https://orcid.org/0000-0002-5609-3811
Abstract
Organizations that perform Health Policy and Systems Research (HPSR) need robust capacities, but it remains unclear what these organizations should look like in practice. We sought to define ‘HPSRIs’ (pronounced as ‘hip-srees’, i.e. ‘Health Policy and Systems Research Institutions’) as organizational models and developed a conceptual framework for assessing their capacities based on a set of attributes. We implemented a multi-method study in the Philippines that comprised: a qualitative analysis of perspectives from 33 stakeholders in the HPSR ecosystem on the functions, strengths and challenges of HPSRIs; a workshop with 17 multi-sectoral representatives who collectively developed a conceptual framework for assessing organizational capacities for HPSRIs based on organizational attributes; and a survey instrument development process that determined indicators for assessing these attributes. We defined HPSRIs to be formally constituted organizations (or institutions) with the minimum essential function of research. Beyond the research function, our framework outlined eight organizational attributes of well-performing HPSRIs that were grouped into four domains, namely: ‘research expertise’ (1) excellent research, (2) capacity-building driven; ‘leadership and management’ (3) efficient administration, (4) financially sustainable; ‘policy translation’ (5) policy orientation, (6) effective communication; and ‘networking’ (7) participatory approach, (8) convening influence. We developed a self-assessment instrument around these attributes that HPSRIs could use to inform their respective organizational development and collectively discuss their shared challenges. In addition to developing the framework, the workshop also analysed the positionality of HPSRIs and their interactions with other institutional actors in the HPSR ecosystem, and recommends the importance of enhancing these interactions and assigning responsibility to a national/regional authority that will foster the community of HPSRIs. When tailored to their context, HPSRIs that function at the nexus of research, management, policy and networks help achieve the main purpose of HPSR, which is to ‘achieve collective health goals and contribute to policy outcomes’.
Building capacities for Health Policy and Systems Research (HPSR) requires strengthening capacities at the individual, organizational and system levels over time, but there exists no structured approach to better understand the attributes that characterize organizations with robust capacities for HPSR.
To address this gap, we conducted a multi-method study in the Philippines to explore the model of ‘HPSRIs’ (pronounced as ‘hip-srees,’ i.e. Health Policy and Systems Research Institutions) and developed a conceptual framework to analyse their capacities based on eight organizational attributes across the domains of research expertise, leadership and management, policy translation and networking.
We identified indicators to assess the degree to which HPSRIs attain these attributes, which can inform purposive organizational development efforts. We also analysed the positionality of HPSRIs in the ecosystem and recommend the need to enhance the interactions between HPSR actors and to assign responsibility to a national or regional authority that will foster the HPSR community.
We proposed HPSRIs to be at the nexus of research, management, policy and networks to perform better in attaining the primary purpose of HPSR, which is to ‘achieve collective health goals and contribute to policy outcomes’. The broad conceptual framework from this study can guide organizational development for HPSR but must be tailored according to the specific context of every HPSRI.
Introduction
A maxim sometimes used in management theory says that ‘If you can’t measure it, you can’t manage it’ (Zak, 2013). Although not everything can be measured, the quote nevertheless suggests that metrics have a role in assessing capacities to manage performance better, including in Health Policy and Systems Research (HPSR). HPSR, initiated in 1996 by the World Health Organization (Bennett et al., 2018), is broadly defined as research ‘that seeks to understand and improve how societies organise themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes’ (Alliance for Health Policy and Systems Research, 2024). Some of the initial metrics used to assess capacities for HPSR in low- and middle-income countries (LMICs) indicated stagnant domestic funding and continued reliance on external assistance to support HPSR in low-income countries (Adam et al., 2011). However, the study also found an increasing number of HPSR-related publications from LMICs, affirmed by a later study that reported a sustained rate of growth in HPSR-related publications from LMICs and with an LMIC lead author (English and Pourbohloul, 2017). These metrics, while useful to estimate progress in capacities for HPSR, nevertheless lack an in-depth assessment of capacities that could better inform policy action to support purposive capacity building. New comprehensive approaches to capacity assessment for HPSR are needed to understand the specific areas of strengths and weaknesses and, consequently, better manage performance at the individual, organizational and system levels of capacities.
The question of capacities for HPSR
One seminal paper from the ‘First Global Symposium on Health Systems Research’ in 2010 advanced an agenda to build the field of HPSR by determining competencies for individuals, finding institutional homes for HPSR, and reforming funding structures, fostering networks and supporting methods development (Bennett et al., 2011). At the level of systems capacity, Mirzoev et al. proposed an overarching framework for HPSR that encompassed the individual–organizational-system interface, recognized the importance of collective efforts among researchers, educators, advocates, practitioners and policymakers, and emphasized the values of equity, inclusiveness, transparency and accountability (Mirzoev et al., 2022). The authors recommended the strengthening of HPSR capacities at all three levels over time, but also acknowledged that capacity strengthening need not address all three levels simultaneously in practice.
