Noormah Darus, Clemencia Rosa Gonzales, Jianlin Hou, Lailanor Hj Ibrahim,.
Baofa Jiang, Rusilawati Jaudin, Yuan Liu, Luu Ngoc Huat, Kalsom Maskon,.
UK Global Health Strategy 2008-1013, Health is Global, 2008, Annex page 76 76 Health is Global
Using evidence and innovation to strengthen policy and practice ‘Stronger emphasis should be placed on translating knowledge into action to improve public health by bridging the gap between what is known and what is actually being done.’ WHO World Report on Knowledge for Better Health142 Knowledge derived from research and experience is of little value unless it is put into practice, and its success monitored and regularly evaluated. Closing the gap between what we know will work to improve health and what is put into practice around the world could save millions of lives over the coming decade.This requires a better understanding of how to promote the uptake and implementation of interventions and policies already shown to be effective.143 We will make sure that our research funding includes support for work in this area and will use the forums above to share best practice. We will continue to make independent advice from our scientiﬁc advisory committees publicly accessible, in line with the Code of Practice for Scientiﬁc Advisory Committees by the Government Ofﬁce for Science.144 If policy makers are going to use the ﬁndings of research, they must be closely involved in owning the work from the onset. Following this principle, we will work with others to develop capability for policy makers to engage in this process effectively.WHO’s
Box 21:WHO Evidence Informed Policy Network ‘EVIPNet is an innovative initiative to promote the systematic use of health research evidence in policy making. Focusing on low- and middle-income countries, EVIPNet promotes partnerships at the country level between policy makers, researchers and civil society in order to facilitate both policy development and policy implementation through the use of the best scientiﬁc evidence available. ‘Low- and middle-income countries have scarce resources to address their health system challenges and need high-quality evidence to use those resources efﬁciently. Scientiﬁc evidence is a fundamental building block to improve the public health situation. If health sector managers and policy makers ignore evidence on the root causes of problems or what works best to address these problems, they risk wasting precious resources on inadequately designed programmes and policies.The direct consequence of ignoring this evidence is poor health for the population.’ WHO Evidence Informed Policy Network website (www.who.int/rpc/evipnet/en)
Evidence Informed Policy Network (EVIPNet) is an example of an important initiative in this area (see Box 21).
142 World Health Organization. World Report on Knowledge for Better Health. Geneva:WHO; 2004. 143 Sanders D and Haines A. Implementation research is needed to achieve international health goals. PLoS Med 2006; 3(6): e186. 144 The Code of Practice was published by the Government Ofﬁce for Science in 2007 and is available at: www.dius.gov.uk/publications/ﬁle42780.pdf.
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angiotensin-converting-enzyme inhibitors should remain the preferred renin-active agent to prevent vascular events in patients with or at high risk for cardiovascular disease.
*Toni L Ripley, Donald Harrison University of Oklahoma College of Pharmacy, Oklahoma City, OK 73190, USA [email protected]
We declare that we have no conﬂict of interest. 1
Jorde UP, Ennezat PV, Lisker J, et al. Maximally recommended doses of angiotensin-converting-enzyme (ACE) inhibitors do not completely prevent ACE-mediated formation of angiotensin II in chronic heart failure. Circulation 2000; 101: 844–46. McKelvie RS, Yusuf S, Pericak D, et al, for the RESOLVD Pilot Study Investigators. Comparison of candesartan, enalapril, and their combination in congestive heart failure: Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) Pilot Study. Circulation 1999; 100: 1056–64. The Heart Outcomes Prevention Evaluation Study Investigators. Eﬀects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high risk patients. N Engl J Med 2000; 342: 145–53. The Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) Investigators. Eﬀects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet 2008; published online Aug 31. DOI:10.1016/S0140-6736(08)61242-8.
The Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008; 358: 1547–59. The EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Eﬃcacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003; 362: 782–88. The Prevention of Events with Angiotensin Converting Enzyme Inhibition (PEACE) Investigators. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med 2004; 351: 2058–68. Granger CB, McMurray JJV, Yusuf S, et al, for the CHARM Investigators and Committees. Eﬀects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet 2003; 362: 772–76. Dahlöf, B, Devereux RB, Kjeldsen SE, et al, for the LIFE study group. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359: 995–1003. Kahn N, McAlister FA. Re-examining the eﬃcacy of β-blockers for the treatment of hypertension: a meta-analysis. CMAJ 2006; 174: 1737–42. Mochizuki S, Dahlöf B, Shimizu M, et al, for the Jikei Heart Study group. Valsartan in a Japanese population with hypertension and other cardiovascular disease (Jikei Heart Study): a randomised, open-label, blinded endpoint morbidity-mortality study. Lancet 2007; 369: 1431–39.
