Health Policy and Planning, 33, 2018, 85–98

doi: 10.1093/heapol/czx147
Advance Access Publication Date: 7 November 2017
Original Article

Health system strengthening: prospects and

threats for its sustainability on the global health

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policy agenda
Joseph F Naimoli1,*, Sweta Saxena2, Laurel E Hatt3, Kristina M Yarrow4,
Trenton M White5 and Temitayo Ifafore-Calfee6
1
11000 Candlelight Lane, Potomac, MD 20854, USA, 2Bureau for Asia/Technical Services, US Agency for International
Development, 1300 Pennsylvania Avenue, Washington, DC 20523, USA, 3International Health Division, Abt
Associates, 4550 Montgomery Avenue, #800N, Bethesda, MD 20814, USA, 4Policy and Strategy/Global Health,
United Nations Foundation, 1750 Pennsylvania Ave NW #300, Washington, DC 20006, USA, 5Bureau for Global
Health/Office of Health Systems, US Agency for International Development, 2100 Crystal Drive, Arlington, VA 22202,
USA and 6Human Diagnosis Project, 1666 K Street NW, Suite 1100, Washington, DC 20006, USA
*Corresponding author. 11000 Candlelight Lane, Potomac, MD 20854, USA. E-mail: joe.naimoli@gmail.com
Accepted on 21 September 2017

Abstract
In 2013, Hafner and Shiffman applied Kingdon’s public policy process model to explain the emer-
gence of global attention to health system strengthening (HSS). They questioned, however, HSS’s
sustainability on the global health policy agenda, citing various concerns. Guided by the Grindle
and Thomas interactive model of policy implementation, we advance and elaborate a proposition:
a confluence of developments will contribute to maintaining HSS’s prominent place on the agenda
until at least 2030. Those developments include (1) technical, managerial, financial, and political
responses to unpredictable public health crises that imperil the routine functioning of health sys-
tems, such as the 2014–2015 Ebola virus disease (Ebola) epidemic in West Africa; (2) similar
responses to non-crisis situations requiring fully engaged, robust health systems, such as the pur-
suit of the new Sustainable Development Goal for health (SDG3); and (3) increased availability of
new knowledge about system change at macro, meso, and micro levels and its effects on people’s
health and well-being. To gauge the accuracy of our proposition, we carried out a speculative
assessment of credible threats to our premise by discussing all of the Hafner-Shiffman concerns.
We conclude that (1) the components of our proposition and other forces that have the potential to
promote continuing attention to HSS are of sufficient strength to counteract these concerns, and
(2) prospective monitoring of HSS agenda status and further research on agenda sustainability can
increase confidence in our threat assessment.

Keywords: Health systems, policy, agenda setting, developing countries

Introduction
In 2013, Hafner and Shiffman applied Kingdon’s public policy proc-
ess model to explain the emergence of global attention to health sys-
tem strengthening (HSS) (Hafner and Shiffman 2013). The authors
questioned, however, HSS’s sustainability on the global health pol-
icy agenda, citing various concerns. Drawing on the Grindle and
Thomas interactive model of policy implementation (Grindle and
Thomas 1991) (henceforth the G&T model) and emerging evidence
about the dynamics of health system change, we advance and elabo-
rate a proposition: a confluence of developments will contribute to
maintaining HSS’s prominent place on the agenda until at least
2030. To gauge the accuracy of our proposition, we carried out a
speculative assessment of the Hafner-Shiffman concerns, which we
consider to be credible threats to our proposition. We conclude that
(1) the components of our proposition, combined with other forces
that have the potential to promote HSS agenda sustainability, are of

C The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
V
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86 Health Policy and Planning, 2018, Vol. 33, No. 1

Key Messages

• The policy literature on agenda-setting is extensive; the literature on agenda sustainability is far less so. This paper
addresses this deficit.
• We posit that health system strengthening (HSS) will maintain a prominent place on the global health policy agenda
until at least 2030 because of a confluence of developments.
• Those developments include (1) technical, managerial, financial, and political responses to unpredictable public health
crises that imperil the routine functioning of health systems; (2) similar responses to non-crisis situations requiring fully

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engaged, robust health systems; and (3) increased availability of new knowledge about system change at macro, meso,
and micro levels and its effects on people’s health and well-being.
• Recent credible speculations about HSS agenda sustainability can work against our proposition.
• Our risk assessment argues that the three components of our proposition, combined with other forces that have the
potential to promote HSS agenda sustainability, are of sufficient strength to counteract current or potential threats.
• We recognize that prospective monitoring of HSS agenda status and further research on HSS agenda sustainability
could increase confidence in our assessment.

