Social Science & Medicine 117 (2014) 150e159

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Social Science & Medicine

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The inter-section of political history and health policy in Asia e The

historical foundations for health policy analysis
John Grundy a, *, Elizabeth Hoban a, Steve Allender a, Peter Annear b
a
School of Health and Social Development, Faculty of Health, Deakin University, Australia
b
Nossal Institute for Global Health University of Melbourne, Australia

a r t i c l e i n f o a b s t r a c t

Article history: One of the challenges for health reform in Asia is the diverse set of socio-economic and political
Received 1 August 2013 structures, and the related variability in the direction and pace of health systems and policy reform. This
Received in revised form paper aims to make comparative observations and analysis of health policy reform in the context of
15 April 2014
historical change, and considers the implications of these findings for the practice of health policy
Accepted 18 July 2014
Available online 18 July 2014
analysis. We adopt an ecological model for analysis of policy development, whereby health systems are
considered as dynamic social constructs shaped by changing political and social conditions. Utilizing
historical, social scientific and health literature, timelines of health and history for five countries
Keywords:
Policy change
(Cambodia, Myanmar, Mongolia, North Korea and Timor Leste) are mapped over a 30e50 year period.
Health and history The case studies compare and contrast key turning points in political and health policy history, and
Social transition examines the manner in which these turning points sets the scene for the acting out of longer term
Health reform health policy formation, particularly with regard to the managerial domains of health policy making.
Findings illustrate that the direction of health policy reform is shaped by the character of political reform,
with countries in the region being at variable stages of transition from monolithic and centralized ad-
ministrations, towards more complex management arrangements characterized by a diversity of health
providers, constituency interest and financing sources. The pace of reform is driven by a country's
institutional capability to withstand and manage transition shocks of post conflict rehabilitation and
emergence of liberal economic reforms in an altered governance context. These findings demonstrate
that health policy analysis needs to be informed by a deeper understanding and questioning of the
historical trajectory and political stance that sets the stage for the acting out of health policy formation,
in order that health systems function optimally along their own historical pathways.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction 1990s, measures were put in place to decentralize health care

1.1. Background to health reform and social transition
Despite rapid economic growth, the Asian region has been beset
by policy challenges of persisting inequities in health care access
and health outcomes, and major health sector governance chal-
lenges presented by macro-level reforms in politics, economics or
civil administration. In China, institutional reforms have failed to
keep pace with broader development policy that was linked to free
market macro-economic reforms in the 1980s (Bloom, 2011). In
Mongolia during the post-Soviet neo-liberal reforms in the early
DOI of original article: http://dx.doi.org/10.1016/j.socscimed.2014.07.048.
* Corresponding author.
E-mail addresses: jgrundy@deakin.edu.au, johnjgrundy@hotmail.com
(J. Grundy).
systems to family group practices (FGPs) and institute health
financing models based on capitation based funding for primary
care (Hindle and Khulan, 2006). In Cambodia, during the post UN-
sponsored election period from 1993, the socialist model of
governance was dismantled and replaced by a more complex
diversified management arrangement, including the scale up of
demand side financing initiatives and the expansion of health
contracting models and of the private medical sector (Grundy and
Moodie, 2008). Similar pathways have occurred in Indonesia
(Ghani, 2012) and the Philippines (Lakshminarayanan, 2003), where
policy makers have developed responses to the administrative
challenges of decentralization and devolution.
A common theme in these observations of health and social
change is the policy and development challenge related to transi-
tion from centralized political orders in the 1980s and 1990s to-
wards more diverse and open pluralist models of administration.

http://dx.doi.org/10.1016/j.socscimed.2014.07.047
0277-9536/© 2014 Elsevier Ltd. All rights reserved.
 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159
The highly diverse pattern of political and economic history con-
tributes to an equivalently diverse set of organizational structures,
institutional arrangements and methods of financing of health care
systems, requiring countries to tailor policy implementation for
universal coverage according to the specificities of national context
(Carrin et al., 2008).
1.2. Theories of policy change
But the question remains as to what combination of social
theories can best explain the varying pace of policy and system
change across national settings, and how this can inform a more
consistent and comprehensive approach to policy analysis.
Bourdieu (1977) makes reference to the notion of “habitus” in order
to emphasise the durable dispositions of behaviours that provide
national institutions with their particular continuity of character.
