The complex definitions and economics of universal health coverage

I indicated the kind of problems health systems specialists are grappling with.  Where does one begin? How does one define universal health coverage, the goal of the global health policy?

Ravi Rannan-Eliya, from the Institute of Health Policy, Sri Lanka,  points out that it is not sufficient to define it in terms of nominal or legal coverage – we all know universal coverage is not a reality anyway.

There is no easy definition of universal health coverage, says Ravi Rannan-Eliya. Credit: WHO

An operational definition of universal health coverage should include both access to health services and risk protection, he told delegates at the symposium, says Ranna-Eliya.

Several published studies show that protection against ‘catastrophic’ expenditures is feasible in low-income settings. Equal service use by the poor is also achievable at low-income settings. What’s needed is political will to implement health reforms.

What financing mechanisms could influence universal health coverage? They broadly fall into four categories – tax-funded integral services where tax payers in a country pay a tax that is used to fund health care for the poor; social health insurance, community health insurance and private or voluntary health insurance.

Two countries that are getting repeated mention at the symposium for the relative success of their national health insurance policies are Ghana and Mexico.

So where does science fit in here? As Julio Frenk, Mexico’s former health minister and dean of the Harvard School of Public Health, said, reforms open up new research opportunities,  such as how “implementation research” can be put into practice and scaled up; whether and how reforms are actually working; and comparative analyses from different countries.

Research is the core of the new era of global health, says Frenk. “Any time a country tries out an innovation, this is a learning opportunity for the rest of the world.”

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

It’s all about incentives

Everyone at the symposium has by now agreed that there exists a huuuuuuge gap between research and policy in the health sector.

For the first time on Wednesday evening, a plenary session put a possible solution on the table – offering  incentives for policy-oriented research.

Economist Lyn Squire, from the Global Development Network  introduced the topic by quoting from Charles Dickens’ Tale of Two Cities. “It’s the best of times, it’s the worst of times.”

According to Squire, the best of times would be when research is very relevant to policy and policy is based on solid, empirical research. Which does not happen that way, as we well know.

And the worst of times? When a funder commissions research in a donor-driven approach, and a policy maker cobbles together a programme under instructions from her minister, and a gets donor funding for a programme that is completely evidence-free.

Ensuring a system of incentives, both from the national governments and international donors, could  ensure that the research commissioned is based on policy, says Squire. According to him, had someone thought of this ten years ago, the current research policy gap that exists could have been a research policy nexus.

The panel discussion that followed Squire’s proposal included speakers from some developing countries. “It’s a great idea,” said Muhammad Pate, from Nigeria’s Primary Health Care Development Agency. “It takes research from an academic context to closer to ground realties.”

Ximena Aguilera, from the centre of epidemiology and public health at the University of Chile, says it is does not suffice to just offer incentives for policy-relevant research. On should to ensure the capacity for such research exists.

Irene Agyepong, from the Ghana Health Service, said there is the element of time, as policymakers want information in a short time, whereas a researcher takes anywhere from six months to two years to get results.

Still, as Robert Hecht from Results for Development and chair of the plenary, observes: “It’s (incentives) an idea that is bubbling here.”  Hope the bubble does not burst.

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

New post-conflict health care projects launched

Health systems research has tended to neglect post-conflict settings. Credit: Flickr/Albert Gonzalez Farran

The global symposium saw the launch of at least two project grants, by the governments of UK and Norway, on Tuesday.

REBUILD, launched by the the UK’s Department for International Development, is all about research for building pro-poor health systems for recovery in conflict-torn African countries. The research consortium involves researchers in Cambodia, Sierra Leone, Uganda and Zimbabwe.

Health systems research has tended to neglect post-conflict settings and there are opportunities to set a pro-poor agenda in the immediate post-conflict period, says Barbara McPake,  director of the Institute for International Health Development at Queen Margaret University in the UK.

Good health systems research involves both qualitative and quantitative approaches, she said, and tries to examine a health intervention in the context in which it was initiated, responds to the intervention over a period of time – as it is difficult to “capture” an effect in a single time period – and involves multiple stake holders.

Abdul Gaffar, executive director of the WHO’s Alliance for Health Policy and Systems Research, tentatively announced seven projects to be given US$2.5 billion by the government of Norway each year for an anticipated five year period.  The governments of Canada and Sweden are also expected to contribute.

The countries selected for the projects are Burkina Faso, Guatemala, India, Kenya, the Middle East -represented by Egypt and Lebanon – Nepal and Uganda. The focus will be on scaling up health interventions on maternal and child health from small ‘block’ levels, typically a few dozen villages, to larger units of several hundred villages.

“Capturing the success stories and also correcting what is not working is important,” Gaffar told me after the launch. “The science of scaling up is not clearly understood.”

That seems to be one among several common woes in the sector.

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

Does social science need rebranding?

Some would argue poor living conditions and gender inequity affect health more than the biological causes of disease. Flickr/LivingWaterInternational

As Forum 2009 closed on Friday, we were left with some thoughts on the future direction of global health research. The conference in general was heavily weighted towards the need to drive health systems research and research on the social determinants of health.

Mention these issues to many lab scientists, however, and they would argue that these fields of study are far too “soft” a science for them to engage with.

This is what really damages research into the social factors affecting health. Traditional robust methods of interrogating an issue and gathering data such as randomised controlled trials have no traction when you are thinking about how a health system functions or when you are trying to evaluate a complex health intervention.

These don’t fit into neat scientific boxes in the way that parasite counts or viral loads do.

But transforming these fields will require rigorous evidence – how else will we know what changes to make to improve health systems across the developing world?

