Good Health at Low Cost

Health Policy
2118 www.thelancet.com Vol 381 June 15, 2013

Good Health at Low Cost 25 years on: lessons for the future
of health systems strengthening
Dina Balabanova, Anne Mills, Lesong Conteh, Baktygul Akkazieva, Hailom Banteyerga, Umakant Dash, Lucy Gilson, Andrew Harmer,
Ainura Ibraimova, Ziaul Islam, Aklilu Kidanu, Tracey P Koehlmoos, Supon Limwattananon, V R Muraleedharan, Gulgun Murzalieva,
Benjamin Palafox, Warisa Panichkriangkrai, Walaiporn Patcharanarumol, Loveday Penn-Kekana, Timothy Powell-Jackson,
Viroj Tangcharoensathien, Martin McKee
In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve
better health and social outcomes than do others at a similar level of income and to show the role of political will and
socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at
Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial
improvements in health or access to services or implemented innovative health policies relative to their neighbours. A
series of comparative case studies (200911) looked at how and why each region accomplished these changes. Attributes
of success included good governance and political commitment, eective bureaucracies that preserve institutional
memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the
capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic
crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a
part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied,
progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil,
learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences
show that improvements in health can still be achieved in countries with relatively few resources, though strategic
investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.
Introduction
Why do some countries achieve better health outcomes
than do others at similar levels of income? In 1985, the
Rockefeller Foundation convened a meeting in Bellagio,
Italy, to consider the experiences of four countries or
regions seen as success stories: China, Costa Rica,
Sri Lanka, and the state of Kerala in India. All had
achieved substantially better health outcomes than other
nations at similar levels of development. The result was a
publication entitled Good health at low cost
1
that not only
dispelled the then widely believed myth that economic
growth was necessary for health improvement but also
identied specic factors associated with success. These
were a commitment to equity, eective governance
systems, and contextually appropriate programmes
addressing the wider determinants of health. Politics also
mattered, and every country or region was run by left-
wing governments of various hues. 25 years later, the
threats to health and the scope to respond are much more
complex. Do the lessons of 25 years ago still apply?
In 2011, we revisited the original countries and regions
and looked at ve dierent places that were judged to have
succeeded in either achieving long-term improvements in
health and access to services or implementing innovative
reforms relative to their neighbours (table).
2
We used a
conceptual framework (gure) to assess how access to
health care and good health are aected by context (global
and national), sector (public and private), and systems
(health and non-health). The nature of the success varies;
some have achieved substantial health gains whereas
others have improved coverage or health system
performance but are yet to see the full eect. Here, we
review the experiences of Bangladesh (panel 1), Ethiopia
(panel 2), Kyrgyzstan (panel 3), the Indian state of
Tamil Nadu (panel 4), and Thailand (panel 5) and reect on
lessons they oer to other countries of low and middle
income that are attempting to strengthen health systems
in constrained or uncertain circumstances.
In 200911, we undertook a series of historical case
studies to investigate how and why these ve countries
or regions made progress in health and access to care
(panel 6). Our conceptual framework (gure) was based
on existing published work
65,8082
and was used to identify
a compre hensive range of factors related to health
Lancet 2013; 381: 211833
Published Online
April 8, 2013
http://dx.doi.org/10.1016/
S0140-6736(12)62000-5
Department of Global Health
and Development, Faculty of
Public Health and Policy,
London School of Hygiene and
Tropical Medicine, London, UK
(D Balabanova PhD, A Mills PhD,
L Gilson PhD, B Palafox MSc,
L Penn-Kekana MA,
T Powell-Jackson PhD,
M McKee MD); Centre for Health
Policy and School of Public
Health, Imperial College
London, London, UK
(L Conteh PhD); USAID Quality
Health Care Project, Bishkek,
Kyrgyzstan (B Akkazieva MSc,
A Ibraimova PhD); College of
Humanities, Language Studies,
Communication, and
Journalism, Addis Ababa
University, Addis Ababa,
Ethiopia (H Banteyerga PhD);
Department of Humanities and
Social Sciences, Indian Institute
of Technology (Madras),
Chennai, India (U Dash PhD,
V R Muraleedharan PhD); Health
Economics Unit, School of
Public Health and Family
Medicine, University of Cape
Town, Cape Town, South Africa
(L Gilson); Global Public Health
Unit, School of Social and
Political Science, University of
Edinburgh, Edinburgh, UK
(A Harmer PhD); Centre for
Equity and Health Systems,
icddrb, Mohakhali, Dhaka,
Bangladesh (Z Islam MSc,
T P Koehlmoos PhD); Miz-Hasab
Research Center, Addis Ababa,
Ethiopia (A Kidanu PhD,
H Banteyerga); International
Health Policy Program (IHPP),
Ministry of Public Health,
Nonthaburi Province, Thailand
(S Limwattananon PhD,
W Panichkriangkrai MPH,
W Patcharanarumol PhD,
V Tangcharoensathien PhD);
Khon Kaen University,
Khon Kaen, Thailand
(S Limwattananon); and Health
Policy Analysis Center, Bishkek,
Kyrgyzstan (G Murzalieva PhD)
Figure: Conceptual framework used for research
Reprinted from reference 2, with permission of the London School of Hygiene
and Tropical Medicine.
Private sector
Health system
Non-health sectors
Public sector
Access to
health care
Good health
..............
National context _.
Global context
Health Policy
www.thelancet.com Vol 381 June 15, 2013 2119
systems, public provisioning (including social pro-
grammes such as literacy and female empower ment),
and politics and values underpinning the public process.
This framework included a mix of quantitative and
qualitative methods.
83
Findings were validated within
and across countries. Our central study question was
what determines achievement? Although the complexity
of health systems, and the broader political systems in
which they are embedded, means that no blueprint is
available for producing a strong health system,
75,77
our
Bangladesh Ethiopia Kyrgyzstan Tamil Nadu Thailand
Economy
GDP per person (PPP constant 2005, Int$), 2010 1488
3
934
3
2039
3
3522
4
7673
3
Demographics
Population (millions), 2010 1487
5
830
5
53
5
721
6
(2011) 691
5
Infant mortality (per 1000 livebirths), 2009 41
7
67
7
32
7
27
8
(2011) 12
7
Under-5 mortality (per 1000), 2009 52
7
104
7
37
7
33
9
(2011) 13
7
Maternal mortality (per 100 000 livebirths), 2008 194 (2010)
10
470
7
81
7
97
11
(200709) 48
7
Life expectancy at birth (years), 2009 64 (male), 66 (female)
7
53 (male), 56 (female)
7
7
12

(estimate 200610)
7
Adult HIV prevalence (% aged 1549 years), 2009 <01%
7
1428%
13
03%
7
044%
14
(2007) 13%
7
Health system capacity
Density of doctors, nurses, and midwives
(per 10 000), 200010
6
7
3
7
80
7
12
15
(2008) 18
7
Hospital beds (per 10 000 population), 200009 4
7
2
7
51
7
10
16
22
7
Health system nancing
Health expenditure, total (% of GDP), 2009 34%
17
43%
17
68%
17
40%
18

(estimate 200405)
42%
17
Health expenditure per person (current US$),
2009
1880
17
1470
17
5710
17
2790
18

(estimate 200405,
US$1=Rs45)
16770
17
Health expenditure per person (constant 2005
Int$), 2009
4850
17
3990
17
15170
17
34470
17
Health expenditure, general government
(% of total health expenditure), 2009
329%
17
476%
17
509%
17
177%
18

(estimate 200405)
759%
17
Out-of-pocket health expenditure (% of total
health expenditure), 2009
648%
17
420%
17
399%
17
820%
18

(estimate 200405)
165%
17
Out-of-pocket health expenditure (% of private
health expenditure), 2009
965%
17
801%
17
813%
17
100%
18

(estimate 200405)
681%
17
Private insurance expenditure on health
(% of total health expenditure), 2009
02%
17
08%
17
.. 02%
18