At the individual level of capacities, Schleiff et al. proposed competencies for HPSR that could serve as a point of reference for standards-setting in curricula and benchmarking between training programmes (Schleiff et al., 2022). Their list included ‘hard technical skills’ (systems thinking, policy relevance, critical appraisal), ‘soft relational skills’ (leadership, partnerships, communication) and attributes related to ‘character’ (ethics and accountability). Nevertheless, a question that remains is how to translate these individual competencies into organizational competencies. An earlier study by Bennett et al. analysed the evolution of ‘health policy institutes’ in selected LMICs and found different administrative configurations (e.g. university-based, government-owned and non-government organizations), with most institutes conducting policy research to respond to government or donor requests and advising policymakers in the form of reports, while only a few institutes facilitated policy dialogues (Bennett et al., 2012). The authors concluded that institutes fostered evidence-informed decision-making when they had some degree of independence in governance and financing, offered timely and actionable recommendations, maintained strong links with policymakers, operated within a supportive policy environment and when governments were motivated to utilize policy advice. A subsequent study by Schroff et al. surveyed research institutes and Ministries of Health in LMICs and identified the barriers to institutional capacity building to include the lack of core funding for HPSR within organizations and incentives to attract the commitment of organizations to give HPSR a home (Shroff et al., 2017). The authors recommended providing incentives for researchers and engaging multiple stakeholders within and outside academia, including governments and funders, as part of coordinated efforts to strengthen the broader HPSR community.
Assessing ‘HPSRIs’—health policy and systems research institutions
We will focus on capacity strengthening for HPSR primarily at the organizational (or institutional) level in the context of LMICs. Although the term ‘institutional’ may refer to the broader ‘norms, rules, ideas and processes in a system’ within which organizations exist (Austin et al., 2023), in this paper we make no distinction and consider institutions and organizations as synonyms On the one hand, strengthening the field of HPSR would require highly competent researchers, but researchers also need the support of well-functioning organizations to perform well (Shroff et al., 2017). On the other hand, the strength of HPSR as a system would depend on the development of organizations and their positionality and interactions with other actors in the system. The literature on organizational development in general is replete with resources, including the Baldrige Excellence Framework developed in the United States to assess the performance of healthcare organizations (US Department of Commerce, NIST, 2010; Beitsch et al., 2015). However, there are few studies on organizational development specifically for HPSR. This gap has emphasized the need for useful guidance on what organizational capacity assessment for HPSR would require, and how this process could be used to inform programmes to foster organizational development. Hereafter, we label organizations that perform HPSR as ‘HPSRIs’ (pronounced as ‘hip-srees’), i.e. ‘Health Policy and Systems Research Institutions’.
Analysing the capacities of HPSRIs is a process that is not straightforward. Although there is a broad definition provided by the Alliance for HPSR, the field still suffers from varying interpretations, which negatively impact how the field is perceived in terms of scope and rigour (Shroff et al., 2017). HPSR is multi- and inter-disciplinary in approach, deploying a wide spectrum of methods, contextual in the application of its findings, tackling various questions at multiple points of the research-to-policy cycle (Sheikh et al., 2011), and characterized less by its methods and more by its instrumentality to bridge research and policy (Bennett et al., 2011). Thus, it also remains unclear which types of organizations qualify as ‘HPSRIs’. It is rare for research organizations to do HPSR exclusively, or explicitly label themselves as an HPSR organization. Some of HPSR is undertaken by researchers in an organization that conducts other types of research (e.g. policy think-tanks or institutes for development) or in a non-HPSR-specific unit within a larger unit (e.g. either a department of health economics or health policy in a school of public health). It also remains to be explored which specific organizational functions of HPSRIs warrant evaluation to assess capacities comprehensively, although what is apparent from the literature is that HPSRIs should go beyond the function of conducting research alone. Clarifying to what extent these ‘other’ organizational functions, such as engaging stakeholders or communicating research findings, should be expected of HPSRIs can guide how these organizations should be further shaped by the authorities that have the mandate to steer the HPSR ecosystem. Developing guidance to analyse the capacities of HPSRIs should involve a process to identify and profile such organizations and understand their functions, which could put HPSR into a prominant position and encourage more organizations to commit to HPSR rather than to do so only when commissioned by governments or funders (Bennett et al., 2011).
Why a framework for analysing HPSRIs?
Frameworks provide a structure or overview of different categories and the relations between them that are relevant to a particular issue at hand, although they do not serve as an explanatory model for a phenomenon or a mechanism for change (Nilsen, 2015). A conceptual framework will indicate the desired organizational attributes of HPSRIs based on their functions and provide a structured approach to capacity assessments and a point of reference for benchmarking of performance between HPSRIs. Through the auspices of a regional or national authority (e.g. Ministry of Heath, research council or a regional network/consortium), a framework can also bring HPSRIs together to address shared challenges and collectively manage their performance in an informed manner. Furthermore, from the perspective of national governments and development partners, the results of capacity assessments are critical to guide investments that target capacity-strengthening for HPSR.
Our goal in this study was to develop a conceptual framework for organizational capacity assessment for HPSR by addressing the following research questions. (1) What are HPSRIs and what are their functions? (2) What are the organizational attributes of HPSRIs with robust capacities? (3) How can we assess organizational attributes to inform organizational capacity-strengthening in HPSR? In doing so, we sought to influence the trajectory of the field of HPSR by advancing the idea of well-performing HPSRIs that ensure fidelity to the overall goal of the field of HPSR to ‘achieve collective health goals and contribute to policy outcomes’.
