Strategizing national health in the 21st century: A handbook

A UHC Partnership Resource

Edited by:
Gerard Schmets
Dheepa Rajan
Sowmya Kadandale


This handbook is designed as a resource for providing up-to-date and practical guidance on national health planning and strategizing for health. It establishes a set of best practices to support strategic plans for health and represents the wealth of experience accumulated by WHO on national health policies, strategies and plans (NHPSPs).

WHO has been one of the leading organizations to support countries in the development of NHPSPs. The focus on improving plans has grown in recent years, in recognition of the benefits of anchoring a strong national health sector in a written vision based on participation, analysis, and evidence.

Chapter 1
Introduction: Strategizing national health in the 21st century

Gerard Schmets
Sowmya Kadandale
Denis Porignon
Dheepa Rajan


This introduces the handbook’s aim of making the case that strategizing – meaning designing plans and policies to achieve a particular goal related to the health of a nation – is absolutely critical in the 21st century. It is not only recommended by the Member States of the World Health Organization (WHO), but is also feasible for all countries in all settings.

Functional health systems that deliver high quality services to the population are the main priority for governments. Achieving this requires permanent, well-structured and dynamic policy-making processes, with a true consensus between governments, services providers and the population. This chapter explains why a solid, evidence-informed policy dialogue is the only real way to achieve this in the 21st century.

The global health environment is becoming increasingly complex. Social, demographic and epidemiological transformations fed by globalization, urbanization and ageing populations pose challenges of a magnitude that was not anticipated three decades ago. In addition, recent global health security threats and the growing mismatch between the low performance of health systems and the rising expectations of societies, are increasingly becoming a cause for political concern. This often leads to countries prioritizing, or re-prioritizing, efforts towards strengthening health systems, moving towards universal coverage and implementing the idea of health in all policies.


Countries recognize that these calls for efficiently strengthening health systems and improving health security must be translated into robust, realistic, comprehensive, coherent and well balanced health policies, strategies and plans. In the post-Millennium Development Goal (MDG) era, they also recognize that in pluralist, mixed, public-private health systems, these policies, strategies and plans have to relate to the entire health sector and cannot be limited anymore to “command-and-control” plans for the public sector.


This handbook builds on the experiences gathered by WHO and its partners during the MDG era. It presents the way of developing national health policies, strategies and plans (NHPSPs) from a new pluralistic perspective, and it advocates for policy dialogue as a means to ensure inclusiveness and the participation of both service providers and the population in debates and the decision-making process with the government, as well as in the follow-up, monitoring and evaluation of NHPSP implementation.



Chapter 2
Population consultation on needs and expectations

Katja Rohrer
Dheepa Rajan


This chapter outlines the aims of a population consultation, its contribution to national health planning, and how 
to undertake a consultation from
 the methodological and conceptual perspectives.  We highlight the advantages, disadvantages, time frame and resource needs of the different methodological options, with some country examples narrated in detail for each methodology.

 What  is the purpose of a population consultation?

  • to capture the population’s demands, opinions and expectations on health-related matters, in order to improve policy responses. 


 Why  is it important?

  • feedback from the population on the current health situation and proposed reforms will enlarge the information base for health policy-making;
  • to increase consultation with the ownership and engagement of the population – especially marginalized groups – and to transform the population into active stakeholders;
  • to provide essential information on the population’s opinions and expectations for improved health outcomes;

  • to strengthen monitoring and evaluation;
  • to strengthen government policy decisions and resource allocation;
  • to improve accountability and transparency. 


 When  should a population consultation be done?

A population consultation can be undertaken at any stage of the health planning cycle. Ideally, it should be one of the first steps of the whole process, so the results can feed into the development of a new national health policy or strategy. It can also be done in the middle of the planning cycle to monitor progress or at the end of the policy development process, in order to get the population’s opinion on what has been done.


 Who  could undertake a population consultation or could be engaged in one?

  • government departments and ministries;
  • independent research institutions and think tanks;
  • foundations;

  • political parties;
  • civil society organizations (CSOs) and non- governmental organizations (NGOs);
  • community leaders and community institutions;
  • market research institutions;
  • media.


 How  should a population consultation be done?

1. Choose the methodological approach that is suited to the national context: face-to-face dialogue, 
consultative methods, one-on-one individual surveys, surveys with invited/selected population groups;

2. Adapt the methodology chosen to your country’s circumstances and planning cycle context;

3. Conduct the consultation, and analyse the results;

4. Ensure a sustainable and transparent follow-up to the consultation (develop a road map including the different institutions involved and their roles and responsibilities, processes and follow-up mechanisms).

