Background
Health research systems (HRS) form a key pillar of the structure of healthcare systems (HCSs), guiding them to deliver better health policies and services [
1,
2]. Research performance in terms of functions and processes does not automatically contribute to better health action; the more useful issue is the process of knowledge generation in order to better understand health problems [
3]. Therefore, developing effective and efficient HRS performance is an important step towards addressing society’s needs [
4] and, consequently, understanding system performance is vital for strengthening it [
5]. This is considered a priority in the context of international efforts to correct the 10/90 gap and to address various health research (HR) gaps [
3,
6‐
8]. The starting point of HRS analysis is to have a clear picture of current HR, and the necessary development actions [
9]. This first requires a deep understanding of the system actors’ perceptions, be they research funders, producers or users, to investigate HRS pillars, particularly assessing their performance and political commitment to HR. Palestine and the region have seen important improvements in research productivity while overall research performance is poor, with critical deficits in stewardship, capacity, translation and problems attributed primarily to both financial and political constraints [
10‐
13].
It is difficult to assess the stewardship owing to the complexity of the HRS and the diversity of players and sectors [
14], with multiple roles in managing and evaluating the system [
15]. The journey from research production to evidence-based practice and health impacts is usually long, non-linear and multi-faceted [
16]. These stages need to be thoroughly understood in order to identify what HRS does and how it performs and works [
9,
17]. This study employs a system perspective as proposed by WHO and the Council on Health Research for Development (COHRED) [
5,
9,
14,
18,
19] with its various conceptual analysis approaches. This study adopts those approaches that include key aspects needed to carry out such a performance assessment. This approach serves to both observe the system performance and its processes as well as to offer a platform from which actions for system improvements can be identified [
9].
Based on perceptions analysis, this assessment comprises stakeholders’ satisfaction, a description of the actual status of HRS performance and political attention, and performance deficiencies and solutions identification during research financing, production or utilisation phases. Any system without systematic monitoring and evaluation is blind, and HRS performance is an essential element falling under the stewardship function [
5]. Making this system performance effective means employing evidenced-based practices, while efficiency engages correct practices with valuable benefits at low costs [
20]. In light of lacking standards or quantitative indicators to monitor and evaluate research and its societal benefits, this study fills an important knowledge gap because it focuses on performance and its deficiencies which are rarely addressed in Palestine and in the region because formal HRSs are lacking [
21]. As used by other authors, this descriptive study employs a qualitative ‘snapshot’ assessment and a complementary approach of HRS performance analysis [
5,
14,
18,
22,
23].
Any HRS has a wide range of stakeholders, who all have interests and influence on how research is defined, performed and used. Three relevant sectors have been purposively targeted in Palestine, namely government, academia, and local and international non-governmental organisations (NGOs). It is worth investigating the technical views of various actors in different sectors to understand the trends of their perceptions [
15]. Moreover, varied perspectives on topics, such as satisfaction with system performance or political support to HR, allow the system to be understood from multiple angles, where actors suggest innovative ideas and strategies for application and strengthening interventions [
24,
25].
This study is in line with the WHO strategic direction on research for health. It is necessary to fill the knowledge gap and demystify ambiguity on HRS performance and the political attention to HR in the face of literature scarcity and unrecognised status. This topic is not sufficiently addressed in the HRS analysis toolkit developed by WHO [
18]. Locally, studies showed that the state of scientific research in Palestine is unclear, with a lack of orientation [
26], and that HRSs in developing countries, including Palestine, are not systemically evaluated to high standards; hence, varying assessment methods to analyse HRS are important [
14,
27]. Globally, evidence has emphasised that this topic is a challenge [
5], and WHO also underlined inadequate system understanding and the fact that HR is not politically appreciated [
3]. Another rationale for this study is that understanding the overall satisfaction with performance and the status of state attention to HR is the main entryway to a functioning system, conceptually and operationally [
5], where awareness would be associated with practices. This understanding leads to a sustainable HRS by recognising trends in HRS and whether performance is improving or declining, and this may reveal whether the Palestinian political attention to a developmental vision of HRS is sufficient or negligent. A lack of understanding misleads the system, may create duplications and inefficiencies, and may also negatively affect the credibility of the produced research [
24,
28]. The current study is part of a national research project aiming to generate an overview of the satisfaction level of the Palestinian health policy-makers, academics and experts on overall HRS performance and the political attention towards HR. Four objectives guide this study, namely (1) to understand stakeholders’ satisfaction with the overall performance pattern; (2) to examine the state of political government support and attention towards HR; (3) to identify the relevant performance gaps echoed by health policy-makers, academics and NGOs experts; and (4) to provide important implications and potential insights towards Palestinian HRS strengthening with regards to performance and political support.
