What will health systems look like in the future? The global economy is transforming rapidly, and health issues are high on the international political agenda. Discussion about the future organisation of health care in low and middle-income countries should not be limited to adapting institutional models from the advanced economies. Instead, we must consider the possibility of quite different arrangements. This is the central argument proposed in the introduction to a special issue of Social Science and Medicine devoted to future health systems. The editors from the Institute of Development Studies at University of Sussex, in the UK, argue that the institutional arrangements in developed countries are a product of historical circumstances and are no longer necessarily optimal. Many countries do not have the institutional environment necessary to support such health systems. In order to take advantage of the opportunity afforded by the current political interest in health, both past failures and new possibilities should be considered. Developing countries are responding with innovations appropriate to their own circumstances that could create new ways of organising the health systems of the future. These new institutional arrangements may well influence health systems globally. The authors suggest that we are reaching a critical point in the development of future health systems as different ways of organising access to health expertise emerge. The special issue was compiled in response to the narrow focus of the debate about health system development in low and middle-income countries, which tends to neglect institutions and politics. It aims to outline alternative ways to think about health systems that reflect new realities, including: state and institutional failure to organise access, delivery and regulation of health services market growth in health goods and services at all levels blurring of boundaries between public and private sectors increased diversity in formal and informal health care changes in access to health related knowledge through media and information technology increased challenge to the professions, suspicion of 'expertise' and assertion of citizens rights to knowledge changing patterns of inequality and re-negotiation of entitlements to health services. In many low and middle-income countries, it is not state bureaucracies but informal markets, non-state institutions and transnational bodies that dominate the health sector. This situation raises both opportunities and concerns over accountability and ensuring access to services for poor people. Key implications for policymakers include the following. The reasons for health system failures need to be understood, and policy makers must be alert to unintended consequences of policy initiatives. Local innovations and their performance deserve closer attention and systematic assessment. Debates about future options for health systems must take into account the changes in health technologies that have occurred over the past few decades. Debates must recognise the dynamism of many countries and give prominence to their various experiences in managing health system change.
Social Science and Medicine (2008) 66 (10) 2067-2075 [doi:10.1016/j.socscimed.2008.01.032] Special issue: Future Health Systems (Eds Bloom, G.; Standing, H.)