EVIPNet Americas: informing policies with evidence Public-health and health-system policies based on sound scientiﬁc evidence and best practices can improve health and equity, and the use of research results is essential for health and development.1–5 Yet accessing and incorporating research evidence to inform decision making does not occur systematically, but is especially critical in low-income and middle-income countries that face tremendous health challenges with insuﬃcient resources. WHO is actively working to address this issue. Evidence-Informed Policy Network (EVIPNet) arose from the Ministerial Summit on Health Research in Mexico City in 2004 and a resolution adopted by the 58th World Health Assembly in 2005.6–8 The goal of EVIPNet is to improve public health and reduce inequities by increasing the systematic use of and access to high-quality applicable evidence that guides the development of policies, and helps to identify and prioritise knowledge gaps that need attention. EVIPNet addresses important issues as identiﬁed by individual countries, such as maternal and child health, HIV and AIDS control, immunisation, and infectious diseases, as well as health-system challenges such as ﬁnancing, distribution of health workers, and governance. EVIPNet’s 1130
framework is based on current evidence on eﬀective strategies for knowledge dissemination that are adapted for local context. EVIPNet has been set up in several regions. EVIPNet was started in Asia in 2005 (with teams in Laos, Malaysia, the Philippines, and Vietnam, and three teams in China), and in Africa in 2006 (with teams in Burkina Faso, Cameroon, Central African Republic, Ethiopia, Mozambique, Niger, and Zambia). Country teams are led by senior health oﬃcials from government, in partnership with representatives from national science and technology institutions and academia, among others. The next wave of EVIPNet is being led by the Pan American Health Organization (PAHO) in the Americas. In 2007, PAHO, through its country oﬃces, identiﬁed countries that had requested technical cooperation for promoting evidence-informed decision making. Bolivia, Brazil, Chile, Costa Rica, Colombia, Mexico (both the national government and a Mexico–USA border oﬃce), Puerto Rico, and Trinidad and Tobago were identiﬁed as the ﬁrst round of EVIPNet participants. Local commitment, as well as the support of health authorities, was essential in planning and developing EVIPNet. www.thelancet.com Vol 372 September 27, 2008
In July, 2007, EVIPNet was introduced to country teams (ﬁgure). In addition, PAHO assembled a strong international resource group with expertise in knowledge transfer for policy making. This group provides technical support, participates in network activities, and has been responsible for reviewing country-work proposals. An evidence portal was launched in 2007 to provide access to reliable evidence sources, including the Cochrane Library (in English) and Cochrane Library Plus (in Spanish). The portal was developed jointly by PAHO’s Latin American and Caribbean Centre on Health Sciences Information.9 A global EVIPNet website is under development and will serve as a knowledge-management tool for all EVIPNet teams, by providing them with a one-stop shop for retrieving evidence summaries and other relevant resources. Lastly, an evaluation protocol has been developed to measure the impact of EVIPNet worldwide. This eﬀort is led by John Lavis at McMaster University. Participating countries have shown tremendous interest and commitment to EVIPNet. What is lacking is ongoing funding dedicated to accessing and promoting research results. For many funding agencies, evidence-informed decision making falls between the cracks. Traditional research agencies see it as development work, and therefore not within their funding remit, while development agencies often consider it within the research realm, and therefore not part of their mandate. Fortunately, a few visionary organisations do recognise that ensuring that the results of research are actually used to inform policy and practice is as important as supporting the production of high-quality research. Other support networks have evolved, and research production and use are becoming components of the public-health agenda in the Americas.10,11 Successful implementation of EVIPNet in the Americas depends on several factors. Ministries of health need to live up to their commitment to EVIPNet by creating mechanisms and long-term strategies that encourage the use of evidence to shape policies, while stimulating a dialogue with the producers of research evidence. EVIPNet teams across Latin America (and around the world), need to work together to share experiences and strengthen their capacities in key areas such as interpreting systematic reviews or summarising existing evidence through the development of policy briefs that address a particular question. Moreover, wealthier countries need to work with those that have fewer www.thelancet.com Vol 372 September 27, 2008
Figure: EVIPNET Americas introductory workshop, PAHO/WHO headquarters, Washington, DC, USA, 2007
resources to stimulate this work. No single person or organisation can inﬂuence systematic change. However, if the collective commitment to EVIPNet’s goals currently displayed is any indication of potential future impact, we are on the right track toward ensuring that research evidence is systematically used to improve health. EVIPNet Americas Secretariat Pan American Health Organization/World Health Organization, Washington, DC 20037, USA [email protected]
Written on behalf of the EVIPNet Americas Secretariat by: Sonya Corkum, Luis Gabriel Cuervo, and Analía Porrás, from PAHO/WHO. We thank Fabio Zicker, Tomas Pantoja, and John Lavis from the EVIPNet Resource Group, and José Luis Di Fabio, and María Luisa Clark from PAHO/WHO, for constructive comments and guidance. We also thank the Swedish International Development Agency, the Alliance for Health Systems and Policy Research, European Commission Framework Programme 7, and Health Canada for ﬁnancial support and commitment to EVIPNet. We declare that we have no conﬂict of interest. 1 2
3 4 5 6 7
Chalmers I. If evidence-informed policy works in practice, does it matter if it doesn’t work in theory? Evidence Policy 2005; 1: 227–42. Lavis JN, Davies HTO, Oxman AD, Denis JL, Golden-Biddle K, Ferlie E. Towards systematic reviews that inform healthcare management and policymaking. J Health Serv Res Policy 2005; 10 (suppl 1): 35–48. Lavis JN, Posada FB, Haines A, Osei E. Use of research to inform public policymaking. Lancet 2004; 364: 1615–21. WHO. World report on knowledge for better health. 2004. http://www. who.int/rpc/meetings/wr2004/en/index13.html (accessed May 16, 2008). Commission on Health Research for Development. Health research: essential link to equity in development. Oxford: Oxford University, 1990. Hamid M, Bustamante-Manaog T, Dung TV, et al. EVIPNet: translating the spirit of Mexico. Lancet 2005; 366: 1758–60. Ministerial Summit on Health Research. The Mexico Statement on Health Research. Knowledge for better health: strengthening health systems. Nov 16–20, 2004. http://www.who.int/rpc/summit/agenda/Mexico_ Statement-English.pdf (accessed May 16, 2008). World Health Assembly. Ministerial Summit on Health Research: WHA 58.34. May 25, 2005. http://www.who.int/gb/ebwha/pdf_f iles/WHA58/ WHA58_34-en.pdf (accessed May 16, 2008). Evidence Portal Virtual Health Library [Internet] BIREME Latin American & Caribbean Centre on Health Science Information. http://evidences.bvsalud. org/php/index.php?lang=en (cited June 13, 2008). Pan American Health Organization. Proposed strategic plan 2008–2012 . October, 2007. http://www.paho.org/english/gov/csp/od328-full-e.pdf (accessed May 16, 2008). Ministers of Health of the Americas. Health agenda for the Americas 2008–2012. June, 2007. http://www.paho.org/English/D/HAgenda_ English.pdf (accessed May 16, 2008).
