Peter Berman

In 1996, economist Paul Shaw at the World Bank Institute saw a need for training senior members of health care systems in various parts of the world, especially in the poorest regions. Shaw asked William Hsiao of HSPH to develop an introductory module for a course he was planning. Hsiao turned to HSPH colleagues Peter Berman, Michael Reich and Marc Roberts for input. The collaboration laid the foundation for the Flagship course, a joint program of HSPH, under the auspices of the International Health Systems Program (IHSP), and the World Bank Institute.

Originally offered at the Institute in Washington, DC, the course moved last year to HSPH. A new book has been published based on the course’s contents.

More than 4,700 participants from 56 countries have undertaken the course over the years, including 35 participants from 18 countries enrolled this month.

The Flagship course is part of a larger, global capacity-building program that has seen HSPH faculty travel recently to Lebanon, Russia and Thailand to conduct courses. Some of the faculty involved in the Flagship course also work with governments on health sector reform. The faculty perceive these collaborative opportunities with governments as an opportunity to do hands-on practice research, which advances the scientific basis of health systems reform, said Berman, who leads IHSP and is co-director of the Flagship course.

Over the course, participants mainly from developing countries learn step by step ways to look at their current health care systems and develop strategic designs for change. All have extensive experience in health care and are committed to improving conditions in their respective countries.

"One of the most important things to remember is there is no single design that is optimal for all countries," said Berman, professor of population and international health economics in the Department of Population and International Health. "But, this doesn’t mean everyone is on their own. We think there are significant lessons that can be learned and generalized about what works, why it works and how it works, and those lessons should be used by all countries."

He added that participants would gain lessons from other countries, saying that even successful reforms may lead to further changes.

"The consequences of reform are difficult to predict," he said. "Health systems have multiple goals. Doing better on one goal may mean doing worse on another. The choices are truly difficult."

Beginning with a study of ethics, the course helps participants define problems and identify outcomes within their country’s health care systems; develop analysis strategies for health system performance; and build reform approaches, according to Berman. They also learn about health care financing, benefits packages, regulations and organizational reform.

Specific "modules" examine the theoretical and empirical basis for reform approaches. Participants working in small groups complete proposals for eight countries as part of a course-long exercise.

The course also teaches participants how to do stakeholder analysis and how to design political strategies, since the process of health reform is profoundly political, said Reich, director of the Harvard Center for Population and Development Studies.

Rakesh Kumar, who works on a health systems development project in India, was a participant.

Working in two clusters, one group argued that selling kidneys from living donors could generate income for poor donors and might financially benefit an entire family or community. The opposing group countered that a donor might suffer unexpected health consequences as a result, beyond what he or she could afford.

Playing the role of the would-be donor, Roberts insisted that he has control over his own body: "It’s my kidney. Why can’t I do with it what I want?" he asked.

He pointed out that similar arguments often arise in discussions about the legalization of the sex trade: Is a person better off poor but not exploited, or earning money while being exploited? And shouldn’t everyone have the right to choose for him or herself?, he challenged. He asked how far a country should go to protect its citizens from the consequences of their choices. Should countries allow or outlaw the sale of body parts, heroin or abortions-on-demand, for example, if private citizens are willing to take on the related risks of each activity?

"Determining an ethical health policy is not simple," said Roberts, but slowing down policy formation to make good decisions is worth it.

Aside from Berman, Roberts, Reich and Hsiao, HSPH faculty participants include Chi-Man (Winnie) Yip, associate professor of international health policy and economics in the Department of Population and International Health, and Thomas Bossert, lecturer on international health policy in the Department of Population and International Health.

-PHC