Understanding the concept and importance of the health research system in Palestine: a qualitative study

The development of health research systems (HRS) has become an international concern in recent years, particularly in low- and middle-income countries. HRS is considered a key pillar of healthcare systems (HCSs) for better health policies and equitable care [1, 2]. Research is defined in WHO’s strategy on research as “the development of knowledge to understand health challenges” [3] through an effective and efficient HRS to address society’s needs [4]. Further, health research (HR) is defined as “the process for systematic collection, description, analysis, and interpretation of data that can be used to improve health” [1]. The concept has undergone numerous refinements, including the development of a conceptual framework for National Health Research Systems (NHRSs) [5] in an attempt to correct the 10/90 gap, whereby less than 10% of global research funds are devoted to diseases that account for 90% of the global disease burden [6, 7]. In addition to establishing the Global Forum for HR to address HR gaps [6], WHO launched an HR strategy focusing on HR culture, priorities, capacity, standards and translation [3, 8].

This study adopts the WHO definition of HRS, as follows, “The people, institutions, and activities whose primary purpose is to generate high-quality knowledge that can be used to promote, restore, and or maintain the health status of populations. It can include mechanisms adopted to encourage the utilization of research” [9]. HRS is an emerging concept for many stakeholders, who expect to conceptualise it and realise it in practice. HRS encompasses a wide range of actors in charge of producing, consuming, managing or evaluating the system [10]. An inclusive understanding of the system concepts, importance and performance from multiple angles, incorporating the perspectives of various stakeholders, is essential [11‐13].

In the Middle East, HR still suffers from lack of investment. There is a paucity of studies on perceptions of the HRS concept and importance. Several countries have not yet sufficiently examined this critical part of system understanding, nor have they assessed the performance of this system with the aim of its appropriate steering [5, 14]. Further, few countries have a formal NHRS, where building HRS is one of the challenges [11]. However, cultivating and improving an evidence-based culture is vital [15]. The Palestinian scientific research scene is unclear with regards to the lack of research orientation [16]. The present study therefore sought to demystify this ambiguity and to fill the knowledge gap in light of insufficient HRS assessments and a scarcity of literature [17], given that the WHO toolkit for HRS analysis does not address the aspect of actors' perceptions in understanding the system or assessing its performance [14, 17].

A conceptual framework designed by WHO setting the foundation of an NHRS, serves as a basis for operational analysis [18]. In this respect, various challenges have been identified, two of which are addressed in this study, namely an inadequate understanding of research and an insufficient appreciation for HRS at the political level [2, 16, 19, 20]. A deep understanding of the HRS concept and its performance is an enabling factor that could support HRS strengthening and application on the ground [10, 21]. This perspective would allow stakeholders to improve their conceptual understanding and technical potentials alike, and allow the achievement of good health outcomes and equity. Overcoming the inadequate understanding of HR is considered one of the study’s motives [18]. Further, a better understanding of the HRS concept and its performance might also lead to improvements in other HRS components such as governance, capacity, policy, priorities and stakeholders.

Such an understanding could lead to a sustainable HRS, whereby HR culture and knowledge is promoted among stakeholders and HR is embedded as a philosophy, based on shared conceptualisation [22, 23] and institutionalisation practices. A shared HR concept would contribute to decision-making and policy development based on evidence. The present study is part of a larger investigative research project that holistically explores Palestinian HRS components. Three diverse and relevant sectors in Palestine have been purposively targeted – government, academia (public health schools), and health non-governmental organisations (NGOs) and international agencies. As a logical first step, this study provides an overview of the perceptions of health policy-makers, academics and experts involved in HRS with regards to their understanding of the HRS concept. Such an overview can provide a foundation on which to build and reinforce a HR culture and strengthen other HRS pillars. Specifically, the paper aims to (1) assess the level of understanding among health policy-makers, academics and experts regarding the definition and conceptualisation of the HRS concept and to capture their perceptions of its goals and functions; and to (2) assess the perceptions of HRS stakeholders in Palestine and the associated gains and losses of adopting or dispensing with HRS in the country.

The approach used herein offered a deep understanding of the importance and performance of HRS for developing a well-functioning national research system [4, 5]. We focused on exploring the understanding of the HRS concept, its goals and functions, and on determining the key concerns related to HRS in terms of what is gained and lost when it is adopted or neglected.

Study participants across all sectors were highly responsive to the thematic questions. The importance of HRS, its role in the health field and its potential for strengthening this system was acknowledged by most. However, participants stated that such a system and its enabling environment have not yet been established. IDI and FGD responses were largely consistent with each other, without a prominent difference of perceptions among the three sectors. The overall understanding of HRS and its relevant components, as defined by WHO, was inadequate, particularly the concept of HRS, where descriptions from most of the policy-makers, academics and NGO experts were not fully aligned with the WHO definition adopted in 2004 [17, 18].

