Health policy and systems research (HPSR) has changed considerably over the last 20 years, but its main purpose remains to inform and influence health policies and systems. Whereas goals that underpin health systems have endured – such as a focus on health equity – contexts and priorities change, research methods progress, and health organisations continue to learn and adapt, in part by using HPSR. For HPSR to remain relevant, its practitioners need to re-think how health systems are conceptualised, to keep up with rapid changes in how we diagnose and manage disease and use information, and consider factors affecting people’s health that go well beyond healthcare systems. The Sustainable Development Goals (SDGs) represent a shifting paradigm in human development by seeking convergence across sectors. They also offer an opportunity for HPSR to play a larger role, given its pioneering work on applying systems thinking to health, its focus on health equity, and the strength of its multi-disciplinary approaches that make it a good fit for the SDG era.Read More
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Morgan R, Ayiasi RM, Barman D, Buzuzi S, Ssemugabo C, Ezumah N, George AS, Hawkins K, Hao X, King R, Liu T, Molyneux S, Muraya KW, Musoke D, Nyamhanga T, Ros B, Tani K, Theobald S, Vong S and Waldman L (2018) Gendered health systems: evidence from low- and middle-income countries, Health Research Policy and Systems, 16:58, DOI: 10.1186/s12961-018-0338-5
Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems.Read More
Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries
This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability; we need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. We suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.Read More
Introduction: Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage
In July 2017, IDS hosted a workshop on ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity’, with the aim of generating dialogue and mutual learning among activists, researchers, policymakers, and funders working towards more equitable health systems and a commitment to Universal Health Coverage (UHC). This issue of the IDS Bulletin is based around three principal themes that emerged from the workshop as needing particular attention. First, the nature of accountability politics ‘in time’ and the cyclical aspects of efforts towards accountability for health equity. Second, the contested politics of ‘naming’ and measuring accountability, and the intersecting dimensions of marginalisation and exclusion that are missing from current debates. Third, the shifting nature of power in global health and new configurations of health actors, social contracts, and the role of technology.For the first time in IDS Bulletin history, themes are explored not only in text but also through a selection of online multimedia content, including a workshop video, a photo story and a documentary. This expansion into other forms of communication is explicitly aimed at galvanising larger numbers of people in a movement towards UHC and the linked agenda of accountability for health equity.The articles and multimedia in this IDS Bulletin reflect the fact that while the desired outcome might be the same – better health for all – accountability strategies are as diverse as the contexts in which they have developed.Read More
‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information
Waldman L, Ahmed T, Scott N, Akter S, Standing H and Rasheed S (2018) ‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information, Globalization and Health, 14:31, DOI: 10.1186/s12992-018-0349-6
Information and Communications Technologies (ICTs) which enable people to access, use and promote health information through digital technology, promise important health systems innovations which can challenge gatekeepers’ control of information, through processes of disintermediation. College students, in pursuit of sexual and reproductive health (SRH) information, are particularly affected by gatekeeping as strong social and cultural norms restrict their access to information and services. This paper examines mobile phone usage for obtaining health information in Mirzapur, Bangladesh. It contrasts college students’ usage with that of the general population, asks whether students are using digital technologies for health information in innovative ways, and examines how gender affects this.Read More
A fundamental challenge for health systems is the need to adapt to changes in the patterns of health service need, scientific and technological developments, and the economic and institutional contexts within which providers of health services are embedded. This is especially true of many low and middle-income countries, where the pace of multiple and interconnected changes is breath-taking. This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries.Read More
ICT-Facilitated Accountability and Engagement in Health Systems: a Review of Making All Voices Count mHealth for Accountability Projects
Information and communication technologies (ICTs) and mHealth innovations hold great potential to improve health systems and health outcomes while at the same time enhancing citizen engagement and accountability. Yet there has been little assessment of the impact of mHealth innovations on the ground.
