1. Policy Forum
Toward a Consensus on Guiding Principles for Health
Systems Strengthening
Robert C. Swanson1*, Annette Bongiovanni2, Elizabeth Bradley3, Varnee Murugan3, Jesper Sundewall4,
Arvind Betigeri5, Frank Nyonator6, Adriano Cattaneo7, Brandi Harless8, Andrey Ostrovsky9, Ronald
Labonte10
´
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 Systems
Action Network, New Delhi, India, 6 Ministry of Health, Accra, Ghana, 7 Institute for Maternal and Child Health, Trieste, Italy, 8 EntrePaducah, Paducah, Kentucky, United
States of America, 9 Health Systems Action Network, Baltimore, Maryland, United States of America, 10 Institute of Population and Department of Epidemiology and
Community Medicine, University of Ottawa, Ontario, Canada
Introduction 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 frequency
strengthening (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 337
Health 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 the
attaining the Millennium Development of 633 documents from peer-reviewed and methodology of the systematic review, and
Goals and to improving global health gray literature for HSS definitions, exam- Text S2 for a list of the keywords
outcomes [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 publications
of 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 health
2010 [3]. Additionally, numerous funding terms ‘‘health system(s) strengthening.’’ professionals representing different aspects
opportunities 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 the
for Vaccines and Immunization (GAVI proceedings, interviews, textbooks, and current HSS literature, we identified ten
Alliance), The Global Fund to Fight policy documents. Based on our review principles for HSS to address the current
AIDS, Tuberculosis and Malaria (Global of abstracts and summaries, we excluded lack of consensus. Finally, we discussed the
Fund), and the World Bank [4], as well as documents (n = 296) that did not meet the principles at six global health conferences in
US President Obama’s Global Health following inclusion criteria: contained a three countries (see Text S3 for a list of
Initiative [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 assisted
need for HSS, there is little agreement on tems; were relevant to the low- or in generating an initial set of principles on
strategies 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 of
provide a common language for strategy researchers then independently conducted principles involved iterative processes that
development and communication in the a full-text review of the remaining 337 incorporated not only the evidence from the
global community. Without a set of documents in order to categorize HSS review, but also the considerable field
agreed-upon principles, frameworks for
policy, practice, and evaluation may be
unclear, 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.1000385
innovation, and improvement. Here we
Published December 21, 2010
suggest a list of ten guiding principles
necessary 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 Reproductive
around the world to discuss challenges and Health of the Johns Hopkins Bloomberg School of Public Health for partially funding one of the attended
opportunities for improving health care in their conferences. He also shared a room for one night while attending a different conference with a colleague that
societies. was paid for by the NGO Food for the Hungry.
* E-mail: ghsias@gmail.com
PLoS Medicine | www.plosmedicine.org 1 December 2010 | Volume 7 | Issue 12 | e1000385

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 inconsistencies
experiences 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 takes
the 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 assessment
applicable to diverse geographical, socio- and training’’ (in 43.8% of all documents)
tools [15], evaluation of the impact that
cultural, and socioeconomic settings, we and ‘‘health service delivery and packag- initiatives have on the existing health
focused on health systems in low- and es/delivery models; infrastructure; de- system [16], and formation of health
middle-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 is
ers who play a role in developing strategic six health systems building blocks (Box 2) framed conditions and constrains the
frameworks for policy, practice, or evalu- [9] were the most commonly used, the range of interventions that follow. With
ations. We use the WHO definition of a mention of all six building blocks occurred HSS, overly specialized approaches or lack
health system as a network that ‘‘compris- in only 5.6% of all documents. of agreement on core principles amongst
es 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 principles
whose primary intent is to improve of the vast and complex nature of HSS for HSS could enhance coordination and
health’’ [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, we
Discussions approach to health would be all-encom- believe it is timely to begin a discourse
HSS 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 identify
39 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 | www.plosmedicine.org 2 December 2010 | Volume 7 | Issue 12 | e1000385

