Health system models and frameworks: WHO, World Bank and resilience
- Page updated onMay 13, 2026
Development cooperation or humanitarian action in health interventions 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, in terms of its functions and objectives
In the World Health Report published by WHO in 2000, a health system model was proposed featuring 4 functions (stewardship/oversight, resource creation, financing, and service provision) connected to 3 objectives (responsiveness to people's expectations, fair financial contributions, and health). This simple model would form the basis for more advanced models that followed (WHO, 2000)World Health Organization. (2000). The world health report 2000: Health systems: Improving performance. World Health Organization. https://www.who.int/publications/i/item/924156198X.
The WHO health systems framework, comprising 6 interrelated building blocks
Seven years after the previous document, in 2007, 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 organisations, institutions, and resources whose primary intention is to produce actions for the promotion, restoration, or maintenance of health (WHO, 2007)World Health Organization. (2007). Everybody's business: Strengthening health systems to improve health outcomes — WHO's framework for action. World Health Organization. https://www.who.int/publications/i/item/everybody-s-business—-strengthening-health-systems-to-improve-health-outcomes.
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 health system 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.
The development of the six building blocks of a health system (inputs) produces certain desirable system characteristics (outputs). These contribute to producing changes in the system itself and improvements in health (outcomes) (WHO, 2010)World Health Organization. (2010). Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. World Health Organization. https://iris.who.int/handle/10665/258734.
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 appears to assign equal weight to all components, which does not reflect reality in practice. Furthermore, these components are presented in a segmented manner without clearly showing the importance of the interactions between them (Papanicolas et al., 2022)Papanicolas, I., Rajan, D., Karanikolos, M., Soucat, A., & Figueras, J. (Eds.). (2022). Health system performance assessment: A framework for policy analysis. World Health Organization. https://www.who.int/publications/i/item/9789240042476. Health system strengthening work often needs to address precisely these interactions, both through technical assistance and advocacy. This includes, for example, how the financing model determines incentives for staff (Tikkanen et al., 2020)Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. (Eds.). (2020). International profiles of health care systems. Commonwealth Fund. https://doi.org/10.26099/7ahs-kn97, or how the information system should support input monitoring. Finally, this framework directs attention towards formal health services, thereby leaving out aspects as important as the community (USAID, 2017)USAID. (2017). Health system assessment approach: A how-to manual (Version 3.0). United States Agency for International Development. https://hsaamanual.org/download-the-pdf and the understanding of the health system as a social determinant of health in its own right.
Other conceptual frameworks help us understand health systems from different angles and perspectives (OECD, 2021)OECD. (2021). Health for the people, by the people: Building people-centred health systems. OECD Publishing. https://doi.org/10.1787/c259e79a-en.
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The World Bank health systems framework, known as the "control knobs"
The World Bank has long used the "control knobs" model as a reference (Roberts et al., 2004)Roberts, M. J., Hsiao, W., Berman, P., & Reich, M. R. (2004). Getting health reform right: A guide to improving performance and equity. Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195371505.001.0001. In this control panel, whatever we adjust by turning one knob or another will have a direct effect on system performance. Furthermore, this effect will be measurable in terms of efficiency, quality (including safety), and access (including coverage). Performance, in turn, has an impact on the health status, satisfaction (as service users), and risk protection 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 the impact of the health system
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 possibly do not yet have a definitive framework that allows us to adequately understand and evaluate any health system (OECD, 2024)OECD. (2024). Rethinking health system performance assessment: A renewed framework. OECD Publishing. https://doi.org/10.1787/107182c8-en. Health systems are, after all, broad and complex. In any case, we have several reference models whose combined use can help us identify areas for technical and financial support to a system (Waitzberg et al., 2024)Waitzberg, R., Pfundstein, I. D., Maresso, A., Rechel, B., van Ginneken, E., & Quentin, W. (2024). Analysis of health system characteristics needed before performance assessment. Bulletin of the World Health Organization, 102(7), 547–549. https://doi.org/10.2471/BLT.24.291760. These frameworks also point to key indicators for measuring outcomes, priorities for ensuring we place people at the centre of health interventions, and elements of public policy that we can influence to achieve transformative change (Papanicolas et al., 2022)Papanicolas, I., Rajan, D., Karanikolos, M., Soucat, A., & Figueras, J. (Eds.). (2022). Health system performance assessment: A framework for policy analysis. World Health Organization. https://www.who.int/publications/i/item/9789240042476. In this way, tangible results will be achieved in the equity and health status of the population (Bryce et al., 2013)Bryce, J., Requejo, J. H., Moulton, L. H., Ram, M., & Black, R. E. (2013). A common evaluation framework for the African Health Initiative. BMC Health Services Research, 13(Suppl. 2), S10. https://doi.org/10.1186/1472-6963-13-S2-S10.
Resilience of complex and adaptive health systems
What is a resilient health system?
