Context

HSs are overall shaped and influenced by wider societal change and are social institutions that reflect the society in which they are embedded. Interaction with the environment involves reaction and adaptation to social, economic, technological, cultural, political, regulatory and environmental developments and transitions over time.

Every country has a HS that reflects its own and unique planning decisions and historical developments (path-dependency) (Riley 2008). There is a constant need for adaptation to new developments and transitions, such as disease burden, new technologies, changing expectations of patients and providers, increased information (through media and information communication and technology) and changing roles of the state in the health and social sectors.

The policy context of the HS can be analysed at different levels, which are intricately interwoven with power configurations and dynamics between international, national and local actors. National policies in low income countries are heavily influenced by the global (financial, economic) regime and policy context. Scanning the global context would entail tracking changes in the global aid environment, global health agenda setting, and the role of major donors, international organisations and global civil society. Even at local level, the influence of global and national actors interferes with that of the local stewards, politicians and other stakeholders. The national context also encompasses the national political system/regime, the political administration, the regulatory system and national civil society. Coordination mechanisms, such as inter-sectoral coordination between ministries, donor coordination or pooling mechanisms and national civil society networks, need to be taken into account. One also needs to consider the administrative decentralisation and/or health sector reforms, because they directly affect the distribution of responsibilities and resources within the HS. Within the policy context, the ministry of finance is a key actor, through its decisive influence on national resource allocation and expenditure. In most countries, the national civil service administration is another central player, responsible for the staffing of the public health system.

Also other sectors, such as education, sanitation and water supply, social services, etc, have an important influence on the outcomes and goals of the system. This is the explicit recognition of the role of other determinants of health in the goals and effects of the HS.

Several colleagues in our network work on the interaction of global/international health policies, national level policies and the implementation of those policies. Visions about these issues are neither static nor entirely homogenous. Views continue to evolve, both in reaction to transitions in the world and inspired by new contacts and fresh ideas. In the two links below, the work of different groups in the network is presented. The visions expressed in these links are views of the authors which wrote them.