Toward a consensus on guiding principles for health systems strengthening


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Toward a consensus on guiding principles for health systems strengthening

  1. 1. Policy ForumToward a Consensus on Guiding Principles for HealthSystems StrengtheningRobert C. Swanson1*, Annette Bongiovanni2, Elizabeth Bradley3, Varnee Murugan3, Jesper Sundewall4,Arvind Betigeri5, Frank Nyonator6, Adriano Cattaneo7, Brandi Harless8, Andrey Ostrovsky9, RonaldLabonte10 ´1 Department of Health Sciences, Brigham Young University, Provo, Utah, United States of America, 2 The QED Group LLC, Washington, D.C., United States of America,3 Yale School of Public Health, New Haven, Connecticut, United States of America, 4 Division of Global Health, Karolinska Institute, Stockholm, Sweden, 5 Health SystemsAction Network, New Delhi, India, 6 Ministry of Health, Accra, Ghana, 7 Institute for Maternal and Child Health, Trieste, Italy, 8 EntrePaducah, Paducah, Kentucky, UnitedStates of America, 9 Health Systems Action Network, Baltimore, Maryland, United States of America, 10 Institute of Population and Department of Epidemiology andCommunity Medicine, University of Ottawa, Ontario, CanadaIntroduction Methodology for Developing a definitions by keywords developed induc- Set of HSS Principles tively during the review process. We A renewed focus on health systems summarized the data using a frequencystrengthening (HSS) in global health has We employed several methods for distribution of keywords tagged. A sepa-emerged in recent years. The World developing a proposed set of guiding rate researcher then reviewed the 337Health Organization (WHO) and others principles for HSS. documents for HSS guiding principles.have promoted HSS as essential to First, we conducted a systematic review (See Text S1 for more details on theattaining the Millennium Development of 633 documents from peer-reviewed and methodology of the systematic review, andGoals and to improving global health gray literature for HSS definitions, exam- Text S2 for a list of the keywordsoutcomes [1,2]. This recent increase in ples, and explanations. For peer-reviewed identified.)interest is highlighted by the organization sources, we searched PubMed, Google We also reviewed 11 key publicationsof the First Global Symposium on Health Scholar, and Scopus for literature pub- (Box 1) that address HSS, and we repeat-Systems Research, held in November lished from 2000 to 2009 using the search edly consulted more than 30 global health2010 [3]. Additionally, numerous funding terms ‘‘health system(s) strengthening.’’ professionals representing different aspectsopportunities with an emphasis on HSS For gray literature sources, we used of health systems involvement (see Acknowl-have been established, including a collab- Google to identify HSS definitions or edgments). Based on our systematic review,orative effort between the Global Alliance approaches in Web sites, conference extensive consultations, and analysis of thefor Vaccines and Immunization (GAVI proceedings, interviews, textbooks, and current HSS literature, we identified tenAlliance), The Global Fund to Fight policy documents. Based on our review principles for HSS to address the currentAIDS, Tuberculosis and Malaria (Global of abstracts and summaries, we excluded lack of consensus. Finally, we discussed theFund), and the World Bank [4], as well as documents (n = 296) that did not meet the principles at six global health conferences inUS President Obama’s Global Health following inclusion criteria: contained a three countries (see Text S3 for a list ofInitiative [5]. definition, explanation, or example of conferences). The systematic review estab- Despite the growing consensus for the strengthening or improving health sys- lished the need for a consensus and assistedneed for HSS, there is little agreement on tems; were relevant to the low- or in generating an initial set of principles onstrategies for its implementation [6]. middle-income country context; and were which there was some normative agree-Widely accepted guiding principles could available in full text in English. Two ment. Our methods to refine the list ofprovide a common language for strategy researchers then independently conducted principles involved iterative processes thatdevelopment and communication in the a full-text review of the remaining 337 incorporated not only the evidence from theglobal community. Without a set of documents in order to categorize HSS review, but also the considerable fieldagreed-upon principles, frameworks forpolicy, practice, and evaluation may beunclear, overly narrow, or inconsistent [7], Citation: Swanson RC, Bongiovanni A, Bradley E, Murugan V, Sundewall J, et al. (2010) Toward a Consensus on Guiding Principles for Health Systems Strengthening. PLoS Med 7(12): e1000385. doi:10.1371/journal.limiting the ability for collective learning, pmed.1000385innovation, and improvement. Here we Published December 21, 2010suggest a list of ten