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This is not a love-fest

[Editor's note: This blog was originally published on the PSinHEALTH website and has been cross-posted here with permission]


On July 6th, the Private Sector in Health Symposium will convene for the third time in six years before the International Health Economics Association (iHEA) World Congress, and builds upon a well-attendedwebinar series in the run-up to the symposium.. The symposium attracts a broad spectrum of scholars from multiple disciplines. It won’t just be economists, and it won’t be a love-fest for unleashing free market economics in health care systems. The private sector in health is problematic, but we are going to have to live with it for quite some time -- so it’s a good thing so many intrepid scholars have joined forces to find ways to get the private sector to effectively deliver high quality services, to reach the poor, and to reduce the financial jeopardy for patients who access it.

The private sector in health is too big to ignore and too complex to leave to just one discipline. As Julio Frenk noted at the key note address of our last meeting in Toronto in 2011--the private sector in health demands stewardship. Stewards do not do all the nitty gritty work, but they ensure that resources that they oversee are used wisely and fairly on behalf of others.

The Sydney Symposium on July 6 will show how this community of scholars has answered Dr. Frenk’s call to assist civil society and governments with stewardship. There are two sessions devoted to “Building Institutions for Private Sector Performance” that focus on ways to assemble public private partnerships and ways that the public sector can become engaged. There are four sessions devoted to improving and assessing the quality of care in private sector practices. Equity and the impact of the private sector on the poor is covered in three sessions and there are two sessions on health care financing in the private sector.

Presenters are global and the areas studied range are global too with the balance weighted towards low- and middle-income countries in Africa, Asia, and Latin America. Our Opening Keynote address by Bruce Bonyhady will address how Australia has grappled with its private sector in health and the Closing Plenary by Mushtaque Chowdhury will draw on experiences from Asia. 

It’s going to be an amazing day! If you are already registered, lucky you. If you are going to be in Sydney but haven't yet signed up to join us, register now. If you can’t make it, keep on eye on Twitter on @psinhealth or follow our hashtag at #healthmkt next July 6 for livetweets from the day. We will also include much of the material from the day, including presentations and short videos on the conference website at http://www.pshealth.org.


The challenges of Research Uptake: Systemic, institutional and individual barriers

[Editor's note: This blog was originally written for and published on the DRUSSA (Development Research Uptake in Sub-saharan Africa) website as a four part series. It was based on a short presentation to the RIMI4AC conference in London, UK. It has been shortened and reproduced with permission.]


As highlighted in a recent DFID-run event for research uptake practitioners entitled: Beyond communications, research uptake is a concept that has been evolving rapidly over the last several decades. As such, a variety of challenges face research uptake practitioners and those wanting to strengthen capacity to get research into use. These operate at three levels: systemic barriers, institutional barriers and individual barriers.

Systemic barriers

The first challenge is probably that the concept of 'research uptake' is little understood.  In brief, it is focused mainly on the demand side of research, working to stimulate an enabling environment among end users of research to commission and find appropriate information to support their own policy processes. This assumes working closely with key stakeholders, but also probably assumes some sort of capacity strengthening for them to understand and demand high-quality research.

But more at a systemic level, the barriers to research uptake are numerous—and have been well articulated by others. In particular, the RAPID programme at ODI notes six lessons for getting research into use. They highlight different time horizons and different notions of evidence between the research and policy spheres. A researcher needs as long as research takes and findings are often wrapped in a variety of qualifications and caveats, but policymakers often need clear findings at key points during the policymaking process. As a former policymaker turned researcher from Brazil so wonderfully put it: “In Brazil we don’t talk about pilots. I can’t go to an official and say ‘give me two years and I’ll give you the answer’. Why? Because we have elections. If a policymaker waited two years to take action he’d be shot.”

