As the first-ever global-level strategy on Health Policy and Systems Research (HPSR), this document represents a unique milestone in the evolution of health policy and systems research. It has three broad aims. First, it seeks to unify the worlds of research and decision-making and connect the various disciplines of research that generate knowledge to inform and strengthen health systems. It is targeted at decision-makers at all levels of the health system - from national policy-makers to front line providers of health services - and seeks support to make HPSR increasingly demand-driven and responsive to the needs of 21st century health systems. Second, this strategy contributes to a broader understanding of the field of HPSR by clarifying the scope and role of HPSR. It provides insight into the dynamic processes through which HPSR evidence is generated and used in decision-making. Finally, it is hoped that this strategy will serve as an agent for change. It advocates for a paradigm that emphasises the need for close collaboration between researchers and decision-makers rather than work along parallel pathways. The strategy speaks to decision-makers and researchers as part of one community and proposes actions that both can take in order to strengthen the performance of health systems. It calls for a more prominent role for HPSR at a time when the health systems mandate is evolving towards broader goals of universal health coverage and equity.
Monitoring equity and research policy
In this report, the author explores how the evaluation of intersectoral action for health (IAH) and health in all policies (HiAP) is being implemented from the experience of expertise directly involved in such work. The World Health Organisation (WHO) selected 11 respondents for their involvement in work on IAH and systems scale analysis. They were interviewed and the documents they provided were reviewed. The respondents were drawn from local government, national- and global-level institutions, mainly from high-income countries with only two from middle- or low-income countries. The findings suggest that having an explicit and shared conceptual framework for IAH work at inception is necessary to clarify the pathways for change, the outcomes and measures for assessing performance and impact, to prioritise action and to test the thinking informing IAH work. While the learning from this may be context-specific, learning networks provide a means for a meta-analysis of case studies, to build more generic knowledge around conceptual frameworks. For most respondents, a model of reflexive or negotiated evaluations was seen as most useful for concept, performance and impact evaluation, embedded within the planning and implementation of IAH, with knowledge jointly constructed by different actors, including local communities, and linked to the review of practice. All those interviewed encouraged further work to develop approaches and methods for the evaluation of IAH. While noting the limitations on generalisations due to the small sample, the findings suggest some recommendations for supporting promising practice on the evaluation of IAH.
Expert consultations were held at the Harvard School of Public Health, Boston, from 8 to 9 May 2013, in order to develop operational strategies that can be used by governments and other stakeholders to embed research into decision-making processes, a key recommendation of the WHO Strategy on Health Policy and Systems Research (included in this newsletter). It was agreed that a framework needs to be developed, to guide the embeddedness of research into decision-making. This framework should be based on the needs, the capacities and the available funding situation of each country. There was also agreement on the need to interact with existing initiatives, such as EVIPNet and make use of existing tools and platforms as starting blocks for new and innovative frameworks.
Despite the growing focus on health systems, the largest global health initiatives continue to have a disease specific focus. In response, the Doris Duke Charitable Foundation launched the African Health Initiative (AHI) to catalyse significant advances in strengthening health systems by supporting Population Health and Implementation Training (PHIT) Partnerships in five diverse sub-Saharan African contexts. Each Partnership is addressing key health systems constraints to improve service delivery and health outcomes. The authors of this article identify a number of overarching lessons from the first three and a half years of implementation, which include the need for a multipronged approach to systems, with the result that most of the teams ultimately included activities in each of six areas identified as health system building blocks by the World Health Organisation. Despite relatively modest funds for the scope of planned activities, teams garnered substantial interest and support at high levels of the Ministries of Health, reflective of the need to plan comprehensively for health systems without the constraint of a single disease focus.
In this study, researchers report on linking data with improved decision-making. Mozambique, Ghana, and Tanzania focus on improving the quality and use of the existing Ministry of Health health information, while Zambia and Rwanda have introduced new information and communication technology systems or tools. All have a flexible, iterative approach in designing and refining the development of new tools and approaches for HIS enhancement, as well as improving decision making through timely feedback on health system performance. The differences are found in the level of emphasis of data collection (patient versus health facility), and consequently the level of decision making enhancement (community, facility, district, or provincial leadership).
