This study dealt with one of the most important pillars of the HRS [30]; exploring the system’s capacities. As the HRS exists in a complex and diverse context [31, 32] and is of increasing concern to health policy-makers, providers, and others [7, 9, 33], the findings of this analysis are expected to contribute to the understanding of capacity components of the HRS in Palestine. This, in turn, will increase the potential for a successful and effective HRS based on active participation and well-strengthened capacity.
The findings of this study indicate that the level of research quality and compliance with good HR standards is still insufficient and needs more attention. A previous study found that in Palestine the subject of HR capacity is under the satisfaction level [26], although research quantity in the MENA region is not only increasing, the quality of HR is also improving [34]. The reasons for the low level of HR quality and non-compliance with HR standards can be related to institutional and environmental challenges. These include namely, the lack of cohesive policies and priorities; capacity and resources, and institutional quality and ethical reviews, as one study proved [16]. Other gaps are caused by the lack of researchers’ knowledge and international exposure to HR quality standards and expertise. This, however, has been refuted by a study which indicated that international collaboration in research output was reported [24]. Moreover, the shortage of trusted and high-quality local journals, individualism instead of interdisciplinarity in HR production, and, more importantly, a severe lack in basic research subjects will have to be tackled inherently by the health schools’ curriculum.
The analysis of participants’ responses across both methods revealed four practical steps that may improve HRQS:
(1) A national policy that prioritizes the quality of HR.
(2) Technological mechanisms such as interactive electronic platforms and hubs that can link external HR knowledge and expertise with the local HR community [24].
(3) The creation of guidelines for improving HRQS and embedding of these guidelines into health schools’ curricula and also integrating them into capacity building programmes to develop researchers’ skills and capabilities. One example is the CONsolidated Standards of Reporting Trials (CONSORT) [26].
(4) Strengthening HR ethical and technical review, evaluation, and follow-up [16]. Embedding such foci in the education and training of health researchers is a central activity for increasing the quality value of HR in Palestine.
The current study further evidently revealed several constraints to HRKTD. These include, for example, the fact that knowledge generally, and research outputs, in particular, are not disseminated regularly and appropriately. As a consequence, the evidence diffusion process remains weak mainly due to inadequate utilization and demand for research [35]. A comparable study showed that building HRSs to support HRKTD for improved health is one of the major challenges across the region [11].
Several impediments to good practice of HRKTD were identified; these include:
- Shortage in the culture of HRKTD among seniors at the high-management levels and research managers and researchers on HRKTD or evidence-informed policy-making concepts, and even HR culture [17, 36].
- HRKTD mechanisms and tools are lacking such as platforms, forums, peer-review journals, press releases, policy briefs, and libraries such as recommended by HINARI [37] and WHO [38]. HRKTD practices are, furthermore, often limited to the micro-institutional and individual levels, rather than through a systematic and inclusive national approach [35].
- HR is carried out for personal purposes or for donors’ agendas, with the result that the publication and dissemination of findings are often either missing or neglected.
- This study, as well as others, emphasized the absence of a regulatory framework such as body and policy, inadequate resources, and local and external poor coordination; this creates confusion in HR production, dissemination, and utilization. Finally:
- Difficulties related to data quality and availability, whether vital national statistics or data collected from HR, as well as the conditions of borders blockage and movement obstacles that prevent the flow of researchers and materials to and from Palestine. Another study added further gaps. such as the low level of engagement in the HRKTD activities due to the little support available in the HRKTD environment, including the lack of incentives [35].
For better HRKTD, as highlighted previously in the HRS stakeholder analysis part, there is a need to increase the involvement of the political level and advance a regulatory framework for HR. This move should make it possible to define the stakeholders’ roles, to improve coordination and the concepts of HR and HRKTD among decision-makers and researchers alike [4, 11, 35, 39]. More investment is necessary to establish HRKTD strategy including innovative tools using technology, for example, a national archive for science data [37], national platforms such as KIP [40], K4P, strategic policy platforms, or research decision-making centres or labs. This strategy should embrace the helpful WHO model for HRKTD [38]. A strengthening of Palestinian national and institutional databases is needed to improve quality, organization, accessibility, and transparency, and enhance the local and international partnerships and collaboration in HR production and dissemination [7].
