2019 by the numbers

Where we work

The Alliance’s core mandate is strengthening health systems in low- and middle-income countries (LMICs) by supporting the generation and use of research. As this year’s annual report shows, we do this by convening key stakeholders, strengthening capacities, investing in cutting-edge research and supporting policy-makers to incorporate evidence into their decision-making processes.

2019 was the fourth year of our current five-year strategic plan. As we start planning for the next period, we have commissioned an external evaluation of the Alliance and have already initiated dialogues with key individuals.

One thing that is already clear are the significant changes and transitions around the world: changes in the climate, changes in societies and politics, and changes in health systems themselves. These shifts require us to think beyond the six traditional building blocks of health systems. Therefore, in 2019 the Alliance kick-started discussions about broadening the span and scope of HPSR and working to redefine the boundaries of the field.

To do this, we are using some of the core approaches and tools from HPSR, such as systems thinking, and applying them to new areas. We are collaborating with colleagues across WHO to test how the use of systems thinking and HPSR can contribute to health systems strengthening while dealing with rehabilitation, road safety, health promotion and creating healthy environments. Our collaborations support the generation of local knowledge and its application for improved policies and decision-making.

We also firmly believe that determinants of health are strong drivers and predictors of health and well-being, and we are, therefore, supporting our WHO colleagues in the Eastern Mediterranean Region on a regional Commission on Social Determinants of Health.

I have no doubt that in 2020 we will continue to push the boundaries of HPSR. We look forward to wider discussion and debate, and we expect that our next flagship report on ‘learning health systems’ later in the year will be a big contributor to those deliberations.

– ABDUL GHAFFAR 

Bringing people together

The LEAP Forum is an important opportunity for the Alliance and its partners to advocate for the field of health policy and systems research. The Forum held an annual meeting in April of 2019, where a new structure and strategic focus for the Forum were agreed. A major activity for the Forum was holding a side event at the 74th United Nations General Assembly called ‘Universal health coverage: Unachievable without evidence’. The event was co-hosted by the Alliance and Health Systems Global (HSG) with support from the Government of Georgia. Representatives from the Doris Duke Charitable Foundation and UNICEF (all LEAP partners) were on the panel. Key issues raised included the need for investing in on-going learning for health initiatives, investing in local research capacity and promoting a culture of evidence use at all levels of health systems.

This has been a year of transformation for the World Health Organization, and that has had an impact on the Alliance. We moved into the newly created Science Division in May 2019. As a cross-cutting division designed to support the evidence needs across the organization, moving into the Science Division has empowered the Alliance to collaborate more widely across all three levels of the organization.

For example, the Alliance has been working with TDR and HRP, under the stewardship of the Chief Scientist, to undertake a programme of work on Country-led Implementation Research for Universal Health Coverage. The project responds to requests from member states and provides support for implementation research projects on topics that countries prioritise as important for the achievement of UHC. In 2019, we worked with India, Ethiopia and Nepal.

In addition to collaborations with others at WHO Headquarters, we have also been working with several regional and country offices. For example, with the Eastern Mediterranean Regional Office (EMRO), we launched a new Commission on Social Determinants of Health chaired by Sir Michael Marmot, and we also established a regional learning platform for the Sustainable Development Goals (SDGs). Our embedded research projects on the health-related SDGs are done in collaboration with TDR and the Pan American Health Organization (PAHO).  

Empowering leaders

Getting on the academic publishing ladder is an important step for emerging researchers. However, there is a gender gap when it comes to publishing and participating in research. To help redress this imbalance, the Alliance established a mentorship scheme for early-career women researchers working in the field of health policy and systems research.

Ten mentees from LMICs were paired with appropriate mentors to get their first academic article published. Six of the mentees ultimately were able to make submissions, and four articles from the mentees were published in 2019. Topics ranged from a review of antenatal care to perceptions of a community health worker programme. Following on from the successes of the first cohort of mentees, the Alliance teamed up with HSG and the journal Health Policy and Planning to launch a new round of mentorship in 2019. A special issue from the next cohort is expected to be launched at the Sixth Global Symposium on Health Systems Research in Dubai in 2020. 

Opening the eyes of young medical students to the bigger picture of health policy and systems research is critical. It can help situate their future careers as medical professionals, but it can also help establish the health policy and systems researchers of the future.

