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Health systems need to be strengthened if the Millennium Development Goals related to health are to be met — and this requires a substantial increase in research into the effectiveness of such systems — according to a report on released by the World Health Organisation (WHO) yesterday (11 November).

In particular, the report points out need to bridge the 'know-do' gap — turning scientific knowledge into action — because biomedical science producing drugs, vaccines and medical devices will have little effect on health unless efficient systems are in place to get those products to the people who need them.

The report adds that health research needs to go beyond academia and find ways of using 'knowledge brokers' to bridge the gap between researchers and policymakers, healthcare providers and the general public.

Andy Haines, dean of the London School of Hygiene and Tropical Medicine, was part of a task force set up by the WHO to identify key priorities in health systems research. Its findings were published this summer in The Lancet medical journal.

Haines told SciDev.Net that key priorities identified by the task force include boosting human resources in health systems, recruiting quality staff, and creating sustainable health financing systems, such as health insurance.

Another priority is to increase the use of effective healthcare methods and reduce the use of ineffective ones — such as indiscriminate use of antibiotics and injections. The WHO report lists improved access to health information as a key aim to improve use of interventions.

"The WHO report marks a turning point for all of us who are working to improve the creation, exchange and use of health information in developing countries," says Neil Pakenham-Walsh, senior programme manager at the International Network for the Availability of Scientific Publications.

He told SciDev.Net that access to such information continues to be plagued by "insufficient understanding of information needs and inadequate support for local producers of health learning and reference materials".

"There continues to be duplication of effort, intense competition for limited resources, and failure to share experience," says Pakenham-Walsh. "In the information age, we should really be doing better — lack of information should no longer be a barrier to healthcare provision."

According to Tikki Pang, WHO's director for research policy and cooperation, health systems research also suffers from an 'image problem'. Compared with biomedical research — which attracts millions of dollars of funding — health systems research is severely neglected. Health systems research accounted for only 0.7 per cent of scientific articles published worldwide in 2000.

The health research that does exist tends to be context-specific and based on case studies, says Pang, which makes it hard to use across different countries. He believes that rigorous quantitative research is needed to provide an evidence base for reforming health systems.

"We need to focus on the 'fundamentals' — that is, improving the methodology," Pang told SciDev.Net. "So far, methodologies have been adapted from other areas and imposed on health services, rather than devising specific and appropriate methods."

Last year's change in leadership at WHO will also determine the way that health systems research is tackled, believes Pang. The current director-general Lee Jong-Wook has moved the focus of WHO activity from the global approach during the previous leader Gro Harlem Brundtland's era to one that is more regional and country-specific.

A country-focused method of research into health systems would make it easier to tap into existing knowledge, Pang told SciDev.Net. Translating this knowledge into action will be key to improving health, he adds.

Excessive decentralisation, however, could mean that problems are not tackled on a wide enough scale, and Pang stresses the need for retaining a hub in Geneva to deal with global issues such the setting of norms and standards — a core function of the WHO.

The report is due to be presented at the Ministerial Summit for Health Research in Mexico next week (16-20 November). If the health ministers of the 30 countries attending the meeting show strong support, the next challenge will be to secure funding.

Funding has traditionally been hard to come by for health systems research, partly because of a perception that such research is inexpensive. In addition, some key players — notably heavyweight funders such as the Bill and Melinda Gates Foundation — remain unconvinced that health systems are a research issue at all. The implication, says Pang, is that this sort of research is often treated as 'B-grade' science.

Even if funding does come through, it's not clear exactly how much will be needed, says Pang, but it will need to be substantially more than is being spent at the moment; in low-income countries, less than one-tenth of one per cent of total health expenditure is spent in this area.  

Pang is adamant that next week's summit should not produce 'empty declarations', but focus on specific goals.

One of these goals is to set up a global registry for clinical trials. The WHO believes it is in a unique position to develop a registry in which every single trial that takes place worldwide can be identified and tracked (see WHO wants global system for tracking clinical trials)

Another goal is to achieve better use of evidence both within countries and within WHO. Pang believes the focus will need to be on policymakers.

"Health systems research tends to generate evidence which in the final analysis is of little direct use to a policymaker," he says,  "The priorities of policymakers and researchers are different, and policymakers wouldn't necessarily look to medical journals for their information, but instead more popular sources of media such as newspapers and television."

Brazil, India, Kenya, Nigeria, Tanzania and Thailand have already expressed support says Pang and he expects most countries' health ministers to endorse these proposals.

Pang will also be looking for a commitment from developing countries themselves in addressing problems with their national health systems. The target will be to increase current spending to at least two per cent of the health budget. Currently, only a few middle-income countries — Cuba, Brazil, India and Mexico — approach this target; most other developing countries spend about 0.1 per cent of their health budget.

The Global Forum for Health Research, which has just launched a report to coincide with the ministerial summit, is also calling for more research into global health. The 10/90 gap — whereby only 10 per cent of global health resources are spent on problems facing 90 per cent of the world's population — still exists, says the Global Forum report,  despite developed countries such as the United States spending more than ever on research (see Global health research: counting the cost).

Improving health systems clearly has a strong public health imperative. The WHO admitted this week that its 3 by 5 initiative — which aims to supply antiretroviral drugs to three million people with HIV/AIDS by the end of 2005 — will not meet its target. And a recent report by the World Bank stressed that strengthening health systems in developing countries will be crucial to meeting the Millennium Development Goal
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