This document provides an overview of conceptual frameworks for understanding health systems. It defines a health system as all organizations, people and actions whose primary intent is to promote, restore or maintain health. It discusses several frameworks developed by the WHO and others to conceptualize the different components, actors and relationships within health systems. It acknowledges that health systems are complex and dynamic, with unpredictable paths of implementation for interventions. The document emphasizes that health systems should be viewed holistically as interconnected systems centered around people.

1. What is a health
system?
ICHS 2
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Introduction to Complex Health
Systems

2. Outline
• Definition of health system
• Conceptual frameworks that help think
about health systems as basis for action

3. Key social goal…
Improve health by
average level of population
health
health inequities
Health systems
“All organizations, people and action whose
primary intent is to promote, restore or maintain
health”
WHO, 2007 http://www.who.int/healthsystems/strategy/en/

4. Health System
Health
• Beyond sickness
– mental & physical health
– social wellbeing
• Beyond the individual
– all agents promoting health &
wellbeing
– domestic/national AND
international factors impacting
on health and HS agents
A system is
any collection of related
parts
that interact
in an organized way
for a purpose

5. STARTING POINTS: WHAT ARE
THE BASIC BUILDING BLOCKS?

6. Moving beyond basic
categorisations
Health Care
Financing
Health Care Delivery
Public Private
Public UK
Private US

7. WHO, 2007
7

8. WHO Building Blocks
Strengths NB
• All health systems have
multiple goals
• Thinking ‘health systems’
requires consideration of
horizontal management &
support functions, and
resources, as well as
services & programmes
Weaknesses
• No sense of the
interactions among
blocks
• No explicit recognition of
the people & relationships
within & across blocks, or
what drives them
• Citizens/users are absent

9. Van Olmen et al. 2012

10. van Olmen et al. 2012
Strengths
• More indication of
relationships among
blocks
– importance given to
leadership & governance,
service delivery
• Population part of the
system
• Influence of context and
values recognised
Weaknesses
• Limited sense of the
people within the system
• Influence of values &
principles still quite
hidden

11. ACKNOWLEDGING ACTORS
AND RELATIONSHIPS

12. COLLECTIVE
MEDIATOR
HEALTH CARE
PROVIDERS
ORGANISATION
POPULATION
ORGANISATION
RESOURCE
GENERATORS
OTHER
SECTORS
Basis for
eligibility
Degree of
control
Degree of
control
Degree of
control
Taxes, Demands
for services
Services with health
effects
Subsidies,
Information,
Ideologies
Potential personnel,
money, data
Schemes for
interpreting human
experience
Human resources,
Payment mechanisms,
Scientific information,
Technology
Formal health services
Community participation
Frenk, 1994
Competition for
responsibilities and
resources

13. Frenk model
Strengths
• More sense of range of
actors in the system e.g.
providers as well as
population recognised
• Nature of relationships
among organisations and
people made clear, and
shown to be quite varied
• Goes beyond health
services!
Weaknesses
• Simplicity AND
complexity

14. consumers providers
purchasers
government/
professional body
payments
health services
regulation
regulationregulation
WHO 1993

15. WHO Financing Framework
Strengths
• Zooms in on particular
actors & relationships
• Considers what drives
relationships
• Basis for generating
ideas for action
Weaknesses
• One particular lens being
used to see health
system: economics lens
– sees only certain actors
– assumes particular
behaviours and
relationships

16. 16
Accountability
Brinkerhoff &
Bossert 2013

17. Brinkerhoff & Bossert model
Strengths
• Zooms in on particular
actors & relationships
• Considers broadly what
drives relationships
• Basis for generating
ideas for action
Weaknesses
• One particular lens being
used to see health
system: accountability
lens
– sees only certain actors

18. RECOGNISING SYSTEM
COMPLEXITY

19. Basic health system framework
INPUTS & PROCESSES
Governance
Finances
Human resources
Medicines,
technologies &
infrastructure
Information
OUTPUTS
Service delivery
• efficiency
• access
• availability
• affordability
• acceptability
• quality
• safety
OUTCOMES
Increased
• effective coverage
• responsiveness
IMPACTS
Improved
• survival
• nutrition
• equity
Reduced
• morbidity
• impoverishment
due to health
expenditures
• OTHER DETERMINANTS OF HEALTH
• (Economic, Social, Political, Environmental)
Modified from: WHO Everybody’s business, 2007 & Health Metrics Network Framework, 2008

