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Unhelpful framing; admirable goal

Posted by AprilH on 20 Oct 2012 at 12:42 GMT

I agree with the authors on the importance of lifting our health systems research "game", and especially with regard to the key policy challenges in developing countries.
However, it strikes me as ill-advised to try to do this by focusing on developing guidance for generic "health systems strengthening".
We would never try to develop guidance on what to do for "ill-patient improvement", because it is nonsensical. To help a person who is ill to become better, we have to first identify the things that are making them ill (including understanding their linkages; and which among the factors is biological, behavioral, and which related to setting). Then we try to apply whatever therapeutic interventions may best help the patient, taking into account all those factors.
The point is: the right thing to do (or, at least, better things to do) to "strengthen a health system" depends on which problem you are addressing, what are the underlying causes in this instance, and which "interventions" have a high likelihood of positively influencing the underlying cause. Such intervention choices also need to take into account the degree to which they are feasible in that setting; and, their likelihood of being implemented. To try to develop guidance on what to do generically for "sick" health systems implies that you can usefully decide what to do without knowing anything about the patient. I expect such guidelines would never be applied, even if developed, as commonsense would intervene. However, to encourage research in this direction could diminish research that actually could help inform actions to strengthen health systems (that is, research to answer specific questions about policies to address specific weaknesses, in particular system settings, taking into account interaction effects, and likelihood of implementation).

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RE: Unhelpful framing; admirable goal

bosch replied to AprilH on 19 Nov 2012 at 17:15 GMT

Thanks for your comment, April Harding.

You are completely right that "We would never try to develop guidance on what to do for "ill-patient improvement"", which would also apply to health systems strengthening. You are also right to point out that "the right thing to do [...] depends on which problem you are addressing, what are the underlying causes in this instance, and which "interventions" have a high likelihood of positively influencing the underlying cause". We have summarized these very same issues in Box 1 in the article.

There may be some misunderstanding on what we were attempting to do: this was NOT about creating "guidelines for ill-systems"; but rather the development of methods that would be eventually used by others to develop guidance on specific problems (see for example, reference 27 in paper 3); pretty much as clinical guidelines developers do following a handbook of methods. When looking at methods used by clinical guidelines developers to adapt them to HS guidance development we found a series of challenges, some of which were addressed and others remained methodological research topics (for example, and as you rightly mention at the end of your note as well: how to frame HS problems, how to take into account HS implementation issues and context...).

So don't worry that generic guidance on ill-health systems will never be produced and even less applied. But hopefully, those who develop HS guidance will be willing to use systematic and transparent methods as described in our handbook (and reported in the article) or other equally relevant sources. You may want also to have a look at the other two papers in the series which address some of these issues. Xavier Bosch-Capblanch

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