Under this model, resilience is understood as the capacity of the health system to absorb the shock, adapt to it and transform, in response to economic crises, pandemics, conflicts and humanitarian emergencies (Blanchet et al., 2017)Blanchet, K., Nam, S. L., Ramalingam, B., & Pozo-Martin, F. (2017). Governance and capacity to manage resilience of health systems: Towards a new conceptual framework. International Journal of Health Policy and Management, 6(8), 431–435. https://doi.org/10.15171/ijhpm.2017.36. Depending on its resilience, the system will (or will not) succeed in maintaining the provision of essential health services and its core public health functions despite the shock, making the necessary organisational adjustments now that the type and quantity of available resources have changed, and ultimately transforming its structure and functions to respond to an environment and population needs that have also changed (Truppa et al., 2024)Truppa, C., Yaacoub, S., Valente, M., Celentano, G., Ragazzoni, L., & Saulnier, D. (2024). Health systems resilience in fragile and conflict-affected settings: A systematic scoping review. Conflict and Health, 18, 2. https://doi.org/10.1186/s13031-023-00560-7.
It is not simply a matter of returning to the pre-shock state, but of learning from the crisis, institutionalising some of the most positive modifications made during the adaptation phase (such as the incorporation of new services or social protection mechanisms, for example), reconfiguring power relations between actors, and thereby making changes that can genuinely and sustainably promote social justice and health equity in the new context.
To operationalise all of this, it is important to understand the relationship between health system resilience and health system strengthening (WHO, 2024)World Health Organization. (2024). Health system resilience indicators: An integrated package for measuring and monitoring health system resilience in countries. World Health Organization. https://www.who.int/publications/i/item/9789240088986. Coordination and convergence between these two approaches allow for a far more coherent response in complex humanitarian crises. Making this possible requires working with more actors, at all levels, and with a broader time horizon (Truppa et al., 2026)Truppa, C., Saulnier, D. D., Bertone, M. P., Yamonn, N., Hafez, S., Witter, S., et al. (2026). Getting unstuck: Reframing health systems strengthening and resilience in fragile and conflict-affected settings. BMJ Global Health, 11, e020061. https://doi.org/10.1136/bmjgh-2025-020061.
What capabilities does a health system need to have to be resilient?
The conceptual framework proposed by Blanchet and colleagues for the resilience of health systems refers to four dimensions necessary to achieve resilience. These are the management and governance capacities that the system must have in order to be able to react to crises:
- Ability to combine and integrate different forms of knowledge. System actors must be able to collect and analyse complex information about services and the context in which they are delivered. Statistical data alone is not sufficient. In crises such as those in the Middle East, the cultural and political knowledge of actors such as UNRWA has been decisive. During the Ebola outbreak in West Africa, the knowledge of community members and frontline health and humanitarian workers about local risk perceptions was decisive (Blanchet, 2025)Blanchet, K. (2025). Getting unstuck: reframing health systems strengthening and resilience in fragile and conflict-affected settings. BMJ Global Health, 11(2). https://doi.org/10.1136/bmjgh-2025-020061..
- Ability to anticipate and deal with uncertainties and unexpected events. The system must have flexible resources and those in charge must have sufficient room for maneuver to make quick decisions when necessary. Examples of this flexibility are the budgets directly managed by the heads of health centers, and the protocols that allow them to hire health personnel and purchase medical products locally and quickly in case of emergency.
- Ability to manage the interdependence of multiple complex structures, in different sectors and at different levels. It is not possible to take a purely technical view that ignores the weight of dynamics and actors outside «health» in the health system. Sectors related to finance, security, labor, education, roads and transportation, or the relationship with external international actors can be determining factors.
- Ability to develop legitimate institutions and socially accepted norms. The resilience of the health system depends on the trust of the community, and to achieve this, consultative processes, participation and public policies that put people at the center and contribute to generating a sense of belonging are needed. When the community feels part of the system and also feels that the health services belong to them, the collective effort is reflected in public health outcomes.
Health system resilience should not be understood as a standalone agenda, but as a nexus between efforts towards health security and efforts towards universal health coverage (WHO, 2022)World Health Organization. (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. World Health Organization. https://www.who.int/publications/i/item/9789240048751.
Recommended readings and references
Recommended readings
For a first introduction to the main health systems frameworks, the building blocks monitoring handbook is particularly practical (WHO, 2010)World Health Organization. (2010). Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. World Health Organization. https://iris.who.int/handle/10665/258734. The document analyses each of them in great detail and facilitates thinking about their operationalisation or strengthening. To think beyond this classic model, the proposal by Kruk et al. offers a very different perspective, focused on quality and, above all, the experience of people who use the health system (Kruk et al., 2018)Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., García-Elorrio, E., Guanais, F., Gureje, O., Hirschhorn, L. R., Jiang, L., Kelley, E., Lemango, E. T., Liljestrand, J., Malata, A., Marchant, T., Matsoso, M. P., Meara, J. G., Mohanan, M., Ndiaye, Y., Norheim, O. F., Reddy, K. S., Rowe, A. K., Salomon, J. A., Thapa, G., Twum-Danso, N. A. Y., & Pate, M. (2018). High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health, 6(11), e1196–e1252. https://doi.org/10.1016/S2214-109X(18)30386-3. Finally, the article by Truppa et al. operationalises in a very practical way the differences between strengthening health systems and building their resilience in humanitarian crises (Truppa et al., 2026)Truppa, C., Saulnier, D. D., Bertone, M. P., Yamonn, N., Hafez, S., Witter, S., et al. (2026). Getting unstuck: Reframing health systems strengthening and resilience in fragile and conflict-affected settings. BMJ Global Health, 11, e020061. https://doi.org/10.1136/bmjgh-2025-020061.
