Abstract
Background: Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the ‘social value of health systems.’ Methods: We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between ‘health systems’ and ‘social values.’ We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory. Results: We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen’s understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups. Conclusion: We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.
Highlights
Paper on Conceptual Issues Related to Health Systems Research to Inform a WHO Global Strategy on Health Systems Research
This paper presents an interpretive synthesis of claims about the relationship between social values and health systems in HPSR literature, exploring conceptualisations of the social value of health systems, and developing an initial explanatory theory for the capacity of health systems to generate social value(s)
Synthesising the Relational Claims Into a Common Frame: Social Values in Dynamic Networks After exploring conceptualisations of the relationship between health systems and social values found in HPSR literature, and suggesting that, together, these relational claims suggest four mechanisms by which the health system can generate social value, we present a synthesis of the relational claims and argue that this points toward an explanatory theory for this capacity of health systems
Summary
This interpretive synthesis follows from a prior qualitative systematic review (reported elsewhere) and utilises that collection of evidence[2].7 The systematic review applied an iterative approach, based on Boell and Cecez-Kecmanovic’s hermeneutic review methodology.[36]. Malone explores the role of language, and metaphor, in this transference, and finds that in the United States, metaphors reflecting neoliberal ideologies came to supplant other ways of understanding healthcare, and restrict what policy changes are considered acceptable or appropriate.[97] Walt and Gilson argue that the dominance of neoliberal ideas challenges, and may undermine or destroy, socially accepted ideas of “public purpose, public morality, and public accountability.”[21] Synthesised into a single frame, these relational claims position national health systems as conduits through which powerful ideas at the global level are transmitted to individuals and communities. Policy problems and policy processes present considerable complexities in their own right, and research that offers conceptual insights of relevance to policyproblems, and shapes the thinking of policy-makers, can have substantial impact in the long-term.[124,132]
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