The political economy of 'strengthening health services': The view from WHO AFRO, 1951-c.1985.

Our contribution to this special issue examines the early history of international striving for universal health care, from the perspective of the World Health Organisation's (WHO's) Regional Office for Africa (AFRO). The aspiration was repeatedly reframed, from 'strengthening health services' in the 1948 constitution of the World Health Organisation (WHO), to 'Health For All' through primary health care (PHC) in the 1970s, to today's articulations of universal coverage and 'health systems strengthening'. We aim to establish how AFRO supported member states in implementing these policies up to the mid-1980s, and with what degree of success. We also compare AFRO's experience to the established historiographical narrative of global health, as over-fixated on vertical interventions, save for the transitory impact of the PHC movement. Using the archives of WHO in Geneva and AFRO in Brazzaville, we first analyse AFRO's influence and capacity through quantitative financial data. The AFRO nations were net recipients of WHO resources, raising questions about their relative autonomy and voice in the organisation. We then examine AFRO's expenditure, showing that though circumscribed by funds with allocated purposes, there was nonetheless a significant proportion committed to services from the early 1960s, specifically capacity for planning and administration and the nursing, maternal and child health workforce. Counter to expectations though, there was no significant boost to these areas, nor to funding PHC projects, in the 1970s/early 1980s, when disease-specific interventions obtained a larger share. Qualitative sources show that despite its slender resources AFRO accomplished much with respect to training, capacity building and supporting innovative service-delivery, while insisting on African policy input into design and implementation. However country level system-wide planning in health was persistently vulnerable, and the bureaucratic capacity of post-colonial states often weak. Thus AFRO's overall impact was decisively bounded by the global structural inequalities in which it operated.

Interrogating the World Bank's role in global health knowledge production, governance, and finance.

BACKGROUND: In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping 'global health' in the current era? MAIN BODY: As a group of historians, social scientists, and public health officials with experience studying the effects of the institution's investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank's position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank's influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda. CONCLUSIONS: As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank's financial and technical investments in the Global South.

Universal health coverage as a global public health goal: the work of the International Labour Organisation, c.1925-2018.

We examine the efforts of the International Labour Organisation (ILO) to extend medical care under social security, through international conventions, advocacy and technical assistance. We consider the challenges faced by the ILO in advancing global health coverage through its labourist, social security model. The narrative begins in the interwar period, with the early conventions on sickness insurance, then discusses the rights-based universalistic vision expressed in the Philadelphia Declaration (1944). We characterize the ILO's postwar research and technical assistance as "progressive gradualism" then show how from the late-1970s the ILO became increasingly marginalized, though it retained an advisory role within the now dominant "co-operative pluralistic" model.

Universal health coverage as a global public health goal: the work of the International Labour Organisation, c. 1925-2018 / Cobertura universal como meta global de saúde pública: o trabalho da Organização Internacional do Trabalho, c. 1925-2018

Abstract We examine the efforts of the International Labour Organisation (ILO) to extend medical care under social security, through international conventions, advocacy and technical assistance. We consider the challenges faced by the ILO in advancing global health coverage through its labourist, social security model. The narrative begins in the interwar period, with the early conventions on sickness insurance, then discusses the rights-based universalistic vision expressed in the Philadelphia Declaration (1944). We characterize the ILO's postwar research and technical assistance as "progressive gradualism" then show how from the late-1970s the ILO became increasingly marginalized, though it retained an advisory role within the now dominant "co-operative pluralistic" model.

Resumo Analisamos os esforços da Organização Internacional do Trabalho (OIT) em ampliar o cuidado médico sob seguridade social, via convenções, amparo e assistência técnica internacionais. Consideramos os desafios da OIT no desenvolvimento da cobertura global de saúde por meio do modelo trabalhista e de seguridade social. A narrativa inicia no período entreguerras, com as primeiras convenções sobre seguro saúde, depois discute a visão universalista baseada em direitos da Declaração da Filadélfia (1944). Classificamos a pesquisa e a assistência da OIT no pós-guerra como "gradualismo progressivo" e mostramos como, a partir do final da década de 1970, a OIT foi marginalizada, embora mantivesse um papel de conselheira dentro do atual modelo "pluralista cooperativo" dominante.

