In the wake of any health threat, the strength of the health system at the national and international levels is often tested [1, 2]. The World Health Organization (WHO) defines health system as “all organizations, people and actions whose primary intent is to promote, restore, or maintain health .” As put forward by Heymann et al.  there is a need to pay attention to health system challenges at all levels of health care delivery in the context of sub-Saharan Africa (SSA). Many debates and disagreements surround the precise definition of health security despite the universal acceptance of health security as an important public health issue that requires close attention . Health security at the national and the global level is said to exist if the following conditions are met: there is protection against any health threat, there are new adaptations and approaches to new health conditions that may arise, new actors are engaged, including military establishments, and synergy is drawn between foreign policy and public health at the national and global levels . Global public health security aims to minimize vulnerability to public health threats across geographic regions and international boundaries . To attain global health security, attaining individual health security at any country level is vital . A country’s health system that is made resilient through strengthening core building blocks in the health care system can promote the capacity of global health security .
In SSA, there is renewed interest in strengthening national health systems to make them resilient to meet national and global health threats [1, 2, 4]. Health system strengthening refers to a change in health performance with the goal of attaining efficiency and effectiveness in the health system . Kruk et al. defined health system resilience as the capacity of health actors, institutions, and populations to effectively prepare for and respond to the public health consequence of any health threat, with the aim of protecting human life and ensuring good health outcomes during and after crises . In 2014, the Ebola outbreak in West Africa was reported as a failure of leadership at many levels . Some identified gaps, such as the absence of surveillance and health reporting systems [2, 10], weak health systems not adaptable to changing health conditions [11, 12], and ineffective health systems at the primary care level [13, 14]. In addition, the absence of vital registration systems [15, 16] and clinic-oriented health system designs which are slow in responding to new epidemiologic and disease threats [17, 18] were also reported as gaps in the health system in areas where many died during the Ebola crises. The functionality of health systems have improved in some SSA contexts [19, 20, 21], while other settings have witnessed slow health system improvements [22, 23] amidst several health challenges [21, 24]. Fundamentally, having an adequate health workforce, health surveillance, and health leadership and governance are identified as major factors in strengthening health systems in SSA , in addition to other health system building blocks  required to make health systems more resilient now and in the future .
This systematic review examined the existing English language literature on health workforce, surveillance, and governance capacity for strengthening health systems in the SSA region. The review addressed the question: how can health systems in SSA be resilient, with regards to the role of the health workforce, surveillance systems, and governance play in the strengthening of health systems? This review is based on the premise that adequate and skilled health workforce, surveillance systems, and governance capacity are vital to attaining resilient health systems [7, 27]. Evidence from this review will add to exiting literature on strengthening health systems in SSA. The review is structured as follows: a detailed methodology outlines the search process, including inclusion and exclusion criteria, quality appraisals, and data extraction, followed by synthesis and discussion of studies reviewed.
Study design and framework for review
We conducted a systematic literature review following guidelines published by Lancet , and the Preferred Reporting Items for Systematic reviews and Meta-Analyses  (PRISMA).
Search strategy and selection criteria
Our search strategy was informed by three out of the six core elements of the WHO health system building blocks. These are the health workforce, health information systems, and leadership and governance . The following keywords were used in the search: health workforce, surveillance system, health governance, health system strengthening, resilient health system, and sub-Saharan Africa. All possible synonyms were generated for the main key words and included in the search using Medical Subject Headings (MsSH) in PubMed. The search was conducted in PubMed, Science Direct, Cochrane library, CINAHL, Web of Science, EMBASE, and EBSCO for literature published between January 2007 and February 2017. Google scholar and the WHO library (WHOLIS) were searched for country-level policy documents and protocols on health system strengthening using the same key words above. Figure 1 shows the PRISMA flow diagram of the publications screened prior to the final selection of reviewed publications. All identified articles were first screened by two authors (MAA, MA) for titles and abstracts, and full-text assessment was carried out for eligibility and inclusion. The reference lists of publications were also searched to identify eligible publications for inclusion.
Inclusion and exclusion criteria
English-language literature that presented findings on health workforce, surveillance, and governance capacities for strengthening health systems in SSA were included. We included health system capacity and gaps identified during the Ebola crises in West Africa. Although the search strategy covered publications across SSA whose populations speak different languages, only English language publications were included in the review.
