Resources:  health systems, their attributes, governance and strengthening

As explained by the World Bank "Access to health services is reduced by health system inefficiencies and deficiencies, including ill-equipped facilities, drug shortages, too few staff, and gaps in their skills. Poor people are affected most and least able to afford treatment. Illness often drives families (deeper) into poverty.

Health systems are complex. They require high levels of human capital and financing, a clear vision, and strong leadership. Countries must plan and allocate their limited resources efficiently to meet their many pressing needs."

WHO has a number of programmes devoted to health systems, and has identified 6 building blocks of health systems:

From: World Health Organization (WHO). Everybody's business - strengthening health systems to improve health outcomes: WHO's framework for action. WHO; Geneva: 2007.

Service delivery
Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources.
Health workforce
A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).
Health information system
A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.
Medical products, vaccines and technologies
A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.
Health systems financing
A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient.
Leadership and governance
Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system-design and accountability.

The World bank is also a key player in health systems: "In the era of sustainable development goals, the World Bank plays a pivotal role in promoting universal health coverage and strengthening health systems. In 2010, the bank provided 32% of the global health systems support budget
  • The World Bank’s health policy focus has shifted from population control (1970s), to primary healthcare direct lending (1980-6), to health reform (1987-96), to the enhancement of healthcare systems (1997-2007), to a health systems approach (2007-present)
  • The World Bank has a comparative advantage over WHO to lead the universal health coverage agenda given its access to ministries of finance, its staff expertise in measurement, its broad multisectorial portfolio, and its lending power
  • The World Bank’s expanded role in global health carries with it the risks of further privatisation of the health sector and major tension between its mandate and the right to health at the heart of universal health coverage"

From Universal health coverage, health systems strengthening, and the World Bank

An excellent summary paper Health systems strengthening, universal health coverage, health security and resilience helps us understand some of the terms used in this section such as: "Set within the political and institutional framework of a country, a health system is “the ensemble of all public and private organizations, institutions, and resources mandated to improve, maintain or restore health."” It summarises: "So here is a simple guide: health system strengthening is what we do; universal health coverage, health security and resilience are what we want."

Health System Strengthening (HSS)

There are a number of global initiatives to strengthen health systems. "Health systems seek to achieve overall health improvement through provision of promotional, preventive, curative and rehabilitative health services. Health systems operate at and across national, district, community and individual levels. Governments have the responsibility to strengthen their health systems. Health system strengthening is defined as building capacity in critical components of health systems to achieve more equitable and sustained improvements across health services and health outcomes. Global Health Initiatives (GHIs) are typically programmes targeted at specific diseases and intended to bring additional resources to the health efforts of countries."

However, it is important to put HSS into context, as in this perceptive paper Why differentiating between health system support and health system strengthening is needed which says: "There is increasing recognition that efforts to improve global health cannot be achieved without stronger health systems. Interpretation of health system strengthening (HSS) has varied widely however, with much of the focus to-date on alleviating input constraints, whereas less attention has been given to other performance drivers. It is important to distinguish activities that support the health system, from ones that strengthen the health system. Supporting the health system can include any activity that improves services, from distributing mosquito nets to procuring medicines. These activities improve outcomes primarily by increasing inputs. Strengthening the health system is accomplished by more comprehensive changes to performance drivers such as policies and regulations, organizational structures, and relationships across the health system to motivate changes in behavior and/or allow more effective use of resources to improve multiple health services."


A thoughtful paper Frameworks to assess health systems governance: a systematic review has identified three key issues:

  • Health system governance is one of the neglected agendas in health system research.
  • There is currently a lack of evidence with regard to how governance can and is assessed at both national and sub-national level.
  • Existing frameworks can be adapted to assess governance overall or specific components of governance.

The authors conclude: "Governance is not an ‘apolitical’ process, and there are no absolute principles that define governance; it is a diffuse concept that cuts across disciplines, and borrows from a range of social science theories. However, whether it is applied to health systems or political science, governance is concerned with how different actors in a given system or organization function and operate and the reasons for this. In the context of health systems governance, we believe a multidisciplinary approach to assessment is necessary."

Health security

The issue of health security should also be considered as we think about health systems The figure below comes from the WHO site Health security and health systems strengthening - an integrated approach which states: "Efforts to strengthen health security and health systems need to be integrated to promote sustainability, efficiency and effectiveness of a country’s preparedness efforts, while avoiding the creation of a vertical health security silo. Strong comprehensive health systems are essential for health security while in turn better health security strengthens health systems"

Developing the evidence base

Building the Field of Health Policy and Systems Research: An Agenda for Action describes an emerging research area:

  • There is an urgent need to build the Health Policy and Systems Research (HPSR) field and in particular to develop understanding across different disciplinary boundaries.
  • The development of HPSR is impeded by a cluster of related issues, namely (i) a heavy reliance on international funding for HPSR, (ii) an excessive focus on the direct utility of HPSR findings from specific studies, and (iii) a tendency to under-value contributions to HPSR from social sciences.
  • Innovations in funding HPSR are needed so that local actors, including policy-makers, civil society, and researchers, have a greater say in determining the nature of HPSR conducted.

Health Systems Evidence "is a continuously updated repository of syntheses of research evidence about governance, financial and delivery arrangements within health systems, and about implementation strategies that can support change in health systems." It is a great resource where you can search for evidence to support policy making.

You may also be interested to see a number of teaching resources on Health Policy and Systems through the CHEPSAA site.

Last modified: Monday, June 7, 2021, 12:46 PM