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Towards a global
strategy to improvemusculoskeletal health

AL ALLIAN
BO

LO S E L E TAKCopyright statement and publishing information

Suggested citation

This work is copyright. It may be reproduced in whole
or in part for study, training or advocacy purposes,
subject to explicit inclusion of an acknowledgementof the source.

Briggs AM, Slater H, Jordan JE, Huckel Schneider C,
Kopansky‑Giles D, Sharma S, Young JJ, Parambath S,
Mishrra S, March L. (2021): Towards a global strategy
to improve musculoskeletal health. Global Alliance
for Musculoskeletal Health, Sydney, Australia.

It may not be reproduced for commercial usage orsale. Requests and enquires concerning reproduction
and rights for the purposes, other than those indicatedabove, requires written permission from:
Global Alliance for Musculoskeletal Health(Sydney Office)
Sydney Musculoskeletal, Bone & Joint Health Alliance.
Institute of Bone and Joint Research, Kolling Institute.
Faculty of Medicine and Health, University of Sydney
New South Wales, Australia.
Email: gmusc.office@gmail.com
Project lead email: A.Briggs@curtin.edu.au

Image acknowledgements
Front cover: Adobe/Dmytro
Back cover: Adobe/Sahil Ghosh
Pillars: Adobe/Vector Gallery/spiral media/blankstock
Flags: Adobe/Vermicule design/Strezhnev Pavel/Lubo
Ivanko/hartinip. 6: Adobe/Andrew Kazmierski
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p. 69: shutterstock/Adriana Mahdalova
p. 74: Adobe/Andrey PopovDesign by Nikki M GroupEXECUTIVE SUMMARY
Why this project?
Musculoskeletal (MSK) health refers to the healthof the human locomotor system, comprisingmuscles, bones, joints and adjacent connective
tissues. MSK health impairments include morethan 150 discrete conditions (e.g. arthritis, gout,
osteoporosis and fragility fractures, sarcopenia,
auto‑immune and rheumatic conditions), pain
associated with MSK tissues/structures or presenting
in MSK tissues/structures (e.g. low back pain, neckpain, fibromyalgia) and injury and trauma of the
MSK system (e.g. sporting, occupational androad traffic injury and trauma).
A healthy MSK system is fundamental to mobility,
dexterity, physical function, participation and qualityof life. MSK health impairments are associated with
pain, disability, reduced ability to work, study andcare for self and others, increased health resource
utilisation, and for many people, premature
retirement from the workforce. These outcomes haveprofound impacts on a person’s quality of life and on
the prosperity of families and communities.
MSK conditions are the leading cause of disability
worldwide, with low back pain identified as the single
condition responsible for the greatest disability
in almost all countries. In high-income countries,
MSK conditions are responsible for the greatest
share of health system expenditure. Of all conditions,the need for rehabilitation globally is greatest for
MSK conditions, in particular low back pain.
Robust population health research suggests
the prevalence, burden and cost of MSK healthimpairments will continue to rise globally,
especially in low and middle-income countries(LMICs), owing to population growth, population
ageing, an increasing prevalence of risk factors fornon‑communicable diseases and increasing ratesof MSK injury and trauma.

These sobering projections paint a stark warning tohealth systems and economies globally – the demandfor health services for MSK health impairments willcontinue to rise and the economic impacts of lost
human capital will increase dramatically. Healthsystems strengthening efforts are urgently needed
to improve the prevention and management of MSK
health impairment and arrest the escalating global
disability and economic burden.

Responding to the problem
Over the last decade, there has been increasing
national and global attention towards thehealth and economic burden associated with
non‑communicable diseases (NCDs) and injury,with multiple recommendations for urgent healthsystems strengthening efforts from the World HealthOrganization (WHO), national governments and civilsociety and advocacy organisations.
The Global Alliance for Musculoskeletal Health(G-MUSC) is a network of national and international
patient, professional, scientific and civil society
organisations around the world focused on raising
the priority for MSK health in global and national
health agendas. In 2020, G-MUSC called for a
strategic global response to address the health,social and economic burden associated with MSK
health impairments. In response to that call, theprogram of work described in this report aimed
to engage and consult with the global MSK healthcommunity and other multi-sectoral stakeholder
groups, to inform the co-design of a blueprint
for a global strategy for MSK health.

1What was done in this project?

Overview of findings

The purpose of the work was not to develop a fullstrategy, but rather, identify requisite components,
i.e. a ‘blueprint’, to guide later strategy developmentthat could be adaptable for global-level and/or
country-level health systems strengthening efforts.
Importantly, the blueprint was co-designed andsupported by the global community, including
people with lived experience. It is intended that thiswork would ultimately support, guide and accelerate
emerging initiatives within the World HealthOrganization (WHO) to prioritise MSK health within
its 13th General Program of Work and the strategic
directions of other global and international agencies.

Thirty-one KIs participated in the qualitative study,
representing 20 countries and 25 peak global orinternational organisations.

Three phases of work were undertaken to derive
the blueprint of actions:
1. Qualitative study: An in-depth qualitative
study of international key informants (KIs) tounderstand the contemporary global landscapefor MSK health and identify the key priorities
and actions for a global strategy to improve
prevention and management of MSK health1.
2. Health policy scoping review: A scoping
review of national health policies and strategies
relevant to MSK health to create a snapshot ofcontemporary policy trends and priorities2.

From Phase 1, the qualitative data were used toconstruct a logic model for the program of workand to create a structure for the framework ofcomponents/actions of a global strategy on MSK
health (Executive Summary Figure 1). The logic
model comprises 5 guiding principles, 8 pillars(strategic priority areas) and 7 accelerators for action.
From Phase 2, the health policy scoping review
identified 41 eligible policy documents from22 countries and 2 regions. Eight priority policy
themes were identified and these mapped closely
to the 8 pillars identified in the logic model.
Finally, in Phase 3 an eDelphi study was deployed,
involving 674 multi-sectoral stakeholders across
72 countries. The Delphi panellists were asked torate the importance of and comment on, a frameworkof 8 pillars and 60 detailed components/‌actions.
Ultimately, a framework of 8 pillars and
59 components/actions was supported(Executive Summary Figure 2).

3. Global eDelphi: Integration of the earlier twophases to create a framework of components
for a global strategy that were presented to
the global MSK health community and othermulti‑sectoral stakeholders for review andpriority ranking in an eDelphi study2.

Executive Summary Figure 1 (on next page):Data-driven logic model developed for the project
directly informed by the Phase 1 qualitative study withinternational key informants. The logic model is adaptedfrom Briggs et al1, 2 and supported by G-MUSC.

2

TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTHG-MUSC vision: A world where prevention andmanagement of musculoskeletal (MSK) health conditions,
MSK pain and MSK injuries/trauma are prioritised inhealth systems to optimise people’s functional ability
and participation across the lifecourse and to reduce
the associated global burden of disability.

Goal: To create an adaptable blueprint for a global strategy
to support country-level health systems strengthening
in value‑based MSK health, injury and pain care that isco‑designed and supported by the global community,
including patients and which targets improving function,
participation and overall quality of life for all ages.

CONTEMPORARY CONTEXTUAL FACTORS RELEVANT TO MUSCULOSKELETAL HEALTH GLOBALLY

Musculoskeletal (MSK) health means MSK conditions, MSK pain and MSK injury and trauma

GUIDING PRINCIPLES

1

2

3

4

5

Adaptability
to local contexts

Inclusiveness throughbroad consultation
across economies andco-design, including
patients/citizens

Improve function,
quality of life andoverall health

Adopt a lifecourse
approach to
MSK health,from childhoodto older age

Equitable
access to early,
value-based care

PILLARS FOR HEALTH SYSTEMS STRENGTHENING FOR MUSCULOSKELETAL HEALTH

Engaging, empoweringand educating communities

Leadership, governanceand shared accountability

Financingapproaches

Servicedelivery

Equitable access to
medicines and technologies

Workforce

Surveillance

Research
and innovation

Strategy components and actions

Adaptable blueprint

ACCELERATORS■ Increase societal and government

awareness of MSK health and theimpacts of MSK-related disability■ Identify essential, evidence‑based

standards or actions to enable
lower‑resourced settings toinitiate reforms■ Align with existing global■ Leverage multi-sectoral■ Provide guidance on MSK health■ Co-design objectives andor regional strategies or policies
in the context of pandemics;
e.g. COVID-19■ Translate guidance into

partnerships and co-operation
performance indicators
for a full strategy

multiple languages

EXECUTIVE SUMMARY

3

PILLARS FOR HEALTH SYSTEMS STRENGTHENING
FOR MUSCULOSKELETAL HEALTHP IL L AR 1

PILLAR 2

P I LLA R 3

P I LLA R 4

Engaging,
empowering andeducating citizens,
communities,
organisations andgovernments

Leadership,
governanceand sharedaccountability

Financingapproaches

Servicedelivery3 actions for integration
with existing policy andsystems strengthening
initiatives

1 action for integrated
financing models

5 priority sectors forpursuing engagement
and forging partnerships
to support prevention
and managementof MSK health
4 priority sectors for
MSK health education
7 priority messages for
public health education
about MSK health
5 priority enablers
to drive advocacy andsupport communitywide education

4 actions for global andnational leadershipto prioritise MSK
health, pain and injury
prevention and care
2 actions formeasurement
and classification
1 action for legislation
and regulation

3 actions for flexibility
for different financing
models2 actions for financing
for the right care, at theright time, by the rightteam, in the right place

4 actions for deliveryof the right care:effective, safe, affordable
and accessible
1 action for careat the right time:
early diagnosis, triage
and intervention forsecondary prevention
1 action for deliveryof care from the rightteam: interprofessional
service models
3 actions for delivery ofcare in the right place:bolstering communityand primary care to
reduce inequity inaccess to care
3 actions for prevention

Executive Summary Figure 2: Eight pillars and their supporting actions.

4

TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTHP IL L AR 5

PILLAR 6

P I LLA R 7

P I LLA R 8

Equitable accessto medicines andtechnologies

Workforce

Surveillance:
monitoring
population healthResearch andinnovation

2 actions

3 actions for workforce
volumes and access
4 actions forworkforce training
1 action for workforce
remuneration

3 actions

5 priority fieldsof research
2 capacity building
priorities in
MSK research
1 action for funding
MSK health research
2 actions for innovationand evidence translation

EXECUTIVE SUMMARY

5

Ten components/actions of the framework wereconsidered essential, irrespective of the levelof economic development across countries.
These essential actions included:

Essential, globally-relevant health systems
strengthening actions for MSK health
1. Drive engagement and partnerships
with citizens, patients and civil society
organisations.
2. Drive engagement and partnerships
with industry, workplaces and employers.
3. Drive engagement and partnerships withnational and sub-national governments.
4. Deliver MSK health education across thefollowing sectors: schools and higher
education facilities; workplaces; healthworkforce; and the community, to improve
prevention and management of MSK health.
5. Foster and support country-level leadershipto prioritise MSK health impairment by
national governments.
6. Extend global and national health andperformance indicators beyond mortality
reduction to consider function andparticipation.
7. Integrate health promotion and healthcare delivery for MSK health into existing
healthcare financing models.
8. Ensure service models for MSK conditions
support early diagnosis and triage andmanagement through local care pathways.
9. Prioritise evidence-based diagnostic andtherapeutic practices in service models
over approaches that are not supported byevidence, are costly and potentially harmful.

What does this meanfor health systems?
Without action on MSK health, including
population‑level prevention and appropriate
management, the demand on international
healthcare systems attributed to MSK healthimpairments will continue to rise rapidly andbecome unsustainable.
The framework of pillars and priority actions/components outlined in this report provides a
blueprint for the development of a global strategy
to improve the prevention and management of
MSK health. A global strategy should then be
adapted to local contexts for targeted healthsystems strengthening efforts.

10. Identify, resource and provide access toessential therapeutics and rehabilitation
for priority MSK conditions.

6

TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTHCONTENTS

Executive summary

1
2
3
4

1

Why this project?

1

Responding to the problem

1

What was done in this project?

2

Overview of findings

2

What does this mean for health systems?

6

List of abbreviations9

About this report

10

The importance ofmusculoskeletal health

11

What is ‘musculoskeletal’ (MSK) health?

12

Burden of disease

12

Health systems strengthening responses

13

Context for this work

13

Aims and objectivesof the program of work

14

Developing this report

16

Overview of results

18

4.1	Phase 1: Interviews with key informants and establishment of a logic model 19
4.2	Phase 2: Musculoskeletal health policy scoping review

25

4.3

31

Phase 3: Global eDelphi

7

5
6
7
8

8

Framework of requisite components

39

What is the Framework?

40

How to use this section

40

5.1	Pillar 1: Engaging, empowering and educating citizens, communities,
organisations and governments to act on MSK health

41

5.2	Pillar 2: Leadership, governance and shared accountability

46

5.3

Pillar 3: Financing approaches

50

5.4

Pillar 4: Service delivery

52

5.5	Pillar 5: Equitable access to medicines and technologies

56

5.6	Pillar 6: Workforce: building workforce capacity, systems and tools

57

5.7	Pillar 7: Surveillance: monitoring population health

60

5.8

62

Pillar 8: Research and innovation

Implications for health systems
and key recommendations

66

References

69

Governance and Acknowledgements

74

Project team

75

External Steering Group

75

Human research ethics approval

75

Funding

75

Contributors

75

TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

LIST OF ABBREVIATIONSCOVID-19

coronavirus disease

DALY(s)disability-adjusted life year(s)G-MUSC

Global Alliance for Musculoskeletal Health

GBD

Global Burden of Disease study

ICD

International Classification of Diseases

ICF

International Classification of Functioning, Disability and HealthKI(s)key informant(s)LMIC(s)low and middle-income country(ies)

MSK

musculoskeletal

NCD(s)

non-communicable disease(s)OECDOrganisation for Economic Co-operation and Development

PREM(s)patient report experience measure(s)PROM(s)patient reported outcome measure(s)QALY(s)quality adjusted life year(s)SDG(s)

Sustainable Development Goal(s)UHC

Universal Health Coverage

WHO

World Health Organization

YLD(s)

year(s) lived with disability

9

ABOUT THIS REPORT
What is this report about?

How to use this report

This report describes a program of work that aims toprovide global and national-level guidance on healthsystems strengthening priorities for musculoskeletal(MSK) health. The work was undertaken in recognitionof the absence of such guidance at the global level
and an observed lack of prioritisation and policy
responses in many countries. An empirically derived
blueprint is proposed that enables agencies to takeaction on prevention and management of MSK
health impairments.

The report is structured in 8 sections:

Who is this report for?
The report is primarily intended for stakeholders
tasked with designing, implementing, financing andevaluating health systems strengthening responses
for non-communicable diseases (NCDs) and injury
and trauma across the lifecourse. The report is also
relevant to citizens, healthcare providers, educatorsand researchers. The report is intended to support
the work of the World Health Organization (WHO),other global health agencies and policy makers
and health service managers at national andsub‑national levels. For the WHO, it is particularly
relevant to technical units for NCDs, rehabilitation,
injury prevention, child health and ageing andhealth service delivery and financing.

10 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH• Sections 1 and 2 provide the backgroundto the program of work and specific aims
and objectives.
• Sections 3 and 4 provide an overview
of the methods and key results.
• Section 5 is the focus of the report andprovides comprehensive detail on the
blueprint for a MSK health strategy.
• Section 6 provides a commentary about
implications for health systems.
• Sections 7 and 8 provide the supporting
material for the document.

THE IMPORTANCE OF
MUSCULOSKELETALHEALTH

1

WHAT IS ‘MUSCULOSKELETAL’ (MSK) HEALTH?
MSK health broadly refers to the health of themuscles, bones, joints and adjacent connective
tissues – structures and tissues that are
essential for mobility and dexterity. MSK healthimpairments comprise:• established MSK conditions (i.e. more than150 conditions that affect the muscles, bones
or joints; such as arthritis, gout, osteoporosis
and fragility fractures, sarcopenia, auto-immune
and rheumatic conditions)• MSK pain (such as low back pain, neck pain,
fibromyalgia)• MSK injury and trauma.
Persistent and recurrent pain, reduced physicalfunction and impaired quality of life and wellbeing
are unifying features of MSK health impairments.
MSK health impairments and sequelae are relevant
across the lifecourse; they are not just manifestationsof older age. MSK health impairments are common
in children and adolescents and are associatedwith significant functional, educational and social
impacts3–5, highlighting the importance of alifecourse lens to prevention and management.

Burden of diseaseNon-communicable diseases are recognised as themost important issue for population health globally6.
While health systems must respond to emerging
threats and priorities, such as the COVID-19
pandemic and the emerging burden of long-COVID,
the burden of disease associated with NCDs andtheir sequelae has been consistently rising and thefocus of serial global health priority meetings6–8.

