News from Project A04


Adelina Comas-Herrera (LSE) and Prof. Heinz Rothgang (CRC 1342)
Adelina Comas-Herrera (LSE) and Prof. Heinz Rothgang (CRC 1342)
Jour Fixe with Adelina Comas-Herrera on December 15, 2023

As the last event of our Jour Fixe lecture series in 2023, Adelina Comas-Herrera from the London School of Economics and Political Science (LSE) hold a lecture on Friday, December 15. Among others, she presented the Global Observatory of Long-Term Care (GOLTC).

The GOLTC is a platform to facilitate cross-national learning to improve and strengthen care systems. It aims to identify shared challenges in relation to long-term care and showcase how different countries and localities are addressing them, sharing research evidence and supporting collaborations. The Observatory is part of the International Long-Term Care Policy Network (ILPN), at the Care Policy and Evaluation Centre (CPEC) at the LSE. It is funded partly by CPEC and has received a funding award from LSE Innovation.

Furthermore, Adelina Comas-Herrera presented several care-related research projects building on the Theory of Change. The Theory of Change is an outcomes-based approach which describes how a programme brings about specific outcomes through a logical sequence of intermediate outcomes. Applying it as a tool for research it can facilitate policy evaluation and development in that it looks not only at the current status and the process outcome but conceptualizes the – often black- boxed – process steps in between in detail. Adelina Comas-Herrera has applied the Theory of Change approach both in an international contest as well as in research on long-term care in the United Kingdom. For instance, in the STRiDE project, the Theory of Change was used to generate research and policy maps for seven low- and middle-income countries with the aim that people with dementia and their carers live well and their social and health risks are mitigated. In doing so, stakeholder workshops in each country developed goals and steps to strengthen the countries’ response to dementia, including for example the adoption of a national dementia strategy or informal and formal carer training.

Adelina Comas-Herrera is Director of the Global Observatory of Long-Term Care at the Care Policy and Evaluation Centre, LSE. She is co-lead of the Strengthening Responses to Dementia in Developing Countries (STRiDE) project. Funded by the Research Councils UK Global Challenges Research Fund, STRiDE is a multi-national project covering Brazil, India, Indonesia, Jamaica, Kenya, Mexico, and South Africa. The project aims to build capacity to generate research that supports the development of policy responses to dementia, with related projects also under way in Hong Kong and New Zealand. She is the curator of LTCcovid.org, an initiative linked to International Long-Term Care Policy Network that shares evidence and resources to mitigate the impact of COVID-19 amongst those who use and provide long-term care. Her main research interests are economic aspects of care, treatment and support of people with dementia, and long-term care financing, both in the UK and globally. She has extensive experience in developing simulation models of the future resources required to address long-term care needs and needs arising from dementia. She has a background in Economics (BA and MSc, Universitat Pompeu Fabra) and is currently Assistant Professorial Research Fellow at the Care Policy and Evaluation Centre at the London School of Economics and Political Science. She has been a consultant for the Inter-American Development Bank’s ageing and long-term care programme and for the World Health Organisation’s Department of Ageing and Life Course, preparing a country self-assessment tool for long-term care. She was a co-author of the 2016 and 2019 editions of the World Alzheimer Report.

Publications:


Contact:
Dr. Johanna Fischer
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-57074
E-Mail: johanna.fischer@uni-bremen.de

Hüma Nauroozi, Dr. Achim Schmid and Ed Miller, PhD
Hüma Nauroozi, Dr. Achim Schmid and Ed Miller, PhD
Interview with Achim Schmid, postdoctoral researcher, Hüma Nauroozi and Ed Miller, both interns in project A04 “Global Developments in Health Care Systems”

In the framework of their mandatory internships Hüma and Ed are part of the project A04 from October to December, 2023. Hüma Nauroozi is a Bachelor student of Public Health in the 5th semester. Ed Miller is a Master student of "Sozialpolitik" (Political Science) in the 3rd semester.

Could you give us a brief overview of what the A04 project is all about?

