Elsevier

Health Policy

Volume 42, Issue 3, December 1997, Pages 187-209
Health Policy

Comparative research and analysis methods for shared learning from health system reforms

https://doi.org/10.1016/S0168-8510(97)00072-9Get rights and content

Abstract

The pace and breadth of health reforms point to the need for a comparative methodology to support shared learning from country experiences. A common understanding of health reforms is a first prerequisite for comparative research. Dimensions characterising content, sequence, process, purpose and scope of policy change are identified on the basis of a literature review. Reforms can have a gradual build up, starting with piecemeal policy changes that can be eventually integrated to enhance their benefits. Comprehensive reforms can be defined as policy formulation and implementation that comprises the systemic, programmatic, organisational and instrumental policy levels through explicit strategies sustained in well-documented experiences and theories and implemented with the support of a specialised agency with consensus-building capacity. A minimum-data set is proposed on the basis of an extensive literature review to support the comparability of health reform case studies and descriptions. Its components are: the current health system, its background and context, the reform rationale, the specific proposals, political actors and processes, achievements and limitations, and lastly the reform's wider impact. Case studies can be compared historically, through particularistic comparisons, using ideal types and by means of exemplars. The advantages and limitation of each method are analysed as well as how they can be combined to frame the research questions and minimise resources. Finally, the International Clearinghouse for Health System Reform Initiatives is described as an instrument to disseminate comparative research and analysis in support of shared learning.

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.

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