To this end, in 2019 the Alliance teamed up with the International Federation of Medical Students Associations (IFMSA) to support a Pre-World Health Assembly Workshop and to ensure participation from students in LMICs through sponsoring a Change-maker Scholarship. Three scholarship recipients from South Africa, Nepal and Egypt joined the four-day workshop, which included opportunities to develop skills, gain knowledge and contribute to collective advocacy campaigns around issues discussed in that year’s World Health Assembly. The Alliance contributed to the workshop programme, presenting on HPSR, and scholarship recipients had the opportunity to meet Alliance staff in our offices in the World Health Organization headquarters.

Gender and other social factors interact to influence how people are able to maintain good health and well-being around the world. Understanding how these factors intersect in individuals and communities can help inform how health policies and systems are structured.

The Alliance launched a new programme of work on gender and intersectionality for HPSR in the South East Asia Region. The Ramalingaswami Centre for Social Determinants of Health in India was selected as a lead regional mentor institute. They have launched an 18-month research fellowship programme for participants from the region, especially from fragile and conflict-affected settings. Fellows will participate in a mix of in-person and online courses, which will also serve as the basis for a global online resource on gender and intersectionality open to others beyond the initial fellows.

Effective HPSR leadership is supported by strong institutions that ensure a culture of local evidence generation and use for strengthening health systems. We are testing different models for institutional strengthening, including working directly with ministries of health in three East African countries.

HIGH-Res, a three-year, US$ 1 million project co-funded with Wellcome Trust, began in August 2019. The project is implemented by a consortium of health research institutions and ministries of health in Kenya, Uganda and Malawi. It is led by the African Institute of Development Policy (AFIDEP). The project will strengthen existing institutional systems, structures and processes within the ministries of health, while introducing new ones, and integrating individual capacity strengthening to enable sustained evidence-informed decision-making. In 2019, inception activities were completed, and the team in Kenya is working to strengthen capacities within the Research and Innovation sub-committee of the UHC Committee. In Malawi, the team contributed significantly to the development of the recently launched health research policy and will support its implementation strategy.

Creating an enabling environment for HPSR requires strong teaching institutions and policy institutes that can provide relevant and rigorous training in HPSR methods
and models.

The mentor institute (American University of Beirut Knowledge to Policy Centre), has been engaging six mentee institutes, one from each WHO region. Since a capacity strengthening workshop on various models of evidence-informed policy-making in May 2019, the mentor institute has run five webinars. The mentee institutes are advancing work in their home policy and research networks in priority-setting exercises, developing knowledge translation products on identified topics, producing training materials and courses, and trialling prototype policy fellowship programmes.

When is a project health research and when is it health practice? Is research ethics review required for studies of existing policy decisions? These are some of the ethical conundrums HPSR researchers face as they design their studies.

Resolving these issues is not always straightforward. Research ethics committees working in public health may have more experience in biomedical and epidemiological research than in the transdisciplinary field of HPSR. This publication suggests 14 points to consider for researchers and research ethics committees when constructing HPSR studies, and it illustrates and illuminates these points using six case studies. It was one of the most downloaded documents on the Alliance website the month of its release. 

The SDGs recognize that current challenges facing the globe are interrelated – often inextricably linked to each other. However, much work on achieving the SDGs remains in silos. Goal 3 focuses explicitly on health, however, almost all other goals are related to or contribute to health and well-being.

This 14-article collection is focused on policies and programmes outside the health sector – often in collaboration with the health sector – that have health implications through commercial, cultural, economic, environmental, political, or social determinants of health. It gathers critical lessons on effectively engaging other sectors to enhance their health outputs, identifying co-benefits and ‘win-wins’ that enhance human health.

Strengthening primary health care through research: Prioritized knowledge needs to achieve the promise of the Astana Declaration

Strengthening primary health care systems is a critical component to achieve UHC. And while there is increasing eagerness to build, reform and strengthen these systems in many LMICs, country leaders are often unsure where to begin.

In a sweeping new effort, this special issue gathered 76 researchers, practitioners, and policy-makers from 19 countries to identify the gaps in global knowledge about what works in primary health care and prioritize a new research agenda. Key areas of focus include: organization and models of care; quality, safety, and performance management; policy and governance; and financing of primary care systems.

