International comparisons of health sector reform : towards a comparative framework for developing countries

Abstract

Countries reforming their health systems need an understanding of the extent of transferability of reform experience from one country to another. Ideally, a typology or a system of categorization which groups countries according to some of their key features, would be available as a guide. Before such a typology can be developed, an appropriate comparative framework or a hierarchically organized list of key features across which health systems can be compared, would need to be available. Those comparative frameworks and typologies which are available have been driven by the understanding of industrialised country health systems. The best known is that of Roemer (1991). These give inadequate attention to the informal dimension of health systems (unregulated and illegal activities, and the traditional sector) for application to developing countries, and they often supply a political dimension which does not take account of the importance of the stability and strength of government in developing country contexts. Two-dimensional, tabular typologies are static and cannot incorporate the implications of change. The literature offers some promising approaches to development of a more useful comparative framework including more dynamic ways of grouping system characteristics, and the idea of a modular approach which can accommodate the problem of information shortage. Two types of research will be particularly useful in further development of this framework: cross country comparisons of experience with specific reforms, and comprehensive country case studies of reform programmes which enable the full context to be understood.