Strengthening health systems: the role and promise of ...

[Pages:130]Strengthening health systems:

the role and promise of policy and systems research

Strengthening health systems:

the role and promise of policy and systems research

ALLIANCE FOR HEALTH POLICY AND SYSTEMS RESEARCH

An initiative of the Global Forum for Health Research in collaboration with the World Health Organization

Strengthening health systems: the role and promise of policy and systems research.

Geneva, Alliance for Health Policy and Systems Research, 2004 ? Global Forum for Health Research, 2004 ISBN 2-940286-25-6

The reproduction of this book is regulated in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved by the Global Forum for Health Research. The document may be freely reviewed and abstracted, with the usual acknowledgement of source, but not for sale or for use in conjunction with commercial purposes. Requests for permission to reproduce or translate the book, in part or in full, should be addressed to the Secretariat where information on any translation or reprints is centralized. The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Global Forum for Health Research or the Alliance for Health Policy and Systems Research concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Information concerning this publication can be obtained from:

Alliance for Health Policy and Systems Research RPC-EIP, WHO, CH 1211 Geneva 27, Switzerland All current Alliance publications and documents can be ordered in print format or obtained as electronic products through the Alliance website at alliance- or by sending an e-mail to alliance-hpsr@who.int

Design & Layout: L'IV Com S?rl, Morges, Switzerland

Cover photo montage composed of three photos (from left to right): an African doctor (UNAIDS/G. Pirozzi), Bolivian immunization (Pan-American Health Organization), nurse in clinic (ILO/M. Crozet).

ii

CONTENTS

Abbreviations

iv

Acknowledgements

v

Executive summary

vi

Prologue

viii

Chapter 1: Overview

1

Chapter 2: Achieving global health goals: The role of health systems research

7

Chapter 3: The state of the art in selected areas of health system research

25

Chapter 4: Setting priorities in health systems research

39

Chapter 5: Getting research into policy and practice

51

Chapter 6: Health systems research capacity in developing countries

71

Chapter 7: Conclusions: The promise of health systems research

91

Annex 1: Trends in international publications on health systems research

95

Annex 2: Partners of the Alliance for Health Policy and Systems Research

107

Board Members, International Advisory Group and Chapter Co-ordinators and Contributors

117

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ABBREVIATIONS

ASSALUD CEHAT CMH COHRED CSO DALY DANIDA DFID DGIS HNP HRP

IDRC IHPP INCLEN MDGs GAVI GDN GRIPP HEPNet MIM NHS ODI PAHO PEPFAR PMTCT RED SALUD SAREC

SDO TDR

TRIPS ULP WBI

Colombian Health Association Centre for Enquiry into Health and Allied Themes (India) Commission on Macroeconomics and Health Council on Health Research for Development Civil Society Organization Disability-adjusted life year Danish International Development Agency Department for International Development (United Kingdom) Ministry for Development Cooperation (the Netherlands) Health, Nutrition and Population (World Bank) UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction International Development and Research Centre (Canada) International Health Policy Programme International Clinical Epidemiology Network Millennium Development Goals Global Alliance for Vaccines and Immunization Global Development Network Getting Research into Policy and Practice Health Economics and Policy Network for Sub-Saharan Africa Multilateral Initiative on Malaria National Health Service (United Kingdom) Overseas Development Institute (United Kingdom) Pan American Health Organization US President's Emergency Plan for AIDS Relief Prevention of Mother to Child Transmission of HIV Network for Health Systems and Services Research in theSouthern Cone of Latin America Swedish International Development Cooperation Agency (SIDA) Department for Research Cooperation Service Delivery Organization (UK National Health Service) UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases Trade-related aspects of intellectual property rights (WTO agreement) User Liaison Program of the Agency for Health Research and Quality World Bank Institute

