Chapter 4. Thinking in two triangles
p. 52-68
Texte intégral
“I have made no innovations in high theory. My contribution to economics has been to urge the inclusion in our analysis of features of the economic system [i.e. ‘the institutional arrangements which govern the process of exchange’] so obvious that […] they have tended to be overlooked. Nonetheless, once included in the analysis, they will, as I believe, bring about a complete change in […] the way we analyse the working of the economic system and in the way we think about economic policy.”
Ronald H. Coase (1994)
“Elinor Ostrom’s […] methodology of empirical inquiry required on-the-ground knowledge and historical specificity (including not just recognition of cultural beliefs in practice, but detailed knowledge of the physical realities of the situation as well). Methodologically, and as a matter of normative principle, [she] gave priority to the people that were on-the-ground solving social dilemmas in their unique way, rather than the usual one-size-fits-all solutions offered by experts from afar.”
Peter Boettke, Jayme Lemke and Liya Palagashvili (2013)
1Efforts to bring about health equity require knowing how health systems work from the perspective of the people within them. When you approach a health system – local or foreign – the intangible forces at work are often not readily apparent, even to a local analyst. Or they may seem so apparent that you take them for granted. The more distant you are, physically or socially, the more difficult it is to see those intangible forces or take them seriously. I think of these intangible forces in terms of rules: the formal rules (e.g. government regulations and policies) and the informal rules (e.g. social norms and conventions) that govern a system.
2A challenge of working in multidisciplinary fields such as global health or international development is finding a language that is recognisable, understandable and useable by people from different disciplinary backgrounds. Without such language to talk about how systems are governed (Abimbola et al., 2017a), it is hard to think clearly about what it means to act or analyse at a distance (Poteete et al., 2010). A framework that is often used to analyse governance (Bigdeli et al., 2020) presents something of a “triangle of persons”. Each of its three nodes is occupied by a category of persons: policymakers, providers and people (people being citizens or service users). This triangle began its life in the 2004 World Development Report (World Bank, 2004) to map persons involved in accountability relations. It has since gone through several iterations, interpretations and applications (Brinkerhoff & Bossert, 2014; Pyone et al., 2017; Cleary et al., 2013).
3But a focus on persons is insufficient. I am drawn to the definition of governance as “making, changing, monitoring and enforcing the formal and informal rules” (Abimbola et al., 2017a) that shape “collective action and decision-making in a system” (Meessen, 2020). That is, a way of thinking about governance that is concrete and shifts the focus away from governments as the singular governing entities. It focuses instead on the rules that shape and stem from the collective agency of constituted authorities and informal groups. It is a way of considering how a system is governed that lends itself to thinking in two triangles – the first, a triangle of persons, and the second, a triangle of rules.
4The expression “triangle of persons” was first used by the British psychotherapist David Malan (Malan, 1979), who put together two triangles (Figure 3) as a simple framework for psychoanalytic psychotherapy. The first depicts relations between a patient and three sets of persons – past “significant persons” (e.g. parents), the therapist, and current “significant persons” (e.g. spouse). The second, the “triangle of conflicts”, is less tangible, but no less consequential. It depicts what animates relations between persons: defences (e.g. changing or minimising the subject), anxieties (e.g. worry and panic) and feelings (e.g. anger and grief). The “triangle of conflicts” shows how defences and anxieties can block the expression of feelings. The “triangle of persons” shows how this pattern of behaviour began with past significant persons, is maintained with current significant persons, and gets played out with the therapist.
Figure 3 | Two triangles representing what happens in psychoanalytic (or psychodynamic) psychotherapy: defences and anxieties can block the expression of true feelings. These patterns began with past persons, are maintained with current persons, and are often enacted with the therapist (Malan, 1979).

5The point of having frameworks is to simplify, to clarify. Triangles do the “simple but not too simple” job well, in line with Occam’s razor, or the principle of parsimony, which prioritises explanations that use the smallest possible set of elements. Two elements, a single line, are too few, with space for only one two-way interaction. Four elements, a rectangle, are too many. Unlike a triangle, all the elements in a rectangle are not in direct interaction with one another. Triangles are complex, but just enough. Malan did not develop the two triangles, he only put them together. But by doing so, he achieved a framework with explanatory power that far surpasses that of each single triangle used separately (Osimo & Stein, 2012), while maintaining relative simplicity. They are still in use (Lilliengren et al., 2016; Johansson et al., 2013). You can criticise them for their tendency to oversimplify, but if two triangles simplify, one triangle is even more reductive. One triangle is insufficient to capture the necessary complexity involved in psychotherapy. The same is the case when the “triangle of persons” is used to analyse how health systems are governed. Like psychotherapy, health system governance requires a second triangle.
