Future Health Systems Part I: A Little Matter of Institutions
Submitted by
Is it too premature to be thinking of Future Health Systems, especially for low-income and transition countries? Given that the existing systems in sub-Saharan Africa and in low-income Asia are under stress from high disease burden (demand-side) and a lack of resources (supply-side), shouldn't we fix the problems currently at hand? Not premature at all, say the editors of a recent series of papers in the journal Social Science & Medicine.
This special issue, edited by Gerald Bloom and Hilary Standing from the Institute of Development Studies, University of Sussex, focuses on the drivers and dynamics of the organized health system that some low- and middle-income countries are currently creating or re-establishing. Given that organized health systems are based on institutions, and institutions are both sticky (due to path dependency) as well as hard to build from scratch, some would argue that the debate over the nature of such health systems is now far overdue. According to the editors, the determinants of these new health systems - given the size of the nations that are innovating models for the health sector: Brazil, China, India - have enormous potential for replication and for changing the business of health system strengthening.
Given this blog's focus on health system issues, we will generate several posts to cover the issues raised by these papers. Future entries will focus on the papers in the Special Issue which discuss learning from the community health worker program in Bangladesh (Standing and Chowdhury 2008), alternative service delivery models for ART in Southern Africa (Van Damme et al 2008), etc. Our aim is not to review the content of these articles, but to glean the main ideas and critique by contrasting them with what we know of the practice of health system strengthening. We hope this will continue the important debate over what form the nascent organized health systems in low-income countries should take, and thus inform ground-level implementation.
This first blog entry to cover the material will focus mainly on the broad ideas behind the Special Issue as relevant for low-income countries, and on the institutional developments that should underpin the Future Health System as per the article in the issue by Bloom, Standing & Lloyd (2008).
Home-Grown Health Systems
In their introduction, the editors outline several provocative ideas for why the old 'business as usual' (their words) model of exporting the health system institutions prevalent in the OECD to low-income and transition countries will not work:
- The ground realities in low income (LICs) and transition (TC) countries sometimes do not support the health system models from the OECD. The latter feature either highly regulated, insurance and capitation-fee based privately provided care; or tax-funded public health care (or both). For example, the debate over the role of the public and private sector in health service delivery must face the fact that the institutional framework to govern a market-based health economy or to regulate the providers of health services just doesn't exist in most LICs.
- If health systems are social and political artifacts, then as society and politics develop in LIC/TCs, so will health systems. Health is primary to human survival and a requisite aspect of debate in any organized society (consider the current election year in the US). It is as yet unknown what bargains will be struck among social and political actors to define the health system in its focus and goals in LIC/TCs. This uncertainty is only heightened when technological solutions, increasingly affordable yet still notoriously tricky to scale up, are involved. For example, HIS, after a decade of advocacy, still has untapped depths largely unexplored in the mainstream international health literature, according to Bloom & Standing.
- Most LIC offer a fluid mix of socialized health and a plurality of health service providers. In addition, there is a growing marketization of health goods alongside deprofessionalization of providers. While the abilities of the public sector have eroded due to economic and political crises, the needs of the people for health services have risen due to greater awareness, epidemiological shifts (e.g., towards non-communicable diseases) and rising expectations. As a result, the formal and informal markets have taken over the bulk of provision.
Within HS 20/20, the idea of home-grown health systems has been in play; mostly because our activities to assess, advise, and actualize the future health systems in countries are driven by local needs. In addition, governments generally engage civil society and international/domestic NGOs in formulating and implementing the plans for health system strengthening. It is important that HS 20/20 and its partners make note of the systemic developments in middle-income countries and in LICs with extensive plans for future health system organization. It is already quite apparent to us that the solutions for the South must come from the South itself, supported by the technical resources of more developed countries.
Off to the Market we go?
In discussions of the future of multilaterally-funded global health service delivery and systemic strengthening, we increasingly hear that the market will/must play an important role. One aspect of this theme is more recent. This says that the high levels of development assistance for health recently seen cannot be sustained indefinitely, yet the demands for health care in the developing world will continue to outstrip domestic public sector resource envelopes. Many sub-Saharan African countries already devote substantial portions of their public sector budget to health. Domestic public sector resource generation for health has its limits, and this may be reached in many LICs without access to natural resource wealth. This implies that the reality of the high (and increasing) amounts of health expenditure from private - household and firm - sources must be acknowledged and understood. In a paper in this Special Issue, Leach et al. (2008) estimate that 93% of all health-related spending in Guinea occurs outside the state sector.
Donors are generally alive to the need for engaging the private sector. Public-private partnerships (PPP) are being encouraged and supported through funding and TA in many countries. The USAID's IQC-funded efforts, Private Sector Partnerships for Better Health, and its successor Private Sector Partnerships-One, both have innovative projects to support the efficient and effective inclusion of the private sector in the delivery of health care in LICs, as well as other initiatives. While this is an encouraging and continuing story, Bloom, Standing and Lloyd (2008) have concerns in mind that go at a more basic institutional lack when it comes to going to market.
The authors focus on the social contracts that exist between patients and providers, the sellers of medical goods and services in a market and the consumers, and the government and providers within a regulatory regime. All of these social contracts took a lengthy period to develop and become institutionalized in OECD and middle-income countries. The growth of the market in providing services was a phenomenon that accompanied the institutional development of the health system as a knowledge economy and as a complex of formal and informal arrangements. However, LICs have not had the luxury of time even as the market has become the major provider of health services.
A Matter of Reputation
In their paper, Bloom, Standing and Lloyd (2008) focus on the lack of capacity in the public sector in LICs under the greatest stress of economic and social crises. They find find that the usual prescriptions of more government activity within the three types of social contracts above will be difficult to execute. More productive are hybrid, locally-originated concepts to mediate the relationships in the future health systems of LICs. Institutional arrangements that exploit reputational mechanisms to regulate the activities of private providers - especially where standards don't exist, legal recourse for patients is limited, and government oversight and regulation is weak - are especially promising, as they may require little government capacity to initiate and support:
- Organized reputational mechanisms in the form of brands, franchises, and accreditation are one answer - where the organization foots the bill of monitoring quality and communicating standards and norms. Government subsidies for trust-building functions of health care franchises could be an innovation which helps patients and providers better manage their relationship, especially in settings where providers do not earn enough profit to pay for such brand- and reputation-building themselves (Bishai 2002).
- For tertiary care, branded hospital chains are already a reality in middle-income countries like Malaysia, and increasingly so in LICs like India, as mentioned. The brand value and its inherent reputational mechanism can be enhanced by international or national accreditation. However, these chains will only serve the elite proportion of the market.
- Patient collectives (e.g. for PLWHA) and civil society groups which share information on private providers and also help build reputational mechanisms need to be supported. For the information to disseminate, the use of the Internet and media should be encouraged.