Within the breadth of NCDs, MSK conditions
are the leading contributors to disability globally
across the lifecourse, accounting for 17% of all
YLDs in 20199.
This contribution likely underestimates the extent
of the burden of MSK disability, when considering
persistent pain conditions and MSK injury due tobone fragility, accidents and violence and roadtraffic trauma13–15. Importantly, the MSK-attributed
disability burden is greatest in LMICs9. Globally,
rehabilitation services are in highest need for
MSK health conditions and greatest for low backpain10. The burden of disease associated with MSK
conditions, MSK pain and MSK injury and trauma
continues to rise globally, largely attributed to ageing
and the increasing prevalence of NCDs and their risk
factors, and road traffic trauma16–18.
MSK conditions represent the highest healthcare
cost by condition group in high-income economies
like Australia, Europe and the United States17, 19–21.
In LMICs, MSK conditions impose a significant
burden of disease and a threat to economic
and social development for both individuals
and communities12, 22. This will only increase as
population ageing accelerates most rapidly in thesecountries23, 24, together with increasing MSK injury,
falls and trauma25, 26.
There is a strong rationale for considering MSK
health as a priority for care and health systems
strengthening in NCDs, rehabilitation andchildhood health and ageing30–32 due to:Non-communicable diseases are responsible for
64% of disability adjusted life years (DALYs) globallyand 80% of years lived with disability (YLDs)9.
The global health impacts and trajectories associatedwith NCDs, particularly in low and middle-income
countries (LMICs), are well recognised. Urgent
attention to improving prevention and controlof NCDs is recommended6, 10, 11, with a particularfocus on LMICs12.

12 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH• the burden of disease and high prevalenceof MSK health impairments in co- andmulti‑morbidity health states for NCDs27• MSK health impairment as a risk factor
for other NCDs28• MSK health as a key feature of healthy ageing29.
MSK health impairments are the leading cause of
disability globally and the magnitude of disability
has increased over time and on current trends willcontinue to accelerate.

Health systems strengthening
responses
Despite the unequivocal burden of diseaseassociated with MSK conditions and persistent painof MSK aetiology, health systems strengthening
responses to arrest the trajectories of disability
and productivity loss; impaired quality of life andhealthcare expenditure are lacking at the global
level31, 33–36. The global NCD reform agenda isstrongly aligned with performance indicators for
the Sustainable Development Goals (SDG) andfocused on reducing avoidable mortality fromcancer, cardiovascular disease, lung disease anddiabetes (SDG target 3.4). While appropriate, thisfocus inadequately addresses the morbidity burdenof NCDs, driven largely by MSK health conditions
and the increased risk of mortality with chronic
MSK conditions37–40.
Nonetheless, several nations have initiated nationaland sub-national policy and strategy responses toaddress MSK conditions and persistent MSK pain in
their populations, such as Australia and the United
Kingdom31. While other nations have also explicitly
integrated MSK health and persistent pain priorities
into policy responses for NCDs, a recent systematic
policy analysis suggests that such integration has
been undertaken by only half of the Member Statesof the Organisation for Economic Co-operation
and Development (OECD)30. Population healthmonitoring of MSK health conditions is also lacking41.
While the 2000–2010 Bone and Joint Decade was
effective in raising awareness of the global burden
and impact of MSK conditions42, global leadershipin stewarding a response to address these issues has
not been prioritised by policy makers31. There is now
a strong need to address this global leadership gap
by empirically defining the requisite components
of a global strategy for improving MSK health.

Context for this work
Building on the activities from the 2000–2010 Boneand Joint Decade and subsequent calls for action31,
in 2020, the Global Alliance for Musculoskeletal
Health (G-MUSC) called for a strategic global
response to improving MSK health. In response tothat call, this project aimed to engage and consult
with the global MSK health community and othermulti-sectoral stakeholder groups to inform theco‑design of a blueprint for a global strategy for
MSK health.
The purpose of this project was not to develop acomprehensive strategy. Rather, to identify requisite
components, for guiding later strategy developmentthat could be adaptable for global-level and/or
country-level health systems strengthening efforts.
Specifically, the work aimed to create a blueprint
for value-based MSK health, injury and pain carethat is co-designed and supported by the global
community, including people with lived experience.
The intention of this work is to ultimately support,
guide and accelerate emerging initiatives within
the World Health Organization (WHO) to prioritise
MSK health within its 13th General Program of Workand the strategic directions of other global andinternational agencies.
The purpose of defining empirical, consensus-driven
and prioritised components†/actions of a global
strategy is to enable and guide the WHO and otheragencies to accelerate work on developing a fulland detailed global strategy, inclusive of actions,
resourcing requirements and performance indicators.
By defining the components, the global MSK
community has the opportunity to identify andcommunicate key areas for system-level and servicelevel reform by Member States that are relevant
across the globe, providing the critical foundation
work for the development of a full strategy.

† Components are defined as topic areas of focus
or priority within the structure of a global strategy.
The components may be broad and be supported by
specific and more detailed sub-components or actions.
PART 1: THE IMPORTANCE OF MUSCULOSKELETAL HEALTH

13

2

AIMS ANDOBJECTIVES OF
THE PROGRAM
OF WORKThe aim of this program of work was to engage andconsult with the global MSK health community andother multi-sectoral stakeholders, including people
with lived experience, to inform the co-design ofprioritised components/actions for a global strategy
for improving MSK health. Here, MSK health refers
to MSK conditions, MSK pain and MSK injury andtrauma. The specific objectives were to:
1. Identify and synthesise:(a) the contemporary challenges in deliveryof value-based care for the prevention andmanagement of MSK health impairment

2. Synthesise current national policy approaches
to improve MSK health.
3. Empirically derive the requisite components
and priorities for a global strategic response
to improve MSK health.
Detailed research papers have been developed(and are in development) for each objective1, 2.
The purpose of this report is to provide an overview
of the key findings with emphasis on describing
the requisite components of a global strategy
on prevention and management of MSK health,as outlined in Section 5.

(b) globally-relevant priorities for action/reformin health systems and services to achieve
improved prevention and managementof MSK health impairments.

PART 2: AIMS AND OBJECTIVES OF THE PROGRAM OF WORK

15

3

DEVELOPING
THIS REPORTThree research designs were adopted for the project,aligned to each of the objectives. Each design
enabled unique evidence to be derived that could
inform a global strategic response for MSK health.
The designs included:
1. an in-depth qualitative phase
2. a policy scoping review phase
3. a global eDelphi phase.

These three discrete research designs wereadopted to enable several rich sources of data to
be triangulated and to strengthen the evidence ofthe final product. Importantly, the first two phases –the qualitative research and policy scoping review– were designed to inform the quantitative eDelphi
phase from which a final framework of components/
actions for a global strategy was derived.
Figure 1 outlines the sequencing of each phaseof work undertaken between May 2020 andMarch 2021.

P H AS E 1

PHA SE 2

Qualitative studyof 31 international
key informantsfrom 20 countries

Scoping reviewof 41 health policy
documents

May to August 2020

July 2020 to March 2021

Initial framework of components for a global strategy

Global eDelphi Round 1:
Rate importance, collect written feedback
P HA SE 3

Revised framework of components for a global strategy

Global eDelphi
Oct 2020 to Jan 2021

Global eDelphi Round 2:
Re-score components and identify essential components

Final framework of prioritised requisite components
for a global strategy

Figure 1: Phased components of the program of work. Phases 1 and 2 triangulated to inform Phase 3.
PART 3: DEVELOPING THIS REPORT17

4OVERVIEWOF RESULTS

4.1

PHASE 1: INTERVIEWS WITH KEY INFORMANTS
AND ESTABLISHMENT OF A LOGIC MODEL

Who participated?
Key informants were sampled across six eligibility
criteria (Box 1).
Other than the category of ‘thought leader’, KIs wereintentionally sampled as affiliates or representativesof organisations to enable results to be reflectiveof broader perspectives, beyond just those of
the individual. However, the data presented do
not necessarily reflect the endorsed views of theorganisations represented.
31 KIs from 20 countries (40% LMICs based on
the World Bank list of economies, June 2020)
participated. The demographic and geographic
profiles are summarised in Table 1.

Box 1: Sampling criteria for Phase 1
key informants
1. A President/Chair, Vice President orappropriately delegated senior-level official(e.g. leader of a special interest group or
subcommittee) of an international or global
clinical/professional organisation relevant to
MSK health, persistent pain care and/or injury
and trauma, having held this post for at least
12 months.
2. A President/Chair, Vice President orappropriately delegated senior-level official of
an international or global advocacy (including
patient advocacy) organisation relevant to MSK
health, persistent pain care, injury, ageing,
NCDs, or health systems strengthening, having
held this post for at least 12 months.
3. An official of the WHO with a scope of work
relevant to MSK health, ageing and lifecourseor NCDs, having held this post for at least
12 months.
4. A senior officer in a national Ministry of Healthhaving held a position for at least 12 months
that includes international activities in healthsystems strengthening efforts (i.e. beyond asingle national context).
5. A thought leader defined by the publicationof at least 3 peer-reviewed academic journal
papers or health policies in the last 5 years thathave a focus on health system reform or healthpolicy relevant to MSK health, persistent pain
care or injury and trauma.
6. A person with a lived experience of an MSK
health condition and/or persistent MSK pain
for more than 5 years.

PART 4: OVERVIEW OF RESULTS

19

P HAS E 1

This phase involved an in-depth qualitative study
with 31 international key informants (KIs). The
detailed methods and results of this phase havebeen reported elsewhere1. Individual semi-structured
interviews were undertaken between May andAugust 2020, including a pilot phase.

P HAS E 1Table 1: Demographic and geographic profile of the KIs (n = 31) from Phase 1.

Sampling categories#

Demographic characteristics• Person with a lived experience of an MSK
condition or persistent MSK pain: 7

Mean (SD) age, range:• Global or international clinical/professionalorganisation relevant to MSK health, persistent
pain care and/or injury and trauma: 20

Mean (SD) years of experience in healthcare, range:• Global or international advocacy organisation
relevant to MSK health, persistent pain care,injury and trauma, ageing, NCDs or healthsystems strengthening: 11• 57.9 (10.8), 41–77 years• 30.4 (11.2), 6–53 years
Registered clinicians:• 22 (71%)• Thought leader in health system reform or healthpolicy relevant to MSK health, persistent pain,
or injury and trauma: 7• World Health Organization: 3• National Ministry of Health: 1

11 clinical disciplines

20 countries included

Chiropractors: 2

Argentina

Italy

Family medicine physician: 1

Australia

Japan

Neurologist: 1

Bangladesh

Emergency medicine physician: 1

Occupational therapist: 1
Orthopaedic or trauma surgeons: 3

BrazilPaediatric rheumatologist: 1

CanadaPhysical medicine and rehabilitation physicians: 2
Physiotherapists: 3
Public health physicians: 2
Rheumatologists: 5

Ethiopia
Finland

Kenya
Malaysia
NorwayPhilippines
South Africa
Switzerland

FranceUnited Kingdom

Germany

United StatesIndia# groups are not mutually exclusive, meaning a KI could identify as representing one or more of the sampling categories.

20 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTHOrganisations represented
Global (n = 14; 56%)
Global Alliance for Musculoskeletal Health(G-MUSC); Health Systems Global (HSG);
International Association for the Studyof Pain (IASP); International Society ofPhysical & Rehabilitation Medicine (ISPRM);
International Federation on Ageing (IFA);International Osteoporosis Foundation (IOF);
Osteoarthritis Research Society International(OARSI); Rehabilitation International; SociétéInternationale de Chirurgie Orthopédique(SICOT); World Federation of Chiropractic (WFC);
World Federation of Occupational Therapists(WFOT); World Health Organization (WHO);
World Physiotherapy (IFOMPT sub-group);
World Spine Care.

International high-income (n = 4; 16%)Australia and New Zealand Musculoskeletal
Clinical Trials Network (ANZMUSC); European
Alliance of Associations for Rheumatology(EULAR); European Society for Clinical andEconomic Aspects of Osteoporosis, Osteoarthritis
and Musculoskeletal Diseases (ESCEO);EUROSPINE.
International low and middle-income (n = 3; 12%)African League Against Rheumatism (AFLAR);AO Alliance Foundation; Santokba Durlabhji
Memorial Hospital (India).

International mixed income (n = 3; 12%)Asia-Pacific League of Associations forRheumatology (APLAR); Community Oriented
Program for Control of Rheumatic Disorder(COPCORD)s; Pan-American League of
Associations for Rheumatology (PANLAR).

What did the key informants tell us?
Transcripts of the interviews were analysed in aphased approach using an inductive, groundedtheory method43, 44. The data from the transcripts
were organised into five categories to build a logic
model for the project (Figure 2). This logic model
provided the foundation to the project, to which
subsequent phases were anchored.
The logic model was built around the following
categories:
1. Context: the contemporary landscape for MSK
health at the global level, as described by KIs.
2. Goals: suggested goals or targets for a global
strategy on MSK health.
3. Guiding principles: concepts or approaches thatshould underpin all activities or actions withina strategy. These principles are reflected in the
final framework of pillars and components in
Section 5 (page 39). These principles may be
applied by countries/organisations to develop
national-level strategies.
4. Strategic priority areas or Pillars: groupsof components or actions important for acontemporary global strategic response toimprove MSK health. These Pillars, along with
their detailed components for action, were
further informed by the Phase 2 policy scoping
review. These were ultimately used to build thefinal framework presented in this report, after
validation in a global eDelphi study (refer to
Section 4.3, page 31).
5. Accelerators: processes or supportsthat enable action on strategic priority
areas. The accelerators represent foci for
implementation planning that can be usedby countries or organisations to operationalise
the components of the framework.
This report focuses on Category 4 – ‘Pillars’, while thedetail underpinning other areas has been reported
elsewhere1. Broad contextual considerations
expressed by KIs are summarised on pages 23–24.

Ministries of Health (n = 1; 4%)
Public Health England.

PART 4: OVERVIEW OF RESULTS

21

P HAS E 1

A total of 25 organisations were represented.

Goal: To create an adaptable blueprint for a global strategy
to support country-level health systems strengthening
in value‑based MSK health, injury and pain care that isco‑designed and supported by the global community,
including patients and which targets improving function,
participation and overall quality of life for all ages.
Musculoskeletal (MSK) health means MSK conditions, MSK pain and MSK injury and trauma

CONTEMPORARY CONTEXTUAL FACTORS RELEVANT TO MUSCULOSKELETAL HEALTH GLOBALLYP HAS E 1

G-MUSC vision: A world where prevention andmanagement of musculoskeletal (MSK) health conditions,
MSK pain and MSK injuries/trauma are prioritised inhealth systems to optimise people’s functional ability
and participation across the lifecourse and to reduce
the associated global burden of disability.

GUIDING PRINCIPLES

1

2

3

4

5

Adaptability
to local contexts

Inclusiveness throughbroad consultation
across economies andco-design, including
patients/citizens

Improve function,
quality of life andoverall health

Adopt a lifecourse
approach to
MSK health,from childhoodto older age

Equitable
access to early,
value-based care

PILLARS FOR HEALTH SYSTEMS STRENGTHENING FOR MUSCULOSKELETAL HEALTH

Engaging, empoweringand educating communities

Leadership, governanceand shared accountability

Financingapproaches

Servicedelivery

Equitable access to
medicines and technologies

Workforce

Surveillance

Research
and innovation

Strategy components and actions

Adaptable blueprint

ACCELERATORS■ Increase societal and government

awareness of MSK health and theimpacts of MSK-related disability■ Identify essential, evidence‑based

standards or actions to enable
lower‑resourced settings toinitiate reforms■ Align with existing global■ Leverage multi-sectoral■ Provide guidance on MSK health■ Co-design objectives andor regional strategies or policies
in the context of pandemics;
e.g. COVID-19■ Translate guidance into

partnerships and co-operation
performance indicators
for a full strategy

multiple languages

Figure 2: Data-driven logic model developed for the project directly informed by the Phase 1 qualitative study
with international KIs. The logic model is adapted from Briggs et al1, 2 and supported by G-MUSC.

