Dear “HSSR” Readers,

With some delay here it comes another issue of the “Health Systems Selected Readings”.  This time we have a critical comment by our colleague Karen Pesse from PUCE on “promoting participation in rights-based approaches to health”. I summarized articles on health systems support vs strengthening, public health systems analysis, mobile health (mHealth) innovations, and performance based financing as health system reform.

I’d like to thank Kristof Decoster for his suggestions, Karen for her review, and Ildikó Bokros for putting this newsletter on line.

I wish you all a good and stimulating reading!


Alicia Ely Yamin (2009) Suffering and Powerlessness: The Significance of Promoting Participation in Rights-Based Approaches to Health

Health and Human Rights Vol. 11, No. 1 pp. 5-22 Article Stable URL:

Review by Karen Pesse, Pontificia Universidad Católica del Ecuador (PUCE) 

This articles presents a quite comprehensive and interesting review of main publications on the controversial theme of participation in health; worth not only reading, but also reflecting on it, by all who are involved in the operationalization of this approach in health programme, services and policies, as well as for professionals trying to develop conceptual frameworks on participation and related issues like empowerment, democratisation of management, etc. It calls attention on the well –known but easily forgotten fact that there are many forms of understanding and operationalizing participation, and that these forms depend on how we conceptualize power and on the ideals of social organization we pursue, thus situating the debate where, at least to my understanding, it belongs: the political arena.

However, the article would gain more importance and usefulness, especially for the first group of readers mentioned above, if more concrete ideas or examples on how to implement or strengthen participation in a right-based approach to health could be actually achieved. Although it is truth that no one-recipe-fits-all can or should be applied, to have these real life examples would serve as motivation as well as a ground for building better strategies.

The authors declares she “outlines three ways of thinking about domination and participation-as-empowerment”; differences between the “neoliberal understanding” as she names it, and critical approach are well described, but differences between the second and third way of conceiving participation remain a bit unclear , at least for me.

An important asset of this publication is to include also articles being written some decades ago, thus in some way acknowledging it, isn´t a new topic; most of the issues and arguments presented in the article have been put on debate for decades by now. The specific added value of a right-based approach to these (historical) debates isn´t clear enough.

In her conclusions the authors states that “…human rights is an unapologetically modernist project for social emancipation…”; a very important recognition, since it implies that its defenders hold an occidental viewpoint, even if strongly critic to the current situation of world affairs characterised by “brutal inequalities”, with marginalization and alienation of large parts of the population, for which powerlessness means suffering. However we miss a more in depth discussion and recognition of the potential contradiction of this approach with the proposal/intention of respecting others (non-modernists) views and understanding of the world, society, and wellbeing.


Chee G. et al. (2013) Why differentiating between health system support and health system strengthening is needed.

Int J Health Plann Mgmt 2013; 28: 85-94.  Available at

Summary by Valéria Campos da Silveira, Institute of Tropical Medicine Antwerp (ITM, A)

The authors argue that distinguishing between health system support and strengthening is needed so that countries, donors, and implementers can look beyond identifying the input gaps to identifying the policy and structural constraints that impede better performance.  They define health system supporting as any activity that improves services, primarily by increasing inputs and it can be short term and narrowly focused. In contrast, health system strengthening involves more comprehensive changes to policies and regulations, organisational structures, and relationships across the health system building blocks that motivate changes in behaviour. Health system strengthening is about permanently making the system function better, not just filling gaps or supporting the system to produce short-term outcomes. The authors still propose four questions in order to distinguish support from strengthening health systems:

  • Do the interventions have cross-cutting benefits beyond a single disease?
  • Do the interventions address policy and organisational constraints of strengthen relationships between the building blocks?
  • Will the interventions produce permanent systemic impact beyond the term of the project?
  • Are the interventions tailored to country-specific constraints and opportunities, with clearly defined roles for country institutions?


Thunhurst C.P. (2013) Public health systems analysis – where the River Kabul meets the River Indus.

Globalization and Health, 9:39

Available at

Abstract: This paper reviews two paradigmatic shifts and consider how a two-way flow has been critical to the emergence of new thinking and new practices. The first area relates to the understanding of the nature of public health systems and the shift from a medical paradigm to a more holistic paradigm which emphasises the social, economic and environmental origins of ill-health and looks to these as key arenas in which to tackle persistent inequalities in populations’ health experiences. In respect of this paradigmatic shift, it is argued, developing countries were in advance of their more developed counterparts. Specifically, the Alma Ata Declaration and the Primary Health Care Approach which was central to its implementation pre-figured elements of what was to be called in developed countries The New Public Health such as the need for greater community involvement and recognition of the importance of other sectors in determining health outcomes. But this paradigmatic shift added a new complexity to the understanding which made the identification of appropriate policy responses increasingly difficult.

