An institutional economic analysis of public health care organisations in low-income countries
(2009)
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- Abstract
- (en) Low-income countries still face a number of major health challenges. Public health services respond to them with great difficulty. This low performance is traditionally attributed to a lack of resources. Our hypothesis is that the observed low performance stems also from the institutional organisation of the public health systems. Our belief is that the institutional dimension has not been correctly appreciated so far in theories and policies of health service organisation in low-income countries. Our general strategy is to tap recent developments in organisational economic theory to gain more insights in the related scientific questions and the connected health policy issues. Our investigation is organised in two parts. Part 1 aims mainly at validating the utilisation of economics (and its institutional branches in particular) to analyse the organisation of public health systems. This validation is done in successive steps. In our chapter 1, we introduce public health systems in rural areas in low-income countries. This largely descriptive and historical chapter is helpful to provide the situation of reference discussed throughout the thesis. With the next chapters, we shift to economic theory. Our chapter 2 provides a review of recent developments in the economics of institutions; it sketches the overall theoretical background and allows us to situate our own research program in this panorama. The next four chapters are dedicated to concepts that are helpful for the economic study of public health systems, concepts that we draw from this literature. Our chapters 3 and 4 introduce respectively the concepts of institutions and organisations. In our chapters 5 and 6, we highlight how institutions structure property rights and how property rights set incentives to economic agents. This tedious application of organisational economics to our case of study allows us to highlight a few pending conceptual questions in institutional economic theories. In our chapter 7, we put these different concepts together and propose an institutional economic framework to study public health care organisations. Among other things, we show that this framework can help to structure the study of the performance of the public health systems. In our chapter 8, we come back to the rural health systems introduced in our chapter 1. Thanks to our institutional economic framework, we put forward a new explanation for the low performance of public health systems. Part 2 of the thesis explores the reform alternatives. Our chapter 9 is dedicated to the empirical scrutiny of two recent reforms: the Performance Initiative in Rwanda and the Health Equity Fund in Cambodia. The chapter consists in a collection of four papers published in peer-reviewed public health journals. Each paper is introduced and linked to the first part of the thesis. Our chapter 10 is the prescriptive one. We propose ways forward for reforming public health systems in low-income countries. Whereas our ten ‘propositions’ are to some extent speculative, they are clear enough to be falsifiable in the future. This allows us to identify some possible tracks for the expansion of our research program. Our thesis ends with a conclusion highlighting our contribution to the scientific and policy debate.
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Citations
Meessen, B. (2009). An institutional economic analysis of public health care organisations in low-income countries. https://hdl.handle.net/2078.5/58380