The authors of this paper assessed recent evaluations of health systems (HS) strengthening interventions in low- and middle-income countries from 2009–10. Out of 106 evaluations, less than half (43%) asked broad research questions to allow for a comprehensive assessment of the intervention’s effects across multiple HS building blocks. Only half of the evaluations referred to a conceptual framework to guide their impact assessment. Overall, 24% and 9% conducted process and context evaluations, respectively, to answer the question of whether the intervention worked as intended, and if so, for whom, and under what circumstances. None incorporated evaluation designs that took into account the characteristics of complex adaptive systems such as non-linearity of effects or interactions between the HS building blocks. The authors call for more comprehensive evaluations of the range of effects of an intervention, when appropriate. They identify some barriers to more comprehensive evaluations as limited capacity, lack of funding, inadequate time frames, lack of demand from both researchers and research funders, or difficulties in undertaking this type of evaluation.
Monitoring equity and research policy
The current trend towards the devolution of government responsibility is usually accompanied by severe cuts in public sector budgets, forcing government departments to develop different ways of working via partnerships of various types (government and non-government) and at various levels (national, regional and local). The challenge, the authors of this paper argue, will be finding ways for these partnerships to engage all partners fully in delivering public policy whilst recognising that each partner has a different mandate and different objectives that will align to different degrees with the policy’s stated goals. They argue that devolution of government responsibility has negatively affected policymaking as Ministers tend to focus on a small number of core activities, or outputs, rather than being accountable for delivering the final outcomes that solve or ameliorate societal problems. And any further devolution of responsibility is likely to give rise to ‘messy’ partnerships as well. The authors propose that current policy-making tools based on logic and prediction will fail to deal with the complexity of partnership working, and instead they recommend techniques like outcome mapping and social frameworks, which are covered in detail in the paper.
Strengthening health systems for improved policy making in low- and middle-income (LMIC) countries requires sustained efforts from many people, working collaboratively across multiple levels. Accordingly, the authors of this paper argue that the complexity of health systems necessitates approaches that are grounded in systems thinking at the global, national and subnational levels, and that recognise the need for ways of working that promote integration rather than fragmentation. Network structures represent a broad set of collaborative approaches that are useful for bringing stakeholders together. The authors propose that health systems in LMIC countries will be strengthened if policy researchers, policy makers and other stakeholders are able to explicitly and purposefully apply systems thinking concepts to the design, implementation, monitoring and evaluation of networks.
Malaria vector studies are a very important aspect of malaria research as they assist researchers to learn more about the malaria vector. Research programmes in various African countries include studies that assess various methods of preventing malaria transmission including controlling the malaria vector. Various institutions have also established mosquito colonies that are maintained by staff from the institutions. Malaria vector research presents several dilemmas relating to the various ways in which humans are used in the malaria vector research enterprise. A review of the past and present practices reveals much about the prevailing attitudes and assumptions with regard to the ethical conduct of research involving humans. The focus on the science of malaria vector research has led some researchers in African institutions to engage in questionable practices which reveal the ethical tensions inherent in the choice between science and the principles of justice, nonmaleficence and respect for individuals. The analysis of past and present choices in malaria vector research has relevance to broader questions of human dignity and are in line with the current emphasis on ethical research worldwide.
This paper examines the challenges and opportunities in establishing and sustaining north– south research partnerships in Africa through a case study of the UK-Africa Academic Partnership on Chronic Disease, which brought together multidisciplinary chronic disease researchers based in the UK and Africa to collaborate on research, inform policymaking, train and support postgraduates and create a platform for research dissemination. During the funded period researchers created a platform for research dissemination through international meetings and publications, but other goals, such as engaging in collaborative research and training postgraduates, were not as successfully realised. Enabling factors included trust and respect between core working group members, a shared commitment to achieving partnership goals, and the collective ability to develop creative strategies to overcome funding challenges. Barriers included limited funding, administrative support, and framework for monitoring and evaluating some goals. As chronic disease research partnerships in low-income regions operate within health systems that prioritise infectious diseases, their long-term sustainability will therefore depend on integrated funding systems that help build capacity, the authors argue. They identify social capital, measurable goals, administrative support, creativity and innovation and funding as five key ingredients that are essential for sustaining research partnerships.
