Health PolicyGood Health at Low Cost 25 years on: lessons for the future of health systems strengthening
Introduction
Why do some countries achieve better health outcomes than do others at similar levels of income? In 1985, the Rockefeller Foundation convened a meeting in Bellagio, Italy, to consider the experiences of four countries or regions seen as success stories: China, Costa Rica, Sri Lanka, and the state of Kerala in India. All had achieved substantially better health outcomes than other nations at similar levels of development. The result was a publication entitled Good health at low cost1 that not only dispelled the then widely believed myth that economic growth was necessary for health improvement but also identified specific factors associated with success. These were a commitment to equity, effective governance systems, and contextually appropriate programmes addressing the wider determinants of health. Politics also mattered, and every country or region was run by left-wing governments of various hues. 25 years later, the threats to health and the scope to respond are much more complex. Do the lessons of 25 years ago still apply?
In 2011, we revisited the original countries and regions and looked at five different places that were judged to have succeeded in either achieving long-term improvements in health and access to services or implementing innovative reforms relative to their neighbours (table).2 We used a conceptual framework (figure) to assess how access to health care and good health are affected by context (global and national), sector (public and private), and systems (health and non-health). The nature of the success varies; some have achieved substantial health gains whereas others have improved coverage or health system performance but are yet to see the full effect. Here, we review the experiences of Bangladesh (panel 1), Ethiopia (panel 2), Kyrgyzstan (panel 3), the Indian state of Tamil Nadu (panel 4), and Thailand (panel 5) and reflect on lessons they offer to other countries of low and middle income that are attempting to strengthen health systems in constrained or uncertain circumstances.
In 2009–11, we undertook a series of historical case studies to investigate how and why these five countries or regions made progress in health and access to care (panel 6). Our conceptual framework (figure) was based on existing published work65, 80, 81, 82 and was used to identify a comprehensive range of factors related to health systems, public provisioning (including social programmes such as literacy and female empowerment), and politics and values underpinning the public process. This framework included a mix of quantitative and qualitative methods.83 Findings were validated within and across countries. Our central study question was what determines achievement? Although the complexity of health systems, and the broader political systems in which they are embedded, means that no blueprint is available for producing a strong health system,75, 77 our approach meant we could identify common patterns plausibly linked to better health and health care of potential relevance beyond the countries studied.77 We describe here the main emerging themes focused on the health systems, with reference to topics related to other sectors and the wider context (panel 7).
Section snippets
Characteristics of well functioning health systems
Four characteristics linked to improvements in health and health care emerged from our analysis. The first was good governance and political commitment; the second was effective bureaucracies and institutions; the third factor was the ability to innovate, especially with respect to service delivery; and the final point was health system resilience (panel 8).
Good governance and political commitment
Governance underlies all health system functions80 in addition to broader social development,93 although the meaning of governance in relation to health systems is diverse and contested.94, 95 It includes the regulatory and managerial arrangements through which the health system operates, including how overall goals are set and monitored and how various components of the health system interact to achieve these goals. Governance also includes normative values (equity, transparency) and political
Effective bureaucracies and institutions
Development of sound policies and plans does not guarantee their effective implementation. In our study, functioning bureaucracies and institutions were deemed important for successful reforms. These organisations could be within the health sector (eg, ministries of health, district and subdistrict health institutions, or donor agencies) or outside it but whose operation influences the functioning of health systems (eg, other ministries, the media, or development non-governmental organisations
Innovation
All study countries showed innovation in various aspects of their health systems. Particular originality was seen in the workforce (which is a severe constraint in all countries), financing mechanisms, and means of delivering services.
Building resilience in the health system
Health systems are sometimes vulnerable to unexpected shocks, leading to growing interest in how to foster resilience.79, 124 Thailand and Ethiopia have recently been affected by large-scale natural disasters and have subsequently put in place systems to prepare for similar events in the future. Long experience with seasonal floods and cyclones has made Bangladesh a model of development for appropriate infrastructure and systems to coordinate emergency responses, such that recent natural
Cross-cutting lessons
Here, we have attempted to distil cross-cutting lessons from our analytical case studies of Tamil Nadu in India, Bangladesh, Kyrgyzstan, Thailand, and Ethiopia. Cross-country analysis of national or regional experience has value for identification of common themes, even if the detailed characteristics vary. Although we do not present a roadmap for success, our synthesis draws attention to health system and non-health system factors that seem to be important across our study countries for
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