We would like to thank all of the authors from around the world for their invaluable and insightful contributions to this book. We also want to thank Holly Shakya for her exceptional job and hard work as editorial assistant. Holly brought her own perspectives and much appreciated professionalism to this project, often serving in the valued role of third editor. Additionally, we
thank Jacqueline Walker for her dedicated effort as editorial secretary to the project and Jonathan Venn for his editorial contributions. Finally, we thank Katey Birtcher and Kate Stein at Jones and Bartlett for their guidance and support as we worked our way through this multifaceted international undertaking.
Can anyone doubt that health systems are the most complex and resource-intense network of organizations and people that have ever been invented by human beings? In country after country, responding to healthcare challenges and opportunities attracts our best and brightest researchers, thinkers, leaders, and healers. Billions of dollars are invested annually. Huge successes have been achieved and more are possible. At the same time, it is patently obvious that health systems exist in an environment where rapid, discontinuous changes of all kinds drive everyone to keep responding in new ways. Research studies, such as the one I heard presented in the summer of 2008 by one of this book’s co-authors, Dr. James Johnson at the Organization Development World Congress in Sardinia, Italy, report on where health system growth and improvement is needed. Models and theories abound throughout the world. For example, in the book Who Is Wounding the Healers, my co-author Bill Bergquist and I look at four key internal cultures that we believe fundamentally describe the health systems in Canada and the United States. Economic, sociological, psychological, and anthropological analyses have all been carried out in an attempt to comprehend and learn what we need to
know about health and health care. The level of complexity involved in all the various parts of these systems is increasing in almost every way. We are also learning that much of what has been achieved may not be sustainable. This book contributes another important framework. It is directed at examining how our interconnected and interdependent world affects healthcare decisions and processes across many boundaries and borders. It matters that we understand how these systems work (and do not work). It matters because health care is about life on the planet. We have the capacity to do so much more by understanding the variability of our worldwide health policies and practices. The challenge is to think in new ways and come up with innovations that will enable us to develop organizations, processes, policies, and practices that can be in balance over the long term. This book is intended to help students to think more deeply about how health care is organized and delivered. Each country has invented its system to respond to a particular set of forces. By examining each of the systems presented in the book, students will come away with new perspectives and ideas. These can then
be used as a series of lens to first get new insights about each person’s “home” country system. Each country has been successful in its own way. Celebrating and valuing each of these are important. In addition, examining various approaches can enable readers to understand the connections between and among the variety of health systems. We need local systems that nourish good health as well as structures that foster international sustainable health and wellness. To achieve sustainability, we need to change our health systems. From a change perspective, success is sometimes more difficult to deal with than failure. People have a lot more difficulty letting go of what has worked or is working, especially when an alternative, appealing worldview has yet to emerge. As we consider how changes might be made to achieve both local and worldwide balance in delivering healthcare services, we need thinkers who can deeply analyze, value, and understand what exists and what might then be created to meet 21st-century needs. These chapters are intended to provide solid evidence so that readers can examine all of this complexity to generate new, persuasive ideas about what might come next. The literature on organizational change tells us that at key moments of transformation, overwhelming levels of complexity are often rethought and reorganized into more profound and useful ways of getting things done. An example has to do with how we once determined pregnancies. We used to do blood tests that involved killing rabbits and weeks of analysis. As we came to understand more about hormones and created new ways to analyze body fluids, new assessment processes emerged. Today women can simply use a urine stick. This kind of simplicity rests on a tremendous amount of research, experimentation, and innovation. That is exactly what needs to occur in order to change and improve health systems. This book represents an excellent resource for building our knowledge base so that the rest of the development process can emerge.
As a result of analyzing the various approaches to managing and organizing health care in different countries around the world, students will be able to engage in critical thinking and go beyond mere description of the various systems. Readers will gain a deeper understanding about how and what the various systems accomplish, look at their relationships to each other, and reach some conclusions about what is most important about them. These kinds of comparisons are useful for illuminating, critiquing, or challenging reader ideas about health systems. We invite readers to extend their thinking. Is the Canadian, Nigerian, or Portuguese system really what you expected or thought it was going to be? Based on what facts or evidence? What surprised you about the various approaches to health care? We invite you to think about the significance of the various parts of the systems. Where do the various healthcare systems meet, for instance? We want you to reflect about how and why you are interpreting the evidence in particular ways, and we expect you to answer the “so what” question. What is the point of all of this anyway? Finally, we want you to be able to assemble the information that is here for yourselves and interpret what it means. What is the point of this comparison? Why does this comparison matter? I share with Drs. Johnson and Stoskopf the hope that readers will see unexpected results, similarities, and differences and come up with coherent, new interpretations and new ideas for the policies, systems, and structures that serve us all. —Dr. Suzan Guest International organization development consultant based in British Columbia, Canada and author of the book Who Is Wounding the Healers— The Four Cultures of Healthcare.