Achim Schmid: The project pursues three research goals: first, to describe the evolution of healthcare system generosity, its inclusiveness and scope of benefits, worldwide, from its inception to the present; second, to identify and explain the temporal and spatial patterns of inclusion and benefit dynamics; and third, to explore the role of specific causal mechanisms and to explain the findings of the project’s first phase concerning the timing and emergence of specific healthcare system types in select African countries.

Currently, the main focus lies on the measurement and portrait of inclusiveness ("Which social groups are covered by the healthcare system?") and scope of benefits ("What kind of benefits are covered?") based on healthcare legislation. After the manual annotation of selected documents, we plan to use AI-learning models to extract generosity information. The information will contribute to the Welfare State Information System (WeSIS) of the CRC.

What are your academic interests and what tasks do you have in the project?

Hüma Nauroozi: I am studying Public Health at the University of Bremen in the 5th semester and I am currently looking for a topic for my bachelor thesis. My research interests relate primarily to qualitative and quantitative empirical research of health care systems in a global context. My main tasks include data collection and analysis of health legislation as well as preparing a country brief on the Rwandan healthcare system with its own peculiarities.

Ed Miller: I am a retired Army Officer with a PhD in Public Policy from the University of Maryland. Previously, I was a consultant at Booz Allen Hamilton Inc. At present, I am doing a Double Degree Master Program in Political Science/Sozialpolitik at the University of North Carolina and the University of Bremen. As part of my internship, I focus on the complex healthcare system of the United States of America. In this regard, I examine legal texts and laws.

Two months behind and one month ahead: How do you look back on your internship here at the CRC 1342?

Ed Miller: We appreciate that we have the opportunity to make a real contribution to research of the CRC 1342. In our team, we have the feeling that we work on an equal footing with our colleagues. We are very pleased that the results of our work are to be published at the end of our internship.

Hüma Nauroozi: A personal highlight for me was the Africa workshop organized by Julian Götsch and Lorraine Frisina-Doetter in November. The discussions and meeting experts on Kenya and Nigeria, some of whose work I had previously only read in class, was a great experience for me and I learned a lot.

Achim Schmid: We are very happy about Hüma’s and Ed’s contribution to our project and of course we hope that they can also profit from their research experience.


Contact:
Dr. Achim Schmid
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-58526
E-Mail: aschmid@uni-bremen.de

A04 workshop from November 1 to 3, 2023, at Haus der Wissenschaft in Bremen

The workshop "Exploring healthcare system introductions and historical developments in Kenya and Nigeria within the context of nation-building and post-colonialism" of the project A04 "Global Developments in Healthcare Systems" took place from 1.11.2023 to 3.11.2023 at the Haus der Wissenschaft, Bremen, and was organized by Lorraine Frisina-Doetter and Julian Götsch.

The aim of the workshop was to bring together leading experts on the historical development and current design of healthcare systems in Nigeria and Kenya. The focus was on the influence of colonialism and nation-building on the introduction and subsequent reforms of the healthcare systems in the two countries. Philip Aka (International University of Sarajevo, Bosnia and Herzegovina), Mario Azevedo (Jackson State University, USA), Joseph Balogun (Chicago State University, USA), Diana Cassells (Purchase College, New York, USA), Pascal Grosse (Charité Berlin, Germany), Daniel Künzler (University of Fribourg, Switzerland), Rebecca Martin (London School of Hygiene and Tropical Medicine, UK), George Ndege (Saint Louis University, USA) and Friday Okonofua (University of Benin, Nigeria) participated in the workshop as experts on the historical development of the healthcare systems in Kenya and Nigeria.

After an introduction and welcome speech by Heinz Rothgang of the A04 project, the workshop opened with a presentation by Mario Azevedo on the impact of colonialism on health systems in Sub-Saharan Africa. Followed by presentations and subsequent discussions of the A04 project's work by Lorraine Frisina Doetter and Sebastian Haunss, the first day concluded with an extensive and critical roundtable discussion on the utility and the limitations of the concept of nation-building in the post-colonial context of sub-Saharan Africa. From the very beginning, the workshop was characterized by lively discussions and intensive exchange, which characterized it until the end.

