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This article aims to prompt reflection about the everyday politics of health systems, their importance to health policy implementation, and what sort of leadership, provided by whom, is required to address them. It is founded on insights drawn from empirical and theoretical literature, combined with practical experience developed through relevant research and teaching. Ultimately it argues that the everyday politics of the health system represent the multiple actors, interests, and choices that frontline leaders routinely address and that influence the collective action taken through the system in pursuit of public value. Leadership to address these everyday politics entails the practice of power and support for collective sense-making. Nurturing these political leadership skills through new forms of leadership development is therefore a vital component of health system development.

The launch of Global Health Initiatives in early 2000' coincided with the end of the war in Burundi. The first large amount of funding the country received was ear-marked for human immunodeficiency virus (HIV) and immunization programs. Thereafter, when at global level aid effectiveness increasingly gained attention, coordination mechanisms started to be implemented at national level.This in-depth case study provides a description of stakeholders at national level, operating in the health sector from early 2000' onwards, and an analysis of coordination mechanisms and stakeholders perception of these mechanisms. The study was qualitative in nature, with data consisting of interviews conducted at national level in 2009, combined with document analysis over a 10 year-period.One main finding was that HIV epidemic awareness at global level shaped the very core of the governance in Burundi, with the establishment of two separate HIV and health sectors. This led to complex, nay impossible, inter-institutional relationships, hampering aid coordination. The stakeholder analysis showed that the meanings given to 'coordination' differed from one stakeholder to another. Coordination was strongly related to a centralization of power into the Ministry of Health's hands, and all stakeholders feared that they may experience a loss of power vis-à-vis others within the development field, in terms of access to resources. All actors agreed that the lack of coordination was partly related to the lack of leadership and vision on the part of the Ministry of Health. That being said, the Ministry of Health itself also did not consider itself as a suitable coordinator.During the post-conflict period in Burundi, the Ministry of Health was unable to take a central role in coordination. It was caught between the increasing involvement of donors in the policy making process in a so-called fragile state, the mistrust towards it from internal and external stakeholders, and the global pressure on Paris Declaration implementation, and this fundamentally undermined coordination in the health sector.

Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context. Change occurs at many layers of a health system, shaped by social, political, and economic forces, and brought about by different groups of people who make up the system, including service users and communities. The seeds of transformative practice in HPSR lie in amplifying the breadth and depth of dialogue across health system actors in the conduct of research - recognizing that these actors are all generators, sources, and users of knowledge about the system. While building such a dialogic practice, those conducting HPSR must strive to protect the autonomy and integrity of their ideas and actions, and also clearly explain their own positions and the value-basis of their work. We conclude with a set of questions that health policy and systems researchers may wish to consider in making their practice more people-centred, and hence more oriented toward real-world change.

RESYST members Jane Doherty and Lucy Gilson have published a report following a three-day consultative workshop in Cape Town. The workshop brought together 35 leadership training experts from a range of institutions to enhance the capacity and capabilities of the people and systems engaged in leadership development. "Fast-changing and unpredictable health systems require creative, intelligent and resilient leaders" The norm in leadership training is formal, residential training programmes which face a number of limitations and can be disruptive to service delivery. The participants brainstormed how training institutions and governments can better support public health sector leaders to realise their leadership potential through enabling learning in the workplace. The report addresses several questions including: - What are the key challenges faced by leaders trying to operate effectively in the public health sectors of their own countries? - What type of leadership does the public health sector need? - What tools and approaches can best to support workplace-based learning? -How can we make workplace-based training sustainable? The informal report is intended to generate excitement for designing and supporting workplace-based learning in low- and middle-income country settings. It also includes detailed sections outlining experiences, strategies, critical reflections and recommended techniques that were discussed during the workshop. The report also recommends useful resources for further development.

This article provides the first ever review of literature analysing the health policy processes of low and middle income countries (LMICs). Based on a systematic search of published literature using two leading international databases, the article maps the terrain of work published between 1994 and 2007, in terms of policy topics, lines of inquiry and geographical base, as well as critically evaluating its strengths and weaknesses. The overall objective of the review is to provide a platform for the further development of this field of work. From an initial set of several thousand articles, only 391 were identified as relevant to the focus of inquiry. Of these, 164 were selected for detailed review because they present empirical analyses of health policy change processes within LMIC settings. Examination of these articles clearly shows that LMIC health policy analysis is still in its infancy. There are only small numbers of such analyses, whilst the diversity of policy areas, topics and analytical issues that have been addressed across a large number of country settings results in a limited depth of coverage within this body of work. In addition, the majority of articles are largely descriptive in nature, limiting understanding of policy change processes within or across countries. Nonetheless, the broad features of experience that can be identified from these articles clearly confirm the importance of integrating concern for politics, process and power into the study of health policy. By generating understanding of the factors influencing the experience and results of policy change, such analysis can inform action to strengthen future policy development and implementation. This article, finally, outlines five key actions needed to strengthen the field of health policy analysis within LMICs, including capacity development and efforts to generate systematic and coherent bodies of work underpinned by both the intent to undertake rigorous analytical work and concern to support policy change.

