The Western Cape Province has a local-level mortality surveillance system that has been upgraded to do automated cause of death coding using IRIS software, in concordance with the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes. This paper reviews the achievements in providing district-level and subdistrict-level mortality data, and describes the lessons learnt and the challenges for sustaining such a system. Cause of death coding was upgraded from a shortlist to full ICD-10 coding for natural causes of death in a customised data capture system. A total of 33 564 deaths from natural causes were coded for 2009, with 9.4% due to ill-defined causes. Completeness was estimated at 83.7% and mortality profiles were provided for all health districts for the first time, highlighting district variations in age-standardised mortality rates, although HIV and tuberculosis were the leading causes of premature mortality across all districts. It is necessary to train data capturers in medical terminology and doctors in death certification, as well as building quality assurance measures into the system. Local cause of death coding enables quality issues to be identified and addressed directly at source. IRIS makes it possible to standardise coding across districts for routine cases. Dissemination of local mortality information creates a demand for updated results, which are sometimes difficult to meet. Challenges include securing the appropriate resource allocation, integrating into a fragmented health system, and ensuring co-operation between government departments. Utilisation of information technology opportunities (eg, electronic registration of death) remains a challenge.
Monitoring equity and research policy
INTREC (INDEPTH Training and Research Centres of Excellence) was established to provide training for researchers from the INDEPTH network on associations between health inequities, the social determinants of health (SDH), and health outcomes, and on presenting their findings in a usable form to policy makers. The authors of this paper assessed the current status of SDH training in three of the African INTREC countries – Ghana, Tanzania, and South Africa – as well as the gaps, barriers, and opportunities for training. Results indicated that SDH-relevant training is available, but the number of places available for students is limited, the training tends to be public-health-oriented rather than inclusive of the broader, multi-sectoral issues associated with SDH, and insufficient funding places limitations on both students and on the training institutions themselves, thereby affecting participation and quality. The authors argue that there is a clear role for INTREC to contribute to the training of a critical mass of African researchers on the topic. This work will be accomplished most effectively by building on pre-existing networks, institutions, and methods.
According to this letter, the Global Fund indicators that have been used in the past do not reflect a commitment to strengthening the response for women and girls. Many key indicators of progress do not address the differing realities for women and girls versus men and boys. For example, the indicator for new HIV infections is not disaggregated by sex. Similarly, the Global Fund has administered many grants with a focus on orphans and vulnerable children (OVC), but few of the programmes use indicators that reflect that the experiences of orphans and vulnerable children who are girls will differ from those of boys, both in the opportunities and obstacles they will encounter. The author argues that failure to measure progress in preventing new infections among women, or to measure the effects of OVC programmes on girls, means there is no incentive for countries that receive Global Fund grants to ensure that their efforts are addressing the specific challenges faced by women and girls. Other necessary indicators must be developed about the specific effects of HIV and AIDS on women, such as access to testing, counseling, and treatment among women who are not pregnant. Integration of HIV services and contraception provision, as well as violence experienced by all women - not just those who are married or cohabiting – need to be addressed, especially as research has repeatedly shown that sexual violence puts women and girls at elevated risk of contracting HIV.
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.
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.