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Towards sustainable healthcare system performance in the 21st century in high-income countries: a protocol for a systematic review of the grey literature
  1. Jeffrey Braithwaite1,
  2. Yvonne Zurynski1,
  3. Kristiana Ludlow1,
  4. Joanna Holt1,
  5. Hanna Augustsson1,
  6. Margie Campbell2
  1. 1 Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
  2. 2 Centre for Health Economics Research and Evaluation, University of Technology, Sydney, New South Wales, Australia
  1. Correspondence to Professor Jeffrey Braithwaite; jeffrey.braithwaite{at}


Introduction There is wide recognition that, if healthcare systems continue along current trajectories, they will become harder to sustain. Ageing populations, accelerating rates of chronic disease, increasing costs, inefficiencies, wasteful spending and low-value care pose significant challenges to healthcare system durability. Sustainable healthcare systems are important to patients, society, policy-makers, public and private funders, the healthcare workforce and researchers. To capture current thinking about improving healthcare system sustainability, we present a protocol for the systematic review of grey literature to capture the current state-of-knowledge and to compliment a review of peer-reviewed literature.

Methods and analysis The proposed search strategy, based on the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, includes Google Advanced Search, snowballing techniques and targeted hand searching of websites of lead organisations such as WHO, Organisation for Economic Cooperation and Development, governments, public policy institutes, universities and non-government organisations. Documents will be selected after reviewing document summaries. Included documents will undergo full-text review. The following criteria will be used: grey literature document; English language; published January 2013–March 2018; relevant to the healthcare delivery system; the content has international or national scope in high-income countries. Documents will be assessed for quality, credibility and objectivity using validated checklists. Descriptive data elements will be extracted: identified sustainability threats, definitions of sustainability, attributes of sustainable healthcare systems, solutions for improvement and outcome measures of sustainability. Data will be analysed using novel text-mining methods to identify common concept themes and meanings. This will be triangulated with the more traditional analysis and concept theming by the researchers.

Ethics and dissemination No primary data will be collected, therefore ethical approval will not be sought. The results will be disseminated in peer-reviewed literature, as conference presentations and as condensed summaries for policy-makers and health system partners.

PROSPERO registration number CRD42018103076.

  • healthcare delivery system
  • sustainable performance
  • resilience
  • quality and efficiency
  • grey literature

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  • Contributors JB conceptualised the study and leads the team. JH, KL and MC drafted the initial search strategy. JB, YZ, KL, JH, HA and MC contributed to the refinement of selection criteria. YZ developed the overarching methodology framework and drafted the manuscript. All authors had the opportunity to contribute to the final manuscript and approved the final submission.

  • Funding This work is supported by the National Health and Medical Research Council Partnership Centre grant in Health System Sustainability (ID: 9100002).

  • Competing interests None declared.

  • Patient consent Not required.

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

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