Keywords
Health policy, health systems, systems thinking, policy analysis, implementation research, research uptake, evidence-informed decision making, capacity building, MCH and NCDs, reciprocity
Description of the research
Global inequalities in health must be tackled. Health policies and systems are widely recognized to be vital elements of the social fabric of every society. They are not only critical for the treatment and prevention of ill-health but are central strategies for addressing health inequity and wider social injustice (Commission on the Social Determinants of Health, 2008). Health policies and systems also provide the platform from which to launch dedicated efforts to address major diseases and health conditions that burden low-income populations, such as HIV/AIDS, tuberculosis and malaria and increasingly non-communicable diseases (NCDs). Given these roles, the early 2000s saw a significant expansion of international and national interest in health systems as one component of sustainable development in low and middle income countries (LMICs). Health system strengthening is now seen to be essential for the achievement of the Millennium Development Goals (Travis et al., 2004) and the post-2015 development agenda. However, the knowledge base to support health system strengthening and policy change in LMICs is surprisingly weak (World Health Organization, 2009). The body of available work is quite limited compared to other areas of health research.
A central feature is the “know-do” gap, and efforts to bridge it, that is the difference between what we know and what we do, what actually reaches the persons in need. An example is that we have sufficient knowledge to prevent/avoid 2/3 of the annual 6.5 million under five deaths, if available and even
affordable knowledge was implemented at scale (Jones, 2003). This know-do gap exists in all parts of the world, and often has a large (in)equity component to itself within a country setting.. The area of
implementation research strives to generate generalizable knowledge on how to narrow and close the
“know-do” gap, ie to get health systems- both “supply” and “demand” side, to function better. This type of research is relevant in all settings of the world.
Health policy and systems research (HPSR) is defined as a field that seeks to understand and improve how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes. By nature, it is
multidisciplinary, a blend of economics, sociology, anthropology, political science, public health and epidemiology that together draw a comprehensive picture of how health systems respond and adapt to health policies, and how health policies can shape − and be shaped by − health systems and the broader determinants of health (Alliance for Health Policy and Systems Research, 2011.). It includes concern for global as well as national and sub-national issues, as global forces and agencies have important influences;
encompasses research on, or of, policy, which means that it is concerned with how policies are developed and implemented, and the influence that policy actors have over policy outcomes – it addresses the politics of health systems and health system strengthening; promotes work that explicitly seeks to influence policy, that is, research for policy. In addition also included is, the implementation of disease control programs (i e HIV, TB, NCDs, SRH), governance, accountability and participation (with a focus on district level), human resources, and financing. HPSR strives to derive its research questions from policy and practice, and formulate them in consultation with policy makers and practitioners, rather than first doing the research and then attempt to get it into policy (Parkhurst). Lately the term ‘Implementation research’ is often used. Some organizations like The Global Fund call this operational research, the strengthening of which that recently was called for by the EU (Quaglio et al. 2014).
One of the main strengths of HPSR is its multidisciplinary approach, recognizing the importance of addressing the complexity of health policy and systems challenges. Hence, HPSR is a field that takes into account a breadth of analytical perspectives and methods (Peters et al. 2013). Health systems encompass not only various elements but also the interactions and interrelationships between those elements and
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between the various individuals within the system (Frenk, 1994). These relationships both support service delivery towards universal health coverage and are also central to the wider social value generated by the health system (Gilson, 2003). The interconnections among the health system building blocks (governance;
financing; human resources; drugs and other technologies; information; service delivery) are essential.
(ANNEX)
There are a number of national examples that serve to demonstrate how HPSR has influenced national policies, strengthened strategies used by priority disease control programme, and changed the terms of international debates. The Thai Universal Health Coverage Scheme is a good example where research played a critical role in: a) getting the issue of financial protection and coverage onto the policy agenda, b) designing the new universal coverage scheme and, c) monitoring and evaluating the implementation of the scheme. (Alliance for Health Policy and Systems Research, 2004). HPSR played a similar role in the case of the major reform of the health system in Mexico, which aimed to provide comprehensive financial risk protection to the poor, the centre-piece of which was the social insurance programme Seguro Popular. The scheme has provided significant financial risk protection with a reported 54% reduction in catastrophic expenditures at the national level. (Galaragga et al, 2011).