sufficient strength to counteract those concerns, and (2) prospective
monitoring of HSS agenda status and further research can increase
confidence in our threat assessment. The policy literature on
agenda-setting is extensive (Baumgartner 2016; Green-Pedersen and
Walgrave 2014); the literature on agenda sustainability is far less so.
This paper helps address this deficit.
Methods
Definitions
Health systems strengthening
A consensus on an operational definition of HSS remains elusive
(Reich and Takemi 2009); consequently, we have adopted a broad
and inclusive formulation that reflects WHO’s definition and accom-
modates multiple perspectives in use. WHO defines HSS 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’ (World
Health Organization 2014a). The instrumental or extrinsic perspec-
tive views system strengthening as an intentional or unintentional
consequence of improvements in the performance of categorical
health programs and the achievement of their short-term objectives.
The intrinsic perspective views HSS as a range of interdependent,
purposeful strategies and approaches that address the root causes of
sub-optimal health system performance (e.g. inadequate governance,
weak or missing policies and regulations, insufficient financing, and
poor organization of health service delivery) that limit the ability of
the health system as a whole to achieve sustainable, equitable,
health-promoting outcomes at scale for all people (Chee et al. 2013;
Travis et al. 2004; World Health Organization 2007).
Agenda sustainability
According to Kingdon, a policy agenda is ‘the list of subjects or
problems to which government officials, and people outside of gov-
ernment closely associated with those officials, are paying some seri-
ous attention at any given time’ (Kingdon 1995). Agenda setting
comprises a series of decision-making processes that result in an issue
or problem (chosen from a range of specified alternatives) rising to a
level of prominence on the policy agenda (Kingdon 1995). Agenda
sustainability is a consequence of the implementation of the policy
decision, particularly the ability of the issue or problem to maintain
its agenda prominence over time in response to various challenges
that promote or inhibit implementation (Grindle and Thomas 1991).
Conceptual framework
Our proposition about HSS agenda sustainability is grounded in the
G&T model (Table 1) (Grindle and Thomas 1991), which emerged
from their analysis of a range of policy reform cases across multiple
sectors in numerous developing countries under varying political
regimes over many decades. Although the model is based on obser-
vations of actors and processes at country level, we believe it can be
applied to actors and processes that influence HSS sustainability at
the global level. The first stage in the model—agenda setting—was
the subject of the Hafner-Shiffman well-known publication on HSS.
Applying Kingdon’s policy model (Kingdon 1995), they identified
the factors, pressures, and sources that they believed led to the emer-
gence of global attention to HSS (Table 2).
Once on the agenda, a reform faces a series of authorization and
implementation challenges—the second and third stages in the G&T
model. Decisions are reversible: they can be altered by implementa-
tion experience. Determining reform feasibility and implementation
success require anticipating in which arena (public or bureaucratic)
the reform will occur, identifying those who support and oppose it,
and undertaking strategic actions informed by this knowledge.
A burgeoning literature on implementation research in health in
low- and middle-income countries (LMICs) promises to provide
new insights on the relationship between implementation and policy
formulation and reformulation (Peters et al. 2013).
The focus of this paper is sustainability, the fourth stage in the
G&T model. During the implementation process, the authors iden-
tify four kinds of resources that decision makers and policy manag-
ers must mobilize to sustain any reform: technical, managerial,
financial, and political. Resource mobilization occurs in both situa-
tions of crisis (which play out in the public arena) and non-crisis
(which play out in the bureaucratic arena). Policy makers’ percep-
tion of whether a situation is a crisis or a non-crisis is fundamental:
it affects the pressures for change, the stakes for reform, the identity
of the decision makers, and the type and timing of change.
Proposition
We posit that a confluence of the following developments will con-
tribute to maintaining HSS’s prominent place on the global agenda
until at least 2030.
• Local, regional, and global responses to unpredictable public
health crises
Health Policy and Planning, 2018, Vol. 33, No. 1 87

Table 1. The Grindle and Thomas interactive model of policy implementation

The Grindle and Thomas interactive model of policy implementation4 conceives of policy reform as a dynamic process: different actors exert pressure
for or against a policy, at different points along the pathway to reform. Different reactions to policy change initiatives, such as promoting, revising,
or reversing a policy, influence which of multiple potential outcomes will emerge. Understanding which policy outcome will emerge requires knowl-
edge of the location, strength, and stakes involved in each reaction. The model comprises different stages: placing reforms on the policy agenda,
authorization, implementation, and sustainability.
The agenda-setting phase is characterized by pressures from many sources to place a particular reform on the policy agenda, some of which are acted
upon, some of which are acted upon but not implemented, and many of which are never acted upon.
The authorization or decision process for a specific agenda issue involves a series of both formal and informal stages, often engaging both the bureauc-

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racy and higher orders of political decision-making. Decisions are reversible: they can be overturned at higher levels or revised, often as a function of
implementation experience when the implications of the policy gradually become more visible.
Implementation of the initiative as intended is influenced by its characteristics (e.g., distribution of costs and benefits, technical complexity, administra-
tive intensity, timing of impact), which determine not only the arena in which the reaction to the initiative will occur (public or bureaucratic), but
also the resources required for successful implementation.
To sustain a reform, decision makers and policy managers must mobilize political, financial, managerial, and technical resources. As with other stages
in the policy process, obtaining the necessary resources for sustainability is a contested undertaking.

Table 2. Emergence of global attention to health system strengthening: Hafner’s and Shiffman’s application of Kingdon’s public policy proc-
ess model

In his model of policy formulation, Kingdon recognizes the important roles of both actors and processes, and distinguishes between them. Regarding
the latter, he conceives of three process streams—each of which is largely independent of the others and develops in accordance with its own rules
and dynamics—that flow through any system. They are problems, policies, and politics.5
According to Kingdon, ‘. . .at some critical junctures, the three streams are joined, and the greatest policy changes grow out of that coupling of
problems, policy proposals, and politics. . .solutions become joined to problems, and both of them are joined to favourable political forces.
The coupling is most likely when policy windows—opportunities for pushing pet proposals or conceptions of problems—are open.’
Hafner and Shiffman6 adopted and adapted Kingdon’s model to explain the emergence of global attention to health systems strengthening. The factors
they cited included emerging evidence of a health workforce crisis and problematic relationships between global health initiatives (GHIs) and health
systems (problem stream); a legacy of attention to horizontal strategies for strengthening health sectors7,8 and the emergence and influence of a
health systems research policy community (policy stream); and, slow progress and pressure to achieve the health-related Millennium Development
Goals (MDGs), combined with donor moves toward aid coordination (politics stream).

• Local, regional, and global responses to protracted non-crisis its accompanying UHC target. Finally, based on our collective judg-
situations ment, we offer a purposeful selection of salient emerging research
• Increasing availability of emerging evidence on health system that can help policy makers and practitioners better understand the
change. complex dynamics (technical, managerial, financial, and political) of
health system change.
We have chosen 2030 for three reasons.

1. Any number of new or re-emergent public health crises can
occur in the next 13 years, as demonstrated recently by the re-
occurrence of Ebola virus disease (Ebola) in the Democratic
Republic of Congo (World Health Organization 2017a) and
local transmission of Zika virus infection throughout much of
South and Central America and the Caribbean (Centers for
Disease Control and Prevention 2017).
2. Policy experts have set 2030 as the deadline for the achievement
of the Sustainable Development Goal for health (SDG3) and its
principal target, Universal Health Coverage (UHC). The success-
ful attainment of the goal and target will rely upon robustly
functioning health systems (Ahoobim et al. 2012).
3. We anticipate new evidence on health system change and its
effects on health and other outcomes will become increasingly
available between now and 2030 (WHO and Alliance for Health
Policy and Systems Research 2017).
Proposition assessment
To assess adequately the accuracy of our proposition, we would
need data from prospective monitoring and analysis of HSS agenda
status at intervals between now and 2030, and/or a retrospective
assessment closer to 2030. In the absence of these data at this time,
we propose a speculative assessment. We view the Hafner-Shiffman
concerns about HSS sustainability as credible threats that could
potentially work against our proposition. In the discussion section,
we address, in ascending order of threat level (in our judgment),
their four concerns:
• a weak evidence base (low);
• pendulum swings in global health (low-moderate);
• effects of the global financial crisis on HSS (moderate); and
• preoccupations about some organizations’ embrace of HSS for
its instrumental value (high).

