International society for health systems research

The society aims to harness science to accelerate universal health coverage. Credit: Flickr/iwishmynamewasmarsha

It’s curtains for the First Global Symposium on Health Systems Research and we close with a proposal to set up an international society on health systems research (HSR), knowledge and innovation.

The society aims to harness science to accelerate universal health coverage. It will support regional and national efforts to strengthen HSR and catalyse scientists’ contributions towards setting norms, standards and practices in HSR.

You can find out more about the society in an upcoming SciDev.Net news story.

T. V. Padma, South Asia Regional Coordinator, SciDev.Net

Problems in the South, research in the North

Poor countries bear the brunt of health problems. Credit: Flickr/Kaj17

The problems –  such as mothers and babies dying during delivery, and inadequate care – are all there in poor countries. And the research to solve them is all there in the rich countries.

The number of publications focusing on low and middle income countries (LMICs) has increased between 2004 and 2009, according to the WHO’s Alliance for Health Policy and Systems Research.

The lead authors are from the high income countries, John-Arne Rottingen, chief executive of the Norwegian Knowledge Centre for the Health Services, said on Friday. Only ten per cent of health systems research on LMICs is by researchers based in these countries.

In the area of human resources for health, for example, high income countries account for 63 per cent of the publications, compared to 11 per cent from Latin America and the Caribbean,  nine per cent from the Middle East and seven from South Asia.

Grants for health policy systems research may appear to have increased in LMICs, but all this is due to international funding.

There is a  need to bridge gaps in many areas, said Rottingen. For example, between researchers and policymakers (we’ve heard that before many times);  between disease-oriented and systems-oriented research; between epidemiology and economics, and policy analysis and social sciences; and between knowledge translation and knowledge management …

There are many platforms to build too: platforms for collaborative research and training; for coordinating working methods; for creating and sharing teaching material; and for translating health systems research into a  more understandable format for policymaking.

Looks like there’s lots of bridge- and platform-building ahead …

T. V. Padma, South Asia Regional Coordinator, SciDev.Net

What’s and where’s the evidence?

Andy Haines. Credit WHO

Third day of the symposium, and health experts are getting down to the nittie-gritties.  Thursday morning saw the lens turned on evidence.

As Andy Haines, from WHO’s task force on guidance for health systems strengthening, observed at the morning plenary, increasing investments in health systems is driving a demand for guidance from national policy makers. The drive for better evidence in guidance is in turn exposing the need for greater investment in health systems.

Haines highlighted the challenges in generating and using evidence for guidance on health systems, unlike the case of the well-defined clinical guidelines.

These include the complexity of the subject, the lack of capacity in health systems, and the strong political and ideological drivers of health policies in countries.

Besides, as Lucy Gilson from the University of Cape Town observes, health systems complexity is rooted in the people who access and receive services and provide health care, and the relationships among the people that “are at the heart of any health systems research”.

So how does one glean evidence from such complex systems?  Systemic reviews (SRs) are one option. Or individual case studies that provide rich data.

But before hunting for evidence, one must be clear about evidence for what.   Christopher Murray, Institute of Health Metrics and Evaluation at the University of Washington, says it is hard to have standardized definitions about health systems.

Christopher Murray. Credit WHO

Using a health system framework approach could be a way out, except that that there are too many competing frameworks that add to the confusion.

One could use ‘typologies’ or grouping health systems round the world, based on a specific parameter, for example, the dominant mode of health financing.  But, while there are fewer competing typologies, they do not always provide the right answers.

Or there is the ‘metrics’ or measurement systems.  But, says Murray, “comparable metrics have been slow to improve over the last 20 years,” and one “could keep doing it all our lives.”

T V Padma, South Asia Regional Coordinator, SciDev.Net

Mind the design

The double burden of HIV and TB is a huge problem in two regions – Africa and central Europe, especially Ukraine and Russia.

In the case of Africa, we know the answer lies in an absolute shortage of resources for health. But what about Ukraine and Russia?

“It is certainly not shortage of health infrastructure and human resources (in central Europe). It is because of the weaknesses in the way health systems are designed,” observed Rifat Atun, cluster director at the Global Fund for AIDS TB and Malaria (GFTAM), who gave the Health Policy and Planning annual lecture at the symposium on Wednesday.

