Health policy and systems research: a change-generating field
Health policy and systems research (HPSR) is widely recognised as a critical element of the action needed to achieve the health-focused Millennium Development Goals, strengthen primary health care, and promote universal health coverage [
1]. Focussed on generating knowledge on how best to organize collective responses to promoting health and tackling disease over time, this research field studies international, national, subnational, and local health systems and their interlinkages, as well as policies made and implemented at all levels of the health system. In 2012, the successful 2nd Global Health Systems Research Symposium, and the formation of a Health Systems Research society, drew a large community of interested groups together not only to examine the available research knowledge but also to work towards developing and strengthening the practice and approach of the research conducted. Publication of the 2012 WHO HPSR strategy also sought to contribute to this latter goal by supporting the development of an identity for the field of work, with ‘
its own standards for evaluating evidence, assembling knowledge, and translating it into recommendations that decision makers in the health system can comprehend, trust, and implement’ [
2], p. 15. In 2014, this research and policy community will meet in South Africa to discuss ‘The Science and Practice of People-centred Health Systems’, the theme of this year’s Global Symposium on Health Systems Research.
There is consensus on some key features of HPSR [
3,
4]. Focus areas within it include the performance of health systems and their subcomponents (resources, organizations, and services), as well as consideration of how links among the subcomponents shape performance, what forces influence those links, and how to strengthen health system performance over time. HPSR is also recognized as a hybrid, or ‘trans-disciplinary’ field, drawing on different disciplinary traditions and methodological approaches, and with links back to the older field of health services research. Most critically, HPSR is applied research, undertaken with an orientation towards influencing policy and wider action to improve the performance of health systems, in the short or long term.
However, as those who work in this field come from different knowledge traditions, these differences continue to influence how they view health systems and how they approach knowledge generation and evaluation. In line with prior arguments [
5‐
7], we seek in this commentary to elaborate directions for the practice of HPSR founded on the particular understanding that i) health systems are social and political constructs that, as part of the fabric of any society, provide vital opportunities for tackling social injustice; ii) human agency, in interaction with broader societal structures, fundamentally shapes health systems; and iii) social science perspectives and approaches offer particular value to this area of trans-disciplinary research. As authors, we come from eclectic backgrounds in public health, health policy studies, health economics, international relations, development studies, and medicine, with experience of HPSR mostly from India and sub-Saharan Africa. From these various bases, we argue that the potential of HPSR to achieve health system change hinges on it becoming more people-centred in how it is conceived, conducted, and utilized.
System change begins and ends with people because people, operating in various roles, ultimately make up any system and fundamentally shape how it works. Acknowledging that health systems are constituted by people and operate in social, political, and economic contexts defined by people and groups with varying interests and values, opens up a panoply of opportunities to influence and change them. It also requires researchers to acknowledge and address questions around their own role and power as actors in the same system.
The following sections both unpack our foundational understanding and outline directions for the emergence of such a people-centric practice of HPSR. Using three brief case studies from our own work, we consider how health policy and systems are conceptualised (seeing), as well as the roles that researchers play within health policy and systems (being) and in the conduct of HPSR itself (doing). We end by outlining questions researchers might use to deepen these three dimensions of their practice. The audience we address are all people engaged in conducting HPSR, working in government, NGO, or university settings with full-time or part-time research roles, who seek to support change in health policies and systems so as to improve people’s lives and address social inequalities.
Conclusions
We have argued that the guiding principles of a people-centred and change-oriented practice of HPSR inherently entail understanding the human and people-defined attributes of health systems more closely (seeing), actively considering the relationship of the researcher to the research (being), and working with an understanding of research quality that embraces context and relevance (doing). We conclude by proposing a set of questions across these three dimensions that health policy and systems researchers may wish to consider in making their practice more people-centred, and hence more oriented toward real-world change:
Seeing: health systems with people at the core
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Does the research explicitly address dynamism and complexity, allowing for the social, political, and economic drivers of human behaviour?
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Have I situated the topic and findings in their immediate policy contexts, and in their broader social/political contexts?
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Does my research design advance understanding of the human attributes (choices, needs, preferences, interests, power, values, etc.) of the health system/policies in the setting of the research?
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Does my approach to the health system/health policy allow for power, equity, and justice?
Being: considering the researcher’s position
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Have I considered my intentions for undertaking the research, and my position vis-à-vis the research subject?
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Have I explicated my own position vis-à-vis my power, my influences, and my interests related to the research, and my value basis, as indicated by my philosophical position and the change I wish to see?
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Have I engaged with other researchers investigating this theme? What do I contribute to, and gain from being part of, the community of health policy and systems researchers?
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How do I, as a researcher, engage with other health policy and systems actors, on what terms and with what consequences for my research and for effecting change in health policy and systems?
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Do I have autonomy in developing my own research ideas and conducting my research?
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Does my research hold a transformative intention, beyond informing the choices of designated policymakers? Do I have a strategy for actualizing such transformative change?
Doing: relevant, high quality research
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Who is my research for? Who do I see as the primary users of my research findings?
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How has my research been influenced, directly or indirectly, by the experiences and perspectives of health system actors (including service users and communities)? Which health system actors? Have I engaged, directly or indirectly, with any of them in the process of defining my thematic focus and research questions, and while interpreting findings?
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Is my choice of research approach matched to the research question?
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Does my research design and analysis approach apply parameters of rigour and quality that are appropriate to the methodology used?
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(Especially if the subject/setting is previously poorly explored) Does my research design incorporate the exploration of non-formal publications and relevant social and political discourse pertaining to the setting(s) in which my research is likely to be utilized?
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Have I considered the consequences of the interpretation or application of my research findings in the settings in which they are likely to be used? Have I considered the intended and unintended effects on other social and policy agendas?
Acknowledgements
We are grateful for comments received from Helen Schneider, Irene Agyepong, Krishna Hort, and John Porter in developing this paper and thankful to Vrinda Mehra for her inputs. Asha George is a member of the Future Health Systems Consortium (
http://www.futurehealthsystems.org) and Lucy Gilson is a member of the Consortium for Resilient and Responsive Health Systems (RESYST) (
http://resyst.lshtm.ac.uk). This document is an output partially funded by the UK Aid from the UK Department for International Development (DFID) for the benefit of low and middle income countries. However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KS, AG, and LG conceived of the article. KS wrote the first draft. KS, AG, and LG jointly revised the manuscript critically for important intellectual content and gave final approval of the version to be published.