To avoid data that may not fit our aim, we excluded publications on disease-specific conditions that have not been documented as an epidemic in SSA. Publications on food security and health, climate change, and bioterrorism interlinkages as other broader determinants of health security and a measure of resilience to the health system were excluded. Clinical or trial studies on health system strengthening were excluded. Publications related to pharmacovigilance were excluded. Non-English literature was excluded in the review because the research team were all English native speakers.
Screening and extraction
To minimise bias in our data extraction process, two authors (MAA, NA) independently screened the initial publications for eligibility and inclusion for review. The two authors independently identified six publications that were difficult to classify into the three areas under the review because they presented cross-cutting issues reflecting in all three areas of interest. Four out of six publications were resolved through consensus-based discussions. A third author (VM) assisted in resolving classification disagreements of two publications among MAA and NA. From each eligible publication, the following information was extracted: publication origin and year, sample demographic, study title, design and setting, analytical approach, and main findings on health workforce, surveillance, and governance issues for health system strengthening for SSA.
Narrative synthesis approach was used to summarize the findings. This procedure was preferred because it applies a textual approach to data synthesis and story-telling . Five team members (MA, AA, NK, DDK, and JG) independently coded tabulated findings on the three areas of the review and mapped out common codes, concepts, and categories. Two other team members (VM, RO) built upon five team members’ work by categorizing and synthesizing salient and emergent codes into final relevant themes. Two other team members (MAA, JG) cross validated all synthesized findings and resolved any discrepancies, ensuring findings reflected the three areas under review.
Study quality appraisal
We appraised the internal validity of individual articles using the Crowe Critical Appraisal Tool (CCAT). This technique for checking quality was chosen because of its usefulness for diverse research designs . Applying eight domain elements under CCAT, and following the procedure conducted by Crowe et al.  we appraised and scored each domain element within a range of 0–5. The average score for all 31 studies was 4, indicating a high quality CCAT across all studies.
General characteristics of studies
A total of 1,548 publications were retrieved across all databases. In applying our inclusion and exclusion criterion, 31 English-language publications in SSA countries qualified for full review, as presented in Figure 1. Table 1 shows the list of publications and the African regions included in the review. A detailed breakdown is provided as a supplementary file. Three authors (MA, GJ, VM) screened and classified publications into the three areas guided by the WHO framework on health system strengthening that fell within the scope of this review. Three publications were classified under health workforce, 10 publications under surveillance capacity, and 18 publications under governance.
|SSA Region||Number of publications|
|Global perspective with focus on SSA||6|
Health workforce capacity for health system strengthening
Findings on health workforce capacity for health system strengthening are presented in Table 2. Three publications were reviewed regarding health workforce. The studies were based in Rwanda, Nigeria, and Botswana. The three publications [33, 34, 35] focused on health workforce for health system strengthening in the country context. Four critical issues were drawn from these publications: (1) continual job training for the health workforce yields better results compared to long term offsite training of a cadre of the health workforce , (2) planning for attrition should be anticipated within African health systems, with rigorous development of strategies for attrition, recruitment, and training [33, 34, 35] (3) mHealth technologies can improve community health workers’ (CHW) health service delivery capacity in low resource settings , and (4) Improving managerial skills and competencies of cadre of workforce to effectively generate and use reliable data to inform health system improvement needs at country level .
|Reference Publication||Study Title||Design/Setting/Data/Analytical Approach||Main findings on local health system strategies|
|Ledikwe et al. 2013 , Botswana||Establishing a health information workforce: innovation for low- and middle-income countries||Mixed method approach with qualitative and quantitative data was used. Tools included pre and post-test, interviews during stakeholder site visits, a survey focusing on achievements, focus group discussions, and an attrition assessment||
|Otu et al. 2016 , Nigeria||Using a mHealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: A before-and-after study||Quantitative cross-sectional survey in 14 health facilities in Ondo state, Nigeria||
|Sayinzoga et al.
