Widening the debate on health systems research

22 Nov 2010

Paul Chinnock

Source: TropIKA.net

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Paul Chinnock gives his personal views on proceedings at the First Global Symposium on Health Systems Research held 16-19 November 2010, Montreux, Switzerland, which he attended “virtually” following the debate via the webcam in the main conference hall.

When I told people that I was taking part in a conference on health systems research (HSR), no one knew what this meant. I explained that, thanks to research, a range of “tools” are now available to fight infectious diseases in poor countries and that more are in the pipeline, but these often fail to reach the people who need them the most. This is because the health systems of poor countries rarely function well. The response I usually got was to the effect that surely it just needs better management. I pointed out that it simply isn’t clear why one healthcare programme is a success while another ends in failure; and that the last few years have seen an acceptance of the idea that, just as rigorous research methods are used in developing new tools, they can also be employed to find the best ways of delivering them.

But despite my efforts there was still some scepticism. Do we need to create a new research discipline? Must we hold an expensive international symposium to ponder problems that are already well known and develop new theories, when what really matters is what happens on the front line of care?

Certainly a good deal of time was spent at the Symposium listing – and bewailing – some long-established concerns:

vertical (“silo”) programmes focused on just one disease often work well but comprehensive quality care is much harder to deliver
we are a long way from universal coverage and it is the poorest who are not reached
the political commitment (and therefore the money) is still lacking
the mix of inefficient public and unregulated private care provision is adding to the problems
policy makers are rarely interested in research
the developing world has few institutions with the capacity to carry out quality HSR.

And to bear out all this we heard case studies from individual countries where – predictably – all of these problems are to be found. Many speakers told us the issues were “complex” and that there was so much that we didn’t know. Any health professional working at the point of care surely already knows this.

So has the Symposium helped us to know more and to resolve some of the complexity? In itself of course it has not, but some very interesting suggestions were presented as to how we might now proceed. Here a few of them:

develop new research methodologies suited to public health interventions
create “national evaluation platforms”
use research to improve health system financing
find ways to incentivise policy makers, donors and researchers to ensure that HSR takes place and that its results are acted upon
starting with clinical guidelines as a model, create guidelines to assist the work of policy makers
improve the access of policy makers to information, perhaps with repositories including examples of good and bad practice
improve the capacity of research institutions in developing countries.

Also much heard during the meeting were the now familiar calls for evidence-based policy making, interdisciplinarity, transparency and accountability, and for better communication, cooperation and collaboration. But while all these things have been said before they are still key issues and a conference must inevitably return to them. Rightly the Symposium kept in mind the ethical and political aspects of health system reform, as well as the technical issues. Many speakers reminded us that each country should decide on its own priorities, drawing on ideas developed elsewhere but adapting them to local situations.

What is of course needed now is for the new ideas and principles debated in Montreux to be put to use. It is customary for a meeting like this to conclude that holding another meeting is a priority; in this case there will be another Global Symposium in two or three years’ time. It was also decided to launch an international society for health systems research, knowledge and innovation. To the sceptic this might sound like the creation of more talking shops. There is no doubt that delegates at this meeting want to see action as well as debate but, when a meeting focuses on the importance of research evidence for policy making, it seems a pity that we have no means of evaluating the effectiveness of international conferences as an intervention for improving the health of the world’s poorest people.

So how was it to participate in an event like this via the internet? There were a few technical problems, sometimes affecting, for example, the downloading of the slides for the presentations. And there was throughout a sense of isolation; I did not experience the “buzz” of a large meeting nor have the opportunity to speak with other delegates informally. I emailed questions during some of the sessions but have no idea whether these got through. Nevertheless, the experience was good. From my own office – and at no cost – I was able to see and hear presentations from leading figures in HSR. I certainly feel much better acquainted with the challenges and some of the potential solutions that are now under consideration.

The internet can be used both to widen the debate and to cut costs. It would be interesting to know how many other virtual participants took part in this Symposium and – crucially – how many of them were doing so from disease-endemic countries. Widening the debate will only be worthwhile if it enables the participation of those who are on the front line.