Despite spending huge sums of money on health every year the African regions burden of disease is persistently high. Weaknesses are identified in factors as health leadership and governance, service delivery, health workforce, medicines, vaccines, and health technologies; health information; and health system financing that have undermined the capacity of health systems of countries in the region to improve population health without wastage of resources. In this book, the author applies a data envelopment analysis technique, interlacing lecture notes with research articles and case studies to equip students and practitioners of economics, operations research, management science, and public health with knowledge and skills for undertaking technical efficiency, allocative efficiency, cost efficiency, and total factor productivity analyses.
Monitoring equity and research policy
This literature review was conducted to identify examples of embedded health policy and systems research (HPSR) used to inform decision-making in low- and middle-income countries (LMICs). The authors found that multiple forces converge to create context-specific pathways through which evidence enters into decision-making. Depending on the decision under consideration, the literature indicates that decision-makers may call upon an intricate combination of actors for sourcing HPSR. While proximity to decision-making does have advantages, it is not the position of the organisation within the network, but rather the qualities the organisation possesses, that enable it to be embedded. These findings suggest that four qualities influence embeddedness: reputation, capacity, quality of connections to decision-makers, and quantity of connections to decision-makers and others. In addition to this, the policy environment (e.g. the presence of legislation governing the use of HPSR, presence of strong civil society, etc.) strongly influences uptake. The authors’ conceptual model highlights several important considerations for decision-makers and researchers about the arrangement and interaction of evidence-generating organisations in health systems.
In Uganda, a team of researchers, policy makers, civil society and the media has been formed to build a collaboration that would help in discussing appropriate strategies to mitigate the high disease burden in Uganda. A preparatory secretariat identified researchers and key resource persons to guide four workshops, which were held between 2006 and 2009. A total of 322 participants attended of whom mid-level policy makers, researchers and the media were consistently high. The workshops generated a lot of interest that lead to presentation and discussion of nationally relevant health research results. The workshops had an impact on the participants’ skills in writing policy briefs, participating in the policy review process and entering into dialogue with policy makers. A number of lessons were learned: getting health research into policy is feasible but requires few self-motivated individuals to act as catalysts; and adequate funding and a stable internet are necessary to support the process. Mid-level policy makers and programme managers had interest in this initiative and are likely sustain it as they move to senior positions in policy making, the authors report.
For this report, the authors conducted interviews with senior health systems researchers, high-level policy makers and policy brokers in 26 low- and middle-income countries (LMICs) in order to map health systems research capacity, health systems research undertaken and policy uptake of this research. They found that health systems research was dependent on a cluster of enabling factors: charismatic and strategically thinking individuals with a talent for networking, technical competence and scientific credibility, appropriate international alliances and trends, emergent local knowledge translation structures and increasing national ownership of research agendas, more and better training courses for researchers as well as workshops for decision makers to make them more attuned to each others’ world and constraints, increasing trust between decision makers and researchers, a critical mass of health systems researchers and competing institutions ‘able to deliver’, an entry point for health systems research in decision making circles, sufficient domestic and international funding, and even political transitions, shock events or other windows of opportunity. However, country contexts diverge widely. In most LMIC countries studied, health systems research appears to be gaining momentum, and its potential for informing policy is increasing.
Health systems research is widely recognised as essential for strengthening health systems, getting cost-effective treatments to those who need them, and achieving better health status around the world. However, there is significant ambiguity and confusion in this field’s characteristics, boundaries, definition and methods. Adding to this ambiguity are major conceptual barriers to the production, reproduction, translation and implementation of health systems research relating to both the complexity of health systems and research involving them. These include challenges with epistemology, applicability, diversity, comparativity and priority-setting. According to this report, three promising opportunities exist to mitigate these barriers and strengthen the important contributions of health systems research. First, health systems research can be supported as a field of scientific endeavour, with a shared language, rigorous interdisciplinary approaches, cross-jurisdictional learning and an international society. Second, national capacity for health systems research can be strengthened at the individual, organisational and system levels. Third, health systems research can be embedded as a core function of every health system. Addressing these conceptual barriers and supporting the field of health systems research promises to both strengthen health systems around the world and improve global health outcomes, the authors conclude.