guiding principlesnecessary for effective HSS. Copyright: ß 2010 Swanson et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The authors received no specific funding for this article. RL is supported through the Government of Canada "Canada Research Chair" program.The Policy Forum allows health policy makers Competing Interests: RCS received US$1000 from the Department of Population, Family, and Reproductivearound the world to discuss challenges and Health of the Johns Hopkins Bloomberg School of Public Health for partially funding one of the attendedopportunities for improving health care in their conferences. He also shared a room for one night while attending a different conference with a colleague thatsocieties. was paid for by the NGO Food for the Hungry. * E-mail: PLoS Medicine | 1 December 2010 | Volume 7 | Issue 12 | e1000385
  2. 2. Summary Points used in the literature. Many authors highlighted ways that vertical programs strengthen health systems [10,11] while N Despite the expanding consensus about the need for health systems others indicated that horizontal approach- strengthening (HSS), there is a lack of a common definition and set of guiding principles that can inform strategic frameworks used to develop policy, practice es better illustrated HSS [12]. Similarly, and evaluations. some approaches seemed to emphasize local ownership and aid effectiveness [13] N Without a set of agreed-upon principles, these frameworks may be unclear and while others focused on improving the inconsistent, limiting the ability for collective learning, innovation, and improvement. efficiency of those aspects of the system that deliver their particular service [14]. N A set of ten guiding principles for HSS is proposed in this paper that is based Previous literature has reported a selective upon a systematic review and consultation with experts in three countries. approach to HSS on the ground based on N They are: holism, context, social mobilization, collaboration, capacity enhance- the priorities of different global health ment, efficiency, evidence-informed action, equity, financial protection, and actors [7]. satisfaction. N The authors welcome and encourage further discussion of these findings at all The Need for a Consensus on levels so that a broad consensus on HSS principles is obtained. Guiding Principles for HSS The findings from our review demon- strate the diversity and inconsistenciesexperiences of those who participated in the HSS (see Text S2 for a complete list). The regarding HSS definitions and approach-process, and rigorous discussion amongst most commonly used keywords were es. The approach that an institution takesthe authors of the paper. ‘‘health workforce related national policies in defining HSS may influence many Although our proposed principles are and investment plans; norms, standards activities, including choices of assessmentapplicable to diverse geographical, socio- and training’’ (in 43.8% of all documents) tools [15], evaluation of the impact thatcultural, and socioeconomic settings, we and ‘‘health service delivery and packag- initiatives have on the existing healthfocused on health systems in low- and es/delivery models; infrastructure; de- system [16], and formation of healthmiddle-income countries from the per- mand for care’’ (in 43% of all documents). systems training courses [17]. It is gener-spective of external funders and stakehold- Although keywords relating to the WHO’s ally accepted that how a policy approach isers who play a role in developing strategic six health systems building blocks (Box 2) framed conditions and constrains theframeworks for policy, practice, or evalu- [9] were the most commonly used, the range of interventions that follow. Withations. We use the WHO definition of a mention of all six building blocks occurred HSS, overly specialized approaches or lackhealth system as a network that ‘‘compris- in only 5.6% of all documents. of agreement on core principles amongstes all organizations, institutions and re- The fact that HSS definitions encom- different actors could limit its effectiveness.sources devoted to producing actions passed 39 separate categories is indicative Greater consensus on guiding principleswhose primary intent is to improve of the vast and complex nature of HSS for HSS could enhance coordination andhealth’’ [8]. policy. We found little consistency and collaboration among global health actors. wide variation among the definitions cited. Given that HSS continues to gain prom-Outcomes of the Review and It can be expected that taking a systems inence in funding, policy, and practice, weDiscussions approach to health would be all-encom- believe it is timely to begin a discourseHSS Definitions and Approaches in passing in terms of topics, but contradic- regarding such guiding principles.the Literature tions were observed in common examples Existing HSS frameworks [9], principles Review of the 337 documents identified of HSS. For example, we found substantial [13], and