Proposition application
We apply our proposition by examining responses to one recent cri-
sis—the failure of health systems in West Africa to respond
adequately to the Ebola outbreak—and one persistent, non-crisis sit-
uation—the latest global effort to address the longstanding chal-
lenge of achieving health for all, affordably, with equity—SDG3 and
Results
Unpredictable public health crises: the case of Ebola
We believe the attributes of the 2014–2015 Ebola epidemic in West
Africa are consistent with the G&T characterization of a crisis
(Table 3). Ebola, and the prospect of future public health
88 Health Policy and Planning, 2018, Vol. 33, No. 1

Table 3. Characterization of a crisis (Grindle and Thomas) and its application to the case of Ebola

Crisis situations (Grindle and Thomas)

A crisis encompasses a range of macropolitical events (such as macroeconomic, customs, or financial system reforms affecting multiple sectors) that are
perceived by upper-level decision makers as having high political and economic stakes. The stakes are high because they threaten the power, prestige,
legitimacy, and duration of national governing elites or interest groups; and/or social stability; and/or costs and benefits to major national interests.
In a crisis situation, the pressure for reform is acute, often originating with small groups of governing elites and often influenced by interests outside
of government. A crisis demands urgent action; the societal, political, and economic stakes of inaction are high. A crisis often precipitates major
changes from existing policy.9
Case: Ebola

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During the 2014–2015 Ebola crisis in West Africa, more than 11, 000 people died in Liberia, Sierra Leone, and Guinea.10 Adverse health outcomes,
combined with the social, economic, and political upheaval Ebola provoked, resulted in a full-scale crisis in West Africa that affected all sectors.
For example, in Liberia, President Ellen Johnson Sirleaf closed all beaches, imposed a quarantine and curfew in a Monrovia slum, suspended traditional
burial practices, and imposed mandatory cremation, all of which contributed to social unrest.11–13 Schools closed between September 2014 and
February 2015, impacting child education and household productivity.14 Arwady and colleagues reported that as early as 2014 the economy had
already contracted, with a rise in the prices of commodities and certain foods.15 One survey of 337 Liberian businesses found 12% closed nationwide
and 20% closed in Monrovia. Across Liberia, 24% of employees lost their jobs.16 The IMF estimated that Liberia’s real GDP growth dropped from
8.9% in 2013 to 0.7% in 2014.17 The government banned election rallies and postponed senatorial elections from October 2014 to December
2014.18,19 When elections were held, President Sirleaf’s governing party lost its majority in the Senate.20
Ebola exacerbated the Liberian population’s already fragile confidence in its health system.21 Fear and distrust of government authorities and outsiders
subjected some health workers and expatriate responders to physical violence and threats.22 There is suggestive evidence that the population reduced
its use of basic health services; for example, monthly childhood vaccination rates dropped 60% by the end of 2014.23 The reduced availability of
services and health workers, among other factors, lessened communities’ trust in their system.24

emergencies, are likely to keep global attention focused on HSS. We
postulate that the nature of the crisis in West Africa and the resour-
ces mobilized in response, have had and will continue to have
important policy implications not only for HSS, but also for the pur-
suit of enhanced global health security (GHS) and greater health sys-
tem resiliency. As Kutzin and Sparkes recently observed, HSS is not
an end unto itself, but rather a vital means for achieving these and
other ends (Kutzin and Sparkes 2016).
Technical/managerial response
Although the Ebola crisis was limited to three West African coun-
tries, the message it conveyed about the urgent need to attend to
weak health systems reverberated regionally and globally.
Regional response. Health systems were particularly ill-prepared in
four critical areas: surveillance (McNamara et al. 2016), infection
prevention and control (Hageman et al. 2016), health workforce
readiness (Greenemeier 2014), and community outreach (Bedrosian
et al. 2016). The outbreak demonstrated the need for a coordinated
response to these kinds of system deficiencies, particularly with
regard to surveillance. Countries with shared borders relied on one
another for data and cross-border reconnaissance (Moon et al.
2015). When it became known that a traveller with Ebola arriving
in Lagos from Monrovia had unprotected contact with multiple
Ebola responders, the Nigerian government rapidly activated its
existing national polio surveillance system, which helped restrict the
outbreak to 19 cases and limit its spread to the rest of Nigeria,
Africa, and beyond (Bell et al. 2016; Liu 2016). In January 2017,
the African Union launched the Africa Centres for Disease Control
and Prevention (African CDC) to help member states improve sur-
veillance (via functional and linked laboratory networks in the five
African sub-regions) and their overall response to public health
emergencies (Nkengasong et al. 2017). The WHO Regional Office
for Africa’s 2016–2020 strategy seeks to establish a regional health
workforce to promptly respond to future emergencies (Regional
Office for Africa 2016).
Global response. With the exception of Medecins Sans Frontiers,
which repeatedly alerted the global community to the seriousness of
the outbreak, helped draft the first case management protocols, and
instructed others how to treat patients (Hayden 2015), the response
was delayed (Moon et al. 2015; Siedner and Kraemer 2014), but
ultimately robust. Multilateral (e.g. WHO, the World Bank, UN
Agencies, African Development Bank), bilateral (e.g. the U.S. and
the U.K.), and over 60 non-governmental organizations
(Light 2014) provided direct or indirect technical and management
support to Liberia, Sierra Leone, and Guinea. Four global commis-
sions that emerged in Ebola’s aftermath consistently recommended
strengthening national health systems as part of a broad agenda for
improving global health preparedness and response for future infec-
tious disease threats (Gostin et al. 2016). Ebola also triggered a
reconsideration of countries’ capacity to comply with the
International Health Regulations (IHR), which represent the core
functions of a public health system, and the role the international
community plays in enhancing such capacities (World Health
Organization 2016 b). Recent reviews of the status of countries’
implementation of the IHR indicate significant room for improve-
ment (Gostin et al. 2015; Moon et al. 2015) and WHO has devel-
oped guidelines to help governments determine whether they are
meeting core capacity requirements (Gostin et al. 2015; WHO
Director-General 2015; World Health Organization 2016a). The
Health Data Collaborative, a partnership of international agencies,
governments, philanthropies, donors, and academics committed to
improving health data, is developing standards for integrating out-
break surveillance data into routine health information systems
(World Health Organization 2015).
Financial response
The crisis stimulated global dialogue and action about future techni-
cal cooperation and financial assistance for HSS, particularly in
fragile states. For example, the crisis triggered a call for an interna-
tional health systems fund to address emergencies and long-horizon
health system development (Gostin 2014). A combination of
national governments, regional organizations, and international
finance institutions disbursed the majority of funds to aid Ebola
recovery (Office of the United Nations Special Envoy on Ebola
2015). Thirty-one governments contributed at least $1 million, with
the U.S., the U.K., Japan, Germany, and Canada leading the list of
Health Policy and Planning, 2018, Vol. 33, No. 1 89

