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Building a Workforce for Future Health Systems: Reflections from Health Policy and Systems Research.

The World Report on Knowledge for Better Health, the Bamako Call to Action on Research for Health, the WHO Strategy on Health Policy and Systems Research, and the World Health Report 2013 all make a plea for better use of research in decision making for health to improve health systems performance (WHO 2004, 2012, 2013; Ministerial Forum 2008). Health services research (HSR) and health policy and systems research (HPSR) are overlapping fields that produce the type of knowledge needed to inform system-wide decision making. Coined before HPSR, health services research has also evolved over the time to be defined as "the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being." (Lohr and Steinwachs 2002) Health policy and systems research (HPSR) is conducted at the intersect of health systems and policy, examining systems functioning as a result of shifts in rules and policy as well as the influence of interests and values from key players (Peters 2014; De Savigny, Blanchet, and Adam 2017). While similar in nature, HPSR is differentiated from HSR through its slightly broader global scope--concerning itself with both health care and more holistic definitions of health and well-being (Gilson 2013). HPSR includes in its boundaries, policy processes, and global influence (Gilson 2013). HSR's longer evolution means that it hosts a wealth of lessons that can be applied to strengthening the HPSR workforce (Lohr and Steinwachs 2002). Health services research can also, in turn, continue to evolve by applying lessons learned in HPSR to further refine available tools and approaches in understanding complex health problems from a global perspective (De Savigny and Adam 2009).

The Sustainable Development Goals (SDGs)--interconnected and intersectoral--challenge decision makers and researchers alike to look beyond their disciplinary boundaries and collaborate effectively (Le Blanc 2015; WHO 2016). SDG 3, Good health and well-being, has universal health coverage (UHC) as one of its nine targets. However, several targets found under other SDGs are health-sensitive and play important roles in achieving the overarching goal of good health (Le Blanc 2015; Nunes, Lee, and O'Riordan 2016). This is a key step in broadening the disciplinary backgrounds required to meet population health needs beyond biomedical, disease-driven agendas (Shroff et al. 2017). HSR HPSR, and similar boundary-spanning fields such as operational research and implementation research are well suited to this changing landscape. To fulfill their potential in catalyzing and sustaining system-level change, those working in system-oriented fields would benefit from better coordinating efforts, sharing lessons learned from innovative approaches to intersectoral and transdisciplinary research, and contributing to capacity strengthening through training and institutional support. This commentary will share reflections on challenges and strategies in managing the HPSR workforce to stimulate dialogue and cross-learning across similar fields.

WHAT IS THE HPSR WORKFORCE?

HPSR is a complex endeavor that requires multiple perspectives, approaches, and skill sets (Gilson et al. 2011). For this reason, it cannot be done alone by those who have been defined traditionally as researchers. The HPSR workforce must be diverse not only in terms of disciplinary background (e.g., social sciences, management sciences, and engineering), but also in terms of the role that individuals they play within the health system (e.g., decision makers or civil society). Not everyone needs to be trained to become full researchers, but they must be empowered to engage in HPSR (Koon et al. 2013; Sheikh, George, and Gilson 2014).

The past few years have seen increased active engagement of implementers and policy makers in conducting implementation research from a systems perspective, which is then used to inform program design (Koon et al. 2013). For example, implementation research supported by communities of practice in Mexico and Nicaragua triggered quality monitoring of maternal health programs and improved uptake of evidence in addressing implementation problems (Langlois et al. 2017). Similarly, there has been enhanced engagement of communities and civil society--groups that have often been seen as marginal in the academic-policy nexus--in "on the ground" HPSR efforts, albeit with varying levels of success (Sheikh, George, and Gilson 2014; George et al. 2015). Participatory action research (PAR) within HPSR amplifies the community's voice and involves communities in the identification and resolution of problems (Loewenson et al. 2014). Experiences in PAR, such as in the case of indigenous Ayta community in the Philippines, demonstrate PAR's value in increasing social awareness and advocacy, capacity strengthening of community actors, and coproduction of knowledge at the grassroots level (Estacio and Marks 2010). However, these experiences also highlight the challenges that power structures pose when attempting grassroots participation (Estacio and Marks 2010).

STRATEGIES TO SUPPORT THE HPSR WORKFORCE

With the value of HPSR lying, in part, in the convergence of perspectives and disciplines, there is a need to explore different models of capacity development and incentives to support a diverse workforce with variable needs. Effective engagement of key policy and civil society actors in generation and use of HPSR remains a challenge (El-Jardali et al. 2011; George et al. 2015). Surveys of research institutions and ministries of health identified lack of core funding, definitional clarity for HPSR, and academic incentive structures as constraints to the generation of HPSR, while highlighting lack of available locally relevant evidence, poor presentation of research findings, and low institutional prioritization of evidence uptake as constraints to use of HPSR knowledge (Shroff et al. 2017). The following are proposed strategies for addressing some of these constraints and enhancing support for those working in HPSR.

Definitional Clarity of Expected Competencies and Coordination across HPSR

A review of HPSR training globally found there to be a lack of institutional and personnel support; inconsistencies in definitions of competencies required; low levels of interdisciplinary collaboration; and low accessibility of such courses for nonresearchers researchers (e.g., policy makers) (Tancred et al. 2016). To strengthen capacity in training of the HPSR workforce, these courses require more investment, improved support networks, enhanced coordination across the field, and alternative approaches that go beyond the traditional classroom model (Tancred et al. 2016). Open-access online courses, webinars, and technical support networks address these needs to some extent. For example, the popular online course on Systems Thinking has over 2000 active learners (Coursera, 2017); a technical assistance center established at the University of Toronto supports capacity strengthening for the conduct and use of rapid reviews in health policy and systems, holding train the trainers workshops, and producing research briefs to be shared with teaching and training programs in HPSR (Tricco, Langlois, and Straus 2017); a Health Policy and Systems Research Methodology Reader was widely disseminated to schools of public health and used in building curricula (Gilson 2013); Health Systems Global (HSG) thematic working group on teaching and learning health policy and systems research provides a database of training materials, opportunities, and resources and hosts health policy and systems research teaching and learning clinics at the Global Symposia on Health Systems Research (Schleiff et al. 2016); and in-country protocol development workshops between researchers and decision makers support capacity strengthening in the development of research questions and coproduction of health systems knowledge (Tran et al. 2017). Learning from these experiences to further meet needs and anticipate future requirements of the growing workforce is a key component of improved workforce development.