(all India, 200405)
59%
17
Formal population coverage (% covered by
insurance or tax-based arrangements), 2007
04%
19
100%
20
(depth of
coverage varies, 2010)
100%
21

(nominal gure, 200506)
977%
19
Health-care coverage, most recent year available
Births with skilled birth attendant 18%
22
(2007) 10%
23
(2011) 98%
24
(2006) 91%
25
(200506) 97%
26
(200506)
Children (aged 1224 months) vaccinated
with three doses of combined diphtheria,
pertussis, tetanus
91%
22
(2007) 37%
23
(2011) 95%
7

(1-year-olds in 2009)
96%
25
(200506) 94%
26
(200506)
Children (aged 1224 months) vaccinated
with measles
83%
22
(2007) 56%
23
(2011) 99%
7

(1-year-olds in 2009)
93%
25
(200506) 96%
26
(200506)
Currently married (or in union) women using
modern contraceptives
48%
22
(2007) 27%
23
(2011) 46%
24
(2006) 60%
25
(200506) 70%
26
(200506)
Children under-5 with suspected pneumonia
taken to health provider
37%
22
(2007) 27%
23
(2011) 62%
24
(2006) 75%
25
(200506) 84%
26
(200506)
Children under-5 with diarrhoea receiving
appropriate treatment (oral rehydration therapy
or increased uids, and continued feeding)
68%
22
(2007) 31%
23
(2011; among
those who received any
oral rehydration therapy)
22%
24
(2006) 47%
27
(200506) 46%
26
(200506)
Estimates are based on the most current data available; where possible, indicators have been drawn from a common source to allow comparability across countries. As such, some gures might dier from those
reported in Good health at low cost 25 years on,
2
which were the most current data at the time of publication. Furthermore, infant and under-5 mortality values were drawn from those estimated by the UN
Interagency Group for Child Mortality Estimation, as reported in World Health Statistics 2011.
7
These estimates are based on tting mortality rate trend lines using all available data for every region, which is added
to as new surveys are done over time. As such, every successive round of estimates could dier from and not be comparable with previous sets of estimates and the most recent underlying country data. GDP=gross
domestic product. PPP=purchasing power parity.
Table: Economic, demographic, and health systems data for the ve regions
Correspondence to:
Dr Dina Balabanova, Department
of Global Health and
Development, Faculty of Public
Health and Policy, London School
of Hygiene and Tropical
Medicine, London WC1H 9SH, UK
dina.balabanova@lshtm.ac.uk
Health Policy
approach meant we could identify common patterns
plausibly linked to better health and health care of
potential relevance beyond the countries studied.
77
We
describe here the main emerging themes focused on the
health systems, with reference to topics related to other
sectors and the wider context (panel 7).
Characteristics of well functioning health systems
Four characteristics linked to improvements in health
and health care emerged from our analysis. The rst was
good governance and political commitment; the second
was eective bureaucracies and institutions; the third
factor was the ability to innovate, especially with respect
to service delivery; and the nal point was health system
resilience (panel 8).
Good governance and political commitment
Governance underlies all health system functions
80
in
addition to broader social development,
93
although the
meaning of governance in relation to health systems is
diverse and contested.
94,95
It includes the regulatory and
managerial arrangements through which the health
system operates, including how overall goals are set and
monitored and how various components of the health
system interact to achieve these goals. Governance also
includes normative values (equity, transparency) and
political systems within which health systems function. It
links closely to the idea of stewardship, which was
popularised by the 2000 World Health Report
96
that
informed our approach. Stewardship implies a role of
government to create a vision, formulate evidence-based
policies, design responsive services, and monitor results.
94,97

Increasingly, alliances have to be built around shared goals
in more pluralistic health systems.
80
Governance is also
linked to political will, identied in the 1985 Good health at
low cost report
1
as crucial to promote change, particularly in
unfavourable economic circumstances.
We identied several elements of good governance.
Eective leadership was manifest in a clear political vision
enshrined in a plan. In Ethiopia, leadership came from
the prime minister Meles Zenawi (19912012) and the
health minister Tewdros Adhanom (200512), although
within a strongly decentralised system. In Tamil Nadu and
Bangladesh, district level leadership was important
for adaption of strategies to local conditions. Political
leadership need not reside entirely in government: the
Thai royal family have had a key role, promoting annual
public health conferences and galvanising public support
for reform. Indeed, we identied several inspirational
leaders and key political workers committed to improve-
ment of health in our study countries. Leadership seemed
especially important to overcome the potentially damaging
results of political upheaval.
Clear priorities and realistic policy goals also emerged
as important. Kyrgyzstans priorities were laid out clearly
in its ambitious Manas plan (19962006), endorsed soon
after independence, and subsequently the Manas Taalmi
Panel 1: Health transcends poverty in Bangladesh
In 1971, the Government of the newly independent Peoples Republic of Bangladesh was
recovering from a devastating war of liberation in which about 3 million people died and
much of the countrys infrastructure was destroyed. Worse, the country had high rates of
mortality, low female literacy, and vulnerability to natural disasters, particularly ooding
and famine.
28,29
Despite this di cult start, Bangladesh has made enormous health advances and now has
the longest life expectancy, the lowest total fertility rate, and the lowest infant and
under-5 mortality rates in south Asia, despite spending less on health care than several
neighbouring countries.
30,31
The speed of change is striking: under-5 mortality has fallen
from 202 per 1000 livebirths in 1979 to 65 per 1000 livebirths in 2006.
22
Comparable falls
have been reported for maternal mortality.
10,32
Contributory factors include pronounced
expansion of health-care coverage, with 75% of children younger than 1 year now fully
immunised,
33
and a striking decline in fertility.
34
As a result, Bangladesh is on track to
achieve the health-related Millennium Development Goals.
We identied several factors associated with Bangladeshs success. A high-level political
commitment to health dates back to independence. This commitment has endured
despite major political changes, including transition from military to civilian rule, and has
been facilitated by institutional continuity of civil servants and by partnerships between
government and the non-governmental sectoran extender of government exemplied
by the Bangladesh rural advancement committee.
Bangladesh has pursued four important health policies. First, in a population policy,
family planning was made a priority. A separate directorate was created within the
ministry of health and family welfare that secured sustained investment and developed
innovative community-based interventions.
35

Second, in 1982, a drug policy established a list of mainly generic essential drugs, and the
Gonoshasthaya Kendra (Bengali for peoples health centre) provided a model for
small-scale integrated primary care.
36
In 1983, the government established an essential
drugs company to produce and distribute drugs within the public sector. This investment
in indigenous expertise has created a substantial private pharmaceutical industry.
34
By the
1990s, more than 80% of essential medicines were produced locally. The resulting price
stability has ensured that essential medicines are aordable. In 1998, a sector-wide
approach was introduced that meant the many projects of dierent donors could be
coordinated under the umbrella of a consortium led by the World Bank while ensuring
that government remained in the driving seat.
The third policy of human resources innovation created cadres of health assistants and
family-welfare assistants. Early recruits were male eldworkers who were engaged in vertical
programmes against smallpox and malaria in the 1960s and early 1970s; later they were
joined by female health assistants. They work mainly in rural areas, delivering immunisation,
health education, and distribution of essential medicines and contraceptives. Family welfare
assistants were introduced in 1976. These workers are married woman who visit other
married women of reproductive age in their homes to oer advice on contraception and
provide free family-planning supplies. They are supported by a rapidly expanding network of
primary health centres and a strengthened supply system.
Bangladesh also pursued progressive policies outside the health sector, including
education and female empowerment. Strengthening of the transport infrastructure and
widening of access to electronic media facilitated access to health facilities and
information. Bangladeshs disaster preparedness, based on intersectoral planning, has
also improved health system resilience.
37