A parallel shift was taking place in the field of operational research/systems analysis which was adding to the ability to analyse and to identify key points of intervention in complex systems. This led to the emergence of new techniques for problem structuring which overcame many of the limitations of formal mathematical models which characterised the old paradigm. In this paradigmatic shift developed countries have led the way, specifically in the new fields of Community Operational Research and Operational Research for Development, but only by drawing strongly on the experience and philosophies to be found in developing countries.


Short comment by Valéria Campos da Silveira, ITM, A

The very attractive title of this article called my attention together with the promise of paradigm discussion.  Indeed, in the subchapters, the discussion on change and innovation brought about by paradigm shifts was an interesting and rich lecture.  Understanding of system and complexity adds to the capital importance of a “whole-system approach” for the analysis of health systems suggested by the author.  The strategic planning approach presented for developing countries is, however, not new. It’s proposed a planning framework derived from the logical framework, employing problem trees and prioritisation ranking exercises as “newly emerging analytic techniques”, while this has been used since the 70s of the XXe century.  The conclusion of the paper is, by contrary, interesting: clear statement of levels (macro, meso, micro), emphasis on “integrity of a whole-systems approach”, essential role given to involvement of community representatives, inclusive from other sectors than health, and the need of appropriate analytical skills of health planners in a system perspective.



Labrique A. B. et al. (2013) mHealth innovations as health system strengthening tools: 12 common applications and a visual framework.

Global Health Science and Practice, Vol. 1, Nr 2

Available at:

Summary by Valéria Campos da Silveira, Institute of Tropical Medicine Antwerp (ITM, A)

This article lays out a framework with 12 common mHealth applications used as health system strengthening innovations across the reproductive health continuum.

A proliferation of mHealth projects has demonstrated, conceptually, how mHealth can alleviate specific health system constraints that hinder effective coverage of health interventions.  Large-scale implementation of these mHealth innovations has been limited by shortage of empirical evidence supporting their value in terms of cost, performance and health outcomes. Communicating mHealth technologies as tools that can enhance delivery of life-saving interventions through improvements in health systems performance, such as coverage, quality, equity, or efficiency, will resonate with health decision-makers. Hence, mHealth strategies should be viewed as integrable systems that should fit into existing health system functions and complement the health system goals.

The authors dressed a list of 12 common mHealth and ICT applications that had been vetted by a wide group of stakeholders, ranging from academic researchers to policy implementers and give examples of mobile phones functions.  These applications are:

  1. Client education and behaviour change communication
  2. Sensors and point-of-care diagnostics
  3. Registries and vital events tracking
  4. Data collection and reporting
  5. Electronic health records
  6. Electronic decision support (information, protocols, algorithms, checklists)
  7. Provider-to-provider communication (user groups, consultation)
  8. Provider work planning and scheduling
  9. Provider training and education
  10. Human resource management
  11. Supply chain management
  12. Financial transactions and incentives

The authors give an illustration placing the 12 applications within the Reproductive, maternal, new-born, and child health framework.

Witter S. et al (2013) Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation.

BMC Health Services Research 13:367

Available at

Summary by Valéria Campos da Silveira, ITM,A

The authors’ concept of PBF is to “promote a results-orientation by linking incentives to desired outputs and encouraging entrepreneurial behaviour by staff and managers”. These features implies that PBF is a “systems change, involving changes in the relationships between actors, structures and processes, as for other provider payment reforms”, what means that there is a need to think systematically. Their hypothesis is that “the interaction of changed incentives, sanctions, institutional changes and supporting mechanisms with existing intrinsic and extrinsic motivation of providers will determine any behavioural changes, which in turn will affect organisational and health systems performance”.  Based on their definition, it follows that PBF should, if implemented fully, involve a change in institutional roles and enforcement mechanisms, as well as strengthening of managerial functions. With this in hand they have key nodes to develop a monitoring and evaluation framework.  They first provide a framework to better understand PBF/health systems interactions structured around five domains of context, the development process, design implementation and effects.

They then proceed to adapt a framework for monitoring and evaluation of a health system reform, focusing on its application to the introduction of PBF.  Key questions for monitoring and evaluation are highlighted, and it is proposed a systematic approach to monitoring effects, structured according to the health systems pillars (service delivery, human resources, governance, health financing), but also according to inputs, processes and outputs.

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