25 years ago the Rockefeller Foundation convened a group of scholars to explore the concept they termed Good Health at Low Cost. It was somewhat of a misnomer, as it was less about cheap health care and more about the ability of countries that had limited resources to achieve good health outcomes. The group met at the Rockefeller Centre in Bellagio, Italy, and examined in detail the experience of four jurisdictions, China, Costa Rica, Sri Lanka and the Indian state of Kerala. Cuba would have been included but wasn’t, for political reasons. The project identified several key features of the successful countries. These included a strong political commitment to health as a social goal, a social welfare orientation in development policies, widespread political participation, a commitment to equity, and intersectoral linkages.

Last week, another group of scholars came together in Bellagio to revisit this concept. The team, led by my colleague Dina Balabanova, has been updating the experiences of the original jurisdictions, which have had mixed fortunes, and has looked at the experiences of five new ones. These are Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu. Although diverse, each stands out from its neighbours in one or other aspect of health system development. For example, Kyrgyzstan, despite (or perhaps because of) lacking the natural resources of some of its neighbours, has achieved a single payer system, reduced informal payments, and made major strides in improving the quality of care. It has done so even though it has undergone several quite turbulent changes of government. Ethiopia has overcome the challenges of a highly fragmented country to develop a Health Extension Programme that has already had major success against malaria. Tamil Nadu stands out for its progress in maternal health. And so on....

So what lessons can we learn from these examples. We are still working through the rich discussions that took place but initial thoughts highlight the role of:

• individuals, especially politicians with vision and drive;
• institutions, that can support a process of change and, in particular, learn from experience at home and abroad;
• events, such as political changes or even natural disasters, which those with vision can take advantage of to bring about change; and
• context, which includes the system of political representation, culture, and beliefs.

We will be presenting the initial findings at the Global Forum on Health Systems Research, in Montreux in November, and will be publishing a book in the New Year.

For further reading, check out the blog by Tracey Koehlmoos, one of the Bangladesh team members, on the BMJ website.