Skip to 0 minutes and 11 secondsBARBARA MCPAKE: Hello again. Frameworks such as WHO's building blocks and the World Bank's control knobs offer a static and linear representation of how to tackle health system development. Looking at the two graphic representations of the building blocks and the control knobs framework, it's clear that they represent a simplified reality in which controllable things on the left side of the figures produce in turn changes in the variables to their right. Surely the authors of all these frameworks recognise that this representation is a simplification. As with all simplifications, complexity has been filtered out. What matters is whether what remains captures what's important while filtering inconsequential complexity, or whether what is left in the simplified framework is the relatively inconsequential.

Skip to 1 minute and 7 secondsHas the baby been thrown out with the bathwater? Clearly this is a matter of judgement, but important critiques of static linear frameworks focus on those elements that have been filtered out and make the case that there are critical elements without appreciation of which health system strengthening efforts will fail. van Olmen et al from 2012 focus on the complexity introduced by recognising the political dimensions of health system strengthening. There is a lot of information in this slide, and you might like to look at the original.

Skip to 1 minute and 40 secondsStarting in the 1950s and charting the course of developments up to 2012, what it illustrates is how thinking about health systems has evolved in the context of changing dominant political ideologies at the global level and shifting importance of different global health actors. For example, the authors point to the rise of neoliberalism in the later 1980s and highlight some of the global health developments we discussed in the last session that followed, including the 1993 World Development Report and the DALY framework, the parallel focus within health system thinking on health sector reform, often emphasising the value of market and market-like approaches to health system development.

Skip to 2 minutes and 23 secondsIn the recent period, the authors point to the growing complexity of the global health landscape, which has both multiplied the number of major global actors and the set of competing proposals for health system development in the list at the bottom right of the figure. We might argue with the specific choices of elements to include in this figure and whether the right events and descriptions of the political status quo have been selected. But this doesn't affect the essence of van Olmen et al's argument, which they state concisely near the beginning of the paper. They say frameworks on health systems are products of their time, emerging from specific discourses.

Skip to 3 minutes and 2 secondsThey are purposive, not neutrally descriptive, and are shaped by the agendas of their authors. These agendas range from supporting the strengthening of comprehensive health services and empowerment of communities to advocating integration of targeted disease programmes or stimulating free markets. Better understanding the underlying discourse of these frameworks will help the reader to more clearly understand their origins and thus their differences. What does this mean for our understanding of frameworks and of how to think about health systems development approaches? The article reminds us that we're not just technicians when we involve ourselves in health systems strengthening efforts.

Skip to 3 minutes and 43 secondsWe have particular perspectives on what matters, what we think health systems should be trying to achieve, and we might underestimate the tensions between visions of different global health actors if we assume that all place equal weight and define identically the set of goals that Shakarishvili et al identify as common to all the frameworks they considered.

Thinking Systematically

While health systems frameworks such as the ‘control knobs’ and ‘building blocks’ may be a useful starting point to understanding the core elements and functions of health systems, a more complex understanding of what constitutes a health system, and how actors and processes in the system interact, is vital when developing health systems strengthening approaches.

As you watch the animation in the next step, the first in a series throughout this course which explores complexity within health systems, think about the value of simplification and ‘rules of thumb’ when working on complex issues, but also the risk of failing to see the true complexity of a system and account for it.


Why do we (as individuals, and organisations) tend to favour simple (even simplistic) explanations for how things work, and how they can be changed? Think about this for a moment before moving on to the next step.

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Health Systems Strengthening

The University of Melbourne

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