Chapter 3
Situation analysis of the health sector

Dheepa Rajan


The strategic directions and the principal orientation of a national health policy, strategy or plan (NHPSP) need to be grounded in a sound understanding of the status of the health sector. This chapter aims to elaborate on a participatory, inclusive health sector situation analysis methodology to address that simple but very basic need of obtaining a realistic snapshot of the strengths and weaknesses of a country’s health system, as well as a more profound understanding of the reasons behind those strengths and weaknesses, so as to better enable a viable alternative (or successful scale-up). 

 What  is a situation analysis of the health sector?

A health sector situation analysis should aim:

(a) to realistically assess the current health sector situation, with all its strengths, weaknesses, opportunities and threats, including their root causes and effects;

(b) to provide an evidence-informed basis for responding to health sector needs and expectations of the population;

(c) to provide an evidence-informed basis for formulating future strategic directions for the health sector.

Several characteristics are recommended to ensure a sound health sector situation analysis. These are further detailed in this chapter: participatory and inclusive; analytical;
comprehensive; evidence-based.


 Why  should a situation analysis be done?

A whole-of sector situation analysis is a crucial step in the planning cycle and should be undertaken at least once in the cycle and updated every few years.
It gives a voice and a platform to all health sector stakeholders, increases accountability and transparency, and supports and strengthens M&E. Additionally, it contributes to concretizing roles and responsibilities and helps to establish consensus on the status of health in the country. To ensure a sound health sector situation analysis, it should be participatory and inclusive, analytical, relevant, comprehensive, evidence-based.


 When  should a situation analysis take place?

It should be done as a key initial step in the development of a NHPSP. Ideally, it should be undertaken at least once during the health policy and planning cycle, and updated every few years, because an updated, in-depth technical analysis that includes stakeholder viewpoints is an invaluable resource for the whole health sector.


 Who  should be involved in a health sector situation analysis?

When examining the roles and responsibilities of the various health sector stakeholders, it is important to keep in mind the three main functions which are needed for a successful situation analysis: active and inclusive multi-stakeholder participation, decision-making, and organization and coordination. Some health actors will be active on all three fronts, while others will only be involved in one or another function, as described in more detail in this chapter.


 How  should it be conducted?

It is recommended to go for an approach which is as participatory and inclusive as possible, with a core team coordinating working groups. The working groups should comprise of relevant experts and health stakeholders who are given adequate space and time for dialogue. This process is a crucial investment, whose potential to unite together those who have a stake in health into a common understanding of health sector challenges and solutions should not be underestimated. This methodology is based on three distinct streams of analysis as depicted in the below image.  These 3 streams should be examined by the situation analysis working groups  and is elaborated upon in more detail in this chapter. 



Chapter 4
Priority-setting for national health policies, strategies and plans

Frank Terwindt
Dheepa Rajan
Agnes Soucat


Priority-setting determines the strategic directions of the national health plan. Led by citizens who are the principals and decision-makers, priority-setting is a shared responsibility between the ministry of health (MoH) and the entire health stakeholder community. This chapter elaborates various criteria and approaches for priority-setting. It closes with some specificities of the priority- setting exercise in particular contexts such as the decentralized and highly centralized setting, fragile states, and an aid-dependent environment.

 What  is priority-setting?

The process of priority-setting is inherently political, which means that it is a process where societal values and goals are important, and resulting priorities reflect a compromise among stakeholders. That being said, the aim of the process is to select among different options for addressing the most important health needs, as highlighted in the health sector situation analysis, in the best way (“best” here depends on a number of criteria, explained in the course of this chapter), given limited resources (rationing). In health, priority-setting determines the key objectives for the health sector for a given period, thus directly feeding into the content of the national health plan.


Priority-setting definitions v2


 Why  is it important?

Priority-setting is necessary everywhere, as resources are never unlimited. Choices must be made that reflect a society’s values and vision for the health system, and integrate reflections on explicitly chosen criteria. In addition, a priority-setting exercise is where the principal decisions are made after the situation analysis discussions; these decisions feed directly into national health plan development.




 When  should priority-setting be done?

The priority-setting exercise generally follows a situation analysis and precedes decisions on resource allocation and planning. Priority-setting can be done at different intervals in the policy and planning cycle of a sector, a programme or project. For this handbook, it is discussed notably in the context of national health planning in the medium-term.


 Who  should undertake or be engaged in priority-setting?

Actors such as government (ministries) have a formal responsibility for priority-setting. In an inclusive approach, stakeholder groups of various levels are consulted, as are the population.


 How  can priority-setting be done?
 What are the criteria and approaches?

Priority-setting is a multifaceted process that is usually informed by the situation analysis. It is based on criteria set by health sector stakeholders, where evidence is examined to feed into the formulation of the national health policy, strategy or plan (NHPSP). Possible criteria and approaches are elaborated upon in this chapter.


Additional information is available in the form of a webinar. Please find the slides for download at this link (in English), and the audio recording of the webinar below (in French).

