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PART I
INTRODUCTION
The introductory section of the book provides a summary of analytical frameworks used in comparative studies, with a special focus on health care financing studies on universal coverage. This section will also provide a detailed discussion on research methodologies for such studies and the methodology used for the review summarized in this book.
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CHAPTER 1
ANALYTICAL FRAMEWORK
This chapter of the book will provide a review of analytical frameworks for understanding health care financing reforms. It will review historical approaches to balancing the role of the state and private sector in social policy and health care, including known determinants of public policy, normative functions of modern governments, outcomes from health policy and policy processes.
Health systems are a complex integral part of society. To fully understand a health system and health policy, it is necessary to look beyond the health system itself to the environment in which it exists. For the purpose of the cross-national comparisons that will be made in this volume the following broad framework will be used. The country context will include an analysis of the countries’ history, politics, institutions, its socio-economic and demographic aspects and its business environment and investment climate. The evolution of the countries’ health systems will include both their history and reform processes. The structure of the countries’ health systems will include their organization, ownership and resources. And the function of the countries’ health systems will include the roles of government and the public sector, the roles of markets and the private sector and areas where the public and private sector work in collaboration or competition with each other. See Table 1.1.
Table 1.1 A Comparative Health Systems Analysis Framework
Key Domain | Components of Analysis |
Country context | Historical, political & institutional context
Socio-economic, demographic context & cultural context
Business environment & investment climate |
Evolution | History
Reform Process |
Characteristics | Structural features Organization (organogram & health pyramid) Ownership (public/private structure, concentration & de-concentration) Resources (input level, range & quality) Functions Roles of governments & public sector
Stewardship
Policy making process
Governance Roles of markets & private sector
Manufacturing (goods & services)
Distribution (wholesale & retail)
Trade (import & export) Roles of partnerships between public & private sectors
Management and M&E (monitoring & evaluation)
Financing (revenue collection, risk pooling & purchasing/allocation)
Service delivery (preventive, diagnostics, curative, rehabilitation, & palliative)
Medical education, research & development Performance
Inputs, outputs & process
Proxy measures
Impact |
Source: Author.
A.HISTORICAL ROLE OF THE STATE
For centuries, political philosophers have debated the nature of the relationship between the state1 and its citizens, “why, how and to what effect different governments pursue a particular course of action or inaction.”2 In recent times, social scientists have carried out extensive investigation on the determinants (why), normative functions and instruments (how or what) and outcome (effects) of policies that define the normative function of modern governments. The following brief historical sketch draws attention to the perennial dilemma between individualist and collectivist concerns about the role of the state, which has a significant impact on the issues and policy options that will be explored in the study. “In dilemmatic situations, the reasons on each side of a problem are weighty ones, and none is in any obvious way the right set of reasons.”3 This debate can be extended to health care, which is one of the many complex expressions of modern welfare states — the content of specific health policies, the reasons they were introduced and their impact on both the health sector and society in general.
Religious and natural law theories on the role of the state in western societies are deeply rooted in antiquity4 by the scriptures5 and classical thought.6 Plato was an elitist who believed that knowledge was a virtue and ignorance, a vice. The privileged few were entrusted to govern the ignorant masses.7 Health systems are not only an integral subset of the state but often microcosms of their socio-economic, political and administrative systems. The papyri, dating to the second millennium B.C., give fascinating evidence that Imhotep, an archetypal physician, priest and court official in ancient Egypt, introduced collective services with healers who were paid by the community.8 This early experiment in organized health care did not survive the test of time. The Code of Hammurabi (1792–1750 BC) laid down, inter alia, a system of direct fee-for-service payment based on the nature of services rendered and the ability of the patient to pay.9 For the next 3,000 years, the involvement of the state in health care revolved mainly around enforcing the rules of compensation for personal injury and protection of the self-governing medical guild.10 At best, financing, organization and provision of health care was limited to the royal courts of kings, emperors and other nobility who might have a physician for their personal use and troops at the time of battle. The masses got by with local healers, midwives, natural remedies, apothecaries and quacks.
The Dark Ages, Renaissance and Reformation enshrined the twin sources of European civilization — religious and state absolutism.11 Supported by the scourge of recurrent bouts of plague, superstition spread its poison across the continent through burning at the stake and executions. King Henry VIII gave sweeping powers to the College of Commonalty of the Faculty of Medicine of London in 1518 to punish quacks and pretenders, but did little else to change the status quo.12 These events fostered an individualist backlash that eventually led to the transfer of political power from absolute monarchies and feudal states to the rising property-owning classes. Hobbes believed that individuals entered into a social contract by which they mutually agreed to form a sovereign state (Leviathan) that would limit its role to providing peace, protection and justice: “the liberty each man, hath, to use his own power, as he will.”13 Locke believed that the only valid state restriction on the innate right to liberty and freedom was to preserve “life, liberty, health, limb or goods of another.”14 Organized care for the sick, disabled and poor, who according to natural law had brought their destiny upon themselves, was left to local parishes.15 The transition from Catholicism to Protestantism in northern Europe undermined these early efforts as sequestration of ecclesiastical properties left many reform movements without resources to carry out even minimal custodial care.16
The emergence of scientific thought during the Enlightenment of the eighteenth century confronted the tyranny of divine right and abuses of state sovereignty with critical reasoning.17 Kant stressed the responsibility of individuals to be autonomous and choose their own fate as free and rational beings: “autonomy of the will ... the supreme principle.”18 As was characteristic of the individualism of the times, he believed that freedom and liberty would protect civil and political rights. In contrast, Rousseau and other early defenders of collectivism favored a social contract to protect economic and social rights.19 Adam Smith was specific in his description of appropriate limitations in the function of the laissez-faire capitalist state: protecting society from violence and invasion; protecting individuals from injustice and oppression of others; and maintaining necessary public works and institutions that are of no personal interest to individuals.20 The first two functions are carried out by all organized societies in the form of defense, police, justice and administration. The third, which anticipates a role in the allocation of resources, is more complex because it leaves scope for interpretation. Poor law relief brought on by industrialization and urbanization, unintentional as it may have been, became one of the earliest expressions of secular involvement by the state in health care.21 The criteria for admission were “less concerned with the alleviation of poverty than with preventing public subsidy of the idle.”22
By the nineteenth century, utilitarian theories on the role of the state formally challenged the supremacy of religious and natural law philosophies.23 “Utilitarianism is a maximising and collectivising principle that requires governments to maximise the total net sum of the happiness of all their subjects ... in contrast to natural rights theory which is a distributive and individualizing principle that assigns priority to specific basic interests of each individual subject.”24 Appealing to “reasonable men”, Bentham felt that natural rights were “simple nonsense ... nonsense upon stilts.”25 Mill believed that individuals should be free in ...
