The Palestinian health research system: who orchestrates the system, how and based on what? A qualitative assessment

Stewardship and governance are indispensable pillars of health research systems (HRSs), representing two sides of a single coin in the building and development of HRSs. Given growing international concern, this study addresses the aspect of stewardship, wherein functions should be vision driven, well operated, and priority based. The work presented herein forms part of two relevant studies the first of which dealt with the overall understanding of the HRS concepts (AlKhaldi et al., 2018, in press). Herein, the aspect of HRS performance will be analysed. WHO emphasises the importance of research to achieve universal health coverage [1] and focuses on the performance of HRS analysis exercises, including stewardship functions, encompassing governance, policies and prioritisation, to be embedded into HRS [2, 3]. Since health research (HR) often fails to be prioritised, is politically undervalued and poorly organised, WHO has called for a cohesive management based on effective policy and a priority for HR to build national HRSs [4].

Certainly, a successful HRS essentially builds on stewardship, which is a contemporary concept and a model of governance [5‐7]. Stewardship is characterised by (1) a regulation and coordination structure with a normative dimension; (2) adopting a clear strategic HR policy; and (3) dynamic priority-setting derived from needs [8]. A strong political will is crucial for the development of a HRS and to make important and sometimes difficult decisions about health improvements [9]. A healthcare system (HCS) is defined as “The organizations, people, and actions whose primary intent is to promote, restore, and maintain health…” [10], indicating that governance is one of HCS’s building blocks in the framework of systems thinking. Governance falls under stewardship, which, in turn, is defined as the “responsible management of the well-being of the population” [11]. These functions are assumed to be the tasks of policy-makers with the presence of a well-functioning system to generate, adapt and apply HR results to address challenges [12]. The aim of HRS analysis is first to understand its concepts and performance (AlKhaldi et al., 2018, in press) and subsequently its functions and capacity. This will ensure that, based on a strategic vision, the system is well governed and resourced. Governance sub-functions include system vision, structure, policy formulation, priority-setting, monitoring and evaluation, advocacy, and the setting of norms, standards and ethical frameworks [4, 6].

Although it is rarely conducted, conceptualising the role of HCS governance is a valuable necessity [11]. Being poor should not disqualify a country from such conceptualisation, because effective research management gives such countries much stronger responsibility for the essential priorities. HR is not only one of these priorities but also a fundamental pillar for achieving the Sustainable Development Goals [13]. Evidently, political support, governance and resources are essential to enhance system performance [14] as hinted by AlKhaldi et al. (2018, in press). Good practice in research systems is required to aid effectiveness, and understanding the system context and governance capacity is essential for system strengthening [15].

In many developing countries, bad governance, poorly functioning policy and a lack of prioritisation still pose obstacles and remain the weakest pillar of HRSs [7, 16‐18]. HRS functions are often not recognised where many of them operate almost in an ‘ad hoc’ way and isolated from other research endeavors [19]. Building HR capacity by understanding these practicalities is imperative to improve HR ethics and quality [20]. Therefore, governance is essential to promote a good HR that complies with ethical guidelines and is relevant to the needs of the society [4].

Donor support for countries to build proper research institutions is often inadequate [5]. This weakness may be at its most extreme in the Middle Eastern Region (MER), where formal HRS and functions are considerably fragmented and uncoordinated. As its concepts are often not understood (AlKhaldi et al., 2018, in press), basic building blocks for HRS, including stewardship, are lacking, alongside a deficit in political pledge [21, 22]. Policies and prioritisation are inadequate due to stakeholder disengagement, data unavailability and capacity constraints [23]. Published HR in the region does not align with stated priorities, and governance represents the main gap in health policy and systems research [24].

This study meets the international calls and regional demands for analysing HRSs, with its results expected to have a positive impact on health and other sectors. Assessments in fragile settings such as Palestine are needed to understand options for strengthening of the HRS [25], which is of a particular national strategic need in Palestine given that it is in the process of being built. Further, there is an urgent need to build a system able to economise resources and improve health. Much like other MER countries, Palestine is facing a real crisis in governance and leadership, mainly due to the Israeli occupation and political instability [26‐28]. There are other gaps, such as insufficient resources and strategic planning, inequity and poor quality of care, fragmented information, and other interconnected development challenges [29]. To realistically address these gaps, a responsive, effective, resilient and flexible HRS is required.