Similarly, Huntington (2006) defines institutions in terms of stable,
valued and recurring patterns of behaviour. This durability and
continuity of institutions and their related behaviours contributes
to what others have referred to as the trajectory (Walt et al., 2008)
or path dependence (Altenstetter and Busse, 2005) of health policy.
The concept of “path dependence” has common features
including the observations that early events in sequence matter and
that later events have an inertia related to the earlier sequence
(Mahoney, 2000). Despite the presence of historical inertia, path
dependence does not rule out the availability of policy choice,
although the band of choice is conceptually narrowed based on
context (Kay, 2005). The related idea of “process sequencing” is that
trajectories are not random but are outgrowths of earlier tra-
jectories(Howlett 2009). Policy activity can also be reactive in
transforming the wider policy context and directions. In accounting
for the changing of trajectories, analysts have put forward the ideas
of “critical junctures” (Kay, 2005) or “policy turning points”
(Abbott, 1997), whereby periods of crisis are reported to contribute
to ideational change and subsequent re setting of policy directions.
1.3. Analytic framework
The historicism of policy formation (policy turning points)
demonstrates that policies do not operate in a vacuum but in
contrast originate from past time and are contextualized in place
(Capano, 2009). This being the case, the formation of managerial
ideas is located within a wider field of social and political ideas and
institutions that are subject to periodic historical transformations.
This concept of health care as forming part of an ”ecosystem” is
related in part to the limitation of systems analysis, which em-
phasizes elements of the internal organization and management of
health care systems. This limitation presents major challenges for
comparative systems and policy analysis, whereby a predominance
of hybrid forms seems to defeat efforts for a consistent set of health
system classifications or ideal types (Freeman and Frisina, 2010).
The metaphor of ecosystem is also relevant in so far as health
policy and systems change demonstrates an adaptive, organic and
evolutionary quality, as it periodically shifts directions, responds to
shocks or crises, and seeks to re-establish system equilibrium in
response to fundamental changes in a wider field of economic,
social and political relations. Feedback processes, including insti-
tutional rule adaptation and behavioural changes, allow policy and
systems to re-adjust to changing circumstances, leading to the
establishment of new and longer term equilibriums (homoeostasis)
in policies and systems (Howlett, 2009). This re-establishment of
policy and systems equilibrium in a new order responds to the need
to reset patterns of institutional behaviours (Huntington, 2006), as
systems struggle to re-align with higher level economic and polit-
ical reform. The phenomenon of policy dis-equilibrium can be
151
defined as the delayed policy or institutional response to political
or economic change, as institutions struggle to adapt their tradi-
tions of management or “habitus” (Bourdieu, 1977) to a radically
altered governance context.
From this standpoint, rather than viewing health systems sim-
ply as technical constructs engineered by technical planners and
decision makers, health systems can also be viewed as dynamic
social constructs shaped by the control parameters of changing
political and social conditions (Glass and Mc Atee, 2006).
Through illustration of case studies in health system develop-
ment from the Asian region, this paper aims to make comparative
observations and analysis of health policy reform in the context of
historical change, and considers the implications of these findings
for the practice of health policy analysis. The main variables of in-
terest is macro-political change, as defined by major shifts in the
exercise of political or economic power, in terms of free market
reform, decentralization and constituency emergence. The variable
of interest is the health policy turning point, which is defined as the
critical juncture at which health policy is reformed in the direction
of this political or economic transformation.
2. Methods
2.1. Target countries and sources of data
The country cases were selected based on the authors' published
observations and analyses in the five countries under study. As an
observer and participant in the policy and planning environment in
these country settings for variable periods of time between 1993
and 2013, the opportunity was provided to observe the influence of
history and politics in reshaping the health policy landscape in each
national setting and to access the grey health systems and policy
literature. These observations and analyses were detailed into
published country case studies of health system strengthening in
the cases of Myanmar (Tin et al., 2010), North Korea (Grundy and
Moodie, 2008), Cambodia (Grundy et al., 2009) and the
Philippines (Grundy, 2003).
We reviewed literature in Pubmed data base, using the search
terms “universal health coverage” as a title search (122 responses).
As noted by Walt et al. (2008), we found limited reference to his-
torical analysis of the evolution of health policy. The literature on
theories of “policy change” (Title search) returned 198 responses, of
which only two were relevant to an Asian setting, and of which
there were no systematic attempts to analyse policy change across
country health systems. The search terms “History” and “Health
system” (Title search) returned 21 responses, but with no responses
for Asia. Literature has been reviewed on systems thinking,
complexity theory and theories of policy change. The literature on
social and political history in each of these countries is quite
extensive, so historical sources were not systematically searched,
but were sourced selectively in order to construct a broad outline of
the historical timelines outlined in Figs. 1e5.
