Bloom Gerald, Standing Hilary, Lloyd Robert
The Institute of Development Studies, Brighton, UK.
Soc Sci Med. 2008 May;66(10):2076-87. doi: 10.1016/j.socscimed.2008.01.034. Epub 2008 Mar 7.
This paper explores the implications of the increasing role of informal as well as formal markets in the health systems of many low and middle-income countries. It focuses on institutional arrangements for making the benefits of expert medical knowledge widely available in the face of the information asymmetries that characterise health care. It argues that social arrangements can be understood as a social contract between actors, underpinned by shared behavioural norms, and embedded in a broader political economy. This contract is expressed through a variety of actors and institutions, not just through the formal personnel and arrangements of a health sector. Such an understanding implies that new institutional arrangements, such as the spread of reputation-based trust mechanisms can emerge or be adapted from other parts of the society and economy. The paper examines three relational aspects of health systems: the encounter between patient and provider; mechanisms for generating trust in goods and services in the context of highly marketised systems; and the establishment of socially legitimated regulatory regimes. This analysis is used to review experiences of health system innovation and change from a number of low income and transition countries.
本文探讨了非正式市场和正式市场在许多低收入和中等收入国家卫生系统中日益重要的作用所带来的影响。它关注的是在医疗保健存在信息不对称的情况下，如何通过制度安排使专家医学知识的益处得以广泛传播。文章认为，社会安排可被理解为行为主体之间的社会契约，以共同的行为规范为支撑，并嵌入更广泛的政治经济之中。这种契约通过多种行为主体和机构来体现，而不仅仅是通过卫生部门的正式人员和安排。这样的理解意味着，诸如基于声誉的信任机制的传播等新的制度安排可以从社会和经济的其他部分产生或加以调整。本文考察了卫生系统的三个关系层面：患者与提供者之间的接触；在高度市场化系统中建立对商品和服务信任的机制；以及建立具有社会合法性的监管制度。这一分析被用于审视一些低收入国家和转型国家卫生系统创新与变革的经验。
