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Unit 3 Health Policy and Systems Research Priority Setting and Utilization
Introduction
Health Policy and Systems Research (HPSR) can be usefully defined as the production of new knowledge and applications to improve how societies organize themselves to achieve health goals, including how they plan, manage and finance activities to improve health, as well as the roles, perspectives and interests of different actors in this effort. HPSR contributes to sound, socially relevant and ethically acceptable guidance for more effective, efficient and sustainable health policies and systems. The health system functions of regulation, organization, financing and delivery of services are the focal subjects of HPSR. Broader determinants directly affecting the health system are also considered within the purview of HPSR, such as social and economic policies affecting key health system structures and processes (Baris 1998). HPSR can be particularly useful in improving the process of health policy making. It assists in identifying present and potential problems of a health system and the opportunities relevant for addressing them through an analysis of the socioeconomic and political environment for policy formulation and implementation. In doing so, HPSR analyzes the values and goals of specific social settings including their economic relations, political cultures, the distribution of power and authority relations. HPSR is also concerned with the analysis of costs, inputs and resources required for policy implementation, and the extent and levels of participation by stakeholders to ensure ownership. Effective HPSR therefore has the following attributes (International Organizing Committee 2001): Knowledge production, management and use. This includes the generation of information, its dissemination and advocacy to assist in the development of strategies to solve health problems. Stewardship. It includes the creation of a supportive environment for dialogue and networking, priority setting and monitoring amongst stakeholders in HPSR. Financing. This includes resource mobilization for research, its allocation and administration. Capacity development. It includes training in research, financial management, research to action/policy, involvement of stakeholders, leadership and advocacy. 2

Practical and Learning Objectives

1. To understand the usefulness of HPSR as a knowledge base for decision making to improve the performance of health systems. 2. To understand why HPSR needs to be viewed in the specific context of health

systems and development situations. 3. To become familiar with processes for prioritizing HPSR and with factors contributing to the utilization of research for policy. 4. To understand the importance of the participation of stakeholders in HPSR and explore strategies for dealing with their different interests and viewpoints.

Usefulness of Health Policy and Systems Research

Jenkins defines policy as [a] set of interrelated decisions taken by a political actor or group of actors concerning the selection of goals and the means of achieving them within a specified situation where these decisions should, in principle, be within the power of those actors to achieve (1978:15). Policy-related research, thus, aims at illuminating the understanding of policy or decision makers about a problem they seek to solve and ways of solving it. The basic justification for the utilization of HPSR for policy making and systems development is that policies that are informed by research will be better policies than otherwise would have been the case (Hanney et al 2002). According to Hanney et al: Research exposes policy-making to a wider range of validated concepts and experiences than those that could be drawn from the normal time-limited and politically constrained processes of policy deliberation. It thus allows a broader choice of policy options to emerge. Research can also enable policies to be generated upon technically well-informed bases. It gives warnings of reasons why some policies succeed and others fail. It can make connections between otherwise separate factors such as the nature of the substantive field and organisational patterns set up to manage them, or the power of environments over health outcomes. It legitimises some policies and throws legitimate doubts on others (Hanney et al 2002). HPSR addresses both research for policy and research on policy. Research for policy seeks to tackle health and health system problems that are likely to be useful in a wide range of settings and situations and to find solutions to them as an integral part of the overall process of development. HPSR assists in identifying urgent and 3 potential problems that need to be addressed by policy makers and the resources or inputs required for addressing these problems. Research on policy improves understanding about the stakeholders in research. It addresses social reality and identifies the perceptions of people about health problems. It assists in consensus building about the nature of the problem and ways of finding solutions to it for the benefit of all stakeholders. It assists in identifying power structures, authority relations, and interest groups associated with a health problem. It helps in recognizing the political, social and economic dimensions of a problem and the analysis of the perceptions and expectations of community members, health managers and professionals and policy makers. It also assists in the development of alternative models for addressing health problems and their

respective implications.

