The authors of the article, “Why Differentiating between Health System Support and Health System Strengthening is Needed”, are to be congratulated for a fresh conceptual contribution to health systems thinking (Chee et al., 2012). They combine elements of three different conceptual perspectives on the health sector into a “health system cube”. However, their pursuit of a “common understanding” of health system strengthening is both worthy, in a Sisyphean sense, and self-defeating. It is essential that we continue to have multiple perspectives from which to view the health sector (not just systems within the sector), as complexity demands the multi-disciplinary analytical thinking that is so essential to effective problem-solving in an increasingly complex globalized world. Let us look first at the architecture of their cube, its strengths and limitations, and finally at the utility of striving for a common understanding versus multi-disciplinary perspectives.
VERTICAL OR DISEASE-SPECIFIC PROGRAMS: THE EPIDEMIOLOGICAL PERSPECTIVE
Disease-specific interventions provide one dimension of the cube: tuberculosis, HIV/AIDS, immunization and family planning (relevant primarily in developing countries, but other diseases could be substituted for more developed contexts). The increased flow of disease-specific funding from new agencies and programs1 at the beginning of this century creates a perverse incentive to build silos (Dybul et al., 2012). Criticism of the silo approach has fueled discussion of the need for strengthening health systems more broadly. This is not a new debate. The vertical-versus-horizontal pendulum has swung back and forth over past decades, even as the vertical programs have changed. Malnutrition (or obesity in a developed world context) could have been included on this dimension of the cube, whereas family planning, previously a strong vertical program in developing countries (when there was more foreign aid support for it), is now increasingly integrated, primarily because foreign aid funding dwindled.
In some circumstances, there are solid arguments to be made for specific vertical programming, and the merits of these arguments shift with epidemiological trends and the passage of time. The eradication of small pox set a gold standard in establishing immunization as a key vertical program, and the possibility of eradication of a disease (e.g., polio and guinea worm) is a compelling argument for vertical programming. Given the devastation wrought by the HIV/AIDS pandemic and the linked potential threat of multi-drug resistant tuberculosis, the arguments for support of these vertical programs are strong, but other (possibly less compelling) arguments are made for other vertical interventions. At the same time, as funding migrates to priority vertical programs (with the attendant attention), the larger health system can become weaker because it is not seen as the priority. And so attention and debate shifts back to service delivery integration or health systems strengthening–however these are defined.
THE SIX BUILDING BLOCKS: THE SUPPLY-SIDE PUBLIC POLICY PERSPECTIVE
The six health system “building blocks”, as defined by the World Health Organization (WHO), are depicted as another dimension of the cube: (i) service delivery, (ii) health workforce, (iii) information, (iv) pharmaceuticals and medical technology, (v) financing and (vi) leadership and governance (World Health Organization, 2007a). The architects of the cube observe that a common criticism of the WHO building blocks is the lack of any attention to demand from consumers. With “the market” so central to the business world, a health industry perspective would make consumer demand (and possibly its manipulation) a cornerstone in any strategy. However, WHO tends to be dominated by those trained in the medical model and public policy formulation, and this disciplinary training supports a benevolently paternalistic supply-side perspective, assuming that what is best for the population is known by policy makers and that a rational approach to service delivery is largely what is needed. Consideration of demand (no matter how irrational) and how to shape that demand is frequently absent or naively ineffective.
Just as vertical programs can be useful, the building blocks can be useful in framing thinking about service delivery, but another weakness of the WHO framework is the static nature of the blocks. Although WHO's definition of health systems strengthening includes interactions between the blocks, this is not well articulated. When I served on the Global Fund's Technical Review Panel, a WHO staff member presented the building blocks as part of a session on how we might interpret grant applications for health systems strengthening. He was apologetic for the superficial nature of the presentation and, when questioned on the relationship between the blocks, he smiled and answered with the now stock tongue-in-cheek “that's above my pay grade”. A WHO report on The Global Fund's approach to health system strengthening describes a “diagonal” approach that uses desired health outcomes as a starting point while addressing health system strengthening in various ways (World Health Organization, 2007b).
The building blocks are something of a double-edged sword, as they provide a useful framework (with its limitations), but, because they are broadly used in foreign aid programs, they are often the only common language used for health systems strengthening among those working in foreign aid – which is why the architects of the cube use them as the cornerstone of their own arguments. More recently, WHO has developed a handbook for monitoring the building blocks (World Health Organization, 2010), and the architects of the cube point out that the WHO building blocks model can fragment the system, just as the vertical programs fragment the system, by encouraging investment in specific blocks. Therefore, they added a more dynamic third dimension to their cube.
