Johanna Fischer and Gabriela de Carvalho explain in an interview how the country reports are produced and what added value they offer compared to other sources.

The twentieth issue of the CRC 1342 Social Policy Country Briefs was published a few days ago. On this occasion, could you briefly explain what this series is about?

Johanna Fischer: The series consists of short reports which each focus on a specific social policy field in an individual country. For instance, the latest two reports were published on the The Health Care System in Bulgaria (No 19) and the The Long-Term Care System in Sweden (No 20). In line with the CRC’s current focus on social policy emergence, the Country Briefs focus on the introduction of social protection policies and systems and their further development until today. The aim of the series is to give country and policy experts the opportunity to share their knowledge in a semi-structured format, to disseminate the information through the online open access publications, and to shed light on under-researched cases, in particular those found beyond high-income economies.

How did this series come about?

Gabriela de Carvalho: Within our project A04 on the Global Developments in Health Care Systems and Long-term Care as a New Social Risk (as well as the CRC as a whole), we are collecting a lot of data for instance on the introduction points of health and long-term care systems, their characteristics, and subsequent reforms. From this we have plenty of indicators which are stored in the CRC’s Global Welfare State Information System (WeSIS) and can be used by us and others for research. However, this information is contained into – mainly – categorical and numerical indicators. We have established the Country Brief Series to complement these datasets with more in-depth descriptions in a story-telling format and information that country experts or team members have accumulated. We thought that it would be a pity if this comprehensive knowledge about health and long-term care system beginnings and development would not be recorded and published. For the future it is planned that the Country Briefs will also be stored in WeSIS as an additional country-based resource.

What is the particular benefit of the series compared to existing social policy country profiles?

Johanna Fischer: There are several benefits of the CRC 1342 Social Policy Country Briefs which are not fully covered by other publication series. One is the explicit historical focus – in line with the CRC’s research agenda – on the initial introduction and further chronological development of social protection systems. Other publications do focus much more on providing a snapshot of the currently existing systems. However, we think it is important to contextualise current developments with a thorough understanding of their historical trajectories to understand why they look like as they do today and also for comparing countries at different stages of development.

Gabriela de Carvalho: We also emphasise the role of the state in health and long-term care systems, and the different ways in which this actor took responsibility for health and elder care. Even though we plan to publish briefs on all countries of the world, we particularly target under-researched cases from the Global South. Examples are the reports on the healthcare systems of Equatorial Guinea and Mozambique which are currently under review.

Gabriela, you have written the first issue of the series - what is the biggest challenge in such a report?

Gabriela de Carvalho: The biggest challenge in writing such a report is, I would say, the 'novelty' of the content. As here at the CRC we have an explicit interest in historical developments and the role of the state in social policies, our country briefs shed light on these topics, which is different from existing descriptions of social policies. Therefore, a historical analysis and reflection of each case is necessary before producing the report.

There are also conceptual challenges: For instance, experts have different ways to measure and operationalise what a system is, and when a system starts. This requires an open and constant dialogue between the editors of the series (the A04 project) and the authors.

Further, data availability differs greatly among countries. Authors often need to slightly adapt the provided template to accommodate for issues of data availability and reliability.

How do you choose the topics of the issues (policy field and country)?

Johanna Fischer: At the moment we are working on the both policy fields covered by our project, that is health and long-term care. As for the countries, we have started mostly with the ones where we had an established contact to potential authors for instance because they had participated in our expert surveys already. Furthermore, we tried to cover a diverse set of countries situated in different regions. Our aim is explicitly to cover cases outside the standard Northern/Western country samples often analysed, even though we are of course happy to also include reports on the more well-known cases. For long-term care, for instance, many reports have so far focused on the long-standing members of the Organisation for Economic Co-operation and Development or the European Union. We are therefore happy that we were already able to extend this sample, for instance with the Country Briefs on Uruguay, Costa Rica, Taiwan, Singapore, Ukraine, and Serbia.

Gabriela de Carvalho: In the case of healthcare, reports on countries such as Jamaica, Mozambique, Albania, and Mexico have already been published or are currently under review.

Will the series cover other policy fields in the future as well?

