Social Science & Medicine 117 (2014) 150e159

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The inter-section of political history and health policy in Asia e The historical foundations for health policy analysis John Grundy a, *, Elizabeth Hoban a, Steve Allender a, Peter Annear b a b

School of Health and Social Development, Faculty of Health, Deakin University, Australia Nossal Institute for Global Health University of Melbourne, Australia

a r t i c l e i n f o

a b s t r a c t

Article history: Received 1 August 2013 Received in revised form 15 April 2014 Accepted 18 July 2014 Available online 18 July 2014

One of the challenges for health reform in Asia is the diverse set of socio-economic and political structures, and the related variability in the direction and pace of health systems and policy reform. This paper aims to make comparative observations and analysis of health policy reform in the context of historical change, and considers the implications of these findings for the practice of health policy analysis. We adopt an ecological model for analysis of policy development, whereby health systems are considered as dynamic social constructs shaped by changing political and social conditions. Utilizing historical, social scientific and health literature, timelines of health and history for five countries (Cambodia, Myanmar, Mongolia, North Korea and Timor Leste) are mapped over a 30e50 year period. The case studies compare and contrast key turning points in political and health policy history, and examines the manner in which these turning points sets the scene for the acting out of longer term health policy formation, particularly with regard to the managerial domains of health policy making. Findings illustrate that the direction of health policy reform is shaped by the character of political reform, with countries in the region being at variable stages of transition from monolithic and centralized administrations, towards more complex management arrangements characterized by a diversity of health providers, constituency interest and financing sources. The pace of reform is driven by a country's institutional capability to withstand and manage transition shocks of post conflict rehabilitation and emergence of liberal economic reforms in an altered governance context. These findings demonstrate that health policy analysis needs to be informed by a deeper understanding and questioning of the historical trajectory and political stance that sets the stage for the acting out of health policy formation, in order that health systems function optimally along their own historical pathways. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Policy change Health and history Social transition Health reform

1. Introduction 1.1. Background to health reform and social transition Despite rapid economic growth, the Asian region has been beset by policy challenges of persisting inequities in health care access and health outcomes, and major health sector governance challenges presented by macro-level reforms in politics, economics or civil administration. In China, institutional reforms have failed to keep pace with broader development policy that was linked to free market macro-economic reforms in the 1980s (Bloom, 2011). In Mongolia during the post-Soviet neo-liberal reforms in the early

DOI of original article: http://dx.doi.org/10.1016/j.socscimed.2014.07.048. * Corresponding author. E-mail addresses: [email protected], [email protected] (J. Grundy). http://dx.doi.org/10.1016/j.socscimed.2014.07.047 0277-9536/© 2014 Elsevier Ltd. All rights reserved.

1990s, measures were put in place to decentralize health care systems to family group practices (FGPs) and institute health financing models based on capitation based funding for primary care (Hindle and Khulan, 2006). In Cambodia, during the post UNsponsored election period from 1993, the socialist model of governance was dismantled and replaced by a more complex diversified management arrangement, including the scale up of demand side financing initiatives and the expansion of health contracting models and of the private medical sector (Grundy and Moodie, 2008). Similar pathways have occurred in Indonesia (Ghani, 2012) and the Philippines (Lakshminarayanan, 2003), where policy makers have developed responses to the administrative challenges of decentralization and devolution. A common theme in these observations of health and social change is the policy and development challenge related to transition from centralized political orders in the 1980s and 1990s towards more diverse and open pluralist models of administration.