Finally, Bangladesh has prioritised research and development. Innovations range from
medical interventionssuch as widespread implementation of oral rehydration solution,
zinc to treat diarrhoea, and integrated management of childhood illnessto
organisational responses, such as novel models of service delivery.
Health Policy
plan, which set the agenda for a comprehensive overhaul
of the health system. This clear and coherent vision
paved the way for the only sector-wide approach in
central Asia and attracted considerable donor support.
98

This clarity of vision was unique among former Soviet
republics; much wealthier Kazakhstan only began to
formulate such a plan in 2011.
46
The Ethiopian
Government led a coordinated programme including
many development partners, with a focus on access to
essential services in isolated areas, based on an innovative
health extension programme.
99,100
We found evidence of good governance and respon-
siveness to diverse population needs and expectations.
Investment in district health systems that could reach
rural, isolated, and marginalised populations was
especially apparent in Thailand, Bangladesh, and Ethiopia,
all of which faced major challenges because of their large
size and diverse populations. Initiatives to increase access
to primary care by underserved groups entailed more
home visits (Bangladesh and Tamil Nadu), scaling up of
the primary care workforce (Thailand), and community
engagement (Tamil Nadu and Thailand). Thus, since the
early 1960s, Thailands health plans have reected an
explicit egalitarian ethos among leaders and a commitment
to cover underserved rural populations through the
expansion of health infrastructure and deployment of
health workers, particularly in rural areas; this pledge was
facilitated by economic growth and institutional stability.
In Ethiopia, services were extended to rural areas through
the health extension programme; in Bangladesh, the
voluntary sector was encouraged to reach out to
geographically or socially isolated groups unable to access
mainstream services. In both Ethiopia and Thailand,
political leaders came from, or had worked in, rural areas
and ensured that reduction of inequalities between urban
and rural areasin health care and other sectors
remained on the political agenda for many years.
2
Continuity of reform was present, even with changes of
government, in all study countries. Initial blueprints
typically served as a basis for subsequent reforms and
made monitoring of their implementation possible. In
Kyrgyzstan, these reforms continued over 15 years and
through two revolutions, thus, lessons could be learnt
and eective interventions scaled up. In Tamil Nadu,
remarkable advances in maternal and neonatal health
(eg, by improvements to emergency obstetric care
accessed by poor populations) have been attributed to a
strong political commitment to health that has been
unaected by political changes. Consolidation of
nancial protection schemes in Thailand, leading
ultimately to universal coverage in 2002, also survived
many changes of government, as did the purposeful
expansionworking closely with voluntary organisations
of district-level maternal and child services and
managerial capacity in Bangladesh.
Careful sequencing emerges as an important factor,
particularly when it allows scope for experimentation.
Early progress can create momentum that overcomes
opposition to later, more controversial, initiatives.
101,102

The rapid achievement of high immunisation coverage
in Tamil Nadu paved the way for eective family planning
Panel 2: Health is placed central to development in Ethiopia
In the 1980s, images on live television of children dying in Ethiopia, which were
transmitted across the world over satellite links, brought home to those in rich countries
the scale of a tragedy unfolding. The transitional government that came to power in 1991
inherited one of the poorest and least developed countries in Africa that, on top of all of
its other problems, was just emerging from a bitter civil war.
38
20 years later, the transformation of Ethiopia is remarkable. Although still very poor, the
country has achieved sustained economic growth. It has overcome the tensions that resulted
from its status as one of Africas ethnically most diverse countries by means of a federal
constitution that balances regional autonomy and a national vision. Under-5 mortality has
fallen rapidly, overtaking several east African neighbours such as Sudan, Tanzania, and
Uganda.
3
Deaths from malaria fell by more than 50% between 200104 and 2007, a decline
associated with a tenfold increase in use of insecticide-treated mosquito netsnow among
the highest level of use in the region (33%).
3
Between 2004 and 2008, the percentage of
births attended by a skilled attendant doubled, although this proportion is still less than 10%
of all births.
23
Immunisation rates have also increased greatly.
39
These gains are attributable in large part to an innovative approach to create a health
workforce.
40
Faced with very few trained health professionals, in 2003 the Ethiopian
Government launched a health extension programme, which was managed by district
governments. Women with at least 10 years of education were recruited from local
communities and given basic training in how to tackle common diseases. The programme is
now seeking to improve retention and career progression and to cover nomadic populations
in which very few women have even basic education and with complications for the supply
chain.
40,41
As part of the health extension programme, new medical schools were opened and
training of nurses and mid-level health o cers was scaled up. The mid-level o cers took
responsibility for delivery of antiretroviral drugs and prevention of mother-to-child
transmission of HIV. These initiatives have been backed up by regional and national
investment in primary care infrastructure, essential drugs supplies, and management
information. Progress is apparent in other sectors too. Primary school enrolment has
reached 91%
3
and the prevalence of stunting fell by half between 2000 and 2005.
42
Access to
clean water has also improved greatly.
39
The success in Ethiopia required peace and stability. The transitional government, although
initially dominated by Tigrayans, built a multiethnic coalition, and the governing and major
opposition coalitions are now dened in terms of ideology rather than ethnic origin. The
multiethnic composition of the transitional government, coupled with a highly
decentralised system of governance, has facilitated measures to redress historical
inequities. It also needed leadership. The prime minister and health minister have been
identied repeatedly by key informants from government and development partners in
health as individuals committed to development, with the technical expertise and the
political skills to communicate their vision. Successive sustainable development and
poverty reduction programmes saw health as a contributor to and beneciary of
development.
43,44
Investment was made in institutional strengthening. The pharmaceutical
fund and supply agency is credited with reducing the time taken to procure drugs, from
360 days to 60 days.
45
Finally, Ethiopia has beneted from its geopolitical context, including
its military intervention in Somalia. Western nations, particularly the USA and UK, have a
strong stake in Ethiopias success, providing much development assistance. Without this
funding, how Ethiopia could have achieved what it has is di cult to see. However, as the
experience of other countries in Africa shows, development assistance can make little
dierence without visionary individuals and eective institutions.
Health Policy
programmes as maternal and child health rose on the
political agenda. Coherence among reform elements is
seen as a reason why Kyrgyzstan is one of the most
successful reformers among former Soviet republics,
despite di cult economic conditions.
103
A commitment
to evaluate changes created feedback loops to inform
further reform.
Successful leaders took advantage of windows of
opportunity, although this approach needed support
from institutions that could implement change. In 1972,
leaders drafting a new Bangladeshi constitution inserted
a legal right to health and created an environment open
to voluntary and donor-led initiatives that complemented
state programmes. In Ethiopia, the government that
came to power in 1994 established a new health policy
that was attractive to external donors. The Kyrgyz
Government seized the opportunity to rebuild the
collapsing health system after independence, creating a
receptive environment for international support. Thai
public health reformers took advantage of a populist
political party to get universal coverage into their election
manifesto, and they supported policy design and
implementation after electoral success.
Greater accountability safeguards scarce resources and
boosts trust in health systems, ultimately aecting how
people perceive and access them. This assurance includes
measures to make nancing ows more e cient and
transparent, thus tackling corruption and misuse of
resources. The Tamil Nadu Medical Services Corporation
provided an innovative model for increasing access to
essential drugs but, crucially, reducing leakage. Similarly,
in Thailand, the intersectoral 2004 programme about
good governance for medicines
104
reduced ine ciencies
in procurement and prescription of pharmaceuticals,
achieving lower costs. It engaged voluntary organisations,
such as the Rural Doctors Society, in raising awareness
about corruption and unethical practices. Kyrgyzstan has
undertaken a major investment in strengthening
accountability and transparency, both in allocation of
resources within the health system and tackling informal
payments at facility level.
Eective bureaucracies and institutions
Development of sound policies and plans does not
guarantee their eective implementation. In our study,
functioning bureaucracies and institutions were deemed
important for successful reforms. These organisations
could be within the health sector (eg, ministries of health,
district and subdistrict health institutions, or donor
agencies) or outside it but whose operation inuences
the functioning of health systems (eg, other ministries,
the media, or development non-governmental organ-
isations [NGOs]). We identied several important char-
acteris tics of eective institutions: strong regulatory and
managerial capacity; the ability to provide information
and evidence; a stable bureaucracy; su cient autonomy
and exibility to manage health systems eectively;
willing ness to engage with several stakeholders, includ-
ing non-state actors and local communities; synergy
between governments and donors acting together to
formulate and implement policy; and use of the media as
a catalyst for change.
Panel 3: Kyrgyzstan is a regional leader in health system reform
The Kyrgyz Republic was one of the poorest of the 15 Soviet republics; its situation
deteriorated even further after independence in 1991. Kyrgyzstan is mountainous, with
less than 10% of land suitable for agriculture, and internal communications are often
di cult. It has seen two revolutions since independence, the second associated with
considerable bloodshed.
20
Yet, despite these problems, Kyrgyzstan stands alone in central
Asia as an example of successful health system reform.
46
It has implemented a
functioning health insurance system and has succeeded in shifting care out of hospitals
and into a strengthened system of primary care, achieving nearly universal access.
47
Corresponding improvements have been noted in health outcomes. Infant mortality fell
by almost 50% between 1997 and 2006, with similar declines in under-5 mortality.
24

