From «Planning» to «Systems Analysis»: Health services strengthening at the World Health Organisation, 1952–1975

Abstract

This article discusses the early postwar history of international engagement with the strengthening of health services by the World Health Organisation (WHO). Standard narratives emphasise that the WHO prioritised vertical programmes against specific diseases rather than local capacity-building, at least until the Alma Ata Declaration of 1978 launched a policy focus on primary health care. There was, however, a longer lineage of advisory work with member states, and our aim is to examine this intellectual and policy history of health services planning and administration. We begin by surveying the relevant secondary literature, noting that this theme appears only briefly in the institution's first official histories, with minimal contextualisation and analysis. We then proceed chronologically, identifying an early phase in the 1950s when, despite its marginalisation at the WHO, the interwar European social medicine tradition kept alive its ideals in work on health planning. However, the sensitivities of the USA and of the colonial powers meant that consideration of social security, health rights and universal coverage was absent from this discussion. Instead it was initially concerned with propounding Western models of organisation and administration, before switching to a focus on planning techniques as an aspect of statecraft. In the 1960s such practices became incorporated into economic development plans, aligning health needs with infrastructure and labour force requirements. However, these efforts were entangled with Western soft power, and proved unsuccessful in the field because they neglected issues of financing and capacity. In the 1970s the earlier planning efforts gave rise to a systems analysis approach. Though in some respects novel, this too provided a neutral, apolitical terrain in which health policy could be discussed, void of issues of rights and redistribution. Yet it too foundered in real-world settings for which its technocratic models could not account.

Power analysis in health policy and systems research: a guide to research conceptualisation

“…Power dynamics have also influenced health systems planning and research, by defining what is seen as a health system, and the translation or adaptation of health systems models across distinct geographic contexts over time. 4 5 …”

Global Health: Definition, Principles, and Drivers

“…However, over the years the limitations, for example, of achieving large-scale vaccination coverage to address child health, in many low-and middle-income countries led away from this largely horizontal focus to greater attention on health systems and the focus on primary health care. The pivotal moment here was certainly the declaration of Alma Ata with the aim of Health for All by the year 2000 (Gorsky and Sirrs 2019). While certainly an enduring concept and one that many see as the origins of today's focus on the concept of Universal Health Coverage, as well as the strategy underlying the Sustainable Development Goal (SDGs) 3 to achieve health and well-being for all, the commitment to universality quickly became eroded and replaced not least due to funding constraints with the concept of selective primary health care (Newell 1988).…”

Global health in the making: health demonstration areas in Europe, 1950s and 1960s

“…As a British consultant recorded in 1967, this issue lay at the core of professional public health theories at that time (Brockington, 1967). Meetings of the Expert Committee on Public Health Administration held in 1951, 1953 and 1959 put forward recommendations and plans for devising basic schemes, as noted by Gorsky and Sirrs (2019), to provide "reasonably adequate health coverage of the total population" (WHO, 1968, p.22).…”

“…Still, I believe insufficient research has been dedicated to the history of health service planning and administration, an inner thread in the Organisation's fabric which significantly contributed to its development as an international actor, in the sense applied by Chorev (2012). Cueto (2004Cueto ( , p.1866 has pointed out that, from the late 1960s, increasing numbers of WHO projects were related to basic health services, which he views as the "institutional predecessors" of the primary health care programmes, while Gorsky and Sirrs (2019) have recently focused on the lineage of advisory work carried out by the WHO concerning health services and explored the intellectual history of health service organisations.…”

“…The study of local case projects by the WHO in health services during the 1950s and 1960s in the health services domain enables us to uncover some of these paths and locate valid explanatory clues. By following the patterns of the organisation and implementation of the health demonstration and teaching areas as a model of basic rural health services, my approach complements the theoretical stance taken by Gorsky and Sirrs (2019).…”