Chapter 5
Strategic planning: transforming priorities into plans

Frank Terwindt
Dheepa Rajan


In health, strategic planning aims at identifying, sequencing and timing medium- term interventions for the health sector in
a comprehensive way. The end product is the sector strategic plan which guides the activities and investments that are necessary for achieving medium-term outcomes and impact.

In line with this definition, the purpose of strategic planning in health is to define a medium-term orientation and focus for the development of the health system. Decision-making should be based on a thorough analysis of the current situation, lessons learned from previous plans, expected available resources and chosen priorities.

In this chapter, guidance is provided on developing a relevant NHPSP that is referred to, consulted and used. Steps are proposed to manage the NHPSP development process and common challenges and mistakes are pointed out with suggested solutions.

 What  is strategic planning?

In health, strategic planning aims at identifying, sequencing and timing medium-term interventions for the health sector in a comprehensive way. The end product is the medium-term sector strategic plan that guides activities and investments necessary for achieving medium-term outcomes and impact.

Strategic Planning NHPSP outline



 Why  is it important to transform priorities into a plan?

-to concretize priorities;
-to keep focus on the medium to long term without deviating from the optimal path;
-to avoid fragmentation of the health sector;
-to help focus the policy dialogue on health sector priorities;
-to guide operational planning, resource allocation, and sector monitoring and evaluation. 


 When  should operational planning take place?

In the context of ongoing comprehensive health sector development, strategic planning is an iterative process that should be conducted every 3–5 years (medium-term). The strategic planning exercise generally comes after the phase of priority-setting and precedes operational planning.


 Who  should be a part of strategic planning?

Strategizing for health will be more effective if a wide range of stakeholders are involved in it, and both the process and the product are truly owned by the country. To make the process effective, health sector stakeholders will need to come to a common understanding of the key issues and share institutional goals and expectations. Such an inclusive approach is likely to be more potent, not only in terms of planning the right vision and activities, but also in ensuring that implementation of the strategic plan is jointly undertaken by all actor groups.


 How  do we transform priorities into plans?

In this chapter, guidance is give on: preparation of NHPSP development; setting goals (or strategic directions) in line with commonly agreed priorities;
 setting objectives in the form of targets (and their baselines); 
formulating broad activity areas;
providing orientation on NHPSP implementation;
 approval and dissemination of the NHPSP; NHPSP document structure.


Additional information is available in the form of a webinar. Please find the slides for download at this link (in English), and the audio recording of the webinar below (in French).

Chapter 6
Operational planing: transforming plans into action

Dean Shuey
Maryam Bigdeli
Dheepa Rajan


Operational planning is the link between strategic objectives of the national health policy, strategy or plan (NHPSP) and the implementation of activities. It is about transforming the strategic-level plan into actionable tasks. At this stage, most steps of the NHPSP have been completed and the budgeting has been done. Operational planning, done by the budget centre, will identify the activities to be carried out to achieve the objectives of the strategic plan.

Planning is often made into something complicated, a mystery wrapped in
 jargon, process and politics. Planning is sometimes left to the professional planners or the managers to control and do. That is a mistake. The best operational plans, and certainly the ones most likely to be implemented, are those that are developed with the people who will carry them out (as well as other stakeholders).

Everyone in the health sector is an operational planner and everyone has a plan, even if they don’t recognize it as such. The simplest operational plan is a “to-do” list, which may be written down or carried in a health worker’s head. A calendar of activities that defines the what, when and who of tasks is also a plan. The operational plan determines the day-to-day activities of the unit for which it is written.

 What  is operational planning?

Operational planning is typically based on a NHPSP that defines the vision, goals and objectives for the health sector. Operational planning is managerial and shorter term, as opposed to strategic planning, which usually has a 5–10 year horizon, sometimes even longer. Operational planning deals with day-to-day implementation and often has a one-year time horizon.

An operational plan is a practical plan of activities to undertake that are in line with the overall NHPSP, but is concrete enough for practitioners at each level of the health system to know what they are responsible for. Operational planning takes place when most other steps of the planning cycle are completed, at the level of budget centres.


 Why  is operational planning crucial to strategizing for health?

Operational plans are necessary to concretize NHPSPs. They provide a framework for action based on the strategic vision given by the NHPSP. The operational planning process has the potential to greatly assist stakeholders in gaining a better understanding of the NHPSP target population and its needs, as well as stakeholders’ own capabilities and limitations in implementation. Especially when defined jointly, an operational plan is critical for the clarity it offers as to what needs to be done, by whom, how, and with which monies.


 When  should operational planning take place?

The health operational planning process should be synchronized with the budgeting process of the financing entity. This typically means a complete operational plan with budgets done on a yearly basis. This can be on a two-yearly basis in settings that are very stable from a political or social point of view. Operational planning can be done even more frequently, for example every six months or even three months, in situations where insecurity and instability force decision-makers to adapt activities to a rapidly-evolving context.


 How  does an operational plan work?