6The distinction between the triangle of persons and the triangle of rules is subtle. Like Malan’s triangles, one represents persons, and the other what governs their actions, decisions and relations (Figure 4). The triangle of rules is about the rules that they make, change, monitor and enforce: the rules that govern their actions, decisions and relations; and the rules that emanate from those actions, decisions and relations (Figure 5). This was inspired by the Institutional Analysis and Development framework developed by the American political scientist and economist Elinor Ostrom (Ostrom et al., 1994; McGinnis, 2011), although she and her colleagues did not explicitly conceive of the framework as a triangle, but rather as “three worlds of action” (Kiser & Ostrom, 1982) or “three levels of rules” (Polski & Ostrom, 2017).
Figure 4 | The two triangles that represent what happens in health system governance: policymakers, people and providers make, change, monitor and enforce formal and informal rules, which may be constitutional, collective and operational, and these rules in turn influence their actions, decisions and relations.

7The rules-in-use (de facto rules) at the operational node may diverge significantly from the rules-in-form (de jure rules) from the constitutional node. An important mediator of that gap are actors at the collective node (McGinnis, 2011; Bushouse, 2011). For example, consider the operational rule that shapes the opening hours for outpatient services in a public sector health facility. Constitutional rule-making entities (say, policymakers in the headquarters or capital city) may decide that the operational rule should be 9:00 am to 5:00 pm. Or they may decide that such a rule should be made at the collective node (say, by the council of chiefs or the governing board of a health facility, or by the health committee in each community). The council of chiefs may, in turn, decide that this rule should instead be made by operational actors (say, the manager or health worker in charge of the facility).
8If such a rule is only made, changed, monitored and enforced at the constitutional node, problems may arise. Because of where they are located, the constitutional actors are distant from this health facility, and may not be able to monitor and enforce this 9:00 am to 5:00 pm rule. Distant constitutional actors may also be unable to access information and feedback from the community to make and change rules in a way that is responsive to people locally. Women may be dissatisfied with the 9:00 am to 5:00 pm rule if on market days they are unable to take their children in for immunisation during those hours. On those days, they may want the heath facility to open earlier, at say 7:00 am, so that they can go to the immunisation clinic before heading to the market.
Figure 5 | The types and attributes of the rules that make up the “triangle of rules”.
Who makes them | What they shape | What shapes them | |
Operational rules | Individual choices Market forces of demand and supply |
How individual actors make day-to-day decisions How market rules (as prices), informal rules (as social norms) and formal rules (as government policies) shape how people in a community use (i.e. demand) and provide (i.e. supply) health and other social services |
Constitutional rules and collective rules Constitutional rules may influence operational rules directly and indirectly through their influence on collective rules |
Collective rules | “Close-to-ground” governing entities that may be informally constituted (e.g. women’s groups or community health committees) or formally constituted (e.g. a small-scale district government or local council) | How, by whom, and on what terms rules at the constitutional node and at the operational node are made, changed, monitored and enforced The operational node may be the day-to-day operational activities on the demand side or on the supply side |
Constitutional rules Feedback, pressures and demands from the operational node |
Constitutional rules | “At-a-distance” governments (e.g. national or subnational governments with large jurisdictions) or government-like entities (e.g. headquarters of large NGOs with subnational, national or supranational reach) | How, by whom, and on what terms rules at the collective and operational nodes are made, changed, monitored and enforced To shape the rules that are in use at the operational node, constitutional rules may pass through – and be modified at – the collective node |
Social norms Feedback, pressures and demands from the collective and operational nodes |
(McGinnis, 2011; Kiser & Ostrom, 1982; Polski & Ostrom, 2017; Bushouse, 2011; Abimbola et al., 2014).
9If the constitutional actors are distant and ineffective, collective node actors may play the role of changing this rule, whether or not they have the constitutional mandate to do so. But what if the collective actors are also absent or too disengaged; say, a council of chiefs that does not care? What you then have is a situation in which the de facto rules (rules-in-use) that govern opening hours may depend only on relations between demand and supply operational actors. At the operational node, workers may do what the women want because their income, sense of fulfilment, or social standing depends on it; or in exchange for a bribe or informal fees; or because it is convenient for them to open early and close early on market days, so that they too can shop at the market.
