What's the RAP for Bamako? Tim Evans, Assistant Director General, Information, Evidence and Research Cluster, WHO Third Expert Consultation on Positive Synergies between health systems and Global Health Initiatives 2 October, 2008

Overview Background to the Bamako Ministerial Forum on Research for Health What's the RAP (research action plan) for synergies?

1990: Commission on Health Research for Development 1996: Ad Hoc Committee on Health Research Relating to Future Intervention Options 2000: International Conference on Health Research for Development (Bangkok) 2004: Ministerial Summit on Health Research (Mexico) 2008: Bamako Ministerial Forum The Road to Bamako!

Bamako, Mali November 17-19, 2008 Global Ministerial Forum on Research for Health

Themes Review & build on achievements since Mexico 2004 Ministerial Summit on Health Research Make new commitments drawing on "Research for Health" theme AFRICA FOCUS – role of research in alleviating Africa's health problems

Nature of Meeting High Level research POLICY forum whereby official country delegations (currently 60 including >40 Ministers) commit to Bamako Action Plan….that will go to WHO and UNESCO governing bodies Announcements and LAUNCHES of initiatives Scientific FORUM on specific topic areas in health security, health development and innovation for health

Global Context The race for results Systems are in fashion!:  GAVI/GFATM – increasing "systems" funding  G8 focus on finances, workers, information  Intl Health Partnership++++  Delivery/operations research exploding  Africa Health Initiative - $100 million!  … but research activities are too adhoc and fragmented ….

The challenges to scale up services for HIV, TB, malaria, and immunization HIV/UA assessment report Global Plan to stop TB World Malaria report GAVI/Norad report Inadequate financing HR crisis Affordable commodities Stigma, discrimination… Accountability Partnership alignment Inadequate financing Laboratory capacity HR crisis Quality drugs Drug efficacy Information system Inadequate financing HRH and Community services M&E HR crisis Inadequate financing Leadership and management Inter-agency coordination

What's the opportunity for "synergies" research in Bamako? Follow-up from Mexico Figure prominently in the Bamako Action Plan …  Research Priorities  Research Capacities  Research Standards  Research Translation

Health need Measurement of the problem – diagnosis Understand causes of the problem – determinants Development of solutions Translation and delivery of the solution Evaluation of the effectiveness of the solution A framework for health research priorities at WHO

Patient Safety Research Measurement of the problem – diagnosis Understand causes of the problem – determinants Development of solutions Translation and delivery of the solution Evaluation of the effectiveness of the solution Patient Safety Research: Establishing global research priorities - use of a Delphi method, expert peer review and a priority framework of harm relative to knowledge gap, likelihood of research delivering a solution, political support. Measuring the burden of unsafe care Understanding the main causes & organizational and system failures that lead to patient harm Identification of locally effective and affordable solutions Adaptation of effective solutions to local contexts ensuring local effectiveness and affordability Evaluation of cost- effectiveness of solutions PSP

Jordan MoroccoEgypt South Africa Tunisia Kenya Yemen Sudan Multi-country studies on prevalence of unsafe care Argentina Peru Mexico Colombia Costa Rica Brazil

Research on neglected priority systems issues Measurement of the problem – diagnosis Understand causes of the problem – determinants Development of solutions Translation and delivery of the solution Evaluation of the effectiveness of the solution Alliance HPSR research areas Alliance HPSR works across all areas, given relatively limited (although growing) number of other partners in the field and limited existing research. The Alliance currently focuses on three specific themes – health financing, human resources for health, role of the non-state sector. Variable quality of metrics Critical need to improve understanding of problems E.g.. factors underlying poor health worker motivation, growth of the private health sector. Key area of focus e.g.. incentives for health workers to locate in underserved areas, strategies to promote universal coverage Supporting the development of solutions e.g. mechanisms to identify the poor Advocating for and supporting evaluations of health system strengthening interventions Alliance HPSR

Striking synergies: a three level approach to research 1. Community/Clinical the "coal face"; innovative delivery models, transformative technologies 2. Systems/Policy support Financing, workforce, governance 3. Comprehensive assessment monitoring and evaluation

Research Priorities Agenda Monitoring and Evaluation Research Agenda – Coverage surveys of GHI interventions Cross-country survey on the strength of health systems Essential and non-essential indicators (data reduction!) Convergence – look at ways individual/clinical/facility based records can be linked to population monitoring Evaluate specific efforts at synergy e.g. GAVI-HSS window Real-time or continuous evaluation of scaling up e.g. UNICEF Catalytic Initiative

Research Capacity Stewardship  Clearer "identity" required to facilitate greater strategic collaboration/networking  Advocacy for policy and funding priority Financing  Longer term structural change in research funding e.g. "National Institute for Delivery Research"  Nearer term opportunities e.g. tap "research" funds from global sources such as global fund grants Individuals and Institutions  The research curricula, cadres, cohorts, careers  Institutions Academic/training Research – observatories, country learning platforms, public health institutes, Twinning

Standards Concepts/Frameworks  International classification on health systems and GHIs?  Systems boundaries, functions, building blocks require greater clarity  What constitutes a "synergy"? Measurement/Methods  health systems metrics e.g. measures of coverage, governance  Attributable fractions to systems, GHIs? Conduct  Ethics – informed consent,  Information privacy, access to results Innovative Research Designs  GFATM-TDR – "operations research"  UNICEF - "real-time scaled evaluation"

Standards of Evidence If gold standard evidence for clinical medicine is the RCT, what is it for scaling up health systems and striking synergies with GHIs? Retrospective:  case studies of success and failure Prospective:  Four cell designs  Real time experiments in implementation  Innovative randomization New Approaches to research:  Complex adaptive systems

An emerging "field" of research Beyond serendipity  Towards "savvy" in striking systems synergies A new science needed to:  Illuminate the black box of delivery?  Avoid the black hole of systems?  Scale-up services more quickly, safely, equitably and efficiently

Translation to Policy and Public Cultivating demand for this research by actively engaging key policy constituencies  G8 – Japan follow-up and lead into Italy…Canada  GHI leadership, H8  Civil society  Implementers Accelerate translation of research to policy/action  Facilitating mangers and policy makers to make evidence-informed decisions e.g. EVIPNET Facilitate access to research  Health Systems Evidence Libraries e.g. Cochrane, Campbell –like effort for health systems  Innovative IT applications e.g. "Itropica" for synergies