22 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Important contextual considerations for a global
strategic response identified by the KIs are outlined
below and reflect six overarching themes, with
examples of supporting quotes. Comprehensive
reporting of these considerations has been
undertaken previously1.
1. MSK health is afforded a relatively lower
priority status compared with other healthconditions and is poorly legitimised.
“I think that MSK conditions are not directly
life-threatening diseases, so the importanceof MSK conditions has been underestimated.
I think that lower back pain and knee
osteoarthritis are two major targets inmusculoskeletal conditions, but many people
feel that conditions such as knee osteoarthritis
would be far less important compared tocancer or cardiovascular disease.” (KI 1, Japan)“I think MSK would need to compete withso many other priorities that low and middleincome countries are faced with, but I think
the important difference here is you can show
a very high number on mortality on so many
NCDs and even communicable diseases.
The mortality number is missing (for MSK),
although there is a tremendous burden on
disability and other things that we can talkabout. But I think the sheer fact that there isno hard number on mortality that you cancount, it just slips very low on the priority
side.” (KI 19, India)

2. Improving MSK health is more than justhealthcare. It needs inter-ministerial
prioritisation, co-operation and collaboration.
Attention must extend beyond healthcare
to also consider industry, transport andinfrastructure as well as the built environment.
“You may not really want to ever get out of yourhome because it’s really challenging to movearound. Then you find where the road systems
have improved, like in the capital city here we
now have nice, really beautiful highways, but
the highways actually have limited places where
you can cross on foot. So, if you’re physicallychallenged and the vehicles are cruising at ahigh speed – or if there’s a crossing, it is very,
very far away, it is so far that you can’t walk that
distance. These are not major, but they are
major to the quality of life.” (KI 3, Kenya)“People who do not have secure housing, who
do not have access to nutritious food, who do
not have safe places to recreate and move,it’s not like they’re just making choices to notchange their lifestyle; their environment isprohibitive of them being able to change theirlifestyle. So, there are things that can be done
to change that too, like created environments,
built environments can go a long way towards
including musculoskeletal health that aren’t
ever going to be done in the clinic, they haveto be done in the community.” (KI 8, USA)

3. Global-level guidance such as thatfrom the World Health Organization,is needed for country-level health systems
strengthening in MSK health.
“I think that raising awareness in whatever formis critical if we are to gain any sort of successwhen it comes to MSK disorders. We needto raise that awareness and without a global
strategy I think the management of MSK
disorders will continue to be suboptimal, it’ll
continue to be relegated. So, I think just merely
stating that there’s a problem is not the answer.
I think we all know there’s a problem and justmitigating that is not the answer. So, I think any
action that is taken needs to be significant andit needs to be sustained.” (KI 7, UK)

PART 4: OVERVIEW OF RESULTS

23

P HAS E 1

Category 1: The current global
landscape for MSK health:contextual considerations forhealth systems strengthening

P HAS E 1

4. The COVID-19 pandemic will have an impact
on MSK health globally and opportunities
for health system strengthening in MSK
healthcare may be compromised.
“Like, for example, if you look at homerehabilitation services for people withdisabilities, now because of COVID we are notable to provide home-based rehabilitation
services because most rehabilitation services
require physical contact. So, because of this,most rehab in institutions in Addis Ababa andsome African countries, they’re almost not
functioning at this point. This situation worsens
the conditions for people with disabilities
like, for example, children with cerebral palsy
who need regular exercise, people who needregular rehab exercises. Since they’ve alreadystopped doing the exercise, their condition
will worsen and the same thing will happen inmusculoskeletal and other disabling situations.
So, the impact is really huge.” (KI 30, Ethiopia)

5. There are multiple inequities (health,social, economic and work) associatedwith impaired MSK health. For this reason,
the social determinants of MSK health mustalso be considered.
“I’ve done some work in Botswana… andI recognise that when the breadwinner iscompromised through MSK disorders thenthat has a real ripple effect throughout
the whole family and into the community.
I think particularly in areas where the social
determinants of health are such that citizens
are poorly supported, an inequity leads toan exacerbation of these MSK disorders.”(KI 7, UK)“…because in our country there will be many
people whose income level is lower andthey don’t bother about the loss of income,they lie in their home, so they have to makeeffort to report to the facility whenever they
are ill and they also don’t give time to themusculoskeletal pain often.” (KI 5, Bangladesh)

24 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

6. Service delivery for MSK health ischaracterised by multiple complexities,
such as a very large number of diseases/
conditions, multiple practitioners responsible
for care and service delivery spanning
community to tertiary-level care. There is also
no universally accepted classification system
for MSK health impairment.
“…there is the fact that for all these otherchronic conditions that you have said,a specific physician is treating them. In
musculoskeletal conditions, apart from thefact it can be a physiatrist or as it happens insome countries directly a physiotherapist that
can treat them, it can be a rheumatologist,
it can be an orthopaedic surgeon. It’s also
sometimes really difficult for the patient tounderstand who should take care of them.”(KI 29, Italy)“The nomenclature for musculoskeletal
disorders is actually quite unsatisfactory.
We have competing professions and thisleads to an awful lot of confusion. So you’ll
have chiropractors, osteopaths, MD doctors,
orthopaedic surgeons and physical medicine
rehab doctors all using similar but different
terminology to describe the same phenomena
and everybody’s confused, so a lot of people
throw their hands up and say, “We can’t pay
attention to this because it’s too fragmented.”(KI 18, India)

4.2	PHASE 2: MUSCULOSKELETAL HEALTH POLICYSCOPING REVIEW
Searching for policy documents

This phase involved a systematic search andappraisal of national health policies relevant to
MSK health. The approach to undertaking the reviewaligned with the methodologic framework proposed
by Arksey and O’Malley45 and subsequently adapted
by Anderson et al46 for policy mapping. The aim of
the review was to derive a snapshot of contemporary
MSK-specific national policy approaches andpriorities in order to: i) enable policy learning fromlocal policy action and ii) to further inform theframework of components derived from Phase 1.

Policy documents were identified using a numberof search strategies, including:A health policy document was defined as:
1. government issued; published by government
departments; or explicitly endorsed bygovernment departments as representing
the policy of a specified jurisdiction
2. targeting population-level improvement in
MSK health; or containing substantial content
dedicated to MSK health or any category of
MSK health condition (e.g. MSK pain, injury,
MSK conditions)
3. containing jurisdiction-wide strategies,
action plans or system-level Models ofCare or Models of Service Delivery47,
consistent with an earlier approach30.

1. a systematic online desktop search across the
30 most populated nations† using standardised
keywords
2. identifying policy documents known to the
G-MUSC International Co-ordinating Council
members and known policy researchers (expert
round), including access to raw data from anearlier integrated NCD policy review of OECD
Member States30
3. snowballing methods that also allowed
for inclusion of multi-national policies
4. policy documents being identified by panellists
in the eDelphi phase (Phase 3, Section 4.3).
The yield of policy documents was reviewed
for eligibility for inclusion by two reviewers.

Analysing policy documents
Data extraction was undertaken by a single reviewer
and analysis was undertaken inductively using acontent analysis method to identify the key themes
from the included policies. These policy themes
were then compared with the logic model derived
in Phase 1 to further develop and refine the Pillars
in preparation for Phase 3.

† based on UN World Population Prospects (2019)
PART 4: OVERVIEW OF RESULTS

25

P HAS E 2

Approach to the review

P HAS E 2

Review outcomes

165 policy documents were identified with 41 (24.8%)48–88 retained after exclusions and removal of
duplicates (Figure 3). The final yield represented policies from 22 countries (20 (90.9%) high-income
nations; 2 (9.1%) upper middle-income nations) and two multi-national regions (Table 2).

Identification

Multimodal search,n = 165• Systematic desktop search: 123• Expert network input: 11• Snowballing: 12• eDelphi panel input: 19

Screeningand eligibility

Records after duplicates
removed, n = 159

Full text reviewed for
eligibility, n = 159

6 duplicates excluded

118 excluded• Clinical guideline: 56• Non-government report: 17• Government report on disease
burden only: 14• Not policy document: 14
Included

Policy documents
retained, n = 41

Figure 3: PRISMA-aligned flowchart of policy search and selection process.

26 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH• No substantial MSK component: 10• Document older than 2010: 7

Country or region

Year published(Years operational)

Title of policy (Publisher)

Australia 150

Australian National Strategic Action Plan on Arthritis(Australian Government Department of Health)2019

Australia 251

Australian National Strategic Action Plan on Osteoporosis(Australian Government Department of Health)2019

Australia 349

Australian National Strategic Action Plan for PainManagement (Australian Government Department of Health)2019

Belgium 152

Aanpak van chronische pijn in Belgie: Verleden, heden en
toekomst (Management of chronic pain in Belgium: past,present and future) (Federal Public Agency for Public Health,
Safety, Food and the Environment, Belgium)

2011

Canada 165

Institute of Musculoskeletal Health and Arthritis Strategic
Plan 2014–2018: Enhancing Musculoskeletal, Skin and Oral
Health (Canadian Institute of Health Research)

2014(2014–2018)

Canada 248

Joint Action on Arthritis – a framework to improve arthritis
prevention and care in Canada (Arthritis Alliance of Canada)

2012

Canada 384

Chronic Pain in Canada: Laying a Foundation for Action(Health Canada)

2019

Chile 162

Estrategia Nacional De Salud Para el cumplimiento de losObjetivos Sanitarios de la Década 2011–2020 (National
Health Strategy to complete the Health Objectives of
the Decade) (Government of Chile)

2011(2011–2020)

Columbia 170

Plan Nacional de Seguridad y Salud en el Trabajo
2013–2021 (National Plan for Safety and Healthat Work 2013–2021) (Ministry of Labor, Columbia)

2014(2013–2021)

Denmark 171

Anbefalinger for tværsektorielle forløb for mennesker
med kroniske lænderygsmerter (Recommendations
for multidisciplinary management of low back pain)(National Health Board of Denmark)2017 European Union
160

European action towards better musculoskeletal health(EFORT/EULAR/IOR)

2017 European Union
259

Occupational health and safety risks in the healthcare
sector-Guide to prevention and good practice(European Commission, Luxembourg)

2010

PART 4: OVERVIEW OF RESULTS

27

P HAS E 2

Table 2: Table of included policies by country/regionP HAS E 2Country or region

Title of policy (Publisher)Year published(Years operational)

Finland 161

Kroonisen kivun ja syöpäkivun hoidon kansallinen
toimintasuunnitelma vuosille 2017–2020 (National Action
Plan for the Treatment of Chronic Pain and Cancer Pain)(Ministry of Social Affairs and Health, Finland)

2017

France 168

Plan d’amélioration de la prise en charge de la douleur,2006–2010 (Monitoring Plan for National Pain Program)(Ministry of Health and Solidarity, France)

2006(2006–2010)

France 269

Plan santé au travail, 2016–2020 (Occupational Health Plan
2016–2020) (Ministry of Labour, France)

2016(2016–2020)

Hungary 163

Egészséges Magyarország 2014–2020 (Health Hungary 2014– 20152020 Health Sector Strategy) (Ministry of Human Resources,
State Secretariat for Health, Government of Hungary)International 153

A Framework to Evaluate Musculoskeletal Models of Care
(Global Alliance for Musculoskeletal Health of the Boneand Joint Decade, United Kingdom)

2016

Italy 157

Piano Nazionale della Cronicità (National Plan for Chronic
Disease) (Directorate-General of Health Programming, Italy)

2016

Ireland 180

The Model of Care for Rheumatology in Ireland (Royal
College of Physicians of Ireland)2015

New Zealand 172

National Health Committee Low Back Pain: A Pathway toPrioritisation (National Health Committee, New Zealand)

2014

New Zealand 273

Low Back Pain (LBP) Tier 2 Assessment (National HealthCommittee, New Zealand)2015

New Zealand 375

The Mobility Action Program (New Zealand Ministry of Health) 2015

Norway 158

Norway: Together for a good working environment(European Agency for Safety and Health at Work)

2007–2010

Norway 276

Folkehelsemeldinga 2018–2019: Gode liv i eit trygt samfunn(Public Health Report 2018–2019: Good Life in a Safe
Society) (Norwegian Ministry of Health and Care Services,
Government of Norway)

2018(2018–2019)

Portugal 156

Plano Estrategico Nacional De Prevencao E Controlo Da Dor(PENPCDor) (National Strategic Plan for Pain Prevention andControl (PENPCDor) (Directorate General Health, Portugal)

2017 Republicof Korea 167

제3차 국민건강증진종합계획 (2011~2020) (The 3rd National
Health Promotion Plan 2011–2020) (Korean Ministry of Healthand Welfare)

28 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

2011

Year published(Years operational)

Spain 154

Estrategiade Atenciónal Dolor 2017–2020 (Pain Care
Strategy 2017–2020) (City of Madrid, Spain)2017(2017–2020)

Switzerland 182

Nationalen Strategie Prävention nichtübertragbarer
Krankheiten (NCD-Strategie) 2017–2024 (National strategy
for the prevention of noncommunicable diseases 2017–2024)(Federal Office of Public Health and Swiss Conference ofCantonal Health Directors, Bern, Switzerland).

2016(2017–2024)

Switzerland 283

Nationale Strategie Muskuloskelettale Erkrankungen(2017–2022) (National Strategy for Musculoskeletal Disorders
2017–2022) (Rheumaliga Schweiz, Switzerland)

2017(2017–2022)

Turkey 178

Türkiye Kas ve İskelet Sistemi Hastalıkları Önleme ve Kontrol
Program (2015–2020) (Turkey Musculoskeletal Disease
Prevention and Control Program 2015–2020) (Ministryof Health, Turkey)

2015(2015–2020) United Kingdom(England) 185

Developing partnerships and a whole-system approachfor the prevention of musculoskeletal conditions in England(Public Health England, England)2018 United Kingdom(England) 279

Musculoskeletal core capabilities framework for the firstpoint of contact practitioners (Health Education Englandand NHS England, England)2018 United Kingdom(England) 355

Musculoskeletal health: A 5-year strategic framework forprevention across the life course (Department of Health andSocial Care, Public Health England and Department for Workand Pensions, England)

2019(2019–2023) United Kingdom(Scotland) 486

Allied Health Professional (AHP) Musculoskeletal Pathway
framework (National Minimum Standard) (The Scottish
Government, Scotland)2014 United Kingdom(Scotland) 581

Future Provision of Specialist Residential Chronic PainManagement Services in Scotland: Consultation Report(The Scottish Government, Scotland)2014 United Kingdom(Wales) 688

Living with Persistent Pain in Wales(Welsh Government, Wales)2019 United Statesof America 187

Improving pain management and support for workers
with musculoskeletal disorders: Policies to Prevent Work
Disability and Job Loss (US Department of Labor/IMPAQInternational, USA)2017

PART 4: OVERVIEW OF RESULTS

29

P HAS E 2

Title of policy (Publisher)

Country or regionP HAS E 2Country or region

Year published(Years operational)

Title of policy (Publisher) United Statesof America 274

National Institute for Occupational Safety and Health(NIOSH) Musculoskeletal Health Program (National Institutefor Occupational Safety and Health, USA)2019

 United Statesof America 377

A National Public Health Agenda for Osteoarthritis: 2020
Update (Osteoarthritis Action Alliance, Centre for Disease
Control and Prevention, Arthritis Foundation, USA)2020

 United Statesof America 466

National Pain Strategy: A Comprehensive Population
Health-Level Strategy for Pain (Department of Health andHuman Services / Interagency Pain Research Coordinating
Committee, USA)2011

 United Statesof America 564

Relieving Pain in America: A Blueprint for Transforming
Prevention, Care, Education, and Research. (Institute ofMedicine, USA)2011

A detailed analysis of the policy documents is reported elsewhere2. Eight policy themes were identified
across the 41 included documents, each supported by a number of sub-themes (Figure 4). The detailed
sub‑themes underpinning each of these 8 policy themes were then compared and contrasted with thedetailed components underpinning the Pillars of the logic model from Phase 1. These policy data thensupplemented the components underpinning the Pillars of the logic model to create a final frameworkof components for Phase 3 of the project (Section 4.3).

1

2

3

4

Citizens, consumers
and communities

Leadershipand governance

FinancingServicedelivery

5

6

7

8

Medicines
and technologies

Workforce

Data andinformation systems

Research
and innovation

Figure 4: Eight policy themes derived from content analysis of policy documents. Each of the 8 policy
themes were supported by a number of sub-themes (data not shown).

30 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

4.3

PHASE 3: GLOBAL eDELPHI
Participants

A global eDelphi was undertaken between October
2020 and January 2021. The purpose of the eDelphi
was to engage a large, international, cross-sectoral
panel to review, rate and revise the framework ofcomponents of a global strategic response, defined
empirically from the data in Phase 1 and Phase 2.

The panellists for the eDelphi were sampled as
individuals or organisations, meeting at least oneof the nine criteria outlined below (Box 2).

P HAS E 3

PurposeRecruitment of panellists was undertaken through:• contact databases held by G-MUSC (compliant
with privacy standards)• a systematic desktop search of clinical and civilsociety organisations relevant to MSK health anddisability across the 30 most populated nations
based on UN World Population Prospects• through open invitations on social media
platforms.

Box 2: Sampling criteria for Phase 1 key informants
1. A person with a lived experience of a MSK
health impairment (MSK condition, MSK pain,
MSK injury) for at least 5 years.
2. A registered clinician or other health worker,
working in MSK health, pain care or injury care
for at least 5 years.
3. An officer of a clinical/professional organisation
relevant to MSK health, pain care or injury careand have held this post for at least 12 months.
4. An individual currently involved in global
or national health policy, service design orservice implementation related to MSK health,
MSK pain, injury, NCDs, ageing, disability or
rehabilitation for at least 2 years.

6. A thought leader, defined as an individual who
has published at least 2 peer-reviewed papers
or health policies in the last 5 years related to
global health systems or health service reformfor MSK health, MSK pain, injury, NCDs, ageing,
disability or rehabilitation.
7. An individual holding an academic (e.g.
research or teaching) or workforce training
position(s) related to MSK health, MSK pain,
injury, NCDs, ageing, disability or rehabilitation
for at least 2 years.
8. An officer of the WHO.
9. An officer of a national or sub-national
Ministry of Health.

5. An individual currently involved in advocacy(including patient advocacy) in the context of
MSK health, MSK pain, injury, NCDs, ageing,
disability or rehabilitation for at least 2 years.

PART 4: OVERVIEW OF RESULTS

31

P HAS E 3

Development of a framework of components
The rich and detailed qualitative data obtained from the KI interviews in Phase 1 were used to define thecomponents within each Pillar of the logic model. These components were then further extended by thepolicy data derived from Phase 2. Finally, components were expressed as action statements for health systems
and services in preparation for presentation to the eDelphi panel and creating a final framework of requisite
components for a global strategy on MSK health (Figure 5).