Figure 6 | The “triangle of rules” showing examples of bidirectional relations between each of the nodes of the triangle, using the example of rules that may govern service delivery within a community.

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10I use this triangle of rules, often implicitly, in my own work and to reinterpret others’ work. But I bear in mind four starting points for doing the Arendt-style kind of “representative thinking” (Arendt, 1968) that I want to do and wish others would do, for thinking from a local standpoint, for taking on a local pose. First, I remind myself to analyse the rules from the bottom up – to start the inquiry from the operational node. After all, this is where individuals make choices and where rules-in-form become rules-in-use. I ask myself: what are the rules-in-use at the operational node? Are they rules from the operational node (e.g. the interplay of demand and supply), or from the constitutional or collective node? Or did they result from a combination of processes at two nodes or all the three nodes? Bottom-up questions shine a light on informality, on how rules-in-use diverge from rules-in-form. I find myself asking: why are people in a community seeking care from unlicensed drug sellers, or from traditional birth attendants, healers, or bone setters? Why do they ignore or take too long to reach regulated or non-traditional service providers (Abimbola et al., 2015a, 2016; Godlonton & Okeke, 2016; Reid, 2012)?
11The answer may be found in context. It may be socioeconomic – e.g. the inability to afford formal providers may lead people to “shop around” at informal providers. It may be geographical – e.g. if a village is large there may be many informal providers, and for many in the community, it may be difficult to physically access a single formal provider. Or it may be institutional, i.e. the rules-in-use in the local health care market (for example, the constitutional rules to regulate informal providers) are neither monitored nor enforced (McGinnis, 2011; Kiser & Ostrom, 1982; Polski & Ostrom, 2017; Bushouse, 2011; Abimbola, 2020). Interacting with one another, these factors combine to shape trust, power and accountability relations, which also strongly influence the choice of provider. When constitutional rules are not monitored and enforced, the rules of the marketplace may dominate at the operational node. Or collective rules may dominate. The collective rules that dominate may be the “professional code” of informal providers that shape their practice, and perhaps makes them the preferred providers, even if constitutional rules (that would otherwise regulate their practice) are neither monitored nor enforced.
12You may try to change existing rules that govern informal providers so that they refer their clients to formal providers or work alongside formal providers. You may spread information about the costs of inappropriate care in the community so that people can change their care-seeking behaviour. But these strategies require changing local norms (i.e. informal rules), which can take decades to shift (Abimbola et al., 2016; Reid, 2012). You may also try to change constitutional rules to enable the supply of more formal providers or reduce out-of-pocket costs of care at formal providers. But this requires political engagement strong enough to alter those constitutional rules. Or you may seek to improve the monitoring and enforcement of the constitutional rules that limit informal providers' practice. But entrenched local norms and informal practices are hard to know or regulate at a distance (Godlonton & Okeke, 2016; Reid, 2012). If there is a large distance between the constitutional and operational nodes, it may be more effective to strengthen the hand of collective actors (including through constitutional rules that legitimise their role) to make new rules or change existing ones in ways they can monitor and enforce.
13The second thing I remind myself is that rules function in a dynamic balance as they shape social action (Abimbola et al., 2017a; Abimbola, 2020; Dixit, 2009) to provide public goods (e.g. rules on using taxes and other collective resources to provide a social safety net and health infrastructure); to define and protect rights (e.g. rules on the rights and conditions under which individuals and communities benefit from a resource, including the right to access, use and manage public or quasi-public goods such as health facilities and services); and to facilitate social exchange (e.g. by ensuring that information, regulation and coordination work to align demand with supply and vice versa).
14Each set of rules may originate from any of the three nodes, functioning in a dynamic balance to shape social action (Bushouse, 2011; Dixit, 2009; Abimbola, 2020). The rules for facilitating transactions, and thus promoting the use of formal providers may be made at any of the nodes. But when rules are effectively made, changed, monitored and enforced from the constitutional node, there is less role for collective rules, and so constitutional rules would often prevail at the operational node (Bushouse, 2011; Abimbola et al., 2014; Abimbola, 2020). The weaker the constitutional node, the stronger the roles of actors at the collective and operational nodes. But constitutional actors may deliberately configure the rules so that some are made, changed, monitored and enforced at the collective node, and others at the operational node.
