Here comes the second issue of the Health Systems Network Newsletter!
In this issue you’ll find reviews of articles focusing on methodology and concepts to access health systems such as mixed methods, systematic reviews and a conceptual framework on access; discussions on resources such as human resources and the use of data; and the interface of health systems and disease control.
We thank all those who contributed to this Newsletter and wish you all a good reading! Comments and suggestions of articles to be included in this newsletter are welcome at firstname.lastname@example.org
Valéria Campos da Silveira on behalf of the SWIHPS Network
1. Methodology & Concepts
Moat et al (2013) Twelve myths about systematic reviews for health system policymaking rebutted
Journal Health Services Research & Policy, Vol 18, 1: 44-50
Review by Karen Pesse
Another article by the group of Moat and colleagues, who have been advocating and proposing strategies for increasing the use of research evidence, and specially systematic reviews findings in decision-making, mainly at health policy level. Contributing to this aim, the article describes and intents to refute twelve obstacles for the use of this kind of information by policymakers, with a short introductory part justifying the importance of more evidence-informed decisions. Although already discussed in previous papers and not the main focus of this document, a brief description on what is meant by “informed policy-making” and its differences with i.e. “evidence based decisions”, could have helped to better understand what the authors want us to know and apply about this theme.
Addressed “myths”, as the authors call them, refer to the availability, pertinence, and quality of systematic reviews, but particularly to difficulties in finding valid and usable information by decision-makers who are seen, although not explicitly, as having no time nor knowledge to understand long or complicated research reports. Although this may hold truth in the majority of cases it´s still doubtful if this is the only or main cause for them not using research findings. The article does not discuss the possibility of systematic reviews being biased by political views of researchers carrying them out.
Advices and examples on the possibilities to overcome obstacles in using research evidence for decision-making might be quite useful for academics trying to influence health sector policy and systems. However, some of the arguments for contesting the identified “myths” seem somewhat weak to me: for example they say that a systematic review can be of high quality even if the primary evidence is not, just because it accomplishes with the criteria established for its methodological process, but without considering the validity of its conclusions. It might be good to keep in mind that authors themselves acknowledge that most evidence used for contesting “misconceptions” about the relevance of systemic reviews for policymaking are drawn from the Health System Evidence repository, a very good initiative of McMaster University. Nevertheless, since two of the authors are part of this academic institution it would be advisable to explore potential conflicts of interest leading to an overly optimistic view of this database and its utility.
Ozawa and Pongpirul (2013) 10 best resources on… mixed methods research in health systems
Health Policy and Planning, 1-5.
Review by Bruno Marchal
This paper usefully brings together key papers and books on mixed methods research, but fails to position the mixed methods approach in the broader landscape of HSR. In social sciences and health systems research, mixing methods has been a longstanding tradition in approaches and designs such as case studies, action research and theory-driven approaches, and it would have been useful for the authors to explain why this approach emerged on the research scene and to clearly indicate why we need this approach.
The claims of mixed methods adherents about its usefulness have been refuted by some authors. In its barest essence, ‘mixed methods’ can be considered as nothing else than the combination of qualitative and quantitative methods of data collection and analysis in one study. Mixing methods, however, does not help us much if it just remains a combination of quantitative and qualitative methods. Lipscomb (2008), for instance, found that a number of mixed methods studies lack validity and coherence of argumentation, because the theoretical and philosophical foundations of the research design were underdeveloped. This author also argued that mixed methods research in itself does not enhance external validity, for which building and refining theories is needed.
2. Health Systems & Control of Diseases
Cohen R.L. et al (2013) An Evaluation of the President’s Emergency Plan for AIDS Relief Effect on Health Systems Strengthening in Sub-Saharan Africa
Acquir Immune Defic Syndr Volume 62, Number 4
Review by Peter Delobelle
The objective of this study was to evaluate the impact of PEPFAR on health outcomes in sub-Saharan African countries with a generalized HIV epidemic, by comparing time trends in proximal and distal indicators of health systems strengthening before and during PEPFAR activities. Results indicate a strong and statistically significant association with improvements in HIV-related indicators, in particular TB and life expectancy, but inconsistent associations with improvements in other distal indicators (incl. IMR, U5MR and vaccination rates). The study was hampered by several limitations, including the lack of available data on indicators of health systems strengthening, and concludes that global health efforts must further prioritize the collection of more comprehensive and reliable data sets to inform evidence based global health practice.”
Atun R, Jaffar S, Nishtar S, Knaul F, Barreto M, Nyirenda M, Banatvala N & Piot P (2013) Improving responsiveness of health systems to non-communicable diseases.
The Lancet 381(9866), 690-697
Review by Werner Soors
Atun and colleagues’ viewpoint in The Lancet is the first article in the fourth of the journal’s series on non-communicable diseases (NCDs). For over half a decade now, a vast and still growing body of publications has stressed the need to counter the equally growing burden of NCDs. Despite all evidence-based advocacy, the response of policymakers and health systems has been minimal.
The present Lancet series follows up on the 2011 UN General Assembly’s and 2012 World Health Assembly’s calls  to take action. The latter targets a 25% reduction in preventable deaths from NCDs by 2025. In his editorial comment to the series (The Lancet, same edition, p510), Richard Horton states that “we are now beginning to appreciate that controlling chronic diseases will not succeed only with a focus on conventional risk factor prevention and a concerted global and national multi-sectoral response”.
