The centrality of behavior change in health systems development

The centrality of behavior change in health systems development T he Global Health: Science and Practice editorial, ''The 6 domains of behavior change: the missing health system building block,'' 1 serves as a welcome reminder of the pivotal role of behavior change in health systems development. Moreover, we agree that serious attention to health systems strengthening (HSS) and behavior change is necessary to achieve the ambitious Millennium Development Goals (MDGs) for health by 2015 and beyond. The editorial makes certain assumptions , however, about HSS and behavior change that we believe merit a response and clarification. First, the editorial assumes that the absence of a ''building block'' on behavior change in the World Health Organization HSS framework 2 represents a failure of the framework to adequately address the importance of behavior change in health systems development. Yet even a cursory review of the building blocks (governance, financing, service delivery, human resources, information , and medicines/vaccines/health technologies) reveals the crucial role of behavior change and the presence of behavior change interventions in each of the 6 subsystems represented by the framework. The targets of behavior change are not limited to individuals but include the full spectrum of health system actors, including client groups, communities, governments, non-governmental organizations, and other entities. For example, to increase transparency, accountability , and responsiveness to citizens, governments in low-and middle-income countries (LMICs) throughout the world are adopting new policy and regulatory interventions to alter the way they conduct business in the health sector to improve governance. In health financing, LMICs are using financial and nonfinancial incentives to encourage the adoption of health-promoting practices by providers, provider cooperatives, and consumers of health services. Many countries are adopting innovative health workforce and organizational change strategies to improve the delivery of health services that target multiple diseases. LMICs are increasingly recognizing that ensuring citizens' appropriate use of medicines, vaccines, and technologies is equally as important as guaranteeing their timely access to high-quality, efficacious products. Second, by focusing solely on the building blocks framework, the editorial seems to imply, perhaps unintentionally , that professionals working to improve health systems—a diverse community that draws upon multiple social science disciplines—subscribe to a single approach or framework for HSS. Shakarishvili and colleagues have identified at least 11 different health systems frameworks that are in use by the global health community. 3 We cite one example of an alternative framework that explicitly addresses behavior …