In this paper, we attempted to draw a picture of the evolution of health systems thinking over the last thirty years, framing them against the background of the political and economic context.
Our first observation is that the transformation of thinking over time does not reflect a progressive accumulation of insights. Instead, theories and frameworks seem to have developed in reaction to one another, partly in line with prevailing paradigms and partly as a response to very different needs. Health System frameworks in themselves are not neutral; they frame health, health systems and policies in particular political and public health paradigms, although these underlying assumptions are virtually never specified by their authors or proponents. For instance, the reform perspective considering health systems as projects to be engineered and typical of the 1950-60s era is fundamentally different from the organic view that considers a health system as a mirror of society – which is much more recent. Another example is the continuing co-existence of health systems and disease-focused approaches, which can be recognized in, for instance the ‘Systems thinking’ framework of de Savigny
] and the integration framework of Atun
], respectively. These examples indicate that the different frameworks are complementary and that merging them into an ‘ultimate’ synthetic model is not possible, or desirable. This is to a large extent due to their very different underlying worldviews, which are hardly compatible.
The graphic representations of health systems frameworks in Figure
provide insight in some of these underlying assumptions. They attempt either to clearly indicate the structural elements of the systems or to point out the processes and relationships between elements of the systems. The recent models increasingly attempt to capture the complexity of those relationships. Robert’s ‘control knobs’ metaphor, for instance, suggests a strong belief in the possibility to steer a system and a belief that this should be done by a central authority. Both the control knobs’ and the building blocks’ framework suggest a mechanical approach with a more or less comprehensive package of universally valid elements and measures, to be constructed or implemented in any particular country. Complexity thinking provided a new paradigm to react against such universalist approaches, pleading for more comprehension of interactions and of context, and for planning of change based upon local processes. The systems thinking framework and the health system dynamics framework emphasize the linking between the elements and importance of negotiation and priority setting by stakeholders in the local context.
Graphic representations of Health Systems Frameworks over time.
Our second observation is that the contestation of theories and methods for health systems analysis and for their strengthening relates almost exclusively to LIC. The results of the HiT country profile analyses reveal the high differentiation and path-dependency of health systems in the European region. As much as they might be a source for internal debate in European countries, in the global public health debate, these templates – and the results of their analysis - are hardly discussed. At the global level, health system strengthening remains firmly narrowed down to its instrumental dimension – through well-targeted and specific interventions, most HSS programmes aim at contributing to improve specific health outcomes or financial protection of specific groups. This fits with the mechanical paradigm of most health system frameworks and is in strong contrast to a broader conceptualization of health systems as social institutions that are shaped by societal values and at the same time act as social determinants in themselves
]. The current economic global climate provides global and bilateral actors with the excuse not to engage in such long-term and costly approaches.
Our third observation is that health systems frameworks are designed to serve a specific purpose. A first category of frameworks is meant to conceptualise and describe health systems. The early frameworks, for instance those of
] and Roemer
], fall in this group, but also the building blocks framework of 2007
]. Another category of frameworks goes further, analyzing processes and outcomes and looking at mechanisms for change and its effects, analyzing processes and outcomes, such as the WHR 2000 and the performance framework of Kruk
]. A few frameworks in this category explicitly prepare for strategic action, the control knobs being most outspoken. The systems thinking framework also fits in this category, although its comprehensive and participatory approach is essentially different from the paradigms of strategic planning and control that prevail in most other frameworks in this category.
Other frameworks focus the analysis on specific aspects of health systems. An example is the way health system frameworks deal with integration of focused disease control actions in the total system
]. No single framework incorporates the various interpretations given to the word integration, referring to a wide variety of organisational arrangements of programmes into health systems, either at service delivery or health system organisation level. Other examples of how health system frameworks deal with a specific aspect of societal issues are the analyses of Gruskin et al.
] and of Mikkelsen-Lopez et al.
], on respectively human rights and governance.
An aspect of the frameworks that would merit an in-depth analysis is health system performance. We noted that each framework views performance as related to its underlying paradigm. The more mechanical frameworks, which start from a set of universal outcomes and outputs, seem to focus on the processes how to best achieve these and consequently to focus on efficiency. The frameworks with a more dynamic approach stress the importance of local adaptation and prioritization and conceptualise performance as a complex output of interactions between the health system and its context.
In order to understand global health systems debates and the tensions between actors, it helps to recognise differences between different frameworks and the paradigms underlying them. Strikingly, however, very little political analysis enters the literature and political choices are not made explicit. This brings us to the question whether it is feasible to develop one comprehensive framework that is acceptable for all actors. The lack of real progress in the Health Systems Funding Platform suggests the contrary: the current global health landscape is marked by many actors who interact in multiple ways, but each on the basis of a specific rationale. Ignoring this would assume that all frameworks are merely ‘technical’ in nature, which they are not.
The different purposes of each framework may appear to make them to a large extent complementary. However, the differences between the three groups of frameworks reflect the tensions between the implicit paradigms that underlie them. Tensions in global health politics are part of that reality: “Health systems approaches to aid may be intellectually correct, but they are politically problematic
]. The understanding of the underlying rationale of a chosen model facilitates an open dialogue, may make some choices more clear and could help in comparing frameworks and strategy.
In the end, the choice for a particular health system model to guide discussions, analysis or improvement, should fit the purpose, for instance the building blocks to frame audit findings and the control knobs to identify interventions. The insights of this paper could provide some inspiration and tools to people working in HSS to strengthen the foundation of their choices and make them explicit for themselves and others.