PHASE 1P HA SE 2

P HA SE 3

Interviews with 31 key
informants (Phase 1)

Policy review toderive policy themes
and detailed policy
components (Phase 2)

Translation ofcomponents withineach Pillar to action
statements (Phase 3)

Further developmentof detailed components
within each Pillar of the
Logic Model

Presentation to Delphi
panel as frameworkof components andactions (Round 1)

Construction of logic
model: Pillars anddetailed components

Revision of frameworkof components andactions

Final framework ofcomponents andactions presented toDelphi panel (Round 2)

Figure 5: Process of deriving the components and actions
underpinning each Pillar of the logic model throughto creating a final framework of requisite components
and actions for a strategy on MSK health.

32 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Outcomes

Panellists responded to two online surveys in
October 2020 (Round 1) and December 2020
(Round 2).

The Delphi panel characteristics are summarised
in Infographic 1.

Round 1In Round 1, panellists rated 60 discrete components
according to their importance for health systems
strengthening for MSK health. Panellists provided
free-text comments where revisions were required.
Where the rating of importance of a component/
action met a pre-specified threshold†, thecomponent was retained in the framework,revised (if appropriate) and re-presented to thepanel in Round 2. Where a component did notmeet the threshold for retaining, it was removed
from the framework.

674 valid responses (47% female) were recorded
for Round 1 (109 organisation-level responses
and 565 individual-level responses) and 439 valid
responses (65%) in Round 2. Seventy-two countries
were represented in Round 1 (46% LMICs) and 66 inRound 2 (44% LMICs), covering all UN geographic
regions (Figure 6A). At a panellist-level, most of thepanellists were resident in Europe and Central Asia
and North America (Figure 6B).

Round 2In Round 2, panellists considered a revised
framework of components/actions and identified,
which they considered ‘essential’, ‘desirable’ or‘unsure’‡. Panellists also rated the final framework
according to its value and credibility for healthsystems strengthening.

† Across the components presented in Round 1, the panel medianwas categorised as 1–3: ‘not important’, 4–6: ‘equivocal’, or 7–9:
‘important’. An item was retained for Round 2 where the overall
panel median score was ≥7 with level of agreement of ≥70% by
panellists within the band 7–9. An item with a panel median of
4–6 or other median band with a consensus of <70% within thesame band was defined as ‘uncertain’ and flagged for re-ratingin Round 2. An item with a panel median of 1–3 and a level ofagreement of ≥70% by panellists within the band 1–3, wasdefined as ‘unimportant’ and removed from the framework.
‡ A component was considered ‘essential’ where ≥80%of the panel ranked it as ‘essential’.

PART 4: OVERVIEW OF RESULTS

33

P HAS E 3

Data collection

Infographic 1

DELPHI PANEL
Round 1Round 2

48.3

49.7

(n = 439)(n = 674)

P HAS E 3

Age

Mean (95% CI)

Gender

(47.3, 49.3)(48.5, 50.8)

Male351 (52.1)

231 (52.6)

Female316 (46.9)

206 (46.9)

Other

7 (1.0)2 (0.5)

72

66

46%

44%

109

85

Countries
represented

Percentage low
to middle income

Type of response, n (%)
Organisation

565

Total years healthcare
experience

Total years lived experience
with MSK health condition(21.1, 23.3)

18.7

20.9

517

Registered clinician / health worker

290

Academic or workforce training position

149

180

Ofﬁcer of clinical / professional organisation

149(29.7)

Person with a lived experience of a MSK health condition

128

Thought leader

126

39

(54.2)

Advocacy role

103

494

Health policy / service design / implementation ofﬁcer

8(73.3)

Low to middle income(17.9, 23.9)(Round 1 only; categories are not mutually exclusive)

By participant(45.8)(20.2, 22.0)

Sample by respondent category(World Bank Classifications 2020)(Round 1 only)

33

22.2

(16.4, 21.0)

Mean (95% CI)

By country(80.6)

21.1

Mean (95% CI)(19.4)

354(83.8)

Individual

Economic band

(16.2)High income

National Ministry of Health ofﬁcer

30

34 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

WHO ofﬁcer
100

200

300

400

500

600

P HAS E 3

AAASeries1
Series1
138
138

B

Powered by Bing
© Australian Bureau of Statistics, GeoNames, Microsoft, Navinfo, TomTom, Wikipedia
Powered by Bing
© Australian Bureau of Statistics, GeoNames, Microsoft, Navinfo, TomTom, Wikipedia

B
B

1

Series1
138

Powered by Bing
omTom, Wikipedia

1

Figure 6: 	Global geographic heatmap showing distribution of participants in Phase 3. Graphic powered by Microsoft
Excel (Microsoft Corporation, Redmond, WA, USA).
 	Panel A illustrates the distribution of countries represented in Phase 3 (n = 72). Consistent blue shadingreflects the countries represented.

 	Panel B illustrates the distribution of participants (n = 674) by country, ranging from 1 to 138 participantsby country. Graded blue shading represents frequency of participants by country, with darker shading
representing a greater number of participants in that country.
PART 4: OVERVIEW OF RESULTS

35

1

P HAS E 3

The 116 organisations represented in Phase 3, in addition to G-MUSC, are listed below.

Clinical societies
1. African League of Associationsof Rheumatology (AFLAR)

2. American Academy of Orthopaedic
Manual Physical Therapists (AAOMPT)

26. International Association for the Study of Pain
(IASP): Musculoskeletal Pain Special Interest
Group; Pain, Mind and Movement Special
Interest Group

3. American Association of Nurse Practitioners(AANP)

27. International Federation of Podiatrists (IFP)

5. American Physical Therapy Association (APTA)

30. International Society of Physical andRehabilitation Medicine (ISPRM)

4. American College of Rheumatology (ACR)

6. Associazione Italiana per lo Studio del Dolore(Italian Association for the Study of Pain)
7. Associazione Nazionale Malati Reumatici –Anmar Onlus (Italian National Associationof Rheumatic Diseases)
8. Belgian Chiropractic Union

9. British Chiropractic Association

10. Canadian Chiropractic Association

11. Chiropractic Association of South Africa
12. College of Podiatry, UK

13. Cyprus League Against Rheumatism

14. De Nationale Vereniging ReumaZorg
Nederland (National Association of Reuma
Care Netherlands)
15. Deutsche Rheuma-Liga

16. Deutschen Gesellschaft für Orthopädie
und Orthopädische Chirurgie (DGOOC)(German Society for Orthopedics andOrthopaedic Surgery)

17. Deutschen Gesellschaft für Unfallchirurgie(DGU) (German Society for Trauma Surgery)
18. European Academy of Chiropractic

19. European Alliance of Associations forRheumatology (EULAR) – People with Arthritis
and Rheumatism sub-group
20. European Chiropractors’ Union

21. European Federation of National Associationsof Orthopaedics and Traumatology (EFORT)
22. European Society for Clinical and Economic
Aspects of Osteoporosis, Osteoarthritis andMusculoskeletal Diseases (ESCEO)
23. Hellenic League Against Rheumatism

24. Hungarian Chiropractors’ Association

25. International Association for the Study ofPain (IASP) Global Alliance of Pain Patient
Advocates Presidential Task Force

36 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

28. International Maitland Teachers Association
29. International Pediatric Association (IPA)

31. Japanese Association of Chiropractors

32. Japanese Society of Chiropractic Science
33. Kenyan Society of Physiotherapists

34. Malaysian Allied Health Profession Council
35. Malaysian Physiotherapy Association

36. Medical Rehabilitation Therapists (registration)
Board of Nigeria
37. Mongolian Physical Therapy Association
38. Mongolian Society of Physical andRehabilitation Medicine

39. Netherlands Chiropractors’ Association
40. Norwegian Chiropractors´ Association

41. Norwegian Interdisciplinary Organisationin Rheumatology
42. Pain Society of the Philippines

43. Pan Arab Osteoporosis Society (PAOS)
44. Pan-American League of Associations
for Rheumatology (PANLAR)
45. Russian Association on Osteoporosis

46. Sociedad Argentina de Reumatología(Argentinian Society for Rheumatology)

47. Société Internationale de Chirurgie
Orthopédique et de Traumatologie(International Society of Orthopaedic Surgery
and Traumatology) (SICOT)
48. Spanish Pain Society

49. Syrian National Osteoporosis Society
50. Turkish Chiropractic Association

51. World Federation of Chiropractic (WFC)
52. World Federation of Occupational
Therapists (WFOT)

53. World Physiotherapy (including International
Federation of Orthopaedic Manipulative
Physical Therapists (IFOMPT) subgroup)

Research organisations

54. Al-Aleem Medical College; Rheumatology
Faculty University of Health Sciences (UHS),
Pakistan

77. Academic Consortium for Integrative Medicine
and Health, USA

55. Care & Public Health Institute, University
Maastricht, Netherlands
56. Fatima Jinnah Medical University (FJMU),
Pakistan
57. Journal of Joint Diseases and Related Surgery
58. Lee Kong Chian Medical School, Nanyang
Technological University, Singapore
59. Maastricht University Medical Center,
Netherlands

78. American Society for Bone and Mineral
Research (ASBMR)
79. Australia and New Zealand Musculoskeletal
Clinical Trials Network (ANZMUSC)
80. Osteoarthritis Research Society International(OARSI)
81. The Center for the Study of Pain of Mongolia
82. The Japanese Society for Bone and Mineral
Research

60. National University of Mongolia,
Department of Physiotherapy

Health service organisations

61. Philipps-Universität Marburg, Germany,

83. Afyafrica Orthopedic Services, Kenya

62. Seminars in Arthritis and Rheumatism(scholarly journal)

84. Defence Forces Physiotherapy Ireland

63. Universidad del Norte, Columbia

86. Johnson and Johnson Physical Therapy, USA

64. Universiti Teknologi MARA Shah Alam,
Malaysia
65. University College of Osteopathy, UK

85. IPA Manhattan – Physical Therapy, USA
87. National Hospital & Medical Center (NH&MC),
Pakistan

66. University of Pittsburgh, USA

88. Pain Center of Hospital das Clinicas of
University of Sao Paulo School of Medicine,
BrazilGlobal health agencies

89. Pain Relief and Physical Therapy, USA

67. Global Fragility Fracture Network (FFN)

90. Pain Relief and Physical Therapy Orthopedic
Physical Therapy Residency, USA

68. Humanity & Inclusion

91. Peking University People’s Hospital, China

69. International Osteoporosis Foundation (IOF)

92. Tan Tock Seng Hospital, Singapore

70. NCD Alliance

93. The Karen Hospital, Kenya

71. NCD Child
72. Osteoarthritis International Foundation
73. Paediatric Global Musculoskeletal Taskforce(Global Alliance for Musculoskeletal Health)74. Rehabilitation International
75. World Health Organization (WHO)76. World Spine CarePART 4: OVERVIEW OF RESULTS

37

P HAS E 3

Academic organisations

P HAS E 3

National civil society organisations

National Ministry of Health

94. American Bone Health
95. American Chronic Pain Association
96. Ankylosing Spondylitis Association
South Africa
97. Arthritis & Osteoporosis Western Australia(AOWA)
98. Arthritis and Musculoskeletal Alliance UK

116. Public Health EnglandAt the conclusion of Round 2, 59 components across
8 Pillars were retained. While all components were
defined as important, 10 were identified as essential
by the panellists. The components are presented in
the following section (Section 5).

99. Arthritis Care Foundation, Pakistan
100. Associazione Malati Reumatici del Piemonte(Rheumatic Patients Association of Piedmont)
101. China Disabled Persons’ Federation
102. Institute for the Study and Treatment of Pain,
Canada103. Institute of Physical Art
104. Juvenile Arthritis Research105. Lupus Foundation of Bangladesh
106. MiracleFeet, USA
107. Musculoskeletal Australia
108. Norwegian Association for Women with
Pelvic Girdle Pain
109. Norwegian Council for Musculoskeletal
Health110. Programa Municipal de Espalda Saludable(Healthy Back Programme of City Council,
Spain)
111. Rheumatology for All
112. Turkish Joint Diseases Foundation
113. Tzeadim-Israeli Association for Joint Disease
and Joint Implanted People
114. US Pain Foundation
115. Vision Community Based Rehabilitation
Association, Ethiopia

38 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTHFRAMEWORKOF REQUISITECOMPONENTS

5

What is the Framework?

How to use this section

This section of the report provides a summary of therequisite components/actions for each of the 8 Pillarsof the logic model, derived across the three phasesof the project (Figure 7).

The 8 Pillars and their associated actions are outlined
across the following 8 sub-sections (5.1 to 5.8). Eachsub-section provides:

Each Pillar represents a strategic priority area,
while the actions aligned to each Pillar explain how
the Pillar can be operationalised in health systems.
The Framework of Pillars and actions provide theguidance for what and how to strengthen healthsystems for optimising MSK health.

• a table of actions/components and theirdefinitions/scope.

G-MUSC vision: A world where prevention andmanagement of musculoskeletal (MSK) health conditions,
MSK pain and MSK injuries/trauma are prioritised inhealth systems to optimise people’s functional ability
and participation across the lifecourse and to reduce
the associated global burden of disability.

• a definition of the Pillar and its scope.

• actions/components identified as essential
are highlighted with a star .

Goal: To create an adaptable blueprint for a global strategy
to support country-level health systems strengthening
in value-based MSK health, injury and pain care that isco-designed and supported by the global community,
including patients and which targets improving function,
participation and overall quality of life for all ages.

CONTEMPORARY CONTEXTUAL FACTORS RELEVANT TO MUSCULOSKELETAL HEALTH GLOBALLY

Musculoskeletal (MSK) health means MSK conditions, MSK pain and MSK injury and trauma

GUIDING PRINCIPLES

1

2

3

4

5

Adaptability
to local contexts

Inclusiveness throughbroad consultation
across economies andco-design, including
patients/citizens

Improve function,
quality of life andoverall health

Adopt a lifecourse
approach to
MSK health,from childhoodto older age

Equitable
access to early,
value-based care

PILLARS FOR HEALTH SYSTEMS STRENGTHENING FOR MUSCULOSKELETAL HEALTH

Engaging, empoweringand educating communities

Leadership, governanceand shared accountability

Financingapproaches

Servicedelivery

Equitable access to
medicines and technologies

Workforce

Surveillance

Research
and innovation

Strategy components and actions

Adaptable blueprint

ACCELERATORS■ Increase societal and government

awareness of MSK health and theimpacts of MSK-related disability■ Identify essential, evidence-based

standards or actions to enable
lower-resourced settings toinitiate reforms■ Align with existing global■ Leverage multi-sectoral■ Provide guidance on MSK health■ Co-design objectives andor regional strategies or policies
in the context of pandemics;
e.g. COVID-19■ Translate guidance into

partnerships and co-operation
performance indicators
for a full strategy

multiple languages

EXECUTIVE SUMMARY3PILLARS FOR HEALTH SYSTEMS STRENGTHENING FOR MUSCULOSKELETAL HEALTH

Engaging, empoweringand educating communities

Leadership, governanceand shared accountability

Financingapproaches

Servicedelivery

Equitable access to
medicines and technologies

Workforce

Surveillance

Research
and innovation

Strategy components and actions

Adaptable blueprint

Figure 7: Logic model derived from this project, highlighting the 8 Pillars for health systems strengthening.

40 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

5.1	PILLAR 1: ENGAGING, EMPOWERING AND EDUCATINGCITIZENS, COMMUNITIES, ORGANISATIONS AND
GOVERNMENTS TO ACT ON MSK HEALTHP IL L AR 1

Scope and summary

Engaging, empowering and educating citizens, communities, organisations and governments to act on MSK health

There is a need to establish and sustain multi-sectoral partnerships and deliverwidescale education about MSK health to empower citizens, communities,
organisations and governments to act on prevention and management of
MSK health conditions, MSK pain and MSK injury and trauma.
In particular, a multi-sectoral approach that supports engagement with and education of thecommunity (people, patients, organisations, governments) and the establishment of partnerships
between government and non‑government agencies is strongly advocated to improve theprevention and management of MSK health, pain and injury/‌trauma care. There is also a needto consider cultural differences in terms of how health is conceptualised.
Four priority areas for action are proposed:(i) Engage and forge partnerships with a range of sectors including citizens, patients and civilsociety organisations; industry, workplaces and employers; schools and educational facilities;
and national governments.
(ii) Tailor public health education messages to different sectors including schools and higher
education facilities; workplaces and employers; health workforce; and society in general.
(iii) Raise awareness and understanding of MSK conditions in the population including theimportance of MSK health across the lifecourse; why physical activity and play are essential;and highlighting the range of effective management strategies available for MSK conditions.
(iv) Harness enablers to drive advocacy and deliver educational messages. Enablers include:
empowering people with lived experiences of MSK conditions to share their stories,
utilising social media widely and partnering with patient and professional organisations.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

41

P IL L AR 1

Requisite components or actions for this Pillar
Priority sectors for pursuing engagement and forging partnerships to support prevention
and management of MSK healthEngaging, empowering and educating citizens, communities, organisations and governments to act on MSK health

Item

Component or action

1.1

Improving prevention andmanagement of MSK healthrequires engagement andpartnerships with:

Definition

Citizens, patients and civilsociety organisations.

