This paper seeks to describe two important ‘market’ systems in health – treatment and disease transmission – in which international development actors have sought to intervene to improve health outcomes in developing countries. Donors may be seen to perform a direct role in delivering or supporting delivery of health goods and services, or to take a systemic approach that avoids any such direct role. The argument is that, while sometimes beneficial, there are shortcomings with direct interventions that predominate in health, and the nature of those benefits or shortcomings depends on four considerations related to the treatment and transmission systems: the nature of the health problem, the scale of intervention impact, the requirement for ongoing provision, and the importance of individual agency in the transaction. The paper briefly describes the systemic approach to development intervention before looking at examples from Kenya and Tanzania of innovative programming in the health sector that has begun to apply such an approach. While more evidence is required in order to explain the determinants of health intervention success or failure, it is nevertheless possible to suggest that the importance of ensuring ongoing provision and accounting for individual agency is underestimated. For ongoing health problems with an important demand-side component, a sustainable and locally responsive system for delivery of treatment and control of transmission is required.

Bloom, G., Standing, H., Lucas, H., Bhuiya, A., Oladepo, O. and Peters, D.H. (2011) ‘Making health markets work better for poor people: the case of informal providers’, Health Policy and Planning 26(Suppl. 1): i45–52 <http://dx.doi.org/10.1093/heapol/czr025>.

Bloom, G., Kanjilal, B., Lucas, H. and Peters, D.H. (eds.) (2012) Transforming Health Markets in Asia and Africa: Improving Quality and Access for the Poor, Abingdon, UK: Routledge.

De Graft Aikins, A., Unwin, N., Agyemang, C., Allotey, P., Campbell, C. and Arhinful, D. (2010) ‘Tackling Africa’s chronic disease burden: from the local to the global’, Globalization and Health 6(1): 5.

De Savigny, D., Webster, J., Agyepong, I. A., Mwita, A., Bart-Plange, C., Baffoe-Wilmot, A. and Lengeler, C. (2012) ‘Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems’, Health Policy and Planning 27(Suppl. 4): iv32–43 <http://dx.doi.org/10.1093/heapol/czs087>.

Elliot, D., Gibson, A. and Hitchins, R. (2008) ‘Making markets work for the poor: rationale and practice’, Enterprise Development and Microfinance 19(2): 101–19 <http://dx.doi.org/10.3362/1755-1986.2008.011>.

GiveWell (2013) A Conversation with Marcy Erskine on September 18, 2003 [pdf] <http://files.givewell.org/files/conversations/Marcy%20Erskine%209-18-13%20(public).pdf> [accessed 15 October 2015].

Hawley, W.A., Phillips-Howard, P.A., ter Kuile, F.O., Terlouw, D.J., Vulule, J.M., Ombok, M., Nahlen, B.L., Gimnig, J.E., Kariuki, S.K., Kolczak, M.S. and Hightower, A.W. (2003) ‘Community-wide effects of permethrin-treated bed nets on child mortality and malaria morbidity in western Kenya’, The American Journal of Tropical Medicine and Hygiene 68(Suppl. 4): 121–7.

Lengeler, C. (2004) ‘Insecticide-treated bed nets and curtains for preventing malaria’, Cochrane Database of Systematic Reviews 2(2): CD000363 <http://dx.doi.org/10.1002/14651858.CD000363.pub2>.

Levine, R. (2004) What’s Worked? Accounting for Success in Global Health, Washington, DC: Center for Global Development.

Miguel, E. and Kremer, M. (2004) ‘Worms: identifying impacts on education and health in the presence of treatment externalities’, Econometrica 72(1): 159–217.

Mills, A. (2004) Strengthening Health Systems: The Role and Promise of Policy and Systems Research, Alliance for Health Policy and Systems Research, Geneva: World Health Organization (WHO).

Murray, C.J., Ortblad, K.F., Guinovart, C., Lim, S.S., Wolock, T.M., Roberts, D.A. and Alvis-Guzman, N. (2014) ‘Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013’, The Lancet 384(9947): 1005–70.