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Grantham-McGregor SM, Powell CA, Walker SP, Himes JH. Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican study. Lancet 1991; 338: 1–5. Walker SP, Grantham-McGregor SM, Powell CA, Chang SM. Effects of growth restriction in early childhood on growth, IQ, and cognition at age 11 to 12 years and the beneﬁts of nutritional supplementation and psychosocial stimulation. J Pediatr 2000; 137: 36–41. Walker SP, Grantham-McGregor SM, Himes JH, Powell CA, Chang SM. Early
childhood supplementation does not beneﬁt the long-term growth of stunted children in Jamaica. J Nutr 1996; 126: 3017–24. Pollitt E, Gorman KS, Engle PL, Martorell R, Rivera J. Early supplementary feeding and cognition: effects over two decades. Monogr Soc Res Child Dev 1993; 58: 1–99. Pollitt E, Watkins WE, Husaini MA. Three-month nutritional supplementation in Indonesian infants and toddlers beneﬁts memory function 8 y later. Am J Clin Nutr 1997; 66: 1357–63.
EVIPNet: translating the spirit of Mexico
It has been said that policymakers see research as the opposite of “action” rather than the opposite of “ignorance”. How can we overturn such sentiments so that policymakers see research as a means of accessing knowledge and as the foundation for effective action? In November, 2004, 20 ministers of health and senior policymakers from 52 countries met in Mexico to discuss how research can help them in their daunting task to develop and implement effective health policies.1,2 Informed by the World Report on Knowledge for Better Health,3 the outcomes of the ministerial summit made their way into resolutions at the World Health Assembly in May, 2005,4 with speciﬁc steps recommended on how knowledge can be used to strengthen national health systems in the developing world. A year after Mexico, what progress has been made beyond meetings, reports, and resolutions? How will these ideas translate into reality and, at a practical level, how can ministers and other senior policymakers be better served by research? EVIPNet (Evidence-informed Policy Network) hopes to provide the answer to these questions. The initiative,
launched by WHO in June, 2005, is an innovative attempt to strengthen the links between research and policy in low-income and middle-income countries. Focusing on a bottom-up approach, countries were invited to form national teams and submit letters of intent. A workshop was convened where country teams presented their proposals and worked together to improve them, with assistance from colleagues who had experience of similar initiatives. A ﬁnal version of these proposals was submitted and is currently undergoing external review for possible funding. Seven proposals were received for the initial planning phase from Laos, Malaysia, Philippines, Vietnam, and China (Sichuan and Shandong provinces, Beijing municipality) to be followed, hopefully, by a longer-term implementation phase over 5 years with more substantial funding. What is unique about EVIPNet? Country teams were formed with the close involvement of ministries of health, and had to consist of both researchers and policymakers. Although it was explained from the outset that the process is a competitive one, we observed strong camaraderie among participants and a genuine desire to help and learn from each other. EVIPNet also builds on similar, successful recent experiences in the developing world—eg, in Africa5 and Latin America.6 The interaction between participants has already led to the establishment of a regional network, EVIPNet-Asia, and an ongoing electronic discussion platform.7 We hope to extend the initiative to other countries in the region and to other parts of the world. Following the lead set by the Ministries of Health for Kenya, Tanzania, and Uganda for their Regional East African Community networking initiative (REACHPolicy), planning is already underway for the EVIPNetAfrica initiative to be launched in seven further countries in Africa in early 2006. Will it work? Policy formulation is a multidimensional and complex process, and there is inadequate www.thelancet.com Vol 366 November 19, 2005
knowledge about the crucial factors in strengthening links between research and policy. Although much has been written,8–10 information about what actually works is limited, esp-ecially in the often challenging setting of developing countries. Questions abound, such as: what constitutes the best evidence and how relevant, feasible, and affordable is this evidence in a developing world setting,11 and what is the role, if any, of knowledge brokers? Herein lies another unique feature and opportunity presented by EVIPNet. Faced with this knowledge gap, together with the belief that the participating countries have valuable experiences of their own to contribute, we decided not to present the countries with a ﬁxed template, model, or framework of best practices developed by so-called experts in the developed world. From the proposals we received it was clear that each country faces a unique set of challenges and constraints, and that this diversity can actually be seized on as an unprecedented opportunity for further research based on a learning-by-doing approach. This research component will be built into the project from the start. Ultimately, EVIPNet will not only result in better policies and stronger health systems, but will also hopefully help to push the boundaries of knowledge in this under-researched area.3 The learning process has already begun as, on the basis of their experiences, participants themselves identiﬁed some practical, commonly-shared “drivers” that they felt would enhance their chances of success. Strategic alliances between researchers and policymakers were deemed crucial, and researchers should be involved in scale-up activities. Continuous dialogue was essential, as was the need to simplify and package research on the basis of convincing and accurate evidence. Research should be embedded in implementation and a realistic longer time-frame should be adopted for strengthening links between researchers and policymakers. Access to evidence and information, and national capacity for synthesising and presenting such evidence, were deemed to be critically important, as was a one-stop shopping and rapid-response function to address key policy challenges related to hot topics for government. The participants’ perceptions of important impediments to success were equally valuable. These included absence of quality assurance in research, unavailability of timely data for policymaking, poor communication, poor understanding of the value of research, distortion www.thelancet.com Vol 366 November 19, 2005