Intersectoral and integrated approaches in achieving the right to health for refugees on resettlement:
a scoping review

By Shirley Ho et al. in BMJ Open
ahpsr.org/refugees

This article is the result of a joint programme of work on migration and health with the Swedish Institute for Global Health Transformation (SIGHT), which aims to enhance the integration of refugee health services within health systems and identify research needs to advance the right to health for refugees. The scoping review explores the barriers and facilitators to the integration of health services for refugees, the processes involved and the different stakeholders engaged in leveraging intersectoral approaches to protect refugees’ right to health on resettlement. It formed the basis of a session at the Prince Mahidol Award Conference (PMAC) in January 2020.

Embedding implementation research to enhance health policy and systems: a multi-country analysis from ten settings in Latin America and the Caribbean

By Etienne Langlois et al. in Health Research Policy and Systems
ahpsr.org/eirLAC

The Alliance has a long track record of supporting embedded implementation research projects around the world. But what have we learned about the approach? An article learning from one set of these projects across in the region of the Americas was published in November. It identifies 17 facilitators and eight barriers to embedding research into policy and systems. The principal facilitating factors were actionability of findings, relevance of research and engagement of decision-makers, whereas the main barriers were time and political processes.

Conceptual framework of equity-focused implementation research for health programs (EquIR)

By J. Eslava-Schmalbach et al. in the International Journal of Equity in Health
ahpsr.org/equir

The Alliance contributed to the development of EquIR: the equity-based framework for Implementation Research of health programmes, policies and systems. EquiIR is a conceptual framework proposed for use by decision-makers and researchers during the implementation of programmes, policies or health interventions aiming to reduce or prevent the increase of existing inequities during implementation.

Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review 
by Ijeoma Nkem Okedo-Alex et al. in BMJ Open
ahpsr.org/mentee1

How local context influences access to neuropsychological rehabilitation after acquired brain injury in South Africa 
by Noorjehan Joosub in BMJ Global Health
ahpsr.org/mentee2

Are formal self-care interventions for healthy people effective? A systematic review of the evidence 
by Nilushka Perera and Shade Agboola in BMJ Global Health
ahpsr.org/mentee3

Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa 
by Shehnaz Munshi et al. in BMJ Global Health
ahpsr.org/mentee4

THE CHALLENGE

The Public Health Institute (PHI) of Republic of Srpska has a mandate from the Ministry of Health and Social Welfare to monitor health outcomes in the region, paying particular attention to epidemiology, health surveillance, water and food control, and generating and managing health statistics. One of its branches, the Health Management Centre (HMC), was focused on providing capacity building, carrying out services for the PHI and undertaking advisory work for the public and private sector in the country. However, the Centre had little experience undertaking research – even though there was significant interest among its staff to do so, as several of them also taught at local universities.

THE ALLIANCE’S INPUT 

In 2014, the Alliance put out a call for research proposals on the role of non-state providers to move toward UHC. Staff at HMC spotted the call and put together a proposal in the hopes of kick starting its research programme.

The nature of the HMC’s work made its staff quite aware of the challenges facing the health sector in Republic of Srpska – a major one being that the majority of private health care providers failed to adopt the safety and quality standards introduced in 2012 by the Ministry of Health and Social Welfare. The HMC proposed research into the reasons why some private health care facilities were adopting the new standards while others were not, and were ultimately successful in winning a research grant from the Alliance. 

Before starting work on the two-year research project, the Alliance offered the opportunity to spend time designing the project’s research protocol. This process took almost an entire year. During the protocol design phase, the HMC and seven other grantees of the Alliance worked closely with Johns Hopkins University Bloomberg School of Public Health, which had been contracted by the Alliance to provide  technical support and quality control to the studies. Johns Hopkins helped the HMC with the protocol design and throughout the research process.

The HMC team used a mixed-methods approach, which was new for the HMC, and indeed for the wider PHI. Because of their limited experience with research, the support from the Alliance and Johns Hopkins was fundamental in securing local stakeholders’ acceptance of the chosen methods. The study also provided some new ideas on how evidence may be generated and used for policy-making in the Ministry.

After the research was completed in 2018, the findings were presented to the Ministry of Health, associations of private health care providers, and the union of medics, dentists and pharmacists. The fact that their results were backed by both the Alliance and Johns Hopkins University was important to assure local credibility. The results and recommendations were well received – even if they have yet to be implemented.