Public health today enjoys commitment, resources, and powerful interventions but the power of these interventions is not matched by the power of health systems to deliver them to those in greatest need, on an adequate scale and in time. According to this document, this arises, in part, from the fact that research on health systems has been so badly neglected and underfunded. In the absence of sound evidence, we will have no good way to compel efficient investments in health systems. Outlined in this document are a number of options for action by stakeholders to facilitate evidence-informed decision-making and the strengthening of health systems. These complementary options are intended to support the embedding of research within decision-making processes and promote a steady programme of national and global investment in HPSR. Member States of WHO may opt to pursue some or all of these actions, based on their individual context . 1. Embed research within decision-making processes. 2. Support demand-driven research. 3. Strengthen capacity for research and use of evidence. 4. Establish repositories of knowledge. 5. Improve the efficiency of investments in research. 6. Increase accountability for actions.
The Mozambique Population Health Implementation and Training (PHIT) Partnership focuses on improving the quality of routine data and its use through appropriate tools to facilitate decision making by health system managers; strengthening management and planning capacity and funding district health plans; and building capacity for operations research to guide system-strengthening efforts. This seven-year effort covers all 13 districts and 146 health facilities in Sofala Province. The Mozambique PHIT Partnership expects to provide evidence on the effect of efforts to improve data quality coupled with the introduction of tools, training, and supervision to improve evidence-based decision making. This contribution to the knowledge base on what works to enhance health systems is highly replicable for rapid scale-up to other provinces in Mozambique, as well as other sub-Saharan African countries with limited resources and a commitment to comprehensive primary health care.
The challenge of improving healthcare information in countries with meagre resources will require more than just highlighting insufficiencies, according to this editorial. The right to access health information is a key component of a strong health system, but to be effective it requires evaluation and synthesis of evidence, translation of evidence into educational materials, and implementation and dissemination. Health information is key to improving weak health systems. If governments are legally obliged to support the right to access reliable health information, what can be done to ensure that they do so? It is suggested that a legal approach may not work, but that locating access to reliable health information within the broader human rights framework may generate benefit from the momentum of human rights advocacy.
In this study, the authors aim to provide a comprehensive description of available data sources, propose a set of indicators for monitoring the global landscape of health research and development (R&D), and present a sample of country indicators on research inputs (investments), processes (clinical trials), and outputs (publications), based on data from international databases. Total global investments in health R&D (both public and private sector) in 2009 reached US$240 billion. Only about 1% of all health R&D investments were allocated to neglected diseases in 2010. Diseases of relevance to high-income countries were investigated in clinical trials seven-to-eight-times more often than were diseases whose burden lies mainly in low-income and middle-income countries. This report confirms that substantial gaps in the global landscape of health R&D remain, especially for and in low-income and middle-income countries. Too few investments are targeted towards the health needs of these countries. Better data are needed to improve priority setting and coordination for health R&D, the authors argue, ultimately to ensure that resources are allocated to diseases and regions where they are needed the most. The establishment of a global observatory on health R&D, which is being discussed at WHO, could address the absence of a comprehensive and sustainable mechanism for regular global monitoring of health R&D.
Tackling health inequalities must be a central plank of public policy for any Government, and this report is intended to help to shape the policy direction, and influence the targeting and delivery of services, in tackling inequalities. The evidence base about “what works” is still fairly weak, but there is now a commitment to address this. Resources are going into research and development to advance our knowledge and understanding of what works. This report works in parallel to that research, in terms of measuring inequalities in order to plan, set targets, monitor and evaluate. The authors recommend establishing mechanisms to monitor inequalities in health and to evaluate the effectiveness of measures taken to reduce them. This report is relevant to anyone involved in addressing health inequalities, as it presents the complicated science of the measurement of inequalities in a rigorous but accessible way.