Building institutions for an effective
health system
Gerald Bloom
Institute of Development Studies
iHEA, Beijing
July 12, 2009

Building complex health systems
 Context matters (the importance of institutional
arrangements)
 History matters (time and path dependency)
 Theories matter (narratives, framing and policy
options)

Narratives of health system change
 Insurance, tax and universal access
 Rules, norms and corruption
 Health workers, ethics and incentives
 Markets, reputation and trust
 Information, knowledge and influence
 Regulation and partnership

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.