Defining Health System Strengthening – Questions, Challenges and the Way Forward

Health system strengthening (HSS) has historically been a significant focus for Canada’s investment in global health but tracking progress in HSS continues to be a challenge. 

HSS was a priority in the Muskoka Initiative for Maternal, Newborn and Child Health (MNCH), a ten-year $6.35 billion commitment to improving women and children’s health worldwide. Currently, HSS is at the forefront of global health priorities amid the ongoing COVID-19 crisis, which has reinvigorated the discussion about the importance of resilient health infrastructure and systems

The ability to track, aggregate and analyze HSS efforts through clear measurement frameworks is paramount for achieving not only short term goals, such as responding to the COVID-19 pandemic, but also for transforming global health programming and meeting the Sustainable Development Goals (SDGs). However, robust tracking of HSS at the project-level has been complicated by its broad definition within the sector. 

This expansive definition of HSS, combined with the existing challenges in tracking project-level work, leads to ambiguity in exactly what we are doing to advance HSS and how well we are doing it.

A useful framework

Global Affairs Canada has utilized the WHO framework for health systems strengthening, which is comprised of six ‘building blocks’ – all of which represent the essential functions of a health system: 

  • Service delivery
  • Health workforce
  • Information
  • Medical products, vaccines & technologies
  • Financing 
  • Leadership/governance

This framework suggests that all six components are necessary and interconnected. Each must be sufficiently robust in order to reach the goals of improved health levels and equity, responsiveness, adequate social and financial risk protection and improved efficiency. 

Yet even within this WHO framework, HSS as a concept remains broadly defined and open to interpretation. According to some scholars, HSS interventions should be country specific, with cross-cutting benefits beyond a single disease. These interventions should address policy and organizational constraints, strengthen relationships between the six building blocks, or should include HSS activities that focus on long-term solutions and extend beyond the life of one specific activity or project. 

Most experts do agree that in order to be labeled as HSS, an intervention should have system-level rather than organizational-level effects. In other words, strengthening health systems should affect the whole ecosystem of health in a country, rather than only specific sub-units, such as hospitals or facilities, within that ecosystem.

As a funding strategy, the Muskoka Initiative recognized HSS as critically important and included it as a pillar under both MNCH programming cycles.  However, it is not clear that projects were defined or tracked to adequately assess how much of the overall investment can be attributed to HSS activities, even when using the above framework. 

This tracking deficit is identified as a challenge and discussed by Global Affairs Canada in a final evaluation report on MNCH projects. In the report, the authors suggest that HSS could be framed as an overarching theme for health projects – something to be considered in the design process – rather than being a distinct stream of programming itself.  The 2017 Feminist International Assistance Policy, while including a brief commitment to “strengthen health and data systems,” does not explicitly name HSS as a main action area. 

Measuring Progress 

Following our own review of project activities and outputs through the CanWaCH Project Explorer and Global Affairs Project Browser, we discovered that many Muskoka Initiative projects appear to include health systems-related interventions using the WHO framework. Health personnel training activities were a main focus and many projects had additional elements of capacity-building at various levels (local, regional, national). 

In our review, Muskoka projects that include an HSS focus or elements were classified under multiple DAC sector codesand were not easily searchable or comparable without significant time spent examining and categorizing text-based descriptions. This is not surprising; in coding systems such as the IATI Standard HSS projects are classified across multiple sector codes that cover some of the WHO building blocks (i.e. health service infrastructure, health system management, etc.) but there is no ‘primary’ sector code to capture HSS as a whole. When examining the IATI Standard DAC codes, health systems strengthening is mentioned explicitly in the description of the code 12110 (“health policy and administrative management”); however, this code is not always used to track GAC projects that include HSS activities.  

In another recent global review of HSS research, it was found that more operational topics, such as supply chain management and health information systems, have received less attention in the literature as compared to health system areas like the workforce or financing. Is this an accurate reflection of programming, or a matter of confusing data? 

Ultimately, without clear codes and definitions that are consistently applied for what constitutes HSS, how can our sector track its impact or identify ongoing gaps without conducting labour-intensive research? How can we see what building blocks are being strengthened and which are being neglected? 

Next Steps

It is more apparent than ever that we need stronger, more resilient health systems and that properly tracking, aggregating and analyzing HSS efforts is imperative to truly gauge progress. 

Going forward, Canadian practitioners, researchers, and government colleagues should consider how we can collectively tackle HSS programming and measurement in the next era of funding. Part of this will need to include a re-examination of current frameworks and standards that reflect evolution and developments in technology and global health ecosystems, as well as a clarification of Canada’s priorities and commitments around strengthening change at the systemic level. 

As CanWaCH and its membership continue to explore how our sector might continue to track and talk about our collective HSS efforts, we invite researchers, data specialists and practitioners working in this area to reach out and share resources and ideas.


May 9, 2020