Health Systems Strengthening in Africa: Why Stronger Systems Can’t Wait

 Author: Azuka Chinweokwu Ezeike, MBBS, FWACS, FMCOG, MSc (PH)

         Highlights

• The foundation of health systems strengthening in Africa rests on the six WHO building blocks.
  
  
• Improving service delivery is essential for accessible, efficient, and quality care across diverse contexts.
  
  
• A robust health workforce is critical for reducing gaps in human resources and ensuring equitable coverage.
  
  
• Strong health information systems enable data-driven decisions and better public health outcomes.
  
  
• Reliable access to medical products and technologies improves treatment, safety, and health outcomes.
  
  
• Leadership and governance reforms ensure accountability, while sustainable domestic financing supports long-term resilience.

Introduction

A health system is beyond a hospital or clinic. It is the collective organisations, institutions, resources, and personnel responsible for enhancing health services, aimed at improving health determinants through quality care, preventive measures, and rehabilitative interventions. It requires a workforce, funding, information networks, and overall guidance to function effectively.

A weak health system makes the populace vulnerable. In Africa, this is a major concern, as access to quality healthcare is not possible for many for myriad reasons. One of the reasons is the health system’s inability to address the health needs of the population. This was why, in the wake of the COVID-19 pandemic, the greatest fear in the minds of many was how Africa’s weak health system would be able to handle the impact. 

While efforts have been made over the years and some improvements have been seen, the disease burden in the region remains unacceptably high. The 2018 World Health Organization (WHO) African Region report on the state of healthcare showed that, though the region experienced some improvement with the Millennium Development Goals (MDGs), there is some unfinished business that the Sustainable Development Goals (SDGs)  were meant to complete.

Achieving Goal 3 of the Sustainable Development Goals (SDGs) in Africa requires a resilient health system.1 However, health systems strengthening efforts across the continent have been inconsistent, as they have largely been driven by development partners, with national governments playing a subordinate role. Many African countries lack local frameworks or policy documents dedicated to health systems strengthening, leaving most programs to operate under donor-developed structures.

Changing the narrative requires a conscious effort to improve the state of healthcare delivery within countries by improving local understanding and developing homegrown implementation strategies.This article aims to improve our knowledge of the concept of health systems strengthening, its benefits, and implementation strategies in Africa.

State of Healthcare in Africa

Africa lags behind the rest of the world in nearly all health indicators. Compared to global averages, life expectancy is lower, and the ten countries with the lowest life expectancy are all in Africa. Maternal and child mortality rates remain alarmingly high, though there has been moderate improvement in recent years.

According to Dr Babatunde Sanni, a global health expert with experience working in Africa and the United States, “Africa is not a homogeneous continent, and its health system challenges differ greatly by context, whether rural or urban, resource-rich or resource-constrained, or shaped by terrain, conflict, or geography”.

Although the continent accounts for only about 15% of the world’s population, it bears nearly 50% of the global burden of communicable diseases. An unhealthy population is a non-productive population, and this translates to significant economic losses. The region loses an estimated 2.4 trillion dollars in annual output due to poor health. 

These poor health outcomes are largely due to limited access to healthcare, driven by inadequate funding and dysfunctional health systems. One major contributor to this is the deficit in health financing. Current investment in health infrastructure stands at around 4.5 billion dollars, far below the estimated 26 billion dollars required to meet regional needs.

“The most critical gaps I encountered relate to inadequate human resources, poor and unpredictable funding, and weak infrastructure. These challenges translate into limited access to quality care, persistent dual burdens of infectious and non-communicable diseases, overstretched frontline workers, and health facilities that often operate far below their potential”, Dr Sanni said 

“Importantly, the issue has never been the absence of strong policies or well-crafted strategies; Africa has produced some of the most forward-thinking health policies globally. The real challenge lies in mobilising and sustaining the enablers required to translate those policies into effective implementation”, Dr Sanni continues

Between 2021 and 2025, Official Development Assistance (ODA) to Africa declined by 70%, while external debt continues to rise. Consequently, many African health systems face severe funding pressures, further worsened by low domestic investment, as most countries allocate only about 10% of their national budgets to health.

