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Building Institutions for an effective health system



This presentation was given by Gerald Bloom at the Global Symposium on Health Systems Research, November, 2010.

This presentation was given by Gerald Bloom at the Global Symposium on Health Systems Research, November, 2010.



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    Building Institutions for an effective health system Building Institutions for an effective health system Presentation Transcript

    • 1
      Building institutions for an effective health systemGerald Bloom
    • Building complex health systems
      Context matters (the importance of institutional arrangements)
      History matters (time and path dependency)
      Theories matter (narratives, framing and policy options)
    • Institutions
      Formal and informal rules, rewards and punishments
      Behavioral norms and expectations of behavior
      Institutions take time to construct and the arrangements are sticky leading to path dependency
    • Organizations
      Groups of individuals bound together by some common purpose
      Organizations differ in their coherence, complexity, values and goals
      Actors in organizations are influenced by both individual and organizational goals
    • Aspects of institutional analysis
      Map organizations and key actors
      Map relevant rules and incentives
      Understand the economic, institutional and political context and its influences on the performance of health system actors (providers and users of services, funders, regulators, accountability organizations)
      Understand explicit and implicit contracts, trust and beliefs (construction of institutional arrangements)
    • China: policy challenges
      Rapidly rising costs
      Problems with quality
      Financial barriers to access
      Illness-poverty linkages
    • China: debates about reform
      Design of rural health insurance scheme
      Health safety net for the poor
      Define basic package of public health services
      Focus on formal design rather than institutional development or sequencing of reforms
    • China: contextual issues 1990s
      Public finance (devolution, limited fiscal transfers, resistance to unfair taxes – political impossibility of compulsory insurance)
      Human resources (overstaffing, transition in pay structure)
      Local government accountability (substantial autonomy, little priority given to health)
      Facility management (lack of systematic approaches to management)
      Local planning and regulation (need to redefine role of government and build capacity)
    • China: contextual issues 2006
      Public finance (end of agriculture tax, increased fiscal transfers and change in public expenditure priorities)
      Human resources (retirement of unskilled personnel and large numbers of new graduates becoming available)
      Local government accountability (continuing issue, new emphasis on trust, higher priority given to health)
      Local planning and regulation (rapid infrastructure expansion, measures to reduce “corrupt practices”, FDRA established, licensing village doctors)
    • China: reform 2009
      Strong government support for rural health and very large increases in public finance
      Establishment and rapid spread of rural health insurance
      Provision of government funds for basic public health services
      Increasing concern about quality and the cost-effective use of public funds and the creation of effective institutions to influence provider performance
    • Politics, legitimacy and narratives of health reform
      There is a growing national consensus on the health system’s problems and the government has invested political capital in promising change
      The creation of a national health system which includes common understandings of roles, responsibilities and entitlements in a context of changing patterns of social and economic inequality is a work in progress.
    • Conclusions
      Health-related markets have expanded faster than the creation of appropriate institutions
      Knowledge of the patterns of incentives and responses to particular interventions is limited
      The construction of institutions takes time and their pathways of development are influenced by power imbalances and politics
      Institutions, and the social contracts they imply, are strongly influenced by attitudes, expectations and understandings
      We have robust theories of the performance of stable health institutions in modern regulatory states but we have much less understanding of how to construct these institutions.