Health systems frameworks in their political context: framing divergent agendas

van Olmen, Josefien, Marchal, Bruno, Damme, Wim Van, Kegels, Guy and Hill, Peter S. (2012) Health systems frameworks in their political context: framing divergent agendas. BMC Public Health, 12 1: 774.1-774.13. doi:10.1186/1471-2458-12-774

Author van Olmen, Josefien
Marchal, Bruno
Damme, Wim Van
Kegels, Guy
Hill, Peter S.
Title Health systems frameworks in their political context: framing divergent agendas
Journal name BMC Public Health   Check publisher's open access policy
ISSN 1471-2458
Publication date 2012-09
Sub-type Article (original research)
DOI 10.1186/1471-2458-12-774
Open Access Status DOI
Volume 12
Issue 1
Start page 774.1
End page 774.13
Total pages 13
Place of publication London, United Kingdom
Publisher BioMed Central
Collection year 2013
Language eng
Formatted abstract
Despite the mounting attention for health systems and health systems theories, there is a persisting lack of consensus on their conceptualisation and strengthening. This paper contributes to structuring the debate, presenting landmarks in the development of health systems thinking against the backdrop of the policy context and its dominant actors. We argue that frameworks on health systems are products of their time, emerging from specific discourses. They are purposive, not neutrally descriptive, and are shaped by the agendas of their authors.


The evolution of thinking over time does not reflect a progressive accumulation of insights. Instead, theories and frameworks seem to develop in reaction to one another, partly in line with prevailing paradigms and partly as a response to the very different needs of their developers. The reform perspective considering health systems as projects to be engineered is fundamentally different from the organic view that considers a health system as a mirror of society. The co-existence of health systems and disease-focused approaches indicates that different frameworks are complementary but not synthetic.

The contestation of theories and methods for health systems relates almost exclusively to low income countries. At the global level, health system strengthening is largely narrowed down to its instrumental dimension, whereby well-targeted and specific interventions are supposed to strengthen health services and systems or, more selectively, specific core functions essential to programmes. This is in contrast to a broader conceptualization of health systems as social institutions.

Health systems theories and frameworks frame health, health systems and policies in particular political and public health paradigms. While there is a clear trend to try to understand the complexity of and dynamic relationships between elements of health systems, there is also a demand to provide frameworks that distinguish between health system interventions, and that allow mapping with a view of analysing their returns. The choice for a particular health system model to guide discussions and work should fit the purpose. The understanding of the underlying rationale of a chosen model facilitates an open dialogue about purpose and strategy.
Keyword Health systems
Health systems strengthening
Donor policies
Global health governance
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ
Additional Notes Article number 774

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2013 Collection
School of Public Health Publications
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Citation counts: TR Web of Science Citation Count  Cited 18 times in Thomson Reuters Web of Science Article | Citations
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Created: Fri, 04 Jan 2013, 15:03:38 EST by Geraldine Fitzgerald on behalf of School of Public Health