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Toward a Consensus on Guiding Principles for Health Systems Strengthening

  • Robert C. Swanson mail,

    ghsias@gmail.com

    Affiliation: Department of Health Sciences, Brigham Young University, Provo, Utah, United States of America

    X
  • Annette Bongiovanni,

    Affiliation: The QED Group LLC, Washington, D.C., United States of America

    X
  • Elizabeth Bradley,

    Affiliation: Yale School of Public Health, New Haven, Connecticut, United States of America

    X
  • Varnee Murugan,

    Affiliation: Yale School of Public Health, New Haven, Connecticut, United States of America

    X
  • Jesper Sundewall,

    Affiliation: Division of Global Health, Karolinska Institute, Stockholm, Sweden

    X
  • Arvind Betigeri,

    Affiliation: Health Systems Action Network, New Delhi, India

    X
  • Frank Nyonator,

    Affiliation: Ministry of Health, Accra, Ghana

    X
  • Adriano Cattaneo,

    Affiliation: Institute for Maternal and Child Health, Trieste, Italy

    X
  • Brandi Harless,

    Affiliation: EntrePaducah, Paducah, Kentucky, United States of America

    X
  • Andrey Ostrovsky,

    Affiliation: Health Systems Action Network, Baltimore, Maryland, United States of America

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  • Ronald Labonté

    Affiliation: Institute of Population and Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, Canada

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  • Published: December 21, 2010
  • DOI: 10.1371/journal.pmed.1000385

Reader Comments (3)

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Having the right people at the right place at global, country and local levels

Posted by Josefienvanolmen on 03 Feb 2011 at 13:21 GMT

Authors of comments:
van Olmen, J (Institute of Tropical Medicine Antwerp Belgium), Pesse, P (Instituto de Salud Pública, Pontificia Universitad Católica del Ecuador), Keugong, B (Institute of Tropical Medicine Antwerp Belgium), Prashanth, NS (Institute of Public Health, Bangalore, India) & Patil, D ( Institute of Public Health, Bangalore, India)

This paper is the result of a process that was started with an open call on a website to contribute to a consensus statement and a guiding publication in the Lancet in 2009 (2;3). We appreciate the initiators’ efforts and would like to contribute to the debate with a number of comments, on the intention, the process and the results.
The intention.
The repetitive calls for common guidelines over the past years have come from different corners. Decision-makers and implementers call for universal practical guidelines, researchers have reacted with frameworks (4;5). We believe, with the authors, that it is not possible to develop universal strategic guides for HSS, but the analysis of individual cases can lead to a number of principles for action. As illustrated by De Savigny & Adams (2010), HSS principles more about the process than about the content of HSS (6).
The process.
The authors have combined a literature review with an open call for input and expert consultations to develop their consensus statement, intending to combine literature (scientific) evidence with field expertise.
Of the 37 authors and acknowledged people, only five people were explicitly mentioned from low income countries. This all the more striking, since one of the principles is to develop local and national capacity in those countries. We state that the acknowledgement that the paper is written “from the perspective of external funders and stakeholders”, is one of its main pitfalls and we would have expected the authors to recall this limitation in their conclusion, with the recognition for the need of looking for the local actors’ perspective. We think that international networks and initiatives, such as our network on International Health Policies and Systems and the Emerging Voices initiative, which explicitly focus on involving people from low income countries, are crucial for the credibility and sustainability of efforts like the authors’ contributions (2;7;8).
The results.
Having done a similar literature review as the authors, we concluded that this statement does not contain much more guidance than the already existing literature. The authors can be credited for putting the elements from different sources in a common document. We propose to add and emphasize a number of elements.
We observe a contradiction between the recognition of conflicts of interest (in principle two) and the wishful thinking of authors to reach harmony and consensus and to satisfy all stakeholders (principle ten and four). HSS is inherently a process of setting priorities and making choices that are difficult without trade-offs. Although a full consensus among all actors is therefore inherently difficult, it is imperative to make all actors in a health system responsible for overarching goals and to improve alignment and coordination through dialogue, in addition to other steering mechanisms such as bureaucratic control and financial incentives. We emphasize that the right people at all levels of the health system (both central and operational) take and are given the lead in the priority setting and are being accountable. Strengthening governance capacity is therefore a core priority within HSS.

