The Alliance’s new five-year strategic plan

“The Alliance has historically focused on strengthening the six building blocks of health systems. While the building blocks will remain central to the mandate of the Alliance, it is also time to look beyond them.”

- Broadening horizons: Strategic Plan 2021–2025

This year is the first year of the Alliance’s new five-year strategic plan. This plan outlines three core objectives of the Alliance and this annual report is structured around them.

We advance knowledge through supporting the generation and synthesis of policy-relevant health systems research;

We catalyse change through the promotion of dissemination and use of HPSR;

We empower leaders by facilitating the development of capacity for HPSR among researchers, policy-makers and other stakeholders.

And while these objectives maintain core elements of the Alliance’s approach, we recognize the context has changed significantly and we need to evolve, too.

This annual report showcases both how we continue to invest in actionable research for stronger health systems, but also how we are working toward resilient and responsive health systems that are able to respond to emergencies and, more broadly, how to foster healthier populations.

Tracking progress on the strategic plan

The 2021-2025 strategic plan contains a results framework along with a set of must-achieve actions and key performance indicators (KPIs) for the five years. To monitor progress toward these targets, the Alliance has been developing a tracking system that shows our progress against these indicators in the first year. The charts below also indicate whether or not we are on track to meet the five-year target. In many cases, we are already at or well beyond where we should be in the first year.

Strategic Objective 1. We advance knowledge.

The Alliance will stimulate the generation and synthesis of policy-relevant health systems knowledge, encompassing evidence, tools and methods.

Must accomplish actions

• Supporting generation and synthesis of HPSR evidence for stronger health systems

• Developing methods, frameworks and concepts to build the field of HPSR

Strategic Objective 2. We catalyse change. 

The Alliance will promote the dissemination and use of health policy and systems knowledge to improve the performance of health systems.

Must accomplish actions

• Convening stakeholders to advance HPSR

• Increasing the use of evidence

• Strengthening the Alliance Partnership

Strategic Objective 3. We empower leaders.

The Alliance will facilitate the development of capacity for the generation, dissemination and use of HPSR knowledge among researchers, policy-makers & other stakeholders

Must accomplish actions

• Strengthening capacities to generate and use HPSR

• Supporting partnerships to disseminate and use HPSR

Where we work

2021 by the numbers

2021 at a glance

While the COVID-19 pandemic continued to have devastating impacts around the world, in 2021 we also saw signs of hope that the end of the acute crisis stage of the pandemic may be near. Despite the uncertainty, the Alliance Secretariat was able to adapt and innovate in the way it approaches its activities.

2021 was the first year of our new five-year strategic plan. Developed through a consultative process, Broadening horizons sets out an ambitious agenda that moves the Alliance beyond the traditional health systems building blocks. In this strategic plan, we committed to: doing more policy analysis, supporting health systems to better prepare and respond more effectively during emergencies, creating healthier populations and engaging more deeply with all levels of the World Health Organization. Even in the first year of the strategy, this report is a testament to the strong progress the Alliance is making on these fronts.

In fact, 2021 was one of the most productive years for the Alliance in its history. We supported or were involved in the publication of seven journal supplements. A total of 107 journal articles were published. We also launched our flagship report on learning health systems and the digital only Partners’ HPSR report 2021.

The Alliance has always championed equity, especially in the field of health policy and systems research, and our ability to expand participation in our activities has significantly improved. Over the last year, we hosted and participated in an increasing number of webinars. While the digital divide remains, we were pleased to see that more than 70% of registrants for our webinars indicated that they were based in low- or middle-income countries (LMICs).

These may be turbulent times, but the Alliance remains committed to its core objective of strengthening health systems through better, and more policy-relevant research. The Secretariat staff have been working harder than ever to ensure that the Alliance is able to deliver, and I thank the Secretariat, our partners and grantees for their dedication. We have also benefited greatly from the oversight and guidance provided by our Board and Scientific and Technical Advisory Committee during this last year. 