Operational Plans (1)

The following steps for sound operational planning are elaborated upon in this chapter:

1. taking stock of the situation (where are we now?), including identification of stakeholders (who is involved?);

2. setting operational priorities;

3. putting together the operational plan (what are we going to do?), including the operational budget;

4. implementation of planned activities (how are we going to do it?);

5. monitoring and evaluation of the operational plan (what have we accomplished so far?).


 Who  are the main actors involved in operational planning?

Ideally, all of those who are responsible for an activity in the health sector will be involved in operational planning, either directly or through having their interests represented by someone involved in the formal planning process. Key stakeholders are the national and local health authorities, health service providers and health system end users. 

Chapter 7
Estimating cost implications of a national health policy, strategy, or plan

Karin Stenberg
Dheepa Rajan


This chapter discusses the estimation 
of costs in relation to a national health policy, strategy, or plan (NHPSP). The process of estimating costs can be a crucial step within the NHPSP formulation process which allows decision-makers to consider the extent to which policy objectives and strategic orientations are feasible and affordable. The process of costing a strategy should be considered an essential part of the planning process and not something to be undertaken after the overall plan has been completed and presented as a finalized document.

Several rounds of refining the costing exercise may be needed as the priorities are discussed and matched to the available resource envelope – potentially through scenario analysis.

Within this chapter, we outline key steps 
and principles to follow when estimating
 cost implications of the strategies outlined within a NHPSP. We provide an overview 
of methodological issues, along with recommendations on the various stakeholder groups which should be involved and the type of accompanying documentation that should be produced.

The focus of this chapter is thus a cost estimation in relation to an overarching vision for the entire health sector, as opposed to disease-specific estimates.

 What  is meant by “cost implications” of a NHPSP?

Estimating the costs of a strategy serves to indicate the financial resource needs of planned activities. Broad policy objectives can be translated into activities and targets by year, to quantify the resources needed for implementation, estimate the related costs, and then assess aspects related to feasibility, affordability and efficiency.

Costing is an iterative process and several rounds of discussion and calculation can be necessary to fine-tune the numbers. The aim is to inform the user of the potential overall magnitude of the costs and the main cost drivers.

Costing results can inform the budget exercise. The estimated costs should be compared with the projected available financial resources, to assess affordability and potential resource gaps.




 Why  is it important?

To improve the soundness of the NHPSP in terms of setting feasible and financially attainable targets, thus improving accountability. Affordability and therefore “cost” being key criteria in the priority-setting process, information on costs should inform the discussion on priorities in the health sector, which may include considering different sequencing of activities and reforms to match the resource availability. Strategies should also focus on increasing efficiency of current spending to make progress toward universal health coverage.
 Cost projections for the NHPSP can be used for advocacy to mobilize additional resources. The estimated NHPSP costs can feed into a Medium-Term Expenditure Framework (MTEF) and annual budgeting process and help gear resource allocation towards strategic priorities in order to improve health system performance and overall health outcomes.


 When  should costs be estimated for the NHPSP?

Costs can be estimated as part of the planning process. A rough estimate of costs can start as soon as the major policies and overall direction of the health plan is agreed upon. Costing should match planned policies to the likely resources available, and closely follow discussions around the policy scenarios and strategies proposed for the NHPSP. Several rounds of refining the costing may be needed as the priorities are discussed and matched to the available resource envelope – potentially through scenario analysis.

The cost estimates should not be interpreted as fixed resource needs but rather as an initial projection of resources needed, acknowledging that the environment is dynamic with a certain level of uncertainty related to population risks, and where best practice strategies and prices of goods and services constantly evolve.


 How  is costing of the NHPSP carried out?

The cost estimation should be integral to the overall planning process. An initial scoping analysis gathers information on likely trends in available financing and fiscal policy “ceilings” over the planning period, along with planned reforms – including those that may impact on the cost structure, such as civil servant reforms, health provider payment reforms, etc. For example, what strategies are being considered to increase efficiency of current spending and make progress toward universal health coverage? 

A costing team can form the liaison between the broader planning discussions and the cost estimation process. The team is often headed by specialists in the ministry of health (MoH) planning department, along with cadres from the MoH department of finances, but works closely with a range of stakeholders (e.g. various technical agencies and departments including the Ministry of Finance (MoF), district managers, development partners) to promote participatory processes and gain buy-in.

Inputs are gathered from a range of technical planning units (e.g. health workforce, maternal health, mental health, etc.) regarding their planned activities and targets, while taking into account the expected outcomes of their activities in relation to broader policy objectives and planned health reforms.

Scenarios on costs are presented and discussed through a series of consultations, including data validation processes with technical counterparts. Presenting cost data compared with estimated financing projections informs discussions on priority-setting as needed. Multiyear cost projections are continuously updated as required in a dynamic planning environment, and linked to mid-term reviews and annual plans.


