What role can health policy and systems research play in supporting responses to COVID-19 that strengthen socially just health systems?

Abstract

To say that we live in turbulent times is a massive understatement. COVID-19 ruthlessly exposes the fault lines of health services and systems, and the responses put in place to prevent its spread or mitigate its effects may affect people more than the actual infection. The outbreak in Wuhan quickly grew to a pandemic that has affected countries and regions all over the world in many, and as of yet, little understood ways. This is a global infectious disease outbreak of a scale not seen since the Spanish Flu. For many countries, it is an extreme stress test of the health system and of society at large. All over the world, people, patients, providers, health service managers, health and other sectoral policymakers and politicians, are dealing with high levels of uncertainty and severe challenges to the resilience of their systems. The governance not only of health, at national and global levels, but also of trade, communication and globalization itself is under scrutiny. The virus exposes, yet again, the structural determinants that lead to health inequalities (Shadmi et al., 2020), including racism and colonial legacies. Many see this as a key moment of reckoning, nationally and globally: the pandemic and its responses have precipitated unprecedented economic, social and health crises that may shape the decades ahead. At the same time, the role of health systems in responding to COVID-19 and the need to (re-)invest in these systems through the state offers transformative opportunities. In the light of this, we outline how health policy and systems research (HPSR) can both address current short-term challenges, and support the system transformations needed to strengthen people-centred and equitable health systems over the long term. The HPSR community has responded to the COVID-19 pandemic quickly, following the wave of publications on epidemiological and clinical aspects of the disease. Initial studies have included those describing the capacity of hospitals, intensive care units and first line health services required to respond to the disease, and those reporting specific experiences at community and local levels, including the denial of care and the inequitable effects of disease control measures. Many commentaries and calls for action have been published (COVID-19 Clinical Research Coalition, 2020; English et al., 2020; Shamasunder et al., 2020). Inevitably, however, due to the acute nature of the crisis, few papers have yet focused on how health systems are coping with or adapting to the pandemic, or how health policy-making and decision-making has (or has not) changed in this time of crisis. Yet, there is an urgent need to develop a structured research agenda to inform health policy and system responses to COVID-19 that can move us beyond the current crisis, and into the future. This commentary makes proposals towards such an agenda. In line with the audience of Health Policy and Planning, we specifically focus on low- and middle-income country (LMIC) HPSR needs, drawing on our collective experience as a group of HPS researchers based around the world. The Health System Research and Health Policy Processes section editors initiated the process and purposefully sought inputs from HPS researchers in a range of LMICs . The process was also supported by both the Alliance for Health Policy and Systems Research and Health System Global. We organized an online consultation process, whereby the first authors invited the co-authors to identify research priorities, questions and themes. In a second round, these were compiled and categorized in themes and sent out for further comment. In a final round, the issues and questions within each theme were examined and gaps and overlaps eliminated. We consider, first, key dimensions of the overall approach of HPSR to frame the further work needed, and second, in an annex, we suggest an initial categorization and listing of possible research topics. We present these ideas to prompt wider reflection—and we conclude by proposing ways of engaging further with these ideas, acknowledging the fast-changing nature of the pandemic and the need to review research priorities regularly. We start by reviewing how the defining features of HPSR, including the systems approach, multi-disciplinarity and the emphasis on policy and power may be applied to the pandemic. One defining feature of HPSR is its systems approach. This frames COVID-19 and the responses to it in a critical–analytical perspective, zooming out from specific experiences to seek the root causes of the differential impact of the pandemic across individuals and population groups as a function of society’s power structures and dominant cultures—as reflected in their social, political and economic position, and their race, gender, caste, class and more. Groups that become vulnerable due to systemic and structural inequities include those living in informal settlements in cities or in geographically isolated areas, informal workers, migrant and refugee communities, people without citizenship rights, sex workers, single-women households, LGBTQI+ communities and indigenous peoples. The systems lens equips HPS researchers to understand how, for such groups, health system fault lines interact with the histories of discrimination and disenfranchisement that underpin other determinants of vulnerability, risks and infection. Some people have already faced worse effects from COVID-19 responses than from (the possibility of) infection itself, due to social exclusion, racism and human