Methods
Project design and setting
As part of a regional initiative in Asia to shape the future of HPSR in the region (Health Systems Strengthening Accelerator, 2024), we implemented a multi-method project in the Philippines where the Department (Ministry) of Health (DOH), has taken the responsibility to develop the domestic HPSR community in support of evidence production and utilization for health policy on a national scale (Sales et al., 2023). Strengthening HPSR has a legislative basis under the Universal Health Care (UHC) Act (Republic Act 11 223) which has served as a policy window for the DOH, together with other government entities, to establish mechanisms that integrate evidence into policy and decision-making, including advancing HPSR, in the country (Department of Health of the Philippines, 2019).
An institutional partnership for the project was formalized through a memorandum of understanding between the Alliance for Improving Health Outcomes (AIHO) (AIHO 2024), a non-government organization in the Philippines focused on health systems strengthening, and the Health Policy Development and Planning Bureau, the unit within the DOH with the mandate to develop and coordinate sectoral strategies for health research and policy development in the country (Department of Health of the Philippines, 2017). The project had three main components: (1) a qualitative study that analysed the perspectives of organizations that play various roles in HPSR; (2) a conceptual framework development workshop that involved researchers, policymakers and programme implementors; and (3) development of a survey instrument to identify indicators and assess the capacities of HPSRIs based on a set of organizational attributes.
The research proposal received technical approval from the Health Systems Strengthening Accelerator (Health Systems Strengthening Accelerator, 2024) and ethics approval from the DOH Single Joint Research Ethics Board in the Philippines (SJREB-2023-01).
Qualitative study
Interview guide
We prepared an interview guide that set out to explore the perspectives of key informants regarding: (1) their understanding of HPSR as a field; (2) how they would define an organization that performs HPSR and its functions; (3) the desired attributes of an organization that performs HPSR; (4) their strengths and weaknesses as an organization performing HPSR; and (5) their ideas for potential strategies to strengthen their organizational capacities for HPSR (Interview Guide in supplementary File 1, see online supplementary material).
Key informants
We used purposive sampling to identify key informants from different types of organizations, both public and private, including research organizations, policy development or programme implementation organizations, educational or training organizations, and funding or development agencies. We performed in-depth interviews in the first quarter of 2023 with 33 informants, which was the stage when the project team ascertained that data saturation was reached (Saunders et al., 2018). Informants were comprised of representatives from academia (11), research organizations (9), funding and development agencies (6), programme managers and practitioners (5), and policymakers (2). All interviews were conducted via Zoom (Zoom Inc., San Jose CA, USA) in English or Filipino.
Analysis
We transcribed the audio recordings into Microsoft Word (Microsoft Corp., Redmond WA, USA) using Trint (Trint Ltd, London, UK), after which a team of research assistants reviewed the transcripts to detect and correct errors manually. We did not a priori align with a theory but implemented a deductive approach for the analysis based on: (1) the definition of HPSRIs; (2) functions of HPSRIs; (3) desired attributes of HPSRIs; (4) strengths and weaknesses of HPSRIs; and (5) strategies to strengthen the capacities of HPSRIs. We followed the methods of framework analysis as described by Gale et al. (Gale et al., 2013). Four co-authors reviewed the transcripts independently to familiarize themselves with the content and to identify initial codes. We created a matrix on a shared Google Sheet (Google LLC, Mountain View CA, USA) that served as our charting tool to organize quotes according to categories. A sample sheet showing how charting was organized with selected excerpts from interview transcripts can be found in supplementary File 2 (see online supplementary material). The shared spreadsheet allowed the members of the team to engage with the data simultaneously to identify patterns, including repetitive themes, and the categories that contained the most quotes. The team met virtually to discuss the themes that would be used as material for discussion in a subsequent workshop.
Framework development
Workshop participants
We convened an in-person workshop in Quezon City, Philippines in the second quarter of 2023 with 17 purposively selected stakeholders who represented various organizations that play a role in HPSR: five policymakers from the DOH at the national level; one programme implementer from the DOH at the regional level; one senior manager from the national health research council; three senior and four junior researchers from three different non-government research organizations; one college dean from a public university; one emeritus professor from a private university; and one early-career researcher from a foreign university. We also invited one senior government official (undersecretary of health or deputy minister of health) and one country representative of a development partner (United States Agency for International Development) as guests who commented on the outputs at the end of the workshop.
Process
The specific objectives of the workshop were: (1) to define what HPSRIs are and determine their functions; (2) to describe the organizational attributes of robust HPSRIs and organize these attributes in a conceptual framework; and (3) to explore indicators for assessing the capacities of HPSRIs based on the framework. The stages of the workshop included the following.
Orientation to organizational mandates
Participants introduced their respective organizations and described their overarching mission and their activities in HPSR.
