Editorial: Does Brussels listen? European health systems research in developing countries at the edge of extinction
Axel Kroeger Liverpool Institute of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK. E-mail: firstname.lastname@example.org
Research into health systems all over the world has contributed to the development of new disease control strategies, modernized hospital and outpatient care, alternative financing mechanisms, cost-effective interventions and monitoring tools which resulted in improved delivery of care and public health services. But financing of such research is a problem in many European countries – particularly when the study is to be carried out outside the European Union – as it does not fall into the classical categories of basic science, medical science or development of drugs and vaccines and may not have an immediate impact on European health services. In view of this, a European programme for strengthening health systems research in developing countries (INCO-DEV) was set up by the European Commission in Brussels in 1983 which was integrated into the Science and Technology for Development programme on an increasing budget. For two decades it has facilitated high quality health systems research influencing health policies worldwide. Examples for INCO-funded projects are given below.
Cost-effective strategies for vector-borne disease control in Latin America (Liverpool School of Tropical Medicine)
Basic entomological, epidemiological and socio-economic research in five Latin American countries proved the protective efficacy of insecticide-treated materials for the control of malaria, Chagas disease and cutaneous leishmaniasis, the cost-effectiveness of this strategy and the acceptability of the approach to the population. Operational research identified different models of sustainable provision of treatment and retreatment services. In 1998, the Colombian government and the Mexican Social Security System commissioned the researchers to conduct national training programmes for disease control staff and to assist in writing national guidelines for vector-borne disease control; other countries are following, showing that research findings have lead to important policy changes.
Towards good pharmacy practice in Thailand and Vietnam (Karolinska Institute, Stockholm)
Providing pharmaceuticals is one of the main pillars of medicine, and in many low-income countries pharmaceuticals make up half or more of health care costs. Increasingly consumers turn to private pharmacies for attaining their primary health care needs through self-medication of broad spectrum antibiotics and even anxiolytics. Few attempts have been made to develop national standards for good pharmacy practice and improving provision of drugs by private pharmacies in developing countries. The Ministries of Health in Vietnam and Thailand collaborated in developing and evaluating a multi-faceted intervention package to improve drug provision and to give policy-makers a scientific basis for decisions relating to national drug policy reform. A randomized controlled trial resulted in significant improvements of rational antibiotic dispensing and management of sexually transmitted infections by private pharmacies based on a question, advice and treatment strategy and pharmacy treatment guidelines. Other achievements included capacity-building and intersectorial collaboration.
Health systems research in the Middle East and Asia (University of Cambridge)
Public health work in the Middle East (Lebanon and Palestine) and South and South East Asia (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Malaysia) has resulted in the creation of major academic networks that are multidisciplinary in their approach and equitable in terms of partnerships in both regions. Each group of scientists has been exposed to the health systems of the others. Dissemination of health systems research methods has permeated often anachronistic institutions within developing countries and in the European region. This has created exciting potential for research and policy-making across a range of public health issues. Research capacity in the field of epidemiology and the social sciences has been strengthened; there is a focus on applied research and policy-making and an improved understanding of comparative health systems (e.g. context, history, user and provider perceptions, age, class and gender issues in different settings) and their role in developing a research strategy. The findings from both regions have been taken on board by policy makers, notably in Palestine. In South Asia, too, public health policy is continually being improved through the use of health systems research conducted by the partner institutions. This is having a visible impact both at the level of capacity and upon policy makers.
Action research for the improvement of health care in Burkina Faso (University of Heidelberg)
After a number of analytical studies in the late 1980s, a Demographic Surveillance System of 6000 households was established in 1992 in north-west Burkina Faso (Nouna Division) to study and improve the participation of the population in financing health services; to improve service quality through standardization of medical tasks, essential drug supplies, prescription and compliance patterns; and to strengthen mothers' skills in treating key childhood illnesses. In an iterative process research questions were investigated, the results integrated into the reform process, evaluated, adjusted and fed back into the planning process. Health systems research methodology courses were offered to central and district health managers so that a growing number of staff became familiar with key methods of measuring health services quality and impact. In 1999, the Ministry of Health in Burkina Faso established the Nouna Health Research Centre, which is funded by the German Ministries of Science and Technology as a collaborative project between the Ministry of Health of Burkina Faso, the University of Heidelberg and several other research groups.