Johanna Fischer: We are open to extend the series to other policy fields. In the future we would therefore like to more closely collaborate with other CRC projects to make this happen.

Contact:
Dr. Gabriela de Carvalho
Dr. Johanna Fischer
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-57074
E-Mail: johanna.fischer@uni-bremen.de

De Carvalho studied the role of global actors in shaping health systems in the Global South, Henninger the interplay of immigration and social policy in authoritarian regimes.

Gabriela de Carvalho's thesis is titled "The role of global actors in shaping healthcare systems: Advancing analytical frameworks to better portray the empirical reality of Global South countries" and was graded "magna cum laude".

The primary aim of her dissertation is to analyse the role global actors play in shaping healthcare systems in Global South countries in order to advance typological work to better portray the empirical manifestations of healthcare systems worldwide, especially in middle and low income nations. My dissertation consists of three papers: The first study empirically examines whether and how IOs, more precisely the World Bank (WB), influence the (legal) foundations of healthcare systems in the nations of the Global South (Article A). The second investigation consists of a systematic literature review of the scholarship on healthcare system typologies to verify whether existing frameworks (a) take into account the increasing role global actors play in healthcare system arrangements, and (b) are able to portray the universe of healthcare systems worldwide, with a special focus on LMICs (Article B). Finally, a conceptual and analytical framework of healthcare systems to display and compare arrangements is proposed, taking into consideration the particularities of Global South systems (Article C).

Article A:
de Carvalho, G. (2021). The World Bank and healthcare reforms: A cross-national analysis of policy prescriptions in South America. Social Inclusion (in press).

Article B:
de Carvalho, G., Schmid, A., & Fischer, J. (2021). Classifications of healthcare systems: Do existing typologies reflect the particularities of the Global South? Global Social Policy, 21(2), 278–300. https://doi.org/10.1177/1468018120969315

Article C:
Frisina Doetter, L., Schmid, A., de Carvalho, G., & Rothgang, H. (2021). Comparing apples to oranges? Minimising typological biases to better classify healthcare systems globally. Health Policy OPEN, 2, 1–8. https://doi.org/10.1016/j.hpopen.2021.100035

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Jakob Henninger's doctoral thesis is entitled "The Politics of Immigration and Social Protection in Electoral-Authoritarian Regimes" and was graded "summa cum laude" (examination committee: Susanne K. Schmidt, Friederike Römer, Christian Joppke, Heiko Pleines, Patrick Sachweh, Johanna Kuhlmann).

Jakob Henninger's findings include:

• Concerns about immigration are more likely to lead to an increase in demand for social security in authoritarian regimes than in democracies.
• Questions in parliament are also a means for opposition MPs to criticise the government's immigration policy in electoral authoritarian regimes.
• In electoral authoritarian regimes, the goals and actions of civil society organisations advocating for immigrants' rights are significantly weaker than in democratic states.

A paper on which the thesis is based has already been published:
Choose your battles: How civil society organisations choose context-specific goals and activities to fight for immigrant welfare rights in Malaysia and Argentina, with Friederike Römer (2021) in Social Policy & Administration. Two further papers are existing as manuscripts.

Contact:
Dr. Gabriela de Carvalho
Dr. Jakob Henninger
DeZIM e.V.
Mauerstraße 76
10117 Berlin
E-Mail: jakob.henninger@uni-bremen.de

Gabriela de Carvalho explains in an interview why existing typologies of health care systems have a strong Global North bias and why this is problematic.

Gabriela de Carvalho, Achim Schmid and Johanna Fischer have examined the literature on health care system classifications. The existing typologies, the team has found, have a strong Global North bias and thus fail to capture important features of health care systems of the Global South. Gabriela de Carvalho, the first author of the paper published in Global Social Policy, explains some details of their findings and what this means for researchers and policy makers.

You have reviewed the literature for existing classifications of health care systems and found that they are poorly suited to support research on the Global South. What is the reason?

