Dear Colleagues and Readers,

Some changes happened within the Health Systems Network since we last communicated.  In fact, from now on, I’ll be in charge of the editing of our newsletter in collaboration with our new media expert, Ms. Ildikó Bokros.  YES!! I’m pleased to inform you that “Selected Readings in Health Systems” is back!! After a very long break here is the first newsletter of the year 2013.  Our plan is to issue 6 newsletters a year, bi-monthly.

We’d like to count on your support, creativity and participation to recommend articles or reports or any paper you think it is interesting and useful to be disseminated.  Your reviews are most welcome to enrich viewpoints and stimulate debate.

For this issue we thank those who contributed with recommendations or articles or with reviews:  Ildikó Bokros, Kristof Decoster, Peter Delobelle, Bruno Marchal, Karen Pesse, Prashanth NW and Josefien Van Olmen. Thank you!!

Hoping in hearing from you soon and wishing good reading,
Valéria Campos da Silveira


WHO Alliance HS Research. “Changing Mindsets: Strategy on Health Policy and Systems Research”

World Health Organization, 2012
(reviewed by Prashanth NS)

changing mindsetsOn 1 November, 2012 at the Second Global Symposium on Health Systems Research at Beijing, the WHO Alliance for Health Policy and Systems Research launched a strategy document, “Changing Mindsets: Strategy on Health Policy and Systems Research”. The document is an important contribution to the movement towards clarifying and strengthening the scope and reach of health systems research (also health policy and systems research). The document was an outcome of the earlier Montreux Symposium where over 1200 delegates working as researchers, policymakers, practitioners and other actors, called for a strategy in order to align research evidence and decision-making. It contains four sections. It begins in earnest acknowledging the complexity involved in policymaking and implementation but underscores the importance of generating research evidence that is demand-driven and is relevant to decision making in health systems.

It begins with a brief introduction to the value and promise of health systems research, carrying case studies from China, India, Mexico and Thailand. The case-studies however are very brief. In the case of India for example, the setting up of a few institutions at the central and provincial levels and elevation of a government research institute into a department are cited as examples of evidence-generation and incorporation into policy. Thailand’s case (again very brief) however, seems to carry more details on why the institutions established for supporting decision making in that country worked. This is followed by a section that situates health policy and systems research (HPSR) within health research.

The third section on transformational thinking is perhaps at the core of this strategy. Beginning with a quote from Victor Hugo “There is nothing more powerful than an idea whose time has come”, the chapter titled “Changing Perspectives” calls for a shift in mindset in terms of the type of questions that researchers choose for their research, as well as a much greater involvement of policymakers and other actors in research question generation and implementation; these actors are traditionally seen as mere consumers of high quality research. Identifying “triggers of transformation” based on five case studies (again brief) from Chile, Ghana, Nepal, Lebanon and Zambia, the strategy ends with a final section on options for action: (1) embed research within decision-making processes, (2) support demand-driven research, (3) strengthen capacity for research and use of evidence, (4) establish repositories of knowledge, (5) improve the efficiency of investments in research, and (6) increase accountability for actions.

The strategy does not add much in way of clarifying the field or practical guidance to researchers or policymakers. Rather, it consolidates the strong calls being made globally and at national levels on making health research more practical and relevant to decision-makers. It could be a useful guiding document to advocate for similar direction within national and sub-national institutions at country levels.

The background papers that informed the strategy document carry much more details on the case studies and are available at the above link for download.

Chee, G. et al. “Why differentiating between health system support and health system strengthening is needed”

Int J Health Plann Mgmt (2012)
(reviewed by Bruno Marchal)

The authors of this paper aim at informing the debate on what constitutes health system strengthening. They propose to differentiate supporting the health system from strengthening it. Health systems support includes any activity that improves services, mainly by increasing inputs. Strengthening the health system occurs when changes to performance drivers such as policies and regulations, organizational structures, and relationships aim at improving multiple health services. They go on to propose the health system cube, that aims at combining the 6 building blocks model with the performance drivers from Roberts et al. control knob framework and health programmes as the third dimension.

While the authors make their point in a clear way, their key message isn’t all that new. Furthermore, it is not clear how the cube resolves the issue of assessing the relations and interactions between the 6 building blocks of WHO’s model. Conclusion: a slightly disappointing paper, even more because it is shallowly referenced.

Huff-Rousselle, M. “Reflections on the frameworks we use to capture complex and dynamic health sector issues”

Int J Health Plann Mgmt (2013)
(reviewed by Bruno Marchal)

This author present a commentary on the above paper, looking first at how Chee et al. constructed the health system cube and then assessing its strengths and weaknesses. She points out how financing and payment, two powerful control knobs of Roberts et al’s framework, were taken out of the health system cube, thereby reducing its power to understand key drivers of health systems. She goes on to say that striving to develop a common understanding of health system strengthening may be self-defeating, as a thing as complex as health systems benefits from multiple perspectives. Multi-disciplinary perspectives are indeed needed to make sense of complex health problems. All in all, a sensible review of the paper by Chee and colleagues.

Campion E. and Morrissey S. “A Different Model – Medical Care in Cuba”

N Engl J Med 368; 4 (2013)
(reviewed by Karen Pesse)

Although for many of us, and especially for Latin-Americans like me, this short paper doesn´t present real new information, it is worth reading. First of all, because it presents a more or less balanced description of the Cuban Health System, with its strengths and weaknesses, but mainly because it is written from a very personal perspective: the one of two United State doctors visiting the island, I suppose for the first time.

