Health systems.

There is an avalanche of interest in health systems with countries, donors, international experts and academic institutions all rushing to promote, fund or build capacity to address this wave of interest. As Anne Mills documents in an article in this volume, there is also a growing literature on how to think about health systems, how to use research on health systems to improve their performance, and pleas for greater investment in knowledge about health systems. We are probably riding on the crest of this new wave and it will be important to make use of it to further our knowledge about how to achieve health system effectiveness. With continuing global economic uncertainty, this wave may pass if we do not take advantage of it now. It is useful to reflect on why there is such interest in this theme now. There are probably many converging causes but the most important, to my mind, is a replay of an old debate between vertical programmes and horizontal, integrated approaches that has experienced swings of interest at least since the Alma Ata Conference in 1978 emphasized the integrated primary health care approach. During the last decade or more, there has been a major focus on vertical disease-specific programmes supported by greatly increased funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Alliance for Vaccines and Immunisation (GAVI), US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill and Melinda Gates Foundation, among other donors. The major claim of these programmes was that by focusing on clear disease-specific objectives they would be more effective in shorter time periods and they could be held more accountable to donors (since the results could be more measurable) than the difficult and diverse efforts to improve the many elements of a health system through the horizontal integrated approach. While there were evident successes in these programmes, there was also a growing recognition that health system constraints—especially in human resources and logistics systems—were becoming major obstacles to achieving even their limited objectives of increased coverage of HIV/AIDS, tuberculosis, malaria and immunizations. With the added emphasis on the Millennium Development Goals (MDGs) and the slow progress toward their achievement in many countries, the international community and national governments have turned increasingly toward attempting to reduce the health system constraints—an approach that is closer to the integrated horizontal approach. Both GAVI and the Global Fund have added a separate fund for health systems interventions. In 2008, the G8 called for greater attention to health system strengthening as compatible with the prior focus on vertical programmes (Reich et al. 2008). In 2009, the World Bank convened a seminar on health system strengthening attended by representatives from the World Health Organization (WHO), GAVI and Global Fund. A task force on Healthy Women and Healthy Children calling for a health system funding platform was initiated at the UN General Assembly. In 2010, the WHO and others sponsored the First Global Symposium on Health Systems Research in Montreux, Switzerland. While many observers are trying to argue that the two approaches are now more compatible, at least in rhetorical terms it seems that the pendulum is shifting toward greater attention to health system strengthening. So how do we, the readers of Health Policy and Planning, take advantage of this interest? Health Policy and Planning is dedicated to the publication of high quality research that, as the name implies, improves decisions on policy and planning. This poses for us a central question: how can we do research that will improve health systems? The answer is complex for it requires attention to the kind of knowledge that is both researchable and leads to practical, implementable recommendations. The place to start is with a framework of analysis that is both analytical, in that it provides empirically based categories about health systems, and purposive, in that it is oriented toward how to improve the system. Many of the frameworks that are available provide a recognizable set of functional issues whose boundaries help focus attention on specific interactions that can be studied, such as financing, service delivery, human resources, governance (Mills et al. 2001). The WHO Building Blocks framework is a very popular approach that is guiding much of the discussion and research in health systems (WHO 2007). Another approach developed by Harvard School of Public Health faculty is oriented toward using analytical categories in a purposive manner that starts with an ethically derived vision of what we would like to achieve, and works back toward finding the reasons why we have not achieved those objectives. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine The Author 2011; all rights reserved. Advance Access publication 17 February 2011 Health Policy and Planning 2012;27:8–10 doi:10.1093/heapol/czr008