We also know that the research-policy-practice interface is a complex and dynamic one. Not only do those trying to get research into policy need to have some knowledge about where in a particular policy cycle the research topic is, they must also understand who is working to influence that process, what their drivers are and how they’re doing it. And unfortunately, one of the corollary barriers is that change doesn’t happen the same way twice, which means a lot of experimentation, expertise and critical thinking are required to link research, policy and practice. This latter point also helps explain why research uptake is focusing so heavily on strengthening the demand-side—if a policymaker is requesting research findings, half the battle is already fought.

This brings in another systemic barrier—research funders distort demand. While research funders aren’t necessarily the end users of research, they are the ones that set the priorities through what they are willing to fund. Often some sort of demonstration that there is a gap in existing knowledge and some demand for the research results is part of the grading criteria when selecting proposals, but the distortionary effect of the donor cannot be overlooked.

There are also perverse incentives on both the supply and demand side that act as a significant barrier to research uptake. On the research side, promotion is most often dependent on publishing as many papers as possible in peer-reviewed journals with high impact factors, not in communicating that research. There are also time pressures—a student knocking on the office door is more likely to capture a researcher’s attention than a distant policymaker in a capital city far away. And funding is a chronic problem—with researchers perpetually chasing the next grant, who has time to do “extra” work communicating research findings? On the policy side, incentives tend to focus on maintaining political legitimacy. That might include carrying through on promises made during electoral processes, adhering to a particular ideological standpoint (and let’s be clear, evidence-informed policy is a clear ideological position too), or just not looking idiotic in the public eye.

Finally, at a systemic level, research uptake requires a diverse skills set to deliver. In addition to strong research skills, Simon Maxwell likes to argue that policy entrepreneurs require four key skills: story telling, policy engineering, networking and political fixing. But these skills are underpinned by a huge area of oft-overlooked technical skills, including:

  • Editing and language skills
  • Digital engagement skills
  • Graphic design and desktop publishing
  • Media planning and engagement
  • Event planning and management
  • Database management
  • Data analysis
  • Information literacy
  • Knowledge management
  • Budgeting and programme management
  • Marketing and public relations
  • IT skills

Institutional barriers

Focusing now mainly on the supply side of research at an organisational level, given all the systemic challenges, one of the biggest barriers to research uptake is figuring out where to start and how to institutionalise appropriate systems and processes that support research uptake activities. Does a research institute need a central communications/ marketing/ dissemination/ media relations/ knowledge management team? If so, where should it sit? In a grant management office? By itself? As part of the IT department? In the library?

On top of that, where are the capacities for research uptake best placed? Certain skills probably need to remain with individual researchers, but some are probably better supported by an outside team.

Funding research activities is also usually a challenge. It depends on the funding models employed by an individual institute, but many (maybe even most, particularly in Sub-Saharan Africa) institutes lack core funding, and must raise money through projects or other sources. Striking a balance between support to projects versus strengthening and supporting institutional engagement is key, and is also hugely difficult. Does a central team get funded out of overheads? Do they try to support themselves through their own projects and research?

And from an institutional perspective, brain drain is always a worry. If organisations invest in building research uptake skills, there’s no guarantee staff will stick around and that they will continue to benefit from these skills. Researchers may end up in a relevant ministry, for example (though this could turn out to be a good thing for the institution). More centralised teams with specific transferable skills often find themselves poached by the private sector, and in developing countries, especially, by international agencies and non-governmental organisations.

Individual barriers

Last but not least, at an individual level, barriers to research uptake are multiple. One of the most frequent points of opposition to research uptake that I hear, and one that I’m hugely sympathetic to, is that researchers must, first and foremost, be good researchers and that if policymakers or practitioners want to use their work, it’s their prerogative. This is a notion we must counter, strongly and with a moral imperative. It is not just the responsibility of policymakers and practitioners to seek out research—it is also the researcher’s responsibility to make it accessible, especially when it can (and does!) save lives.

Another individual barrier is the ego—and I mean this in two ways. At one level, effective research uptake activities require strong brands from strong researchers. This means that researchers must at some level be sure of themselves and of their findings and be confident to take them out into the big wide world. On the flip side, researchers must be willing to accept help and advice and work with others. Just because a researcher, who has more often than not been focusing on a study for a significant period of time, understands the findings doesn’t mean everyone will—EVERYONE needs a good editor, always. Also, given the diverse skills required for research uptake, it’s highly unlikely that any one person knows best.