– ABDUL GHAFFAR 

Advancing knowledge in 2021

A new flagship report from the Alliance advances a comprehensive understanding of what is meant by and how to create learning health systems. It outlines the benefits of learning health systems and the actions needed to build such systems. This is because learning — at individual, team, organization and cross-organization levels — is fundamental to health systems strengthening and the achievement of health goals. Yet especially in LMICs, many health systems still do not have adequate capacity to generate and use the knowledge that they need to be effective.

The report was launched at a webinar that saw a record number of registrants. It was covered in an editorial in the International Health Policies (IHP) newsletter. It has been presented at diverse fora since launch and it has been well received. The thirteen case studies included in the report have garnered particular interest, as they present clear examples of the benefits of integrating learning approaches into health systems strengthening.

A special edition of Public Health Research & Practice supported by the Alliance provides the most comprehensive analysis to date of the state of funding for health policy and systems research (HPSR), covering more than 50 countries, regions and territories spanning all six WHO regions.

Its editorial suggests that the COVID-19 pandemic has clearly demonstrated the need for stronger health systems and the context-relevant knowledge that HPSR can provide. It adds that several factors are at play in the underfunding of HPSR. One is the over-medicalisation of health research, in part due to the pharmaceutical industry’s emphasis on disease-oriented rather than prevention-oriented health care. Another is the issue of randomized controlled trials as the gold standard in health research. However, it argues that health policy and health system reforms deal with complex and interconnected systems and other methods may be more helpful.

The Commission on the Social Determinants of Health in the Eastern Mediterranean was established in 2019 by the WHO Regional Director for the Eastern Mediterranean as an independent, expert Commission co-sponsored by the Alliance. The Commission conducted an extensive review of health inequities in the region and produced a report, including a research agenda, which was launched in March of 2021. The report, Build back fairer: achieving health equity in the Eastern Mediterranean Region, provides detailed analysis of the status of health inequities and a list of actionable recommendations.

Throughout 2021, the Alliance was also worked with Wilton Park to co-convene a series of dialogues on healthier populations. The first dialogues, held in April 2021, focused on the urgent actions and lessons from the COVID-19 pandemic. This was followed by four regional workshops exploring how to develop collective visions and narratives around healthy societies. We have also launched two new research programmes focusing on the broader determinants of health – one that will develop detailed policy analysis case studies on the implementation of taxes on harmful products like tobacco and alcohol. Another is examining how health systems are responding to the climate crisis.

Co-production of knowledge through research involves collaborations between researchers and end-users of research, including patients and the public, health professionals, health system managers and policy-makers. This approach is being advocated globally and across sectors. But there remains uncertainty on what co-production of research entails, how to do it, when and when not to do it. More evidence on these issues is essential if the co-production of research is to deliver on its promise to produce knowledge and share power and responsibility from the start to the end of research and avoid wasting time, resources, and the good will of end-users.

The Alliance collaborated with the BMJ to release a special collection on Increasing the impact of health research through co-production of knowledge. It provides an overview of the evolution, potential, influence, learning and challenges in co-producing evidence to inform decision-making in health policy and practice, and points to the core principles which should underpin it.

Power and the commercial determinants of health: ideas for a research agenda
By Jennifer Lacy-Nichols and Robert Marten in BMJ Global Health

COVID-19 pandemic: a unique opportunity to ‘build back fairer’ and reduce health inequities in the Eastern Mediterranean Region 
By Ahmed Al-Mandhari, Michael Marmot, Abdul Ghaffar et al. in the Eastern Mediterranean Health Journal

Public health education post-COVID-19: a proposal for critical revisions 
By Abdul Ghaffar, Sabina Faiz Rashid, Rhoda Wanyenze and Adnan Hyder in BMJ Global Health

Time to reconceptualise health systems 
By Zubin Shroff, Robert Marten, Jeanette Vega, David Peters, Walaiporn Patcharanarumol and Abdul Ghaffar in The Lancet

Applied systems thinking: unlocking theory, evidence and practice for health policy and systems research 
By Aku Kwamie, Solip Ha and Abdul Ghaffar in Health Policy and Planning

Why strengthening health systems is vital across the world 
By Kabir Sheikh in the Medical Research Council blog

Catalysing change in 2021

In January 2021, the Alliance embarked on a collaborative and collective process with some of its partners to develop an annual account of national-level HPSR production in low- and middle-income countries (LMICs).