strategies [14] tend to identify39 distinct keywords that characterized inconsistencies in the definitions of HSS components of HSS or provide broad recommendations about key elements but do not provide a comprehensive list of Box 1. Key Documents That Outline Major Health Systems guiding principles that are widely accept- Strengthening Principles ed. In contrast, our analysis focuses on underlying principles that can be a guide N Systems Thinking for Health Systems Strengthening [2] for specific frameworks already in use or to N Everybody’s Business: Strengthening Health Systems to Improve Health be developed. Therefore, despite these Outcomes [9] existing frameworks and approaches, we N GAVI Alliance Health Systems Strengthening Guiding Principles [13] argue that there is value in providing N Just and Lasting Change: When Communities Own Their Futures [24] overarching guiding principles for action, N Getting Health Reform Right: A Guide to Improving Performance and Equity in contrast to recommending any specific action, which may be consistent with a [27] particular framework or strategy. In this N The World Health Report 2000 – Health Systems: Improving Performance [30] way, there can be broad consensus on N The Paris Declaration on Aid Effectiveness [31] general concepts that might direct strate- N Challenging Inequity through Health Systems. Final Report, Knowledge gies and their respective programs. Network on Health Systems 2007 [36] N Declaration of Alma-Ata [40] Proposed Principles for HSS N The NGO Code of Conduct for Health Systems Strengthening [41] To initiate a discourse on guiding N Health Systems and the Right To Health: An Assessment of 194 Countries [42] principles on HSS and based upon our review and discussions, we propose ten key PLoS Medicine | 2 December 2010 | Volume 7 | Issue 12 | e1000385
  3. 3. Box 2. The WHO Health Systems Building Blocks [9] cacy to influence change in these determi- nants [20]. The WHO Commission on 1. Service delivery: Packages; delivery models; infrastructure; management; Social Determinants of Health highlighted safety and quality; demand for care the positive health impact of programs aimed at reducing poverty; at improving 2. Health workforce: National workforce policies and investment plans; gender equality, education, nutrition, and advocacy; norms, standards, and data sanitation; and at providing social protec- tion measures to buffer market-driven 3. Information: Facility and population-based information and surveillance inequalities [21]. systems; global standards, tools 4. Collaboration—HSS is a complex, 4. Medical products, vaccines, and technologies: Norms, standards, policies; iterative process. Global efforts at HSS reliable procurement; equitable access; quality require long-term partnerships with com- munities, and their governments, that 5. Financing: National health financing policies; tools and data on health include appreciation for the nuances of expenditures; costing local culture and the ever-changing polit- ical and social environments. Improve- 6. Leadership and governance: Health sector policies; harmonization and ments in the health status of a population alignment; oversight and regulation often depend on policies and activities in other sectors. The influence of health professionals to promote ‘‘health in allHSS principles (Box 3): holism, context, by the resources they command and the policies’’ [22] rests, in part, on thesocial mobilization, collaboration, capacity power they wield. Assumptions and beliefs development of relationships with col-enhancement, efficiency, evidence-in- about health and how services should be leagues in environment, education, eco-formed action, equity, financial protection, delivered may differ among communities nomic growth, democracy and gover-and satisfaction. Each of these principles is as well. These important asymmetries nance, media, and other sectors. Suchdescribed briefly below. must be understood within any given collaborative relationships must take place 1. Holism—Health systems are con- national or local context. Apart from on a national level among various minis-tinually changing and cannot be under- differences amongst engaged and affected tries, and at district and community levelsstood completely or effectively strength- communities, there might be inherent among and between providers and pro-ened by disaggregating their different parts conflicts within HSS efforts that require gram planners, implementers, and users.