Social Science _ Medicine Volume 117 issue 2014 [doi 10.1016_j.socscimed.2014.07.047] Grundy, John; Hoban, Elizabeth; Allender, Steve; Annear, Peter -- The inter-section of political history and hea.pdf

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Social Science & Medicine 117 (2014) 150e159 Contents lists available at ScienceDirect Social Science & Medicine journal homepage: The inter-section of political history and health policy in Asia e The historical found
  The inter-section of political history and health policy in Asia  e  Thehistorical foundations for health policy analysis  John Grundy  a ,  * , Elizabeth Hoban  a , Steve Allender  a , Peter Annear  b a School of Health and Social Development, Faculty of Health, Deakin University, Australia b Nossal Institute for Global Health University of Melbourne, Australia a r t i c l e i n f o  Article history: Received 1 August 2013Received in revised form15 April 2014Accepted 18 July 2014Available online 18 July 2014 Keywords: Policy changeHealth and historySocial transitionHealth reform a b s t r a c t One of the challenges for health reform in Asia is the diverse set of socio-economic and politicalstructures, and the related variability in the direction and pace of health systems and policy reform. Thispaper aims to make comparative observations and analysis of health policy reform in the context of historical change, and considers the implications of these  󿬁 ndings for the practice of health policyanalysis. We adopt an ecological model for analysis of policy development, whereby health systems areconsidered as dynamic social constructs shaped by changing political and social conditions. Utilizinghistorical, social scienti 󿬁 c and health literature, timelines of health and history for  󿬁 ve countries(Cambodia, Myanmar, Mongolia, North Korea and Timor Leste) are mapped over a 30 e 50 year period.The case studies compare and contrast key turning points in political and health policy history, andexamines the manner in which these turning points sets the scene for the acting out of longer termhealth 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 ad-ministrations, towards more complex management arrangements characterized by a diversity of healthproviders, constituency interest and  󿬁 nancing sources. The pace of reform is driven by a country'sinstitutional capability to withstand and manage transition shocks of post con 󿬂 ict rehabilitation andemergence of liberal economic reforms in an altered governance context. These  󿬁 ndings demonstratethat health policy analysis needs to be informed by a deeper understanding and questioning of thehistorical 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. 1. Introduction 1.1. Background to health reform and social transition Despite rapideconomic growth,theAsian region hasbeen besetby policy challenges of persisting inequities in health care accessand health outcomes, and major health sector governance chal-lenges presented by macro-level reforms in politics, economics orcivil administration. In  China , institutional reforms have failed tokeep pace with broader development policy that was linked to freemarket macro-economic reforms in the 1980s (Bloom, 2011). In Mongolia  during the post-Soviet neo-liberal reforms in the early1990s, measures were put in place to decentralize health caresystems to family group practices (FGPs) and institute health 󿬁 nancing models based on capitation based funding for primarycare (Hindle and Khulan, 2006). In  Cambodia , during the post UN-sponsored election period from 1993, the socialist model of governance was dismantled and replaced by a more complexdiversi 󿬁 ed management arrangement, including the scale up of demand side  󿬁 nancing initiatives and the expansion of healthcontracting models and of the private medical sector (Grundy andMoodie, 2008). Similar pathways have occurred in  Indonesia (Ghani,2012)andthe Philippines (Lakshminarayanan,2003),wherepolicy makers have developed responses to the administrativechallenges of decentralization and devolution.A common theme in these observations of health and socialchange is the policy and development challenge related to transi-tion from centralized political orders in the 1980s and 1990s to-wards more diverse and open pluralist models of administration. DOI of srcinal article: *  Corresponding author. E-mail addresses:, Grundy). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: ©  2014 Elsevier Ltd. All rights reserved. Social Science & Medicine 117 (2014) 150 e 159  The highly diverse pattern of political and economic history con-tributes to an equivalently diverse set of organizational structures,institutional arrangements and methods of  󿬁 nancing of health caresystems, requiring countries to tailor policy implementation foruniversal coverage according tothe speci 󿬁 cities of national context(Carrin et al., 2008). 