This study approaches health systems not simply as a technical field of service provision, but as a form of public policy design shaped by ideological preferences, institutional structures and social expectations. Bringing together the literature on welfare regimes and social policy with institutionalist approaches, it examines how the state–market balance, conceptions of solidarity and the search for legitimacy help to frame policy choices in healthcare. On this basis, four core dimensions of health system design are proposed: (i) financing and risk pooling, (ii) the organisation of service delivery, (iii) governance and regulation, and (iv) mechanisms of access and equality. The framework is then made concrete, from the perspective of health system management, through three enduring axes of tension: cost control versus access; performance and standardisation versus professional autonomy; and centralisation versus decentralisation. The final section considers how the dynamics of health security, digitalisation and migration, which became more visible in the aftermath of the COVID-19 pandemic, have reshaped debates on access to services, entitlement, data governance and institutional capacity from a health management perspective. Overall, the study aims to offer health managers and policy analysts a conceptual framework that is modest in its claims, yet holistic and explanatory.