[2]. Strengthening one component or even deliberation and informed choice. For Effective partnerships are based onseveral components of a health system example, some HSS efforts may reflect respect and dialogue that result in relation-does not necessarily strengthen the entire conflicts between equity and efficiency. ships of trust and that recognize thesystem; isolated actions directed to short- Such trade-offs must be negotiated with a important, unique contributions that indi-term goals may even weaken the overall rigorous review of the contexts in which viduals and groups can contribute tosystem. Rather, global health programs health systems function. improving health [23]. Given the inherentshould improve the overall system, with 3. Social mobilization—HSS efforts difference in power of donors and recipi-due consideration for national and local depend considerably on social mobiliza- ents, and the often differing underlyingpriority setting processes. Therefore, glob- tion and political change. Lessons from the assumptions that determine action, it isal health planners should consider the highly successful HIV/AIDS movement incumbent upon donors to put in place andimpact that their activities will have on all exemplifies the confluence of civil society abide by mechanisms that foster andmajor components, processes, and rela- and public health activism leading to sustain equal partnerships. A positivetionships within a health system. This first substantial changes in global and national health system vision of the future that isprinciple also calls on planners to assess policies and practices. Strengthening owned by all stakeholders is a powerfultheir activities against all of the guiding health systems necessarily includes effec- force for change that is just and lasting [24].principles. For example, it is not enough to tive health policy reform. Many civil 5. Capacity enhancement—Localensure donor coordination and improve society organizations have successfully capacity to detect or anticipate challengessupply chain management without (among mobilized local groups to link communi- and to solve problems is an essentialother considerations) also considering the ties with the formal health systems in their component of a strong health system.equity of those activities, the extent to countries, such as Bangladesh Rehabilita- Institutional capacity at the facility andwhich they increase local capacity, and tion Assistance Committee’s (BRAC) vil- regulatory levels is essential to developingwhether they most efficiently improve the lage organizations [18]. Some health a health system’s ability to respond topopulation’s health. professionals have been described as emerging and existing health challenges 2. Context—HSS activities require ‘‘social entrepreneurs’’ whose particular within rapidly changing environments.consideration of specific contexts and of skill sets include the ability to initiate new Institutional capacity is dependent onthe overall architecture of each specific civil society relationships that lead to effective leaders and management process-system. Global health efforts involve enduring partnerships and health-promot- es. A review of service delivery mecha-multiple communities (e.g., host country ing activities [19]. These mobilization nisms suggested a strong statistical associ-governments, international donors, health skills should be recognized as important ation between strong local leadership andprofessionals, civil society) who may have health system contributions to population positive health outcomes [25]. Strongdiffering values and priorities about what health improvement. Training health pro- management skills [26] and supervisionhealth systems are, what they should viders should include understanding of of health providers [25] are also crucial forprovide, and how they should be financed social determinants of health and skill success. Ultimately, capacity must beand organized. These communities vary development in social and political advo- enhanced at all levels from the household PLoS Medicine | 3 December 2010 | Volume 7 | Issue 12 | e1000385
  4. 4. Box 3. Ten Health Systems Strengthening Guiding Principles (See for discussion) 1 HOLISM – Consider all systems components, processes, and relationships simultaneously. – Include all health systems strengthening principles listed below. 2 CONTEXT – Consider global, national, regional, and local culture and politics. 3 SOCIAL MOBILIZATION – Mobilize and advocate for social and political change to strengthen health systems and address the social determinants of health. 4 COLLABORATION – Develop long-term, equal, and respectful partnerships between donors and recipients within the health sector and among other sectors. – Develop and commit to a shared vision among partners by challenging underlying beliefs and assumptions. – Ensure frequent communication among actors. 5 CAPACITY ENHANCEMENT – Enhance capacity and ownership at all levels, from individuals and households to ministries of health, including leadership, management, institutional strengthening, and problem solving. 6 EFFICIENCY – Train and supervise the most appropriate personnel to meet health needs. – Utilize appropriate technology. – Coordinate external aid and activities. – Minimize waste. – Allocate funds where they are needed most. 7 EVIDENCE-INFORMED ACTION – Strengthen structure, systems, and processes to gather, analyze, and apply data locally. – Make decisions, whenever possible, based on evidence. – Monitor progress of programs, and adjust accordingly. – Ensure transparency and accountability. 