This paper reviews the experiences of seven mHealth initiatives funded by the Making All Voices Count programme: OurHealth, eThekwini WACs and Thuthuzela Voices (all in South Africa), Mobile Mapping for Women’s Health (Tanzania), Text2Speak (Nigeria), SMS Gateway (Indonesia) and Citizen Journalism for Quality Governance of Universal Health Insurance Scheme (also Indonesia). It discusses the accountability model adopted by each project, and the challenges they faced.Read More
This Working Paper explores the literature on accountability in health systems and on mHealth and to build theoretical and empirical bridges between them. In so doing, the authors lay out a clearer understanding of the role that mHealth can play in accountability for public health services in LMICs, as well as its limitations. At the centre of this role is technology-facilitated information which, for instance, can help governments enforce and improve existing health policy, and which can assist citizens and civil society to communicate with each other to learn more about their rights, and to engage in data collection, monitoring and advocacy. Ultimately however, information, facilitated as it may be by mHealth, does not automatically lead to improved accountability. Different forms of health care come with different accountability challenges to which mHealth is only variably up to task. Furthermore, health systems, embedded as they are in diverse political, social and economic contexts, are extremely complex, and accountability requires far more than information. Thus, mHealth can serve as a tool for accountability, but is likely only able to make a difference in institutional systems that support accountability in other ways (both formal and informal) and in which political actors and health service providers are willing and able to change their behaviour.Read More
New technological breakthroughs in biomedicine should have made it easier for countries to improve life expectancy at birth (LEB). This paper measures the pace of improvement in the decadal gains of LEB, for the last 60-years adjusting for each country’s starting point of LEB.Read More
Doctoral level research and training capacity in the social determinants of health at universities and higher education institutions in India, China, Oman and Vietnam: a survey of needs
Ali F, Shet A, Yan W, Al-Maniri A, Atkins and Lucas H (2017) Doctoral level research and training capacity in the social determinants of health at universities and higher education institutions in India, China, Oman and Vietnam: a survey of needs, Health Research Policy and Systems, 15:76, DOI: 10.1186/s12961-017-0225-5
Research capacity is scarce in low- and middle-income country (LMIC) settings. Social determinants of health research (SDH) is an area in which research capacity is lacking, particularly in Asian countries. SDH research can support health decision-makers, inform policy and thereby improve the overall health and wellbeing of the population. In order to continue building this capacity, we need to know to what extent training exists and how challenges could be addressed from the perspective of students and staff. This paper aims to describe the challenges involved in training scholars to undertake research on the SDH in four Asian countries – China, India, Oman and Vietnam.Read More
Achieving universal health coverage (UHC) has become a dominant policy preoccupation within the global health community. For Africa, progress towards UHC involves ambitious goals for expanding access to a range of effective health services, a substantial increase in health expenditure, and establishing a greater reliance on prepayment and pooling mechanisms to finance healthcare. According to one set of calculations, achieving UHC requires countries to spend at least $86 per capita in 2012 dollars on healthcare, and a minimum of 5% of Gross Domestic Product (GDP). Clearly, expanding the ‘fiscal space for health’ will be key to the success of UHC.Read More
Socioeconomic inequalities in under-five mortality in rural Bangladesh: evidence from seven national surveys spreading over 20 years
Chowdhury AH, Hanifi SMA, Mia MN and Bhuiya A (2017) Socioeconomic inequalities in under-five mortality in rural Bangladesh: evidence from seven national surveys spreading over 20 years, International Journal for Equity in Health (2017) 16:197, DOI: 10.1186/s12939-017-0693-9
Socioeconomic inequality in health and mortality remains a disturbing reality across nations including Bangladesh. Inequality drew renewed attention globally. Bangladesh though made impressive progress in health, it makes an interesting case for learning. This paper examined the trends and changing pattern of socioeconomic inequalities in under-five mortality in rural Bangladesh. It also examined whether mother’s education had any effect in reducing socioeconomic inequalities.Read More
Khatun F, Heywood AE, Hanifi SM, Rahman MS, Ray PK, Liaw ST and Bhuiya A (2017) Gender differentials in readiness and use of mHealth services in a rural area of Bangladesh, BMC health services research, 17:573, DOI: 10.1186/s12913-017-2523-6
Traditional gender roles result in women lagging behind men in the use of modern technologies, especially in developing countries. Although there is rapid uptake of mobile phone use in Bangladesh, investigation of gender differences in the ownership, access and use of mobile phones in general and mHealth in particular has been limited. This paper presents gender differentials in the ownership of mobile phones and knowledge of available mHealth services in a rural area of Bangladesh.Read More
Learning by doing in practice: a roundtable discussion about stakeholder engagement in implementation research
Arwal SH, AulakhBK, Bumba A and Siddula A (2017) Learning by doing in practice: a roundtable discussion about stakeholder engagement in implementation research, Health Research Policy and Systems, 15(Suppl 2):105, DOI: 10.1186/s12961-017-0275-8
Researchers and policy-makers alike increasingly recognise the importance of engaging diverse perspectives in implementation research. This roundtable discussion presents the experiences and perspectives of three decision-makers regarding the benefits and challenges of their engagement in implementation research.
Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda
Kananura RM, Ekirapa-Kiracho E, Paina L, Bumba A, Mulekwa G, Nakiganda-Busiku D, Oo HNL, Kiwanuka SN, George A and Peters DH (2017) Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda, Health Research Policy and Systems, 15(Suppl 2):107, DOI: 10.1186/s12961-017-0274-9
The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders’ decision-making in eastern Uganda.
A participatory action research approach to strengthening health managers’ capacity at district level in Eastern Uganda
Tetui M, Coe A-B, Hurtig A-H, Bennett S, Kiwanuka SN, George A and Ekirapa Kiracho E (2017) A participatory action research approach to strengthening health managers’ capacity at district level in Eastern Uganda, Health Research Policy and Systems, 15(Suppl 2):110, DOI: 10.1186/s12961-017-0273-x
Many approaches to improving health managers’ capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers’ capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers’ capacity in Eastern Uganda.
Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda
Paina L, Wilkinson A, Tetui M, Ekirapa-Kiracho E, Barman D, Ahmed T, Mahmood SS, Bloom G, Knezovich J, George A and Bennett S (2017) Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda, Health Research Policy and Systems, 15(Suppl 2):109, DOI: 10.1186/s12961-017-0272-y
The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.
Engaging stakeholders: lessons from the use of participatory tools for improving maternal and child care health services
Ekirapa-Kiracho E, Ghaosh U, Brahmachari R and Paina L (2017) Engaging stakeholders: lessons from the use of participatory tools for improving maternal and child care health services, Health Research Policy and Systems, 15(Suppl 2):106, DOI: 10.1186/s12961-017-0271-z
Effective stakeholder engagement in research and implementation is important for improving the development and implementation of policies and programmes. A varied number of tools have been employed for stakeholder engagement. In this paper, we discuss two participatory methods for engaging with stakeholders – participatory social network analysis (PSNA) and participatory impact pathways analysis (PIPA). Based on our experience, we derive lessons about when and how to apply these tools.
Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda
Bennett S, Mahmood SS, Edward A, Tetui M and Ekirapa-Kiracho E (2017) Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda, Health Research Policy and Systems, 15(Suppl 2):108, DOI: 10.1186/s12961-017-0270-0
Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.
Engaging stakeholders in implementation research: lessons from the Future Health Systems Research Programme experience
Peters DH, Bhuiya A and Ghaffar A (2017) Engaging stakeholders in implementation research: lessons from the Future Health Systems Research Programme experience, Health Research Policy and Systems, 15(Suppl 2):104, DOI: 10.1186/s12961-017-0269-6
Implementation research and the engagement of stakeholders in such research have become increasingly prominent in finding ways to design, conduct, expand and sustain effective and equitable health policies, programmes and related interventions. How to bring together key sets of health systems stakeholders, including affected communities, health workers, health system managers, health policy-makers and researchers, as well as non-state and non-health sector actors, is a critical challenge. Stakeholder engagement plays important roles across intersecting research, policy and management processes, from selecting and defining the most relevant research questions to address policy and management concerns, to designing and conducting research, learning from and applying evidence, making changes to policy and programmes, and holding each other accountable. The articles in this supplement examine some of the tools and approaches used to facilitate stakeholder engagement in implementation research, and describe learning from the experience of the Future Health Systems (FHS) Research Programme Consortium.Read More