What are Health Systems?
Health systems consist of interrelated elements that contribute to health of the concerned population. Health systems are open and adaptive. They include health seeking behaviour of the concerned population and the dynamics of all healthcare contacts. As the interfaces are inherently diffused, specific inclusion and exclusion criteria are often necessary to delineate boundaries of a health system, for operational purposes. For any health system to function well, it’s interdependent subsystems ought to be mutually aligned, for which systems thinking and a systems approach is useful.
Healthcare providers such as doctors & nurses, hospitals & diagnostic facilities, essential medicines & surgery, are all key contributors to medical care. A doctor, a midwife or a physiotherapist, each acting alone can be helpful to some extent. However, there is a limit to usefulness of medical and healthcare professionals acting alone. Even this simple arrangement of solo practitioners providing care to their patients operates within the context of prevalent state, national and global health systems. In fact, solo practice by medical and healthcare providers is invariably backed up by elaborate systems of medical and allied health education, professional credentialing, availability of pharmaceuticals, hospitals, diagnostic facilities, public health programs, research and development.
Production of medical and healthcare services employ a wide-range of human resources, built infrastructure, and ancillary services. Thus, healthcare institutions of increasing complexity from a clinic or health centre to tertiary and subspecialty hospitals emerge as we aspire for a wider range of healthcare services. Organisation mean systems, policies and procedures. Complex systems and subsystems emerge, as the scope and scale of healthcare organisations grow. Health systems involve many actors from multiple disciplines. Often fundamental problems in national or state health systems affect program implementation and service delivery. For any health system to function well, it’s interdependent subsystems ought to be mutually aligned.
Definition of health systems viewed from different perspectives:
The definition of health systems often varies, depending on context. For example, various Oxford dictionaries articulate the concept with subtle differences in scope and emphasis. According to the Oxford dictionary of sociology, ‘health-care system’ loosely refers to the arrangements in a given society for the provision of preventive and curative health-care whether organized into a coherent system or not.
The Oxford dictionary of epidemiology, defines ‘health system’ as the human and material resources that a nation or community deploys for health and medical care and the corresponding organizational arrangements. The main components of the system are primary community-oriented personal health care, hospital-based specialized care, and public health services.
The Oxford dictionary of public health defines health care delivery system as the set of national, regional, or local organizations to finance and provide medical and health care services. Sometimes a circumscribed system such as that under the auspices of a specific medical and hospital insurance carrier or health maintenance organization is also referred to as a health system.
It is important to recognise that health systems are open and adaptive systems in a dynamic relationship with cultural, socio-political, technological, economic and environmental contexts (McCoy et al. 2021). As its interfaces are inherently diffused specific inclusion and exclusion criteria are often necessary to delineate boundaries of a health system, for purposes of description, analysis, and interventions in various contexts.
WHO’s definition of health systems:
The World Health Organization (WHO) defined health system as the complex of interrelated elements that contribute to health (WHO, 1984). Health systems ‘include all organizations, people and the activities whose primary intent is to promote, restore or maintain health’ (WHO 2000, 2007, 2011). Many factors contribute to people’s health. And we don’t yet know all of them. As our knowledge base expands, we learn more and more about the multitude of factors contributing to health. But, at any point of time, we would still not know all of them. Therefore, it can be argued that health system extends to all sectors, in effect dissolving the concept. This poses a problem for identification of health system boundary for purposes of analysis and tangible action. The ‘primary intent’ qualifier in WHO’s definition helps identify boundaries of health systems. In fact, WHR-2000 elaborates on this principle to clarify the extent of health systems. Thus, subsystems for medical & health care services, public health activities are included. Household production of health ; such as mothers adopting oral rehydration therapy to treat childhood diarrhea, is included. Activities whose primary purpose is something else are excluded, even if such activities have a secondary health enhancing benefit. Thus, general education sector is excluded, but medical and health related education is included. Similarly, ‘efforts to influence determinants of health’ and ‘inter-sectoral action by health staff’ are included (WHO 2007).
