Francisco Becerra-Posada

Informed choices for attaining the Millennium Development Goals: towards an international cooperative agenda for health-systems research

Health systems constraints are impeding the implementation of major global initiatives for health and the attainment of the Millennium Development Goals (MDGs). Research could contribute to overcoming these barriers. An independent task force has been convened by WHO to suggest areas where international collaborative research could help to generate the knowledge necessary to improve health systems. Suggested topics encompass financial and human resources, organisation and delivery of health services, governance, stewardship, knowledge management, and global influences. These topics should be viewed as tentative suggestions that form a basis for further discussion. This article is part of a wide-ranging consultation and comment is invited. The potential agenda will be presented at the Ministerial Summit on Health Research in November, 2004, and revised in the light of responses. Subsequently, we hope that resources will be committed to generate the evidence needed to build the equitable, effective, and efficient health systems needed to achieve the MDGsHealth systems constraints are impeding the implementation of major global initiatives for health and the attainment of the Millennium Development Goals (MDGs). Research could contribute to overcoming these barriers. An independent task force has been convened by WHO to suggest areas where international collaborative research could help to generate the knowledge necessary to improve health systems. Suggested topics encompass financial and human resources, organisation and delivery of health services, governance, stewardship, knowledge management, and global influences. These topics should be viewed as tentative suggestions that form a basis for further discussion. This article is part of a wide-ranging consultation and comment is invited. The potential agenda will be presented at the Ministerial Summit on Health Research in November, 2004, and revised in the light of responses. Subsequently, we hope that resources will be committed to generate the evidence needed to build the equitable, effective, and efficient health systems needed to achieve the MDGs.

Defining research to improve health systems.

Robert Terry and colleagues present working definitions of operational research, implementation research, and health systems research within the context of research to strengthen health systems.

A framework for mandatory impact evaluation to ensure well informed public policy decisions

Trillions of dollars are invested yearly in programmes to improve health, social welfare, education, and justice (which we will refer to generally as public programmes). Yet we know little about the eff ects of most of these attempts to improve peoples’ lives, and what we do know is often not used to inform decisions. We propose that governments and non-governmental organisations (NGOs) address this failure responsibly by mandating more systematic and transparent use of research evidence to assess the likely eff ects of public programmes before they are launched, and the better use of well designed impact evaluations after they are launched. Resources for public programmes will always be scarce. In low-income and middle-income countries, where there are often particularly severe constraints on resources and many competing priorities, available resources have to be used as effi ciently as possible to address important challenges and goals, such as the Millennium Development Goals. Use of research evidence to inform decisions is crucial. As suggested by Hassan Mshinda, the Director-General of the Commission for Science and Technology in Tanzania: “If you are poor, actually you need more evidence before you invest, rather than if you are rich.” But neither the problem nor the need for solutions is limited either to health or countries of low and middle income. Expenditures and the potential for waste are greatest in high-income countries, which also have restricted resources and unmet needs, particularly during a fi nancial crisis. Having good evidence to inform diffi cult decisions can be politically attractive, as shown, for example, by the US Government’s decision to include US

Bridging the gaps between research, policy and practice in low- and middle-income countries: a survey of health care providers

1·1 billion for comparative research (including systematic reviews and clinical trials) as part of its

HRWeb Americas: a tool to facilitate better research governance in Latin America and the Caribbean

787 billion economic stimulus bill. To paraphrase Billy Beane, Newt Gingrich, and John Kerry, who have argued for a health-care system that is driven by robust comparative clinical evidence by substituting policy makers for doctors: “Evidence-based health care would not strip [policymakers] of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that [policymakers] can deliver the best quality care at the lowest possible cost.” Lancet 2010; 375: 427–31

Perspectives on the methods of a large systematic mapping of maternal health interventions