This is a book whose time has come. Drs. Johnson and Stoskopf have anticipated and documented the core concerns faced by nations. Health and health care are at the forefront of international concern, especially in a time of global financial turmoil and insecurity. This book is absolutely essential to understanding what’s at stake and to charting a path through the maze of issues confronting healthcare planners and healthcare recipients, healthcare professionals and financing managers, politicians and bureaucrats. It’s more than a matter of systems and approaches; it is about the security of the global community. According to Dr. Margaret Chan, Director-General of the World Health Organization: “Healthy human capital is the very foundation for productivity and prosperity. Equitable distribution of health care and equity in the health status of populations is the foundation for social cohesion. Social cohesion is our best protection against social unrest, nationally and internationally. Healthy, productive and stable populations are always an asset, but must especially so during a time of crisis.” (November 2008, G-8 follow-up, Tokyo, Japan)
The recipients of health care must be heard above the din of competing claims of equity and effectiveness. “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care. Primary health care...requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate.” (Declaration of Alma-Ata International Conference on Primary Health Care, Articles IV and VII, Alma-Ata [Khazakstan], USSR, 6–12 September 1978)
Obtaining decent care, which acknowledges the voice of the people through the values of agency and dignity, interdependence and solidarity, subsidiarity and sustainability, raises the ante a bit higher. Political and healthcare leaders, financial managers, and medical and healthcare professionals must be reminded amidst the policy debate that where the people are invested in
their own care the formulas for success and sustainability changes. Where the people are engaged in determining the levels and resource allocations for care, there is also more room than those charged with determining formulas can imagine. The healthcare debate must finally factor in the people who it claims are to be served and sustained with improved health. Lest we miss the point—“the highest attainable level of health for all people”—leading to a just and equitable society, then the various financial models and healthcare systems will still not bring us the long-needed satisfaction and support we need today. U.S. President Barack Obama has stated repeatedly that “health care is a right.” This notion, enshrined three decades ago at Alma-Ata, changes the
rules and reorganizes the lines of accountability along with our thinking and expectations. Where health is a right, then social responsibility will lead to an enhanced commitment to improved health. The formula ceases to be about “those people” or “their problems” and becomes about us! As we proceed through these pages it will be important to ask how this approach will help ensure that the people are heard and heeded. —Dr. Ted Karpf International health advocate, World Health Organization, Geneva, Switzerland and author of the book, Restoring Hope: Decent Care in the Midst of HIV/AIDS.
Over the past decade, I have taken graduate students to Geneva, Switzerland each summer to study global health. While there, we visit the World Health Organization (WHO), which is receiving updates on global health and interacting with senior scientists, health practitioners, and leaders in the mission of “health for all.” In addition to being spellbound by descriptions of the many initiatives and great successes of the WHO, we repeatedly hear of one major limitation that continues to impede even the greater progress. That is the poor state of health systems in many parts of the world. There are models of success as well as models of absolute failure. Most health systems are oriented toward disease care, and many are underfunded and understaffed, whereas some countries expend large portions of their national resources on health. Some health systems are operated by governments, and others are more involved in the private sector. Regardless of scope or scale, every program, every initiative, every policy, and every course of treatment are imbedded within a particular country-specific health system. Several years ago, my friend and colleague Dr. Carleen Stoskopf joined me on one of the trips to Geneva.