1.2. Theories of policy change But the question remains as to what combination of socialtheories can best explain the varying pace of policy and systemchange across national settings, and how this can inform a moreconsistent and comprehensive approach to policy analysis.Bourdieu (1977) makes reference tothe notionof   “ habitus ”  in orderto emphasise the durable dispositions of behaviours that providenational institutions with their particular continuity of character.Similarly, Huntington (2006) de 󿬁 nes institutions in terms of stable,valued and recurring patterns of behaviour. This durability andcontinuity of institutions and their related behaviours contributesto what others have referred to as the trajectory (Walt et al., 2008)or path dependence(Altenstetterand Busse, 2005) of health policy.The concept of   “ path dependence ”  has common featuresincludingtheobservationsthatearlyeventsinsequencematterandthat later events have an inertia related to the earlier sequence(Mahoney, 2000). Despite the presence of historical inertia, pathdependence does not rule out the availability of policy choice,although the band of choice is conceptually narrowed based oncontext(Kay,2005).Therelatedideaof  “ processsequencing ” isthattrajectories are not random but are outgrowths of earlier tra- jectories(Howlett 2009). Policy activity can also be reactive intransformingthewiderpolicycontextanddirections.Inaccountingfor the changingof trajectories, analysts haveput forwardthe ideasof   “ critical junctures ”  (Kay, 2005) or  “ policy turning points ” (Abbott,1997), whereby periods of crisis are reported to contributeto 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 incontrast srcinate from past time and are contextualized in place(Capano, 2009). This being the case, the formation of managerialideas is located within awider 󿬁 eld of social and political ideas andinstitutions that are subject to periodic historical transformations.This concept of health care as forming part of an  ” ecosystem ”  isrelated in part to the limitation of systems analysis, which em-phasizes elements of the internal organization and management of health care systems. This limitation presents major challenges forcomparative systems and policyanalysis, wherebya predominanceof hybrid forms seems todefeatefforts fora consistent setof healthsystem classi 󿬁 cations or ideal types (Freeman and Frisina, 2010).The metaphor of ecosystem is also relevant in so far as healthpolicy and systems change demonstrates an adaptive, organic andevolutionary quality, as it periodically shifts directions, responds toshocks or crises, and seeks to re-establish system equilibrium inresponse to fundamental changes in a wider  󿬁 eld of economic,social and political relations. Feedback processes, including insti-tutional rule adaptation and behavioural changes, allow policy andsystems to re-adjust to changing circumstances, leading to theestablishmentofnewandlongertermequilibriums(homoeostasis)in policies and systems (Howlett, 2009). This re-establishment of policyandsystemsequilibriuminaneworderrespondstotheneedto reset patterns of institutional behaviours (Huntington, 2006), assystems struggle to re-align with higher level economic and polit-ical reform. The phenomenon of policy dis-equilibrium can bede 󿬁 ned as the delayed policy or institutional response to politicalor economic change, as institutions struggle to adapt their tradi-tions of management or  “ habitus ”  (Bourdieu, 1977) to a radicallyaltered governance context.From this standpoint, rather than viewing health systems sim-ply as technical constructs engineered by technical planners anddecision makers, health systems can also be viewed as dynamicsocial constructs shaped by the control parameters of changingpolitical and social conditions (Glass and Mc Atee, 2006).Through illustration of case studies in health system develop-ment from the Asian region, this paper aims to make comparativeobservations and analysis of health policy reform in the context of historical change, and considers the implications of these  󿬁 ndingsfor the practice of health policy analysis. The main variables of in-terest is macro-political change, as de 󿬁 ned by major shifts in theexercise of political or economic power, in terms of free marketreform, decentralization and constituency emergence. The variableofinterestisthehealthpolicyturningpoint,whichisde 󿬁 nedasthecritical juncture at which health policy is reformed in the directionof this political or economic transformation. 2. Methods  2.1. Target countries and sources of data Thecountrycaseswereselectedbasedontheauthors'publishedobservations and analyses in the  󿬁 ve countries under study. As anobserverandparticipantin thepolicyandplanningenvironmentinthese country settings for variable periods of time between 1993and 2013, the opportunitywas provided to observethe in 󿬂 uence of historyandpoliticsinreshapingthehealthpolicylandscapeineachnational setting and to access the grey health systems and policyliterature. These observations and analyses were detailed intopublished country case studies of health system strengthening inthe 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 searchterms  “ universal health coverage ”  as a title search (122 responses).As noted by Walt et al. (2008), we found limited reference to his-torical analysis of the evolution of health policy. The literature ontheoriesof  “ policychange ” (Titlesearch)returned198responses,of which only two were relevant to an Asian