That may sound like a lot of barriers and I’d hate to leave people thinking it cannot be done. A number of examples of incredibly impactful research uptake activities exist—and they can and have improved and saved the lives of many. It just means there’s some work to do.


Are informal providers a dangerous detour on the road to universal health coverage?

At the Second Global Symposium on Health Systems Research, the unifying theme was 'universal health coverage' (UHC). A commitment to achieving UHC was enshrined in the Beijing Statement, and much discussion at the symposium targeted the post-2015 agenda with one health goal.

But the road to universal health coverage is long, and the devil is in the details. Human resources for health is critical in meeting the access element of universal health coverage, and working with informal providers to improve care is one way of bolstering the health workforce. Some, however, argue that working with informal providers in the private sector is a dangerous distraction from meeting UHC. Several panels, however, were quick to point out the critical role informal providers play across health systems, especially one convened by the Center for Health Market Innovations entitled, which Tom Feeny of HANSHEP blogged about before.


In the videos above, several respondents challenge the notion that informal providers are a dangerous distraction. Dominc Montagu, of UCSF, for example, takes a pragmatic stance by suggesting that millions of people around the globe already get their health services from informal providers, and that 'their not going to change that just because someone has a vision'. Meenakshi Gautam, of the Centre for Research on New International Economic Order, India, stresses that primary care must be within a half-hour walk from the village, but that in India there are over 600,000 villages -- more than the number of formally trained doctors in the entire country. She suggests that informal providers are better placed to fill this gap. And Oladimeji Oladepo from the University of Ibadan gives an example from Nigeria where informal providers have played a key role in getting anti-malarial drugs to the rural poor at low costs.

[Editor's note: This blog and videos were originally co-produced by Future Health Systems and the Center for Health Market Innovations for the Private Sector in Health.


Participatory action research for health systems

A mother in Kamuli district smiles with her new baby after using the voucher scheme for transport to a local health facility to access a safer delivery.

There were many methodologically focused sessions during the 2nd Sympsoium on Health Systems Research, including several focusing on more qualitative methods. Future Health Systems participated in one on participatory action research, highlighting their research in Easter Uganda to help improve mothers’ access to safe deliveries. Below are some reflections from the two FHS participants.



What are my responsibilities as part of the District Health Management Team (DHMT) in Kamuli District?

My responsibilities include: the planning, soliciting, receiving and distributing of additional resources for district health needs; monitoring and providing feedback on the implementation of programs; and providing supportive supervision, mentoring and coaching to health providers so as to improve the quality of health care services provided. I have been a senior nursing office for many years and more recently part of the DHMT.

What have I learned from the panel on action research and being at the conference?

It has been an educative experience for me, pushing me to think how best I am learning, doing, improving. Action research has enriched our program as it makes us think broadly, strengthens our planning, makes us prioritize the issues of concern. It has made me think of contingency plans required, to come up with a plan B, in case things change. It has made me consider things not usually talked about, such as what the community is doing today and tomorrow, rather than always depending on technocrats, especially when concerned about sustainability. The conference has been a wide, wide, wide exposure. It has made me think out of the box. I have done a,b,c, now what about d? What can I share with others and contribute?



What was I presenting at the symposium?

I have been working with Makerere University and Ministry of Health, Uganda over the past year while they have been re-strategising the Safe Deliveries project to ensure more local action, ownership and sustainability. We strengthened our skills in participatory action research and undertook a series of dialogues at national, district and community level in iterative phases with multiple stakeholders including adolescent mothers, male partners, transport workers, local leaders and other district and national officials. We first discussed the current project and identified challenges or issues that had to be addressed to support local action, ownership and sustainability. After identifying the most important challenges, we worked with stakeholders to brainstorm possible strategies to address the challenges and prioritize them in order of feasibility.

