Health system strengthening – what is it, how should we assess it, and does it work?

Presentation given by Sophie Witter, Dina Balabanova and Sandra Mounier-Jack to the Department for International Development in July 2019.

NB This presentation is based on a 2019 review commissioned by the UK’s Department for International Development (DFID) from the ReBUILD and ReSYST research consortia. Read that report and the 2021 update here.

The associated peer-reviewed paper – Health system strengthening—Reflections on its meaning, assessment, and our state of knowledge – is now available. Read it here. 


Comprehensive reviews of health system strengthening  interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. In our talk, we will reflect on the process of undertaking such an evidence review for DFID recently (attached again), drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spill-over effects and their contribution to meeting over-arching health system process goals. We will make some initial suggestions about such goals, to reflect the features that characterise a ‘strong health system’. We will highlight current findings on ‘what works’ but also that these are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to re-think evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks and methods can support more coherent HSS investment.


Sophie Witter is Professor of International Health Financing and Health Systems at the Institute for Global Health and Development, Queen Margaret University, Edinburgh. There she leads research on health system reconstruction in shock-affected settings, on health financing strategies and on health worker incentives (including performance-based financing) in low- and middle-income countries.

Dina Balabanova is Associate Professor in Health Systems and Policy in the Department of Global Health and Development at the London School of Hygiene and Tropical Medicine. She conducts health systems and policy research – governance, effective delivery and system-wide responses to non-communicable diseases – across a range of low- and middle-income countries.

Sandra Mounier-Jack is an experienced health systems and policy researcher in low- and middle-income countries and the UK. She is involved in studies investigating health systems, health systems strengthening, the delivery of communicable diseases programmes (eg. vaccination programmes) and integrated care.

Further information

Sophie Witter discusses the recent DFID commissioned ‘Evidence review of what works for health systems strengthening, where and when?’

The slides alone are here.