Beyond Forum 2012: some final reflections

David Dickson

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There’s been much talk in Cape Town at Forum 2012 over the past week of the need for a paradigm change in thinking about health research for development.

Certainly the concept is a useful one to describe the switch from an approach focussed primarily on the allocation of research resources, to one that addresses the need to build systems of innovation in the health field (as elsewhere).

It helps us move beyond a fixation with the famous 90/10 imbalance between research expenditure on developed and developing world health priorities, to embrace a wider perspective.

But at the end of three days of lively discussions, I remained unclear whether talking about “Beyond aid” – the theme of the meeting – represented a radical idea, or a useful way of labelling a set of trends that have been in motion for some time, and identifying the general direction in which they point.

Either way, however, such a discussion is timely.

First, as Carl Ijsselmuiden, executive director of the Council on Health Research for Development (COHRED), the main organiser of the conference, pointed out in his opening remarks, it captures the growing feeling that “foreign aid as hand-outs to the poor” is no longer workable.

The approach may not be one that wins many votes for aid-providing governments. But in the long-term, these realise that “foreign aid as capacity building” is much more likely to produce lasting results.

 Second, talking about what happens next – particularly in an area such as health research and innovation, and at a time when external sources of funding are drying up – provides a spur to developing country governments to address their own responsibilities.

Ending on an up-note: the singer Princess Chaka Chaka, UN Goodwill Ambassador and a champion of Africa's fight against malaria, leads participants of Forum 2012 in a farewell chorus (Gabi Falanga)

This has both funding and policy implications. Health research spending needs to become a higher priority for these governments. And they need to create the incentives that will allow the result of this research to be translated into medical products – such as drugs – and services.

Finally, there is the pragmatic issue that, as aid budgets start falling in many developed countries as a result of their financial difficulties, anything that promises to “do more with less” with what funding remains available becomes increasingly attractive.

Moving from “aid as hand-out” to “aid as capacity building” does just that.

So, three good reasons for embracing the concept of a paradigm change. But it also became clear in the Forum 2012 discussions that there are reasons for not expecting too much, too soon.

There may be consensus on what needs to change. But this consensus does not necessarily extend to agreement on what this change should be.

For example, those seeking a new international convention on health research and development argue that it is needed to make up for the failure of the market system to provide developing countries with access to medicines at affordable prices.

Pharmaceutical companies may agree that this is a challenge. And that they need to work with governments – and aid agencies – to tackle it. But their interests ultimately lie in benefitting from the market, not in seeing alternatives put in place.

Similarly health ministers may be persuaded of the arguments for developing home-grown health industries, better equipped to meet local health needs.

But the people who really need convincing work in finance ministries. And the financial case for operating in a new way, rather than, for example, just importing technologies from abroad, is not always self-evident.

Paradigms get embedded in social – and political – systems. Changing them is not just a question of rational debate (even in science). It also requires challenging the interests that the old paradigm served.  And it can have costs attached.

So, big challenges ahead. The major contribution of Forum 2012 was to help cement the idea that “aid for capacity building” is the new mantra that needs to frame aid and government policies, in developed and developing countries alike.

Also that, as in fields such as agriculture and energy, health needs to move away from the idea that developments are research-driven, to recognising that research is one component of a holistic system of innovation – each part of which needs to be addressed.

The immediate task, as always, is to work out what all this means in practice, identifying needs and opportunities, and assessing the potential contributions of all interested parties (including the media).

Not quite the “Beyond aid” vision that the organisers are aiming for. But a step in that direction.

David Dickson is editor of SciDev.Net

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012.

Better support needed for Africa e-health solutions

Maina Waruru
Freelance journalist, SciDev.Net

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While mobile phones use has expanded at an astonishing rate in Africa, this on its own is insufficient to bring so-called E-health solutions to the millions of people living in remote, poor rural areas.

Cellphone use must be complemented by other relevant technologies, infrastructure and applications that will ensure the cost of accessing health ICT is made cheaper and cost effective, the first African conference on Science Technology and Innovation for Youth Employment, Human Capital Development and Inclusive Growth was told on Monday.

“We must never over-rely on mobile phones alone as a means of delivering E-health, and must move to other technologies such telemedicine and video conferencing — which could be a bit expensive, but whose cost can be brought down if we start manufacturing of the requisite devices here in Africa,” said Robert  Jalang’o of the Multimedia University College of Kenya.

Mobile phone use has expanded enormously in Africa, but the conference heard other technologies and infrastructure is needed to roll out e-health solutions to all the continent's peoples.

Mr Jalang’o addressed a session on E-health at the conference, which is underway in Nairobi, saying that the high cost of foreign technologies must be brought down if ICT use in the sector is to be fully realised. This, he said, needed to involve undergraduate and post-graduate students  in producing these technologies, which he added would not only give them specialist knowledge, but provide them with jobs as well.

Speakers at the session noted that back-up infrastructure — such as transmission masts and solar power facilities to power the stations and handsets —  must also be in place to serve people living in the most remote regions of the continent.

While it was agreed that mobile phones should not be over-relied on to deliver health solutions, there was a consensus at the session that these gadgets will be the most popular option to deliver E-health in rural Africa into the foreseeable future.

As a result, the participants said, there is a need to make addressing the challenges relating to access a priority at all levels — not just for policymakers.

“Let’s teach our people  how they can develop content for e-health even at grassroots level as well, so that through using [mobile] phones they can share their expertise in fields such as indigenous health knowledge,” Muhammadou Kah, vice-chancellor of the University of the Gambia, told the session.

He said involvement in generating content for e-health solutions should engage people at village level, noting that locally-produced content would be the most relevant in addressing local health needs.

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

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

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

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

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

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