Framework for developing a health systems research agenda

Framework for developing a health systems research agenda In recent years a range of global initiatives have been directed at improving access to effective interventions for major diseases such as AIDS, TB and malaria, supportingg the development and availability of vaccines and broadening access to health information (1,2,3) However there are major constraints to providing access to effective health care because of pervasive weaknesses in health systems in many countries. At current rates of progress attainment of the UN Millenium Development Goals related to health is unlikely in several regions, notably sub Saharan Africa (4). Major deficiencies in financing of health systems and in the availability of appropriately trained health personnel are obstacles to progress but there are also substantial gaps in knowledge about how to manage, organise and deliver health care in resource poor settings. Traditionally health systems research has been under funded and has largely failed to benefit from increases in research funding for diseases of poverty in recent years (5). As a consequence much health systems research has been small scale and the findings have been of limited applicability. It has therefore been difficult for HSR to demonstrate the extent of its potential contributions to improving access to effective health care. This paper outlines a research agenda for HSR directed towards bridging knowledge gaps that will enable substantial progress to be made towards the MDGs A useful overarching definition of health policy and systems research is the production of new knowledge and applications to improve how societies organise themselves to achieve health goals, including how they plan, manage and finance activities to improve health, as well as the roles, perspectives and interests of different actors in this effort. The health systems function of regulation, organisation, financing and delivery of services are the focal subjects. (6) Broader determinants directly affecting the health system are also considered within the purview of such research. The Ad-Hoc Committee on Health Research developed a five step process for research priority setting, comprising the magnitude of the problem in terms of disease burden; the determinants responsible for the persistence of the burden; the assessment of the cost of the promise of the R&D effort, with regards to its potential to reduce costs and improve cost effectiveness; and the current level of investment into research for the topic in question.(7) This is a logical approach for research directed at a specific disease or risk factor but cannot be readily applied to research directed at health systems issues which underpin the effective prevention and care of a range of health problems. Different stakeholders may have different views on the constraints to achieving the MDGs and how new knowledge can contribute to overcoming the barriers to progress. Researchers, policymakers, health personnel, research funding organisations, non-governmental organisations and the wider public may all have legitimate views about such priorities. Health systems research can be conceptualised and classified in many ways depending on the perspective taken. It is possible to analyse a research agenda in HSR from the perspective of the potential beneficiary or the broad issue such as equity, the health problem or disease group and the

perspectives of key stakeholders. For the purposes of this exercise, which has been undertaken with limited time and resources, we have identified what appear to be the key constraints to achieving the Millennium Development Goals as they relate to health and the role that new knowledge might have in addressing these goals. In doing this we have built on work undertaken by the WHO Commission on Macroeconomics and Health that developed a taxonomy of constraints to achieving the MDGs. We have also considered the health policy and systems research portfolio derived from a survey undertaken by the Alliance for Health Policy and Systems Research between 2000 and 2002 of 100 developing country research producing partners. We have also taken into account priorities suggested by researchers at the London School of Hygiene & Tropical Medicine in response to the request from the UK Department for International Development for suggestions of research priorities to achieve the MDGs. Finally, we have taken into account experience from high income countries such as the UK National Health Service Research and Development Programme which funds a programme of research on Service Delivery and Organisation. We have taken a broad view of HSR and have included within it, issues of management, organisation and delivery of health services and research relevant to the development and implementation of policy related to health systems. Criteria for selecting priorities in HSR A number of principles can inform priority setting in HSR in relation to the MDGs. Firstly there needs to be clear evidence that the problem related to health systems is preventing attainment of the MDGs and that this problem is potentially tractable if addressed by new knowledge from research. Thus we need to distinguish between the need for better research evidence and solutions that do not require new knowledge, e.g. an absolute lack of resources that prevents delivery of basic services. Research can however contribute to problem solving in resource poor environments by, for example, leading to more appropriate policies for financing of health systems, for prioritising the use of resources and developing an appropriate workforce. Secondly, it is important to understand the degree to which methodological development is necessary in order to tackle a given research problem and finally to understand how new research can bridge gaps in the existing research portfolio. The role of systematic reviews in summarising the strength and relevance of the evidence and helping to set a research agenda is well established in clinical trials but less well established in HSR, in part because of the methodological challenges of synthesising evidence from different context using a range of methodological approaches. Nevertheless many of the systematic reviews undertaken by the Cochrane Collaboration Effective Practice and Organisation of Care group, fall within the broad definition of HSR and include within the reviews, not just randomised controlled trials but other experimental designs. Constraints to the delivery of effective health interventions and services that will be necessary in order to achieve the MDGs are categorised in the Table. (8) The first three of these levels are particularly relevant to HSR. A review of the evidence of effective approaches to overcoming constraints to health

