The Structure Of Health Systems

While health systems vary in the role of the private sector, the priority given to primary and specialized care, the level of access enjoyed by citizens, and a host of other characteristics, most health systems (particularly in less developed states) share a basic structure based on a hierarchical organization of health care provision. Most citizens’ primary point of contact with health systems is usually through health posts, health clinics, and health centers.

Health posts are the smallest facility in many health systems. They are staffed with one or more nurses and provide basic medical services to small communities. Health clinics are larger than health posts and provide a wider range of primary health care services including community health, basic diagnostics, ambulatory and emergency care, immunizations, and pharmaceuticals. These facilities are often are staffed by a small number of nurses with regular visits from a doctor shared by multiple clinics. The largest sub-hospital facilities are health centers, offering a greater range of primary care services than clinics and are assigned one or more dedicated doctors.

In urban areas, health centers can provide care to populations of around 50,000 (Westwood and Power 2007). Health posts, clinics, and centers are particularly common in rural areas, providing governments with an affordable means to expand health care access to underserved areas without the expense of a full hospital. In addition to providing health care, these facilities often play a critical part in health surveillance and data collection, from which health interventions are derived.

Minor urban areas are often served by a district hospital. These hospitals are responsible for offering a range of primary care services within their catchment area and are staffed by general practice doctors and other health workers. District hospitals are responsible for addressing the most common conditions. In addition, district hospitals often provide the laboratory services (e.g. blood and tissue tests) for nearby health posts, clinics, and centers.

Patients with conditions requiring specialized care are referred to regional hospitals. Regional hospitals are located in major urban areas and – like district hospitals – provide primary care for their local catchment area. However, regional hospitals are also responsible for providing secondary care services to large geographic regions. Therefore, in addition to general practitioners, regional hospitals are also staffed by pediatricians, surgeons, and other specialists. Regional hospitals often also provide other important health system functions. These additional functions can include health administration, medical education, and public health programs. A district hospital is “the powerhouse of the region” and a vital node in the national health system (Westwood and Power 2007, 215).

The heart of most health systems is located in the capital and major urban centers. These areas often receive a disproportionate share of the health system’s budget (Macrae 1995). In addition to having their own health clinics, centers, and district hospitals, these cities have other critical components of the health system. First, major urban areas contain the state’s tertiary care referral hospitals, housing the country’s sub-specialists medical professionals (e.g. cardiologists, oncologists, and neurologists). Not only are these health professionals often the sole providers of sub-specialized care in the country, they also have a central role in improving care nationally by driving research and innovation. Central hospitals are also key nodes of international partnerships with health professionals abroad through cross-national medical exchange programs and research projects. Thus, these facilities are a major source of knowledge, education, and capacity building.

Second, capitals contain the health system’s main administrative center: the Ministry of Health (MoH). The Minister of Health and his staff conduct unglamorous – yet critical – bureaucratic functions. They manage the distribution of resources and plan the organization of the health system. Furthermore, the ministry is the primary point of connection between the political leadership of the state and the health system. Finally, the organization is a point of contact between the domestic health system and the international health community.

The entire system is organized hierarchically. At the bottom are health posts, clinics, and centers. Patients requiring more specialized care or equipment are referred to district and regional hospitals. If these facilities cannot provide treatment, the patient is referred to a tertiary hospital. The number of facilities of each type becomes less numerous as patients move up the hierarchy. Liberia’s health system exemplifies this type of hierarchical organization. Before Liberia’s civil war, the country’s public and private health system included 761 health clinics and health centers, 25 county (district) hospitals, and a single tertiary referral hospital in the capital (Joint Needs Assessment Report 2004). The capital also contained the Ministry of Health and the country’s only medical school (International Medical Education Directory 2010).

Sources

  • “International Medical Education Directory.” 2010. Foundation For The Advancement of International Medical Education And Research. http://www.faimer.org/resources/imed.html (Accessed October 27, 2010).
  • Macrae, J. 1995. “Dilemmas of’post’-conflict transition: Lessons from the health sector.” Network Paper 12.
  • Westwood, Tony, and David Power. 2007. “Levels Of Health Care With Special Reference To Children.” In Child Health for All, eds. Maurice Kibel, Haroon Saloojee, and Tony Westwood. Oxford University Press Southern Africa.