Country ownership and vertical programmes in health, health information and health research

Abstract

In the March 2008 issue, the Bulletin of the World Health Organization published two related items on the complex issue of ownership of health information in international health programmes and on the “vertical versus horizontal” nature of the health programmes responsible for generating this information.1,2 The first is an editorial by Sanjoy Bhattacharya of the Wellcome Trust, which highlights (once again) the divide between protagonists of vertical and horizontal health programmes, and makes a call for “adaptive verticality” to optimize the potential of international health programmes to integrate with primary health care systems in low-income countries and strengthen these in the process.1 The second is a news item: an interview with Sally Stansfield of the Health Metrics Network in which she calls for country-ownership of health information and for “vertical” health programmes to integrate with and strengthen national health information systems. These she argues should become the source of information for improved public-health decision-making and, at the same time, for information needed by donors and by specific (“vertical”) health programmes.2 The problems raised by Bhattacharya and Stansfield are not confined to the health sector nor to health information. On the contrary, the issue of ownership of data and the practice of vertical programming is, in many ways, far worse in the domain of health research. In most low- and middle-income countries, foreign-funded initiatives determine national health research agendas, even in countries in which governments contribute substantially to supporting national health research systems, institutions and personnel. As a result, research activities in many low- and middle-income countries reflect more closely foreign and global health research priorities than the research needs of the countries in which research is being conducted. As externally funded research is virtually monopolised by HIV/AIDS, tuberculosis and malaria,3 little if any funding or research capacity is left to deal with other diseases, conditions or the improvement of health systems, let alone for research with a more expanded goal of social and economic development (i.e.“research for health”). The concept of “responsible vertical programming”4 defines a health research programme as “responsible” if it “succeeds in building the capacity of a country’s researchers and the national research system – in the process of achieving its own research goals”. It sets out some practical steps that decision-makers in countries and in research programmes can take to increase the synergy between national research capacity and research programme implementation. Countries have to take responsibility to put in place and resource a basic national health research system that provides mechanisms for research governance, identifies national priorities and formulates and implements a policy framework to enhance the effectiveness of the national research effort. Vertical programmes have to realize that their research cannot be conducted in isolation from national contexts and that their contributions to the research infrastructure from which they benefit will enhance research output and quality in the future. They can do this by ensuring that – as a minimum – activities align with, rather than fragment, national research system needs and by investing in equitable partnerships that strengthen the capacities of national researchers, research institutions and research systems. It is clear that health system strengthening needs both information and research. Stated in another way, national health information systems and national health research systems are key tools in generating the evidence needed to guide health and health system improvement in low- and middle-income countries, just as they are in high-income countries. “Responsible vertical programming” is about supporting long-term sustainable development as the primary objective of all development interventions in low- and middle-income countries. At the same time, we agree with Bhattacharya in acknowledging that there is still much to be learned about how best to integrate “vertical” and “horizontal” programmes. What is not in any doubt, however, is that strengthening of national research and information systems should be a key component of (large) health and health research programmes. ■