(January 2005) When Donald Simeon speaks of the Caribbean’s mosquito control program, he does so with a wry smile.
“Most people like to see when you spray, they feel you are doing something, it looks good and it brings in votes,” says Simeon, director of research at the Caribbean Health Research Council (CHRC).
But Simeon says that research has shown that spraying is not the best way to tackle the region’s mosquito problem. “It stinks up the place and ends up killing all kinds of other creatures—honeybees, for example,” he says.
The program is just one example of the difficulties facing health officials worldwide in incorporating health research into policies and practices. Simeon says destroying mosquito breeding sites is the most effective way of controlling the mosquito populations and of reducing the incidence of dengue fever, which is endemic to the region.
But governments have run up against what could be seen as “common-sense solutions” to the problem. In other words, if you have an insect problem, you spray.
And common-sense practices that do not take into account the latest health research have had disastrous consequences in other areas, such as neonatal deaths. For example, practices such as bathing babies immediately after birth can actually harm the child, according to Save the Children’s Elizabeth Ransom.
“To prevent hypothermia, the baby should be dried and wrapped and its first bath should be delayed,” says Ransom. But, she adds, traditional and common sense practices dictate that you bathe infants covered in goo.
Neonatal Deaths and the Knowledge-to-Practice Gap
The difficulty in translating knowledge gained by health research into actual practices in communities and into government policies is stymieing efforts to achieve healthy populations in developing countries. The high levels of child deaths worldwide demonstrate the problem.
The October 2004 Bulletin of the World Health Organization (WHO) reports that 10.8 million children under age five die every year. Some 4 million of those children die within the neonatal period—the first month of life. But while interventions to prevent child mortality have helped reduce overall child deaths over the past 30 years, deaths of newborns have not fallen as quickly.
“More research needs to be done on how to get appropriate interventions to the people who need them,” says Cesar Victora, researcher with the epidemiology department at Brazil’s Universidade Federal de Pelotas.
“This [research] is crucial in the area of child mortality,” Victora adds. “We know how to cut child mortality; we just have not been able to get these interventions to the populations most in need of them.”
A 2003 report from Save the Children and PRB entitled Why Invest in Newborn Health? notes that, on average, neonatal deaths comprise 40 percent of child mortality in developing countries. The report cites Bolivia as a good example of this disparity: While child mortality in the country fell by 29 percent between 1989 and 1998, neonatal mortality there declined by only 7 percent.
Effective and low-cost interventions such as vaccines, vitamin supplements, and insecticide-treated bednets can prevent two-thirds of under-age-five mortality. But the WHO Bulletin argues that not enough is known about how to make these interventions more widely available to people who need them.
And health experts say that malfunctioning health delivery systems in developing countries are failing to address childhood infections, maternal deaths, and other diseases. According to WHO’s World Report on Knowledge for Better Health, countries with limited resources struggle with creaking infrastructure, inadequate budgets, too few doctors and nurses, and limited information on health indicators.
The report adds that research on strengthening health delivery systems to make them functional and equitable could reap significant public health benefits such as health equity. However, according to Ronald Labonte at the University of Ottawa’s Institute of Population Health, global health equity would require policies that support the following:
- Sufficiently funded and universally accessible health systems, with adequate numbers of health professionals;
- Equitable access to key health indicators, such as nutrition, education, water, sanitation, and housing;
- Targeted health programs to reduce the burden of specific diseases on poor populations;
- Increased research into diseases that affect the world’s poor;
- Increased financing for global health and development; and
- Trade agreements that respect the “special and differential” development status of poorer nations.
Using Research for Targeted Interventions
Knowing how health systems function is key to knowing how to reform these systems, according to health experts. Tanzania’s Essential Health Interventions Project (TEHIP) provides a model for ways in which health-systems research and reform can reduce adult and child deaths.
As part of efforts to reform its health care system, Tanzania tested the World Development Report 1993 hypothesis that targeting most health spending on prevalent local diseases rather than on expensive and specialized hospital services would prove both cost-effective and reduce mortality.