The following days were dedicated to the historical developments of the healthcare systems in Nigeria and Kenya. In their presentations on Nigeria Joseph Balogun, Friday Okonofua, Rebecca Martin, Diana Cassells and Philip Aka highlighted different perspectives on the evolution of the healthcare system. They shed light on the historical development of health professions, the evolution of health services and the collaboration of different actors during colonialism, the impact of the Coloniality of Sovereignty and the continuing British influence on healthcare in Nigeria today. In their presentations on Kenya, George Ndege and Daniel Künzler focused on the institutional continuities of the healthcare system from colonialism until today, discussed the history of health reforms in the country and analyzed the political rhetoric that accompanies them. The workshop ended with Pascal Grosse's presentation on the connection of Public Health and colonialism in Sub-Saharan Africa today.

The workshop contributed to an intensive exchange among the participants by sharing expertise and different perspectives on the two countries. Furthermore, two focus group discussions that were conducted during the last day will contribute to the work on a comparative case study of the developments of the healthcare system in the two countries. Beyond the scope of the workshop, the possibility of a long-term exchange within the group and a joint publication was discussed.


Contact:
Dr. Lorraine Frisina Doetter
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-58561
E-Mail: frisina@uni-bremen.de

Julian Götsch
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 5
28359 Bremen
Phone: +49 421 218-58540
E-Mail: goetschj@uni-bremen.de

@ Pixabay (RosZie)
@ Pixabay (RosZie)
Within the frame of the A07 project “Global Dynamics of Long-term Care Policies”, the team supervised by Heinz Rothgang and Simone Leiber is looking to implement innovative research on long- term care systems in international comparison.

A particular aspect of the A07 project is the application of case vignettes to investigate the inclusiveness of different benefits schemes in a selected sample of countries. The goal is to identify and assess the legislative strength and relevance of various factors influencing eligibility, with particular attention to care needs, cognitive limitations, and socio-economic conditions. To properly discuss the implementation and select the variables and eligibility conditionalities to include in the vignettes, the A07 team is organising two workshops with a group of renowned international experts with extensive knowledge on the topic of long-term care, who agreed to support and consult the team throughout the process.

Using vignette cases allows for combining the details and complexity of real-life scenarios with experimental designs’ variable modifications, which in turn provides the chance to assess the relevance of a single variable. While this methodology is mainly applied to interpret individual judgement, beliefs, and intended conduct, team A07’s approach to the methodology is different as it profiles the method to be used in the field of social policy, where vignette studies are still underused. In this application, the vignettes present different carefully constructed profiles of people needing long-term care through constructed descriptions, including various aspects of needs for care, economic situation, family constitution, and living conditions. The vignettes, obtained by the symmetrical and orthogonal combination of the selected variables from these fields, are then going to be presented through a questionnaire to a group of respondents with in-depth knowledge of the single long-term care systems eligibility assessment methodologies to evaluate which benefits could be granted to the different profiles in each country. Against the background of the A07 project’s aim, which pays particular attention to the risk of dementia in long-term care, the role of the syndrome in granting potential access to benefit schemes will be under scrutiny.

The results will then be analysed quantitatively to identify correlations between specific conditionalities and the inclusion in the target population for particular types of benefits.

The first and more informational meeting took place on Thursday, the 23rd of March, 2023. It produced a fascinating discussion on the methodology and the aspects and factors that need to be considered to make the application of the method feasible while balancing the intrinsic trade-off between depth and case complexity that using vignettes requires. Building on the feedback obtained in the first meeting, the A07 team plans to organise a draft formulation of the different vignettes and the questionnaire for data collection. The second meeting with the consulting experts will take place on the 24th of May, 2023, and will focus on reviewing and refining the drafted vignettes before finalising the questionnaire.


Contact:
Prof. Dr. Simone Leiber
CRC 1342: Global Dynamics of Social Policy, Faculty of Education
Universitätsstraße 2
45141 Essen
Phone: +49 201 183-2319
E-Mail: simone.leiber@uni-due.de

Prof. Dr. Heinz Rothgang
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-58557
E-Mail: rothgang@uni-bremen.de

Dr. Lorraine Frisina-Doetter (SOCIUM and CRC 1342 member) served as rapporteur for the WHO/Europe at their first-ever “Health in the Well-Being Economy” Regional Forum on 1-2 March 2023 at UN City, Copenhagen, DK.