“A key insight that has stayed with me is the growing gap between the 'real need' and the 'felt need.’ Because of funding shortages, countries sometimes shape their priorities around what donors are willing to support rather than what the epidemiology, culture, and local context truly require. As a result, stopgap measures often take precedence over long-term reforms, even when they do not fully address the underlying health system weaknesses. My position has become clearer over time: African countries must take greater ownership of their health systems, from defining priorities to financing interventions, and from designing locally relevant models to ensuring accountability for results”, Dr Sanni reiterates

What is Health Systems Strengthening? 

Health systems strengthening refers to initiatives and strategies aimed at improving one or more components of the health system to achieve better health outcomes. This is done by enhancing access, coverage, quality, and efficiency, ensuring that the system is strong enough to effectively address health threats.

The strength of a health system is shaped by health service, economic, and political factors.  Therefore, a resilient health system requires a well-trained and motivated workforce, adequate funding, efficient service delivery, a reliable supply of medicines, and an enabling social and political environment.

For any health system strengthening strategy to be effective, it must be primary health care–oriented and designed within the context of a country’s socioeconomic realities. This is because Primary Health Care (PHC) forms the foundation for achieving Universal Health Coverage (UHC).

Measuring the performance of health systems involves assessing key health indicators to determine the impact on the population. Such data are essential for developing responsive and people-centred health systems that meet real health needs and ultimately drive the achievement of Universal Health Coverage.

Health Systems Building Blocks

The World Health Organization (WHO) groups health system building blocks into six components. This was launched by the WHO in 2007.2 Although different health systems have their unique characteristics, these components are shared features of every functional health system. A 2017 study in Ethiopia showed that the performance of public hospitals was 60% when measured against the WHO building blocks.3

They include: 

• Service delivery
• Health workforce
• Health information systems
• Medical products, vaccines and technologies
• Health system financing
• Leadership and governance

Service delivery

A strengthened health system involves the delivery of effective, safe and good quality healthcare to those in need of it without waste of resources. How services and inputs are organised and managed determines the quality of care that the patient receives.

Efficient service delivery involves:

• Adequate supplies for the health workforce to improve their work.
• An organisational environment that offers incentives to clients and users.
• Understanding users' perspectives and lowering barriers to care through social interaction (stakeholders’ initiative)
• Providing health packages that match population demands
• Maintaining an ordered provider network to prevent service duplication and fragmentation.
• Efficient resource management for waste reduction
• Provision of the required infrastructure logistics

A well-functioning health system should have the following key characteristics:

• Comprehensiveness: Provides a full range of preventive, curative, palliative, rehabilitative, and health promotion services tailored to population needs.
  
  
• Accessibility: Ensures permanent, barrier-free access to care that’s close to people, at home, in the community, workplace, or primary care facilities.
  
  
• Coverage: Guarantees that all individuals within the target population, regardless of health or socioeconomic status, are reached.
  
  
• Continuity: Delivers seamless care across conditions, services, and life stages within the health network.
  
  
• Quality: Offers safe, effective, timely, and patient-focused care.
  
  
• Person-centredness: Organises services around people’s needs and preferences, encouraging participation and shared responsibility for health.
  
  
• Coordination: Promotes active collaboration across providers, care levels, and sectors to ensure smooth service delivery and emergency preparedness.
  
  
• Accountability and efficiency: Manages resources responsibly, delivers measurable results, and involves the community in oversight.

Health workforce

The health workforce refers to “all people engaged in actions whose primary intent is to enhance health.” It consists not only of health service providers but also of health management staff, encompassing both the public and private sectors. The density of the health workforce in any country is directly proportional to its health service coverage and health outcomes. 