8 EQUITY – Target those who are disenfranchised. – Plan for equity by empowering the disenfranchised, with a particular emphasis on gender. – Disaggregate indicators to track disenfranchised groups. 9 FINANCIAL PROTECTION – Ensure that funding streams are predictable. – Consider insurance schemes to protect from financial catastrophes. 10 SATISFACTION – Respond to needs and concerns of all stakeholders. – Demonstrate accountability to constituents. – Implement and respond to feedback mechanisms measuring quality and provider/client health facilities to government health enhancement is critical to enable effective 6. Efficiency—Efficiency is ‘‘achievingagencies. Particular attention should be community, district, and national owner- as much of one’s objectives as possible,paid to knowledge generation and appli- ship. Local ownership allows health sys- given finite resources’’ [27]. Technicalcation at the household and community tems to generate and manage relevant efficiency refers to ‘‘situations in which alevels through formative research and data, perform research independently, and good or service is produced at minimumbehavior change communication strate- respond rapidly to evidence by setting cost’’ [27] and can be applied to all aspectsgies, which can lead to stronger health policy and practice priorities, and imple- of global health practice, from humansystems in the long term. Such capacity menting effective programs. resources to technology. Providers and PLoS Medicine | 4 December 2010 | Volume 7 | Issue 12 | e1000385
  5. 5. practitioners at all levels should be trained, ment and reporting is central to effective review of the literature demonstrates thesupported, and evaluated in ways that lead HSS. need for a consensus on guiding principlesto maximum performance given financial 8. Equity—Equitable health systems for HSS. The principles that we list haveinputs. Evidence strongly suggests that minimize systematic disparities that are already been applied to differing degreesprimary health care approaches lead to avoidable by reasonable action [21]. in the policies and practices of manyimproved health outcomes [12], highlight- Although many disparities are caused in global health initiatives and such approaches as foundational ele- the first instance by inequalities in social However, to our knowledge, there hasments in HSS. The need for more health determinants of health, health systems can been no unified application of a set of HSSpersonnel equipped with necessary training either exacerbate or help to reduce them, guiding principles to facilitate communi-and technology, especially public health partly by how they are financed or cation and collaboration between donorsproviders [28], is well documented. In- organized. Gender equity has been iden- and recipient states and communities. Wecreasing evidence also suggests that com- tified as an especially important compo- offer the principles above as a contributionmunity-based and household-level health nent of strong health systems. Three ways to the ongoing discussion and debatepromotion interventions can have a signif- to meet the challenge of making health around the language and practice oficant impact on health [29], given that from systems more equitable and capable of HSS. Our principles need to be field-70% to 90% of all sickness care is managed reducing health inequities have been tested and evaluated in an array ofin the home [30]. Technical efficiency in proposed: first, measure and report objec- settings, such as in health systems impactglobal financing for HSS implies greater tives that are disaggregated to highlight assessments [39], programmatic interven-coordination of donor aid that is aligned disenfranchised populations, and set and tions, and research activities with supportwith national priorities, plans, and struc- report targets in terms of progress among from a variety of major global healthtures, and that is predictable over time [31]. these groups; second, modify service stakeholders. We invite global healthIt also refers to reducing waste in the delivery approaches, based on experiences leaders and planners to scrutinize andsystem, including redundant measurement, from innovative efforts to reach those who counter these principles, and we hope thatexcessive bureaucracy, corruption, and typically are neglected in the health such a discussion will establish a commonnon-productive activity. system; and third, empower clients who set of principles that will serve as the Allocative efficiency, on the other hand, are poor to play a more active role in the foundation for future HSS discussions andrefers to whether health systems are design and operation of health systems strategies.generating the right collection of interven- [34].tions required to maximize health out- 9. Financial protection—The fi- Supporting Informationcomes. Programs aimed at disease and nancing of health systems must includeinjury prevention, health promotion, re- mechanisms to minimize catastrophic Text S1 Methodology for Comprehen-productive health, vaccine dissemination, financial impacts from ill health. Approx- sive, Systematic Review of Current HSSmental health, chronic disease, and ‘‘ne- imately 150 million people worldwide Definitionsglected’’ tropical diseases have all been each year suffer financial catastrophe in Found at: doi:10.1371/journal.pmed.argued as underfunded globally, relative to order to pay for their health services [35]. 