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An overview of different health systems frameworks

How can frameworks help us make sense of, and strengthen health systems? This article introduces us to two key frameworks from WHO and the World Bank.
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© Nossal Institute for Global Health at the University of Melbourne

While there are many frameworks to describe health systems, the two most influential are WHO’s Building Blocks framework and the World Bank/Harvard’s Control Knobs framework.

The World Health Organization’s “Building Blocks” framework

In 2007, WHO published a framework, commonly known as the “WHO building blocks”, to focus attention on the need to strengthen health systems, and to guide a common conceptual understanding of what constitutes a health system, in order to go about strengthening it.

According to this framework (see ‘the WHO system framework’ image below), six building blocks constitute a health system or in other words, there are six essential functions of the health system. These building blocks are: + service delivery; + health workforce (human resources); + information (data and data systems); + medical products, vaccines and technologies; + financing; and leadership and + governance (stewardship).

These six building blocks need to be strong to achieve the overall goals of a health system, which were improved health; responsiveness (that is, how well the system responds to changing health needs or other changes in the system); social and financial risk protection; and improved efficiency. Intermediate goals are access, coverage, quality and safety.

Image source: The WHO’s Health System Building Blocks Framework. World Health Organization. Everybody’s Business: Strengthening health systems to improve health outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.) Re-used with permission.

A more detailed description of the WHO framework can be found in the ‘see also’ section below.

The building blocks framework, while widely used, also received criticism for not acknowledging how the building blocks were inter-connected and interacted with each other; and for ignoring the consumers and communities at the centre of the health system.

In 2009, in a seminal publication on systems thinking, WHO published an adapted version of the building blocks framework. This placed “people” at the centre and showed the interconnectedness of the different blocks (see figure below).

Image source: Interconnection between building blocks. World Health Organization. Systems thinking for health systems strengthening. Edited by Don de Savigny and Taghreed Adam. WHO, 2009, page 32). Re-used with permission.

For more information on this, please refer to the web links provided in the ‘see also’ section below.

The World Bank Flagship Program “Control Knobs” framework

Roberts et al (2008) published a framework to assess health systems performance and guide health systems strengthening efforts. This approach was jointly developed by the World Bank Institute (WBI) and the Harvard University School of Public Health and is taught in the WBI-run Flagship Program on Health Sector Reform and Sustainable Financing.

The focus of this framework is to identify areas of policy action to modify health systems and improve their performance. This framework identifies five “control knobs” that can be adjusted/changed to strengthen health systems (see figure below).

Source: The Control knobs for health sector reform (Source: Roberts, M.J., W.C. Hsiao, P. Berman, and M.R Reich. 2003. Getting Health Reform Right. New York: Oxford University Press, page 27). Re-used with permission.

Briefly, the five control knobs are:

  • Financing: this control knob deals with the mechanisms which mobilise money to fund healthcare and how it is allocated. In other words, how much money is available, who pays for health sector activities, and how are the funds distributed?
  • Payment: this control knob looks at how providers are paid and the incentives or disincentives this creates to influence performance.
  • Organization: this control knob looks at how healthcare delivery systems are organized and managed.
  • Regulation: these are the coercive requirements imposed by the state to direct the behaviour of health care providers and organisations.
  • Behaviour: this control knob is around influencing the behaviour of providers and consumers through population-based interventions, since these are grounded in social and cultural structures and therefore influenced by beliefs, perceptions, attitudes and cultural norms.

Health system goals according to this framework are improved health status, customer satisfaction and risk protection (fairly similar to the WHO framework) and intermediate goals are access, quality and efficiency.

From your own experience, are there other functions or components of a health systems that these frameworks do not cover? Do you think they address all the most important aspects? Use the comments section below to share your thoughts.

De Savigny, D. and Adam, T. (eds.) 2009, Systems thinking for health systems strengthening, World Health Organization, Geneva.
World Health Organization 2007, Strengthening Health Systems to Improve Health Outcomes: WHO’s Frame Work for Action, Geneva.
© Nossal Institute for Global Health at the University of Melbourne
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