HPSR Teaching Blogs

“I know that in computer science we have hardware and software. I didn’t know that this concept also applies to health systems and policy research”.

This insight came to Kofi Bobi-Barimah, lecturer at the Ghana Institute of Management and Public Administration, as a result of participating in CHEPSAA’s Introduction to Complex Health Systems and Introduction to Health Policy and Systems Research during the 2015 Winter School of the University of the Western Cape.

For educators, this is what it is all about: guiding students to those “a-ha moments” when they take on board threshold concepts; key ideas that forever transform their understanding.

As researchers, policy-makers and health system officials are exposed to the emergent, growing and multi-disciplinary field of health policy and systems research - often through short courses chock-a-block with new content – they encounter a wealth of new insights and approaches, without necessarily having much time to reflect on the origins of this new knowledge.

In the case of the distinction between the “hardware” and “software” of health systems, the earliest full elaboration of this notion appeared in a 2003 background paper by Duane Blaauw, Lucy Gilson, Loveday Penn-Kekana and Helen Schneider. It originated in critical reflection on health sector reform and the assessment that reform had often failed to improve health system functioning because it was focused mainly on the infrastructure, technology and economics of health systems (“hardware”), thereby neglecting their human and social dimensions (“software”).

In outlining this distinction, and arguing for “software” to be taken more seriously, Blaauw and colleagues drew on social theory and organisational and institutional studies – which had been marginal to the health systems literature – to describe three key organisational metaphors relevant to health sector reform and health systems research debates.

Source: Blaauw et al. (2003)

From the machine perspective, a common way of understanding health systems that brings to mind the image of a bureaucracy, organisations are comprised of clear and ordered components that work efficiently and reliably together. Organisational components are coordinated by formal rules and procedures and to the extent that the human dimension of organisational life is dwelled on, people are regarded as cogs in the organisational machinery and expected to simply comply with changes. This perspective, and its faith in the formal and technical, is associated with reforms and strategies such as decentralisation, the creation of executive agencies, continual organisational restructuring and organogram changes, the prioritisation of technological innovations, top-down implementation, the formulation of new rules and procedures, and the specification of standardised packages.

Unlike the mechanistic perspective’s focus on formal rules and authority, the economic perspective revolves around the assumption that rational, individualistic people will act in their own economic interest. Some economic perspectives hold more complex assumptions, but these have not been very influential in health sector reform debates. This perspective brings to mind the image of the market, where the correct mix of incentives can induce people to act as intended. This perspective is linked to arguments about giving the private sector more responsibility and limiting the public health sector’s functions and associated with reforms and strategies such as downsizing, outsourcing, privatisation, internal markets, competition and contracting, performance management systems and performance contracts. As with the mechanistic perspective, economically driven reforms have also tended to be implemented in an unparticipative, top-down manner.

In contrast to the mechanistic and economic thinking so prevalent in health sector reform, the underlying assumption of the socio-cultural perspective – long dominant in organisational theory, despite its lack of uptake in health – is that social interactions and relationships shape people’s behaviour in organisations. This brings to mind the image of community with its emphases on cultural norms, social relationships, informal networks, values and trust. People’s compliance with reforms and changes is rooted in them being reflective and responsive beings embedded in social relations, which de-emphasises the importance of formal rules or incentives and suggests the importance of internal motivations and controls, as well as change strategies built around shared goal development, the promotion of organisational values, maintaining relationships, influencing social networks, and building trust.

Blaauw and colleagues argued that the limited recognition of the more complex, socialised apporoaches had contributed significantly to the failure of health sector reform initiatives. Basically, their argument was for opening up the "black box" of health systems functioning to recognise the “software” that, in interaction with the “hardware”, is essential to understanding how health systems and the people they are made up of might experience and respond to reform.

Although it has been around for a while, the insight about “hardware” and “software” remains interesting and compelling.

For those just entering the field of health policy and systems research, this “a-ha moment” will likely come to take its place along other key insights. What comes to mind immediately is the fact that the fate of a policy is not only determined by its content, but also by the process of development and implementation, as well as the idea that a policy’s fortune is not linear or pre-determined, but something that can be influenced by strategic action and the exercise of power – ideas that are all central to CHEPSAA’s courses.

For those of us who have been around longer, these threshold concepts will remain, even as we continue to explore other perspectives, some of our most deeply held, while also serving as a reminder of the profound influence on our thinking and action of often-implicit assumptions and perspectives.

Author: Ermin Erasmus, CHEPSAA coordinator

More recent references to “hardware” and “software" in health systems include:

• Topp S.M., Chipukuma J.M., Hanefeld J. (2015). Understanding the dynamic interactions driving Zambian health centre performance: a case-based health systems analysis. Health Policy and Planning, Vol. 30: 485-499.
• Gilson L. (ed.). (2012). Health Policy and Systems Research: A Methodology Reader – The Abridged Version. Geneva: World Health Organisation / Alliance for Health Policy and Systems Research.
• Sheikh K., Gilson L., Agyepong I.A., Hanson K., Ssengooba F., Bennett S. (2011). Building the Field of Health Policy and Systems Research: Framing the Questions. PLoS Med 8(8): e1001073. doi:10.1371/journal.pmed.1001073.