Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts

Abstract

BackgroundThis paper explores the evolution of schemes for rural finance in China as a case study of the long and complex process of health system development. It argues that the evolution of these schemes has been the outcome of the response of a large number of agents to a rapidly changing context and of efforts by the government to influence this adaptation process and achieve public health goals.MethodsThe study draws on several sources of data including a review of official policy documents and academic papers and in-depth interviews with key policy actors at national level and at a sample of localities.ResultsThe study identifies three major transition points associated with changes in broad development strategy and demonstrates how the adaptation of large numbers of actors to these contextual changes had a major impact on the performance of the health system. Further, it documents how the Ministry of Health viewed its role as both an advocate for the interests of health facilities and health workers and as the agency responsible for ensuring that government health system objectives were met. It is argued that a major reason for the resilience of the health system and its ability to adapt to rapid economic and institutional change was the ability of the Ministry to provide overall strategy leadership. Additionally, it postulates that a number of interest groups have emerged, which now also seek to influence the pathway of health system development.ConclusionsThis history illustrates the complex and political nature of the management of health system development and reform. The paper concludes that governments will need to increase their capacity to analyze the health sector as a complex system and to manage change processes.

The role of health system governance in strengthening the rural health insurance system in China

“…From 2003 to 2005, NCMS pilots were conducted in approximately 300 counties; and in 2006 a large-scale evaluation of already implemented NCMS was conducted [49]. All these pilots and evaluations helped to inform the final design of NCMS [10, 11].

“ The many efforts to re-establish a social health financing scheme in rural areas during the 1990s provided very useful lessons for policy makers.

…”

Determinants of village doctors’ job satisfaction under China’s health sector reform: a cross-sectional mixed methods study

“…The only research on this topic was carried out in one province and suggested that the job satisfaction of village doctors was low [18]. However, it did not discuss the relevant policy factors and how they affect job satisfaction and using data from only one province ignores the varied economic status and health reform processes among different areas of China [19–21]. The purpose of this mixed-method study is to describe village doctors’ job satisfaction under the context of health sector reform and investigate the associated factors, using a survey data from three provinces.…”

Exploring community participation in project design: application of the community conversation approach to improve maternal and newborn health in Zambia

“…Engaging communities often requires a form of “social contract” that defines clear roles and contributions from all parties [8, 9]. In this study, both the community and the project obligations were used to define a “social contract” agreed to by the community members that responsible parties can be held accountable through local leaders.…”