As a work of comparative analysis and synthesis incorporating
both historical and health systems analysis, we note here the lim-
itations that are the characteristics of any trans-disciplinary study,
particularly with regard to challenges of validity related to a com-
plex web of causation. But here we would also stress that this
complex web of causation represents a model of the health policy
analysis in the real world, and is a means by which to tackle the
problem of “the considerable gap between normative accounts of
how health systems operate and realities on the ground.” (Bloom
et al., 2008 Page 2076e77). We have attempted to manage these
limitations through testing and posing of a single research ques-
tion, and to consistent reporting of the variables of interest e
namely, historical trajectory and political transformation, health
152 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159
policy turning points, and the resetting of policy directions. As this
paper is a synthesis of previously published papers with data from
publicly available data sources, no application for ethics clearance
was made to an institutional ethics committee.
2.2. Analysis
We constructed health and history timelines for each country
which provide comparative observations between political and
socioeconomic history on the one hand (the history timeline), and
evolution in public health status, health care systems and policies
over the last 30e40 years on the other (health timelines) (see
Figs. 1e5). We thereafter illustrate periods of health policy reform
that correspond to periods of political or economic reform. Each
case study is structured according to (a) the description of historical
trajectory, (b) the identification of major turning points in health
policy history, and (c) the new policy directions reset by the
changing political and social conditions.
3. Main findings
3.1. Cambodia
3.1.1. Historical trajectory
Fig. 1 below describes health and history timelines for
Cambodia. Three periods of historical development have been
tracked for this country over the last 40 years which include
totalitarian, centralist and neo-liberal reform periods.
The totalitarian period was characterized by the near total
destruction of the post-colonial health care system, and its
replacement by a system based on traditional health care (Sokhym,
2002). Only 50 doctors survived the Khmer Rouge regime (Sokhom,
2002). In the 1980s during the socialist rule of the Republic of
Kampuchea when the country was occupied by Vietnamese forces,
there were efforts to reconstruct the health care system. The model
was centralist, with limited civil society participation; this period
was characterized by the beginning of international development
assistance through United Nations agencies and non-government
organizations (Heng and Key, 1995). Post 1993, following the
United Nations-sponsored general elections, the third and current
period of neo-liberal reform was established, characterized by
democratization, development of free market economic systems
Fig. 1. Health and history timelines Cambodia 1975e2012.
and expansion of political decentralization through elected
commune councils. From 1997 international development assis-
tance and foreign investment expanded, with the country experi-
encing a final period of relative peace and stability, including steady
rates of economic growth.
3.1.2. Health policy history
The major health policy turning point occurred in the post
transition period, from 1993 onwards. A remodelling of the health
system took place after 1996, with reallocation of health facilities
and health staff based on revised population catchments (MOH
Cambodia, 1996a). A network of over 1000 primary health centers
and 76 district referral hospitals were operational by 2011 (MOH
Cambodia, 2011). In order to offset the impacts of free market
systems on health access, a financing charter was introduced in
1996 to regulate the system of user fees (MOH Cambodia, 1996b).
From 2002, a system of hospital health equity funds was extended
across the country to minimize the impact of catastrophic health
payments on the poor (Bigdeli and Annear, 2009) with related
policy measures including the establishment of national health
financing guidelines and a social protection framework (RGC
Cambodia, 2013). Health contracting models were trialed in order
to boost health system performance in an increasingly decentral-
ized administrative context (Soeters and Griffiths, 2003). Civil so-
ciety organizations for health have expanded to over 100 in number
(Medicam, 2013) and in 2010 the private medical sector was the
first choice for primary illness care for 56.8% of the population
(MOP Cambodia, 2010). Despite these policy responses, health in-
equities remain a significant challenge, as evidenced by wide dis-
parities in access and outcomes relating to wealth quintile (Soeung
et al., 2012).
3.1.3. Health policy directions
These developments represent a significant diversification of
the system of provision and financing in an increasingly pluralistic
health system (Meesen et al., 2011) characterized by multiple
sources of health financing and provision through public, private
and civil constituencies. The parameters for health policy have
therefore shifted markedly from the 1980s era of central command
management, and represents significant health policy and institu-
tional adaptation measures to political change.