2016 , Rwanda
|Drivers of improved health sector performance in Rwanda: A qualitative view from within||Web-based survey among district health managers on opinions that drive performance in the health sector||
A study in Botswana found continual job trainings on health information systems (HIS) used for tracking and reporting health indices was effective in improving patient care outcomes . The absence of clear administrative roles and command structures can lead to high health workforce attrition rates, particularly in health emergencies. Clearer roles, responsibilities, job security, and appropriate career trajectories for both old and new cadres of health professionals can reduce attrition rates in the health sector. One study  reported on-the-job trainings for CHWs can improve health worker responsiveness to dealing with emergency health threats in Botswana. Additionally, effective monitoring of health worker support roles in the health service delivery system can bring good health returns, as reported in Rwanda . Overall, the three publications highlighted the need for country health systems to address technical and operational concerns in recruitment, training, and retention of a health workforce willing and able to support, prevent, detect, and respond to any health threats within the health care delivery system.
Surveillance and health information capacity for health systems strengthening
Table 3 summarizes the findings on surveillance capacity for health system strengthening. In Kenya and Uganda, strong surveillance investments improved the strength of the health system . Two publications [37, 38], one on malaria surveillance in endemic regions in SSA and the other on the Guinean Ebola crises, reported the importance of remote sensing and early warning systems for improving future health emergencies in Africa. The application of appropriate and sustainable case monitoring systems acts as a means of both providing reliable information and building data for the health systems, as evident during the Ebola crises in Guinea .
|Reference Publication||Study Title||Design/Setting/data/Analytical Approach||Main findings on local health system strategies|
|Martha Gyansa-Lutterodt 2013 , Ghana||Antibiotic resistance in Ghana||Comment on antibiotic use and its growing resistance in Ghana||
|Justine Davis et al. 2017 , Africa||Sustainable clinical laboratory capacity for health in Africa||Comment on laboratory capacities across Africa||
|Lancet Editorial 2017 , Africa||Global health security: How can laboratories help?||Editorial comment with focus in Africa||
|Jones et al. 2008 , Kenya and Uganda||District-based malaria epidemic early warning systems in East Africa: Perceptions of acceptability and usefulness among key staff at health facility, district and central levels||Development and testing of a district-based malaria surveillance system in four pilot districts of Kenya and Uganda. Health staff interviews conducted among 52 health staff at districts and Ministries of Health in Kenya and Uganda||
|Cox et al. 2007 , Africa||Early warning systems for malaria in Africa: From blueprint to practice||Review of evidence in Africa||
|Peckham et al. 2017 , West Africa||Satellite and the new war on Infection: Tracking Ebola in West Africa||Data synthesis of available evidence of study aim||
|Haskew et al. 2015 , Kenya||Implementation of a Cloud-Based Electronic Medical Record to Reduce Gaps in the HIV Treatment Continuum in Rural Kenya||Project evaluation of an electronic medical record systems for HIV cases in rural Kenya||
|Kiberu et al. 2014 , Uganda.||Strengthening district-based health reporting through the district health management information software system: The Ugandan experience||Training facilitation for cadre of health professional on the use of the district health management information software system version 2 (DHIS2) across 112 districts.||
|Mate et al. 2009 , South Africa||Challenges for Routine Health System Data Management in a Large Public Programme to Prevent Mother-to-Child HIV Transmission in South Africa||A survey conducted between January-December 2007 on completeness and accuracy of HIV data for decision making in South Africa||
|Wong et al. 2009 , Ethiopia||Developing patient registration
and medical records management
system in Ethiopia
|Pre-post intervention study in large referral hospital||
Weak epidemiologic data gathering and application was reported in three publications [39, 40, 41] as a threat to combating future health threats at country levels. Investments in novel surveillance systems, such as the cloud-based electronic medical systems, was reported in Kenya  to have improved clinical outcomes among HIV patients. Three publications in Uganda, South Africa, and Ethiopia [43, 44, 45] reported that innovative data management systems used at the lower level of the health system structure can improve primary health care outcomes. Novel data managing processes, such as merging patient registrations and medical records into a unified process, assists in providing a timely response for patient care outcomes in Ethiopia .
Reliable data generation and use can support monitoring and controlling growing disease resistance for opportunistic infections such as HIV and tuberculosis . Incompleteness and poor data accuracy poses a challenge for improving HIV patient outcomes, as reported in South Africa . In Ethiopia, a study reported prompt, efficient, and timely medical record documentation was vital to improving population health outcomes . Onsite support and training for data managers and professionals can improve data management efficiency . Additionally, electronic record management systems can aid in generating alerts and reports on health service outcomes [37, 43] and strengthen health system preparedness to handle health threats [45, 47]. In addition, the application of problem solving and quality improvement techniques can improve population health outcomes [43, 45, 47].
