Introduction to Health Systems & Reform 3(4)

This issue marks the completion of Health Systems & Reform's third year of publication. As I reflect on these past three years of publishing a start-up journal, I am gratified to see that HS&R is attracting excellent articles on the challenges of improving the performance of health systems around the world. Further, a recent editorial in the Bulletin of the World Health Organization called for more cross-country comparative research on health systems issues, the development of measures and methods for health policy and systems research, and more synthesis of evidence and policy translation.¹ The editorial nicely captures the mission of this journal. Health Systems & Reform thus fills a critical niche in global health research. Through commentaries and articles, Health Systems & Reform is identifying and analyzing critical areas and themes in health systems and reform, in order to propose recommendations on how to strengthen performance and, ultimately, improve health.

This issue's articles exemplify the journal's mission. They explore themes of health system structure and financing, management aspects of health reform, policy responses to aging societies and mental health care, and ethical analysis and the political dimensions of reform. These topics, often neglected in the literature, fall squarely in the domain of Health Systems & Reform. Following are brief overviews and comments on the articles.

This issue contains two commentaries. The first commentary examines the policy implications of the rapidly aging population in Chile, an upper-middle-income country. Thumala and colleagues review social and health policies for the elderly in Chile and conclude that many gaps exist, at least in comparison with high-income countries. The commentary describes how Chile has both a contributory pension system and a social pension system (for the poor). The social pension, however, is low relative to what elderly people need. The authors also note the considerable heterogeneity among Chilean elderly people's health and needs. Older individuals are likely to be poorer than an average Chilean, and poorer elderly people are more likely than their richer counterparts to face serious health problems, especially dementia. Although the government has sought to reduce inequalities in health coverage by expanding the list of conditions covered under the public health insurance system (known as FONASA) on which the elderly rely, dementia remains uncovered. Further, though there are dependency and social welfare risk assessments for elderly people, referral linkages to follow-up services are weak. The authors conclude that Chilean social and health services are not effectively integrated to address the considerable variation in needs across the elderly population, and they call for additional research and policy evaluation.

The second commentary examines the hotly debated question of how globally organized disease-specific interventions (for HIV/AIDS, tuberculosis, malaria, and other conditions) affect national health systems. Shroff and colleagues unpack two of the most popular metaphors used to describe the intersection of disease-specific programs and national health systems: the “diagonal approach” (which emerged from the “vertical versus horizontal” debate and Mexico's experiences of health reforms) and the “T-shaped approach” (which appeared in a review of Japan's history of health improvement²). The authors note, “Both of these approaches are instinctively appealing” but argue that both have problems in guiding governments on how to use disease-specific programs to improve health system performance. The authors express particular concern about the difficulty of generalizing from past experiences of Mexico and Japan. The complex realities of low- and middle-income countries today are strikingly different—too different to extrapolate from, according to these authors. They argue that the diagonal and T-shaped metaphors do not work across large temporal, geographic, and geopolitical gaps. In the end, the authors offer another metaphor. They propose focusing more on the pie (the entire system) than on the slice (the specific disease). They advocate a shift to system-level efficiency, in order to align disease-specific interventions with positive impacts on health systems. How to do this in practice seems challenging (and could have negative impacts on equity), but changing the focus and the metaphor may be an important starting point.

This issue next presents five articles of new research on challenges for health systems, including two that revisit the experiences of Japan and Mexico (as highlighted in the second commentary). In the first research paper, Ezoe and colleagues review the evolution of Japan's policies for noncommunicable diseases (NCDs). They argue that though public health interventions and socioeconomic factors contributed to making Japan into the number one country for healthy life expectancy, health promotion policies for NCDs also played a major role. Municipal governments began addressing health promotion in the late 1950s. Then in 1978, the national government introduced its first ten-year policy package for NCDs and has since revised the plan every decade. The plans articulate disease-specific policies as well as risk factor–specific policies. The plan introduced in 2000 identified 79 targets in nine areas for action: nutrition and diet, physical activity and exercise, rest and promotion of mental health, tobacco smoking, alcohol intake, and dental health, plus diabetes, cardiovascular diseases, and cancer. The current plan (2013–2025) has ambitious goals: “To achieve a vibrant society with healthy and spiritually affluent lives according to each life stage so that all people have hope and meaning in life.” The authors offer five lessons from Japan for other countries seeking to address the surge of NCDs that accompanies aging societies: “the role of multi-sectoral approaches, clear goals and targets with effective monitoring and evaluation mechanisms, addressing social determinants of health, adjusting policies to fit the local context, and predicting and responding to future demographic transitions.” These lessons from Japan's experiences are well worth studying and heeding.