of evidence, and a shortage of post-policy research. Weak capacity in health-systems research and the absence of an appropriate research agenda were also cited as obstacles. By providing a bridge between research and policy, EVIPNet hopes to turn research into effective action and problem solving to improve people’s health—arguably the true spirit of the Mexico summit. When the next ministerial summit convenes in Africa in 2008, a review of the effects of this living laboratory will be the true test of its value. Maimunah Hamid, Thiel Bustamante-Manaog, Truong Viet Dung, Kongsap Akkhavong, Hongpeng Fu, Yuanxin Ma, Xinqui Zhong, Reijo Salmela, Ulysses Panisset, *Tikki Pang Institute for Health Systems Research, Ministry of Health, Kuala Lumpur, Malaysia (MH); Health Policy Division, Department of Health, Manila, Philippines (TBM); Department of Science and Training, Ministry of Health, Hanoi, Vietnam (TVD); National Institute of Public Health, Ministry of Health, Vientiane, Laos (KA); Beijing Centres for Disease Prevention and Control, Beijing, China (HF); Shandong Provincial Health Bureau, Jinan, China (YM); Sichuan Provincial Health Bureau, Chengdu, China (XZ); WHO Western Paciﬁc Regional Ofﬁce, Manila, Philippines (RS); and Research Policy and Cooperation, World Health Organization, CH-1211 Geneva, Switzerland (UP, TP) [email protected]
We thank Sonya Corkum, Irving Gold, John Lavis, Soe Nyunt-U, Nelson Sewankanbo, Andy Oxman, Parminder Raina, Don de Savigny, Abu Bakar Suleiman, and Jimmy Volmink for their help in the development of this initiative, and Jonathan Lomas for the initial idea for the project. We also thank the participants and team members from the countries: Dam Viet Cuong, Noormah Darus, Clemencia Rosa Gonzales, Jianlin Hou, Lailanor Hj Ibrahim, Baofa Jiang, Rusilawati Jaudin, Yuan Liu, Luu Ngoc Huat, Kalsom Maskon, Noorimi Morad, Nik Shamsidah, Nik Ibrahim, Merlita Opena, Kotsaythoune Phimmasone, Bounfeng Phoummalaysith, Lingzhong Xu, Haining Xue, and Xiaohua Zheng, from whom we learnt so much, and the Secretariat Staff at the Malaysian Institute for Health Systems Research for strong support. We acknowledge the sponsors of the initiative, including the Netherlands Research Organization, the Alliance for Health Policy and Systems Research, the Canadian Health Services Research Foundation, the Canadian Institutes of Health Research, and the WHO Western Paciﬁc Regional Ofﬁce. We declare that we have no conﬂict of interest. 1 2 3
The Lancet. Mexico, 2004: global health needs a new research agenda. Lancet 2004; 364: 1555–56. The Lancet. The Mexico Statement: strengthening health systems. Lancet 2004; 364: 1911–12. WHO. World report on knowledge for better health. Geneva: World Health Organization, 2004. http://www.who.int/rpc/wr2004 (accessed Nov 1, 2005) WHO. Ministerial summit on health research. Document WHA58/34. May 25, 2005. http://www.who.int/gb/ebwha/pdf_ﬁles/WHA58/ WHA58_34-en.pdf (accessed Sept 19, 2005). de Savigny D, Kasale H, Mouya C, Reid G. Fixing health systems. IDRC Canada and Ministry of Health Tanzania, 2004. http://www.idrc.ca/tehip (accessed Nov 1, 2005). Frenk J, Sepulveda J, Gomez-Dantes O, Knaul F. Evidence-based health policy: three generations of reform in Mexico. Lancet 2003; 362: 1667–71.
7 8 9
IBP Electronic Communication System. WPROep community. http://ibp.wa-research.ch/communities.aspx (accessed Nov 1, 2005). Lavis JN, Becerra Posada F, Haines A, Osei E. Use of research to inform public policymaking. Lancet 2004; 364: 1615–21. Sheldon TA. Making evidence synthesis more useful for management and policy-making. J Health Serv Res Policy 2005; 10 (suppl 1): 1–5.
Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull World Health Organ 2004; 82: 724–31. Pablos-Mendez A, Chunharas, S, Lansang MA, Shademani R, Tugwell P. Knowledge translation in global health. Bull World Health Organ 2005; 84: 723.
Cochrane Collaboration and the evolution of evidence The 13th Cochrane Colloquium was held in Melbourne on Oct 22–26.1 The opening plenary session challenged delegates, by asking “is evidence ever enough?” An articulate debate followed, informed by some of the greatest advocates of evidence. Yet the conclusion was that compiling evidence alone is inadequate, and to fully realise the beneﬁt of research, ﬁndings must be synthesised in a targeted manner and made readily available at the point of need. Rather than a downhearted response to this news, reviewers in the 700-strong gathering, or corroboree, appeared full of enthusiasm and imagination about ways in which the Collaboration could shake off its dowdy image and provide more helpful information to consumers. One reason for optimism was the rapid response with text-light, tsunami-tailored evidence earlier in the year, which showed both the value of this
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unique database and the possibility of rewriting turgid reviews in a form that can be more easily understood and acted on.2 With this impetus, there is now a refreshing interest in expanding the group’s work to include different research designs, complex interventions, more focused outcomes, and wider participation—particularly in the developing world. Cooperative ventures with other health and policy organisations, such as the Australian National Institute of Clinical Studies, to achieve these aims seem likely. The Cochrane Library has been justiﬁably criticised for its lack of accessibility, ﬂexibility, and relevance. To be effective, a change in emphasis from the product to its users will need to be more thorough than just rebranding, but must not compromise the rigour and quality for which their reviews are renowned. Much is at stake. If Cochrane fails to become an integral part of daily decision-making, health-care systems, providers, and consumers will continue to be deprived of safer, cheaper, and more effective interventions. However, if “new Cochrane” succeeds, not only will clinical care beneﬁt from the application of established evidence, but the future research agenda will be challenged to provide evidence that focuses on the real needs of patients and those who provide for them. William Summerskill
The Lancet, London NW1 7BY, UK 1 2 Melbourne, Australia, host of the 2005 Cochrane corroboree
Cochrane Collaboration. XIII Cochrane Colloquium, 2005. http://www.colloquium.info (accessed Nov 11, 2005). Cochrane Collaboration. Evidence Aid: summaries relevant to natural disasters and healthcare emergencies, 2005. http://www.cochrane.org/ docs/tsunamiresponse/index.htm (accessed Nov 11, 2005).
