Health systems strengthening in German development cooperation: making the case for a comprehensive strategy

In the aftermath of the Ebola crisis and with renewed attention to resilient health systems, the process of improving approaches of global health actors to health systems strengthening is of great relevance. Despite the increased amount of attention paid to health systems strengthening, there is no standard definition of this concept among global health actors. Germany is no exception. Though there have been recent commitments to increase resources allocated to health systems strengthening, German Development Cooperation has no comprehensive strategy for its pursuit. This article sheds light on how HSS can be more clearly defined in German bilateral health cooperation, and makes a case for the adoption of a comprehensive HSS strategy.A strategic analysis of the German Development Cooperation's orientation towards health systems strengthening reveals the focal areas and cross-cutting approaches of Germany's engagement with the health systems strengthening. These elements are then linked to the building blocks of the health system, as defined by the World Health Organization. The resulting framework should be further elaborated with data from implementation to develop a comprehensive health systems strengthening strategy. Both the U.S. and U.K. have also recently reviewed their own health systems strengthening efforts and concluded with clear statements on the need for well-defined health systems strengthening strategies. We argue that in developing such strategies, a sound base can be provided by a health systems strengthening framework that is based on both strategic inputs from existing health policies as well as implementation experiences.Despite its limitations, the current framework provided in this review shows how the German Development Cooperation intends to enact health systems strengthening, and can thus have several uses: (1) ensure the systemic nature of health systems strengthening planning and implementation (2) guide the consistency of Germany's approach to health systems strengthening within partner countries and (3) create theories of change for health evaluations. This approach can potentially be applied to systematically interpret health systems strengthening strategies of other global health actors, leading to better coherence and accountability in health development efforts.