 Who  should contribute to the costing of an NHPSP?

The costing of a NHPSP relates to the entire health sector. As such, it is led by the MoH, but must be relevant to all stakeholders involved in the planning process. The role of civil society, development partners and other government ministries is crucial when it comes to providing input data, ensuring consistency with government policies and plans put forth in other sectors, validating the final estimates in terms of targets, costs and related projected outcomes such as accessibility to care and overall population health impact. 

Chapter 8
Budgeting for health

Dheepa Rajan
Helene Barroy
Karin Stenberg


Engaging in budget preparation, understanding guiding principles of budgeting as well as the political dynamics that enable the budget elaboration and approval process, is essential for health planners and managers. In many countries, the consequences of not doing so means that health policy-making, planning, costing and budgeting take place independently of each other, leading to a misalignment between health priorities and allocation and use of resources.

Health is financed by public and private funds. To make progress toward universal health coverage (UHC), a predominant reliance
 on public, compulsory, prepaid funds is necessary. Therefore, the way budgets are formed, allocated and used in the health sector is at the core of the UHC agenda. This chapter outlines the overall budget process for the public sector, discusses the specific role of health within it, in particular the role of the ministry of health (MoH) and other health sector stakeholders, to provide timely inputs into the budgeting process.

 What  is meant by budgeting for health?

Budgeting is related to the process of defining the allocation of resources to produce the best outputs given the level of revenues. A health budget, typically included in the general government budget, is more than a simple accounting instrument to present revenues and expenses – rather, it is a crucial orienting text, declaring key financial objectives of the country and its real commitment to implementing its health policies and strategies. While every implementing health organization develops a budget, in this chapter we discuss the national government budgeting process, which includes inputs from a wide range of health sector stakeholders.


 Why  is it important to understand the health budgeting process?

For those who seek to influence resource allocation in country, a good understanding of the guiding principles of budgeting as well as the political dynamics that enable the budget elaboration and approval process is essential. In many countries, a lack of understanding of budgeting issues results in delinked processes such that health policy-making, planning, costing and budgeting take place independently of each other. This leads to a misalignment between the health sector priorities outlined in overall strategic plans and policies and the funds that are ultimately allocated to the health sector through the budgeting process. This misalignment has negative consequences: resources are not used as intended, and accountability is weakened. On the other hand, a good understanding of the budget process and engagement by MoH and other health sector stakeholders at the right time during the budget cycle will increase the chances that the final resource allocation matches planned health sector needs.


 When  does the budgeting process take place?

The budgeting process starts with a preparation/formulation stage of budget proposals, which includes a negotiation phase between MoH and ministry of finance (MoF) and ends up with parliamentary review and approval. In many countries the fiscal year follows the 12-month calendar year, beginning on 1 January; in some countries, the fiscal year may start at a different date (e.g. 1 October in the United States of America, 1 July in Australia and New Zealand). In a given year, there are three cycles potentially taking place at the same time: the implementation of the current budget, which essentially takes place throughout the year, at any given time; budget preparation for the next year; and audit or review of the previous year.




 Who  are the people involved and engaged in the health budgeting process, in particular the budget preparation phase?

Ministries of budget/finance and related entities are the leading agents for budget development. Ministries of health play a critical role to prepare, present and negotiate credible, priority-oriented budget proposals for the sector. Civil society and the general public can seek to influence health budget definition by engaging with the executive or the legislature.




 How  does the budgeting process work from the point of view of national health policy/strategy/plan (NHPSP) stakeholders?

The budget cycle starts with the government planning for the use of the coming year’s resources. To allow this to be done in accordance with health priorities, health planning stakeholders have to engage strategically in this process and be prepared to support it. This chapter takes the reader through the steps of the budget cycle and some practical issues for the health community to consider.


Additional information is available in the form of a webinar. Please find the slides for download at this link (in English), and the audio recording of the webinar below (in French).

Chapter 9
Monitoring, evaluation and review of national health policies, strategies and plans

Kathryn O’Neill
Kavitha Viswanathan
Eduardo Celades
Ties Boerma 


This chapter outlines the aim and importance of monitoring, evaluation and review as the basis for tracking progress and performance of national health policies, strategies and plans (NHPSP) and to inform the health policy dialogue. Monitoring, evaluation and review require an integrated approach that builds on a single country-led monitoring 
and evaluation (M&E) platform. Key components and attributes of a strong country-led platform for monitoring, evaluation and review are specified here; in addition, key recommendations are made for countries to move forward and strengthen the platform.

 What  do we mean by monitoring, evaluation and review of NHPSPs?

Monitoring, evaluation and review are essential functions to ensure that priority health actions outlined in the NHPSP are implemented as planned against stated objectives and desired results. Monitoring means bringing all data together to analyze the progress of implementation of activities. 
Evaluation builds upon monitoring and assesses whether the desired results of a NHPSP intervention have been achieved. Based on the evidence gathered through M&E processes, reviews are used to assess overall progress and performance, to identify problems and take corrective actions.