www.thelancet.com Vol 366 November 19, 2005
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Published 25 November 2008, doi:10.1136/bmj.a2733 Cite this as: BMJ 2008;337:a2733
Editorials Global research for health Should tackle health needs and inform policy Last week delegations from 59 governments, international agencies, and researchers met in Bamako, Mali, to discuss the state of global health research. It was an opportunity to review progress since their last meeting, four years earlier, in Mexico City, and to set an agenda for the future.1 The meeting in Mexico is widely seen as a turning point, where the importance of research tackling the greatest health needs was emphasised, and where a strategy for meeting these needs was proposed. Arguably, in a world with scarce resources efforts should be focused on where they can do most good. To make this happen, those attending the conference in Mexico advocated greater investment in research on health systems and policy, the development of national health research policies, and the incorporation of evidence into health policy. The consensus is that some progress has been made since Mexico. Funding for health systems and policy research has increased, and some politicians now accept that evidence based policies are desirable.2 Yet we still have much to do. The births, lives, and deaths of many of the world’s population remain unrecorded.3 Large scale programmes and healthcare reforms are still implemented without evaluation.4 The reasons why they succeed or fail are often unknown. And large parts of the world are effectively untouched by health research. One purpose of a meeting like this is to facilitate dialogue among groups of people who might not otherwise meet. In this it succeeded. Governmental delegations heard about the opportunities offered by health research and the obstacles to achieving them, in some cases seemingly for the first time. Although good intentions often collide with financial and political realities at home, many remarks made by ministers indicated that they had taken the messages on board. But what did the meeting achieve? The most tangible outcome was a "call to action."5 In it, governments committed themselves to developing health research strategies and to funding them adequately, allocating at least 2% of the budgets of their ministries of health. They also committed to creating research infrastructure, including ethical review procedures, clinical trials registries, and open access to data, while promoting knowledge translation as a means of developing evidence based policies. Finally, they accepted the need to build a critical mass of young researchers. Others must also play a role. International development agencies are called on to devote at least 5% of their spending on health to development of research capacity, while they and research funders should pursue innovative financing mechanisms and align their support with national plans. So what next? The call to action sets out an ambitious agenda, but so did the declaration at the Mexico City summit. An immediate need is to establish a monitoring mechanism that can track progress against stated intentions, so that next time it will be possible to assess what has been achieved and by whom. It is not obvious who should undertake this role, and that fact argues for a reassessment of the often confusing roles of the different bodies that oversee global health research. Yet whoever does it, they should report regularly and publicly, so that governments can be held to account by their populations. The widespread view was that research funding must change. Short term project based funding should coexist with long term investment in research capacity. Research portfolios should be balanced; they should include basic and applied research, as well as generalisable and context specific studies. These last studies are often the ones that make the greatest difference. The importance of knowledge transfer was stressed, and successes such as the Evidence-informed Policy Network were given as examples.6 Calls were also made for partnerships, in which researchers would work with governments, civil society, and more controversially, the drug industry. The last of these stimulated the greatest debate. A few speakers highlighted past transgressions by the industry, seemingly implying that the growth of clinical trials in developing countries was in itself a bad thing. But as Mark Walport, director of the Wellcome Trust, noted, it is industry that makes the drugs that save lives, not academics. Another area of debate was the role of national research strategies. These are clearly important but should not exclude innovative investigator led research.
The real challenge will be within countries. One of the most striking images was a map of the world, which showed research capacity.7 The heaviest shading was, as expected, in the developed countries of Europe, North America, and East Asia. Large parts of the map were completely empty, however, in west and central Africa, the Middle East, and the former Soviet Union. The unresolved challenge is what we should do where there is virtually nothing to build on. Increasing global funding alone will not help. External donors can help, if they are willing to invest strategically and recognise that the results of their funding may take a decade or more to become apparent. However, governments must also act, by tackling the corruption and failures of governance that prevent not just the development of health research but also the development of the basic institutions needed for anything to work. Cite this as: BMJ 2008;337:a2733 Martin McKee, professor of European public health 1
London School of Hygiene and Tropical Medicine, London WC1E 7HT
m.ac.uk Competing interests: MM attended the Bamako conference on behalf of the European Region of WHO. He is a member of WHO’s advisory committee on health research and has recently completed a term as a member of the Wellcome Trust’s population and public health panel. Provenance and peer review: Commissioned; not externally peer reviewed.
References 1. Ministerial Summit on Health Research. The Mexico statement on health research. Mexico City. 2004. www.who.int/rpc/summit/agenda/en/mexico_statement_on_health_research.pdf. 2. Bennett S, Adam T, Zarowsky C, Tangcharoensathien V, Ranson K, Evans T, et al; Alliance STAC. From Mexico to Mali: progress in health policy and systems research. Lancet 2008;372:1571-8.[Medline] 3. Mathers CD, Fat DM, Inoue M, Rao C, Lopez AD. Counting the dead and what they died from: an assessment of the global status of cause of death data. Bull World Health Organ 2005;83:171-7.[ISI][Medline] 4. The state of health research worldwide. Lancet 2008;372:1519.[Medline] 5. The Global Ministerial Forum on Research for Health. The Bamako call to action on research for health. Strengthening research for health, development, and equity. 2008. www.bamako2008.org/dmdocuments/CTA_3.pdf. 6. WHO. Evidence-informed Policy Network. 2008. www.who.int/rpc/evipnet/en/. 7. Global Forum for Health Research. Global forum update on research for health. Vol 5. Fostering innovation for global health. Geneva: GFHR, 2008.
Relevant Article Developing countries should have a greater say in local research agendas Robert Walgate BMJ 2008 337: a2713. [Extract] [Full Text]
Rapid Responses: Read all Rapid Responses Global research for Health Harald M Lipman bmj.com, 1 Dec 2008 [Full text]
Country Survey on Health and Climate Change
! Homes were inspected and treated on a regular basis in areas where aedes aegypti mosquitoes and larvae were present and where there were increased activity such as dengue. ! Integrated biological and chemical control measures for the management of all vector species of mosquitoes (particularly, Aedes Aegypti) were implemented in certain localities for example the Mt Hope Medical Sciences Complex. ! Within the framework of the Emergency Services and Disaster Preparedness Coordinating Unit there is the establishment of an Emergency Operations Center (EOC) in each Regional Health Authority. The common functions of all EOCs are to collect, gather and analyse data; make decisions that protect life and property, maintain continuity of the organisation, within the scope of applicable laws; and disseminate those decisions to all concerned agencies and individuals.
7. What are the current policy gaps in addressing climate change and health?
strengthen its capacity for evidence-based decision-making. The Ministry is also in the process of strengthening its National Health Research and its Health Information Management System in order to improve its health programmes and service delivery systems. In addition, the Ministry of Health is in the process of planning and implementing an Evidence Based Policy Network (EVIPNet). The establishment of such a network in Trinidad and Tobago will facilitate the availability of timely and credible evidence for use in decisionmaking and policy development.
