“For the first time, public health has commitment, resources and powerful interventions. What is missing is this. The power of these interventions is not matched by the power of health systems to deliver them to those in greater need, on adequate scale, in time…….. Margaret Chan, (WHO, 2007).
The responses of many health systems so far have generally considered inadequate and na├»ve it has been argued. Inadequate, in so far as they not only fail to anticipate, but also to respond appropriately, too often with too little, too late or too much in the wrong place. Na├»ve is so far as a system’s failure requires a system solution not a temporary remedy. Systems’ thinking is an essential approach for strengthening health systems, particularly in designing and evaluating interventions.
┬áRecently, there has been growing global consensus for instance around the need to include Men who Sex with Men (MSM) in national response to the HIV epidemic. The 2011-2015 strategy for UNAIDS sets a goal that sexual transmission of HIV should be reduced by half among men who sex with men. The Global Fund and PEPFAR have also recently undertaken to strengthen the response to HIV as it affects Men who have sex with men.┬á Epidemiologic evidence shows increasingly that MSM face high HIV prevalence rates and incidence rates. The HIV epidemics’ among MSM are driven by many factors including the criminalization of same sex practices, stigma and marginalization.
In Botswana there has also been ongoing conversation (s) calling for introduction of health care policy reforms that are all inclusive, those that allow for the decriminalization of sodomy, commercial sex work and lately abortion. The primary objective being to include in the national strategic plans interventions that are geared towards bringing about change in health policy. The national strategic plans have a central role in coordinating the work of stake holders in a national response to HIV/AIDS. However, much of the proposed health care policy reforms in Botswana have been met with much skepticism and strongly criticized and sometimes perceived as western culture by denialists. It must be noted however, that reform and renewal fundamental features of every health system. After 50 years of independence, Botswana strives for an improved health system that better meets the needs and preferences for treatment, care and dignity of its population.Various policy, organizational and resource allocation reforms have been implemented in the country. None the less recent reviews have highlighted slow progress in establishing functional health system. Towards universal health coverage and in line with global policy directions, Botswana has, therefore, placed renewed urgency on primary health care.
In Botswana, dispersed accountability, complex rules and procedures within it also overwhelm rational policy debate and the implementation of new policies. As a result, Botswana health system remains strongly hospi-centric and specialized with decision making driven more by service than population needs.  The pro-active pursuit of population health needs and equity goals in primary health care strengthening requires therefore fundamental changes in the way health system actors think and work in its organization culture supported by new forms of health system leadership.
Sodomy (Matanyola, or Maotwana as it is commonly referred to in Setswana), no matter how much we may down play and pretend it does not exist in our culture, is a fallacy. It is there, so is commercial sex work as well as back street abortion taking place on day to day basis. Understanding the complexity and dynamics of how the national agenda is set is essentially an explanation of the policy making process in many countries and Botswana is not an exception. Locating the real policy agenda of the government requires an in-depth and prolonged analysis of broad arenas of political action, policy formulation and policy formulation.
The challenges of meeting the Millennium Development Goals (MDGs) for health remain formidable.┬á Despite a strong range of health interventions that can prevent much of the burden of diseases in the poorest countries with ever improving interventions in the pipeline, effective coverage of these interventions is expanding slowly and health inequities widening.┬á In many countries, the fundamental problem lies with the broader health system and its ability to deliver interventions to those who need them. Weaknesses and obstacles exist across the system including overall stewardship and management issue, critical supply side issues such as human resources, infrastructure and service provision and demand side issues such as people’s participation, knowledge and behavior.
From the foregoing discussion it is important to note that few health systems have the capacity to measure or understand their strengths and weaknesses especially in regard to equity, effectiveness and their respective determinants. It is therefore, imperative that there is an understanding of the complex effects, synergies and emergent behavior of system intervention. As investment in health are expanded and as funders increasingly support broader initiatives for health system strengthening, there is need to know not only what works but for whom and under what circumstances.
The health system has been defined by WHO as consisting of all organizations, people and actors whose primary intent is to promote, restore or maintain health. Its goals are improving health and health equity in ways that are responsive, financially fair and make the best or most efficient use of available resources. WHO framework for action on health systems provides six clearly defined health system building blocks that together constitute a complex system. These blocks are service delivery, including effective safe and quality personal and non personal health interventions, health workforce, responsive, fair and efficient given available resources and circumstances, health information, medical technologies, health financing, raising adequate funds for health in ways that ensure people can use needed services and are protected from financial catastrophe, leadership and governance, ensuring strategic policy frameworks combined with effective oversight, coalition building, accountability and attention to system design.
Systems’ thinking is an approach to problem solving that views problem as part of a wider dynamic system. It involves much more than a reaction to present outcomes or events. It demands a deeper understanding of the linkages’, relationships, interactions and behaviors among elements that characterize the entire system. It offers a comprehensive way of anticipating synergies and mitigating negative emergent behaviors with direct relevance for creating policies that are more system reading.
The application of systems thinking in the health sector is accelerating a more realistic understanding of what works, for whom and under what circumstances.
 
*Seleke is a researcher in health policy and health systems
