health systems and multiple budgets with different incentive structures. If emergency preparedness means stockpiling resources that are then not readily available for meeting routine health needs, that is better done as a trade-off within a global budget. Where different budgets address these competing needs in a more fragmented system, unnecessary redundancies or other forms of inefficiency and inadequacy in decision-making are more likely to be found. Similarly, compliance with resource constraints might be easier to achieve if the resource allocation results from a closed budget that puts all people on the same footing; otherwise, compliance is more easily undermined by "gaming of the system." Specifically, a mixed system with competing budgets and resources might lead to more uncontrolled forms of hoarding and noncompliance with resource constraints than a system that places competition for resources on a level playing field.

7. Policy

Health systems encompass all the entities and means whose primary goal is to improve the health of individuals and the population. Critically, health systems carry out service provision, resource generation, financing, and stewardship, with the overall objectives of achieving good health, responsiveness to the expectations of the population, and fairness of financial contribution. Although health systems vary significantly from country to country, many poor nations have weak health systems, which become a major barrier in terms of delivering essential health services.

Lack of meaningful community engagement has been one of the major downfalls in the implementation of health policies and programs in many countries. While some of the vertical funders of global health initiatives have played an important role in disease control, particularly in disease-burdened settings, the reality is that the negative outcomes of such initiatives are often overlooked.

The governments of the recipient countries often find themselves in a bind, as they critically need the financial support to address the disease burdens in their respective countries, but are unable to confront the vertical funders about their concerns, largely due to fear of losing the financial support. As such, the reality is that since the international vertical funders have the financial power, they end up driving the disease response agenda in the recipient countries. Such an agenda tends to be largely medicalized and neglects the other fundamental principles of health and sustainability.

Some of the global vertical funders do focus on addressing aspects such as poverty as an important component of health. In such cases, the poverty-reducing interventions and programs are designed and implemented according to the so-called evidence-based international norms and standards. However, such standards fall short of understanding the context of how the recipient populations perceive themselves and what solutions they think will work and be sustainable. Recipient governments themselves tend to follow a similar stance to that of the international vertical funders by designing and implementing health policies without having meaningfully engaged with the population.

8. Leadership

The WHO (World Health Organization) recognizes that governance or stewardship is ultimately concerned with the oversight of the entire health system and that healthcare financing is the primary challenge facing low- and middle-income countries. It can be inferred that the main channels through which the health system is influenced are through leadership and its impact on healthcare financing and related effects such as multi-stakeholder harmonization and service delivery.

Fragmented and poorly-led health systems are a silent killer as they cause more suffering and disproportionate numbers of deaths within populations, similar to epidemics. Although it is often technically and medically known what is required to reduce disease and save lives, what is often lacking is the shortage of knowledge and skills to lead and manage the complexities of health systems.

Evidence shows that there is a lack of an enabling environment for health systems leadership to thrive, especially in low- and middle-income countries such as in sub-Saharan Africa, and this calls for a disruption of the status quo. Typically, current leadership practices are a barrier to health systems strengthening as they tend to exhibit features of authoritarian rather than participatory governance style, decision-making is largely centralized or individualized, and the dominance of medical professionals is an obstacle to progress. Such a status quo is a recipe for disaster as it could exacerbate the fragility of the other key building blocks of health systems.

9. Financing

Healthcare financing is one of the critical challenges facing health systems of low and middle-income countries, and, more recently, healthcare financing features prominently on the global health policy agenda. The challenges are largely brought about by the problem of fragile health systems, amidst an ever-increasing disease burden, and the prevailing economic shocks. This is no simple matter, and questions are raised as to how health should be financed, as it is inevitable that the activities required to achieve desired health outcomes must be financed somehow, regardless of the prevailing health systems challenges of those countries.

With the recognition of the inefficiencies of their respective health systems and that donor financing is not going to last forever, many recipient low- and middle-income countries are beginning to seriously consider possible financing mechanisms to improve or replace the existing financing mechanisms. One such mechanism is the basket fund mechanism, which involves the pooling of funds from various sources such as government, the private sector, and donors to fund priorities and ensure adequate resource allocation for agreed-upon program areas. While early experiences of basket funds in countries such as Nigeria show that they enhance the availability of funds, accountability, and transparency, basket funds should be part of a multi-pronged approach to improve healthcare financing.

