• health policy
• health services research
• health systems evaluation
• health systems
• intervention study

At the turn of the century, the Millennium Development Goals (MDGs) set targets to dramatically improve human welfare by 2015. These ambitious aims included reducing extreme poverty by 50%, under-5 mortality by 66% and maternal mortality by 75%, and were accompanied by international support. Now, most African countries have international funding and policy commitments to treat HIV, tuberculosis (TB) and malaria, provide contraceptives to women, vaccines for children, and implement WHO-recommended treatment guidelines for maternal and child health, supported by front-line community health workers (CHWs).

Why then, if the treatments are known, affordable at scale and supported by standard policies, did only a few countries achieve their health-related MDGs and what does that mean for the prospects of the Sustainable Development Goals? One answer is that even simple technologies require complex delivery systems—a value chain of staff, stuff, systems and space—to align at the point of care and serve each individual patient. The recognition of this challenge has led to a growing movement towards health system strengthening (HSS) based on WHO’s six building blocks—personnel, supplies, finance, leadership, services and information systems.

Those who see the global health challenge primarily through the lens of scale—including policymakers, international stakeholders and social ventures—point out that the HSS building blocks do not actually guide implementers, as they consist of many dimensions that are difficult to prescribe.1 The result is an enduring tendency for the international community to invest in uncoordinated vertical efforts, often undermined by challenges with integration into local health systems that are unable to adequately support them.2 3 Such vertical approaches can be easily measured through process indicators (such as quantity of services delivered), but rarely demonstrate population-level impacts such as on coverage or mortality rates.4

In contrast, an alternative paradigm is to integrate HSS initiatives with clinical programmes …