Context-Specificity of HPSR
A health system is a set of cultural beliefs about health and illness that informs the basis for health seeking and health promoting behaviour, the institutional arrangements within which that behaviour occurs, and the socio-economic, political, and physical context for those beliefs and institutions. HPSR is therefore more context specific than other health-related research because health systems and policy are themselves highly embedded in national and local socio-economic, cultural, political and geographical realities. HPSR and its emerging findings are likely to be of minimal value unless it is conceptualized in the context of a specific socioeconomic and political milieu. The contributions to health status of sectors like education, agriculture, housing, water and sanitation, which together with the health care delivery system constitute the components of the health system, are likely to vary in different national settings. This makes HPSR more context-specific than other health-related research. HPSR ultimately leads to action to improve the health of communities, by enhancing the efficiency and effectiveness of the health system as an integral part of the overall process of socio-economic development. HPSR, therefore, provides health managers, investors and community leaders with relevant information for decision making on current health problems to enhance health development. Problems at one level of a health system are usually interrelated or connected with problems or deficiencies at other levels. HPSR relates to national health priorities that emanate from the research needs of the health system. It addresses problems from the different perspectives of all those directly or indirectly involved with the problem. HPSR is also more context specific than other health-related research to the extent that it is linked to equity. Equity can be defined as equal access for equal need. Equity in health implies a societal commitment to equal capabilities for achieving good health outcomes, conditional on respect for human diversity and individual autonomy, and achieved through health action for the unfairly disadvantaged (TanTorres Edejer 2001: 8.) It connotes differentials in health status that are unfair, unjust and avoidable. 4 Health policy and systems research linked to equity often focuses on the effects of poverty and material deprivation and their social consequences of powerlessness, vulnerability and loss of self-esteem on the health of individuals and communities. The conceptualization of HPSR in terms of health equity results in linking the health of individuals to the health of communities and ultimately leads to measures to improve equity in health status of communities. HPSR seeks to promote strategic improvements in health that are particularly of concern to the poor, as the driving force to economic productivity and human development. It seeks to develop health systems to equitably improve health outcomes and reveals the impact of alternative health policies. It focuses on mechanisms that redress market failures and emphasizes the publicgood characteristics of health research, which can lead to substantial improvements in the health status of individuals and communities.

Assessing the Kind of Health Policy and Systems Research Most Likely to Influence Policy
An assessment of the kind of HPSR most likely to influence policy should focus on its ability to improve health systems and services and ultimately lead to better health. The fairness and inclusiveness of the priority setting processes (see also Unit 2 of this module) are as important as the technical criteria that are brought to bear on the problems. HPSR that is most likely to influence policy can be identified, as with other kinds of research, through the application and weighting of several criteria: the relevance of the research, its scientific quality, the feasibility of its execution and application (both political and technical), and its ethical acceptability. Relevance. The importance of HPSR topics has often been equated with the burden of disease and the availability of knowledge, technologies and mechanisms to deal with it. Disease specific problems such as health emergencies and epidemics, water-borne diseases, malaria HIV/AIDS and road accidents are highly visible and socially acknowledged public health problems. Furthermore, these problems are often justified in technical and non-political terms that are easily understood and accepted by public health and clinical professionals, who are most often at the helm of health systems. Research on disease-specific health system problems is therefore more likely to influence policy in developing countries. System-wide issues such as ineffective resource allocation, poor accessibility to services and maldistribution of human resources can be equally important from the point of view of their impact on public health. However, these problems are often perceived by health policy makers as more complex and intractable because they are couched in more eclectic social science terms, 5 have close association with ideological positions, and involve actors and sectors beyond the purview of the policy makers (Hanney et al 2002). Systemwide issues thus require different priority setting procedures, which may not be easy to combine with disease-specific priorities (see Tools and Resources section of this unit). The relevance of research is a key element in ensuring accountability to the public. If key sectors in society are convinced that relevant research is being undertaken, then politicians and investors may be more easily convinced to provide adequate funds and resources and to address the findings emerging from the research. Thus, research that addresses public concerns and that is solicited is more likely to influence policy than research that is science-driven and investigator initiated. Scientific quality. The scientific quality of research is critical in assessing the likelihood of research to influence policy. HPSR, just as any other science, should aim to produce robust and convincing results through clear conceptual frameworks and appropriate methods. HPSR should provide new or contextualized information to decision makers that would not be otherwise available. Research that is of high scientific quality is more likely to

