AGREE II Instrument

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AGREE-HS: Health Systems


Health systems guidance (HSG) documents are systematically developed statements produced at global and national levels that provide recommendations to address a health system challenge. These recommendations can be used to inform policy decisions related to health system governance, financial arrangements, system organization, or design and delivery of health programs and services. No tools exist to evaluate the quality of HSG or to direct the development and reporting of HSG documents.

The aim of this project is to develop a tool that will be used to direct the development, reporting, and appraisal of HSG.


 Critical Interpretive Synthesis

 The AGREE-HS research team conducted a critical interpretive synthesis of the literature to identify factors that affect HSG quality and implementability. Thirty distinct factors were identified in the literature and formed the candidate criteria for a HSG appraisal tool. The results of the critical interpretive synthesis have been published in the following article:

Ako-Arrey D, Brouwers MC, Lavis J, Giacomini M, AGREE-HE Team. Health System guidance  appraisal – a critical interpretive synthesis. Implement Sci. 2016;11:9

Concept Evaluation and Preliminary Usability Testing

 Health systems and policy experts were invited to review the list of criteria identified in the critical interpretive synthesis and assess each criterion’s importance in the development, reporting and appraisal of HSG. All thirty criteria were rated favourably. Based on the results of the concept evaluation study, a 32-item framework of HSG quality and implementability was developed. Based on that framework, a draft HSG appraisal tool was created. A second group of health systems and policy experts was invited to apply the draft tool to a HSG document and complete a usability survey. Results were generally positive but suggested that further refinement of the tool was necessary. Results of these studies were published in the following article:

Ako-Arrey D, Brouwers MC, Lavis J, Giacomini M, AGREE-HS Team. Health System guidance appraisal – concept evaluation and usability testing. Implement Sci. 2016;11:3.

The AGREE-HS research team is in the process of finalizing a revised AGREE-HS tool based on feedback received. Two international studies will be initiated in Summer 2016 to assess the content and structure of the revised AGREE-HS and to test its reliability and usability. Potential study participants include HSG developers and users and people with expertise in health systems and health policy.  If you are interested in participating in the AGREE-HS study, please send an email to

Funding: Canadian Institutes of Health Research (CIHR)
Research Team: AGREE-HS Research Team
Contact Us: For any questions or comments, please contact us.