‘Health Systems in History’ consists of four inter-linked projects.
Project 1: ‘The Idea of a Health System: its Intellectual and Political Context’ provides a critical history of the concept, treating it not as an unproblematic descriptor, but as something contingent and time-bound, which itself has shaped understandings. What were the circumstances in which it emerged, and to what purpose?
This project will develop a genealogy of health systems from early articulation to the millennium. Research will trace the concept through precursors in health policy texts (1890s-1940s), to early comparative analysis (1950s-1960s), to consolidation from the 1970s in scholarly and political contexts. It then integrates intellectual history with international health politics, asking what factors brought health systems thinking from the margin to the centre of global policy. Content will include mid-century debates about state agency and social insurance, the fluctuating attention devoted to systems by international health organisations in development programmes, and cost containment debates in the West. There will also be a focus on the technical development since the 1930s of increasingly complex national health indicators to facilitate comparison and policy learning. These include: beginnings of national health accounting by the LNHO and ILO; its later development by the OECD: different gauges of effectiveness like amenable mortality and the DALY; and the extension to incorporate markers of satisfaction and equity, culminating in the World Health Report rankings of 2000.
Project 2: ‘The Idea of a Health System: its Application in International Health Policy’ asks how the health systems approach has been deployed in international development contexts, whether as an object of policy or as a mode of policy-making. What can we learn from case studies of its past application in the Global South?
The goal of this project is a critical history of health systems thinking and policy, spanning its different usages and its various material conditions, from the Cold War era through to the millennium. The levels at which such a history will be articulated include: the international, pursued through examination of the African and Western Pacific regional offices of the WHO; the national, taking country case studies of the Philippines and Nigeria to explore different experiences of ‘system strengthening’; and the local, considering specific research or implementation projects in the field.
Project 3 ‘Health systems and Development: the case of Nigeria 1946-c.2000’, is a PhD developing this theme through a national case study.
This linked PhD analyses policy history in Nigeria, a state often held to exemplify weak health system development. Arguably this is surprising given its relative wealth, and repeated adoption of system-level health plans. The study will follow these from late colonial planning through to independence when health was initially prioritised in quinquennial national development plans. It will examine the role of colonial legacy, interests and actors, governance structures and conjunctural events in system development.
Project 4: ‘‘Progressives to laggards’? Health system reform in Britain and New Zealand, 1948-1993’ is a post-doctoral research position using health systems as a category of analysis in the comparative history of high-income countries. What can detailed national studies tell us about the emergence of system types, the diffusion of ideas about improving performance, and the factors that determined policy trajectories?
This project uses cross-national comparison to examine the quest for efficiency and equity in advanced health systems. Britain and New Zealand are typically regarded as pioneers in developing equitable systems on a NHS model which in the 1980s both moved to introduce market disciplines. The project aims to account for this changing agenda of health policy-making, with its clear parallels and broadly similar timeframe, and for its outcomes. The research will examine the ways both nations problematized issues such as: the supply and quality of primary care; the private sector contribution; the challenge of spatial and sectoral allocation; balancing localism and central control; and the need for system integration. Through comparison of debates, policies and the networks informing them, it will evaluate the utility of a ‘family of nations’ model of health system change.
The current lead researcher on this project is Dr Hayley Brown.