{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:26:03Z","timestamp":1790814363153,"version":"4.1.0"},"reference-count":51,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2019,8,6]],"date-time":"2019-08-06T00:00:00Z","timestamp":1565049600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000278","name":"Department for International Development","doi-asserted-by":"publisher","award":["Supported by the ReBUILD and ReSYST RPCs"],"award-info":[{"award-number":["Supported by the ReBUILD and ReSYST RPCs"]}],"id":[{"id":"10.13039\/501100000278","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Health Planning &amp; Management"],"published-print":{"date-parts":[[2019,10]]},"abstract":"<jats:title>Summary<\/jats:title>\n                  <jats:p>Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a \u201cstrong health system.\u201d We highlight that current findings on \u201cwhat works\u201d are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to rethink evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks, and methods can support more coherent HSS investment.<\/jats:p>","DOI":"10.1002\/hpm.2882","type":"journal-article","created":{"date-parts":[[2019,8,6]],"date-time":"2019-08-06T08:59:16Z","timestamp":1565081956000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":88,"title":["Health system strengthening\u2014Reflections on its meaning, assessment, and our state of knowledge"],"prefix":"10.1002","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7656-6188","authenticated-orcid":false,"given":"Sophie","family":"Witter","sequence":"first","affiliation":[{"name":"Institute of Global Health and Development, Queen Margaret University  Edinburgh UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natasha","family":"Palmer","sequence":"additional","affiliation":[{"name":"Associate Consultant, Itad Ltd  Brighton UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dina","family":"Balabanova","sequence":"additional","affiliation":[{"name":"Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandra","family":"Mounier\u2010Jack","sequence":"additional","affiliation":[{"name":"Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tim","family":"Martineau","sequence":"additional","affiliation":[{"name":"International Public Health Liverpool School of Tropical Medicine  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Klicpera","sequence":"additional","affiliation":[{"name":"Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charity","family":"Jensen","sequence":"additional","affiliation":[{"name":"Global Family Care Network  UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miguel","family":"Pugliese\u2010Garcia","sequence":"additional","affiliation":[{"name":"Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucy","family":"Gilson","sequence":"additional","affiliation":[{"name":"Department of Global Health and Development, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine  London UK"},{"name":"Division of Health Policy and Systems University of Cape Town  Cape Town South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,8,6]]},"reference":[{"key":"e_1_2_7_2_1","unstructured":"WitterS PalmerN BalabanovaD et al.Evidence review of what works for health system strengthening where and when? 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