influence policy than research lacking in methods and clear conclusions or bearing on problems already investigated or where answers can be derived from common sense. The usefulness of qualitative methods that are common in HPSR has to be clearly explained and demonstrated. Feasibility. This relates to the complexity of the problem being investigated and the resources available to carry out the investigation in terms of the personnel, time, equipment and funds for the study. Given the complexity of health system issues and problems, special consideration has to be given to ensuring that research tackles only critical variables through appropriate methods. The political acceptability of the research is also important in assessing feasibility, an issue that is very important in HPSR. However, researchers have the right and ethical obligation to propose research that may be at variance with the priorities of decision makers. Research that is likely to influence policy should be applicable. This means that in addition to its acceptance to the authorities and community members, resources should be available for implementing the recommendations of the study. There is, therefore, the need for linkages to be fostered between researchers, policy makers and community members, both at the resource and intellectual level, to promote ownership of the research and its results by all stakeholders and facilitate the use or implementation of these results. This implies that effective HPSR must be demand-driven to ensure that funds are allocated not only for the execution of research but also for the implementation of its recommendations. Ethical considerations. HPSR has to comply fully with the national and internationally agreed norms to protect the dignity, autonomy and safety of informants and participants in research. Given the nature of HPSR, these considerations will normally not be an issue in the undertaking of research. 6

Linking HPSR with Related Research in Other Sectors

Unlike biomedical research, HPSR encompasses a variety of sectors because of its multi-disciplinary nature. Since some of the major determinants of health lie outside the healthcare sector, it is important that health research is linked to health-related research in other sectors, in particular when it comes to making a radical impact at reducing health inequalities. HPSR can be linked to research in other sectors through the creation of alliances and networks for collaborative research in sectors such as education, agriculture, finance, housing, water and sanitation and local government. Such collaborations could engage in research towards mutually-agreed, purpose-specific, equity-oriented research goals and support the research efforts of each other through the exchange or sharing of knowledge, resources and personnel.

Exercise 1:
There is an outbreak of cholera in one of the districts in your country for the second time in five years. The Ministry of Health is determined to find the root cause of this problem so that it can take steps to prevent the resurgence of the disease in the

district. You recognize that any specific intervention program (in this case, a nutritional intervention) must be considered within a broader systems context specifically, the district health system. Also, the intervention program must not only be efficacious in the demonstration setting, but eventually be cost-effective and feasible in a regular health system infrastructure. Further, you recognize that the issue of selecting one intervention (e.g., nutrition) or another (e.g., spinal cord injury prevention) cannot be done independent of overall health and health research priorities at various levels district and national. You are the Head of the Research Division of the Ministry and have been tasked by the Minister to constitute a five-member team to conduct an investigation into the epidemic. Indicate the category of persons you will include in your team and the role each category of person(s) will play. 7