The ideal health workforce density depends on the national and local context, including the disease burden, demography, health worker skill mix, division of labour, and distribution of health services.

According to the World Bank, most countries face acute shortages of health workers, with fewer than 2.3 health workers per 1,000 population. The WHO forecasts an 11 million health workforce shortage by 2030, primarily in low- and lower-middle-income countries. The increasing international migration of health workers further worsens these shortfalls.The characteristics of a well-performing health workforce are:

• Availability: The presence of sufficient health workers where and when they are needed.
• Competency: The ability of health workers to perform their duties effectively, safely, and in line with professional standards.
• Responsiveness: The capacity of health workers to meet patients’ needs and expectations with respect and sensitivity.
• Productivity: The efficient use of skills and resources by health workers to achieve optimal health outcomes.

Improving the performance of the health workforce requires:

• Implementing well-designed training and retraining programmes
  
  
• Scaling up the availability, distribution, and performance of health workers
  
  
• Ensuring adequate budgetary allocation to absorb trained health workers
  
  
• Organising effective health service delivery systems
  
  
• Providing fair pay
  
  
• Retaining an efficient and motivated workforce

Health Information Systems

A health information system (HIS) comprises people, tools, and methods that interact at different stages of the health information production process. The health information component is one of the key building blocks of health system strengthening. A well-functioning health information system ensures the production, analysis, dissemination, and use of reliable and timely information by decision-makers at different levels of the health system.

The key functions of a health information system include:

• Data generation
  
  
• Data compilation
  
  
• Data analysis and synthesis
  
  
• Data communication and use
  
  

Within the health information system, three domains of information are critical:

• Determinants of health: Socioeconomic, environmental, behavioural, demographic, and genetic factors shaping the context in which health systems operate.
  
  
• Health system: Inputs, processes, outputs, and immediate outcomes that reflect health service organisation, availability, quality, and coverage.
  
  
• Health status: Levels of mortality, morbidity, disability, and well-being, influenced by both health interventions and broader determinants.

This data underpins decision-making across all the building blocks of the health system.

To fulfil this mandate, a strong health information system must include:

• Facility-based information systems that produce reliable data
  
  
• Electronic data storage and retrieval systems
  
  
• Integrated systems that avoid parallel reporting streams
  
  
• Up-to-date technology for reporting public health data
  
  
• Metrics to track system performance
  
  
• Standard classification tools and methods

Medical products, vaccines and technologies

Proper access and use of medicines save lives, while misuse or poor-quality products harm health. A well-functioning health system requires equitable access to essential medical products, vaccines, and technologies that are of assured quality, safety, efficacy, and cost-effectiveness, as well as their rational and scientifically sound use. This building block involves not just supply, but also effective utilisation. 

The pharmaceutical system is the component of the health system that fulfils this function. It includes the human and material resources that ensure optimal access to quality pharmaceutical products and related services.This building block requires synergy with other health system building blocks to support access to and use of medical products, vaccines, and health technologies.

Optimal access and use of essential medical products requires:

• National policies and regulations that support supply
  
  
• Standardised pricing regimes
  
  
• Reliable manufacturing practices
  
  
• Efficient procurement, supply, and distribution systems
  
  
• Guidelines that promote the rational use of medicines

Health System Financing

Health system financing means how money for health care is raised, shared, and spent to meet the health needs of individuals and communities. It is one of the key functions of a strong health system and is vital for achieving Universal Health Coverage (UHC).

In many African countries, people still struggle to afford good-quality health services. Even those who can pay often get poor-quality care because of weak health systems. When people pay directly from their pockets for health services, it can lead to catastrophic health spending, pushing families into poverty and making it harder to achieve UHC.

The main functions of health system financing are:

• Revenue generation: Raising money for health from different sources such as taxes, insurance premiums, out-of-pocket payments, and external funding from donors.
  
  
• Pooling of funds: Putting collected funds together so that financial risks are shared across the population, protecting people from high medical costs.
  