While there, we discussed the need for a book that would describe a range of health systems so that students could better understand the limitations and opportunities offered in the diversity that we had each seen in our own international work. We felt that one of the best ways for students to learn about the range of systems would be through comparative study. As with many invigorating sidewalk café conversations in Europe (and elsewhere), we set this idea aside and returned to the busy activities of our academic positions at the time—Carleen, a Department Chair at the School of Public Health at the University of South Carolina in Columbia and myself, a Department Chair at the Medical University of South Carolina in Charleston. A few years later, however, at a meeting of the American Public Health Association in Boston, in a conversation with publisher Michael Brown, the topic came back up and momentum for such a book grew quickly. We conceptualized the book as a text to be used in courses in international health, comparative studies, global health, international affairs, health administration, and public health. In an increasingly interconnected and interdependent world comprised of wide
variations in health delivery systems, practices, and policy, the book was developed to offer students some understanding through comparative study. In seeking to achieve this goal, we enlisted contributors from many countries to write about the systems that they had worked in and were familiar with. Thus, every chapter that describes a health system is written by at least one person from that country. Chapters also ended up having U.S.-based co-authors, as we used our own professional network in schools of public health, medicine, administration, and policy to identify chapter contributors. Needless to say, the book project emerged as a significant multicultural undertaking involving authors from every continent and from the largest possible range of health system types. To further the objective of comparative study, we imposed a framework on each chapter that would allow students to compare and contrast such divergent systems as Canada, India, Japan, Nigeria, Germany, Australia, Mexico, and many others. The framework used to develop each chapter included the following: Country Description • History • Size and geography • Government and political system • Macroeconomics (GDP, OECD) • Demographics (including religion, gender, poverty) Brief History of the Healthcare System • Description of health system • Facilities • Workforce • Technology and equipment
• Access • Current and emerging issues and challenges Although these chapters were developed by in-country authors and their collaborators, Carleen and I, working with colleagues, developed other chapters that are overarching. This includes a chapter that describes health systems and one that provides an overview of disease. Dr. Walter Jones contributed a very useful chapter discussing health policy and economics, and Dr. Gerald Ledlow, Matthew Walker, and my son, Allen Johnson, contributed a chapter describing the role of nongovernmental organizations (NGOs) as an important, though sometimes overlooked, component to health systems and global health. Additionally, we included a chapter that outlines future challenges, a resource list, and a glossary that should be useful to students and professors. Having worked in and traveled to 22 countries myself, I can say with great confidence that this book will serve to broaden the reader’s understanding. It will also likely change their perspectives on global health. They will learn that although highly developed countries continue to offer profound breakthroughs in medical science and technology, as well as reform and continuous improvement of health systems, the best solutions don’t always emerge in the wealthiest countries. As stated by Dr. Barry Bloom, Dean of the Harvard School of Public Health, the huge disparities in health that exist between countries remain one of the great moral and intellectual problems of our time. This book can serve as one tool among many that will be needed to empower students to become effect change agents in this ongoing challenge.
Beatrice Wiafe Addai, PhD, MD (Ghana) Ministry of Health Accra, Ghana Ahmed Adu-Oppong, PhD, MSc, MBA, MHA (Ghana) University of Cape Coast School of Medical Science Cape Coast, Ghana Omowale Amuleru-Marshall, PhD, MA, MEd, MPH (Guyana) St. George’s University Grenada, West Indies Pedro Pita Barros, PhD, MSc (Portugal) Universidade Nova de Lisboa Lisbon, Portugal Joan Buckley, PhD, MBS (Ireland) University College Cork Cork, Ireland
M. Nicholas Coppola, PhD, MS, MHA (United States) Texas Tech University Health Sciences Center Lubbock, Texas, United States Glenn Croxton, MBA (United States) Henry Ford Health System Detroit, Michigan, United States Linda F. Dennard, PhD, MPA (United States) Auburn University Montgomery, Alabama, United States Clara E. Dismuke, PhD (Portugal) Medical University of South Carolina Center for Health Economics and Policy Studies Charleston, South Carolina, United States R. Paul Duncan, PhD, MS (Canada) University of Florida College of Public Health and Health Professions Gainesville, Florida, United States