15Let’s look at another example: health worker absenteeism. One set of rules shape how many health workers are available in a health system or within a country (rules that provide public goods). Another set of rules shape who has access to those health workers (rules that define and protect rights, e.g. the rules governing the posting and transfer of health workers to rural communities, which can then shape the access of these communities to health workers). Yet another set of rules shape how, once health workers are in a community, people access the services they provide – are people aware that health workers are available, what time of day are they available, are they available when the community is able to access them, do they provide high quality services, are they respectful, are they responsive to the people (rules that facilitate social exchange) (Abimbola et al., 2015a, 2016a, 2016b; Abimbola, 2020)?
16To understand high levels of rural health worker absenteeism, you may ask: Are there no rules governing operating hours? (Unlikely.) Are the constitutional rules not monitored or enforced? (More likely.) Are there collective rules crafted to govern operating hours in ways that allow health workers to be present only when the community needs them most? Are health workers absent because the rules protecting the rights of rural communities to have access to them are inadequate? Are health workers left to sort out their accommodation when transferred to rural communities? Are they without a travel allowance? Is the collective node so absent that health workers at the operational node make their own rules (Abimbola et al., 2015b, 2016a, 2016b, 2017b; Onwujekwe et al., 2019, 2020)? The triangle of rules helps to explore how absenteeism (like other actions, decisions and relations that reflect how a system is governed) is a complex and adaptive phenomenon. When one node of governance fails, the extent of the failure can be assuaged or compensated for by governance at or from another node (Bushouse, 2011; Abimbola et al., 2014).
17The third thing I keep in mind is that rules have a distance and scale effect. As a governing entity, the number of units you have to govern can determine how effective you are able to govern, just as the distance from the units you govern can determine how effective you are able to govern. An important consideration here is that this distance and scale effect can be about knowledge. Rules have epistemic properties. Health systems are, after all, knowledge systems. How rules are made, changed, monitored and enforced (mediated by distance and scale) can lead to varying capacities to generate the knowledge to wield rules effectively, equitably and responsively (Bushouse, 2011; Boettke, 2018; Lewis, 2020). It is important to consider the distance that may exist between the constitutional or collective node and the operational node, and the scale or number of operational units that are the subject of rules. Distance and scale, themselves mediated by power, resources and technology, also influence how governance actors use local knowledge and feedback to make, change, monitor and enforce rules.
18Let’s say there was a major constitutional reform in country X, which meant that the governance of tertiary hospitals in X becomes decentralised from a national ministry of health to regional (that is, subnational) governments (Barasa et al., 2017). Pre-decentralisation, there were 50 tertiary hospitals, run from the “distant” national ministry of health of country X, the constitutional node. Each hospital had a governing board, i.e. the collective node. Pre-decentralisation, the “proximate” boards exercised power and discretion in the day-to-day activities of each hospital, i.e. the operational node. This was in part because the centre was far away from most of the 50 hospitals, thus diminishing the national ministry’s ability to make, change, monitor and enforce rules for all 50 hospitals across X. By default, much of this responsibility fell to each hospital’s governing board. But with decentralisation, constitutional governance shifted to 50 locations across the country, which are now much less “distant” to each hospital. Previously influential, each of the 50 hospital boards (collective node) become much less powerful, as the operational day-to-day rules are made, changed, monitored and enforced more directly at (newly decentralised) constitutional nodes – by regional governments – leading to “recentralisation” and poorer hospital performance, as in their responsiveness to communities (Bushouse, 2011; Barasa et al., 2017; Lipunga et al., 2019).
19Now consider an alternative, almost opposite, scenario in region Y, the largest region in country X, five years after the nationwide reforms in X. As part of the reforms in region Y (carried out independent of the national government), aspects of the governance of primary health care facilities become decentralised from the government of region Y (that is, a subnational government) to community health committees (Mabuchi et al., 2017; Loevinsohn et al., 2019). Pre-decentralisation, day-to-day operational decisions were shaped by constitutional rules made by the ministry of health or region Y for, the 75 primary health care facilities in region Y. Pre-decentralisation, there was little or no formal role for collective governance by community health committees. With decentralisation, the “proximate” community health committees (one for each of the 75 primary health care facilities) make, change, monitor and enforce the rules governing the finances of their own health facility. The performance of these health facilities improves (as in their responsiveness to communities) compared to when decisions were made predominantly or exclusively at the constitutional node which is located in the capital city of region Y (Bushouse, 2011; Mabuchi et al., 2017; Loevinsohn et al., 2019).