Improving the integration of tuberculosis control programs (TCP) into health services in Latin America (Université Libre de Bruxelles)
The applicability of a method was tested to improve the integration of TCP activities in both private and public health services in El Salvador, Nicaragua and Peru. The purpose was to identify bottlenecks in the integration process of TCP activities in first-line health services, to propose locally adapted recommendations and to promote at national and international level the use of this method by academic and other institutions. Field experience of health professionals involved in the TCP integration process was documented and analysed to build an operational model with an action research perspective. The results show that even with well-performing TCPs, interventions are urgently needed to facilitate the access of tuberculosis patients to health services: decreasing social stigma, reducing indirect costs, improving case-finding and the overall quality of care. Policy makers have learned from this research that to be more effective in the fight against tuberculosis, local health systems have to be reinforced.
Reforming health services for equity and efficiency in urban China (Shanghai Medical University, China)
The project was jointly conducted by three Chinese and three European institutions over 3 years. The researchers produced many important findings and practical policy recommendations, some of which have been put into practice by two municipal governments in health sector reform. The project also supported south/south and south/north exchanges between China and India and between China and Europe. These activities have produced benefits to both researchers and policy-makers.
Development and strengthening of the public health system in Cuba (Institute of Tropical Medicine, Antwerp)
This collaborative project with Cuban, Mexican, Irish and Belgian partners investigated pilot reforms in the Cuban health system to assure their scientific guidance and evaluation and to prepare their possible generalization. Operational research contributed to rationalizing levels of care and referral patterns in the Cuban health system. Starting from key problems identified in the subsystem of emergency services, adaptations were designed and put in place in several areas. The reform reduced unnecessary use of hospital emergency services and reoriented the demand for care towards the primary level. A second research axis introduced cost analysis into the Cuban first-line health care system. A method was developed that allows to evaluate, from service user as well as provider perspective, both direct and indirect costs associated with the treatment of specific pathologies. The analysis of the data is underway and will result in recommendations for improving the efficiency of care without jeopardizing its effectiveness and accessibility. The Cuban experience with participative health sector reforms which simultaneously enhance sustainability is also valuable to European institutions aiming to produce scientific evidence for equitable health policy formulation.
In the above examples, mainly the European institutions are mentioned through which the INCO-DEV resources were administered. However, a distinctive feature of this north–south co-operation was the establishment of partnerships between institutions in European and developing countries based on the `sense of co-responsibility for the problems faced by developing countries with a special role for the scientists who have chosen to address the problems of development' (De Bruycker & Hagan 1996). Providing an opportunity for genuine co-operation and co-authorship creates the feeling of `being included', a signal which cannot be underestimated in the context of fighting poverty. In many cases the partnership approach led to long-lasting research networks and on several occasions to project leadership by partners in the south. As health systems research is interdisciplinary by nature, co-operation of researchers with different professional backgrounds has been encouraged, strengthening particularly the role of social scientists, economists and managers in the field of public health.
Considering the unknown impact of globalization on social development (McMichael & Beaglehole 2000), the ongoing worldwide health sector reforms involving costly interventions implemented by international agencies, and the new funds created to control specific diseases (particularly acquired immunodeficiency syndrome, tuberculosis and malaria) it is a priority to promote research and networks to evaluate these interventions and to capitalize the experiences. An INCO-DEV Programme is precisely the kind of initiative we need to be able to answer these challenges.
Are the underlying values and concerns of the programme outdated fossils of a social orientation in health of the past century? Why does an imminent shift of European research funding policy towards `hard science' with product orientation and biotechnology at its centre (Boelaert et al. 2001) occur?
INCO-DEV as such will be abandoned in the new framework agreement. Other programmes such as the new European Clinical Trial Platform serve completely different objectives and do not include the notion of partnership. The drift to narrow technological, albeit important, solutions focused on isolated aspects of health (such as vaccines and genetics) diverts the attention from societal problems and their solutions. Will the academic community be consulted, and will impartial technical advice be sought in the ongoing process of EU research policies? If Brussels does not listen to those involved in health systems research and development, damage will be done to north–south co-operation and to public health in developing countries.