Background: Gaps continue to exist between research-based evidence and clinical practice. We surveyed health care providers in 10 low- and middle-income countries about their use of research-based evidence and examined factors that may facilitate or impede such use. Methods: We surveyed 1499 health care providers practising in one of four areas relevant to the Millennium Development Goals (prevention of malaria, care of women seeking contraception, care of children with diarrhea and care of patients with tuberculosis) in each of China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania. Results: The proportion of respondents who reported that research was likely to change their clinical practice if performed and published in their own country (84.6% and 86.0% respectively) was higher than the proportion who reported the same about research and publications from their region (66.4% and 63.1%) or from high-income countries (55.8% and 55.5%). Respondents who were most likely to report that the use of research-based evidence led to changes in their practice included those who reported using clinical practice guidelines in paper format (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.03–2.28), using scientific journals from their own country in paper format (OR 1.70, 95% CI 1.26–2.28), viewing the quality of research performed in their country as above average or excellent (OR 1.93, 95% CI 1.16–3.22); trusting systematic reviews of randomized controlled trials (OR 1.59, 95% CI 1.08–2.35); and having easy access to the Internet (OR 1.90, 95% CI 1.19–3.02). Interpretation: Locally conducted or published research has played an important role in changing the professional practice of health care providers surveyed in low- and middle-income countries. Increased investments in local research, or at least in locally adapted publications of research-based evidence from other settings, are therefore needed. Although access to the Internet was viewed as a significant factor in whether research-based evidence led to concrete changes in practice, few respondents reported having easy access to the Internet. Therefore, efforts to improve Internet access in clinical settings need to be accelerated.

The spirit of Mexico: a decade on

Major progress has been made in improving health in Latin America and the Caribbean and life expectancy has increased considerably in the Americas. However, major concerns still exist since this progress has not reached all members of society and inequality remains high in the region 1. Research can address this problem and fortunately there is growing international recognition that quality research can improve health, reduce health inequities and foster development 2,3,4,5,6,7,8,9,10,11,12,13. Research enables countries to address complex health problems and find innovative solutions. Notwithstanding, a 2002 assessment of progress regarding the eleven Essential Public Health Functions (EPHF) in the Americas found that “research in public health” (one of EPHF) remains amongst the weakest of these functions despite being essential to attaining more functional and efficient health systems 2. A number of events led a multidisciplinary and intersectorial working group in the Americas to recognize that a national health research system (NHRS) with good governance is essential for research to play an effective role in advancing health and creating a robust health system that improves the health of the population with equity. This group also defined the components of this system 2,3,6,7,8,9,13. After the Follow-up Meeting to the First Latin American Conference on Research and Innovation for Health (Havana, Cuba, 2009), the Pan American Health Organization (PAHO) and the Council on Health Research for Development (COHRED) joined forces to focus on strengthening NHRSs 7 and to this end the HRWeb Americas was created and is the focus of this article.

Maternal health research outputs and gaps in Latin America: reflections from the mapping study

BackgroundMapping studies describe a broad body of literature, and differ from classical systematic reviews, which assess more narrowly-defined questions and evaluate the quality of the studies included in the review. While the steps involved in mapping studies have been described previously, a detailed qualitative account of the methodology could inform the design of future mapping studies.ObjectivesDescribe the perspectives of a large research team on the methods used and collaborative experiences in a study that mapped the literature published on maternal health interventions in low- and middle-income countries (2292 full text articles included, after screening 35,048 titles and abstracts in duplicate).MethodsFifteen members of the mapping team, drawn from eight countries, provided their experiences and perspectives of the study in response to a list of questions and probes. The responses were collated and analysed thematically following a grounded theory approach.ResultsThe objectives of the mapping evolved over time, posing difficulties in ensuring a uniform understanding of the purpose of the mapping among the team members. Ambiguity of some study variables and modifications in data extraction codes were the main threats to the quality of data extraction. The desire for obtaining detailed information on a few topics needed to be weighed against the benefits of collecting more superficial data on a wider range of topics. Team members acquired skills in systematic review methodology and software, and a broad knowledge of maternal health literature. Participation in analysis and dissemination was lower than during the screening of articles for eligibility and data coding. Though all respondents believed the workload involved was high, study outputs were viewed as novel and important contributions to evidence. Overall, most believed there was a favourable balance between the amount of work done and the project’s outputs.ConclusionsA large mapping of literature is feasible with a committed team aiming to build their research capacity, and with a limited, simplified set of data extraction codes. In the team’s view, the balance between the time spent on the review, and the outputs and skills acquired was favourable. Assessments of the value of a mapping need, however, to take into account the limitations inherent in such exercises, especially the exclusion of grey literature and of assessments of the quality of the studies identified.