rights abuse. Meanwhile, privilege and social networks have largely allowed wealthy elites to avoid the negative social and economic effects of lockdowns, deepening inequalities. Health systems have, in turn, generally been poorly equipped to respond fast enough either to the medical and psychological demands of the pandemic or to the wider public and social action needed to address multiple disadvantage and vulnerability. HPSR is well placed to contribute in understanding the layered causes and effects of the pandemic on people and systems. Identifying how health system gaps and weaknesses interact with the root causes of vulnerability to COVID-19 is a vital responsibility that HPSR needs to shoulder—not only as an obligation of itself (referring to HPSR’s social justice agenda), but also as an opportunity to strengthen health systems in more just and inclusive ways than before. The multi-disciplinary approach of HPSR will be key to this task because of the complex nature of health and its determinants, as well as of health policies and health systems. This multi-disciplinary approach supports consideration of how agents and systems interact and of the inter-connections among the systems relevant to health. These include community, workplace and government systems; health and other government sectors; local, national and global systems and markets, corporate actors and the private sector in its full heterogeneity. HPSR can assist in distinguishing COVID-19-related challenges that are simple problems, from those that are better considered as complex problems and that demand appropriate context-sensitive response strategies. It can also nurture and sustain the systemic responses to COVID-19 and its impacts that are vital for the long-term. It supports a system-based approach in anticipating the collateral effects of policies aimed at responding to the pandemic, generating ideas about how mitigate the damages and optimize the gains. The pandemic specifically demands recognition of the interactions of human, animal and ecological systems. The spill-over of the virus from animal to human reservoirs inevitably calls for a critical exploration of how humans continue to interfere with fragile equilibria in the natural world through urbanization, deforestation and more. Beyond ‘one health’ research, attention should be paid to the dominant economic growth paradigm on health, development, trade, society and the natural world and the role of populist and isolationist ideologies in framing the response. Another defining feature of HPSR is its focus on policy, policy-making and how health systems are nested in and influenced by power dynamics and political forces, histories and cultures: the ‘p’ in HPSR. This is another vital lens for research in the time of COVID-19. It supports inquiry into governance, decision-making and health policy responses in times of crisis, as well as how both to inform and strengthen system change. It encourages consideration of the values driving decision-making and the ethical demands of leadership. In addition, this lens underpins investigation of the political economy of the pandemic response and whether and how health systems and political action align to address the structural determinants of ill health and inequity which COVID-19 exposes. It can expose the lack of accountability towards some marginalized groups and the focus on politically important constituencies, the lack of stewardship/leadership at multiple levels and how efforts towards decentralizing and commercializing health system responsibilities lead to fragmented health systems. It could focus on new forms of sub-national and national governance arrangements and investigate how that deepens community-level and inter-sectoral action for health and societal development. The pandemic forces us to consider governance not only at national level, but also at global level: Should we redefine global health? How can we promote better global leadership to coordinate and enforce efforts across countries, including the need for consideration of global public goods and global health ethics? Drawing on well-established bodies of knowledge and evidence from other disciplines (e.g. political science, policy studies, public administration, sociology, complexity theory, critical studies), HPSR can make major contributions to learning how better to deal with pandemics. But HPSR must also do more than help systems absorb future shocks. It must help establish the foundations of more just, equitable and better health systems—health systems that demonstrate resilience through their capacity to be transformative as they respond to shock and stress. Crucial in this effort will be research around how health systems can be transformed for the better during or in the wake of the pandemic. This includes work around adaptive governance as well as on other fundamental system drivers—such as the health workforce, and information and financing systems. Prioritizing among research topics is not straightforward. Such prioritization must, first, be informed by the views of vulnerable groups, community groups, health system decision-makers and health policymakers in the broadest sense and be situated in specific settings. Below, we discuss a few waypoints that may help in thinking about HPSR priorities in relation to COVID-19. As Marquette (2020) has argued for social science more generally, more immediate needs for research are likely to include understanding the root causes of vulnerability to support response activities and limit their negative effects. However, she notes that even mid- to longer-term research to understand secondary effects and long-term