Life expectancy exceeds that of several of the more prosperous former Soviet republics,
including Russia.
48
Fertility has fallen by almost 50% since the 1970s, skilled birth
attendants are present at 98% of deliveries, and immunisation rates exceed 90%.
49
The reform process began soon after independence. The scale of the crisis made radical
reform imperative. Kyrgyzstan turned to the outside world for assistance, recognising that
the old system was unsustainable. The rst of a series of health reform programmes was
launched in 1996; it was promoted as an example of how government reforms would
benet the people, thus linking its success to that of the government.
50
One of the main goals of the health reform programmes was to restore universal health
coverage. A mandatory single payer health insurance fund was created, expanding as
resources have allowed and now covering more than 80% of the population. This fund is
complemented by a state-guaranteed benets package for vulnerable populations; an
additional drugs package subsidises essential medicines. A prospective case-based system
for inpatient care and a capitation-based scheme for primary care have been
implemented. Endemic informal payments have been reduced substantially.
51
The inherited health system was dominated by the hospital and had an abundance of sta,
but few of these health workers had the necessary skills to practise modern medicine and
basic equipment and drugs were scarce. This system has now been downsized, with 42% of
hospitals closed between 2000 and 2003.
52
Community health centres were upgraded to
compensate for these closures. Almost all primary care doctors were retrained as family
practitioners, supported by nurses and midwives and better-trained mid-level health
workers, including Soviet-era feldshers (auxiliaries).
53
Coverage gaps in isolated mountain
areas were addressed by village health committees, with volunteers contributing to basic
preventive and treatment interventions.
We identied several factors associated with Kyrgyzstans achievements. The rst was the
need for reform. The inherited health system faced collapse and action was needed to
maintain the legitimacy of the regime. The second was leadership. The countrys rst
president, Askar Akayev, identied health-care reform as a priority and gave it
considerable support while opening Kyrgyzstan up to the international community, by
contrast with the situation in other former Soviet republics. This move also paved the way
for signicant development assistance. The third factor was a functioning legislative
system. Laws have survived two revolutions. They include not only those underpinning
the comprehensive health reforms but also those guaranteeing the independence of civil
servants, ensuring continuity of programmes (seen in the successive Manas health
programmes) and sta at times of political change. Furthermore, investment in research
was provided, with skilled expatriate advisers contributing substantially to capacity
within the health ministry.
Health Policy
Strong regulatory and managerial capacity were judged
important, particularly where resources were scarcest. In
Kyrgyzstan, a functioning legislative processenabling
passage of three major laws enacting changes in the
health system over 4 yearsaccelerated the move towards
compulsory health insurance and universal coverage. In
Tamil Nadu, we doubt whether many innovations would
have been successful without the states unique public
health management cadre at district level, with power to
plan and manage services.
105
In Bangladesh, a district
management group, with delegated authority, imple-
mented government programmes and supervised con-
tracts with diverse NGOs and private providers.
Managers were supported by provision of intelligence
and evidence to evaluate outcomes of reforms, including
widespread use of pilot schemes in Kyrgyzstan and
Thailand. Tamil Nadu developed a system of mandatory
surveillance and audit of maternal deaths covering both
public and private sectors.
106
This move enabled
identication of systemic weaknesses, and district
o cers were empowered to develop locally appropriate
solutions. Those ideas that proved eective were
replicated in other districts, feeding into evidence-based
protocols at state level.
107
Both Kyrgyzstan and Thailand
created research institutes associated with their health
ministries, to support transfer of knowledge into policy.
Panel 4: Tamil Nadu is a success story in India
Of Indias 28 states, Tamil Nadu is the seventh most populous.
Despite spending only about 1% of its gross domestic product
on health, this region has made great progress in improving
population health. Between 1980 and 2005, infant mortality
fell in Tamil Nadu by 60%, compared with 45% for India as a
whole,
8
with the greatest gains in rural areas. In 2006, this
state had the third lowest rate of under-5 mortality in India, at
355 deaths per 1000 livebirths, compared with 743 deaths per
1000 livebirths for India as a whole.
25
However, the greatest
achievement in Tamil Nadu has been reduction of maternal
mortality, from 319 deaths per 100 000 livebirths in the early
1980s to 111 deaths per 100 000 livebirths in 200406, the
second lowest of any Indian state.
54
This decline was much
faster than in India overall. By 2006, fertility was below
replacement rate.
8
A characteristic of Tamil Nadus success is the high health-care
coverage: 90% of deliveries are attended by a skilled birth
attendant,
25
almost 25% of deliveries take place in primary
health-care facilities,
55
and 81% of infants are fully immunised.
25

Four health system-related factors underpin these achievements.
First, Tamil Nadu was one of the rst states in India to
implement in large scale a multipurpose worker scheme in
1980. Women with at least 10 years of schooling were trained
for 18 months to become village health nurses. Existing
maternity assistants were retrained and new training facilities
were built.
Second, an initiative was proposed by the Indian Government
to build a network of primary health-care centres; Tamil Nadu
was one of the rst states to build a vast network of these
facilities. By 2005, about 1500 primary health centres were
open in the state, every one serving about 30 000 people on
average, and a further 8680 subcentres were availableone
of the highest levels of coverage of any Indian state.
Innovative approaches to funding and construction were used
in Tamil Nadu, including volunteer labour from communities.
Obviously, to build health facilities is not enough, they must
also be open and responsive to needs. 24-h opening began in
the mid-1990s and is now the norm, with performance
monitored monthly.
56

Third, immunisation schedules were scaled up rapidly, assisted
by UNICEF, the Rotary Club, and the Christian Medical College in
Vellore. By the early 1990s, Tamil Nadu had achieved the
highest immunisation coverage in India, with the narrowest
gap between the richest and poorest quintiles and between
rural and urban areas. Integration of immunisation within
primary care had assisted this achievement.
57
Finally, a reliable supply of essential drugs was established in
Tamil Nadu. The autonomous Tamil Nadu Medical Services
Corporation was created by the Indian Government in 1995 to
purchase and distribute pharmaceuticals to public health
facilities. It replaced the former drug procurement and
distribution system, which had faced persistent di culties
including misuse of funds, inappropriate prescribing, high
distribution costs, and stock outs. The new system, providing
about 250 generic essential drugs, is credited with substantial
improvements in drug supply and transparency. It has also
contributed somewhat to driving down the cost of drugs
supplied in the private sector.
58,59
Outside the health sector, important successes in Tamil Nadu
have included female empowerment and investment in
infrastructure, in particular electricity and clean water.
6062
The achievements seen in Tamil Nadu were made possible in
several ways. First, a strong commitment to health was made
by successive state governments, which persisted despite
frequent changes to the party in power. Second, successive
health secretaries drove forward innovation and were
supported by civil servants with both technical expertise and
power to implement wide-ranging reforms. Sometimes,
quasi-governmental organisations had to be created, such as
the Tamil Nadu Medical Services Corporation, which could
circumvent tardy bureaucratic processes.
58
Third, investment in
managers trained in technical public health skills and
management at district level was sustained over many years, a
unique cadre in India. A system of career progression has
allowed Tamil Nadu to attract and retain high-calibre sta.
63