11. Have national resources been allocated to address climate change and health in your country? If so, approximately how much has been allocated and for what issues? The national resources that have been allocated to address climate change and health are incorporated in the overall health budget. This makes it difficult to quantify the funding that was specifically allocated to the issue of climate change.
There is the need for an overarching policy to deal with climate change and health.
12. Is the Ministry of Health working together with other ministries (such as Ministries of Agriculture, Environment, Fisheries or Finance) to address health and climate change issues?
8. How well equipped is your health system to cope with the impacts of climate change?
The Ministry of Health currently works with the Ministry of Local Government to address the issue of dengue and control of the vector aedes aegypti mosquito. Under the National Disaster Management System a National Task Force was established. This is made up of 15 Task groups, with the specific responsibility of planning for, mitigating against and responding to disasters. The Ministry of Health chairs the Health Task Group. The Ministry of Health also works with the Ministry of Agriculture in the surveillance of yellow fever. The Ministry of Health works indirectly with the Ministry of Works and Transport in the areas of clean up campaign and the prevention of flooding.
! We have established mechanisms for the early warning systems for the diseases which are likely to proliferate due to the climatic change such as malaria, cholera and Rift Valley fever. ! Rapid response teams have been trained and equipped ready for any sign of the outbreak of such diseases.
9. Have you made any changes to your health system in response to increased risks resulting from climate change and if so, what changes have you made? The Ministry of Health has made changes to the health system in response to increased risks resulting from climate change in the following areas: ! The establishment of a focal point, the International Cooperation Desk, to monitor the implementation of plans and programmes that are required to fulfil Trinidad and Tobago’s obligations under International Agreements and Conventions, for example, the United Nations Framework Convention on Climate Change (UNFCCC). ! The establishment of an Emergency Services and Disaster Preparedness Coordinating Unit to deal with natural disasters. ! The decentralisation of services to the Regional Health Authorities. ! Improvement in the primary healthcare network. ! Implementation of the safe hospital initiative to mitigate against the loss of healthcare services in the event of a natural disaster. Further changes will be made as the Ministry of Health continues the implementation of its transformation plan.
10. What are the main constraints to addressing the health impacts of climate change in your country and how will these be addressed? The main constraints that can be identified to addressing the health impacts of climate change are a lack of scientific evidence to guide policy, and also a lack of resources, both human and materials. To address these areas the Ministry of Health, as stated before, is currently engaged in a transformation process which is geared to
146 Commonwealth Health Ministers’ Update 2009
13. Has your country been involved in work to manage climate change and health at the international level? Yes. Trinidad and Tobago is a signatory to the United Nations Framework Convention on Climate Change (UNFCCC). A working group has been established that has oversight of the implementation of obligations under the United Nations Framework Convention on Climate Change (UNFCC).
14. How would you describe the capacity of your country to participate at the global level on climate change and health? There is moderate capacity. However, the Ministry of Health is continuing to work towards increasing its capacity.
Figure 3: IHP+ framework for monitoring performance and evaluation of the scale-up for better health
Harmonization • Aligned international efforts with national plan • Well coordinated and harmonized support
National plan implementation • Systems strengthening • Priority interventions scale-up Capacity building • Programmes • Institutions • People Accountability • Performance monitoring Results focus and evaluation Use for better practices
Increased service utilization and intervention coverage
Plan • Coherent, prioritized and funded
Access, safety, quality and efficiency
Funding • Domestic sources • International sources
Health system strengthened Governance, human resources, medical products and information
Reduced inequity (e.g. gender and socioeconomic position) Responsiveness • No drop-off non-health sector interventions (e.g. water and sanitation)
Improved survival • Child mortality • Maternal mortality • Adult mortality due to infectious diseases Improved nutrition • Children • Pregnant women Reduced morbidity • HIV, tuberculosis and malaria, repr. health Improved equity Social and financial risk protection • Reduced impoverishment due to health expenditures
Monitoring and evaluation action
Aid process monitoring Resource tracking
Health system monitoring
Strengthen country health information systems
Evaluation: process, health system strengthening and impact
IHP+, International Health Partnership and related initiatives. Source: (54 ) research. Their involvement in research will increase the likelihood that results are used to inform their decisions. Moreover, a greater sense of the utility of health systems research will help to foster greater demand for such research, which will lead to a virtuous cycle. For example the Malawi Emergency Human Resources Programme, which was based on research driven by the Government of Malawi, has resulted in significant improvements in training and retention of health workers within a space of five years (57 ). Translation of research into policy and practice can be accelerated by support for appropriate networks and communities of practice. One example of these is the WHO Evidence-Informed Policy Network (EVIPNet), which promotes the systematic use of health research evidence in policy-making (Box 5). Country teams, linked through regional networks in Africa, Asia and the Americas facilitate policy development and implementation through summarizing evidence, hosting policy dialogues and intensifying exchange between researcher and policy communities (58 ).
Scaling up research and learning for health systems: now is the time
Policy-making is a complex process and research evidence is just one of the many factors that influence policy. For policy-makers, who may not be schooled in research, it can be challenging to assess the quality of research. Furthermore, research results are often nuanced without clear evidence that a particular policy or strategy is effective under all conditions. Accordingly, capacity development is necessary to enhance the skills of policy-maker to apply research evidence in the policy process, and this should be pursued as part of a broader capacity development strategy. Also related are dedicated knowledge brokering functions – supporting evidence-informed policy through encouraging connections that ease knowledge transfer – which are beginning to emerge in low- and middle-income countries, The Zambia Forum for Health Research being one example (59 ). The Task Force recommends that:
Box 5: WHO evidence-informed policy network (EVIPNet) EVIPNet is an innovative initiative to promote the systematic use of health research evidence in policy-making. Focusing on low- and middle-income countries, EVIPNet promotes partnerships at the country level between policy-makers, researchers and civil society in order to facilitate both policy development and policy implementation through the use of the best scientific evidence available. Low- and middle-income countries have scarce resources to address their health system challenges and need highquality evidence to use those resources efficiently. Scientific evidence is a fundamental building block to improve the public health situation. If health sector managers and policy-makers ignore evidence on the root causes of problems or what works best to address these problems, they risk wasting precious resources on inadequately designed programmes and policies. The direct consequence of ignoring this evidence is poor health for the population. Source: (28 )
2.1 mechanisms be developed at country level to ensure that key stakeholders (particularly policy-makers but also civil society) are engaged from identification of research priorities, through conception of studies, to interpretation of findings; 2.2 WHO further develop its knowledge brokering role at country level and also support the emerging knowledge brokering platforms; 2.3 mechanisms be developed that enable the research community and other stakeholders to access relevant research evidence in a succinct and easily understood format, when needed. To accelerate growth of the global knowledge-base on health systems, it is recommended that country, regional and global repositories for evidence on health systems be established, similar to existing repositories for clinical evidence such as the Cochrane Collaborative.
