Thank you for your thoughtful response to our article, Mr. Ramirez.

While I agree with your contention that the WHO (and many others) have already provided guiding principles for health systems strengthening (HSS), I wholeheartedly disagree with your suggestion that our paper is "business as usual," and that we are "inventing the wheel again and again." Consider the following:

1. The link that you provide is for health systems topics (formerly health systems building blocks), not for guiding principles. The WHO does provide guiding principles; we used this document in our review: http://www.who.int/health....

2. Our purpose was not to provide "new" principles (though my opinion is that some, like holism, have been nearly absent from the HSS discussion including the WHO link that you reference), but to move the discussion in the direction of a consensus on and universal application of principles that are already being discussed. Our review strongly suggests that a consensus does not exist.

Which principles should be considered essential to HSS? How can we mobilize to ensure a more uniform application of widely accepted principles in communication and practice? A shared vision of what HSS means and how to go about it could be a powerful force for positive change.

3. My experience and discussions suggest that uniform consideration and application of ALL of the principles in all global health activities would result in a paradigm shift, a complete transformation in the way the global health is approached. In my opinion, an increased consideration of holism, allocative efficiency, capacity enhancement, social mobilization, and the other principles would significantly change the focus of donors, the time frames for projects, the indicators used to measure success, the role of various actors, the emphasis of training institutions, the processes that organizations and institutions implement, the consideration of the interrelationships between various health subsystems and building blocks, etc. There would likely be a greater emphasis on the social determinants of health, long-term relationships that enhance capacity, and systems that are designed to most efficiently improve population health. Hardly business as usual!

Best Regards,

R. Chad Swanson, DO, MPH
Lead Author