Type of HPSR Most Likely to be Useful to Change Agents

HPSR that is most likely to be used by change agents will focus on how the results will be used. HPSR is undertaken primarily to provide information to support decision or policy making to improve the functioning of the health system. Since health problems are multi-faceted, change agents are most likely to be influenced by multi-disciplinary research that is participatory and focuses on priority health problems. This should include skills from disciplines such as medicine, epidemiology, behavioural science, and economics. HPSR that is most likely to influence change agents should provide an effective linkage between research and policy and action. It should focus on priority health problems and emphasize comparatively simple, short-term research designs that are likely to yield practical results relatively quickly. Research that is most likely to be useful to change agents should have research designs focusing on cost-effective, low cost studies with the aim of developing timely solutions or research results that are action-oriented. The results of the research should be clearly communicated to change agents and key stakeholders and presented in formats most useful to them with a summary of the major findings adapted to suit them. In order to influence change agents, health research should be participatory. It should facilitate the process of multi-stakeholder priority setting, involving the identification of relevant research questions and the building of coalitions around specific problems, to ensure that the results of research are used. The active participation of policy makers, researchers and community members in the research process enhances the ownership, acceptability and applicability of its results and makes it more likely to influence change agents.

Choosing Between Immediate Challenges and Longer Term Options for Improving Health System Performance

The immediate challenges of a health system are likely to constitute urgent problems, requiring quick and timely responses or solutions. Placing a higher priority on them in the short term is likely to be more important and appealing to policy makers, political office holders and powerful interest groups than identifying longer-term options for improving health system performance. It should be noted, however, that identifying strategies to deal with immediate challenges of a health system, without making efforts to improve long-term health system performance, might render these strategies ineffective. If the performance of 8 the health system is poor, identifying strategies to deal with immediate challenges of the health system is likely to result in sheer wastage and ineffective use of scarce resources, in particular if the institutional structure for addressing these challenges is weak. This implies that placing more emphasis on identifying longer-term options for improving health system performance, might increase the efficiency, effectiveness and sustainability of the health system and increase the effectiveness of strategies to deal with immediate challenges of the health system. Hence, it might not be prudent even in the short-term to concentrate research efforts on identifying strategies to deal with immediate challenges of a health system to the complete neglect of identifying longer-term options for improving health system performance.

Exercise 2:
An International Non-Governmental Organization (NGO) that has been operating in your country for the past five years will wind-up its activities and leave next year. During the five years that the NGO has been in your country, it provided nutritional support to malnourished children under ten years of age in two districts. Evidence provided by the NGO indicates that the nutritional status of children in the two districts has improved considerably over the five years that the nutrition intervention program has been in place. The government, with the assistance of some donor agencies, is interested in continuing support for the nutrition intervention program when the NGO leaves and also in extending the support to two other districts where children are known to be malnourished. There is, however, information from one of the districts receiving support from the NGO that spinal cord injury is on the increase. The government is, therefore, also considering launching a program to either prevent or reduce spinal cord injury in the affected district. It does not have enough resources to do both. The government has requested proposals for research to be conducted into these problems. The proposals are intended to provide a basis for decision-making by the government, on whether to continue support for the nutrition intervention program or start a program to prevent or reduce spinal cord injury. You suspect that the reasons for a repeat disease outbreak (such as this cholera one) likely include some broader system-wide determinants. In addition, you believe that the recommendations of the review team should include policy recommendations so that there will not be a third outbreak. You are the Head of the Health Policy Research Centre in the country and you have been invited by the Minister of Health, as a member of a three-member team to evaluate the research proposals and advise the government on whether to continue with the nutrition intervention program or start a program to prevent or reduce

spinal cord injury in one of the districts. How will you set about this task? 9 In the short-term, therefore, a countrys research portfolio should maintain some strategic balance, which places more emphasis on identifying longer-term options for improving health system performance while still pursuing efforts to identify strategies to deal with immediate challenges of the health system. This will result in building an efficient and effective health system, which will provide a framework for identifying and implementing effective and sustainable strategies to deal with immediate challenges of the health system.