Peters, D.H. (2014) ‘The application of systems thinking in health: why use systems thinking?’ Health Research Policy and Systems 12(1): 51 <http://dx.doi.org/10.1186/1478-4505-12-51>.

Peters, D.H., Garg, A., Bloom, G., Walker, D.G., Brieger, W.R. and Hafizur Rahman, M. (2008) ‘Poverty and access to health care in developing countries’, Annals of the New York Academy of Sciences 1136: 161–71 <http://dx.doi.org/10.1196/annals.1425.011>.

Peters, D. H., Paina, L. and Bennett, S. (2012) ‘Expecting the unexpected: applying the Develop-Distort Dilemma to maximize positive market impacts in health’, Health Policy and Planning 27(suppl. 4): iv44–53.

Plsek, P.E. and Greenhalgh, T. (2001) ‘The challenge of complexity in health care’, British Medical Journal 323(7313): 625.

Smith, J.P. (1999) ‘Healthy bodies and thick wallets: the dual relation between health and economic status’, Journal of Economic Perspectives 13(2): 145–66.

Springfield Centre (2015) The Operational Guide for the Making Markets Work for the Poor (M4P) Approach, 2nd edn, funded by SDC & DFID, Durham, UK: Springfield Centre.

Taylor, B. (2014) ‘Who wants to give forever? Giving meaning to sustainability in development’, Journal of International Development 26: 1181–96 <http://dx.doi.org/10.1002/jid.3033>.

USAID (2014) Local Systems: A Framework for Supporting Sustained Development [pdf], Washington, DC: USAID <https://www.usaid.gov/sites/default/files/documents/1870/LocalSystemsFramework.pdf> [accessed 2 March 2016].

Victora, C.G., Hanson, K., Bryce, J. and Vaughan, J.P. (2004) ‘Achieving universal coverage with health interventions’, The Lancet 364(9444): 1541–8.

Wagstaff, A. (2002) ‘Poverty and health sector inequalities’, Bulletin of the World Health Organization 80(2): 97–105.

World Bank (2015) ‘World Development Indicators’ [database] Washington, DC: World Bank <http://data.worldbank.org/data-catalog/world-development-indicators> [accessed 7 January 2016].

World Health Organization (2012) ‘New report signals slowdown in the fight against malaria’, News release 17 December 2012 [online], Geneva: WHO <www.who.int/mediacentre/news/releases/2012/malaria_20121217/en/> [accessed 15 October 2015].

World Health Organisation (2015) ‘Global Health Observatory data repository’ [online], Geneva: WHO <http://apps.who.int/gho/data/node.home> [accessed 16 March 2016].

Yadav, P. (2010) ‘In country supply chains: the weakest link in the health system’, Global Health Magazine 5 (Winter 2010): 18–9.

Bloom, G., Standing, H., Lucas, H., Bhuiya, A., Oladepo, O. and Peters, D.H. (2011) ‘Making health markets work better for poor people: the case of informal providers’, Health Policy and Planning 26(Suppl. 1): i45–52 <http://dx.doi.org/10.1093/heapol/czr025>.

Bloom, G., Kanjilal, B., Lucas, H. and Peters, D.H. (eds.) (2012) Transforming Health Markets in Asia and Africa: Improving Quality and Access for the Poor, Abingdon, UK: Routledge.

De Graft Aikins, A., Unwin, N., Agyemang, C., Allotey, P., Campbell, C. and Arhinful, D. (2010) ‘Tackling Africa’s chronic disease burden: from the local to the global’, Globalization and Health 6(1): 5.

De Savigny, D., Webster, J., Agyepong, I. A., Mwita, A., Bart-Plange, C., Baffoe-Wilmot, A. and Lengeler, C. (2012) ‘Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems’, Health Policy and Planning 27(Suppl. 4): iv32–43 <http://dx.doi.org/10.1093/heapol/czs087>.

Elliot, D., Gibson, A. and Hitchins, R. (2008) ‘Making markets work for the poor: rationale and practice’, Enterprise Development and Microfinance 19(2): 101–19 <http://dx.doi.org/10.3362/1755-1986.2008.011>.