References:
Reference List
(2) Swanson R. Invitation to Contribute to a Consensus Statement on Health Systems Strengthening. http://ghsia wordpress com/2009/09/01/invitation-to-contribute-to-a-consensus-statement-on-health-systems-strengthening/ 2009;
(3) Swanson R, Mosley H, Sanders D, Egilman D, De MJ, Chowdhury M et al. Call for global health-systems impact assessments. Lancet 2009 August 8;374(9688):433-5.
(4) Hsiao W, Siadat B. Health Systems: Concepts and Deterministic Models of Performance. A Background Paper for the Workshop on Research Agendas on Global Health Systems, held at Harvard University. 2008 Dec 3; 2009.
(5) Reich M, Takemi K. G8 and strengthening of health systems: follow-up to the Tokayo summit. Lancet 2009 January 15;373(9662):508-15.
(6) De Savigny, D. and Adam, T. Systems Thinking for Health Systems Strengthening. Geneva: World Health Organisation; 2009.
(7) Institute for Tropical Medicine. International Health Policies. http://internationalhealt... blogspot com/?zx=e36530fb7baf270c 2011;
(8) Institute for Tropical Medicine. Health Research towards Universal Coverage. Calling upon Emerging voices to make the difference. http://www itg be/internet/colloq2010/essay%20competition%20rules html 2011

No competing interests declared.

RE: Having the right people at the right place at global, country and local levels

chads replied to Josefienvanolmen on 17 Feb 2011 at 07:45 GMT

We appreciate the thoughtful comments of Dr van Olmen and colleagues. The comments contribute to what we hope will be a robust global dialogue about principles in health systems strengthening (HSS). We agree that HSS is a process that requires guiding principles as opposed to a rigid, universal approach.

We disagree with the view that the statement does not add much to the existing literature. In fact, to synthesize and prioritize a large body of literature in what would be a consensus from many differing viewpoints represents a step forward in the discussion and planning for HSS globally. We contend that the consideration of HSS mandates that a set of agreed-upon guiding principles be considered simultaneously, as explained under our “holism” principle. Such a consideration requires health planners and practitioners to consider priority setting, unintended consequences, interrelationships, and delayed effects. The value of our paper, then, lies in its proposing 10 principles that should be considered simultaneously by those who play a role in developing strategic frameworks for policy, practice or evaluations.

We respond to three specific comments below:

1. “We observe a contradiction between the recognition of conflicts of interest (in principle two) and the wishful thinking of authors to reach harmony and consensus and to satisfy all stakeholders (principle ten and four).”

Although we recognize the benefits of a consensus among HSS principles, we do not believe we were overly optimistic in our approach. What the authors observe to be a contradiction is not necessarily so given that guiding principles are not mutually exclusive. We acknowledge in the paper that health systems strengthening (HSS) is a “complex iterative process” (principle 4), and that “there might be inherent conflicts within HSS efforts that require deliberation and informed choice” when there are conflicts between principles (principle 2). Collaboration is a necessary process in order to reach consensus among stakeholders. Through collaboration, context is considered. Through collaboration, stakeholders can aim for mutual satisfaction. Indeed, we concur that HSS is a process and these principles offer guidance to that process.

2. “We emphasize that the right people at all levels of the health system (both central and operational) take and are given the lead in the priority setting and are being accountable. Strengthening governance capacity is therefore a core priority within HSS.”

We agree and contend that we make similar points in principles 5, 6, and 10.

3. “Of the 37 authors and acknowledged people, only five people were explicitly mentioned from low income countries.”

We agree wholeheartedly with the importance of engaging people from low-income countries in HSS, as apparent in almost all of our principles. Their contributions were actively sought and heavily weighed. Many wished to remain anonymous, or contributed informally, so the contribution proportion that van Olmen and colleagues mentioned above is underestimated. We also acknowledge and appreciate the authors’ efforts at engagement through their “network on International Health Policies and Systems and the Emerging Voices initiative.”

In summary, we appreciate the comments of van Olmen and colleagues and their contribution to the discourse on HSS guiding principles. We hope that they will consider and comment on the primary questions that we attempted to answer: First, is there a shared vision of guiding principles for HSS? If not, should there be? Second, do the ten principles that we propose provide an adequate foundation for effective communication, learning, and research, and the development of effective HSS measurement tools and approaches? We believe that the answers to those questions by stakeholders and their respective actions will have a long-lasting impact on the health of those who suffer most. We look forward to further discussion on this important topic.

Robert C. Swanson 1, Annette Bongiovanni 2, Elizabeth Bradley 3, Varnee Murugan 3, Jesper Sundewall 4, Arvind Betigeri 5, Frank Nyonator 6, Adriano Cattaneo 7, Brandi Harless 8, Andrey Ostrovsky 9, Ronald Labonté 10

1 Department of Health Sciences, Brigham Young University, 2 The QED Group LLC, 3 Yale School of Public Health, 4 Division of Global Health, Karolinska Institute, 5 Health Systems Action Network, 6 Ministry of Health, Accra, Ghana, 7 Institute for Maternal and Child Health, Trieste, Italy, 8 EntrePaducah, 9 Health Systems Action Network, 10 Institute of Population and Department of Epidemiology and Community Medicine, University of Ottawa

No competing interests declared.