Members' Research Service By / February 10, 2015

Strengthening health systems in developing countries

According to the World Health Organization, a health system is the sum total of all the organisations, institutions and resources…

© stockWERK / Fotolia
Strengthening health systems in developing countries
© stockWERK / Fotolia

According to the World Health Organization, a health system is the sum total of all the organisations, institutions and resources whose primary purpose is to improve health. A good health system requires a robust financing mechanism, a well-trained and adequately paid workforce, reliable information on which to base decisions and policies, well-maintained facilities and logistics to deliver quality medicines and technologies. These elements are part of the debate on how to strengthen health systems, one of the key strategies for fighting poverty and fostering development. They attracted renewed attention in the recent discussion on the international response to the Ebola outbreak in Africa. This keysource summarises statistics, research and policies.


As stated by the WHO , today more than one billion people cannot obtain the health services they need, because those services are either inaccessible, unavailable, unaffordable or of poor quality.

The WHO World Health Statistics 2014 ( Part III Global health indicators , Chapter 6, Health systems, p. 128-140) address inter alia the density of health workforce (persons currently participating in the health labour market), infrastructures and technologies – including the density of hospital beds, which is regarded as an indicator for the availability of inpatient services. Data are derived from multiple sources, including national population censuses, labour-force and employment surveys, health-facility assessments, and routine administrative information systems.

The following tables show selected data and regions:

Density of health workforce (per 10 000 population),2006–2013
Physicians Nursing and
African Region 2.6 12.0 0.5 0.9
South-East Asia Region 5.9 15.3 1.0 3.8
European Region 33.1 80.5 5.0 5.1
Global 14.1 29.2 2.7 4.3
Infrastructures and technologies
Hospitals beds (per 10 000
Psychiatric beds (per 10 000 population)
Radiotherapy units
(per million
African Region n.a. 0.6 0.1
South-East Asia Region 10 0.3 0.3
European Region 53 6.3 4.0
Global 27 2.5 1.8

According to the WHO Report on the State of health financing in the African Region , published in January 2013, the Member States of the African Region of the World Health Organization are on average still far from meeting key health financing goals such as the Abuja Declaration target of allocating 15% of the government budget to health.

The report includes statistical information on

  • trends in total health expenditure per capita (Table 2.1),
  • external sources of health financing as a percentage of total health expenditure (Table 2.3) ,
  • total health expenditure and level of out-of-pocket payments (Table 2.7),
  • a selected list of countries that have abolished user fees or provide formal exemptions (Table 2.8).

Overviews and country-specific studies

Health systems , one of the WHO topic pages on the subject, provides general and technical information.

The WHO May 2010 publication on the Key components of a well-functioning health system , May 2010 (2 p.) expects a well-functioning health system to

  • improve the health status of individuals, families and communities
  • defend the population against what threatens its health
  • protect people against the financial consequences of ill-health
  • provide equitable access to people-centred care
  • make it possible for people to participate in decisions affecting their health and health system.

Health financing in Africa , a Special Issue of The African Health Monitor (July 2013, 60 p.) defines three aspects to universal health coverage as:

  • access to all health services needed,
  • efficient and effective quality services,
  • the absence of financial hardship (or financial risk protection).

It focuses on national health financing interventions and reforms in Rwanda, Zanzibar, Gabon, Chad, Burundi, Uganda, and the relationship between out of-pocket payments and health expenditure in Burkina Faso, Mauritania and Senegal.

According to the Multi-Country Study of June 2012 ( Health Systems in Africa : Community Perceptions and Perspectives, 97 p.) African countries should enhance the quality of health care through reforms that improve infrastructure, in particular health facilities, qualified staff, essential medicines and financing. More specifically, they should

  • establish community-based surveillance systems for detecting and reporting the most common health problems;
  • establish appropriate health financing mechanisms including social health insurance, taxation, community financing and other options towards universal health coverage (chapter 7, Recommendations , p. 59).

The Routledge handbook of global public health , edited by Richard G. Parker and Marni Sommer (Routledge, 2011, 521 p.) provides a broad selection of articles on developments and policies of global public health including aid.

In their chapter on “The Politics of Global Aid” Peter Muennig and Celina Su summarize various models of global aid for public health and the criticism these have been provoking (p. 285-286).

