In This Article Expand or collapse the "in this article" section The Health Systems of Low- and Middle-Income Countries

  • Introduction
  • General Overviews
  • Textbooks
  • Conceptualizing and Analyzing Health Systems
  • Governance and Regulation
  • Financing
  • Resource Allocation
  • Health Services Provision
  • The Private Sector
  • Universal Coverage
  • Assessing Health System Performance
  • Journals
  • Data Sources
  • Toolkits for Health Systems Assessment
  • Other Online Resources and Websites

Public Health The Health Systems of Low- and Middle-Income Countries
Anne Mills
  • LAST MODIFIED: 24 September 2020
  • DOI: 10.1093/obo/9780199756797-0199


“Health system” is a term generally considered to be relatively recent. It is defined as all organizations, institutions, and resources that produce actions whose primary purpose is to improve health, whether these be targeted at individuals (such as health-care delivery) or populations (such as public health measures). Health-care and public health institutions have a long history, but the notion of an organized “health system” is a relatively recent development (dating from the mid-20th century). In low- and middle-income countries (LMICs), Western medicine was often introduced by former colonial authorities through the construction of public hospitals, health centers, and training schools, with church authorities also making a major contribution. As in high-income countries, there was a gradual process over the latter half 20th century to construct an organized and coordinated national health system. However, health systems became a key focus of international attention only in the late 1990s, when it became apparent that achieving the health-related Millennium Development Goals (e.g., reduction of child and maternal mortality; control of HIV, TB, and malaria) was threatened less by the availability of technical solutions and more by the ability of health systems to put them into practice. More recently, the Ebola epidemic in West Africa highlighted the critical importance of health systems in ensuring health security. In response to the increased awareness of the role of health systems, significant attention has been paid to defining the health system and its goals, categorizing its elements, assessing problems and testing solutions, and seeking to identify the relationship between different health system configurations and overall performance. Over time, specific issues within the general area of health systems have received special attention, including achieving universal health coverage (where the whole population of a country has access to health care and protection against its costs), the role of primary health care, the relative merits of different ways of financing a health system, the relative roles of public and private health sectors, and the appropriate mix of different types of health worker. Many disciplines can contribute to improved understanding of health systems, including economics, sociology, anthropology, history, political science, and management science. Until recently, the discipline of economics has tended to dominate the study of health systems. However, with the emergence of health policy and systems research as an important area of study, other disciplines have been making growing contributions, especially political science and the behavioral sciences concerned with the behavior of both individuals and organizations.

General Overviews

This section includes publications which either provide overviews of the development of health systems as a field of study or represent landmark publications which shaped knowledge and opinion. The historical antecedents of the concept of a health system are explored in Gorsky 2016, which argues that it was the construct of leading social democratic thinkers in the mid-20th century, and identifies the tension, which is more generally apparent in the literature, between technical analyses and value-based approaches. Bennett, et al. 2018 provides a historical analysis of the evolution of the field of health policy and systems research (HPSR) since 1996, listing key publications and events. Initially, the development of the literature focused on technical analysis. The seminal 1993 World Development Report (World Bank 1993) employed burden of disease and cost-effectiveness analysis to identify limited packages of public health and essential clinical interventions which should be top priorities for government finance, and more broadly analyzed health systems and their problems and proposed solutions. The equally famous—or infamous—World Health Report 2000 defined the goals of a health system and developed methods and metrics which were used to rank country health system performance. Subsequent World Health Reports have explored specific aspects of health systems, including the health workforce in World Health Organization 2006, primary health care in World Health Organization 2007, and financing and universal coverage in World Health Organization 2010. The World Bank continued its focus on what governments should do by addressing the failure of public services to meet the needs of the poor in World Bank 2003. Comparative country studies are adding depth to these global overviews of how health systems function and can be improved. For example, Balabanova, et al. 2011 sought to understand how five countries have made progress toward the goal of health systems at low cost and the role of the health system in their achievements. Conventional conceptual frameworks for analyzing health systems are critiqued by Gilson 2012 using an “institutional” lens and drawing on a range of organizational and policy implementation theories.

  • Balabanova, D., M. McKee, and A. Mills, eds. 2011. ‘Good health at low cost’ 25 years on: What makes a successful health system? London: London School of Hygiene & Tropical Medicine.