 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159
3.2. The Republic of the Union of Myanmar (Burma)
3.2.1. Historical trajectory
Fig. 2 outlines the health and history timelines for the Union of
Myanmar between 1960 and 2012 with three historical periods
identified. The first period of military socialist rule between 1962
and 1988 was dominated by a centralist command style of
administration. The second period of military rule was character-
ized by the introduction of free market economic systems between
1988 and 2008. The third period from 2008 onwards has been
characterized by constitutional reforms and the initial steps taken
towards democratization, decentralization and more open inter-
national relations (ICG, 2011).
The second period can be distinguished from the first by the
introduction of free market economic reforms from the early 1990s.
This second period was also characterized by sustained economic
and trade sanctions and low rates of international aid and domestic
investment in the health care system (Grundy et al., 2012). This
decline in investment in social sectors is being reversed in the third
constitutional reform era post 2008, where social sector invest-
ment and decentralization options are being actively explored
(UNIC, 2012) and where international development assistance is
being gradually extended in response to the more open political
climate and the related opening of diplomatic relations.
3.2.2. Health policy history
Commencing in the early 1960s, the rural health care system
was expanded, with a rural health centre located in every district by
1964 (KoKo, 2006), and a network of 1137 rural health centers
established by 1988 (MOH, Myanmar, 2012). In the second period of
free market reform, evidence began to emerge of poor access to
health care based on affordability factors (MOP Myanmar 2010). In
response, in 1993 the Government introduced a health policy to
regulate user fees through introduction of a community cost
sharing model (MOH Myanmar 2009). This period was also marked
by very low rates of national and international investment in the
health sector (Grundy et al., 2012). It was mainly in the post Nargis
natural disaster and constitutional reform period from 2008 on-
wards that health system strengthening initiatives (Tin et al., 2010)
and civil society partnerships were expanded (Htwe, 2011).
Fig. 2. Health and history timelines Myanmar (Grundy et al., 2014).
153
3.2.3. Health policy directions
Political reforms have accelerated rates of development assis-
tance as well as contributing to exploration of social sector policy
options including increased health sector budgets (UNIC, 2012),
decentralized health planning, alternative health financing models
€nnroth et al.,
(Tin et al., 2010), and publiceprivate partnerships (Lo
2007), all of which are opening up a new health policy landscape in
Myanmar.
3.3. Mongolia
3.3.1. Historical trajectory
Fig. 3 describes health and history timelines for Mongolia. Three
periods of historical development have been identified which
include the beginnings of the socialist system, establishment of the
system, and the neo-liberal reform era since the early 1990s (MOH
Mongolia, 2012).
For the majority of the 20th century, Mongolia functioned as a
socialist republic under the tutelage of the Soviet Union. This
period had a mixed historical record, with gradual expansion of
the education and health sectors from the early 1920s, as well as
programs of industrialization and development of urban centers.
However, the period was also characterized by intermittent civil
conflict and religious and political oppression particularly during
the rule of Stalin in the 1930s (Baabar, 1999). By the late 1980s, the
Soviet Union was providing 85% of development aid amounting to
35% of the government's annual budget (Manaseki, 1993). The
closure of the Soviet era in the late 1990s resulted in a rapid po-
litical transition towards a system of administration modelled on
neo-liberal lines e that is, parliamentary democracy, free market
economics, and emergence of private and civil society sectors.
This latter period has been characterized by a remarkable social
transition, with rapid urbanization, sustained high rates of eco-
nomic growth and persisting and even widening social in-
equalities (Rossabi, 2005).
3.3.2. Health policy history
Due to the introduction of socialist models of administration,
the first constitution of Mongolia ratified in 1924 stated that health
services were to be provided free of charge. A Department of
154 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159
Fig. 3. Health and history timelines Mongolia.
People's Health Protection was established in 1925, and by 1940
there were 37 hospitals in the aimags (provinces) and the estab-
lishment of bagh (community) level practitioners had commenced
(MOH Mongolia, 2012). The second period of health system
development ensued when the multi-tiered socialist health care
system was established incorporating tertiary hospitals, soum (sub
district) hospitals and basic primary health care providers.
Following the first multi-party government in Mongolia and the
institution of free market economic models, there were sharp turns
in health policy history which included the establishment of a
National Health Insurance Law in 1993 and public private collab-
orations for primary health care (Hindle and Khulan, 2006). Na-
tional health sector planning processes incorporating models of
decentralization (MOH Mongolia, 2006) were also instituted. In
recent years the number of private health facilities has increased
from 683 in 2005 to 1184 in 2011, including expanded participation
by non-government organizations in health activities (WHO &
MOH, 2012).