Given the shortage of HRS stewardship literature, this study seeks to bridge the knowledge gap by analyising this vital component to generate visions to strengthen it. As a logical progressive step, the study is the third in a larger investigation that aims to examine the Palestinian HRS in order to achieve a comprehensive and system understanding. The study intends to investigate the landscape of stewardship functions and recognise the relevant gaps by exploring the status of HRS governance, policy and priority-setting. This study examines the perceptions of relevant health experts to realise the following objectives:

The study’s approach applied the methods and setting of the other studies in the series (AlKhaldi et al., 2018, in press). System analysis frameworks were used, mainly the framework according to Pang et al. [30], as illustrated in Fig. 1, together with other approaches such as system thinking and comprehensive HRS assessment [2, 6, 10, 16, 30]. These approaches help to provide the groundwork for system improvement and contribute to a better understanding of the subject from different perspectives [31]. The participating institutions’ profile across, government, academia, and the local and international non-governmental organisations (NGOs), inclusion and exclusion selection criteria as well as the study tools were similar to the study of AlKhaldi et al. (2018, in press). The study setting was in Palestine, West Bank (WB) and Gaza Strip (GS), and ran from January until July 2016. Two qualitative methods, namely in-depth interviews (IDIs) and focus group discussions (FGDs), were used to inductively assess the perceptions on the stewardship functions based on different system analysis frameworks [2, 4, 16, 31, 32].

Diverse participants have been purposefully selected equally from both sites in WB and GS based on advance knowledge and experts’ consultations. In order to attain adequate information, participation and representation, criterion sampling, critical case, snowball and homogeneous sampling were performed [33]. A total of 52 IDIs, lasting on average 45 minutes and 6 sectorial FGDs were conducted with 52 participants for 1 hour and a half on average. Data collection was performed by a research-trained team and supervised by the principal investigator. Data were audio-recorded in the native language Arabic, translated into English and transcribed into MS word sheets at the same time, precisely revised, checked and cleaned for accuracy. Thematic and content approaches were applied using MAXQDA 12 (VERBI GmbH, Berlin), a software package for qualitative data management and analysis. All these procedures, along with data revision and coding for IDIs and FGDs, were performed by the principal investigator.

The overall findings indicated that stewardship within the Palestinian context is generally disappointing, not only in the HRS but also in the whole Palestinian HCS [26, 28], as in many developing countries [29]. The study found that a national governance structure for HRS is not clearly framed and defined yet. Different studies affirmed the absence of a formal NHRS [22, 34, 35]. Moreover, the functions of HRS governance and relationships among stakeholders are not well articulated nor well performed. In return, some HR institutions demonstrate good practice in terms of the established governance structure. Other consistent findings revealed that only four out of 10 countries had national HRS governance structures, whereas the overall research performance was poor with a critical deficit in stewardship function [17, 21].

As shown, the HRS architecture in Palestine is not clear-cut and to a large extent fragmented. In fact, it even appears to be uncertain regarding the functional and organisational flow of tasks and relationships. As HRS is complex [34], several national bodies were identified to lead HRS in Palestine both bilaterally or unilaterally, whereas the performance of these bodies leadership are unsatisfactory. In the current HRS map, the MOH, alongside with the three bodies PNIPH, PCHR, and SRC, seem to be those currently leading HRS, but not in a harmonised and synergic manner. The suitability of PNIPH to lead HRS remains controversial, since it is a project-based initiative formed via an agreement between the government, WHO and a Norwegian donor, and geographically not well represented [36]. In contrast to the known international standards, Palestinian universities and some NGOs and national agencies are HR producers, while the government is supposed to be only an HR user, as two studies revealed [37, 38]. HRS capacity in Palestine, while still weak, is present mainly in academia and NGO sectors [37, 39]. Importantly, this study found a wide discrepancy of perceptions concerning the functions and capacity of these institutions to act as a governance body. Because HRS governance is a collective and conjoint responsibility and cannot fall under one leadership, HRS entities require substantial reshaping and a harmonisation of their efforts to be comprehensively placed into a unified national perspective [6, 40]. This could be ensured by a collaborative strategic governance framework as well as very clear, well-negotiated definitions and descriptions of the roles of each actor [4, 41].