What did I learn from the action research panel?

While I was familiar with action research used by those involved in community health, I was very impressed by the number of health systems researchers engaged with action research methodology at the conference and in the panel audience. It was motivating to know that one is not working in isolation.

I realized that we got lost in the challenge of documenting the process (number of meetings, at what stage, with whom) and failed to present how participatory action research is particularly suited for addressing power relations. I perceived our team addressing power by being critically aware of who is involved and what is discussed. Despite the success of the voucher scheme in increasing women’s access to facility services, through this participatory process the following issues were identified as being critical: lack of male engagement in supporting women’s health savings or decision making; low awareness by women of their entitlements; community transport and savings systems still requiring strengthening; and poor quality of care at facilities, including providers being rude, insisting on unofficial payments and making women delivery in positions that ran contrary to their local social norms.  Makerere played a critical role in consulting with marginalized groups on their own, before facilitating dialogues that included their participation with other more powerful stakeholders, and ensuring that the issues they raised didn’t get swept under the table. Most striking were my memories of local religious leaders and politicians; as their involvement was not always a one way monologue.  Interestingly, the district managers on the panel discussed power in a different way. While I as a researcher was concerned about how power can exclude stakeholders and their concerns or stereotype them in frames that perpetuate their marginalization, the district managers viewed power as a positive force. They felt it was their responsibility to unleash power at every level to support positive change.

It was striking to see the commonalities across the projects presented. That action research helped to change perceptions of district managers reorienting them to more community and public health needs; foster trust relationships;  and provide a space to focus, reflect and support more strategic planning in the middle of routines and environments that are more typically characterized by diminished resources, competing demands, overburdened workloads.  

Valuable concerns raised by the audience included:

  • the duration of time or number of action cycles that needed to be undertaken to see effects
  • similarities between action research and quality improvement cycles
  • whether action research efforts stay on islands of excellence or whether the skills seep into other areas of practice
  • the challenge of generalizing the experience to other contexts
  • the challenge of influencing change at levels higher than where the action research initiatives are taking place, especially when higher level officials maybe less process oriented and more demanding for visible, quick results  

Most striking for me was realizing the experience it takes to know when to follow the rules or power configurations and when to break them. It was sobering to recognize how challenging it is to present such a rich experience amidst strangers in a foreign land far from the familiar. It takes time to open up, understand and trust one another in order to freely discuss all the questions and issues that arose from the panel and audience interacting. The room was full of ideas, energy, questions, experiences and it seemed rather unfair but entirely understandable and pragmatic decision to stay within the time constraints that bounded the panel. No doubt the discussions sparked and intrigued interests that will go beyond the boundaries of the panel workshop and conference.   


Would you pee on your tomatoes? Where the HSR approach to knowledge translation is falling short


As the Policy Influence and Research Uptake Manager for the Future Health Systems research consortium, knowledge translation is central to what I do. I was very pleased to hear, then, that it was a key theme of the 2nd Global Symposium on Health Systems Research. During the symposium, I had the opportunity to participate in several related sessions (though I wish I could have made even more!), and while there were a few interesting insights, it seems to me the health systems research (HSR) approach to knowledge translation is still falling short. Here's why.

I’m relatively new to HSR, but one of the impressions I’m left with from this Symposium is that it took the topic a long while to crystallise as an area of study because it is so inherently multidisciplinary. Health economics, medical epidemiology and the full gamut of political and social sciences, not to mention complexity science, all seem to fall under the HSR umbrella. And so I’m surprised that much of the learning and approaches to ‘knowledge translation’ discussed here seem to come from the medical sector. At one level, that’s likely because evidence-based medicine is widely recognised as the progenitor of the evidence-based policy movement. But the understanding of evidence-based policy has moved on a lot since the 90s (heck, people hardly anyone refers to it at ‘evidence-based policy’ anymore, preferring the idea of ‘evidence-informed policy’). So why aren’t health systems researchers looking elsewhere for inspiration? And why are they working so hard to re-invent the wheel?