Strengthening health systems: the promise of policy and systems research

iv

ACKNOWLEDGEMENTS

T he principal writers of this review were Anne Mills (editor-in-chief ), Sara Bennett, Gerald Bloom, Miguel Angel Gonz?lez-Block (coordinating editor) and Indra Pathmanathan. The review was directed by the Board of the Alliance for Health Policy and Systems Research and valuable input was received from an international advisory group, whose members are listed at the end of the book. Contributions were provided by David Dror, Edward Elmendorf, Abdul Ghaffar, Steven Hanney, Rene Loewenson, Yuri de Lugt, Tim Martineau, Vic Neufeld, Yvo Nuyens, Jose Maria Paganini, Siriwan Pitayarangsarit, Bill Savedoff, Don de Savigny and Aparnaa Somanatha. Comments are gratefully acknowledged from Celia Almeida, Elsie Le Franc, Adnan Hyder, Stephen Matlin, Di Mcintyre, Don de Savigny, Yvo Nuyens, Ritu Sadana and Fabio Zicker. Statistical and editorial support was provided by Ajay K Gupta, Mark Bloch and Chris Zielinski. Full details of Board members and the international advisory group, as well as biographies of chapter co-ordinators and contributors, are given at the end of the book.

v

EXECUTIVE SUMMARY

I mproved performance in controlling emerging and re-emerging diseases in developing countries is dependent on the quality, equity and efficiency of health systems. Rapid progress towards targets is greatly hampered by weak, poorly functioning or in some cases non-existent health systems. It is critical to know how best to approach health system strengthening, and what specific actions are appropriate in different settings. Much is known about the barriers or constraints to greatly increasing (`scaling up') health services. However, remarkably little is known about how best to relax these constraints, whether through reformed service delivery strategies, or different human resource management policies, or new organizational structures.

The central concern of this book is how knowledge of health systems can be increased and applied to improve the health of the worst-off of the world's population. Health systems research has much to contribute to our understanding of health systems and policies. Research can play a major role in policy formulation, especially when policy questions can be formulated in terms of clear and empirically verifiable hypotheses. The book provides case studies showing that the application of health systems research has contributed to problem resolution, and that a widely applicable scientific body of knowledge is developing. Progress is reviewed in the areas of equity, user fees, community health insurance, management reforms and the role of civil society organizations. Decision makers and community advocates can benefit from this knowledge for the design and implementation of sound policy.

Funding for health systems research in developing countries and by developing country researchers is meagre. Evidence suggests that such funding is at most 0.02% of health expenditure, far too low to have an impact on health system development. Funding should be mobilized from within national health systems as well as from science and technology budgets and international sources. Priority problems for research need to be identified in relation to health system and development goals and in consensus with policy makers. The book presents the results of a survey of priorities identified at country level, as an input to further thinking on national and global research agendas.

Much can be done to support the information needs of decision makers at all levels by strengthening the process of "getting research into policy and practice" (GRIPP). Analysis of successes and failures are used to develop a framework for systematically enhancing the use of evidence. Key GRIPP elements include:

improving the capacity of decision-makers to recognize the benefits, and identify and use research information to strengthen health policies and practices;

identifying and updating research priorities with participation from all key stakeholders, and applying financial and human resources to address the priority agenda;

producing good quality, timely and credible research outputs for the identified priority agenda, including realistic recommendations that reflect understanding of the policy context and constraints, and synthesizing research into evidence that can support decision-making;

communicating evidence in ways appropriate to audience needs, using advocacy strategies including mobilizing the influence of networks and key stakeholders to convey critical evidence to decision-makers;

recognizing the pressures and elements that influence policy-making, and being opportunistic and enterprising in inserting evidence into decision-making processes.

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Strengthening health systems: the promise of policy and systems research

The book assesses capacity for health systems research in developing countries, identifying project funding and skill levels, among other indicators. Capacity strengthening strategies are then proposed as an integral part of health system development. This demands an innovative and comprehensive re-thinking about how health systems research can be scaled-up and strengthened. Five challenges are put forward for the health systems research community to consider:

1. Health systems research in all its aspects, including capacity strengthening, must become a more integral part of national health system development--for example, contributing strongly to on-going evidencebased health system planning.

2. Health systems research must become more visible within the current movement for strengthening national health research systems.

3. A broader and more comprehensive view of institutional research capacity strengthening is needed. 4. More innovative applications of the knowledge management revolution should be considered. 5. The health systems research community should challenge itself to explore problem-oriented alliances

with other disciplinary and topic-based groups who share the same concerns of strengthening health systems.

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