Table 4. Characterization of a non-crisis situation (Grindle and Thomas) and its application to the case of the SDG for health

Non-crisis situations (Grindle and Thomas)

Non-crisis situations encompass a range of largely bureaucratic events (such as the restructuring of a government ministry or administrative unit within
a ministry, trade or industrial reforms, or reforms within specific sectors, such as health and education) that are perceived by middle- and lower-level
government officials as having low political and economic stakes. The stakes are low because their implications relate largely to bureaucratic issues,
such as careers, budgets, organizational behaviour and procedures, and agency power within government. They demand incremental, non-urgent
actions. Compared with crises, the pressure for reform in a non-crisis situation is more moderate, often originating with larger groups of middle- and
lower-level government bureaucrats concerned about government performance. The urgency to act is not as strong and the stakes for inaction are
lower. Although non-crises do not threaten the interests of national elites, they usually are rich in micro-political and bureaucratic activity. Policy

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change associated with non-crisis problems is usually incremental, which often prolongs the duration of non-crisis reforms.25
Case: SDG for health
In contrast to the Ebola response, which manifested itself largely in a highly visible public arena, the response to the challenge presented by SDG3 and
UHC is unfolding in bureaucratic arenas, at both global and country levels. In contrast to the engagement of high-level political leaders throughout
the world, the primary actors in the pursuit of these goals are government officials and a range of global actors working in and across government
agencies, foundations, academic institutions, and others. In contrast to the urgent actions required by the pressures exerted by the Ebola crisis, global
and country actors have until 2030 to achieve their aims. Failure to achieve the 2000–2015 health Millennium Development Goals (MDGs) did not
threaten the prestige or legitimacy of governing elites or interest groups in any country. The same is likely for the SDGs, where the stakes for non-
binding consensus accords are lower (e.g., sub-optimal system and organizational performance are the principal risks).
Although the SDG for health envisions more cross-cutting and perhaps even more cross-sectoral approaches to global health assistance, it represents,
nonetheless, an incremental step forward from previous initiatives for various reasons: (1) it embraces the unfinished agenda of the health MDGs,
which focused primarily on communicable diseases and conditions;26–27 (2) it comprises concerns of particular and longstanding interest for middle-
income countries, such as non-communicable diseases, substance abuse, and road injuries;28 and, (3) it revisits many of the themes of Alma Ata and
the Primary Health Care Movement launched in the 1970s.29
Furthermore, country government officials and global actors are not facing an unknown threat or uncertainty about how to address it: they benefit from
an accumulation of existing and emergent knowledge about the performance of health systems, which normative bodies, such as the World Health
Organization and the World Bank, have translated into new perspectives, templates, and guidance for how to achieve the SDG and UHC goals.30

top contributors. Although the focus of funding was to provide
emergency relief to end Ebola transmission, disbursements were also
intended to stabilize and strengthen national health systems, includ-
ing support for essential health services, over the long term (UNDP
2015; United States Department of State 2015; World Bank 2015).
WHO provides a detailed breakdown of donations, by contributor,
on its website (World Health Organization 2016c).
Political response
Ebola delivered a wake-up call to senior African health officials and
political leaders around the world about the need to strengthen weak
health systems in resource-constrained countries (Kaasch 2016;
World Health Organization 2014b). In 2014, eleven West African
health ministers initiated emergency talks to coordinate a high-level
regional response (Al Jazeera 2014). Many political leaders from
industrialized countries responded to the call with explicit appeals
for addressing health system deficiencies. During a press conference
in 2014 at the U.S. Centers for Disease Control and Prevention
(CDC), then-President Obama cited ‘building up Africa’s public
health care system’ as one of four goals of the U.S. response to Ebola
in West Africa (Jackson and Szabo 2014). In preparation for the G7
meeting in 2015, the ‘Future Charter’ of the German government
made explicit mention of helping the poorest countries to strengthen
their health systems (Kaasch 2016). During the 70th World Health
Assembly in May 2017, preparedness, surveillance, and response in
health emergencies shared top agenda billing with a series of HSS
topics, including the health workforce, medicines and other medical
products, and research (World Health Organization 2017b).
Rhetorical response
Ebola has changed the way governments and the global health com-
munity talk about health systems and HSS. It is now increasingly
difficult to find any discussion of these topics in the media, within
donor governments, or in the professional literature that does not
include the adjectives ‘resilient’ and/or ‘sustainable’(Kieny et al.
2014; Kruk et al. 2015; Rodin and Dahn 2015; UNICEF 2016). The
Japanese government facilitated discussions around GHS, strategies
to build resilient and sustainable health systems, and UHC at the
2016 G7 Summit, which it hosted (Abe 2015; Japan Center for
International Exchange 2015). The title of the most recent global
symposium on health systems research was ‘Resilient and
Responsive Health Systems for a Changing World’ (Health Systems
Global 2016). Kruk and colleagues have posited that the concept of
resilience is advancing the field of health systems by introducing a
dynamic dimension into more static health system models, offering
new ideas from other sectors, and bridging disparate health and
development agendas (Kruk et al. 2017a).
Protracted non-crisis situations: the case of the SDG
for health
The global commitment to SDG3 and UHC serves as an example of
how responses to protracted, non-crisis challenges can also promote
HSS agenda sustainability. We believe the attributes of efforts by
governments and their global health partners to address these chal-
lenges are consistent with the G&T characterization of a non-crisis
situation (Table 4). The Ebola crisis re-focused the world’s attention
on the status of health systems in resource-poor countries (Kaasch
2016); we posit that the pursuit of SDG3 and UHC will have a simi-
lar, although protracted, effect.
During the next two decades, the pursuit of SDG3 and UHC will
continue to engage a range of local and global actors. How will
what transpires at local levels, through different processes and at
varying pace, repeated and dispersed over multiple countries, influ-
ence HSS’s position on the global policy agenda? In Table 5, we
describe three promising translational mechanisms: global monitor-
ing, learning networks, and high-level consultations. Similar to their
response to Ebola, global actors and country officials are mobilizing,
or are likely to mobilize, important technical, managerial, financial,
and political resources to boost HSS’s role in facilitating countries’
progress toward achievement of SDG3 and UHC.
90 Health Policy and Planning, 2018, Vol. 33, No. 1