3.3.3. Health policy directions
Mongolia has carefully managed new health policy directions
through institution of early and highly reflexive social protection
and sector planning policy responses. Nevertheless, the country is
still challenged in policy terms to manage the post transition shock
of the health inequities associated with rapid economic growth and
urbanization. Despite double digit rates of economic growth fuelled
by a mining boom, and a sizeable share of GDP allocated to health
(4.7%) (WHO MOH Mongolia, 2012), studies document significant
inequities in health care access between socio-economic groups
(Lhamsuren et al., 2012) despite the fact that social health insur-
ance coverage was 82.6% in 2010 (WHO MOH Mongolia, 2012).
3.4. The Democratic People's Republic of Korea (North Korea)
3.4.1. Historical trajectory
Fig. 4 identifies four periods of historical and political change in
North Korea. First is the conflict period 1950e1953, where 3.5
million Koreans perished in the multi-national war for the conquest
of the Korean Peninsula (Martin, 2004). The second period, be-
tween 1953 and the early 1980s, represented the zenith of the
northern regime in terms of its political and economic fortunes,
with embarkation upon a rapid program of Soviet backed recon-
struction and rehabilitation. As a result the GDP of the North su-
perseded that of the South up until the late 1970s (Cha, 2012).
Nevertheless, fortunes were reversed in the early 1990s in the
post-Soviet era, leading to a catastrophic halving of GDP within a
five year period (MOF DPRK, 2004). This economic situation was
exacerbated by natural disasters, food insecurity and a focus on
“military first” politics, where an estimated 25%e30% of the GDP of
28 billion $US is invested in defence (Cha, 2012). A famine in the
mid-1990s was reported to have resulted in losses of 3%e5% of the
total population (Haggard, 2007). The final era up until 2012 has
concluded in an international relations stalemate, characterized by
tense military confrontation, nuclearization of the Korean Penin-
sula, and economic stagnation and sanctions.
3.4.2. Health policy history
In the post war second period of rehabilitation, the primary
health care system was rapidly expanded with immunization ser-
vices being introduced as early as the 1960s, and the network of
health care delivery facilities rapidly expanded (Pak, 2011). A key
turning point was reached in the period between 1989 and 1991,
when the Soviet era drew to a close, GNP collapsed, and economic
sanctions were strengthened and with ”military first” politics
prioritizing defence development over other forms of public policy.
The very low rate of recurrent operational investment can be
contrasted with the vast investment in health facilities and primary
care medical doctors (Grundy and Moodie, 2008). Primary care
doctors are over 44,000 in number, providing it with one of the
highest staff to population ratios in the region (MOPH, 2011). There
are 3.29 physicians per 1000 in the DPRK, compared to 1 and 1.29
per 1000 in China and Vietnam respectively (WHO, 2013).
Tense international relations were also an impediment to
favourable aid flows, with rates of aid up to 15 times lower than
countries with comparable levels of development, such as Laos and
Cambodia (Grundy et al., 2012). In the mid-1990s, the public health
 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159 155

Fig. 4. Health and history timelines DPRK 1950e2012.

system was in crisis, with a halving of immunization coverage 3.5. The Democratic Republic of Timor Leste
(reaching only 40% of children in 1997) (WHO, 2012), 35% of chil-
dren stunted (Hoffman and Lee, 2005) and significant rises in child 3.5.1. Historical trajectory
and maternal mortality between 1990 and 1995. Fig. 5 outlines three health and development periods in Timor
Leste including the early development of PHC health systems up
until the late 1970s, post conflict rehabilitation between 1999 and
3.4.3. Health policy directions
2005, and the current period of extension of PHC systems to hard to
In the most recent period between 2005 and 2012, there is ev-
reach or unreached populations.
idence of a moderate recovery in public health, as the Government
In the late 1970s, following centuries of Portuguese rule the
of the DPRK developed partnerships in such areas as malaria pre-
Republic of Timor Leste (current population 1.1 million) declared
vention and treatment and tuberculosis control (Global Fund, 2012)
independence. Several weeks later, occupation by Indonesia
and childhood immunization and health system strengthening
resulted in 30 years conflict. During the occupation, the Gov-
(GAVI, 2012; Grundy and Moodie, 2008). By 2011, immunization
ernment of Indonesia undertook commercial, infrastructure and
coverage had recovered to be above 90% for all antigens (WHO,
social sector developments, including the establishment of a
2012) and malaria and TB case fatality rates have declined
health care system that extended into the mostly mountainous
sharply in the last 10 years (Global Fund, 2012). Nevertheless, there
districts of Timor Leste. Immediately following the UN plebiscite,
are ongoing reports of acute shortages of essential medicines and
public infrastructure, including nearly all medical facilities was
equipment and of food insecurity (Grundy 2008) and with only
destroyed by militias in 1999 (Margesson and Vaughan, 2009).
modest reductions in child and maternal mortality in recent years
Following United Nations-sponsored elections in 1999,
(CBS, 2009).