The study found HRTUDP a central concept emphasized by the WHO Eastern Mediterranean Regional Office (WHO-EMRO) in its strategic directions for research for health, a pivotal tool for health development and informing health policy improvement [35]. HRTUDP was first demonstrated by the Canadian Institute of Health Research (CIHR) to bridge the knowledge-practice gap and is being now widely used with interchangeable terms in the literature (e.g. knowledge transfer, research utilization, evidence implementation) [41]. HRTUDP in Palestine exists under constrained circumstances and has, so far, not been a key tool in the decision-making process in the country’s HCS. This study identifies knowledge and policy gaps and it recommends enhancing the research-policy interface [35]. The problem of an unsupportive culture for research to become acknowledged should be addressed, where decisions or policies are mostly not evidence- and knowledge-based, and decision-makers are not knowledge-oriented [42]. This is also consistent with AlKhaldi et al., on the deficient conceptualization level on HR or HRS at large [17]. In return, a study carried out in the region denies the presence of negative attitudes among policy-makers towards research evidence, its use, and benefits in practice, and it calls for fostering evidence-informed policy-making by establishing a clear understanding of the national context in which policy decisions are made [35].
Other identified technical constraints are a deficit in trust and inconsistent relations [43] between the knowledge-producers and the decision-makers, which weakens knowledge diffusion. Moreover, academic knowledge production was found to be an area of low investment by the state. A further limitation related to HR quality and credibility is HR deficiency in addressing real priorities with plenty of descriptive studies compared to a paucity of experimental studies, which offer more trustworthy evidence. This is clearly emphasized by a similar study [44]. Finally, with the absence of good HR governance, policies, and priorities, scarcity of resources, and institutional management changes, and political instability as literature demonstrated [8, 23, 35, 45–47], knowledge and research-informed policy-making will remain impossible unless these fundamental hindering issues are addressed. Therefore, substantive structural and technical-procedural changes should be implemented to promote knowledge translation and decision-making practices and to eliminate preference-based decisions, whereby the health systems could eventually be strengthened [43, 48].
These are the changes and improvements suggested:
First: Urgent synergized efforts to establish a well-structured HRS, involving and organizing all HR components, including HRTUDP. This is largely consistent with the debate at the Global Forum 2015 which attributed the low uptake of evidence partly to weak governance and sub-optimal collaboration and engagement among research, industry, policy-making, and community societies [43].
Second: The concept of HRTUDP and evidence and knowledge-based practices, as others such as HR, HRS values, goals, and stewardship functions, HRQS, and HRKTD concepts, need to be entrenched among the health system’s decision-makers and researchers.
Third: Building knowledge translation strategies consisting of effective communication channels and interactive integration spaces mandated by MoH and academia, as proposed in HRKTD, such as national HR or knowledge-policy networks, forums [40], models [51], journals, labs, Hackathons, centres, clubs, policy briefs magazines, and media releases [38, 43]. Fourth: Maintaining synergy and dynamic mechanisms between HRTUDP and HRKTD as both complement each other [44].
Fifth: On top of that, capacity building and education programmes on HRKTD should be provided in collaboration with local and international partners. In Palestine, some active bodies, such as local universities, PNIPH, and different initiatives, such as LPHA, are likely to be driving forces to achieve that.
The study limitations can be summarized as follows:
(1) The substantial knowledge gap of relevant literature on the subject as well as the lack of data availability, quality, organization, and accessibility;
(2) Time constraint for an even more comprehensive analysis, linked to the restrictions on the freedom of movement of the research team as a result of the closure and security checkpoints; and
(5) The constant environmental and political fluctuations and institutional changes.
Consequently, the present study proposes further research in the following key areas:
- A national need assessment study or quantitative study may be useful to precisely determine and assess the HRSC currently available such as practices, assets, resources, and facilities at the individual, institutional and national levels.
- There is a need to examine, perhaps by using observation or case study methods, specific knowledge transfer and application practices.