Social Science & Medicine 117 (2014) 160e161

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Commentary

History, complexity and health systems research Gerald Bloom Institute of Development Studies, University of Sussex, Brighton, BN1 9RE, UK

a r t i c l e i n f o Article history: Received 27 June 2014 Accepted 18 July 2014 Available online 18 July 2014 Keywords: Policy change Institutional development Social transition Health reform

There is a big gap between the clear and simple health development goals that national governments and international organisations put forward and the messy reality of many health sectors. A recent paper on Bangladesh, for example, describes a pluralistic health system with a wide variety of service providers in terms of training, ownership and relationship to the regulatory framework (Ahmed et al., 2013). It identifies several factors that have contributed to substantial mortality reductions and argues that we need new ways to analyse this kind of system. In a recent paper in this journal, a colleague and I highlighted the challenges associated with the management of health system development in places undergoing rapid and interconnected economic, social and demographic changes (Bloom and Wolcott 2013). We argued for more research that situates this kind of pluralistic health system in its context. We identified several intellectual traditions on which this research could draw including the study of complex adaptive systems, historical institutionalism, studies of transitions of sociotechnical or economic regimes and the political economy of social policy. The paper by Grundy et al. (2014), makes an important contribution to thinking on this topic. It advocates an “ecological model for analysis of policy development, whereby health systems are considered as dynamic social constructs shaped by changing political and social conditions”. It reports the findings of comparative case studies, which explore the link between health policy and the

DOI of original article: http://dx.doi.org/10.1016/j.socscimed.2014.07.047. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.socscimed.2014.07.048 0277-9536/© 2014 Elsevier Ltd. All rights reserved.

transition “towards more diverse and open pluralist models of administration” in several countries in East and Southeast Asia. In doing so, it challenges simplistic understandings of health policy processes that ignore the importance of context. The Grundy et al. paper presents timelines of both political/ economic/social development and health policy change in the study countries and demonstrates a temporal relationship between the former and the latter. It then argues that the historical and development context strongly influences health system organisation. The authors argue that their historical approach raises serious questions about the way that system thinking has been applied to the health sector. They emphasise the importance of beliefs and social attitudes for the stability of a health system and argue that this is one reason why health systems are highly path dependent. They also focus on how health policy turning points emerge in response to political and/or economic transformation. Their critique of certain types of systems thinking is rather similar to the one put forward by a growing number of health systems researchers, who are applying methods associated with the study of complex adaptive systems to the health sector (Adam and de Sevigny, 2012: Paina and Peters, 2012). However, Grundy et al. emphasise the need for more research that situates health system development in its historical and political economic context. This is an important agenda for future research. The Grundy et al. paper says rather little about the political processes that have led to specific outcomes in the study countries. This would have required a clearly articulated theory of health institution-building with testable hypotheses. The lack of an explicit analytical framework may have led the authors to make some unsubstantiated statements. For example, they assert that the so-called Washington Consensus of large international organisations, such as the IMF, World Bank and Asian Development Bank, strongly influenced decisions about both broad development strategies and health system organisation in the study countries. This is the first time they include an international policy dimension in their analysis. They do not explain why they consider these documents more important than, for example, those reflecting Chinese thinking about their transition to a market economy. They also do not explore the relative influence of local and global factors, including new ideas, on the major changes in political and economic regime that have emerged in many of the study countries and on how health sector reform options have been framed. In