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The highly diverse pattern of political and economic history contributes to an equivalently diverse set of organizational structures, institutional arrangements and methods of financing of health care systems, requiring countries to tailor policy implementation for universal coverage according to the specificities of national context (Carrin et al., 2008). 1.2. Theories of policy change But the question remains as to what combination of social theories can best explain the varying pace of policy and system change across national settings, and how this can inform a more consistent and comprehensive approach to policy analysis. Bourdieu (1977) makes reference to the notion of “habitus” in order to emphasise the durable dispositions of behaviours that provide national institutions with their particular continuity of character. Similarly, Huntington (2006) defines institutions in terms of stable, valued and recurring patterns of behaviour. This durability and continuity of institutions and their related behaviours contributes to what others have referred to as the trajectory (Walt et al., 2008) or path dependence (Altenstetter and Busse, 2005) of health policy. The concept of “path dependence” has common features including the observations that early events in sequence matter and that later events have an inertia related to the earlier sequence (Mahoney, 2000). Despite the presence of historical inertia, path dependence does not rule out the availability of policy choice, although the band of choice is conceptually narrowed based on context (Kay, 2005). The related idea of “process sequencing” is that trajectories are not random but are outgrowths of earlier trajectories(Howlett 2009). Policy activity can also be reactive in transforming the wider policy context and directions. In accounting for the changing of trajectories, analysts have put forward the ideas of “critical junctures” (Kay, 2005) or “policy turning points” (Abbott, 1997), whereby periods of crisis are reported to contribute to ideational change and subsequent re setting of policy directions. 1.3. Analytic framework The historicism of policy formation (policy turning points) demonstrates that policies do not operate in a vacuum but in contrast originate from past time and are contextualized in place (Capano, 2009). This being the case, the formation of managerial ideas is located within a wider field of social and political ideas and institutions that are subject to periodic historical transformations. This concept of health care as forming part of an ”ecosystem” is related in part to the limitation of systems analysis, which emphasizes elements of the internal organization and management of health care systems. This limitation presents major challenges for comparative systems and policy analysis, whereby a predominance of hybrid forms seems to defeat efforts for a consistent set of health system classifications or ideal types (Freeman and Frisina, 2010). The metaphor of ecosystem is also relevant in so far as health policy and systems change demonstrates an adaptive, organic and evolutionary quality, as it periodically shifts directions, responds to shocks or crises, and seeks to re-establish system equilibrium in response to fundamental changes in a wider field of economic, social and political relations. Feedback processes, including institutional rule adaptation and behavioural changes, allow policy and systems to re-adjust to changing circumstances, leading to the establishment of new and longer term equilibriums (homoeostasis) in policies and systems (Howlett, 2009). This re-establishment of policy and systems equilibrium in a new order responds to the need to reset patterns of institutional behaviours (Huntington, 2006), as systems struggle to re-align with higher level economic and political reform. The phenomenon of policy dis-equilibrium can be

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defined as the delayed policy or institutional response to political or economic change, as institutions struggle to adapt their traditions of management or “habitus” (Bourdieu, 1977) to a radically altered governance context. From this standpoint, rather than viewing health systems simply as technical constructs engineered by technical planners and decision makers, health systems can also be viewed as dynamic social constructs shaped by the control parameters of changing political and social conditions (Glass and Mc Atee, 2006). Through illustration of case studies in health system development from the Asian region, this paper aims to make comparative observations and analysis of health policy reform in the context of historical change, and considers the implications of these findings for the practice of health policy analysis. The main variables of interest is macro-political change, as defined by major shifts in the exercise of political or economic power, in terms of free market reform, decentralization and constituency emergence. The variable of interest is the health policy turning point, which is defined as the critical juncture at which health policy is reformed in the direction of this political or economic transformation. 2. Methods 2.1. Target countries and sources of data The country cases were selected based on the authors' published observations and analyses in the five countries under study. As an observer and participant in the policy and planning environment in these country settings for variable periods of time between 1993 and 2013, the opportunity was provided to observe the influence of history and politics in reshaping the health policy landscape in each national setting and to access the grey health systems and policy literature. These observations and analyses were detailed into published country case studies of health system strengthening in the cases of Myanmar (Tin et al., 2010), North Korea (Grundy and Moodie, 2008), Cambodia (Grundy et al., 2009) and the Philippines (Grundy, 2003). We reviewed literature in Pubmed data base, using the search terms “universal health coverage” as a title search (122 responses). As noted by Walt et al. (2008), we found limited reference to historical analysis of the evolution of health policy. The literature on theories of “policy change” (Title search) returned 198 responses, of which only two were relevant to an Asian setting, and of which there were no systematic attempts to analyse policy change across country health systems. The search terms “History” and “Health system” (Title search) returned 21 responses, but with no responses for Asia. Literature has been reviewed on systems thinking, complexity theory and theories of policy change. The literature on social and political history in each of these countries is quite extensive, so historical sources were not systematically searched, but were sourced selectively in order to construct a broad outline of the historical timelines outlined in Figs. 1e5. As a work of comparative analysis and synthesis incorporating both historical and health systems analysis, we note here the limitations that are the characteristics of any trans-disciplinary study, particularly with regard to challenges of validity related to a complex web of causation. But here we would also stress that this complex web of causation represents a model of the health policy analysis in the real world, and is a means by which to tackle the problem of “the considerable gap between normative accounts of how health systems operate and realities on the ground.” (Bloom et al., 2008 Page 2076e77). We have attempted to manage these limitations through testing and posing of a single research question, and to consistent reporting of the variables of interest e namely, historical trajectory and political transformation, health

