Health system strengthening – reflections on its meaning, assessment and our state of knowledge

You can download this International Journal of Health Planning & Management paper here.

NB This paper is based on a review commissioned by the UK’s Department for International Development (DFID) from the ReBUILD and ReSYST research consortia. Read that report here.

It also formed the basis for a presentation given to the UK’s Department for International Development in July 2019. A video of the presentation, an interview with Sophie Witter and the slides alone are available here.


Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base.

The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability  (effects being sustained over  time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness).

We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a “strong health system.” We highlight that current findings on “what works” are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to rethink evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks, and methods can support more coherent HSS investment.

Accessing the paper

You can download this International Journal of Health Planning & Management paper here.


Sophie Witter1, Natasha Palmer2, Dina Balabanova3, Sandra Mounier-Jack3, Tim Martineau4,  Anna Klicpera3, Charity Jensen5,  Miguel Pugliese-Garcia3 & Lucy Gilson3,6

1Institute of Global Health and Development,Queen Margaret University, Edinburgh, UK

2Associate Consultant, Itad Ltd, Brighton, UK

3Department of Global Health and Development and Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

4International Public Health, Liverpool School of Tropical Medicine, London, UK

5Global Family Care Network, UK

6Division of Health Policy and Systems,University of Cape Town, Cape Town,South Africa

Referencing the paper

Witter S, Palmer N, Balabanova D, et al. Health system strengthening—Reflections on its meaning, assessment and our state of knowledge. International Journal of Health Planning & Management. 2019;1–10.

This resource was produced by the ReBUILD programme – the precursor of ReBUILD for Resilience.