When discussing the efforts of “Health System Strengthening” (“Past, Present, Future”, p. 473-480) and summarizing the current debate, Sara Bennett hints on the potentially harmful effects of disease-specific funding which is not accompanied by investments in health systems (p. 475).

The comprehensive publication on Comparative health systems: global perspectives , published by James A. Johnson and Carleen H. Stoskopf in 2010 (451 p.), includes descriptions of national health care systems in India (p. 248-253), the Democratic Republic of Congo (p. 294-295), Nigeria (p. 307-310) and Ghana (p. 327-329).

The WHO working 2005 paper Improving health services and strengthening health systems (Adopting and implementing innovative strategies – An exploratory review in twelve countries, 29 p.) reviews the implementation and impact of strategies for improving service delivery in twelve low-income countries – Cambodia, Ethiopia, Ghana, Indonesia, Kenya, Mali, Mozambique, Myanmar, Papua New Guinea, Tanzania, Uganda, and Viet Nam. Strategies included user fees exemptions, subsidies for the poor and performance related pay.


Health personnel

When discussing The human right to health (2012, 192 p.), Jonathan Wolff’s 2012 addresses the shortage of health workers in the developing world, the subsequent problem of country-to-country migration and the negative effects of recruiting trained staff for well-funded vertical programs on health systems which takes them away from their original work (p.112-113). Nevertheless he proposes “well-thought-out human right to health campaigns” to generate resources for the developing world (p. 129).

In the same vein, Sophie Harman points to the “brain drain” element of health professionals leaving to work abroad, one of the many reason for a lack of “health strengthening”. She hints on the challenges of economic globalization – labour rights, intellectual properties, global inequalities and their effect on wage scales ( Global health governance , 2012, 177 p., chapter 5, Neglected Health, p.135).

A Global Public Health article of September 2011 hints on the fact that mid-level workers, often regarded as the backbone of health systems in Africa, work in circumstances in which providing high quality care is challenging. In this view, additional staffing might not substantially change health system performances. ( Innovation to improve health care provision and health systems in sub-Saharan Africa – Promoting agency in mid-level workers and district managers, Sharon Fonn, Sunanda Ray, Duane Blaauw, Vol. 6, Issue 6, p. 657-668, 12 p.).


While advocating the local production of medicines and other essential health commodities in Africa, the June 2014 WHO Bulletin finds that the need for a growing range of medicines and assistive technology cannot be fulfilled with Africa’s existing manufacturing capacity – the continent remains dependent on imports ( Commodities for better health in Africa — time to invest locally , Michel Sidibé, LI Yong, Margaret Chan, Vol. 92, Issue).

A 2011 analysis on Health systems performance in sub-Saharan Africa (Governance, outcome and equity, Anna E. Olafsdottir, BMC Public Health, 2011, Vol. 11, Issue 1), advocates a broader definition of health systems that include the governance and its relationship to health and health equity. It examines the relationship between health systems outcomes and equity and governance as a part of a process.

Response to Ebola

The European Union’s response to Ebola / At a glance, published by Marie Lecerf, European Parliamentary Research Service, on 11 September 2014
A number of West African countries are currently experiencing the worst Ebola epidemic in history. As the situation continues to deteriorate rapidly, the European Commission has stepped up its response since March 2014 and is now pledging more than €147 million in response to the devastating human, sanitary, economic and political effects of this crisis for the region. Since the beginning of the epidemic, the European Parliament has shown its concern as regards this critical situation.

EU’s response to the Ebola outbreak / Keysource, European Parliamentary Research Service, published on 27 August 2014
Through its Emergency Response Coordination Centre (ERCC) the European Commission is closely monitoring the situation together with the Member States’ health authorities, the European Centre for Disease Prevention & Control (ECDC), the World Health Organization (WHO) and other international organizations. This keysource provides an overview of EU’s response to this Ebola outbreak.

The 2014 Ebola Outbreak: International and U.S. Responses / CRS Report, Tiaji Salaam-Blythe, Congressional Research Service (CRS), 26 August 2014 , 26 p.

Ebola Outbreak 2014 / Sarah Barber, Carl Baker, Commons Library Standard Note, 22 October 2014, 18 p.

According to an Oxford Analytica Daily Brief of 1 October 2014 ( West Africa Ebola will not transform health aid ), the Ebola outbreak tests the ability and adaptability of global health governance institutions. Vertical disease-specific interventions have been typical for Western health approaches for Africa, but are now attracting growing criticism.