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 all
HSS principles (Box 3): holism, context, by the resources they command and the policies’’ [22] rests, in part, on the
social 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. Such
described 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 levels
stood 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 on
several 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 the
system; 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 to
system. Rather, global health programs health systems function. improving health [23]. Given the inherent
should 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 underlying
priority setting processes. Therefore, glob- tion and political change. Lessons from the assumptions that determine action, it is
al health planners should consider the highly successful HIV/AIDS movement incumbent upon donors to put in place and
impact that their activities will have on all exemplifies the confluence of civil society abide by mechanisms that foster and
major components, processes, and rela- and public health activism leading to sustain equal partnerships. A positive
tionships within a health system. This first substantial changes in global and national health system vision of the future that is
principle also calls on planners to assess policies and practices. Strengthening owned by all stakeholders is a powerful
their 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—Local
ensure donor coordination and improve society organizations have successfully capacity to detect or anticipate challenges
supply chain management without (among mobilized local groups to link communi- and to solve problems is an essential
other 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 and
which they increase local capacity, and tion Assistance Committee’s (BRAC) vil- regulatory levels is essential to developing
whether they most efficiently improve the lage organizations [18]. Some health a health system’s ability to respond to
population’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 on
the 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 and
professionals, civil society) who may have health system contributions to population positive health outcomes [25]. Strong
differing values and priorities about what health improvement. Training health pro- management skills [26] and supervision
health systems are, what they should viders should include understanding of of health providers [25] are also crucial for
provide, and how they should be financed social determinants of health and skill success. Ultimately, capacity must be
and organized. These communities vary development in social and political advo- enhanced at all levels from the household
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4. Box 3. Ten Health Systems Strengthening Guiding Principles
(See http://ghsia.wordpress.com/ 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 relationships.
to health facilities to government health enhancement is critical to enable effective 6. Efficiency—Efficiency is ‘‘achieving
agencies. 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]. Technical
cation at the household and community tems to generate and manage relevant efficiency refers to ‘‘situations in which a
levels through formative research and data, perform research independently, and good or service is produced at minimum
behavior change communication strate- respond rapidly to evidence by setting cost’’ [27] and can be applied to all aspects
gies, which can lead to stronger health policy and practice priorities, and imple- of global health practice, from human
systems in the long term. Such capacity menting effective programs. resources to technology. Providers and
PLoS Medicine | www.plosmedicine.org 4 December 2010 | Volume 7 | Issue 12 | e1000385

5. practitioners at all levels should be trained, ment and reporting is central to effective review of the literature demonstrates the
supported, and evaluated in ways that lead HSS. need for a consensus on guiding principles
to maximum performance given financial 8. Equity—Equitable health systems for HSS. The principles that we list have
inputs. Evidence strongly suggests that minimize systematic disparities that are already been applied to differing degrees
primary health care approaches lead to avoidable by reasonable action [21]. in the policies and practices of many
improved health outcomes [12], highlight- Although many disparities are caused in global health initiatives and institutions.
ing such approaches as foundational ele- the first instance by inequalities in social However, to our knowledge, there has
ments in HSS. The need for more health determinants of health, health systems can been no unified application of a set of HSS
personnel 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 donors
providers [28], is well documented. In- organized. Gender equity has been iden- and recipient states and communities. We
creasing evidence also suggests that com- tified as an especially important compo- offer the principles above as a contribution
munity-based and household-level health nent of strong health systems. Three ways to the ongoing discussion and debate
promotion interventions can have a signif- to meet the challenge of making health around the language and practice of
icant 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 of
in the home [30]. Technical efficiency in proposed: first, measure and report objec- settings, such as in health systems impact
global 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 support
with national priorities, plans, and struc- report targets in terms of progress among from a variety of major global health
tures, and that is predictable over time [31]. these groups; second, modify service stakeholders. We invite global health
It also refers to reducing waste in the delivery approaches, based on experiences leaders and planners to scrutinize and
system, including redundant measurement, from innovative efforts to reach those who counter these principles, and we hope that
excessive bureaucracy, corruption, and typically are neglected in the health such a discussion will establish a common
non-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 and
refers 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 Information
comes. Programs aimed at disease and nancing of health systems must include
injury 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 HSS
mental health, chronic disease, and ‘‘ne- imately 150 million people worldwide Definitions
glected’’ 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 Keywords
tant 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. Experience
implications this might have for policies suggests that systems with high participa- Text S3 Conferences Where the Health
within 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 Debated
Strong 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 levels
in ways that improve performance and of all persons working within, seeking care Acknowledgments
satisfaction. 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 and
need 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 the
and 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 for
sions 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 Medicine
changes based on that feedback; 2)
and Hygiene), Susan Higman (Global Health
flexibility and adaptation to local circum- Council), Erika Linnander (Yale University
stances; and 3) accountability to constitu- Toward a Consensus Global Health Leadership Institute), Kaelan
ents. 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 | www.plosmedicine.org 5 December 2010 | Volume 7 | Issue 12 | e1000385

6. Christine Pilcavage (Ideas 4 Health), W. Henry RCS would like to thank the Department of RL. Designed the experiments/the study: RCS
Mosley (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 the
Bloomberg 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 the
Miller, Sean Rutschke, Joshua West, Fiona
Author Contributions
contents of the manuscript during the various
Wright. ICMJE criteria for authorship read and met: drafting phases: AB.
Many others contributed anonymously RCS AB EB VM JS AB FN AC BH AO RL.
through discussions at conferences, emails, and Agree with the manuscript’s results and conclu-
other media. sions: RCS AB EB VM JS AB FN AC BH AO
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PLoS Medicine | www.plosmedicine.org 6 December 2010 | Volume 7 | Issue 12 | e1000385