Two dimensions of governance challenges impede the establishment of a coherent HRS, namely (1) national and (2) structural and technical challenges. Nationally, disagreement on HRS visions dispersed the efforts and created parallel bodies with autonomous performance and significant inefficiency in using available resources. Furthermore, a lack of sovereignty over national resources and political instability caused by the Israeli occupation and intra-Palestinian division remain a key national challenge. The key features of the occupation affecting not only HRS, but also all governance sectors, are the closure of the international crossings and geographical segregation, inclduing blockage of the GS or checkpoints in the WB, which constrain the freedom of movement of patients, delegations and researchers, as well as the entry of goods [42‐44]. Other effects are the excessive use of force, settlement expansion, illegal exploitation of natural resources, destruction of institutions’ and private property, and violation of international humanitarian and human rights laws affecting the social and economic conditions of the people [26, 45]. The intra-Palestinian division has affected the unanimity of Palestinian decisions and the institutional structures, leading to a severe decline in services and reduced wages of public servants due to tensions between the authorities in the WB and GS [46]. Recently, a reconciliation agreement was signed between the Palestinian parties [47], and this political shift may resuscitate the development of all sectors, and in articular the HCS and HRS.

The overwhelming technical and structural challenges facing the HRS are that concepts and practice are not fully entrenched in the health sector, as previously evidenced [48], a lack of leadership, accountability, monitoring and evaluation, regulated policy and C&C. This provides two indications:

Most of these findings are consistent with previous studies [7, 17, 21, 22, 32, 35, 37, 38], albeit revealing different gaps, most notably the lack of a conducive research environment and poor overall research performance, which is due to critical deficits in system stewardship, governance and infrastructure, lack of strategies, and political transitions. It is important to address these gaps while working on HRS strengthening and developing strategies or allocating resources [49]. It is expected that donors should work towards a unified HR agenda, since internal challenges and the lack of a unified vision concerning HRS repeatedly cause diverse and negative influence of donors on HRS [13], preventing the system from gearing its priorities appropriately [50]. This paper argues that the abovementioned gaps impede any serious actions towards restructuring HRS governance to reflect the national priorities.

Based on that, many studies coincide with this study’s recommendations of how to address these gaps [17, 21, 22, 24, 35, 37, 39]. The emphasis on the importance of political commitment towards the creation of a unified and clearly structured governance body embracing a legislative and organisational framework under an advisory board is essential. It is suggested that such a body should hold three assignments. Initially, to embed HRS values and the concept of stewardship into HCS and to develop an effective NHR strategy that includes instrumental policies. Subsequently, to establish a regular and needs-driven ENHRPs mechanism that involves all stakeholders. Finally, to promote the consolidated C&C and divide the roles of actors, as well as to exploit the existing efforts and opportunities.

This study noted that C&C for HRS is currently at a low level of performance. Its findings of a considerably fragmented C&C concur with previous studies [21, 22, 37]. Experts described C&C as being fragile, unsatisfactory and vague, with currently limited relationships and performance based on personal interests. Strikingly, one study refuted these findings, revealing that the international collaboration in research is evidently growing in Palestine [39]. Locally, it is recognised that C&C is a real challenge not only in HRS but also in HCS [26]. As in the governance part, the current poor C&C status of HRS is an inevitable reflection of the absence of a policy framework regulating the roles and responsibilities. Likewise, the lack of partnerships and teamwork is a key organisational gap. Another technical gap that contributed to poor C&C is the influence of donor agendas on HR [50]. All this leads to HRS work duplication and inconsistency of agendas. Additionally, there is the scarcity of resources and a disassociation between the decision-making and research levels [51]. These gaps create difficulties in data flow and knowledge sharing among HRS stakeholders [52]. Again, the political obstacles, whether induced by the Israeli occupation or the intra-Palestinian division, remain the main challenges for HRS development [39, 53] and clearly caused a structural and functional breakdown in the national institutions and relations. Thus, ending the occupation can unleash the Palestinian HCS, particularly HRS, and restore its full potential and capacity [44]. Additionally, unifying these institutions under a clear reference authority [54] is the nucleus for adopting the C&C model of COHRED, which calls for establishing well-synergised mechanisms for better HRS [55]. Regarding ERC in Palestine, there is a common perspective that ERC is weak with unpersuasive performance. Palestine is no real exception here, as different MER countries have insufficient ethical review and assessment capacity [56]. Nationally, so far, ERC has not been given much attention, although many Arab countries have recently started doing so [57, 58]. The Helsinki committee which is deemed as the only ERC national board is established in 1988. It constitutes various experts and academics mandated to assess the ethical aspects of HR. This committee is affiliated to the PHRC, while its political and legal ties with the MOH still need to be legally institutionalised. As ERC is structurally lacking, it is striking that the geographical work scope of this non-institutionalised committee is limited to review research in the GS, while this committee seldom scrutinises HR submitted from the WB. There is an urgent necessity to advance its professional performance and to make it more geographically representative.

