Strong health systems are efficient, effective, and provide access to essential, quality health services for every community. Health systems are the institutions, resources, people, and communities focused on improving health — including hospitals, workers, pharmacies, vaccines, technologies, policies, and business practices, as well as financial, information, and communications systems. Health systems strengthening (HSS) refers to the activities that improve a health system’s efficiency, quality, accessibility, or effectiveness.

Strong health systems even in areas of conflict or weakened security help ensure outbreaks are contained, epidemics are prevented, and other emerging health threats are detected early. Such systems provide quality services to communities with the least access to care and the most marginalized populations, including women, children, the rural poor, and religious and ethnic minorities.

Strong health systems also support overall economic growth, reduced poverty, and sustainable progress in global health. Functioning public and private health systems are essential for the success of disease-specific initiatives and for meeting U.S. commitments to address global health security threats, end preventable maternal and child deaths, and combat infectious diseases such as HIV/AIDS.

U.S. leadership has a unique policy opportunity to invest in low- and middle-income countries (LMICs) and other partners who are working to create strong, sustainable health systems, that in turn, support self-reliance. What makes this moment unique is the rapid economic growth currently enabling many countries to show interest in ending their dependence on development assistance and in financing essential HSS with their own resources.


Mandate that all future investments and programs related to global health help strengthen partner country systems, scaling their capacity to deliver essential, quality health services to all communities. Make sure that these efforts place a strategic focus on communities with the least access to quality health services, building a diverse network of providers that includes frontline health workers, faith-based organizations (FBOs), and community members.

Encourage federal agencies to develop a cross-agency strategy for global health programs that integrate across development sectors, leverage multisector investment, strengthen health systems, and build resilience and self-reliance. In addition, the strategy should have well-defined targets and clear accountability mechanisms. 

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

The U.S. government should partner with nongovernmental organizations (NGOs), FBOs, and others who implement HSS assistance programs to find the most effective means for leveraging the health systems knowledge that already exists in these and other donor communities. This expertise should be incorporated into HSS programming efforts led by the United States.

Credit: PAI/Sala Lewis
Credit: PATH/Aaron Joel Santos


In 2015 the U.S. Agency for International Development (USAID) issued the Vision for Health Systems Strengthening, providing a commitment to integrate HSS into all USAID work on global health through 2019. This commitment highlights four strategic HSS outcomes that support sustained health impact:

  • Financial Protection — the cost of essential health services must permit people to seek and use them without becoming impoverished;
  • Essential Services — high-quality prevention, promotion, treatment, and health care services must be available to all;
  • Population Coverage — those of all socioeconomic statuses must have the same access to essential health services; and
  • Responsiveness — quality health services must be delivered in a timely and confidential manner that ensures dignity and respect for all.

Due to improved biomedical technologies, increased use of information technologies, and sustained public and private investments, significant strides have been made to strengthen global health systems. As a result, deaths due to preventable causes have decreased, equitable access to quality health services has improved, and populations are healthier and more stable. However, many countries still face severe inequities in access to health services,[1] critical gaps in access to qualified health workers, weak information systems, irregular supply chains, inefficient use of resources, or weak governance and accountability mechanisms. USAID’s four strategic HSS outcomes can be achieved by ensuring access to safe medicines, increasing capacity to detect and contain infectious disease threats, strengthening financial management systems, and training and equipping frontline health workers to deliver essential services.

The Zika epidemic in Latin America, the Ebola epidemic in West Africa, and frequent natural disasters around the world underscore how easily global health threats can cross borders and how vital strong health systems are for all countries, regardless of income level. Especially in areas of conflict and states with weakened security, strong health systems are essential to global well-being.

As the U.S. government continues to promote health system sustainability and self-reliance in other countries and at home, HSS will grow increasingly important. Investments in HSS have multiplier effects that enhance inclusive economic growth.[2] For example, HSS plays a vital role in the Global Health Security Agenda, an initiative developed in 2014 to address and strengthen the global capacity to prevent, detect, and respond to infectious disease threats through multilateral and multisectoral engagement. Investments in HSS also create a path toward systems that provides timely, essential, and financially accessible health services. Underutilization of essential health services by the poor leads to an ongoing cycle of poverty, as people who are sick and vulnerable are less able to participate in the labor market. HSS can assist in stopping this cycle of poverty and guiding countries toward a more holistic approach to improving global health.


  1. USAID’s Vision for Health Systems Strengthening
  2. USAID’s Programs in Global Health: Savings Lives and Helping People Thrive


Vince Blaser, IntraHealth International,
Crystal Lander, Living Goods,
Faustine Wabwire, Management Sciences for Health,
Jason Wright, Management Sciences for Health,


[1] “Tracking universal health coverage: First global monitoring report,” WHO/World Bank Group.

[2] “Working for health and growth: Investing in the health workforce,” WHO.

©2019 Global Health Council