Improving Institutions: Ingredients, Not Recipes
the centralized authority of the state by creating an independent SHI agency with a steady funding flow and freeing provision from the constraints imposed by a sclerotic state. To a lesser extent, this pattern also unfolded in some post-Soviet states. This regionwide SHI “experiment” also ushered in new provider payment mechanisms, typically a shift from historical budgets to fee-for-service or approaches based on diagnosis-related groups (DRGs) (Wagstaff and Moreno-Serra 2009; Moreno-Serra and Wagstaff 2010). A related theme has been the decentralization of hospital ownership from the ministries of health to municipalities in many countries, again motivated partly by a desire to roll back the influence of central authorities and partly in the hope that local entities would be more responsive to population wishes. But this decentralization has arguably created as many problems as it has solved, as the hospitals became local political assets that SHI agencies had to contract with and could not shut down, thus hindering rationalization policies. Moreover, their municipal owners did not impose hard budget constraints, as funding flows and bailouts still came from the center (Preker and Harding 2003). A final reform area of note has been public health. Historically, the sanitary-epidemiological system was hierarchical and top heavy and had little interface with the population. In some countries, this reality has persisted, while in others, it has been replaced outright, while in still others, new and old structures operate side by side. Generally, these systems have been more successful at sustaining long-standing vaccination programs but less so at promoting health, especially as it applies to noncommunicable diseases. These systems have also struggled to deal with new challenges such as HIV/AIDS (Maier and Martin-Moreno 2011). Finally, it bears mentioning that “health reform” is arguably a journey and not a destination, as nearly all advanced health systems have also been subject to ongoing health reform initiatives in recent decades. Major themes have included improving both access to and quality of care while maintaining fiscal sustainability (Docteur and Oxley 2003). Health reform in rich countries has followed a pattern whereby the main objectives of new initiatives have alternated between better access and equity on the one hand (for example, through coverage expansions or supply-side investments) and efficiency on the other (spending controls and cost sharing, for example) and then back again, depending on fiscal imperatives and popular views of the day (Cutler 2002). It has been argued that, over time, OECD reforms have converged
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