Other flaws of the ethics committee are the unavailability of an ethical and legal national framework due to governance deformities and, consequently, a lack of guidelines and standards under the umbrella of the existing research ethics international guidelines [59] at the national level. A comparative study reported many differences to international guidelines in ethical practices in the MER [60]. However, certain institutions have institutional ERC or Institutional Review Boards or particular ERC procedures, notably in academia and some local and international NGOs. This study, along with other relevant studies, emphasises the importance of improving the efficiency of ERC [57, 58, 61] by founding a unified HRS. This would include an accountable and appropriate national REC board; one of its components is a regulatory, technical, scientific and legal framework aligned with international guidelines. Furthermore, efforts regarding the institutional ERC and capacities of professionals and researchers need to be enhanced. This can be realised through political decisions and guidance as well as the enactment of national legislation. Interestingly, ERC was not essentially addressed in the articles of the Palestinian Public Health Act or even in the MOH and PNIPH strategies; only regulations for the health professions, medications oversight, and healthcare improvement have been tackled [62, 63].

For NHRP, the findings show that a policy devoted to HR in Palestine virtually does not exist. In fact, only two out of ten countries in the region have dedicated NHRPs [22, 51]. There is a belief that absence of NHRP is a hindering factor for strengthening the HRS, together with the governance pitfall. On the other hand, as many experts affirmed, there are institutional HR policies organising research work. The Palestinian National Health Strategy for the years 2017–2022 [62] stated HR as peripheral, meaning that HR is not inherently a core component of this strategy. The reasons behind the absence of this policy are poor insight into the necessity of creating a strategic HRS vision as a basic component of the Palestinian HCS, low awareness of a HRS culture, and deficit of resources [21, 22, 24, 38, 51], while other less important sectors have the biggest share of the state’s public budgets. Furthermore, HR is not on the government’s agenda. Concerning the C&C, inappropriate collaboration and unhelpful competition as well as work duplication hinder efforts to build a unified NHRP. Likewise, misconducting ENHRPs makes the HR activities ill-directed and also restricts any strategic move to give precedence to designing an HRS regulatory framework. Finally, as delineated earlier in HRS governance, is the impact of politics, primarily the disintegration of the political and social system, on top of the donors’ imposition of their agendas at the expense of the national needs. In fact, it is of paramount importance to create an NHRP framework, which is a keystone of an effective NHRS [6]. As many experts revealed, challenges related to NHRP can be tackled through unwavering political and sustained financial support under the inclusive regulatory body and policy framework supervising the implementation and evaluation of this policy. This policy comprises a set of mechanisms and guidelines taking into consideration all HRS components [6, 19, 64]. Concurrently, the culture of HRS needs to be enhanced, and the existing strategies and bodies need to be re-employed to build this policy synergistically.

