Building Institutions for an effective health system


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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

  1. 1. 1 Building institutions for an effective health system Gerald Bloom
  2. 2. Building complex health systems  Context matters (the importance of institutional arrangements)  History matters (time and path dependency)  Theories matter (narratives, framing and policy options) 2
  3. 3. 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 3
  4. 4. 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 4
  5. 5. 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) 5
  6. 6. China: policy challenges  Rapidly rising costs  Problems with quality  Financial barriers to access  Illness-poverty linkages 6
  7. 7. 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 7
  8. 8. 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) 8
  9. 9. 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) 9
  10. 10. 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 10
  11. 11. 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. 11
  12. 12. 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. 12