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Commentary
Square peg in a round hole: re-thinking our approach to evaluating health system strengthening in low-income and middle-income countries
  1. Josephine Borghi1,
  2. Zaid Chalabi2
  1. 1 Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
  2. 2 Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Dr Josephine Borghi; jo.borghi{at}lshtm.ac.uk

https://doi.org/10.1136/bmjgh-2017-000406

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    Summary box

    • Health system strengthening is an essential step towards achieving universal coverage goals in low-income and middle-income countries (LMICs). However, health systems are complex and health system strengthening initiatives are often introduced with limited understanding of how they will work in practice and the risk of potential adverse events

    • Aid flows to health systems in LMICs have increased substantially in the last 15 years. Donors want to know whether their investments in health system strengthening represent value for money relative to disease control programmes and how to optimise the design of such programmes.

    • Conventional evaluation methods ignore the complex dynamic nature of health systems and are insufficient to serve donor needs.

    • System dynamics and agent-based modelling methods can reflect the complexity of health systems and be used to estimate value for money for health systems investments in LMICs and predict health system response to any stimulus prior to its introduction, including the detection of potential adverse events.

    • There has been very limited application of system dynamics and agent-based modelling within the evaluation of health system strengthening initiatives in LMICs, and their future use by researchers is highly recommended.

    To function effectively, health systems require adequate financing; an effective workforce; reliable information for decision making; good governance; and available medicines and health technologies to deliver quality services to their populations.1 In low-income and middle-income countries (LMICs), health systems are often limited in this respect and fail to provide comprehensive population coverage of quality healthcare interventions. Health system strengthening comprises strategies to improve one or more of the functions of the health system in order to improve access, coverage, quality or efficiency,1 and is recognised to be an essential step towards achieving universal coverage goals.2 Only when health systems function efficiently and effectively can they deliver services to meet population needs. …

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