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Year : 2007  |  Volume : 20  |  Issue : 2  |  Page : 59

Towards Unity for Health: Time to Think Systems

Council on Health Research for Development (COHRED)

Date of Submission27-Jun-2007
Date of Web Publication21-Aug-2007

Correspondence Address:
Carel B Ijsselmuiden
1-5, route des Morillons, 1211 Geneva 2, Switzerland

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Source of Support: None, Conflict of Interest: None

PMID: 18058689

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How to cite this article:
Ijsselmuiden CB. Towards Unity for Health: Time to Think Systems. Educ Health 2007;20:59

How to cite this URL:
Ijsselmuiden CB. Towards Unity for Health: Time to Think Systems. Educ Health [serial online] 2007 [cited 2022 Oct 1];20:59. Available from:

TUFH - ‘its ambition is to positively affect not only the development of human resources in health but the performance of the health system as a whole, by reducing its fragmentation and creating a unity of purpose and action among stakeholders’. Although this objective reflects primarily a systems approach, the activities of TUFH have focused mostly on changing medical education and on primary care research to achieve this aim.

Many of those committed to TUFH will be familiar with the COPC (Community-Oriented Primary Care) model as applied at the Ben Gurion University of the Negev in Be’er Sheva, Israel - aiming to optimise care by linking academia to community with services, research and human resource development. Started in the 1970s, I recall a comparison of graduates from Be’er Sheva and from Jerusalem with a more ‘traditional’ medical curriculum done many years later: to the surprise of the authors, the proportion of graduates having specialised and working in classical clinical environments was the same in both groups. The key to understanding this outcome - and possible interventions - is ‘systems thinking’.

Consider that medical education is an ‘input’ - only one input - into a complex health care system. Put together with many other inputs, and after going through a complex set of ‘black box’ processes, the outputs of any system can only be very indirectly linked to individual inputs. Such is the case in health care as well. There is probably a relatively direct link between medical education curricula and the technical ability of doctors in the health system. But, as the Be’er Sheva example shows, there will only be a very indirect link between ‘aspirations’ built into a medical curriculum and actual system performance in relation to equity promotion, comprehensiveness or impact on the health of the poor - simply because the goal is so much more ambitious and because there will be so many more factors (‘inputs and processes’) impacting on these particular outcomes.

Even without the benefits of knowing what articles will make up the collective of this special edition, it is likely that too little effort is going into research and intervention at the system level. For TUFH to be able to follow its ambition with even more effect in this important area of human endeavour, it needs to promote a systems approach to its work far more explicitly. The focus can be more narrowly defined and centre on understanding the role and interactions of medical education in the overall health care systems in countries, or, it can be defined more widely, and also consider researching and intervening in inputs and processes that make medical education deviate from its intended scope. This latter - much more complex, but potentially more rewarding scope - could include political science, health economics, and sociology in addition to health services research. It could consider the relation between religion and health, understanding how to regulate private practice to embrace equity without losing its edge in quality, and many more issues.

TUFH can make major contributions towards better health for all by promoting the description and understanding of those components of the health system(s) - beyond medical and public health education and educational institutions - that are key towards achieving its mission. In doing so, it is essential to be country specific as there are few, if any, national health systems that are the same. Therefore, while the search for understanding may be generic and global, the solutions will have to be specific and country-focused.

Two examples from South Africa may illustrate how ‘system’ interventions work in a developing country: one good, one bad:

  • The ‘homelands’ or ‘Bantustans’ were developed by the old South Africa’s apartheid system to keep the Black population divided and segregated. Homeland services were designed so that ‘internal’ services could be taken care of by homeland government departments such as education, agriculture, or health. Because the homelands were designed at short notice, simplicity was a main feature. In the context of health, for example, the typical structure was to divide homelands into ‘health wards’ (which could now be called ‘districts’) that included general hospitals, clinics, environmental health services, community outreach, and various other services. The responsible officer for all care in a ‘health ward’ was the superintendent of the main hospital, and there was often only one budget. As a result, where leadership prevailed, ‘health’ became the outcome and services were adapted to maximize the health impact of the collective of staff and other resources available. There are many examples of great health impacts being achieved under the very low resource and discriminatory conditions prevailing in the homelands. From measles and trachoma elimination in the north to a 15-fold reduction in infant mortality in the west, and to innovative community based nutrition improvements in the east - all achieved in the dire conditions in the homelands. The most likely reason this could be achieved was the integrated health management system - one responsible officer with one budget - where allocation could be done on the basis of data and presumed or proven interventions. This is unlike most current systems, with an extensive compartmentalisation usually between community and curative, between general and specialist, and between individual and public health care. Now, 12 years after democracy, all homelands have been abolished - fortunately - but with them also the comprehensive health care system. A case of ‘throwing away the baby with the bathwater’ - and care in rural areas may well be the worse for it.

  • On a more positive note is the following system intervention. South Africa pioneered ‘community oriented primary care’ in the 1940s, and has spent relatively much time on introducing medical students to rural systems and on designing new curricula aiming to promote health care for equity, and it has been a global contributor to public health - academically and practically. Yet, it did not really succeed in staffing the health facilities for its poorest people to any significant extent… until the introduction of compulsory ‘community service’ since the late 1990s - first for doctors, and now for many other graduates as well. In a matter of a few years, the staffing in rural hospitals and clinics has increased substantially, and early results show that there is an increased interest in careers in rural communities (it is not clear that this also applies to peri-urban areas, the urban slums, which are now worse than most rural areas in terms of poverty and quality of life). Certainly, there are now many more general practitioners in rural areas, and a likelihood that the educational and other support institutions will develop services that will further increase the attractiveness of remaining in rural health care. A ‘simple’ system intervention like this has probably had greater and more immediate effect than all the past medical curriculum transformation efforts together.

Two questions remain from the perspective of TUFH, however: 1) will compulsory community service really result in better care for the poor in South Africa? (we need evidence to monitor this - and efforts are underway), and 2) how can medical education institutions align themselves better to support this development started by government? What changes in curriculum, in training format, in post-graduate course offerings, in academic credit, library access, tele-support services, and other areas, can be made to support careers in rural and peri-urban health, and to link them to the other members of the ‘district health teams’ now also operating ‘community service’?

As we are nearing the 30th anniversary of ‘Health for All’ in 2008, the mission of TUFH remains as valid as ever. Vertical - problem focused - programming and global thinking have developed massively at the virtual exclusion of national ownership of our health systems. Priority setting in health and health research, obtaining evidence through national research efforts, and creating accountability for health rather than for financial outcomes, and a long-term commitment to change are key ‘enabling’ factors to make the health professions have more impact on health. Beyond these, however, there is the need to understand the complexities of the systems that produce health, including political will (as the example above shows) that will lead to effective and sustainable interventions - nationally and globally. TUFH has much to contribute still!


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