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policy turning points, and the resetting of policy directions. As this paper is a synthesis of previously published papers with data from publicly available data sources, no application for ethics clearance was made to an institutional ethics committee.

and expansion of political decentralization through elected commune councils. From 1997 international development assistance and foreign investment expanded, with the country experiencing a final period of relative peace and stability, including steady rates of economic growth.

2.2. Analysis We constructed health and history timelines for each country which provide comparative observations between political and socioeconomic history on the one hand (the history timeline), and evolution in public health status, health care systems and policies over the last 30e40 years on the other (health timelines) (see Figs. 1e5). We thereafter illustrate periods of health policy reform that correspond to periods of political or economic reform. Each case study is structured according to (a) the description of historical trajectory, (b) the identification of major turning points in health policy history, and (c) the new policy directions reset by the changing political and social conditions. 3. Main findings 3.1. Cambodia 3.1.1. Historical trajectory Fig. 1 below describes health and history timelines for Cambodia. Three periods of historical development have been tracked for this country over the last 40 years which include totalitarian, centralist and neo-liberal reform periods. The totalitarian period was characterized by the near total destruction of the post-colonial health care system, and its replacement by a system based on traditional health care (Sokhym, 2002). Only 50 doctors survived the Khmer Rouge regime (Sokhom, 2002). In the 1980s during the socialist rule of the Republic of Kampuchea when the country was occupied by Vietnamese forces, there were efforts to reconstruct the health care system. The model was centralist, with limited civil society participation; this period was characterized by the beginning of international development assistance through United Nations agencies and non-government organizations (Heng and Key, 1995). Post 1993, following the United Nations-sponsored general elections, the third and current period of neo-liberal reform was established, characterized by democratization, development of free market economic systems

3.1.2. Health policy history The major health policy turning point occurred in the post transition period, from 1993 onwards. A remodelling of the health system took place after 1996, with reallocation of health facilities and health staff based on revised population catchments (MOH Cambodia, 1996a). A network of over 1000 primary health centers and 76 district referral hospitals were operational by 2011 (MOH Cambodia, 2011). In order to offset the impacts of free market systems on health access, a financing charter was introduced in 1996 to regulate the system of user fees (MOH Cambodia, 1996b). From 2002, a system of hospital health equity funds was extended across the country to minimize the impact of catastrophic health payments on the poor (Bigdeli and Annear, 2009) with related policy measures including the establishment of national health financing guidelines and a social protection framework (RGC Cambodia, 2013). Health contracting models were trialed in order to boost health system performance in an increasingly decentralized administrative context (Soeters and Griffiths, 2003). Civil society organizations for health have expanded to over 100 in number (Medicam, 2013) and in 2010 the private medical sector was the first choice for primary illness care for 56.8% of the population (MOP Cambodia, 2010). Despite these policy responses, health inequities remain a significant challenge, as evidenced by wide disparities in access and outcomes relating to wealth quintile (Soeung et al., 2012). 3.1.3. Health policy directions These developments represent a significant diversification of the system of provision and financing in an increasingly pluralistic health system (Meesen et al., 2011) characterized by multiple sources of health financing and provision through public, private and civil constituencies. The parameters for health policy have therefore shifted markedly from the 1980s era of central command management, and represents significant health policy and institutional adaptation measures to political change.

Fig. 1. Health and history timelines Cambodia 1975e2012.