A path dependence analysis of hospital dominance in China (1949-2018): lessons for primary care strengthening.

Although China's community health system helped inspire the 1978 Alma Ata Declaration on Health for All, it currently faces the challenge of strengthening primary care in response to hospital sector dominance. As the world reaffirms its commitment towards primary health services, China's recent history provides a salient case study of the issues at stake in optimizing the balance of care. In this study, we have used path dependence analysis to explain China's coevolution of hospital and primary care facilities between 1949 and 2018. We have identified two cycles of path-dependent development (1949-78 and 1978-2018) involving four sets of institutions related to medical professionalization, financing, organization and governance of health facilities. Both cycles started with a critical juncture amid a radically changing societal context, when institutions favouring hospitals were initiated or renewed, leading to a process of self-reinforcement empowering the hospitals. Later in each cycle, events occurred that modified this hospital dominance. However, pro-primary care policies during these conjunctures encountered resilience from the existing institutional environment. The result was continued consolidation of hospital dominance over the long term. These recurrent constraints suggest that primary care strengthening is unlikely to be successful without a comprehensive set of policy reforms driven by a primary care coalition with strong professional, bureaucratic and community stakes, co-ordinated and sustained over a prolonged period. Our findings imply that it is important to understand the history of health systems in China, where the challenges of health systems strengthening go beyond limited resources and include different developmental paths as compared with Western countries.

From «Planning¼ to «Systems Analysis¼: Health services strengthening at the World Health Organisation, 1952-1975.

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.

Health Planning in 1960s Africa: International Health Organisations and the Post-Colonial State.

This article explores the programme of national health planning carried out in the 1960s in West and Central Africa by the World Health Organization (WHO), in collaboration with the United States Agency for International Development (USAID). Health plans were intended as integral aspects of economic development planning in five newly independent countries: Gabon, Liberia, Mali, Niger and Sierra Leone. We begin by showing that this episode is treated only superficially in the existing WHO historiography, then introduce some relevant critical literature on the history of development planning. Next we outline the context for health planning, noting: the opportunities which independence from colonial control offered to international development agencies; the WHO's limited capacity in Africa; and its preliminary efforts to avoid imposing Western values or partisan views of health system organisation. Our analysis of the plans themselves suggests they lacked the necessary administrative and statistical capacity properly to gauge local needs, while the absence of significant financial resources meant that they proposed little more than augmentation of existing structures. By the late 1960s optimism gave way to disappointment as it became apparent that implementation had been minimal. We describe the ensuing conflict within WHO over programme evaluation and ongoing expenditure, which exposed differences of opinion between African and American officials over approaches to international health aid. We conclude with a discussion of how the plans set in train longer processes of development planning, and, perhaps less desirably, gave bureaucratic shape to the post-colonial state.

The Rise and Fall of "Universal Health Coverage" as a Goal of International Health Politics, 1925-1952.

The UN Sustainable Development Goals of 2015 have restored universal health coverage (UHC) to prominence in the international health agenda. Can understanding the past illuminate the prospects for UHC in the present? This article traces an earlier history of UHC as an objective of international health politics. Its focus is the efforts of the International Labor Organization (ILO), whose Philadelphia Declaration (1944) announced the goal of universal social security, including medical coverage and care. After World War II, the ILO attempted to enshrine this in an international convention, which nation states would ratify. However, by 1952 these efforts had failed, and the final convention was so diluted that universalism was unobtainable. Our analysis first explains the consolidation of ideas about social security and health care, tracing transnational policy linkages among experts whose world view transcended narrow loyalties. We then show how UHC goals became marginalized, through the opposition of employers and organized medicine, and of certain nation states, both rich and poor. We conclude with reflections on how these findings might help us in thinking about the challenges of advancing UHC today.

Resource Allocation for Equity in the British National Health Service, 1948-89: An Advocacy Coalition Analysis of the RAWP.