Building on the growing awareness of the importance of health to well-being economies, the Forum demonstrated how countries are already shifting investment, spending and resources.
The Forum also focused on actions needed to be taken going forward, as the European Region faces the interlinked challenges of climate change, the war in Ukraine, the COVID-19 pandemic and the cost-of-living crisis. These challenges are placing health, social care and welfare systems under strain, and widening health inequities across the Region.

The event gathered high-level representatives from ministries of health, finance and economy, together with government advisors working on recovery, resilience and sustainable development policies, public health policy-makers, and representatives of national and international banks, nongovernmental organizations, the United Nations and European Union agencies.

Key speakers included: Dr Hans Henri P. Kluge, WHO Regional Director for Europe; Katrin Jakobsdóttir, Prime Minister of Iceland; Professor Mario Monti, Former Prime Minister of Italy and European Commissioner; Professor Sir Michael Marmot, Director, Institute of Health Equity, University College London.


Contact:
Dr. Lorraine Frisina Doetter
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-58561
E-Mail: frisina@uni-bremen.de

Johanna Fischer
Johanna Fischer
Fischer has studied the development of social policy in the field of long-term care both in a comparative and conceptual perspective.

Johanna Fischer is working in project A04 "Global Developments in Health Systems and Long-Term Care as a New Social Risk" and has written her doctoral thesis entitled "The Emergence of Social Policy in the Field of Long-term Care. A Comparative Analysis of the Introduction and Types of Long-term Care Systems in a Global Perspective".

Her work is based on three papers:


Johanna Fischer's work includes the first comprehensive comparative study on the introduction of long-term care systems worldwide and the development of a multi-dimensional, actor-centred typology of long-term care systems. Based on this, she has presented a systematic international comparison of long-term care systems and especially of social insurance-based long-term care systems.


Contact:
Dr. Johanna Fischer
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-57074
E-Mail: johanna.fischer@uni-bremen.de

Gabriela de Carvalho, Johanna Fischer
Gabriela de Carvalho, Johanna Fischer
Johanna Fischer and Gabriela de Carvalho explain in an interview how the country reports are produced and what added value they offer compared to other sources.

The twentieth issue of the CRC 1342 Social Policy Country Briefs was published a few days ago. On this occasion, could you briefly explain what this series is about?

Johanna Fischer: The series consists of short reports which each focus on a specific social policy field in an individual country. For instance, the latest two reports were published on the The Health Care System in Bulgaria (No 19) and the The Long-Term Care System in Sweden (No 20). In line with the CRC’s current focus on social policy emergence, the Country Briefs focus on the introduction of social protection policies and systems and their further development until today. The aim of the series is to give country and policy experts the opportunity to share their knowledge in a semi-structured format, to disseminate the information through the online open access publications, and to shed light on under-researched cases, in particular those found beyond high-income economies.

How did this series come about?

Gabriela de Carvalho: Within our project A04 on the Global Developments in Health Care Systems and Long-term Care as a New Social Risk (as well as the CRC as a whole), we are collecting a lot of data for instance on the introduction points of health and long-term care systems, their characteristics, and subsequent reforms. From this we have plenty of indicators which are stored in the CRC’s Global Welfare State Information System (WeSIS) and can be used by us and others for research. However, this information is contained into – mainly – categorical and numerical indicators. We have established the Country Brief Series to complement these datasets with more in-depth descriptions in a story-telling format and information that country experts or team members have accumulated. We thought that it would be a pity if this comprehensive knowledge about health and long-term care system beginnings and development would not be recorded and published. For the future it is planned that the Country Briefs will also be stored in WeSIS as an additional country-based resource.

What is the particular benefit of the series compared to existing social policy country profiles?

Johanna Fischer: There are several benefits of the CRC 1342 Social Policy Country Briefs which are not fully covered by other publication series. One is the explicit historical focus – in line with the CRC’s research agenda – on the initial introduction and further chronological development of social protection systems. Other publications do focus much more on providing a snapshot of the currently existing systems. However, we think it is important to contextualise current developments with a thorough understanding of their historical trajectories to understand why they look like as they do today and also for comparing countries at different stages of development.

