1. O/IR in Health & Disease Control Programs: Experiences & Lessons from Ghana (1989-2008) Presented by Irene Akua Agyepong, Ghana Health Service 18 th November 2008, Bamako

2. Introduction IR/OR is an important tool to support evidence-based program development and scale-up and to share best practices of IR/OR Other terminology e.g. Health Systems Research, Health Services Research –What does it matter if a cat is black or white so long as it catches mice Chinese proverb: quoted from John Adair in Develop your leadership skills Critically needed in LMIC but remains relatively under developed, appreciated and funded Yet has the potential to make major impacts on health status Many LMIC are still struggling with effective scale up of proven effective interventions because of these weakness Illustration next slide (source of data – GAR multiple indicator cluster surveys): ITN proven effective in the last decade of the 20 th century – over 10 years on, still struggling with effective application issues in the first decade of the 21 st century

3. A scale up problem: ITN availability in households with children under 5 by district in GAR

4. Background: OR/IR/HSR in Ghana Development of public sector OR/IR/HSR capacity started with the 1987 OR TBA in southern Ghana. DMS (Dr. Moses Adibo) directed that a mechanism be put in place to facilitate the generation and use of research information from this and future studies in health policy and program decision making and implementation. A central OR unit that was later renamed the health research unit (HRU) was established and a director (Dr. Sam Adjei) for health research appointed in 1990. The position of research officer in the health sector was advocated for. Actual establishment took over 10 years and there remain problems with salary scales & creating adequate nos of positions Peripheral health research centres were established in Navrongo (after the completion of the VAST trials) and Dangme West in 1992, and Kintampo.in 1994.

5. Case Studies of research and its translation in Ghana (DC) National Filariasis Control program –Research played a major role in the establishment of the national lymphatic filariasis control program Gyapong J. (2000) Lymphatic filariasis in Ghana: From research to control. Trans. R. Soc. Trop. Med. Hyg. Nov – Dec; 94(6) pp 599 - 601 National Malaria Control program –Current NMCP manager: HSR and malaria control research –Improving Malaria treatment adherence by prepackaging Ansah E.K., Gyapong J.O., Agyepong I.A., Evans D.B. (2001) Improving adherence to malaria treatment for children: the use of pre-packed chloroquine tablets vs. chloroquine syrup. Tropical Medicine and International Health. Vol. 6 No. 7 pp 496-504, July 2001 Yeboah-Antwi et al Prepackaging study in BA –ITN Studies from Navrongo Binka et al Margaret Gyapong et al –Resistance monitoring Koram et al in Noguchi

6. Case Studies of research and its translation in Ghana (HS) Service Delivery: Primary Health Care –Community Based Health Planning and Services (CHPS) program Nyonator F.K, Awoonor Williams K.J., Philips J.F., Jones C.T., Miller R.A. (2005) The Ghana Community Based Health Planning and Services Initiative for Scaling up service delivery innovation. Health Policy and Planning. 20 (1) pp25 – 34 Health Financing –National Health Insurance Scheme Atim et al Nkoranza evaluation Annual reports of the Dangme West health insurance experiment Agyepong I.A. & Adjei S. (2008) Public Social Policy Development and Implementation: A Case Study of the Ghana National Health Insurance Scheme. Health Policy and Planning. 23. pp150 – 160.

7. Success factors The high level policy support for health research Development and institutionalization of a culture of health research within the public sector Development and retention of committed researchers within institutions grounded in the health system, with the capacity to write proposals and attract research funding. Development of capacity /understanding /appreciation within health system & program managers High retention of researchers in research institutions has been related to career development opportunities, grants to continue research, international & national recognition, ability to earn extra income, & supportive organizational environment /culture & role models who stay

8. Challenges Continuing weakness in national leadership, priority setting, coordination, and harmonization (strong research institutions but weak national research system) Fragmented research funding sources – usually international with weak or no national control /engagement Limited government funding for health research Result: Institutions and researchers put well funded international priorities over national ones.

9. Challenges Despite the gains, the system remains vulnerable because it rests on a relatively small core of expertise in strong institutions with a weak coherent national system and systemized support and fragmented financing that is not always linked to the most pressing priorities Skills in policy analysis, advocacy and evidence translation and IR/OR for scale up of proven effective intervention still in short supply Many of these skills lie in social science disciplines and the ability to do good quasi-experimentation, and qualitative and quantitative evaluation. Despite the efforts and gains made, attracting adequate support and financing in this area remains a major challenge It is also still an area that does not appear to be the priority of national or international funders despite gains in recent years

10. Balancing Capacity Development Priorities for a strong system Priority setting Conduct of research Evidence synthesis & translation Evidence Application Leadership& coordination Researchers++++++ ++++++ Research funders +++-+++++++ Policy elites++++-+++++++ Operational translators ++++++ ++++ Program funders +++-++ ++++ Cmties/Civil society +++++++++++