Review of DOH initiatives to advance HPSR
Representatives from the DOH presented an overview of past and current initiatives to promote and strengthen the HPSR community in the Philippines. This phase ensured that the framework to be developed would closely align with future DOH plans for advancing HPSR at the national level.
Discussion on the definition and functions of a HPSRI
First, the project team presented the themes from the qualitative study to highlight key issues affecting capacity building for HPSR at the organizational level. These themes included the common organizational functions reported during the in-depth interviews. Across the different groups of key informants (i.e. educators, researchers, funders, practitioners and policymakers), workshop participants identified research as a cross-cutting function. Second, workshop participants reviewed the scope of the field of HPSR based on the definition from the Alliance for HPSR. Third, workshop participants reviewed the mandates and activities of five illustrative organizations in the Philippines to explore what it would mean for an organization to be a ‘HPSRI.’ These organizational examples included: Institute of Health Policy and Development Studies of the University of the Philippines (UPM-NIH, 2024), AIHO (AIHO 2024), Zuellig Family Foundation (ZFF, 2024), Health Justice Philippines (HealthJustice Philippines, 2024) and the Philippine Council for Health Research and Development (DOST-PCHRD, 2022). Workshop participants noted that the first three conduct research in the field of HPSR, while the latter two organizations do not conduct research per se but rather perform advocacy and research governance, respectively. The discussions in comparing these organizations, in light of the Alliance definition for HPSR and the findings from the in-depth interviews, led to the participants’ consensus to define a HPSRI as an organization that conducts research as its minimum essential function. We reached consensus on the definition of HPSRIs not through formal voting but in the absence of objection from any workshop participant (UN Dag Hammarskjöld Library, 2024). Our consensus meant that other organizations, such as those that provide funding for HPSR or perform advocacy based on HPSR but do not, in practice, conduct research, would not be considered HPSRIs. However, participants also recognized that other essential functions on top of the research function may characterize a well-capacitated HPSRI depending on its primary mandate and strategic priorities. To identify these other organizational functions, participants examined the positionality of HPSRIs across the policy-action cycle (Macaulay et al., 2022) and analysed the relations between the various organizational functions through a group activity that involved the use of ropes to demonstrate interlinkages between the functions (Figure 1). Finally, participants mapped the interactions of a hypothetical HPSRI with other institutional actors in the HPSR ecosystem to identify bottlenecks in processes that affect their performance (note: we use ‘ecosystem’ to refer to the HPSR network where a HPSRI is positioned while ‘system’ refers to the broader scope of interactions beyond HPSR).
Participants mapping the roles of organizations across the policy action cycle (top) and analysing the interlinkages between organizational functions and attributes (bottom) during a workshop in Quezon City, Philippines (April 2023)
Visualizing the conceptual framework
Participants translated the organizational functions into organizational attributes and identified eight organizational attributes of a well-capacitated HPSRI. A conceptual framework was visualized by structuring the eight organizational attributes into four domains. Here we made a distinction between an organizational function, attribute and capacity where ‘function’ referred to what a HPSRI does (e.g. conducting research) while ‘attribute’ referred to the quality of performing the function (e.g. excellent research) and ‘capacity’ referred to the extent an organization meets the attributes expected of it (e.g. an organization has a high level of capacity if it conducts research in an excellent way).
Exploring potential indicators
The last part of the workshop involved exploring preliminary indicators or metrics that could be used to assess the attributes of HPSRIs based on the framework.
Development of survey instrument
We developed a survey instrument based on our framework by initially expanding from the questionnaire previously used by Tangcharoensathien et al. to assess HPSR capacities in Ethiopia and Ghana (Tangcharoensathien et al., 2022) and adding our own questions. We re-organized the survey questions according to the eight attributes outlined by our framework. The survey instrument was designed as a self-administered tool to be answered by the head, manager and/or a qualified representative of an organization. The first section of the survey involved a list of questions to characterize the administrative configuration, mission and activities of the organization to determine whether it performs HPSR and, thereafter, whether it could be considered as a HPSRI. Organizations considered to be HPSRIs continued with the rest of the survey to provide both quantitative and qualitative information that describes their performance in eight organizational attributes. The complete survey instrument can be found in supplementary File 3 (see online supplementary material). The conceptual framework and its accompanying survey instrument were also shared with collaborators in Nepal and have been adapted according to their context to explore the applicability of the framework for HPSRIs in other LMIC contexts. Findings from the survey of HPSRIs in the Philippines and the use of the framework in Nepal will be reported in separate publications.
Results
Defining the organizational model of a HPSRI
We define a HPSRI as an institution or organization that conducts research based on HPSR as its minimum essential function. It was not our intent here to reiterate the definition of HPSR beyond how the Alliance has already defined the field (Alliance for Health Policy and Systems Research, 2024) in addition to other references on defining HPSR based on the framing of the research questions (Sheikh et al., 2011) and the methods used to answer these questions (Gilson et al., 2011; Gilson, 2012). We further define a HPSRI as a formal group of individuals that perform HPSR, whether as a standalone organization or as a unit within a larger organization that is constituted through some form of regulation, rules, bylaws or statutes. Therefore, we do not consider an organization where only a single, individual researcher is conducting HPSR, or an ad hoc group or a loose association of individuals who perform HPSR, as HPSRIs. Organizations that do not de facto perform research but perform related functions, such as training, advocacy or funding for HPSR are also not HPSRIs but are considered as other institutional actors in the HPSR ecosystem.
