Peters Health Research Policy and Systems (2018) 16:84

https://doi.org/10.1186/s12961-018-0359-0

COMMENTARY Open Access

Health policy and systems research: the

future of the field
David H. Peters

Abstract
Health policy and systems research (HPSR) has changed considerably over the last 20 years, but its main purpose
remains to inform and influence health policies and systems. Whereas goals that underpin health systems have
endured – such as a focus on health equity – contexts and priorities change, research methods progress, and
health organisations continue to learn and adapt, in part by using HPSR. For HPSR to remain relevant, its
practitioners need to re-think how health systems are conceptualised, to keep up with rapid changes in how
we diagnose and manage disease and use information, and consider factors affecting people’s health that go
well beyond healthcare systems. The Sustainable Development Goals (SDGs) represent a shifting paradigm in
human development by seeking convergence across sectors. They also offer an opportunity for HPSR to play
a larger role, given its pioneering work on applying systems thinking to health, its focus on health equity,
and the strength of its multi-disciplinary approaches that make it a good fit for the SDG era.
Globally, population health is being challenged in different ways, from climate change and growing air pollution
and toxic environmental exposure to food insecurity, massive population migration and refugee crises, to
emerging and re-emerging diseases. Each of these trends reinforce each other and concentrate their harms
on the most vulnerable populations. Multi-level governance, together with novel regulatory strategies and
socially oriented investments, are key to successful action against many of the new challenges, with HPSR
guiding their design and evolution.
The HPSR community cannot be complacent about its successful, yet short, history. Tensions remain about
how different stakeholders use HPSR such as the contrast between embedding research within government
institutions versus independently evaluating and holding decision-makers accountable. Such tensions are inevitable in
the boundary-spanning field that HPSR has become. We should strive to enhance the influence of HPSR by staying
relevant in a changing world and embracing the strength of our diversity of disciplines, the range of problems
addressed, and the opportunity of the SDGs to ensure that health and social benefits are more inclusive for
people within and across countries.
Keywords: Health policy, Health systems, Health systems research, Sustainable Development Goals

In 1962, Burnet, the Nobel prize-winning immunologist, One safe prediction is that the HPSR landscape will con-
wrote that the twentieth century would be witness to tinue to change and grow in complexity.
“the virtual elimination of infectious disease as a signifi-
cant factor in social life” [1] – a reminder to be humble
when predicting the future effects of health research. The value of HPSR
Nonetheless, the last 20 years has brought impressive The central idea behind HPSR is that research should
change in the growth of health policy and systems re- inform and influence policies and systems to pursue
search (HPSR), and the settings in which it is applied. health goals [2]. Health systems goals and the values that
underpin them are enduring and should continue to be
examined through HPSR. Contexts will change and new
Correspondence: dpeters@jhu.edu challenges will emerge, but research will still be needed
Department of International Health, Johns Hopkins University, Bloomberg
School of Public Health, 615 N. Wolfe St, Suite E-8527, Baltimore, MD 21205, to inform how to achieve the multiple health systems
United States of America goals – improving effectiveness, equity and efficiency,
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Peters Health Research Policy and Systems (2018) 16:84 Page 2 of 4

