Not sure what it is but I keep seeing the phrase ‘health system’ at the moment. It always seems to be in the context that it should be obvious to the reader what the ‘health system’ of interest is – as if it isn’t open to different understandings.
So let’s pick this apart a little…
First of all I want to bring into play a key distinction made by Checkland and explained by Ison (2010, page 46).
A choice can be made about how to think of ‘a system’.
The first is to treat a system as ontological – as if it is a tangible thing out there in the world – it leads to the thought “I spy a system I can engineer”. So in this sense the whole world is made up of systems – and that makes the elusive ‘health system’ one of them. As Ison says “an unintended consequence of adopting this position is that too often it is assumed that there is agreement about the nature of ‘the system’ i.e. what it is, what its elements are, and most importantly where the boundaries lie and thus what a change for the better might be” (page 45/46).
The second is to treat a system as an epistemological device – or more simply put – as a tool for thinking. You start from the stance “I spy complexity and confusion – but I can organise my exploration of it using systems”. Systems in this sense are a means of inquiry about a situation. Identifying a system is therefore an act of ‘distinction’ or ‘bringing forth’ some elements, components in a situation and drawing a boundary around them. Creating a system of interest is therefore the result of a thinking process, not a discovery process.
I find, in my work, that most of the time it is more helpful to start out with the second choice. I find that it means I don’t fall into the trap of assuming that others perceive the same ‘system’ with the same ‘boundaries’ and ‘purpose’ as me – it leads me to conversation and dialogue, not assumptions. It is from that stance that I am giving my ‘perspective’ on what ‘health system’ is/are.
The second bit of ‘theory’ I want to bring into play, is the explanation of ‘system’ that I am familiar with through my Open University studies. Here a system is:
A collection of entities
That are seen by someone
As interacting together
To do something
(Ison 2010, page 44)
I’ve kind of covered off the ‘seen by someone’ aspect already – someone distinguishes a system from a wider situation by drawing a boundary around some entities and leaving others out.
But it is also important to think about the ‘to do something’ – this means that the someone is ascribing a purpose to the entities that are interacting together. So back to ‘health system’ – a collection of entities that are seen by someone as interacting together to make health?…just seems a little vague to work with. And that’s the problem, different people can really have different things in mind when they talk about a ‘health system’.
Here’s my exploration of some of the more specific ways I think ‘health system’ is being/could be used.
A lot of the time ‘health system’ is used in connection with health care. Here, the purpose is ‘getting rid of or minimising the progression of disease’. On a generic level, I think ‘health care system’ or a ‘disease improvement system’ is a better label than ‘health system’. It also helps to be a little more precise in bringing forth a system – so I could for example, perceive of a collection of entities interacting together to ‘treat and support people with diabetes in Newcastle’ or a collection of entities interacting together to ‘enable people to achieve maximum recovery and functioning after a stroke’. These sorts of ‘starter definitions’ can lead to great conversations about what is ‘in’ and what is ‘out’ according to the different perspectives of those involved.
The phrase ‘health systems strengthening’ is often used in connection with low and middle income countries. Here, I think people are talking about the country-wide system of health care – investing in building the necessary institutions, facilities and workforce to make sure those with a disease can get a high quality service when they need it. But they could also be talking about ‘prevention’ – the collection of entities interacting together to prevent the onset or progression of disease. Or maybe they are talking about both – that’s why it is important to have conversations about the boundaries you are drawing and purposes you ascribe.
Moving away from the phrase ‘health system’, there are examples of systems of interest associated with particular diseases or risk factors for disease. Famously, the Foresight report on obesity presented an ‘obesity system’ (see page 89 of the report) highlighting the factors perceived by the Foresight team that interact to create obesity. I am sure similar maps have been done for other conditions of concern.
But then I remind myself of the definition of health embedded in the constitution of the World Health Organisation:
Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease of infirmity
All my examples so far have focused on the ‘disease’ and what prevents them or treats them or minimises the impact of them. But this definition reminds us that a ‘health system’ could also (should?) be thought of as the collection of entities that interact together to create a ‘state of complete physical, mental and social wellbeing’.
Now look at the start of the WHO’s explanation of a ‘setting for health’
the place or social context in which people engage in daily activities in which environmental, organisational and personal factors interact to affect health and wellbeing (WHO, 1998, p19, my emphasis)
A setting for health (a workplace; a school; a city) could be understood by thinking of it as a ‘system’ – the elements interacting together have consequences for health. Ideally they interact together to create ‘good health’ for all people engaged in that setting – but the consequences of the interactions could be ‘poor health’ for all or – as is often the case – good health for some and poor health for others (aka the social gradient in health). Dooris (2012, page 348) highlights how the settings approach embraces a systems perspective and is concerned with creating settings that enhance – rather than harm – health.
Systems can be perceived at many levels – and ultimately, I’d like to think of society itself through the lens of ‘health system’. I don’t think others necessarily share this perspective but I think the purpose of society – including its governance – is to ensure the wellbeing and health of the citizens – equally and fairly. I am reminded again of the Robert Virchow quote “Medicine is a social science, and politics is nothing else but medicine on a large scale”. The fact that at the moment our UK society isn’t anywhere near achieving this purpose is to me a systemic failure.
Ison, R., 2010. Systems Practice: how to act in a climate-change world, Milton Keynes/London: The Open University/Springer Publications.
World Health Organisation (WHO) 1998. Health promotion glossary, Geneva, WHO
Dooris, M., 2012. Chapter 12: Settings for promoting health. In Jones, L. and Douglas, J. (Editors) Public Health: Building innovative practice. London/Milton Keynes: Sage Publications/The Open University, pp. 346–376.
this is so thought-provoking Helen. It makes me think of my work and farming systems. I wonder if people are sharing the same boundaries when they talk about those.
What I’ve realised through writing this blog is that it is really useful to go back to the simplest principles of systems thinking in practice – rather than focussing all the time at the ‘advanced’ level.
Do you think a farming system is a sub-system of a health system? (-:
It would seem that just about everything is open to different perspectives for those with open eyes.
Great blog. Sorry it took so long for me to find it.