THE FIVE CONTROL KNOBS – THE “WHAT MAKES THINGS TICK” PERSPECTIVE
Developed by a group of health sector (not only “system”) experts at Harvard (Roberts et al., 2004), the five control knobs are used as a kind of “dashboard” framework in the World Bank's flagship course on health sector financing and reform. The knobs include: (i) financing, (ii) payment, (iii) organization, (iv) regulation and (v) behavior or persuasion. Although the WHO blocks include “financing”, the distinction within the control knobs between “financing” (the sources and magnitude of available funding) and “payment” (the mechanisms used to disperse the funding) is a very central one, and the distinction reflects the thinking of those trained in economics and political science who track down and attempt to adjust incentives in the system, answering those “what makes things tick” questions. The “behavior” knob – now referred to as the “persuasion” knob – captures the demand side and highlights other incentives, including life style changes impacting health. The knobs also do a better job of addressing the issue of balance in what is, unfortunately, a growing public–private divide (Mintzberg, 1996).
Partly because of their dynamic nature, the knobs have more potential conceptual appeal than the building blocks, but despite 20,000 participants in World Bank Flagship courses over the past dozen years (among other channels for expanding awareness), the control knobs are less well known than the building blocks as a conceptual framework. Like any framework, they also have their own limitations. William Hsiao, a health economist and one of the architects of the knobs, told me that it was useful to consider the blocks and the knobs in combination. When I asked another of the architects of the knobs, Marc Roberts, about the politics of system strengthening and reform – he said that was a question of “who had their hands on the knobs”. A third architect of this framework, the political scientist Michael Reich, did seminal work on “political mapping” decades ago, which – depending on context – can provide a very useful conceptual framework for looking at either health “system” strengthening and/or health “sector” reform (Reich, 2002; Reich and Cooper 2010). Indeed, the United States could be a prime example of a context where political analysis (with a small “p” in political, as well as a large “P”) could be the most relevant and useful framework for both sector analysis and strategic action.
THE THREE-DIMENSIONAL CUBE – AN ATTEMPT AT SYNTHESIZING FRAMEWORKS (WITH AN AGENDA)
A central argument, or agenda, of the architects of the cube (which combines most elements of the three perspectives described previously) is that health systems “support” (in the form of funding and priority attention to either vertical programs or the building blocks) is not the same as system “strengthening”. Their cube includes only three of the control knobs along its last dimension: (i) policies and regulation, (ii) organizational structures and (iii) behavior (or persuasion). These three are collectively labeled as “performance drivers” on the cube, and specific sub-sets of these performance drivers cut across both vertical programs and the WHO building blocks.
The architects of the cube argue that “support” can be short-term and narrowly focused (again in the form of funding and attention), whereas “strengthening” is “accomplished by more comprehensive changes to policies and regulations, organizational structures and relationships across the health system building blocks that motivate changes in behavior and/or allow more effective use of resources”. They acknowledge that both support and strengthening are important and necessary. One might also argue that the two are so inter-connected that their distinction is artificial. More importantly, by excluding the first two knobs of the five control knobs – financing and payment – from the final dimension of their cube, the architects of the cube have eliminated what many would argue are the two most important performance drivers. After all, what is a more powerful performance driver than how much financing we put into the health sector and the payment mechanisms we use to distribute that financing?
These two “control knobs” are powerful performance drivers. We can strengthen a system, but if the system is starved of funding, it will malfunction and weaken, or fail. Indeed, this is the argument made as service delivery periodically declines in developed country systems (such as Quebec province as one of Canada's 10 provincial systems where I occasionally use services) when cost control measures reduce funding flows. There may be nothing fundamentally wrong with the system that a fresh injection of funding would not correct.
Still, the architects of the cube have a valid point with their three performance drivers. For example, the US health sector, with financing at approximately double the per capita cost of the next most expensive national health sector, has such poor health status performance indicators that a YouTube video pokes fun at the country's dismal status as Number 37 (Hipp, 2009) in WHO's somewhat controversial comparative ranking of national health systems (World Health Organization, 2000). Certainly, the strengthening that the cube architects describe – improved policies, regulations and organizational structures – could change “what makes things tick” in the US health sector for the better, especially if the strategy for implementing such changes were designed in tandem with the use of good political analysis and a clever social marketing campaign to change underlying attitudes about how market dynamics operate in the health sector. The US health sector – which does not have a health care delivery “system” but may be described as many overlapping and inefficient systems – is fundamentally flawed and fraught with vested interests because of the enormous (and wasteful) flow of financing and the fragmented and irrational mechanisms for distributing that financing and providing services. It is big business: recent trends suggest US health sector expenditure is flattening out, but the sector continues to represent an enormous slice of the world's largest economy, currently estimated at 17% of GDP.
