Abstract
Growing international concern about the need for improved health systems in Africa has catalyzed an expansion of the health systems literature. This review applies a bibliometric procedure to analyze the acceleration of scientific writing on this theme. We focus on research published during the Millennium Development Goal (MDG) era between 1990 and 2014, reporting findings from a systematic review of a database comprised of 17,655 articles about health systems themes from sub-Saharan African countries or subregions. Using bibliometric tools for co-word textual analysis, we analyzed the incidence and associations of keywords and phrases to generate and visualize topical foci on health systems as clusters of themes, much in the manner that astronomers represent groupings of stars as galaxies of celestial entities. The association of keywords defines their relative position, with the size of images weighted by the relative frequency of terms. Sets of associated keywords are arrayed as stars that cluster as "galaxies" of concepts in the knowledge universe represented by health systems research from sub-Saharan Africa. Results show that health systems research is dominated by literature on diseases and categorical systems research topics, rather than on systems science that cuts across diseases or specific systemic themes. Systems research is highly developed in South Africa but relatively uncommon elsewhere in the region. "Black holes" are identified by searching for terms in our keyword library related to terms in widely cited reviews of health systems. Results identify several themes that are unexpectedly uncommon in the country-specific health systems literature. This includes research on the processes of achieving systems change, the health impact of systems strengthening, processes that explain the systems determinants of health outcomes, or systematic study of organizational dysfunction and ways to improve system performance. Research quantifying the relationship of governance indicators to health systems strengthening is nearly absent from the literature. Long-term experimental studies and statistically rigorous research on cross-cutting themes of health systems strengthening are rare. Studies of organizational malaise or corruption are virtually absent. Trend analysis shows the emergence of organizational research on specific priority diseases, such as on HIV/AIDS, malaria, and tuberculosis, but portrays a lack of focus on integrated systems research on the general burden of disease. If health systems in Africa are to be strengthened, then organizational change research must be a more concerted focus in the future than has been the case in the past.
Highlights
This paper aims to take stock of this proliferation of financing, programming, and research that occurred in the wake of these historic milestones by conducting a bibliometric review of keywords associated with articles about health systems in sub-Saharan Africa published during the Millennium Development Goal (MDG) era (1990–2014)
The pace of expansion was associated with the onset of the MDG era, with concomitant acceleration in the publication and proliferation of themes consistent with systems deliberations
This expansion of analytical writing is much needed, as systems constraints to health development are widely acknowledged to be more prominent in subSaharan Africa than in any other region
Summary
Global Health: Science and Practice 2015 | Volume 3 | Number 3 generating a wide array of scientific and policy articles on problems encountered and lessons learned.[2,3,4,5,6]This commitment to health systems development in Africa can be traced to modality innovations, diseasecontrol initiatives, and vertical programs launched in the 1970s and 1980s.6 The 1978 Alma Ata Conference catalyzed critically important health systems action and writing.[7,8,9] The subsequent focus of the international community on health systems integration, reform, and decentralization received impetus from internationalHealth Systems Research in Africa www.ghspjournal.org partnerships. Global Health: Science and Practice 2015 | Volume 3 | Number 3 generating a wide array of scientific and policy articles on problems encountered and lessons learned.[2,3,4,5,6]. This commitment to health systems development in Africa can be traced to modality innovations, diseasecontrol initiatives, and vertical programs launched in the 1970s and 1980s.6. The ‘‘sector-wide approach,’’ financed by the World Bank and other international initiatives,[10] influenced policies and program implementation throughout the region.[11,12] With the onset of the United Nations Millennium Development Goals (MDGs)[13,14] and corresponding concerns about capabilities of African countries to achieve them, donor assistance, funding, and priority programs directed attention to the need for health systems strengthening in sub-Saharan Africa.[5,10,11,12,13,14,15,16,17,18]
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