Kieran Walsh: Contextualised and evidence based health systems strengthening

The principles of evidence-based medicine demonstrate shortcomings in the current research around health systems strengthening, says Kieran Walsh

EBM Live is a conference that aims to make evidence relevant and replicable for policy, patients and professionals in healthcare.” It aims to “identify and fix the problems with research evidence, develop better research evidence, enhance real-world practice, and add capacity in EBM globally.” 

I attended the first day of EBM Live as a delegate this year with a specific aim in mind: to help me interpret the evidence base for a complex interventionthat of health system strengthening. I even brought a paper with mea scoping review of the international literature on what we know about the needs and challenges of health systems by Roncarolo et al. [1] This paper was not presented at EBM Live, but my plan was to “flip the conference” to see if I could get answers to my questions about the paper by attending various sessions. 

The concept of health systems strengthening has grown in prominence over the past ten years. If implemented using a strategic approach, it could make a major difference to healthcare systems around the worldboth in low and middle resource countries. Health systems strengthening should ideally be based on the individual needs and requirements of the countries where it is to be implemented. It is a wide-ranging conceptso a needs-based approach should enable it to target particular components to areas where the need is greatest. But is health systems strengthening really based on the requirements of countries where it is to be implemented?

Roncarolo and colleagues have attempted to answer this question in their scoping review of what we know about the needs and challenges of health systems. Before attending EBM Live, I thought I had a reasonable understanding of the paperbut now I realise that my understanding was relatively superficial. 

One of the themes that is featured in many of the talks and posters is that of context. Most evidence is produced in a specific context and so will work in that context and may not work in others. The context might be as wide as an intervention being shown to work in a certain country or as narrow as an intervention being shown to work in a small group of patients with a specific genotype.

So how does that help with the scoping review? Well most of the studies in the review were in countries with a high Human Development Indexthat is, in wealthy countries. But much of the discourse surrounding health systems strengthening is based in poor countriesso it is surprising that much of the evidence base comes from a different context. 

Another form of context is that of the health sector. Here the authors of the review found that the “most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%).” This is another revelation as health systems strengthening is frequently suggested as the solution to structurally weak primary healthcare systems. The challenges that were most often reported in the papers were related to human resources, leadership and governance, and health service delivery. Thankfully these last challenges in the literature are compatible with the issues that health systems strengthening is increasingly used to address. 

Another theme from the conference is the enthusiasm of speakers, poster presenters and delegates to delve into the details of the evidence. So the question of what works evolves quickly into what works compared to other interventions or what works to achieve certain outcomes or what exactly the “what” (the intervention) actually is. Spurred on by this enthusiasm, I decided to reread the details of the evidence base unearthed in this scoping review. On rereading I find that challenges in health service delivery were more frequently the subject of studies conducted in wealthy countries. Thus, if we are to practice evidence-based health systems strengthening, we should be wary of applying the evidence base related to challenges in health service delivery to poor countries (as it simply might not apply).  

A final theme from the conference is patient and public involvement. At many conferences, patients are given short slots to speak at the end of sessions. However, patients are an inherent part of the programme of EBM Live. This reminds me to look at the scoping review for evidence of patient involvement. One of the authors is Canada Research Chair in Patient and Public Partnership in Montrealso this issue must at least be something that has been taken into account in the review.   

So, has the conference helped me find answers to my questions? I have concluded from the paper that the evidence base for health systems strengthening is the same as most other evidence. It is not yet comprehensive, and it is best to check the context in which it has been developed before applying it to what might be a very different context. 

The process has also made me think further about how I go to conferences. Going with this question drove me to pop in and out of specific sessions, search out certain posters, and ask precise questions with a clear end in mind.

Kieran Walsh is clinical director of BMJ Learning and BMJ Best Practice. He is responsible for the editorial quality of both products. He has worked in the past as a hospital doctor—specialising in care of the elderly medicine and neurology. 

Competing interests: Kieran Walsh works for BMJ which is a media partner for EBM Live and which produces learning and clinical decision support resources (BMJ Learning and BMJ Best Practice) that enable health systems strengthening. 


1. Roncarolo FBoivin ADenis JLHébert RLehoux P. What do we know about the needs and challenges of health systems? A scoping review of the international literature. BMC Health Serv Res. 2017 Sep 8;17(1):636.