Health policy and systems research

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Health policy and systems research (HPSR) is a field of inquiry that studies "how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes". HPSR is interdisciplinary and brings together expertise in a variety of biomedical and social sciences such as economics, sociology, anthropology, political science, public health and epidemiology.

The Commission on Health Research for Development and the Ad Hoc Committee on Health Research (1996) both highlighted the urgent need for focusing research methods, funding and practice towards addressing health inequities and embracing inter-disciplinary and intersectoral thinking. These reports and other academic and activist voices linked to them argued for greater voice and participation of developing countries in defining research priorities. In 1997, at the Lejondal Meeting in Stockholm with senior scientists including Göran Tomson, policymakers and representatives of various agencies with a stake in HPSR, an Interim Board for the Alliance was proposed. Since then creation of the Alliance for Health Policy and Systems Research in 2000 and that of Health Systems Global in 2012 have consolidated the practice community of HPSR. In 2010, the first global symposium on health systems research was held in Montreux. PLoS Medicine commissioned three articles on the state-of-the-art in HPSR authored by a diverse group of global health academics. These articles critically examined the status of HPSR, current challenges and mapped the need to build capacity in HPSR and support local policy development and health systems strengthening, especially in LMICs. The series positioned HPSR as a field of inquiry that is driven by the nature of research question as opposed to being guided by the research methods.

HPSR is a multidisciplinary field that seeks to understand and improve how societies organise themselves to achieve collective health goals. It addresses the design, implementation, and evaluation of health policies and the broader functioning of health systems. It can be distinguished from related fields of inquiry such as health services research from particular focus on wider systemic, structural and societal phenomena. The key concepts and themes in HPSR include:

HPSR approaches health systems as dynamic, complex entities composed of interacting components. This systems thinking perspective recognises the non-linear, context-sensitive, and adaptive nature of health systems.

HPSR tends to focus on problems and solutions that arise beyond specific health facilities and services, but arising in the governance of health systems. Health systems governance refers to how power, authority, and decision-making are distributed and exercised within health systems. It encompasses institutions, processes, and relationships that determine how policies are formulated and implemented.

HPSR emphasizes the importance of equitable access to health services and the reduction of disparities in health outcomes. Research in this area explores how social, economic, and structural determinants influence health equity.

People-centred care places individuals, families, and communities at the core of health system design and delivery. HPSR promotes approaches that are responsive, respectful, and participatory.

HPSR addresses the challenges of translating evidence-based interventions into policy and practice. While Implementation research has matured as a field of inquiry of its own, HPSR contributes to aspects of implementation research with components focusing on theory generation, explanation or evaluation of policies and programs using a health systems approach with a focus on equity. HPSR approaches employ a systems perspective is critical in evaluating and learning from implemented policies.

Political economy analysis in HPSR explores how power, institutions, and incentives shape health policies and programs. It considers the role of formal and informal actors and how global, national, and local politics influence system performance.

Conceptually resilience as an property of a system (in the case of HPSR, a social system) refers to a health system’s capacity to absorb shocks, adapt to changing contexts, and continue functioning effectively. HPSR explores how systems can be made more resilient in the face of crises such as pandemics or conflict. Resilience has also been conceptualised as a system capability that emerges from systemic resources and interactions. In line with this, a system that allows learning across actors is understood as being resilient.

Embedded research involves integrating research activities within health systems to support real-time decision-making. It encourages collaboration between researchers, policymakers, and practitioners to co-produce knowledge.

HPSR promotes continuous learning and adaptation within health systems. This theme supports the use of monitoring, evaluation, and feedback to drive iterative improvements. Health systems improvements occur and sustain not only through improvements in infrastructure and resources, but through a culture of learning for resilience and adaptability as has been seen in many diverse country settings.

Health Policy and Systems Research (HPSR) is defined more by the questions it asks (typically on functioning, reform, and governance of health policy and systems) than by specific methodologies (it is methods agnostic). It employs a wide range of research approaches, drawing from diverse disciplines such as public health, sociology, political science, and health economics, and using both qualitative and quantitative methods, theory-oriented and/or participatory methods to suit complexity-aware and context-sensitive needs and based on fit to the inquiry.

This approach views health systems as complex adaptive systems with multiple interacting components. They evolve over time, are non-linear, exhibit feedback loops, emergent properties, and various other complex systems properties that require an understanding of the wider context in shaping health outcomes. Such a perspective when integrated in research and practice helps better understand and intervene in the functioning of health systems. Systems thinking supports the design of resilient and responsive health interventions, especially in the face of uncertainty and change in low- and middle-income country contexts.

HPSR heavily incorporates critical social science perspectives to explore lived experiences, norms, and power dynamics. Interpretive and constructivist approaches, including ethnography and case studies, are often used to understand how actors engage with health systems.

Policy analysis in HPSR examines how policies are developed, adopted, and implemented. Political economy approaches explore how interests, institutions, and power relations influence these processes, often using frameworks such as the policy triangle, a conceptual framework of policy analysis that approaches the policy analysis through critically examining the actors, context, policy process its content.

Implementation research within HPSR focuses on how to improve the effectiveness of interventions through building theories (on how public health programs work), devising frameworks to guide and evaluate implementation, and improving co-production of knowledge on interventions and implementation strategies for their effective implementation and scaling up by creating generalisable knowledge on how to implement public health interventions in diverse health system settings. Implementation research approaches emphasize the importance of the specific context in which programs are implementated, the need for their adaptation, and adequate stakeholder engagement.

Analytical frameworks help structure research design and guide interpretation of findings in HPSR. Popular frameworks include the RE-AIM framework, Consolidated Framework for Implementation Research (CFIR), and realist evaluation, which enable researchers to analyze multi-level implementation factors, mechanisms of change, and context-specific outcomes. These frameworks support generalizability of findings across settings while preserving contextual nuance.

Given the complex and context-sensitive nature of health systems, HPSR frequently employs mixed methods designs, combining quantitative analysis (e.g., health service utilization data, surveys) with qualitative inquiry (e.g., interviews, focus groups) to triangulate findings. Comparative case study approaches are also widely used to understand variation across settings and to develop explanatory insights about what works, for whom, and under what conditions.

• WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland
• Health Systems Global