2020 by the numbers

Where we work

The COVID-19 pandemic has tested the ingenuity and resilience of the Alliance Secretariat, and our ability to work in entirely new ways in the face of a crisis. It has been a challenge, but we have passed that test.

We supported rapid reviews, held webinars on COVID-19, and co-hosted the Sixth Global Symposium on Health Systems Research in November, which focused on re-imagining health systems. In spite of it all, we have diligently worked to reinforce the knowledge base around health policy and systems to ensure that it is fit for purpose in the years to come.

We were proud to launch key special issues of journals that explored primary health care and innovations in embedded implementation research. We also have a number of capacity strengthening initiatives that were able to adapt their methods and continue their work to create the next generation of health policy and systems researchers and policy-makers.

The pandemic has only reinforced our commitment to improve the health of people in low- and middle-income countries (LMICs)through evidence that strengthens their health systems. We also undertook an external evaluation and a management review, all of which has informed our thinking as we lay the groundwork for our next strategic phase.

This year we started to re-align our areas of work to more closely fit the Triple Billion targets set by WHO, which aim to ensure that 1 billion more people benefit from universal health coverage (UHC), 1 billion more are protected from health emergencies and 1 billion improve their overall health. While our long-term focus has been – and will likely continue to be – on research to support UHC, the past year has seen an expansion of our work around health emergencies. We also recognize that people’s overall health depends on many factors. We are, therefore, expanding our partnerships on areas such as non-communicable diseases and broader determinants of health, like climate change, with the aim of reinforcing and strengthening health systems..

In this context, I must thank all of the Alliance staff, partners and other colleagues who have worked together to achieve so much under such difficult circumstances over the past year. This report is, above all, a testament to their dedication.

– ABDUL GHAFFAR 

Responding to the COVID-19 pandemic

Just months after the COVID pandemic was declared a public health emergency of international concern, the Alliance was able to convene a small group of experts and policy-makers to identify priority areas of research to support the COVID response beyond the biomedical and epidemiological realms. The group identified three key areas of focus: a) better understanding influences on government decision-making around COVID-19, b) engaging vulnerable populations and, c) disruption to routine health service provision.

Based on these areas, the Alliance commissioned 14 studies from teams across Bangladesh, Burkina Faso, Ethiopia, India, Georgia, Ghana, Mexico, Mozambique, Nigeria, Pakistan, Trinidad and Tobago, Uganda and Viet Nam. Initial findings from these studies have been shared at both the national and global levels, and the studies will be published in 2021.

The ERA initiative, which operated in Georgia, India, Malaysia and Zimbabwe, enabled government decision-makers to call on trained and trusted researchers who could provide quick answers to burning questions – never more important than during the COVID-19 pandemic. 2020 was the final year of the initiative, and Alliance-trained teams of rapid research responders in all four countries were able to put their expertise to use to capture and summarize the best available evidence on COVID-19 that would shape elements of national responses.

In Georgia, amid concerns that health services would be overwhelmed, the team from the Curatio International Foundation (CIF) gathered evidence on how other countries flattened the curve of infections to develop caseload models based on social distancing. The team delivered its report in seven days and the findings went viral, sparking discussions on – and promoting – distancing measures. Georgia has since been praised internationally for its initial response to the pandemic. As Dr George Gotsadze, CIF’s Executive Director, says “The ERA project has clearly shown its worth, especially during this crisis”.

In India, the government gave the team at The George Institute for Global Health in New Delhi three days to produce a review on protecting India’s frontline health workers and communities from COVID-19, and ensuring that Accredited Social Health Activists (ASHAs) could maintain services that were not related to COVID-19. The review, delivered on time, emphasized the need for social distancing, and its guidelines went straight into a handbook for ASHAs that was distributed by state governments..  

Working together

What are the priority challenges being faced by decision-makers as they work to maintain primary health care (PHC) services while responding to the COVID-19 crisis? Uncovering the answer to that question across the Asia and the Pacific is at the heart of this new initiative, which is being spearheaded by the WHO Science Division and the Alliance, in partnership with the WHO Special Programme on Primary Health Care, the South-East Asia Regional Office of WHO, the Western Pacific Regional Office of WHO, UNICEF and the United Nations University International Institute for Global Health.