In all, 16 country teams across all six WHO regions and two global HPSR entities were involved in the development of this work. The result — the Partners’ HPSR Report 2021 — gives insights into the development and evolution of HPSR in various LMICs and advocates for far greater investments in HPSR, particularly at country-level. The Report reflects the complex and varied nature of HPSR across a diversity of countries, highlighting the different ways that HPSR is organized around the world.

As an outgrowth of its project on Systems Thinking for District-level Health Systems (ST-DHS), the Alliance has spent 2021 working with partners to develop the Systems Thinking Accelerator (SYSTAC), a community-of-practice for applied systems thinking that seeks to be a platform for systems thinking science and practice; a community; and an amplifier of applied systems thinking in LMICs.

SYSTAC now hosts more than 100 members in its Alliance Hive sub-community. Regional institutions have also conducted five regional assessments and local activities as well as leading capacity webinars and developed ‘how-to’ briefs and short videos through its capacity stream. A limited podcast series hosted by SYSTAC members was released in July. In November, a two-day global meeting was held with 185 participants from all regions. During the meeting, regional institutions presented their findings, multi-disciplinary panels featuring experts from within and outside the health sector shared insights, and breakout sessions enabled participants to share their own perspectives.

The Alliance has been partnering with the United Nations Children’s Fund (UNICEF) with support from Gavi, the Vaccine Alliance to undertake more than 50 embedded implementation research studies focusing on immunization across 16 countries. Many findings from this substantial body of work were published in 2021, with the release of three journal special supplements: one on Decision Maker Led Implementation Research on Immunization, one showcasing results from Ethiopia and another from Pakistan. Taken together, these studies spotlight challenges and bottlenecks for improving vaccination coverage, and they identify and test strategies to address immunization service delivery constraints.

But immunization is not the only area where the Alliance has been pursuing this approach. In 2021 we also shared results from embedded implementation studies looking at how to achieve the health-related sustainable development goals, a programme done in partnership with the Pan American Health Organization and the Special Programme for Research and Training in Tropical Diseases.

The Sehat Sahulat Insurance Program, a social health protection initiative in Pakistan, has enrolled over 37 million poorer Pakistani families and been responsible for reimbursing more than three million hospitalization cases. It is a cornerstone of Pakistan’s move towards universal health coverage (UHC). To help with the roll out of the programme, the Ministry of National Health Services, Regulation and Coordination in Pakistan worked with the Alliance to develop research studies to support programme implementers to help address any challenges during roll out.

Four research teams were brought in to undertake studies responding to themes identified by a range of stakeholders involved in the programme. In addition to detailed reports, study teams have developed policy documents that summarize the main findings of the research and provide actionable recommendations to improve programme design and implementation.

Empowering leaders in 2021

Since 2019, the Knowledge to Policy Center at the American University of Beirut has provided a wide-range of support to help institutions in Cambodia, Georgia, Indonesia, Nigeria, Trinidad and Tobago, and the United Arab Emirates to identify priority health needs, gather and analyze the evidence, and share key findings with policy-makers in a way that will influence policy decisions. The initiative has helped to build a cadre of young research teams that are skilled in the application of HPSR approaches, and it has also bolstered the reputation and influence of the participating institutions.

