• Health system strengthening is an essential step towards achieving universal coverage goals in low-income and middle-income countries (LMICs). However, health systems are complex and health system strengthening initiatives are often introduced with limited understanding of how they will work in practice and the risk of potential adverse events
  • Aid flows to health systems in LMICs have increased substantially in the last 15 years. Donors want to know whether their investments in health system strengthening represent value for money relative to disease control programmes and how to optimise the design of such programmes.
  • Conventional evaluation methods ignore the complex dynamic nature of health systems and are insufficient to serve donor needs.
  • System dynamics and agent-based modelling methods can reflect the complexity of health systems and be used to estimate value for money for health systems investments in LMICs and predict health system response to any stimulus prior to its introduction, including the detection of potential adverse events.
  • There has been very limited application of system dynamics and agent-based modelling within the evaluation of health system strengthening initiatives in LMICs, and their future use by researchers is highly recommended.