Although most countries in sub-Saharan Africa lack an effective and comprehensive national civil registration and vital statistics system (CRVS), in the past decades the number of Health and Demographic Surveillance Systems (HDSSs) has increased throughout the region. The authors of this paper argue that, in the absence of an adequate national CRVS, HDSSs should be more effectively utilised to generate relevant public health data, and also to create local capacity for longitudinal data collection and management systems. If HDSSs get strategically located to cover different geographical regions in a country, data from these sites could be used to provide a more complete national picture of the health of the population. Strategic planning is needed at national levels to geographically locate HDSS sites and to support these through national funding mechanisms. The authors emphasise that HDSSs should not be seen as a replacement for civil registration systems. Rather, they should serve as a short- to medium-term measure to provide data for health and population planning at regional levels with possible extrapolation to national levels. HDSSs can also provide useful lessons for countries that intend to set up nationally representative sample vital registration systems in the long term.
Health decision-makers need to rely more on data to inform their decision making, according to this paper. The failure to consider empirical evidence regularly before making programme and policy decisions is due primarily to the complex causal pathway between data collection, its use, and improvement in health outcomes, she argues. Further, specific and comprehensive guidance to improve data demand and use is lacking. This paper fills this gap by providing specific recommendations for how to improve data-informed decision making by suggesting domains of interventions, activities, actors, tools, and resources to involve in the process in each step. The eight activity areas listed in the conceptual framework and the further detail provided in the logic model provide a comprehensive roadmap for how to design, monitor, and evaluate interventions to improve the demand for and use of data in decision making. More experience is needed applying the comprehensive framework in different contexts, the authors warn. The factors influencing demand for and use of data are dependent on the local context and specific needs. It is probable that all of the activity areas discussed in this paper may not need to be implemented as part of an intervention to improve the demand for and use of data; and that other activity areas not listed here, will be relevant instead. Moreover, the relative importance of each activity area is unknown, as is the level of intensity of each activity area. Nonetheless, this conceptual framework and logic model should contribute to the literature on comprehensive approaches to improving the use of data in decision making.
Exploring some of the assumptions underlying ‘evidence based’ approaches to poverty reduction, this paper argues that the discourse of Evidence-Based Policy (EBP) offers poor guidance to those who seek to ensure that social policy making is informed by the findings of social science. EBP discourse relies on a technocratic, linear understanding of the policy making process and on a naïve empiricist understanding of the role of evidence. This renders it unable to engage with the role of the underlying discursive frameworks and paradigms that render evidence meaningful and invest it with consequence: EBP discourse does not help us understand either how policy changes, or what is at stake in dialogue across the ‘research-policy divide’. Rather than simply focusing on evidence, approaches to policy change need to focus on how evidence is used in the politically loaded and ideologically compelling ‘policy narratives’ that contest rival policy frameworks. The paper considers an example from the South African context – the shift to the ‘two economies’ framework and the policy interventions associated with the Accelerated and Shared Growth Initiative for South Africa (ASGISA)– and explores the implications for approaches to research more attuned to the realities of the policymaking process. It concludes with a discussion of the implications for social researchers and policy makers.
As there is little published evidence about processes in research-policy partnerships in different contexts, this paper aims to help fill this research gap by analysing experiences of research-policy partnerships between Ministries of Health and research organisations for the implementation of the Mental Health and Poverty Project in Ghana, South Africa, Uganda and Zambia. The authors developed a conceptual framework for understanding and assessing research-policy partnerships to guide the study and collected data via semi-structured interviews with Ministry of Health Partners (MOHPs) and Research Partners (RPs) in each country. The principles of trust, openness, equality and mutual respect were identified by respondents as constituting the core of partnerships. The MOHPs and RPs had clearly defined roles, with the MOHPs largely providing political support and RPs leading the research agenda. The authors also found that taking account of influences on the partnership at individual, organisation and contextual/system levels can increase its effectiveness. A common understanding of mutually-agreed goals and objectives of the partnership is essential. Although partnerships are often established for a specific purpose, such as carrying out a particular project, the effects of partnership go beyond a particular initiative.
Greater health systems research and development is needed to support the global malaria eradication agenda, argues the malERA Consultative Group on Health Systems and Operational Research. In this paper, the Group focuses on the health systems needs of the elimination phase of malaria eradication and analyses groupings of countries at different stages along the pathway to elimination. It examines the difference between the last attempt at eradication of malaria and more recent initiatives, and considers the changing health system challenges as countries make progress towards elimination. The paper contains a review of recent technological and theoretical developments related to health systems and the renewed commitment to strengthening health systems for universal access and greater equity. The Group identifies a number of needs for research and development, including tools for analysing and improving effective coverage and strengthening decision making and discuss the relevance of these needs at all levels of the health system from the community to the international level.