The World Health Organization (WHO) refers to health systems as “all the organizations, institutions and resources that are devoted to producing health actions” [12
]. It includes patients, their families and communities, the Ministry of Health, health financing bodies, behaviour change and vector-control programmes, health services organizations, pharmaceutical companies and others. It also includes intersectoral actions across government that impact on health [13
]. The goals of health systems include “improving health and health equity in ways that are responsive, financially fair, and make the best, or most efficient, use of available resources” [14
As entities, health systems may also be vulnerable – at a macro level vulnerability occurs when they are marginalised within political and national priorities; and at a macro level where the pillars that make up the health system are fragile. Robust health systems moderate the effects of health risks and vulnerabilities [15
] by providing a continuum of health services including primary, secondary and tertiary prevention, as well as other intersectoral actions to protect and promote health. Care is not guaranteed simply by the existence of medical facilities [12
] (p 9), the facilities in turn need to be strong and equitable to cope with potential access by all.
Vulnerability of health systems translates into reduced protective resources and poor health outcomes for individuals and groups, and forfeiture of potential national socio-economic gains. In addition, the population level and global dimensions of health problems witnessed in relation to HIV and AIDS, severe acute respiratory syndrome (SARS), and recent disasters as in Haiti and Fukushima are also a reminder of the significance of the resilience and vulnerability of health systems in relation to population and global health.
Governance is another significant factor related to the vulnerability of health systems and requires increasing government effectiveness; control of corruption; and participation from all stakeholders including users [16
]. Corrupt practices occur across a continuum ranging from inefficiency and minor mismanagement to absenteeism of health workers from work, ‘under-the table’ payments for public services and procurement of supplies, and the absence of regulatory policies, standards and mechanisms [16
]. Government effectiveness includes efficiency and adequacy of capacity of technical and administrative skills of public institutions and servants [17
], competent discharge of its roles, coherent internal policy and program formulation, and consistent external coordination with other sectors. The World Health Report 2010 states that about 20-40% of health spending is wasted which could otherwise be used to achieving universal coverage [18
]. Voice to the people is an important form of external accountability and ensures participation and a collaborative model of governance. However, it depends on the democratic freedoms accorded by the political system, a national anti-corruption strategy, robust regulatory frameworks and enforcement by the government, and the independence of the judiciary and the media among other things. Accountability helps to keep in check corruption, inefficiencies and ineffectiveness.