Introduction

The current global health system agenda focusses on strengthening health systems with a system-thinking approach [1, 2]. Health policy and systems research (HPSR) seeks to understand and improve how societies organize themselves to achieve collective health goals and how different actors interact in policy implementation to contribute to policy outcomes [3]. HPSR is experiencing a diverse level of interest [4], and has been identified as essential to scaling up interventions to achieve different health goals in general and universal health coverage (UHC) in particular [5]. Moreover, HPSR is a vital research approach for a responsive, adaptive and resilient health system. It helps with collaboration, fund mapping and priority, efficient and effective resource allocation, as well as with improving health system performance [6]. However, current research priority-setting exercises often do not address HPSR well. HPSR prioritization is crucial, as it helps to best utilize available resources in areas that maximize the impact of research on population health [7]. It also significantly impacts the relevance and utility of evidence to policymakers and decision-makers [3]. Low- and middle-income countries, including Ethiopia, face serious resource scarcity to the healthcare system; these countries need critical, informed, evidence-based decisions on properly allocating resources to the health system [2, 8]. Cognizant of this, allocating limited resources to essential areas of the health system with high impact, priority-setting and ranking the areas of interest is a strategic approach. Timely evidence generation and utilization while allocating resources, designing, implementing and evaluating appropriate interventions is paramount.

Ethiopia has developed and implemented a national health policy since 1993 emphasizing health promotion and disease prevention in rural areas. Moreover, several national health strategic plans and initiatives have been developed for the last 30 years [9]. In 2015, the country launched a long-term health sector transformation roadmap titled Envisioning Ethiopia’s Path towards Universal Coverage through Strengthening Primary Health Care. This health sector transformation plan has four phases and a 5-year implementation period. The strategic plan aims to achieve sustainable development goals (SDGs), UHC and global health agendas and targets [10, 11].

Despite all the efforts of developing different strategic health plans, initiatives and transformation agendas, the health outcome improvement of the nation is not progressing as expected. The performance of key health variables and progress towards UHC is still low [12, 13]. The challenges include poor resource allocations, lack of evidence-based decisions, weak public–private partnerships, weak inter-sectoral collaboration and weak academia and health policymakers’ collaborations [14,15,16]. In many developing countries, including Ethiopia, health policy and systems research studies are not the primary focus and lead to decisions without sufficient evidence; thus, the practice of evidence-based initiative, strategic plans and policy development in the health system is limited. Research findings and evidence for different decisions are essential to overcome the challenges.

Most health research in Ethiopia has focussed on clinical and biomedical research and HPSR receives little attention. A scoping review has shown that the research prioritization exercises done in Ethiopia focussed on reproductive maternal, newborn, child and adolescent health and nutrition (RMNCAHN); human immunodeficiency virus (HIV); sexually transmitted diseases; tuberculosis; and coronavirus disease 2019 (COVID-19) [17,18,19,20]. Therefore, this paper aimed to conduct a collaborative HPSR priority agenda-setting exercise in the case of Ethiopia.

Methods

Priority-setting approach

In the present paper, the authors employed the WHO’s plan, implement, publish and evaluate (PIPE) model [21] and the Delphi technique for the health policy and systems research (HPSR) priority-setting exercise. The PIPE model, which was used in other similar settings [22, 23], served as a framework to guide the overarching implementation of this priority-setting activity. During the planning phase, a scoping review was done to identify what was already known and what was already done in the country, as well as identifying the principles that guide the priority-setting exercise, agreeing upon the methodology and developing an implementation proposal. Key priority-setting activities were done in the implementation phase according to the proposal. At the publishing stage, the findings were communicated with key stakeholders and this manuscript was developed. The final evaluation role was given to the Ministry of Health (MoH) and the Ethiopian Public Health Institute (EPHI) (Fig. 1).

