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.
Monitoring equity and research policy
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.
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.
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).