expanding health services coverage, and enhancing peo- linkages between stakeholders and functions in a health
ple’s financial protection, while minimising costs and im- system, and connections between health systems and
proving accountability and trust. HPSR provides the other related systems (e.g. education, economic devel-
tools for Ministries of Health and other health organisa- opment, ecology, etc.). To apply research to questions
tions to become learning organisations, serving to lead concerned with the linkages across sectors – as envi-
and adapt to changes in the health sector. sioned by the SDGs – it will be more important to con-
sider the roles of people (as individuals, families,
Re-thinking health systems in a changing context communities and larger populations) and the dynamic
The changing context will also challenge how we think connections between policies and systems that affect
about health systems; HPSR should have a central role people both inside the traditional health sector and
in understanding change and how to intervene. The so- through related sectors.
cial, political and environmental conditions for healthy
living are rapidly shifting, as are expectations about the Growing challenges for HPSR
role of the state, civil society and business. Information There are many new issues and evolving roles for differ-
communications and other technologies are transform- ent stakeholders in a health system, as well as novel
ing the diagnosis and management of disease, as well as ways in which we can study and influence health sys-
the collection, analysis and sharing of individual and tems. Globally, population health is being challenged in
population health data. Additionally, there are growing different ways. Ambient air pollution in cities and indoor
population pressures due to environmental degradation, air pollution in rural homes have become important risk
urbanisation and aging along with new threats due to factors for chronic diseases. Food insecurity is again a
emerging diseases and the failure of poorly organised critical public concern, as climate change is projected to
market systems for health services, technologies and fi- decrease crop yields, particularly in South America, Af-
nancial products. Each condition is both a driver of rica, South Asia and Australia, while contributing to in-
change and an effect of another; they are interdependent creased food price volatility [6]. Poor nutrition, exposure
issues in an increasingly interconnected world. to environmental toxins and a resurgence of vector-
The Sustainable Development Goals (SDGs) represent a borne diseases, such as malaria and dengue, are all con-
shifting paradigm in human development, moving from sequences of environmental degradation. The poor are
the building up of individual core sectors within countries especially vulnerable, as they are most exposed to the
to seeking convergence across co-influencing and direct and indirect shocks of environmental degradation,
co-dependent sectors. In a world where wealth inequality are more vulnerable because they lose relatively more
is escalating, the SDGs mark a shift from efforts to provide wealth, and are less resilient because they do not have
overall benefits to a nation to focusing on inclusive growth the financial and social safety nets required to manage
and tackling inequities as the core of development efforts. them and recover [7].
HPSR is well placed to take on these issues of the future The growing phenomenon of antimicrobial resistance
since it has a traditional focus on understanding and ad- is another major threat to global health that needs to be
dressing different types of disadvantage and inequity, tak- tackled in both the health and agricultural sectors at
ing advantage of various disciplines and approaches to local, national and global levels. The failure to develop
address inequities, including social epidemiology, eco- new antimicrobials or ensure equitable access to existing
nomics, participatory action research and ethics [3]. Fur- antibiotics, while counterfeit and substandard drugs
ther, HPSR has pioneered the application of systems flourish, represent major market failures [8, 9]. New
thinking in health, providing a wide set of theories, regulatory strategies, socially oriented investment and a
frameworks and tools to examine and test how different realignment of incentives are needed at all levels.
elements of systems – actors, functions and their relation- Multi-level governance is the key for successful action in
ships – fit together to make an overall whole [4]. containment strategies, supported by HPSR to assess
Efforts to strengthen health systems have been both fa- how well they work and guide their evolution.
cilitated and constrained by the dominance of the Health Population migration is another major social, political
Systems Building Blocks model [5]. The model focuses and health systems challenge. One billion individuals are
on inputs and selected functions of a healthcare system, now on the move globally, one-quarter of whom are
but was designed as a communication tool to indicate crossing national borders. The estimated refugee popula-
options for government investment, and not as an ana- tion reached an unprecedented 19.6 million individuals
lytic or explanatory model of a complete health system. worldwide in 2015, half of whom are children [10]. Health
The building blocks model has especially neglected systems are at the forefront of the response to the ongoing
people (indeed the entire demand side of a health sys- crisis facing refugees and other migrants, both at first
tem) and institutions, the importance of dynamic point of contact and later during resettlement. There is a
Peters Health Research Policy and Systems (2018) 16:84 Page 3 of 4

need to develop more effective approaches that respond Conclusions

to the health needs of displaced populations, yet the evi- This is a time when the technical skills, knowledge con-
dence base regarding which interventions are effective is tributions and historical values of HPSR are needed
quite weak. more than ever. We need a HPSR agenda to better
understand and meet peoples’ expectations, and to
sharpen our science of communication, both issues
Opportunities for HPSR within the remit of HPSR. However, the HPSR commu-
HPSR has developed as a boundary-spanning field, not nity cannot be complacent about its successful but
only crossing disciplinary lines, but also linking stake- short-lived history. We should strive to enhance the in-
holders with very different roles (e.g. policy-makers, health fluence of HPSR by staying relevant in a changing world,
practitioners, researchers, civil society leaders, the media). embracing the strength of our diversity of disciplines,
As such, HPSR should continue to influence policy both the range of problems addressed, and the opportunity of
within and across countries. HPSR has served in each of the SDGs to ensure that health and social benefits are
six types of research utilisation as described by Weiss [11], more inclusive for people within and across countries. If
though in recent years it has tended to be used most dir- we are to have policies and interventions that promote
ectly in a problem-solving model (to facilitate decisions by justice and good health whilst being grounded in evi-
policy-makers and managers) or to otherwise contribute dence, then we must ensure that our thinking and prac-
to complex policy-making through an interactive model of tice of HPSR help us rise to these challenges.
health research. However, there is also a growing tension
Abbreviations
between new approaches that promote embedded and HPSR: health policy and systems research; SDGs: Sustainable Development Goals
implementer-led research, which pursues problem-solving
from ‘within’ [12, 13] and research that takes an external Author’s contributions
perspective, seeking to independently evaluate policy DP was sole author. The author read and approved the final manuscript.
effects, identify neglected problems or hold decision-
Ethics approval and consent to participate
makers accountable [14, 15]. HPSR should be used to Ethics approval was not required for this Commentary, as it does not involve
serve each of these perspectives, and not become cap- human subjects research.
tive to a single approach.
Consent for publication
Encouraging diversity and equity has become part Not applicable.
of the shared values of many practitioners and users
of HPSR, crossing contexts and types of research util- Competing interests
isation. For example, the Alliance for Health Policy The author declares that he has no competing interests.

and Systems Research, along with many partners

working in global health, have expressed a very Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
clear set of values – “to address problems of inequity, maps and institutional affiliations.
poverty and disadvantage” [16] and to support part-
nerships and collaboration on an inclusive and par- Received: 24 January 2018 Accepted: 12 March 2018
ticipatory basis.
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