Building health research systems to achieve better health

Health research systems can link knowledge generation with practical concerns to improve health and health equity. Interest in health research, and in how health research systems should best be organised, is moving up the agenda of bodies such as the World Health Organisation. Pioneering health research systems, for example those in Canada and the UK, show that progress is possible. However, radical steps are required to achieve this. Such steps should be based on evidence not anecdotes. Health Research Policy and Systems (HARPS) provides a vehicle for the publication of research, and informed opinion, on a range of topics related to the organisation of health research systems and the enormous benefits that can be achieved. Following the Mexico ministerial summit on health research, WHO has been identifying ways in which it could itself improve the use of research evidence. The results from this activity are soon to be published as a series of articles in HARPS. This editorial provides an account of some of these recent key developments in health research systems but places them in the context of a distinguished tradition of debate about the role of science in society. It also identifies some of the main issues on which 'research on health research' has already been conducted and published, in some cases in HARPS. Finding and retaining adequate financial and human resources to conduct health research is a major problem, especially in low and middle income countries where the need is often greatest. Research ethics and agenda-setting that responds to the demands of the public are issues of growing concern. Innovative and collaborative ways are being found to organise the conduct and utilisation of research so as to inform policy, and improve health and health equity. This is crucial, not least to achieve the health-related Millennium Development Goals. But much more progress is needed. The editorial ends by listing a wide range of topics related to the above priorities on which we hope to feature further articles in HARPS and thus contribute to an informed debate on how best to achieve such progress

The utilisation of health research in policy-making: Concepts, examples, and methods of assessment