Health systems develop to meet felt needs, within local, state and national contexts. Defining a health system does not imply any particular degree of integration, controlling authority and structure. ‘In this sense, every country has a health system, however fragmented it may be among different organizations or however unsystematically it may seem to operate. Integration and oversight do not determine the system, but they may greatly influence how well it performs’ (WHO, 2000). Organisation of healthcare varies across national, state and local contexts, and changes over time in the same area. Characterization of national and state health systems is primarily a descriptive exercise to understand the totality of extant policy, priorities, promotional and regulatory environment, production of human resources for health, prevalence of institutional forms for health service delivery, public health activities and infrastructure, accountability mechanisms, utilisation, access, availability and convenience aspects, etc. Descriptive and comparative studies of various national health systems provide useful insights and possible connections between systemic characteristics and socially desired outcomes. For example; in order to translate the ‘Global Strategy for health for all by the year 2000’ the WHO developed a simplified model of a national health system, consisting of five major components, namely;
- Development of manpower (human resources for health), health facilities, equipment, supplies & knowledge (biomedical & health systems research);
- Organization of health authorities, public financing (health insurance) mechanisms, regulatory agencies, various other governmental agencies with secondary role towards health, voluntary agencies and private sector;
- Delivery of primary, secondary and tertiary healthcare service and public health services;
- Economic support (financing): public sources of finance, employees’ contributions, organized voluntary agencies, community financing, household expenditure and external assistance for health;
- Health services management: Leadership, decision-making, planning, implementation, monitoring & evaluation, information support and regulation; (Kleczkowski, Roemer and Werff, 1984).
More recently, the WHO visualized six building blocks to describe health systems (WHO 2007). These are;
- Service delivery: Personal health interventions (medical care) and non-personal health interventions (public health services).
- Health workforce: Human resources for health (medical, nursing, allied health professionals, and health services management education, continuing professional education, health workforce cadre management etc.)
- Health Information System: Production, analysis, dissemination and use of information on health determinants, health systems performance and health status.
- Medical products, vaccines & technologies.
- Financing: Public and private financing mechanisms. Tax-based funding, social health insurance, out-of-pocket heath expenditure, etc.
- Governance: Policy frameworks, oversight, partnerships & coalition, regulatory environment and accountability.
Area health systems:
Although health systems are often defined as country-level entities, the concept is relevant for a range of social, geographic, political and organisational contexts. Broader approaches encompass various determinants of health and the complete range of scientific, industrial and socio-economic infrastructure supporting healthcare services and public health interventions within state, national, and regional contexts. Circumscribed definitions of health system highlight medical and health care services within a well-defined organisation, network and/or community. For example; area, district, regional health systems.
Network or Local health systems:
Network of satellite healthcare facilities centred around tertiary or secondary referral facilities emerge to facilitate continuum of care . Such networks may be viewed as one kind of local health systems. For example; the United States Department of Health & Human Services - Agency for Healthcare Research and Quality (AHRQ) defines ‘a health system to include at least one hospital and at least one group of physicians that provides comprehensive care (including primary and specialty care) who are connected with each other and with the hospital through common ownership or joint management’. This is a working definition. The AHRQ recognise limitation of this definition due to the ‘at least one hospital’ requirement (AHRQ, 2018).
Is health system a ‘black box’?
A common misconception is that the health system is a black box, and its intricate mechanisms are hard to understand. The ‘black box’ misconception often leads to the belief that one should mobilise resources and then outputs will somehow work their way. On the other hand, suspicion of a ‘black box’ should stimulate the quest for evidence and information to reveal more and more of what is in that box. There is some truth in ‘health systems are hard to understand’ part of the ‘black box’ misconception. That is why, one needs to view health systems from multiple perspectives, using tools and approaches developed within a variety of settings all which might not have direct connection with the health sector. The black box metaphor has its value. For example; user of a complicated mechanical or electronic device need not know the intricacies of its internal mechanism. But someone has to know its internal systems, to debug in case of malfunction.
Health Systems Research:
Medical anthropologists have studied various aspects of health system for a long time (Closser, 2022). Dr. Halfdan Mahler (WHO Director-General, 1973-1988), who had been deeply influenced by a 10-year period of fieldwork in India, promoted health services and health systems research (WHO, 2010). By 1984, it was recognised that health services research was mostly devoted to functioning of hospitals, but several determinants of health are outside conventional health sector. Hence, the WHO advocated health systems research as a wholistic approach (Taylor and WHO, 1984; Weisz, 2022,). The field of health policy and systems research has developed significantly in recent times (Bennet et al. 2018).
Is health system merely a ‘laundry list’ of its components?
Another critical view is that health systems are defined as a ‘laundry list’ of different organisations, human resources, and activities employed to produce health services without much attention to integration and coordination. Incomprehension of the systems concept and preoccupation with territorial concerns may lead to superficial interpretation of health system component lists, oblivious of their dynamic interrelationships. Although health systems are more than mere collection of listed components, there is a need to constantly remind ourselves about real world dynamics of any social system and the importance of systems thinking.
