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Public private partnerships and value for money investments in health system strengthening « Back to Blogs

Health systems strengthening has been defined as “any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency”. (1) As this definition suggests, health system strengthening is complex and multifaceted, and its different components are inter-related.

As a result, it is difficult to measure the value for money of investments in health system strengthening. We often use tools such as cost-effectiveness analyses when assessing the effectiveness of interventions; however, such tools work best when there is a clear-cut intervention with a clear-cut comparison intervention and where both interventions can be costed and linked to associated outcomes. Almost none of these factors are in place in the setting of health system strengthening. Health system strengthening interventions are typically complicated; comparison interventions are often impossible; and even costing is not straightforward. The same is true of other economic methodologies such as cost-benefit analyses. 

Yet it is important that we have some means of measuring the cost and value of health system strengthening interventions.

This is not least because these interventions are expensive and the outcomes that they are trying to achieve are important. This is especially so in primary care where most of healthcare is delivered and in public-private partnerships – where both partners will want to ensure that they get value for money. So what is the best methodology to evaluate the health system strengthening from an economic perspective? Verguet at al have published an important paper on this subject. (2) In the paper the authors describe new approaches to economic evaluations in this field that will help policymakers make better decisions. Fundamentally they call for the development of analytic models that take into account the fact that different components of health systems are dynamic and continually interact with each other. These models will ultimately be based on systems thinking – recognising the fact that the health service is made up of multiple moving parts – some of which are internal (such as primary care and secondary care) and some external (such as social care and education). Modelling will be required to simulate the adaptations that certain parts of the health system will make in response to changes in other parts. 

At an even more fundamental level, costing health system strengthening interventions is a difficult undertaking. Costs are made up of multiple components – from human resources to technical infrastructure. In terms of human resources, the people involved in health system strengthening interventions will often spend just some of their time on the intervention and the rest of their time on their usual day to day assignments. Costing health system strengthening interventions will need to be sufficiently granular to examine this level of detail, and this will especially be the case when complex public-private partnerships are in place. An ingredients approach will be needed to cost health system strengthening interventions – this involves cost researchers discovering all the individual ingredients of the intervention and then assigning a cost to each of them. This simply takes time and expertise. Nonetheless ensuring that health system strengthening interventions is value for money is worthwhile, and so the investment of time, expertise and resources is essential. 



  1. Islam, M., ed. 2007. Health Systems Assessment Approach: A How-To Manual. Submitted to the U.S. Agency for International Development in collaboration with Health Systems 20/20, Partners for Health Reform plus, Quality Assurance Project, and Rational Pharmaceutical Management Plus.


  1. Verguet S, Feldhaus I, Jiang Kwete X, Aqil A, Atun R, Bishai D, Cecchini M, Guerra Junior AA, Habtemariam MK, Jbaily A, Karanfil O, Kruk ME, Haneuse S, Norheim OF, Smith PC, Tolla MT, Zewdu S, Bump J. Health system modelling research: towards a whole-health-system perspective for identifying good value for money investments in health system strengthening. BMJ Glob Health. 2019 Apr 28;4(2):e001311. 

Competing interests 

KW works for BMJ Learning which produces educational resources on a range of subjects – including primary care. 



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