Donor support for Health Policy and Systems Research: barriers to financing and opportunities for overcoming them.

BACKGROUND: The vast investments that have been made in recent decades in new medicines, vaccines, and technologies will only lead to improvements in health if there are appropriate and well-functioning health systems to make use of them. However, despite the growing acceptance by major global donors of the importance of health systems, there is an enthusiasm gap when it comes to disbursing funds needed to understand the intricacies of how, why and when these systems deliver effective interventions. To understand the reasons behind this, we open up the black box of donor decision-making vis-à-vis Health Policy and Systems Research (HPSR) financing: what are the organizational processes behind the support for HPSR, and what are the barriers to increasing engagement? METHODS: We conducted 27 semi-structured interviews with staff of major global health funders, asking them about four key issues: motivations for HPSR financing; priorities in HPSR financing; barriers for increasing HPSR allocations; and challenges or opportunities for the future. We transcribed the interviews and manually coded responses. RESULTS: Our findings point to the growing appreciation that funders have of HPSR, even though it is often still seen as an 'afterthought' to larger programmatic interventions. In identifying barriers to funding HPSR, our informants emphasised the perceived lack of mandate and capacities of their organizations. For most funding organisations, a major barrier was that their leadership often voiced scepticism about HPSR's long time horizons and limited ability to quantify results. CONCLUSION: Meeting contemporary health challenges requires strong and effective health systems. By allocating more resources to HPSR, global donors can improve the quality of their interventions, and also contribute to building up a stock of knowledge that domestic policymakers and other funders can draw on to develop better targeted programmes and policies.

Global financing for health policy and systems research: a review of funding opportunities.

Health policy and systems research (HPSR) is a neglected area in global health financing. Despite repeated calls for greater investment, it seems that there has been little growth. We analysed trends in reported funding and activity between 2015 and 2021 using a novel real-time source of global health data, the Devex.com database, the world's largest source of funding opportunities related to international development. We performed a systematic search of the Devex.com database for HPSR-related terms with a focus on low- and middle-income countries. We included 'programs', 'tenders & grants' and 'contract awards', covering all call statuses (open, closed or forecast). Such funding opportunities were included if they were related specifically to HPSR funding or had an HPSR component; pure biomedical funding was excluded. Our findings reveal a relative neglect of HPSR, as only ∼2% of all global health funding calls included a discernible HPSR component. Despite increases in funding calls until 2019, this situation reversed in 2020, likely reflecting the redirection of resources to rapid assessments of the impacts of the coronavirus disease 2019 (COVID-19) pandemic. Most identified projects represented small-scale opportunities-commonly for consultancies or technical assistance. To the extent that new data were generated, these projects were either tied to a specific large intervention or were narrow in scope to meet a specific challenge-with many examples informing policy responses to the Covid-19 pandemic. Nearly half of advertised funding opportunities were multi-country projects, usually addressing global policy priorities like health systems strengthening or development of coordinated public health policies at a regional level. The Covid-19 pandemic has shown why investing in HPSR is more important than ever to enable the delivery of effective health interventions and avoid costly implementation failures. The evidence presented here highlights the need to scale up efforts to convince global health funders to institutionalize the inclusion of HPSR components in all funding calls.

A health systems resilience research agenda: moving from concept to practice.

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.