GiveWell (2013) A Conversation with Marcy Erskine on September 18, 2003 [pdf] <http://files.givewell.org/files/conversations/Marcy%20Erskine%209-18-13%20(public).pdf> [accessed 15 October 2015].

Hawley, W.A., Phillips-Howard, P.A., ter Kuile, F.O., Terlouw, D.J., Vulule, J.M., Ombok, M., Nahlen, B.L., Gimnig, J.E., Kariuki, S.K., Kolczak, M.S. and Hightower, A.W. (2003) ‘Community-wide effects of permethrin-treated bed nets on child mortality and malaria morbidity in western Kenya’, The American Journal of Tropical Medicine and Hygiene 68(Suppl. 4): 121–7.

Lengeler, C. (2004) ‘Insecticide-treated bed nets and curtains for preventing malaria’, Cochrane Database of Systematic Reviews 2(2): CD000363 <http://dx.doi.org/10.1002/14651858.CD000363.pub2>.

Levine, R. (2004) What’s Worked? Accounting for Success in Global Health, Washington, DC: Center for Global Development.

Miguel, E. and Kremer, M. (2004) ‘Worms: identifying impacts on education and health in the presence of treatment externalities’, Econometrica 72(1): 159–217.

Mills, A. (2004) Strengthening Health Systems: The Role and Promise of Policy and Systems Research, Alliance for Health Policy and Systems Research, Geneva: World Health Organization (WHO).

Murray, C.J., Ortblad, K.F., Guinovart, C., Lim, S.S., Wolock, T.M., Roberts, D.A. and Alvis-Guzman, N. (2014) ‘Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013’, The Lancet 384(9947): 1005–70.

Peters, D.H. (2014) ‘The application of systems thinking in health: why use systems thinking?’ Health Research Policy and Systems 12(1): 51 <http://dx.doi.org/10.1186/1478-4505-12-51>.

Peters, D.H., Garg, A., Bloom, G., Walker, D.G., Brieger, W.R. and Hafizur Rahman, M. (2008) ‘Poverty and access to health care in developing countries’, Annals of the New York Academy of Sciences 1136: 161–71 <http://dx.doi.org/10.1196/annals.1425.011>.

Peters, D. H., Paina, L. and Bennett, S. (2012) ‘Expecting the unexpected: applying the Develop-Distort Dilemma to maximize positive market impacts in health’, Health Policy and Planning 27(suppl. 4): iv44–53.

Plsek, P.E. and Greenhalgh, T. (2001) ‘The challenge of complexity in health care’, British Medical Journal 323(7313): 625.

Smith, J.P. (1999) ‘Healthy bodies and thick wallets: the dual relation between health and economic status’, Journal of Economic Perspectives 13(2): 145–66.

Springfield Centre (2015) The Operational Guide for the Making Markets Work for the Poor (M4P) Approach, 2nd edn, funded by SDC & DFID, Durham, UK: Springfield Centre.

Taylor, B. (2014) ‘Who wants to give forever? Giving meaning to sustainability in development’, Journal of International Development 26: 1181–96 <http://dx.doi.org/10.1002/jid.3033>.

USAID (2014) Local Systems: A Framework for Supporting Sustained Development [pdf], Washington, DC: USAID <https://www.usaid.gov/sites/default/files/documents/1870/LocalSystemsFramework.pdf> [accessed 2 March 2016].

Victora, C.G., Hanson, K., Bryce, J. and Vaughan, J.P. (2004) ‘Achieving universal coverage with health interventions’, The Lancet 364(9444): 1541–8.

Wagstaff, A. (2002) ‘Poverty and health sector inequalities’, Bulletin of the World Health Organization 80(2): 97–105.

World Bank (2015) ‘World Development Indicators’ [database] Washington, DC: World Bank <http://data.worldbank.org/data-catalog/world-development-indicators> [accessed 7 January 2016].

