Abstract
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.
Highlights
What works for health system strengthening (HSS), where and when? A review was commissioned by the UK's Department for International Development (DFID) to provide answers to this question, based on existing evidence, in order to inform strategic planning for the implementation of health systems strengthening interventions in lowand middle-income countries (LMICs).[1]
They included (a) governance and leadership-centred interventions strengthening spillover effect on the overall health system and population health outcomes, (b) “governance plus” (interventions paired with ones addressing another health system function, and (c) governance policies and reforms embedded within broad programmes aiming at whole-system transformation
Our review highlights the need to build consensus about what HSS means and how it is assessed, as well as the limited nature of the literature examining systemic effects of investments, and makes suggestions to strengthen these areas. This is important as governments and donors are moving away from vertical programmes and seeking to invest in HSS, so having an agreement on concepts and indicators of success will support programme design and targeting of resources
Summary
Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term and 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. We 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. 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. Frameworks, and methods can support more coherent HSS investment
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