Unfortunately, this appreciation is less widespread than Horton pretends: Atun and colleagues’ proposal for a way forward is entirely centred around risk profiling. The authors also advocate a stepwise scaling up of NCD services by piggybacking on HIV (and tuberculosis) platforms. Understandable as this might be from an HIV-activists perspective in times of scarcity – and without denying any of the lessons to be learned from HIV/Aids responses – it can be argued that augmenting this parallel track can hardly be considered genuine health systems strengthening. Is it really inconceivable to integrate HIV, together with all other chronic conditions, into a unique and comprehensive health system? I would argue that it is not. Tiny Costa Rica for example proves that this is perfectly possible, and sustainable, but receives no mention in the article.
Besides, the authors’ focus on the personal level and self-management of risk factors is (I’ll be polite) regrettable. Difficult to understand even, as UNDP’s Helen Clark in the same edition (p510-511) more than clearly points at the need to “tackle the underlying social, economic, political, environmental, and cultural determinants” of NCDs. The good news is that UNDP is preparing a discussion paper on the social determinants of NCDs. The sad news is that so much evidence on social determinants has already fallen on deaf ears. What remains to be seen is if the struggle for fairness becomes stronger than the power of status quo. I tend to be skeptically optimistic.
 UN General Assembly (2011) Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases (A/66/L.1) http://goo.gl/CMWlU & 65th World Health Assembly (2012) Prevention and control of non-communicable diseases (A65/6) http://goo.gl/d2wZJ
3. Health Systems & Resources
Kaplan, A. et al. (2013). Human resource governance: What does governance mean for the health workforce in low- and middle-income countries?
Human Resources for Health 11(6)
Review by Bruno Marchal
In this paper, the authors set out to examine the links between governance and the health workforce, two of the 6 building blocks. They argue that the important linkages between these blocks are neglected. Eight principles of governance were identified through a literature review, and the authors then developed a frame to analyse countries’ approaches to governance of the health workforce. To do this, they crossed the Health System Assessment framework and the HRH Action Framework. Finally, they applied their framework to the data sets of the Health System Assessment initiative of 20 countries. The conclusion is that the challenges remain big and that further research is needed.
This paper unfortunately remains stuck in a macro analysis of country policies based on a new framework, which in itself is based on a quite superficial review of the governance literature. Their 8 key elements of governance include information, accountability, strategic vision, transparency, efficiency, equity, responsiveness and voice/participation, and in my opinion, this list remains just a list. More progress would have been made if the authors had developed a more comprehensive view on the link between governance and health workforce, including attention for the policymaking processes, implementation issues, actual operational management approaches. Furthermore, an in-depth discussion of the underlying mechanisms that are supposed to make governance of the health workforce work is missing.
Tara Nutley & Heidi Reynolds (2013) Improving the use of health data for health system strengthening
Global Health Action 6: 20001
Available at http://dx.doi.org/10.3402/gha.v6i0.20001
Review by Werner Soors
This article by Nutley and Reynolds – of MEASURE Evaluation, UNAID’s unit for monitoring and evaluation – puts forward a logic model (or logical framework, in similar lingo) for designing, monitoring and evaluating interventions to strengthen health systems. It does so in a very particular way, by focusing on improved demand for and use of data from health information systems (HIS).
While better use of HIS data is certainly a laudable aim, the model’s focus (on use of data) and logic (data will lead to data-informed decision making) are at the same time its weaknesses. No innovative ways to improve data quality are proposed, which nevertheless can be seen as a pre-condition. Without a substantial improvement in data quality, how much sense does it make to stimulate demand and use?
The model’s basic assumption is that of a single logic, that of the programme designer. In real life however, we know that programmes inherently follow many logics, as many as actors are involved. Every stakeholder – be it programme designer, implementer or user – has its own logic, or ‘programme theory’, and interests. As a result, pure data-informed decision making and implementation are extremely rare and interventions are shaped within a interplay of power. This reality makes a ‘logical’ framework at best suitable for initial design of an intervention. For real-life monitoring and evaluation, due attention to the processes between all actors in their changing context – as in realist evaluation – will be needed.
4. Organisation of Health Systems
Levesque J-F, Harris M.F., Russell G (2013) Patient-centred access to health care: conceptualizing access at the interface of health systems and populations
International Journal for Equity in Health 12:18
Review by Valéria Campos da Silveira
Levesque et colleagues propose an useful framework for exploring access to health care. They argue that there exists a variety of interpretations across authors and suggest a framework integrating determinants from demand and supply sides – the interface of health systems and populations. They performed a literature review and developed a reviewed conceptual framework for access. Their framework considers five dimensions of access: 1) approachability; 2) acceptability; 3) availability and accommodation; 4) affordability; and 5) appropriateness and adequacy. These dimensions interact with corresponding abilities of populations: 1) ability to perceive needs and desire for care; 2) ability to seek health care; 3) ability to reach the health system; 4) ability to pay for care at primary and secondary levels; and finally, 5) ability to engage, that’s to say, participation and involvement of users. For the authors, “access to optimal care ultimately requires the person to be fully engaged in care and this is seen as interacting with the nature of the servicer actually being offered and provided”. The authors emphasize the character of patient-centeredness of the framework, placing the actual process of seeking care, including the various stages that a patient has to go through to actually receive care, in the centre of their analysis.
I found this framework very interesting and potentially useful for analysis of health systems performance. It will allow a deeper analysis of problems affecting actual utilisation of health systems and its responsiveness to heath needs.