Systems Thinking for Capacity in Health

We believe that systems thinking and complexity science can be transformational in global health by increasing local capacity and shared learning, and minimizing unintended consequences.

“Gonzalez would no doubt be thoroughly dismayed”

“There is no present or future, only the past, happening over and over again, now”
-EUGENE O’NEILL, A Moon for the Misbegotten

In 1965, a Venezuelan technical adviser to the WHO named C. L. Gonzalez wrote an 86-page document entitled “Mass Campaigns and General Health Services.” In it, he discussed the question of how to coordinate so-called vertical health programs with the general health service. He wrote: “the question under review is not new, … it has been a matter of growing concern during the past two decades”.

In 2007, Anne Mills of the London School of Hygiene and Tropical Medicine wrote a review of his document entitled “Mass campaigns versus general health services: what have we learnt in 40 years about vertical versus horizontal approaches?”. She claims that “”Gonzalez would no doubt be thoroughly dismayed” with the current global health situation, and that “it is high time for adequate resources to be invested in these vital questions of service delivery, so that in 10 years’ time, at the 50th anniversary of Gonzalez’s paper, we can provide a more optimistic account of what we know.” I agree.


Here is a sampling of Gonzalez’s writing:

Quoting the WHO’s “The General Programme for Work for the First Period” (extending from 1952 to 1957): “in many cases it has been thought justifiable during, the initial stages of development in the organization of health activities to start with projects in specialized fields…”, adding, however, that those specialized projects “should be a stage towards the ultimate goal – a balanced and integrated programme for the country”

He noted that this was an “important and controversial issue – even to the point of engendering acrimonious discussion in national and international circles.”

“The first requirement for the carrying out of mass campaigns is to obtain the fullest and earliest possible support from all the components of the normal machinery of health administration.”

“Obviously every effort should be made to co-ordinate the activities of the two services with a view to the earliest possible merger.”

“It is an obvious prerequisite that the planning and implementation of any mass campaign should be envisaged within the framework of the general health policy of the government concerned.”

“It is theoretically conceivable that a mass campaign could be planned and carried to completion in so self-sufficient a fasion as to remain entirely separate from other health activities. From a realistic point of view, however, this is neither practical or desirable, for a number of reasons… to obviate the duplication of efforts … and waste of funds”

“The participation of the peripheral health services … must be sought at the onset…”

“One point should … be stressed: that … the participation of the peripheral services should start as soon as possible and be expanded progressively so that problems connected with the end-point of the mass campaign do not -as has generally happened in the past – arise too abruptly.”

“It is obvious that the planning of a given mass campaign should flow from a recognition of the campaign as an essential element in the total health effort of the country.”


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This entry was posted on July 15, 2009 by in Need for GHSIAs.

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