References
- Blanchet, K., Nam, S. L., Ramalingam, B., & Pozo-Martin, F. (2017). Governance and capacity to manage resilience of health systems: Towards a new conceptual framework. International Journal of Health Policy and Management, 6(8), 431–435. https://doi.org/10.15171/ijhpm.2017.36
- Blanchet, K. (Ed.). (2025). Health system resilience: Understanding complex adaptive systems. MIT Press. https://doi.org/10.7551/mitpress/14871.001.0001
- Bryce, J., Requejo, J. H., Moulton, L. H., Ram, M., & Black, R. E. (2013). A common evaluation framework for the African Health Initiative. BMC Health Services Research, 13(Suppl. 2), S10. https://doi.org/10.1186/1472-6963-13-S2-S10
- Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., García-Elorrio, E., Guanais, F., Gureje, O., Hirschhorn, L. R., Jiang, L., Kelley, E., Lemango, E. T., Liljestrand, J., Malata, A., Marchant, T., Matsoso, M. P., Meara, J. G., Mohanan, M., Ndiaye, Y., Norheim, O. F., Reddy, K. S., Rowe, A. K., Salomon, J. A., Thapa, G., Twum-Danso, N. A. Y., & Pate, M. (2018). High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health, 6(11), e1196–e1252. https://doi.org/10.1016/S2214-109X(18)30386-3
- OECD. (2021). Health for the people, by the people: Building people-centred health systems. OECD Publishing. https://doi.org/10.1787/c259e79a-en
- OECD. (2024). Rethinking health system performance assessment: A renewed framework. OECD Publishing. https://doi.org/10.1787/107182c8-en
- Papanicolas, I., Rajan, D., Karanikolos, M., Soucat, A., & Figueras, J. (Eds.). (2022). Health system performance assessment: A framework for policy analysis. World Health Organization. https://www.who.int/publications/i/item/9789240042476
- Roberts, M. J., Hsiao, W., Berman, P., & Reich, M. R. (2004). Getting health reform right: A guide to improving performance and equity. Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195371505.001.0001
- Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. (Eds.). (2020). International profiles of health care systems. Commonwealth Fund. https://doi.org/10.26099/7ahs-kn97
- Truppa, C., Saulnier, D. D., Bertone, M. P., Yamonn, N., Hafez, S., Witter, S., et al. (2026). Getting unstuck: Reframing health systems strengthening and resilience in fragile and conflict-affected settings. BMJ Global Health, 11, e020061. https://doi.org/10.1136/bmjgh-2025-020061
- Truppa, C., Yaacoub, S., Valente, M., Celentano, G., Ragazzoni, L., & Saulnier, D. (2024). Health systems resilience in fragile and conflict-affected settings: A systematic scoping review. Conflict and Health, 18, 2. https://doi.org/10.1186/s13031-023-00560-7
- USAID. (2017). Health system assessment approach: A how-to manual (Version 3.0). United States Agency for International Development. https://hsaamanual.org/download-the-pdf
- Waitzberg, R., Pfundstein, I. D., Maresso, A., Rechel, B., van Ginneken, E., & Quentin, W. (2024). Analysis of health system characteristics needed before performance assessment. Bulletin of the World Health Organization, 102(7), 547–549. https://doi.org/10.2471/BLT.24.291760
- World Health Organization. (2000). The world health report 2000: Health systems: Improving performance. World Health Organization. https://www.who.int/publications/i/item/924156198X
- World Health Organization. (2007). Everybody’s business: Strengthening health systems to improve health outcomes — WHO’s framework for action. World Health Organization. https://www.who.int/publications/i/item/everybody-s-business—-strengthening-health-systems-to-improve-health-outcomes
- World Health Organization. (2010). Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. World Health Organization. https://iris.who.int/handle/10665/258734
- World Health Organization. (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. World Health Organization. https://www.who.int/publications/i/item/9789240048751
- World Health Organization. (2024). Health system resilience indicators: An integrated package for measuring and monitoring health system resilience in countries. World Health Organization. https://www.who.int/publications/i/item/9789240088986
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How to cite this page
Abarca, B. (May 13, 2026). Health system models and frameworks: WHO, World Bank and resilience. Salud Everywhere. https://saludeverywhere.com/en/health-in-humanitarian-crises/introduction-to-health-systems/