A major obstacle to the progress of the Millennium Development Goals (MDGs) has been the inability of health systems in many low- and middle-income countries to effectively implement evidence-based interventions. Several studies on MDG 6 (combating HIV/AIDS, malaria and other diseases) explicitly outline that people at risk of malaria and children under the age of five must sleep under insecticide-treated bed nets (ITNs) due to their effectiveness in reducing childhood mortality and morbidity as a result of malaria.⁽²⁾ However, only 35% of young children were sleeping under bed nets in 2010 in Sub-Saharan Africa (SSA), which is still below the World Health Assembly target of 80%. Over the past few years, there has been growing interest in strengthening the use of health systems research (HSR) to achieve MDGs in low income countries, including those in SSA.⁽³⁾ Health systems research is an approach aimed at improving public health outcomes by conducting research that informs decision-making and interventions among health managers and policy makers.⁽⁴⁾ However, several barriers reduce uptake of research. This paper analyses the role of health systems research in Africa, barriers to and measures that can be taken to improve uptake and utilisation of research.
The research-to-policy map

The utilisation of research for policy-making is a complex process consisting of several distinctive steps, each of which influences, and is influenced by, several other steps in the process.⁽⁵⁾ In brief, the key steps in the process can be characterised as: (a) ‘managing the research agenda’, which consists of setting research priorities and aligning resources towards those priorities; (b) ‘producing evidence’ on priority issues, by producing research and by absorbing and/or synthesising knowledge, not only from local research results, but also from relevant elements drawn from the global body of knowledge; (c) ‘promoting’ the use of evidence, and (d) utilising evidence in ‘decision-making’ in policy and practice. The process is described in detail in the Figure 1 (see right):

Figure 1: The research to policy and practice cycle ⁽⁶⁾

In Africa, HSR started gaining prominence in the 1990s after a World Health Organization (WHO) Study Group on Health Systems Research in Congo Brazzaville created a network of national Health Systems Research centres in Botswana, Malawi, Mauritius, Tanzania and Zimbabwe.⁽⁷⁾ By the end of phase 1 in 1990, 14 countries were core participants, and a number of new, associate and observer countries continue to enquire on the activities with the aim of participating.

In Africa, HSR has played an important role in informing health policy and improving health outcomes. In 2000, HSR in Kenya fed into the development of national guidelines and a national quality assurance plan for HIV voluntary counselling and testing (VCT). In Malawi, findings from community-based research informed a new National TB Programme (NTP) strategy to incorporate gender sensitive and equitable engagement with informal healthcare service providers. In Nigeria, HSR results have been incorporated into national policies and action plans, with close involvement of health advocates within the states.⁽⁸⁾ Prior to 1994, South Africa did not have a national maternal care policy on pre-eclampsia.⁽⁹⁾ Consequently, tertiary hospitals had their own policy guidelines on the management of pre-eclampsia; and the lack of standardisation across the country caused difficulties among collaborating health professionals from different backgrounds. With the change of government in 1994, policy development and maternal and child health came to the forefront and opened new discussions between researchers and government regarding maternal health. In 1998, the first national policy on maternal care was launched. Having been informed by evidence from scientific trials, the policy recommended the use of magnesium sulphate for the management of eclampsia.

Barriers and solutions to health systems research uptake and utilization

Disconnect between researchers and policy makers

The apparent disconnect between research and policy occurs when researchers do not inform policymakers about their research activities, choose not to share their research results or, in some instances, simply because policy makers are not interested in the developments relating to research.⁽¹⁰⁾ Twinning has been used effectively to bridge the gap between researchers and policy makers. Twinning refers to the partnering of two entities with shared characteristics, such as universities and research institutions, to achieve a common goal.⁽¹¹⁾ For example, South Africa experiences high rates of HIV and TB co-morbidity. The American International Health Alliance (AIHA) established a partnership between the University of the Free State’s Centre for Health Systems Research and Development (CHSRD) and the State University of New York’s Downstate Medical Center in 2007. The two partners study the evolving HIV-TB epidemic in South Africa’s Free State Province and develop appropriate, effective responses to the scourge and disseminate research findings in the Free State and throughout South Africa through policy briefs, journal articles and newsletters.⁽¹²⁾ This indicates that creating partnerships is more likely to improve research dissemination and uptake.