Therefore they present a somewhat “fresh” look of the system, in plain words and without sophisticated public health concepts. It´s interesting to see, though, how the socio-political and cultural contexts, as well as the professional background of the authors are so (implicitly) present in what captures their attention. Most probably it is not just by chance that already in the introduction, they mention credits cards and smartphones. And by describing the health system, quite a lot of emphasis is put on economic aspects and individual free choice; we could bet that this represents more the authors’, than the Cuban population´s concerns about their medical care.

Even so, the sole fact that an article like this is published in the New England Journal of Medicine, the oldest and most prestigious (north-) American medical journal, edited by the Massachusetts Medical Society is very interesting. Could it be, as a friend of mine asked, a sign that the crisis is making them look for alternatives that were completely out of question just a couple of years ago?

Hafner T. and Shiffman J. “The emergence of global attention to health system strengthening”

Health Policy & Planning (2013), 28: 41-50
(Reviewed by Karen Pesse)

It is always good to remember (or to know for the first time) that many of the most recent initiatives and discussions in world’s public health agenda are not really new. Acknowledging efforts done by many different actors in the past is important, not only because of a minimum sense of justice, but also to learn from experiences. What did we succeed in when trying to convince powerful decision makers on the importance of Health System Strengthening (HSS)? Was it the failure of the existing model, or a really good new idea, or the form it was presented, or just the right contextual moment to get it into the debate? Probably a mixture of all these four, and other factors…

This paper provides us with a quite comprehensive review of who, when, and why attention was given to HSS in the last decade at global context, focusing on international health organizations, their interests and motivations. Description of methodological issues on how to construct a case using process-tracing is also interesting for researchers working in the field of health policy analysis. All the same, more information about the historical socio-political moments when this theme was raised (and when and why it declined) could have enriched this study.

We share authors´ concerns on being too optimistic about the (re-)emergence of interest in HSS, and their call of attention on the lack of a clear concept and solid evidence to promote initiatives targeting this goal. Nevertheless, it´s worth keeping in mind that history has shown us that courses of action are never completely cyclical; they never get again to exactly the same starting point. We should rather think of them as iterative processes, with a lot of drawbacks but also some general advances. In this case, the sole fact that more and more people think and acknowledge HSS as a problematic issue, could already be considered as a positive development.

Bigdeli M. et al. “Access to medicines from a Health System perspective”

Health Policy and Planning (2012;1–13)
(reviewed by Josefien Van Olmen)

This paper views the “problem” of medicine in a holistic way. In most classic frameworks, drugs have been regarded as a resource of input in the health system and most analysis focused on supply chain issues. But looking at medicines in relation to the other elements in the health system reveals many other issues essential for good outcomes. For instance, medicines are part and parcel of health care delivery, thus how they prescribed is important. Medicines are important in the self-care behaviour of people, thus the ways access is regulated influences the ability of people to act.

The value of their paper is two-fold. Firstly, the authors elaborately explain the problems of access to medicines for people and how these relates with other elements of the health system in a very clear way, make every lay person able to understand the essence of these complicated issues. Secondly, their modification of the health system dynamics framework illustrates how this generic framework can be adapted to fit the analysis of a particular problem in more depth.

World Economic Forum “Sustainable Health Systems: Visions, Strategies, Critical Uncertainties and Scenarios” ( 2013)
(reviewed by Peter Delobelle)

sustainable health systemsThis document, released by the World Economic Forum, is the result of a global effort engaging health system leaders, policymakers, and experts, in an exercise to provide a long-term and holistic analysis of sustainable health systems. The report presents visions of an ideal future health system, the strategies to achieve those aspirations, the critical uncertainties that may influence the context of these future health systems, and three possible scenarios that are plausible, ranging from fully privatised systems (‘Health Inc’) to fully nationalised health systems (‘New Social Contract’), and a mixed scenario with super-empowered individuals who manage their own health in a competitive market.

By focusing thirty years ahead, the report provides a perspective that is devoid of short-term concerns and constraints, and pushes for long-term political approaches towards future health systems that include policies, products and services aimed at disease prevention and well-being. The report hence makes the difference between healthcare systems defined by supply-side based decision-making and health systems defined as a balance between supply and demand that also include actors beyond the traditional health sector who influence and affect health in society.

All the talents. How new roles and better team work can release potential and improve health services.

Report. All-Party Parliamentary Group on Global Health and the Africa All-Party Parliamentary Group, United Kingdom, July 2012
(reviewed by Valéria Campos da Silveira)

As well said in the preface, the key message of this report is a call to make better use of potential and talents of all people working in health care; to make much better use of the “most valuable asset of all:  People and their energy, skills and passion”.
The report provides various examples from around the world where unqualified health workers have safely taken on wider roles in health care and performed them well.  Depending on the case, they had improved access to services, improved quality or reduced costs, or sometimes all three.  In fact, this approach has been developed since the times of Alma Ata Primary Health Care Declaration in 1978, with what was then called “delegation of tasks”, and now widely known as “task shifting”…

The authors of the report recognize the potential dangers and difficulties of this approach but identify success factors that are essential to guarantee care of good quality.  These “success factors” are good leadership and planning; appropriate job design and recruitment; formal training and scope for progression; supervision and referral systems; and, recognition for health workers and good teamwork.

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