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3.2. The Republic of the Union of Myanmar (Burma) 3.2.1. Historical trajectory Fig. 2 outlines the health and history timelines for the Union of Myanmar between 1960 and 2012 with three historical periods identified. The first period of military socialist rule between 1962 and 1988 was dominated by a centralist command style of administration. The second period of military rule was characterized by the introduction of free market economic systems between 1988 and 2008. The third period from 2008 onwards has been characterized by constitutional reforms and the initial steps taken towards democratization, decentralization and more open international relations (ICG, 2011). The second period can be distinguished from the first by the introduction of free market economic reforms from the early 1990s. This second period was also characterized by sustained economic and trade sanctions and low rates of international aid and domestic investment in the health care system (Grundy et al., 2012). This decline in investment in social sectors is being reversed in the third constitutional reform era post 2008, where social sector investment and decentralization options are being actively explored (UNIC, 2012) and where international development assistance is being gradually extended in response to the more open political climate and the related opening of diplomatic relations. 3.2.2. Health policy history Commencing in the early 1960s, the rural health care system was expanded, with a rural health centre located in every district by 1964 (KoKo, 2006), and a network of 1137 rural health centers established by 1988 (MOH, Myanmar, 2012). In the second period of free market reform, evidence began to emerge of poor access to health care based on affordability factors (MOP Myanmar 2010). In response, in 1993 the Government introduced a health policy to regulate user fees through introduction of a community cost sharing model (MOH Myanmar 2009). This period was also marked by very low rates of national and international investment in the health sector (Grundy et al., 2012). It was mainly in the post Nargis natural disaster and constitutional reform period from 2008 onwards that health system strengthening initiatives (Tin et al., 2010) and civil society partnerships were expanded (Htwe, 2011).

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3.2.3. Health policy directions Political reforms have accelerated rates of development assistance as well as contributing to exploration of social sector policy options including increased health sector budgets (UNIC, 2012), decentralized health planning, alternative health financing models €nnroth et al., (Tin et al., 2010), and publiceprivate partnerships (Lo 2007), all of which are opening up a new health policy landscape in Myanmar. 3.3. Mongolia 3.3.1. Historical trajectory Fig. 3 describes health and history timelines for Mongolia. Three periods of historical development have been identified which include the beginnings of the socialist system, establishment of the system, and the neo-liberal reform era since the early 1990s (MOH Mongolia, 2012). For the majority of the 20th century, Mongolia functioned as a socialist republic under the tutelage of the Soviet Union. This period had a mixed historical record, with gradual expansion of the education and health sectors from the early 1920s, as well as programs of industrialization and development of urban centers. However, the period was also characterized by intermittent civil conflict and religious and political oppression particularly during the rule of Stalin in the 1930s (Baabar, 1999). By the late 1980s, the Soviet Union was providing 85% of development aid amounting to 35% of the government's annual budget (Manaseki, 1993). The closure of the Soviet era in the late 1990s resulted in a rapid political transition towards a system of administration modelled on neo-liberal lines e that is, parliamentary democracy, free market economics, and emergence of private and civil society sectors. This latter period has been characterized by a remarkable social transition, with rapid urbanization, sustained high rates of economic growth and persisting and even widening social inequalities (Rossabi, 2005). 3.3.2. Health policy history Due to the introduction of socialist models of administration, the first constitution of Mongolia ratified in 1924 stated that health services were to be provided free of charge. A Department of

Fig. 2. Health and history timelines Myanmar (Grundy et al., 2014).

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Fig. 3. Health and history timelines Mongolia.

