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National governments and global funders are failing to invest sufficiently in strengthening health systems, despite shortcomings exposed by the COVID-19 pandemic, experts argue in a series of papers published today.

A special issue of Public Health Research & Practice, a peer-reviewed journal of the Sax Institute, 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 across the globe. The edition has been prepared in collaboration with the Alliance for Health Policy and Systems Research, an international partnership hosted by the World Health Organization.

Emerging in the mid-nineties, HPSR seeks to understand and enhance the relationship between health policy and health systems to improve health and is essential for developing strong and equitable health systems.

One paper from Professor David Stuckler, of Bocconi University in Milan, atrovent and proair and colleagues finds that less than two cents of every dollar in total global health funding is being spent on wider investment in or research into health systems. They note that, just like the response to the HIV/AIDS epidemic, there has been more of a focus on developing technologies and medical solutions than on the structures, skills and resources required to make these solutions available to those who need them most.

But history doesn’t have to repeat itself, the authors say. “The price of inaction on strengthening health systems to address HIV was staggering. And although we can’t set those past mistakes to right, we can honor the legacy of those who suffered and prevent the same mistakes from happening again,” they write.

They add that “the political window of opportunity could not open any wider” to mobilize resources and partners to strengthen our health systems and address the shortcomings of the global COVID-19 response, where the emphasis on developing vaccines has overshadowed investment in the health systems that can deliver them.

Another paper in this issue tackles the ‘invisibility’ of funding for HPSR in low- to middle-income countries. It finds that while it is almost impossible to reliably estimate HPSR funding in most countries under study, health research funding in general prioritizes biomedical and clinical research over HPSR. Recommendations in this paper include creating mechanisms to ensure funds are allocated to HPSR, creating a database to track HPSR funding and advocating for the value-add of HPSR.

In the editorial in this issue, Professor Vivian Lin of the University of Hong Kong and colleagues agree that the COVID-19 pandemic has clearly demonstrated the need for stronger health systems and the context-relevant knowledge that HPSR can provide.

Several factors are at play in the underfunding of HPSR, they write. One is the over-medicalisation of health research, in part due to the pharmaceutical industry’s emphasis on disease-oriented rather than prevention-oriented healthcare. Another is the issue of randomized controlled trials as the gold standards in health research. However, health policy and health system reforms are classic ‘wicked problems’ that deal with complex and interconnected systems, the editorialists argue.

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