Fig. 1
figure 1

The PIPE framework used for the HPSR priority-setting exercise adapted from WHO research priority-setting exercise [21]

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In addition, we conducted two rounds of the Delphi technique, which involved rating and ranking exercises, to reach a consensus on the identified research topics (Fig. 2). The Delphi technique, established during the 1950s, consists of a systematic, multistep procedure that involves expert panellists engaging in a sequence of rounds to pinpoint, elucidate and ultimately reach an agreement on a specific matter. Each round consists of clear, unbiased statements on the basis of prior responses. The goal is to achieve consensus through information feedback and repetition, concluding once the agreement has been obtained [24,25,26]. Different countries used the Delphi technique as a consensus-building approach for health research priority-setting [27,28,29,30,31,32].

Fig. 2
figure 2

HPSR priority-setting Delphi technique process

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Selection of participants for priority-setting

To select the participants for HPSR priority-setting, the research team, in consultation with the Policy, Strategy, and Research Executive Office of the Ministry of Health of Ethiopia, developed the selection parameters. Initially, before mapping the participants we group the potential HPSR topics on the basis of the WHO health system building blocks and we set parameters to identify participants under each thematic area. The participants were identified on the basis of the parameters set by the research team: active engagement in the area by health system leadership, program implementation, policy development, research and evidence generation, partnership and funding programs. During participant selection we also tried to include participants from different types of organizations who have an active stake in the health system and policy of Ethiopia. Considering their representatives, 112 participants were chosen from diverse organizations such as the MoH, regional health bureaus (RHB), national health agencies, research institutes, universities, development partners, private facilities and community representatives.

The WHO’s health system building blocks were used as a foundation for assigning experts in different healthcare areas, including health policy leadership management and governance (LMG), health information systems (HIS), human resources for health (HRH), healthcare financing (HCF) and medical supplies and service delivery [33].

The priority-setting exercise comprised an expert panel workshop complemented by an online assessment survey. Two rounds of workshop for agenda-setting and consensus-building were conducted to ensure a comprehensive approach to the priority-setting process.

Agenda-setting through expert panel workshop and online assessment survey

The HPSR agendas were mapped using the expert panel workshop supplemented by the online assessment survey.

An expert panel workshop was organized with 40 participants to set the HPSR agendas from 21–25 December 2022. During the agenda-setting workshop, the several key activities were performed.

To mention some: the research team presented six HPSR prioritization criteria to workshop participants, and a discussion took place. The prioritization criteria were adapted by review different priority setting approaches by considering importance of the topic in improving the body of knowledge or solving the problem, the alignment with national priority health initiatives, its adaptability to the local context, the capacity of implementation and the key stakeholders’ demands [34, 35]. Participants discussed and agreed on the presented priority-setting criteria and their respective weights. The criteria are relevance to policymakers, impact on the health, workability (ability to answer the question using existing data), feasibility (cost, ethics, expertise), availability of evidence and practicability of results (to be translated into action) (Table 1).

Table 1 HPSR priority-setting criteria with their weights
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The workshop participants were grouped into seven groups using the WHO health system building blocks as a base framework and adding health policy theme. The group formation was based on the participants’ profession and expertise. The groups were used as a theme for the identified HPSR research agendas. Each group was assigned to set the HPSR agendas under each theme on the basis of their opinion and the above-mentioned criteria. After setting the HPSR topics, each team presented the identified research topics for the workshop participants, and further discussions were conducted on the topics’ scope and context from the HPSR perspective. After the discussions, feedback was forwarded to each team for revision and amendments. In addition, after the discussion, additional cross-cutting research topics were identified. The team makes revisions to the topics they set and submit by the end of the workshop.

The HPSR agenda-setting practice was also supplemented by an online assessment survey from 72 participants from January to April 2023. The online participants were also identified from different fields of expertise on the basis of the identified themes.

