A handbook to develop health system guidance
It is increasingly recognised that the effects of clinical and public health interventions are often jeopardised by the weaknesses of the health systems through which they are implemented. For example, antimalarial treatments or vaccinations can hardly reach the people they are meant to in health systems where stock-outs of drugs are frequent or where the cold chain is broken. This has led to renewed efforts by the international health community to place health systems research at the top of the health research and development agendas: health systems and their components (e.g. human resources, health information) have become the subjects of research. As in the clinical and public health fields, findings from health systems research would be translated into guidance to inform health policies (we use the term 'guidance' to emphasise the less prescriptive character of recommendations related to highly contextual health systems). Can health systems guidance be developed using the same approaches as clinical guidelines?
The World Health Organisation (WHO), acknowledging the urgent need to respond to requests for evidence informed guidance on health systems, commissioned the production of a handbook to develop health systems guidance to the Swiss Tropical and Public Health Institute, supported by the Norwegian Knowledge Centre for Health Services and an ad hoc task force. The first draft of the handbook has been recently completed and in the following paragraphs a few of the challenges encountered are outlined.
- Is evidence on health systems robust enough?
The effects of health systems interventions are assessed through a variety of study designs often categorised as 'low quality' based on the level of confidence that can be placed on those findings. For example, it would be hardly imaginable to use an experimental design to compare the effects of different health insurance schemes; but, still, some recommendations may need to be formulated
- Should implementation issues be prominent when developing guidance?
The implementation issues (how effective interventions are actually deployed in real life situations) are much more crucial in health systems guidance because the health system determinants of what works and how are abundant and only partially known at its best. For example, task shifting between physicians and nurses can only work if the regulatory context allows for it and if physicians do not feel that their competencies are being downgraded; which are highly contextual issues.
- Is ‘research’ evidence enough?
Even with the best guidance, policy makers may choose not to take it into account or to overrule it on the basis of contradictory colloquial evidence. Policy makers have many different backgrounds (e.g. managers, economists) and a variety of vested interests which influence their decisions. For example, policy makers may reject an option to introduce co-payment of services if this jeopardises their electoral prospects.
Other challenges included: how to frame health system problems in terms of interventions (suitable for research) in a way that can be used to organise services and programmes (suitable for policy making); or how to produce guidance timely when it is needed. The handbook, which is compliant with the WHO Guidelines Review Committee, systematically describes the processes involved in developing health systems guidance; for example, it proposes to adapt existing approaches (e.g. the GRADE tool to assess the quality of evidence); suggests combining different types of evidence using balance sheets or addresses the issues of guidance dissemination and implementation to reach policy makers.
We would like to set up an online discussion to exchange ideas on this topic. If you are interested in participating, please contact Xavier Bosch-Capblanch, at the Swiss TPH (firstname.lastname@example.org), indicating your main interest.
Xavier Bosch-Capblanch (Swiss TPH), Simon Lewin (NKCHS), Tikki Pang (WHO), Andy Haines (LSHTM)
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