What are the key ethics issues in health systems research?
Health systems research is a field that draws on different disciplinary traditions and methodological approaches. Its overall aim is to influence policy and wider action to improve health system performance.
Health policy and systems research focuses on:
- The performance of health systems and their sub components (resources, organisations, and services)
- How links between the sub components shape performance, and what forces influence those links
- How to strengthen health system performance over time
Existing guidelines and research ethics committee members’ training tends to focus predominantly on the ethics of biomedical research. This is challenging for health systems research, which often operates at system or population as opposed to individual level. Also, in some health systems research (for example some embedded or participatory research) the distinction between research and practice that is central to much biomedical research ethics guidance is deliberately blurred.
There are very few guidelines and papers which deal directly with the ethics of health systems research. We have gathered together the ones that do in the Useful Resources section below. Many of these papers were led by Bridget Pratt and Adnan Hyder who have put considerable effort into synthesising existing literature and adding analysis based on their work within health systems consortia, for example, Future Health Systems.
The resources begin with a 2019 paper from the Alliance for Health Policy and Systems Research. It outlines a series of “points to consider” for the identification, consideration and communication of ethical issues.
This is followed by a recording of a webinar organised by the Health Systems Global Thematic Working Group on the Ethics of Health Systems Research. The Group is a great community of practice for those who want to share and learn on the topic. The webinar tackles issues such as how we conceptualise ethics in relation to non-human subjects (such as hospitals or communities), consent, and ensuring that risks are minimised and benefits maximised.
We have included a blog by Molyneux et al (2017) because it gives a quick round-up of what ethical issues were discussed at the Fourth Global Symposium on Health Systems Research raising issues such as social justice, micro-level ethics questions, and obligations and responsibilities in the face of multiple needs and inequities.
Having provided this overview, a series of papers provides more detailed insights. Krubiner and Hyder (2014) provide overarching domains in which we could consider health systems ethics: holism, sustainability, evidence and effectiveness, efficiency, public engagement and transparency, accountability and feedback, equity and empowerment, justice and fairness, responsiveness, collaboration, and quality.
Pratt et al. (2016) call upon the field of bioethics to move their focus beyond clinical trials to look at issues such as operations research, implementation research, health systems research, and research on the social determinants of health. The paper by Wassenaar and Rattani (2016) applies the Emanuel Framework for Clinical Research to health systems research to see how this might further Hyder’s call for more contemplation of ethics. The paper by Luyckx et al. (2017) draws on an expert meeting and calls for greater understanding and exploration of these issues within Ethics Review Boards.
Pratt et al. (2017) lead us through a scoping review of the literature related to health systems research, a conceptual exploration of the issue, how systems thinking might be applied to the topic, a review of field experiences and a call to action.
USEFUL RESOURCES

ChatGPT and global public health: Applications, challenges, ethical considerations and mitigation strategies
Abstract The advancement of deep learning and artificial intelligence has resulted in the development of state-of-the-art language models, such as ChatGPT. This technology can analyze large amounts of data, identify patterns, and assist in the analysis and understanding of risk factors for diseases. Despite its potential, the applications, challenges, and ethical considerations have not been […]

The Cape Town Statement on fairness, equity and diversity in research
The benefits of scientific collaboration are too often skewed towards wealthier countries. Bioethicists and others present guidance on how stakeholders such as researchers can change this. As awareness has grown about fraud and misconduct in science, the World Conferences on Research Integrity have become a leading forum for the discussion and study of ways to […]

Culturally responsive research ethics: How the socio-ethical norms of Arr-nar/Kreng-jai inform research participation at the Thai-Myanmar border
Abstract Despite advances, international research ethics guidelines still tend to consist of high-level ethical principles reflecting residual influence from North American and European traditions of ethics. Local ethics committees and community advisory boards can offer more culturally-sensitive approaches to training but most institutions lack substantive practical ethics guidance to engage rich moral understandings in day-to-day […]

Offline: The silencing of the South
League tables are addictive. From football to motorsport, tennis to golf, we relish following who is up and who is down. Understandably so, given that sport is fiercely competitive between individuals and teams. But universities? Provosts and Presidents of our greatest higher education institutions obsess over their rankings. Three dominate—the Times Higher Education (THE) World […]

Four approaches to supporting equitable research partnerships
Four approaches to supporting equitable research partnerships Transforming the global research partnership ecosystem in ways that increase equity and restore balance requires consistent action and reflection; the crux is finding a balance between flexibility and equity that enhances trust and respect among all partners. Drawing on the experience of funders, research organisations and researchers in […]

On an ethic of not going there
Fieldwork – “going there” – is the presumed norm and baseline of geographical research. In this commentary, I propose a framework for challenging the normative framing of fieldwork in geography and other fields (including those beyond academia): an ethic of not going there. I argue that fieldwork, rather than a neutral rite of passage, is deeply entwined […]

‘The Lancet’ journal rejects papers that don’t acknowledge African researchers
Respected global medical journal The Lancet will continue to reject papers with data from Africa that fail to acknowledge African collaborators, in the interest of building African research and of promoting integrity, equity and fairness in research collaboration, according to senior executive editor Sabine Kleinert. The journal made the decision after coming across manuscripts submitted by researchers […]

What counts? Knowledge and ideology in global health research
This piece was published on the Collective blog and the original can be found here. Research priorities set by funding institutions are steeped in ideology. In this piece, Collective member Ramya Kumar reflects on what these ideologies mean for knowledge production in global health. Research requires funds, which are of limited availability in low- and lower-middle […]

Nature addresses helicopter research and ethics dumping
New framework aims to improve inclusion and ethics in global research collaborations amid wider efforts to end exploitative practices. Exploitative research practices, sadly, come in all shapes and sizes. ‘Helicopter research’ occurs when researchers from high-income settings, or who are otherwise privileged, conduct studies in lower-income settings or with groups who are historically marginalized, with […]

The rise of citational justice: how scholars are making references fairer
An emerging movement aims to push researchers to pay more heed to inequities in scholarly citations. Christen Smith was at a conference in October 2017 when she felt a familiar jolt of frustration. A presenter showed a slide with passages that had been paraphrased from one of her books — and, to her dismay, had […]