Rating, ranking and consensus building

A workshop with 38 participants was organized from 22–26 July 2023 to conduct rating and ranking exercises and build consensus on the identified research topics. The rating, ranking and consensus building on the priority topics were done through the following steps. Initially, the participants were grouped into seven and discussed the identified topics’ relevance, duplication and comprehensiveness.

Then participants conducted the rating and ranking exercise. The rating and ranking exercise was done at the sub-theme level. First, each participant gave their scores and displayed them to the group members for discussion. After brainstorming and a thorough discussion, the group members gave the final and agreed score for each research topic with consensus. The scoring was done by evaluating each research topic under each sub-theme using the pre-defined priority-setting criteria and scoring 0 to 10. For example, under the health policy theme, policy implementation and evaluation sub-theme, five identified topics were evaluated and scored from 0 (least valued) to 10 (highest valued) for each of the six criteria. The average score from the scores given at each criterion was generated for each research topic. Even if the score was considered from 60, in the end we computed it from 100. The ranking was done by comparing the average scores of each research topic from 100 at the sub-theme level.

Each group then presented the final list of priority research topics with scores and ranks for the workshop participants. After discussions, each group collects feedback from the workshop participants for finalization. Finally, the workshop participants presented and approved the revised list of topics as a final list of priority HPSR topics.

Ethical clearance

Ethical clearance was obtained from the University of Gondar’s ethical review board (ref. VP/RTT/05/218/2022). Consent was received from the participants, and the participant’s anonymity was maintained.

Finding

Participant characteristics

A total of 112 participants participated in the HPSR priority-setting exercise through expert panel workshops and online assessment surveys; 30 experts were from universities and 50 were from national research institutes and the MoH. In addition, 18 experts from developmental partners and 10 from RHBs participated. There were also four participants from private facilities and other government sectors (Table 2).

Table 2 Participant characteristics
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Prioritized HPSR topics

Findings from the HPSR agenda-setting workshop and the online survey

Under 8 themes, 34 sub-themes and 227 research topics were identified with the agenda-setting workshop and online assessment survey.

Rating, ranking and consensus building of HPSR-identified topics

After the discussion during the consensus building workshop, the participants agreed to approve 182 research topics under 32 sub-themes and 8 themes (Table 3). The identified topics were allied with the current national and global health priority issues and transformation agendas. The average score given during rating ranges from a minimum of 73.3 to a maximum of 96.7 out of 100.

Table 3 HPSR themes, sub-themes, and priority research topics identified after the consensus-building workshop
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Leadership, management and governance (LMG)

Under LMG-related HPSR topics, 29 research topics were identified under 5 sub-themes (Table 4). The priority topics were healthcare leadership skills and competencies, social governance and accountability, and healthcare management. The evidence on the identified topics will help produce sound evidence and design appropriate and context-specific interventions on one of the critical components of the health system. Transforming healthcare leadership is one of the transformations of Ethiopian HSTP to enhance the healthcare leadership capacity, regulation, accountability, and health planning skills to dive into national health initiatives [11].

Table 4 Top five health-related HPSR priority topics under each respective sub-themes
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Health-policy-related priority HPSR topics

Under the health policy theme, 28 research topics under 3 sub-themes were identified (Table 5). The identified priority topics were focussed on population policy needs, policy formulation, implementation and evaluation.

Table 5 Top five HIS-related HPSR priority topics under each respective sub-theme
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Health information system

For HIS HPSR priority-setting, 35 research topics from 5 sub-themes were identified, and a subsequent rating and ranking exercise was also done (Table 6). The identified research topics, which focussed on digitalization data quality, analysis and use, received priority. These topics align with the national health information system strategy, digital health blueprint initiatives and HSTP transformation agenda. Evidence generated on the selected priority topics will enhance informed decision-making and the county’s progress towards stated HIS targets [11, 36, 37].

