This article presents a comprehensive scoping review of how the concept of health system software has been utilized in health policy and systems research (HPSR) since a specific call for such research was made in 2011. The authors, Nicola Burger and Lucy Gilson, aim to synthesize current knowledge and generate lessons to deepen the understanding and research of health system software.
The foundation of this research lies in understanding health systems as Complex Adaptive Systems (CASs), which are characterized by dynamic relationships and interactions among their various components. Within this conceptualization, health systems are viewed as comprising both hardware and software elements.
- Hardware represents the concrete, visible, and infrastructural components of a system.
- Software encompasses elements that influence actions and underpin relationships, such as processes, values, norms, ideas, interests, relationships, and power. The article further differentiates between tangible forms of software (e.g., formal processes, knowledge, and skills) and intangible forms (e.g., values, norms).
Historically, HPSR has largely neglected these software components, tending to focus more on health system hardware. This oversight is often linked to a focus on short-term operational needs, donor interests seeking measurable returns, or a positivist research paradigm that views health systems as vehicles for technological solutions rather than social and political contexts. The lack of clear conceptualization for ‘software’ has also contributed to its neglect. In response to these challenges and following the First Global Symposium on Health Systems Research in 2010, influential papers in 2011 called for theoretical development of health system software to understand the complex social dynamics impacting health systems.
To assess the progress since this 2011 call, Burger and Gilson conducted a two-phase qualitative scoping review, systematically searching databases like PubMed, Scopus, EBSCOhost, Web of Science, and Google Scholar. Their analysis of 98 papers revealed varied uses of the software concept:
- Approximately one-third of the papers used the software concept rather superficially, mainly acknowledging its importance.
- Another one-third used it to conceptualize the significance of selected software elements.
- The remaining one-third applied the concept to examine specific health system experiences, such as preparedness or resilience.
A significant finding of the review is the limited understanding of how to investigate interactions among hardware and software elements. The authors emphasize that future HPSR should purposively investigate these hardware–software interactions to gain a deeper understanding of the complex, adaptive nature and operations of health systems, ultimately institutionalizing CAS thinking within the field. The study also highlights the value for health system actors, beyond researchers, to be aware of health system software, as it can offer actionable insights for influencing behaviors and improving system performance.
Reference: Burger, N., & Gilson, L. (2025). How has the concept of health system software been used in health policy and systems research? A scoping review. Health Policy and Planning, 40(3), 391–408. https://doi.org/10.1093/heapol/czaf001.