THE PRIMORDIAL POND OF HEALTH SECTOR (AND SYSTEMS) THINKING IN A GLOBALIZED WORLD
We need more conceptual frameworks and models to understand an industry and marketplace that represents over 10% of GDP in most developed countries and an enormous slice of our rapidly globalizing world economy. Six building blocks do not explain health sector dynamics, nor do five control knobs, nor does a cube, but they all serve a purpose. We need more ways of looking at the world we inhabit and the problems we are attempting to address. It is useful to attempt to combine frameworks and divergent perspectives, if only to better understand the original ideas, how they might interrelate with different ways of assessing the health sector and when they might be of practical value within a given context. Different frameworks are appropriate depending on what types of questions are being posed or which types of problems are being addressed, but often it is essential to look at the health sector through multiple lenses to decide what should receive priority attention. In their pursuit of a “common understanding” of health system strengthening the architects of the cube have rallied to a cause that is worthy because they have attempted to merge different conceptual frameworks. However, the possibility of arriving at a common understanding of how a health sector functions (and how systems within that sector can be strengthened) seems both unlikely and potentially self-defeating because the model would be so complex that only a few would understand it, or it would focus on a “system” that ignores other factors at play in the health “sector” – which is a market place (albeit heavily regulated) that interacts with and is influenced by forces beyond its own vague boundaries (as for example, the agriculture sector influences nutritional status). But we should all be imitating what the architects of the cube were attempting: venturing out of our limited disciplinary ways of framing issues and engaging with other disciplines and perspectives developed from within organizational or intellectual silos we do not normally inhabit.
Clayton Christenson has provided another framework, portrayed in concentric circles that interact in the reverse manner of those concentric circles created when a pebble creates ripples on a water's surface, with disruptive innovation moving in from smaller entities positioned on the outer peripheral circles and dislodging the larger entities at the center – the unpredictable changes that occur as a combined result of industry innovation (in products or services) and consumer behavior. With a US focus, “The Innovator's Prescription” includes dozens of diagrams to explain a health sector in flux (Christensen et al., 2009). Although Christenson's disruptive innovation is slowed and sometimes blocked by the abnormal economics that characterize the health sector (including regulation) – as originally described by Bill Hsiao in a cautionary tale for former soviet states embracing market economics in every sector (Hsiao, 1995) – this disruption is happening both within and beyond the US borders as the health sector globalizes. Low-cost generic pharmaceuticals from emerging market suppliers have made enormous market gains in the US market, eating into the market share of Big Pharma as their block buster brands fall out of patent and lose their monopolistic market rights. Trained professionals immigrating to the US and other wealthy countries represent a controversial brain drain, as the developing world subsidizes professional health education for service provision in the over-developed world market (McAllester, 2012). And – perhaps unknowingly – the over-developed world is imitating operational reforms that have been ongoing in the developing world for decades. Those working in developing countries adopted checklists as a way of ensuring quality of care long before Atul Gawande made the checklist a manifesto (Gawande, 2009). A recent article in The Economist, “Squeezing out the doctor”, describes task shifting activities in the US health sector that have been an ongoing initiative in the health sectors of developing countries with severe shortages of physicians for years (Economist, 2012). As providers trespass both geographic and professional boundaries, patients are also trespassing national borders to seek services that are less expensive or more easily accessed: health tourism is flourishing. In the recently released British comedy, “The Best Exotic Marigold Hotel”, the character played by Maggie Smith travels to the eponymous hotel in India so she can bypass the waiting list for a hip replacement while simultaneously saving the British Health Service expenses. As that film was being released in theaters in North America, The New Yorker's financial page, titled “Club Med”, covered the attraction of the flourishing health tourism industry to US consumers seeking affordable health care (Surowiecki, 2012). Those who question the potential for disruption in the health sector – despite the sector's abnormal economics – might think again.
The health economist, Phil Musgrove (who died tragically in 2011), was fond of using the lowly amoeba as a metaphor to explain the health sector, demonstrating how you could poke an amoeba in one place and then watch how it might reshape itself in some totally unpredictable way, or split into two or even three amoeba. Phil's very apt metaphor does not speak to the futility of studying health sector dynamics. He was simply pointing out how very difficult it is to explain or predict changing dynamics within the sector and what a fascinating area of study the health sector presents. We should applaud the architects of the cube for contributing to the primordial pond of health system or sector thinking, but we should not hesitate to poke and prod the cube, to encourage it to adapt and interact with the other creatures that inhabit the ever evolving space populated by conceptual frameworks and theories.
In addition to those who are cited previously or in the bibliography that follows, I would like to thank Paul Carlile, of the Boston University School of Management, for influencing my thinking; Richard Culbertson, of the Tulane University School of Public Health and Tropical Medicine and Michael Reich, of the Harvard University School of Public Health, for their comments on previous drafts; my colleague Giovanni Cascone, of the University of Rome, for his flattering observation that this commentary is akin to the creativity of Wormold, the fictional comic-hero in Graham Greene's “Our Man in Havana” who fabricated espionage evidence from a variety of vacuum cleaner parts, and finally my friend, Frank Dobyns, for his tirade against health sector jargon, which is its own Tower of Babble.
Examples would include as follows: GAVI or the Global Alliance (formerly the Global Alliance for Vaccines and Immunization), the Global Fund to Fight AIDS, Tuberculosis and Malaria (aka The Global Fund) and the President's Emergency Program for AIDS Relief (PEPFAR).