The author of this article argues that one decade into the 21st century it is clear that the current situation in African leadership is not conducive to building strong national health research systems in the continent. Consequently, the promise of health systems strengthening may remain elusive, despite positive efforts. He says African countries are not acting according to international declarations, and are reneging on their commitment to take the lead by increasing their investments in health and research for health. More than two-thirds of external funding for health is bypassing government, in contradiction to the guidance of the Paris Declaration and the Accra Plan of Action. The author calls for broader dialogue on how international assistance for health is conceived will be needed to achieve results that can be scaleable and sustainable. Both African governments and external funders will need to examine how they engage to improve health systems, a critical step in improving population health.
This study describes the issue of research use in decision making from the perspective of embeddedness of research institutions in policy making. Its findings suggest that multiple forces converge to create context-specific pathways through which research enters the policymaking environment. The authors argue that while proximity to a decision making core does have advantages, it is not the position of the institution within the network, but rather, the qualities that institution possesses that enable it to be embedded: reputation, capacity, quality, and quantity of connections to decision makers. They also expected the policy environment to influence the uptake of research. Decision makers sourced evidence from research institutions in a variety of ways - leveraging personal networks, accessing peer-reviewed publications, developing formal links with national statistics agencies, academic, or independent research institutions, or by assembling expert committees for a well-defined task. However, findings from key informants suggested that the quality – and not the quantity – of connections was important for embedding research institutions in policy making, particularly where researchers were involved in policy making, where research institutions were part of the decision making body or where collaborative planning occurred to identify and prioritise research needs.
In this article, the author considers the disadvantages of over-reliance on evidence-based medicine. He argues that a publishing bias exists against studies with negative or inconclusive findings, which skews overall results. Sometimes, there is a significant finding in favour of a trial drug if the study was funded by for-profit organisations, which could not be explained by methodology, statistical analysis or type of study. He also points to a growing trend in industry-sponsored studies: the initial draft is compiled by company employees, before academically affiliated authors, often regarded as key opinion leaders, are sourced as principal or second authors without having substantially contributed to the study. And with increasing levels of data fabrication, the author warns against abandoning clinical experience and judgement in favour of evidence-based approaches.
According to this report, the monitoring process for the Millennium Development Goals (MDGs) has taught important lessons on how to maintain focus on internationally agreed development goals and targets, while keeping stakeholders informed of achievements, problem areas and emerging issues. The Working Group argues that global statistics organisations should continue to occupy a strategic, oversight position on statistics and indicators for monitoring. One key lesson learned is that there is clear need for a broad-based technical but inclusive monitoring group, and for a succinct annual report for the public on progress and challenges. The Working Group argues that the UN System Task Team on the Post-2015 UN Development Agenda has played a critical role for the coordination, credibility and sustainability of global monitoring and reporting and should be maintained in some form post-2015. Another finding has been the importance of investment in country capacities for data collection and reporting, leading to progress in disaggregation as well as towards the development of new indicators. Finally, the monitoring process has brought to the fore the necessity of having well-defined, objectively measurable indicators that can be used to track progress across countries and be aggregated to represent regional and global trends.
In this paper, the authors describe the components of the African Health Initiative framework; this includes the conceptual model, core metrics to be measured in all sites, and standard guidelines for reporting on the implementation of partnership activities and contextual factors that may affect implementation, or the results it produces. They also describe the systems that have been put in place for data management, data quality assessments, and cross-site analysis of results. The conceptual model for the Initiative highlights points in the causal chain between health system strengthening activities and health impact where evidence produced by the partnerships can contribute to learning. This model represents an important advance over its predecessors by including contextual factors and implementation strength as potential determinants, and explicitly including equity as a component of both outcomes and impact. Specific measurement challenges include the prospective documentation of programme implementation and contextual factors. Methodological issues addressed in the development of the framework include the aggregation of data collected using different methods and the challenge of evaluating a complex set of interventions being improved over time based on continuous monitoring and intermediate results.