A single country-led platform brings together all the elements related to monitoring, evaluation and review of the health sector plan, including national policy and plans relating to M&E and country health information systems (HIS), well-functioning data sources, institutional capacity for data collection, management analyses and use, as well as the country review processes for planning and decision-making.

M&E definitions v2


 Why  is it important?

  • progress and performance of the national health strategy need to be tracked;
  • country monitoring is the basis for regional and global monitoring of priority health issues;
  • reporting progress on health-related Sustainable Development Goals (SDGs) requires sound M&E systems;
  • health inequities need to be monitored; countries need functional surveillance mechanisms; 

  • accountability is a necessary basis for policy dialogue.




 How  to strengthen monitoring, evaluation and review?

1. assess the key attributes of the M&E platform as required and identify priority actions to address key gaps and weaknesses;

2. review and select core indicators and develop baseline and targets for monitoring national priorities and health goals;

3. develop a comprehensive M&E plan, including alignment of disease-specific plans and identification of priority actions;

4. cost the M&E plan and develop a common investment framework as the basis for government and partner investments;

5. review and evaluate the M&E platform regularly.


 Who  are the key stakeholders?

  • national and sub-national policy-makers;
  • programme managers and planners;
  • civil society and development partners.


 When  should monitoring, evaluation and review take place?

Monitoring, evaluation and review should be linked with the country planning cycles, when progress and performance of the sector are discussed and remedial actions are taken. 


Additional information is available in the form of a webinar. Please find the slides for download at this link, and the audio recording of the webinar below (both in English).

Chapter 10
Law, regulation and strategizing for health

David Clarke 


For the national health planning process, regulation represents a key means by which a government gives effect to its health policy preferences, especially through the exercise of a government’s law-making powers. The last 25 years have seen major changes to the way that governments organize themselves, provide services and make and implement policy. A range of decisions that were once taken by a health minister of a health ministry are now taken by regional and local government, autonomous public sector agencies, private firms, nongovernmental organizations and individuals. As a result, regulation has grown in importance as a key lever for governments to affect the quantity, quality, safety and distribution of services in health systems.

 What  is law and regulation?

The term “regulation” is commonly used in two ways. First, it is used in a narrow sense to describe a category of delegated decision-making involving the use of secondary legislation.

However, in this publication the term is used in a second and broader sense to cover the use of instruments of various types for the implementation of socioeconomic policy objectives and includes laws.

Laws are rules that govern behaviour. Laws can be made by a legislature, resulting in primary legislation (often called statutes or acts), by executive or local government through the issue of secondary legislation (including decrees, regulations and bylaws), or by judges through the making of binding legal precedent (normally in common law jurisdictions). 


Law and regulation defintions



Law and Regulation checklist

 Why  is law and regulation important?

National health planning process: Law and regulation set the ground rules for the health planning process.

National Health Policy/Strategy/Plan (NHPSP) implementation: Law and regulation are key implementation mechanisms for translating major health policy objectives into action through the setting of standards and requirements and the use of sanctions and incentives to exert leverage over the health system (and its participants).


 When  should work on law and regulation take place in the national health-planning process?

Thinking about law and regulation should take place at the start of the planning process. It is important for key actors involved to understand any legal rules and requirements that relate to how the process should be carried out. Specific issues about law and regulation should be taken into account during the various planning activities.


 Who  should be involved in work on law and regulation?

The many people involved in work on laws and other forms of regulation, include political decision-makers, lawyers, policy analysts, health planners, health providers, health professionals and members of the public. The roles of the various actors vary, and encompass decision-making, resource mobilization and provision, contribution to the policy/regulatory dialogue, and implementation.


 How  do we go about work on law and regulation?

At the beginning of the process make sure that you understand any legal requirements to be met as part of running the planning process, including legal requirements relating to the budget process. Read any relevant laws and guides; get legal advice if necessary.

Meet with the MoH’s policy and legal team to discuss your respective roles in any work on law and other forms of regulation, and discuss how this work might affect the planning process. 

Identify other key people that you need to work with on law and other forms of regulation.

Map out any specific tasks that need to be carried out on law/regulation as part of your work on NHPSP implementation activities, and factor in work on these tasks as part of the process.

As it proceeds, assess at each stage in the process what issues, tasks and inputs you need to consider with regard to law and other forms of regulation.