A lot of the findings I’ve seen from the presentations are in line with some of the already well-established lessons on linking research, policy and practice, which is heavily informed by political and social sciences. For example, one paper emphasised the importance of timing to influence policy… something Kingdon has been emphasising through the idea of ‘policy windows’ since at least 1995 (though I can’t imagine Kingdon was the first person to talk about the importance of timing). In a closed satellite meeting I attended, a Brazilian policy-maker underscored the point: ‘In Brazil,’ he said, ‘we don’t talk about pilots. Why? Because we have elections every four years – we can’t say to an elected official “give me two years and I’ll give you the answer”. If the officials waited that long to take action, they’d be shot’.

And despite this well established and once-again reiterated knowledge on best practice, at the symposium another panel insisted the best way to answer a policy question was to spend up to two years on a systematic review that could be summarised in a policy brief, a mere year-and-a-half (at least) past the policy window...

Within HSR, we also need to challenge this notion of a large gap between research and policy that must be bridged. The fact is that there are a large number of mechanisms already in place in most countries to bridge that gap – technocratic networks of old school chums are a good place to start, but think tanks, the media, research institutes, patient interest groups, parliamentary libraries, professional associations, political parties and more all exist. When I hear about a ‘gap’ it’s more often than not because the researcher isn’t in the right networks to influence their target. But many of the best policy-oriented researchers have served some time in a local, regional, national or international governing body or two. And many of the best policy-makers have decent degrees and bounce between government and (quasi)academia. Indeed, I found it ironic that the person presenting on this supposed gap had already left his researcher job to work for the Ministry of Health.

Which brings me to another point about the role of evidence in health systems research: there seems to be a strange notion among HSR practitioners that evidence speaks for itself. If an RCT or systematic review finds something to be true, then it must be the BEST solution and should be adopted as policy. But we know that in policy-making spheres, it’s hugely important how that evidence plays in the value systems, customs, and general context of the target population. Sure, science might say the cheapest way to ensure a bumper tomato crop is to urinate on them, but that doesn’t necessarily mean that smallholder-farmers are likely to accept the advice. Need more convincing? A five-minute talk with just about any health economist should disabuse you of the acceptability of all forms of evidence in the health systems sphere. So let’s call this the tomato test – if you wouldn’t pee on your own tomatoes then you may need to rethink your approach to policy influence.

Despite these shortcomings, there were some really insightful findings and approaches presented too.

I am somewhat sceptical of the idea of a professionalised body of ‘knowledge brokers’. Researchers and policy makers need to be able to talk to each other directly – the best knowledge brokers facilitate that process, the worst insert themselves in between. And so I was pleased to hear of an interesting example of effective knowledge brokers in a study across several sub-Saharan African countries. The study noted that having ‘champions’ within the Ministry of Health was key to changing the policy. Again, the importance of champions is something we’ve known about for a long time, but the reason they were important here was not just because of their persistence, but also because they were able to effectively synthesise international and local data to determine winning arguments that would help move the agenda along within the ministry.

I was also particularly impressed with the EVIPNET/SURE Project’s rapid response units – though I was slightly worried at the suggestion that such mechanisms were unique. In fact such ‘help desks’ are institutionalised in a number of mechanisms in a wide variety of countries and on a wide number of topics: for example in the UK the Parliamentary Office on Science and Technology (POST), produces briefings based on demand. And in China, the Ministry of Health has an attached think tank, the CNHDRC – among several other academic bodies – to help ministry officials analyse key issues. And in the development arena, the new DFID-funded PEAKS projects provide rapid responses to queries from policy makers. But we don’t see these in enough countries and in enough areas, which is why the SURE initiative is important.

Overall, I’m delighted to see a focus on knowledge translation at the symposium. But I encourage HS researchers interested in linking research, policy and practice to look elsewhere for inspiration. The upcoming conference on the ‘Politics of Poverty Research and Pro-Poor Policy Development’ hosted by an agriculturally focussed institute might be an interesting place to start.