In 2021, members of the different teams along with policy-makers with whom they had developed relationships through the programme participated in a high-level panel as part of the closing session of the Sixth Global Symposium for Health Systems Research. Each of the six institutions has created a fellowship scheme. They have also prioritized areas for influence and worked on creating policy briefs and hosting policy dialogues, though some in-person activities were delayed by COVID-19. 

The HIGH-Res project is led by the African Institute for Development Policy (Afidep) in Kenya. It is working with partners and ministries of health in Kenya, Malawi and Uganda to strengthen institutional capacity for the systematic use of evidence for health systems strengthening.

Members of the re-activated technical working groups on research that were established within each of the ministries have undertaken training on rapid evidence synthesis. Several reviews were subsequently undertaken in response to requests from the relevant ministries. In Kenya, the training has been followed up with a six-month mentorship scheme and the Ministry of Health has committed to establishing an evidence synthesis mechanism through its Research Division. In Uganda, 16 ministry staff who had previously received training through the project have since become ambassadors for evidence use in ongoing policy review processes.

As part of the embedded implementation research projects on immunization supported by Gavi, the Vaccine Alliance, two technical support centres have been established to coordinate the research projects and to provide mentorship and guidance, one in Ethiopia and one in Nigeria.

In Nigeria, the Alliance is partnering with the Health Policy Research Group (HPRG) at the University of Nigeria. The group has been able to secure additional resources to strengthen the teams’ capacity for data analysis. This has allowed the HPRG to work closely with the teams at baseline and assist them with designing the interventions. This in-depth approach to baseline data analysis has generated interesting findings and resulted in the development of blogs, policy briefs and manuscripts. A strengthened approach to endline data analysis will also be supported through these funds.

The Alliance is working with the Ramalingaswami Centre for Excellence in the Social Determinants of Health (RCESDH) at the Public Health Foundation of India and the United Nations University – Institute of Global Health (UNU-IIGH), Malaysia on an initiative to strengthen capacity in HPSR on gender and intersectionality. As part of the project, nine research fellows have been selected and are being mentored by RCESDH to undertake HPSR projects on gender equity and intersectionality, including research conducted in fragile contexts. An online course has been developed and consists of nine modules and uses case-based learning with voice-over presentations, embedded videos, podcasts, and reading resources. It has been piloted for 33 participants in UNU-IIGH, and is being finalized for general access. 

The Alliance kicked off a new fellowship programme focusing on low-income countries in Africa that predominantly speak French to strengthen capacities for HPSR. The programme is supported by a mentor institute and targets mid-level faculty, as they are already experienced in conducting their own research, may have established professional networks, but desire further experience in developing curricula, training and supervising students, and managing modest-sized grants.

In May, the Alliance launched a call for the mentor institute to develop and deliver the fellowship programme. La Laboratoire d’études et recherches sur les dynamiques sociales et le développement local (LASDEL), in Niger, was chosen and began curriculum adaptation, integrating Alliance materials on systems thinking and implementation research. Ten fellows have been selected from across Benin, Cameroon, Côte d’Ivoire, the Democratic Republic of the Congo, Niger and Togo. After the training, fellows will be invited to apply to a closed Alliance call to develop a two-year programme of HPSR training at their home institutions.

2021 finances and donors

The Alliance gratefully acknowledges the core financial support in 2020 from the Norwegian Agency for Development Cooperation (Norad), the Swedish International Development Cooperation Agency (Sida), and the United Kingdom of Great Britain and Northern Ireland Foreign, Commonwealth and Development Office (FCDO).

Other donors and those supporting ongoing activities in 2020 include the Doris Duke Charitable Foundation, Gavi, the Vaccine Alliance, UNICEF, the United States Agency for International Development (USAID) and Wellcome Trust. We also received specified funding from the Ministry of Foreign Affairs, Sweden and the Norwegian Agency for Development Cooperation (Norad).

Governing bodies

NOTE: People listed on this page served on the Board or STAC or were employed by the Secretariat at some point during 2021. They do not necessarily reflect the current composition of these bodies.