People's Health Protection was established in 1925, and by 1940 there were 37 hospitals in the aimags (provinces) and the establishment of bagh (community) level practitioners had commenced (MOH Mongolia, 2012). The second period of health system development ensued when the multi-tiered socialist health care system was established incorporating tertiary hospitals, soum (sub district) hospitals and basic primary health care providers. Following the first multi-party government in Mongolia and the institution of free market economic models, there were sharp turns in health policy history which included the establishment of a National Health Insurance Law in 1993 and public private collaborations for primary health care (Hindle and Khulan, 2006). National health sector planning processes incorporating models of decentralization (MOH Mongolia, 2006) were also instituted. In recent years the number of private health facilities has increased from 683 in 2005 to 1184 in 2011, including expanded participation by non-government organizations in health activities (WHO & MOH, 2012). 3.3.3. Health policy directions Mongolia has carefully managed new health policy directions through institution of early and highly reflexive social protection and sector planning policy responses. Nevertheless, the country is still challenged in policy terms to manage the post transition shock of the health inequities associated with rapid economic growth and urbanization. Despite double digit rates of economic growth fuelled by a mining boom, and a sizeable share of GDP allocated to health (4.7%) (WHO MOH Mongolia, 2012), studies document significant inequities in health care access between socio-economic groups (Lhamsuren et al., 2012) despite the fact that social health insurance coverage was 82.6% in 2010 (WHO MOH Mongolia, 2012). 3.4. The Democratic People's Republic of Korea (North Korea) 3.4.1. Historical trajectory Fig. 4 identifies four periods of historical and political change in North Korea. First is the conflict period 1950e1953, where 3.5 million Koreans perished in the multi-national war for the conquest

of the Korean Peninsula (Martin, 2004). The second period, between 1953 and the early 1980s, represented the zenith of the northern regime in terms of its political and economic fortunes, with embarkation upon a rapid program of Soviet backed reconstruction and rehabilitation. As a result the GDP of the North superseded that of the South up until the late 1970s (Cha, 2012). Nevertheless, fortunes were reversed in the early 1990s in the post-Soviet era, leading to a catastrophic halving of GDP within a five year period (MOF DPRK, 2004). This economic situation was exacerbated by natural disasters, food insecurity and a focus on “military first” politics, where an estimated 25%e30% of the GDP of 28 billion $US is invested in defence (Cha, 2012). A famine in the mid-1990s was reported to have resulted in losses of 3%e5% of the total population (Haggard, 2007). The final era up until 2012 has concluded in an international relations stalemate, characterized by tense military confrontation, nuclearization of the Korean Peninsula, and economic stagnation and sanctions. 3.4.2. Health policy history In the post war second period of rehabilitation, the primary health care system was rapidly expanded with immunization services being introduced as early as the 1960s, and the network of health care delivery facilities rapidly expanded (Pak, 2011). A key turning point was reached in the period between 1989 and 1991, when the Soviet era drew to a close, GNP collapsed, and economic sanctions were strengthened and with ”military first” politics prioritizing defence development over other forms of public policy. The very low rate of recurrent operational investment can be contrasted with the vast investment in health facilities and primary care medical doctors (Grundy and Moodie, 2008). Primary care doctors are over 44,000 in number, providing it with one of the highest staff to population ratios in the region (MOPH, 2011). There are 3.29 physicians per 1000 in the DPRK, compared to 1 and 1.29 per 1000 in China and Vietnam respectively (WHO, 2013). Tense international relations were also an impediment to favourable aid flows, with rates of aid up to 15 times lower than countries with comparable levels of development, such as Laos and Cambodia (Grundy et al., 2012). In the mid-1990s, the public health

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Fig. 4. Health and history timelines DPRK 1950e2012.

system was in crisis, with a halving of immunization coverage (reaching only 40% of children in 1997) (WHO, 2012), 35% of children stunted (Hoffman and Lee, 2005) and significant rises in child and maternal mortality between 1990 and 1995. 3.4.3. Health policy directions In the most recent period between 2005 and 2012, there is evidence of a moderate recovery in public health, as the Government of the DPRK developed partnerships in such areas as malaria prevention and treatment and tuberculosis control (Global Fund, 2012) and childhood immunization and health system strengthening (GAVI, 2012; Grundy and Moodie, 2008). By 2011, immunization coverage had recovered to be above 90% for all antigens (WHO, 2012) and malaria and TB case fatality rates have declined sharply in the last 10 years (Global Fund, 2012). Nevertheless, there are ongoing reports of acute shortages of essential medicines and equipment and of food insecurity (Grundy 2008) and with only modest reductions in child and maternal mortality in recent years (CBS, 2009).

