As I look back on 2018, I am struck by all the hard work emerging from the Alliance Secretariat and its grantees – work that has continued to advance the field of health policy and systems research in various ways. One of our focus areas has been working to stimulate policymaker demand and use of relevant evidence, and working with researchers to respond appropriately to that demand. Our main approach to this has been embedding research into decision-making processes – whether it is through implementer-led projects or by developing platforms in ministries of health to support rapid evidence synthesis.

In line with the World Health Organization’s new General Programme of Work, we have been working closely with countries to ensure our approaches are driven by local demand. As part of an initiative spearheaded by the WHO Chief Scientist, we have worked directly with the governments of Nepal, India and Ethiopia to shape the research that underpins their universal health coverage (UHC) initiatives as they work toward SDG 3.

Equity has also been a major pillar of our work. Following a stakeholders meeting in Dubai at the beginning of 2018, we have launched a capacity building initiative on gender and intersectionality. Our commitment to promoting women leaders in HPSR is demonstrated in all our projects – which require at least 50% of team members are women – and through specific initiatives, such as publication mentorship. I’m pleased that this year we are also able to start reporting on the gender breakdown of a few key statistics, like lead authorship of peer reviewed publications (see 2018 by the numbers). We are committed to collecting, and reporting, on further data that takes into account gender and other forms of historic advantage and disadvantage.

Working with partners, we made significant contributions to new knowledge in 2018 by publishing valuable articles, guides, readers and other resources. This includes a reader designed to encourage and deepen health policy analysis work in low- and middle-income countries (LMICs), a methods guide on evidence synthesis, and a journal special issue on understanding the role of non-state providers in achieving UHC.

Finally, I would be remiss not to note the Fifth Global Symposium on Health Systems Research, of which the Alliance is a co-sponsor, as a highlight of the year. It was a highlight not just for the Alliance, which had a strong presence there in Liverpool (see page 6), but for the wider HPSR community and for the organizers at Health Systems Global. Ensuring there are opportunities for HPSR practitioners – from researchers to policymakers to practitioners and knowledge brokers – to foster connections remains a priority in our field.

– ABDUL GHAFFAR 

Bringing people together

The Alliance played a key role in founding the Global Evidence Synthesis Initiative (GESI), which helps LMICs countries to build the capacity to generate and use research synthesis to enhance public policy and service delivery. 

One of the hallmarks approaches being developed through this consortium is the early and active engagement of policymakers in identifying priorities for syntheses to ensure they respond to current needs. The GESI Network currently consists of 46 centres from 24 LMICs from across the globe. In 2018, GESI organized sessions at global conferences and hosted a series of webinars on evidence synthesis and the use of review findings to support policy and practice. 

For the last two years, the Alliance has coordinated a network of networks that work on HPSR: the Learning Engaging and Advocating for Policy and Systems Research (LEAP) Forum. LEAP is a platform for collaborative problem-solving and discussing ways of generating and using policy-relevant knowledge. 

LEAP builds on gains the Alliance has already made in working with policy- and decision- makers and other partners in different regions to identify barriers and incentives to using evidence. The LEAP Forum met at the Symposium in Liverpool and agreed that a full meeting would take place in 2019.

The Alliance has partnered with Ariadne Labs and Harvard T. Chan School of Public Health to develop a Primary Health Care Measurement and Implementation Research Consortium. Launched in Liverpool, the consortium convenes researchers and policymakers from multiple disciplines and representing academic institutions, government agencies, international organizations and non-governmental organizations to accelerate progress in primary health care (PHC) research in LMICs. 

The goal is to develop a robust PHC global research network structure and to secure the resources needed to carry out prioritized and policy-relevant PHC research. The ultimate intent is to support better measurement, implementation and improvement efforts in priority areas for PHC in LMICs. Funded by the Gates Foundation, initial PHC studies are being undertaken by George Washington University, American University of Beirut, Stellenbosch University, The George Institute for Global Health and the World Organization of Family Doctors.