Chapter 11
Strategizing for health at sub-national level

Katja Rohrer 


“Sub-national” describes any government entity below the national level, regardless of the political, financial and administrative design of the country. “Strategizing at sub-national level” refers to all systematic planning and programming as well as budgeting and resource allocation processes below the national level, i.e. at local, district or regional level. Moving the planning function to sub-national level, either through deconcentration, delegation or devolution (elaborated further in this chapter), can have positive impacts on the accountability of public policy to the recipients of services. In addition, it can help increase community participation, increase flexibility in planning, and
 help mitigate geographical and social imbalances. In this chapter, challenges specific to the decentralized context
and planning processes are detailed; this guidance is sorted according to the target audience of the national level (what should this level watch out for in a decentralized country when undertaking national-level health planning?) and sub-national level (what are the issues to consider when engaging in a planning process at sub-national level?).

 What  is strategizing for health at sub-national level?

“Strategizing at sub-national level” refers to all systematic planning and programming as well as budgeting and resource allocation processes below the national level, i.e. at local, district or regional level. Sub-national planning is generally determined by the dimension and range of decentralization, as well as the degree of autonomy of the sub-national planning authority.

Subnational definitions v2 (1)


 Why  is strategizing for health at sub-national level important?

The features of decentralization have a strong influence on the structure, content, the different steps and the outcome of overall national health policies, strategies and plans (NHPSPs). In addition, Planning at sub-national level, either in deconcentration, delegation or devolution contexts (elaborated further in this chapter), can have positive impacts on the accountability of public policy to the recipients of services. In addition, it can help increase community participation, increase flexibility in planning, and help mitigate geographical and social imbalances. Furthermore, in some cases, it is simply a legal necessity, and not being aware of the consequences of decentralized planning is a missed opportunity.


 When  should sub-national planning be considered during the planning cycle?

National planning authorities must take sub-national planning into account throughout the policy and planning cycle. That being said, it is crucial that the arrangements and schedule for sub-national planning be carefully considered from the beginning in relation to the overall process of strategizing for health. Sub-national input is absolutely critical for shaping the over- arching national health plan. At the same time, national-level collaboration in sub-national planning processes is necessary to ensure coherence across regions and sub-national structure, and to enable aggregation of data and information at national level.


 Who  should be engaged in sub-national planning?

All stakeholders involved in the national health planning process, be they within the ministry of health (MoH) or outside it, should be attentive to the decentralized health system structure and its consequences for sub-national and national planning. Nongovernmental actors or external partners (e.g. United Nations, bilateral organizations) who are supporting planning processes should acknowledge the decentralized setting and act in accordance to its rules and regulations. The MoH has a special oversight function to provide guidance and capacity sup- port to sub-national entities, ensuring overall coherence with the national health sector vision.


 How  to strategize for health at sub-national level?

Sub-national planning is relevant to each step of the policy and planning cycle. In this section, each such step is addressed in relation to planning at sub-national level per se, as well as in relation to national-level planning in a decentralized context. Concrete recommendations and special issues to consider are elaborated upon.

Chapter 12
Intersectoral planning for health and health equity

Erik Blas
Nathalie Roebbel
Dheepa Rajan
Nicole Valentine


This chapter outlines the need and practical action for including intersectoral planning for health and health equity within the overall process of strategizing for health.  Reducing health inequities is pivotal to achieving the goal of UHC, one of the distinct strategic directions of many national health policies, strategies and plans (NHPSPs). Without intersectoral action as a fully integrated component – and indeed, mindset – embedded in the national health planning process, health inequities will likely persist, and as a result, the health of any nation’s population will suffer.

In this regard, this chapter’s objective is to describe the need and practical action for including intersectoral planning for health and health equity within the overall national health planning process. It discusses why and how to integrate other sectors into national health planning processes, with the objective of ensuring better health and health equity.

 What  is intersectoral planning for health and health equity?

Health equity is acknowledged as a critical component of the post-2015 sustainable development agenda, and is an essential element of any country’s path towards universal health coverage (UHC). Intersectoral planning implies that governments and other stakeholders proactively address the determinants for health inequities by identifying and promoting intersectoral action as an integral and vital component of the national health planning process.


 Why  do we need intersectoral planning?

Intersectoral planning addresses determinants of health, alongside clinical services, in order to achieve greater sustainability of results through: determining and confronting risk factors of ill health in a concerted effort; 
increasing the level and equity in distribution of health within populations; supporting achievement of the SDGs.


2_IP Wisconsin Health Gaps Report. Madison: University of Wisconsin Population Health Institute; 2015 (, accessed 19 May 2016).


 When  should we engage other sectors?

One should engage from the beginning of the national health planning process. However, intersectoral planning is not a linear process and thus several entry points exist. These different entry points find their correspondence in the approved SDGs. Intersectoral planning for health should be viewed as a multi-directional, continuous and constantly evolving process.


 Who  should be involved: roles and responsibilities?

The health sector, and in particular the ministry of health, should lead and understand the different interests and roles of many other sectors. Partnerships with or sponsorships by levels of government that have responsibility across sectors (e.g. ministry of planning, prime minister’s or president’s office, etc.) should be sought.