3.5. The Democratic Republic of Timor Leste 3.5.1. Historical trajectory Fig. 5 outlines three health and development periods in Timor Leste including the early development of PHC health systems up until the late 1970s, post conflict rehabilitation between 1999 and 2005, and the current period of extension of PHC systems to hard to reach or unreached populations. In the late 1970s, following centuries of Portuguese rule the Republic of Timor Leste (current population 1.1 million) declared independence. Several weeks later, occupation by Indonesia resulted in 30 years conflict. During the occupation, the Government of Indonesia undertook commercial, infrastructure and social sector developments, including the establishment of a health care system that extended into the mostly mountainous districts of Timor Leste. Immediately following the UN plebiscite, public infrastructure, including nearly all medical facilities was destroyed by militias in 1999 (Margesson and Vaughan, 2009). Following United Nations-sponsored elections in 1999,

Fig. 5. Health and history timelines Timor Leste.

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Fig. 6. Resetting health policy parameters post political transition.

independence was declared in 2002, and the country established a free market and multi-party democratic system. The overall development strategy is based on poverty alleviation, the rebuilding of institutions, infrastructure investment and human resource development (GTL, 2012), and on sustainable utilization of substantial oil and gas reserves (GTL, 2013). The strategy also focuses on free market reforms and rural development, increased foreign investment and a policy and legal commitment to a decentralized model of governance (GTL, 2012). A transition plan was developed in 2011 (GTL 2011) in preparation for the exit of the United Nations forces from Timor-Leste which took place in late 2012, following the second popular election for the new Government of Timor Leste in the same year. 3.5.2. Health policy history During the Indonesian occupation of 1975e1998, much of the district health system was established, although it was during the same time that population health suffered under the pressure of sustained conflict. The second period from 1999 until 2005 may be classified as the recovery and rehabilitation period, under which much of the health infrastructure were reconstructed and health human resources trained. Timor-Leste's new Constitution of 2002 defined medical care as a fundamental right for all citizens, with services required to be universal, free of charge, and decentralised and participatory. In this third period, the first health sector planning and health information processes were established, and services were further extended outwards to the population through an integrated health outreach program (MOH GTL, 2012). Despite the rehabilitation efforts in this second period, there remains extensive service delivery gaps in Timor Leste. Thirty percent of deliveries are attended by trained personnel, with a very high rate of 557 maternal deaths per 100,000 births (NSD GTL, 2010), and with the reach of immunization services limited by widely dispersed populations residing in small hamlets across mountainous terrain with poor transport links and shortages of human resources in remote areas (Nelson, 2012). 3.5.3. Health policy directions As reflected in the subsequent National Health Sector Strategic Plan (NHSSP) 2011e2030 (MOH GTL, 2012), efforts will focus on development of human resource and management

capacity to extend social services to unreached populations. Governance, planning and financial management reforms are proposed to increase middle level management capacity to extend these services to unreached populations through integrated health outreach and human resource placements in remote areas (MOH GTL, 2012).

4. Discussion 4.1. Historical trajectory and health policy turning points: resetting the parameters for health policy making This review of the linkages between health and history has found that the trajectory of policy and system development is steered by two interconnecting forces of technical and sociopolitical direction. Technical direction represents pressures for the attainment of specific health goals most often embodied in national Health Plans. Socio-political direction represents pressures for economic, administrative and political reform at a macro-level. As indicated in the case studies (and as illustrated in Fig. 6), the impact of periodic political and social transitions ”tilts” managerial policy and planning in the direction of the overarching social and political transformation, contributing to key turning points in the evolution of health care systems and policies. In some cases, these turning points result in radical redirection of health policy. Examples include the introduction of the National Health Insurance System and Family Group Practices in Mongolia post neo-liberal reform in the mid-1990s (Hindle and Khulan, 2006), the introduction of social protection and health contracting models in the post UN period in Cambodia (Bigdeli and Annear, 2009), and the moves to decentralized planning and social sector policy options in Myanmar post constitutional reform in 2008 (UNIC, 2012). Similarly, in the DPRK and Myanmar, the closure of the Soviet era and the collapse of GNP in the former case, and the Nargis disaster and constitutional reform in the latter case, were triggers for the opening up of international partnerships, a trend which has dominated the health policy landscape ever since (Grundy et al., 2012). As these cases demonstrate, it is the intersection of these macro-level political transitions with health policy that creates the conditions for the resetting of the policy parameters for health reform.