There is consensus that equity in healthcare financing should be related to an individual’s ability to pay. More specifically, it is acknowledged that individuals (or families) with different ability to pay should make ‘appropriately different payments’ for healthcare with higher income individuals paying more than those with a lower income (referred to as vertical equity). At the same time, it would also be equitable for individuals (or families) with the same ability to pay to contribute the same amount towards their healthcare costs (referred to as horizontal equity). However, there is less agreement on what is meant by ‘appropriately different payments.’ When considering the equity of healthcare financing, one cannot simply consider who bears the burden of paying for health services; it is equally important to consider who derives the benefit from each source of financing. Thus, it is the combination of the distribution of healthcare payment burdens relative to the ability to pay, and the distribution of health benefit benefits relative to need, that determine the equity of individual healthcare financing mechanisms.

The method of financing health services will influence whether poor people can access them. Tax-financed universal healthcare is the most equitable, despite disproportionate use by the better-educated and well-off, but may also be subject to high administrative costs and poor governance. Comprehensive mandatory social health insurance can combine risk-pooling and distribute the financial burden according to the ability to pay. Prepayment into a community financing scheme tailored to local needs, to pool risk, has to date delivered only limited coverage. Voluntary private insurance benefits those able to pay and will often exclude individuals with chronic conditions. Out-of-pocket payment at the time of illness is the most regressive form of financing, yet in many low-income countries it is the source of well over half of all financing for healthcare. User charges levied by public and private providers of healthcare have had mixed effects, but almost universally result in deterring access by poor people or impoverishing those on or near the poverty line.

10. Health Security

The recent trend defining the changing nature of policy regarding biological weapons involves the need to prepare for and respond to biological weapons attacks. Under the bio-deterrence approach, states did not allocate time, energy, or resources to prepare for the actual use of biological weapons by their adversaries. National security concerns about biological weapons did not translate into public health activities domestically or internationally to prepare for biological attacks. The absence of biological warfare between states in the post-World War II period diminished the urgency of policy interest in public health preparedness and response to biological attacks.

However, in recent decades, there has been growing policy interest and action on preparing societies to respond to biological weapons attacks. Much of this policy trend flows from the concern that neither bio-deterrence nor the Biological Weapons Convention (BWC) has any direct impact on terrorists interested in biological weapons. With bio-deterrence and arms control being ineffective, governments had to consider the unthinkable—the actual use of biological weapons against their societies.

As noted earlier, policymakers in the 1990s began to recognize the vulnerability of their societies to such attacks. The shock of the Bacillus anthracis attacks, and the U.S. government’s less-than-stellar response, underscored the need to focus on preparing to respond to biological attacks.

This need made a nation’s public health system crucial for national and homeland security. The integration of public health preparedness into strategies for national and homeland security in the United States represented significant policy shifts for both security and public health. This development is part of the larger biosecurity challenge of integrating security and public health, and the relationship between biosecurity and public health in terms of both emerging infectious diseases and biological weapons. The policy actions taken to elevate the security importance of public health are noteworthy as they form part of the modern landscape of biological weapons governance.

The exceptional nature of making public health a security concern has not meant that improving public health preparedness for biological attacks has been uncontroversial. Debates have erupted in the United States regarding specific actions and the overall direction of preparedness and response policy.

11. Conclusion

Protection, preservation, and improvement of the health of the population, including as a special group the able-bodied population through the protection of public health interests, early recognition of the risk of diseases and occupational diseases related to work, prevention of diseases, injuries at work, and treatment and rehabilitation of the sick. The starting principle of the health policy is quality health care available to everyone, according to the principles of comprehensiveness, accessibility, and solidarity. A high-quality and comprehensive set of health services must be equally accessible to all citizens, and the patient must be at the center of the health system.

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