The Theory of Change diagram for the NIHR Global Health Policy and Systems Research (Global HPSR) programme is a nested theory of change, which should be viewed as a subset of the overarching Global Health Research Portfolio Theory of Change.
The Global HPSR Theory of Change demonstrates the inputs, activities, outputs, outcomes and impacts that reflect the core aims, objectives, and funding criteria of the Global HPSR programme. It provides a visual representation of the programme’s core principles and ambitions, shown in a series of logical steps.
This Global HPSR Theory of Change shows the inputs that are required to enable the programme to work effectively and the activities that take place using these inputs. It also highlights how these inputs and activities are expected to result in short-term outputs, mid-term outcomes and long-term impacts, which occur at various points in time.
Blue boxes with arrows on grey background indicate the assumed causal flow starting with how the resources deployed (inputs) enable activities to take place leading to a set of expected results (outputs) in the short-term. These then feed into changes (outcomes) in the medium-term and finally culminate in long-term impacts occurring after around ten to twenty-five years.
Inputs, activities, and outputs are stages within the direct sphere of control of the NIHR Global HPSR programme (as indicated by the light grey box - sphere of direct control) while the outcomes may be directly influenced (rather than controlled, as indicated by the mid grey box - sphere of direct influence) and impacts are only indirectly influenced ( as indicated by darker grey box - sphere of indirect influence). The impacts relate to the global needs that the programme awards were designed to play a role in addressing; these become progressively harder to measure as they move from outputs to outcomes and impacts, as represented by the increasing density of grey shading within the different spheres of control box frames.
Some significant reverse flows (feedback loops) are expected, and these are indicated by green lines with arrows from bottom to top (e.g. global networks are created as an outcome of Development Awards, which will likely feed into inputs in future research funding rounds for Commissioned and Researcher-led Awards).
The first stage of the diagram focuses on the inputs for the successful working of the Global HPSR programme Development awards on the left-hand side and how these planning awards feed into the Commissioned Awards and Researcher-led Awards on the right-hand side.
Focusing on the left hand side first, Development Awards are small research planning awards designed to help researchers in LMICs and the UK to establish and develop equitable partnerships and review the local context to identify LMIC-led priorities in HPSR to address. In addition, the awards support engagement with local communities and stakeholders to inform research priorities and needs and the planning of the strategies for research dissemination and uptake. All these activities are intended to contribute to the development of a competitive substantive application for research and capacity strengthening to address identified HPSR needs able to be submitted to NIHR or other global health funders.
Development awards
Development Awards are managed by the Global HSPR programme. Within the programme’s sphere of direct control are a series of Inputs that enable activities to take place leading to a set of expected results (outputs) in the short-term, which feed into changes (outcomes).
The first stage of the Development Awards includes the following Inputs:
- Multidisciplinary LMIC and UK researchers interested in forming new HPSR global partnerships
- External experts’ expertise and time
- Research and research-enabling staff and facilities
- Background intellectual property (IP), know-how and research data
These inputs then feed into the second stage consisting of the activities undertaken by global HPSR research teams using their inputs throughout the development award period.
- Develop equitable LMIC/UK partnerships
- Identification and engagement of stakeholders & performance of context and/or needs analysis
- Development plans for research capacity strengthening
- Development of a strategy for research dissemination and uptake
The third stage consists of the intended outputs that are expected in line with Development Award activities. Outputs include:
- Submission of competitive, high quality research funding applications in response to existing and emerging LMIC needs and priorities
- Establish plans for sustainable programme of capacity and capability strengthening at an individual and institutional level to support global HSPR
- Engage key stakeholders in the research dissemination and uptake strategy
- Improved understanding of the enablers and barriers to HSPR given local contexts
There are also several funder level outcomes that NIHR would expect to see which flow from inputs, activities, and the outputs of the Development Awards. These include
- Strengthened equitable research partnerships between LMIC’s and UK to deliver large-scale HPSR projects
- An increased capacity in LMIC and UK institutions to engage with relevant stakeholders to identify global health policy and systems priorities
- Self-sustaining multi-disciplinary global networks are created in HSPR
The outcomes of the Development Awards then naturally lead into the inputs for the Researcher-led Awards. Development Awards are expected to result in substantive and competitive research applications able to openly compete for Global HPSR Researcher-led Awards or other opportunities. This would not necessarily always be the case for Commissioned Awards which specifically invite research applications from established partnerships to address identified HPSR priorities in LMICs as specified for each specific call.
Commissioned Awards and Researcher-led Awards
The right-hand side focuses on the inputs for Commissioned Awards and Researcher-led Awards which involve submission of high-quality research applications from established LMIC/UK research partnerships and independent assessment:
- Multi-disciplinary research teams with established LMIC/UK partnerships and existing track record of internationally recognised HPSR in ODA-eligible countries
- External experts’ expertise and time in funding processes
- Research staff and research-enabling staff, support for training and facilities
- Background IP, know-how and research data
As a funder, the NIHR supports these inputs by providing financial resources to commission, manage and oversee the programme.
These inputs then feed into the second stage consisting of the activities undertaken by Global HPSR research teams using their inputs throughout the award period. The activities undertaken by Global HPSR research teams are:
- Develop, consolidate, and expand equitable LMIC/UK research partnerships and networks
- Strengthening institutional capacity in research and research-enabling staff
- Conduct high-quality HPSR with a whole systems approach that responds to context specific LMIC needs or identified priority areas
- Develop and implement strategy for research dissemination and uptake
At the funder level, NIHR supports researchers with their research activities through the monitoring and evaluation of awards; facilitating training, learning, networking and knowledge exchange; communication and guidance.