Fig. 5. Health and history timelines Timor Leste.

156 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159

Fig. 6. Resetting health policy parameters post political transition.

independence was declared in 2002, and the country established capacity to extend social services to unreached populations.
a free market and multi-party democratic system. The overall Governance, planning and financial management reforms are
development strategy is based on poverty alleviation, the proposed to increase middle level management capacity to
rebuilding of institutions, infrastructure investment and human extend these services to unreached populations through inte-
resource development (GTL, 2012), and on sustainable utilization grated health outreach and human resource placements in
of substantial oil and gas reserves (GTL, 2013). The strategy also remote areas (MOH GTL, 2012).
focuses on free market reforms and rural development, increased
foreign investment and a policy and legal commitment to a
decentralized model of governance (GTL, 2012). A transition plan 4. Discussion
was developed in 2011 (GTL 2011) in preparation for the exit of
the United Nations forces from Timor-Leste which took place in 4.1. Historical trajectory and health policy turning points: resetting
late 2012, following the second popular election for the new the parameters for health policy making
Government of Timor Leste in the same year.
This review of the linkages between health and history has
found that the trajectory of policy and system development is
3.5.2. Health policy history
steered by two interconnecting forces of technical and socio-
During the Indonesian occupation of 1975e1998, much of the
political direction. Technical direction represents pressures for
district health system was established, although it was during the
the attainment of specific health goals most often embodied in
same time that population health suffered under the pressure of
national Health Plans. Socio-political direction represents pressures
sustained conflict. The second period from 1999 until 2005 may be
for economic, administrative and political reform at a macro-level.
classified as the recovery and rehabilitation period, under which
As indicated in the case studies (and as illustrated in Fig. 6), the
much of the health infrastructure were reconstructed and health
impact of periodic political and social transitions ”tilts” managerial
human resources trained. Timor-Leste's new Constitution of 2002
policy and planning in the direction of the overarching social and
defined medical care as a fundamental right for all citizens, with
political transformation, contributing to key turning points in the
services required to be universal, free of charge, and decentralised
evolution of health care systems and policies.
and participatory. In this third period, the first health sector plan-
In some cases, these turning points result in radical redirection
ning and health information processes were established, and ser-
of health policy. Examples include the introduction of the National
vices were further extended outwards to the population through an
Health Insurance System and Family Group Practices in Mongolia
integrated health outreach program (MOH GTL, 2012). Despite the
post neo-liberal reform in the mid-1990s (Hindle and Khulan,
rehabilitation efforts in this second period, there remains extensive
2006), the introduction of social protection and health contract-
service delivery gaps in Timor Leste. Thirty percent of deliveries are
ing models in the post UN period in Cambodia (Bigdeli and Annear,
attended by trained personnel, with a very high rate of 557
2009), and the moves to decentralized planning and social sector
maternal deaths per 100,000 births (NSD GTL, 2010), and with the
policy options in Myanmar post constitutional reform in 2008
reach of immunization services limited by widely dispersed pop-
(UNIC, 2012). Similarly, in the DPRK and Myanmar, the closure of
ulations residing in small hamlets across mountainous terrain with
the Soviet era and the collapse of GNP in the former case, and the
poor transport links and shortages of human resources in remote
Nargis disaster and constitutional reform in the latter case, were
areas (Nelson, 2012).
triggers for the opening up of international partnerships, a trend
which has dominated the health policy landscape ever since
3.5.3. Health policy directions (Grundy et al., 2012). As these cases demonstrate, it is the inter-
As reflected in the subsequent National Health Sector Stra- section of these macro-level political transitions with health policy
tegic Plan (NHSSP) 2011e2030 (MOH GTL, 2012), efforts will that creates the conditions for the resetting of the policy parame-
focus on development of human resource and management ters for health reform.