Our definition of HPSRIs supports the idea that organizational functions in addition to performing research are necessary for HPSRIs to be well-capacitated in meeting the overall goal of HPSR, including the organization’s capacity to lead and manage its operations, inform policy development and network with other actors in the HPSR ecosystem. These functions were translated into eight organizational attributes structured into four domains as summarized by our conceptual framework for capacity assessment (Figure 2). The following sections describe each of these organizational attributes and outline selected indicators from the survey instrument to assess capacities around these attributes.
Conceptual framework for analysing the organizational attributes of HPSRIs towards the purpose of HPSR to achieve collective health goals and contribute to policy outcomes
Domain A: research expertise
This domain refers to a HPSRI’s capacity to perform its essential function of research that is not limited to a single discipline or methodological approach. A HPSRI with robust capacities in this domain has the attributes of ‘excellent research’ and a ‘capacity-building driven’ organization. The following quote from the interviews illustrates how HPSRIs perceive their important role in advancing research and facilitating capacity building in research skills.
‘[We] teach students how to do research or provide them with the experience and appreciation to do research because [their] perception sometimes of research is [that it is] difficult “academic research” but in reality, research is fun, not [something] to be afraid of in developing as a skill.’ (Associate professor in a department of health policy and administration in the national university).
Attribute 1: excellent research
A HPSRI with excellent research produces high-quality research as evidenced by its research publications and other forms of research products that tackle various issues in HPSR, draw from international evidence, and withstand the scrutiny of peer review or quality control. It is comprised of a highly skilled and multi-disciplinary research staff with expertise in a wide range of methods as demonstrated by their advanced training and their postgraduate qualifications. Possible indicators to assess the attribute of excellent research are summarized in Table 1 (see also supplementary File 3 for the complete list of indicators).
Selected indicators for assessing the eight organizational attributes of HPSRIs (full list of indicators available in supplementary File 3)
| Domain | Organizational attributes | Selected indicators |
|---|---|---|
| Research expertise | Excellent research |
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| Capacity-building driven |
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| Leadership and management | Efficient administration |
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| Financially sustainable |
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| Policy translation | Policy orientation |
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| Effective communication |
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| Networking | Participatory approach |
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| Convening influence |
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| Domain | Organizational attributes | Selected indicators |
|---|---|---|
| Research expertise | Excellent research |
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| Capacity-building driven |
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| Leadership and management | Efficient administration |
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| Financially sustainable |
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| Policy translation | Policy orientation |
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| Effective communication |
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| Networking | Participatory approach |
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| Convening influence |
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Selected indicators for assessing the eight organizational attributes of HPSRIs (full list of indicators available in supplementary File 3)
| Domain | Organizational attributes | Selected indicators |
|---|---|---|
| Research expertise | Excellent research |
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| Capacity-building driven |
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| Leadership and management | Efficient administration |
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| Financially sustainable |
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| Policy translation | Policy orientation |
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| Effective communication |
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| Networking | Participatory approach |
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| Convening influence |
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| Domain | Organizational attributes | Selected indicators |
|---|---|---|
| Research expertise | Excellent research |
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| Capacity-building driven |
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| Leadership and management | Efficient administration |
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| Financially sustainable |
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| Policy translation | Policy orientation |
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| Effective communication |
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| Networking | Participatory approach |
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| Convening influence |
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Attribute 2: capacity-building driven
A capacity-building driven HPSRI makes concrete efforts to support the further training and continuing professional development of its staff. Such efforts are best sustained through the existence of internal procedures that enable staff to apply for training opportunities that the organization may be able to support directly or indirectly. The following quote also illustrates the importance of ensuring multi-disciplinarity in building the capacities of HPSRI staff.
‘The key is multi-disciplinarity. My background is clinical epidemiology and infectious diseases and HPSR cannot be done by just clinical epidemiologists. So [we] involve economics, [because] there are health financing questions. We also have social scientists… An example of a HPSRI that I would cite has a cadre of very well-trained researchers in various disciplines.’ (Professor emeritus in the national university who was also involved in the development of the Alliance for HPSR).
Domain B: leadership and management
We include leadership and management as an important domain because the capacity of HPSRIs to produce high-quality research is also negatively impacted by a lack of planning, administrative inefficiencies and unsustainable funding streams. The following quote illustrates why most organizations consider efficient management as important.
‘Let’s say we just get a grant for an entire year that already includes [budget for] training, developing the research methods and hiring researchers from different fields and from different institutions, but that [timeframe] is not going work with poor administration’ (Research group leader in a national health policy institute).
We combined leadership and management during the workshop into one domain to keep our conceptual framework simple as these two notions are related although distinct (Gavin, 2019). Leadership refers to the HPSRI’s capacity to plan strategically and set a vision for the organization, while management refers to the capacity to operate efficiently to support the timely completion of projects and ensure financial sustainability. A HPSRI with robust capacities in leadership and management has the attributes of ‘efficient administration’ and a ‘financially sustainable’ organization.