It’s good news then that the EU announced yesterday at the meeting that its next call for grants in January 2010 would focus heavily on research into the social determinants of health.

Some would argue that poor living conditions and gender inequity affect health even more than the biological causes of disease. There is only one way to find out, of course: more research, and more robust evaluation of that research.

Priya Shetty, http://www.scidev.net, priya4876@gmail.com

Dragging health up the climate change agenda

The realities of climate change. Photo credit: Flickr / UN Photo-Evan Schneider

Those in the know about the draft agenda for the Copenhagen climate change meeting next month have bad news: health does not seem to be high on the agenda.

This may well change as the meeting draws closer, but panellists at a session yesterday on climate change and health equity suggested that the poor links between health researchers and environment experts may explain part of this disconnect.

Look through the pages of the BMJ, The Lancet and Nature and you’ll find most papers on links between climate change and health written by researchers who study the social determinants of health.

Their input is vital for explaining how alterations in living conditions or air quality will affect health, but climate science is complex and the technologies developed to study it are continuously being updated. Environmental scientists, meanwhile, publish their own papers separately.

BMJ editor Fiona Godlee, who chaired yesterday’s session, wants to see an end to this “silo mode of operation”. Forging stronger links between the disciplines should ensure that climate agreements cannot ignore health impacts.

Kumanan Rasanathan, a WHO technical officer on ethics, equity, trade and human rights, summed it up well: “It’s time that the rhetoric around intersectoral collaboration be put into practice,” he said.

Priya Shetty, http://www.scidev.net, priya4876@gmail.com

Where there is a will…

Studying gender inequality won't fix health without the political will

Claudio Schuftan, an advocate for the right to health based in Vietnam, sounded a pessimistic note yesterday in a discussion on research into the social determinants of health.

As participants discussed the best ways to ensure that research into poor living conditions and gender inequality is treated as a rigorous science, Schuftan asked us whether we “were living in a dream world”. His point was that the scientific community talks of the need for more evidence – but what about the political will?

This is an obvious point but one worth making again amidst calls for more evidence-based policies. First, we have a lot of evidence already for what works and what doesn’t. Second, all the evidence in the world will not convince a policymaker who does not see the political will to alter health-care policies.

This was the point that Carlos Morel, director of the Center for Technological Development in Health at FIOCRUZ in Brazil, made when I spoke to him about translating innovation from Cuba to the rest of the world.

Morel said that there would be little point in Cuba transferring knowledge to countries that don’t have the capacity to use that information. Cuba’s political dictatorship – in essence, its unswerving political will – is what ensured that it first developed a robust health system on which to build more advanced scientific institutions, he said.

Africa needs to find a way now to imbue its own democracies with that strong political will for healthcare reform.

Priya Shetty, http://www.scidev.net, priya4876@gmail.com

Can product-development partnerships deliver?

Public-private partnerships in drug development were intended to marry the business savvy and deep pockets of big pharma with academic rigour. But this morning representatives from the biggest partnerships – including the International AIDS Vaccine Initiative (IAVI) and the Global TB Vaccine Foundation – gathered to convince us their presence hasn’t been for nought.

In 2004, PDPs were responsible for 75 per cent of R&D in neglected diseases. It’s hard to quantify, however, how much of the R&D boost over the past decade or so has been due to PDPs and how much to a rising profile of global health issues.

What struck me most was the desire of several of the PDPs to “move beyond product development”.  At the conference so far, there has been much talk of moving away from short-term goals of rolling out antiretrovirals to a more holistic long-term approach to ensuring health systems are equipped for big health programmes to parachute in.

But surely if any organisation could be forgiven for focusing solely on a product, it would be a product-development alliance? It’s commendable that, as IAVI’s Holly Wong said, some PDPs share clinical site capacities and help build capacity. But their primary goal must be to develop urgently drugs for TB and neglected diseases.

Most PDPs are relatively young . It’s still a little too early to question whether they have fulfilled their promise but in a few years they will need to be accountable. In the meantime, they must concentrate on getting products to market.

Priya Shetty, http://www.scidev.net, priya4876@gmail.com

Global Forum for Health Research 2009, Havana, Cuba

Welcome to the blog for Forum 2009, taking place this week in sunny Havana!

The theme of the meeting, innovation, is the lifeblood of research. Without it, countries never truly develop a thriving science base and are relegated to the shadow of innovative neighbours.

It’s appropriate then that scientists from around the world have gathered in Cuba to discuss scientific and technological innovation.

Political circumstances have forced Cuban researchers to innovate and develop with homegrown talent. The question now is how these lessons can be translated to the rest of Latin America – and to Africa and Asia.

Transferring knowledge isn’t the only issue of course – developing countries need to create an innovation-friendly environment for researchers to thrive in.

I’ll be writing more about how to bridge these knowledge gaps, through better knowledge translation and South-South collaboration, for example.

Another issue that I’ll write about this week is innovation in health systems research. This is an enormously tricky topic in global health. We know that developing countries need better health systems but we know very little about the science of how to improve them.

Tim Evans, assistant director-general for for information, evidence and research at the WHO and TDR scientist Shenglan Tang are leading sessions this week on health systems research as a prelude to the first global symposium on health systems research that they are hosting next November in Switzerland.

Over dinner last night, Evans maintained that innovation is most urgently needed in health systems research. It’s certainly true that while funders and big pharma fall over themselves to pump money into research for drugs and vaccines, few line up to pour money into developing an evidence-base for improving health systems.

Do you agree? We’d like to hear your thoughts on the top priorities in innovation for developing countries. Comment below to share your ideas.

Priya Shetty, SciDev.Net, priya4876@gmail.com