--- module: 103-02 language: en chapter: 103 title: "Social Determinants, Health Systems, Economics, and Global Burden" module_title: "Health systems, financing, economics, quality, and resource allocation" source_sha256: 2f92d0a566cbd7c554c0092f06f1f1ec8cac1e18fe5ef634ca136f22fb492b6a --- # Health systems, financing, and allocation ## System goals and structure ### People, organisations, resources, rules, relationships ### Performance not judged by volume alone ### Health, responsiveness, financial protection ### Fair distribution and resilience ### Primary care: first contact, continuity, coordination #### Resolves common problems, manages multimorbidity ### Gatekeeping improves coordination #### Harmful if slow or budget-driven ### Referral needs clear questions and feedback ### Centralisation helps when volume matters #### Travel and separation create burdens ## Coverage and financing ### Universal health coverage #### Needed quality services without hardship ### Who, which services, how much cost ### Entitlement can coexist with informal fees ### Promises without workforce create queues ### Financing: revenue, pooling, purchasing ### Pooling shares uncertain costs ### Fragmented pools select low-risk members ### Out-of-pocket payment risks catastrophe ## Insurance and provider payment ### Adverse selection destabilises voluntary pools ### Risk adjustment can be gamed ### Moral hazard includes beneficial forgone use ### Cost sharing deters poorer, sicker patients ### Fee-for-service encourages volume ### Salary: predictable, weaker marginal incentive ### Capitation promotes prevention #### Risk selection or under-service ### Case-based payment invites coding, early discharge ### No mechanism aligns every objective ### Quality bonuses neglect unmeasured care ### Payment can displace other motives ## Economic evaluation ### Compares costs and consequences ### Cost-effectiveness: cost per extra outcome ### Cost-utility: quality-adjusted life years ### Cost-benefit: inputs and outcomes in money ### Assumptions: whose costs, horizon, discounting ### ICER: cost difference over effect difference #### Compare alternatives on efficiency frontier #### Cheaper and more effective dominates #### Unstable when differences are small ### Threshold reflects opportunity cost, not life's price ## Opportunity cost and equity ### Value forgone from next best alternative ### New technology can displace better care ### Budget impact differs from cost-effectiveness ### Equal gain may carry unequal priority ### Distributional weights are ethical choices ### Efficiency and equity can improve together ### Deliberate trade-offs transparently ## Priority setting and waiting ### National, organisational, bedside levels ### Relevant reasons, transparency, appeal, enforcement ### Wealth or celebrity must not decide access ### Waiting list is an allocation system ### Waiting rations care without price #### Long waits worsen disease and inequity ### Separate referral, assessment, treatment intervals ### Moving delay elsewhere is not improvement ## Quality and safety ### Safety, effectiveness, timeliness, equity ### Structure, process, outcome ### Process measures matter if linked to outcomes ### Over-adjustment excuses poor care ### Patient experience differs from outcome ### Adverse events emerge from system conditions ### Reporting systems underreport ### Root-cause analysis beyond final error ### Redesign beats reminders ## Workforce, information, resilience ### Numbers, skills, distribution, retention ### Training more clinicians takes time ### Task sharing needs training and support ### Burnout and turnover are system outcomes ### Interoperability lets information follow patients ### Documentation burden and copied error ### Governance balances privacy and public benefit ### Resilience: prepare, absorb, adapt, learn ### Redundancy looks inefficient until shocks ### Protect routine care during crises ## Systems as ethical institutions ### Financing decides who bears risk ### Payment defines incentives ### Queues distribute time ### Success is health gained, fairly distributed