In the case-studies presented in this paper, the authors analyse findings from sexual and reproductive health (SRH) and HIV research programmes in sub-Saharan Africa. In their analysis, they emphasise the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change – especially in SRH – where there are complex interactions between policy actors. Policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximise research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural and practical.
Monitoring equity and research policy
It is estimated that more than US$130 billion is invested globally into health research each year, yet, according to this paper, priority setting in health research investments remain inequitable. The authors reviewed selected priority-setting processes at national level in low and middle income countries, and outlined a set of criteria to assess the process of research priority setting and use these to describe and evaluate priority setting exercises that have taken place at country level. Data were gathered from presentations at a meeting held at the World Health Organisation in 2008 and a web-based search. A number of findings emerged. Across the countries surveyed there was a relative lack of genuine stakeholder engagement, while countries varied markedly in the extent to which the priority setting processes were documented. None of the countries surveyed had a systematic or operational appeals process for outlined priorities, and in all countries (except South Africa) the priorities that were outlined described broad disease categories rather than specific research questions. The authors argue that priority setting processes must have in-built mechanisms for publicising results, effective procedures to enforce decisions as well as processes to ensure that the revision of priorities happens in practice.
The GAVI Alliance was created in 2000 to increase access to vaccines. More recently, GAVI has supported evidence-based health systems strengthening to overcome barriers to vaccination. The objectives of this study were: to explore countries' priorities for health systems strengthening; to describe published research summaries for each priority area in relation to their number, quality and relevance; and to describe the use of national data from surveys in identifying barriers. From 44 health systems-strengthening proposals submitted to GAVI in 2007 and 2008, the researchers analysed the topics identified, the coverage of these topics by existing systematic reviews, and the use of nation-wide surveys with vaccination data to justify the needs identified in the proposals. Thirty topics were identified and grouped into three thematic areas: health workforce, organisation and management, and supply, distribution and maintenance. The researchers found no reviews that dealt with health information systems, however. Only seven of the reviews were categorised as ‘highly relevant for policy’. In conclusion, researchers found little quality research that was relevant to managers’ needs. Few proposals used national surveys evidence to identify barriers to vaccination. The author recommends that researchers generating or adapting evidence about health systems need to be more responsive to managers' needs.
Malaria is highly endemic in the Democratic Republic of Congo (DRC), but the limits and intensity of transmission within the country are unknown. It is important to discern these patterns as well as the drivers which may underlie them in order for effective prevention measures to be carried out, the authors of this study argue. Using the 2007 Demographic and Health Survey (DHS) for the DRC, the authors generated prevalence estimates and explored the ecological drivers of malaria. Of the 7,746 respondents, 29.3% were parasitaemic, with males were more likely to be parasitaemic than older people or females, while wealthier people were at a lower risk. Increased community use of bed nets and community wealth were protective against malaria at the community level but not at the individual level. This research demonstrates the feasibility of using population-based behavioural and molecular surveillance in conjunction with DHS data and geographic methods to study endemic infectious diseases. The authors suggest that spatial information and analyses can enable the DRC government to focus its control efforts against malaria.
In this study, researchers aimed to validate vaccination data from a longitudinal population-based demographic surveillance system (DSS) against data from a clinical cohort study. The sample included 821 children in the Vertical Transmission cohort Study (VTS), and researchers found that vaccination data in matched children in the DSS was based on the vaccination card in about two-thirds of the cases and on maternal recall in about one-third. In conclusion, the addition of maternal recall of vaccination status of the child to the child’s card information significantly increased the proportion of children known to be vaccinated across all vaccines in the DSS. The authors recommend that information based on both maternal recall and vaccination cards should be used to identify which children have received a vaccination and which have not.
In this study, researchers systematically reviewed the evidence on the impact of interventions for seeking, appraising, and applying evidence from systematic reviews in decision-making by health policymakers or managers. A total of 11,297 titles and abstracts were reviewed leading to retrieval of 37 full-text articles for assessment; four of these articles met all inclusion criteria. Three articles described one study where five systematic reviews were mailed to public health officials and followed up with surveys at three months and two years. The studies found that from 23% to 63% of respondents had used the systematic reviews in policymaking decisions. One trial indicated that tailored messages combined with access to a registry of systematic reviews had a significant effect on policies made in the area of healthy body weight promotion by health departments.
Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible - not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2.65 million stillbirths were estimated worldwide in 2008, of which 98% occured in low-income and middle-income countries. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. National estimates of causes of stillbirths are scarce, and multiple classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed, according to the authors of this article.
According to this paper, science is increasingly being applied to systems that are complex, non-linear and dynamic, including questions about climate, environment, society, health and human behaviour, with limited results. At the beginning of the 21st century, policy makers and their expert advisors are working in an environment where the values and outputs of science are questioned by an increasingly informed, involved and vociferous society. Science and technology are now focused on complex systems, in part because it is around such complexity that governments must make decisions. Broadly, improvement in the use of science-based evidence is likely to be gradual and incremental and will require ‘buy-in’ from many stakeholders. The author argues that progress will be dependent on attitudes and approaches taken by agency heads. Other areas may need additional work – for example in establishing across-government principles for protecting the integrity of scientific advice.
Despite substantial investment in health capacity building in developing countries, evaluations of capacity building effectiveness are scarce. By analysing projects in Africa that had successfully built sustainable capacity, the authors of this stuy aimed to identify evidence that could indicate that capacity building was likely to be sustainable. Four projects were selected as case studies using pre-determined criteria, including the achievement of sustainable capacity. The authors found that indicators of sustainable capacity building increased in complexity as projects matured and included: early engagement of stakeholders; improved resources; and funding for core activities secured, with management and decision-making led by Southern partners. Projects became sustainable after a median of 66 months. The authors identified the main challenges to achieving sustainability as high turnover of staff and stakeholders, and difficulties in embedding new activities into existing systems, securing funding and influencing policy development.
According to Mozambique’s scorecard, a national IHP+ Compact was signed in 2008. Prior to that, a SWAp and pooled fund mechanism was in place from 2007. A National Health Sector Plan/Strategy is in place with current targets and budgets that have been jointly assessed. There is currently a costed and evidence based HRH plan in place that is integrated with the national health plan. In 2009 Mozambique allocated 6.8% of its approved annual national budget to health. In 2009, 73% of health sector funding was disbursed against the approved annual budget. In 2009 there was a transparent and monitorable performance assessment framework in place to assess progress against the national development strategies relevant to health and against health sector programmes. Mutual assessments are being made of progress implementing commitments in the health sector, including on aid effectiveness.