Social Science & Medicine 117 (2014) 160e161
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Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
Commentary
History, complexity and health systems research
Gerald Bloom
Institute of Development Studies, University of Sussex, Brighton, BN1 9RE, UK
a r t i c l e i n f o
Article history:
Received 27 June 2014
Accepted 18 July 2014
Available online 18 July 2014
Keywords:
Policy change
Institutional development
Social transition
Health reform
There is a big gap between the clear and simple health devel-
opment goals that national governments and international orga-
nisations put forward and the messy reality of many health sectors.
A recent paper on Bangladesh, for example, describes a pluralistic
health system with a wide variety of service providers in terms of
training, ownership and relationship to the regulatory framework
(Ahmed et al., 2013). It identifies several factors that have
contributed to substantial mortality reductions and argues that we
need new ways to analyse this kind of system. In a recent paper in
this journal, a colleague and I highlighted the challenges associated
with the management of health system development in places
undergoing rapid and interconnected economic, social and de-
mographic changes (Bloom and Wolcott 2013). We argued for more
research that situates this kind of pluralistic health system in its
context. We identified several intellectual traditions on which this
research could draw including the study of complex adaptive sys-
tems, historical institutionalism, studies of transitions of socio-
technical or economic regimes and the political economy of social
policy.
The paper by Grundy et al. (2014), makes an important contri-
bution to thinking on this topic. It advocates an “ecological model
for analysis of policy development, whereby health systems are
considered as dynamic social constructs shaped by changing po-
litical and social conditions”. It reports the findings of comparative
case studies, which explore the link between health policy and the
DOI of original article: http://dx.doi.org/10.1016/j.socscimed.2014.07.047.
E-mail address: G.Bloom@ids.ac.uk.
http://dx.doi.org/10.1016/j.socscimed.2014.07.048
0277-9536/© 2014 Elsevier Ltd. All rights reserved.
transition “towards more diverse and open pluralist models of
administration” in several countries in East and Southeast Asia. In
doing so, it challenges simplistic understandings of health policy
processes that ignore the importance of context.
The Grundy et al. paper presents timelines of both political/
economic/social development and health policy change in the
study countries and demonstrates a temporal relationship between
the former and the latter. It then argues that the historical and
development context strongly influences health system organisa-
tion. The authors argue that their historical approach raises serious
questions about the way that system thinking has been applied to
the health sector. They emphasise the importance of beliefs and
social attitudes for the stability of a health system and argue that
this is one reason why health systems are highly path dependent.
They also focus on how health policy turning points emerge in
response to political and/or economic transformation. Their
critique of certain types of systems thinking is rather similar to the
one put forward by a growing number of health systems re-
searchers, who are applying methods associated with the study of
complex adaptive systems to the health sector (Adam and de
Sevigny, 2012: Paina and Peters, 2012). However, Grundy et al.
emphasise the need for more research that situates health system
development in its historical and political economic context. This is
an important agenda for future research.
The Grundy et al. paper says rather little about the political
processes that have led to specific outcomes in the study countries.
This would have required a clearly articulated theory of health
institution-building with testable hypotheses. The lack of an
explicit analytical framework may have led the authors to make
some unsubstantiated statements. For example, they assert that the
so-called Washington Consensus of large international organisa-
tions, such as the IMF, World Bank and Asian Development Bank,
strongly influenced decisions about both broad development stra-
tegies and health system organisation in the study countries. This is
the first time they include an international policy dimension in
their analysis. They do not explain why they consider these docu-
ments more important than, for example, those reflecting Chinese
thinking about their transition to a market economy. They also do
not explore the relative influence of local and global factors,
including new ideas, on the major changes in political and eco-
nomic regime that have emerged in many of the study countries
and on how health sector reform options have been framed. In
 G. Bloom / Social Science & Medicine 117 (2014) 160e161
consequence, although the paper argues convincingly that changes
in health policy have been influenced by the wider political and
economic context, it is difficult to take the analysis much further in
exploring processes of policy change, without further research.
