Comparative research and analysis methods for shared learning from health system reforms
Introduction
In many countries throughout the world health financing and service institutions are being reformed to meet diverse yet conflicting pressures: on the one hand, there are structural adjustments of national economies to meet fiscal crisis and national debt, leading to a shrinking role of the state. On the other, there is a growing pressure on health systems due to rising health needs and costlier technology. These conflicting forces meet in the context of globalisation, a process whereby nations increase their interrelatedness and interdependency through the spread of democracy, the dominance of market forces, the integration of economies in a world-wide market, the transformation of production systems and labour markets, the spread of technological change and, last but not least, the media revolution [1]. Globalisation has the impact of contributing to better health, for example through the benefits of democracy on equity, coverage, choice, quality services and dignified care. However, globalisation can also mean greater financial instability while freedom of choice for some may imply restrictions to others and the widening of social differentiation.
Globalisation is leading to the establishment of trading blocks such as the European Union (EU) and the North American Free Trade Agreement (NAFTA). The EU exemplifies the trend where public affairs such as the regulation of drugs and the environment and the support of vital research areas are increasingly taken up by supra-national governing bodies. On the other hand, NAFTA exemplifies a trend where manufacturing jobs are exported to Mexico while the United States and Canada become ever more highly specialised service economies. Meanwhile, social security is being redefined in these three countries in an effort to increase their international competitiveness. There is a trend towards more individualised benefits, more limited public responsibilities and greater burden in the family to care for the elderly and the sick.
Much of the transformation of the State has been informed by orthodox neo-liberal models. Yet the peculiar nature of health and disease and the values that guide the provision of health services require an appropriate theory to guide the processes of health reform towards equity, efficiency, quality and sustainability. A comprehensive economic and social theory is required that takes account of the peculiar nature and objectives that societies assign to health and to health systems [2]. An adequate theory must enable the restructuring of the state to assure the transition of health systems to a realm of social and economic accountability, while recognising and supporting the values, principles and purposes that are appropriate to health and that meet the criteria for sustainable development [3]. Furthermore, health reformers in developing countries must be cautious when emulating experiences from developed nations and which demand capabilities that may be non-existent [4].
An appropriate theory for health reform in the context of globalisation requires grounding on empirical research and shared learning of experiences in a wide range of countries. Several industrialised nations are well advanced in this direction and numerous analytical and critical publications are emerging, together with networks and clearinghouses to support analysis and research 5, 7, 8. In developing countries that have embarked on health reform international exchange of experiences are now in vogue [9]. A recent WHO-led request for proposals to support health system reform research met with 217 valid responses from 49 countries [10]. Furthermore, the Pan American Health Organisation recently obtained reports on health reform initiatives purportedly under way in most of its member nations [11]. A bibliometric analysis of the indexed journal articles covering health policy change in developing countries from 1992 to 1996 reveals intense reform activity in China, Vietnam, South Africa, Israel, Brazil, Chile and Mexico, while important health policy changes are reported for at least 41 of the 115 developing countries [10].
However, the vast majority of health reform research in developing countries focuses on case studies without consensus on a minimum data-set to assure their comparability. The handful of comparative studies have been undertaken with a diversity of methods, whose potential for shared learning needs to be further analysed. Health reform has become a `fuzzy concept' due to the vagaries of description as well as the complexity of the policy process itself [12].
This article discusses, first, the need for shared learning of health reform experiences and the role of comparative research in this effort. A framework for the understanding of health reforms is then presented to establish, from a variety of perspectives, the identity and the range of variation in the object of study. A minimum data-set is then proposed to facilitate the comparison and aggregation of case studies. More ambitious comparative methods are analysed that have the potential to contribute to international research design and project coordination. The application of these methods is exemplified with a real case to offer a perspective on how they can be combined to fulfil various requirements and suit diverse circumstances. Finally, the International Clearinghouse of Health System Reform Initiatives (ICHSRI) is described as an instrument to disseminate experiences in support of shared learning.