Empowering leaders

Rapid reviews of health policy and systems evidence can provide relevant and actionable evidence at every step of the decision-making process.

The Embedding RApid Reviews in Health Systems Decision-Making (ERA) initiative embeds rapid review production directly within health decision-making institutions in LMICs. Four ERA platforms have been established in Georgia (Parliament of Georgia, Healthcare and Social Issues Committee), India (National Health Systems Resource Centre, Ministry of Health and Family Welfare), Malaysia (Ministry of Health, National Institutes of Health, Institute for Health Systems Research) and Zimbabwe (Ministry of Health and Child Care). All countries selected committed to co-funding the ERA activities through in-kind and/or financial support. 

The ERA platforms benefit from scientific support provided by a technical assistance centre – a consortium between Makarere University (Uganda) and the University of Toronto (Canada) – with the Alliance. The Alliance convened a workshop in July 2018 in Kuala Lumpur, Malaysia, with decision-makers and researchers to devise a strategy to establish the ERA platforms and stimulate demand and uptake of rapid syntheses of health policy and systems evidence in LMICs. 

The Alliance has invested in a group of Health Policy Analysis (HPA) Fellows, who are LMIC-based PhD students working with world leaders to develop their skills. Nine Fellows were selected for this programme, the majority of whom are women. After an initial protocol development workshop in December 2017, they have been working on their research studies, incorporating an HPA lens into their doctoral theses. 

The HPA Fellows had a strong presence in Liverpool, where some of the fellows presented their findings and analyses during two organized sessions. An additional workshop brought together these fellows in Cape Town, South Africa, at the end of 2018 to reflect on progress of their work. The research resulting from this programme will culminate in a series of articles planned for 2019.

Peer-reviewed publications are important for communicating scientific work, gaining recognition within the research community and career progression. However, women in academia often lag behind their male colleagues in publications. There are many potential reasons for this, and women often face unique challenges, including competing professional and personal roles, and difficulties navigating male-dominated work environments. This programme hopes to address these challenges through targeted support from experienced mentors.

In 2018, we selected 10 mentees who are working with nine mentors from around the world to develop their research into peer-reviewed journal articles. They have benefited from a joint webinar and as well as personal guidance on their articles from their mentors.

Evidence Synthesis for Health Policy and Systems: A Methods Guide provides a rationale for synthesizing evidence from HPSR to support health policy-making and health systems strengthening. It introduces key challenges in synthesizing HPSR evidence and provides guidance on addressing these issues.

This guide examines various synthesis methods – quantitative, qualitative and mixed methods – and provides practical guidance to engage decision-makers in evidence synthesis, enhance the policy relevance of syntheses, and foster the uptake of review findings in policy and practice. The guide was introduced at the Fifth Global Symposium on Health Systems Research in 2018 to a standing-room-only crowd. All hard copies available were distributed there, and the guide was downloaded over 250 times from the Alliance website in the month of October alone. 

A Health Policy Analysis Reader: The Politics of Policy Change in Low- and Middle-income Countries aims to encourage and deepen health policy analysis work in LMICs. It illuminates the range of health policy analysis studies that have been conducted in LMICs, highlights relevant theories and points to new directions for such work. 

The reader includes methodological and analytical pointers and includes considerations about how to use health policy analysis prospectively to support health policy change. It was launched during the Symposium in Liverpool, and despite its heft, all available hard copies and soft copies were distributed.

Moving towards universal health care: engaging non-state providers

One of the article collections supported by the Alliance this year was a special issue of the International Journal of Equity in Health. It focuses on the role of non-state providers of health (NSPs) in achieving UHC. 

This publication pulls together seven country case studies and a cross-country study that examines what lessons can be drawn for effective contracting of NSPs in LMICs by governments keen to explore ways to move more efficiently and effectively towards UHC.