 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159
4.2. Health policy directions e health policy responsiveness to post
transitions shocks
Given the impact of these macro-political transitions in trig-
gering health reform, health policy makers and development spe-
cialists are then confronted by the challenge of navigating their way
through a transformed social and political landscape. In consid-
ering implications for policy and practice, it is helpful to consider
the transitional “shocks” of these political transformations that
require careful health policy and institutional adaptation.
4.2.1. Conflict shocks
The case studies demonstrate the extent to which both internal
and external conflicts have precipitated social and political transi-
tions, and have in most cases overshadowed health development
ever since. The major turning points in health policy relate not only
to the political and social transformation that these conflicts
generate. These turning points also relate to the broader develop-
ment challenges of rebuilding institutions and the health workforce
post conflict. In the case of Timor Leste and Cambodia, this meant
rebuilding the health care workforce almost from scratch (MOH
GTL, 2012, Heng and Key, 1995). In contrast, the siege mentality
of the North Korean State and the militarization of its society is
highly illustrative of the extent to which conflict (or the constant
threat of it) distorts public policy priorities away from human se-
curity issues onto a predominant focus on the security and survival
of the State (Grundy et al., 2012). In the Union of Myanmar, nearly 50
years of military dictatorship (1962e2008) and continuous internal
conflict has contributed to a command and control managerial
culture, with the country now tasked with the “unnatural transi-
tion” from central control (Risso-Gill Page 8 2013) to a decentral-
ized model of governance (Tin et al., 2010). In every case, with the
possible exception of Mongolia, the development impacts of conflict
reverberate across generations of institutional and human devel-
opment, and are the defining historical pivots on which the sub-
sequent patterns and pace of health policy turn. It is highly
illustrative of the observation that health policy formation operates
within a wider field of political relations, of which conflict and its
aftermath are dominant drivers.
4.2.2. Free market shocks
Liberal economic reforms were accelerated by reorientation of
international health policy in this period, particularly through
multi-lateral agencies such as the International Monetary Fund, the
Asian Development Bank, and the World Bank. The 1987 Agenda for
Change (Akin et al., 1987) proposed the introduction of user fees at
government health facilities to raise revenue. In 1993, Investing in
Health (World Bank, 1993) proposed that governments in devel-
oping countries be responsible for funding only a US$12 minimum
package of primary care services with the remainder being pro-
vided through the public sector. In Cambodia, the initial response to
liberal reforms was to introduce user fees through a health
financing charter in 1996 (MOH, 1996b). This was followed by
wider protection measures through development of hospital health
equity fund models from the late 1990s (Bigdeli and Annear, 2009).
In Mongolia, the neo-liberal reforms in 1990 resulted in a rush of
policy responses, including establishment of a National Health In-
surance Law and institution of capitation based funding models for
primary care (Hindle and Khulan, 2006). In Myanmar in 1993
following market reforms, user fee models were introduced by
establishing community cost sharing and drug revolving funds
(MOH Myanmar 2009). Following political reforms in 2008,
consideration of social sector policy options have been considered
including test and development of health financing schemes (Tin
et al., 2010) and scale up of tax based health insurance. Despite
157
these initiatives, countries are still playing “catch up” in response to
the impacts of economic reforms, as evidence emerges of wide
inequities of access and outcomes based on socio economic status
in Timor Leste (NSD GTL, 2010), Cambodia (MOP Cambodia, 2010)
and Mongolia (Lhamsuren et al., 2012). The challenge of adaptation
to changing health policy parameters that are reset by free market
economic reform is that it requires highly reflexive policy and
system responses, particularly in terms of health financing, human
resource management and health planning.
4.2.3. The governance shock
Political transformation in most cases has required a radical shift
in management cultures from command and control styles of
central management to negotiated contractual arrangements with
middle level managers. These health policy adaptations are illus-
trated by the cases of Family Group Practices in Mongolia (Hindle
and Khulan, 2006) and contracted operational districts in
Cambodia (Soeters and Griffiths, 2003). In Timor Leste, the National
Health Plan (MOH GTL, 2012) expresses its intent to shift towards
performance based management models, while in Myanmar early
attempts have been made to establish decentralized and coordi-
nated planning systems at Township level (Tin et al., 2010). These
new regulatory and management mechanisms are intended to
address the governance challenge associated with transition from
monolithic state control using centralized models of administra-
tion, to diverse and decentralized models of management with a
mix of funding sources, providers and stakeholder interests.