Systems Thinking and Systems Approach:
Systems thinking and systems approach is the underlying logic in labelling the set of entities and their relationships for production healthcare as health systems. Systems approach focusses on interrelationships of policy environment, resource entities, organisation of services, health seeking behaviour, all of which require multidisciplinary perspectives and interdisciplinary work. A broader perspective creates the understanding needed for sustainable solutions and better coordinated response to public health challenges. Systems thinking allows us to deal with complex problems involving many actors, legacy issues, inappropriate metrics, misaligned incentives, ineffective coordination, unresponsive healthcare. Systems thinking is oriented to the linkage of various disciplines, appraisal of issues from many angles to identify potential pitfalls and synergies to improve people’s health. (Savigny, Taghreed and AHPSR, 2009; Kaplan et al. 2013).
In summary …
Health systems consist of interrelated elements that contribute to health of the concerned population. Health systems are open and adaptive. They include health seeking behaviour of the concerned population and the dynamics of all healthcare contacts. Health system is defined broadly so as to include professional, technological, behavioural, social, economic, cultural and other sub-systems. As the interfaces are inherently diffused, specific inclusion and exclusion criteria are often necessary to delineate boundaries of a health system, for operational purposes. For any health system to function well, its interdependent subsystems ought to be mutually aligned, for which systems thinking and a systems approach is useful.
References and further readings:
- AHRQ; 2019. Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2018, Technical Documentation. Rockville, MD: US Dept. of Health & Human Services - Agency for Healthcare Research and Quality (AHRQ); 2019 Jan; AHRQ Publication No. 20(21)-0011.
- Bennett, S., Frenk, J. & Mills, A.; 2018. The evolution of the field of Health Policy and Systems Research and outstanding challenges. Health Res Policy Sys 16, 43 (2018).
- Berman Peter; Kendal Carl, and Bhattacharya Karabi; 1994. The household production of health: integrating social science perspectives on micro-level health determinants. Social Science and Medicine. 1994; 38(2):205-215.
- DaVanzo Julie and Gertler Paul; 1990. Household Production of Health: A Microeconomic Perspective on Health Transitions. Santa Monica, CA, USA: The RAND Corporation; 1990 Jan; A RAND Note.
- Frenk Julio; 2010. The global health system: strengthening national health systems as the next step for global progress. PLoS Med. 2010 Jan;7(1):e1000089. doi: 10.1371/journal.pmed.1000089. Epub 2010 Jan 12.
- Kaplan, G., G. Bo-Linn, P. Carayon, P. et al.; 2013. Bringing a Systems Approach to Health. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC.
- Kleczkowski, Roemer and Werff; 1984. National health systems and their reorientation towards health for all: guidelines for policy-making. Bogdan M. Kleczkowski, Milton I. Roemer, Albert van der Werff. World Health Organization.
- McCoy, D., & Allotey, P.; 2021. An Introduction to Health Systems. In J. Martins, I. Pathmanathan, D. Tan, S. Lim, & P. Allotey (Eds.), Systems Thinking Analyses for Health Policy and Systems Development: A Malaysian Case Study (pp. 3-16). Cambridge: Cambridge University Press.
- Savigny, Donald de, Adam, Taghreed, Alliance for Health Policy and Systems Research & World Health Organization; 2009. Systems thinking for health systems strengthening; edited by Don de Savigny and Taghreed Adam. World Health Organization.
- Taylor, Carl Ernest & World Health Organization; 1984. The uses of health systems research; World Health Organization.
- Weisz George; 2022. Creating an Applied, Multi-disciplinary Research Field: The World Health Organization and Health Systems Research 1960–2000); Social History of Medicine, Volume 35, Issue 2, May 2022, Pages 612–634.
- WHO; 1981. Global Strategy for health for all by the year 2000. Geneva: World Health Organization (WHO); 1981; "Health for All" Series.
- WHO; 1984. Glossary of Terms used in the "Health for All"; series No.1-8. Geneva: World Health Organization (WHO); 1984; Health for All Series, (9).
- WHO; 2000. The World Health Report 2000. Health Systems: Improving Performance. Geneva: World Health Organization; 2000.
- WHO; 2007. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization (WHO); 2007.
- WHO; 2010. Research and the World Health Organization: a history of the Advisory Committee on Health Research, 1959-1999. World Health Organization.
- WHO; 2011. WHO Health Systems Strengthening Glossary. Geneva: World Health Organization (WHO); 2011 Jan (9).