The goal of health systems strengthening (HSS) is to improve health outcomes, save lives, and make investments in health more efficient.

Health systems consist of all the institutions, resources, and people whose primary purpose is to improve health. These include hospitals, clinics, health workers, pharmacies, financing and pharmaceuticals, information and communications systems, and policies and business practices.

HSS refers to activities that improve a health system’s efficiency, quality, access, and effectiveness and lead to better health outcomes for everyone regardless of ethnicity; gender; religion; income; or any other economic, political, or social status.

Weak health systems make it difficult for people to receive proper or sufficient care, especially among those who need it most (i.e., women, children, the rural poor, the marginalized and stigmatized, and religious and ethnic minorities). These weaknesses are far more acute in fragile states and areas of conflict.

Functioning public and private health systems are essential to the success of disease-specific health initiatives and to meeting the U.S. global health goals of ending preventable child and maternal deaths, ensuring global health security, and achieving an AIDS-free generation. Strengthening health systems ensures that U.S. investments in global health are sustainable.

Strong health and community systems are key to preventing and responding to epidemics, new diseases, or unexpected events, such as the Zika epidemic in Latin America, the Ebola epidemic in West Africa, or natural disasters.

Integrated Health Project in the DRC Credit: Warren Zelman


Ensure funds are allocated to health systems strengthening in all future global health-related legislation to ensure that capacity is built within a country’s system and through other providers of health services, such as faith-based institutions and community-based organizations to maximize efficiencies in tackling diseases and health issues.

Encourage the U.S. Agency for International Development (USAID), the State Department, and the Department of Health and Human Services, including the Centers for Disease Control and Prevention, to:

Develop a comprehensive HSS strategy that identifies and advances measurable objectives for all six World Health Organization (WHO) Building Blocks (see below) and includes specific support for frontline health workers and community-based health service delivery and access. Each agency implementing U.S. global health programs should identify an HSS lead as part of the strategy.

Develop and regularly update HSS technical guidance to help inform the work of country-based U.S. government teams. Relevant agencies should provide substantive guidance to their field staff that includes practical advice on how to design, implement, and assess HSS programs.

Define and apply clear metrics to assess the impact of U.S. investments in HSS. In early 2013, U.S. agencies began the process of determining indicators to measure the impact of its HSS efforts. Monitoring and managing progress are essential for ensuring programs are achieving desired results.

Invest in global health research and professional training for students from developing countries to build a sustainable health workforce capable of effectively addressing population needs and responding to public health threats (see brief on Frontline Health Workers).

Local communities, including faith communities, should be integrated into the U.S. government approach to HSS. Community involvement and participation are key ingredients to well-functioning health systems. The U.S. government should actively include local communities in deciding the direction of its health-improving activities and the delivery of health services, particularly through social accountability mechanisms.

The U.S. government should work with nongovernmental organizations (NGOs), faith-based organizations (FBOs), and others who implement HSS assistance programs to find the most effective means for optimizing its partnerships. The U.S. government should take advantage of the HSS knowledge that already exists in the NGO, FBO, and donor community and incorporate that expertise into its HSS programming.

Integrated Health Project in the DRC Credit: Warren Zelman
Integrated Health Project in the DRC Credit: Warren Zelman


The WHO defines six “Building Blocks” that are essential to strong health systems: [1]




(medicines, vaccines, etc.)




These building blocks represent the structures and resources needed to provide efficient and effective health services to ensure healthy outcomes. Yet, many countries have severe inequities in access to health services;[2] face critical health workforce shortages;[3] and suffer from weak information systems, irregular supply chains, inefficient use of resources, and weak governance and accountability mechanisms. These vulnerabilities pose financial, political, and health risks not just to developing countries, but also to the whole world.

Ultimately, health systems strengthening is about helping countries improve health and save the lives of all their citizens, including the most marginalized and vulnerable. Due to improved biomedical technologies, increased use of information technologies, and sustained public and private investments, significant efforts have been made to strengthen health systems. As a result, deaths due to preventable causes have decreased, equitable access to quality health care has improved, and populations are healthier and more stable.

HSS is key as the U.S. government continues to promote country ownership and sustainability. USAID is committed to HSS and sees it as a central goal of all U.S. global health programming. USAID’s Office of Health Systems leads the agency’s work on HSS, ensuring access to safe and good quality medicines; strengthening capacity to detect and contain infectious disease threats; training and equipping a frontline health workforce to deliver essential services where they are needed most; and strengthening financial management systems.

HSS is even more important in the current U.S. fiscal climate; every dollar invested in global health must add sustainable value and demonstrate progress toward achieving priority health outcomes. New evidence shows investments in health systems also have multiplier effects that enhance inclusive economic growth.[4] Strong health systems are imperative for maximizing the impact of U.S. global health investments.


  1. WHO Health Systems Framework


Vince Blaser, IntraHealth International,
Marielle Hart, International HIV/AIDS Alliance,
Filmona Haliemichael, Management Sciences for Health


[1] “WHO Health Systems Framework,” The World Health Organization.

[2] Tracking Universal Health Coverage: First Global Monitoring Report, World Health Organization and the World Bank, 2015.

[3] Global strategy on human resources for health: Workforce 2030, World Health Organization, 2016.

[4] Working for health and growth: investing in the health workforce. High-Level Commission on Health Employment and Economic Growth, United Nations, 2016.

©2017 Global Health Council