Fourth, the partnership between government and
non-governmental organisations was important, especially in
the management of AIDS and tuberculosis.
Health Policy
In Kyrgyzstan, monitoring and evaluation became an
integral part of the policy cycle.
Stability of bureaucracy over time was regarded as
important to sustain the momentum of reforms,
facilitating retention of institutional memory and
values. Despite great political and economic turmoil in
some of the study countries, managers and planners
pursued reform strategies long enough to show results.
Thailands bureaucracy has proven especially resilient
to changes of government. Containing many senior
o cials with substantial rural work experience, the
ministry of public health was able to maintain reforms
through successive 5-year health plans. Despite two
revolutions, Kyrgyzstans health reforms remained on
course (by contrast with the experiences of neighbouring
countries that were politically more stable), helped by
the deliberate policy of creating and retaining a cadre of
managers and planners and reducing political inuence
over appointments.
While ensuring stability, bureaucracies also needed
su cient autonomy and exibility to manage health
systems eectively. The autonomous Tamil Nadu Medical
Services Corporation was able to bypass bureaucratic
procedures to introduce a system of drug procurement,
increasing availability of essential drugs.
Every one of our study countries leaders showed a
willingness to engage with several stakeholders, including
non-state actors and local communities. For example,
Kyrgyzstan established village health com mittees staed
by volunteers to deal with a wide range of local issues,
including public health, and this move facilitated access to
care and health education. In Thailand, district health
authorities were encouraged to establish publicprivate
partnerships that attracted resources and expertise while
remaining free from political interference; these links
were supported by senior ministers and the royal family.
108

Bangladesh has seen a major expansion of NGOs opera-
ting in the health sector since independence in 1972.
Some are now vast organisationsfor example, the
Bangladesh rural advancement committee reaches up to
110 million people through 64 000 village health workers.
These NGOs have made a major contribution to national
goals, such as prevention of diarrhoeal deaths in children
and provi sion of health services to marginalised popu-
lations. Bangladeshi community-based organisations
work ing in health and micronance have supported
locally appro priate interventions, leading to striking
improve ments in access to maternal and child care,
109
but
they have been less successful at aecting policy at
national level because of limited capacity and inuence
and opaque formal consultative processes.
110
Involvement of more than one stakeholder is only
part of the story, however. Also important was a
willingness to look at a range of pragmatic solutions,
such as exible models of publicprivate collaboration
that take account of local context. These sought to build
on complementary capacities in every sector, to expand
Panel 5: Why and how did Thailand achieve good health at low cost?
Thailand has made impressive health gains in the past 25 years. Infant mortality fell from
68 per 1000 livebirths in 1970 to about 10 deaths per 1000 livebirths in 2006.
64
This
decline is one of the fastest seen out of 30 countries with low and middle income
between 1990 and 2006.
65
Improvements in life expectancy have also been noted,
although recent progress has been limited by the spread of AIDS.
66,67
The total fertility
rate, which was 63 births per woman in 1965, had fallen below replacement by 1994.
68

After the Millennium Development Goals (MDGs) were met, Thailand adopted
country-specic targets known as MDG Plus, which underpin its development policy.
69
The achievements seen in Thailand are associated with progressive expansion of
health-care coverage. In 2001, the government unied a series of existing but fragmented
systems to achieve near-universal health coverage even though, at the time, the region
was aected by the Asian nancial crisis. Health-care utilisation increased and
catastrophic expenditure and out-of-pocket payments fell substantially.
70
Reforms to delivery took place from the 1960s onwards as part of a series of 5-year
national economic and social development plans. These measures established and
sustained new hospitals. However, Thailand saw an exodus of doctors during the Vietnam
War, with many Thai graduates moving to the USA. The government introduced a
bonding system, requiring newly qualied doctors to spend 3 years in government health
facilities, mostly in rural areas. This scheme was later extended to other health
professionals. The situation was even more important for nurses, who were trained in
insu cient numbers in universities under the ministry of education. As a result, in 1961,
the ministry of public health established its own nursing and midwifery colleges.
Furthermore, in 1982, a 2-year technical nurse diploma course was introduced in place of
4-year training. After 4 years of mandatory rural health service, technical nurses could
undertake an additional 2 years of training to obtain a bachelors degree and professional
qualication. These policies resulted in substantially augmented numbers of doctors and
nurses serving in rural district health services.
Health gains in Thailand also reect policies outside the health sector, in particular,
sustained investment in rural development, encompassing infrastructure expansion and
improvements in adult literacy, notably among women. Several factors were associated
with these changes.
First, high priority was given to health by successive governments, reected not only in
statements by politicians but also in successive national plans. This step has transcended
changes of government, both military and civilian. Thailand has had several charismatic
health ministers, again under both military and civilian governments, many with a high level
of technical expertise. They have championed the strengthening of rural health care and
expanded coverage of maternal and child health services. However, other inuential leaders
in academia, health-care delivery, and civil society have played a part. In interviews we
undertook with former policy makers at the Ministry of Public Health, professionalism was
reported as a consistent characteristic of these individuals, rather than nancial gain.
Another key factor was the role of the Thai royal family and, in particular, the popular sense
of duty in serving them. The Thai monarchy has provided a point of stability during political
changes and has also had an active role in promotion of healthPrince Mahidol of Songkla,
father of the present king, was trained in public health.
Second, institutional capacity was important in Thailands success. Many senior sta have
trained overseas and have beneted from stable employment in the public sector,
ensuring continuity and institutional memory. Non-governmental organisations and
professional bodies have also played a positive part, such as the Rose Garden group, an
informal group closely linked to the Rural Doctor Society of Thailand, which provides a
forum for policy debate and has helped tackle corruption.
71
Finally, the ability to translate health policies into practice has been facilitated by strong
managerial capacity in provinces and districts,
72
coupled with extensive piloting and
evaluation to ensure that policies take full account of the Thai context.
73,74
Health Policy
services responding to diverse needs. For example, in
Tamil Nadu, the private sector undertakes 80% of
outpatient visits and 60% of admissions, while
preventive maternal and child health care continues to
be provided in the public sector. Publicprivate engage-
ment is common in contracting out clinical and
laboratory services and information cam paigns. Allo-
pathic and non-allopathic wards (Siddha) are located
within the same public facilities, responding to user
preferences.
Many examples exist of synergy between governments
and donors, acting together to formulate and implement
policy and align eort, generally within sector-wide
approaches (SWAps). Kyrgyzstan and Ethiopia, both
beneting from much donor support as a result
of geopolitical factors, achieved consensus among
donors on key reform priorities and how to allocate
resources. The 1998 Bangladesh SWAp brought together
120 separate health programmes, reducing frag men-
tation and creating opportunity for scaling up. Ethiopia
Panel 6: Research approach and methods
In this study, we sought to examine why some countries are
more successful than others in achieving better health or
expanding access to essential services. The starting point was
that health systems are complex
75,76
and entail the interplay of
multiple interacting causes generating a set of often
unpredictable eects.
77
For every country, we aimed to identify
interventions that could be linked to specic health gains,
which were mainly in the area of maternal and child health, a
choice that reected availability of data. We then sought to
understand how and why specic developments took place,
covering factors within health systems and their broader
context, with the aim to identify plausible pathways to health
improvement based on an integrated analysis across levels of
the health system in dierent settings.
77
We used historical methods to trace the development of
policies and programmes over long periods. We incorporated
theories of path dependency of institutional development
78

and of health systems resilience.
79
The countries we studied were selected from a list provided by
the Rockefeller Foundation, which was based on preliminary
analysis of good maternal and infant mortality outcomes
relative to comparator countries with similar levels of total
health spending. Further considerations were given to
experience of innovative system-level reforms despite nancial
constraints. Moreover, geographic, economic, and health
system diversity were considered.
The study design and data analysis protocol were explicitly
comparative. Rigour was achieved with a common conceptual
framework adapted to local settings to support comparisons
(gure) and the methodological approach, and regular
interaction took place among country research teams.
The framework drew on existing health systems frameworks
8082

and encompassed both private and public sectors, recognising
their relevant roles in dierent settings. The framework also
allowed for non-health system factors that aect health
(eg, policies to improve literacy, female empowerment).
Health system and non-health system sectors were
investigated within wider national and global contexts
(eg, governance, economic and political factors, culture) that
aect both the operation of national health systems and
health achievements.
83