Access to published research journals

Expensive journal subscriptions coupled with high internet costs, discourage access to online research publications in SSA. To improve access to research publications in Africa, an initiative by the WHO in association with the Association for Health Information and Libraries in Africa (AHILA), has produced an online library known as the African Index Medicus (AIM).⁽¹³) AIM has enabled free access to journals and covers a wide range of health areas in Africa. In South Africa, one of the country's top academic journals, the South African Journal of Science (SAJS), has become an open-access journal so as to put African research on the map and make it easily accessible to readers in developing countries.⁽¹⁴⁾ Open access journals can widen the participation of scientists from the developing world in global scientific discourse.⁽¹⁵⁾ Research has found that online availability increased citations of recently published articles by around 8%, with the impact of open access journals nearly doubling in developing countries. For instance, open access increased the citation of articles by around 5% in England and Germany, while in India and Brazil, the increase was almost 25% and 30% respectively.

Focus on the impact of investments 

Donors typically focus on inputs and outputs, such as the research grants that they provide and, for example, the number of health workers hired, respectively; without so much as considering the impact of their initiatives (e.g. health outcomes). According to the European Centre for Development Policy Management, traditional donor approaches do not always result in sustainable development impacts because institutional dimensions are not properly understood or strategically integrated into the project cycle; and the dominant pressure to “spend money” perpetuates supply-driven forms of development cooperation, characterised by unrealistic policy objectives and an extensive use of “gap-filling” (expatriate) technical cooperation as a quick fix solution for these institutional constraints.⁽¹⁶⁾ Donors must therefore not only be concerned with the inputs and financial investments, but need to shift focus towards the actual impact of those investments, such as ensuring aid effectiveness in institutions, facilitating local ownership and strengthening existing capacities and resources in order to ensure sustainability and reduce aid dependency.

Aligning research priorities to country needs

Incongruent research priorities between donors and governments present a barrier to research uptake in SSA. At the 2012 Global Maternal Health Conference, Rwanda’s Minister of Health, Dr. Agnes Binagwaho, revealed that a significant portion of research being carried out in that country was not contributing towards the Ministry’s health priorities. According to the Minister, many research groups are engaging in projects that the government is largely unaware of, subsequently publicising results that bring to the fore concerns that the Rwandan Government had not even been aware of. Over-dependence on donors who have their own priorities limits the flexibility of local researchers and their ability to focus on the country’s research needs and priorities. A systematic review in 2011 by the Department for International Development (DFID) on barriers to research utilisation has indeed confirmed that low-income countries’ dependence on material support from multilateral organisations prevents them from focusing on locally-relevant research.⁽¹⁷) This highlights the importance of collaboration between researchers and policy-makers in an attempt to meet any given country’s health needs. In addition to aligning to a country’s health needs, research has to be timely to all stakeholders. The publication of accurate reports in the mass media could be another means of delivering up-to-date evidence-based research to policy-makers. Collaboration between researchers and journalists could result in the use of media reports, press releases, press conferences, and the provision of ready-to-use stories as a platform for the dissemination of research results to decision makers in a timely manner, while simultaneously informing the public.⁽¹⁸⁾

Tailoring research results to suit different audiences

It is important to tailor research findings in a manner that suits a variety of audiences, such as fellow researchers, policy-makers, implementers such as hospital administrators and the general public. For instance, policy makers have different information needs from front-line health workers. In Malawi, despite up-to-date relevant HIV/AIDS and Family Planning (FP) information, there was poor utilisation as the information was poorly understood and not easily accessible to health workers.⁽¹⁹⁾ To counter this, the information in the toolkits was subsequently translated from English to local languages, and a short message service (SMS) programme was launched to ensure that health workers received up-to-date, relevant information through text messages. This resulted in positive changes in the health system that saw improvements in HIV/AIDS and FP service delivery systems, more timely re-stocks of medicines and commodities, improved efficiency of referrals, wider service coverage, and prompt response to disease outbreaks.