1000385.s001 (0.03 MB DOC)need. While efficiency remains an impor- Health financing (either through taxation Text S2 Keywordstant principle, it must also be seen in terms or foreign aid) must be continuous and Found at: doi:10.1371/journal.pmed.of considering why some countries and predictable, especially during financial 1000385.s002 (0.03 MB DOC)sectors have scarce resources and the crises when it is needed most. Experienceimplications this might have for policies suggests that systems with high participa- Text S3 Conferences Where the Healthwithin and between states [32]. tion in prepayment schemes avoid the Sytems Strengthening Guiding Principles 7. Evidence-informed action— impoverishing effects of out-of-pocket pay- Were Discussed and DebatedStrong health systems have structures ments, and maximize equity [36]. Found at: doi:10.1371/journal.pmed.and processes in place to gather and 10. Satisfaction—Finally, HSS must 1000385.s003 (0.03 MB DOC)process data and to apply that information include attention to the satisfaction levelsin ways that improve performance and of all persons working within, seeking care Acknowledgmentssatisfaction. The evidence base for action from, or involved in programs developed Senior Advisors and Contributors: Wa-at the national, regional, facility-based, by such systems. Low levels of health limbwa Aliyi (Uganda Ministry of Health),and community levels is scant in low- worker or client satisfaction, often a result Michael Barnes (Brigham Young University),income countries, despite the tremendous of underfunded or poorly managed health Edwin Bolastig (University of Trinidad andneed to discern what does and does not systems, are associated with lower quality Tobago, Health Systems Action Network),work. Quality improvement is a process care and utilization rates of services and Malcolm Bryant (Boston University), Peter programs [37,38]. This can imperil overall Cross (Innovative Development Expertise &‘‘oriented toward improving performance Advisory Services), Tom Davis (Food for theand using data in the process’’ [33] and is health system performance and reduce the Hungry), Kirk Dearden (Boston University),cyclic, iterative, and often gradual; it must social solidarity important to health system Emily deRiel (Health Alliance International),be planned for. Our review and discus- sustainability. A strong health system is Joseph Dwyer (Management Sciences forsions suggest three primary characteristics one that demonstrates accountability to its Health), Anbrasi Edward (John Hopkins Bloom-of quality programs: 1) regular, frequent constituents through responsiveness to berg School of Public Health), Sampson Ezi-evaluations to measure impact and make their concerns and provider/client rela- keanyi (Nigeria Ministry of Health), Andy tionships they engender. Haines (London School of Tropical Medicinechanges based on that feedback; 2) and Hygiene), Susan Higman (Global Healthflexibility and adaptation to local circum- Council), Erika Linnander (Yale Universitystances; and 3) accountability to constitu- Toward a Consensus Global Health Leadership Institute), Kaelanents. Building the data infrastructure to Our collective experience, discussion Moat (McMaster University), Rakgadi Mohlah-enable transparent outcomes measure- with experts throughout the world, and lane (University of Pretoria in South Africa), PLoS Medicine | 5 December 2010 | Volume 7 | Issue 12 | e1000385
  6. 6. Christine Pilcavage (Ideas 4 Health), W. Henry RCS would like to thank the Department of RL. Designed the experiments/the study: RCSMosley (John Hopkins Bloomberg School of Population, Family, and Reproductive Health VM. Analyzed the data: RCS AB VM BH AO.Public Health), Doyin Oluwole (Africa’s Health of the Johns Hopkins Bloomberg School of Collected data/did experiments for the study:in 2010/AED), David Peters (Johns Hopkins Public Health for partially funding one of the RCS VM AO. Wrote the first draft of theBloomberg School of Public Health). attended conferences. paper: RCS. Contributed to the writing of the Other contributors, editors, and research paper: RCS AB EB VM JS AB FN AC AO RL.assistants: Bryce Johnson, Diogo Metz, Mark Reviewed the 11 key documents, discussed theMiller, Sean Rutschke, Joshua West, Fiona Author Contributions contents of the manuscript during the variousWright. ICMJE criteria for authorship read and met: drafting phases: AB. 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