A Global Perspective on the History of Health Systems

Chris Sirrs

As my PhD research on health and safety comes to an end, I am delighted to be staying on at the Centre, as Research Assistant on Dr Martin Gorsky’s Wellcome Trust Investigator Award, ‘Health Systems in History: Ideas, Comparisons, Policies’.

Over the next three years, I will be grappling with a subject that is equally as complex, nebulous, and fascinating as the history of occupational health and safety regulation. In recent decades, the concept of ‘health systems’ has moved from the periphery to the centre of global health policy. This intriguing term suggests we can think about the organisation of medicine in an overarching and holistic way, describing the relationships that exist between health services, financing, policy and regulation at the level of the nation-state. The term ‘health system’ does not necessarily imply integration, public ownership, or centralised political control, although debates over these ideas were perhaps central to the concept’s evolution, as we we shall find out. For international health organisations such as the World Health Organization (WHO), the term denotes all the institutions, organisations and resources that contribute to health improvement in a country, whether or not these are related together in a planned way, or united under a national health service (such as the British NHS). One of the more controversial implications of systems-based thinking is that we can compare the health performance of individual countries, despite great diversity in the organisation of health services, populations, national wealth, and models of health financing. Moreover, by breaking down health systems into their component parts and objectives, systems logic implies that this performance can be measured: with the construction of indicators such as the Disability-Adjusted Life Year (DALY), policy makers have drawn up league tables (such as in the World Health Report 2000) which attempt to show at a glance how efficient, effective and equitable national health systems are.

As one might expect, systems-based thinking is inherently political and value-based—perhaps why this subject was of such great personal appeal, following my doctoral excursions into occupational health and safety! The concept of health systems brings to the fore issues of national sovereignty in relation to international political organisations, and also mobilises fiercely defended beliefs about how health care should be financed, distributed, organised and directed. Over the coming months, I will be exploring the historical precursors to these ideas and debates, identifying the metrics policy makers have used to compare and evaluate national health services, and situating these metrics within contemporary geopolitics and international health policy. In so doing, I aim to develop a genealogy of the concept, and show how it has evolved. This will tie into the wider aims of Martin’s Investigator Award, working alongside John Manton’s work on the application of the concept in the ‘Global South’, and a new PhD student, currently in recruitment.

Since beginning work on this project in mid-October, I have been eager to immerse myself in this new and unfamiliar subject. Already, I have delved head-first into the institutional politics and technical reports of international health bodies such as the WHO and former League of Nations Health Organization. In November, I accompanied Martin on a fact-finding trip to Geneva, where I carried out research in the archives of the League of Nations, International Labour Office (ILO), and WHO. I am grateful to the Centre for this exciting new opportunity, and look forward to exploring a subject of global relevance.

My interest and enthusiasm for health and safety, meanwhile, has not diminished. Following my viva in January—and depending on its results—I am looking to develop my doctoral research into a series of new journal articles, and possibly a book. These will add to an existing journal article in Social History of Medicine (available open access), and a forthcoming chapter in Tom Crook and Mike Esbester’s edited volume, Governing Risks in Modern Britain. Occupational health and safety potentially offers a lifetime of research, and is a subject I intend to return to in the future.