20What is at play here is not just proximity. There is also a scale effect. Pre-decentralisation, the national ministry of health of country X looked after 50 operational units (that is, tertiary hospitals) and the subnational ministry of health of region Y looked after 75 operational units (that is, primary health care facilities) diluting their effectiveness to make, change, monitor and enforce rules. Post-decentralisation, each governing entity (that is, each regional ministry of health across country X, and each community health committee across region Y) oversees only one operational unit. With decentralisation to regional governments, stronger constitutional governance can reduce the influence previously exercised by default or delegation at the collective node (that is, the governing board of each tertiary hospital). But with decentralisation to community health committees, stronger collective governance can promote local community autonomy and health facility performance (Bushouse, 2011).
21The fourth thing I keep in mind is that the power to make, change, monitor and enforce rules can be diffuse or concentrated. The power is concentrated, for example, in the case of a private sector provider who makes and changes rules without consulting another authority (where the constitutional node, that is, the government responsible for its oversight, is weak and there is no governing board of community members). Or it can be diffuse, say, where a board of governors or a coalition of users is responsible for collective governance, and there are effective, well-resourced and technologically advanced (even if distant) constitutional actors (Munthopa et al., 2019). The rules governing a system are diffuse when rules are made, changed, monitored and enforced at more than one node, and when there is space for contestation between actors across the three nodes (Bushouse, 2011).
22Now let’s say you are in a place where the government is distant or weak. There is a private sector health facility without a governing board of community members (Bushouse, 2011; Bloom et al., 2014; Champion et al., 2012). In that health facility, you may describe the situation as a collapsing – or folding into one – of rules; a concentration of the power to make, change, monitor and enforce rules. The operational rules may reflect whatever the owner decides the constitutional rules are, especially when it is an “on-site” owner who is also the lead service provider. When off-site, the gap between constitutional rules (as made by the owner) and operational rules may depend on the proximity of the owner (Bushouse, 2011). Or imagine you are in a health facility that is owned by a religious or ethnic organisation, with a governing board of community members who are also members of that same religion or ethnicity, with constitutional rules made by the national leader of the religion or ethnic group, supported by subnational deputies. Health workers in that facility are also mostly members of the religion or ethnicity. Here, although the three nodes of governance are present, the lack of diversity within and across the nodes means, in effect, that the power to make, change, monitor and enforce rules is concentrated (Bushouse, 2011).
23Concentrated power – alongside socioeconomic and geographical context – can shape how well operational rules align with local needs and realities. An on-site owner of a private health facility who is governed at the operational node only by the rules of the marketplace, may prioritise only the segment of the community that is able to afford high service charges. On the other hand, an ethnic or religious service provider that is governed by the dominant values of a religion or ethnic group, may be responsive to local needs and realities if the community that relies on it aligns with its values. Where there is a diversity of values and identities, such concentrated power may be mediated by collective node actors, say, a governing board that is representative of that diversity. But the presence of collective node actors (e.g. on the demand side in the form of a governing board of community members or a professional, norm-setting association of health workers) is not enough to guarantee that they will be able to make, change, monitor and enforce rules. Their management rights to do so need to be well defined and protected (Lodenstein et al., 2016; George et al., 2015). They need to have the capabilities to govern and sufficiently favourable geographical circumstances (Abimbola, 2020; Falisse et al., 2012).
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24The triangle of rules can expose you to how little you know, and it can compel you to take the standpoint of “others” in your analyses, to practice “representative thinking” (Arendt, 1968). Your positionality (pose) as an analyst matters (Gilmore, 2019; Harding, 1991). The triangle of rules can make you ask yourself, seriously: How well can I see the granularity of rules – their interractions, what they do, and how they are made, changed, monitored and enforced – at a distance (Poteete et al., 2010; Stiglitz, 2001)? The triangle of rules reminds you of the limits to your perception when you are trying to see at a distance, or when you have limited knowledge of the granular details of context.
25The triangle of rules also asks that you take knowledge as seriously as you take accountability (Ostrom et al., 2017; Pennington, 2013). Given its origins, the triangle of persons focuses on accountability (World Bank, 2004). Accountability requires rules, as it requires knowledge. But knowledge can do its work without accountability – simply by actors knowing the right thing to do and how (Abimbola et al., 2019). So the triangle can also make you ask yourself: What is the optimal strategy to improve governance in this particular setting, for these functions, or at this scale – knowledge, accountability or both? What is the role of technology, which can alter the epistemic properties of the relations between the nodes of the triangle of rules, which can change the meaning of proximity and can make monitoring and enforcing rules at a distance less costly (Polski & Ostrom, 2017; Bloom et al., 2014; Champion et al., 2012; Ostrom et al., 2017)? But if and when that is the case, such technology can lead to less flexibility and freedom to shape rules-in-use locally.
