Health systems thinking

We believe universal health coverage and health security should be available to all, leaving no one behind. To achieve this, health systems need to be resilient and able torespond and adapt to changing circumstances.

But the reality of health systems is that they are complex and messy. They demand solutions that are contextually-appropriate and politically informed.

We apply systems thinking across all our programmes to contribute to health system resilience. Our approach recognises the dynamic and complex nature of health systems and the interactions between a system’s components and its actors, including the core building blocks. We apply tools and approaches to engage with, understand and manage these complex relationships.

Our systems thinking approach is based around three interrelated principles:

  1. Local ownership
  2. Dynamic adaptive learning
  3. Whole-of-society approach

We collaborate with research institutions and experts to contribute lessons from our systems thinking work to global evidence and practice.

Local ownership

The people who are best equipped to identify challenges and the most appropriate solutions are those that are closest to it. We listen and learn from our local partners to understand their priorities, then work with them to design the approach that will improve health system performance in that specific context. This includes:

  • Creating and strengthening decision-making spaces that ensure local constituencies can take part in a meaningful way, so that priorities are set by local voices and preferences. For example, our Evidence for Action programme promotes inclusive decision-making spaces that institutionalise participation and membership from diverse state and non-state actors such as civil society, and that have multi-sectoral governance structures.
  • Identifying and improving existing advocacy and accountability coalitions by strengthening their governance structures, expanding their membership and encouraging active participation of key population groups, such as young people or people with disabilities.
  • Equipping local actors as problem solvers through tailored training and mentoring to ensure the routine use of data. For example, by using problem-based learning approaches across fourteen counties in Kenya in 2020, we helped to improve the Department of Health’s confidence in using data to plan and prioritise.
  • Providing coaching and mentoring to senior leaders. This helps them identify solutions to complex problems. For example, during a time of devolution, widespread industrial action and political change in Kenya, we delivered a coaching programme in Bungoma that supported the county health management team to successfully navigate the changes.

Dynamic, adaptive learning

Our approach to learning is about being able to continuously respond to evidence and changing needs. This is how:

  • Carrying out diagnostic analyses to understand complex systems and make our interventions right for each individual context. For example, we apply bespoke political economy analyses (PEAs) to understand power dynamics within a system, and the formal and informal decision-making spaces that are key to influencing change. This includes using stakeholder mapping to identify entry points and build coalitions to achieve common goals. It also includes process mapping, a participatory approach we use to engage a diverse range of stakeholders and agree to common goals.
  • Creating flexible frameworks that are evidence-based allows complex programmes to be understood and monitored according to each country context.
  • Continuous learning is embedded in the design of each programme. This includes listening to the challenges stakeholders are facing and adapting programmes accordingly.

Whole-of-society approach

Many diverse actors play a role in influencing health system outcomes. Achieving lasting systems change requires diving beneath the surface of a system to identify the unique roles each actor plays and the dynamic relationships between them, in order to spot solutions and identify levers for change. This is how we do it:

  • Identifying, supporting and sometimes creating coalitions and multi-stakeholder forums to generate and analyse evidence to influence decision making. Through our WISH, DESIP and E4A programmes, we engage diverse stakeholders in dialogue to amplify budget advocacy efforts and highlight the importance of investing more domestic funds in high impact health services.
  • Promoting ways for a diversity of sectors and stakeholders to collaborate in order to improve health outcomes. These range from Ministry of Finance, Ministry of Education and international funding institutions, decentralised authorities, research institutions and private sector actors. For example, we collaborated with a research institution to develop robust tools to improve health service delivery during crises.
  • Supporting ministries of health to harness the private sector to achieve health systems goals including health security and universal health coverage. For example, in Kenya, we supported the Ministry of Health to develop a Total Market Approach for Family Planning Strategy (2020-2025) which seeks to increase the market for and the availability of FP products and services by making the public and private sector more coordinated.


  • Over 800 Village Health Committees in Nigeria effectively holding governments and service providers to account for better health services.
  • Maternal mortality in Nepal dropped from 281/
    100,000 births in 2006 to 190/100,000 
    in 2014
  • Better management of human resources in Odisha led to a 39% increase in the number of doctors over a five year period

Our experts

  • Alison Dembo Rath
    Alison has over 20 years’ experience in design, management, monitoring and evaluation of health systems development programmes at policy and implementation levels. Building on her early career in UK nursing, Alison has particular expertise in delivering quality maternal and newborn health services. Alison has experience across Sub-Saharan Africa and Asia, managing UK Aid-funded maternal health and health sector programmes in India and Nepal.
  • Sarah Fox
    Sarah is a health financing specialist with over 15 years’ experience working to advance universal health coverage through health systems reforms. Sarah provides strategic programme support and helps manage a global team of technical specialists. Sarah has worked extensively in Africa, focussing on policy and planning, domestic resource mobilisation for health, results-based financing and financial risk protection.
  • Linet Oyucho
    Linet is a health system strengthening specialist with expertise in advocating to government for health system reforms. She leads on health financing strategies under the FCDO’s flagship WISH2ACTION program across 9 countries in Africa and Asia. This involves advocating to government on the importance of sustainable financing and budget advocacy for family planning. Linet holds a PhD in Health Policy and Systems Development.

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