In many parts of Asia and sub-Saharan Africa there is a growing gap between official accounts of how health systems operate and realities on the ground. Many countries have developed innovations to fit a changing health care landscape where informal markets and different sources of information play an increasingly important role. Researchers from the Institute of Development Studies, in the UK, looked at how to gain access to competent health care in environments where there are growing but un-organised markets in goods and services, blurred boundaries between the public and private health care sectors, and a lack of state regulation. Such environments are increasingly common in many low income and transition countries in Asia and parts of sub-Saharan Africa. This is one of a collection of papers in a special issue of Social Science and Medicine entitled \"Future Health Systems\". The researchers used the frame of the 'social contract' (an implicit agreement among people that results in the organisation of society) to understand the transactions that underpin health systems. They focused on the problem of information asymmetry (inequalities in access to information) and associated power relationships, in particular those between patient and health care provider. Their paper highlights the importance of trust to relationships at all levels of the health system. Trust is achieved through establishing shared norms (standards of behaviour), reputation and legitimacy. Findings show that different ways of generating trust in goods and services, and new forms of regulation have emerged, including self-regulation such as through provider associations; for example patent medicine vendors' association in Nigeria whose functions include penalising members for bad practices including the sale of sub-standard drugs organised reputation-based mechanisms, such as branding, franchising and accreditation schemes; for example health care franchises KIMET in Kenya, Green Star in Pakistan and Janani in India contracts between governments or donor agencies and health service suppliers institutionalised co-production (the creation of partnerships between governments, the private sector and non-governmental and other organisations to 'co-produce' regulatory arrangements) regulatory responses from governments, for example the Nigerian government's attempt to remove sub-standard drugs from the market by strengthening the National Agency for Food and Drug Administration and Control (NAFDAC) in 2001 China's health reform process, which begun in the mid-1990s, introduced systems to license drugs and health workers, gradually establishing minimum quality standards and encouraging health facilities to build trust within the community. The researchers call for greater understanding of the institutional context in which health systems operate in developing countries. They also stress the need to avoid dictating policy according to the experiences of developed countries. Instead, future debates will need to focus on how governments can create regulatory partnerships and enable improved access to information, building on the new social contracts that are already emerging. Conclusions include the following. It is possible to regulate partnerships between governments of low and middle income countries and outside organisations, in a country with a strong state. These partnerships raise issues about how to mediate conflicts of interest and the need to build sustainable institutions in the country of origin. Governments could provide support for self-regulation as well as contracting private sector providers. There is a need for different types of knowledge mediators, beyond health professionals and bureaucracies, to reverse inequalities in access to reliable information and services.
Social Science and Medicine (2008) 66 (10) 2076-2087 [doi:10.1016/j.socscimed.2008.01.034] Special issue: Future Health Systems (Eds Bloom, G.; Standing, H.)