Omur Cinar Elci, PhD, MD (Turkey) St. George’s University School of Medicine Grenada, West Indies Neil Gardner, MPA (United States) U.S. Department of Health and Human Services Philadelphia, Pennsylvania, United States Octavio Gómez-Dantés, MD, MPH (Mexico) Carso Health Institute Mexico City, Mexico Damian E. Greaves, MSc, MPH-candidate (Saint Lucia) St. George’s University Grenada, West Indies Patricia Gunn, MIR (United States/Scotland) Auburn University Montgomery, Alabama, United States Mikiyasu Hakoyama, PhD (Japan) Central Michigan University School of Human Environmental Studies Mount Pleasant, Michigan, United States Whiejong M. Han, PhD, MA (Korea) University of South Carolina Arnold School of Public Health Columbia, South Carolina, United States Joseph Ntein Inungu, DrPH, MD, MPH (Democratic Republic of Congo) Saginaw Valley State University University Center, Michigan, United States James Allen Johnson III, MPH-student (United States) Florida State University Tallahassee, Florida, United States James A. Johnson, PhD, MS, MPA (United States) Central Michigan University Dow College of Health Professions Mount Pleasant, Michigan, United States and Auburn University Montgomery, Alabama, United States Walter J. Jones, PhD, MA, MHSA (United States) Medical University of South Carolina Charleston, South Carolina, United States
Kalu N. Kalu, PhD, MBA (Nigeria) Auburn University Montgomery, Alabama, United States and Yale University New Haven, Connecticut, United States Lois Kisiwaa-Ameyaw (Ghana) Hospital Nutritionist Ghana Astrid Knott, PhD, MA (Germany) Minneapolis VA Medical Center Minneapolis, Minnesota, United States Gerald Ledlow, PhD, MHA, EMT, FACHE (United States) Georgia Southern University Jiann-Ping Hsu College of Public Health Statesboro, Georgia, United States Katherine H. Leith, PhD, MPH, LMSW (Germany) University of South Carolina Center for Health Services and Policy Research Columbia, South Carolina, United States Carol Linehan, PhD, MA (Ireland) University College Cork Cork, Ireland John E. Lopes, Jr., DHSc, MS (United States) Central Michigan University School of Rehabilitation and Medical Sciences Mount Pleasant, Michigan, United States Hala Madanat, PhD, MS, CHES (Jordan) San Diego State University School of Public Health San Diego, California, United States Alexander Mayer, PhD, DrRerOec (Germany) Wuppertal University Wuppertal, Germany and Augsburg University Augsburg, Germany Linda McCarey, MS, BSN, RN (Canada) Haliburton-Kawrtha-Pine Ridge Health Unit Port Hope, Ontario, Canada Puneet Misra, MBBS (MD), MPH, PDGHHM (India) All India Institute of Medical Sciences New Delhi, India
Michael E. Morris, MPH, MPA, PhD-student (United States) University of Florida Gainesville, Florida, United States
Carleen H. Stoskopf, ScD, MS (United States) San Diego State University Graduate School of Public Health San Diego, California, United States
Chinelo Ogbuanu, MD, MPH (Nigeria) University of South Carolina Arnold School of Public Health Columbia, South Carolina, United States
Michael Tatchell, PhD, MSS (Australia) Pharmacy Guild of Australia Baron, ACT, Australia
Ikechukwu Ogbuanu, MD, MPH (Nigeria) University of South Carolina Arnold School of Public Health Columbia, South Carolina, United States Elena A. Platonova, PhD, MHA (Russia) University of North Carolina Charlotte College of Health and Human Services Charlotte, North Carolina, United States Lisa Riste, PhD (United Kingdom) University of Manchester Manchester, England Hani Michel Samawi, PhD, MSc, MS (Jordan) Georgia Southern University Jiann-Ping Hsu College of Public Health Statesboro, Georgia, United States Alexander V. Sergeev, PhD, MD, MPH (Russia) Ohio University College of Health and Human Services Athens, Ohio, United States Leiyu Shi, DrPH, MBA, MPA (Taiwan) Johns Hopkins University Bloomberg School of Public Health Baltimore, Maryland, United States Douglas A. Singh, PhD, MBA (United States) Indiana University-South Bend South Bend, Indiana, United States James H. Stephens, DHA, MHA, FACHE (United States) Georgia Southern University Jiann-Ping Hsu College of Public Health Statesboro, Georgia, United States
Renny Tatchell, PhD, MA (New Zealand) Central Michigan University School of Rehabilitation and Medical Sciences Mount Pleasant, Michigan, United States Thomas Tatchell, PhD, MA (United States) T Squared Consulting Mount Pleasant, Michigan, United States Jenna Tsai, EdD, MAT (Taiwan) Hungkuang University Shalu, Taichung, Taiwan Reyhan Ucku, MD, MPH (Turkey) Dokuz Eylul University School of Medicine Izmir, Turkey George Velez, MBA (United States) St. Jude Children’s Research Hospital Memphis, Tennessee, United States Matthew Walker, MPH, DrPH-student (Australia) Georgia Southern University Jiann-Ping Hsu College of Public Health Statesboro, Georgia, United States DaNita Weddle, MBA (United States) Pierce, Monroe, and Associates, LLC Detroit, Michigan, United States Jörg Westermann, PhD, MA (Germany) Walden University College of Health Sciences Minneapolis, Minnesota, United States Sudha Xirasagar, PhD, MBBS (India) University of South Carolina Arnold School of Public Health Columbia, South Carolina, United States