Discussion
In this study, we aimed first to explore the satisfaction of experts across three sectors involved in HR in Palestine on the overall HRS performance. Second, we investigated their perceptions about the state political interest and commitment to Palestinian HRS. Third, we identified the actual gaps behind system underperformance and lack of official governmental support. Generally, the overall HRS performance in Palestine is perceived to be considerably low. Therefore, the satisfaction pattern was relatively paradoxical; whereas the academics and NGO experts were comparatively satisfied, very few of their government counterparts were fully satisfied. Additionally, the majority of experts found HRS to be ineffective and inefficient.
We reached these findings through analysis of interviews and FGDs with stakeholders that often influence and lead this system. A well-functioning national research system requires a holistic understanding of the system’s conceptual components and performance [
4,
14]. Ensuring a well-performing HRS supported by an official state commitment is essential [
15], because governments and donors are increasingly interested in evaluating the benefits of their investments in HR [
5].
The strengthening of HRS is key to meeting national health and economic needs, particularly the performance component, to monitor and evaluate system operations. Performance frameworks may consist of indicators and models, agreed upon nationally and built in the HCS structure, for systematic measurements [
4]. Besides using those conceptual frameworks, developed by international bodies, to assess HRS performance by compiling certain measurements [
5,
14,
22,
27,
34], a combined analysis is an additional approach that could be useful in understanding the performance of HR from different aspects. Furthermore, using practical tools to measure HRS performance should be technically recognised by system stakeholders on the one hand, yet understanding their views is crucial on the other. For this, integrating both approaches might better support an accurate understanding from a system perspective; nevertheless, such an understanding perspective is lacking [
5]. This work represents only a modest development attempt by employing a descriptive perception analysis to realise the system processes and gaps to be strengthened.
Our study finds that research performance measurements in Palestine, whether quantitative or qualitative, are not established. COHRED found that few Middle Eastern countries have a system of monitoring and evaluation for its HRSs [
34]. Therefore, the study assumes that there is no HRS, as this concept is an emergent one and not fully conceptualised or appreciated [
21,
35,
36]. The lack of monitoring and evaluation for HRSs raises two concerns; first, it means that HR is non-institutionalised into HCS and, second, it indicates a lack of stewardship. A study supported our findings that continuous monitoring and evaluation is required to ensure efficient resource use based on agreed priorities and appropriately conducting research in an ethical manner. It also clarified that assessing HRS governance, which performs these tasks, will provide a broader picture of national HRS capacity and performance [
37].
The results of this study are supported by findings from several other studies [
17,
23,
38] identifying relevant factors that result in HRS underperformance. These factors can be considered as problematic gaps that lead to low HR performance in Palestine. A lack of awareness and an unappreciated culture on HR, as proven by a national study [
26], as well as the lack of incentive policies for researchers and decision-makers, were two of these factors. Moreover, an effective organising body to take over the duty of research evidence embeddedness into decision- and policy-making is absent, and therefore research translation is not significantly applied in Palestine and most Middle Eastern countries [
36]. In fact, there is no country in the Middle East reporting systematic efforts to feed research results into decision-making in the health sector [
35]. Yet, cultivating and improving an evidence-based culture and practice is crucial [
39]. Other major factors for system underperformance were a shortfall of resources and missing political will, which was seen as an obstacle throughout the Middle East region [
2]. Both attributed to the weakness of the crumbling Palestinian entity due to the Israeli occupation and internal political division. This causes an unconsolidated agenda, disagreed HR priorities and needs, and eventually the wasting of resources in this donor-dependent country.
Additional stated factors include that research activities are seasonal, namely that they are geared by the donor and solicited by the Palestinian researchers’ personal interests. Moreover, these activities are unguided developmentally and individual driven, while COHRED considered HRS as an approach for achieving sustainable development [
24,
28,
40]. It is reported that research addresses academic purposes rather than society needs, which are not used for health decisions. Other literature stressed that HR is one of the main driving forces for improving the performance of health systems and ultimately the health of populations, as well as crucially needed to attain and track the achievements of the United Nations Millennium Development Goals [
5].
Fractured, non-participatory coordination among stakeholders in knowledge production and data dissemination is also assumed to be a leading problem that results in underperformance and system frustration in achieving the desired goals [
10,
21,
41]. Lack of system performance means that evidence is not often utilised in decision-making, even in the Eastern Mediterranean Region countries [
42,
43]. In addition, the quality of research produced by many Palestinian institutions is not satisfactory [
44].