  
• Purchasing of services: Using the pooled money to pay health workers and fund facilities to enable quality and efficient care.
  
  

Health expenditure usually comes from three main sources:

• Government spending
  
  
• Private spending
  
  
• External or donor funding

Unfortunately, as donor support continues to reduce and many governments spend too little on health, African countries are facing serious funding challenges that threaten progress toward UHC.

Reflecting on this, Dr. Sanni notes that “Poor financing remains one of the deepest constraints. Underfunded systems become vulnerable systems, characterised by overworked staff, ageing infrastructure, and a dependence on donor resources to fill chronic gaps. My experience in the United States and other Western countries has not changed my perspective; it has reinforced it. I am even more convinced that no external partner can sustainably finance a country’s health system. Domestic resources, used efficiently and aligned with defined national priorities, remain the only viable long-term path to stronger health outcomes”

The health system financing strategies include:

• Reducing out-of-pocket payments by expanding health insurance
  
  
• Providing social protection for vulnerable groups such as women, children, and persons with disabilities
  
  
• Allocating more funds to areas with greater health needs
  
  
• Using available resources efficiently to reduce waste
  
  
• Promoting transparency and accountability in managing health funds
  
  
• Keeping proper records of how health funds are raised and used

Leadership and Governance

Leadership and governance, also called stewardship, is one of the most important and complex functions of a health system. It plays a central role because it influences all other functions of the system.

Leadership and governance determine how governments work with other key players in the health sector, including private organisations, non-governmental groups, and communities. It involves both political and technical actions that help guide decisions, manage resources, and respond to the health needs and expectations of the population.

Stewardship demands that government actors take full responsibility for the health system and the well-being of the populace. Research shows that when governments provide strong leadership and clear direction, people have better access to quality health care, and overall health outcomes improve.4

Key leadership and governance strategies include:

• Developing and implementing sound health policies and guidelines
  
  
• Strengthening systems for data collection, intelligence, and oversight
  
  
• Promoting collaboration across government sectors and with non-governmental stakeholders
  
  
• Establishing clear regulations and ensuring they are properly enforced
  
  
• Ensuring accountability and transparency in all health system processes
  
  
• Designing a well-organised health system that avoids duplication and fragmentation

   Benefits of a Strengthened Health System in Africa

A well-functioning health system is the backbone of any nation’s development. For Africa, the benefits go beyond health; they touch every aspect of society and the economy.

• Improved access to quality healthcare
   Strong health systems ensure that essential services are available, affordable, and accessible to everyone, including people in rural and hard-to-reach areas.
  
  
• Better health outcomes
   When health systems function effectively, deaths from preventable causes decline drastically, and more people live longer, healthier lives.
  
  
• Reduced dependence on foreign aid
   With donor funding steadily declining, Africa needs resilient, self-sustaining systems. A strong health system enables countries to finance and manage their own priorities without relying heavily on external support.
  
  
• Economic growth and productivity
   Healthy populations are more productive. Robust health systems reduce absenteeism, improve labour output, and contribute directly to national development.
  
  
• Equity in healthcare delivery
   Strengthened systems promote fair and equal access to quality care regardless of gender, income, or place of residence. This is a key step toward achieving Universal Health Coverage (UHC).
  
  
• Efficient use of resources
   A coordinated and transparent health system minimises duplication, wastage, and corruption, ensuring that every resource counts.
  
  
• Improved trust in healthcare
   Public confidence grows when people consistently receive reliable, respectful, and effective care. This helps rebuild trust in local health institutions.
  
  
• Enhanced pandemic preparedness and response
   The COVID-19 pandemic revealed how fragile systems can collapse under pressure. Strengthened systems build resilience and enable quicker, coordinated responses to future outbreaks. In May 2025, all 194 WHO member states signed a pandemic agreement aimed at improving global and regional preparedness.