THE ISSUE

Tuberculosis (TB) accounts for one in five deaths globally for people infected with human immunodeficiency virus (HIV). Screening, preventing and treating TB in HIV patients is therefore of the utmost importance. Since 2004, the World Health Organization has recommended integrating treatment of TB with HIV care, but it has been difficult to implement in many countries, including Peru.

THE RESEARCH 

In 2014, the coordinating team of the Ministry’s Strategy for the Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Hepatitis B received funding from the Alliance to conduct research into programmatic barriers to integrated care for people co-infected with HIV and TB. 

The researchers found that patients with co-infection received neither timely nor comprehensive care. It also found that co-infected patients received TB treatment in a primary health care facility, such as the local clinic, and HIV treatment in a tertiary facility, usually a public hospital far from their homes. These findings pointed to the need for a model of integrated prevention and treatment for co-infected patients at the same medical facilities to improve treatment and follow-up care.

This study informed a pilot scheme supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria that tested just such a model. In 2016, these studies resulted in a policy document to the Ministry of Health recommending a new, integrated strategy for the prevention and treatment of HIV/TB co-infection. 

THE RESULT

In 2018, with support from the Ministry of Health, Peru’s President Martin Vizcarra announced at the UN Security Council that US$ 121 million had been allocated for improved care for patients with HIV/TB co-infection. That same year, Peru’s government approved the Ministry of Health’s proposed integrated care strategy. 

This case study illustrates the importance of embedded research and locally-driven policy processes. Although the WHO had advocated for integrated care for people co-infected with HIV and TB, the research to understand how to do that in Peru was critical for informing this new national policy.

THE ISSUE

In 2005, Nigeria implemented a national immunization strategy that resulted in an overall increase in vaccination rates. A decade later in Ogun State, though, only 12 of the 20 local government areas (LGAs) had reached full immunization coverage. The other eight LGAs saw little improvement and continued to have large pockets of unimmunized children.

THE RESEARCH 

To understand better what was occurring in these LGAs and to try to find ways of improving vaccination coverage rates, the Ogun Primary Health Care Development Board, local academic institutions, and the Royal Tropical Institute in the Netherlands (KIT) proposed an investigation of the issue in two wards in Remo North: Ipara and Ilara. The idea was to take a participatory action research (PAR) approach involving dialogue and action between community members, health workers and local government officials to improve access to and use of immunization services in these wards. The research project was embedded into the National Programme on Immunization in these focal wards and received funding and support from the Alliance, UNICEF, and Gavi, the Vaccine Alliance. These groups also provided technical support to design, undertake and share findings from the project. 

The research found that certain vulnerable groups required special attention from health workers. It also found that men needed to be engaged, as they were typically household decision-makers and the research uncovered specific concerns that they had around adverse effects following immunization (AEFI).

THE RESULT

Based on the team’s findings, health workers and community members focused on these particular populations, visiting households and community meetings to talk about vaccination, perceived barriers and ways to minimize AEFI. 

The embedded research project helped bring together key stakeholders to understand and address this pressing issue. As the researchers and implementers were working together, it allowed them to adapt quickly and respond to the barriers identified. And the result was impressive: in the study area, immunization coverage for children above nine months, as assessed by a household survey of caregivers, went from 61% to 91%, and caregiver visits to health facilities for routine immunization services rose from 54% to 83%. The community dialogues also led to spillover benefits beyond the project, such as the return of maternal care services in Ilara.

In addition to supporting this project, the Alliance has helped to expand the networks of the policymakers and researchers involved in this project. They presented the findings as part of the policymaker cohort at the Symposium in Liverpool, and policymakers in other states and national-level policymakers in Nigeria garnered interest in the project and its unique approach – as did policymakers from other countries.

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 supporters include the Bill and Melinda Gates Foundation, Doris Duke Charitable Foundation, Gavi, the Vaccine Alliance, International Development Research Centre, Canada, UNICEF, USAID, and the Wellcome Trust. 

Governing bodies

NOTE: People listed in this section served on the Board or STAC or were employed by the Secretariat at some point during 2018. They do not necessarily reflect the current composition of these bodies.