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System strengthening: the sustainable way forward

To bring lasting, and positive change in fragile and conflict-affected regions, we need to strengthen systems.

Well-functioning health systems, food systems, education systems and justice systems are vital to a prosperous and thriving society where everyone can count on the support they need to live a dignified and healthy life in peace.

But what exactly do we mean by working on system strengthening in fragile and conflict-affected settings? In one sentence: striving to strengthen or transform existing systems through the alignment and integration of approaches with government policies, to improve service delivery and inclusive market access.

What is a system?

Are you still with us? Let’s take a step back and ask a more fundamental question: what is a system anyway?

In very general terms, a system comprises a set of related components (people, institutions, resources and activities) that are coherently organised and interconnected in a structure to fulfil a purpose.

Systems are dynamic and complex and we need to understand them holistically. For instance, systems may consist of various underlying sub-systems with their own purpose. These sub-systems are interconnected and jointly contribute to the functioning of the larger system.

In health systems, the overarching purpose is primarily to promote, restore and maintain health. Within a country’s overall health system, a sub-system could be a drug supply chain which consists of components and processes that collectively work together with the purpose to ensure access to medicines and medical supplies. The health information system can also be seen as a sub-system.

Another example: within the education system, a school can be viewed as a sub-system. Therefore, it’s crucial to clearly define the level of a system you intend to strengthen.

At Cordaid, we don’t consider the strengthening of an individual school, police station or health facility a systemic approach: all relevant actors within a certain geographical area (a district, or even a province) should be involved and strengthened to talk about system strengthening.

Strategies, responses, activities

Now, let’s take it one step further: system strengthening is a set of comprehensive strategies, responses, and activities that are designed to improve and develop resilient systems within a geographical context sustainably and inclusively.

With system strengthening, the purpose or outcomes of the system and its sub-systems, the stakeholders and their interconnectedness need to be considered when identifying interventions at the level of the system where the impact is the strongest.

In our view, in system strengthening there should always be a strong focus on subsidiarity and locally-led decision-making. This will structurally shift autonomy to those who can make optimal choices within their context, engaging communities and creating more equitable outcomes at the level of the local service providers and the population.

Example: health system strengthening

For health systems, the World Health Organization developed a conceptual framework to provide a common understanding of core system components and to be able to measure health system performance. These are commonly known as the six health system building blocks, often complemented by a seventh identified block (community engagement):

Quality service delivery: effective, safe, quality healthcare services from health promotion to prevention, treatment, rehabilitation and palliative care

Health workforce: all people engaged in actions whose primary intent is to enhance physical and mental health

Health information system: this enables decision-makers to identify problems, make data-driven, evidence-based decisions on policies and allocate scarce resources optimally

Access to essential inputs: such as medical products, vaccines and technologies which are of assured quality, safe, efficacious and cost-effective

Financing system: adequate funds for health care and the right financial incentives to providers, to ensure all people can use the services and are protected from financial risk

Leadership and governance: the role of government in managing relations between various stakeholders in health, both public and private

Community engagement: the demand side of a health system, i.e. the wants and needs of individual end-users, their ability to make optimal decisions about the use of health services as well as to hold service providers and governments accountable

These building blocks each have their own function, but they are not independent, rather they are interconnected components that must coherently work together to be effective and improve performance.

Addressing key constraints of the seven building blocks and managing their interactions in ways that achieve more equitable and sustainable outcomes in a cost-effective manner contributes to system strengthening.


System strengthening seeks to maximize impact by aligning and integrating approaches to government policies and value chains. A tangible example of how this can be done is through results-based or performance-based financing (PBF), an approach which links funding to concrete outcomes achieved by schools or health facilities, leading to improved quality of services, higher staff motivation and more satisfied users.

If well designed, PBF can have system-wide effects; in various countries (Rwanda, Burundi, Cameroon, Zimbabwe) governments have now adopted performance-based mechanisms in their own health system.

Other Cordaid focus areas in health include Sexual and Reproductive Health and Rights (SRHR), with an emphasis on the rights of adolescents and youth, Sexual and Gender-Based Violence (SGBV), Mental Health & Psychosocial Support (MHPSS), communicable diseases (HIV/AIDS, tuberculosis and malaria) as well as advocacy for health system strengthening.

Penny wise, pound wise: performance-based financing in health care

Read more

Criteria of a system strengthening intervention

Aspiring to lastingly strengthen – or even change – a system requires not only knowledge, conviction and determination but also a clear understanding of what is needed to accomplish such great ambition.

Whether an intervention can be considered ‘system strengthening’ is mainly about the design of such interventions, whether they contain clear system components and objectives, and have clear positive system-wide effects.

This means, for instance, that an intervention should not strengthen certain elements of the system at the expense of other elements, and that Cordaid does not take up roles and responsibilities for which local actors are already in existence and functioning.

Other criteria include replicability and scalability of the intervention (in a cost-effective and locally owned manner), accountability (upward and downward) and transparency, as well as a plausible strategy for long-term sustainability.

Financing health systems in the face of climate change

Besides conflict, poverty and corruption there is another global challenge we need to take into account in our efforts to make fragile regions more resilient: the changing climate. In this video, expert Jos Dusseljee explains how performance-based financing may also be used to help health facilities prepare for changing conditions and outbreak risks as the climate changes. 

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Our vision for system strengthening

Cordaid works towards strengthened and transformed systems that benefit underserved people in fragile and conflict-affected settings. This entails strengthening health, food, education and justice systems to be inclusive, equitable and effective. 

Cordaid addresses underlying obstacles that constrain access to services and rights, whether these are linked to gender, religion, race, or disability. In doing so we apply a holistic approach, wherever and whenever we work on system strengthening, which implies that we are responsive to individual and societal needs in their full diversity, particularly safeguarding access to essential services for those most at risk.