Population

The population cannot only be viewed as a ‘target’ or ‘beneficiary’ of the health system. Individuals, groups and organisations fulfil a number of different roles, which are linked to different aspects of their involvement in the HS. They are patients and customers, creating a demand for health care. They are citizens with rights and obligations to whom the HS is accountable. They are funders and suppliers of care, and as such participate in and contribute to the functioning of the local health system (Frenk 2010).

People as producers of health (care), participation and empowerment

HS have often been designed by technocrats and health professionals, which leads to a skewed attention for professional health programmes and services. The recognition of the contribution of people as producers of health and health care has often been more implicit. It is often framed as participation in technocratic programmes, for instance community health workers. However, this ignores the spontaneous activities of individuals and collective action of groups in the community. The attention for self-help groups, patient organisations, peer-groups and informal care givers has long been under-valued. One should not underestimate many people’s striving for self-reliance in taking care of their health and well-being. People deploy a wide array of self-help mechanisms before they resort to professional health services, (and make use of preventive activities to stay healthy). We should recognise individuals’ own contributions to their personal health and well-being as a contribution to the health system on its own.
The concept of participation includes a wide variety of approaches on an increasingly empowering scale from mobilising people to contribute to targets, over common decision-making processes, towards increased capacity to recognize and act upon situations oneself (Rifkin 2003). These approaches are not mutually exclusive and depend on the context and issue at stake and one’s perspective on outcomes.
The striving for empowerment as an important goal, both at individual and at community levels is widely recognized, also because it is an essential contribution to reducing inequities and bringing about desired social change (Gilson et al. 2007).  At community level, a stronger community voice in relation to other actors in the health system is important in the striving for empowerment; at individual level it means a changed relationship between patient and provider with the latter being responsible to instead of for the patient. This implies the transformation of power relations and is likely to create resistance. Different approaches are needed, directed at both the care supply and demand sides (van Olmen et al. 2010).

Demand and health seeking behaviour

People are patients and or customers of health services. For some services, such as community-based prevention activities, they are actively approached by health workers (supply side), although they can still decide not to engage. However, for most health services, the locus of decision-making is centred at the demand-side, meaning that the initiative and decision to make use of a service is taken by the individual who has a particular need or demand for a health service.
It is the responsibility of the planners and providers to make sure that the health system provides those services that respond to the needs and demands of the population (proper supply - see responsiveness). But it is the population itself who, for the majority of services, decides whether to make use of these services and, if so, from which provider to get these services. This can be described as health seeking behaviour. The demand for a particular service is related to the perceived (immediate) benefit by people and is generally low for preventive services and high for acute curative care. Patients seeking care have to make a more or less informed choice between these different categories, especially if they imply different kinds of providers. Patients and families usually make such choices on a very pragmatic and eclectic basis, with physical and financial access as strong determinants of their choices, along with the reputation of a provider or a facility regarding the present health problem. Socio-cultural barriers or constraints can also exist; for instance the decision-making power of women in relation to health decision-making in the household is a well-known variable.
In pluralistic health systems, health seeking behaviour is diversified and complex, often involving self-referral and discontinuation of treatment (quite distant from the health planner’s logic, where every health facility has a catchment area, and where patients are referred between facilities).
In an ideal situation, needs, demand and supply overlap as much as possible. Most interventions in HSs deal with the adjustment of supply and carefully assessing the needs. Influencing demand has not always received that much attention. As much as providers can be steered in their behaviour, so can people seeking health care. Examples of mechanisms to influence the demand for health services and health seeking behaviour are the development of financial incentives (or barriers), voucher schemes, but also awareness campaigns about health risks or information about provider characteristics.

Trust in the Health System

The trust that people have in their HS as a whole and in health providers is a central element in the HS. Trust is a major determinant in people’s decisions to make use of health services available in the neighbourhood. Trust is a complex and layered issue that is shaped by trust both at personal and institutional level. At personal level, trust is influenced by technical competence, openness, concern and reliability; at institutional level, service management and regulations are important, such as the qualification of staff, quality control mechanisms, ethical codes, and functioning of the service (Gilson 2003).
In our vision, offering care that is a flexible and dynamic response to people’s felt needs is a crucial step in building a capital of trust. Ensuring quality of the services is a consequent step to maintain trust. Offering an adequate package of care cannot do without a sustained and genuine relationship of dialogue between professionals and individual users and communities. The offer of accessible, acceptable and effective curative care is paramount because it constitutes the needed springboard to make people aware of - and accept - the need to use preventive services, even if the demand for the latter may initially be limited. A relationship of trust also constitutes the necessary foundation for people to understand and accept that ‘not everything is possible’ and there is need to manage the scarce resources in a rational and efficient way.