Britain's National Health Service (NHS) is a universal, single-payer health system in which the central state has been instrumental in ensuring equity. This article investigates why from the 1970s a policy to achieve equal access for equal need was implemented. Despite the founding principle that the NHS should "universalize the best," this was a controversial policy goal, implying substantial redistribution from London and the South and threatening established medical, political, and bureaucratic interests. Our conceptual approach draws on the advocacy coalition framework (ACF), which foregrounds the influence of research and ideas in the policy process. We first outline the spatial inequities that the NHS inherited, the work of the Resource Allocation Working Party (RAWP), and its new redistributive formula. We then introduce the ACF approach, analyzing the RAWP's prehistory and formation in advocacy coalition terms, focusing particularly on the rise of health economics. Our explanation emphasizes the consensual commitment to equity, which relegated conflict to more technical questions of application. The "buy-in" of midlevel bureaucrats was central to the RAWP's successful alignment of equity with allocative efficiency. We contrast this with the failure of advocacy for equity of health outcomes: here consensus over core beliefs and technical solutions proved elusive.

Public health and English local government: historical perspectives on the impact of 'returning home'.

This article uses history to stimulate reflection on the present opportunities and challenges for public health practice in English local government. Its motivation is the paradox that despite Department of Health policy-makers' allusions to 'a long and proud history' and 'returning public health home' there has been no serious discussion of that past local government experience and what we might learn from it. The article begins with a short resumé of the achievements of Victorian public health in its municipal location, and then considers the extensive responsibilities that it developed for environmental, preventive and health services by the mid-twentieth century. The main section discusses the early NHS, explaining why historians see the era as one of decline for the speciality of public health, leading to the reform of 1974, which saw the removal from local government and the abolition of the Medical Officer of Health role. Our discussion focuses on challenges faced before 1974 which raise organizational and political issues relevant to local councils today as they embed new public health teams. These include the themes of leadership, funding, integrated service delivery, communication and above all the need for a coherent vision and rationale for public health action in local authorities.

Hospitals, finance, and health system reform in Britain and the United States, c. 1910-1950: historical revisionism and cross-national comparison.

Comparative histories of health system development have been variously influenced by the theoretical approaches of historical institutionalism, political pluralism, and labor mobilization. Britain and the United States have figured significantly in this literature because of their very different trajectories. This article explores the implications of recent research on hospital history in the two countries for existing historiographies, particularly the coming of the National Health Service in Britain. It argues that the two hospital systems initially developed in broadly similar ways, despite the very different outcomes in the 1940s. Thus, applying the conceptual tools used to explain the U.S. trajectory can deepen appreciation of events in Britain. Attention focuses particularly on working-class hospital contributory schemes and their implications for finance, governance, and participation; these are then compared with Blue Cross and U.S. hospital prepayment. While acknowledging the importance of path dependence in shaping attitudes of British bureaucrats toward these schemes, analysis emphasizes their failure in pressure group politics, in contrast to the United States. In both countries labor was also crucial, in the United States sustaining employment-based prepayment and in Britain broadly supporting system reform.

The 'cultural inflation of morbidity' during the English mortality decline: a new look.

This article contributes to the debate about using insurance records to reconstruct historical experiences of sickness during the Western mortality transition. Critics regard these sources as problematic as they measure morbidity indirectly through absences from work; these might be determined not by timeless biological criteria but by more contingent factors, notably shifting norms surrounding the sick role and responses to economic incentives (for which we adopt the generic term 'cultural inflation of morbidity'). We review historical demographers' contributions to this literature and discuss the concepts of moral hazard and the principal/agent problem as developed by health economists. This leads us to frame three empirical tests for 'cultural inflation' which allow us to assess the validity of insurance records for deriving morbidity trends: was there an increasing frequency of claims for complaints of diminishing severity; were unduly prolonged claims noticeable, particularly by older people for whom sickness benefit may have compensated for income insecurity; and did the insurer satisfactorily manage the agency problem to ensure reliable physician gatekeeping? We analyse records of the Hampshire Friendly Society, an exceptionally well-documented fund operational in Southern England, 1825-1989. Findings are based on a dataset of individual sickness histories of a sample of 5552 men and on qualitative documentary analysis of administrative records. On each count our results fail to demonstrate a cultural inflation of morbidity, except perhaps for those aged over 65. However, occasional discussion in the administrative records of economic incentives encouraging unnecessary prolongation of claims means we cannot rule it out entirely.