Strengths and weaknesses
HPSR in the area of Sexual and Reproductive Health and Rights (SRHR) and its sub-areas has had a strong Swedish profile. Swedish institutions have continued HPSR and capacity building in e.g.
Uganda and Vietnam where also demographic surveillance sites (important infra-structure) have been established. The UNICEF/WHO child health policy integrated community case management of febrile children (iCCM) is an example of how Swedish collaborative research influenced national and global policies (Young et al. 2012). The Joint Learning Initiative on Human Resources for Health drew attention to the immense and long-neglected problem of the health workforce focusing national and international attention to this issue (Chen et al, 2004). Also here Swedish researchers have been active experimenting with intervention studies in public and private service in LMICs health systems for improved coverage of good quality services.
HSPR is established to varying degrees at Swedish universities sometimes at different departments.
Internationally Swedish researchers have played a key role in the establishment of the Alliance for Health Policy and Systems Research WHO and at present chairs their scientific advisory committee. The Alliance is an international partnership located within WHO, Geneva and a global leader in this field (ANNEX).
Sweden has world leading researchers who produce high quality HPSR specifically in the area of maternal
& child health, infectious disease control and medicine policy including attempts to contain antibiotic resistance through influencing use of antibiotics through health system interventions. However, the quantity of staff in Sweden working on these topics is low, which makes it difficult to compete with other more established groups outside Sweden. Capacity building with Swedish researchers collaborating with colleagues at LMICs institutions in research training programs using the sandwich model is however a notable strength. A further strength is the ”historical” relatively large presence of Swedish human capital in many LICs, which has created large networks and good will and a reasonable Swedish human capital in the area of HPSR. A challenge is to make use of the many trained PhDs at present often having difficulties in pursuing post doc and independent research careers. Sweden also has strong capacity in research utilizing and developing health information systems, which also should be further developed. Here research infrastructure investments in LMICs are important.
Weaknesses and Challenges
HPSR is sometimes described as a “set of overlapping areas with fuzzy boundaries” (Gilson, 2012).
Thus, it is sometimes criticized as being unclear in its scope and nature, lacking rigour in the methods it employs and presenting difficulties in generalizing conclusions from one country context to another (Mills, 2012). Review of health policy analysis work, in particular, also shows that research in this area is often weakly contextualized and quite descriptive, and offers relatively limited insights into its
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core questions of how and why policies are developed and implemented effectively over time (Gilson
& Raphaely, 2008).
The size (both in terms of budget and project length) of the Swedish research funding for HPSR is usually not sufficient to allow for innovation and large scale testing of innovative approaches to health system strengthening. Instead research projects tend to focus more on formative research to establish needs, as well as evaluations of existing programmes. Short duration grants makes it difficult to set up long term research collaborations and projects, and to establish long term effects of interventions. A
fundamental weakness is the new funding situation with the lack of a structured approach to build the next generation of Swedish researchers, where previous support mechanisms from e.g. Sida/SAREC have disappeared (Doctorate, Postdoc) and not been replaced by any others. There is also a need for post doc programmes supporting the many LMICs PhD’s trained by Swedish universities but with problems with taking the next step in their careers.
Another weakness is the not yet developed linkages and reciprocal learning opportunities for HPSR between countries and settings at different economic levels, including south-north learning. Also that the Swedish support to the health sector in LICs is not linked to capacity development, nor to private sector initiatives in the same countries. This is a missed opportunity. A weakness is the recent successive withdrawal of presence of Swedish technical expertis in LICs, which only partially has been replaced by shifting to capacity building by means of collaboration with Higher Teaching Institutions (HTI) in Sweden.
A weakness in funding opportunities is also the focus on national boundaries and national averages when judging the need for collaborative capacity building. I.e. only poor populations in poor countries seem to be of interest for collaborative capacity building efforts, which will miss the majority of poor individuals in the world who are to be found as poor populations in large countries which on the average not are so poor anymore.