Section snippets
Towards shared learning through comparative research
Shared learning on the experiences with health reforms is becoming necessary and possible. It is necessary to sound warnings on policies that are ineffective in particular contexts as well as to disseminate successful experiences. The proper understanding of the health system's role and potential and the scope of inter-sectoral action can only emerge from a thorough understanding of international experiences that are being subjected to similar pressures from globalisation as well as responding
A framework for understanding health reforms
Comparative research on health reforms requires a minimum agreement on definitions concerning policy change and health system reform. At its most general, reform refers to the removal of evil or corrupt elements out of the body politic, or to the willed evolution of the social system towards `better' stages of being [42]. Health system reforms have been characterised in terms of content, sequence, process, purpose and scope. A continuum can be identified in what is termed `reform', ranging from
Minimum data-set for comparative health system reform analysis
A framework and minimum data-set should consider the most useful units in explaining a system's structure, function and transformation [46]. Independent studies guided by such a framework would permit an understanding of how specific experiences relate to each other and to regional patterns, historical trends, theoretical constructs and prototypes. Furthermore, such studies would enable the discovery of trends and regional patterns and processes and to generate hypotheses concerning possible
Approaches to compare health reforms
The employment of a descriptive framework to undertake case studies with a minimum data-set is in itself a comparative methodology requiring the least coordination across individual projects. However, four methods can be identified for comparative research beyond the usage of a minimum data-set: the historical approach, the particularistic comparison of a reduced set of experiences, the contrasting of initiatives against an ideal type or construct and the analysis of the benefits and
Undertaking comparative research
Researchers may employ a combination of comparative methods to solve theoretical questions concerning health systems, to assess their development along a given reform path or to help decide on the merits or limitations of specific choices. Which combination of methods are used will depend on questions that have to do with the kind of research problem at hand, the resources and research capabilities available, the extent to which each country case study must comply with national reporting
The International Clearinghouse of Health System Reform Initiatives
Shared learning of health reform experiences through comparative research and analysis has to be supported through specific, international and widely accessible instruments that bring together, analyse, classify and disseminate research results, reform news and updates. This challenge has been taken up by the International Clearinghouse of Health System Reform Initiatives (ICHSRI), a consortium between the World Health Organisation and the Joint Programme for Research on Health Systems and
Conclusions
The process of globalisation is imposing new and often severe restrictions to health system development and reform in most countries. Shared learning on a global scale is now required not only to counter negative trends but, more importantly, to observe how countries cope with similar problems and learn from their success or failure. Comparative research and analysis can help contribute to overcome the limitations of case studies that face enormous complexity, yet are often undertaken with
Acknowledgements
This paper was partly funded with financial support from the Rockefeller Foundation Grant No. HS 9512.
References (81)
Abnormal economics in the health sector
Health Policy
(1995)Health sector reform: making development sustainable
Health Policy
(1995)- et al.
International transfers of national health service reforms: problems and issues
Lancet
(1994) - et al.
Health policy as a fuzzy concept: Methodological problems encountered when evaluating health policy reforms in an international perspective
Health Policy
(1997) Dimensions of health system reform
Health Policy
(1994)Health system reforms: toward a framework for international comparisons
Social Science and Medicine
(1996)User charges for health services in developing countries a review of the economic literature
Social Science and Medicine
(1993)- et al.
Health sector reforms in Sub-Saharan Africa lessons of the last 10 years
Health Policy
(1995) - et al.
Ends and means in public health policy in developing countries
Health Policy
(1995) - et al.
Structured pluralism. Towards an innovative model of health system reform in Latin America
Health Policy
(1997)
Have structural adjustments led to health sector reform in Africa?
Health Policy
Chile's health sector reform lessons from four reform periods
Health Policy
Health care reforms the unfinished agenda
Health Policy
The politics of health sector reform in developing countries three cases of pharmaceutical policy
Health Policy
Reforming China's 50 000 township hospitals—effectiveness, challenges and opportunities
Health Policy
Privatization of the medical market in socialist China a historical approach
Health Policy
Health care reform in Kenya a review of the process
Health Policy
Decentralization of health services in Western Highlands Province, Papua New Guinea an attempt to administer health service at the subdistrict level
Social Science and Medicine
A prepayment scheme for hospital care in the Masisi district in Zaire: a critical evaluation
Social Science and Medicine
The reforms of the Chinese health care system county level changes the Jiangxi Study
Social Science and Medicine
A new focus for dialogue. European Health Reform
Bulletin of the European Network and Database
Health services reforms: political and managerial aims. An international perspective
International Journal of Health Planning and Management
Indexed scientific publications on health reform in developing countries 1992-1997, Informing and Reforming
The Newsletter of the International Clearinghouse of Health System Reform Initiatives
Health sector reform: key issues in less developed countries
Journal of International Development
Health insurance in developing countries: lessons from experience
Health Policy and Planning
The political economy of healthy system reform in Israel
Health Economics
The state of health planning in the '90s
Health Policy and Planning
Comparing health care systems: what nations can learn from one another
Journal of Health Politics, Policy and Law
Privatization—a balancing act
World Health Forum
The public and private sectors in health economic issues
International Journal of Health Planning and Management
Carrot and stick state mechanisms to influence private provider behavior
Health Policy and Planning
Managing the health care market in developing countries prospects and problems
Health Policy and Planning
Cited by (23)
Comparative Health Systems
2016, International Encyclopedia of Public HealthComparative Health Systems
2015, International Encyclopedia of the Social & Behavioral Sciences: Second EditionComparative health systems
2008, International Encyclopedia of Public HealthInformed choices for attaining the Millennium Development Goals: Towards an international cooperative agenda for health-systems research
2004, LancetCitation Excerpt :Contextual factors are generally thought to be important effect modifiers, but are often poorly described by researchers, making it difficult to determine why a particular intervention or policy has been effective or ineffective. Better description of relevant contextual factors and greater reliance on multicentre or multicountry research, where a given research question can be addressed across a range of settings, is needed.48 Recommendations for improved design of non-randomised studies have recently been published.49
A ‘transitional’ context for health policy development: The Palestinian case
2002, Health Policy