Anti-alcohol posters in Poland, 1945-1989: diverse meanings, uncertain effects.

We provide a historical study of the anti-alcohol public health poster in Poland between 1948 and 1990. Our case study illuminates public health policies under communism, with the state as the dominant force in health communication. Poland has a distinctive history of poster art, moving from a Stalinist phase of socialist realism to the diverse styles of the later Polish School. Quantitative and qualitative analysis of 213 posters establishes the major themes and differentiates community approaches, which depict the drinker as a social or political deviant, from those emphasizing individual risk. Medical issues were a minor theme, reflecting public policies geared more toward confinement than treatment. However, Polish School artists used metaphor and ambiguity, and references to the contested cultural symbolism of drink, to complicate and subvert the narrow propaganda intent. Thus, although apparently unsuccessful in restraining overall consumption, these posters offer valuable lessons for policymakers on the use of visual media in health campaigns.

Community involvement in hospital governance in Britain: evidence from before the National Health Service.

An important goal of policy in the British National Health Service (NHS) is to increase public involvement in health care governance. In the hospital sector this led in 2003 to the establishment of foundation trusts with "membership communities," which aim to give local citizens a say in management. This is not the first attempt to introduce greater community participation in the running of British hospitals. Prior to the inception of the NHS in 1948, the hospital contributory scheme movement provided ordinary members of the public with the opportunity to sit on hospital management boards. The article examines the nature and extent of this earlier experiment with local democracy in hospital governance. It argues that historical precedent is not particularly encouraging, either for the prospect of broadening popular participation or for making services more responsive to local needs. Although today's context is very different, the tendency for managerial and professional interests to dominate the policy arena is a feature of both periods.

Public health in interwar England and Wales: did it fail?

British historians initially saw the interwar period as a "golden age" for public health in local government, with unprecedented preventive and curative powers wielded by Medical Officers of Health (MOsH). In the 1980s Lewis and Webster challenged this reading, arguing that MOsH were overstretched, neglectful of their "watchdog" role and incapable of formulating a new philosophy of preventive medicine. The article first details this critique, then reappraises it in the light of recent demographic work. It then provides a case study of public health administration in South-West England. Its conclusion is that some elements of the Lewis/Webster case now deserve to be revised.

Hospital contributory schemes and the NHS debates 1937-46: the rejection of social insurance in the British welfare state?

This article considers the discussion and rejection of social insurance model of funding for the British National Health Service. Specifically it asks why the hospital contributory scheme movement had so little impact on policy debates in the 1940s. We argue that at the start of the policy-making process serious consideration was given to the incorporation of this mode of funding, not least because the contributory schemes, with some ten million members, played a major role in financing existing voluntary hospital provision. Early sections describe the growth and nature of the schemes, noting that, despite their large working-class constituency and the presence of labour movement representatives amongst their leadership, they remained peripheral to discussion of reform in the interwar period. We then trace the emergence of the proposal for an insurance-based 'hotel-charge' in civil servants' discussions about hospital funding the Beveridge Report. Officials, however, remained sceptical about the contributory schemes' capacity to deliver a comprehensive and efficient funding mechanism, given their lack of uniformity, the gaps in their coverage, and the limited progress of reciprocal arrangements between them. Finally, we note the ineffectiveness of the British Hospital Contributory Schemes Association as a player in the policy community. Its leadership had no clear strategy for influencing events and was reluctant to deploy pressure group tactics such as lobbying through the press or parliament. Crucially, the movement was divided internally between those members who supported the voluntary system and others who welcomed a publicly funded health service.