GFATM's Rifat Atun says systems design is crucial. Credit: GFATM

There are structural and financial weaknesses in these two countries, as well as weaknesses in their use of human resources.

“Systems design is critical in improving the outcome,” he told delegates.

Atun cited examples of studies that show that hospital admissions for TB treatment in Russia have nothing to do with the epidemiology of the disease, but the country’s health systems funds in a given financial year. As the financial year comes to a close in January,  hospitals admit fewer TB patients in December.

Health systems worldwide is at cross roads today, says Atun. One the one hand, there are substantial gains in financing for health, but on the other hand, the health outcomes are not progressing.

These conflicting indicators come against a backdrop of a changing economic environment;  broadening of the global health agenda; problems in sustaining long-term health systems, especially to manage HIV, malaria and TB in the long term; and donors’ increasing focus on the value for money, he says. Adding to these problems is the increasing complexity of health interventions that are being rolled out.

The biggest challenge of all is the weak evidence base. Experts do not know what works in practice, why it works and how.

T. V. Padma, South Asia Regional Coordinator, SciDev.Net

The things they did not know

Pitfalls while preparing the global health report: credit: WHO

So you thought preparing the World Health Report means packaging a lot of information readily available to experts who know it all? Wrong.

David Evans, director of health systems financing at WHO, gave some idea about the pitfalls during the report preparation, in a talk on Tuesday evening.

But, first, a peek at what the report will contain: Country experiences and best options available; solutions for some fundamental health financing problems, such as financial barriers to access to services, and inefficiency and inequity in the use of resources; and suggestions on how the international community can help low-income countries improve their health financing systems and institutions.

So, what did the experts not know when they undertook the task? Cross-country data on coverage with health services; and long-term financial hardship or the effect of out-of-pocket spending on health on financial catastrophe and impoverishment, to name some.

Millions continue to suffer financial problems when they spend out of their pocket for a health service, and compromise on education or sanitation to balance out their limited resources. According to WHO data, an estimated 150 million suffer financial hardships every year and 100 million are pushed into poverty for paying out of their pocket.

There was also scant information on what proportion of global disbursements is actually being spent by countries and scattered information on transaction costs of donor disbursements at country level – for example, Rwanda has to report on 890 health indicators to various donors, almost 600 for HIV and TB alone; while Vietnam had 400 aid missions to review projects in 2009.

So why is this information lacking? Evans believes there could be several reasons: researchers may not be interested in these questions, or funders do not fund this type of research, or the potential users of this knowledge do not explicitly demand the data be available.

He is possibly spot-on.

T. V. Padma, South Asia Regional Coordinator, SciDev.Net

All that jazz

Miles Davis: Don't play what's there, play what's not there. Credit: Wikicommons/Tom Palumbo

Montreux is known for its world jazz festival every summer and is home to the statue of Freddie Mercury.  So it is but natural that we got treated to a nice music performance at the opening session – violin by Isabella Mayer and guitar by Dagoberto Linhares. That was a neat treat for us.

And a couple of speakers could not resist reminding delegates about Montreux’s music culture. Tim Evans, chair of the symposium steering committee – and currently Dean at Bangladesh Rural Advancement Centre (BRAC) School of Public Health,  Dhaka – reminded us about  jazz musician Miles Davis’ famous quote: “Don’t play what’s there … play what’s not there”.

So what’s there? Biomedical research in all its glory. What’s not there? Health systems research (remember the poor relation?).

Evans says what’s missing in health systems research is scientific rigour, especially few robust conceptual frameworks and methods, to measure and evaluate the research.

He is also one of the rare breeds who acknowledge the confusion caused by international agencies’ jargon.”The way we describe health systems research is very vague,” he said.  Samples: applied, complexity, delivery, diffusion, evaluation, formative, implementation, operations, scale-up, T2 or translation two …

His words about vague words are music to my ears as, by now, I have humbly accepted myself as language challenged when confronted with some phrases in the international development sector.

T. V. Padma, South Asia Regional Coordinator, SciDev.Net

Alarming gaps in universal health coverage in Sub-Saharan Africa

So why is health systems research gaining global attention now?