3. Strengthen country capacity for health systems research backed up by effective regional and global support Country capacities There is strong global consensus that strengthening capacity for health systems research – particularly at country level – is the key to progress in the field. Few developing countries have the capacity to perform the analyses and syntheses needed to assist leaders and managers to address public health problems. Instead, they often depend on short-term consultants and advisers for analytical work on health systems. The growing trend in overseas development aid towards technical assistance, which now comprises more than 40% of the value of such aid, is indicative of this systematic bias in support to research capacity (14 ). This represents something of a substitution of efforts towards developing technical and research capacity on the ground. There have been some small-scale attempts, such as the now defunct International Health Policy Program (60 ), to develop capacity in the health systems research field; however the scale of the investment has fallen
Scaling up research and learning for health systems: now is the time
October 2009, Volume 8, No. 7, Focus on Health
into policy decision-making is important. Knowledge generated through research and that is systematically and transparently synthesized through systematic reviews provides a state-of-the-art view of a health problem and of policy options to address it. Social actors gain the most comprehensive and best available evidence when it is drawn from both qualitative and quantitative approaches. Thus, questions of comparative effectiveness (whether one intervention is more effective than another), acceptability (whether interventions fit in social and cultural norms and values), and the satisfaction of healthcare providers and patients are more likely to be addressed. Circulating in advance scientific evidence in a way that is “translated” to meet the needs of each social actor involved improves and facilitates the policy-making process. What could governments in the Americas do to increase local research production and synthesis in ways that better inform policymaking? First, governments in the Americas must acknowledge the importance of health research to people’s health and to national development. According to various international recommendations, such as those from the Council on Health Research for Development (COHRED), progress in evidenceto-policy in the Americas may be enhanced if national health research policies are first developed and implemented. The Bolivian government, for instance, lags behind this essential requisite, which is hindering health research priority setting, infrastructure and human capacity building, and focused funding allocation pro-
cesses. Similarly, the governments of Peru and Ecuador could increase current health research expenditure from 0.10 per cent of their countries’ gross domestic product (GDP) to at least 0.54 per cent of the GDP, the Latin American average. Furthermore, according to a Lancet article published by Anastasia Moloney in September 2009, the government of Colombia could increase the number of postgraduate degrees and scholarships on offer, which would increase the current 1.8 per one million Colombian graduates with doctorates annually to at least the Brazilian 50 per one million. International research and development agencies could also help countries in the Latin American and Caribbean region to ensure they use five per cent of international aid for the health sector on research, as recommended by the CORED in 1990. The largest Latin American economies such as Brazil, Mexico, Chile, and Argentina could also enhance health research partnerships with neighboring countries, and with Canada and the United States. Second, social actors should support Knowledge Translation initiatives aiming to improve policy and decision-making processes. Such initiatives are comprised of researchers “pushing” evidence to government, civil society and private groups; government, civil society and private groups “pulling” research evidence; and “exchange” among these social actors. Bolivia, Mexico and Canada are examples of societies striving to foster Knowledge Translation initiatives to varying extents. In 2007, Bolivia and Mexico joined the EvidenceInformed Policy Networks (EVIPNet, www.evipnet.org), sponsored 13
by the World Health Organization. Canada has provided Knowledge Translation expertise and research and development funding to EVIPNet and similar initiatives. The Canadian Coalition for Global Health Research, with the support of the Pan American Health Organization, also organized in 2007 a workshop in Bolivia aiming at perfecting the proposal for research in health for Bolivia. Substantive government stewardship and investment remains essential to strengthen national research capacity in Bolivia. Mexico’s Knowledge Translation experiences entail relative advancement and complexity. This came about partially due to the Mexican statement in the 2004 Ministerial Summit on Health Research, which called on establishing national Knowledge Translation programmes. Moreover, Mexico’s decentralization of healthcare services increased the autonomy of municipalities and states. Thus, building on close ties between the Mexican Ministry of Health and research institutes, including the National Institute of Public Health, networks composed of researchers, government officials, and activists in civil society groups started to be trained through initiatives such as the Research Consortium for the Development of State Health Systems. This initiative included Mesoamerican countries and counted on Canadian collaboration. Despite Mexico’s attempts to implement such initiatives, it faces challenges common to other Latin American countries: socio-economic inequalities, deficient Knowledge Translation-designated research funding, difficult access to high-quality scientific databases, and lack of expertise.
