Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Building institutions for health and health systems in contexts of rapid change


Published on

Dr Gerald Bloom from IDS presents in a plenary session at the Health Systems Reform in Asia conference in Hong Kong on 11 December 2011. He focuses on the need to consider the complex mixed health systems when setting an evaluation research agenda.

  • Be the first to comment

  • Be the first to like this

Building institutions for health and health systems in contexts of rapid change

  1. 1. Building Institutions for Health and Health Systems in Contexts of Rapid Change <ul><li>Gerald Bloom </li></ul><ul><li>Institute of Development Studies </li></ul><ul><li>Brighton, United Kingdom </li></ul>
  2. 2. Implementing the un-implementable <ul><li>Overseeing rapid social and economic development reducing poverty and raising standards of living </li></ul><ul><li>Creating the institutions of a regulatory state that ensure wide access to the benefits of modern technologies and protect the population from associated risks </li></ul><ul><li>A challenge for leaders, managers and researchers </li></ul>
  3. 3. Rapid change – big benefits and big risks <ul><li>Economic growth and shift of labour force from agriculture to industry and services </li></ul><ul><li>Rapid urbanisation and expansion of weakly regulated transitional spaces </li></ul><ul><li>Demographic transition and new health and social vulnerabilities </li></ul><ul><li>Modern production and consumption but slow creation of institutions for safety and effectiveness </li></ul><ul><li>New patterns of inequality and vulnerability </li></ul><ul><li>Environmental and ecological stress </li></ul><ul><li>An effective health system reduces risks and contributes to the creation of a new social contract </li></ul>
  4. 4. Complex health systems Creating order between command & control and chaos <ul><li>Increased agency of providers and users of health goods and services </li></ul><ul><li>Spread of markets and blurring of boundaries between public and private </li></ul><ul><li>Spread of mass media </li></ul><ul><li>New organisations, relationships and institutions </li></ul><ul><li>Public sector decentralisation </li></ul><ul><li>Market organisations for delivery of goods and services </li></ul><ul><li>Civil society organisations for accountability and influence </li></ul><ul><li>Formal and informal institutional arrangements </li></ul><ul><li>Limited capacity of government to control the health sector </li></ul>
  5. 5. Change in complex and dynamic contexts <ul><li>Emergence - spread of new types of organisation, new kinds of relationships between organisations and rules and new institutional arrangements </li></ul><ul><li>History - path dependency and sequencing of change </li></ul><ul><li>Unintended outcomes - crises and risk of disruption </li></ul><ul><li>Transition - possibilities of rapid and irreversible change </li></ul>
  6. 6. Building institutions for an effective and fair health system <ul><li>Markets and the institutions within which they are embedded are co-constructed by a variety of actors </li></ul><ul><li>Common understandings and mutually accepted behavioural norms are an essential element of institution building </li></ul><ul><li>The relative power of actors influences institution design and operation </li></ul><ul><li>There is a tension between the need for safety and for rapid change </li></ul><ul><li>The way change is managed influences outcomes </li></ul>
  7. 7. Safety, legitimacy and high reliability <ul><li>Health systems are concerned with protecting people and society against the impact of disease </li></ul><ul><li>Safety and trust are central to the success of development and the legitimacy of government </li></ul><ul><li>The prevention of bad outcomes requires continual effort and this effort strongly influences the direction of development </li></ul><ul><li>There is a special challenge in building legitimate institutions in contexts of rapidly change patterns of inequality and power struggles </li></ul>
  8. 8. Discontinuity, disruption and transition <ul><li>Growth in demand for inexpensive health care associated with economic growth, demographic change and communications </li></ul><ul><li>The spread of the informal economy and the breakdown of dominant institutional arrangements </li></ul><ul><li>Low cost information, communication and diagnostic technologies are creating new opportunities and new regulatory challenges </li></ul><ul><li>New types of partnership are emerging for safe, effective and affordable health services </li></ul><ul><li>Small changes can result in major and irreversible change </li></ul>
  9. 9. Knowledge about complex and dynamic contexts <ul><li>No-one has the full picture and the picture keeps changing - policy leaders, managers, innovators and other stakeholders know different aspects of the system </li></ul><ul><li>It is important not to confuse a vision of the future with alternative pathways towards achieving that vision </li></ul><ul><li>Testing responses to interventions is a means of generating knowledge about the system </li></ul><ul><li>There are competing narratives about system functioning and the space of possibilities for system change (dominant ones, disruptive ones and those of the relatively powerless) </li></ul><ul><li>An evaluation challenge </li></ul>
  10. 10. Evidence for managing health system change <ul><li>Understand the historical legacy </li></ul><ul><li>Document the existing situation, identify constraints to the achievement of normative goals and the means to overcome them </li></ul><ul><li>Scan the environment </li></ul><ul><li>Assess changes in health needs and access to health services by different social and economic groups </li></ul><ul><li>Look for emergent organisations and institutional arrangements and learn from their performance </li></ul><ul><li>Identify potentially disruptive innovations and assess their likely impact </li></ul><ul><li>Generate knowledge for safe and effective management </li></ul><ul><li>Probe to test system function </li></ul><ul><li>Learn from successes and failures </li></ul><ul><li>Define risks and monitor for early warning of problems and unanticipated outcomes </li></ul>
  11. 11. Evidence for managing health system change <ul><li>Assess governance arrangements </li></ul><ul><li>Partnerships, networks and relationships </li></ul><ul><li>Common understandings, behavioural norms and core ethical values </li></ul><ul><li>Power relationships and their influence over institutions and governance </li></ul><ul><li>Build knowledge of the management of change and institution building </li></ul><ul><li>Retrospective studies of the reform and development process and the factors influencing the choice of pathways </li></ul><ul><li>Prospective studies that test specific aspects of institution-building </li></ul>
  12. 12. Generating evidence for the creation of a modern and fair health system