James A. Johnson, PhD, MS, MPA, is a medical social scientist and professor of health administration and international health at the Dow College of Health Professions, Central Michigan University, and adjunct professor of health policy at Auburn University Montgomery. He was previously chairman of the Department of Health Administration and Policy at the Medical University of South Carolina. Dr. Johnson teaches courses in health organization development, international health, systems thinking, and community health. His publications include over 100 journal articles, most of which are peer reviewed, and 13 books on a wide range of healthcare and organizational issues. His most recent books include Managing Health Promotion and Education Programs and Health Organizations: Theory, Behavior, and Development, published by Jones and Bartlett Publishers. He is also co-editor of the widely used Handbook of Health Administration and Policy, published by Marcel-Dekker. Dr. Johnson has also served as editor of the Journal of Healthcare Man-
agement, published by the American College of Healthcare Executives; editor of the Journal of Management Practice; and founding editor of the Carolina Health Services and Policy Review. He is a contributing editor for the Journal of Health and Human Services Administration. He has served on the Board of Directors for the Association of University Programs in Health Administration and the Scientific Advisory Board of the National Diabetes Trust Foundation. Dr. Johnson has worked in over 20 countries, including Tanzania, Zimbabwe, South Africa, Nepal, China, Belize, and Mexico and has lectured at Oxford University (England), University of Dublin (Ireland), Beijing University (China), and University of Colima (Mexico). He also works on projects with the WHO and the ProWorld Service Corps-Belize and is active in the Organization Development Institute. He completed his PhD in 1987 at the Askew School of Public Policy and Administration at Florida State University and his MPA in health administration at Auburn University Montgomery.
Carleen H. Stoskopf, ScD, MS, is the Director of the Graduate School of Public Health at San Diego State University, after serving in an academic appointment at the University of South Carolina, Arnold School of Public Health for 19 years, advancing chair of the Department of Health Services Policy and Management. Dr. Stoskopf has served as a Fellow of the Accrediting Commission on Education for Health Services Administration. Dr. Stoskopf ’s areas of teaching include financing and reimbursement in healthcare systems and decision making. At the University of South Carolina, she was Director of Doctoral Programs and developed two additional doctoral programs in Asia, specifically Taiwan and South Korea. Prior to entering her career in academia, Dr. Stoskopf served in the U.S. Navy as an Environmental Health Officer with the Third Marine Aircraft Wing at El Toro, California and as Chief of the Preventive Medicine Service at the Naval Regional Medical Center in Okinawa, Japan. She was honorably discharged as a Lieutenant, USN in 1982. She also is also a Registered Sanitarian with the State of California. International health has been an area of interest, and Dr. Stoskopf has worked for a variety of agencies in
countries such as Haiti, Kenya, South Africa, the United Arab Emirates, People’s Republic of China, the Republic of China, Republic of South Korea, the Republic of Georgia, Kazakhstan, Ukraine, and Russia. Dr. Stoskopf’s activities have ranged from lecturing, providing healthcare management training for U.S. AID, healthcare management curriculum reviews, public health assessments, HIV/AIDS research, and hospital management consultation. Dr. Stoskopf has been an active researcher, conducting studies on access, utilization, and outcomes. Specific areas of research include disparities in vulnerable populations such as persons living with HIV/AIDS, those persons living with a mental illness, those living in poverty, older persons, and blacks living in the southern United States. Dr. Stoskopf has received funding from the National Institutes of Health, the U.S. Centers for Disease Control, the Health Resources and Services Administration, as well as a number of state and local agencies and foundations. Dr. Stoskopf has authored over 45 peer-reviewed journal articles. She completed her ScD in 1989 at Johns Hopkins Bloomberg School of Public Health and her MS in environmental health from the University of Minnesota School of Public Health.