Health systems are extremely complex, with multiple interacting components which can lead to varied outcomes depending on the context in which they are placed. Building a systematic understanding is then essential for designing health systems and reforming existing ones. In this paper, we propose an analytical framework that provides an overview of the various actors and processes involved in financing, purchasing, provision and provider payments. We use the framework to show that varying combinations of different actors and processes across functions can give rise to multiple possibilities for health systems design. Acknowledging these multiplicities in pathways possible can facilitate health systems design accounting for institutional and resource capacities, socio-economic-political contexts, and health-related needs and priorities. We use the framework to demonstrate how some of the best-performing health systems in the world have managed to achieve good outcomes through quite different pathways. We also apply the framework to understand the design of the multiple sub-systems currently existing in India. Using insights from the conceptual framework and the country case studies, we conclude with a broad set of principles that can guide the design (or redesign) of India’s health system.
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