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      Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions

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          This paper argues that the global health agenda tends to privilege short-term global interests at the expense of long-term capacity building within national and community health systems. The Health Systems Strengthening (HSS) movement needs to focus on developing the capacity of local organizations and the institutions that influence how such organizations interact with local and international stakeholders.


          While institutions can enable organizations, they too often apply requirements to follow paths that can stifle learning and development. Global health actors have recognized the importance of supporting local organizations in HSS activities. However, this recognition has yet to translate adequately into actual policies to influence funding and practice. While there is not a single approach to HSS that can be uniformly applied to all contexts, several messages emerge from the experience of successful health systems presented in this paper using case studies through a complex adaptive systems lens. Two key messages deserve special attention: the need for donors and recipient organizations to work as equal partners, and the need for strong and diffuse leadership in low-income countries.


          An increasingly dynamic and interdependent post-Millennium Development Goals (post-MDG) world requires new ways of working to improve global health, underpinned by a complex adaptive systems lens and approaches that build local organizational capacity.

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          Most cited references 38

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          Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.

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            An assessment of interactions between global health initiatives and country health systems.

            Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.
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              Understanding pathways for scaling up health services through the lens of complex adaptive systems.

              Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.

                Author and article information

                Global Health
                Global Health
                Globalization and Health
                BioMed Central (London )
                12 February 2015
                12 February 2015
                : 11
                [ ]Department of Health Sciences, Brigham Young University, Provo, UT 84602 USA
                [ ]Department of Global Health and Population, Harvard School of Public Health, Harvard University, 665 Huntington Avenue, Boston, MA 02115 USA
                [ ]Vancouver Coastal Health Research Institute, 6975 Marine Drive West, Vancouver, BC V7W 2 T4 Canada
                [ ]Health Systems Action Network, K-57 A, Sheikh Sarai Phase -II, New Delhi, 110017 India
                [ ]Nucleus of Research in Public Health, Faculdade de Medicina da UFMG, Avenida Alfredo Balena, 190, Belo Horizonte, MG Brasil
                [ ]National Health Foundation, Building 1, 1st Floor, Office of the Permanent Secretary, Ministry of Public Health, Tivanond Road, Nonthaburi, 11000 Thailand
                [ ]World Medical Association, 13 Chemin du Levant, Bâtiment A, le John Keynes, 01210 Ferney-Voltaire, France
                [ ]Warwick Business School, The University of Warwick, Coventry, CV4 7AL UK
                [ ]George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Rd, PO Box M201, Camperdown, NSW 2050 Australia
                [ ]Queen Mary University, London, Blizard Institute, Barts and The London School of Medicine and Dentistry, 4 Newark Street, London, E1 2AT England
                [ ]African Centre for Global Health and Social Transformation, Plot 13 B Acacia Avenue, P.O.Box 9974, Kololo, Kampala Uganda
                [ ]School of Public Health, University of Western Cape, South Africa, Private Bag X17, Bellville, 7535 Republic of South Africa
                [ ]National Health Systems Resouce Centre, NIHFW Campus, Baba Gangnath Marg, Munirka, New Delhi, 110067 India
                [ ]Institute of Tropical Medicine, Antwerp, Belgium and University of Western Cape, Sint-Rochusstraat 2, 2000 Antwerpen, Belgium, South Africa
                © Swanson et al.; licensee BioMed Central. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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