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4.2. Health policy directions e health policy responsiveness to post transitions shocks Given the impact of these macro-political transitions in triggering health reform, health policy makers and development specialists are then confronted by the challenge of navigating their way through a transformed social and political landscape. In considering implications for policy and practice, it is helpful to consider the transitional “shocks” of these political transformations that require careful health policy and institutional adaptation. 4.2.1. Conflict shocks The case studies demonstrate the extent to which both internal and external conflicts have precipitated social and political transitions, and have in most cases overshadowed health development ever since. The major turning points in health policy relate not only to the political and social transformation that these conflicts generate. These turning points also relate to the broader development challenges of rebuilding institutions and the health workforce post conflict. In the case of Timor Leste and Cambodia, this meant rebuilding the health care workforce almost from scratch (MOH GTL, 2012, Heng and Key, 1995). In contrast, the siege mentality of the North Korean State and the militarization of its society is highly illustrative of the extent to which conflict (or the constant threat of it) distorts public policy priorities away from human security issues onto a predominant focus on the security and survival of the State (Grundy et al., 2012). In the Union of Myanmar, nearly 50 years of military dictatorship (1962e2008) and continuous internal conflict has contributed to a command and control managerial culture, with the country now tasked with the “unnatural transition” from central control (Risso-Gill Page 8 2013) to a decentralized model of governance (Tin et al., 2010). In every case, with the possible exception of Mongolia, the development impacts of conflict reverberate across generations of institutional and human development, and are the defining historical pivots on which the subsequent patterns and pace of health policy turn. It is highly illustrative of the observation that health policy formation operates within a wider field of political relations, of which conflict and its aftermath are dominant drivers. 4.2.2. Free market shocks Liberal economic reforms were accelerated by reorientation of international health policy in this period, particularly through multi-lateral agencies such as the International Monetary Fund, the Asian Development Bank, and the World Bank. The 1987 Agenda for Change (Akin et al., 1987) proposed the introduction of user fees at government health facilities to raise revenue. In 1993, Investing in Health (World Bank, 1993) proposed that governments in developing countries be responsible for funding only a US$12 minimum package of primary care services with the remainder being provided through the public sector. In Cambodia, the initial response to liberal reforms was to introduce user fees through a health financing charter in 1996 (MOH, 1996b). This was followed by wider protection measures through development of hospital health equity fund models from the late 1990s (Bigdeli and Annear, 2009). In Mongolia, the neo-liberal reforms in 1990 resulted in a rush of policy responses, including establishment of a National Health Insurance Law and institution of capitation based funding models for primary care (Hindle and Khulan, 2006). In Myanmar in 1993 following market reforms, user fee models were introduced by establishing community cost sharing and drug revolving funds (MOH Myanmar 2009). Following political reforms in 2008, consideration of social sector policy options have been considered including test and development of health financing schemes (Tin et al., 2010) and scale up of tax based health insurance. Despite

