Table 3 Context principles

23. Feasibility

The guidance recommendations are realistic and the actions are pragmatic [4, 5, 53, 55, 57, 59, 61, 63, 68, 70, 81, 84]. The guidance describes facilitators and barriers for implementation [58, 69]. It is clearly demonstrated that the implementation of the guidance is feasible within the proposed practice environment, and the recommendations match local capacities and expectations [4, 8, 53, 61, 63, 69, 71, 80].

24. Affordability

The guidance recommendations are affordable within the financial structure and budgetary allocations of the health system [53, 54, 56, 69]. Potential sources of local government funding and donor organizations are identified. For policy issues in which there may be several sources of funding, the guidance also considers the level of coordination among the donors and between the donors and the local government [56, 58, 59, 61, 69].

25. Flexibility

The guidance is flexible and adaptable to the expertise of the user and the varying local conditions. It acknowledges the importance of professional judgment and discretion and provides recommendations that users can adapt in accordance with their own individual circumstances and needs [57, 71, 80]. The recommendations steer away from the adoption of rigid approaches so as not to inappropriately or unnecessarily limit those in charge of applying them [57, 71].

26. Socio- culturally acceptable

Considering the diversity of values in many regions, the recommendations are robust under societal and cultural scrutiny by adopting a socio-cultural perspective [54, 57, 61–63, 69, 73]. It recognizes socio-cultural expectations and provides an understanding of the role that socio-cultural factors will play in the success of the guidance recommendations [54, 55, 69, 71, 73].

27. Politically sound

The political acceptability of the recommendations is considered in order to assess if they align with political interests/commitments [54, 57, 63, 64, 70, 75, 79, 81, 82]. Implementation of guidance can stir swings in the national mood, lead to changes in the balance of organized forces, such as interest groups, or influence outcome of events within the government, for instance an election [85]. Therefore, options proposed that are in sync with the political climate may garner adequate support from top policy/government officials [58, 73].

28. External factors

Determinants of health system performance that lie outside the formal architecture of the health system but will influence the performance of its functions are considered; for example, judicial system, social system, recession, corruption, state of the economy [48, 54, 73, 79]. These are non-health system factors originating from other local institutional organizations that impact on the usual operations of the health system [54, 59, 64, 80].

29. Generalizability

The recommendations are transferable to other settings with similar health system features; for example other countries or regions [59, 65, 66, 79]. Judgments are made about the applicability of the recommendations beyond its original context (setting or population) to ensure that contexts with similar institutional, socioeconomic, and political demographics facing an identical health system challenges can adapt and use the guidance [55, 60, 65, 74].

30. Sustainability

The guidance provides an indication of the sustainability of the effects of the recommendations to show that long-term outcomes can be continuously achieved and maintained at an acceptable level [56, 61, 64, 69]. Due to constantly evolving health system issues, looming budget cuts, fluctuating resources, rising costs of new technologies, an ageing population, shifting burdens of diseases etc., it is crucial to develop recommendations that will stand the test of time [56, 60, 69].