Table 6 Top three healthcare-financing-related HPSR priority topics under each sub-theme
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Healthcare financing

The other HPSR priority-setting exercise area was healthcare financing, and 23 priority research topics were identified under 5 sub-themes (Table 7). The priority topics focus on evaluating first-generation HCF reforms and testing different strategic payment modalities. In addition, the other identified priority topics are equity, efficiency and effectiveness in implementing HCF reforms and applying digital health systems. Information on the identified priority topics will help design different HCF implementation strategies. This will help achieve the national healthcare financing initiatives and the country’s progress towards universal health coverage [13, 38, 39].

Table 7 Top-five leadership-, management- and governance-related HPSR priority topics under each sub-theme
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Human resource for health (HRH)

A total of 17 research topics under 3 sub-themes were identified for the HRH theme (Table 8). Under this theme, the identified topics focus on human resource adequacy, competency, distribution and HRH practices. Research findings on the identified topics will help achieve the national HRH strategic vision, which is to have an adequate number of well-qualified, committed, compassionate, respectful and caring health workers contributing to the health sector vision of Ethiopia [40].

Table 8 Top-five human resources for health-related HPSR priority topics under each sub-theme
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Pharmaceutical and medical products and supply

A total of 10 research topics were identified under the medical product and supply theme (Table 9). The priority topics are focussed on health technology assessment, medical equipment and supply chain management. The identified topics align with the national pharmaceutical and medical supply initiatives. Evidence produced in pharmaceutical and medical products and supplies will help to progress the targets set in the program area, which aims to ensure the sustainable supply of quality-assured and affordable pharmaceutical and medical equipment, ensure rational use of medicines, and integrate traditional and modern medicine [41].

Table 9 Top three medical product and supply-related HPSR priority topics under each sub-theme
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Service delivery

In the service delivery theme, 31 research questions were generated under 8 sub-themes (Table 10). The identified priority topics focussed on primary healthcare services; reproductive, maternal, neonatal, child, adolescent and youth health services; hospital services; nutrition; communicable and non-communicable diseases; injuries; and mental health. These topics are the priority and public health concerns of the country. Knowledge generation and synthesis on these priority topics will enhance the practice of evidence-based decisions and interventions to improve service quality, equity and access. In addition, the evidence will support the achievements of the county’s HSTP and sustainable development goal targets [11, 42].

Table 10 Top five service-delivery-related HPSR priority topics under each respective sub-theme
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Cross-cutting HPSR priority topics

During the discussion of each research topic under each theme, nine priority cross-cutting research topics were identified, and it was decided to bring the theme into a separate cross-cutting theme (Table 11). Health system resilience, responsiveness, social determinants of health, multi-sectoral collaboration, preferences studies, global initiatives’ role and economic evaluation of healthcare interventions were among the identified cross-cutting topics. Evidence on the cross-cutting research topics will help to understand the multi-contextual and systemic factors of the health system and to design appropriate interventions with the system thinking approach.

Table 11 HSPR research sub-themes on the cross-cutting health system program in Ethiopia, 2023
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Conclusions

A total of 182 priority HPSR topics were identified with the collaboration of key stakeholders. The topic identification was matches with the current Ethiopian and global health initiatives and targets. The identified research topics tried to address different health system components by referencing the health system building blocks. The HPSR topics were identified under the following themes: health policy, HIS, HCF, LMG, HRH, pharmaceutical and medical product and supply, service delivery and cross-cutting issues.

Application of the findings

The identified priority HPSR topics were disseminated to MoH, RHBs, research and academic institutes. Therefore, the research and academic institutes should do the evidence generation and synthesis practice on the priority research topics. Since the topics identified are referencing the current national and global health priorities by experts with a reach experience in each theme, the evidence produced will help improve the program and health system performance. Moreover, the results of this research will have relevance to the context of Ethiopia. Firstly, the participants were mapped and selected with their active engagement and experience in different aspects of Ethiopian health system and policy development and implementation. Secondly, the process of setting priorities in health policy and systems research (HPSR) specifically addresses the needs, gaps and key areas of focus within the Ethiopian healthcare system.