Governance capacity for health systems strengthening
One publication in the West Africa region , shown in Table 4, reported health resource availability and allocation is both a technical and political problem. Health systems with effective communication and support channels can support building leadership capacities in the management of health services . Also, the development of a national-level transformative initiative for health risk mitigation is vital for health system improvements . Three publications [3, 10, 25] reported the need for building strong partnerships and improving stewardship and management of resources to deliver good health outcomes at a population level. Criterion-based audits as a public sector performance management tool can improve health deliverables, as evident in Malawi . A study in Zambia reported community dialoguing and the application of provider and patient score cards were cost-effective approaches for accountability in the health sector .
|Reference Publication||Study Title||Design/Setting/Data/Analytical Approach||Main findings on local health system strategies|
|Heymann et al. 2016 , Lancet, West Africa||Global Health security: Wider lessons from the West African Ebola Virus disease epidemic||Historical and secondary review of Ebola events in West Africa during and post Ebola||
|Drobac et al. 2013 , Rwanda||Comprehensive and integrated district health systems strengthening: The Rwanda population Health Implementation and Training (PHIT) Partnership||Impact evaluation using population level outcome data from demographic health surveys (DHS) in Rwanda (protocol)||
|Sherr et al. 2013 , Mozambique||Strengthening integrated primary health care in Sofala, Mozambique||Evaluation design technique employing a quasi-experimental controlled time-series design to assess impact of partnership strategy on under-5 mortality rates in study setting||
|Cho et al. 2014 , Global Editorial||Out of Africa, Into Global Health Security Agenda||Editorial comment||
|Cho et al. 2015 , Global
|Two Epidemics and Global Health Security Agenda||Editorial comment||
|GHSA Task Force Team 2015 , Brief Report||Global Health Security: The Lessons from the West African Ebola Virus Disease Epidemic and MERS outbreak in the Republic of Korea||Retrospective assessment of Ebola and MERS||
|Patel et al. 2015 , West Africa||Health security and political and economic determinants of Ebola||Correspondence on global health security and its needs||
|Wang et al. 2013 , Global
|New vaccine introductions: Assessing the impact and the opportunities for immunization and health systems strengthening||Mixed approaches that includes a review of published and grey literature, in-depth case studies in three countries, interviews with
key informants from countries and WHO Regional Offices, and a multivariable analysis examining impact of NVI on coverage for
3rd dose of diphtheria–tetanus–pertussis vaccine (DTP3).
|Buseh et al. 2015 , West Africa||The Ebola Epidemic in
West Africa: Challenges, opportunities and policy priority areas
|Literature review of peer-reviewed journals on disease burden and health reforms in developing countries with focus on West Africa||
|Gostin et al. 2015 , Lancet West Africa||A retrospective and prospective analysis of the West African Ebola virus disease epidemic: Robust national health systems at the foundation and an empowered WHO at the apex||A synthesis of public policy issues in post-Ebola outbreak in West Africa||
|Siekmans et al. 2017 , Liberia||Community-based health care is an essential component of a resilient health system: Evidence from Ebola outbreak in Liberia||A descriptive observational study design using mixed methods to collect data among community health workers.||
|Kongnyuy et al. 2008 , Malawi||Criteria-based audit to improve a district referral system in Malawi: A Pilot study||A criteria-based audit by conducting a retrospective review of 60 obstetric emergencies from 12 health centres||
|Topp et al. 2015 , Zambia||The impact of human immunodeficiency virus (HIV)
service scale-up on mechanisms of accountability
in Zambian primary health centres: A case-based
health systems analysis
|Guided by the Mechanisms of Effect framework and Brinkerhoff’s work on accountability. In-depth multi-case study with case data interviews collected among providers. Direct observation and key informant interviews were also used||
|Coovadia et al. 2009 , South Africa||The health and health system of South Africa: Historical roots of current public health challenges||Historical review of South African Health Care Systems||
|Kieny et al. 2014 , Western Africa||Health-system resilience: Reflections on the Ebola crisis in western Africa||Perspectives on the health systems in affected West African countries||
|WHO 2010 ||Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies||A published book on the essential building blocks in health systems strengthening||
|WHO 2007 ||Everybody’s business: Strengthening health systems to improve health outcomes: WHOs framework for action||A published book on making health systems strengthening a priority for all citizens, academics, WHO staff, governments, and donors.||
Topp and colleagues in Zambia  reported the need for health systems to create administrative answerability mechanisms to monitor and deliver health services, particularly during emergencies. Delivering health services in a holistic and integrated manner can help avoid resource fragmentation and improve efficiency in health care delivery [48, 51, 52]. Furthermore, public-private partnerships (PPP) are required to address unmet health service demands in Africa [48, 53]. Policies that address broader determinants of health, such as poverty, inequality, and violence, are vital to enable health systems to function effectively .