Case studies were undertaken from 2009 to 2011 and included
a mix of quantitative and qualitative methods.
2
Secondary analyses or synthesis of statistical data relevant
to health system performance.
A scoping review of published work with an iterative search
process based on the conceptual framework, using PubMed,
Medline, BIDS, HINARI, EconLit, and Google Scholar and
supplemented by media accounts.
84

Documentary review of relevant published and grey
literature at country level, obtained through contacts with
key informants and searches of local resources.
In-depth interviews with current and former employees,
who were key informants identied as especially
knowledgeable on important policies and programmes, and
people working across countries in the region, who were
included to promote a comparative focus.
Focus groups (in some countries).
We asked several questions in every country.
1 Why is the country an example of good health at low cost?
2 What key areas of health improvement have secured good
health at low cost over the last few decades?
3 How has the country achieved these specic health gains
(what diseases or conditions have been tackled)?
4 How did the health system and other sectors support the
eective delivery of these interventions?
5 How and why were these health system developments and
wider policy interventions possible?
6 What other sociocultural and political factors may explain
health gains?
The framework analysis mirrored the conceptual framework and
allowed for particular factors to emerge as dominant within
every country. The process was iterative: as new themes and
propositions emerged in one country, they were sought in the
experiences of the other countries, and reasons for divergence
were investigated. This information was then incorporated into
data collection. At country level, ndings were validated by
triangulation of several data sources, peer review, public debate
with current and past health system actors, and review of
ndings against relevant published work. We also obtained
reviews by international experts on particular issues or
countries. We prepared working papers, discussed them at team
meetings, and undertook a peer-review procedure.
Health Policy
Panel 7: Contribution of non-health system factors to good health
Distinguishing between health system and non-health system
factors is not straightforward. For example, politics and
economics are both integral to WHOs health systems
framework: politics in the guise of leadership and governance,
economics in terms of health nancing. Furthermore, to
distinguish between the two sets of factors could be
detrimental to successful health policy, because a so-called silo
mentalityie, a reluctance by dierent development sectors to
explore cross-sector or synergistic collaborationcould be
encouraged among development agencies. To illustrate the
health eects of non-health system factors, we discuss three
factors that contributed to the good health outcomes reported
in our country studies.
Infrastructure
Some evidence suggests that investment in national
infrastructure has yielded health dividends. For example, rural
electrication in Thailand has been linked to falling fertility.
85
In
Bangladesh, improvements to road infrastructure have
augmented access to emergency obstetric care and birth
outcomes, despite persistent high levels of home-based and
unattended deliveries.
86
The improved transport infrastructure
and targeted subsidies (through a voucher scheme to
reimburse transport costs) are believed to have contributed to
better access to rural clinics.
2
Rapid expansion of
communications technology enabled more people to access
information on healtheg, in the multimedia Bangladeshi
Behaviour Change Communication campaign.
Empowerment
Female empowerment and gender equity are recognised widely
as key determinants of development.
87
Thus, we looked at
gender issues in our ve countries or regions. None had
consistently high results on the standard indicators of gender
equality. For example, in 2008, Thailand ranked 69th on the
United Nations Development Programs gender inequality
index (Kyrzystan was 63rd and Bangladesh 116th).
88
Women in the ve countries or regions enjoy fairly high political
proles. Kyrgyzstan elected the rst female president in central
Asia and has made a considerable achievement in boosting the
political representation of women in parliament, by comparison
with its neighbours. Bangladesh has had a female prime minister
and leader of the opposition for the past two decades and both
the home and foreign ministers in the 2011 cabinets are women.
Thailand appointed a female prime minister in 2011. Since 1991,
a woman has been one of the two alternating chief ministers in
Tamil Nadu. In Ethiopia, many women have held ministerial and
other high government roles, in social aairs, nance, and labour.
However, whether these appointments have really led to
important shifts in attitudes towards, or improvements in,
opportunities for women in Ethiopia is debatable. Our case study
ndings suggest that progress towards empowerment of women
and gender equality in Tamil Nadu, Ethiopia, Bangladesh, and
Thailand owes more to civil society-led and community-based
initiatives than to government activities.
Policies in other sectors have helped to improve the position of
women and their health outcomes. In Bangladesh for example,
families who participated in microcredit programmes achieved
better child survival.
89,90
Furthermore, strengthening of primary
care in Tamil Nadu was accompanied by measures to increase
female literacy and age at rst marriage. By contrast, in
Soviet-era Kyrgyzstan, women had access to education and
paid employment, but since independence throughout central
Asia, some of these opportunities have been threatened by
strengthened religion traditions.
Education
Since the 1970s, the mean years of education for adults aged
25 years or older in the ve countries or regions has risen.
Between 1970 and 2009, respective increases for men and
women were 23 and 20 years in Bangladesh, 18 and 07 years
in Ethiopia, 58 and 65 years in Kyrgyzstan, and 30 and
38 years in Thailand.
91
The eects of expansion of education on
child health have, however, been remarkable, averting
42 million deaths according to one estimate based on a survey
of 175 countries.
91
The growth of female literacy in Thailand shows the importance
of education as a pathway to better health. The proportion of
literate women in Thailand has been high for at least a quarter
of a century, rising from 97% in 1980 to 99% in 2002. An
analysis undertaken for our study shows that, in 2006, the rate
of enrolment into education was higher for females than males,
particularly at the tertiary level. The benets of better education
are clear: augmented employment opportunities and reduced
under-5 mortality rates.
2
Kyrgyzstan has beneted from a model inherited from the era
of Soviet rule, of near-universal education for men and
women, which to a large extent has been sustained in the face
of subsequent nancial shortages. A combination of factors
contributed to increased adult female literacy in Bangladesh
(from 18% in 1980 to 51% in 2008): government provision of
free secondary schooling for girls; active civil society,
particularly the Bangladesh rural advancement committees
involvement in delivery of education; and microcredit.
In Tamil Nadu, factors related to demand (eg, better education
for women) and supply (eg, improved family planning services)
have both been suggested to account for the states impressive
reduction in fertility, which reached a replacement level of 21
by 199091. However, the conclusion of a 2002 study
comparing fertility across several Indian states, including Tamil
Nadu, was that there was no threshold level of female
education or infant mortality that [could] be considered for
augmentation of fertility decline.
92
Neither economic nor social
development factors fully explained fertility transition in Tamil
Nadu. The authors argued that community acceptance of (or
demand for) certain practices associated with fertility decline
(such as contraception or improved education services) had
more of a part to play, rather than individual behaviour.
Health Policy
attracted large quantities of development assistance and
prioritised the improvement of donor harmonisation
for its health sector, leading international eorts in this
area through its support for the inter national health
partnership.
The media has sometimes served as a catalyst for
change, disseminating public health messages, increas-
ing awareness of entitlement to care, and tackling deeply
rooted beliefs about health. In Tamil Nadu, media
campaigns promoted AIDS awareness and family
planning. In Thailand and Bangladesh, the media oered
a means to hold authorities to account and raise local
issues on the national agenda.
Innovation
All study countries showed innovation in various aspects
of their health systems. Particular originality was seen
in the workforce (which is a severe constraint in all
countries), nancing mechanisms, and means of
delivering services.
Innovative health workforce strategies
In the 1985 report Good health at low cost,
1
a link was
made between investment in well trained health workers,
particularly in primary health care
102
(eg, Chinese barefoot
doctors), and better health. The new countries studied in
the follow-up report
2
implemented a combination of
established and innovative strategies to overcome sta
and skill shortages at all levels.
Task shifting and changes in skill mix were common
themes.
111
In Thailand, expansion of human resources
was judged a crucial step towards extension of coverage.
In Kyrgyzstan, a new family medicine training centre led
large-scale retraining of family doctors. Bangladesh
made a major investment in emergency obstetric care in
the public sector, with new facilities and sta trained and
deployed to rural areas. The Ethiopian health extension
programme (panel 2) is perhaps the most ambitious
eort in sub-Saharan Africa to scale up the supply of
primary workers and reduce the imbalance of health
workers between rural and urban areas. These
community-based sta brought essential primary care to
almost two-thirds of the population by 2007,
112,113