World Health Organization (2012) ‘New report signals slowdown in the fight against malaria’, News release 17 December 2012 [online], Geneva: WHO <www.who.int/mediacentre/news/releases/2012/malaria_20121217/en/> [accessed 15 October 2015].

World Health Organisation (2015) ‘Global Health Observatory data repository’ [online], Geneva: WHO <http://apps.who.int/gho/data/node.home> [accessed 16 March 2016].

Yadav, P. (2010) ‘In country supply chains: the weakest link in the health system’, Global Health Magazine 5 (Winter 2010): 18–9.

Bloom, G., Standing, H., Lucas, H., Bhuiya, A., Oladepo, O. and Peters, D.H. (2011) ‘Making health markets work better for poor people: the case of informal providers’, Health Policy and Planning 26(Suppl. 1): i45–52 <http://dx.doi.org/10.1093/heapol/czr025>.

Bloom, G., Kanjilal, B., Lucas, H. and Peters, D.H. (eds.) (2012) Transforming Health Markets in Asia and Africa: Improving Quality and Access for the Poor, Abingdon, UK: Routledge.

De Graft Aikins, A., Unwin, N., Agyemang, C., Allotey, P., Campbell, C. and Arhinful, D. (2010) ‘Tackling Africa’s chronic disease burden: from the local to the global’, Globalization and Health 6(1): 5.

De Savigny, D., Webster, J., Agyepong, I. A., Mwita, A., Bart-Plange, C., Baffoe-Wilmot, A. and Lengeler, C. (2012) ‘Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems’, Health Policy and Planning 27(Suppl. 4): iv32–43 <http://dx.doi.org/10.1093/heapol/czs087>.

Elliot, D., Gibson, A. and Hitchins, R. (2008) ‘Making markets work for the poor: rationale and practice’, Enterprise Development and Microfinance 19(2): 101–19 <http://dx.doi.org/10.3362/1755-1986.2008.011>.

GiveWell (2013) A Conversation with Marcy Erskine on September 18, 2003 [pdf] <http://files.givewell.org/files/conversations/Marcy%20Erskine%209-18-13%20(public).pdf> [accessed 15 October 2015].

Hawley, W.A., Phillips-Howard, P.A., ter Kuile, F.O., Terlouw, D.J., Vulule, J.M., Ombok, M., Nahlen, B.L., Gimnig, J.E., Kariuki, S.K., Kolczak, M.S. and Hightower, A.W. (2003) ‘Community-wide effects of permethrin-treated bed nets on child mortality and malaria morbidity in western Kenya’, The American Journal of Tropical Medicine and Hygiene 68(Suppl. 4): 121–7.

Lengeler, C. (2004) ‘Insecticide-treated bed nets and curtains for preventing malaria’, Cochrane Database of Systematic Reviews 2(2): CD000363 <http://dx.doi.org/10.1002/14651858.CD000363.pub2>.

Levine, R. (2004) What’s Worked? Accounting for Success in Global Health, Washington, DC: Center for Global Development.

Miguel, E. and Kremer, M. (2004) ‘Worms: identifying impacts on education and health in the presence of treatment externalities’, Econometrica 72(1): 159–217.

Mills, A. (2004) Strengthening Health Systems: The Role and Promise of Policy and Systems Research, Alliance for Health Policy and Systems Research, Geneva: World Health Organization (WHO).

Murray, C.J., Ortblad, K.F., Guinovart, C., Lim, S.S., Wolock, T.M., Roberts, D.A. and Alvis-Guzman, N. (2014) ‘Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013’, The Lancet 384(9947): 1005–70.

Peters, D.H. (2014) ‘The application of systems thinking in health: why use systems thinking?’ Health Research Policy and Systems 12(1): 51 <http://dx.doi.org/10.1186/1478-4505-12-51>.

Peters, D.H., Garg, A., Bloom, G., Walker, D.G., Brieger, W.R. and Hafizur Rahman, M. (2008) ‘Poverty and access to health care in developing countries’, Annals of the New York Academy of Sciences 1136: 161–71 <http://dx.doi.org/10.1196/annals.1425.011>.