Evidence-informed decision-making for health is far from the norm, particularly in many low- and middle-income countries (LMICs). Health policy and systems research (HPSR) has an important role in providing the context-sensitive and -relevant evidence that is needed. However, there remain significant challenges both on the supply side, in terms of capacity for generation of policy-relevant knowledge such as HPSR, and on the demand side in terms of the demand for and use of evidence for policy decisions. This paper brings together elements from both sides to analyse institutional capacity for the generation of HPSR and the use of evidence (including HPSR) more broadly in LMICs.The paper uses literature review methods and two survey instruments (directed at research institutions and Ministries of Health, respectively) to explore the types of institutional support required to enhance the generation and use of evidence.Findings from the survey of research institutions identified the absence of core funding, the lack of definitional clarity and academic incentive structures for HPSR as significant constraints. On the other hand, the survey of Ministries of Health identified a lack of locally relevant evidence, poor presentation of research findings and low institutional prioritisation of evidence use as significant constraints to evidence uptake. In contrast, improved communication between researchers and decision-makers and increased availability of relevant evidence were identified as facilitators of evidence uptake.The findings make a case for institutional arrangements in research that provide support for career development, collaboration and cross-learning for researchers, as well as the setting up of institutional arrangements and processes to incentivise the use of evidence among Ministries of Health and other decision-making institutions. The paper ends with a series of recommendations to build institutional capacity in HPSR through engaging multiple stakeholders in identifying and maintaining incentive structures, improving research (including HPSR) training, and developing stronger tools for synthesising non-traditional forms of local, policy-relevant evidence such as grey literature. Addressing challenges on both the supply and demand side can build institutional capacity in the research and policy worlds and support the enhanced uptake of high quality evidence in policy decisions.

The unifying theme of the papers in this series is a concern for understanding the everyday practice of governance in low- and middle-income country (LMIC) health systems. Rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, these papers provide insights into the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice – and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts – in that they influence who accesses benefits and whose voices are heard in decision-making, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity. The papers in the series address governance through diverse health policy and system issues, consider actors located at multiple levels of the system and draw on multi-disciplinary perspectives. They present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings. The overall purpose of the papers in this series is thus to provide an empirical and embedded research perspective on governance and equity in health systems.

The unifying theme of the papers in this series is a concern for understanding the everyday practice of governance in low- and middle-income country (LMIC) health systems. Rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, these papers provide insights into the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice - and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts - in that they influence who accesses benefits and whose voices are heard in decision-making, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity.The papers in the series address governance through diverse health policy and system issues, consider actors located at multiple levels of the system and draw on multi-disciplinary perspectives. They present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings. The overall purpose of the papers in this series is thus to provide an empirical and embedded research perspective on governance and equity in health systems.

Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context. Change occurs at many layers of a health system, shaped by social, political, and economic forces, and brought about by different groups of people who make up the system, including service users and communities. The seeds of transformative practice in HPSR lie in amplifying the breadth and depth of dialogue across health system actors in the conduct of research – recognizing that these actors are all generators, sources, and users of knowledge about the system. While building such a dialogic practice, those conducting HPSR must strive to protect the autonomy and integrity of their ideas and actions, and also clearly explain their own positions and the value-basis of their work. We conclude with a set of questions that health policy and systems researchers may wish to consider in making their practice more people-centred, and hence more oriented toward real-world change.

Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context. Change occurs at many layers of a health system, shaped by social, political, and economic forces, and brought about by different groups of people who make up the system, including service users and communities. The seeds of transformative practice in HPSR lie in amplifying the breadth and depth of dialogue across health system actors in the conduct of research - recognizing that these actors are all generators, sources, and users of knowledge about the system. While building such a dialogic practice, those conducting HPSR must strive to protect the autonomy and integrity of their ideas and actions, and also clearly explain their own positions and the value-basis of their work. We conclude with a set of questions that health policy and systems researchers may wish to consider in making their practice more people-centred, and hence more oriented toward real-world change.