The concept of a “health system” is a heuristic device for un-
derstanding a complex reality. Analysts draw different boundaries
around the system depending on the questions they are trying to
answer. In drawing these boundaries they exclude other questions
and alternative policy options. Leach et al. (2011) argue that the way
a system is “framed” is influenced by the interests and un-
derstandings of the analyst and the policy options they are willing
to consider. They go on to argue that there is a risk that the un-
derstandings and interests of the poor and powerless will not be
taken into account adequately, unless an effort is made to explore
how they understand and analyse the situation. They recommend
that researchers look for alternative framings of a system as part of
an analysis of policy options. One example is the way that health
systems are often defined in terms of the legal status of providers of
health-related goods and services. These criteria exclude informal
providers, who practice outside the legal framework, despite the
fact that they are an important source of health care for the poor in
many low and middle-income countries (Sudhinaraset et al., 2013).
There is evidence that the spread of these markets has increased
access to potentially life-saving drugs, but it has also exposed cli-
ents to risks from ineffective treatment and harmful side effects and
it has increased the danger of the emergence of organisms resistant
to drug therapies. The way the boundaries have been drawn is one
explanation for the dearth of information on these providers and
the lack of effective policies for improving their performance. If
researchers want to analyse the health system used by these clients,
they need to define it to include informal providers.
One contribution of a historical approach to the analysis of
health system development is its focus on the process of change.
Grundy et al. emphasise the importance of path dependency and of
major turning points. They mostly link the direction of change to
the broad macro-economic context. In doing so they leave unan-
swered a number of questions about the different influences on the
particular development pathway that was chosen. This raises
questions about the political economy of the health sector and the
relative roles of national and transnational interest groups and of
their different understandings of the development options.
A growing body of work is bringing a historical perspective to
the analysis of health policy and health system development. Two
recent books have used retrospective case studies to explore factors
contributing to successful health system development (Peters et al.,
2009; Balabanova et al., 2012). They present case studies of “suc-
cessful” processes of health system reform and development and
derive general lessons from these experiences. Both books
conclude that the specific design of a particular policy is much less
important that the management of change and development. They
conclude that in-depth studies of specific change processes are
needed. An important recent example is presented in two papers in
a special issue of the Lancet on Bangladesh (Chowdhury et al., 2013;
Ahmed et al., 2013). The authors, many of whom have very long
experience of work in the Bangladesh health sector, present their
reflections on its development since the 1970s. They analyse the
intersection between developments in health and other sectors and
identify several factors that have contributed to major health im-
provements. They provide tentative explanations which could be
explored in greater depth. Although the findings are convincing for
the specific context of Bangladesh, there are great challenges in
161
identifying those applicable to other contexts. The increasing
involvement of BRAC International, a Bangladeshi NGO, in other
low and middle-income countries, is providing important oppor-
tunities to test the degree to which health system development
strategies can be transferred between contexts.
Research that addresses questions about the processes of health
system development can take several forms. We need more
retrospective studies that document the factors influencing health
system change. These could be country-specific or could involve
cross-country comparisons. This kind of study is often hampered by
the lack of good data. This raises the possibility of prospective
studies of change processes, which anticipate the likelihood of
unintended outcomes and the need for constant correction of
implementation strategies. This kind of study could ensure that
relevant data are collected and, if it were extended over a number
of years, would provide important evidence on what works and
why in the management of large scale health system development
and reform.
Many countries are in the midst of very rapid economic, social
and demographic changes, which necessitate similarly rapid health
sector changes. Technological developments, such as the spread of
mobile phones and the development of low cost diagnostic tests,
are also having a growing influence on health system organisation.
It is impossible to predict the direction of change, but it is safe to
predict that it will be rapid. Those responsible for overseeing health
system development have little guidance on how best to manage
this kind of rapid change. In this context, there is a major risk that
health systems will fail to meet their policy goals. This is a big
challenge for the research community. Research that situates
health systems in a wider context of history and political economy
can help reduce this risk.
Acknowledgements
This paper is an output of the Future Health Systems Con-
sortium, funded by a grant from the UK Department for Interna-
tional Development and the STEPS Centre, funded by the Economic
and Social Research Council, of the UK.
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