Peters, D. H., Paina, L. and Bennett, S. (2012) ‘Expecting the unexpected: applying the Develop-Distort Dilemma to maximize positive market impacts in health’, Health Policy and Planning 27(suppl. 4): iv44–53.

Plsek, P.E. and Greenhalgh, T. (2001) ‘The challenge of complexity in health care’, British Medical Journal 323(7313): 625.

Smith, J.P. (1999) ‘Healthy bodies and thick wallets: the dual relation between health and economic status’, Journal of Economic Perspectives 13(2): 145–66.

Springfield Centre (2015) The Operational Guide for the Making Markets Work for the Poor (M4P) Approach, 2nd edn, funded by SDC & DFID, Durham, UK: Springfield Centre.

Taylor, B. (2014) ‘Who wants to give forever? Giving meaning to sustainability in development’, Journal of International Development 26: 1181–96 <http://dx.doi.org/10.1002/jid.3033>.

USAID (2014) Local Systems: A Framework for Supporting Sustained Development [pdf], Washington, DC: USAID <https://www.usaid.gov/sites/default/files/documents/1870/LocalSystemsFramework.pdf> [accessed 2 March 2016].

Victora, C.G., Hanson, K., Bryce, J. and Vaughan, J.P. (2004) ‘Achieving universal coverage with health interventions’, The Lancet 364(9444): 1541–8.

Wagstaff, A. (2002) ‘Poverty and health sector inequalities’, Bulletin of the World Health Organization 80(2): 97–105.

World Bank (2015) ‘World Development Indicators’ [database] Washington, DC: World Bank <http://data.worldbank.org/data-catalog/world-development-indicators> [accessed 7 January 2016].

World Health Organization (2012) ‘New report signals slowdown in the fight against malaria’, News release 17 December 2012 [online], Geneva: WHO <www.who.int/mediacentre/news/releases/2012/malaria_20121217/en/> [accessed 15 October 2015].

World Health Organisation (2015) ‘Global Health Observatory data repository’ [online], Geneva: WHO <http://apps.who.int/gho/data/node.home> [accessed 16 March 2016].

Yadav, P. (2010) ‘In country supply chains: the weakest link in the health system’, Global Health Magazine 5 (Winter 2010): 18–9.

Bloom, G., Standing, H., Lucas, H., Bhuiya, A., Oladepo, O. and Peters, D.H. (2011) ‘Making health markets work better for poor people: the case of informal providers’, Health Policy and Planning 26(Suppl. 1): i45–52 <http://dx.doi.org/10.1093/heapol/czr025>.

Bloom, G., Kanjilal, B., Lucas, H. and Peters, D.H. (eds.) (2012) Transforming Health Markets in Asia and Africa: Improving Quality and Access for the Poor, Abingdon, UK: Routledge.

De Graft Aikins, A., Unwin, N., Agyemang, C., Allotey, P., Campbell, C. and Arhinful, D. (2010) ‘Tackling Africa’s chronic disease burden: from the local to the global’, Globalization and Health 6(1): 5.

De Savigny, D., Webster, J., Agyepong, I. A., Mwita, A., Bart-Plange, C., Baffoe-Wilmot, A. and Lengeler, C. (2012) ‘Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems’, Health Policy and Planning 27(Suppl. 4): iv32–43 <http://dx.doi.org/10.1093/heapol/czs087>.

Elliot, D., Gibson, A. and Hitchins, R. (2008) ‘Making markets work for the poor: rationale and practice’, Enterprise Development and Microfinance 19(2): 101–19 <http://dx.doi.org/10.3362/1755-1986.2008.011>.

GiveWell (2013) A Conversation with Marcy Erskine on September 18, 2003 [pdf] <http://files.givewell.org/files/conversations/Marcy%20Erskine%209-18-13%20(public).pdf> [accessed 15 October 2015].