Citizens, patients and civil society organisations: Engaging andempowering citizens and patients to learn more about MSK
health and act on prevention and management, such as throughawareness campaigns, will be essential to achieving population
health gains and reducing disability. Forging partnerships between
governments and civil society/community organisations can be aneffective mechanism to drive citizen and patient engagement, inparticular for engaging with vulnerable groups e.g. older adults
and minority groups.

Industry, workplaces
and employers.

Industry, workplaces and employers: Engaging with andsupporting industry, workplaces and employers to act on injury
prevention and management, support return to work after injury
and implement workplace accommodations to enable people
with compromised functional ability due to MSK health conditions
to equitably participate in work will be important for maintaining
national work productivity and financial security of individuals.

Third-party payers/insurers.

Third-party payers/insurers: Engaging with health and industry
insurers to prioritise MSK health in insurance schemes will
be important to facilitate access to care and prevention andmanagement of work-related injury.

Schools and education
facilities.

Schools and education facilities: Engagement and partnershipwith schools and education facilities is needed to support
education about prevention and management of MSK healthconditions and design environments and curriculum that
support healthy behaviours for children, in particular, support
for participation in physical activity, play and healthy eating.

National and sub‑national
governments.

National and sub-national governments: there is a need forwhole-of-community engagement with national and sub-national
governments to define MSK health and advocate for action on
MSK heath given the enormous burden of disease and costs
associated with MSK health impairment. Advocacy around threats
to economic development and sustainability and return on
investment is important in the context of healthcare expenditure,
work productivity loss and absenteeism, taxation revenue loss,
social care payments and socioeconomic consequences forfamilies and communities.

42 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Identified as essential

Component or action

Definition

1.2

Improving prevention andmanagement of MSK healthrequires education across thefollowing sectors: schools andhigher education facilities;
workplaces; health professionals;
and the community.

Priority sectors for education about MSK health:• In schools and higher education facilities prioritise
education about MSK health and its importance acrossthe lifecourse and a contemporary understanding of pain.
• Educate industry and workplace insurance providers
how workplaces can prevent MSK injury (e.g. through risk
identification and mitigation), support healthy work habits(e.g. through promotion of movement and activity) andsupport people with MSK health impairments to maintainproductivity and return to work. In this regard, workplaces
can be used as an effective portal and model for publichealth education.
• Support the dissemination of best-practice evidence forprevention and management of MSK health and injury
to educate the health workforce at scale.
• Educate society and community at large (including
government and policy makers), including tailoredmessages and approaches for vulnerable groups(e.g. those of lower socioeconomic status, people withintellectual and/or developmental disabilities, people
in rural settings, ethnic minority groups). Specifically:— Educate society/community at large concerning theimportance of MSK health for living well (i.e. functional
ability and socioeconomic security and welfare acrossthe lifecourse), so that the value of MSK health is better
understood and misperceptions are corrected.
— Educate society/community at large concerning
exposure to modifiable risk factors for MSK healthloss, including physical inactivity, obesity, malnutrition,smoking and how to adopt and maintain positive healthbehaviours to achieve better MSK health and quality oflife. Education needs to also focus on early detection
and intervention for both disease features and unhelpful
behaviours and beliefs. This is particularly relevant inresource-limited settings.
— Educate the society/community at large to address
misconceptions about management of MSK healthconditions and particularly MSK pain. Specifically,
provide education about what is the right care for
MSK health conditions and MSK pain, the role ofearly detection and treatment and a contemporary
understanding of pain.

Identified as essential
PART 5: FRAMEWORK OF REQUISITE COMPONENTS

43

Engaging, empowering and educating citizens, communities, organisations and governments to act on MSK health

Item

P IL L AR 1

Priority sectors for education about MSK healthP IL L AR 1

Priority messages for public health education about MSK healthEngaging, empowering and educating citizens, communities, organisations and governments to act on MSK health

Item

Component or action

Description

1.3

Improving prevention andmanagement of MSK healthrequires globally-relevant
educational messages
contextualised to local settings.

High priority public health messages include:• MSK health enables function, participation and enjoyment
across the lifecourse, with the impacts of impaired
MSK and persistent pain profound and wide reaching,including increased risk of mortality. This message
should be supported by concrete examples and metrics
that are locally relevant and understandable by thegeneral population.
• Physical activity, play, sport and movement are essential
for good MSK health, mobility, function and preventing
multiple diseases.
• MSK conditions and MSK pain are relevant across the
lifecourse – they are not an inevitable part of ageing
and they impact young people too.
• There are effective strategies to manage many MSK healthconditions and MSK pain to improve function and qualityof life. Interventions are most effective when they are
introduced early and coupled with positive lifestyle andbehavioural changes. On the other hand, there are also
many interventions that are less effective and potentiallyharmful (low-value), particularly for long-term MSK pain
where the experience of pain may not be related tostructural pathology.
• MSK health conditions are the most significant global
healthcare problem in terms of disability (activity
impairment and work loss) and cost to individuals
and communities.
• MSK health is not just about diseases. The majorityof trauma, sporting injuries and workplace injuries
are MSK in nature.
• Many MSK health conditions and injuries can beprevented by raising awareness about modifiablerisk factors and screening for some MSK conditions.

44 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Component or action

Description

1.4

Use mechanisms to drive public
education, including empowering
people with lived experienceto share stories and co-design
messages; mass and social media;
peer support models and engaging
civil society and professionalorganisations.

Priority enablers to drive advocacy and support
community‑wide education:• Empower people with lived experience, including children
and their families, from different settings and with different
conditions and injuries to share stories relevant to local
and cultural contexts and co-design messages. Importantly,
lived experiences should also reflect vulnerable andminority groups.
• Lever mass media and social media to disseminate
education and advocacy messages.
• Peer support models and group-based education,
relevant to the local context, to support people withlong‑term MSK health conditions.
• Support and resource civil society, such as nationalor sub-national advocacy organisations, to champion
advocacy and education initiatives and empower andsupport patients, governments and society with accurate
knowledge about MSK health conditions, their prevention
and management, and strategies for system reform.
• Empower and support professional clinical associations
to assume advocacy roles and foster relationships with
their national government.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

45

Engaging, empowering and educating citizens, communities, organisations and governments to act on MSK health

Item

P IL L AR 1

Priority enablers to drive advocacy and support community-wide education

5.2

PILLAR 2: LEADERSHIP, GOVERNANCE
AND SHARED ACCOUNTABILITY

P IL L AR 2

Scope and summary
Leadership and governance refer to the requirement for global and national-level
leaders to raise the priority for MSK health, pain and injury/trauma within andacross nations.

Leadership, governance and shared accountability

Four priority areas are proposed:(i) Integration with existing policy and system strengthening reforms which refers to incorporating
MSK health into broader reform efforts, such as inclusion with broader NCD prevention andmanagement initiatives; Universal Health Coverage packages of interventions and reform efforts
in ageing, rehabilitation and injury.
(ii) Advocacy and leadership across sectors, ministries and global organisations to increase
the priority status of MSK conditions.
(iii) Measurement and classification of MSK conditions: health state measures need to be extended
to provide a greater emphasis and understanding on function and participation outcomes acrosssociety. There is a need for MSK conditions to be classified into meaningful diagnostic categories
to enable a clearer understanding of the conditions and appropriate management pathways.
(iv) Legislation and regulation needs to be considered across nations to support sustained
health system strengthening for MSK conditions.

Requisite components/actions for this Pillar
Integration with existing policy and system strengthening reforms
Item

Component or action

Definition

2.1

MSK health should be explicitly
integrated with broader reform
efforts for non-communicablediseases (NCDs).

MSK health conditions and MSK pain are not adequately
integrated with NCD prevention and management policy
and financing in a manner commensurate with their burdenof disease. The focus on mortality reduction in NCD reform
substantially deprioritises the disability burden associated withMSK conditions and persistent pain. Consequently, there is anurgent need to more explicitly integrate MSK health conditions
and pain with broader NCD reform efforts by national
governments, with guidance and leadership from the WHO.
Given the shared risk factors and shared management
strategies between many NCDs and MSK health conditions(e.g., smoking, alcohol use, nutrition, obesity, physicalinactivity), integration and strategy alignment would serve
to positively impact not only MSK health conditions, but also
other NCDs. This is further reinforced by the fact that prevalent
MSK conditions are a risk factor for developing other NCDs.

46 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Component or action

Definition

2.2

Universal Health Coverage (UHC)
essential care packages and/or
insurance schemes should include
prevention and management of
MSK health impairment.

Healthcare (prevention and management) for MSK conditions,pain and injury should be guaranteed in all countries through
Universal Health Coverage (UHC). This is warranted due tothe disability burden imposed by these conditions and theprevalence of MSK health conditions in co- and multi-morbid
NCD health states where it is usually the MSK condition(s)that is the main contributor to disability. In countries withhealth coverage through established public, private, social
or statutory insurance schemes, coverage for MSK healthshould be included.

2.3

Strategic global responses for MSK
health should explicitly link with,and support implementation of,existing global and national healthsystem strengthening efforts.

A global strategy for MSK healthcare, pain and injury/trauma
should explicitly link with, and support implementationof, existing global and national efforts in health systemstrengthening, for example in care integration (e.g. WHO
Framework on integrated people-centred health services),ageing (e.g. WHO Global strategy and action plan on ageing
and health), rehabilitation (e.g. WHO Rehabilitation 2030
agenda), disability (e.g. WHO Global disability action plan
2014–2021), NCD care (e.g. WHO Global action plan forthe prevention and control of noncommunicable diseases
2013–2020), injury prevention and trauma care.

Global and national leadership to prioritise MSK health, pain and injury prevention and care
Item

Component or action

Definition

2.4

Global leadership from the WHO inprioritising MSK health is essential
to drive a global response to theburden of MSK health impairment.

Global leadership from the WHO in prioritisation of MSK
conditions, pain and injury is essential to catalyse a global
response to the burden of disease, particularly in LMICs andto inform the strategic activities of global clinical organisations.
In this regard, there is a need for a global Strategy, Action Plan
or Framework to guide Member States to initiate appropriate
policy, financing and health service reform initiatives and forclinical organisations to prioritise their efforts in global reform
and advocacy initiatives.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

47

Leadership, governance and shared accountability

Item

P IL L AR 2

Integration with existing policy and system strengthening reforms

P IL L AR 2

Global and national leadership to prioritise MSK health, pain and injury prevention and careComponent or action

Definition

2.5

Country-level leadership is needed
to prioritise MSK health impairment
by national governments.

National leadership is required to advocate for prioritisation
and action on prevention and management of MSK health andinjury by governments, commensurate with their establishedburden of disease across the lifecourse.

Leadership, governance and shared accountability

Item

To increase prioritisation of MSK health by government, there isa need to communicate the disease burden to all governments,
relative to other health states, where larger proportions ofhealth resources are currently directed.
National governments need reliable evidence on thelocal burden of disease and cost data in order to catalyseleadership for local system reform and to work collectively
with other governments to advocate to the WHO to act on
MSK health. In particular, national leadership in advocacy andpolicy formulation that emphasises the importance of MSKrelated disability prevention on human capital and economic
development (e.g. return on investment) is needed.
Leadership activity should extend beyond advocacy to include
the establishment of local systems to facilitate decision-making
e.g. responding to new evidence. Structurally, this may include
establishment of appropriately regulated expert advisorygroups/taskforces or stakeholder committees within and/or across the health system in partnership with civil society
partner organisations.
2.6

Leadership is needed fromprofessional and civil societies
and citizens that extends beyond
just MSK health.

Collaborative engagement and consultation between
professional/clinical and civil society organisations and citizens
across the health sector (i.e. beyond just MSK health and injury
groups) with national governments and the WHO is neededto advocate for the prioritisation of MSK health and injury
prevention and management in national health reform efforts.

2.7

Global and national multi-sectoral
and inter-ministerial leadershipis needed to prioritise action on
policy and financing for MSK health.

Global and national leadership across sectors and government
ministries (i.e. beyond the health sector e.g. social care,industry, sport, transport) is critically important to elevatethe priority of MSK health prevention and management togovernment, industry and private organisations.
Multi-sectoral and inter-ministerial leadership in MSK healthwill facilitate better integration of prevention and management
initiatives across public policy and financing, which is essential
to achieve impact.
At the government level, leadership may include specific
Ministerial responsibility for MSK health and the establishmentof dedicated focal points in national governments and globalorganisations, such as WHO.

48 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Identified as essential

Component or action

Definition

2.8

Global and national healthand performance indicators
must extend beyond mortality
reduction to consider function
and participation.

Measures of health and performance in health reform must
extend beyond mortality reduction and consider function/
participation restriction and recognise the health andeconomic benefits of disability prevention.

A meaningful, acceptable andinternationally comparable
classification system is neededfor MSK health impairments.

Countries need to classify MSK health states into meaningful
diagnostic categories rather than symptomatology alone,
supported by guidance from WHO and in alignment with theInternational Classification of Disease (ICD) system, in orderto make sense of the wide constellation of MSK conditions.

2.9

Leadership, governance and shared accountability

Item

P IL L AR 2

Measurement and classification

An expansion in targets and performance measures torecognise function and participation will better support
systems strengthening for MSK health.

Such classification is needed to design appropriate local
models of service delivery, workforce configurations andfinancing to support care pathways for different classificationsof MSK conditions. Without classification, the scale of the
problem is too large and too complex to initiate meaningfulaction, particularly for lower-resourced countries.
Classification also enables countries to prioritise responses
to specific groups of MSK conditions based on national
population health need.

Legislation and regulation
Item

Component or action

Definition

2.10

Legislation and regulation areneeded to sustain reform efforts
in health systems strengthening
for NCDs, including MSK health.

National legislation and regulation to support long-term
health system strengthening for NCDs, including MSK health,is needed to sustain efforts with successive changes ingovernments.
This will be particularly important in the wake of COVID-19
as priorities shift to communicable diseases.

Identified as essential
PART 5: FRAMEWORK OF REQUISITE COMPONENTS

49

5.3

PILLAR 3: FINANCING APPROACHESP IL L AR 3

Scope and summary

Financing approaches

Financing refers to how nations pay for prevention and management services
for MSK health, pain and injury care in the context of financing requirements
and priorities for other health conditions.
Integrated financing models; flexibility in approaches to funding and revenue raising;protecting allocated funds; and financing and incentivising effective, safe and interprofessionalcare are recommended. This is particularly relevant in the context of UHC packages.

Requisite components/actions for this Pillar
Integrated financing models
Item

Component or action

Definition

3.1

Existing healthcare financing
models need to integrate healthpromotion and health care delivery
for MSK health.

Existing healthcare financing models need to accommodate
health promotion and health care delivery for MSK healthconditions, MSK pain and MSK injury in multidisciplinary models.
This may be achieved in financing for health promotion,
NCD care, injury and trauma care or ageing and long-termcare. Integrating funding for MSK health care with otherestablished funding priorities will be important, particularlyin the context of COVID-19, where new funding streams will
be extremely limited.
In the context of global burden of disease data, there is a strong
rationale for an increased allocation of funding for MSK health.

Flexibility for different financing models
Item

Component or action

Definition

3.2

Financing models for MSK
health should accommodate
flexibility for public-private
partnerships, partnerships
with civil society, internationalaid, tagged donorships andrevenue‑raising strategies.

Financing models for MSK health promotion and care should
accommodate the flexibility for:• public-private partnerships• partnerships with civil society, international aid, tagged
donorships underpinned by appropriate regulation to avoid
unhelpful commercial influence and conflicts of interest• specific revenue-raising through taxes for specificpurposes, such as supporting care of the injured throughworkplace taxes or transport/fuel taxes.
Flexibility in funding models is also important to enable healthsystems to respond to emerging innovations or technologicaladvancements that may improve health outcomes.

50 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Identified as essential

P IL L AR 3

Flexibility for different financing models
Component or action

Definition

3.3

Support multi-national
foreign aid for MSK carein low resource settings.

Multinational foreign aid is needed to support MSK healthprevention and care in low resource settings and where basiccare for MSK health cannot be sustainably delivered due tocompeting health priorities and limited resources.

3.4

Allocated funding, essential
medicines funding and donor
funding for MSK health and injury
care need to be quarantined.

Governments need a specific budget allocation for prevention
and management of MSK conditions and the ability or
regulation to quarantine donor funds for MSK health services,
particularly to ensure availability of, and accessibility toessential medicines in lower resourced countries.

Financing for the right care, at the right time, by the right team, in the right place
Item

Component or action

Definition

3.5

Financing for MSK healthcare
should cover well defined, highvalue (effective, safe, affordable)
packages of care for prevention,
diagnosis and management,
particularly for community-based
interventions.

Financing models, particularly for LMICs, should beformulated to support essential packages of care for MSK
health conditions and injury, where funding of treatments
and prevention strategies should be based on evidence,safety and cost effectiveness, targeting low cost and high yield.
Ideally, these funding packages should be part of UHC
essential packages and other locally relevant insurance
schemes to minimise or eliminate out-of-pocket expenses.
Packages should be tailored to different levels of the healthsystem from community care through to tertiary care.
Initial priority packages of funding should be directed towards
interdisciplinary community-based care where out of pocket
expenses are minimised or removed. For LMICs in particular,
efforts to integrate packages of MSK interventions withestablished packages (e.g. ‘Best Buys’ for NCDs) should beprioritised to maximise return on investment and integration
across conditions.