impacts and recovery must start now, accompanied by political analysis, and this will be needed to sustain recovery and support the emergence of new and better systems. Critical to this work will be revealing opportunity, agency and resilience, even in the midst of multi-layered challenges. For HPSR, we can also be guided by our understanding of people-centred health systems. This points, e.g. to the importance of understanding community-level COVID-19 experiences, including the experience of marginalized groups, and considering how system software (including power, trust and values) interacts with other system changes to influence the impacts of COVID-19; examining how health systems and COVID-19 responses may exclude people on the basis of their gender, race, income and other characteristics, and how histories of colonialism and racism underpin such exclusion; analysing the power and influence of ideas and framing, and the role of communication in decision-making at every level; and finally, purposefully considering the political economy influences driving COVID-19 and responses to it . Our research must offer new ideas for future health systems—building evidence around new ways of organizing, new ways of caring, new strategies of health development. In responding to COVID-19 and offering new ideas for future health systems, the HPSR community must also consider how to go about doing research. Issues to be reflected upon include the distribution of power within HPSR communities, the balance between global concerns and priorities on one hand and context-sensitivity on the other hand, the challenge of researching what is essentially a fast moving target, the practical problems induced by the control measures (such as social distancing) when collecting data, and finally the issue of research governance. Power-balancing strategies must be reflected in how the research is done—considering, e.g. with whom and how we collaborate, and what forms of knowledge are valued and enhanced through this work. Research responding to COVID-19 must also be relevant to the contexts in which it is located, and acknowledge the imperatives of this moment. In the short term, then, it must be conducted quickly to address immediate needs, and be fed-back into decision-making rapidly. Innovative knowledge translation efforts and new models of collaborations between research, policymaking and stakeholder organizations are of special interest. Being systematic and rigorous will always be important, but we must capture current experience even as we also develop longer-term research activities. To support such HPSR can on and new ways of doing research. These include research et al., action research et al., action learning 2020), research and policy and All multiple forms of knowledge and for researchers to through with in the response in ways of that for HPSR to help shape the world COVID-19. At the same time, in the response to COVID-19 it always important to consider the ethical dimensions and of ethical and In the we will also need to about research and that can be to and vulnerable groups by online and online from experiences, as they their is and social could be a relevant research forms offer other new ways of and such experience et al., other an online of and studies could be to support the HPSR of secondary and simple work can also important, immediate about social and among other evidence drawing on both and and is into the and process research will be important to out the of is also needed both to understand the current experience and from experience and work can offer into the experience of groups and into responses to inform future action 2020). The of will support understanding of system sub-national or can e.g. on critical governance influences over of experience will also always be important to understand the layered vulnerability of people and systems, and the agency and to and must become a of HPSR et al., it is critical to and research governance at all levels to important, research that supports social justice is possible and is and to identify and limit research. We must also and how research governance and the research that is are by COVID-19 and responses to the research of and is for it is of this will not only work but also papers by and by At another level, how can we contribute to global health for whom in the current research on COVID-19 challenges HPS researchers to and in research that to new health systems for the future. HPSR that current needs and experiences will offer important and both about how COVID-19 impacts on our and about the responses to the pandemic. It can help how these responses and or new for just health systems. The HPSR in LMICs must support in the place and capacity for and nationally research, with appropriate Health and research in LMICs must as needed, be to do Research for must also include communities, patients, providers, health service and health and other policy in to society and HPSR must be an as it is for global health more and these are in that the current a new COVID-19 has just been for the on Health Systems Research the of the HPSR are within its theme of health systems for better health and social and for of the political social, economic and forces and and social In the annex, we also present a of HPSR themes and topics the of importance we have already These range from studies the differential impact on people, disadvantage and to those focused on the impacts on health systems, including studies on governance and system of health system towards better and just health systems. We responses to our ideas and proposals for a HPSR in the of to be published in Health Policy