The concept of the “health system” at the macrosociological level

Abstract

The health system is defined as that aggragate of commitments or resources which any national society “invests” in the health concern, as distinguished from other concerns. The health system is viewed in a structural-functional perspective; it provides services to individuals whose role performance might be jeopardized by ill-health and it occupies a specific structural position in social space. The approach is also macrosociological, evolutionary or historical, dynamic, relevant, and comparative. It seeks to test the hypothesis of a “convergence” of the health system of industrial societies toward a fairly common pattern under the impact of certain types of universal constraints. Capacity to perform in social roles is the critical (though not exclusive) problematic of all social systems, and the health system attempts to cope with incapacity due to morbidity and premature mortality. Four cultural types of responses to illness (magical, religious, pastoral, and medical) are isolated, and their implications for medical practice are outlined. A detailed conceptualization of the health system presents, in sequence, the following questions: the functional problems to which the system addresses itself: the major modalities it uses to produce the Gross Medical Product of a society; the boundaries of the system; the major internal components of that system (services, specialized education and research); and the structural supports it requires from society (legitimacy-mandate; knowledge and techniques; personnel; and economic resources). This yields a formal definition: the health system is that societal mechanism that transforms generalized resources into specialized outputs in the form of health services. As such the system competes with other complementary systems for scarce inputs. The articulation of the system with these other systems and with society, and the internal structure of the health system are the important variables. A typology of health systems is proposed: pluralistic (as in the U.S.A.); insurance (as in France or Japan); health service (as in the United Kingdom); and socialized (as in the U.S.S.R. and Eastern Europe). This typology then opens the way to the question of decision and control over the health system, and the need to develop metrics in that area. Suggestions as to the principal types of metrics are given (growth, internal differentiation and convergence). The question of specialization is then examined as part of the differentiation process, as well as some of its implications for the provision of wellrounded health services (access and primary diagnosis, allocation and triage, comprehensiveness and continuity of care, orchestration and integration of care, emotional support and pastoral care). Some of the internal structural arrangements following differentiation are examined. The paper concludes on a series of ten issues arising from a comparative examination of modern health systems: (1) the mandate of the system; (2) primary care; (3) the limits of the demand for services; (4) the need for managerial logic in the health system; (5) the compensation of physicians; (6) the conflict between established values in medicine and demands for equal access to care; (7) the impact of bio-medical technology; (8) the issue of consumer control; (9) the need for flexibility in health systems (10) the integration of the members of the health team in modern medicine.