Late maternal deaths and deaths from sequelae of obstetric causes in the Americas from 1999 to 2013: A trend analysis

www.thelancet.com Published online November 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61893-6 1 November, 2014, marks the 10th anniversary of the Mexico Ministerial Summit on Health Research, attended by 20 ministers of health and delegations from 51 countries. Convened by the Government of Mexico, the Global Forum for Health Research, and WHO, the Summit endorsed the role of knowledge for better health through the Mexico Statement and a resolution passed at the World Health Assembly in 2005. Initially driven by the strong personal commitment and vision of WHO’s then Director-General, the late Lee Jong-wook, much progress has been made in the past decade; however, substantial challenges remain. Although the Summit emphasised the importance of research to strengthen health systems, can the knowledge-to-action message embodied in the spirit of Mexico help to achieve the goals of the post-2015 sustainable development agenda? Let us begin by reviewing the progress made since 2004. First, substantial improvements have been made in the accountability and transparency of research. WHO established the International Clinical Trials Registry Platform (ICTRP) after the Summit and the WHO Trial Registration Data Set now contains records of roughly 280 000 clinical trials. Major trials registries are now partners of the ICTRP and it has defi ned international standards, leading to the establishment of national registries in countries including China, India, and Brazil, as well as a Pan-African registry. Further support for trial registration was provided by the International Committee of Medical Journal Editors (ICMJE), which made trial registration a requirement for publication of the results of clinical trials. The ICMJE example has been followed by developing-country journals (eg, in China and India), major research funders, and countries that now have legislation for the mandatory registration of clinical trials (eg, Argentina, Brazil, Israel, and South Africa). Second, much progress has been made in the strengthening of links between scientifi c evidence and the development of health policy. To promote such links, WHO established EVIPNet (Evidence-Informed Policy Network), which has since created country teams in 39 middle-income and low-income countries to strengthen research-to-policy links. The value of EVIPNet has become evident—for example, in Burkina Faso, where a national policy on malaria treatment was adopted in response to an EVIPNet initiative. Other, similar initiatives have also been launched—eg, in east Africa. WHO itself, upon realising that many of its guidelines were not strictly evidence-based, acted quickly to establish a Guidelines Review Committee, which has greatly improved the quality and credibility of the many guidelines it produces. Third, the Summit called for countries to establish and implement a national health research policy and to give a higher priority to health-systems research. Many developing countries now have such policies and progress has been noted, for example in research for health-system development in the Latin American and Caribbean region, mostly in the context of improved governance, coordination, policies, and regulations. Where has the Mexico Summit fallen short? First, a key resolution, going back to the 1990 Commission on Health Research for Development, urged countries to invest at least 2% of national health expenditures in health research. A recent review of global health research investments suggested that few countries, even among high-income countries, have been able to reach this target. However, the Mexico Summit has probably been a catalyst for increased investments in health research, which totalled US

Bases para el desarrollo e implementación de un modelo de información en salud de la mujer y perinatal orientado a la gestión en Latinoamérica

240 billion in 2009. Second, a resolution urging networking to promote better collaboration hinted at poor coordination and fragmentation of health research eff orts. An eff ective and inclusive network remains an unattained goal despite proposals to improve governance by merging and consolidating diverse eff orts and provision of a more accurate picture of the research landscape through a global health research observatory. Third, despite developing its own strategy for research in 2010, WHO’s own commitment to research seems to be waning. Its highest level scientifi c advisory body, the Advisory Committee on Health Research (ACHR), has not convened for 4 years, although a meeting for a reconfi gured entity is planned in the near future. Although the global ACHR in Geneva seems moribund, the ACHRs in the regions have been active in the promotion of research (eg, in the Americas, European, and Eastern Mediterranean Regions of WHO). The spirit of Mexico: a decade on