service delivery, demonstrated substantial limitations in the existing evidence base. (9) There are also few studies which focus on the evaluation of effective interventions to promote the uptake of research findings in low income countries (10). Community and household level In many countries the majority of deaths occur at home, e.g. in Tanzania around 70% of child deaths occurs in the home. Thus evaluation of approaches to improving the delivery of effective care at the household level and within local communities is likely to be of key importance. In this context whilst there is general support from research literature for the concept of community participation, there is a need for more rigorous research in this area. Greater clarity is needed about potential ways in which communities can be involved in improving their health status including participation in planning and implementation, incorporating communities perceived health priorities and preferred strategies for dealing with them. There is also the need for the evaluation of community funding initiatives such as the Bamako Initiative which aimed to enhance the essential drug supply system. Up until now there are contradictory signals from the results of different studies. The role of community health workers is a key area for further research, including the impact of training and supervision. Although volunteer CHWs may be able to make a positive impact on the coverage of health related activities, they are not substitutes for government health services. Evaluation of regular visiting of households and targeting high risk groups and the impact of community health education programmes is needed. Evaluation is needed of interventions at the community level to promote effective practice. Social marketing approaches have been used to market items such as condoms, insecticide-treated mosquito nets and oral rehydration solutions. There are however concerns about impacts on equity. The use of vouchers to improve coverage of specific public health products also needs further evaluation. Health service delivery level Human resource development is a key issue for health services. In many countries there are substantial gaps between what is needed to achieve MDGs and staff available on the ground. Evaluation of training and continuing development programmes and financial and non-financial incentives to improve motivation, recruitment and retention are required. There is potentially a substantial agenda around service organisation and delivery research. One priority area relates to effective and efficient approaches to dealing with populations with special needs such as dispersed rural populations and populations living in urban slums particularly in order in improve their access to effective services. There is mixed evidence that encouraging private providers to provide health services results in higher quality and greater effectiveness and efficiency. Nevertheless in many

countries the formal and informal private sector plays a major role in delivering health care and therefore research on their contribution is needed. Another priority area is evaluation of the development and implementation of quality assurance strategies, scaling-up interventions and integrating different approaches. In high income countries a range of interventions have been used to improve the practice of health professionals, including clinical guidelines, outreach education, computerised decision support, audit and feedback, social marketing, patient mediated interventions. A small proportion of such studies have been undertaken in low income countries. Other important topics should include research on interventions directed at health personnel and patients to improve adherence to effective drugs, particularly in the light of expanding antiretroviral delivery programmes. The development of widely applicable approaches to priority setting and the integration of disease specific (vertical) programmes with health services are also priority areas. Currently there is considerable rhetoric about how disease specific programmes can strengthen health systems but the evidence is scanty and conflicting.(9) There is a substantial research agenda around approaches to improving drug supplies including, cost-recovery schemes and interventions to improve prescribing and dispensing of applications. These interventions may not be restricted to the formal health sector but also include drug retailers who are important providers of applications in many countries. The rise of HIV/AIDS, TB and non-communicable diseases in many parts of the world has led to greater emphasis on the need for better systems to manage chronic disease. This will require health systems that facilitate continuity of care to support self-management, provide decision support for health workers that is consistent with scientific evidence and patient preference and information systems that will provide, for example, timely reminders to health personnel and patients and feedback on performance to health care providers. Cost effective approaches to developing and implementing chronic disease management systems in low income Health sector policy at strategic management level The key areas for intervention studies include; interventions aimed at strengthening strategic management, national health care financing and human resources strategies. Decentralisation of decision making in health systems is increasing in many countries and takes a number of forms depending on the combination of administrative, managerial, fiscal and risk functions that are transferred to the periphery. Such policies have been largely unevaluated as have the contracting out of health services, drug policy and supply systems. The regulation of private health and pharmaceutical sectors are other national policies requiring further research. A number of countries are using resource allocation formulae which, for example, aim to allocate resources in proportion to need as indicated by

socio-economic measures, and introducing management information and disease surveillance systems including, data for quality assurance purposes. The development, implementation and impacts of such systems require further study. A further area of key importance for national health policy is the balance between vertical and horizontal approaches, and in particular, the integration of disease specific programmes into health systems. This includes assessment of the criteria that can be applied to aid decision making on the balance between vertical and horizontal approaches, and the timescale for the maintenance of a specific vertical programme. A matrix approach Health system research priorities can be considered in the form of a matrix in which topics such as health care financing, human resources or policies to promote equity are evaluated at the three levels outlined above. In this way the knowledge generated is more likely to contribute to changes in policy and practice that will advance progress towards the MDGs The need for research networks Some strategic issues are driven by global or extranational influences such as the impact of Global Trade negotiations on the movement of health personnel, the spread of private health insurance companies and access to essential drugs. Thus HSR needs to take into account global influences on health systems and to incorporate a global perspective into research on issues that may be subject to such influences. The need for larger and more widely applicable research programmes that compare policies and interventions in a range of settings and assess the impact of global factors is a strong argument for the development of multi-country research networks to tackle priority topics and build research capacity. Table 1 Categorization of constraints Levels I. Community and household level II. Health services delivery level III. Health sector policy Constraints - lack of demand for effective interventions - barriers to use of effective interventions (physical, financial and social) - shortage and distribution of appropriately qualified staff - weak technical guidance, programme management and supervision - inadequate drugs and medical supplies - lack of equipment and infrastructure, including poor accessibility of health services - weak and over-centralized systems for

and strategic management level IV. Public policies cutting across sectors V. Environmental and contextual characteristics planning and management - weak drug policies and supply system - inadequate regulation of pharmaceutical and private sectors and improper industry practices lack of intersectoral action and partnership for health between government and civil society - weak incentives to use inputs efficiently and respond to user needs and preferences - reliance on donor funding reducing flexibility and ownership - donor practices that damage country policies - government bureaucracy (civil service rules and remuneration centralized management system; civil service reforms) - poor availability of communication and transport infrastructure A. Government and overall policy framework - corruption, weak government, weak rule of law and enforceability of contracts - political instability and insecurity - low priority attached to social sectors - weak structures for public accountability - lack of free press B. Physical environment - climactic and geographic predisposition to disease - physical environment unfavourable to service delivery References 1. Gonzalez-Block M and Mills A. The alliance for health policy and systems research newsletter. 2000, Issue 1 2. Haines A, Borchert - forthcoming