Research Priorities
A notable paucity of evidence is apparent in relation to most key areas discussed in this chapter. This lack of evidence is illustrated by a recent review of the evidence on the equity of utilization and financing strategies (box 3.8). This and other reviews of the available evidence have led the Lancet to call for a new health systems research specialty ("Mexico 2004: Global Health Needs a New Research Agenda" 2004).
[Box 3.8]
Areas where evidence is especially limited that are identified in this chapter—where research is a high priority—include the following:
-
Evidence on most health system reforms—for example, hospital autonomy reforms and decentralization—is inadequate to draw conclusions about the circumstances under which reforms are likely to improve the efficiency and equity of service delivery.
-
Few studies relate a reform to health outcomes, and even evidence on intermediate outcome measures, such as costs and quality of service provision, is often lacking.
-
Virtually no information is available about the costs of strengthening capacity or the effectiveness of different approaches to capacity strengthening, even though the lack of system capacity is widely noted.
-
Evidence is largely lacking on the characteristics of delivery strategies capable of achieving and maintaining high coverage for specific interventions in various epidemiological, health system, and cultural contexts.
-
Evidence is lacking on what types of governance and institutional arrangements will support the achievement of widespread health improvements, especially for the poorest members of society.
Addressing the deficiencies in the evidence base requires developing better study designs and analytical methods and building expertise in and understanding of health systems research. Capacity for research and analysis in health policy and health systems is currently limited. A recent survey (Alliance for Health Policy and Systems Research 2004) estimated that project funding for health systems research accounted for less than 0.02 percent of the total annual health expenditure of developing countries. More than half of research projects had budgets of less than US$25,000. Of institutions identified as engaged in health systems research, a third had no staff qualified at the doctoral level, and researchers with doctoral degrees made up only a quarter of the research workforce. An analysis of studies cited in Medline showed that only 5 percent of the health systems research literature concerned developing countries.
Given the importance of influencing policy and practice, the approach to research needs to encompass solving operational problems in real-life settings. Ethical issues arise in using limited supplies of talent to study problems unrelated to the local context when the human resources and systems required to improve operational programs are lacking. Moreover, the quality and effect of investigations are much improved when they are based on dialogue with the primary users and set in real-life contexts. The concept of the cycle from research to policy and practice needs to be emphasized more strongly. It encompasses not only generating knowledge but also managing the research agenda, including setting priorities, and promoting the use of evidence through means such as advocacy channels and specific mechanisms designed to link producers and users of research (Alliance for Health Policy and Systems Research 2004). Given the importance of context in translating research evidence into service and system practice, operational research and program evaluation capacity must be built among country-based scientists and practitioners.