A lack of system understanding meant that the majority of experts were only familiar with and sufficiently aware of ‘health research’ as a broader concept, as demonstrated by a study on defining research to improve HCS [29]. Our study intersected with a previous study that found that the largest deficits were in understanding HR from a systems perspective [18]. Similarly, deficient levels of awareness and lack of appreciation for an HR culture are problematic factors contributing to system underperformance [16]. In other words, expert delineations on HRS do not align with the WHO’s definition adopted in this study. Differences in perception regarding the HRS definition were observed across the sectors, where academia defined it from a pure knowledge and scientific perspective, while government and NGOs delineated it from a more practical point of view. This proves that most of the definitions were not framed in a harmonized and integrative way and were not defined from a system perspective. There are different explanations for this finding, including the complexity of the system and its constituents [29], the concept of HRS still being emergent [30], the weakness of the curriculum in schools of public health to cover HRS concepts and of its application not being adequately endorsed, and the lack of leadership concern and unsupportive environment around developing a HR culture and practice. Aggravating the situation is the absence of a political will – HR is not on the agenda of the Palestinian government and this was found to be one of the main obstacles to better system performance [31]. These factors are exacerbated by poor incentives, political difficulties, conflicting priorities and an unappreciated research culture [11, 16, 19, 20, 32, 33]. Findings do show, however, that experts have conceptualised the goals of HRS to some extent, with responses aligning with those of another relevant study [18]. The experts highlighted that the main goal of HRS is to generate knowledge for use in policies to improve health and the community. Other studies assert that HR is needed to attain the Sustainable Development Goals [34]; this response is compatible with the definition of health policy and systems research [35]. Further, the conceptual framework of HRS functions as outlined by the WHO initiative [14] was not appropriately recognised by experts. Among the functions commonly identified by all respondents were guiding health needs, evaluating the results and planning health actions to achieve suitable health conditions.

The policy-makers, academics and NGO experts we met were enthusiastic in their responses, and provided many key thoughts and perceptions about HRS, raising some critical issues. The diversity and volume of thoughts and insights captured contribute to a better understanding of the Palestinian context as it relates to HRS. During their conceptualisation, respondents recognised 10 themes, half of which could be categorised as development ideas and half as the difficulties associated with HRS. Most of the identified themes largely coincided with findings from a particular study that discussed these themes as HRS challenges [3, 36]. These were HCS and service improvement; insufficient resources; population health problems and burden of disease; absence of a regulating system and vision; a donor-driven research agenda rather than a culture-driven or academically based agenda; and policy, planning and decision-making. These six issues were mentioned most frequently, while other less frequent themes addressed the failure to adopt HRS as a development tool and to identify its priorities based on community needs and a general lack of cooperation and connection. The last two themes were data unavailability and accuracy and HRS as the best option for cost-rationalisation [11].

The study also pointed to strengthening factors of HRS in practice, as perceived by experts. HRS was seen as essentially contributing to health status improvement through finding solutions to prevent chronic diseases and to improve lifestyle. This perspective has been emphasised by another recent study [37]. Thus far, HR is still fragile, neglected, devalued and relatively unknown or understood, which can be attributed to weak political will and concern to officially adopt HRS as a strategy and to take the necessary steps to strengthen it. Without political interest, it is not possible to develop most HRS components [36]. A national unified strategy that endorses actual community health needs is a critical in Palestine. This should be accomplished by a national policy developed through wide consultation and consensus with stakeholders and by allocating financial resources and incentives to strengthen HRS across all sectors [13]. At the same time, international organisations can be motivated and become a catalyst for success. Our findings regarding the main obstacles and strengthening actions correspond to conclusions drawn by others [11, 38], namely that those challenges are not only prevalent in Palestine as a low-resource and unstable country, but also throughout the Middle East region in general.

The concept of HRS raised some pivotal issues. We found that there has been an improvement in research productivity in Palestine, as in the Eastern Mediterranean region overall [11]. Yet, the quality of research produced by many Palestinian institutions has not yet reached a satisfactory level [39]. What is worrying, however, is that these efforts inherently stem from personal desires for self-development, rather than being motivated by or performed according to a visionary institutional and national agenda. This reinforces the hypothesis that HR is inefficient and ineffective, where most experts were dissatisfied with its system performance. There is an absence of national vision and dynamic regulation, as well as a lack of integration and cooperation among interested stakeholders; this conclusion coincides with relevant evidence from WHO [40]. Correspondingly, system underperformance is the result of non-participatory coordination among HRS stakeholders [11, 38].