3.6

Financing models should
incentivise prevention andintegrated inter-disciplinary
care for MSK health conditions.

Financing models should incentivise prevention (basedon established modifiable risk factors) and integrated,interprofessional care for MSK health conditions so thata continuum of care is supported, as well as care between
health settings and service providers.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

51

Financing approaches

Item

5.4

PILLAR 4: SERVICE DELIVERYP IL L AR 4

Scope and summary

Service delivery

Service delivery refers to providing access to health information and health services
at a population level to manage established MSK health conditions, MSK pain and
MSK injury (including secondary prevention) and primary prevention efforts.
There is a need for effective, accessible and sustainable service delivery models thatprioritise high-value care† and support established disease and prevention care at the righttime (early access and triage) and in the right place (community settings, where appropriate).
Furthermore, care should be integrated and delivered by the right teams to ensure it is safe,
effective, affordable and acceptable to citizens, while lower-value‡ approaches should bede‑adopted.
Services for MSK health conditions should be integrated with existing service models for NCD
care in community settings or regionally-based centres, linking with service initiatives that target
the broader social determinants of health. Importantly, service models need to be co-designedwith the community and prioritise access for vulnerable groups.
For prevention, three key service delivery areas are relevant:(i) MSK health should be integrated into primary and secondary prevention initiatives for
NCDs given the shared risk factors and frequent co- and multi-morbidity of conditions.
(ii) MSK-specific primary prevention initiatives should be promoted and implemented
where evidence of clinical and cost effectiveness exists.
(iii) National injury (sport, workplace, falls) and trauma prevention strategies and campaigns
are needed to reduce the disability burden associated with MSK-related injury and trauma.

† high value care: care for which evidence suggests
it confers benefit to patients or probabilityof benefit exceeds probable harm89.
‡ low value care: care for which evidence suggests
it confers no or very little benefit to patientsor risk of harm exceeds probable benefit89.

52 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTHP IL L AR 4

Requisite components/actions for this Pillar
Care at the right time: early diagnosis, triage and intervention for secondary prevention
Component or action

Definition

4.1

Service models for MSK conditions
need to support early diagnosis andtriage and management throughlocal care pathways.

Service models need to promote equitable access to early
diagnosis and triage into appropriate, locally-supported
care pathways that include referral systems to provide
emergency or urgent care (e.g. trauma) or specialist-level
care when indicated.

Service delivery

Item

This is important to arrest chronicity and disability, especiallyin younger people and those with inflammatory diseases,
such as rheumatoid arthritis.

Delivery of the right care: effective, safe, affordable and accessible
Item

Component or action

Definition

4.2

Evidence-based diagnostic andtherapeutic practices should beprioritised in service models overapproaches that are not supported
by evidence, are costly andpotentially harmful.

The overuse of technology in MSK care in high income
countries (e.g. the overuse of MSK imaging) has been
associated with overall limited clinical benefit in healthoutcomes and may promote unhelpful behaviours andbeliefs about MSK health and pain care by patients andthe broader community.
A focus on delivery of safe and effective diagnostic(e.g. imaging) and therapeutic interventions (e.g. safe use of
medicines and appropriate indications for surgery) is needed.
This may be supported with global and country-level tools
such as clinical guidelines and quality standards.

4.3

Local care pathways should
support essential packages ofaffordable, effective and safe
care for MSK health impairment,
while de-adopting care that is notsupported by evidence, is costly
and potentially harmful.

Service models should promote the ‘right care’, that is effective(evidence-based), safe, affordable and accessible care throughlocally-supported care pathways that enable interdisciplinary
care and access to tertiary or specialist-level care whenneeded, particularly in areas of high need/limited access.
Care pathways and their components may be derived bydefining essential packages of affordable and effective carefor established classifications of MSK conditions and injuries,
with an emphasis on low cost and high yield interventions.
In many cases, interventions will be non-surgical, outside
the context of trauma and end stage osteoarthritis.
Low value diagnostic tests and interventions should not berecommended in essential packages for funding and should
be defunded. Coupled with the formulation of care pathways
and essential care packages is the need for building workforce
capacity to provide the right care.

Identified as essential
PART 5: FRAMEWORK OF REQUISITE COMPONENTS

53

P IL L AR 4

Delivery of the right care: effective, safe, affordable and accessible
Component or action

Definition

4.4

Services for MSK healthcare should
be integrated with service models
for NCDs and services that target
the broader social determinantsof health.

Services for MSK health conditions, pain care and injury careshould be integrated with existing service models for NCD
care and service initiatives that target the broader social
determinants of health.

Service models for MSK conditions
should support integrated,person‑centred care that targets
functional ability through abiopsychosocial approach.

Services models that promote integrated, interdisciplinary
person-centred care and that target functional ability througha biopsychosocial management approach are needed to shift
from a purely disease-focused and biomedical paradigm.

Service delivery

Item

4.5

In some settings, piloting such integration may be warranted
to produce data on satisfaction, cost and health outcomes. In
this regard, MSK health should be considered as an importantcomponent to holistic, person-centred care healthcare. Thisis justified on the basis of the high prevalence of MSK healthconditions in co- and multi-morbidity health states for NCDs
and the increased risk of developing NCDs on a backgroundof MSK health impairment.

Delivery of care from the right team: interprofessional service models
Item

Component or action

Definition

4.6

Service models for MSK healthcare
should promote community-based
interdisciplinary care.

Service models for MSK conditions should promote
community-based interdisciplinary care tailored to the needsof the person and grounded in common standards of caredelivery across providers.
In some settings, primary care may be best triaged andcoordinated by trained MSK practitioners or other local
providers (e.g. family physicians, paramedical workers, local
healers, female health workers) where there are accesslimitations to specialist medical practitioners. Service models
should also enable timely access to tertiary and/or specialistlevel care when indicated.

54 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Component or action

Definition

4.7

MSK care should be integrated
into existing community- or
regionally-based service models
for NCD care.

Service models for MSK care should be community- or
regionally-based and integrated with existing service models
for NCDs and/or traditional care practices to reduce caredisparity due to geography and better support integrationof care across different health conditions and providers.

Service delivery

Item

Depending on workforce availability, community-led models
could be primarily responsible for risk assessment, deliveryof community-based interventions and on-referral wheremore advanced care is needed and not available locally.
4.8

Community-led service models
for MSK healthcare should beco‑designed by the community.

Community-led service models for MSK healthcare should
be co-designed by the community (inclusive of community
and religious leaders) to ensure services are aligned with
community needs and are appropriate, acceptable, feasible
and sustainable. Decentralisation of health delivery tomunicipalities or communities will also better support
integration of services with existing community-based
initiatives and resources.

4.9

Service models should prioritise
access to health information andcare to vulnerable groups.

Service models need to prioritise access to healthinformation and care to vulnerable groups (e.g. those oflower socioeconomic status, people with intellectual and/or developmental disabilities, people in rural settings, ethnic
minority groups) where care disparities are often wider andhealth outcomes poorer. For example, telehealth services may
be useful in overcoming care disparities due to geography.

Prevention
Item

Component or action

Definition

4.10

Primary and secondary prevention
initiatives for NCDs should include
MSK health.

Primary and secondary prevention initiatives for NCDs should
integrate MSK health conditions and pain care, given theshared risk factors (e.g. smoking, physical inactivity, obesity,
poor nutrition) and frequent co- and multi-morbidity between
MSK health conditions and other NCDs.

4.11

MSK-specific primary prevention
initiatives should be delivered
where evidence of clinical andcost effectiveness exists.

In addition to addressing shared risk factors with other
NCDs, MSK-specific primary prevention initiatives should be
included in service models where evidence of clinical and costeffectiveness exists (e.g. osteoporotic fracture prevention).

4.12

National injury (sport, workplace,falls), trauma prevention strategies
and campaigns are needed.

Injury and trauma prevention models are critical for MSK healthsince most injury and trauma outcomes are MSK-related.
Priorities include prevention initiatives for workplace injury,
sport injury and trauma from road traffic accidents.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

P IL L AR 4

Delivery of care in the right place: bolstering community and primary care to reduce inequity in access to care55

5.5	PILLAR 5: EQUITABLE ACCESS TO MEDICINESAND TECHNOLOGIESP IL L AR 5

Scope and summary

Equitable access to medicines and technologies

Equity in access refers to ensuring access to care, essential medicines andrehabilitation and new technologies to individuals with MSK conditions acrossthe globe regardless of the economic status of a country or context of a pandemic.
There is a need for countries to identify and resource medicines for priority
MSK conditions and improve access to new and/or effective therapies and technologies(e.g. digital innovation and surgical innovation and joint replacement surgery), particularly
in LMICs. Furthermore, greater focus needs to be placed on innovation to aid the developmentof and access to low-cost assistive devices and technologies to support function.

Requisite components/actions for this Pillar
Item

Component or action

Definition

5.1

Countries need to identify,
resource and provide access toessential therapeutics for priority
MSK conditions.

There is a need for secure supply chain mechanisms in lower
resourced nations to facilitate access to essential therapies for
MSK conditions and to enable access to newer, highly effective
therapies that control disease activity and improve function.
The current COVID-19 pandemic has exposed limitationsfor MSK healthcare, particularly in LMICs, including accessto care and availability of essential medicines.

5.2

Global and national prioritisationand management is needed ininnovation of and access to low‑costassistive devices, technologies andinterventions that support function.

Research and private partnerships are needed to develop
and disseminate low- cost assistive devices (living aids)
and technologies (e.g. apps, artificial intelligence,telehealth, surgical innovation such as joint replacement)
to improve function and quality of life for people with MSK
health conditions or injuries, particularly for use in low
resource settings.
Coupled with this, there is a need for country-level healthtechnology assessment and management to ensure safety
and appropriateness for the local population.

56 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Identified as essential

5.6

PILLAR 6: WORKFORCE: BUILDING WORKFORCECAPACITY, SYSTEMS AND TOOLSP IL L AR 6

Scope and summary

Workforce: building workforce capacity, systems and tools

Workforce capacity refers to the capacity of health professionals and othernon‑clinical healthcare workers to identify, triage, refer and appropriately
manage people with MSK health conditions, MSK pain and injury.
Key recommendations for building workforce capacity include:(i) increasing workforce volumes and building capacity in the existing workforce to deliver
the right care and establishing models of service delivery that enable more timely accessto assessment, triage and basic evidence-based care.
(ii) extending training of the current and pre-licensure workforce across disciplines to build
capacity to deliver the right MSK healthcare at the right time, particularly for persistent
pain care.
(iii) increasing remuneration for the health workforce in LMICs to maintain workforce volumes.

Requisite components/actions for this Pillar
Workforce volumes and access
Item

Component or action

Definition

6.1

Increase the number of medical
specialists and allied healthpractitioners for MSK healthcare
in LMICs.

In many LMICs there is very limited access to specialist
physicians, surgeons and some allied health professionals
due to low workforce volumes and distributions being largely
in cities or urban centres.
The limited volume of health professionals and their training
positions in LMICs creates care disparity gaps in access to
specialist-level care for MSK health conditions. In coming years,
the situation is likely to worsen as ageing and retirement of thecurrent medical specialist workforce will further contribute tovolume shortages.
In addition to responding to current workforce needs, there
is a need to engage in future workforce forecasting to inform
appropriate capacity-building strategies.

6.2

Build capacity in the local existing
community-based workforce tocontribute to basic MSK healthand injury care.

Build workforce capacity in LMICs to address MSK and injury
care by leveraging opportunities and building competencies
in the existing local, community-based workforce including:
traditional and complementary medicine practitioners,
volunteers, community health workers, clinicians and otherlocally-relevant cadres working in other disease or health areas
to deliver MSK information/education and care to patients.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

57

P IL L AR 6

Workforce volumes and access

Workforce: building workforce capacity, systems and tools

Item

Component or action

Definition

6.3

Establish flexible service models toenable the non-medical workforce(e.g. nurses, pharmacists, allied
health) to adopt advanced practice/extended scope roles that improveaccess to evidence-based triage,
assessment and management of
MSK conditions and injuries.

Establish flexible service models, supported by locallyappropriate regulation frameworks, to enable the non-medical
workforce (e.g. nurses, pharmacists, allied health practitioners
or new workforce cadres such as ‘primary musculoskeletalclinicians’) to adopt leadership positions. This can be achieved
through advanced practice/extended scope roles to improveaccess to evidence-based triage, assessment and managementof MSK conditions and injuries, particularly in primarycare settings.
This strategy may enable more timely access to care andfacilitate medical and surgical staff to devote time to where
their services are most needed, while building sustainable
workforce networks or communities of practice to support
training and development.

Workforce training
Item

Component or action

Definition

6.4

Integrate MSK health into curricula
across medical disciplines andincrease the number of MSK
medical specialist training positionsin LMICs.

There is a need to expand opportunities for training of medical
specialists in MSK medicine in LMICs and integrate MSK
health conditions management in medical training/curriculum
more broadly to build capacity across medical disciplines(e.g. general physicians, primary care/family physicians).

6.5

Build skills-based competencies
across medical, nursing andallied health disciplines (andnon-clinical roles LMICs) in theidentification of MSK healthproblems and basic prevention
and management practices.

Build skills-based competencies across medical, nursing,
pharmacy and allied health disciplines (e.g. throughprofessional development programs) and non-clinical roles in
LMICs in primary care/community settings in the identification/screening of MSK health problems (including identification of‘red flags’) and best practice basic management of MSK healthconditions and injuries.
Such training may require shifting entrenched beliefs andpractices about MSK and pain care. Competencies should
include early triage and on-referral to more advanced-level
care as indicated, supporting effective self-management anddelivery of basic, evidence-based education and services(e.g. the advice for managing acute low back pain or othersprains/strains).
Workforce competencies could be enhanced through theestablishment of clinical networks or virtual communities
of practice to support learning in clinical care, culturalcompetence and health system literacy.

58 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Component or action

Definition

6.6

Extend training curricula forpre-licensure medical, nursing,
pharmacy and allied healthclinicians in MSK health,persistent pain and injury carewithin a biopsychosocial model.

Extend training curricula for pre-licensure medical, nursing,
pharmacy and allied health clinicians in MSK health, persistent
pain and injury care within a biopsychosocial model thatemphasises person-centred, interdisciplinary care.

Educate healthcare workers
and health planners to deliver
information and care aligned topositive health behaviours for
MSK health and other NCDs.

There is a need for educating and supporting healthcare,public health and health administration/planning workers
to deliver information and care aligned to positive healthbehaviours in order to reduce modifiable risk factors for MSK
health conditions and other NCDs. This includes supporting
healthy life choices (e.g., nutrition, activity) and health literacy.

6.7

In particular, there is a need for enhanced curriculum for
medical students and other health professional students to
support delivery of the right, evidence-based care for MSK
health and for all disciplines in best-practice care for persistent
pain (e.g. aligned with the International Association for the
Study of Pain curriculum recommendations).

A greater emphasis from the health workforce on primaryand secondary prevention may serve to better support publichealth initiatives targeting risk reduction for NCDs. In thiscontext, workforce capacity could be enhanced through theestablishment of clinical networks or virtual communities
of practice to support competencies in positive healthbehaviour change.

Remuneration
Item

Component or action

Definition

6.8

Increase remuneration for thehealth workforce in LMICs tomaintain workforce volumes.

There is a need to increase remuneration for health workers
who manage people with MSK conditions in LMICs in orderto retain the workforce and attract trainees.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

59

Workforce: building workforce capacity, systems and tools

Item

P IL L AR 6

Workforce training

5.7

PILLAR 7: SURVEILLANCE: MONITORING
POPULATION HEALTHP IL L AR 7

Scope and summary

Surveillance: monitoring population health

Surveillance refers to the capacity within countries to accurately and prospectively
measure population health states, including MSK health, with the ability to reporton population health outcomes by age, sex, gender, geography and ICD and ICF
classifications over time.
Three key priorities are suggested to improve monitoring, measurement and reportingof MSK health by countries:(i) Ensure national level surveillance capacity to monitor incidence, prevalence and impactof MSK conditions, MSK pain and injuries over time through integration with existing
surveillance infrastructure and systems.
(ii) Include measurement of function, participation, quality of life and care availability
and accessibility in national surveillance systems.
(iii) National health surveillance capability should ensure data can be reported by narrow age
bands, sex, gender, geography, socioeconomic status and ICD and ICF classifications.

Requisite components/actions for this Pillar
Item

Component or action

Definition

7.1

Build country-level population
health surveillance capacity tomonitor incidence, prevalence
and impact of MSK conditions.

