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. 2026 Jun 16;6:1808077. doi: 10.3389/frhs.2026.1808077

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© 2026 Sethy, Mahapatro, Mundu and Sahoo.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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Systems diagram showing health system components as green circles: Financing, Workforce, Digital Health, and Service Delivery, with Governance, Outputs, and Outcomes as rectangles. Arrows represent empirically tested, hypothesized, and feedback pathways according to the legend. — Conceptual framework of health system performance determinants. sources: The framework adapts WHO (32) building blocks (workforce, financing, service delivery, information systems as digital health); Roberts et al. (5) control knobs (financing, payment, organization, regulation, behaviour integrated into Governance and Inputs); and de Savigny and Adam (4) complex adaptive systems (feedback loops, context moderation, emergent properties via dashed arrows and external context). Thicker arrows indicate empirically tested pathways (SEM results, Table 1).