2.

Health systems Elements and characteristics

Health systems can be defined either by what they seek In terms of the elements they comprise, health systems
to do and achieve, or by the elements of which they are can be understood as:
comprised. 1. Encompassing the population the system serves, as
well as the supply or delivery of services, interven-
tions and activities intended to promote health and
Goals wider value. Members of the population play five
critical health-related roles. They are:
The defining goal of health systems is generally seen as
health improvement – achieved not only through the n
patients with health needs requiring care
provision of curative and preventive health services but n
consumers with expectations of how they will be
also through the protection and promotion of public treated
health, emergency preparedness and intersectoral action n
taxpayers who provide the main source of
financing for the system
(Mackintosh & Koivusalo, 2005).
n
citizens who may have access to health care as a
However, health systems are also part of the social fabric right
in any country, offering value beyond health (Gilson, n
co-producers of health through their healthsee-
2003; Mackintosh, 2001). Their wider goals include king and health-promoting behaviours (Frenk,
equity, or fairness, in the distribution of health and the 2010).
costs of financing the health system as well as protection 2. A set of six functions, or building blocks, some of
for households from the catastrophic costs associated which are clearly represented in the goals outlined
with disease; responsiveness to the expectations of the above (World Health Organization, 2007):
population; and the promotion of respect for the dignity n
service delivery
of persons (World Health Organization, 2007). These last n
health workforce
two goals specifically require: n
information
n
ethical integrity, citizen’s rights, participation and n
medical products, vaccines and technologies
involvement of health system users in policy n
financing
development, planning and accountability and
n
leadership/governance.
respect of confidentiality as well as dignity in service
provision (Mackintosh & Koivsualo, 2005); 3. Incorporating, within the service delivery function
(Van Damme et al., 2010):
n
building and maintaining the social relations that
n
general curative and preventive health services
support sustained resource redistribution, through
and services aimed at specific health problems,
strategies and activities that include, rather than
including specific disease control programmes
exclude, socially marginalized population groups
and personal and population-based services;
within all decision-making activities (Freedman et al.,
2005). n
a range of modes or channels of service delivery
including various levels of facility, other outlets for
Therefore, health systems, through both their service health goods (such as pharmacies or shops) and
provision role and their influence over societal relations, other strategies (such as community-based health
are a critical field of action to address the social deter- workers and activities);
minants of health and the related health inequities n
a complex mixture of service providers – public
(Commission on the Social Determinants of Health, 2008; and private, for profit and not-for-profit, formal
and informal, professional or non-professional,
Gilson et al., 2008).
allopathic or traditional, remunerated and volun-
tary – the pluralistic health care system (Bloom,
Standing & Lloyd, 2008).

Part 1 - Introduction to Health Policy and Systems Research 21

 There has, however, been growing realization of the
Multi-levels of operation strong influence of the broader global context over
Health systems operate at, and across, the macro, meso population health and health care (Smith & Hanson,
and micro levels (Fulop et al., 2001; Van Damme et al., 2011). Critical influences include international trade,
2010). This is illustrated in Figure 1. international aid and global changes, such as economic
trends or climate change. There are also a range of very
As Figure 1 suggests, the macro level has traditionally
influential global organizations and actors, including
focused mainly on the national, or domestic, health system
multilateral and bilateral organizations, and global
whilst recognizing that this system is also influenced by a
public-private initiatives. Therefore, the domestic health
wider national and international context. Key system roles
system must be understood as an open system within
at the national level include:
the global context, influenced by and influencing global
n
balancing policies, strategies, resource allocation and
forces.
health worker reward systems in line with overall
system goals; The meso level comprises both the local health system,
n
coordination across functions and service delivery often called the district health system, and the organiza-
activities and interventions; tional level, such as hospitals. System roles at this level
n
the development of policy and regulations; include:
n
engaging with health system actors, including n
responding to local needs and circumstances, in
citizens; terms of provision of health services and wider health
n
interactions with other national agencies that promoting activities;
influence health as well as international agencies and n
coordination among local actors;
processes.
n
management of health services, activities and health
workers;

Figure 1 The different levels of health systems

MACRO LEVEL
Global & National Context
Domestic Health System
Policy
Elites
MICRO LEVEL:
Individuals