National Investment in HPSR

Trends in health systems research evidence demonstrate a focus on how the $46 billion in development assistance on health is being spent as compared to the comparatively sparse evidence on the efficiency of $317 billion spent by low- and middle-income country governments (Bishai and Cardona 2017; Dieleman et al. 2017). Optimizing the use of funds already being spent at the national level through investment in evidence-informed health systems reform is part of the way forward in achieving UHC (Bishai and Cardona 2017; Stenberg et al. 2017). National investment in HPSR would not only support the generation of the necessary evidence base for building strong health systems, but it would also provide core funding for the HPSR workforce, contributing to improvements in training and incentive structures.

Institutional Capacity for Coproduction of HPSR

While trends in the production of HPSR from 1990 to 2015 show significant growth in both high-income and low- and middle-income countries, the field continues to be dominated by relatively few key institutions and there is low participation by those outside of academia (Defor, Kwamie, and Agyepong 2017; WHO 2017). Practical use of HPSR to achieve health impact requires enhanced capacity for coproduction of HPSR knowledge by researchers, decision makers, and civil society (Defor, Kwamie, and Agyepong 2017). Initiatives such as the establishment of the African Institute for Health Policy and Health Systems Studies in Nigeria are examples of institutional capacity strengthening mechanisms to enhance teaching and training for HPSR and bring together researchers and decision makers (AHPSR 2015). Embedded implementation research models also promote coproduction of HPSR by having policy makers, managers, and implementers serve as coinvestigators alongside researchers (Langlois et al. 2017). These projects are planned and conducted based on key policy priorities as identified by decision makers and with attention to context-specific factors, making them more readily applicable in the policy environment (Tran et al. 2017). Participation of policy makers in the coproduction of HPSR is also important in catalyzing increased national investment in HPSR and strengthening leadership in this area.

Participatory Leadership and Extending HPSR Networks

HPSR requires harmonization and the establishment of mechanisms to support effective collaboration (Lehmann and Gilson 2014). The HPSR community has been making strides in harmonizing the field through membership organizations such as Health Systems Global (HSG), dedicated research symposia (Global Symposium on Health Systems Research), support to young practitioners through programs such as Emerging Voices (EV4GH 2017), and partnership fora established to better link research and policy making communities in setting a common agenda for HPSR. One such forum is a new initiative by the Alliance for Health Policy and Systems Research, called the Learning, Engaging and Advocating for Policy and Systems Research (LEAP) Forum for Health Systems Strengthening (HSS), which brings together policy makers, civil society actors, research institutions, and funders to share lessons learned from their work and to discuss the way forward for HPSR in responding to the dynamic needs of health systems (AHPSR 2017). The driving principle behind these initiatives is participatory leadership, which recognizes the need to empower diverse groups to work together to address complex challenges (WHO 2016). Through participatory leadership, HPSR can leverage the strengths of other disciplines and sectors for gains in population health, for example, big data, machine learning, and disruptive innovation--these are changing the status quo (Syed, Dadwal, and Martin 2013; Dereli et al. 2014). Those already investing their time in computational, data-driven degrees are a pool of talent that HPSR can draw upon by creating attractive opportunities for their involvement (Dereli et al. 2014). Therefore, the workforce would benefit from creating enabling environments for the development of leaders who understand, appreciate, and apply systems thinking to empower and engage diverse groups of stakeholders to collaborate effectively in building stronger health systems.

CONCLUSION

American experiences in HSR and global experiences in HPSR have much to learn from each other and are increasingly informing the knowledge base for more unified fields. There is a need to enable sharing of knowledge to advance these fields and build a workforce capable of appreciating and responding to the dynamic nature of health systems. In this vein, this commentary has discussed HPSR challenges and strategies in supporting a workforce that needs to work across traditional silos, not only in terms of subject or disciplines, but also in terms of roles of researchers, civil society, and decision makers. Creative approaches in training, financing, developing, and leading such a diverse workforce can pave the way for its full-time and part-time members to work seamlessly and contribute to learning systems.

ACKNOWLEDGMENTS

Joint Acknowledgment/Disclosure Statement: Time was committed by staff of the Alliance for Health Policy and Systems Research under the directorship of Abdul Ghaffar. No other financial support was given.

Disclosures: None.

Disclaimer: None.

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SUPPORTING INFORMATION

Additional supporting information may be found online in the supporting information section at the end of the article.

Appendix SA1: Author Matrix.

Dena Javadi [iD], Nhan Tran, and Abdul Ghaffar

Address correspondence to Dena Javadi, M.S.P.H., Alliance for Health Policy and Systems Research, World Health Organization, 20 Ave Appia, 1211 Geneva, Switzerland; e-mail: javadid@who.int. Nhan Tran, Ph.D., and Abdul Ghaffar, M.D., Ph.D., are with the Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland.

DOI: 10.1111/1475-6773.12978
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Author:Javadi, Dena; Tran, Nhan; Ghaffar, Abdul
Publication:Health Services Research
Date:Oct 1, 2018
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