As far as ENHRPs are concerned, it is noticed that the exercise of HR priority-setting in Palestine is growing. This does not necessarily provide the agreed national HR priorities that Palestine lacks [51]. Some studies emphasised that there have been no previous priority-setting exercises in health policy and systems research in MER [65], with only three countries in the region having set national HR priorities [22]. Three important domestic exercises for HR priority-setting have been reported, in addition to other bilateral or multilateral institutional HR priority workshops. The first exercise was initiated by the MOHE with the PHRC in 2014 and resulted in the production of research priority manuals for all disciplines, including health. However, this exercise was limited to Gaza during the period of intra-Palestinian division; therefore, this exercise cannot be scaled-up unless it has national agreement and involvement, political adoption and a follow-up. The second was carried out in the WB, initiated by WHO via bilateral cooperation with the PNIPH. This study constitutes the third attempt, building on the previous two exercises and offering a common ground with them. Certainly, this study views these attempts as an essential step leading to further progress, although these attempts largely do not reflect the societal needs in the area of HRS.

Additionally, there are various gaps concerning prioritisation, mostly the lack of political power and its influence by social, political and environmental factors to meet specific interests, be they the government’s, the donors’ or personal [4]. Furthermore, a deficiency in knowledge and expertise is observed where these exercises are not practiced systematically in an integrated national perspective. Further, the issue of stakeholders’ compliance to the outputs of these prioritisation exercises, along with the scarcity of resources are problematic. The findings of inappropriateness in the application of stated ENHRPs and also improper dissemination agree with relevant research and are therefore considered as areas with a critical gap. For the proper ENHRPs setting, it is necessary to build on what has been achieved locally and to institutionalise exercises in a dynamic, inclusive and systematic approach [23]. Actions are needed, including obtaining political commitment, a regulatory body and national consensus on proper approaches of priority-setting [66]. These three prerequisite actions could ensure agreed ENHRPs and a good steering of the donors’ agendas. These actions could also form a strengthening pathway to develop all other HRS components. Developing them would mean providing the required resources and carrying out training to expand the knowledge and expertise of experts in ENHRP setting, encouraging the strategic dialogue and linkage between decision-makers and researchers, and adopting viable monitoring and updated mechanisms in prioritisation, guaranteeing that ENHRPs are disseminated appropriately among all parties [23, 67]. Additionally, the previous and current exercises and the existence of PNIPH and LPHA need to be developed and well exploited.

Through a comparison of the three HR priority-setting exercises implemented in Palestine, three thematic areas were identified according to frequency and ranking. The most important priorities to be addressed by HRS are the areas of health governance, financing and policy. These findings closely intersect with a local study which found that these areas are the main concern of ENHRPs [68]. Other regional research agrees that financing and workforce are priorities [65]. Further common ENHRPs are non-communicable and communicable diseases, nutritional conditions, disability and environmental issues; these areas form the major burden and causes of death and are the most affected by the escalation of instability and crises in the region [69‐71]. The priorities of this study intersected those in Yemen and Oman, and agreed with priorities covered by LPHA in its research series [22, 72]. The area of medical diagnosis and genetic and molecular diseases was less frequently mentioned, meaning that it received low research priority. Nevertheless, two studies revealed a local discrepancy in priorities, indicating that the area of medical diagnosis and genetic-molecular disease had a high HR priority, while it was graded the seventh rank of the total HR publications in Palestine; this research area has been on top of Lebanon's HR priorities [22, 39].

Our study has four main strengths. (1) It is the first participatory study examining three important HRS components in Palestine, while this subject is inadequately investigated in the MER. (2) The participants and stakeholders were very diverse, including policy-makers, academia, experts, professionals, the private sector, and local and international NGOs. (3) Using mixed qualitative instruments was helpful for getting high trustworthiness of perceptions. (4) The purpose of the study was to generate insights to boost the three components of HRS, namely governance, policy and priority, and forms part of a larger investigation project that will lead to a comprehensive strengthening of the perspectives for the Palestinian HRS.

The study limitations were as follows: (1) A great paucity of relevant literature, reports and data on the subject, whether local or regional, thus not allowing meaningful comparative synthetic analyses and discussions, and making it impossible to use quantitative tools in analysing the HRS in Palestine. (2) Some time-constraints in questioning more participants and targeting of additional relevant institutions to determine all opinions, suggestions and views. (3) As other studies revealed (AlKhaldi et al., 2018, in press), field obstacles to the freedom of movement of the research team as a result of the geographical segregation and closure of security checkpoints. (4) The signing of the reconciliation agreement between the Palestinian political factions in October this year is likely to generate a positive political transformation that may affect some of the study findings, especially those related to the impact of internal political factors on the HRS and the HCS in Palestine.

