Research into health systems is poised for a much-needed renaissance. Global health experts now appreciate that in poor countries, even the most effective vaccines or ingeniously designed drugs always fall at the last hurdle — the broken-down health system.
It has taken time for them to understand that, before attempting to strengthen health systems, we need to research how to go about it, using an evidence-based approach.
Now, that need has caught on. Health systems research is such a hot topic that it threatened to overshadow the main theme — innovation — at the Global Forum for Health Research's annual conference in Havana, Cuba, last month (November).
Yet the health systems evangelists were preaching to the converted in Cuba. They don't really need to convince other researchers, many of whom are well aware of the realities of healthcare in developing countries.
The ones who do need convincing are aid donors. For research that can truly overhaul health systems in poor countries, we need the expertise and creativity that comes with well-funded projects — and these often require external financing.
Such funding is a thorny issue. The Gates Foundation, for example, has refused to engage with health systems research.
It is a hazy field of study that is difficult to quantify. Health systems, with all their inherent complexity, are not easily evaluated by simple empirical studies or clinical trials.
And donors like concrete results. They like to see what they get for their money, especially the more business-oriented donors such as the Gates Foundation.
But health systems research is not like vaccine or drug development — the deliverables and results are far less clear.
The Gates Foundation's intransigence is attracting heavy criticism, with good reason. As one of the world's largest funders — one that dwarfs many government aid programmes — it has a strong hand in steering global health research. And where Gates goes, other donors follow.
During a conversation at the Havana meeting, Richard Scheffler, professor of health economics at the University of California, Berkeley, pointed out that the Gates Foundation is a family organisation with only a few 'votes' that count. "Bill [Gates] believes in great ideas. He had a great idea — Windows. He's thinking 'have a couple of those great ideas and you could solve the healthcare crisis in Africa,'" he said. The reality, of course, is more complex.
At one of the sessions in Cuba, Hassan Mshinda, director-general of the Tanzanian Commission for Science and Technology, explained how the efficiency of a health intervention can plummet because of a poor health system.
A drug that starts out with a scientifically established efficacy of 95 per cent, say, may end up only having a 30 per cent benefit in real terms because logistical barriers such as transport, or lack of medical expertise, mean it just doesn't get to the right people.
Poor countries, already struggling to control infectious diseases such as malaria and tuberculosis, are increasingly having to cope with emerging diseases such as swine flu A(H1N1) and growing rates of chronic diseases.
Developing countries will also bear the brunt of climate change, with all its adverse health impacts. Many of these countries are too poor to bolster their health systems without help.
Donors may prefer to focus on getting antiretrovirals to HIV-positive children, or to ensure that pregnant women have bednets to protect themselves against malaria mosquitoes. But by ignoring health systems, much of their investment will be wasted.
And while the Gates Foundation is an easy target, they are not the only donors who should seriously consider where they put their money.
The Global Fund to fight AIDS, Tuberculosis and Malaria, for example, could do much more. Currently, its website claims the organisation is "making improvements to infrastructure and providing training to those who deliver services."
These are useful and necessary actions of course, but training healthcare workers is an approach on a par with funding drug purchases — easy to do and measure, but inadequate on its own.
Time to plan
An issue that particularly exercised delegates at the Cuba meeting was how to create a significant pot of money for health systems research. One idea was that a portion of all of the massive programmes for drugs and vaccines should go towards research to improve health systems.
Another proposal discussed at the meeting was a separate global fund for health systems research. But with the world's finances still in a parlous state, and aid budgets increasingly being squeezed for maximum efficiency, where would the money or impetus for such a fund come from?
These are not easy questions to answer. But donors who support health in the developing world can no longer avoid them. Next November, the WHO will convene a global symposium on health systems research for researchers, policymakers, funders, and other stakeholders. The aim will be to break through the inertia.
By that time, any funder serious about improving global health must have an action plan for supporting health systems research. Despite the difficulties for donors, they must now engage with health system research, because the situation is reaching crisis point.