Key Strategies for Strengthening Health Systems in Africa

Strengthening health systems in Africa starts with government ownership and context-driven policies. Sustainable progress depends on leadership that aligns national priorities with long-term goals rather than donor cycles. Interventions that are participatory in design (i.e., involve stakeholders) have been shown to have greater impact.5The strategies include: 

1. Developing national frameworks for health systems strengthening

Over-reliance on donor funding often results in unreliable systems that fall outside a country’s socioeconomic framework and are therefore short-lived. As a result, ensuring system continuity becomes a major challenge.A framework crafted by the national Ministry of Health ensures that policies are grounded in the local socio-economic context, realistic and implementable. Without this, efforts risk being donor-driven, fragmented or misaligned.

Each Ministry of Health should design its own health systems strengthening (HSS) framework that reflects the country’s social and economic realities. Tanzania’s Health Sector Strategic Plan V is a good model. It provides a unified plan for health investments, coordination, and performance tracking.

2. Increasing domestic funding and reducing donor dependence.

Sustainable health systems depend on reliable, predictable domestic funding, not just donor grants that may decline or shift priorities. For equity and financial protection, domestic financing is key as relying on external funding weakens long-term sustainability. Nigeria’s Basic Health Care Provision Fund (BHCPF), which allocates at least 1% of national revenue to health care, is an example of domestic financing improving local service delivery.To achieve Universal Health Coverage in Africa, the World Bank advises countries to:

• Spend health funds wisely so that the money already available gives better results for people’s health.
  
  
• Increase government spending on health by adjusting budgets, improving tax systems, and raising funds within the country.
  
  
• Use public funds to make healthcare affordable for everyone through insurance and pre-payment plans.
  
  
• Make sure the poor and those working in the informal sector are included in these plans.

3. Strengthening governance and accountability

Even good policies falter if governance is weak, funds are opaque, parallel systems proliferate, and donors bypass country structures. Health system strengthening must be anchored on strong stewardship.Transparent and coordinated management of health resources builds trust and efficiency.

Ghana’s Sector-Wide Approach (SWAp) established since 1997, has successfully aligned donor support under one national health plan, improving efficiency and oversight. Some other African countries have also followed suit.To achieve this, Ministries of Health must:

• Provide strong leadership and coordination: Act as stewards by defining health strategies, setting regulations, monitoring and evaluating progress, and coordinating all actors, including government agencies, donors, and private organisations.
  
  
• Promote transparency and accountability: Publish annual reports showing how resources are used, how funds are disbursed, and what services are delivered.
  
  
• Strengthen sustainability: Align external assistance with national systems by avoiding parallel procurement or reporting structures and using government systems where possible.
  
  
• Share progress openly: Publish a health sector scorecard every year for public awareness and engagement.

4. Building workforce capacity and decentralising delivery systems.

A well-trained, motivated workforce delivering through strong PHC platforms and supported by decentralised systems is the backbone of a resilient health system. Without it, services remain fragile. This is why training and retraining frontline health workers is key. On the other hand, decentralised supply systems and empowered local managers ensure that medicines and equipment consistently reach facilities.

Achieving this requires:

• Investing in local training programs for frontline workers: Support community health workers, nurses, midwives, and primary healthcare (PHC) staff.
  
  
• Targeting recruitment to fill gaps: Focus especially on rural and remote areas where healthcare workers are most needed.
  
  
• Prioritising PHC as the entry point for UHC: Ensure strong government support, adequate infrastructure, equipment, and medical supplies.
  
  
• Establishing decentralised supply and distribution systems: Enable local actors or grassroots providers to manage supply chains for reliability and community ownership.

5.  Improving data and information systems

 Reliable data are essential for evidence-based decisions and accountability. Strong data systems lead to stronger health outcomes. Strengthening health information systems and promoting data use at all levels enhances planning, resource allocation, and overall health system performance. Without quality data, it is impossible to monitor performance, ensure accountability, make strategic decisions, or adjust interventions. As the saying goes: If you can’t measure it, you can’t improve it.