Attribute 3: efficient administration
A HPSRI with efficient administration undertakes a regular exercise to set a vision and a strategic agenda for the organization. It also absorbs a portfolio of HPSR projects that matches its administrative capacity to deliver satisfactory completion of these projects, including flexibility to adapt implementation when required by the circumstances.
Attribute 4: financially sustainable
A HPSRI that is financially sustainable has a range of revenue streams, including core funding, rather than relying only on external grants to support HPSR projects, hire staff for the long term, and invest in equipment and infrastructure. Information to assess leadership and management are also presented in Table 1.
Domain C: policy translation
Policy translation refers to a HPSRI’s capacity to facilitate the translation of its research findings to influence policy development or decision-making, making it the domain closest to the main purpose of HPSR to contribute to policy outcomes. A HPSRI with robust capacities in this domain has the attributes of ‘policy orientation’ and ‘effective communication’. The following quote illustrates why stakeholders considered this domain as important.
‘Communication is a challenge, [but] we need to do the research and communicate the research results so that we will influence policymakers, [and] advocate for new or enhanced policies. Communication should [also] target the people so that people understand policy’ (Former vice chancellor for research of a university).
Attribute 5: policy orientation
A HPSRI with policy orientation nurtures a working relationship with policymakers in government and regularly facilitates activities to broker knowledge and provide recommendations to decision-makers to influence policy development or programme implementation.
Attribute 6: effective communication
A HPSRI with effective communication converts its research outputs into other forms of knowledge products with less technical jargon and deploys a communications strategy to promote its work to reach non-researchers and other stakeholders in accessible and comprehensible ways.
Domain D: networking
The domain for networking emphasizes that HPSRIs do not function in isolation from the same health systems they seek to understand and are positioned always in relation to other institutional actors. A HPSRI that is well-capacitated in networking has the attributes of a ‘participatory approach’ and ‘convening influence’. The following quote illustrates how one stakeholder appreciated the importance of participation in the organization.
‘[Being] participatory as research organisation is about [giving] the beneficiary, the target population, a say about the research design and their views [are] taken into consideration as part of the research. We require voices from many stakeholders, many perspectives and angles, which make us transparent and also accountable for [the] recommendations from our research’ (Coordinator of a non-government organization focused sanitation and nutrition in schools).
Attribute 7: participatory approach
A HPSRI with a participatory approach can engage an array of stakeholders not only to communicate the findings from research projects but also to foster a relationship with stakeholders in the entire research cycle. A participatory HPSRI makes a constant effort to be inclusive in bringing in the voices of stakeholders, from the conceptualization of research questions to research implementation and until policy translation or programme implementation.
Attribute 8: convening influence
A HPSRI with convening influence can bring different stakeholders together for evidence-informed debates and constructive dialogues, as well as catalyse collective action to improve health policies and programmes. Table 1 includes some of the information to assess both these attributes for networking.
HPSRIs’ positionality and relations in the ecosystem
We present an illustration from our mapping during the workshop of the positionality of a HPSRI and its interactions with other institutional actors in the HPSR ecosystem (Figure 3).
Illustration of the position of a HPSRI and its interactions with other institutional actors in the ecosystem
Every HPSR project begins with a health policy problem or question that drives the conduct of research by HPSRIs, the end goal of which is to contribute to collective health goals and policy outcomes. The capacity of HPSRIs to deliver impact from the initiation of policy inquiry to policy development depends not only on its organizational attributes but also on the quality of its interactions with other institutional actors in the HPSR ecosystem. HPSRIs nurture a relationship with funding or development agencies to finance their research projects; technical and ethics review committees to ensure the quality and integrity of their research projects; educational or training institutions to strengthen the competence of their staff; civil society organizations to advocate for the recommendations arising from their research; and policymaking and implementing agencies to translate their research into policies and programmes. Bottlenecks that exist in any of these relationships would adversely impact the capacities of HPSRIs to perform well. For example, a HPSRI may have the attribute of excellent research and be capacity-building driven, but with bottlenecks in its links to funding or development agencies there may be fewer opportunities to venture into new research programmes, which does not maximize the organization’s research expertise. In another scenario, a HPSRI may have strong capacities for leadership and management as an organization, with sustainable financing and efficient administration, but with poor relations with policymaking and implementing agencies very few of its accomplishments feed into improving health policies and programmes. The use of the framework to assess the organizational attributes of a HPSRI should be combined with an examination of the quality of a HPSRI’s relations with other institutional actors to identify and address any bottlenecks in interactions that affect its performance. Finally, a national or regional authority should be identified and assigned with responsibility as the oversight agency that steers the entire HPSR ecosystem where HPSRIs and other organizations interact with each other. In the Philippines, we have identified this as the DOH, which has assumed the mandate of fostering the HPSR community.
