HEARD News

Undercurrents in health systems research

Prof. Tim Quinlan
Research Director

There is an upsurge in research and funding to 'strengthen health systems' in Africa. The reasons are well known. The 'emergency' response to HIV/AIDS supported large-scale interventions but now, it is realised, at a large cost to other health services and to efforts to keep abreast with the changing burden of disease, particularly the rise in illnesses associated with life style changes. Also, the public health services cannot keep up with the exodus of professional staff.

However, there is already scepticism as to whether the new body of research will actually achieve anything for there has been sound research in the past which showed the need for change and what to do and yet, seemingly, there is little to show for it. This is a valid concern. New health policies may well reiterate past interventions that seemingly just tinker with the challenges; for example, paying doctors and nurses more to keep them in service, adding a few sophisticated facilities to deal with modern diseases or re-emphasising primary health care but defraying the cost by relying on poorly paid and ill-equipped 'community health workers'.

Much depends on the type of research that is conducted and, as importantly, the type of research that policy makers listen to. This is cause for some optimism. There have been numerous innovations in service delivery as a result of HIV/AIDS. Moreover, health systems do change albeit slowly. Concepts such as integration, co-ordination, adaptive management and transformation were novel in health research 20 years ago and often poorly reflected in policies that incorporated them. Today, they are common terms in strategies and plans (though frequently still conceived simplistically).

Orthodoxy in such research, a focus on internal performance of health services (more efficient and effective systems from the perspective of doctors, nurses and health managers) has been challenged by other research, advocacy and human rights legislation that emphasises the external performance of health care (e.g. quality of service, ease of access to services and patients' experience). There is actually no juxtaposition; at least there should not be. Both types of research are useful.

The critical factor is that there is a better climate for doing and communicating research on external performance. Concepts such as 'learning organisations' and 'co-creation' of effective, equitable and efficient services by health professionals and patients, are becoming more familiar. Likewise, the theories and practices that support collaboration to drive institutional change are being used more frequently in interactions between scientists and policy makers and amongst scientists themselves.

A notable example is the WHO-supported conference on health systems to be held later this year. There will be discussions of practical questions about the internal and external performance of health systems and, importantly on innovations advocated and implemented by NGOs and community organisations. It is a significant step by the WHO. As the global arbiter of good practice and standards, it is necessarily conservative and justifiably cautious and so has taken a while to catch up with contemporary research. The conference agenda and in research today is for both systemic and creative changes to health systems. One undercurrent is recognition that the users of health services have a better grip, in times of crisis and failing health services, on creativity than health service planners and policy makers.