Health
Managers
Citizens

Patients
Providers

MESO LEVEL:
Organisation & Local level

22 Gilson L, ed. (2012). Health Policy and Systems Research: A Methodology Reader - The Abridged Version
Alliance for Health Policy and Systems Research, World Health Organization
n
supervision and training of service providers; Interactions and
n
adaptation of national policy and guidelines to local
circumstances. interrelationships
Finally, the micro-level is the level of the individuals in Health systems encompass not only various elements but
the system. It includes providers and patients as well as also the interactions and interrelationships between
citizens, managers and policy elites – and the interac- those elements and between the various individuals
tions between them. Critical roles of individuals at this within the system (Frenk, 1994). These relationships
level include: not only support service delivery towards health
n
the search for care, compliance with health advice improvement but are also central to the wider social
and broader health behaviours; value generated by the health system (Gilson, 2003).
n
the provision of health care and health promoting
The building blocks do not alone constitute a system,
activities;
any more than a pile of bricks constitutes a func-
n
the development of new forms of provider–patient
tioning building. It is the multiple relationships and
interaction, such as the use of patient information for
follow-up; interactions among the blocks – how one affects and
influences the others, and is in turn affected by
n
the development of broader local relationships
between health system agents and the population; them – that converts these blocks into a system
n
managerial decision-making and leadership across (de Savigny & Adam, 2009:31; see Figure 2).
the health system. The relationships are, moreover, shaped and influ-
enced by both the hardware and the software of the
health system and, in turn, influence levels of system
performance.

Figure 2 The interconnections among the health system building blocks

(Source: de Savigny & Adam, 2009:32.)

GOVERNANCE

MEDICINES and
TECHNOLOGIES INFORMATION

PEOPLE

HUMAN
RESOURCES FINANCING

SERVICE
DELIVERY

Part 1 - Introduction to Health Policy and Systems Research 23

 Health system hardware includes the particular organiza-
tional, policy, legal and financing frameworks that struct-
3. Health system
ure any health system, as well as its clinical and service development or
delivery requirements. The software encompasses the
institutions (norms, traditions, values, roles and proce-
strengthening
dures) embedded within the system. As explained in the previous section, health systems are
These two health system dimensions are often tied shaped by both structural (hardware) components and
together. For example, financing mechanisms not only social (software) elements. Therefore, in order to iden-
influence the level of funding available for the health tify actions to develop or strengthen health systems,
system, but also indicate what is valued by that system. researchers need to consider:
Here is an example: the taxation-based elements of n
changes in the structures of the system that are likely
the system signal the extent to which society is prepared to generate performance gains; as well as
to take collective action to support redistribution; whilst n
what can be done to influence the behaviour and
the level of fee for service within the system signals practices of health system agents; and
the extent to which society values choice, allowing those n
how to implement both sets of changes in ways that
are most likely to secure intended effects (Roberts et
who can afford to, to pay for health care to buy more or
al., 2008).
better services. The set of financing mechanisms, more-
over, influence relationships between the state and its These system-level interventions sometimes focus on
citizens as well as between providers and patients, and more than one of the building blocks, such as pay-for-
has a direct influence over levels and patterns of health performance systems that together address human
care utilization, the extent to which the health system resource and financing issues.
offers financial protection in times of health crisis and Alternatively, through the governance or information
the contribution of the heath system to generating social building blocks, such intervention can encompass
solidarity (Gilson et al., 2008). processes and strategies that bring about change across
The recent attention on systems thinking, therefore, the system as a whole – that is, across system building
encourages a focus on the nature of health system blocks, levels and/or dimensions (de Savigny & Adam,
relationships and the synergies emerging from them, 2009). The hardware and software dimensions of health
recognizing that the sum of the whole is more than systems may together be addressed by, for example, new
the sum of the parts (de Savigny & Adam, 2009). accountability mechanisms, or processes, and monitoring
and evaluation strategies. There is also potential for new
leadership and management approaches to focus on the
deliberate development of the institutional and relational
nature of the health system (Gilson, 2012).

Some disease or programme-specific interventions also

have system-wide effects, such as scaling up anti-
retroviral therapy or integrating vouchers for malaria-
preventing bednets into ante natal care (de Savigny &
Adam, 2009). However, most disease programme or
service-specific strategies are unlikely by themselves to
bring about improvements across the health system.
Such strategies suffer one or more of the following
weaknesses (Travis et al., 2004).

24 Gilson L, ed. (2012). Health Policy and Systems Research: A Methodology Reader - The Abridged Version
Alliance for Health Policy and Systems Research, World Health Organization