Gabriela de Carvalho: We also emphasise the role of the state in health and long-term care systems, and the different ways in which this actor took responsibility for health and elder care. Even though we plan to publish briefs on all countries of the world, we particularly target under-researched cases from the Global South. Examples are the reports on the healthcare systems of Equatorial Guinea and Mozambique which are currently under review.

Gabriela, you have written the first issue of the series - what is the biggest challenge in such a report?

Gabriela de Carvalho: The biggest challenge in writing such a report is, I would say, the 'novelty' of the content. As here at the CRC we have an explicit interest in historical developments and the role of the state in social policies, our country briefs shed light on these topics, which is different from existing descriptions of social policies. Therefore, a historical analysis and reflection of each case is necessary before producing the report.

There are also conceptual challenges: For instance, experts have different ways to measure and operationalise what a system is, and when a system starts. This requires an open and constant dialogue between the editors of the series (the A04 project) and the authors.

Further, data availability differs greatly among countries. Authors often need to slightly adapt the provided template to accommodate for issues of data availability and reliability.

How do you choose the topics of the issues (policy field and country)?

Johanna Fischer: At the moment we are working on the both policy fields covered by our project, that is health and long-term care. As for the countries, we have started mostly with the ones where we had an established contact to potential authors for instance because they had participated in our expert surveys already. Furthermore, we tried to cover a diverse set of countries situated in different regions. Our aim is explicitly to cover cases outside the standard Northern/Western country samples often analysed, even though we are of course happy to also include reports on the more well-known cases. For long-term care, for instance, many reports have so far focused on the long-standing members of the Organisation for Economic Co-operation and Development or the European Union. We are therefore happy that we were already able to extend this sample, for instance with the Country Briefs on Uruguay, Costa Rica, Taiwan, Singapore, Ukraine, and Serbia.

Gabriela de Carvalho: In the case of healthcare, reports on countries such as Jamaica, Mozambique, Albania, and Mexico have already been published or are currently under review.

Will the series cover other policy fields in the future as well?

Johanna Fischer: We are open to extend the series to other policy fields. In the future we would therefore like to more closely collaborate with other CRC projects to make this happen.


Contact:
Dr. Gabriela de Carvalho
Dr. Johanna Fischer
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-57074
E-Mail: johanna.fischer@uni-bremen.de

Gabriela de Carvalho, Jakob Henninger
Gabriela de Carvalho, Jakob Henninger
De Carvalho studied the role of global actors in shaping health systems in the Global South, Henninger the interplay of immigration and social policy in authoritarian regimes.

Gabriela de Carvalho's thesis is titled "The role of global actors in shaping healthcare systems: Advancing analytical frameworks to better portray the empirical reality of Global South countries" and was graded "magna cum laude".

The primary aim of her dissertation is to analyse the role global actors play in shaping healthcare systems in Global South countries in order to advance typological work to better portray the empirical manifestations of healthcare systems worldwide, especially in middle and low income nations. My dissertation consists of three papers: The first study empirically examines whether and how IOs, more precisely the World Bank (WB), influence the (legal) foundations of healthcare systems in the nations of the Global South (Article A). The second investigation consists of a systematic literature review of the scholarship on healthcare system typologies to verify whether existing frameworks (a) take into account the increasing role global actors play in healthcare system arrangements, and (b) are able to portray the universe of healthcare systems worldwide, with a special focus on LMICs (Article B). Finally, a conceptual and analytical framework of healthcare systems to display and compare arrangements is proposed, taking into consideration the particularities of Global South systems (Article C).

Article A:
de Carvalho, G. (2021). The World Bank and healthcare reforms: A cross-national analysis of policy prescriptions in South America. Social Inclusion (in press).