Trends, tendencies and prognosis for the future
As the agenda for disease specific programmes, such as malaria, TB and HIV/AIDS moves from investments in measurement of immediate health outcomes, to questions around long term
effectiveness and institutionalisation, the need for HPSR is becoming more prominent. This, along with the post-2015 agenda with less focus on disease specific targets, should raise the profile and funding opportunities for HPSR. The EU is one of the world’s most prolific funders of both research and development cooperation, but only very few actions relate specifically to HPSR including operational/implementation research in LMICs (Quaglio et al 2014). There is ample opportunity to use the available financial and political power to better meet these ends. A key challenge as mentioned above faced by the global health community is how to take proven interventions and implement them in the real world. Affordable, life-saving interventions exist to confront many of the health challenges we face, but there is little understanding of how best to deliver those interventions across the full range of existing health systems and in the wide diversity of possible settings. Our failure to effectively implement interventions carries a price. Each year more than 287,000 women die from complications related to pregnancy and child birth, for example, while approximately 7.6 million children, including 3.1 million new-borns, die from diseases that are preventable or treatable with existing interventions (Peters et al, 2013). The epidemiological transition with the rapid increase in NCDs challenges already frail health systems. Furthermore if not containing antibiotic resistance modern medicine and systems will no longer work.
Embedded research:The field of HPSR encompasses newer or relatively little-used methods and study approaches that could be further developed. Embedded research is one such approach, whereby research is truly embedded in the programme and policy cycles, and programme managers and people on the front line of health care play a central part in the identification, design and conduct of the research undertaken.
WHO’s strategy on HPSR entitled “Changing Mindsets” (2012) advocates for greater embedding of research into decision-making and calls for more demand-driven research as an integral part of programme planning and execution. Knowledge generation and uptake into decision-making are inextricably
connected. Research embedded in the real world fosters integration of scientific inquiry into the
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implementation problem-solving process, along with programmatic improvements in an iterative and continuous manner. Embedded research will also support the scale-up of interventions and their integration into health systems at the national level. Research focused on responsive health systems is of intrinsic value to partners outside academia, and should aim to strengthen health systems in LMIC.
Systems Thinking: Despite strong global consensus on the need to strengthen health systems, there is no established framework for doing so in LMICs, and no formula to apply, or package of interventions to implement. Every intervention, from the simplest to the most complex, has an effect on the overall system, and the overall system has an effect on every intervention. Systems Thinking works to reveal the
underlying characteristics and relationships of systems de (de Savigny and Adam, 2009). Systems thinking can provide a way forward for operating more successfully and effectively in complex, real-world settings that are non-linear, unpredictable and resistant to change, with seemingly obvious solutions sometimes worsening a problem. Systems’ thinking has huge and untapped potential, first in deciphering the complexity of an entire health system, and then in applying this understanding to design and evaluate interventions that improve health and health equity. Development of methodological approaches for systems thinking is an opportunity. The discipline is in some aspects relatively new. While systems thinking in other fields/disciplines/topics have a long tradition, this is not the case within health policy systems research. It is important that we are part of the development of methodological approaches, such as realist evaluations and systems modeling.
Governance, accountability and participation are key areas in HPSR. These are broad issues and focusing on different levels (global, national, district) and programmes/ interventions (being part of implementation research) related to different functions of the system. Such research aims to understand gaps in current practices and also to strengthen processes. Antibiotic resistance has recently been presented by WHO as one of three main challenges to global health. To contain antibiotic resistance multi-level governance is needed. (Laxminarayan et al. 2013). Leadership has given its importance for health systems been surprisingly little studied. However, the next flagship report from the Alliance HPSR will have that as a theme for 2015. More is needed!
Emerging research areas include eHealth/mHealth, and the role it can play in strengthening the effective delivery and efficiency of health care services. While this field is in an early stage, it’s likely to grow rapidly in the next decade, as mobile phone usage and network coverage is increasing exponentially each year. While mHealth solutions traditionally have stemmed from technical university research groups who have developed software solutions which have had limited relevance to the health practitioners, for which the solutions were intended, the trend is now changing towards more collaboration between health professions, medical and technical research institutions, and development of solutions that specifically address identified problems. The number of collaborations that have been established between e.g Karolinska Institutet and The Royal School of Technology show examples of such collaboration. NCDs and the health system implications of the epidemic of type 2 diabetes calls for social innovations not least in resource constrained systems developing “smart systems”. Task shifting lessons learned from MCH research is an opportunity.