Dear colleagues,

The frameworks for health systems and initiatives for health systems strengthening multiply. It is not easy to retain an overview and to know which framework to use for which purpose. Some are very comprehensive and descriptive; others analyze subsystems or make explicit links with performance. We present a number of articles which illustrate the variability. Frenk criticizes the dominant frameworks, Atun proposes one specifically for the integration of disease-specific health programmes, the European Health Report seems not to add to existing frameworks, and finally Nishtar looks at fund flows and delivery mechanisms.

Maybe an interesting topic for a systematic review? If you want to take up the challenge, then SUPPORT gives you tools, not only how to do it, but also how to use it and to make sure that others use it. Networks might be a way to disseminate your ideas and to stimulate action, but networks themselves are dynamic entities, subject to changes and to interests of people involved.

Enjoy your reading.

On behalf of the editorial team,

Josefien van Olmen and Karen Pesse.

‘Selected Readings‘ is an initiative from partners networking on Health Systems Strengthening and is a sister initiative of the ‘International Health Policy’ newsletter. Its aim is to provide a selection of recent health system articles with a short review of the relevance and utility of the article. An archive of the Selected readings and other information can be found at The editorial team includes Werner Soors, Bruno Marchal, Sara Van Belle, Valéria Campos da Sliveria, Delphine Boulenger, Karen Pesse and Josefien van Olmen.

Contact address for all contributions, subscriptions and remarks:

Health Systems Strengthening

· Integration of targeted health interventions into health systems: a conceptual framework for analysis

· A systematic review of the evidence on integration of targeted health interventions into health systems

Rifat Atun, Thyra de Jongh, Federica Secci, Kelechi Ohiri and Olusoji Adeyi

(Reviewed by JVO)

A systematically performed inventory of health programmes and the extent to which they are integrated. Crucial is the framework for assessment of integration, for which the foundation is made in the first article. It has 3 axes: the kind of programmes; elements on which integration was assessed (5 of the 6 building blocks – of which, unfortunately, human resources is missing – and an additional demand generation); and the level of integration. The explanation is clear and the examples illustrative. After the assessment of evaluation, the authors continue to make a beginning with the analysing of determinants of integration: context and nature of disease, which influence opportunity, desirability, necessity. Despite the allusion in the title, the article does not provide an evaluation about the effectiveness of integration.

· The Global Health System: Strengthening National Health Systems as the Next Step for Global Progress

Julio Frenk

(Reviewed by KP)

A short opinion/conceptual paper on Health System Strengthening, discussing important aspects of our (mis)conceptions and (mis)understandings of these systems, as well as 4 ways to improve them. Statements and proposed strategies are not very new, but the form of structuring and presenting them is interesting. Title does not correspond to the article contents, there is no discussion on the National or Global Health System.

· The mixed health systems syndrome

S Nishtar

(Reviewed by JVO)

A very concise article about the present situation in many health systems in LMIC, where there is a combination of dominant out-of-pocket payments and market provision of health services in an environment of co-existing public financed government health care delivery and privately financed market delivery. The solutions are not new (stewardship, regulation and more public financing), but they are discussed pointedly, providing avenues for health system strengthening window of Global Health Initiatives. Also published in the IHP newsletter.

· The European health report 2009. Health and health systems

WHO Regional Office for Europe, Copenhagen, Denmark – December 2009

(Reviewed by WS)

Imagine you’ve read the World Health Report 2000 (Health system: improving performance), the 2003 Report of the Commission on Macroeconomic and Health and the World Health Report 2008 (Primary health care: now more then ever). Would you then still need to read the European Health Report 2009? Not really. Conceptually, there is nothing new to be found in this 178-page publication. Echoing Jeffrey Sachs, WHO Europe makes a plea for investing in health (and health systems) for the sake of the economy. The report pretends to be “designed to provide Member States with essential public health information” and indeed compiles and groups country data from old and new EU countries. Useful maybe, but hardly illuminating.

· Introduction to Health Systems course

Online course, by David Bishai (Johns Hopkins University, Future Health Systems)

(Reviewed by JVO)

This is a course organised from an economic perspective, which addresses a lot of issues relevant for a marketised health system. It gives a balanced explanation of pros and cons, eg about private hospitals, insurance, human behaviour influences by remuneration systems. It is hard to see this as an introduction course for people about health systems, when you come from a LMIC; it is very abstract and it may be difficult to recognize situations from one’s own context. But as an additional course, more focused on the institutions and economic arrangements, it is useful. The explanation of certain concepts is also good.

Accessible after free registration at

Research & Policies & Practice

· TOOLS SUPPORT – Tools for evidence-informed health Policymaking

Lavis JN, Oxman AD, Lewin S, Fretheim

In the December issue, we presented an article of Lavis, in which he pled for better use of systematic reviews in policy making. In the TOOLS SUPPORT series, he offers an ‘online’ course how to do so.

(Reviewed by KP and SVB)

Series of 18 articles, organized in 4 main “areas” that follow the “normal” steps of GRIPP. Articles can also be read independently depending of readers’ interests: all of them target (successfully, in our opinion) various types of audience policymakers, persons/institutions supporting policymaking, stakeholders and researchers. The set of articles can be very insightful and comprehensive for a large set of audiences, policy makers and researchers. The authors including many examples.

The focus of finding, assessing and using evidence is strongly, if not exclusively, on systematic reviews. It takes systematic reviews as the ‘holy grail’, and bypasses the fact that e.g. criteria for systematic reviews for qualitative research are still largely underdeveloped. We contest this approach as biased and not realistic. All articles begin with the presentation of some “scenarios”, but their usefulness for the reader is not developed further.