There is a need to develop national capacity in surveillance of
population health states that includes MSK health conditions,pain and injuries. MSK health surveillance should be integrated
with existing national health surveillance systems, rather thanpromoting the establishment of stand-alone monitoring.
Integration with existing surveillance systems and metrics
is important to ensure a comprehensive understanding of
population health and relative burden of disease. In somecontexts, integration of data may require data linkage systems.
Surveillance capacity requires infrastructure and systems for
accurate population health assessments (e.g. population healthsurveys; occupational injury systems; road traffic injury systems).
The G-MUSC Surveillance Taskforce and the Global Burdenof Disease MSK Expert Group have developed an MSK survey
module for use in population health monitoring. In particular,
there is a need to measure national-level outcomes of incidence,prevalence, morbidity and system impact (e.g. cost and healthservice utilisation) over time.
Local surveillance data inclusive of prevalence, cost and morbidity
are critical to inform appropriate national-level responses to local
burden of disease estimates, support local advocacy efforts andcontribute to global burden of disease research.

60 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Definition

7.2

National health surveillance
metrics need to include
measurement of function,
participation, quality of lifeand care experience.

Surveillance metrics needs to extend beyond disease andinjury measurement (prevalence, incidence) and cost (service
utilisation) to also monitor disease impacts (function, participation,satisfaction and quality of life – for instance, Patient Reported
Outcome Measures [PROMS]) and availability, access andsatisfaction (i.e. Patient Reported Experience Measures [PREMS])
with care in order to inform policy and resourcing decisions at
national and sub-national levels.
For adults, this may include participation in work, while for children
it may include participation in school. The wide-scale use of digital
devices and wearables in many countries may enable rapid andscalable measurement of population health states and healthbehaviours in the future.

7.3

Surveillance outcomesshould be disaggregatedby age, sex and gender,
geography, socioeconomic
status and by the International
Classification of Disease (ICD)and International Classificationof Functioning, Disability and
Health (ICF) systems.

National health surveillance capability should include capacity
for disaggregation of data by narrow age bands, sex andgender, geography, socioeconomic status and ICD and ICF
systems. Such disaggregation and systems for reporting areneeded to determine local priorities by population group(s)and monitor responses across the lifecourse and broad rangeof MSK conditions in real-time (cross-sectionally) and over time
(retrospectively and prospectively).
Country-level disaggregated data can also be used as primarysource data for Global Burden of Disease Study health estimates,
rather than relying on modelling data which are less precise.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

61

Surveillance: monitoring population healthComponent or action

P IL L AR 7

Item

5.8

PILLAR 8: RESEARCH AND INNOVATIONP IL L AR 8

Scope and summary
Four key areas are relevant to support research and innovation in MSK health, namely:

Research and innovation(i) identifying priority areas for national- and international-level MSK health research,with reference to specific research fields ranging from basic science to healtheconomics(ii) building capacity to undertake research (particularly in LMICs) through multi-national
collaborations and partnering with patients and clinicians(iii) advocating for a greater proportion of research funding to be directed towards
MSK health research(iv) harnessing new technologies and big data to explore prevention strategies, dynamic
systems modelling and establishing mechanisms across countries to share innovations.

Requisite components/actions for this Pillar
Five priority fields of research
Item

Component or action

Definition

8.1

Priority research area 1

Research is needed to identify evidence for:

Epidemiologic and population
health research: lifecourse risk
factors; risk assessment tools;
core outcomes for population
health research.

• modifiable and non-modifiable risk factors for MSK healthconditions across the lifecourse and by sex and gender

Priority research area 2

Public health research is needed to:

Public health research: publichealth interventions to shift healthbehaviours; impact of MSK healthon other conditions; dynamic
systems modelling to informpublic health policy.

• examine health behaviour change strategies targeted tomodifiable risk factors and how MSK health impairments
or injuries impact on health outcomes for other NCDs
is needed

8.2• the development of tools to simply identify risk of MSK
conditions for use in clinical care and by the public• a core set of outcome measures or indices for MSK
health that can be used across countries in prospective
population health research.

• evaluate prevention initiatives for priority conditions,such as MSK pain, through public health interventions
and dynamic systems modelling. Such evidence isneeded to inform policy decisions for preventionof MSK health conditions.

62 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTHP IL L AR 8

Five priority fields of researchComponent or action

Definition

8.3

Priority research area 3

Priorities for health policy and systems research include:

Health policy and systems research:
implementation of MSK service
models across contexts; strategies
to reduce health inequalities andaccess inequities; development of
MSK health classification systems;
effectiveness and acceptability ofdigital technologies to support
MSK care and surveillance.

• National-level implementation research on acceptableand (cost)-effective service and financing models, including
innovative pilot programs, to support delivery of theright MSK care in primary and secondary care settings isneeded. Such evidence likely needs to be collated fromresearch using designs other than randomised controlled
trials (e.g. mixed-methods research) with a focus on
examining implementation feasibility and acceptability
to people in different settings and in the context of other
health priorities, local healthcare practices and integration
with existing service models. For example, intrinsic capacity
varies widely among older people, so service models
that aim to increase functional ability need to consider
such variability.
• Research that examines how health systems can be
influenced to support reductions in inequalities in healthoutcomes and inequities in access to MSK healthcare andhow positive health behaviour change can be supported
at the population level is needed.
• Research is needed that supports the development andevaluation (acceptability and utility) of classification systems
for MSK health conditions for use by health systems.
• Health services research is needed to evaluate theeffectiveness and acceptability of digital technologies
in improving access to care and scalable surveillanceof health behaviours.

8.4

Priority research area 4

Basic science research should continue to pursue:

Clinical and basic science research:mechanisms associated with MSK
conditions, including persistent
pain; curative therapies for MSK
conditions; biomarkers, assays anddiagnostic applications; and extend
evidence for non-surgical andnon‑pharmacologic interventions.

• the understanding of mechanisms associated withMSK conditions, including persistent pain
• curative therapies for MSK health conditions (supported
by registries to monitor safety and effectiveness); and• the exploration of new biomarkers for MSK diseases,
assays and early diagnostic applications.
In clinical research, there is a need to maintain andextend evidence for non-surgical and non-pharmacologic
interventions for various MSK health conditions. Such evidenceis needed to inform clinical care and health service design
and funding.

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

63

Research and innovation

ItemP IL L AR 8

Five priority fields of researchComponent or action

Definition

8.5

Priority research area 5

Key priorities for health economics research include:

Health economics: cost of MSK
health conditions and injuries tocommunities and governments;
cost effectiveness of treatments;
cost effectiveness of integrating
MSK health prevention andmanagement within broader NCD
care; and return on MSK healthinvestment for other sectors suchas workforce participation.

• Broad health economics research is needed to produce
robust evidence concerning the scope and size of thecost burden of MSK health impairment to governments
and the cost of the counterfactual argument of not taking
any action.

Research and innovation

Item• Focused health economics research is needed to produce
evidence on the cost-effectiveness and system-level
efficiencies achievable from integrating MSK healthcarewith other health service models (e.g., NCD care).
• Focused health economics research is needed to produce
evidence on the cost-effectiveness of new therapies for
MSK conditions, using metrics such as Quality Adjusted
Life Years (QALYs).
• Health economics research is needed that shows returnon investment for acting on MSK health impairment
prevention and management to sectors outside of health,e.g. workforce and schooling participation, unemployment
benefits, disability payments, long-term care services forolder adults.

Capacity building priorities in MSK research
Item

Component or action

Definition

8.6

Capacity priority 1:

There is a need to increase capacity in MSK health research
globally through supporting national-level MSK healthresearch, supporting multi-national research collaborations andsupporting lower-resourced settings to undertake critical local
research and participate in international research (e.g. throughpostdoctoral fellowships).

Support national-level
MSK health research;
multi‑national andinterdisciplinary researchcollaborations; andlower-resourced settings
undertaking critical
local research.

At a national level, countries with sufficient resourcing may
consider establishment of dedicated MSK health research
institutes to address national priorities/knowledge gaps in
MSK healthcare, to support cross-discipline collaborationand to drive research translation and dissemination.

64 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Component or action

Definition

8.7

Capacity priority 2:

Greater prioritisation for partnering with patient groups andclinicians is needed from the inception of research initiatives
in order to identify research priorities and outcomes that aremeaningful to local population groups.

Support co‑design of researchby people with lived experienceof various MSK health conditions
and clinicians.

These partnerships are also critical to supporting disseminationand driving strategic directions for national MSK healthresearch. This is particularly important for vulnerable andminority groups where care disparities are often wider.

Funding for musculoskeletal health research
Item

Component or action

Definition

8.8

Increase the proportion of researchfunding allocated to MSK research
and allocate additional funding
leveraged through public-private
partnerships.

A greater proportion of research funding (from any source)needs to be directed to MSK research commensurate withthe burden of disease, while specific additional researchfunding for MSK health research may be facilitated throughpublic‑private partnerships.
Countries should identify national health priority areas aligned
to burden of disease and target research investment withinthese priority areas.

Innovation and evidence translation
Item

Component or action

Definition

8.9

Support innovation sharing
between countries and between
researchers and clinicians.

Establish mechanisms and systems that allow countries tofacilitate sharing of interventions or system innovations for
MSK health. This is particularly important to share innovation
between high-income and LMICs to mitigate gaps in accessto research innovations.

8.10

Support research that harnesses
the emerging potential of digitaltechnologies and the collection
and use of ‘big data’ andmachine learning.

Research and innovation that harnesses the emerging
potential of digital technologies and the collection and useof ‘big data’ and machine learning are important for exploring
prevention and management opportunities for MSK healthconditions and MSK pain (e.g. personalised medicine,
identification of personalised risk factors).

PART 5: FRAMEWORK OF REQUISITE COMPONENTS

65

Research and innovation

Item

P IL L AR 8

Capacity building priorities in MSK research

6

IMPLICATIONSFOR HEALTHSYSTEMS AND KEY
RECOMMENDATIONSThe framework of priority areas (Pillars) and underlying
components or actions outlined in Section 5, provide
principle-level guidance for health systems strengthening
to improve prevention and management of MSK healthimpairments. The Framework is intended to guide global
activity; in particular, to inform the development of a
global strategy for MSK health. Such a strategy would
ultimately inform and guide reform efforts at national
levels. The value and credibility of this empiricallyderived framework for health systems strengthening
was deemed to be high by the Delphi panel inPhase 3 (Figure 8).

Calls for Action on MSK health have been
numerous and sustained, preceding, during
and following the Bone and Joint Decade 2000–
201031, 90. Calls have typically focussed on ‘what’needs to be done and placed less emphasis on‘how’ to achieve impactful and sustained healthand health system improvements. This programof work has been undertaken to address this gap,
ensuring the approach is data driven, considers
a person’s lifecourse and is co-designed withmulti-sectoral stakeholders including people
with lived experience.

A
The framework
is valuable forhealth systems
strengthening

0

10

20

30

40

50

60

70

80

90

100

PooledHigh income country
LMIC
Individuals
Organisations
Clinicians
Non-clinicians
Strongly agree

B
The framework
is credible forhealth systems
strengthening

0

10

20

Agree

30

Neutral40

50Disagree60

70Strongly disagree

80

90

100

PooledHigh income country
LMIC
Individuals
Organisations
Clinicians
Non-clinicians
Strongly agree

Agree

NeutralDisagreeStrongly disagree

Figure 8: Ratings by the global eDelphi panel concerning the potential value (A) and credibility (B) of the framework for health systems
strengthening on MSK health. Data are expressed as a percentage (0–100%) in the stacked bar graph. 97.6% and 94.8% agreed
or strongly agreed the framework was valuable (panel A) and credible (panel B), respectively, for health systems strengthening.
PART 6: IMPLICATIONS FOR HEALTH SYSTEMS AND KEY RECOMMENDATIONS

67

Importantly, there is close alignment between
the 8 Pillars for action and their components withexisting models, including the WHO Health Systems
Building Blocks model91 and strong resonance witha contemporary framework of value-creating learning
health systems92. Together with findings from thepolicy scoping review, this provides confidence
in the construct validity of the logic model.
The 5 guiding principles outlined in the logic modelare embedded across the Pillars and action areasand should be considered in any future work totransform the blueprint provided here into a fullstrategy. Importantly, the guiding principles also alignwith other global initiatives: the WHO Rehabilitation
2030 Agenda93; WHO Framework on integrated,people‑centred health services94; WHO Global
strategy on human resources for health: Workforce
203095; WHO model of healthy ageing96 and the
UN Decade of Healthy Ageing 2020–203097.
The actions recommended across the 8 pillars
are intended to be flexible and adaptable tolocal contexts. While all 59 components/actions
are considered important for health systemstrengthening, this represents the combined viewsof a global panel. Priorities and needs of individual
countries will vary, so the level of priority of eachaction may also necessarily vary.

The widespread and enthusiastic contribution of the
global MSK health and other communities over thecourse of this project highlight the importance andurgency of global action on improving MSK healthand arresting global disability trends. The goodwill
and momentum catalysed through this project must
now be harnessed, sustained and targeted to achieve
positive changes to global health.
“So I think a multi-sectoral partnership within
the country where all the stakeholders would
come together, the public, the private sector
especially and citizens, if they get engaged
I think that would help push country’s
response and overall activity in the countries.”(KI 19, India)
While G-MUSC can support health systems
strengthening initiatives, individual champions,civil society organisations and national governments
must rise to the challenge to support not only
national-level work but also global activities, suchas those initiated by the WHO and other global
health agencies. The UN Decade of Healthy Ageing
2020–2030 provides a timely opportunity to harness
such collective effort.

Similarly, the 10 actions ranked as ‘essential’ also
reflect the views of a global panel, based on anarbitrary threshold. While these 10 actions may
be considered essential at a global level, theyshould not be interpreted as the only actions thatare needed or the only actions essentially needed.
Jurisdictional variation will occur. For example, we
identified that panel members in LMICs identified
more actions as essential compared to those inhigh‑income countries2. The definition of ‘essential’
will also depend on the threshold definition usedwith potential movement reflecting contextual
priorities as they evolve.

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8

GOVERNANCE AND
ACKNOWLEDGEMENTS

Project teamAn international project team undertook thisproject including: Prof Andrew Briggs (projectlead), Dr Carmen Huckel Schneider, Prof Helen
Slater, Dr Joanne Jordan, Dr Sarika Parambath,
Dr James Young, Dr Saurab Sharma, Prof Deborah
Kopansky-Giles, Swatee Mishrra, and Prof Lyn March.
Operational activity remained the responsibility of
the Project Team.

External Steering GroupAn external Steering Group, established from theBone and Joint Decade Foundation and International
Co-ordinating Council of G-MUSC oversaw the
progress of the project and provided strategic-leveladvice over the course of the project. The SteeringGroup comprised: Prof Anthony Woolf (chair; United
Kingdom), Prof Kristina Åkesson (Sweden), Neil
Betteridge (United Kingdom), Prof Karsten Dreinhöfer(Germany), Dr Manjul Joshipura (India).

Human Research Ethics Approval
Approval to conduct the project was granted by the
Human Research Ethics Committee, Curtin University,
Australia (HRE2020-0183).

Funding
This work was supported by a grant awarded by
the Bone and Joint Decade Foundation. Additional
funding was provided by Curtin University, Australia.

Contributors
This work was enabled by a network of international
contributors, representing all geographic regions.
The project team sincerely thank the contributors
for sharing their time and expertise in the co-designof the framework proposed.

Core contributors
Nuzhat Ali (UK), Joletta Belton (USA), Prof Fiona
Blyth (Australia), Dr Richard Brown (Canada),
Demelash Debere (Ethiopia), Laura Finucane (UK),Prof Helen Foster (UK), Prof Francesca Gimigliano(Italy), Prof Scott Haldeman (USA), Prof Syed Atiqul
Haq (Bangladesh), Ben Horgan (Australia), Dr Anil
Jain (India), Prof Asgar Ali Kalla (South Africa),

Dr Jakob Lothe (Norway), Prof Shuichi Matsuda(Japan), Prof Ali Mobasheri (Finland), Lillian Mwaniki(Kenya), Prof Margareta C Nordin (France), Marilyn
Pattison (Australia), Prof Felipe J.J. Reis (Brazil),
Dr Enrique R. Soriano (Argentina), Prof Heather Tick
(USA), Dr James Waddell (Canada), Dieter Wiek
(Germany).

Other contributors by country
Argentina
Dr Cecilia Asnal, Ms Mariana Bonetto, Ms Chiara
Buzzelli, Dr Ignacio Gandino, Mr Martin Moro,
Ms Milagros Rossello, Dr Anastasia Secco.

Australia
Assoc Prof Ilana Ackerman, Mr Rob Anderson,
Prof Robert Blank, Dr Jocelyn Bowden, Ms Prudence
Butler, Mr Aidan Cashin, Dr Katie de Luca, Dr James
Debenham, Mr Craig Elliott, Prof James Elliott,
Ms Caitlin Farmer, Mr James Farmer, Mr Giovanni
Ferreira, Prof Manuela Ferreira, Mr Troy Gardiner,
Prof Catherine Hill, Prof Rana Hinman, Dr Emma
Karran, Dr Richard Kwiatek, Ms Jane Males,
Ms Marie March, Mr Rod Mclean, Ms Karime
Mescouto, Dr Serg Mezhov, Ms Jennifer Persaud,
Mr Radd Peters, Ms Rebecca Phillips, Prof Kevin
Pile, Ms Maree Raymer, Mr Rodrigo Rizzo, Dr Luke
Robinson, Dr Geoffrey Speldewinde, Dr Hannah
Seymour, Prof Cathie Sherrington, Ms Cobie
Starcevich, Prof Michele Sterling, Mr Matthew
Stewart, Dr Michael Swain, Mr Patrick Swete Kelly,
Mr Jay‑Shian Tan, Mrs Rosalie Upton, Prof Bill
Vicenzino, Dr Andrew Vitiello, Mr Kevin Wernli,
Ms Mary Wing.

