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The governance of local health systems in the era of Sustainable Development Goals: reflections on collaborative action to address complex health needs in four country contexts
  1. Helen Schneider1,
  2. Joseph Mumba Zulu2,
  3. Kaaren Mathias3,4,
  4. Keith Cloete5,
  5. Anna-Karin Hurtig4
  1. 1School of Public Health and SAMRC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South Africa
  2. 2School of Public Health, University of Zambia, Lusaka, Zambia
  3. 3Emmanuel Hospital Association, New Delhi, Delhi, India
  4. 4Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
  5. 5Western Cape Government:Health, Cape Town, South Africa
  1. Correspondence to Professor Helen Schneider; hschneider{at}


This analysis reflects on experiences and lessons from four country settings—Zambia, India, Sweden and South Africa—on building collaborations in local health systems in order to respond to complex health needs. These collaborations ranged in scope and formality, from coordinating action in the community health system (Zambia), to a partnership between governmental, non-governmental and academic actors (India), to joint planning and delivery across political and sectoral boundaries (Sweden and South Africa). The four cases are presented and analysed using a common framework of collaborative governance, focusing on the dynamics of the collaboration itself, with respect to principled engagement, shared motivation and joint capacity. The four cases, despite their differences, illustrate the considerable challenges and the specific dynamics involved in developing collaborative action in local health systems. These include the coconstruction of solutions (and in some instances the problem itself) through engagement, the importance of trust, both interpersonal and institutional, as a condition for collaborative arrangements, and the role of openly accessible information in building shared understanding. Ultimately, collaborative action takes time and difficulty needs to be anticipated. If discovery, joint learning and developing shared perspectives are presented as goals in themselves, this may offset internal and external expectations that collaborations deliver results in the short term.

  • governance
  • collaborative governance
  • local health systems
  • coordination
  • collaboration
  • shared motivation

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  • Handling editor Seye Abimbola

  • Contributors The case studies (supplementary files and text in the main article) were drawn up by each of the authors, with the lead author providing overall coordination. HS drafted the overall manuscript. All authors commented on and approved the final manuscript.

  • Funding U2U (Umeå-UWC) Collaboration on Health Policy and Systems Research: Strengthening community health systems, funded by the South African National Research Foundation (NRF)/Swedish Foundation for International Cooperation in Research and Higher Education (STINT), Science and Technology Research Collaboration (Grant UID: 106770).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No additional data are available.

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