26The triangle of persons focuses on human agency, while the triangle of rules focuses on the rules that constrain and enable such agency. It asks you to think again about the debate on the relative importance of structure versus agency (Harris et al., 2020; Porter, 2015). You may think that it is easier to change people’s choices than it is to change the rules that constrain or enable those choices. But trying to change people (by appealing to “the better angels of their nature”) may be less effective than aiming to change the rules that govern them or who should be in a position to make, change, monitor and enforce those rules, especially when you are at a distance. Global health involves acting “at a distance” (Abimbola, 2018), with less than optimal knowledge, agency and stake (“skin in the game”). Often, the only things of value you can offer at a distance are design features, based on bottom-up syntheses and abstractions of learning and based on insight from comparative analyses across settings (Stiglitz, 2001; Taleb, 2017; Ostrom, 2005).
27What can a distant (or foreign) analyst really say about governance? What are our/their limits? What are the limits of the foreign pose? The triangle of rules sheds light on potential strategies to alter structure – for example, on how to decentralise governance in ways that facilitate community engagement (Topp et al., 2018). But the closer governing entities are to the ground, the more prone to, say, nepotism, and the lower the ability of central governing bodies to impose beneficial equalising measures top down. The triangle of rules may inform comparative analyses to identify “optimal” points for decentralised governance that minimise its negative consequences – a design feature (i.e. structure) that may be understood in the abstract or influenced at a distance, but not prescriptively, so that features unique to the context can shape the redesign of the system (Ostrom, 2005).
28Thinking in two triangles means you can move persons between nodes, based on the rules they influence or the rules that influence them (Abimbola et al., 2014). The same person who functions as a service provider or user (operational node) in a setting, may simultaneously function as a community leader (collective node) in the same setting and also as a legislator with an even broader jurisdiction (constitutional node). The same governing entity may function at different nodes depending on size and distance: a council of chiefs in a town of 2,000 people may function at the collective node. If the town grows to a population of 200,000, the council of chiefs may become so distant from the operational node that it functions, essentially, at the constitutional node (Bushouse, 2011).
29The actor who functions at each node may also vary depending on the scale or size of the system you are analysing: a district or regional health system, a national health system, or even the dynamics of global health governance. Imagine a pandemic during which the supply and demand of personal protective equipment came under the governance of global markets (operational rules), but also collective rules (groups of countries that came together – or not – to govern the market for a collective good), and the constitutional node (through the World Health Organization, or the “constitutional” rules contained in its International Health Regulations) (Ferhani & Rushton, 2020). The district or regional government may act at the constitutional node when you are analysing dynamics within a district or region, but if you are thinking nationally, depending on its size, the district or region may function, essentially, at the collective node.
30What is said of models is also true of frameworks; all frameworks are wrong, but some are useful. Combining frameworks – without blunting Occam’s razor, i.e. while maintaining the principle of parsimony – adds great value. When used together with the triangle of rules, the triangle of persons is more useful. As for Malan’s two triangles, the need for a second triangle is not unusual. There are other instances of a multi-triangle framework (Bauer & Gaskell, 2008; Andreouli et al., 2015). One of the most widely used triangles in health systems and global health analyses deserves homage for its parsimony – Gill Walt and Lucy Gilson’s policy analysis triangle (Walt & Gilson, 1994). This triangle explicitly spells out three interacting nodes to consider during policy analysis: context, content and process. Yet Walt and Gilson included actors (“persons”) in their various roles – as individuals, groups and organisations (Buse et al., 2007) – which they could easily have called a “triangle of persons” (Figure 7).
Figure 7 | Policy analysis triangle(s) showing the factors (context, content and process) affecting policy and the relations between these factors, and the “persons” interacting as individuals, as groups or as organisations to influence the policy context, content and process.

31The triangle of rules highlights often ignored features of health systems which are worth keeping in mind when trying to understand or improve their governance and performance from a distance; features that are easily missed if the triangle of persons is used alone. What I have tried to do in this essay, to paraphrase the American economist Ronald H. Coase, has been “to urge the inclusion in our analysis, of features of the [health] system so obvious that […] they have tended to be overlooked” (Coase, 1994). The language of rules (or institutions) and their configurations, the lines of inquiry, the transferable insights and middle-range theories they suggest (Ridde, 2016; Van Belle et al., 2017; Ridde et al., 2020), and the analytical stance they require, can improve our analysis of health system governance – especially analyses done at a distance and on which the foreign gaze exerts its powerful pull.

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