Global Health Actors Claim To Support Health System Strengthening—Is This Reality or Rhetoric?

The recent explosion in the number of global health initiatives has dramatically changed the landscape of public health and international aid. During an initial honeymoon period, these initiatives started implementing their disease-specific activities in low-income countries. But the honeymoon is over, and there is now an increasing realisation that such initiatives ignore a wider problem—existing health systems in the developing world are fragile and unable to provide effective health services, especially in sub-Saharan Africa [1,2]. Simultaneously, there is a growing consensus that effective global initiatives require well-functioning health systems [3]. As a result, health system strengthening (HSS) in low-income settings is now regarded, in the words of Alaka Singh at the World Health Organization (WHO), as ‘‘the ‘first-order’, immediate/medium-term goal to create the necessary enabling institutional and systemic environment to achieve and sustain ‘higher order’ MDGs [Millennium Development Goals] in the long(er) run’’ [4]. Despite this new attention upon HSS, the term remains a vague concept, with varying definitions and strategies for HSS, and varying ideas about the role attributed to the health system in improving public health. In this Policy Forum, we argue that most current HSS strategies are selective (i.e., they target a specific disease), and their effects may undermine progress towards the long-term goal of effective, high-quality, and inclusive health systems. There are, however, signs that the main actors in global health are aware of these risks, and a new window of opportunity for redefining HSS may be emerging. In order not to miss this opportunity, we urgently need a systemic approach to HSS that is contextual and that fits the countries’ agendas first. Focusing on country health systems with limited resources, we aim to stimulate the debate on HSS and to suggest a way forward. Methods