Two regional consultations with policy-makers representing more than 20 countries were held in early July, followed by a synthesis consultation bringing together participants from the regional consultations with high-level participants from several global health organizations—including Gavi, the World Bank, the Global Fund, the Bill and Melinda Gates Foundation, the People’s Health Movement and WONCA—to reaffirm commitments to embedded research on primary health care. The consultations provided the impetus for countries to advance the agenda of embedded PHC research and for major global health funders to mainstream embedded research in their support to countries.

The Eastern Mediterranean Region SDG Learning Platform (EMR-SDG) supports the achievement of Sustainable Development Goal 3 and other health-related targets, provides a welcoming space for effective regional networking and is a catalyst for knowledge generation and dissemination in Arab countries. The Platform takes a holistic perspective: recognizing the human rights that underpin health, defining health in terms of human dignity (not just the absence of disease) and positioning health equity as a pillar of good governance and social success.

Over a period of 18 months, the platform built effective partnerships, facilitated wide participation and enhanced learning on areas such as non-communicable diseases, reproductive and sexual health, UHC and more. Highlights included policy briefs and newsletters, analytical reports, pieces by early-career researchers and webinars that attracted hundreds of participants. A virtual portal has been created for international and regional studies and innovative tools, on topics ranging from localizing the SDGs in Egypt to an overview of UHC. The Platform’s success stems from robust partnerships and its engagement with young Arab researchers, practitioners and activists. Drawing on initial funding from the Alliance, the Platform has now secured additional resources for another three years. 

The Alliance has been, and continues to be, a main co-sponsor for this event along with World Health Organization and Health Systems Global. This year’s symposium, HSR2020, focused on ‘re-imagining health systems’, which turned out to be an appropriate theme for 2020.

Because of the COVID-19 pandemic, the symposium was re-imagined into three phases, and the Alliance is involved across all of them. Phase 1, which took place from 8-12 November, brought together over 2 296 people. The Alliance participated in or organized four sessions, including: a funders roundtable, a capacity strengthening session on systems thinking and two launches. Phase 2 started at the end of November and continued through March 2021, with the Alliance contributing to the multimedia strand, holding an organized session and three satellites.

One of the main individual capacity strengthening initiatives the Alliance runs is a mentorship programme for early-career women.

Learning from the first iteration of this initiative, we opted to work in partnership with Health Systems Global and Health Policy and Planning to develop a supplement, which was launched during Phase 1 of HSR2020. The programme received 250 applications and 22 mentee-mentor pairs were created. In the end, nine articles were accepted from first-time women authors from Kenya, Viet Nam, Uganda, Ghana, Ethiopia, Bangladesh, Nigeria and Brazil, examining issues as diverse as immunization, nursing leadership, social accountability, violence in pregnancy, primary health care and indigenous health.

Through the BIRD programme, the Knowledge to Policy Center at the American University of Beirut is mentoring six institutes in Cambodia, Georgia, Indonesia, Nigeria, Trinidad and Tobago and the United Arab Emirates, covering each WHO region. In 2020, the six institutes worked to develop key policy products to respond to the priorities they had identified. In the United Arab Emirates and Trinidad and Tobago, this included the development of rapid response products to inform COVID-19 efforts, as requested by governments. All six institutes developed course syllabi on evidence-informed health policy-making and inaugurated intakes for their policy fellowship programmes..

The true measure of research success is its effective use to make a difference. HIGH-Res implements innovative and responsive interventions to strengthen institutional capacity for the systematic use of evidence within ministries of health in Kenya, Malawi and Uganda.

In 2020, the initiative responded to government requests for rapid reviews and studies on its public communications for COVID-19 in Kenya and Malawi, and supported government-led dissemination of the findings. In Malawi, HIGH-Res worked to reinvigorate Ministry of Health technical working groups and integrate the review of evidence into their terms of reference. The central HIGH-Res team completed curriculum development for training institutions and is now writing manuscripts that draw on the baseline studies in all three countries.