contributing to higher immunisation rates, improved
malaria prevention, and accessible maternal and child
health care in remote areas.
114
In Tamil Nadu, the
multipurpose workers scheme (village nurses), launched
in the early 1980s, was scaled up rapidly. It now delivers
integrated primary care in rural areas, with strengthened
infrastructure and increased drug supply.
Changes made in our study countries included skills
enhancement and task shifting. For example, in
Kyrgyzstan, general practitioners are replacing doctors
trained under the Soviet system,
111
and in Ethiopia,
health extension workers are delivering primary care
that would once have been undertaken by nurses or
doctors. Thailand introduced village health volunteers
while enhancing the skills of public health nurses.
Bangladesh took advantage of the many sta who had
played a part in smallpox eradication and used them to
form the core of a new cadre of health and family
welfare assistants. Many of the existing community
workers became village doctors (palli chikitsok) or
unlicensed providers, particularly in rural areas. These
people have been credited for some of the reduction in
childhood mortality because they have enhanced access
to basic medical advice and low-cost drugs.
115,116
In Tamil
Nadu and Bangladesh, community health workers
increased the scope of their activities, including primary
care and referrals during home visits, which augmented
the level of integration between vertical programmes,
particularly in maternal and child health.
Challenges persist everywhere with respect to
recruitment and retention of health workers in rural
areas.
117
Ethiopian health extension workers were
recruited from local communities into the civil service,
thus providing stable employment, training, and career
progression.
2
In both Tamil Nadu and Thailand, posting
of medical graduates to rural areas was seen as a stage in
professional development.
2

Health system nancing and nancial protection
While all ve study countries have shown a rise in real
total expenditure per person on health since 1995, the
rate of increase has varied.
17
The most pronounced
Panel 8: Characteristics of well-functioning health systems
Good governance and political commitment
Eective leadership and long-term vision
Clear priorities and realistic policy goals
Responsiveness to diverse population needs
Continuity of reform
Careful sequencing of reforms
Seizing windows of opportunity
Enhanced accountability
Eective bureaucracies and institutions
Strong regulatory and managerial capacity
Provision of intelligence and evidence
Stability of bureaucracy
Su cient autonomy and exibility to manage health
systems eectively
Engagement with many stakeholders, including
non-state actors and local communities
Synergy between governments and donors acting
together to formulate and implement policy
Use of the media as a catalyst for change
Innovation
Novel health workforce strategies
New approaches to health system nancing and
nancial protection
Pragmatism in service delivery
Resilience in the health system
Health Policy
growth in spending was in Thailand whereas Ethiopia
showed the smallest increase, which seems surprising in
view of the external support the country has accrued in
recent times, suggesting substantial displacement of
government spending.
118
The increases have paralleled
general economic growth; total health expenditure as a
percentage of the gross domestic product (GDP) has
remained largely stable over the years.
17
Of the study
countries only Kyrgyzstan has had any notable
uctuation, with a sharp drop in total health expenditure
as a percentage of GDP in the late 1990s, followed by
nearly a decade of recovery to previous levels.
As well as understanding total expenditure patterns, we
also must know where funding comes from and goes to.
In Thailand, the share of government health spending in
total health expenditure has been rising over several years
and more sharply since the implementation of universal
coverage in 2001. With the emphasis on publicly funded
health care, out-of-pocket payments in both Thailand and
Ethiopia are relatively low, only 14% of total health
expenditure in Thailand (2010)
119
and 42% in Ethiopia
(2009),
17
which is low compared with India and Bangladesh,
both of which have extensive private sectors. In Bangladesh,
for example, there are three major suppliers of health care
in the non-state sector: NGOs; formal and informal private
sector providers; and suppliers of traditional medicines.
The share of government and out-of-pocket payments has
uctuated in Kyrgyzstan (with recent declines in out-of-
pocket payments),
120
reecting the move to mandatory
social insurance and the long-established formal and
informal top-up paid by users.
All study countries recognised that the nancial burden
of seeking health care aects vulnerable households
disproportionally, through unexpected and sometimes
catastrophic out-of-pocket payments.
121,122
Ethiopia is
developing a system of social health insurance for
employees in the formal sector and community health
insurance for others. Both Thailand and Kyrgyzstan have
achieved almost universal cover age, but in Kyrgyzstan,
some groups remain with out coverage and out-of-pocket
(and informal) payments persist.
The depth of coverage (benets package) is important
as well as its breadth. Kyrgyzstan has gradually
expanded the basic benets package with continued
government support. In Thailand, renal replacement
therapy was included explicitly to avert risk of
catastrophic expenditure. Early adoption of anti-
retroviral treatment was possible because the Thai
Government pharma ceutical organisation produced
low-cost, generic combination therapy. In Kyrgyzstan,
the state guarantee benet package has been revised
annually to reect available funds. However, this review
has not happened in Bangladesh where, despite a rapid
increase in non-communicable disease, the package
remains unchanged.
Another way to increase the resources available for
health is to improve e ciency. Kyrgyzstan implemented
a single-payer system for providers, linking resource
allocation to performance. It was the only country in the
former Soviet republic that radically downsized its
inherited hospital infrastructure, redirecting funding to
patients care.
103
Service delivery
We identied many innovations in service delivery in
our ve study countries or regions. For example, in
Bangladesh, low-cost innovations were introduced to treat
common illnesses, such as oral rehydration solution and
zinc to treat diarrhoea, and these strategies were delivered
by community workers. In Tamil Nadu, publicprivate
partnerships were used to expand capacity. The Ethiopian
health extension programme is another novel idea for
service delivery. All countries reorientated services
towards primary care, although with easier referral to
higher tiers, thus reinforcing the message in the 1985
report Good health at low cost
1
and subsequent evidence
about the important role of aordable community-based
health care.
123
Since the 1970s, a gradual move has taken
place from vertical models of care (eg, family planning in
Bangladesh) towards integrated models prioritising
maternal and child health services, although this transition
has been more di cult in places with diverse providers
(eg, Bangladesh and Tamil Nadu).
Another key area of innovation that has supported
eective service delivery is increased access to aordable
medicines. Both Bangladesh and Tamil Nadu adopted
predominantly public-sector solutions and contracted-
out only some tasks, to promote aordability. In Ethiopia,
greater access to drugs boosted the ability of health
extension workers to deliver eective care. Implemen-
tation of exible service provision models that reect the
context, rather than transplanting models from else-
where, has been instrumental in improving access and
achieving substantial health gains.
Building resilience in the health system
Health systems are sometimes vulnerable to unexpected
shocks, leading to growing interest in how to foster
resilience.
79,124
Thailand and Ethiopia have recently been
aected by large-scale natural disasters and have sub-
sequently put in place systems to prepare for similar events
in the future. Long experience with seasonal oods and
cyclones has made Bangladesh a model of development
for appropriate infrastructure and systems to coordinate
emergency responses, such that recent natural disasters
(eg, cyclone Sidr in 2007) have not led to the mass casualties
seen in previous eras. Thailand has implemented early-
warning systems for tsunami and implemented the 2010
Association of SouthEast Asian Nations (ASEAN) cooper-
ation in ood prevention and rehabilitation. Ethiopia has
enhanced its ability to respond to droughts, although
capacity remains limited, as shown by the eects of the
2011 famine in east Africa. Health systems have been
central to these preparations, creating spillover eects in
Health Policy
terms of improved planning, strengthening of institutions,
and streamlining of processes.
Cross-cutting lessons
Here, we have attempted to distil cross-cutting lessons
from our analytical case studies of Tamil Nadu in India,
Bangladesh, Kyrgyzstan, Thailand, and Ethiopia. Cross-
country analysis of national or regional experience has
value for identication of common themes, even if the
detailed characteristics vary. Although we do not
present a roadmap for success, our synthesis draws
attention to health system and non-health system
factors that seem to be important across our study
countries for achievement of good health outcomes.
Health system strengthening is much more than
mechanistic implementation of a series of essential
interventions, and formal policy fullment can be
hampered by unintended outcomes.
75

