Assessing capacity for health policy and systems research in low and middle income countries*

BACKGROUND: As demand grows for health policies based on evidence, questions exist as to the capacity of developing countries to produce the health policy and systems research (HPSR) required to meet this challenge. METHODS: A postal/web survey of 176 HPSR producer institutions in developing countries assessed institutional structure, capacity, critical mass, knowledge production processes and stakeholder engagement. Data were projected to an estimated population of 649 institutions. RESULTS: HPSR producers are mostly small public institutions/units with an average of 3 projects, 8 researchers and a project portfolio worth $155,226. Experience, attainment of critical mass and stakeholder engagement are low, with only 19$100,000 or more, but they account for 54% of total funding. International sources and national governments account for 69% and 26% of direct project funding, respectively. A large proportion of international funds available for HPSR in support of developing countries are either not spent or spent through developed country institutions. CONCLUSIONS: HPSR producers need to increase their capacity and critical mass to engage effectively in policy development and to absorb a larger volume of resources. The relationship between funding and critical mass needs further research to identify the best funding support, incentives and capacity strengthening approaches. Support should be provided to network institutions, concentrate resources and to attract funding

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. METHODS: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. FINDINGS: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). INTERPRETATION: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. FUNDING: Medical Research Council of South Africa.Medical Research Council of South Africa