Getting information and evidence into policy-making and practice: strategies and mechanisms
Box 12.1 Evidence-Informed Policy Network: EVIPNet In response to a call “to establish mechanisms to transfer knowledge in support of evidence-based public health and health-care delivery systems, and evidence-based health-related policies”, in 2005 the World Health Organization launched the collaborative Evidence-Informed Policy Network (EVIPNet) (26). EVIPNet addresses the integration of two fundamental enabling factors in the process of evidenceinformed policy-making: best practices to promote interaction among stakeholders that generate and use evidence; and capacity to implement research in a local context (27). Focusing on low- and middle-income countries, EVIPNet promotes partnerships at the country level between policy-makers, researchers and civil society in order to facilitate both policy development and policy implementation through the use of the best scientiﬁc evidence available. EVIPNet comprises a series of linked (but distinct) networks that bring together national teams, which are coordinated at regional and global levels. Africa, Asia and the Americas each host regional networks, which together work in some 25 countries. At the regional level, EVIPNet is supported by WHO regional ofﬁces and by small secretariats responsible for promoting regional coordination. A global steering group facilitates exchange between regions and supports international-level activities. The work is guided by a group of international experts in the evidence-to-policy ﬁeld, which provides strategic guidance, organizes technical review of EVIPNet proposals, develops innovative methodologies and provides direct technical support to country teams where necessary. A project priority is to identify best practices in developing capacity of both policy-makers and researchers in working with scientiﬁc evidence-to-policy links, while engaging citizens and advocacy groups to sustain demand for evidence-informed health policy. Since its inception, EVIPNet has worked collaboratively with the Regional East African Community Health Policy Initiative, an institutional mechanism whose mission is to access, synthesize, package and communicate evidence required for health policy and practice and for inﬂuencing policy-relevant research agendas for improved health equity (28). Similar initiatives are emerging in other countries, focusing on supporting governments to use research evidence for health policy decisions – although the speciﬁc scope of activities, nature of collaborative efforts and research evaluation methods are unique across contexts. For example, country teams may organize workshops to build technical capacity; several promote the inclusion of journalists as observers and advocates. Thus EVIPNet has contributed to creating a supportive political environment for delivery of evidence-informed policies. Recently, country teams have began to produce policy briefs based on systematic reviews of research, offering policy options that include governance, delivery and ﬁnancial arrangements adapted to speciﬁc country or district contexts and the reality of existing resources. For instance, in February 2008, EVIPNet Africa country teams produced policy briefs to address current policy challenges related to malaria treatment services in their respective countries.
disseminators, but also proactive actors in policy-making. For example, regular (biennial) regional meetings provide a forum for interactive discussion, sharing and strategic planning. More recently, with increasing global attention and resource mobilization to address the health workforce crisis in Africa, the Africa Health Workforce Observatory (34) has evolved as part of the action agenda. With its secretariat housed by the World Health Organization (WHO), its mission is to “support actions that address HRH challenges by promoting, developing and sustaining a solid knowledge base for HRH information at all
levels: subnational, national, intercountry and regional” (35) (Box 12.2, page 166). Similarly, with support from WHO, the Eastern Mediterranean Region Observatory on Human Resources for Health grew out of an existing regional observatory on health systems with the purpose “to assist Member States in using a proactive approach and sharing the best and most innovative options to tackle HRH-related challenges” (36). Its outputs in the public domain include updated proﬁles on the health workforce situation within and across countries, analyses of correlations between signiﬁcant health workforce
Getting information and evidence into policy-making and practice: strategies and mechanisms
12.4 Opportunities and directions The development and sustainability of long-term, comprehensive HRH policies and plans is a common challenge for all countries to ensure the health workforce is prepared to meet current and future health system objectives and population health needs with equitable and adequate coverage. In many countries, this entails strengthening institutional capacity for deﬁning appropriate policies and revising them periodically, which itself is dependent upon close cooperation among a wide range of stakeholders in the policy dialogue from the inception stages. This includes not only the ministry of health but also other sectors: ﬁnance department, public service commission, educational bodies, health professional regulatory bodies and associations, programme managers (in the public, parapublic and private sectors), development partners and health services users’ groups. In order to achieve balance across the different perspectives, and being mindful that each country has speciﬁc challenges and contexts for workforce development, a common framework needs to be identiﬁed where collaborative efforts can be focused. To this end, this chapter has examined various strategies and mechanisms to ground HRH policies and strategies in scientiﬁc information and evidence. The sustainable provision of timely, reliable and relevant data, information and evidence to improve HRH policies requires mechanisms to facilitate dissemination, access and use in policy-making processes. Different knowledge transfer platforms (such as EVIPNet) and cooperative mechanisms (health workforce observatories) can offer the opportunity for global and national health institutions to take advantage of the latest innovative and sound tools to support decision-making. Their value lies in the forums they extend to facilitate sharing of information and experiences and promotion of collaborations at the national, regional and international levels. In particular, health workforce observatories can be a good mechanism to facilitate the steering and negotiating processes of cooperative partnerships. They can contribute to the strengthening of working relations and development of joint agendas among stakeholders. Their informational products help bring new evidence on the health workforce situation to a broader audience, often in a standardized way to foster better understanding and dialogue for comparisons and benchmarking. Perhaps most crucially, they can effectively raise the priority of HRH issues in the health development agenda; for example, through its working groups and mobilization efforts, the Observatories of Human Resources for Health of the Americas network has been credited as central in shaping the agenda for
long-term, intentional and coordinated efforts for HRH development at the international, national, regional and subregional levels (43). A number of critical success factors in moving forward with health workforce observatories and enhancing their beneﬁts have been identiﬁed (44). They include: t championing HRH issues in the country (including high-level political commitment and leadership); t engaging all key stakeholders in joint planning and nurturing joint work; t ensuring effective coordination; t building awareness and capacity in HRH issues; t developing approaches from different experiences; t harmonizing standards, deﬁnitions and indicators for HRH proﬁling and analysis; t supporting networks of HRH researchers; t institutionalizing coordination mechanisms (mandate and legitimacy); t creating a communication mechanism for tracing the available information for public use (for example a web site); t mobilizing resources (technical and ﬁnancial). In summary, health workforce observatories and other knowledge transfer platforms present dynamic and evolving networks, which can only stand to beneﬁt from increasing numbers of participating countries and institutions. Securing the initial commitment is often a challenge in establishing such mechanisms, but maintaining interest and commitment (often while coping with political changes and shifting donor priorities) is another critical concern. This requires regular dissemination of products that have proven to be useful, active sharing and exchange of information and knowledge, and continuous advocacy activities. The last-mentioned should including a strong, actionable communications strategy – aimed at policy-makers, managers, researchers and other relevant stakeholders inclusively – to advocate recognition of health workers as the foundation of health systems and implementation of effective strategies to directly address HRH bottlenecks, barriers and funding gaps at all levels.