Informing policy around the world in 2020

THE CHALLENGE

Embedded implementation research can play a critical role in improving health services and strengthening health systems. The approach involves bringing researchers and decision-makers together to design, produce and interpret the findings of research together. Ultimately, the objective is to generate evidence and use the direct link with decision-makers, planners and implementers to take action immediately – even as the data is collected.

This approach to research is increasingly understood as critical to support learning health systems. Yet, it is still hindered by a lack of capacity for collaboration between researchers and decision-makers, and a lack of local capacity to conduct implementation research. Back in 2016, Ethiopia was no exception.

THE ALLIANCE’S INPUT 

That year the Alliance started a project – in collaboration with Gavi, the Vaccine Alliance and UNICEF – to support decision-maker-led implementation research for immunization. The eligibility criteria were specific and deliberate: research teams had to comprise of a decision-maker with direct involvement of executing immunization programmes and a researcher affiliated with a local academic or research institute. 

Dr Binyam Tilahun, a health information systems specialist based at the University of Gondar, saw the call and was keen to apply, so he linked up with a local decision-maker to develop a proposal looking at how immunisation data is recorded and reported and the enabling environment for doing so. Their project was selected, along with 12 others from countries around the world.

Their study identified various factors that prevent immunization information from being adequately captured or used, such as the absence of any systematic involvement by communities. Ordinarily, a study about health data in just one of Ethiopia’s hundreds of districts would not draw much attention. However, because the research was co-led by an official from within the health ministry, there was real ownership over it. What is more, it ensured that the research process generated information that was directly relevant to policy. This made senior decision-makers more willing to attend the release of its findings and, with the right people in the room, the data provided actionable plans. An immediate outcome, for example, was the development of a community verification platform for data – a tool that is now being used across the country.

THE RESULT

This was a turning point for Dr Tilahun. Seeing his research translated into real-world changes inspired him to become a passionate advocate for embedded research. Using some resources from his initial Alliance grant, as well as the interest among his peers and a growing network of collaborators, he established eHealthLab Ethiopia. Housed at the University of Gondar, the research unit aimed to use implementation science to explore innovative health information technologies in the health sector.

Off the back of these early successes, the Alliance leveraged this capacity and interest in implementation research by establishing structures to promote its use more systematically. Following consultations with the Government of Ethiopia to better understand national research priorities, the Alliance issued another competitive call in 2019 – again in partnership with Gavi, the Vaccine Alliance and UNICEF. This time, the goal was to establish a local technical support centre to mentor and manage research projects at country level with a focus on immunization services.

Under the leadership of Dr Tilahun, the University of Gondar was selected to take on this role and has since won a further grant to serve a similar mentoring function for an initiative focused on applying the embedded implementation research approach to compassionate and respectful care services. As a result of this institutional experience, implementation science has been integrated into the curriculum of the masters and PhD programmes of the University of Gondar, opening the way to building a cohort of skilled implementation researchers in Ethiopia. Establishing a technical support centre at the university has also brought major benefits, allowing researchers to use this new institutional footing to more meaningfully engage with health policy-makers.

What is more, the Ministry of Health has recognised the University of Gondar as an important resource for evidence-informed decision-making. This has resulted in new funding being provided to support training at federal and district levels, and to offer mentorship to support health workers.

Taken together, this is all helping to increase capacity and leadership to generate, manage and use implementation research to strengthen health systems.

THE CHALLENGE

Decentralisation is meant to improve the responsiveness of primary health care services. But bringing services closer to those who use them can put tremendous pressure on district managers who not only have have to translate broader national priorities and policies, but also have to plan and deliver for the populations they serve. Major crises, like the COVID-19 pandemic, have put further stress on these key health sector actors.

After the first case of COVID-19 was announced in Pakistan on 20 February 2020, teams were tasked with and rapidly implementing contact tracing services to quickly identify people who had potentially come in contact with the virus and who were at risk of further spreading the disease.