20. Characteristics of all complex systems
And ….
• nest sub-systems within them
• but are part of larger systems

21. Self-organising &
Constantly
changing

22. Source
Of Funds
Procurement
Agent/Body
Point of 1st
warehousing
Point of 2nd
warehousing
MEDICAL STORE
PRIMARY HEALTH CARE FACILITYDISTRICT STORE
ZONAL MEDICAL STORE
ESSENTIAL
MEDICINES
ARVs MALARIA TB OI
ARVs
Ped
REAGENT
Blood safety
(+ HIV test)
VACCINES CONDOMS CONTRACEPTIVES
MEDICAL
SUPPLIES
REGIONAL/DISTRI
CT
VACCINE STORE
HEALTH FACILITY
GOVERNMENT
MULTILATERA
L DONOR
BILATERAL
DONOR
NGO/PRIVATE
AXIOS
TEC
&CC
T
CRS IMA CUAMMHOSPITAL COLUMBIA HOSPITAL
TEC
&CC
T
HEALTH FACILITY
HEALTH FACILITY HOSPITAL
TEC
&CC
T
ZONAL BLOOD
SAFETY CENTRE
Point of
Distribution
GOVERNMENT
W
BGLOBAL
FUND
S
I
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A
P
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PATIENT
Tightly linked
Medicines & Technologies building block – Tanzania 2007

23. SUPERVISOR PROVIDERS PATIENTS
FEEDBACK LOOPS SATISFACTION?
ACCEPTABILITY?
SENSE OF
CARE?

24. Health system interventions have
unpredictable paths of implementation
Health system
Intervention
Recognising complexity

25. Health systems are dynamic & interconnected systems at
whose heart are people
Source: de Savigny and Adam (2009)
‘It is the multiple
relationships and
interactions
among the
building blocks ...
that convert these
blocks into a
system’

27. How stakeholder perspectives
can vary
A health system is ….
Source: de Savigny and Adam (2009)

28. Figure 1. Health policy and systems: alternative perspectives.
Sheikh K, Gilson L, Agyepong IA, Hanson K, et al. (2011) Building the Field of Health Policy and Systems Research: Framing the
Questions. PLoS Med 8(8): e1001073. doi:10.1371/journal.pmed.1001073
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001073

29. 29

30. Hardware:
Tangible software:
Intangible software:
capabilities to commit and
engage; adapt & self-renew;
balance diversity and
coherence
Organ-
isational
hierarchy
HR estab-
lishment
Technolog
y
Finance
Management
knowledge
and skills
Formal
management
processes
Values &
norms
Informal
rules
Relation-
ships
Comm-
unication
Understanding organisations
adapted from Aragon, 2010

31. All these ‘conceptual frameworks’
provide the basis for
• understanding
• investigating
• strengthening
health systems (or facets of them)
• and so, for working within them!
(and researching them!)

32. CAVEAT – NO EASY ANSWERS
TO HOW TO IMPROVE A HEALTH
SYSTEM!
POLITICS AND VALUES
MATTER….

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2. Copyright CHEPSAA (Consortium for Health Policy &
Systems Analysis in Africa) 2014, www.hpsa-africa.org
www.slideshare.net/hpsa_africa
This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no.
265482). The views expressed are not necessarily those of the EC.

34. The CHEPSAA partners
University of Dar Es Salaam
Institute of Development Studies
University of the Witwatersrand
Centre for Health Policy
University of Ghana
School of Public Health, Department of
Health Policy, Planning and Management
University of Leeds
Nuffield Centre for International Health and
Development
University of Nigeria Enugu
Health Policy Research Group & the
Department of Health Administration and
Management
London School of Hygiene and
Tropical Medicine
Health Economics and Systems Analysis
Group, Depart of Global Health & Dev.
Great Lakes University of Kisumu
Tropical Institute of Community Health and
Development
Karolinska Institutet
Health Systems and Policy Group,
Department of Public Health Sciences
University of Cape Town
Health Policy and Systems Programme,
Health Economics Unit
Swiss Tropical and Public Health
Institute
Health Systems Research Group
University of the Western Cape
School of Public Health