Table 5. HSS global agenda sustainability: translational mechanisms associated with SDG3 and UHC

Monitoring WHO and The World Bank are tracking global progress toward UHC. They jointly issued the first global monitoring report in
2015.31 Multiple websites exist to monitor implementation.32–35
Learning The Joint Learning Network and the P4H Social Health Protection Network, which function at global and country levels, are
ensuring coordination among development partners around technical assistance for UHC and HSS.36–37 They also are building
strong support networks to ensure local country practitioners can share knowledge and expertise. Regional platforms, such as
the Asia-Pacific Network for Health Systems Strengthening (ANHSS), are addressing the need for knowledge improvement and
exchange around HSS in the Asia region.38
High-level High-level meetings on UHC, such as the WHO/World Bank Ministerial-level Meeting in 2013 in Geneva,39 and the bi-annual

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consultations global symposia on health systems research that Health Systems Global has been organizing since 2010,40 provide fora that
facilitate the exchange of experiences occurring at national and regional levels.

Technical/managerial response Financing response

Technical and managerial feedback from the 15-year pursuit (2000–
2015) of the health Millennium Development Goals (MDGs) identi-
fied weak, under-funded health systems as a major impediment to
their achievement (Bellagio Study Group on Child Survival 2003;
Fox and Reich 2015; Fryatt et al. 2010; Requejo et al. 2015;
UNAIDS 2015; van Olmen et al. 2012). Of the 75 countries
UNICEF and WHO defined as MDG priorities, only 33% achieved
MDG4 (Child health), and 8% MDG5 (Maternal health). Only four
of the 75 countries (5%) achieved both MDGs 4 and 5 (Requejo
et al. 2015). Failure to achieve the MDGs cannot be attributed to
under-performing health systems alone; conflict, poverty, poor gov-
ernance, and other socio-economic and political factors all influ-
enced the outcome, particularly in sub-Saharan Africa. But
increasing recognition by technical experts and managers of the role
of health system performance as one among many critical factors in
achieving a global development goal should contribute not only to
HSS’s continuing place of prominence, but could also influence how
progress toward SDG3 will be measured and monitored at global
level. Seidman recently mapped SDG3 indicators to a theory of
change for health systems performance (Seidman 2017).
LMICs’ pursuit of the MDGs also highlighted the role HSS must
play in ensuring access to essential health services for all segments of
the population in the context of SDG3 and UHC. Despite the many
benefits associated with the pursuit of the MDGs (United Nations
2015), there is strong evidence that the poorest and most disadvan-
taged in many countries are still shouldering a disproportionate
share of the ill-health burden and have less access to essential health
services than wealthier people (Gwatkin et al. 2005; Victora et al.
2003; World Bank 2004). To ensure that the pursuit of UHC pro-
motes equity in terms of technical and managerial health system
inputs and outcomes, Gwatkin and Ergo propose ‘progressive uni-
versalism,’ an approach that ‘ensures people who are poor gain at
least as much as those who are better off at every step of the way
toward universal coverage, rather than having to wait and catch up
as that goal is eventually approached’ (Gwatkin and Ergo 2011).
Gwatkin and Ergo cite Brazil’s Family Health Program and
Mexico’s Seguro Popular initiative as successful examples of this
‘progressive’ approach to health systems improvement—serving ini-
tially those most in need. Carrera and colleagues found that an
equity-focused approach may be more cost-effective than main-
stream approaches in improving child health and nutrition out-
comes, while reducing intervention coverage and out-of-pocket
spending inequities (between the most and least deprived groups and
geographic areas within countries) (Carrera et al. 2012). Many
LMICs will likely require donor technical assistance and investment
that align with a country’s goal of progressive universalism, as they
did during the MDG era.
Experts believe that SDG3 and UHC, in particular, have the poten-
tial to become important policy drivers for HSS in LMICs and for
directing future donor investments (GBD 2015 SDG Collaborators
2016). The goal and target could serve as meaningful signalling
devices for keeping HSS at the center of the global health policy dia-
logue. Munir and Worm recently concluded from their analysis that
the U.S. and U.K. are aligning their HSS investments with SDG3
and UHC, while encouraging technical and financial collaboration
among development partners (Munir and Worm 2016). By increas-
ingly incorporating the UHC goal in their national health sector
plans and health financing strategies (Lagomarsino et al. 2012;
Reich et al. 2016), countries may facilitate a flow of multilateral,
bilateral, non-governmental, and other donor financial support to
HSS to ensure better alignment of assistance with national
priorities.
Political response
A combination of factors—the extent of the network of global
actors (Hoffman et al. 2015), the number and sometimes overlap-
ping mandates and tasks they embrace (Hoffman et al. 2015; Lee
et al. 1996), and calls for more efficient global health governance
and the challenges that such calls present (Frenk and Moon 2013;
Harman 2012)—fosters an environment at global level conducive to
intense micro-political transactions. These micro-political transac-
tions affecting HSS will also become apparent in Geneva and else-
where as the new WHO Director-General attempts to make good on
his commitment to UHC as his top priority (The Lancet Global
Health 2017). Fox and Reich recently developed a framework for
evaluating and addressing the politics of UHC in LMICs (Fox and
Reich 2015).
The literature on path dependency has demonstrated that once
an entity embarks on a chosen path, certain institutional arrange-
ments emerge over time to embed a particular way of thinking and
doing within the entity (Powell and DiMaggio 1991). Changing
course and choosing alternative paths—even ones that might be
more efficient—often entail high costs and can generate considerable
resistance from entrenched interest groups with strong incentives to
maintain the status quo (Powell and DiMaggio 1991). As one
observer has noted, the SDGs will ‘lock in the global development
agenda for the next fifteen years’ (Hickel 2015). Regardless of
implementation adequacy at country level, or whether SDG3 suc-
cessfully improves the health and well-being of the millions of peo-
ple it targets, the perception of HSS as a key driver for ensuring
progress toward a consensus goal is likely to help it maintain a
secure place on the global agenda.
Health Policy and Planning, 2018, Vol. 33, No. 1
Table 6. Summary results of the review of published reviews: documented effects of 13 types of HSS interventions41
Health impacts and health system outcome measures
Types of interventions Improved
service
provision/quality
Accountability and engagement interventions X X
Conditional cash transfers
Contracting out service provision
Health insurance
Health worker training to improve service delivery X X
Information technology supports (m-health/e-health)
Pharmaceutical systems strengthening X
Service integration
Strengthening health services at the community level