Identifying and prioritizing cost-effective interventions during emergencies can control infection and re-infection rates during disease outbreaks . At the apex of global health governance, strong partnership with the WHO and national and global actors is required to avoid late responsiveness, such as during the Ebola crises . Timely and prompt global response at national and international levels by multiple actors is important in pointing the way to meeting national and global health systems goals.
This review covered only eligible English-language literature that examined health workforce, surveillance, and governance capacities for strengthening health systems in SSA. This section discusses country findings in SSA and compares them to those in other countries outside the scope of this review that share similar country level characteristics.
Health workforce capacity for strengthening health systems
Low technical and operational human resource capacity for health is not a new phenomenon and has been reported in other SSA studies as vital for strengthening health systems [13, 56]. Continual on-the-job training for health professionals is a better option compared with long term offsite training of the health workforce, particularly during emergencies. Our results suggest the need for a cadre of health professionals who are adequately trained in the concepts of monitoring and evaluation, in addition to clinical skills, to strengthen country level health systems.
A well-trained monitoring and evaluation workforce is also critical for providing a culture of continuous assessment of key health indicators at points of service delivery . Health information officers’ ability to acquire and apply knowledge on cost-effective monitoring and evaluation methodologies can enhance frontline health workers’ abilities to collect, analyse, and interpret data for quality reporting on health indices [34, 57, 58, 59, 60]. This review has identified the need for health systems to generate reliable and timely data on health workforce gaps useful in making timely decisions regarding human resource capacities requirements to address unmet health service demands in SSA.
The review found mHealth technologies to be effective in some low-resource settings for disseminating information and meeting training capacity of community health workers through (1) improving knowledge and attitudes on clinical care and (2) enabling the delivery of essential medicines and information to distant population groups, especially during emergencies. Growing evidence corroborates mHealth’s role for strengthening health systems in Africa [61, 62, 63, 64]. The WHO indicates that low knowledge and information on mHealth applications is a challenge in Africa, hence the need for investments to assess its use and scale-up .
Fundamentally, no single strategy can address all the health workforce challenges Africa faces today; a mix of strategies and interventions are required. Task shifting, performance-based payments, and results-based financing as strategies for improving skilled health professional numbers have been sparsely piloted in Rwanda, the Democratic Republic of Congo, South Africa, and Kenya [66, 67, 68, 69, 70]. Different models for attracting, recruiting, training, and retaining a critical health workforce must be experimented at country levels.
Surveillance and health information needs for strengthening health systems
This review highlighted the need for investments that will build robust epidemiologic systems to anticipate future threats in the health system [46, 71]. The findings from this review point to the need to initiate or strengthen PPP arrangements that can support building country level capacities and laboratory infrastructure to improve disease surveillance, diagnosis, and treatments.
Health systems that invest in developing surveillance systems for data gathering, monitoring, and feedback can improve disease tracking and control in SSA [72, 73]. Studies from developing countries also support the positive effects of satellite imaging for health service delivery [74, 75]. Furthermore, linking facility level health data to broader determinants of health at the population level can support tracking any potential health threats before they become epidemics .
In SSA, the adoption and use of electronic medical techniques can provide timely detection and response to any health threats to the health system. Our review found that novel electronic and data processing techniques helped to improve HIV treatment outcomes in Kenya , as well to improve disease infection control and prevention at the health facility level. This evidence is corroborated by a study in Guinea, Liberia, and Sierra Leone . Their use and advancement to improve data accuracy, as the case reviewed from South Africa, is also important for most African health systems.