Article B:
de Carvalho, G., Schmid, A., & Fischer, J. (2021). Classifications of healthcare systems: Do existing typologies reflect the particularities of the Global South? Global Social Policy, 21(2), 278–300. https://doi.org/10.1177/1468018120969315

Article C:
Frisina Doetter, L., Schmid, A., de Carvalho, G., & Rothgang, H. (2021). Comparing apples to oranges? Minimising typological biases to better classify healthcare systems globally. Health Policy OPEN, 2, 1–8. https://doi.org/10.1016/j.hpopen.2021.100035

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Jakob Henninger's doctoral thesis is entitled "The Politics of Immigration and Social Protection in Electoral-Authoritarian Regimes" and was graded "summa cum laude" (examination committee: Susanne K. Schmidt, Friederike Römer, Christian Joppke, Heiko Pleines, Patrick Sachweh, Johanna Kuhlmann).

Jakob Henninger's findings include:

  • Concerns about immigration are more likely to lead to an increase in demand for social security in authoritarian regimes than in democracies.
  • Questions in parliament are also a means for opposition MPs to criticise the government's immigration policy in electoral authoritarian regimes.
  • In electoral authoritarian regimes, the goals and actions of civil society organisations advocating for immigrants' rights are significantly weaker than in democratic states.


A paper on which the thesis is based has already been published:
Choose your battles: How civil society organisations choose context-specific goals and activities to fight for immigrant welfare rights in Malaysia and Argentina, with Friederike Römer (2021) in Social Policy & Administration. Two further papers are existing as manuscripts.


Contact:
Dr. Gabriela de Carvalho
Dr. Jakob Henninger
DeZIM e.V.
Mauerstraße 76
10117 Berlin
E-Mail: jakob.henninger@uni-bremen.de

The co-director of project A04 was invited to the podcast run by the City College of New York to talk about health care systems in the Global North and South, global trends and challenges doing research on these topics.

Rights Talk is a City College of New York podcast that addresses current human rights challenges around the world. The podcast invites critical perspectives and questions the future of rights in the twenty-first century.

Lorraine Frisina Doetter, co-director of the CRC project A04 Global Developments in Health Care Systems and Long-term Care as a New Social Risk spoke on the podcast about health care around the world and challenges in comparative health care systems research.

Among other topics, Frisina Doetter touched on topics like health care as a human right, global trends challenging healthcare systems around the world, the inefficiencies of the Us healthcare system and its resistance to change.

Frisina Doetter also presented the work being done at CRC 1342 and the challenges of doing comparative healthcare systems research on a global level: (1) the availability of data, especially historic data on healthcare in the Global Sout, and (2) How to arrive at concepts that can be universally applicable and still meaningful. "Most scholars have a very specific understanding of a health care system with doctors and nurses trained in biological studies as the core", Frisina Doetter says. Other actors are being neglected as well as so called alternative medicine, which is a functional equivalent in many societies. "These and other functional equivalence should not be missed/neglected in our research. We need to develop concepts that capture that in our comparisons. In order to do this, we need to examine our normative and epistemic biases."

Listen to the episode of Rights Talk:
The Right to Health in Comparative Perspective: the WHO, North-South Systems, and Transnational Interdependencies with Dr. Lorraine Frisina Doetter


Contact:
Dr. Lorraine Frisina Doetter
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-58561
E-Mail: frisina@uni-bremen.de

Dr. Achim Schmid, Gabriela de Carvalho, Johanna Fischer (left to right)
Dr. Achim Schmid, Gabriela de Carvalho, Johanna Fischer (left to right)
Gabriela de Carvalho explains in an interview why existing typologies of health care systems have a strong Global North bias and why this is problematic.

Gabriela de Carvalho, Achim Schmid and Johanna Fischer have examined the literature on health care system classifications. The existing typologies, the team has found, have a strong Global North bias and thus fail to capture important features of health care systems of the Global South. Gabriela de Carvalho, the first author of the paper published in Global Social Policy, explains some details of their findings and what this means for researchers and policy makers.

You have reviewed the literature for existing classifications of health care systems and found that they are poorly suited to support research on the Global South. What is the reason?