The blue boxes with arrows against a grey background indicate the causal flow, linking the activities to the third stage – which consists of the intended short-term outputs. These are the tangible, measurable products, goods, and services resulting from the activities. In the short-term, the following primary research-related outputs are expected, in line with the activities:
- Equitable research partnerships and networks are established and/or strengthened
- Strengthened local and/or regional research capacity and capability
- High-quality policy and practice-relevant research outputs tailored and disseminated to key stakeholders
As a funder, NIHR supports the generation of short-term outputs by providing digital open-access platforms and dissemination mechanisms.
After around three to ten years, NIHR expect to see the following mid-term outcomes:
- Self-sustaining global networks are strengthened
- Increased capacity in LMIC and UK institutions to identify and address global HPSR needs
- Strengthened LMIC research and research management capacity to perform health policy and systems research
- Increased inclusion, engagement and research awareness of LMIC communities to support the sustainable co-production of research
- An influence on policy making and practice, as policymakers and practitioners become aware of research outputs and evidence and use these at multiple levels in the health system
- NIHR begin to see positive health outcomes and reduced inequalities for people and communities in LMICs
NIHR would expect to some mid-term outcomes at the funder level. These include positive contributions to strengthening research partnerships and networks in areas of identified need to influence health system resilience in LMICs. In addition, some increasing recognition of the NIHR, as a global health researcher funder, striving for universal health coverage by addressing locally identified LMIC health system priorities both for research and research capacity strengthening.
The final stage of the diagram shows long-term impacts. In the long term (approximately 10-25 years), the changes in policy, practice and behaviour are expected to contribute towards strengthened health policy and systems in LMICs to respond to population needs for prevention, treatment and management of disease, increased individual and community capacity for health promotion and disease prevention, and the sustainable growth of the LMIC research ecosystem. Somewhat harder to measure, but something NIHR still expects to have an impact upon, is economic development and welfare in LMICs. These impacts tie into the Sustainable Development Goals (SDG), notably health related and societal impact through SDG 3 (“ensure healthy lives and promote wellbeing for all at all ages”), broader economic impact through SDG 8 (“promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all”).
The diagram also shows some reverse flows (green line with arrows - feedback loop). So, for instance, the global HPSR networks which are strengthened as a mid-term outcome will feed back into inputs and activities in future funding programmes.
The diagram contains a series of asterixis that represent:
- research enabling staff refers to research managers, finance and administrative staff
- Equitable research partnerships and networks are defined in line with SDG-17 ‘Enhance North-South, South-South and triangular regional and international cooperation on and access to science, technology and innovation and enhance knowledge sharing on mutually agreed terms’
- at multiple levels in health systems mean the patient and practitioners (micro-level); organisation and delivery of health care (meso-level) and; national/regional (macro-level)
- A research ecosystem refers to researchers and their outputs, research institutions, funders, policy makers who use the research to inform policy, communication specialists who share findings with the public, and private sector companies who develop products and employ researchers
Finally, community engagement and involvement, co-production and equitable ways of working are supported and fully embedded in all activities and at all stages of the model and throughout the research lifecycle. This is indicated by the orange line surrounding the entire research pathway and model.
Increasingly, as the theory moves from the top towards the bottom of the diagram, the theory of change relies on set assumptions around the causal links. Where assumptions do not hold true, there is a risk that these will cause a break in the causal links, which could undermine the achievement of the intended outcomes and impacts. NIHR will monitor the assumptions and risks to test if any mitigation is required.
Assumptions
The assumptions are likely to play out differently over time and space; LMIC settings are not homogenous:
Inputs:
- LMIC/UK partnerships can successfully and effectively deliver global HPSR research
- Applications, submitted and funded are based on LMIC-led and needs-driven priorities for sustainable HPSR solutions in support of SDGs
- Applicants have the knowledge and networks for community engagement and involvement (CEI) during the pre-award stage to co-produce strong proposals
- Applicants are able to bring the necessary input resources
Activities:
- Global HPSR teams are able to mobilise, expand and strengthen partnerships and networks
- Research areas in HPSR continue to reflect LMIC-led and needs-driven priorities
- Global HPSR teams are able to achieve equity and collaboration at all levels of working, including at the pre-award stage, and involve South-South as well as North-South collaborations and partnerships
- Global HPSR teams have the ability to effectively identify and engage relevant policy-makers
- Active CEI is maintained throughout the end-to-end research process, including in the generation of priorities for research and dissemination of findings
- NIHR funding and monitoring activities support equitable ways of working within research teams
- Activities are efficient and contribute to value for money
- NIHR communication activities are sustained throughout and reach intended audiences
Outputs:
- Partnerships and networks established are sustainable and able to attract funding from other sources
- Research outputs consider access, coverage, quality, efficiency and equity
- NIHR award level dissemination platform/mechanisms are recognised and used
- Learning and translation between partners and settings is accepted and acted upon
Outcomes:
- Policy-makers/practitioners have the resources and the political will and ability to understand and use research findings generated and disseminated
- Institutional capacity for research is supported within the LMIC environment and trainees are retained within the LMIC research ecosystem to support future sustainability
- Locally-driven work packages have potential for wider geographic generalisability
Risks:
- Researchers do not have skills, knowledge and networks to disseminate findings effectively to policy-makers and practitioners
- External influences e.g. social, political, economic, environmental, technological, legal, demographic, cultural context hamper the research process or the uptake of research evidence.