Bangladesh
Prof Rowsan Ara, Mr Mohammad Lutfullah,
Prof Mujibur Rahman, Dr Shadab Sunny.

Belgium
Prof Liesbet De Baets, Ms Mairead Groarke,
Mr Tom Michielsen, Ms Nadine Vanhollebek.

BhutanMr Monu Tamang.

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75

Brazil
Dr André Barbosa Adriano, Prof Cristina
Cabral, Prof Thais Chaves, Dr Eduardo deMelo Carvalho Rocha, Dr Adriana Dell’Aquila,
Prof João Garcia, Dr Thaisa Infurna Gomes,
Prof Pedro Lima, Ms Marina Magalhães,Prof Guilherme Moreira de Barros, Dr Mauro
Salles, Dr Marcela Santa Rosa, Dr Bruno
Saragiotto, Mr Marcelo Sternick, Ms Izabel
Tavares, Dr Lin Yeng, Prof Fernando Zikan.

CanadaDr Carlo Ammendolia, Dr Jane Barratt, Dr Lauren
Beaupre, Dr Mark Bodnar, Dr Douglas Brandvold,
Prof Auri Bruno Petrina, Prof Pierre Côté, Dr Diana
De Carvalho, Mr Darren Frohlich, Dr Isabelle Gagnon,
Ms Annie Grenier, Dr Andrea Guidolin, Mr Stephen
Guy, Prof Jeffrey Hebert, Ms Catherine Hofstetter,
Dr Greg Kawchuk, Ms Rosemary Kirungyi, Dr Jasmin
Ma, Ms Rhona McGlasson, Ms Annette McKinnon,
Mr Keith Meldrum, Dr Silvano Mior, Dr Anish Naidu,
Dr Paul Nolet, Dr Geoff Outerbridge, Ms Ronda
Parkes, Dr Jairus Quesnele, Dr Paolo Sanzo,
Dr Patricia Tavares, Dr Natalja Tchajkova, Ms Aileen
Tran Mapletoft, Dr Jeff Warren, Dr Jackie Whittaker,
Mr Muhammed Zama.

Colombia
Mr Luis Henriquez Fuentes, Mr Enrique Sepulveda,
Dr Kai Fu, Prof Yueqin Huang, Prof Zhanguo Li,
Dr Kiran Shah, Dr Luis Alvarez, Prof Wilson Bautista
Molano, Dr Carlo Caballero, Dr Sebastian Herrera,
Dr Ryan Murillo, Dr Carlos Toro Gutierrez.

Croatia

Denmark
Prof Jan Hartvigsen, Ass Prof Morten Hoegh,
Prof Alice Kongsted, Prof Claus Nielsen,
Ms Anne Skov Østergaard, Ms Mette Toft.

Egypt
Dr Hazem Abdelaziz, Prof Ahmad Aly.

Estonia
Dr Karin Laas.

Finland
Dr Minna Stolt.

FranceDr Yargui Audrey, Mr Gaetan Barbier, Prof Francis
Berenbaum, Prof Federico Canavese, Dr Karine
Cheng, Dr Charlene Chéron, Dr Emmanuelle Cugy,
Dr Grace Dubois, Dr Nadège Lemeunier, Dr Mathieu
Ménard, Ms Olivia Parker, Dr Audrey Parkinson,
Dr Mégane Pasquier, Ms Agathe Wagner.

Germany
Dr Gemma Adib, Mr Peter Böhm, Mrs Trisha Davies
Knorr, Prof Klaus Günther, Prof Frank Hildebrand,
Ms Christine Kuberka Wiese, Prof Andreas Niemeier,
Mr Francis Osei, Ms Uta Prehl, Dr Alexandra Rauch,Prof Kati Thieme.

GreeceMs Arezoo Abdi, Ms Katy Antonopoulou, Dr Vasileios
Gkolfinopoulos, Dr Christos Topalis.

Dr Lovro Lamot, Dr Sime Mijic.

CyprusGuatemalaProf Manuel Padrino.

Mr Marios Kouloumas, Ms Souzi Makri.

Czech Republic

Honduras
Dr Hugo Alonzo.

Dr Tomas Novotny.

Hong Kong (S.A.R.)
Ms Sheila Purves.

76 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Hungary
Ms Katalin Forgács Kristóf, Dr Zoltán Grauzer,
Dr Zsolt Kálbori, Dr Monika Redly.

India
Dr Mohan Bairwa, Ms Shellette D Almeida, Prof Anil
Gupta, Mr Shrikant Iyengar, Prof Ashok Johari,
Dr Kalaivanan Kanniyan, Mr Niraj Karamchandani,
Mr Raghava Neelapala, Dr Akshat Pandey, Dr Ruchita
Parikh, Dr Dhara Patel, Dr Vivek Ramanandi,
Dr Abhinav Singh.

Indonesia
Ms Defianti Ariani, Dr Rudy Hidayat,
Mr Firmansyah Purwanto.

Ireland
Dr Éilish Burke, Mr John Casey, Mrs Wendy
Costello, Ms Blanaid Coveney, Dr Anne Dempsey,
Ms Petrina Donohue, Ms Angela Doyle, Dr Roger
Feely, Dr Diarmaid Fitzgerald, Ms Laura Fletcher,
Ms Brenda Foley, Mr Frank Foley, Ms Marion
Glasheen, Ms Michelle Heraughty, Ms Margaret
Kelleher, Dr Gráinne Kelly, Ms Marie Kelly, Ms Orla
Madden, Ms Eimear Ní Fhallúin, Dr Marie O’Mir,
Ms Helen O’Reilly, Dr Mary O’Keeffe, Dr Kieran
O’Sullivan, Ms Aisling Reynolds, Ms Stephanie
Skeffington, Dr Clodagh Toomey, Ms Grainne Treacy,
Ms Mary Walsh.

IsraelMs Carola Oppenheimer Rosenthal, Dr Tali Sahar,
Prof Shlomo Wientroub.

Italy
Dr Diego Alemanno, Dr Paola Antonaccio, Dr Maria
Brugnoli, Dr Luca Canzoneri, Ms Antonella Cardone,
Dr Rosario Furnari, Dr Paolo Galimberti, Dr Romano
Graziani, Dr Alessandro Guzzo, Prof Francesca
Ingegnoli, Dr Gianluca Maniscalco, Prof Paolo
Marchettini, Dr Mario Marinelli, Dr Cinzia Marzilli,Prof Marco Monticone, Dr Tiziana Nava, Dr Guindani
Nicola, Prof Maria Pace, Dr Vincenzo Pota, Dr Bernd
Raffeiner, Dr Vincenzo Sidoti, Dr Madalina Sofica,
Ms Silvia Tonolo, Dr Ugo Viora.

Japan
Ms Masae Ikeya, Mr Hironobu Kuruma,
Dr Kei Takeyachi.

Kenya
Mr Shadrack Okumu, Mr Henry Opondo.

LatviaDr Vladimirs Gromakovskis.

LebanonDr Charbel Najem.

Malaysia
Ms Nur Abdul Halim, Dr Amir Abdul Latiff, Dr Haidzir
Manaf, Dr Jocelyn Ooi, Dr Shivani Rajasegaran,
Dr Kandiah Raveendran, Dr La Reina Sangaran,
Dr Swee Tang, Prof Meow Thong, Dr Yi Kai Wong.

MexicoDr Ingris Pelaez Ballestas.

Mongolia
Dr Zolzaya Batdavaajav, Ms Batlkham Dambadarjaa.

Montenegro
Dr Sonja Nejkov.

Myanmar
Prof Thaingi Hlaing, Dr Lu Maw Win.

Nepal
Ms Nibha Bajracharya, Ms Anushree Balla,
Mr Marvin Dewan, Mr Shamed Katila, Ms Bimika
Khadgi, Mr Dildip Khanal, Ms Elisa Maharjan, Ms Riju
Maharjan, Prof Buddhi Paudyal, Mr Vimal Prajapati,
Ms Kanchan Sapkota, Ms Ranjeeta Shijagurumayum
Acharya, Mr Bishwas Shrestha, Dr Shaili Thapa.

PART 8: GOVERNANCE AND ACKNOWLEDGEMENTS

77

Netherlands
Dr Tjarco Alta, Prof Annelies Boonen, Dr Maarten
Heinsius, Dr Nathan Hutting, Dr Alan Jenks,
Dr Dagmar Kempink, Ms Patricia Pennings,
Prof Johannes Rasker, Dr Mark Scheper, Ms Gitte
Tonner, Dr Brenda van der Vossen, Prof Harry vonPiekartz, Dr Frank Wagenaar Dr Annemarie de Zoete.

PolandMrs Jolanta Grygielska, Dr Barbara Jasiewicz.

Portugal
Prof Jose Da Silva, Dr Ricardo Ferreira, Dr Margarida
Freitas, Prof Andréa Marques, Prof Alexandrina
Mendes, Dr Anabela Silva.

New Zealand
Dr Jason Chua, Assoc Prof Ben Darlow, Dr Jenny
Keightley, Mrs Susan Kohut, Assoc Prof Peter Larmer,
Dr Bronwyn Lennox Thompson, Dr Ramakrishnan
Mani, Dr Daniel Ribeiro, Dr David Rice,Prof Debra Waters.

Romania
Prof Mihai Berteanu, Dr Constantin Munteanu.

Russian Federation
Prof Olga Lesnyak.

Nigeria
Prof Olufemi Adelowo, Mrs Racheal Kareem,
Dr Abubakar Yerima.

NorwayMr Hans Engvold, Camilla Fongen, Mr Thor
Holmgard, Ms Olea Kvalsvik, Prof Emer Tore Kvien,
Dr Lise Lothe, Ms Amy Martinsen, Dr Rikke Moe,
Dr Espen Ohren, Dr Tim Raven, Prof May Risberg.

Saudi Arabia
Dr Hadeel Bakhsh.

Singapore
Assoc Prof Madelynn Chan, Mr Anthony Goff,
Dr Janet Sosna.

Slovenia
Prof Radko Komadina.

Pakistan
Dr Dilshad Al Arabia, Prof Sumaira Farman.

Palestine (West Bank and Gaza)Prof Alaaeldin Ahmad.

PanamaDr Antonio Cachafeiro, Dr Enrique Giraldo.

Peru

South Africa
Prof Stanley Brighton, Dr Bridget Bromfield,
Mr Grant Bush, Dr Kendrah Da Silva,
Ms Dershnee Devan, Dr Ina Diener, Ms Patricia
Dunn, Ms Magdalena Ferreira, Mrs Wilna Foot,
Prof Pragashnie Govender, Ms Andrea Linser,
Dr Victoria Madden, Prof Girish Mody, Dr Farzana
Moosajee, Mr Tom Paulsen, Ass Prof Christiaan
Scott, Mrs Veronica Tinley, Ms Maranda van Dam,
Mrs Meagan Wright.

Dr Manuel Ugarte Gil.

Philippines
Assoc Prof Romel Cabazor, Dr Eunice Co,
Prof Monalisa Lim Dungca, Dr Donald Manlapaz,
Mr Chris Munoz, Dr Sheila Reyes, Asst Prof Kathryn
Reyes, Dr Maria Gudez-Santos, Ass Prof ChristianRimando, Ms Zyra Sicat, Dr Lisa Traboco.

Spain
Dr Mercedes Boada, Dr Jose Campos, Prof Loreto
Carmona, Dr Gustavo Fabregat, Prof Enrique
Gomez Barrena, Dr Pedro Gonzalez Herranz,
Dr David Hernandez Herrero, Prof Antonio Herrera,
Dr Francisco Luna Cabrera, Dr Víctor Mayoral,
Dr Juan Ovalles Bonilla, Dr María Padilla del Rey,Dr Miren Revuelta, Mr Jon Royo, Dr Francisca Sivera,
Dr Javier Vidal Fuentes, Dr Marianna Vitaloni.

78 TOWARDS A GLOBAL STRATEGY TO IMPROVE MUSCULOSKELETAL HEALTH

Sri Lanka
Ms Thusharika Dissanayaka.

SwedenAssoc Prof Allan Abbott, Assoc Prof Iben Axén,
Prof Leif Dahlberg, Prof Ewa Roos, Prof Anne
Söderlund.

Switzerland
Prof Christine Cedraschi, Mr Guillaume Christe,
Dr Alarcos Cieza, Ms Renée de Ruijter, Prof Jean-Yves
Reginster, Dr Yuka Sumi, Mr Peter Timmers.

Syrian Arabic Republic
Dr Layla Kazkaz.

ThailandAss Prof Sirirat Charuvanij, Ass Prof Krit Pongpirul.

TurkeyDr Mustafa Agaoglu, Prof Gulseren Akyuz,
Prof Osman Atik, Dr Ayse Bahsi, Prof Deniz Evcik,
Prof Hakan Gunduz, Prof Ozgur Kasapcopur,
Prof Erkan Kozanoglu, Dr Koncuy Sivrioglu,
Dr Nuri Ulutas, Dr Vasyl Tsokalo.

United Arab Emirates
Dr Manoj Nair.
 United Kingdom of Great Britain

and Northern Ireland

Prof Adewale Adebajo, Mr Richard Beesley,
Mr Peter Bobak, Dr Helen Branthwaite, Prof Cyrus
Cooper, Prof Matthew Costa, Prof Emeritus Peter
Croft, Dr Jerry Draper Rodi, Dr Carol Fawkes,
Dr Rob Finch, Dr Guy Gosselin, Mrs Sarah Helmy,
Dr Lee Herrington, Prof Michael Hurley, Mr Jonathon
Kruger, Mr Stephen Mack Smith, Prof Iain McInnes,
Mrs Valerie Moody, Mr Peter Moore, Dr Chris
Penlington, Dr Catherine Quinn, Dr Emma Roberts,
Ms Claire Small, Dr Toby Smith, Dr Ai Lyn Tan,
Ms Jacqueline Thompson, Mr Nick Welch.

United States of America
Ms Christine Anderson, Dr Harvey Aikman,
Dr Ivy Alexander, Dr Kris Anderson, Dr Nancy Baker,
Dr Cameron Banks, Dr Ann Barry, Dr Anita BemisDougherty, Dr Craig Benton, Ms Jane Borgehammar,
Dr William Boissonnault, Dr Harvey Brockman,
Dr Melissa Buehler, Mr Daniel Chelette, Ms Kathleen
Cody, Dr Kim Coelho, Dr James Corcoran, Dr Zachary
Cupler, Dr Jenifer Dice, Dr Jonathan Dolutan,
Dr Jan Dommerholt, Dr Matthew Drake, Ms Ann
Elderkin, Ms Jennifer Everhart, Dr Mychelle Farmer,
Ms Mariann Farrell, Dr Kyle Feldman, Dr Amy
Fletcher, Prof Walter Frontera, Dr Angelo Gaffo,
Ms Tammy Gersh, Dr Lima Ghulmi, Mr Jeff Giulietti,
Prof Joseph Godges, Dr Christine Goertz, Dr Steven
Goostree, Dr Erik Groessl, Dr Anthony Hamm, Dr Kim
Hecht, Dr Liz Henry, Prof Marc Hochberg, Dr ClaireHorn, Dr Evelyn Hsieh, Prof Nitin Jain, Dr Kristin
Jerger, Dr Bringa Johnson, Mr Gregory Johnson,
Mr Howard Kagan, Dr David Karp, Dr Gary Kearns,
Dr Jeff Kittelson, Prof Jonathan Klein, Dr DonnamarieKrause, Dr William Lawson, Dr Craig Liebenson,
Dr David Logerstedt, Prof Jonathan Lowery, Ms Tyres
Marcy, Prof Lee Marinko, Prof Eric Matteson,
Dr Michele Meltzer, Mr Ernest Merritt, Prof Michael
Millis, Dr Brittany Minniear, Dr Matthew Morretta,
Dr Nathaniel Mosher, Dr Bradley Myers, Lt Col
Joseph Norris, Dr Bryan O’Halloran, Dr Kenneth
Olson, Dr Colette Peabody, Mr Matt Peale, Prof JanetPoole, Dr Peter Potena, Dr Guillermo Quiceno,
Dr Matthew Regulski, Dr Daniel Rendeiro, Dr Robert
Rowe, Dr Chris Showalter, Dr Emily Slaven, Dr Marcia
Spoto, Dr Christine Stamatos, Dr Eric Stedje-Larsen,
Dr Howard Phillips, Dr Brocha Stern, Dr Kimberly
Templeton, Ass Prof Jake Thompson, Dr RobertTrager, Dr Frank Tudini, Mr Philip Tygiel, Mr Stefan
van Duursen, Prof Stuart Weinstein, Dr Julie Werner,
Dr Adam Wielechowski, Dr Jeff Williams, Dr Richard
Wilson, Dr Jeffrey Yaver, Mr Al Zanetell.

Uruguay
Dr Miguel Albanese.

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79