Discussion
First, our conceptual framework offers a structured approach to organizational capacity-strengthening with clarity on the desired attributes to aspire to and the measures to assess these attributes. The framework and its accompanying survey instrument offer a tool for HPSRIs to undertake self-assessments, although the utility of the framework may not be limited to LMICs but may also be useful as a reference for HPSRIs to adapt in their contexts, including those in high-income countries. The framework provides a platform for HPSRIs to reflect on the attributes they are good at and the attributes where there is room for improvement. There is a need to explore additional ways to assess each of the eight organizational attributes which, because of their complexities, are not always measured directly by our survey tool. The framework does not provide a basis to develop a summative measure of HPSRI performance (e.g. a composite index or a scoring system that ranks HPSRIs). Summative quantitative measures defeat the purpose of an in-depth understanding of the various aspects of organizational capacities. Rather, the framework might serve as a dashboard for HPSRIs to use to guide their development as learning organizations (Sheikh and Abimbola, 2021).
Second, based on consensus among stakeholders in the Philippines, the minimum essential function of HPSRIs is research, but HPSRIs need to develop capacities in other research-enabling functions outlined by our framework. There remains a tendency to focus on publications as a metric of organizational performance in HPSR. HPSRIs are not to be recognized only for their ability to publish quality papers but also for their capacities for leadership and management, policy translation and networking. The importance of strengthening both research and research-enabling capacities aligns with Schleiff’s individual competencies for HPSR that included relational skills and character in addition to research competencies (Schleiff et al., 2022), and Mirzoev’s emphasis on the importance of researchers working with various stakeholders to strengthen the HPSR ecosystem (Mirzoev et al., 2022). The idea of HPSRIs with multi-functional capacities also resonates with recent discussions outside the field of HPSR about new organizational models to maximize impact in the public health space, such as the recommendation that national public health institutes be responsible for fostering multi-sectoral linkages beyond their essential public health functions (Zuber et al., 2023); the suggestion for higher educational institutions to become hybrid organizations that do both research and implementation to attain the Sustainable Development Goals (Saric et al., 2023); or the emerging model of knowledge-brokering organizations that span the boundaries of research, translation and policy (MacKillop and Downe, 2023). With the assumption that HPSRIs operate at the nexus of research, management, policy and networks, and that each of these domains reinforce one another through synergy, multi-functional HPSRIs can be positioned to play impactful roles in advancing socially just and people-centred health systems (Gilson et al., 2020). Although we recognize that the performance of HPSRIs vary depending on the context in which they find themselves, the organizational attributes in the conceptual framework are broad to facilitate an analysis of different aspects of capacities of HPSRIs across contexts. As demonstrated in this study, organizational capacities based on the framework must be combined with an analysis of the positionality of the HPSRI in the ecosystem, as HPSRIs will vary in their mandates, priorities and capacities based on several factors including their level of operation (international, national or subnational), ownership (public, private or hybrid) or typology (academic, think tank, civil society organization, etc.), among others. The conceptual framework provides a platform to assess organizational capacities regardless of the HPSRI typology, and leaves the HPSRI with the flexibility to decide for itself in which domains it might want to strengthen itself as an organization.
Third, our study highlighted the role of a national or regional authority (e.g. government agency) in fostering the HPSR community. In the case of the Philippines, this role has been fulfilled by the DOH through the policy window offered by the passage of the UHC Act. In other countries, their ministries of health or science, or their national institutes for health and national research councils could potentially fulfil the role. Because there is usually a ‘wax and wane’ cycle in interest in the value of HPSR, having a national agency for cultivating HPSR means there would be sustained attention on and resources for organizational and network development across the country as part of shaping an overall supportive environment for HPSRIs. Depending on the extent to which the political governance structure of a country allows, having a national or regional authority with a mandate to foster the HPSR community can help ensure that relationships between HPSRIs and other actors in the ecosystem are functional, rather than assuming an ‘invisible hand’ that will move the HPSR ecosystem to develop organically. The involvement of a national agency also ensures government ownership of capacity-strengthening efforts and translation of research findings into a concrete policy for advancing HPSR on a national scale, as evidenced by the revised DOH policy called ‘AHEAD with HPSR Program’ which was informed by results from this study (Department of Health of the Philippines, 2024) and which was an iteration of the national programme to advance HPSR in the Philippines (Staff Reporter 22 January 2024, Lopez et al., 2019).
Finally, we acknowledge that the framework is not a theory of change but only determines ‘what’ organizational attributes are important. Further studies are needed to understand ‘how’ HPSRIs could best achieve these attributes. In the Philippines, the findings from the survey of HPSRIs will be used by the DOH to better understand the collective capacities of domestic HPSRIs. The framework has also served as a platform for the DOH to convene HPSRIs in selected regions to give them dedicated time to undertake self-assessments, prepare their respective organizational capacity-development plans, learn from the experiences of other HPSRIs, and guide subsequent co-creation activities towards forming stronger networks of HPSRIs to facilitate mutual learning and collaboration to address shared challenges. Governments and development partners may also use this framework to guide investment decisions that go beyond the usual focus on individual-level capacity-strengthening through funding instruments or partnering arrangements that support organizational development and incentivize interventions that will move HPSRIs closer to attaining the eight attributes of our framework. Follow-up studies are needed to monitor improvements in the capacities of HPSRIs in different LMIC contexts as an outcome of these efforts—which need to be sustained as changes will take time.