It is certainly laudable that issues of applicability and local context are addressed (see e.g. article 11). Local context and the public are only addressed / involved as secondary factors, while in reality pressure of constituencies or drivers in the local context might thwart the whole policy making or getting research into evidence process. The article set implies that researchers are separate from public / civil society /consumers (the three main categories in the public). While researchers do have a specific role to play, this might not always be perceived as such from the policy makers’ perspective.

We have read with more attention the following articles.

· Article 2: “Improving how your organization supports the use of research evidence to inform policymaking”

· Article 14: “Organizing and using policy dialogues to support evidence-informed policymaking”

These 2 articles don’t present a real tool, but rather a (short) list of questions that are well structured and surely helpful for designing and implementing the proposed strategies. Most of the proposed “actions” are based on already published literature and/or author’s personal experience. Not all recommendations have been sufficiently proved and evaluated on the field, but when this is the case it is clearly indicated. Examples included are interesting; although sometimes their relation with the issue they are supposed to show is not very clear. Both articles include very concrete and practical recommendations and “tips”, as well as link to related tools developed by other institutions, and to websites dealing with the theme.

· Article 7: ‘Finding systematic reviews’

· Article 8: ‘Deciding how much confidence to place in a systematic review’

· Article 9: ‘Assessing the applicability of the findings of a systematic review’

· Article 11: ‘Finding and using evidence about local conditions’

· Article 15: ‘Engaging the public in evidence-informed policy making’

Full series and individual articles available at:

· Making Research Findings Actionable


(Reviewed by KP)

This document provides a quick reference of suggested communication approaches for health researchers and M&E professionals in order to facilitate stakeholders’ use of health information for decision-making. A very practical and concise guide on how to develop and implement a communication strategy for informing decision makers about research evidence (here called “information”). Emphasizes the need for adapting the communicational strategies, objectives, messages, channels, and tool to (the needs of) each audience, and provides with tips on the do and don’t with each of them. It briefly mentions some assessment methods for these strategies, but does not include conceptualization nor discussions on the role of research in policymaking, nor on that process.

Human Resources

· Scaling Up the Stock of Health Workers – A review

Gilles Dussault, Inês Fronteira, Helen Prytherch, Mario R. Dal Poz, Dorothy Ngoma, Juliana Lunguzi, and Kaspar Wyss

(Reviewed by BM)

A well structured synthesis of what has been written on strategies to increase the number, distribution, competence and productivity of the health workforce. Not bad, but not much new either.’>

Participation, Empowerment

· Health Capability: Conceptualization and Operationalization

Jennifer Prah Ruger

(Reviewed by WS)

Jennifer Prah Ruger is no small fish. She was a driving force behind WHO’s Gro Harlem Brundtland when health financing became synonym for commodification. She was speechwriter for the World Bank’s James Wolfensohn when he claimed to have the final solution for poverty. Brundtland now works for Pepsi, Wolfensohn leads his own investment firm, but Prah Ruger still dwells strongly in policy spheres. When the renowned Yale professor announces to “offer a conceptual model of health capability” expectations are high, and I hold my breath.

With 8 references to her own work and 2 to Amartya’s Sen’s conceptualisation of the capability approach, the reader of the American Journal of Public Health might easily have the impression that Prah Ruger invented the wheel. After careful reading her article, I’m afraid she just put it on another car. There is of course nothing wrong with applying the capability approach to the field of health (in our masters’ course, Guy Kegels strives for this noble aim since years). It is no easy task either; for most of us Sen’s layering of functionings and capabilities can be as confounding and confining as a the Knossos labyrinth, at first sight. A closer look however reveals how precise Sen’s concepts are and how they allow for correcting policies, in search of a just world. When Guy Kegels applies the capability approach to health and inequalities, he arrives unequivocally at power relations as the key issue. So did Sen, who finally re-explained capability as “the power to do something” in his latest “The idea of justice” (2009). When Prah Ruger’s takes up the capability approach, she takes a big step back. Amartya Sen has been accused of being too libertarian; Jennifer Prah Ruger is entirely libertarian. Sen talks of agency and structure; Prah Ruger omits structure. Sen does arrive at a function of the state best described as duty bearer; Prah Ruger starts from the concept of the state interfering with the choices of individuals termed “paternalism”. I don’t have to be a Marxist to disagree with the latter, it is sufficient to be European. Prah Ruger ends with a plea for measuring capability in what she calls a “health capability profile”, to “identify how well individuals can act as agents of their own health”. As if the Commission on Social Determinants of Health had never existed.

So is this article worth reading? Of course, to be able to critically resist its application – for the sake of justice, and health.


· Network resilience in the face of health system reform

Rod Sheaff, Lawrence Benson, Lou Farbus, Jill Schofield, Russell Mannion, David Reeves

(Reviewed by KP)

Article presenting “first-hand” research findings on a quite unexplored issue: dynamics of different types of networks related to health and care. Some of the results and conclusions may seem a bit obvious (that “artefacts” change faster than values and the latter faster than underlying assumptions…) and other are very specific for the context of the introduction of quasimaket reforms at the UK-NHS. But, at least to my understanding, main value of this article lies on its direct, systematic and well structured conceptualization and study of networks, their dynamics and the categorization of the internal and external factors influencing their processes of change… all this using qualitative research methods. Another interesting point of this article is that changes are not necessarily seen as something positive, neither by the interviewed network actors, nor by the authors themselves.

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