Chapter 1: Introduction and Background • The importance of utilising health research in policy-making, and therefore the need to understand the mechanisms involved, is increasingly recognised. Recent reports calling for more resources to improve health in developing countries, and global pressures for accountability, draw greater attention to research-informed policy-making. • For at least twenty years there has been recognition of the multiple meanings or models of research utilisation in policy-making. It has similarly been long recognised that a range of factors is involved in the interactions between health research and policy-makers. • The emerging focus on Health Research Systems (HRS) has identified additional mechanisms through which greater utilisation of research could be achieved. Assessment of the role of health research in policy-making is best undertaken as part of a wider study that also includes the utilisation of health research by industry, medical practitioners, and the public. Chapter 2: The Nature of Policy-Making, Types of Research and Utilisation Models • Policy-making broadly interpreted includes national health policies made by government ministers and officials, policies made by local health service managers, and clinical guidelines from professional bodies. In this report, however, the main focus is on public policy-making rather than that conducted by professional bodies. The utilisation of health research in policy-making should eventually lead to desired outcomes, including health gains. Research can make a contribution in at least three phases of the policy-making process: agenda setting; policy formulation; and implementation. Descriptions of these processes, however, can over-estimate the degree of rationality in policy-making. Therefore, the analysis is informed by a review of the full range of policy-making models. These include rational and incrementalist models. • Various categories of research are likely to be used differently in health policy-making. Applied research might be more readily useable by a policy system than basic research, but health policy-makers tend to relate more willingly to natural sciences than social sciences. When research is based on the priorities of potential users, and/or is research of proven quality, this increases the possibility that it will be translated into policies. There also appears to be a greater chance of research being used in clinical policies about delivering care to patients, than in national policies on the structures of the health service. • Models of research utilisation in policy-making start with a link to rational or instrumental views of policy-making, and include descriptions of how commissioned research can help to find solutions to problems. Other models relate to an incrementalist view in which policy-making involves a series of small steps over a long period; research findings might gradually cause a shift in perceptions about an issue in a process of ‘enlightenment’. Interactive models of research utilisation stress the way in which policy-makers and researchers might develop links over a long period. Research can also be used symbolically to support decisions already taken. Chapter 3: Examples from Previous Studies • A study of health policy-making in two southern African countries illustrates how policy-making processes can be analysed. It addresses agenda setting, policy formulation and implementation. The methods used included documentary analysis and key informant interviews. • Many previous studies of research utilisation can provide lessons for future assessments. Two broad approaches can be identified. Some studies start with pieces, or programmes, of research and examine their impact. Others consider policy on a particular topic and assess the role of research in the policy-making. There are advantages and drawbacks in each approach, and overlaps between them. • To facilitate comparison, studies of research utilisation are best organised around a conceptual framework. Despite that, the influence of contextual factors in different settings makes it difficult to generalise. • The two methods used most frequently, and usually together, come from the qualitative tradition: documentary analysis and in-depth interviews. Questionnaires, bibliometric analysis, insider knowledge and historical approaches have all been applied. A few recent studies have attempted to score or scale the level of utilisation. • The examples suggest there is a greater level of utilisation and final outcomes in terms of health, health equity, and social and economic gain than is often assumed, whilst still showing much underutilisation. There is considerable variation in the degree of utilisation, both within and between studies. Chapter 4: Key Issues in the Analysis of Research Utilisation in Policy-Making • Increasing attention is focusing on the concept of interfaces between researchers and the users of research. This incorporates the idea that there are likely to be different values and interests between the two communities. • In relation to utilisation, the prioritisation debate revolves around two key aspects: whether priorities are being set that will produce research that policy-makers and others will want to use, and whether priorities are being set that will engage the interests and commitment of the research community. • Interactions across the interface between policy-makers and researchers are important in transferring research to policy-makers. This fits especially well with the interactive model of utilisation. Actions by individual researchers can be useful in generating interaction, but it is desirable to consider the role of the HRS in encouraging or facilitating interactions, networks and mechanisms at a system-wide level. The HRS could provide funding and organisational support for various items including: long-term research centres; research brokerage/translator mechanisms; the creation of official committees of policy-makers and researchers; and mechanisms for review and synthesis of research findings. • There is increased recognition of the significance of policy-makers in their role as the receptors of research. In relation to the perspective of policy-makers there is a spectrum of key questions. These range from whether relevant research is available and effectively being brought to their attention, to whether they are able to absorb it and willing to use it. The HRS has a responsibility, especially in the early parts of the spectrum, but the wider health system also has a responsibility to create appropriate institutional mechanisms and ensure there are staff willing and able to incorporate relevant research. • More attention should be given to the role of incentives, both for researchers to produce utilisable research, and for policy-makers, at the system or individual level, to use it. The assessment of utilisation becomes a key issue if rewards are to focus on relevance as well as research excellence. • An appropriate model for assessing research utilisation in policy-making combines analysis of two issues: the role of receptors and the importance of actions at the interfaces. An emphasis on the role of the receptor is necessary because ultimately it is up to the policy-maker to make the decisions. Any assessment of the success of the HRS in relation to utilisation must accept that the wider political context is beyond the control of the HRS, but consider the activities of the HRS, within its given context, to enhance the utilisation of research by increasing the permeability of the interfaces. Chapter 5: Assessment of Research Utilisation in Health Policy-Making • The reasons for assessing the utilisation of research in policy-making include: advocacy, accountability, and increased understanding. For the World Health Organization there could be a role in conducting such assessments with the aim of providing evidence of the effective use of research resources. This could support advocacy for greater resources to be made available for health research. It is important that the purposes of any assessment are taken into account in planning the methods to be used. • Previous studies demonstrated the difficulties of making generalisations about specific factors associated with high levels of utilisation. To address this in any cross-national WHO initiative involving a series of studies in a range of countries, it would be desirable to structure all the studies around a conceptual framework (such as the interfaces and receptor framework considered here) and base the studies in each country on common themes. These could include policies for the adoption of multi-drug therapy for treating leprosy, and for the equitable access to health services. • Analysis of documents and semi-structured interviews would be appropriate methods in each study assessing the role of research in policy-making on a specific policy theme. Questionnaires could also have a role. These approaches would provide triangulation of methods and data-sources and should also provide material to help identify the relative importance, in relation to the level of utilisation recorded, of the HRS mechanisms described in the previous analysis. The types and sources of research used, and reasons for their use, should also be recorded and attempts made to correlate them with the previous priority setting approaches. It is expected that each study will produce its own narrative or story of what caused utilisation in the particular context, but the data gathered could also be applied to descriptive scales of the level research utilisation. The four scales could cover the consistency of policy with research findings, and the degree of influence of research on agenda setting, policy formulation, and implementation. • The findings from the assessments in each participating country should be collated. For each policy theme or topic the analysis would compare two sets of data: the scales for level of research utilisation in each country, and the contextualised lists of the HRS activities and other mechanisms and networks thought to be important. Although the account here has focused on research impact on policy-making, the evaluations would be stronger as part of a wider analysis covering research utilisation and interactions with practitioners, industry and the public. • Given appropriate and targeted topic and country selection, this approach is likely to meet the purpose of using structured methods to provide examples of effective research utilisation. The approach should contribute towards enhanced understanding of the issues and could provide the basis of an assessment tool which, if used widely in countries, could lead to greater utilisation of health research.Research Policy and Co-operation (RPC) Department of the World Health Organization, Geneva; UK Department of Health’s Policy Research Programme; Alliance for Health Policy and Systems Research from the governments of Norway and Sweden; World Bank and International Development Research Council of Canad

The state of international collaboration for health systems research: what do publications tell?

