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Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study

Wilbroad Mutale12*, Virginia Bond3, Margaret Tembo Mwanamwenge3, Susan Mlewa3, Dina Balabanova4, Neil Spicer4 and Helen Ayles23

Author Affiliations

1 Department of Community Medicine, University of Zambia School of Medicine, Lusaka, Zambia

2 Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK

3 ZAMBART Project, Ridgeway Campus, University of Zambia, Nationalist Road, Lusaka, Zambia

4 Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

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BMC Health Services Research 2013, 13:291  doi:10.1186/1472-6963-13-291

Published: 1 August 2013



The primary bottleneck to achieving the MDGs in low-income countries is health systems that are too fragile to deliver the volume and quality of services to those in need. Strong and effective health systems are increasingly considered a prerequisite to reducing the disease burden and to achieving the health MDGs. Zambia is one of the countries that are lagging behind in achieving millennium development targets. Several barriers have been identified as hindering the progress towards health related millennium development goals. Designing an intervention that addresses these barriers was crucial and so the Better Health Outcomes through Mentorship (BHOMA) project was designed to address the challenges in the Zambia’s MOH using a system wide approach. We applied systems thinking approach to describe the baseline status of the Six WHO building blocks for health system strengthening.


A qualitative study was conducted looking at the status of the Six WHO building blocks for health systems strengthening in three BHOMA districts. We conducted Focus group discussions with community members and In-depth Interviews with key informants. Data was analyzed using Nvivo version 9.


The study showed that building block specific weaknesses had cross cutting effect in other health system building blocks which is an essential element of systems thinking. Challenges noted in service delivery were linked to human resources, medical supplies, information flow, governance and finance building blocks either directly or indirectly. Several barriers were identified as hindering access to health services by the local communities. These included supply side barriers: Shortage of qualified health workers, bad staff attitude, poor relationships between community and health staff, long waiting time, confidentiality and the gender of health workers. Demand side barriers: Long distance to health facility, cost of transport and cultural practices. Participating communities seemed to lack the capacity to hold health workers accountable for the drugs and services.


The study has shown that building block specific weaknesses had cross cutting effect in other health system building blocks. These linkages emphasised the need to use system wide approaches in assessing the performance of health system strengthening interventions.