There are alarming gaps in health coverage in Sub-Saharan Africa, says Martin Dahinden. Credit: SADC

Despite progress by a handful of middle-income countries such as Costa Rica, Mexico, Thailand and South Korea towards innovative universal health coverage – thanks to a combination of political commitment and financial resources for improving national health systems – the rest of the landscape is bleak, to put it mildly.

“The most alarming gaps in coverage are still reported from Sub-Saharan Africa, Asia and the Middle East,” Martin Dahinden, director-general of the Swiss Agency for Development and Cooperation, told the opening plenary of the global symposium on health systems research on Tuesday.

Among the 32 countries in Sub-Saharan Africa, 12 offer no coverage at all, while others such as Gambia, Kenya, Namibia and Rwanda, are slowly reaching 10 per cent coverage.

In Sub-Saharan Africa, financial resources for health are starting to become available, “but there is reason to doubt the political commitment in some countries,” he says.

Dahinden says the future lies in “integrated, inter-linked approaches, where knowledge is the primary factor defining health systems interventions”.

The key lies in evidence the drive the debate and decision-making towards universal health coverage, he says. To achieve this, science and public health communities have to engage in dialogue and collaboration with politicians, ministers of health and finance, and civil society.

I only hope it does not become a dialogue among the deaf.

T V Padma, South Asia Regional Coordinator, SciDev.Net

HSR – a poor cousin?

HSR not a poor relation of biomedical research, says WHO's Marie-Paul Kieny

The first global symposium on health systems research kicked off with a strong message that health systems research (HSR) should no longer be treated as the poor cousins of biomedical research.

“Biomedical research has had impressive successes in part because  – to be blunt – it has attracted significant financial investment. Unfortunately this has not been the case for health systems research, which has been the poor relation,” said Marie Paul Kieny, assistant director-general for innovation, information, evidence and research at the WHO, at the opening plenary session.

Kieny reminded delegates of the urgent need to focus research efforts on scaling up the delivery of health services in a way that is equitable and accessible. HSR should generate new knowledge that can help governments strengthen their health systems and improve health outcomes of their people.

That something is not ticking on the health front has finally sunk in. Despite impressive vertical efforts against priority diseases, the “health systems” that deliver and sustain life-saving interventions are “ailing and weak”, pointed out Judith Rodin, president of Rockefeller Foundation. Which is why a baby might be saved from HIV, but end up dying from diarrhoea, she observed.

Rodin prescribes three levels of action. Provide technical and financial support to countries to re-organise their health systems. Second, build  a case that health sector reform towards universal coverage is a sound investment and should be a piroity target for foreign aid in the next decade. Third, more information on the mechanisms to link UHC with global poverty reduction programmes.

Rodin says there is a window of opportunity to turn things around. Which is what this symposium hopes to usher in.

T. V. Padma, South Asia Regional Coordinator, SciDev.Net

First Global Symposium on Health Systems Research 2010

Welcome to the blog from the First Global Symposium on Health Systems Research 2010. I open with a true story.

In a remote village in India’s northern state of Bihar, 20-year-old Lal Munni (name changed) is terrified that she will soon lose her diarrhoea-stricken baby – her third to go that way in as many years. She is delighted to find a health worker visiting her village, which still has no access to a primary health centre. But the health worker’s sole brief is to give oral polio drops under a massive national polio eradication campaign, and she has no diarrhoea remedies. Even assuming the baby somehow survived the diarrhoea, the polio vaccine would have been lost in the frequent stools.

Lal Munni’s plight is seen in many developing countries — that frustrating disconnect between policymaking and the ground realties of sound health services.

Just 0.02 per cent of health spending in low- and middle-income countries goes into health systems research. This prompted the WHO to convene a task force in 2008 on scaling up research and learning for health systems.

Now, the WHO and other partners will hold the first global symposium on health systems research, in Montreux, Switzerland, this week to address this issue.

The symposium will focus on science to accelerate universal health coverage, and seeks to improve the scientific evidence needed by health policymakers and practitioners to implement this. As the WHO’s Tim Evans observes, health systems approach is the third pole of any health research alongside biomedical and clinical research.

It comes amidst concerns that some organizations are turning health systems research into rhetoric and not reality, and the resignation of the global forum’s controversial director Anthony Mbewu. So will it just be rhetoric or will something meaningful emerge? Watch this space for posts next week.

T. V. Padma, South Asia Regional Coordinator, SciDev.Net