Lucy Gilson

The Author is Professor, University of Cape Town and London School of Hygiene & Tropical Medicine

Key Highlights:

In this article, Professor Gilson talks about:

• Rethinking Health Systems by considering health systems as a network of interconnected parts working together to promote overall well-being instead of just focusing on individual sickness.
• Adopting a Comprehensive Approach by taking a holistic view when analysing health systems, considering all six key building blocks (service delivery, governance, human resources, financing, information, medicines & technologies) together. A comprehensive approach recognizes that improving population health requires more than just medical care and involves strengthening governance, resource allocation, community involvement, and collaboration across sectors.
• Understanding How People Interact by exploring how different groups within the health system act together and with each other. This includes their connections, as well as the attitudes and thought processes that influence their actions.
• Uncovering Hidden Factors by acknowledging the importance of the invisible aspects of health systems like informal networks, power dynamics, emotions, and organizational culture, which support the visible aspects in functioning.
• Digging Deeper for Health System Improvement which involves sharing power, creating accountability mechanisms, developing leadership across the system, and making changes to the organizational culture. It's a complex process that requires persistence and collaboration at different levels of the system.

In thinking about ‘health systems’ we need to recognize, first, that population health goes beyond thinking about sickness at the individual level to considering broader social wellbeing. A system, meanwhile, is any collection of related parts that interact in an organized way for a purpose; and to understand a system we can adopt two thinking principles: a) Thinking system wide and b) Thinking system deep.

In health systems analysis, the WHO building block framework[1] is commonly used. It reminds us that people are central to any system and that there is much more to health systems than service delivery. In considering how to go about health system strengthening it suggests that there is a need to think about the interconnections among all six building blocks of service delivery, governance, human resources, financing, information, medicines & technologies (Figure 1). Such ‘system-wide thinking’ acknowledges that improving population health requires more than health care. The body of global evidence indicates we must also think about how to strengthen the governance and resourcing platform for action to promote health, as well as encouraging local level actions, engagement with communities and intersectoral collaboration.

To consider the linkages within the health system, the interactions between elements and people that bring the system alive, we can also consider a framework adapted from J. Frenk[2] (1994). This highlights that to understand a health system one needs to identify groups of actors, such as resource generators, health care providers, public governance structures and their interactions, as well as consider the connections between the various agents of a health system. These connections include the ‘schemes for interpreting human experience’ at play at the provider-patient level i.e. the way providers interpret ill-health in their interactions with patients, and their power over patients. Interactions with any health system are not just about the obvious connections but also about mindsets and thinking processes that feed into these activities. An example which showcases how these interactions are connected, and the feedback loops within a system, is that where supervisors and health providers demonstrate respect for each other, these positive relationships in turn affect provider-patient interactions positively; and vice versa. Such interactions ultimately have long term consequences for quality & equity of access.

Looking beyond the types of interactions and relationships, ‘thinking systems deep’ requires looking into what shapes these interactions. The iceberg metaphor (Figure 2) highlights that what we see (the tip of the iceberg) is a small part of a much larger picture (what lies beneath the surface of any system). Organizational theory also suggests that the visible part of an organization - the vision mission, goals, strategies – is underpinned by the invisible part:? informal networks, power patterns, feelings, interpersonal relations, organizational culture etc. Similarly for health systems we can think about the interactions between hardware, tangible and intangible software as influencing how health systems ‘work’. The hardware refers to aspects such as organizational structures, finances, human resources, infrastructure. Tangible software includes management knowledge, practices and intangible software refers to the norms, power, trust etc. embedded in the system. As an open and nested system, the health system is infused with influences from the broader socio-cultural context, political and economic pressures & interests, including global factors, and historical forces. In a complex health system, the building blocks might be thought of as the visible part of the system, but what lies beneath the surface is the human dimension i.e., people, teams, relationships with community actors, and the various forms of system ‘software’ that influence human interactions.

Thinking system deep, finally, directs our attention to issues for health systems strengthening. These include decentralizing power within a system, establishing mechanisms of mutual accountability, the importance of distributed leadership development, or purposeful interventions for organization culture change – all of which take time and persistence to be implemented. We need to think of health system strengthening as requiring action beyond any one building block and instead, as a complex process of adaptation & development working across various levels within a nested system and engaging various actors.

[1] WHO: Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action.Geneva, WHO; 2007,1-56

[2] Frenk J. Dimensions of health system reform. Health Policy. 1994;27(1):19–34. Available from: https://dx.doi.org/10.1016/0168-8510(94)90155-4