Background and context – fragmentation and frustration
By the late 2000s, health reforms were expanding across many countries, yet results often fell short of expectations.
Plans were commonly built on linear logic – assuming that a single intervention would produce a predictable improvement. At the same time, international support was frequently organized through siloed, disease-specific programmes, each with its own targets, funding streams and reporting systems. In reality, health systems behaved differently. Actions in one area triggered unexpected consequences in others, and ministries struggled to agree on priorities across fragmented institutions shaped by vertical aid and competing mandates.
Policy-makers needed a new approach that could reveal the relationships between the building blocks of health systems – financing, workforce, medicines, information and governance – and place people, not programmes, at the centre.
Alliance input – reframing how health systems are understood
In 2009 the Alliance published the flagship report Systems thinking for health systems strengthening, edited by Don de Savigny and Taghreed Adam. The report argued that health systems are complex adaptive systems that cannot be understood or improved using reductionist models. It invited the field to move from asking “Which intervention should we add?” to “How will the whole system respond?”
The publication changed the frame in three important ways:
- From bricks to relationships – the six building blocks were not discarded, but reinterpreted as parts of a living system connected through feedback loops and human behaviour.
- From control to learning – reform was presented as an iterative process drawing on collective stakeholder wisdom.
- From black box evaluation to explanation – success judged by understanding context and process, not just outcomes.
Impact and change – a new conversation across the field
Fifteen years later, the reframing continues to shape global health thinking. The evidence of its reach is clear, with more than 1500 cumulative citations, reflecting steady use across academic and policy sectors globally.
Annual citation growth (2009–2024)
Flagship report published; establishing foundations of systems approach.
14 new articles in Health Research Policy and Systems expand the evidence base.
Ranked #6 most influential publication in the field of systems thinking in a bibliometric review.
UNU-IIGH publishes a book using the flagship report as the basis for a case study of Malaysia.
The most significant impact has been less visible: meetings that ask different questions, evaluations that look beyond inputs and outputs, and reforms that recognise that no intervention is simple. The report helped the field accept that policy resistance and unintended consequences are normal features of systems.
Looking ahead