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these initiatives, countries are still playing “catch up” in response to the impacts of economic reforms, as evidence emerges of wide inequities of access and outcomes based on socio economic status in Timor Leste (NSD GTL, 2010), Cambodia (MOP Cambodia, 2010) and Mongolia (Lhamsuren et al., 2012). The challenge of adaptation to changing health policy parameters that are reset by free market economic reform is that it requires highly reflexive policy and system responses, particularly in terms of health financing, human resource management and health planning. 4.2.3. The governance shock Political transformation in most cases has required a radical shift in management cultures from command and control styles of central management to negotiated contractual arrangements with middle level managers. These health policy adaptations are illustrated by the cases of Family Group Practices in Mongolia (Hindle and Khulan, 2006) and contracted operational districts in Cambodia (Soeters and Griffiths, 2003). In Timor Leste, the National Health Plan (MOH GTL, 2012) expresses its intent to shift towards performance based management models, while in Myanmar early attempts have been made to establish decentralized and coordinated planning systems at Township level (Tin et al., 2010). These new regulatory and management mechanisms are intended to address the governance challenge associated with transition from monolithic state control using centralized models of administration, to diverse and decentralized models of management with a mix of funding sources, providers and stakeholder interests. These responses to internal post transition shocks are not only dependent on the internal evolution of Nation States. As the cases of the DPRK and Myanmar demonstrate, the ebbs and flows in international relations, particularly with respect to economic embargoes, defence expenditures and restriction of migration of people and ideas, have acted as major constraints on health system development (Grundy et al., 2012). Equally, as the cases of Cambodia (Bigdeli and Annear, 2009; Meessen et al., 2011), Mongolia (Hindle and Khulan, 2006), and the Philippines (Lakshminarayanan, 2003) demonstrate, the globalizing forces of democratization and market exchange internationally have seen fundamental shifts in the ways health services are managed, purchased and provided. 4.3. Implication for health policy analysis These observations serve to illustrate that, rather than being an inert set of engineered technical constructs or building blocks, health organizational systems and policies are dynamic social constructs that are highly open to the shifting influences of social and political superstructures as they transform through time. In this regard, health policies and systems are products of their time (van Olmen et al., 2012). The impact of these transitional shocks also illustrates the inherent organizational instability, disequilibrium, and complexity of health care systems that is related to their openness to the influences of these wider social and political ideas and forces. In this way, the teleological objectives of health planners for desired end states of health organization meshes with the complexity and transience of wider social and political organization. The tensions between the two result in fundamental turning points in health systems and policies, characterized by remarkable case studies in policy innovation as organizational systems re-establish their equilibrium in response to new macro policy directions. These wider ecological perspectives on health policy formation are central to deepening our understanding of the way in which health systems and policy making is permeated and shaped by the forces of history and its related ruling and transient paradigms of

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political power. From a policy makers or development specialists perspective, the comparative element in such a diverse set of contexts is the coming to terms with application of what is consistent across all contexts (the scientific aspects of health policy), and that which requires careful adaptation to context (the managerial aspects of health policy). Generally speaking, the value of comparative health systems analysis is that it enables a nuanced understanding of how to “change the channel” in policy terms, in order to tune into the historically defined development trajectories. This enables health system applications to be feasibly and effectively implemented along a specific national pathway. Although this does not negate the value of the system thinking approach (Adam and de Savigny, 2012; Atun, 2012), there is nonetheless a stronger case for closer alignment of systems thinking with historical thinking. The purpose of this closer alignment of systems analysis with historical and political analysis is to provide a deeper understanding of the pressures and trajectory for policy change, which are highly variable and specific to national context. The specificity of country settings as well as their dynamism is testament to the fact that the drivers of policy change, whether actors, institutions, ideas or stakeholder interests, cannot be replicated from one context to the next (Bloom et al., 2008). This amounts to what has been referred to as the specific “configuration of policy dynamics” (Capano, 2009) that has to be learnt in setting. It is within this web of causal complexity that greater attention to historical trajectory and the political transformations that reset health policy parameters is required. This is one important means by which policy makers and development specialists can identify more feasible entry points for longer term policy analysis and action. 5. Conclusions These case studies demonstrate that political and social transitions are critical to the reformation of the health policy landscape in low income country settings. This presents significant development challenges in such settings, particularly in relation to adaptation to the post conflict, free market and governance shocks arising out of such periodic social and political transformations and the related requirement to institutionally adapt to new policy directions. The main implication of these findings is that analysis needs to be informed by a deeper understanding and questioning of the historical trajectory and political stance that sets the stage for the acting out of health policy formation. By recognizing the historical and political foundations of policy and systems change, policy makers and development specialists will be better informed of the feasibility, challenges and boundaries for realistic health policy reform in such settings. Such a historically and ecologically informed policy debate should reduce the lag time between the social and political transitions and the required health policy response, enhancing the capability of health and social systems to operate optimally along their own historical pathways. Acknowledgement Allender is supported by funding from an Australian National Health and Medical Research Council/Australian National Heart Foundation Career Development Fellowship (APP1045836). Allender is a researcher within a NHMRC Centre for Research Excellence in Obesity Policy and Food Systems (APP1041020). Allender is an investigator on a US National Institutes of Health grant titled Systems Science to Guide Whole-of-Community Childhood Obesity Interventions (1R01HL115485-01A1).

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