The “era of health systems strengthening” can be dated to a ministerial summit held in Mexico City in 2004, which resulted in the Mexico Statement on Health Research and signaled the emergence a new era for global health. It called on national governments to commit more funding to research on health systems and other funders of health research to “support a substantive and sustainable program of health systems research aligned with priority country needs” [1].
This call came shortly after the launch of large-scale disease-specific initiatives to address HIV, malaria, and tuberculosis, and just as global mobilization began in earnest to address the Millennium Development Goals (MDGs). At least three major factors aligned to drive a shift in attention and resources to health systems strengthening: realization that weak health systems impede the achievement of health MDGs, growing evidence on the adverse effects of global health initiatives on national health systems, and the recognition by global health initiatives that strong health systems were critical to the achievement of their organizational goals [2].
The shift occurred despite the absence of a solid body of evidence supporting the theory and practice of health systems strengthening and Africa was at the center stage of this development. Addressing the knowledge gap led to a growing call for health-related research into operations, systems, policy and implementation issues, highlighted nearly a decade and a half previously in the work of the Commission on Health Research for Development. Between 2006 and 2008 alone, six high-level meetings were held in Africa that led to declarations of commitment and call to action for health systems strengthening: Abuja, Nigeria (March 2006); Accra, Ghana (June 2006); Johannesburg, South Africa (April 2007); Ouagadougou, Burkina Faso (April 2008); Algiers, Algeria (June 2008); and Bamako, Mali (November 2008). In addition to building member country buy-in for an emerging agenda, this intensive schedule attempted to escalate investment in health research — a pathway to evidence-based strategies. These African meetings helped shape the current African vision for health and the World Health Organization strategy for research on health, which identifies health systems strengthening as a top priority [3].
Recognition of the growing role of research increased over time. At the emergence of the global consensus on health systems strengthening, the dominant state of mind is embodied by the African Regional Health Report of 2006 [4]. While recognizing the critical need to strengthen health systems, the only type of research envisaged in the report was “research and development to find more effective medicines and vaccines!” But this position evolved extremely quickly and later was broadened substantially at two high-level ministerial meetings on health research held in Abuja in March 2006 and in Accra three months later. The stated purpose of the Abuja meeting was explicitly to “develop an African perspective on health research for achieving and sustaining health MDGs in the African continent.” These two meetings recognized the existing knowledge gaps in the performance of health systems and the critical need for health systems research in providing evidence-informed strategies for health policy and systems strengthening. Acknowledging the role of non-biomedical health -related research was a large step. Convinced that African governments should provide coordinated leadership and influence regional and global health research agendas, the participants committed to developing a comprehensive national health research policy framework by 2007.
The African vision for health research was nailed down in the “African Health Strategy 2007-15” that was approved by the Third Session of the African Union Conference of Ministers of Health held in Johannesburg in April 2007 [5]. The strategy is an attempt to harmonize the existing health strategies and to provide an “inspirational framework” for the Africa Union, member States and Regional Economic Communities. It reaffirms the focus on health systems strengthening with the aim to better reach the poor, those most in need of health care and to reduce poverty. It also declared the centrality of research to guide this effort, so that what works would be distinguished from what doesn’t, thereby assuring that scarce resources were well spent. The strategy explicitly calls on countries to build research capacity and invest at least 2% of national health expenditure and 5% of aid funds in research that contributes to improving the performance of their health systems.
Ouagadougou (April 2008) and Algiers (June 2008) were a prelude to the Global Ministerial Forum on research for Health which was held for the first time in Africa, Bamako 17-19 November 2008. The Ouagadougou meeting on primary health care and health systems in Africa took stock of lessons learnt in the implementation of primary health care (PHC) since Alma Ata (September 1978) and urged countries to rekindle the Primary Health Care approach with a view to strengthening health systems to achieve the health MDGs. The Algiers Ministerial Conference on Research for Health in the Africa Region (23-25 June 2008) reaffirmed the critical role of research and called on countries to take the driver’s seat by identifying their own health priorities and investing in the development of strong national health research systems. Algiers provided an opportunity to agree on a common African declaration for submission to the Bamako Forum.