The second research article, by González-Robledo and colleagues, assesses the effectiveness of contracting, a central managerial component of Mexico's Seguro Popular health reform. No one has previously published an evaluation of the health contracting processes in Mexico. Strategic purchasing is often considered to be a key leverage point for improving health system performance, especially when financing is separated from delivery. Good purchasing depends on good contracting. This article uses five characteristics of good contracts to assess Mexico's health system contracts from 2006 to 2014. The authors examined the actual contracts between public agencies as well as those between public agencies and private companies, at various levels of government. Their assessment finds improvement in some areas (such as clear definition of responsibilities, identification of services, and growing use of quality indicators). But it also found two significant deficiencies: a lack of pay-for-performance components and a lack of explicit definition of the volume of services to be provided. The authors suggest that these deficiencies in contracting have contributed to persistent efficiency and quality problems in Mexico's health system. Of course, the source of performance problems is not only how contracts are written (what they include) but also how they are used in practice. As the authors point out, ongoing problems of “misuse of financial resources” (also known as corruption) show that there is still scope for strengthening the role of contracting to improve health system performance in Mexico. These lessons are surely relevant in other countries as well.

The next article addresses the critical arena of health financing, examining the sources of funding for national health systems, with a focus on Africa. Ly and colleagues (from the US Agency for International Development and the World Bank) call for increased “domestic resource mobilization.” In short, the authors call on some countries in Africa to use more government money to finance the health system, rather than relying on donor assistance. They consider which countries could do this, how much they could afford, and over what time period. The article uses quantitative analysis to forecast future health spending patterns in African countries, concluding that some countries will still need to rely on donor assistance (as well as out-of-pocket spending by the population) to finance health services. The authors then assess policy options for three categories of African countries: current middle-income countries (that could pay for essential health services out of domestic resources), countries that are likely to become middle-income countries (that would need transitional policies), and countries that are unlikely to achieve middle-income status (that would remain dependent on donor assistance). The authors call for a process of “progressive pragmatism,” in which national policy makers and donor agency leaders utilize flexible policies in order to make these transitions. The authors assert that this would “ensure that policies designed to achieve [Universal Health Care] align with the economic reality of available domestic and donor financing.” It is not entirely clear who is intended to be pragmatic in this process—perhaps donors should not expect, nor be expected, to pay for everything for everyone, and economically growing countries in Africa must expect to take more responsibility over time (progressively) to fund their own health services. I wonder whether this term will catch on in global health.

The fourth research article shows how ethical analysis can be a core health reform process in moving toward universal health care (UHC). Voorhoeve and colleagues start from the premise that moving toward UHC inevitably involves trade-offs in values. They note that the World Health Organization consultative group on ethical choices for UHC recommended three central principles: maximizing population health, assigning priority to the worst-off, and shielding people from health-related financial risks. (Interestingly, the WHO group did not include patient satisfaction as a core ethical goal, as others have done.³) The authors then examine how these principles could be applied to three specific debates: first, whether to expand dialysis or provide additional preventive services for diabetes; second, whether to expand coverage first to the formal sector or to the poor; and third, whether to introduce voluntary or mandatory health insurance for the non-poor informal sector. In applying the principles to these three cases, the authors show how recommendations that advance social justice can be proposed. They note, however, “It is not straightforward what each principle requires in a given case.” Ultimately, they conclude, there is “no alternative to discernment and careful, well-informed discussion.” They also recognize that their article is “not attempting to answer questions of politics or political economy,” although those often determine the policy decisions made. The authors call for public deliberations by various “members of the general public” to apply principles of justice when making difficult health policy choices in the move toward UHC. At least for me, it remains something of a mystery how to conduct such public deliberations while avoiding the intrusion of politics and power. The recent public debate in the United States over what to do with Obamacare (I am sorry to raise this painful example) provides a striking case in point about the difficulties of insulating policy discussion from political intervention.⁴

The final article in this issue, by Shen and colleagues, examines the neglected problems of mental health care in health systems around the world. The authors conducted 78 interviews with experts from 42 countries to explore why a globally accepted policy goal—of deinstitutionalization, or shifting the locus of care from institutions to communities, for mental health care—is not widely implemented. They note that progress has been “uneven and slow, especially in [low- and middle-income countries].” In their analysis, the authors found lack of agreement among the experts about the definition of deinstitutionalization, as well as limited commitment from key actors involved. They also found that moving deinstitutionalization processes forward could be facilitated by partnerships and strong relationships among key actors. The authors recommend engaging three groups of key actors in implementing deinstitutionalization: government officials, health care professionals, and local experts. As they describe it, “The formation of partnerships among these three forces is ultimately important in overcoming resistance, gaining financial investment, and pursuing evidence-based innovations through implementation.” Engaging these groups, according to the authors, is assisted by “soft” political skills, “such as social astuteness, interpersonal influence, networking ability, and communication of sincerity.” (Interestingly, this approach leaves out the patients themselves.) This article highlights, once again, a recurring theme in Health Systems & Reform: that managing the actors involved in health system reform (i.e., managing the politics of change) is necessary in order to move forward.

We, too, look forward to moving forward in sharing the latest research, case studies, analyses, and commentaries on health systems in this issue and in the upcoming fourth year of the journal.