These responses to internal post transition shocks are not only
dependent on the internal evolution of Nation States. As the cases
of the DPRK and Myanmar demonstrate, the ebbs and flows in in-
ternational relations, particularly with respect to economic em-
bargoes, defence expenditures and restriction of migration of
people and ideas, have acted as major constraints on health system
development (Grundy et al., 2012). Equally, as the cases of
Cambodia (Bigdeli and Annear, 2009; Meessen et al., 2011),
Mongolia (Hindle and Khulan, 2006), and the Philippines
(Lakshminarayanan, 2003) demonstrate, the globalizing forces of
democratization and market exchange internationally have seen
fundamental shifts in the ways health services are managed, pur-
chased and provided.
4.3. Implication for health policy analysis
These observations serve to illustrate that, rather than being an
inert set of engineered technical constructs or building blocks,
health organizational systems and policies are dynamic social
constructs that are highly open to the shifting influences of social
and political superstructures as they transform through time. In
this regard, health policies and systems are products of their time
(van Olmen et al., 2012). The impact of these transitional shocks
also illustrates the inherent organizational instability, dis-
equilibrium, and complexity of health care systems that is related
to their openness to the influences of these wider social and po-
litical ideas and forces. In this way, the teleological objectives of
health planners for desired end states of health organization
meshes with the complexity and transience of wider social and
political organization. The tensions between the two result in
fundamental turning points in health systems and policies, char-
acterized by remarkable case studies in policy innovation as orga-
nizational systems re-establish their equilibrium in response to
new macro policy directions.
These wider ecological perspectives on health policy formation
are central to deepening our understanding of the way in which
health systems and policy making is permeated and shaped by the
forces of history and its related ruling and transient paradigms of
158 J. Grundy et al. / Social Science & Medicine 117 (2014) 150e159
political power. From a policy makers or development specialists
perspective, the comparative element in such a diverse set of
contexts is the coming to terms with application of what is
consistent across all contexts (the scientific aspects of health policy),
and that which requires careful adaptation to context (the mana-
gerial aspects of health policy). Generally speaking, the value of
comparative health systems analysis is that it enables a nuanced
understanding of how to “change the channel” in policy terms, in
order to tune into the historically defined development trajectories.
This enables health system applications to be feasibly and effec-
tively implemented along a specific national pathway.
Although this does not negate the value of the system thinking
approach (Adam and de Savigny, 2012; Atun, 2012), there is
nonetheless a stronger case for closer alignment of systems
thinking with historical thinking. The purpose of this closer align-
ment of systems analysis with historical and political analysis is to
provide a deeper understanding of the pressures and trajectory for
policy change, which are highly variable and specific to national
context.
The specificity of country settings as well as their dynamism is
testament to the fact that the drivers of policy change, whether
actors, institutions, ideas or stakeholder interests, cannot be
replicated from one context to the next (Bloom et al., 2008). This
amounts to what has been referred to as the specific “configuration
of policy dynamics” (Capano, 2009) that has to be learnt in setting.
It is within this web of causal complexity that greater attention to
historical trajectory and the political transformations that reset
health policy parameters is required. This is one important means
by which policy makers and development specialists can identify
more feasible entry points for longer term policy analysis and
action.
5. Conclusions
These case studies demonstrate that political and social transi-
tions are critical to the reformation of the health policy landscape in
low income country settings. This presents significant development
challenges in such settings, particularly in relation to adaptation to
the post conflict, free market and governance shocks arising out of
such periodic social and political transformations and the related
requirement to institutionally adapt to new policy directions. The
main implication of these findings is that analysis needs to be
informed by a deeper understanding and questioning of the his-
torical trajectory and political stance that sets the stage for the
acting out of health policy formation. By recognizing the historical
and political foundations of policy and systems change, policy
makers and development specialists will be better informed of the
feasibility, challenges and boundaries for realistic health policy
reform in such settings. Such a historically and ecologically
informed policy debate should reduce the lag time between the
social and political transitions and the required health policy
response, enhancing the capability of health and social systems to
operate optimally along their own historical pathways.
Acknowledgement
Allender is supported by funding from an Australian National
Health and Medical Research Council/Australian National Heart
Foundation Career Development Fellowship (APP1045836).
Allender is a researcher within a NHMRC Centre for Research
Excellence in Obesity Policy and Food Systems (APP1041020).
Allender is an investigator on a US National Institutes of Health
grant titled Systems Science to Guide Whole-of-Community
Childhood Obesity Interventions (1R01HL115485-01A1).
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