Strong health systems are learning health systems

The COVID-19 pandemic has brought to the surface discussions about the need for stronger health systems, especially in poorer countries. Global health funders are beginning to back up their rhetoric in this area with investments. The EU, USA, UK, France, and Germany, among others are investing billions [1] on the health systems strengthening (HSS) agenda in poorer countries. Among multilateral funders, the Global Fund currently spends $1 billion each year [2] on their “resilient and sustainable systems for health” portfolio, and Gavi’s new 5-year strategy will likely infuse $1.7 billion [3] into strengthening health and immunization systems. These sums are insignificant compared to the loss to lives and livelihoods and the trillions [4] in economic losses that are the cost of inaction—and this slew of investments in HSS is welcome news. But there is a hitch. Policymakers and practitioners who work in those health systems are accustomed to seeing the global interest in HSS fluctuate. It is mainly when emergencies (such as Ebola or COVID-19) strike, that the world wakes up to the importance of HSS, and by then, it is often too late [5]. We expect a lot from our health systems. We expect them to deliver high quality, efficient care, and provide universal coverage. We also expect them to be resilient in the face of shocks, keep us safe, and shield us from crises. When faced with catastrophe, we ask health systems to deliver results quickly. There is still a disconnect between our lofty expectations from health systems, and the inputs that they receive to make them stronger. Health systems do not become stronger overnight. Many investments purport to strengthen them but fail to do so. The gains of well-intentioned and well-designed investments to strengthen health systems are limited, when they do not focus on strengthening the ability of health systems to learn.