Good health at low cost 25 years on. What makes a successful health system?
women), visionary leadership, and the status of the health ministry
within government; and social and cultural factors, such as the level of
social, ethnic and religious cohesion. There are also less widely
recognized contextual factors which affect health systems. One is
geography (for example, whether countries are landlocked); another is
population size (for example, the ability to create a critical mass of
expertise within government) and yet another is a country’s history (for
example, attitudes to solidarity or individualism). Elements of national
context can affect health status and health systems directly. Thus, a
country with a failing economy, where the health ministry is weak and
where the government favours military rather than health spending is
unlikely to have an effective health care system.
All of these factors are influenced by the global position of the
country. For example, whether donor funding is important, or what the
scope is for migration and brain drain (influenced, for example, by what
languages are spoken widely). The global position of a country will have
implications for how its health system is shaped and also directly for the
health of its population (for example, its openness to trade will affect
food security and the prevalence of health-affecting foods and beverages).
Approach to the research
Given these considerations relating to the conceptual framework, our
approach was driven by several imperatives.
(i) Seeking to capture some of the complexity of the determinants of
health and the factors that enable functioning health systems.
Determinants of health are inherently complex. Complexities are
manifested in the sheer number of pathways involved, the ways in which