Supply-side performance-based financing
Task sharing/shifting
User fee exemptions
Voucher programs
Emerging evidence about health system change
We posit that continuing efforts to share evidence about how to
manage health system reforms; to synthesize and generate evidence
of HSS’s effects; and to support the production of global knowledge
will contribute to keeping HSS at the centre of discussions about
how best to respond to crisis and non-crisis events.
Evidence sharing around how to manage health system reforms
The World Bank has characterized UHC as necessitating system-
wide, transformational reforms (Cotlear et al. 2015; Maeda et al.
2014), because it requires comprehensive, intentional actions on
many inter-related fronts—political, economic, social, and techno-
cratic. If UHC requires a health system transformation, then the
HSS global policy community and policy makers in LMICs will need
knowledge about how to manage complex, large-scale health system
reforms. Three recent compilations of World Bank case studies
(Cotlear et al. 2015; Dmytraczenko and Almeida 2015; Maeda et al.
2014), all of which examined efforts of countries around the world
to move towards UHC, are essential resources.
In addition, some of the factors that have been consequential in
health system transformation in Central Asia during the last 20 years
provide additional insights into the practice of large-scale, compre-
hensive HSS (Abt Associates 2015). For example, unlike many of
the countries that have engaged in UHC reforms in the last decade—
a number of which are struggling to achieve basic health service cov-
erage for their populations—in the early 1990 s the then-newly inde-
pendent countries of the former Soviet Union faced a significant
systemic challenge of inferior health care service quality (Abt
Associates 2015). The Central Asia experience in improving quality
of care, including how development partners collaborated in pro-
moting progress, offers an important set of insights that address con-
cerns that some UHC observers have expressed about quality
(Lindelow et al. 2015).
Finally, some important comparative systems research has identi-
fied the characteristics of successful health system change at scale
that could inform country policies and practices (Balabanova et al.
2013). For example, four characteristics of successful change that
Balabanova and colleagues identified in Bangladesh, Ethiopia,
Kyrgyzstan, Thailand, and Tamil Nadu were good governance and
political commitment; effective bureaucracies and institutions;
91
Increased Increased Uptake Reduced
financial service of healthy morbidity,
protection utilization behaviors mortality
X X
X X X
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X X X
X X X
X
X X
X X X
X X X
X X
X X
X
X X X X
ability to innovate, especially with respect to service delivery; and
resilience. The December 2014 launch of the journal Health Systems
and Reform (HS&R), whose objective is to serve as ‘a global plat-
form for sharing cutting-edge analysis, methods, and lessons in
health systems and reform. . .’ will further promote knowledge trans-
fer about the most recent advances in HSS (Antoun and Reich
2015).
HSS evidence synthesis and generation
In 2015, Hatt and colleagues reviewed the impact of HSS interven-
tions—encompassing a wide range of purposeful change strategies,
policies, regulations, programs, and activities—on health outcomes
in LMICs (Hatt et al. 2015). The review sought to identify docu-
mented effects of such interventions on health status (including mor-
tality, morbidity, life expectancy, fertility, nutritional status,
fertility, and DALYs) and health status proxies (including service
utilization, service provision, uptake of healthy behaviors, and
financial protection) through a review of systematic reviews. The
investigators identified 13 HSS interventions with documented
effects (Table 6), and concluded that there was substantial, available
quantitative evidence linking these interventions with positive health
impacts and health system outcomes. They also found that innova-
tions and reforms in how and where health services are delivered,
how they are organized and financed, and who delivers them can
improve the health of populations in LMICs.
Advancing the HSS evidence agenda is not limited to improving
our understanding of transformational, so-called ‘big bang’ reforms,
such as UHC (Cotlear et al. 2015; Fox and Reich 2015), but also of
purposeful, HSS change strategies or interventions at more meso
and micro levels. This is important because movement towards
UHC in lower-income countries is still modest (Lagomarsino et al.
2012). Many countries, particularly those in sub-Saharan Africa, are
not yet in a position to undertake comprehensive reforms, because
they do not have all the institutional, technical, political, and finan-
cial resources necessary to pursue such changes at scale.
Nevertheless, feasible cross-cutting interventions that affect the
functioning of multiple health programs with the potential to sustain
their short-term gains (Travis et al. 2004) provide, in accordance
with organizational theory, a platform for transformational change
and the means to institutionalize it (Weick and Quinn 1999).
92
Figure 1. Promoting HSS global agenda sustainability: proposition elaboration
Finally, SDG3 may stimulate more health systems research.
A recent study found a significant increase in research in sub-
Saharan Africa and an important increase globally following the
introduction of the MDGs in 2000 (Phillips et al. 2015). An SDG-
driven HSS research agenda, informed by the MDG experience, has
the opportunity to develop a better understanding of complex, adap-
tive health system change: what does it look like, how does it occur
in practice, how can it be measured, and how can systems be
strengthened to what ends and at what cost?
Support for advancing global knowledge
Health Systems Global (HSG),1 launched in 2010, is the only inter-
national membership organization dedicated to promoting health
systems research and knowledge translation. HSG has successfully
organized four global symposia on health systems research. The
2016 symposium, in Vancouver, built upon the momentum created
by its three predecessor meetings, during which researchers and
practitioners met to learn and discuss how best to conduct research
to yield credible evidence for promoting improvements in health.
Professional journal-led efforts, such as The Lancet Global Health
Commission on High-Quality Health Systems in the SDG Era, a
science-based commissioned report, will further disseminate what is
and is not known about HSS (Kruk et al. 2017b).
Several multilateral and bilateral development agencies, inde-
pendently and in collaboration with partners, have demonstrated a
continuing commitment to growing the knowledge base on HSS.
The Alliance for Health Policy and Systems Research supports a
health systems research advisory group, which seeks to improve
coordination among governments, non-governmental organizations,
and academic institutions with a shared interest in synthesizing HSS
evidence to inform decision makers (Langlois et al. 2015). In the
U.K., the Department for International Development (DFID), the
Economic and Social Research Council (ESRC), the Medical
Research Centre, and the Wellcome Trust jointly fund the Health
Systems Research Initiative, which seeks, among other objectives, to
Health Policy and Planning, 2018, Vol. 33, No. 1
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generate evidence on how to strengthen and improve health systems