Conclusion
Sustainable capacity-strengthening for HPSR must address individual-, organizational- and system-level capacities. Capacity-strengthening of organizations for HPSR needs a structured approach that allows an assessment of their capacities across multiple functions and helps them enhance their agency to achieve desired organizational attributes. Well-capacitated HPSRIs serve as a home for nurturing the competencies of individual researchers in HPSR and as important actors working with other actors in a functional HPSR ecosystem. With an evidence-informed process to support their organizational development, HPSRIs at the nexus of research expertise, leadership and management, policy translation and networks could better manage their performance to achieve the main purpose of HPSR to ‘contribute to collective health goals and policy outcomes’.
Supplementary data
Supplementary data is available at HEAPOL Journal online.
Data availability
All relevant data are included in the article and in the online supplementary files. The complete interview transcripts cannot be made publicly available without indirectly revealing the identities of informants. Anonymized excerpts from the interview transcripts and related data from this study may be made available through a formal request to the corresponding author.
Funding
This article is an output from a research collaboration entitled ‘Forum for Advancing Better Health Policy and Systems Research Institutions’ (FAB-HPSRIs) supported by the Health Systems Strengthening Accelerator, Results for Development, and the United States Agency for International Development (USAID) (contract no. R4D-001482-001). The Department of Health of the Philippines provided counterpart funding to support project activities in Manila. H.J.L. and A.F. acknowledge the financial support of the Lindenhof Foundation. The publication of this article was funded by the open-access fund of the University of Bern and swissuniversities.
Acknowledgements
We thank Undersecretaries Lilibeth David and Kenneth Ronquillo and Directors Frances Mamaril and Lester Tan of the Department of Health of the Philippines for supporting this initiative. We acknowledge the assistance in data collection provided by Carlo Lumangaya. We also acknowledge the contributions of the participants in the workshop in Manila on 13–14 April 2023, namely, Manuel Dayrit, Paul Ernest De Leon, Anna Leah Dipatuan, Fernando Garcia, Joseph Lachica, Erika Modina, Leonido Olobia, Gloria Nenita Velasco, John Q. Wong and Maria Eufemia Yap, and the secretariat support from Ghelvin Aguirre and Xyllea Abanilla. We thank Sushil Baral, Achyut Raj Pandey and Bipul Lamichanne of HERD International, Nepal for their feedback, Amanda Folsom, Kavita Hatipoglu and Leah List of Results for Development, USA and Aku Kwamie of the Alliance for Health Policy and Systems Research for supporting the learning process, and Vivian Lin of the University of Hong Kong for her insights on the discussion of findings.
Author contributions
H.J.L. conceptualised the study and co-led project development and implementation with K.A.R. and P.J.A. F.R.A.F. performed data collection with the assistance of R.L.T. H.J.L., F.R.A.F., K.A.R. and P.J.A. led data analysis and interpretation with intellectual contributions from R.L.T., L.D.V., R.L.C.-G. and A.F. R.L.T. and R.L.C.-G. provided technical and administrative support to project implementation. H.J.L. led the framing and writing of the manuscript with assistance from F.R.A.F. and R.L.T. All authors contributed to the initial drafting and subsequent revision of the manuscript and approved the final version. HJ.L. acts as the guarantor.
Reflexivity statement
We ensured gender and institutional balance by including three male (H.J.L., R.L.T., P.J.A.) and five female (F.R.A.F., K.A.R., L.D.V., R.L.C.-G., A.F.) authors who represent a range of institutional types, including academic (H.J.L., F.R.A.F., K.A.R., R.L.T., L.D.V., A.F., P.J.A.), private research (H.J.L., F.R.A.F., K.A.R., R.L.T.) and national government institutions (L.D.V., R.L.C.G., P.J.A.). The authorship team is multidisciplinary as evidenced by expertise in global health systems (H.J.L.), medical anthropology (F.R.A.F.), health systems and health promotion (K.A.R.), public health (R.L.T., L.D.V.), health policy and research management (R.L.C.-G.), social science and community health (A.F.), and health policy, research management and research ethics (P.J.A.). Although 4/8 authors report affiliations in high-income countries, namely, Switzerland (H.J.L., A.F.), USA (K.A.R.) and Australia (L.D.V.), most authors (7/8) (H.J.L., F.R.A.F., K.A.R., R.L.T., L.D.V., R.L.C.G., P.J.A.) also report joint affiliations in the country of study (Philippines), which ensured the inclusion of perspectives from both the Global North and South. In terms of career stages, 3/8 are junior researchers (F.R.A.F., R.L.T., R.L.C.-G.) and 5/8 are early- and mid-career researchers (H.J.L., K.A.R., L.D.V., A.F., P.J.A.).
Ethical approval.
The study proposal and informed consent forms were approved by the Single Joint Research Ethics Board, Department of Health, Manila, Philippines (SJREB-2023-01).
Conflict of interest:
The findings from this study include an analysis of the governance role for health policy and systems research of the Department of Health of the Philippines where three of the authors (L.D.V., R.L.C.G. and P.J.A.) are employees.