Novel surveillance systems can help solve health problems by introducing data quality improvement techniques at health facility levels to improve patient health outcomes. The evidence from the review points to the need for health managers to invest in designing and monitoring health performance using cost-effective surveillance systems. Novel surveillance systems can facilitate a country’s quick response during a disease emergency, as well as support the design and preparation of health emergency preparedness plans. Evidence from the WHO corroborates this and emphasizes the need for integrated surveillance systems in SSA during health emergencies, as evidenced during the Ebola crises .
Governance capacity for health system strengthening
Two health governance shifts were reported as vital to strengthen health systems in Africa: the political and technical commitments to strengthen health capacities. A key political decision in strengthening health systems is financial commitment at the national level. Despite the Abuja declaration on health financing requirements for African governments, many health systems operate with minimal support from their governments . To deliver real-time health responses to health threats, country level commitments across SSA that will mobilize and allocate resources appropriately to strengthen existing weak health systems are vital. Governments in SSA need to create health systems that are inclusive and provide accountability at all levels of the health structure. To enhance weak accountability systems, administrative answerability mechanisms must be effectively developed. Effective accountability systems can help deliver positive health system outcomes [11, 12].
Strengthening health partnerships at country level and across SSA has the potential to address technical and logistical capacity regarding the delivery of health services. Review findings point to the fact local partnership building improves PPP initiatives to support health systems so they function effectively. Strong health partnerships assist to address technical and logistics supply needs and to provide mentorship for country level health system improvements, as reported in a Rwandan publication . Furthermore, health partnerships along multiple district levels can help provide effective health leadership, communication, and support channels across many health sectors [80, 81].
Health leadership and governance policies that address broad social determinants needs can yield better health outcomes. Financial investments that address broader determinants of health is a good investment to guarantee global health security . The evidence reviewed from the South African health systems after the Apartheid show strengthening social determinants on HIV stigma, subordination of women, poverty, inequality, reducing violence, and traditional practices can improve health care system capacities and improve quality of life . An inclusive approach should be taken among governments, civil society, and local level actors to advance partnership to drive the delivery of health services.
While a substantial amount of financial commitment at country and global levels are vital to deliver large scale changes to population health systems, other cost-effective strategies exist that can equally deliver timely and responsive health care outcomes for populations. This review found community dialoguing and the application of patient score cards were cost-effective strategies that can improve health service delivery at the micro-level. Applying cost-effective health approaches can help overcome health system constraints  and help deliver appropriate health solutions  for country health system improvements.
The review has limitations. Although we searched several databases, there is the potential that we might have missed other relevant publications. We acknowledge that our exclusion of other periodicals, protocols, and publications from health development partners may have limited our scope of evidence. Our inclusion criteria for only publications in English from SSA might limit generalisability of our findings across French and Portuguese-speaking countries. Also, we did not find and include any policy document at country levels on health security. We acknowledge this limitation on country level evidence on what strategies exist on improving their health systems. We found most evidence on country examples in West Africa stemming from the Ebola crises. None was examined in North Africa. Other cases of country evidence presented came from East and South African countries. Despite these country or regional coverages, our findings remain relevant and applicable across other countries in SSA that share similar health care system capacity needs or barriers.
This review re-emphasizes the role of an effective cadre of health care workers, good investments in surveillance for decision making, and strong governance in health as critical for the success of any country health system. A health system that trains a cadre of health professionals on the job, reduces health workforce attrition levels, and builds local capacity for health care workers to apply innovative mHealth technologies in delivering services can improve health worker motivation and support for the health sector. Building novel surveillance systems can improve clinical care and health system preparedness for health threats. A strong health leadership and partnership can help deliver financial and logistical capacity for the effective delivery of essential health services. A mix of strategies in addition to the main areas covered under this review, as advocated by the WHO, is needed for strengthening health system capacities . Overall, policy shifts in African countries’ health systems that prioritize training a cadre of health care workers willing and able to provide timely responses to any disease or health threat, investing in building a robust and cost-effective surveillance capacity, and creating financial accountability in health financing and governance can assist in strengthening country level health capacities to deliver better health outcomes.