AIM: International collaboration for health system development has been identified as a critical input to meet pressing global health needs. North-South collaboration has the potential to benefit both parties, while South-South collaboration offers promise to strengthen capacity rapidly and efficiently across developing countries. There is an emerging trend to analyze the fruits of such collaboration. This paper builds on this trend by applying an innovative concept-based bibliometric method to identify the international scope of collaboration within the field of health policy and systems research. Two key questions are addressed: to what extent are papers comparing developing countries as against reporting on single country studies? To what extent are papers in either case being produced by researchers within their respective countries or through North-South or South-South collaboration? METHODS: A total of 8,751 papers published in Medline between 1999 and 2003 with data on health systems and policies in developing countries were identified and content-analyzed using an innovative concept-based search technology. A sample of 13% of papers was used to identify the corresponding institution and countries covered. The sampled data was then analyzed by income group. RESULTS: Papers with an international, cross-country focus account for only 10% of the total. Just over a third of all papers are led by upper middle income country authors, closely followed by authors from high income countries. Just under half of all papers target low income countries. Cross-country papers are led mostly by institutions in high income countries, with 74% of the total. Only seven countries concentrate 60% of the papers led by developing country institutions. Institutions in the United States and the United Kingdom concentrate between them as many as 68% of the papers led by high income countries. Only 11% of all single-country papers and 21% of multi-country studies are the product of South-South collaboration. Health Financing is the topic with the greatest international scope, with 26% of all papers in the topic. Topics such as Costing and Cost Effectiveness, Finance, Sector Analysis and Insurance, regardless of their national or international scope, are led in 38% to 54% of cases by high income authors. CONCLUSION: While there is modest health systems research capacity in many developing countries for single country studies, capacity is severely limited for multi-country studies. While North-South collaboration is important, the number of international studies is still very limited to produce the kind of knowledge required to learn from experiences across countries. The fact that lead institutions as well as study countries are concentrated in a handful of mostly middle income countries attests to great disparities in research capacity. However, disparities in research capacity and interest are also evident in the North. It is urgent to build cross-country research capacity including appropriate forms of South-South and North-South collaboration

Service utilization in community health centers in China: a comparison analysis with local hospitals

BACKGROUND: Being an important part of China's Urban Health Care Reform System, Community Health Centers (CHCs) have been established throughout the entire country and are presently undergoing substantial reconstruction. However, the services being delivered by the CHCs are far from reaching their performance targets. In order to assess the role of the CHCs, we examined their performance in six cities located in regions of South-East China. The purpose of this investigation was to identify the utilization and the efficiency of community health resources that are able to provide basic medical and public health services. METHODS: The study was approved by Peking University Health Science Center Institutional Reviewing Board (NO: IRB00001052-T1). Data were collected from all the local health bureaux and processed using SPSS software. Methods of analysis mainly included: descriptive analysis, paired T-test and one-way ANOVA. RESULTS: The six main functions of the CHCs were not fully exploited and the surveys that were collected on their efficiency and utilization of resources indicate that they have a low level of performance and lack the trust of local communities. Furthermore, the CHCs seriously lack funding support and operate under difficult circumstances, and residents have less positive attitudes towards them. CONCLUSION: The community health service must be adjusted according to the requirements of urban medical and health reform, taking into account communities' health needs. More research is required on the living standards and health needs of residents living within the CHC's range, taking into consideration the users' needs in expanding the newly implemented service, and at the same time revising the old service system so as to make the development of CHCs realistic and capable of providing a better service to patients. Several suggestions are put forward for an attainable scheme for developing a community health service

Institutional capacity for health systems research in East and Central African Schools of Public Health: strengthening human and financial resources

