Health systems research is the best medicine



Theresa Braine

Mexico City



Every year millions of people die of diseases such as malaria and tuberculosis for which a cure has existed for decades. This gap — between knowledge and practice in public health — is at the heart of WHO-sponsored proposals to be considered this month by WHO's Executive Board.

The proposals, known as the Mexico Statement, call on governments, foundations and other bodies that fund research as well as the international research community to strengthen malfunctioning health systems by promoting more research into those systems.

Unlike previous research initiatives, the Mexico Statement calls specifically for more attention to be paid to research into health systems, for better ethical management of such research and better translation of these findings into public health practice.

"Research", the Mexico Statement says, "has a crucial but under-recognized part to play in strengthening health systems, improving the equitable distribution of high-quality health services, and advancing human development".

If the Statement wins Executive Board backing at a meeting in Geneva from 19 to 24 January, the World Health Assembly in May will consider adopting a WHO resolution that would commit signatory states more closely to the proposals.

The Mexico Statement was presented at a Ministerial Summit on Health Research in Mexico City, where 22 health ministers and other officials from 51 countries gathered from 16–20 November. Its goal is to tackle obstacles preventing low- and middle-income countries from achieving the Millennium Development Goals.

In a 12-point action plan intended to transform the way research is done and how its findings are disseminated, the Statement calls on governments to make research into health systems a priority; to give people in developing countries better access to knowledge and to base health policy decisions on scientific evidence.

It proposes establishing an international clinical trials register as one way of achieving these goals.

Although ministers agreed to "fund the necessary health research to ensure vibrant health systems and reduce inequity and social injustice," their final statement stopped short of its original more concrete recommendation that developing countries should spend 2% of national health expenditures on health research.

A recommendation that development agencies allocate 5% of their health-sector financing for the same purpose ended up as a footnote. There were no specific proposals for industrial nations' contributions.

Dr Tikki Pang, Director of Research Policy and Cooperation in WHO's Evidence and Information for Policy cluster, said the Mexico Statement was vital because research into health systems tended to be neglected and under-funded in comparison with the field of biomedical research.

"Progress will only occur if countries show commitment and support for a spectrum of activities which will help to bring research into health system activities into the mainstream," Pang told the Bulletin.

The Statement won backing from officials attending the summit — a follow-up to a conference on health research in Bangkok in 2000 — but some delegates said it was too vague. Dr Elias A. Zerhouni, director of the U.S. National Institutes of Health, said translating knowledge into action was key but that the effective application of this knowledge was different in each specific context or local situation.

"The connection between policy-makers, leaders and evidence-based intervention needs to be strengthened by research," Zerhouni told the Bulletin before speaking at the Summit opening plenary session. "What we've also come to realize is that there isn't really a health research solution that is global in nature. Health systems are very local. What is effective in one system may not be effective in another."

If that is not taken into account, Zerhouni said, "what you have is a full disconnect between political leadership, policy-makers and deployment of health resources".

Dr Lincoln C. Chen, Director of the Global Equity Initiative at the Asia Center of Harvard University and head of the Commission on Health Research for Development — the 1990 precursor to current efforts — said the proposals were not concrete enough.

Chen said that the past 14 years had seen a "huge revolution in developing countries coming up with research systems" but that he "would like to see something a little bit more specific".

WHO officials said the aim of the summit was to develop programmes and a methodology in four crucial public health areas: finance, workforce management, generating knowledge and managing supplies.

WHO's Pang argued that there were simple, cost-effective ways of making great strides for public health and cited the example of a district in the United Republic of Tanzania where child mortality was recently reduced by 46% after local officials re-directed part of their US$ 2 per capita annual health budget into research to isolate the causes of child death and to addressing the underlying cause of the problem.

"It seems so obvious, and yet if you survey the literature it's very clear that very little attention is being given to this," Pang said, referring to health systems research, adding that since this involves human behaviour, society, economics, education and poverty: "It's just a very complicated area".

Dr Ariel Pablos-Méndez, Director of WHO's Knowledge Management and Sharing department, said the Mexico meeting underscored the need for a culture of knowledge translation and effective problem solving, new professional capabilities and different incentives in research systems in public health.

Pablos-Méndez said: "The Mexico Summit marks a shift in focus most timely and appropriate for the millions of poor people left behind, and offers a vision and a challenge to the international research community and national governments".

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