There are several strategies that can be used to share information with different stakeholders.⁽²⁰⁾ For policymakers, executive summaries can provide a brief overview of the research problem, findings, conclusions and recommendations. For the frontline health workers, actionable recommendations may be more suitable. For the general public, summaries of findings with real-life illustrative examples may engage them more effectively. Research and policy initiatives can be enhanced by support from key opinion makers, such as political and religious leaders, to disseminate key research findings.

Concluding remarks

Carrying out health systems research is not an end to itself; it is important to ensure uptake by all stakeholders, from policy makers to end-users. In addition, utilisation must also be ensured through the use of research findings to inform and improve health policies and practices. Health researchers must take into cognisance factors that influence or prevent the utilisation of their research, and consider ways in which to optimise such utilisation throughout the research process.

Written by Janet Mugo ⁽¹⁾

NOTES:

(1) Contact Janet Mugo through Consultancy Africa Intelligence's Public Health Unit ( public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Tsholofelo Thomas and was edited by Liezl Stretton.
(2) Panisset, U., et al., 2012. Implementation research evidence uptake and use for policy-making. Health Research Policy and Systems, 10(20), http://www.health-policy-systems.com.
(3) ‘Research for health and health system strengthening in Africa’, Council on Health Research for Development (COHRED), 2009, http://www.cohred.org.
(4) Weber, S., et al., ‘Synopsis of health systems research’, the World Bank Group, 2012, http://siteresources.worldbank.org.
(5) ‘Strengthening health systems: The role and promise of policy and systems research’, Alliance for health policy and systems research, 2004, http://www.who.int.
(6) Ibid.
(7) ‘Health systems research: Does it make a difference?’, The Joint Project on Health Systems Research for Eastern and Southern Africa, 1996, www.healthresearchweb.org.
(8) Theobald, S., et al., ‘Towards building equitable health systems in Sub-Saharan Africa: Lessons from case studies on operational research’, Health Research Policy and Systems, 2009, http://www.health-policy-systems.com.
(9) ‘Translating research into maternal health care policy: A qualitative case study of the use of evidence in policies for the treatment of eclampsia and pre-eclampsia in South Africa’, Health Research Policy and Systems, December 2008, http://www.health-policy-systems.com.  
(10) Mitchell, V., ‘Can research impact policy and actually save lives?’, Knowledge for Health, January 2013, http://www.k4health.org.
(11) ‘University of the Free State, Centre for Health Systems Research and Development / State University of New York Downstate Medical Center’, HIV/AIDS Twinning Centre, November 2011, http://www.twinningagainstaids.org.
(12) Ibid.
(13) ‘African Index Medicus’, World Health Organization, http://indexmedicus.afro.who.int.
(14) Munyaradzi, M. and Scott, C., ‘Top South African journals to go open access’, SciDev Net, March 2009, http://www.scidev.net.
(15) Evans, J.A. and Reimer, J., ‘Open access and global participation in science’, Science, February 2009, http://www.sciencemag.org. 
(16) Bossuyt, J., ‘Mainstreaming institutional development: Why is it important and how can it be done?’, European Centre for Development Policy Management (ECDPM), 2001, http://www.ecdpm.org.
(17) Christine, C., et al., ‘Systematic review: What are the effects of interventions to improve the uptake of evidence from health research into policy in low and middle-income countries?’, DFID, April 2011, http://www.dfid.gov.uk.
(18) Ibid.
(19) ‘The intersection of knowledge management and health systems strengthening: Implications from the Malawi knowledge for health demonstration project’, USAID/Knowledge for Health, October 2012, http://www.k4health.org.
(20) ‘An assessment of individual and institutional research utilization by policy-makers and programme managers at state and national levels in Nigeria’, National Agency for the Control of AIDS (NACA), 2012, http://www.popcouncil.org.