Gabriela de Carvalho: The main goal of our research was to evaluate the health care system typology literature and its ability to capture the particularities of health care systems of the Global South. The findings of our study points to limitations of several features of existing typologies: their coverage, methods used, and criteria they build on. Regarding coverage, health care systems of LMICs (low- and middle-income countries) are rarely taken into consideration in the literature, as classified cases consist of a 1:5 ratio of Global South to Global North countries. With respect to methods, the overreliance on inductive approaches to classification often excludes countries that cannot be measured in numeric terms. Health statistics mostly focus on the Global North, and has only recently included more data on countries from the South, hampering the analysis of arrangements beyond high-income nations. The use of inductive typologies to classify systems may result in poorly informed classifications especially if the study aims at the creation of a tool for applicability beyond their sample of cases. With regard to the criteria and characteristics health care systems are compared by, dominant features of health care systems that mostly exist in LMICs such as the segmentation of the system for different population groups, are not taken into consideration in many typologies. This often results in typologies that do not capture the empirical reality of the South.

In your paper you write that the health care systems in many countries of the Global South are very different from those of the Global North. What are the most important points?

Gabriela de Carvalho: All health care systems regardless of the country face numerous challenges and the current pandemic made this even more evident. Still, it is undeniable that systems of the Global South endure even greater financial and technical constraints. Besides larger disparities in health care per capita spending, number of health care professionals, and burden of diseases, LMICs are more prone to rely on international actors (transnational organisations, INGOs, and third countries) to finance, provide services and even regulate their systems. Another very important characteristic of many health care systems of the Global South is segmentation, the coexistence of different schemes targeting different population groups according to income, social status and/or type of employment. As a general rule, the poor are beneficiaries of public services due to their exclusion from formal employment, while the upper classes are covered by social and/or private insurance. This stratification leads to extensive health inequalities, as public services only provide basic care, and supplementary services are only used by those who are able to afford them.

What do you see as the reasons why these aspects have not been sufficiently considered in the classification literature so far?

Gabriela de Carvalho: In general, we believe that scientific research is still concentrated in and revolve around OECD countries due to data availability, financial and technical resources, institutional capacity, and the interest of researchers. Of course, recent decades have seen an expansion of (health care systems) scholarship on LMICs, mainly in the form of in-depth case studies, but it still lacks in comparison to the Global North literature, especially when systematic comparison is concerned. If more varied cases are not taken into account, the literature will continue to only partially represent the empirical reality, amplifying the ‘invisibility’ of less studies countries/regions. Particularly to the scholarship we are analysing, it is clear that classification and the development of meaningful typologies is much more complicated when dealing with countries of the Global South. Reasons for that vary from segmentation/parallel (public) systems, parts of the population and/or health services left to markets, and the existence of less „mature”systems. While systems found in the Global North can also be mixed or hybrids in some way, it is much harder to condense the information and assign an LMIC to an ideal type.

What are the consequences of the mismatch between the existing classifications in the literature and the health systems existing in the Global South - for scientific research and for practice/policy?

Gabriela de Carvalho: As the literature often relies on health care systems of the Global North to develop classificatory tools, it seems reasonable to assume that the models resulting from these typologies are more prominent and influential in shaping researchers and policymakers’ ideas of what a health care system does – and should – look like. We argue that high-income examples can be (mis)interpreted as portraying ‘best’ models or ‘benchmarks’, which may lead to standard setting for other countries, disregarding particular and fundamental characteristics of health care systems in LMICs. This could also translate into policy advice being modelled in terms of the well-known types. For scientific research, this bias towards the North may hinder novel knowledge production that could potentially focus on less analysed cases, as research tends to gravitate around seminal works, leaving aside unfamiliar cases or new theoretical considerations.


Read the full paper (Open Access): Classifications of health care systems: Do existing typologies reflect the particularities of the Global South?

More about the research of Gabriela de Carvalho, Achim Schmid and Johanna Fischer and the whole project A04 team:
Global Developments in Health Care Systems and Long-term Care as a New Social Risk


Contact:
Dr. Gabriela de Carvalho
Dr. Johanna Fischer
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-57074
E-Mail: johanna.fischer@uni-bremen.de

Dr. Achim Schmid
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-58526
E-Mail: aschmid@uni-bremen.de