Hawley, W.A., Phillips-Howard, P.A., ter Kuile, F.O., Terlouw, D.J., Vulule, J.M., Ombok, M., Nahlen, B.L., Gimnig, J.E., Kariuki, S.K., Kolczak, M.S. and Hightower, A.W. (2003) ‘Community-wide effects of permethrin-treated bed nets on child mortality and malaria morbidity in western Kenya’, The American Journal of Tropical Medicine and Hygiene 68(Suppl. 4): 121–7.

Lengeler, C. (2004) ‘Insecticide-treated bed nets and curtains for preventing malaria’, Cochrane Database of Systematic Reviews 2(2): CD000363 <http://dx.doi.org/10.1002/14651858.CD000363.pub2>.

Levine, R. (2004) What’s Worked? Accounting for Success in Global Health, Washington, DC: Center for Global Development.

Miguel, E. and Kremer, M. (2004) ‘Worms: identifying impacts on education and health in the presence of treatment externalities’, Econometrica 72(1): 159–217.

Mills, A. (2004) Strengthening Health Systems: The Role and Promise of Policy and Systems Research, Alliance for Health Policy and Systems Research, Geneva: World Health Organization (WHO).

Murray, C.J., Ortblad, K.F., Guinovart, C., Lim, S.S., Wolock, T.M., Roberts, D.A. and Alvis-Guzman, N. (2014) ‘Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013’, The Lancet 384(9947): 1005–70.

Peters, D.H. (2014) ‘The application of systems thinking in health: why use systems thinking?’ Health Research Policy and Systems 12(1): 51 <http://dx.doi.org/10.1186/1478-4505-12-51>.

Peters, D.H., Garg, A., Bloom, G., Walker, D.G., Brieger, W.R. and Hafizur Rahman, M. (2008) ‘Poverty and access to health care in developing countries’, Annals of the New York Academy of Sciences 1136: 161–71 <http://dx.doi.org/10.1196/annals.1425.011>.

Peters, D. H., Paina, L. and Bennett, S. (2012) ‘Expecting the unexpected: applying the Develop-Distort Dilemma to maximize positive market impacts in health’, Health Policy and Planning 27(suppl. 4): iv44–53.

Plsek, P.E. and Greenhalgh, T. (2001) ‘The challenge of complexity in health care’, British Medical Journal 323(7313): 625.

Smith, J.P. (1999) ‘Healthy bodies and thick wallets: the dual relation between health and economic status’, Journal of Economic Perspectives 13(2): 145–66.

Springfield Centre (2015) The Operational Guide for the Making Markets Work for the Poor (M4P) Approach, 2nd edn, funded by SDC & DFID, Durham, UK: Springfield Centre.

Taylor, B. (2014) ‘Who wants to give forever? Giving meaning to sustainability in development’, Journal of International Development 26: 1181–96 <http://dx.doi.org/10.1002/jid.3033>.

USAID (2014) Local Systems: A Framework for Supporting Sustained Development [pdf], Washington, DC: USAID <https://www.usaid.gov/sites/default/files/documents/1870/LocalSystemsFramework.pdf> [accessed 2 March 2016].

Victora, C.G., Hanson, K., Bryce, J. and Vaughan, J.P. (2004) ‘Achieving universal coverage with health interventions’, The Lancet 364(9444): 1541–8.

Wagstaff, A. (2002) ‘Poverty and health sector inequalities’, Bulletin of the World Health Organization 80(2): 97–105.

World Bank (2015) ‘World Development Indicators’ [database] Washington, DC: World Bank <http://data.worldbank.org/data-catalog/world-development-indicators> [accessed 7 January 2016].

World Health Organization (2012) ‘New report signals slowdown in the fight against malaria’, News release 17 December 2012 [online], Geneva: WHO <www.who.int/mediacentre/news/releases/2012/malaria_20121217/en/> [accessed 15 October 2015].

World Health Organisation (2015) ‘Global Health Observatory data repository’ [online], Geneva: WHO <http://apps.who.int/gho/data/node.home> [accessed 16 March 2016].

Yadav, P. (2010) ‘In country supply chains: the weakest link in the health system’, Global Health Magazine 5 (Winter 2010): 18–9.