All sectors should be linked to the 17 SDGs. While all sectors can do something to improve the health situation, the mechanisms the different sectors have and their potential strength in influencing the top risk factors and the most important social determinants vary.


 How  should we plan for and implement intersectoral action?

Each country is different and needs to prepare and present its own case for intersectoral action on health inequities. It is important to: keep the target audience of non-health people in mind;
find a common ground and build a common understanding between the health sector and all other relevant sectors; make good use of the situation analysis phase of the national health planning cycle; engage in policy dialogue and negotiation; link groups of indicators, including on social determinants, across dimensions of inequity and levels of results chains, as well as across different sectors.


Chapter 13
Strategized in distressed health contexts

Enrico Pavignani
Sandro Colombo


This chapter does not propose detailed instructions to be mechanically followed, nor does it attempt to simplify the issues at stake, in the firm belief that no blueprinted approach can produce satisfactory outcomes. The challenges posed
 by policy and strategy formulation and planning
 in health systems under stress are discussed, highlighting the main differences with these processes in more stable environments. Lessons learnt in “fragile” contexts are used to suggest adapted policy and planning approaches and to provide suggestions for avoiding the most common mistakes.



 Section 1 

Sets the scene, looking at how different situations of weakness, poverty and violence fit uneasily into the “fragile state” concept and category. The section introduces the main determinants of fragility and stresses their self-reinforcing nature. It emphasizes the need for understanding the context and its possible evolution before formulating strategies.


 Section 2 

Discusses aid in fragile states, an issue receiving renewed interest. The section looks at requirements and principles of aid management in fragile states, as well as at some of the most important donor agendas and instruments, arguing that current approaches are ill-suited to unstable contexts and new modalities are needed to improve aid effectiveness.


 Section 3 

Looks at those characteristics of fragile states that impact on health policy and planning and that require adapted approaches. It considers the dynamic and unpredictable context and the mix of actors within and outside of the health field. Performing a situation analysis in these settings, including assessing the capacity of key public and private health actors is critical, but challenging. Like in stable countries, strategy formulation and planning in fragile contexts are political, iterative and continuing processes, which require negotiation with the many stakeholders.

A strong monitoring and evaluation component is the link between strategy formulation and implementation. It provides indications about necessary adjustments to strategies and plans. To facilitate the tailoring of approaches to specific situations, a new empirical typology of situations is proposed, with suggestions about the possible courses of action. Critical aspects related to key subsectors (financing, human resources, medicines and infrastructure) are then discussed. 


AFR – accountability for reasonableness
BPEHS – basic package of essential health services
BPRS – basic priority rating system
CEA – cost-effectiveness analysis
CHWs – community health worker
CSOs – civil society organizations
DALYs – disability-adjusted life years
DHS – district health system
EC- European Commission
EU – European Union
EVD – ebola virus disease
FGM – female genital mutilation
GHIs – global health initiatives

HDC – health data collaborative
HiAP- Health in All Policies
HIS- health information systems
HMIS – health management information system
HRH- human resources for health
HSS – health system strengthening
HTA – health technology assessment
ICD- International Classification of Diseases
IDP- internally displaced persons
IHP+ – International Health Partnership
IHR – international health regulations

ILO – International Labour Organization
IMCI – integrated management of childhood illnesses
IPCHS – integrated people-centered health services
JANS – joint assessment of national strategies
JAR- Joint Annual Review
JPWF – joint programme of work and funding
LiST – lives saved tool
M&E – monitoring and evaluation
MBB- Marginal Budgeting for Bottlenecks
MCDM – multi-criteria decision-making
MCH – maternal and child health
MDGs – Millennium Development Goals
MDTFs- multi-donor trust funds
MoF – ministry of finance
MoH – ministry of health
MTEF – medium-term expenditure framework
MTR- Mid-term Review
MVT – multivoting technique
NCD- non-communicable disease
NGO – nongovernmental organization
NGT – nominal group technique
NHPSP – national health policy, strategy, and plan
NSO- national statistics office
NTDs – neglected tropical diseases
OBI – open budget index
OECD – Organisation for Economic Co-operation and Development
PBF- performance-based financing
PBMA – programme budgeting and marginal analysis
PEARL – Property, economics, acceptability, resources and legality component
PFM – public financial management
QALYs – quality-adjusted life years
RIA- Regulatory Impact Analysis
RoR – rule of rescue
SAI – supreme audit institution
SDGs – Sustainable Development Goals
SDHs- social determinants of health
SWAp – sector-wide approach
SWOT – strengths, weaknesses, opportunities, threats analysis
TB- tuberculosis
UHC – universal health coverage
UN- United Nations
UNAIDS- Joint United Nations Programme on HIV/AIDS
UNDP – United Nations Development Programme
UNFPA- United Nations Population Fund
UNICEF- United Nations International Children’s Emergency Fund
USAID – United States Agency for International Development
WHO – World Health Organization