HR is obviously absent from the agenda and does not get attention at the official political level, yet political will and commitment is a necessary factor, as described by WHO in its strategy on research for health [
3]. Most of the experts highlighted a lack of strategic political concern, where research is not a priority and legitimately embraced. Additionally, there was an identical commonality from most of the experts on the neglected role of government and other major health organisations towards HRS. The Palestinian government, and the MOH in particular, did not distinctly indicate health or scientific research as inherent components in neither its national agenda 2017–2022 nor in its central budgets [
45,
46]. This means that the Palestinian official concern basically focuses on security, politics, crises management and service-sustained systems due to the exceptional political and security situation. Therefore, the government concern is intermittent and does not come in the context of a constant national perspective, which may also be reflected at the institutional level.
However, a variety of factors hinder the improvement of performance, the most prominent limitation expressed being unsatisfactory political interest and unsupportive leadership that has not yet adopted a clear vision and regulating body for HRS.
Our study strengths include (1) it being the first HRS descriptive research conducted in Palestine; (2) the sampling of a very diverse group of stakeholders across three sectors, including policy-makers, academia and representatives from local and international NGOs; (3) the use of IDIs and FGDs based on internationally developed frameworks; (4) the focus being primarily on the policy level of the HRS and system understanding; and (5) the fact that the study could be a significant basis for the national and international bodies in any upcoming strengthening endeavours such as MOH, WHO and COHRED. The study limitations included (1) a lack of sufficient and up-to-date reports and data on the HR components, as well as a lack of literature, particularly investigating the perceptions of system players; (2) research team movement was restricted in the field; and (3) the unavailability of high seniors due to time limitations, and therefore the lack of involvement of more leadership levels across sectors. Further, some IDIs and FGDs were shorter than expected and some questions were insufficiently answered due to a lack of knowledge, practices and time constraints.
Conclusion
HR in Palestine is progressing, despite the unprecedented conditions, instability and fragility. However, there remain substantial windows of opportunity for actions to make positive changes in the HR structure and performance. Nevertheless, without systematic assessment and mapping mechanisms, HRS performance will remain below the satisfactory level. Several factors behind system underperformance have been recognised; first, the weakness of the research culture within institutions, and the lack of political will and serious adoption and support. Secondly, research activity is individualistic, non-development oriented and non-invested in decision-making, with a fragility of coordination. Finally, the severe shortage of resources and, therefore, capacity.
Due to the serious insufficiency of literature in the local and regional levels regarding assessment of HRS performance, it is very important to intensify further efforts to assess the performance of HR in Palestine using internationally adopted analysis frameworks. On the other hand, it is also valuable to conduct national studies to realise the impact of HR on the HCS and society alike.
In general, HR is neither ineffective nor efficient; however, serious development actions should be taken in order to establish integrated and well-functioning system components. In this respect, study findings can help inform and steer future plans and activities for the Palestinian health decision-makers in contributing to the development of not only the research performance assessment, but also the other system components to be cohesively structured and successfully functioning. This study proposes various policy development insights related to system performance in particular and other system pillars combined.
These suggestions depend on a myriad of actions that need to be shared on a basic level with Palestinian HCS policy-makers and seniors. First and foremost is the availability of political decision and willingness from the three sectors’ leaderships with the support of international partners. Official political concern can be encouraged through political interaction, policy dialogs and advocacy campaigns. In doing so, shaping governance structure and building a national body for HR unifying all relevant stakeholders is essential. This body should formulate a national policy dedicated to HR; one of these policy components requires focusing on HR performance issues to be inherently promoted. This policy should focus on (1) actions to address the deficiency of research awareness and culture, as a philosophy and practice, among all health professionals through regular awareness and orientation actions; (2) a serious emphasis on tackling the lack of skills and capabilities by implementing systematic capacity-building and educational programmes targetting the decision- and policy-makers on the topic of HR assessments; and (3) reducing unsystematic and individualistic research efforts, HR needs to be institutionalised and functionally performed from a development perspective, as well unified in an interdisciplinary and well-coordinated manner. This should be based on established and agreed-upon performance guidelines, whether qualitative or quantitative, to be integrated institutionally and nationally. The guidelines or monitoring and evaluation measurements can be taken from developed international frameworks for HRS, concurrently seeking to establish a national observatory platform for HR, led by the MOH and academia, in order to assess the three phases of HR (financing, production and utilisation) and to track research trends in terms of quality, quantity, relevance and impacts.