We should be cautious when we interpret our
conclusions because our study had several limitations.
We could only analyse ve countries in detail, although
within the study we did undertake a broader review
of published work on health system performance to
inform our methods. We focused on a specic set of
countries judged to have had a fair amount of success in
achieving health gains and improving coverage.
To undertake in-depth research in countries with similar
character istics, but that had not made comparable
progress, was beyond the scope of our study. Major data
gaps were seen in all countries (less so in Thailand),
particularly for reliable longitudinal data at subnational
level, and the scarcity of counterfactuals that could be
used to investigate associations between health policies,
cover age of inter ventions, and outcomes meant that we
were only able to identify plausible associations rather
than imply a causal attribution. Recognising these
challenges, we aimed to strengthen rigour with analytical
and methodo logical approaches, including a historical
perspective (panel 6). We sought comparability through
setting the experience of study countries in the context
of their regions, where possible, and analysing similar
experiences in dierent settings.
125

The phrase good health at low cost conveys the
message that health improvements can be achieved in
countries at relatively low income levels. The national and
regional experiences show how progress in health and
access to care has been possible even with limited
resources. Coverage of essential interventions delivered in
primary care settings has improved, with support from
health-promoting policies in other sectors and without a
substantial increase in the share of national resources
spent on health. Although we acknowledge that sustained
nancial investment in health systems is essential for
further progress, the experiences we describe show what
committed politicians, eective managers, motivated
health workers, eective institu tions, and involved com-
munities can do in constrained circumstances.
We have highlighted the importance of individuals in
creating ideas and generating political momentum. But
community matters too, as the relation between
education and fertility transition in Tamil Nadu shows.
In all countries and regions, good governance and
leadership were important for determining whether the
health systems operated eectively. Our study reiterates
many of the messages that emerged from the original
Good health at low cost report,
1
and other well established
evidence, about the need to orientate health systems
towards primary care, backed up by eective referral
systems, the importance of strategic action, supported by
multiple stakeholders. The relevance of inclusive and
community-orientated primary health care is restated
elsewhere,
123,126
and the report of the Commission on
Social Determinants of Health emphasises the need for
intersectoral action to promote health.
127,128
Specic
aspects of governance encompass leadership and vision
by government and translation of this vision into action,
including the ability to maintain continuity despite
turmoil, to seize windows of opportunity, to be responsive
to population needs, and to be committed to account-
ability. Stable institutions and bureaucracies that have
adequate regulatory and managerial capacity and
institutional memory provide means to learn from
experience. A degree of autonomy and exibility in the
way a government operatesenabling adaption to
chang ing circumstancesand engagement with diverse
actors and sectors were important in these increasingly
pluralistic environments. Faced with growing demands
for health workers, inadequate supply and di culties
with migration and retention, and shortages in remote
rural areas, every country and region has developed
Panel 9: Action points
Countries of low and middle income can make substantial improvements to delivery of
health care, despite limited resources, and can increase coverage and augment health in the
long term. Investment and political initiatives, both globally and nationally, should address
four aims to boost the chances of success. Actions to strengthen systems can include:
Building capacity with skilled individuals who have the ability to inspire and are
supported by strong institutions
Promotion of continuity by providing the stability necessary for reforms to be seen
through to completion, coupled with the institutional memory that helps to learn
lessons amid changing priorities
Identication of catalysts for change and to seize windows of opportunity to promote
key reforms and build broad political support
Ensuring that policies are responsive to needs and social values and are adapted to the
circumstances of the country in question, and to make sure that learning can be
achieved across countries facing similar situations
Health systems research should take a longer term approach in view of the social,
economic, and political context in which social institutions (in the health sector or
beyond) are embedded, which would also help to account for their success or failure.
Comparative research can inform policies seeking to achieve universal coverage and
create opportunities for learning across countries sharing similar geographic and
socioeconomic characteristics.
Health Policy
innovative strategies to increase the size and skills of the
health workforce and improve retention in underserved
and rural areas.
We have shown that progress was possible in the
ve study countries under dierent health nancing
arrange ments. In all places, expansion of nancial risk
protection was acknowledged to be necessary; Thailand
and Kyrgyzstan have achieved universal coverage where-
as Bangladesh and Tamil Nadu are only just beginning,
with Ethiopia making some progress from a low baseline
in a short time. Advances in maternal and child health
outcomes and access to services were achieved despite
high levels of out-of-pocket payments in several coun-
tries. A new nding was the importance of building
resilience into the health system, making a response to
political turmoil, economic crises, and natural
disasters easier.
What we have added with our study is new evidence on
the factors that enabled these ve countries and regions to
pursue pathways to good health despite political and
economic constraints. We have identied broad principles
translated into practical policies that facilitate progress in
improving health and delivering health care, which are
likely to be applicable elsewhere. Our key conclusion is
that four interlinked elements were common to all study
countries (panel 9): capacity, comprising skilled and
frequently inspirational individuals, supported by strong
institutions; continuity, providing the stability necessary
for reforms to be seen through to completion coupled
with the institutional memory that helps to learn lessons
amid changing priorities; catalysts for change, or seizing
of windows of opportunity; and sensitivity to context,
meaning adaption of policies to the circumstances of the
country in question rather than simply being transplanted
from somewhere else. Although these fundamentals
might not guarantee sustained progress, if they are all
present health gains are more likely.
Strategic investment in health systems remains key to
accelerate and sustain the achievements in health and
access to essential services reported here. Continued
health system development will allow countries to move
beyond picking the low-hanging fruit that make up the
common causes of childhood death, onto tackling
chronic diseases that are accelerated by growing
urbanisation and changing lifestyles. This reorientation
could well require increases in funds and other resource
inputs that health systems need, if high-quality services
are to be available to all population groups at an aordable
cost and if health systems are to respond to growing
population expectations.
Contributors
DB, MM, and AH wrote the rst draft of the paper. All authors then
made equal contributions to writing and further clarications. DB, MM,
AM, and LC made extensive revisions and produced the nal version.
All authors contributed ideas to the study, its design, and data analysis
leading to this report.
Conicts of interest
We declare that we have no conicts of interest.
Acknowledgments
We thank the Rockefeller Foundation for continued support, as part of
the Good Health at Low Cost 2011 project, particularly
Ariel Pablos-Mendes, Stefan Nachuk, Lily Dorment, and
Mushtaque Chowdhury; the steering committee, particularly Gill Walt,
Carine Ronsmans, Simon Cousens, and Ulla Gri ths, for valuable
guidance on framing the research questions, study design, and
interpretation of ndings; and the experts who participated in the
Bellagio project meeting in 2010, who advised on the comparative
chapters. This study was funded by the Rockefeller Foundation. The
opinions expressed in this report do not necessarily reect the policies of
the London School of Hygiene and Tropical Medicine or the Rockefeller
Foundation. The study was approved by the ethics committee of the
London School of Hygiene and Tropical Medicine (GHLC 5560
04.08.09). All study countries obtained approval from their national
ethics committees.
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