for people living in LMICs. The World Bank and many academic
institutions in high-, middle-, and low-income countries are continu-
ing a sustained tradition of supporting health systems and policy
research (Alliance for Health Policy and Systems Research 2004;
Phillips et al. 2015; Weber et al. 2010). Figure 1 summarizes our
applied proposition for HSS agenda sustainability.
Discussion
Insufficient passage of time and the absence of data about HSS
agenda status constrain any assessment of the accuracy of our prop-
osition. Despite these limitations, we can still consider reasonable
speculations that could work against our premise. For that reason,
we turn our attention to the Hafner-Shiffman concerns about HSS
sustainability. We present and discuss these threats to our proposi-
tion, in ascending order of what we judge to be the level of threat.
Weak evidence base (low threat)
Hafner and Shiffman observed that limited evidence on how to bring
about system change and the effects of HSS interventions on health
status and its proxies (Bennett et al. 2011; Hatt et al. 2015; World
Health Organization 2012) presents a challenge for HSS agenda sus-
tainability. Although the field of health systems research continues
to mature, long-standing challenges remain. The most recent World
Report on Health Policy and Systems research cites three: fragmen-
tation and definition of the field; the dominance of a northern, bio-
medical research model; and the lack of demand for health policy
and systems research (WHO and Alliance for Health Policy and
Systems Research 2017). The report acknowledges the persistence of
these challenges, but also describes three promising developments
for addressing them: sustained global advocacy for health policy and
systems research; efforts to clarify the content and focus of the field;
and the promotion of the greater use of evidence in policy- and deci-
sion-making.
Health Policy and Planning, 2018, Vol. 33, No. 1
Pendulum swings in global health (low to
moderate threat)
Citing the history of pendulum swings in the priorities of global health
organizations, namely, ‘moving from vertical to horizontal
approaches and back again,’ Hafner and Shiffman questioned
whether recent attention to HSS should be interpreted as a sign of
transformation in traditional patterns of agenda status instability in
global health. We believe that the likelihood of further dramatic
swings is low to moderate from now until 2030. Pleas to put to rest
the vertical vs. horizontal debate (Uplekar and Raviglione 2007), and
the proposal of a ‘diagonal approach’ as a ‘third way’ (Ooms et al.
2008) are now a decade old. SDG3 and UHC are encouraging a grad-
ual shift in focus from the primacy of disease control initiatives to
efforts to strengthen and sustain the health systems in which these ini-
tiatives function and in which public health emergencies unfold
(Ahoobim et al. 2012; Institute of Medicine 2014). In our view, both
vertical and horizontal approaches are likely to co-exist within the
context of SDG3 and UHC, as long as Global Health Initiatives con-
tinue to be a major force on the global health landscape and they and
bilateral donors continue to pursue disease-specific objectives. The
pressing issue—finding synergies between these approaches—has
been formally analysed and discussed at length, is well-documented
(World Health Organization 2009b), and supported in practice by
WHO (World Health Organization 2009a).
On the ground, with national governments and their health strat-
egies supposedly leading the way toward achievement of SDG3 and
UHC, will it become increasingly difficult for categorical health pro-
grams to by-bass the system to obtain a priority position on
countries’ health agendas, as was possible under the MDGs? Will
Ebola-stimulated efforts to improve surveillance and address other
health system deficiencies that the crisis exposed result in permanent
improvements to LMIC health systems? These are synergy-driven
empirical questions that merit scientific inquiry.
Effect of the financial crisis (moderate threat)
In 2013, Hafner and Shiffman asserted that the global financial cri-
sis had acted as a constraint to donor commitments to HSS, thereby
raising doubts about HSS’s place of prominence on the global health
policy agenda. Using OECD official development assistance data,
they pointed out that aggregate donor commitments to HSS from
2004 to 2009 ‘grew at an average annual rate of 7.1%, considerably
slower than for total health and population funding (13.1%) and
only slightly exceeding the rate of increase for all donor aid (6.2%).’
The situation since 2013 and between now and 2030 is equivocal.
It should be noted that measuring how much the global health
community spends on HSS is an inexact science. For example,
USAID is a major funder of HSS, but because all HSS USAID fund-
ing is channeled through U.S. Congress-mandated categorical health
programming (Committee on International Relations/Committee on
Foreign Relations 2003; USAID 2009), estimating total spending on
HSS is problematical. Analysts who may not all interpret HSS in the
same manner calculate the estimates, which can lead to various
measurement errors, such as misclassification of HSS activities and
coding inconsistencies. Even the Institute for Health Metrics and
Evaluation (IHME), which provides annually the most comprehen-
sive, consistent, and disaggregated analysis of global health funding
(‘Financing Global Health’ reports) has changed its definition of
HSS over the years—from ‘health sector support/SWAps’ in 2014 to
‘health system strengthening/SWAps’ in 2015 (Institute for Health
Metrics and Evaluation 2017).
93
Despite such challenges, IHME has attempted to estimate spend-
ing on HSS, using donor budgets and programming documents.
IHME’s latest analysis in their 2016 report indicated a global trend
of increasing expenditures for HSS strategies and initiatives for the
period 1990–2015 (3.83 growth rate) (Institute for Health Metrics
and Evaluation 2017). They reported the same pattern of positive
growth for the periods 2000–2015 (1.04), and 2009–2015 (0.09).
However, the period 2010–2015 registered a negative growth rate
(0.12). Funding has fluctuated from a high of US 2.7 billion in
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2013, to a low of US 2.4 billion in 2014, with a modest rebound in
2015 to US 2.6 billion.
Another source of HSS funding is LMIC domestic budgets.
Historically, LMICs have favoured specialist, hospital-based tertiary
care over primary health care (World Health Organization 2008).
As more and more countries strive to achieve UHC, however, it is
reasonable to expect that governments will endeavour to mobilize
more domestic resources to implement system reforms necessary to
advance the UHC agenda. UHC2030 multi-stakeholder consulta-
tions identified domestic resource mobilization as an area in need of
better practices for effective development cooperation, and
HSS technical support for countries transitioning from low- to
middle-income status (International Health Partnership for
UHC2030 2016).
Instrumental bias toward HSS (high threat)
Hafner and Shiffman viewed some global health assistance organiza-
tions’ embrace of HSS for its instrumental value—enlisting interven-
tions labelled HSS to satisfy short-term, disease-specific program
and service delivery objectives—as another threat to HSS agenda
sustainability. Chee and colleagues and others have observed that
