Health Policy www.thelancet.com Vol 372 November 1, 2008 1571 From Mexico to Mali: progress in health policy and systems research Sara Bennett, Taghreed Adam, Christina Zarowsky, Viroj Tangcharoensathien, Kent Ranson, Tim Evans, Anne Mills, Alliance STAC* In 2004, the ministerial summit in Mexico drew attention to the historic neglect of health policy and systems research (HPSR) and called for increased funding, investment in national institutional capacity for HPSR, and resources for selected priority research topics. On the basis of meeting discussions, published reports, and available data from research funders and organisations in low-income and middle-income countries, we discuss how HPSR has evolved since the summit in Mexico. Funding for HPSR, particularly in low-income countries, is mainly supported by international and bilateral organisations. Increased interest in health systems has translated into increased support for HPSR. However, small grants and lack of coordination between funders inhibit capacity development, and substantial gaps remain between institutional capacities of high-income and low-income countries. Lack of national capacity is judged to be the key constraint to the development of HPSR. Recommendations from the summit in Mexico remain pertinent, and momentum towards their achievement must be accelerated through the ministerial forum in Mali and beyond. Introduction In 2004, stakeholders in global health research—including ministers of health, researchers, research funders, and civil society organisations—met in Mexico to discuss key challenges of international health research. One of the crucial issues that emerged from the background documents, 1,2 the ministerial summit itself, 3,4 and the subsequent World Health Assembly resolution 5 was the historic neglect of health policy and systems research (HPSR). The invigoration of HPSR was one of the main recommendations of the summit. Recommendations and subsequent related documents called for: • Increased funding for HPSR. Grants should support a substantial and sustainable programme of health- systems research aligned with priority country needs, and national governments should make commitments to fund health research to strengthen national health- research systems; 3,5 • Increased institutional capacity for HPSR. Investments in HPSR should be “complemented by a strong effort to build national capacity and effective institutions for health systems research to flourish”; 1 • Knowledge development in HPSR. Prioritisation of 12 issues identified by the Task Force on health-systems research as key elements of a priority global research agenda, and recommendations to governments to set priorities for research, particularly health-systems research. 3,5,6 Our aim was to understand how HPSR, particularly in low-income and middle-income countries, has evolved since the summit in Mexico. We aimed to (i) critically assess developments in HPSR in low-income and middle-income countries, and its application to policy, (ii) highlight current gaps, priorities, and challenges in HPSR that need to be addressed, and (iii) address how best to move HPSR forward. 7 Here, we focus on the progress of the summit recommendations, drawing on the stocktaking meeting discussions, and the collective knowledge of the authors (panel 1). We believe that progress is essential on all three recommendations to achieve the benefits of stronger health policies and systems that can improve the health of populations in low-income and middle-income countries. Health-services research, to which HPSR is closely related, emerged as a distinct research area in developed countries in the early 1960s. 8 Health-services research in low-income and middle-income countries began to be developed during the 1970s, but it is often viewed as lacking in prestige, and hence funding has been insufficient. 9 Recommendations of the summit in Mexico invited increased attention to health-services research, particularly in low-income and middle-income countries. With HPSR we refer to the creation of new knowledge to improve how societies organise themselves to achieve health goals, focusing on policies, organisations, and programmes, but not on clinical management of patients or basic scientific research. HPSR is not specific to a disease or service, but rather relates to any of the six parts of the health system: leadership and governance, health financing, health workforce, medical products and technologies, information and evidence, and service delivery. 10 Attention to health systems has greatly affected the profile of health-systems research. Since the 1970s, development approaches have alternated between focusing on a cross-cutting health-systems approach and a vertically-oriented disease-specific approach. In 2004, the balance began to shift towards a health-systems approach, after several years in which the focus had been disease-specific. 11 This shift mirrored: (i) the increasing recognition that scaling up priority health services (notably, antiretroviral therapy and maternal and child health services) was unlikely to be successful without a serious investment in health systems; 12–15 (ii) concerns about aid structure and, in particular, the fragmented and directed nature of donor funding, 16 which has led to a stronger focus on country Lancet 2008; 372: 1571–78 See Editorial page 1519 See Comment page 1529 *Members listed at end of paper Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland (S Bennett PhD, T Adam PhD, K Ranson PhD); International Development Research Centre, Ottawa, ON, Canada (C Zarowsky PhD); International Health Policy Programme, Bangkok, Thailand (V Tangcharoensathien PhD); World Health Organization, Geneva, Switzerland (T Evans PhD); and London School of Hygiene and Tropical Medicine, London, UK (Prof A Mills PhD) Correspondence to: Dr Sara Bennett, Alliance for Health Policy and Systems Research, WHO, Avenue Appia 20, 1211 Geneva 27, Switzerland bennetts@who.int