Attention to HRS functions is mounting, and there is a consensus that strengthening this system is imperative, especially in developing countries like Palestine. A well-functioning HRS is an inevitable reflection on an appropriate visionary management and policy. Therefore, the study provides a valuable snapshot of the three most important stewardship functions, attempting to understand them, to determine the obstacles and to generate solutions for a national well-performing HRS. The study primarily emphasises the importance of understanding the experts’ conceptual pattern of the three important functions, which is a basic demand in system analysis towards strengthening HRS. The importance of the study lies in its three dimensions. (1) Locally, it is the prominent research addressing this subject. (2) It contributes to filling a knowledge gap in the region. (3) It corresponds to international calls, notably by WHO and COHRED, encouraging countries to analyse their HRSs in order to boost national development.

The study found that the three stewardship functions are still not performing as they should. A structural HRS governance framework is missing; most of the HR activities are scattered and uncoordinated. Despite limited demonstrated good practices, the process of ERC is still weak due to the lack of an agreed national committee, lack of procedural quality, and non-compliance with ethics guidelines. Indeed, a functioning HRS cannot exist without a strategic national operational policy and regulatory mechanisms, which are lacking in Palestine. However, the exercises of prioritisation appear to be evolving despite the deficiencies, lack of consensus and low levels of knowledge and experience. It is noticed that the lack of political pledge, resources and capacity support, the absence of a national unified body, and the effects of the political conditions are the key factors impeding the strengthening of the HRS stewardship functions in Palestine.

In order to cover this subject fully, further empirical research is needed to explore the more evident institutional HR operations related to the three functions, as well as to examine the applicability of the HRS functions and its compliance with international approaches, models and guidelines.

There is an imperative need to initiate serious efforts to develop a national HRS in Palestine through focusing on strengthening the three functions. Initially, the attention of decision-makers in the various sectors should be drawn by informing them of these facts and obtaining political commitment and more mobilisation through a strategic policy dialogue. This dialogue shall involve all stakeholders to establish national consensus and agreed actions on three tracks towards enabling the three functions of the system. First, the importance of founding a unified national HRS body – the MOH is likely to be given the lead mandate to orchestrate this body regarding stewardship, resources mobilisation and regulation. The PNIPH could be that body – it was authorised by the state last year – but only after redeveloping it to become more representative and well-institutionalised nationally. Secondly, the necessity to start the formulation of a national policy for HRS through this body. This policy needs to comprise a technical, scientific, administrative and legal framework to ensure that the three HRS functions are appropriately working. More importantly, there is a need to reform the existing ERC for it to become a national and integrated professional committee that adopts international standards and has precise and clear procedures in the ethics process. Third, such a policy could essentially address the exercises of ENHRPs setting that need to be reviewed and combine all implemented exercises under a unified national entity. This is necessary in order to ensure a national consensus, comprising an inclusive involvement, systematic prioritisation, priority–needs matching, and well-disseminated priorities with a follow-up on their application. Additionally, raising knowledge and expertise concerning this exercise among stakeholders is essential.

These proposals constitute an important roadmap that could inspire all stakeholders to move forward. In fact, enabling the stewardship functions is a fundamental move that would lead to great benefit to the state authorities, who could take the mandate to regulate all HRS activities with unwavering support and utilise the outputs from HR. Other key stakeholders, such as academia, NGOs and the private sector, are also required to involve themselves actively in terms of HRS assignments, whether by funding, production or use. This should be realised through a well-shaped and coherent HRS framework where the roles are defined and coordinated, the operational policy is formulated and unified, and priorities are exercised systematically.

Therefore, ensuring the implementation of these strategic proposals even in a country like Palestine, with all its difficulties, can give a precious opportunity towards strengthening these system functions. This would encourage the Palestinian institutions to produce meaningful knowledge and useful evidence to be utilised for the optimal use of existing resources, improving the performance of the Palestinian HCS, and thus promoting the health of the people.