just because an activity is labelled ‘health system strengthening’ does
not necessarily mean that it strengthens the system (Chee et al.
2013; Marchal et al. 2009; Travis et al. 2004). Chee and colleagues
argued that ‘if activities fail to produce improvements in health sys-
tem performance, because they were incorrectly labelled as ‘health
system strengthening,’ the value of HSS investments can be discred-
ited, expectations of stronger systems will remain unmet, and critical
system strengthening activities may be neglected.’ We believe that a
continuing bias toward investing in programs and interventions
likely to support but not necessarily strengthen health systems
(Kaasch 2016) poses an important, plausible threat to our HSS sus-
tainability proposition.
After 2000, several large global health initiatives (GHIs) emerged
to address the major health threats targeted by the MDGs, namely,
malaria, HIV/AIDS, tuberculosis, and vaccine-preventable diseases
(van Olmen et al. 2012). Recognizing the threats to their success
posed by weak health systems, the Global Fund and GAVI opened
special funding ‘windows’ for activities labelled HSS. A 2013 study
reported that 37% of all funding for Round Eight of the Global
Fund was allocated to HSS (Warren et al. 2013). Of that allocation,
however, the majority of the money (62%) was channeled to dis-
crete health program operational support activities, while 38% was
for generic system-level interventions. This finding echoes those of a
2009 external evaluation of GAVI HSS support, which found that
few countries were using these funds to address the underlying prob-
lems of weak health system performance (HLSP 2009). The Global
Fund and GAVI have been investing in what they label HSS for close
to a decade; however, a persistent lack of precision regarding when
this assistance is of a broad architectural nature and addresses the
root causes of program and system failures, when it is instrumental
and supports health systems by enhancing the more narrow
94
operations of disease-specific health programs and services, and, on
occasions, when it may be doing both or neither, has left these initia-
tives and HSS agenda sustainability susceptible to all the preoccupa-
tions of Chee et al. and others.
Chee and colleagues recognize that both kinds of activities are
important and necessary, and that a country’s context and priorities
should determine the balance between them (Chee et al. 2013). They
cite, for example, various emergency situations in which immediate
inputs to bolster health services must take precedence over longer-term
strengthening interventions. Yet, even in non-emergency situations, the
balance continues to be skewed in favour of monitoring disease out-
comes over system performance measures (GBD 2015 SDG
Collaborators 2016; Seidman 2017) and investing in HSS support over
strengthening activities (HLSP 2009; Warren et al. 2013). Recent
papers by Bowser et al.2 and Patel et al.3 suggest a continuing bias
toward health system support (Bowser et al. 2014; Patel et al. 2015).
Interest in and attention to HSS could eventually diminish if global
health actors and recipient LMIC governments fail to find a better
balance between system-wide strengthening and selective health pro-
gram support activities. To address this imbalance, we endorse the
Atun and colleagues’ recommendation of harmonizing the gover-
nance, financing, and organizational support functions of health pro-
grams with mainstream health systems (Atun et al. 2008). As Reich
and colleagues have observed, non-governmental organizations could
help ensure that the broader system is strengthened and that lessons in
doing so are learned and applied (Reich et al. 2008). How to achieve
this harmonization efficiently and effectively when concerns persist
about the extended time required to implement and observe changes
in health system performance, and about the difficulty of measuring
HSS impact remains a political, policy, and operational challenge and
a critical research opportunity for the future.
Conclusion
Recently concluded and impending national elections in several high-
income countries have raised questions about the future of development
assistance for health, particularly the effects of potential policy changes
on the global administration of health aid and the implementation of
disease-specific programming and HSS activities in LMICs. Barring
dramatic changes in the political economy of health in LMICs and
international donor agencies in the near future, we argue that HSS is
likely to maintain a prominent place on the global health policy agenda
until at least 2030. We attribute this proposition to three developments:
(1) there will continue to be unpredictable public health crises that
imperil the routine functioning of health systems and that will require
regional and global partner collaboration with LMIC governments to
bolster them; (2) protracted, non-crisis problem-solving requiring fully
engaged, robust health systems that benefit from technical cooperation
with global partners will continue to take place in the pursuit of SDG3
and UHC; and (3) emerging knowledge about system change and its
effect on people’s health and well-being will become increasingly avail-
able. As a complement to our proposition, we recognize that continuing
efforts to improve GHS and to operationalize the concept of health sys-
tem resilience will also promote HSS agenda sustainability.
We have discussed four threats that could work against our prop-
osition and acknowledge the possibility that others may arise. With
respect to the four we have considered, taken together, we believe
they are not of sufficient strength to overcome the combination of
components in our proposition and other forces likely to promote
continuing global attention to HSS. We acknowledge, however, that
our speculative assessment and threat ratings are subjective and
Health Policy and Planning, 2018, Vol. 33, No. 1
informed by currently available information alone. This leads us to
conclude as well that prospective monitoring of HSS agenda status
and further research on HSS agenda sustainability could increase
confidence in our assessment. Our judgments about threats to our
proposition would benefit from answers to a range of outstanding
questions, such as whether increased global advocacy, focus, and use
of evidence can overcome traditional structural and operational chal-
lenges to further advancing the HSS evidence base; the feasibility of
finding synergies in traditional approaches in global health to stabilize
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and enhance health system performance; whether domestic resource
mobilization can help increase financing of health system interven-
tions and thereby accelerate progress toward SDG3 and UHC; and
whether donors can find a way to balance their extrinsic and intrinsic
preferences for HSS so neither approach is worse off and LMIC
health systems become the beneficiaries of a durable equilibrium.
Acknowledgements
We thank April Harding and Michael Reich for discussions and comments on
earlier versions of the paper prior to its submission. The views and opinions
expressed in this paper do not necessarily reflect those of the U.S.
Government, the UN Foundation, or Abt Associates.
Funding
The authors acknowledge receiving no financial or material support from any
sources in the preparation of this paper.
Conflict of interest statement. None declared.
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