BACKGROUND: Despite its importance in providing evidence for health-related policy and decision-making, an insufficient amount of health systems research (HSR) is conducted in low-income countries (LICs). Schools of public health (SPHs) are key stakeholders in HSR. This paper, one in a series of four, examines human and financial resources capacities, policies and organizational support for HSR in seven Africa Hub SPHs in East and Central Africa. METHODS: Capacity assessment done included document analysis to establish staff numbers, qualifications and publications; self-assessment using a tool developed to capture individual perceptions on the capacity for HSR and institutional dialogues. Key informant interviews (KIIs) were held with Deans from each SPH and Ministry of Health and non-governmental officials, focusing on perceptions on capacity of SPHs to engage in HSR, access to funding, and organizational support for HSR. RESULTS: A total of 123 people participated in the self-assessment and 73 KIIs were conducted. Except for the National University of Rwanda and the University of Nairobi SPH, most respondents expressed confidence in the adequacy of staffing levels and HSR-related skills at their SPH. However, most of the researchers operate at individual level with low outputs. The average number of HSR-related publications was only <1 to 3 per staff member over a 6-year period with most of the publications in international journals. There is dependency on external funding for HSR, except for Rwanda, where there was little government funding. We also found that officials from the Ministries of Health often formulate policy based on data generated through ad hoc technical reviews and consultancies, despite their questionable quality. CONCLUSIONS: There exists adequate skilled staff for HSR in the SPHs. However, HSR conducted by individuals, fuelled by Ministries’ of Health tendency to engage individual researchers, undermines institutional capacity. This study underscores the need to form effective multidisciplinary teams to enhance research of immediate and local relevance. Capacity strengthening in the SPH needs to focus on knowledge translation and communication of findings to relevant audiences. Advocacy is needed to influence respective governments to allocate adequate funding for HSR to avoid donor dependency that distorts local research agenda.DFI

Health systems research in Lao PDR: capacity development for getting research into policy and practice

<p>Abstract</p> <p>Background</p> <p>Lao PDR is a low-income country with an urgent need for evidence-informed policymaking in the healthcare sector. During the last decade a number of Health Systems Research (HSR) projects have been conducted in order to meet this need. However, although knowledge about research is increasing among policymakers, the use of research in policymaking is still limited.</p> <p>Methods</p> <p>This article investigates the relationship between research and policymaking from the perspective of those participating in HSR projects. The study is based on 28 interviews, two group discussions and the responses from 56 questionnaires.</p> <p>Results</p> <p>The interviewees and questionnaire respondents were aware of the barriers to getting research into policy and practice. But while some were optimistic, claiming that there had been a change of attitudes among policymakers in the last two years, others were more pessimistic and did not expect any real changes until years from now. The major barriers to feeding research results into policy and practice included an inability to influence the policy process and to get policymakers and practitioners interested in research results. Another barrier was the lack of continuous capacity development and high-quality research, both of which are related to funding and international support. Many of the interviewees and questionnaire respondents also pointed out that communication between those conducting research and policymakers must be improved.</p> <p>Conclusion</p> <p>The results show that in the case of Lao PDR, research capacity development is at a crucial stage for implementing research into policy and practice. If research is going to make a consistent impact on policymaking in the Lao health care sector, the attitude towards research will need to be changed in order to get research prioritised, both among those conducting research, and among policymakers and practitioners. Our findings indicate that there is awareness about the barriers in this process.</p

Building health research systems to achieve better health

Health research systems can link knowledge generation with practical concerns to improve health and health equity. Interest in health research, and in how health research systems should best be organised, is moving up the agenda of bodies such as the World Health Organisation. Pioneering health research systems, for example those in Canada and the UK, show that progress is possible. However, radical steps are required to achieve this. Such steps should be based on evidence not anecdotes. Health Research Policy and Systems (HARPS) provides a vehicle for the publication of research, and informed opinion, on a range of topics related to the organisation of health research systems and the enormous benefits that can be achieved. Following the Mexico ministerial summit on health research, WHO has been identifying ways in which it could itself improve the use of research evidence. The results from this activity are soon to be published as a series of articles in HARPS. This editorial provides an account of some of these recent key developments in health research systems but places them in the context of a distinguished tradition of debate about the role of science in society. It also identifies some of the main issues on which 'research on health research' has already been conducted and published, in some cases in HARPS. Finding and retaining adequate financial and human resources to conduct health research is a major problem, especially in low and middle income countries where the need is often greatest. Research ethics and agenda-setting that responds to the demands of the public are issues of growing concern. Innovative and collaborative ways are being found to organise the conduct and utilisation of research so as to inform policy, and improve health and health equity. This is crucial, not least to achieve the health-related Millennium Development Goals. But much more progress is needed. The editorial ends by listing a wide range of topics related to the above priorities on which we hope to feature further articles in HARPS and thus contribute to an informed debate on how best to achieve such progress