setting, and of whichthere were no systematic attempts to analyse policy change acrosscountry health systems. The search terms  “ History ”  and  “ Healthsystem ” (Titlesearch)returned21responses,butwithnoresponsesfor Asia. Literature has been reviewed on systems thinking,complexity theory and theories of policy change. The literature onsocial and political history in each of these countries is quiteextensive, so historical sources were not systematically searched,butweresourcedselectivelyinordertoconstructabroadoutlineof the historical timelines outlined in Figs. 1 e 5.As a work of comparative analysis and synthesis incorporatingboth historical and health systems analysis, we note here the lim-itations that are the characteristics of any trans-disciplinary study,particularly with regard to challenges of validity related to a com-plex web of causation. But here we would also stress that thiscomplex web of causation represents a model of the health policyanalysis in the real world, and is a means by which to tackle theproblem of   “ the considerable gap between normative accounts of how health systems operate and realities on the ground. ”  (Bloomet al., 2008 Page 2076 e 77). We have attempted to manage theselimitations through testing and posing of a single research ques-tion, and to consistent reporting of the variables of interest  e namely, historical trajectory and political transformation, health  J. Grundy et al. / Social Science & Medicine 117 (2014) 150 e 159  151  policy turning points, and the resetting of policy directions. As thispaper is a synthesis of previously published papers with data frompublicly available data sources, no application for ethics clearancewas made to an institutional ethics committee.  2.2. Analysis We constructed health and history timelines for each countrywhich provide comparative observations between political andsocioeconomic history on the one hand (the history timeline), andevolution in public health status, health care systems and policiesover the last 30 e 40 years on the other (health timelines) (seeFigs. 1 e 5). We thereafter illustrate periods of health policy reformthat correspond to periods of political or economic reform. Eachcasestudyisstructuredaccordingto(a)thedescriptionofhistoricaltrajectory, (b) the identi 󿬁 cation of major turning points in healthpolicy history, and (c) the new policy directions reset by thechanging political and social conditions. 3. Main  󿬁 ndings  3.1. Cambodia 3.1.1. Historical trajectory Fig. 1 below describes health and history timelines forCambodia. Three periods of historical development have beentracked for this country over the last 40 years which includetotalitarian, centralist and neo-liberal reform periods.The totalitarian period was characterized by the near totaldestruction of the post-colonial health care system, and itsreplacement bya system based on traditional health care (Sokhym,2002).Only50doctorssurvivedtheKhmerRougeregime(Sokhom,2002). In the 1980s during the socialist rule of the Republic of Kampuchea when the country was occupied by Vietnamese forces,there wereefforts toreconstruct the health caresystem. The modelwas centralist, with limited civil society participation; this periodwas characterized by the beginning of international developmentassistance through United Nations agencies and non-governmentorganizations (Heng and Key, 1995). Post 1993, following theUnited Nations-sponsored general elections, the third and currentperiod of neo-liberal reform was established, characterized bydemocratization, development of free market economic systemsand expansion of political decentralization through electedcommune councils. From 1997 international development assis-tance and foreign investment expanded, with the country experi-encinga 󿬁 nalperiodofrelativepeaceandstability,includingsteadyrates of economic growth.  3.1.2. Health policy history The major health policy turning point occurred in the posttransition period, from 1993 onwards. A remodelling of the healthsystem took place after 1996, with reallocation of health facilitiesand health staff based on revised population catchments (MOHCambodia,1996a). A network of over 1000 primary health centersand 76 district referral hospitals were operational by 2011 (MOHCambodia, 2011). In order to offset the impacts of free marketsystems on health access, a  󿬁 nancing charter was introduced in1996 to regulate the system of user fees (MOH Cambodia, 1996b).From 2002, a system of hospital health equity funds was extendedacross the country to minimize the impact of catastrophic healthpayments on the poor (Bigdeli and Annear, 2009) with relatedpolicy measures including the establishment of national health 󿬁 nancing guidelines and a social protection framework (RGCCambodia, 2013). Health contracting models were trialed in orderto boost health system performance in an increasingly decentral-ized administrative context (Soeters and Grif  󿬁 ths, 2003). Civil so-cietyorganizationsforhealthhaveexpandedtoover100innumber(Medicam, 2013) and in 2010 the private medical sector was the 󿬁 rst choice for primary illness care for 56.8% of the population(MOP Cambodia, 2010). Despite these policy responses, health in-equities remain a signi 󿬁 cant challenge, as evidenced by wide dis-parities in access and outcomes relating to wealth quintile (Soeunget al., 2012).  