The social and political construction of health-care systems – historical observations from selected countries in Asia

Across the Asian region, models of health administration vary from centralized management arrangements to more open decentralized systems. Utilizing a historical perspective, this review compares and contrasts health systems transition in seven countries (the Democratic People’s Republic of Korea, Myanmar, Timor Leste, Bhutan, Mongolia, Cambodia and the Philippines) against the background of macro-political and economic reform, and then considers the implications of these findings for approaches to health policy analysis. Four management areas are presented to demonstrate variation in health system design over the last 40 years: centralization and decentralization, human resource management, health financing and constituency emergence. Historical records illustrate that these functions have evolved through political reform eras of centralist, early reform, established reform and pluralist models of administration, with the main driver of system change being periodic historical shifts in the design of the macro-political and socio-economic order. The cross referencing of management variables with these stages of transition illustrates the degree to which health policy parameters are reset by periodic historical shifts in the political and social order. The findings in these case studies call for a more nuanced classificatory system for health systems and policy analysis that unites a technical perspective with a wider social and political field of vision, and, in doing so, builds a more comprehensive picture of the way in which health systems function in the real world.