Not Just Cogs In The Machine: Using SBC to Enable Critical Behaviors Across Health Systems Actors

By Andrea Ferrand, Senior Advisor, Social & Behavior Change, PSI

Today, over 3.5 billion people lack access to quality essential healthcare. In adopting the 2015 Sustainable Development Goals (SDGs), world governments committed to achieving universal access to essential healthcare without financial hardship by 2030. Health systems the world over were stressed in unprecedented ways during the COVID-19 global pandemic. The urgent need to fortify and ensure the resilience of health systems while repairing trust in public health institutions is palpable in countries across the globe. 

Health systems are powered by people – consumers of products or services, health workers, data analysts, health program managers, policymakers and political appointees, among others. Health systems also have a critical role to equitably support health by influencing and paving the way for the practice of health behaviors. For decades social and behavior change (SBC) was applied, studied, and refined to support people to live healthier lives. While many think of SBC as an approach to get consumers or patients to change behaviors, we believe it is just as effective in changing the behaviors that drive health systems. This includes using evidence to develop policy, managing health services, making decisions about financing health programs, and strengthening governance for mixed health systems. SBC offers great potential to improve how health systems work and help lay the groundwork for universal health coverage to become a reality.

As the SBC community responds to current priorities in global health, we increasingly couple SBC approaches with supply-side investments, and consequently shape policies, health systems, and markets to meet the varied needs and preferences of consumers. At PSI, we are looking forward to delivering on the promise of SBC over the next several years, as our network members and esteemed partners collaborate to expand the application of SBC disciplines for behavioral outcomes that are just now on the horizon:

  • Health systems behaviors. PSI works to shape mixed health systems through innovative delivery channels, health financing, governance, self-care, and private sector integration. This calls for the adoption of new behaviors by consumers and various actors at all levels of the health system. Depending on the context, new behaviors within health systems might include new health governance behaviors such as fostering relations and establishing mechanisms that allow all relevant stakeholders to participate in policymaking and planning or taking action to align public and private structures, processes, and institutional architecture. Beyond behaviors of actors, health systems will continue to lay the legal, policy, supply, and demand foundations to enable new health behaviors. For example, building self-care as a unique health system layer expands consumer choice and agency. Behavioral evidence and insights are at the core of developing, introducing and scaling self-care diagnostics and devices. This includes supporting shifts in new consumer and provider behaviors, such as, recent shifts in consumers self-injecting contraceptives and providers counseling clients to overcome barriers to self-inject.

  • Trust in systems. Addressing trust is fundamental to building more resilient health systems. Health systems must actively address mistrust driven by infodemics and conspiracies, while simultaneously building trust by transparently and accountably delivering improved quality of care, effective SBC, increased health financing, and improved health governance. Using SBC design, implementation, and monitoring methods in the coming years to actively repair trust in systems may help avert the next emerging threat from reaching pandemic levels.

  • Refined focus on equity. Enhanced focus on equity as a health system outcome requires applying principles and practices from SBC design, implementation, and monitoring to continue to engage and support quality health for all. Advancements in public policy and health systems that move to recognize, support, and provide specifically for historically unrecognized or heavily stigmatized groups and identities, such as LGBTQIA+ or migrant populations, will require tailored programming at scale. Social and behavioral research and implementation approaches are necessary to address stigma, trauma, and structural oppression; support people’s unique intersectional needs and preferences; and holistically address the social determinants of health. SBC may be applied to change social norms and discriminatory practices related to marginalized identities, build empathy for stigmatized populations among service providers to improve quality of care, measure causal pathways from determinants to health system behaviors, and support marginalized individuals to receive dignified health care, respect in their communities, and improved well-being.

  • Behavioral maintenance throughout the life course. Health systems will require continued innovation for behavioral maintenance. We can achieve this through ongoing testing and scaling approaches to help consumers practice behaviors for more extended periods, such as lifelong medication adherence and contraceptive method switching. It will also involve supporting consumers in the face of emergent diseases and their treatments, and climate shocks that impact the ability to practice behaviors such as natural disasters that destroy improved sanitation facilities. These approaches must take into consideration advancements in consumer preferences and needs as young people are successfully engaged in the practice of healthy behaviors that they continue throughout their life course.

SBC has always been at the core of what we do. For decades, PSI’s locally rooted, globally connected network members have drawn from social marketing, strategic communication, human-centered design, and immersive research methods to understand consumers and sharpen our approach to consumer-powered health and behavior change. Historically, this looked like creating novel products and service delivery models, scaling products across markets, and applying social marketing for behavioral outcomes.

PSI turned 50 during the global pandemic. As we look to the future, we are beginning to bridge our institutional expertise in behavior change to identify and address behaviors among actors within health systems. We are refining our approaches to blend systems thinking with behavior design to more holistically assess, prioritize, and support improved health. It also means reflecting on power dynamics and redressing our role in perpetuating them, and more effectively learning from and promoting solutions led by local partners.  

We welcome you to join us on this journey through partnership, practice, good-natured provocation, and the vulnerability of redefining how we apply SBC to improve health and well-being for all.


[1] Engaging the private health service delivery sector through governance in mixed health systems: strategy report of the WHO Advisory Group on the Governance of the Private Sector for Universal Health Coverage. Geneva: WHO; 2020.

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