Stakeholder Interests and Points of View

Health Policy and Systems Research is participatory. It involves all parties concerned with the research from policy makers to community members at all stages of the research process. The stakeholders in HPSR include policy makers, health managers, healthcare providers and community members. In broad terms, however, there are four major stakeholders in HPSR: research donors and investors, policy makers, researchers and the community. It is not always possible to have a convergence of interests between stakeholders. Communities tend to be less interested in knowledge for its own sake but are concerned rather with the relevance of the research to their lives. They are likely to expect some tangible benefits either to themselves, their family or community within a reasonable timeframe in return for their participation in research. They may therefore lose interest in participating in research when they perceive that such benefits are not likely to materialize. Policy makers are interested in information that provides effective linkages between research, policy and action. This enables them to make fast or quick decisions to solve urgent health problems. They tend to prefer simple, easily understood information that is applicable to specific health problems. Policy makers, however, are also potentially interested in having a moderately effective and stable research system at hand which can be relied upon for policy and system development. Their interest in strengthening research capacity at national and local levels should therefore not be underestimated. Many policy makers think researchers are inclined to study issues that are mainly academic. They often perceive researchers as persons who provide information, which is couched in excessive scientific jargon and has low social relevance. They sometimes also think researchers do not take into account resource or political constraints in the implementing of findings. Researchers are curious and creative individuals who delight in discovering relationships between phenomena. They sometimes undertake research mainly for academic interest or for career advancement. They often think that policy makers and community members cannot appreciate the merits of the scientific information they provide. Many researchers also perceive policy makers as bureaucratic and conservative individuals who think that research is common sense. 10 In general, researchers try to be objective in their work. They can become uncomfortable with attempts by either decision makers or community members to influence the conduct of their research. The fruits of research are, however, likely to

be ignored if the social, political and economic context in which research is conducted is not taken into account or the traditional practices and beliefs of communities, associated with the research, are not considered. This means that policy makers and community members should be involved in the identification of health research priorities, the execution of research and the analysis of its findings, and the implementation of the results of the research. The involvement of policy makers in the research process contributes to the implementation of results, whilst the involvement of researchers in the implementation of their recommendations ensures their concern for the feasibility of the recommendations they make. The involvement of community members in the research process, particularly in problem identification, priority setting and implementation of research results, ensures that the priority health needs of the people are taken into account in relation to their development needs and aspirations. It also ensures community ownership of the research results. It increases the acceptance of the results of research and the effectiveness and sustainability of health programs that are implemented as a result of the recommendations from the research. Donors and investors can play a critical role in setting research priorities. The main avenue of influence is through identifying topics of interest for funding or specifying areas for research as part of wider development project investments. Commissioned research will normally identify the key questions to be researched. In developing countries, research institutions are the initiator in only about a third of HPSR projects, while another third are initiated by a donor agency, international research partner or by a private contractor. Governments initiate projects in about 24% of cases (Gonzalez Block & Mills 2002). Research also indicates that international donors are the most important influence in terms of number of projects funded, funding 60% of the total, while governments fund 30% and private and other sources 10%. However, donors or investors are seldom represented in the governing boards of institutions, and there is little informed interaction between researchers and donors or investors beyond announcing and requesting funds and reading about research undertaken through scientific journals. There is particular weakness in assessing the impact of research on policy and in gaining community-wide recognition for producer institutions as sources of high quality, objective HPSR. Institutions are generally confident of their efforts to strengthen stakeholder engagement, although this view may consider a rather low expectation of the potential of HPSR to influence policy. There is therefore a need to establish linkages or coalitions and alliances to identify priority health problems and funding across all relevant stakeholders. Such coalitions and alliances can draw on their knowledge and experience to define common research objectives, commit resources and develop solutions to health problems. 11 Attempts should therefore be made to establish dialogue between the stakeholders in research. Researchers should communicate research information in appropriate ways. They must develop communication and advocacy skills and understand the processes for decision making on resource allocation and policy development,

implementation and monitoring. Policy makers, on their part, must develop an interest and inclination for evidencebased decision making. They should appreciate the importance of investing in multistakeholder health research and support health and development discussions as crucial to addressing problems of inequity in health.