Introduction
Future health systems: Why future? Why now?

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The historical legacy

Every society organises itself to help people avoid illness and cope with its effects, but “modern” health systems date from the creation of institutional arrangements to make the fruits of scientific knowledge and associated technologies available to the general population (Mokyr, 2002). This process began in the 17th Century and accelerated during the technological revolution of the past 150 years. From small beginnings, the health sector now accounts for around 9% of the global economy.

The

Health as a knowledge economy

Health systems are generally thought of as complex technical systems for organising specialised services (prevention, diagnostics and treatment) and goods (pharmaceuticals and equipment). We find it useful to start from a slightly different perspective – that is health systems as knowledge economies. They are ways of organising access to expert knowledge or expertise (defined as information plus interpretation and best judgement), embodied in both people and products, and in which multiple

Pluralism and its challenges

A combination of several secular trends is resulting in a challenge to the 20th Century model for making expert knowledge available to users. In particular, the boundary between the socialised health sector and a variety of economic activities concerned with health-related issues has become blurred. Key factors, with particular relevance to low-income and transition countries are:

  • Economic crises leading to state and institutional failures in access, delivery and regulation.

  • Rampant marketisation

Organisation of the Special Issue

One challenge we faced in constructing this Special Issue was to make evidence-based projections of future arrangements. We have employed a combination of approaches. The first is to rethink present understandings of health systems and the institutional arrangements that have been established. The second is to identify trends relevant to the development of health systems, such as economic, social and institutional changes, the emergence of new technologies and changing patterns of health need.

Conclusions

The papers in this Special Issue provide glimpses of new realities that are emerging in a number of low and middle-income countries. They reveal contexts much more complex than many debates about health system reform and development suggest. From very different starting points they all indicate the extent to which health systems are increasingly co-constructed by multiple actors, local, national and global. Many of these actors are powerful in ways that would have been unthinkable only decades

Acknowledgement

We would like to thank the workshop participants for their very insightful contributions and, ultimately, for the excellent papers many of them produced. We would particularly like to thank Chris Pell, who supported the preparation of the background papers. This paper is an output of the Future Health Systems Research Programme Consortium (www.futurehealthsystems.org). The authors express their appreciation for the financial support (Grant # H050474) provided by the UK Department for

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    The ideas for this Special Issue were first generated at a workshop on Future Health Systems at the Institute of Development Studies, University of Sussex in October 2004, made possible by a grant from the Institute's strategic development fund.

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