A view from Lebanon: Challenges of conducting Health Policy and Systems Research in a context of uncertainty
By Racha Fadlallah
A few months ago, we had the pleasure of welcoming our colleagues Etienne V Langlois and Karen Daniels to Lebanon. Shortly after the visit, Karen, who is a Specialist Scientist in the Health Systems Research Unit at the South African Medical Research Council wrote a reflection piece on what we gain from talking to colleagues who live and work in challenging contexts. In her reflection, Karen posed an interesting question: “how do I use my skills as a researcher in contributing to the creation of a people-centered health system that is truly universal and not just limited to our country’s citizens?”
As a junior health policy and systems researcher working in the Eastern Mediterranean Region (EMR), the question resonates well with our existing health systems that are operating in the context of “uncertainty”. While the region has been at the center of global news since the Arab Spring and in particular, the Syrian refugee crisis, the state of “uncertainty” is not recent here. Indeed, for people who live in the region, war is not transient, but rather, their daily reality and part of the context in which they live and work. This means that our health systems are constantly being challenged, pressured, and shaped by unexpected changes in health care demands and politics. This in turn renders Health Policy and Systems Research (HPSR) instrumental to transform the health systems in the region and promote resilient, people-centered systems.
However, as an emerging voice in HPSR working in such a context, I am confronted with the following challenges:
The first challenge relates to the limited production of HPSR in the region in comparison to the actual needs, especially in the context of uncertainty which requires prompt responses from researchers. Often when such research is available, it is not necessarily policy-relevant. Indeed, I would say that the context of uncertainty can create both an opportunity and an obstacle – an opportunity in the sense that if you have evidence, you can push it forward to achieve reform; and an obstacle because when such evidence is not available decisions still need to be taken. The findings from a recent study where we mapped the gaps in the production of HPSR evidence in 15 countries in the EMR showed persistently low production of HPSR in the region and demonstrated the need for aligning the production of HPSR with policy needs and priorities and for building the capacity in conducting HPSR at the individual, team, institutional and system level.
A second challenge relates to the limited awareness of policymakers and stakeholders about the relevance and value of HPSR in reforming and strengthening health systems and their limited capacity to apply it in decision-making. The rapidly changing priorities and the political instability in the region further hinder our ability to establish a sustained partnership with policymakers and stakeholders.
A third challenge relates to the limited funding for HPSR. This may reflect the fact that the impact of HPSR cannot be felt immediately nor measured directly due to its complex nature and the multiple factors working simultaneously to achieve change. Thus, funders may be discouraged from investing in HPSR particularly in the region where HPSR is yet to be fully appreciated as a unique field of research.
Finally, it is important to realize that the availability of policy-relevant research and funding alone may not automatically translate into evidence-informed decision-making. Indeed, what we need in many countries in the region is a mechanism or a platform for researcher-policy-maker interactions to promote the use of HPSR evidence in decision-making and consequently strengthen the existing health systems.
As researchers in the EMR, we work within these constraints and specifically within a context where we don’t have many health policy and systems researchers. Yet, some progress is being made. I consider myself at an advantage to be able to work closely with experts in the fields of HPSR and systematic review. Indeed, my close collaboration with Dr Fadi El-Jardali and Dr Elie Akl, and their ongoing mentorship has instilled in me systems thinking and has enhanced my skills in synthesizing research evidence and conducting systematic reviews on HPSR priorities.
As part of the joint collaboration between the Center for Systematic Reviews of Health Policy and Systems Research (SPARK) and the Knowledge to Policy (K2P) Center at the American University of Beirut, we are working on policy-relevant priorities in our attempt to produce relevant HPSR evidence and to promote their use in informing decision-making, thus pushing the research agenda forward. Drawing on our work on the Syrian refugee crisis in Lebanon, we were able to produce a systematic review on questions raised by policymakers in Lebanon and hold a dialogue session with 28 key policymakers and stakeholders to disseminate the findings. This eventually led to the adoption of the recommendations put forward to promote coordination efforts and enhance the access of Syrian refugees to health care.
In conclusion, it is instrumental to invest more in HPSR and build the critical mass needed to promote the production and use of HPSR evidence to strengthen health systems in the EMR region.