3.1.3. Health policy directions These developments represent a signi 󿬁 cant diversi 󿬁 cation of the system of provision and  󿬁 nancing in an increasingly pluralistichealth system (Meesen et al., 2011) characterized by multiplesources of health  󿬁 nancing and provision through public, privateand civil constituencies. The parameters for health policy havetherefore shifted markedly from the 1980s era of central commandmanagement, and represents signi 󿬁 cant health policy and institu-tional adaptation measures to political change. Fig. 1.  Health and history timelines Cambodia 1975 e 2012.  J. Grundy et al. / Social Science & Medicine 117 (2014) 150 e 159 152   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 periodsidenti 󿬁 ed. The  󿬁 rst period of military socialist rule between 1962and 1988 was dominated by a centralist command style of administration. The second period of military rule was character-ized by the introduction of free market economic systems between1988 and 2008. The third period from 2008 onwards has beencharacterized by constitutional reforms and the initial steps takentowards democratization, decentralization and more open inter-national relations (ICG, 2011).The second period can be distinguished from the  󿬁 rst by theintroductionoffreemarketeconomicreformsfromtheearly1990s.This second period was also characterized by sustained economicand trade sanctionsand lowratesofinternational aid and domesticinvestment in the health care system (Grundy et al., 2012). Thisdecline in investment in socialsectorsis being reversed in the thirdconstitutional reform era post 2008, where social sector invest-ment and decentralization options are being actively explored(UNIC, 2012) and where international development assistance isbeing gradually extended in response to the more open politicalclimate and the related opening of diplomatic relations.  3.2.2. Health policy history Commencing in the early 1960s, the rural health care systemwasexpanded,witharuralhealthcentrelocatedineverydistrictby1964 (KoKo, 2006), and a network of 1137 rural health centersestablishedby1988(MOH,Myanmar,2012).Inthesecondperiodof free market reform, evidence began to emerge of poor access tohealth care based on affordability factors (MOP Myanmar 2010). Inresponse, in 1993 the Government introduced a health policy toregulate user fees through introduction of a community costsharing model (MOH Myanmar 2009). This period was also markedby very low rates of national and international investment in thehealth sector (Grundy et al., 2012). It was mainly in the post Nargisnatural disaster and constitutional reform period from 2008 on-wards that health system strengthening initiatives (Tin et al., 2010)and civil society partnerships were expanded (Htwe, 2011).  3.2.3. Health policy directions Political reforms have accelerated rates of development assis-tance as well as contributing to exploration of social sector policyoptions including increased health sector budgets (UNIC, 2012),decentralized health planning, alternative health  󿬁 nancing models(Tin et al., 2010), and public e private partnerships (L  € onnroth et al.,2007), all ofwhich are openingup a newhealth policylandscape inMyanmar.  3.3. Mongolia 3.3.1. Historical trajectory Fig.3 describes health and history timelines for Mongolia. Threeperiods of historical development have been identi 󿬁 ed whichinclude the beginnings of the socialist system, establishmentof thesystem, and the neo-liberal reform era since the early 1990s (MOHMongolia, 2012).For the majority of the 20th century, Mongolia functioned as asocialist republic under the tutelage of the Soviet Union. Thisperiod had a mixed historical record, with gradual expansion of the education and health sectors from the early 1920s, as well asprograms of industrialization and development of urban centers.However, the period was also characterized by intermittent civilcon 󿬂 ict and religious and political oppression particularly duringthe rule of Stalininthe 1930s (Baabar,1999). By the late1980s,theSoviet Unionwas providing 85% of development aid amounting to35% of the government's annual budget (Manaseki, 1993). Theclosure of the Soviet era in the late 1990s resulted in a rapid po-litical transition towards a system of administration modelled onneo-liberal lines  e  that is, parliamentary democracy, free marketeconomics, and emergence of private and civil society sectors.This latter period has been characterized by a remarkable socialtransition, with rapid urbanization, sustained high rates of eco-nomic growth and persisting and even widening social in-equalities (Rossabi, 2005).  3.3.2. Health policy history Due to the introduction of socialist models of administration,the 󿬁 rst constitution of Mongolia rati 󿬁 ed in 1924 stated that healthservices were to be provided free of charge. A Department of  Fig. 2.  Health and history timelines Myanmar (Grundy et al., 2014).  J. Grundy et al. / Social Science & Medicine 117 (2014) 150 e 159  153
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