THE ALLIANCE’S INPUT

To support local decision-makers to use new ways of seeing and addressing service coordination and delivery issues, the Alliance started the Systems Thinking for Strengthening District Health Systems (ST-DHS) initiative in 2019, coordinated by the Swiss Tropical and Public Health Institute (Swiss TPH) who work with teams in three countries: Botswana, Pakistan and Timor Leste. Systems thinking offers a philosophical approach, methods and specific tools to break out of linear models of thinking and help health practitioners visualize the complexities created by different actions over time, and multiple stakeholders with competing priorities.

In Pakistan, the ST-DHS team is led by Dr Shamsa Rizwan from the Centre of Excellence in Women and Child Health. Although it was not the original plan, after the pandemic started, they identified COVID-19 contact tracing as an area where systems thinking could potentially add lifesaving value. Specifically, they sought to use process mapping, a systems thinking tool, to identify challenges and see how the policy was working in real life.

Representatives from the district health office, rapid response units, public and private health facilities, surveillance response teams and others, worked together to map out the contact tracing service in practice. Bottlenecks at various steps of the COVID-19 tracing process, and even broader systemic challenges, were made easier to identify as the actors involved were able to actually see the point in the chain-of-actions where a problem was happening and reflect through group discussions to understand why. For example, one reflection session revealed the need for more surveillance teams across the district. Another pointed to weaknesses in data collection and the need to fix the software being used to gather it.

THE RESULT

Process mapping gave district managers a way to see and solve key implementation problems. It also improved communications between different actors, supported day-to-day monitoring.

In short, it made the invisible visible.  

In Kenya, at the request of the government, HIGH-Res project partners conducted a national COVID-19 knowledge, attitudes, perceptions, and practice (KAPP) survey. Results of this survey were disseminated through an MoH-led dialogue and published as a policy brief. In his remarks during the dialogue, the Director General of the Kenyan MoH called on its Research Division to translate the key evidence and recommendations from all the research shared in the session into policy recommendations that MoH’s senior leadership would act on. This follows on HIGH-Res’s ongoing embedded work to support the MoH Research Division to define its vision, mission and objectives in line with the MoH’s Health Policy 2014-2030, and the current Strategic Plan covering 2018-2022. HIGH-Res has been instrumental in ensuring that the development of the MoH annual workplan has evidence dialogues at its core.

Yogyakarta Provincial Health Office has developed, introduced and implemented an electronic immunization registry called SIMUNDO that has been running effectively without external funding for over five years. While the national government had identified the system as innovative, and there is interest in rolling it out in other parts of Indonesia, no systematic assessment of SIMUNDO had been conducted. The Alliance supported researchers from Universitas Ahmad Dahlan’s Department of Public Health to collaborate with officials from the provincial health and carry out a research study to uncover key enablers and barriers to implementing SIMUNDO with a view to informing scale up.

Ministries of health have a unique mandate over population health, charged with ensuring the health and wellness of millions. What kinds of capacities does an MoH require to govern responsibly and effectively to address the big societal challenges of today? The evolving governance roles of MoHs have required a rethink about what capacities are necessary to perform them. In partnership with the Health Systems Governance Collaborative and the Universal Health Coverage Partnership at WHO, the alliance contributed to a working paper presenting a new multidimensional governance capacities framework that will potentially enable Member States to benchmark governance capacities, identify capacity gaps and guide capacity strengthening strategies.

2020 finances and donors

The Alliance gratefully acknowledges the core financial support in 2020 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 Foreign, Commonwealth and Development Office (FCDO).

Other donors and those supporting ongoing activities in 2020 include the Doris Duke Charitable Foundation, Gavi, the Vaccine Alliance, UNICEF, the United States Agency for International Development (USAID) and Wellcome Trust. We also received specified funding from the Ministry of Foreign Affairs, Sweden and the Norwegian Agency for Development Cooperation (Norad).

Governing bodies

NOTE: People listed on this page served on the Board or STAC or were employed by the Secretariat at some point during 2020. They do not necessarily reflect the current composition of these bodies.