The study found that HRS is generally appreciated, but it is unfortunately not realised on the ground. Most of the experts elaborated numerous fundamental thoughts, which were reflected as themes, during their conceptualisation. The study assumed that the gains of HRS identified indicated its importance, whereby the goals and functions of HRS were similarly characterised. In contrast, the stated losses from HRS were assumed to indicate a lack of importance. The overall perceptions indicated that HRS was seen as important, particularly toward guaranteeing HCS improvements, proper management and evidence for decisions. HRS was also seen as contributing to the overall development of resource-poor countries by helping to address its problems, support successful planning and policy formation, encourage optimal use of resources and, ultimately, identify priorities and needs [37, 41]. In contrast, neglect of HRS was seen to lead to enormous technical losses in the form of random and uncoordinated healthcare actions, research duplication and inefficiency, and ineffectiveness and mismanagement. Moreover, at the system level, neglecting HRS is seen as leading to unimproved HRS and HCS and unsolved problems, unsuccessful planning and policies, different visions, continuous wasting of resources, and shallowness of priorities and needs. Evidently, ensuring that we do not lose sight of the goals and importance of HR would allow us to see the significant benefits of research in everyday practice [18, 42].

The study has some limitations. Relevant literature, particularly studies investigating the perceptions of HRS players, was not adequately implemented, likely due to poor political attention and culture towards HR. Furthermore, the research team was limited in its access to other relevant institutions and experts due to movement restrictions. Further, time limitations prevented the involvement of more leadership levels across sectors, but this was addressed through the assistance of key experts who facilitated intensive communication and cooperation of their senior partners across institutions. Some IDIs and FGDs were shorter than the expected time, and some questions were not sufficiently answered, either due to limited knowledge, practice or time constraints.

HRS is increasingly appreciated globally as a substantial pillar of the HCS structure to improve health [11]. Hence, there is a need to functionally link research to HCS. To achieve this, a shared understanding of HRS concepts is an important first step towards developing this system. By realizing these concepts, relevant actors are likely to increase their commitment and involvement, which may ultimately lead to better outcomes in research management, production and utilisation. This requires performers to conceptualise the system, which may also create a pioneering orientation among health policy-makers to coordinate their actions with each other and with other development sectors. Varying definitions or vague conceptualisations may cause confusion and become an obstacle to progress [23].

The study assessed the perceptions of policy-makers, academics and experts to emphasise the importance of addressing their conceptual understanding pattern of the HRS, which is a basic requirement in system analysis towards system strengthening [9]. The overall understanding of Palestinian policy-makers and experts on the HRS concept is strikingly inadequate, yet the importance of the system and its benefits were certainly recognised. Therefore, we conclude by calling for a serious move to increase understanding and awareness of HRS [11, 16, 20].

The concept of HR is more understandable among respondents than the HRS, as evidenced by the ambiguous and imprecise conceptualisation of the system and its components compared to the WHO definition. There are significant HR attempts among respective researchers and policy-makers. However, the process of increasing awareness and understanding remains sluggish, which suggests that HR is not sufficiently internalised or embedded in the culture. Another interpretation is that HR is not performed in a systematic way based on a collective vision, but rather spontaneous and individually, which may have limited yields.

Many of the system components, such as governance, policy, finance, knowledge sharing and coordination, are not practically applied in the Palestinian health sector. The importance of the system is fully appreciated by most of the experts as a major gain, while neglecting it is recognised as a great loss. However, the goals and functions of the system, as delineated [4, 8, 18], were sufficiently recognised. Moreover, the concept of HRS correlates with improvement approaches [9], where most respondents linked HRS to developmental ideas (e.g. HCS improvement, meeting societal needs, effective policies and planning, correct decisions, tackling health problems, and resource conservation). In contrast, others more readily associated HRS with the difficulties or challenges facing the system.

The analytical approach used in this study, based on stakeholders’ perceptions, could be a useful analytical framework and basis for broader system analysis. Stakeholders’ perceptions of other system components could be investigated, and indeed this approach has not been adequately addressed in most of the respective attempts to analyse the system [5, 9, 14, 18]. A qualitative investigation to assess conceptualisation patterns could reflect the real internal mentality and state of thinking among those involved in the system. Additionally, the present analytical approach may also be used as a complementary and operational assessment method alongside other known approaches, leading to a better and inclusive understanding of HRS [9, 18]. More empirical research is needed to more clearly identify the reasons behind the apparent lack of awareness and knowledge about the HRS concept and its uses and applications.

To conclude, enhancing the level of HRS knowledge and culture among researchers and policy-makers is indispensable for HRS strengthening. Knowing the stakeholders’ conceptualisation patterns contributes to enabling system practices and applications, creating opportunities for successfully institutionalisation of appropriate system components within the Palestinian HCS. In other words, a well-conceptualised system makes research a practical and essential tool for analysing and solving health problems. If this issue is successfully addressed politically, HR and HRS in all sectors could become reality rather than rhetoric. To embed the HRS concept and its components in research culture and to make it applicable by policy-makers and experts, HCS decision-makers should adopt the following strategies: