This presentation was given by Gerald Bloom at the Global Symposium on Health Systems Research, November, 2010.

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Building institutions for an effective
health system
Gerald Bloom

2. Building complex health systems
 Context matters (the importance of
institutional arrangements)
 History matters (time and path
dependency)
 Theories matter (narratives, framing and
policy options)
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3. Institutions
 Formal and informal rules, rewards and
punishments
 Behavioral norms and expectations of
behavior
Institutions take time to construct and the
arrangements are sticky leading to path
dependency
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4. Organizations
 Groups of individuals bound together by
some common purpose
 Organizations differ in their coherence,
complexity, values and goals
 Actors in organizations are influenced by
both individual and organizational goals
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5. Aspects of institutional analysis
 Map organizations and key actors
 Map relevant rules and incentives
 Understand the economic, institutional and
political context and its influences on the
performance of health system actors
(providers and users of services, funders,
regulators, accountability organizations)
 Understand explicit and implicit contracts,
trust and beliefs (construction of
institutional arrangements)
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6. China: policy challenges
 Rapidly rising costs
 Problems with quality
 Financial barriers to access
 Illness-poverty linkages
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7. China: debates about reform
 Design of rural health insurance scheme
 Health safety net for the poor
 Define basic package of public health
services
Focus on formal design rather than
institutional development or sequencing of
reforms
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8. China: contextual issues 1990s
Public finance (devolution, limited fiscal transfers,
resistance to unfair taxes – political impossibility of
compulsory insurance)
Human resources (overstaffing, transition in pay
structure)
Local government accountability (substantial
autonomy, little priority given to health)
Facility management (lack of systematic
approaches to management)
Local planning and regulation (need to redefine
role of government and build capacity)
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9. China: contextual issues 2006
Public finance (end of agriculture tax, increased
fiscal transfers and change in public expenditure
priorities)
Human resources (retirement of unskilled
personnel and large numbers of new graduates
becoming available)
Local government accountability (continuing
issue, new emphasis on trust, higher priority given
to health)
Local planning and regulation (rapid
infrastructure expansion, measures to reduce
“corrupt practices”, FDRA established, licensing
village doctors)
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10. China: reform 2009
 Strong government support for rural
health and very large increases in public
finance
 Establishment and rapid spread of rural
health insurance
 Provision of government funds for basic
public health services
Increasing concern about quality and the cost-effective
use of public funds and the creation of effective
institutions to influence provider performance
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11. Politics, legitimacy and narratives
of health reform
There is a growing national consensus on the health
system’s problems and the government has invested
political capital in promising change
The creation of a national health system which includes
common understandings of roles, responsibilities and
entitlements in a context of changing patterns of social
and economic inequality is a work in progress.
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12. Conclusions
 Health-related markets have expanded faster than
the creation of appropriate institutions
 Knowledge of the patterns of incentives and
responses to particular interventions is limited
 The construction of institutions takes time and their
pathways of development are influenced by power
imbalances and politics
 Institutions, and the social contracts they imply,
are strongly influenced by attitudes, expectations
and understandings
We have robust theories of the performance of stable
health institutions in modern regulatory states but we
have much less understanding of how to construct
these institutions.
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