Analysis of adequacy levels for human resources improvement within primary health care framework in Africa

Human resources in health care system in sub-Saharan Africa are generally picturing a lack of adequacy between expected skills from the professionals and health care needs expressed by the populations. It is, however, possible to analyse these various lacks of adequacy related to human resource management and their determinants to enhance the effectiveness of the health care system. From two projects focused on nurse professionals within the health care system in Central Africa, we present an analytic grid for adequacy levels looking into the following aspects: - adequacy between skills-based profiles for health system professionals, quality of care and service delivery (health care system /medical standards), needs and expectations from the populations, - adequacy between allocation of health system professionals, quality of care and services delivered (health care system /medical standards), needs and expectations from the populations, - adequacy between human resource management within health care system and medical standards, - adequacy between human resource management within education/teaching/training and needs from health care system and education sectors, - adequacy between basic and on-going education and realities of tasks expected and implemented by different categories of professionals within the health care system body, - adequacy between intentions for initial and on-going trainings and teaching programs in health sciences for trainers (teachers/supervisors/health care system professionals/ directors (teaching managers) of schools...). This tool is necessary for decision-makers as well as for health care system professionals who share common objectives for changes at each level of intervention within the health system. Setting this adequacy implies interdisciplinary and participative approaches for concerned actors in order to provide an overall vision of a more broaden system than health district, small island with self-rationality, and in which they operate

Trends of public health research output from India during 2001-2008

BACKGROUND: An understanding of how public health research output from India is changing in relation to the disease burden and public health priorities is required in order to inform relevant research development. We therefore studied the trends in the public health research output from India during 2001-2008 that was readily available in the public domain. METHODS: The scope and type of the published research from India in 2007 that was included in the PubMed database was assessed and compared with a previous similar assessment for 2002. Papers were classified based on the review of abstracts and original public health research papers were assessed in detail. Impact factors for the journals were used to compute quality-adjusted research output. The websites of governmental organizations, academic and research institutions and international organizations were searched in order to identify and review reports on original public health research produced in India from 2001 to 2008. The reports were classified based on the topics covered and quality and their trends over time were assessed. RESULTS: The number of original health research papers from India in PubMed doubled from 4494 in 2002 to 9066 in 2007. This included a 3.1-fold increase in public health research papers, but these comprised only 5% of the total papers in 2007. Within public health, the increase was lowest for the health system and policy category. Several major causes of disease burden in India continued to be underrepresented in the quality-adjusted public health research output in 2007. The number of papers evaluating population health interventions increased from 2002 to 2007, but there were none on the leading non-communicable causes of disease burden or on road traffic injuries. The number of identified original public health research reports increased by 64.7% from 204 in 2001-2004 to 336 in 2005-2008. The proportion of reports on reproductive and child health was very high but decreased slightly from 38.7% of the total in 2001-2004 to 31.5% in 2005-2008 (P = 0.09); those on the leading chronic non-communicable conditions and injuries increased from 6.4% to 13.4% (P = 0.01) but this was still much lower than their contribution to the disease burden. Health system/policy issues were the topic in 27.4% reports but health information issues were covered in a miniscule 0.6% reports. The proportion of reports that were evaluations increased slightly from 26% in 2001-2004 to 31.5% in 2005-2008, with this proportion being higher among the reports commissioned by international organizations (P < 0.001). The proportion of reports commissioned by Indian governmental organizations alone, or in collaboration with international organizations, doubled from 2001-2004 to 2005-2008 (P < 0.001). Only 25% of the total 540 reports had a quality score of adequate or better. The quality of reports produced by collaborations between Indian and international organizations was higher than those produced by Indian or international organizations alone (P < 0.001). CONCLUSION: This is the first analysis from India that includes research reports in addition to published papers. It provides the most up-to-date understanding of public health research output from India. The increase in available public health research output and the increase in commissioning of this research by Indian governmental organizations are encouraging. However, the distribution of research topics and the quality of research reports continue to be unsatisfactory. It is necessary for health policy to address these continuing deficits in public health research in order to reduce the very large disease burden in India.13 page(s