Stakeholder views

United Nations

Target 6.B of the Millennium Development Goals, aims to a chieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it.

While acknowledging the dramatic increase in access to life-saving antiretroviral therapy (ART) over recent years, the UN Millennium Development Goals Report 2014 sees important disparities in access between populations, concluding that treatment programmes are not reaching enough children, adolescents and key populations that face high risk of HIV infection (p. 37).

In a “Thematic Think Piece” on Health in the post-2015 UN development agenda of May 2012, the UN System Task Team on the Post-2015 Development Agenda underlined the need to focus on the access to services, innovation and universal health coverage instead on health systems that are dealing with selected diseases (p. 6).

European Union

European Parliament

The European Parliament resolution of 18 September 2014 on the EU’s response to the Ebola outbreak (2014/2842(RSP))
to strengthen technological support in the areas affected by this outbreak, with a view to setting up clinical, epidemiological and diagnostic infrastructures, including sustainable infrastructures and surveillance, and paying particular attention to the engagement of local staff, including training (par. 11).

Prior to this, the European Parliament resolution of 7 October 2010 on health care systems in sub-Saharan Africa and global health (2010/2070(INI)) called on the Commission to promote the strengthening of national health systems (par 15).

The European Parliament resolution on Major and Neglected Diseases in Developing Countries (2005/2047(INI)) of 8 September 2005, while addressing the prevention and treatment of specific diseases, called as well for initiatives to provide accelerated local access to appropriate diagnostics and safe blood collection methods (par. 43) and the improvement of working conditions for medical staff practising in developing countries, the provision of suitable medical equipment and transfer of technology (par. 46).

In its Resolution on human resources for health in ACP countries of June 2013, par. 2, the ACP-EU Joint Parliamentary Assembly calls on the ACP countries ,
even with limited public budgets, to develop stronger health systems and strategies aiming at:
(i) promoting the development of a human rights and gender-based approach,
(ii) expanding the human resources pool and leading to an effective use of human resources, in particular by increasing access to services via task shifting/sharing,
(iii) achieving universal health care with sufficient skilled health workers;

European Commission

In his speech The Role of Europe in Global Health , given at the 5th World Health Summit of 20 October 2013, the former EC president José Manuel Durão Barroso underlined the EU’s role in global health initiatives like the GAVI Alliance for vaccines and immunisations and the Global Polio Eradication Initiative.

Relevant Commission documents include:

Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions: The EU Role in Global Health SEC(2010)380 SEC(2010)381 SEC(2010)382
/* COM/2010/0128 final */, Brussels, 31.3.2010

Par.3.2. addresses the challenge of universal coverage, suggesting to step up policy dialogue on health systems and their financing arrangements.

Par 4.2. focuses on basic quality health care, stressing the need to support the strengthening of health systems to ensure that their main components – health workforce, access to medicines, infrastructure and logistics and decentralised management – are effective enough to deliver basic equitable and quality health care for all without discrimination on any grounds as defined by Art. 21 of the Charter of Fundamental Rights .

Contributing to universal coverage of health services through development policy . Accompanying document to the Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions: The EU Role in Global Health {COM(2010) 128}{SEC(2010) 380}{SEC(2010) 381}, Brussels, 31.3.2010

See in particular chapters 1.3. Weak health systems , p. 6-7; 2. The global response , p. 8-9.

Communication from the Commission to the European Parliament and the Council – A European Programme for Action to tackle the critical shortage of health workers in developing countries (2007–2013) /* COM/2006/0870 final */

Commission staff working document : European programme for action to tackle the critical shortage of health workers in developing countries (2007 – 2013). Progress report on implementation, SEC(2008) 2476, 16.9.2008

Council of the European Union

The Council conclusions on the EU role in Global Health of 10 May 2010, par. 7, express the EU’s concern with slow progress in MDG 5 [Improve maternal health], particularly in Sub-Saharan Africa. Health systems should pay special attention to gender equality, women’s needs and rights.

In its conclusions on the European Programme for Action to tackle the critical shortage of health workers in developing countries (2007-2013) of 15 May 2007, the Council recognizes the need for the strengthening of national health systems (par. 5) and calls on the Commission and the Member States to consider the critical shortage of health workers in their health programming with developing countries (par. 6), with a priority to be given to action in Africa (par. 7).

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