and We also a future for papers for a special issue of this that may and the COVID-19 pandemic and the responses at sub-national and as well as responses by people, communities health and social providers, decision-makers including community and from a analysing COVID-19 responses in of health and social including and on the of decision-making in a time of to the impact of the pandemic and the responses at sub-national and through e.g. studies, policy and decision-making analysis, of is a of the Health and is for the views in the which do not the or policies of the Health ethical was required for this is the of the pandemic and the response on the and of first line services for and by vulnerable groups people with and the and health response services for and LGBTQI+ service is the differential impact of COVID-19 on and how it affect the health of people, and people work from are the impacts of COVID-19 How to sex in and systems to understand the of How to COVID-19 measures to impacts on vulnerable groups, such as those living in informal refugee the and the are the of and how can of those test for COVID-19 and those have from COVID-19 (including health be How in is to trust and of response to a disease How power out in the governance of COVID-19 responses and within new forms of governance and that How do power and the COVID-19 and evidence and knowledge is in decision-making around is the balance of political and and how do governance histories and structures shape this and how and or limit over the and how to address this COVID-19 global health in e.g. more emphasis on global health and from health will COVID-19 in the global political economy of health? COVID-19 to and collective to global health it to of and knowledge and are COVID-19 how this between countries, and what is How is within government and with private agents and and what are longer-term for action on the social determinants of health? are invited to support the what evidence and how is that and over histories and structures shape these is for what and is invited as an and is there policy or through policy in COVID-19 is the role and influence of of experience for including and from communities and health is the role of and and the impact on communication of the of is the of policy communication in a time of crisis, including the framing of the role of and and and the for trust in COVID-19 responses and in policies or that support or vulnerable in COVID-19 responses have been and what decision-making dynamics to the prioritization of these is the impact on the role of in global health How is the global new forms of global leadership are that can assist in and efforts across countries, including the need for consideration of global public goods and global health ethics? is the impact of COVID-19 responses on attention to and of to other health including effects are and how can these be How can critical services be the COVID-19 response in is the impact of COVID-19 on the and health of the health workforce, and of in ways of is the impact of COVID-19 on the of health in the in countries work is the role of including Health in the COVID-19 How is learning for health human How do COVID-19 responses impact on the of system and and with what for system How is the in systems of How are local and national for a pandemic as to natural the COVID-19 pandemic our views on is the impact on changes in global financing and in national health are the changes in and global in health, in health in health system is the role of public in the pandemic are the and of global pandemic financing To HPSR the system we include in this some issues to the and that are are the and gaps between levels of care care during the services during are the role private sector actors in service How can an balance of care be within the health system under How to strengthen workplace health for the health How to for the acknowledging is the place of public health within the wider health and how can it be is the role of national health in the COVID-19 response within is the place of in the health system and in the COVID-19 The issues of infection and control in the to and is the of health information systems in to COVID-19 responses (e.g. models and infectious disease models be with HPSR such as by health systems and the dominant are the ethical and of community based or The required to an COVID-19 and the challenges of and lines The challenges of and distribution of medical in the light of global and local of and The in demand for and information in health in bodies and to COVID-19 and How to address in for whom is and The of and is and with what Health during a pandemic how and which new forms of governance and leadership at local or other levels, work with community organizations and engaging and and and how they are or over is the for COVID-19 e.g. for or from the private sector health actors and and how, with what is the role and place of community-level action for to engaging with and responding to priorities and and beyond health? How can that have been transformative for vulnerable be and through health policy and system into the forms of local develop that address social the social determinants of what are the for more people-centred How the pandemic inform and wider action on and is the role of national and and research in and global health crises How can research governance during crises such as COVID-19 support important, research that supports social How is COVID-19 on is and is the role of global in research and research knowledge translation efforts and models of collaborations between research, policymaking and stakeholder organizations during

Topics & Concepts