Achieving this in Africa requires:

• Strengthening health information systems (HIS): Ensure reliable and timely data collection, analysis, and reporting, with strong quality assurance mechanisms.
  
  
• Training staff to use data for decision-making: Allocate resources to maintain and upgrade systems, so staff can turn data into actionable insights.
  
  
• Embedding monitoring, evaluation, and learning mechanisms: Integrate these into the health system framework to track progress, learn from experience, and adapt interventions quickly.

6.  Adopting inclusive, migrant-sensitive, and climate-resilient policies.

Health systems in Africa face dual pressures: population mobility (migrants, refugees, displaced persons) and climate change (extreme weather, changing disease patterns). Ignoring these undermines equity and resilience.To ensure health equity, health systems must integrate climate risks and migration into policy and service delivery. 

The WHO urges African countries to build climate-resilient and migrant-inclusive systems. Nigeria’s integrated health services,  launched in 2025 for vulnerable populations, show how this can be achieved.

Drawing on his global experience with diverse health systems, Dr.Sanni recommends the following interventions to strengthen health system performance and resilience in Africa:

“Many African countries already have solid reform frameworks, Nigeria’s Sector-Wide Approach (SWAp), South Africa’s Ideal Clinic model, and Kenya’s Primary Care Network (PCN) reforms are clear examples. The challenge is not a lack of vision; it is the persistent gap between policy design and policy implementation, largely driven by inadequate financing and weak execution capacity”.

From global experience, several strategies are well-suited for adaptation:

First, financing reforms must prioritise predictable domestic funding and strategic purchasing. Health resources should increasingly be channelled toward quality, equity, and outcomes, rather than fragmented, input-based spending. The continued expansion of health insurance across the continent is encouraging, and countries should leverage this momentum to accelerate progress toward Universal Health Coverage (UHC).

Second, strengthening primary health care (PHC) remains essential. Effective PHC must serve as the true backbone of the system; integrated, people-centred, and closely linked with communities. Globally proven models show that when PHC is properly organised, staffed, and financed, it improves access, continuity, and resilience while reducing the cost of care. Africa must adapt these lessons to create delivery models that integrate prevention, chronic care, community engagement, and referral coordination.

Third, investing in digital health and data systems is critical. This means prioritising interoperability, real-time decision-making tools, and strong national data governance. Digital systems should not exist as donor-driven parallel platforms; they must be developed as part of a sustainable national infrastructure that strengthens accountability, surveillance and service delivery.

In my experience, the most transferable lesson from well-performing health systems is clear: implementation discipline, supported by consistent domestic investment, is what ultimately drives improved health outcomes.

“Africa has no shortage of policies or ambition; what we need now is ownership, financing discipline, and the courage to fund the real needs of our people. When we lead our systems, we unlock our solution."

Conclusion

The strength of Africa’s health systems depends on how seamlessly each building block supports the next. As service delivery evolves and the workforce becomes trained and better-equipped, communities will experience a transformative impact.

Reliable medicine supply, advanced data systems, and transparent leadership will drive trust and innovation. Sustainable domestic funding will empower countries to fully own and shape their health futures. With all six blocks strengthened, Africa will be positioned to build resilient, adaptive systems capable of meeting tomorrow’s health challenges and improving lives across the continent.

Acknowledgement

I appreciate the valuable contributions and expert insights provided by Dr Babatunde Sanni, a global health expert and Chief Executive Officer of Optidel, a global public health and environmental consulting firm. He has worked in Africa and the United States, serving with organisations including the World Health Organization,  JSI, and Management Sciences for Health.

References

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2. Ferrinho P, Daniel-Ribeiro CT, Ferrinho R, Fronteira I. Building-blocks to develop one health systems. One Health [Internet]. 2023 Dec 1 [cited 2025 Oct 14];17:100624. Available from: https://www.sciencedirect.com/science/article/pii/S2352771423001441
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Published December 4, 2025