The final stage in the process of health systems policy development is the preparation of a document (or documents) produced within a national government to support decision-making by that government. A range of names might be applied to the document(s), which is ideally informed by global guidance, a national policy brief, and other inputs, but for simplicity, we refer to this decision-support document as a policy proposal.
The health systems guidance (which emphasizes global evidence), policy brief (which emphasizes global and national research evidence), and policy proposal (which emphasizes the many considerations supporting a preferred course of action) all need to synthesize what is known and not known about the pros and cons of the options under consideration. They also all need to assess the factors that can influence the choice, implementation, and monitoring and evaluation of these options in different settings (or in the case of the policy brief and policy proposal, at least refer to the synthesis contained in the guidance and policy brief, respectively, when they exist). While varying in emphasis, each of these documents would ideally document:
- Key features of an assessment about how to address a health system problem;
- Key features of a health system (or health systems) that can influence decision-making about how to address a health system problem;
- Key features of a political system (or political systems) that can influence decision-making about how to address a health system problem.
Key Features of an Assessment about How to Address a Health System Problem
An assessment about how to address a health system problem requires working through the underlying problem, the appropriate options to address the problem, and implementation issues (see Table S1
). Much of what is known and not known about each of these areas can be derived from available data and research evidence. Health systems guidance that is produced at the global level can present overall summaries of the answers to these questions and identify patterns in the variation in these answers across health systems and political systems. Synthesized research evidence about health systems is increasingly available, and initiatives to make it easier to find and use evidence can support guidance development at the global level (e.g., Health Systems Evidence at http://www.healthsystemsevidence.org
, which is now available in Arabic, Chinese, English, French, Portuguese, Russian, and Spanish). A policy brief produced at the national level can supplement the data and research evidence contained in global health systems guidance with local data and research evidence in order to present as clearly as possible what is known about how to address a health system problem in a particular country.
Key Features of Health Systems That Can Influence Decision-Making about How to Address a Health System Problem
An assessment of the key features of health systems that can influence decision-making about how to address a health system problem involves working through existing governance, financial, and delivery arrangements to determine which arrangements might help or hinder any options being considered (). A new health systems intervention such as pay-for-performance might “fit” into one health system, but the same intervention or part of the health system might require significant adjustment or complementary interventions to fit into a system where performance data are not collected systematically. Moreover, any new health systems intervention may have unanticipated consequences for the existing health system arrangements in which it is introduced, for example, by removing incentives for some types of activity.
Key features of a health system that can influence decision-making about how to address a health system problem.
Some of what is known and not known about the key health system arrangements can be derived from available data and research evidence. Health systems guidance that is produced at the global level can present overall summaries of what is known about which arrangements are key for achieving the desired impacts in different health system contexts. A policy brief produced at the national level can enrich these summaries with local data and research evidence in order to present as clearly as possible what is known about how existing health system arrangements may influence the selection and implementation of options. In this way, policy-making about health systems can be informed by a good understanding of the system-level context for an option and the range of its potential desired and undesired system-wide effects, and any adaptation and re-design of the option (and potentially other health system arrangements) that is needed to optimize synergies among health system elements.
Key Features of Political Systems That Can Influence Decision-Making about How to Address a Health System Problem
An assessment of the key features of a political system that can influence decision-making about how to address a health system problem involves working through the institutions, interests, and ideas that currently drive decision-making, as well as the “external factors” that can open windows of opportunity to introduce change (). As above, globally produced health systems guidance can ideally present overall summaries about what is known about which features are key and identify patterns in the variation of these features across health systems and political systems. A policy brief produced at the national level can enrich the data and research evidence from health systems guidance with local data and research evidence. Moreover, a policy dialogue conducted at the national level can further enrich the available data and research evidence with local views, experiences, and tacit knowledge about how the political system really works and which system features are most important for the issue at hand.
Key features of a political system that can influence decision-making about how to address a health system problem.
How Do These Assessments Relate to One Another and to Other Approaches?
These three types of assessment are clearly interrelated. For example, empirical research has shown that an option is often deemed an appropriate solution if it is technically feasible (which can come from Tables S1
and ), fits with dominant values and the current national/provincial mood (which can come from ), and is acceptable in terms of affordability (which can come from Tables S1
and ) and likely political support or opposition (which can come from ) 
. The Handbook for Developing Health Systems Guidance
, , and
. Unpacking these assessments further, as we have done here, can help to provide a more systematic and transparent assessment.
As we discuss in the next paper, existing approaches to grading the quality of recommendations about clinical options will likely require significant modification for use in a health system context 
. The GRADE approach 
, for example, focuses only on two of the system-level factors that we have described—“values and preferences” and “feasibility”—but there are many more factors that will influence the choice of options for addressing a health system problem in different settings (as well as the implementation and the monitoring and evaluation of the preferred option). Also, the GRADE approach is typically executed by experts, and, while it can inform and complement policy dialogues and other stakeholder-engagement processes, it cannot substitute for these processes in the assessment of system factors.