Kabir Sheikh

Building the field of health policy and systems research: social science matters.

In the second in a series of articles addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Lucy Gilson and colleagues argue the importance of insights from the social sciences.

Building the field of health policy and systems research: framing the questions

In the first of a series of articles addressing the current challenges and opportunities for the development of Health Policy & Systems Research (HPSR), Kabir Sheikh and colleagues lay out the main questions vexing the field.

Building the field of health policy and systems research: an agenda for action.

In the final article in a series addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Sara Bennett and colleagues lay out an agenda for action moving forward.

People-centred science: strengthening the practice of health policy and systems research

Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context. Change occurs at many layers of a health system, shaped by social, political, and economic forces, and brought about by different groups of people who make up the system, including service users and communities. The seeds of transformative practice in HPSR lie in amplifying the breadth and depth of dialogue across health system actors in the conduct of research – recognizing that these actors are all generators, sources, and users of knowledge about the system. While building such a dialogic practice, those conducting HPSR must strive to protect the autonomy and integrity of their ideas and actions, and also clearly explain their own positions and the value-basis of their work. We conclude with a set of questions that health policy and systems researchers may wish to consider in making their practice more people-centred, and hence more oriented toward real-world change.

Explorations on people centredness in health systems

Health systems should ultimately seek to serve people and society. They must aim to bring value in people’s lives not only by caring for them when sick or giving support to prevent or limit illness and its effects, but also, more broadly, by offering the promise of economic security to all for times of great vulnerability. Health systems are also human systems. At their heart is a personal encounter, the interaction between the patient and the health provider—sometimes tenuous, often contested, but always with the potential for humanity and compassion. But many different types of people—individuals, groups and communities—make up health systems, ‘live’ within them, have roles, stakes and power in them, and are central to their existence and functioning. People make all the most important decisions in health systems—either by accessing services as patients, setting rules and allocating resources as policymakers, or enacting, coping with and subverting those rules, as implementers, managers, providers and service users. Communities and citizens influence these systems by shaping the social norms and contexts in which they operate. Community norms and behaviour drive health market forces and practices, influence how individuals and families access services, and can help hold systems accountable. Citizens may also influence system development through their electoral voting power, exercising the ‘long route’ to accountability. People centredness embraces this essentially human character of health systems. Yet, the term is surprisingly new in health system debate and the common response to its use is ‘what does that mean?’ This supplement advances the conversation by exploring varied perspectives on the concept of people centred health systems (PCHS). PCHS emerges as a multi-faceted concept, with ideological power and also carrying huge potential for practical thinking and change in health systems. While Universal Health Coverage has become emblematic globally for health systems change for better health care access and quality, and social protection, PCHS offers opportunities to elaborate and deepen our understanding of what such change should entail in the operational practices of health systems. The initial 11 articles in this collection, published as a printed supplement, begin to illustrate different aspects of the PCHS concept (further articles on the theme will be released in an online collection, and will be scattered through subsequent print editions of the journal). Four overarching themes that define and represent different aspects of PCHS emerge from this set of articles, and from other existing writing on PCHS and related themes. These aspects are summarized in Box 1, and also provide a framework for the subsequent discussions in this editorial. Box 1. Aspects of people centred health systems (PCHS) Putting people’s voices and needs first PCHS are ultimately shaped by community voices and needs. Participatory governance mechanisms can channel the power of communities to mould health systems in the public interest, and hold them accountable. People-centred governance can also confront entrenched power imbalances within health systems, and address their broader social determinants. People centredness in service delivery PCHS put people’s needs first in the design and delivery of health care and services. Important principles of this approach are quality, safety, longitudinality (duration and depth of contact), closeness to communities and responsiveness to changing requirements. Capacity building in PCHS focuses, foremost, on creating capabilities to respond to people’s health care needs. Relationships matter: health systems as social institutions PCHS are social institutions, which operate through chains of relationships between different health systems actors—including administrators, health care providers, service users and researchers—each acting in their respective contexts. As such, systems thrive on mutual trust, dialogue and reciprocity, and their effectiveness correlates to the quality of these human relationships. Values drive people centred health systems In PCHS, decision making is informed by people centred values around justice, rights, respect and equality, and the principles of primary health care. Values drive people’s decisions within the health system contributing to change, and conversely, system reforms can have impacts on people’s values within the system.

What explains regulatory failure? Analysing the architecture of health care regulation in two Indian states

Regulating health care is a pre-eminent policy challenge in many low- and middle-income countries (LMIC), particularly those with a strong private health sector. Yet, the regulatory approaches instituted in these countries have often been reported to be ineffective-India being exemplary. There is limited empirical research on the architecture and processes of health care regulation in LMIC that would explain these regulatory failures. We undertook a research study in two Indian states, with the aims of (1) mapping the organizations engaged with, and the written policies focused on health care regulation, (2) identifying gaps in the design and implementation of policies for health care regulation and (3) investigating underlying reasons for the identified gaps. We adopted a stepped research approach and applied a framework of basic regulatory functions for health care, to assess prevailing gaps in policy design and implementation. Qualitative research methods were employed including in-depth interviews with 32 representatives of regulatory organizations and document review. Several gaps in policy design were observed across both states, with a number of basic regulatory functions not underwritten in law, nor assigned to a regulatory organization to enact. In some instances the contents of regulatory policies had been weakened or diluted, rendering them less effective. Implementation gaps were also extensively reported in both states. Regulatory gaps were underpinned by human resource constraints, ambivalence in the roles of regulatory organizations, ineffective co-ordination between regulatory groups and extensive contestation of regulatory policies by private stakeholders. The findings are instructive that prevailing arrangements for health care regulation are ill equipped to enact several basic functions, and further that the performance of regulatory organizations is subject to pressures and distortions similar to those characterizing the wider health system. This suggests that attempts to strengthen health care regulation will be ineffectual unless underlying governance failures are addressed.

