Health systems: orphan of research

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According to the World Health Organisation (WHO), only a small proportion of the money spent on studying the health problems of the developing world goes on improving the effectiveness of health delivery systems. The imbalance is a distorted reflection of real needs.

There are no Nobel Prizes for ground-breaking research into the best ways of delivering health care — particularly in developing countries. Nor is a research paper on the topic, however brilliant or original, likely to get published in the top scientific journals. Indeed leading specialists in the field are unlikely to find themselves offered prestigious chairs in the world’s major research universities.

All this is despite the fact that, in terms of the world’s health needs, effective mechanisms for getting the result of biomedical research to the patients who could most benefit from it remains near the top of the priority list. More than six million children die each year in the developing world, for example, from diseases that could be prevented by simple interventions (and even in the United States, it is estimated that one half of the population does not receive medical treatment from which it could benefit). Yet debate on scientific priorities continues to focus primarily on the more glamorous end of the spectrum: the research leading to drugs, vaccines and treatments that does win prizes, gets published in high-profile journals, and opens the door to glittering academic careers.

This distortion in research priorities is highlighted in a report published last week by the World Health Organisation. Claiming that half of the world’s deaths could be prevented with simple and cost-effective interventions, the World Report on Knowledge for Better Health underlines the extent to which “disparities and inequities in health remain major development challenges in the new millennium, and malfunctioning health systems are at the heart of the problem” (See WHO calls for more health systems research).

The principle targets of the report are health ministers and top health administrators attending an international summit this week in Mexico City. Hopefully, these will be persuaded that, at both a national and international level, research on health systems should be given much higher priority than it currently receives. The WHO report recommends that about two per cent of a country’s health budget should be spent in this area; at present, in many developing countries, the expenditure is less than one-twentieth of that.

Better communication

But the message needs wider acknowledgement. One group that needs to develop an adequate response is the gatekeepers of biomedical research results, and those responsible for getting such results into the hands of decision-makers. For, as the WHO report points out, much more attention is needed to ways of doing this effectively, not only using modern communications tools (such as the Internet) but also the professional skills of those expert in translating specialist knowledge into terms that non-specialists can understand.

A second group that needs to take on board the message of the WHO report is the world’s biomedical community. This is because of the central role that scientists themselves play not only in setting their research objectives, but also in establishing the criteria by which success in achieving such objectives is judged. And it has been these criteria that have been partly responsible for the low esteem in which such research is widely held in the academic community.

To some extent this has perhaps been an inevitable consequence of the nature of health systems research. Conventional academic research — particularly in the natural sciences — tends to be universal in both its subject matter and its application. In contrast, health systems research tends to be localised; it is unlikely that the best way of caring for HIV/AIDS patients in Botswana is going to be immediately relevant to the situation in Thailand or Bolivia.

Another, related, factor is the relative lack of robust methodologies. Much of health systems research, for example, remains excessively qualitative, and where rigid assessment techniques have been devised, they are often the result of adapting analytical methods that have been developed for entirely different purposes. Far too little effort has gone into supporting efforts by those in the field to build their own, subject-specific methodologies for producing the robust evidence on which effective health policies need to be based.

Academic research is not enough

Behind each of these factors lies the notion that the principal route to better health in the developing world lies in ensuring that diseases experienced largely in the developing world are given sufficient attention by academic researchers.

Academic research is certainly an essential dimension of the problem; as the Global Forum for Health Research is constantly reminding us, only ten per cent of the world’s health research funding is spent on diseases that effect the 90 per cent of its population.

But research will only make an impact if it is applied. And this means that the work of academics must come to be seen by both policy-makers and researchers as part of ‘systems of biomedical innovation’ requiring the involvement of a range of professional expertise (including social scientists, government officials, and even the media).

Where this exists, the results can be impressive (and rewarding). Take, for example, the Tanzania Essential Health Interventions Project (TEHIP) project that has been taking place for more than a decade. Financed by Canada’s International Development Research Centre — one of the sponsors of SciDev.Net — this has been looking at ways of bringing the priorities of local health care systems more closely into line with the actual distribution of disease. One result: a 40 per cent drop in childhood mortality since the late 1990s.

The challenge of bridging the ‘know-do’ gap

The Tanzanian experience shows that health systems research, if carried out with commitment and a concern for its application, can have just as big an impact on health as new drugs or vaccines. The WHO is now examining ways in which the research results may be applied to other countries in the region. And the project has been highlighted (for example, in a prominent feature article and supportive article in The Economist last year) as a convincing example of the way that carefully targeted and implemented aid projects can make a significant impact on the lives of those they seek to help.

The key challenge — and it is one which applies to the whole development scene — is finding better ways of closing what the WHO report describes as the ‘know-do’ gap. Knowledge itself, and the skills to generate it, is essential for development. But knowledge can only have an impact if it is put into practice. And that requires a separate, equally essential, set of knowledge and skills.

If the meeting in Mexico City this week can provide meaningful political support for this message — and find its own way of ensuring that this message is taken on board by both the world’s biomedical research community and decision-makers in developing countries — it will have taken a small but significant step towards reducing the burden of disease on those who, given recent developments in biomedical science, should not still be suffering.

World Report on Knowledge for Better Health
Ministerial Summit on Health Research