Gabriela de Carvalho: The main goal of our research was to evaluate the health care system typology literature and its ability to capture the particularities of health care systems of the Global South. The findings of our study points to limitations of several features of existing typologies: their coverage, methods used, and criteria they build on. Regarding coverage, health care systems of LMICs (low- and middle-income countries) are rarely taken into consideration in the literature, as classified cases consist of a 1:5 ratio of Global South to Global North countries. With respect to methods, the overreliance on inductive approaches to classification often excludes countries that cannot be measured in numeric terms. Health statistics mostly focus on the Global North, and has only recently included more data on countries from the South, hampering the analysis of arrangements beyond high-income nations. The use of inductive typologies to classify systems may result in poorly informed classifications especially if the study aims at the creation of a tool for applicability beyond their sample of cases. With regard to the criteria and characteristics health care systems are compared by, dominant features of health care systems that mostly exist in LMICs such as the segmentation of the system for different population groups, are not taken into consideration in many typologies. This often results in typologies that do not capture the empirical reality of the South.

In your paper you write that the health care systems in many countries of the Global South are very different from those of the Global North. What are the most important points?

Gabriela de Carvalho: All health care systems regardless of the country face numerous challenges and the current pandemic made this even more evident. Still, it is undeniable that systems of the Global South endure even greater financial and technical constraints. Besides larger disparities in health care per capita spending, number of health care professionals, and burden of diseases, LMICs are more prone to rely on international actors (transnational organisations, INGOs, and third countries) to finance, provide services and even regulate their systems. Another very important characteristic of many health care systems of the Global South is segmentation, the coexistence of different schemes targeting different population groups according to income, social status and/or type of employment. As a general rule, the poor are beneficiaries of public services due to their exclusion from formal employment, while the upper classes are covered by social and/or private insurance. This stratification leads to extensive health inequalities, as public services only provide basic care, and supplementary services are only used by those who are able to afford them.

What do you see as the reasons why these aspects have not been sufficiently considered in the classification literature so far?

Gabriela de Carvalho: In general, we believe that scientific research is still concentrated in and revolve around OECD countries due to data availability, financial and technical resources, institutional capacity, and the interest of researchers. Of course, recent decades have seen an expansion of (health care systems) scholarship on LMICs, mainly in the form of in-depth case studies, but it still lacks in comparison to the Global North literature, especially when systematic comparison is concerned. If more varied cases are not taken into account, the literature will continue to only partially represent the empirical reality, amplifying the ‘invisibility’ of less studies countries/regions. Particularly to the scholarship we are analysing, it is clear that classification and the development of meaningful typologies is much more complicated when dealing with countries of the Global South. Reasons for that vary from segmentation/parallel (public) systems, parts of the population and/or health services left to markets, and the existence of less „mature”systems. While systems found in the Global North can also be mixed or hybrids in some way, it is much harder to condense the information and assign an LMIC to an ideal type.

What are the consequences of the mismatch between the existing classifications in the literature and the health systems existing in the Global South - for scientific research and for practice/policy?

Gabriela de Carvalho: As the literature often relies on health care systems of the Global North to develop classificatory tools, it seems reasonable to assume that the models resulting from these typologies are more prominent and influential in shaping researchers and policymakers’ ideas of what a health care system does – and should – look like. We argue that high-income examples can be (mis)interpreted as portraying ‘best’ models or ‘benchmarks’, which may lead to standard setting for other countries, disregarding particular and fundamental characteristics of health care systems in LMICs. This could also translate into policy advice being modelled in terms of the well-known types. For scientific research, this bias towards the North may hinder novel knowledge production that could potentially focus on less analysed cases, as research tends to gravitate around seminal works, leaving aside unfamiliar cases or new theoretical considerations.

Read the full paper (Open Access): Classifications of health care systems: Do existing typologies reflect the particularities of the Global South?

More about the research of Gabriela de Carvalho, Achim Schmid and Johanna Fischer and the whole project A04 team:
Global Developments in Health Care Systems and Long-term Care as a New Social Risk

Contact:
Dr. Gabriela de Carvalho
Dr. Johanna Fischer
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-57074
E-Mail: johanna.fischer@uni-bremen.de

Dr. Achim Schmid
CRC 1342: Global Dynamics of Social Policy
Mary-Somerville-Straße 3
28359 Bremen
Phone: +49 421 218-58526
E-Mail: aschmid@uni-bremen.de