Strengthening health systems: 5 tips for DfID (and other donors)

A patient consults with a doctor at community health clinic built and supported by U.K. aid in Danismand, Afghanistan. Since 2013, DfID has spent approximately $584 million on health systems strengthening programs. Photo by: Sam French / Development Pictures / DfID / CC BY-NC-ND

How much has the U.K. Department for International Development spent on health systems strengthening programs in 2013 to 2014?

It all depends on who you ask and how you define HSS.

In June, the British parliament’s International Development Committee set out to review DfID’s HSS programs, wanting to find out its strengths and weaknesses, and how the aid agency can improve its performance on a development challenge. This sentiment has been gaining traction among donors after the ongoing Ebola outbreak in West Africa exposed weak national health systems utterly incapable of dealing with the disease on their own.

Since 2013, DfID has spent approximately 360 million pounds ($584 million) on HSS. However, a representative from the aid agency pointed out this figure is “likely to be a substantial underestimate” given that other programs focused on particular diseases or population groups also have a “significant health systems component.”

Other organizations invited to present evidence on DfID’s HSS work, meanwhile, provided a different breakdown on the aid agency’s expenditures.

Although it may just seem like a matter of lack of detailed available data, the problem actually runs much deeper.

“It is impossible to know how well DfID is delivering its health systems strengthening strategy without knowing how much it spends or having indicators of its performance,” the IDC said in its report published Friday. “Nor can DfID allocate its resources efficiently in the dark.”

Here are five IDC recommendations meant to improve international HSS work that may also be of interest to other development institutions:

1. Set indicators to track progress. Strengthening health systems in developing countries is no easy task, but having a guide at least to assess performance levels could be a great step forward. These indicators would also allow the aid agency to provide its partners — particularly multilaterals that get a bigger portion of its health funding — a bit of direction on how to evaluate progress before deciding whether to withhold funds from those unable to come up with “better measures of system strengthening expenditure and performance.”

2. Provide detailed spending data. While DfID is hailed as a transparency champion, the report shows there’s still room for improvement. The aid agency itself cannot point out how much it is actually spending on HSS, including expenditure from partners. It’s crucial to address this issue so HSS efforts are properly and accurately reported to avoid confusion.

3. Encourage domestic spending on HSS by partner country governments. DfID — or any other donor — should never give a “blank check” to governments, which bear the ultimate responsibility over strengthening their own health systems. So the aid agency should take a “tough line” with those who are not making this effort. Although what this really entails is unclear, one could argue it should definitely not mean cutting off citizens from much-needed health services.

4. Develop a clear accountability feature for partners delivering on its health budget. DfID must be able to evaluate where its funding for HSS is more effective. If more of its money is channeled through implementers like nongovernmental organizations and multilaterals, then there must be a reason why — and this should be justified.

5. Lead by example. Each donor and government has its own set of priorities, and DfID cannot blame any particular one for not having a strong focus on HSS. The aid agency, however, can show the benefits of spending money this way to encourage others to follow its lead.

Many international development experts contend that strengthening health systems in developing countries could make a huge difference in public health challenges that are not prime concerns for donors like noncommunicable and neglected tropical diseases, and mental health. Like a public health expert recently told Devex, DfID should play a role in building health systems, not just “short-term fixes.”

What do you think about the British aid agency’s HSS efforts? Please let us know by sending an email to or leaving a comment below.

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About the author

  • Ravelo jennylei

    Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.