    In 1985, the Rockefeller Foundation published a seminal report, “Good Health at Low Cost,” highlighting and seeking to explain achievements of China, Costa Rica, Cuba, the Indian state of Kerala, and Sri Lanka. Twenty-five years later, the Foundation commissioned research to revisit these countries and examine in depth five more countries. The book demonstrates how rich historical analysis can shed light on the contribution of health systems to health improvement.

  • Bennett, S., J. Frenk, and A. Mills. 2018. The evolution of the field of health policy and systems research and outstanding challenges. Health Research Policy and Systems 16:43.

    DOI: 10.1186/s12961-018-0317-x

    Recognition of the importance of health systems has been accompanied by efforts to establish health policy and systems research as a field of inquiry which can support countries to improve health system performance. This paper identifies challenges and how they have been addressed, concluding that there remain issues such as those of strengthening research capacity and bringing together the rather separate bodies of knowledge in high- versus low- and middle-income countries.

  • Gilson, L. 2012. Health systems and institutions. In Health systems in low- and middle-income countries: An economic and policy perspective. Edited by R. D. Smith and K. Hanson, 21–45. Oxford: Oxford Univ. Press.

    Highlights the dominance of a mechanical perspective of organizational functioning in conventional health system frameworks, and a command and control approach to health systems strengthening. Proposes two alternative approaches to supporting change within health systems: soft systems methodology and strengthening trust-based relationships.

  • Gorsky, M. 2016. The idea of a health system: International health organizations and the genesis of comparative health systems research, 1891–1969. China Journal of the Social History of Medicine and Health 1.1: 28–57.

    Applies historical research methods to understand how the concept of a health system developed, identifying its early use in the 1930s and 1940s, and escalating use in the late 1960s and 1970s. Suggests that the current aspiration to provide robust comparative data for policymakers ignores the centrality of issues of political philosophy and ideology in debates on health system design and performance.

  • World Bank. 1993. World Development Report 1993: Investing in health. New York: Oxford Univ. Press.

    Still stands as a model of applying rigorous economic and epidemiological thinking to identify government policies for improving health in low- and middle-income countries. Many aspects of its recommendations were disputed, but it brought together evidence and analysis to address questions that persist in the early 21st century: e.g., the relative roles of government and market, and priorities in the provision of public health and clinical services.

  • World Bank. 2003. World Development Report 2004: Making services work for poor people. New York: Oxford Univ. Press.

    Adds intellectual depth to the 1993 World Development Report by focusing on common deficiencies across public services which help explain why they fail poor people—in access, quality, and quality. Takes institutional perspective and argues that improvements require strengthened accountability between poor people and providers, poor people and policymakers, and policymakers and providers. Calls for donors to reinforce these accountability relationships, not undermine them.

  • World Health Organization. 2000. The World Health Report 2000: Health systems: Improving performance. Geneva, Switzerland: World Health Organization.

    The first major analysis by the WHO on health systems and their performance. Proposes three goals for health systems (i.e., better health, fair financing, and responsiveness) and four functions that health systems need to carry out (i.e., delivering services, financing, creating resources, and engaging in stewardship). Assesses health system performance according to this framework. The framework has been widely used, though the ranking of country performance proved highly controversial and has not been repeated.

  • World Health Organization. 2006. The World Health Report 2006: Working together for health. Geneva, Switzerland: World Health Organization.

    First major analysis of the human resource crisis especially affecting health systems of low-income countries and proving one of the most intractable challenges to address. Focuses on all stages of health workers’ careers from entry to health training, job recruitment, and retirement. Includes discussion of the global “brain drain” where rich countries recruit from overseas. Recognizes that solutions are not straightforward and there is no consensus on action.

  • World Health Organization. 2007. The World Health Report 2007: Primary health care: Now more than ever. Geneva, Switzerland: World Health Organization.

    Continues the series of World Health Reports addressing various dimensions of health systems. Issued to coincide with the thirtieth anniversary of the famous Declaration of Alma Ata and makes the case for a focus on primary health care within health systems strengthening. Proposes four sets of reforms: universal coverage reforms, service delivery reforms, leadership reforms, and public policy reforms.

  • World Health Organization. 2010. The World Health Report: Health systems financing: The path to universal coverage. Geneva, Switzerland: World Health Organization.

    Directly addresses universal coverage, but concentrates on the financing function: raising money, pooling funds, and paying providers. Useful review of issues and how to address them. Chapter titles of “More Money for Health” and “More Health for the Money” mean balanced coverage on how to increase the volume of funds versus how to use those funds efficiently.

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