Review Article

Stewardship in Health, Designing a Multi-Layer Meta Model: A Review Article


Background: In the current study, we aimed to explain the concept of stewardship by employing a critical review perspective and, finally, to develop a model.

Methods: Critical review method and Carnwell and Daly approach and using particular keywords related to stewardship, and searching databases were used. In the initial search, until 2018, 1050 studies were obtained, which using targeted sampling method, 32 studies were finally selected. Then, selected studies were criticized and finally, and the conceptual model of stewardship was designed and explained.

Results: After reviewing and criticizing; the concept and aspects of the model were categorized in the sub-tasks
of knowledge-generation, strategic framework, evidence-based policy-making, system design, resource allocation, capacity building, enforcement/alignment, that through operation leads to achieving goals. Final model was categorized into three effective levels.

Conclusion: Some studies mentioned the governance and stewardship as same concepts, while our results showed that policy-making, governance and leadership, and many other concepts, can be categorized as a part of stewardship.



1. Organization WH (2000). The WHO report 2000: health systems: improving perfor-mance: WHO. Available from:
2. Saltman RB, Ferroussier-Davis O (2000). The concept of stewardship in health policy. Bull World Health Organ, 78 (6):732-739.
3. Avery G (2001). WHO report 2000. Lancet, 29; 358 (9287):1097.
4. Boffin N (2002). Stewardship of health sys-tems: Review of the literature [internet]. Antwerp; Institute of Tropical Medicine. Available from:
5. Biglar M, Bastani P (2013). The Challenges of Stewardship in Medical Education System: A Qualitative Approach. Payavard Salamat, 7 (4):299-311.
6. Travis P, Egger D, Davies P, Mechbal A (2002). Towards better stewardship: con-cepts and critical issues. Available from:
7. Organization PAH (2002). Public health in the Americas: conceptual renewal, per-formance assessment, and bases for ac-tion: Pan American Health Org. Available from:
8. Veillard JHM, Brown AD, Barış E, et al (2011). Health system stewardship of na-tional health ministries in the WHO eu-ropean region: Concepts, functions and assessment framework. Health Policy, 103 (2-3):191-199.
9. Alvarez-Rosete A, Hawkins B, Parkhurst J (2013). Health system stewardship and evidence informed health policy. Lon-don: GRIP-Health Programme, London School of Hygiene and Tropical Medi-cine. Available from:
10. Siddiqi S, Masud TI, Nishtar S, et al (2009). Framework for assessing governance of the health system in developing coun-tries: gateway to good governance. Health Policy, 90 (1):13-25.
11. Barbazza E, Tello JE (2014). A review of health governance: definitions, dimen-sions and tools to govern. Health Policy, 116 (1):1-11.
12. Smith PC, Anell A, Busse R, et al (2012). Leadership and governance in seven de-veloped health systems. Health Policy, 106 (1):37-49.
13. Grant MJ, Booth A (2009). A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J, 26 (2):91-108.
14. Carnwell R, Daly W (2001). Strategies for the construction of a critical review of the literature. Nurse Educ Pract, 1 (2):57-63.
15. Kass HD (1988). Stewardship as a Fundamental Element in Images of Public Administration. Taylor & Francis, Ltd, 10 (2):2-48.
16. Davis JH, Schoorman FD, Donaldson L (1997). Toward a stewardship theory of management. Academy of Management Re-view, 22 (1):20-47.
17. Moran M (1999). Governing the health care state: a comparative study of the United Kingdom, the United States, and Germany. Manchester University Press. Available from:
18. Murray CJ, Frenk J (2000). A framework for assessing the performance of health sys-tems. Bull World Health Organ, 78 (6):31-717.
19. Kaufmann D, Kraay A (2008). Governance indicators: Where are we, where should we be going? . World Bank Res Obs, 23 (1):1-30.
20. Ten Asbroek A, Arah O, Geelhoed J, et al (2004). Developing a national perfor-mance indicator framework for the Dutch health system. Int J Qual Health Care, 16 (suppl 1):i65-i71.
21. Davies P (2001). “Stewardship: what is it and how can we measure it?”. Presenta-tion to meeting on Health economics in developing and transitional countries: the changing role of the state, Department for International Development, York, United Kingdom, 26 July 2001.
22. Kickbusch I, Gleicher D (2012). Govern-ance for health in the 21st century: WHO Geneva. Available from:
23. Cerchione R, Esposito E (2017). Using knowledge management systems: A tax-onomy of SME strategies. Int J Inf Man-age, 37 (1):1551-1562.
24. Shams L, Akbari Sari A, Yazdani S (2016). Values in Health Policy – A Concept Analysis. Int J Health Policy Manag, 5 (11):623-630.
25. Andermann A, Pang T, Newton JN, et al (2016). Evidence for Health III: Making evidence-informed decisions that inte-grate values and context. Health Res Policy Syst, 14 (1):16.
26. Ika LA, Donnelly J (2017). Success condi-tions for international development ca-pacity building projects. International Jour-nal of Project Management, 35 (1):44-63.
27. Roberts M, Hsiao W, Berman P, Reich M (2004). Getting health reform right: a guide to improving performance and equity. Oxford University Press, p. 332 ISBN: 0 19 5162323.
28. Ashton J (2001). Taxonomy of health sys-tem standards. Bethesda, Maryland, Cen-ter for Human Services, Quality Assur-ance Project, 25 p. (Project Report). Available from:
29. Tahani B YS, Khoshnevisan MH (2014). Proposed Standards for Evaluating the Stewardship of National Oral Health Sys-tem; Part 1: Evaluation of Regulations. Hakim Health Sys Res, 17 (2):108-117.
30. Yazdani S (2011). Family Physicians: Whats and Whys.Capacity Building in Health Network. Ministry of Health and Medical Educa-tion Network Management Center.
31. Benhabib J, Bisin A (2006). The distribution of wealth and redistributive policies. Department of Economics, New York University.
32. Rudolph, L, Caplan, J., Ben-Moshe, K., & Dillon, L (2013). Health in All Policies: A Guide for State and Local Governments. Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute.
33. Shams L, Yazdani S, Takian A, Nasiri T (2018). Multi-sectoral Requirements of Non-Communicable Diseases Steward-ship in Iran. Revista Publicando, 5 (16): 134-151.
34. Popescu GH, Predescu V (2016). The role of leadership in public health. Am J Med Res, 3 (1):273.
35. David V. McQueen MW, Vivian Lin, et al (2012). Intersectoral Governance for Health in All Policies, Structures, actions and experiences. European Observatory on Health Systems and Policies. Obser-vatory Studies Series No. 26. Available from:
IssueVol 48 No 4 (2019) QRcode
SectionReview Article(s)
Stewardship Governance Leadership Model

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How to Cite
NASIRI T, TAKIAN A, YAZDANI S. Stewardship in Health, Designing a Multi-Layer Meta Model: A Review Article. Iran J Public Health. 2019;48(4):579-592.