G. Bloom / Social Science & Medicine 117 (2014) 160e161

consequence, although the paper argues convincingly that changes in health policy have been influenced by the wider political and economic context, it is difficult to take the analysis much further in exploring processes of policy change, without further research. The concept of a “health system” is a heuristic device for understanding a complex reality. Analysts draw different boundaries around the system depending on the questions they are trying to answer. In drawing these boundaries they exclude other questions and alternative policy options. Leach et al. (2011) argue that the way a system is “framed” is influenced by the interests and understandings of the analyst and the policy options they are willing to consider. They go on to argue that there is a risk that the understandings and interests of the poor and powerless will not be taken into account adequately, unless an effort is made to explore how they understand and analyse the situation. They recommend that researchers look for alternative framings of a system as part of an analysis of policy options. One example is the way that health systems are often defined in terms of the legal status of providers of health-related goods and services. These criteria exclude informal providers, who practice outside the legal framework, despite the fact that they are an important source of health care for the poor in many low and middle-income countries (Sudhinaraset et al., 2013). There is evidence that the spread of these markets has increased access to potentially life-saving drugs, but it has also exposed clients to risks from ineffective treatment and harmful side effects and it has increased the danger of the emergence of organisms resistant to drug therapies. The way the boundaries have been drawn is one explanation for the dearth of information on these providers and the lack of effective policies for improving their performance. If researchers want to analyse the health system used by these clients, they need to define it to include informal providers. One contribution of a historical approach to the analysis of health system development is its focus on the process of change. Grundy et al. emphasise the importance of path dependency and of major turning points. They mostly link the direction of change to the broad macro-economic context. In doing so they leave unanswered a number of questions about the different influences on the particular development pathway that was chosen. This raises questions about the political economy of the health sector and the relative roles of national and transnational interest groups and of their different understandings of the development options. A growing body of work is bringing a historical perspective to the analysis of health policy and health system development. Two recent books have used retrospective case studies to explore factors contributing to successful health system development (Peters et al., 2009; Balabanova et al., 2012). They present case studies of “successful” processes of health system reform and development and derive general lessons from these experiences. Both books conclude that the specific design of a particular policy is much less important that the management of change and development. They conclude that in-depth studies of specific change processes are needed. An important recent example is presented in two papers in a special issue of the Lancet on Bangladesh (Chowdhury et al., 2013; Ahmed et al., 2013). The authors, many of whom have very long experience of work in the Bangladesh health sector, present their reflections on its development since the 1970s. They analyse the intersection between developments in health and other sectors and identify several factors that have contributed to major health improvements. They provide tentative explanations which could be explored in greater depth. Although the findings are convincing for the specific context of Bangladesh, there are great challenges in

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identifying those applicable to other contexts. The increasing involvement of BRAC International, a Bangladeshi NGO, in other low and middle-income countries, is providing important opportunities to test the degree to which health system development strategies can be transferred between contexts. Research that addresses questions about the processes of health system development can take several forms. We need more retrospective studies that document the factors influencing health system change. These could be country-specific or could involve cross-country comparisons. This kind of study is often hampered by the lack of good data. This raises the possibility of prospective studies of change processes, which anticipate the likelihood of unintended outcomes and the need for constant correction of implementation strategies. This kind of study could ensure that relevant data are collected and, if it were extended over a number of years, would provide important evidence on what works and why in the management of large scale health system development and reform. Many countries are in the midst of very rapid economic, social and demographic changes, which necessitate similarly rapid health sector changes. Technological developments, such as the spread of mobile phones and the development of low cost diagnostic tests, are also having a growing influence on health system organisation. It is impossible to predict the direction of change, but it is safe to predict that it will be rapid. Those responsible for overseeing health system development have little guidance on how best to manage this kind of rapid change. In this context, there is a major risk that health systems will fail to meet their policy goals. This is a big challenge for the research community. Research that situates health systems in a wider context of history and political economy can help reduce this risk.

Acknowledgements This paper is an output of the Future Health Systems Consortium, funded by a grant from the UK Department for International Development and the STEPS Centre, funded by the Economic and Social Research Council, of the UK.

References Adam, T., de Sevigny, D., 2012. Systems thinking for strengthening health systems in LMICs: need for a paradigm shift. Health Policy Plan. 27, iv1eiv3. Ahmed, S.M., Evans, T., Standing, H., Mahmud, S., 2013. Harnessing pluralism for better health in Bangladesh. Lancet 382, 1746e1755. Bloom, G., Wolcott, S., 2013. Building institutions for health and health systems in contexts of rapid change. Soc. Sci. Med. 96, 216e222. Balabanova, D., McKee, M., Mills, A., 2012. Good Health at Low Cost' 25 Years On: What Makes a Successful Health System. London School of Hygiene and Tropical Medicine, London, p. 47. Chowdhury, M., Bhuiya, A., Chowdhury, M., Rasheed, S., Hussain, Z., Chen, L., 2013. The Bangladesh paradox: exceptional health achievement despite poverty. Lancet 382, 1734e1745. Grundy, J., Hoban, E., Allender, S., Annear, P., 2014. The intersection of political history and health policy in Asia: the historical foundations for health policy analysis. Soc. Sci. Med. 117, 150e159. Leach, M., Scoones, I., Sterling, A., 2011. Dynamic Sustainabilities: Technology, Environment Social Justice. Routledge, London. Paina, L., Peters, D., 2012. Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy Plan. 5, 365e373. Peters, D., El-Saharty, S., Siadat, B., Janovsky, K., Vujicic (Eds.), 2009. Improving Health Service Delivery in Developing Countries. World Bank, Washington. Sudhinaraset, M., Ingram, M., Lofthouse, H.K., Montagu, D., 2013. What is the role of informal healthcare providers in developing countries? A systematic review. PloS ONE 8 (2), e54978.

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