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Introduction to health systems
- Page updated onFebruary 26, 2025
Development cooperation interventions or humanitarian action in health do not occur in a vacuum or in isolation. Whether with a long-term or short-term objective, or through the provision of services with a mobile team in places where there are apparently no other actors, intervention takes place within the framework of a health system that is weakened, maintained or strengthened.
In international cooperation we must understand what a health system is, what functions and elements it has and how they are related. For this we have different models and ways of understanding them.
Table of contents:
The health system, from its functions and objectives (WHO, 2000)
The World Health Report published by the WHO in 2000 proposed a health system model in which they proposed 4 functions of the system (administration/supervision, creation of resources, financing and provision of services) that were connected with 3 objectives (response to people's expectations, fair financial contributions and health. This simple model would form the basis of other more advanced models.
The health system, made up of 6 interrelated blocks (WHO, 2007)
Seven years after the previous document, in 2007, the WHO produced the health systems framework and analysis that has been most widely used to date. According to this proposal, a health system is the set of organizations, institutions and resources whose main intention is to produce actions to promote, restore or maintain health.
This definition opens up the scope of action of the system beyond the offices of public health authorities, outpatient centers and hospitals. Within this framework, a person who performs care work for a dependent, an NGO with a project against gender-based violence, a community health promoter promoting breastfeeding and a legislative initiative for a national public health insurance, for example.
This WHO framework also sets out the goals pursued by a health system (better health and health equity, responsiveness, social and financial risk protection and improved efficiency), its intermediate objectives (access, coverage, quality and safety) and, above all, the basic components of the system.
Strengthening the health system requires strengthening 6 components and the relationship between them
According to the 2007 framework, health systems strengthening is the improvement of the six basic components of the health system and the interactions among them to achieve improvements in services that in turn improve health outcomes. Those six components are:
- Provision of services. This element refers to the services offered to meet the needs of the population and how they are offered, the way in which the network of providers is managed and organized, the necessary infrastructure and the generation of demand for health care.
- Health personnel. The existence of competent and well-performing health personnel requires adequate regulations and strategies for the development and strengthening of these personnel, which also take into account important aspects such as training and economic costs.
- Information. It is necessary that data and research be generated and that this information be used for better decision making. To this end, health information systems should be established that include surveillance, reporting and monitoring mechanisms.
- Medicines and medical supplies. Access to cost-effective, safe, quality essential medicines and medical supplies is a priority for a well-functioning system. This requires strong regulatory and supply systems, as well as efforts to ensure the availability of access and quality.
- Financing. A good health system collects, pools and spends economic resources on services and goods in ways that ensure equitable access for the entire population to the services they need without causing them financial hardship.
- Governance and leadership. The government has the mandate and responsibility to guide all actors involved in a health system while protecting the public interest. This requires the development and implementation of policies, plans and regulatory frameworks, but also adequate accountability and coordination among actors.
A development of the six fundamental components of a health system (inputs) produces certain desirable characteristics of the system (outputs). These contribute to producing changes in the system itself and improvements in health (outcomes).
Although this framework is the best known and most widely used, it has limitations
Over the years, many people have pointed out the limitations and weaknesses of the World Health Organization's 6-block conceptual framework.
To begin with, the framework seems to give all components the same weight, which is not real in practice. Moreover, these components are presented in a segmented manner without clearly showing the importance of the interactions among them. Precisely, health systems strengthening work often needs to address these interactions, both from technical assistance and advocacy. This includes, for example, how the financing model determines incentives for staff, or how the information system should help in the control of inputs. Finally, this framework directs our attention to the formal health services. Thus, it practically leaves out such important aspects as the community or the understanding of the health system as yet another social determinant of health.
Other conceptual frameworks help us to understand health systems from other angles and perspectives.
The health system as "control knobs" (World Bank, 2004)
The World Bank has long used as a reference the "control wheel" model developed by Mark J. Roberts, et al, in 2004. In this control panel, what we control by turning one or the other wheels will have a direct effect on system performance.. In addition, this effect will be measurable from its efficiency, quality (including security) and access (including coverage). Performance, in turn, has an impact on the health statusthe satisfaction (as users) and the protection against risks of the reference population.
This model proposes five elements of public health policy on which action should be taken
Where this model really shines is in going beyond just supplying inputs to a system’s foundational components. It enables us to focus on five key elements of health policy that can be adjusted by turning the control knob in one direction or another.
- Financing refers to the mechanisms (taxes, insurance premiums and direct payments) for collecting the funds needed to pay for health services and how the institutions that provide them operate.
- Payment refers to the manner (reimbursements, budgets, capitation payments, direct out-of-pocket payment, etc.) in which money is transferred from these institutions to health care providers and the management of the incentives that occur.
- Organization refers to the internal functioning of health care providers and how their functions are determined, how they may compete with each other or at what level and in what way they coordinate.
- Regulation refers to the ways in which the state can influence or impose how the actors that make up the health system, including service providers, service insurers and users, behave. Regulating is not just legislating, but also requires effective implementation of the rules.
- Behavior refers to the ways in which what people (users and providers) do in relation to health and health care is influenced: from their habits and behaviors to the application of preventive measures and even to the way in which users are persuaded to accept existing restrictions on freedom of choice of provider, for example.
Quality, necessary for health system impact (Kruk, 2018)
There are many other health systems models and conceptual frameworks. One of them is particularly useful for thinking about health system strengthening. It is the one recently proposed by Margaret E. Kruk. This model focuses on system quality, as a prerequisite for the system to really contribute to improving people's health.
Kruk's model posits that a high-quality health system is one that optimizes care in a given context by consistently delivering care that improves or maintains health outcomes, is valued and trusted by all people, and is responsive to the changing needs of the population. This framework puts people, their health, their economic benefit, their trust in the system, their positive user experience, and their needs and expectations at the center.
We may not yet have the definitive framework that allows us to properly understand and evaluate any health system. Health systems, after all, are broad and complex. In any case, we have several reference models, the combined use of which can help us identify areas of technical and financial support to a system. In addition, these frameworks also point to key indicators for measuring outcomes, priorities to ensure that we put people at the center of health interventions, and elements of public policy that we can influence to achieve transformational change. From this we will achieve tangible results in equity and population health status.
Health systems
External links
- WHO, 2024. Health system resilience indicators: an integrated package for measuring and monitoring health system resilience in countries.
- WHO, 2022. Health system performance assessment: a framework for policy analysis.
- WHO, 2022. Health systems resilience toolkit: a WHO global public health good to support building and strengthening of sustainable health systems resilience in countries with various contexts.
- Kruk, 2018. High-quality health systems in the Sustainable Development Goals era: time for a revolution.
- USAID, 2017. Health system assessment approach v3.0.
- WHO, 2007. Everybody’s business — strengthening health systems to improve health outcomes.
- Roberts, 2004. Getting Health Reform Right: A Guide to Improving Performance and Equity.
- WHO, 2000. World Health Report 2000. Health systems: improving performance.
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