The next twenty years of health policy and systems research
By Kumanan Rasanathan, HSG Board Member
How far has the field of health policy and systems research (HPSR) advanced in the last twenty years? What could it achieve in the next twenty? What are the key challenges to realizing its potential?
Twenty years of the Alliance for Health Policy and Systems Research
We’ve been thinking about these questions in Stockholm as we’ve celebrated twenty years since the Lejondal Meeting here paved the way for the Alliance for Health Policy and Systems Research. Fittingly the meeting was hosted by SIDA and Norad who, along with DFID, have been the great funders and champions of the Alliance. The meeting also launched the first World Report on Health Policy and Systems Research, a comprehensive document on the current status of HPSR – an essential read for everyone in HSG.
But much more than a celebration, 50 passionate researchers and practitioners came together to discuss and debate the future, with everyone from HPSR giants instrumental in the Alliance’s birth to Emerging Voices who’ve so energised our Symposia and HSG as a whole.
I’d like to highlight two “big picture” issues that came up during the two days.
In 2017 is health policy and systems research truly a global enterprise, or something for “LMIC”?
First, in the context of the SDGs and the drive towards UHC in all countries by 2030, HPSR, remains essential and relevant for all countries, regardless of income levels. As Tim Evans noted at the UHC Financing Forum in D.C. last week, no country has got their health systems completely right, or achieved UHC for that matter, so all countries can learn from each other. We had differing views on whether a focus on or the use of the category “low- and middle-income countries” (LMIC) remains useful for HPSR.
I think it remains useful as a descriptor but much less so as a comparator. We still need to pay attention to the differential capacity for and application of HPSR between countries, which tracks incomes to an extent – but only to an extent. But the variation among countries grouped as LMIC is so large that using this as the comparison to “high income countries” (HIC) is problematic. Moreover, in all countries there are tremendous internal disparities in the performance and capacity of health systems. For example, one participant noted that in Africa, some people viewed South Africa as a HIC. At the same time, the large contingent of South Africans at the meeting pointed out that HPSR remains fragile there, for all the strength of some South African institutions. Simple comparisons of HIC versus LMIC when trying to improve equity of resources for HPSR risks exacerbating inequities, particularly for countries and communities within the LMIC label who are worst off.
We didn’t reach consensus on whether the focus of HSG and the Alliance’s efforts for HPSR should be truly global or whether a focus on the worst off countries (or LMIC) should be retained. But it’s not either/or. We do need to advocate for HPSR for all health systems, while at the same time prioritizing our efforts to support countries and communities with the least resources and capacity – which isn’t the same as saying prioritising efforts in LMIC!
How do we better engage policy-makers in HPSR?
Second, we had a robust debate on how to engage policy-makers more in the generation and use of HPSR. We acknowledged that despite the tremendous progress in the field in the last twenty years, HPSR remains poorly funded, poorly understood and poorly applied in most contexts – especially in comparison to biomedical and clinical research. I proposed that we need to map the interests of decision-makers (including policy-makers, managers, implementers, civil society and the private sector) to understand what might drive them to use HPSR, in terms of their political incentives, funding and accountabilities; change the power dynamic in HPSR with researchers ceding some of their power and leadership to decision-makers; change the way we communicate beyond papers and conference presentations to forms that are more accessible to decision-makers (as many undertaking HPSR already do with success); and change the way we measure success, prioritising more impact on policy and programming, and at least coming up with a theory of how every HPSR effort might have this impact, allowing that this is difficult to evaluate or ensure.
Towards the next twenty years of health policy and systems research
Other issues that were brought up were the need for HPSR to engage more deeply with human rights approaches and consider more comprehensively its ethics, the importance of doing cross-country studies and the linked challenge of funding them, the pressing imperative in the SDG era to think more on multisectoral action and the system for health rather than just the health sector, and how to catalyse better both domestic and global financing resources, as aid for health becomes increasingly less important in many countries with growing total domestic health spending.
The Alliance will produce a meeting report shortly that will capture these discussions more thoroughly, and also consider which parts of the ample advice given they feel they are best placed to act upon for the future. But all of us in HSG and the HPSR community would do well to reflect where we want the field to be in another 20 years, and what health systems would look like if we had the success in the generation and, moreover, use of HPSR that we aspire to. Let’s redouble our efforts to make this happen to maximize HPSR’s contribution to achieving UHC. And once more congratulate the Alliance on its achievements over the last two decades!