The past two decades witnessed unprecedented expansion of investment in healthcare in developing countries, which coincided widespread improvement in health indicators. Though, still, there remain four hundred million people without basic access to primary care. Closing this global health delivery gap is typically framed as an issue of scale-up, accomplished primarily through integrating international donor funds with broad-based health system strengthening (HSS) efforts. However, there is no established process by which healthcare systems measure improvements at the point of service and how those, in turn, impact population health. There is no gold standard, equivalent to randomized trials of individual-level interventions, for health systems research. Here, we present a framework for district-level HSS in Madagascar in which national policies are implemented to allow for bottom-up adaptation. The program simultaneously strengthens the WHO's six building blocks of HSS at all levels of the health system within a government district and pioneers a data platform that includes 1) strengthening the district's health management information systems; 2) monitoring and evaluation dashboards; and 3) a longitudinal cohort demographic and health study of over 1,500 households, with a true baseline in intervention and comparison groups. The data platform allows for the evaluation of system output indicators as well as population-level impact indicators, such as mortality rates. This provides a powerful foundation for integrating field-based implementation with policy research and scientific innovation to advance the science of sustaining health.

Advancing A Science For Sustaining Health: Establishing A Model Health District in Madagascar