Editorial: Advancing the Mexico agenda for health systems research – from clinical efficacy to population health

Abstract

The Ministerial Summit on Health Research in 2004 in Mexico called for an enhancement of global health research with a focus on health systems, to achieve the health related Millennium Development Goals (MDGs; Anonymous 2003). Since then, several western countries have taken up the initiative to strengthen their contribution to health systems research in low-income countries to improve the dialogue between health systems research and policy and to translate knowledge into action (Surr et al. 2002; Minister for Development Cooperation 2005; RAWOO 2005; Di Ruggiero et al. 2006). At the heart of these initiatives is the observation that many low-income countries are unlikely to achieve the MDGs – to decrease maternal and child mortality, and to combat AIDS, malaria and other diseases by 2015 – because of malfunctioning health systems (World Health Organization 2004; United Nations 2005). Many of the necessary medical procedures and interventions to reduce ill health in low-income countries are already well established, but there are multiple health systems barriers that prevent them from being optimally delivered and used. A lack of finance is undoubtly a part of the reason why access to good quality health services is not achieved for all. For example, total health expenditure in many low-income countries is between US$4 and US$30 per capita per year (http://www.who.int/countries/en/). However, with the advent of global ‘billion dollar funds’ initiatives like the Global Fund to fight AIDS, TB and Malaria and PEPFAR the money may no longer be the most important barrier. There is growing consensus that ‘a primary bottleneck to achieving the MDGs is health systems that are too fragile and fragmented to deliver the volume and quality of services to those in need’ (Travis et al. 2004). If health systems are lacking capabilities such as the health workforce, drug procurement and supply, financial management, and information systems, they may not be able to translate clinically efficacious interventions into improved population health (Freedman et al. 2005). For example, whereas drugs to treat malaria are estimated to be 85% effective, the community effectiveness of treatment is estimated to be only 3% in Burkina Faso: only a small proportion of people with malaria attend health centres, and those who come receive low quality care, or do not all purchase and/or take the drugs as prescribed (Krause and Sauerborn 2000). It is obvious that, if these health systems barriers would be removed, related mortality would fall sharply. In contrast to the growing recognition of the importance of solving health systems issues to achieve the MDGs, health systems research has until now only received little attention. Funding has typically been too small to build research capacity in this area, and to undertake any major operational studies (Alliance for Health Policy and Systems Research 2004). At the same time, health systems research has already made clear contributions to the knowledge about effective strategies to strengthen health systems. For example, while user fees were strongly advocated by various agencies during the 1980s as a means to overcome financial constraints, a sound body of knowledge now shows that user fees are likely to have negative effects upon access to care, especially for the poor, unless certain pre-conditions are met (WHO 2000). The World Health Organisation reviewed the current state of global health research in 2004 in its World Report on Knowledge for Better Health – Strengthening Health Systems (World Health Organization 2004). It concluded that (i) much more investment is needed for a new innovative approach to research on health systems; (ii) health research must be managed more effectively if it is to help strengthen health systems and build public confidence in a science; (iii) stronger emphasis should be placed on translating knowledge into action to improve public health by bridging the gap between what is known and what is actually being performed. In the same year, the WHO Task Force on Health Systems Research defined a research agenda to support the attainment of the health related MDGs (Task Force on Health Systems Research 2004). A number of western countries have recognized these concerns, and the need for coordinated global health (systems) research. For example, in Canada, government and research institutes developed the Global Health Research Initiative (GHRI) in 2001 to coordinate and build upon Canada's global health research activities (Di Ruggiero et al. 2006). The GHRI's mission is to develop practical solutions for health problems in low-income countries. Its creation has been highly influential in attracting funding for health and global health research in Canada, and in improving the use of research results for policy making. The GHRI has a partnership with NGOs, through the Canadian Coalition on Global Health Research. In 2005, the GHRI initiated a dialogue with WHO on global health research to explore the contribution that Canada can make to strengthening health systems research in developing countries. In the UK, the Department for International Development (DfID) coordinates global health research, with a focus on the achievement of the MDGs and the needs of the poor as the main framework for determining the research strategy and priorities. A recent review of DfID research activities recommended to bring all research previously managed in sector programmes together under a Central Research Department, in order to eliminate duplication (Surr et al. 2002). In the Netherlands, there has also been a reaction to the observed fragmentation of global health research, with several agencies highlighting the need for a strategic country focus (Minister for Development Cooperation 2005; RAWOO 2005). The Dutch Ministry of Foreign Affairs recently stressed the importance to develop research on MDGs and reproductive health and AIDS, with an emphasis on health systems strengthening to foster the scaling up of interventions, and to improve the information-base for evidence-based policy making. A round table conference with all stakeholders in policy and research was held in April 2006. The conference served as one of the first platforms where three Ministries – Health, Foreign Affairs and Education and Science – discussed collaboration with the research community in global health. The initiative was well received by all, and it was decided to develop definite steps towards a national mechanism around global health systems research that could bring more synergy in activities, and better inform policy making. Several countries thus advance the Mexico agenda on health system research, and undertake steps to reorient and better coordinate their global health research to strengthen health systems. We applaud the development of these initiatives, but also call for similar collaborative action in other western countries as well as for partnerships with developing countries, e.g. through the Global Forum for Health Research. Such efforts are important to the successful implementation of clinically efficacious interventions in low-income countries and translate them into improved population health, and ultimately, to achieve the health-related MDGs.