The field of public health (including health systems science and health policy) is moulded by dynamic relationships between actors from scientific, policy and operational backgrounds as well as the public in the form of patient groups, consumer associations and other interest groups/actors from the private sector. The significant influence of all these stakeholders with different backgrounds and paradigms contributes to the perceived lack of clarity.

The recent orientation of health systems research to the domain of research has brought a plethora of research questions, approaches and methods. However, there has been an observed recurring theme that the way to start conceiving of health systems research is from a conceptual framework that can frame and interpret empirical research. Health systems strengthening is an abstract and multi-interpretable concept within health systems research. Thus, frameworks can aid in clarifying the concept and linking it to other concepts. This would enhance the understanding of the underlying mechanisms, determinants of emergent phenomena or a new pathway to change.

(Shakarishvili et al. 2010) give a comprehensive and analytical overview of the differences in existing health system frameworks.

The authors believe that most of the existing frameworks that have been published in the last decade have a limited capacity to scrutinize the interactions and equilibriums between different elements of a health system. Additionally, most do not give attention to values as mechanisms that direct people’s behaviour and coincidently their choices and process in health systems.

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This framework contains elements of existing frameworks, such as the WHO building blocks, but it goes further than most. First, it stresses that health systems should be geared towards outcomes and goals, but that these should be based on a set of specific values and principles. Second, this framework prioritizes certain elements over others. For example, is emphasizes the organization and delivery of healthcare services as a central axis that incorporates leadership, governance and interaction with the population and other actors. This results in a framework that consists of ten elements and their dynamic interactions:

1) goals and outcomes.
2) values and principles.
3) service delivery.
4) the population.
5) the context.
6) leadership & governance.
7-10) the organization of resources: 7) finances; 8) human resources; 9) infrastructure and supplies; 10) knowledge and information.

This framework describes outcomes as the direct results of the organisation of healthcare delivery and goals as the expected impact of improved health and social and financial protection (more long-term than outcomes), which is in line with the WHO. As we can see from the placement of goals, they are not solely dependent on the health system. Therefore, this framework acknowledges that social, economic, political and other factors are major determinants of health and the well-being of people.
 

The dynamic characteristic of this framework is based on Complex Adaptive Systems. Health systems are open systems that draw and abstract resources from their environment but also respond to it. Interactions between many actors are nonlinear and difficult to predict. Interactions by elements take the shape of feedback loops and contribute to generative processes. These interactions lead to the emergence of temporary equilibriums. Finally, CAS exhibit path-dependence, so a historical analysis can help us understand how strategic choices are made when a health system responds to opportunities and constraints. Through the Health System Dynamics framework, we are forced to consider all of these elements, interaction and emergent decisions and outcomes when describing and analysing health systems.

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Outcomes and Goals

This framework describes outcomes as the direct results of the organisation of healthcare delivery and goals as the expected impact of improved health and social and financial protection (more long-term than outcomes), which is in line with the WHO. As we can see from the placement of goals, they are not solely dependent on the health system. Therefore, this framework acknowledges that social, economic, political and other factors are major determinants of health and the well-being of people.

 

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Values and Principles

 

Health systems are not these mechanically engineered structures that deliver health care. They are social institutions, shaped around values and these values emanate in the structures, institutions and interpersonal relationships of health systems. These values and principle vary among societies and actors and thus their effect can be seen through power structures and relations within society such as processes that affect effectiveness, efficiency, and sustainability.

Priority-setting, especially in LMIC, comes inherent with the tension of choosing between different options with different shirt term and longer term goals that reflect different values. An essential function of health system governance becomes seeking balance by considering the values and principles of actors in the system and negotiating on the basis of fair processes, whilst (1) being accountable to the ultimate beneficiary – the population – and, (2) minimizing harmful effects, especially for the most vulnerable groups.

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Context

 

Because health systems resemble open systems, they are shaped and influenced by wider societal changes. Therefore, a country’s health system will reflect its political decision-making and historical evolution. It also implies that health systems need to be able to respond to new developments and transitions, such as an ever-evolving disease epidemiology, new technologies, changing expectations of patients and providers, increased availability of information and the changing roles of actors and the state in the health system.

A contextual analysis would consider governance (including evolutions in political regimes, institutional arrangements, the organisation of the public sector and public financial management), the policy context (which should be analysed at all levels concurrently), global financial and economic regimes and their associated actors.

In addition to this, there has been a recognition of the influence of water and sanitation on the burden of infectious diseases and of good education as a determinant for maternal and child health. There is evidence that points to the influential role of private sector, more so the pharmaceutical, tobacco and food industry, in shaping the environment and the concordant behaviour of people (Labonte et al. 2011).

 

 

Service Delivery

Service delivery in healthcare is the process through which providers, health facilities, programmes and policies are coordinated and implemented in order to reach the goals of the health system. It relates to services and activities with the primary purpose of improving health and includes primary prevention; secondary prevention; curative care and rehabilitation (Marchal et al. 2011).

The scarcity of resources and the need for rationing requires intervention to be prioritized but in practice, this takes the form of bundling intervention into one delivery platform. This bundling is informed by various factors.

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Population

The population in the health system involves patients. Customers, right-bearing citizens and funders, suppliers or even producers of care (spontaneous activities and collective action). The understanding of participation varies widely – thinking of the Ladder of Participation. Empowerment (the transformation of power relations) at the individual and community level is considered an important goal as it contributes to reducing inequalities and bringing about desired social change. This requires different approaches on both the supply and demand side and fair processes in decision-making to ensure their voices are taken into account.

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Governance

Governance involves policy guidance for the whole health system, coordination of actors, regulation of functions, efficient allocation of resources and ensuring accountability to the population and all stakeholders.

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Information and Knowledge

Information and knowledge are needed for monitoring, evaluation and research, clinical decision-making, organizational management and planning, analysis of health trends and communication. The priority of routine information systems should be to develop and maintain their potential to contribute to sound decision-making, limiting the collection to data that are necessary for that purpose. Knowledge and information should flow optimally in all directions on a need-to-know basis, vertically and horizontally, so that the ongoing processes of practice, education and research can feed into each other. A comprehensive knowledge strategy covers all levels of the knowledge-value chain and fosters optimal collaboration between all knowledge holders (Meessen et al. 2011b).