Everything has its place: understanding how health systems are organised

When we think about health, we might think of a hospital or an outpatient clinic. However, health care is just one part of a diverse and multifaceted system. From primary care to specialised services to deciding what is covered by the public sector and implementing policies to promote and protect health, health systems encompass a wide range of components.

?What are health systems?

The World Health Organization (WHO) defines health systems as “all organisations, people and actions whose primary intent is to promote, restore or maintain health.” This means that anyone influencing health plays a role in health systems. Yes, everyone. That is why when we talk about health systems, we talk about a complex environment where any action has a knock-on effect on other parts of the system.

?What makes up a health system?

Frameworks are the principles that form the structure of an organisation. We use them to understand complex problems (i.e., unhealthy behaviours) or organisations, such as health systems. The WHO developed one of the most used frameworks to approach health systems. It’s called the health system building blocks, and it includes leadership and governance, service delivery, health information, health workforce, access to essential medicines, and healthcare financing (figure 1).

Since this framework was published, we have continued to understand health systems and have developed other frameworks to assess better how health systems perform. An example of an updated framework is the Health System Performance Assessment produced by the European Observatory of Health Systems and Policies (figure 2). This framework identifies four main functions: governance, financing, resource generation, and service delivery. It then breaks down these functions into sub-functions. For example, resource generation includes the health workforce, which involves the assessment and planning of the availability of healthcare workers and setting quality standards, among others.

Context matters and determines how the system works!

While frameworks help us understand health systems, context plays a fundamental role in how a system operates. The building blocks or functions of health systems remain the same across health systems; however, how each operates varies across and within countries. For example, financing in countries like the United Kingdom is mainly through general taxation. In contrast, other countries like Mexico have multiple financing systems, including employee and employer contributions, fee-for-service, and general taxation, due to the various providers and systems within the country. The same applies to the other health systems blocks, such as governance (i.e., centralisation vs decentralisation) and access to medicines and technologies (i.e., deciding what the public system covers).

Equally important is to acknowledge that each function or block of the system involves a network of people and organisations interacting. Understanding what constitutes a health system is the first step to approaching them. We should then understand how a particular system (or sub-system, in the case of States or devolved nations) works and what functions are allocated to the system’s actors.

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