Anchoring contextual analysis in health policy and systems research: A narrative review of contextual factors influencing health committees in low and middle income countries

Health committees, councils or boards (HCs) mediate between communities and health services in many health systems. Despite their widespread prevalence, HC functions vary due to their diversity and complexity, not least because of their context specific nature. We undertook a narrative review to better understand the contextual features relevant to HCs, drawing from Scopus and the internet. We found 390 English language articles from journals and grey literature since 1996 on health committees, councils and boards. After screening with inclusion and exclusion criteria, we focused on 44 articles. Through an iterative process of exploring previous attempts at understanding context in health policy and systems research (HPSR) and the HC literature, we developed a conceptual framework that delineates these contextual factors into four overlapping spheres (community, health facilities, health administration, society) with cross-cutting issues (awareness, trust, benefits, resources, legal mandates, capacity-building, the role of political parties, non-governmental organizations, markets, media, social movements and inequalities). While many attempts at describing context in HPSR result in empty arenas, generic lists or amorphous detail, we suggest anchoring an understanding of context to a conceptual framework specific to the phenomena of interest. By doing so, our review distinguishes between contextual elements that are relatively well understood and those that are not. In addition, our review found that contextual elements are dynamic and porous in nature, influencing HCs but also being influenced by them due to the permeability of HCs. While reforms focus on tangible HC inputs and outputs (training, guidelines, number of meetings held), our review of contextual factors highlights the dynamic relationships and broader structural elements that facilitate and/or hinder the role of health committees in health systems. Such an understanding of context points to its contingent and malleable nature, links it to theorizing in HPSR, and clarifies areas for investigation and action.

Private providers and HIV testing in Pune India: challenges and opportunities.

Abstract We explored HIV testing practices of private medical providers in an urban Indian setting in Pune, western India. 215 private practitioners (PPs) and 36 persons-in-charge of private laboratories were interviewed in separate surveys. 77% of PPs had prescribed HIV tests and 94% of laboratories had performed HIV tests, or collected samples for HIV testing. Among those providers who had prescribed/performed tests, practices which violated national policy guidelines were found to be common. 55% of PPs and 94% of laboratories had not prescribed/performed confirmatory HIV tests, 82% of PPs had conducted routine HIV screening tests, 53% of PPs and 47% of laboratories had never counselled patients before testing, and 39% of laboratories reported breaching confidentiality of test results. PPs’ knowledge about HIV tests was also inadequate, with 28% of PPs who had prescribed HIV tests being unable to name the tests they had advised. Prolific HIV testing in the private medical sector is accompanied by inappropriate practices and inadequate knowledge, reflecting deficiencies in the implementation of policy guidelines. The perspectives and needs of private providers, the major source of health care in India, need to be acknowledged. Supportive and regulatory mechanisms can be used to involve private providers in the delivery of better HIV testing services.

Fair publication of qualitative research in health systems: a call by health policy and systems researchers

Fair publication of qualitative research in health systems : a call by health policy and systems researchers

Cultural consonance, constructions of science and co-existence: a review of the integration of traditional, complementary and alternative medicine in low- and middle-income countries

This review examined the determinants, patterns and imports of official recognition, and incorporation of different traditional, complementary and alternative systems of medicine (TCAM) in the public health establishment of low- and middle-income countries, with a particular focus on India. Public health systems in most countries have tended to establish health facilities centred on allopathy, and then to recognize or derecognize different TCAM based on evidence or judgement, to arrive at health-care configurations that include several systems of medicine with disparate levels of authority, jurisdiction and government support. The rationale for the inclusion of TCAM providers in the public health workforce ranges from the need for personnel to address the disease burden borne by the public health system, to the desirability of providing patients with a choice of therapeutic modalities, and the nurturing of local culture. Integration, mostly described as a juxtaposition of different systems of medical practice, is often implemented as a system of establishing personnel with certification in different medical systems, in predominantly allopathic health-care facilities, to practise allopathic medicine. A hierarchy of systems of medicine, often unacknowledged, is exercised in most societies, with allopathy at the top, certain TCAM systems next and local healing traditions last. The tools employed by TCAM practitioners in diagnosis, research, pharmacy, marketing and education and training, which are seen to increasingly emulate those of allopathy, are sometimes inappropriate for use in therapeutic systems with widely divergent epistemologies, which call for distinct research paradigms. The coexistence of numerous systems of medicine, while offering the population greater choice, and presumably enhancing geographical access to health care as well, is often fraught with tensions related to the coexistence of philosophically disparate, even opposed, disciplines, with distinct and unaligned notions of evidence and efficacy, and ethical and operational challenges of the administration of a plural workforce.