THE RESULT

Even if the research did not immediately lead to impact in the adoption of safety standards, it did have important consequences for the HMC, PHI and the role of evidence in policy. Although the PHI’s mandate had included the provision of policy recommendations on health systems to the Ministry of Health and Social Welfare, the HMC had not done so until 2015 with the Alliance’s grant. This project constituted the first time the HMC effectively undertook research to provide evidence-based policy recommendations.

After this experience, the PHI decided to strengthen its capacity to provide more, and better, evidence-based policy recommendations to the ministry. In 2018, it changed the mandate of the centre and it was renamed the Centre for Health System Development and International Cooperation (CHSDIC). 

As a consequence, CHSDIC has turned its attention to submitting more applications for research funding. It has been successful in a recent bid from the Alliance to look at citizen-responsive insurance schemes. This has strengthened its relationship with the Ministry, having formed a joint team to design projects and submit applications. 

THE CHALLENGE

Dr Chigozie Jesse Uneke is a parasitologist by training and a professor from Ebonyi State University in Nigeria. He was interested in epidemiology and the diseases affecting the most vulnerable and poor, but he found that policies to tackle epidemics in rural Nigeria were often not very effective because they had not been tailored to the diversity of contexts where they were meant to be implemented.

His suspicion was that this was down to a lack of interaction between policy-makers and researchers. There was, in fact, no effective collaboration or any kind of partnership between them in Ebonyi State.

THE ALLIANCE’S INPUT

Dr Uneke and his team at the Ebonyi State University applied for and received a grant from the Alliance in 2009 to begin a process of bringing together policy-makers and researchers and to enhance the capacity of researchers to produce the kind of evidence that policy-makers required – all while showing policy-makers the advantages that evidence-informed policy could present for them and for the country. 

The grant allowed them to undertake several capacity-building workshops with both policy-makers and researchers. The constant interaction between them helped participants to understand each other better. Some of the challenges that created and maintained the divide between them were addressed – mutual mistrust of their motivations being the main one. This issue was solved mainly through the friendships that developed from these constant interactions. Only after this first barrier was overcome were they able to begin working together. This led to the development of a shared research agenda that was relevant for both groups. 

As a result of this first process, the Health Policy Advisory Committee was created in 2011. This committee was made up of senior policy-makers from the Ebonyi State Ministry of Health and senior researchers from Ebonyi State University who come together to tackle issues raised by its members.

A second grant from the Alliance, in 2014, helped the group to set up a digital policy information platform that offers evidence syntheses, policy briefs, policy notes and other materials relevant for health policy-making. After a series of consultations with both policy-makers and researchers, the site was launched in 2015 and continues to be active. This second grant also led to the formation of Ebonyi State University’s African Institute of Health Policy and Health Systems (AIHPS). AIHPS undertakes research and offers postgraduate degrees on health policy and systems research, as well as short training sessions and a postgraduate diploma. 

This experience helped to deepen the understanding each group had of each other’s work, thus facilitating future collaboration. 

THE RESULT

The Alliance’s long-term investment in these projects has helped to strengthen the relationship between policy-makers and researchers in Ebonyi state. This relationship was then consolidated in the formation of two new institutions, critical for any functioning evidence-informed health system: the Health Policy Advisory Committee and the AIHPS. 

The policy information platform is both an output and an outcome of this process, as it represents the impact of the new working relationships that were developed. 

These changes demonstrate a progressively nuanced and transformative change. First, new relationships were forged; they were then put into practice through the development of an advisory body and they were further institutionalized through the foundation of a new institute.  

2019 finances and donors

The Alliance gratefully acknowledges the continued core financial support from the Norwegian Agency for Development Cooperation (Norad), the Swedish International Development Cooperation Agency (Sida), and the United Kingdom of Great Britain and Northern Ireland Department for International Development (DFID).

Other donors and those supporting ongoing activities in 2019 include the Doris Duke Charitable Foundation, Gavi, the Vaccine Alliance, the International Development Research Centre, Canada (IDRC), UNICEF, the UN Foundation, the United States Agency for International Development (USAID) and Wellcome Trust. 

Governing bodies

NOTE: People listed on this page served on the Board or STAC or were employed by the Secretariat at some point during 2019. They do not necessarily reflect the current composition of these bodies.