Health systems and services

Health systems differ across the world, reflecting each country’s economic, political and social conditions and aspirations and willingness to prioritise health. Not all are equitable, with access in some systems dependent on social status, location and money. Many are fragile, with shortages of health workers particularly affecting healthcare systems in low income and transitional economies. For individuals, service delivery is the most visible part of a health system. Services are often judged on their responsiveness to immediate problems, on their apparent appropriateness to the local context, on their capacity to meet particular needs of the communities in which they function and on whether they can provide quality services with sufficient resources and motivated staff.

Box 1

With a strong health system, becoming and remaining healthy is easier for individuals. Six building blocks have been identified as the basics of a strong health system [2]. These are:

While an effective health system has an impact beyond service delivery, the way that services are organised and delivered depends on the availability of goods and services through trade, food and water, transport, sanitation, industry and the quality of the wider social, political and physical environment. Unemployment, insecure work or working in poor conditions have negative consequences for health and health services [1]. For health systems to function effectively, a healthy workforce, and well established health facilities are essential, but so are things that are often ignored, such as health literacy of staff and patients, the appropriate use of effective medical technologies including laboratories and engineering support, alongside effective management and oversight underpinned by financial stability (see Box 1).

There is also a role for health systems in helping understanding who the ‘choice makers’ in society are – the multi-nationals who produce and market the food on our shelves, the advertisers who create desire and demand, the planners and programmers who develop and decide the layout of the environment – and in showing how they influence choice, and demonstrating the consequences of these choices.

Effective health systems aim to provide a ‘chain of care’ that stretches from prevention of illness through to palliative and end of life care. The best health systems are based on the need to ensure comprehensive, universal access which is integrated, continuous and people centred. Health systems have a responsibility to develop clinical and public health interventions which must be safe, as well as being cost effective. We often take it for granted but Scotland enjoys good health governance. Strategic policy frameworks exist, based on widespread involvement and regulation with legislation supporting these frameworks to create an enabling environment for a healthy, well Scotland.

Across the world the poorest and least well educated often have the least power to speak out about their health needs and, in many countries, even struggle to enter into the health system. Where tailored services are developed to support specific needs of more vulnerable communities, these are more likely to receive fragile or short term funding. Unfortunately, this is as true in Scotland as in countries with more fragile mainstream funding [3, 4].

Delayed access to prevention or treatment is the major preventable factor in the global burden of disease. Unattended obstructive labour, lasting days on end, is not uncommon in Africa where health workers are scarce. Maternal and child mortality is high. Many of those who survive develop fistulas, leaving them rejected and stigmatised, kept away from others because of their constant leaking of urine and faeces. This is preventable if they had received early enough care, remediable if they are supported to come to one of the few fistula services, but rarely prioritised by health systems struggling to cope with more visible diseases.

Late presentations or failure to attend appointments are not about indifference, or forgetfulness, but about desperation, no-one to make initial referrals, no money and travel or childcare difficulties. In Uganda, for example, 45% of patients who finally arrive at the country’s main hospital in Kampala arrive too late to be treated. Most either die in the hospital or leave to die at home, with conditions that could have been prevented or treated if the right care had been received in time. These experiences help explain the way that newer residents of Scotland expect health services to work in Lothian. Helping staff and patients understand the past and responding appropriately to their needs increases our ability to enable people to engage with prevention and treatment.

Service costs

While cost is not the only factor that can make it difficult for people to use health services, it is one of the most important. Health systems vary in the proportion of the population that is covered. Most health services in Scotland are ‘free at the point of delivery’. However, this is not the case in other parts of the world. In the United States, for example (see Box 2), the cost of treatment for major acute illnesses and for ongoing chronic disease is often out of the reach of lower income families. As the costs of treatment rise as a proportion of disposable income, more households experience catastrophic costs or impoverishment [5].

Why do different healthcare systems matter here in Lothian?

A new Commonwealth fund report [6] allows us to look at overall differences between the healthcare systems of seven developed countries. This year the UK ranked first for efficient and effective healthcare measures. Comparing care in Lothian with that in other countries can provide ideas and models to improve our health system. While health systems in many low income countries face problems because of a lack of resources and few diagnostic tools, practitioners may focus more on understanding the multiple social, spiritual and family needs of their patients. The engagement with communities and the role of other agencies in healthcare, notably from a faith based background, is often greatest where health systems are most fragile. Many low income countries in Africa rely on community transport systems to bring patients to hospital, on community social networks to provide care for patients living with incurable illnesses. People are not only cared for in the community but by the community and in a spirit of ‘community’, and of togetherness. Traditionally, as health systems strengthen and economies grow, control of health is tightened into a central organisation. Yet understanding the importance of shared care could transform healthcare in many high income countries.

Our own health system, like many health systems in high income countries, was initially structured to deliver health services as if diseases came as individual travellers, visiting one at a time. Yet health needs are becoming increasingly multiple and complex. The mark of a 21st century health system is its capacity to respond flexibly and equitably to changes in the composition of the population and their health needs. Year on year, the global movement (of people, ideas, beliefs, materials, money and tools) increases, creating public health opportunities but also public health challenges. Old diseases like TB or new diseases such as H1N1 can potentially travel around the world in under a day. Our health system is adapting to respond to emerging health problems and new diseases. Being in constant touch with other health systems, charting the rise and fall of disease patterns, allows our system to improve its capacity to cope.

People also move from across the globe into Lothian. NHS Lothian is committed to providing a quality service for all those seeking care, regardless of their cultural background or country of origin. Their needs are diverse and changing and the mark of a truly effective service is its capacity to respond to care for each individual patient as if that patient were the most important person in the world. One way the NHS in Lothian has approached this movement has been to engage with other health systems from countries to learn from their strengths. Health workers from all backgrounds – medical and nursing staff, information technologists, nutritionists, physio- and occupational therapists, engineers, technicians, public health staff and managers from across NHS Lothian – have spent time in low income countries supporting their colleagues. Many have travelled during their own time, using holidays to work. Lessons learned from experiences in working in many different health systems are invaluable to NHS Lothian. New approaches to disease prevention, new understanding about care expectations, better ways of performing simple clinical tasks, and above all an enthusiasm to care have contributed enormously to the development of local health services.

Perhaps the most important lesson our staff learn from working in other healthcare systems is how the services in people’s countries of origin shape their expectation of care here. Work that we have undertaken in Lothian shows that new migrants to Scotland may often expect to pay for services (which may be a barrier to their use) and may spend their own, often scant, resources having investigations privately that they would have normally received in their home country but are not offered by the NHS here. One example is ultrasound investigations during pregnancy. Our work in maternity care also shows that many migrants may be unaware of the roles, training and expertise of NHS staff. Consequently a large effort is going into cultural competency and diversity awareness training to ensure that our staff are providing a first class service and that migrant and other groups with additional needs are not excluded from services.

Compared to many health systems across the globe, the Lothian health system is strong, with excellent resources, skilled practitioners at every level, equitable access to care for all, and comprehensive coverage of health needs.

Key points


The Lothian health system needs to remain strong and flexible enough to continue to meet the needs of different local communities as it does successfully now by:

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