Work on TEHIP began in the Tanzanian districts of Rufiji and Morogoro in 1997. The project provided local district health managers with tools, strategies, and modest funding increases—all of which allowed these managers to aim resources at the largest contributors to the local burden of disease and to improve healthcare delivery. According to WHO, TEHIP has seen a number of impressive results:
- A 16 percent rise over five years in funds allocated to prevention and treatment programs for malaria (a disease that, from 1996 to 1997, accounted for 30 percent of healthy years lost due to deaths in Tanzania);
- More spending on common childhood diseases, such as pneumonia, diarrheal diseases, and measles; and
- Investment in training personnel in the Integrated Management of Childhood Illnesses (IMCI)—a holistic approach to the treatment of major childhood illnesses that focuses on serious risk factors and on prevention through immunization and improved nutrition.
According to the WHO World Report on Knowledge for Better Health, the latest data after a five-year follow-up of TEHIP show a 54 percent reduction in infant deaths in the two districts, a 47 percent drop in under-five mortality, and an 18 percent drop in adult deaths.
Using Research to Guide Policies
Program planners who have relied on evidence provided by research have seen positive results. In late 2003, the South African government ordered its provinces to initiate the country’s Comprehensive Care and Treatment Program that provides free anti-AIDS treatment to those in need. In the South African province of Free State, researchers began working with health officials to implement the program.
“We immediately brought in the researchers,” said Dr. Ron Chapman, executive manager for Health Support Services at Free State’s Department of Health. “I am a former researcher myself, so I understand the benefits researchers bring to programs such as this.”
Canada’s International Development Research Center (IDRC), one of the program’s collaborating institutions, says the Free State program holds the potential for research to contribute in a lasting way to health policy, management, and care. Free State has some 470,000 HIV-positive residents—some 30,000 of them at a stage of the illness when they are eligible for antiretroviral drugs.
Chapman and his colleagues were particularly concerned about the program’s effective implementation since HIV can develop drug resistance if patient compliance is poor. Department officials were also concerned about the effect the program could have on other basic public health sectors—for example, by drawing personnel away from immunization and other key programs.
Researchers designed methods of delivery, developed local training guidelines, monitored the program, studied its impact on patients as well as on their families and communities, and documented the entire process. Most importantly, says Chapman, the researchers provided health officials with critical and impartial information on the program’s progress.
“Researchers will tell you the truth about what’s going on, while your staff may tell you what they think you want to hear,” says Chapman. “So you get unbiased, honest answers to questions that need answering. With research going hand in hand with implementation, we get to know very quickly when something is not working and we can change tack almost immediately.”
Building Public Trust in Health Research
Involving researchers has also ensured a more transparent program, according to Chapman. “We have everything exposed,” he says. “That means that people see that what we are engaged in is a process. They see when we make mistakes, and they see when we correct them, and that has led to less criticism. It’s amazing.”
Health advocates say this kind of transparency helps to build public trust in scientific research, a factor that is necessary to achieve healthy outcomes for populations in developing countries. Operating within local social and cultural contexts also helps build public trust and confidence.
“It’s all about perspective,” says Ritu Priya of the Center of Social Medicine and Community Health at the Jawaharlal Nehru University in India. “You have to start from the felt needs in the community rather than the international epidemiologist or the social scientist telling you what needs to be done. The community actors know how to do some things, so you have to look at the strengths of the local context and build on that.”
But health advocates warn it is also essential to develop ways to make technical experts, policymakers, and service providers accountable. Accountability is best achieved, they say, by involving communities and civil society actors—including professional associations, religious groups, labor unions, advocacy groups, and others.
Debra Anthony is a freelance writer based in Mexico City.
Don de Savigny et al., Fixing Health Systems: Linking Research, Development, Systems, and Partnerships (Ottawa: IDRC, 2004).
“Health Research for Equity in Global Health,” Statement by the Global Forum for Health Research at the conclusion of Global Health Research Forum 8, Mexico City (November 2004), accessed online at www.globalforumhealth.org/forum8/Statement.html, on Dec. 20, 2004.
Tikki Pang, Ariel Pablos-Mendez, and Carel Ijsselmuiden, “From Bangkok to Mexico: Towards a Framework For Turning Knowledge Into Action to Improve Health Systems,” Bulletin of the World Health Organization 82, no. 10 (2004).
Ritu Priya, Health Policy and Systems Research: Informing the HIV and AIDS Research Agenda, Presentation for the Global Health Research Forum 8, Mexico City, November 2004.
World Bank, World Development Report 1993: Investing in Health (New York: Oxford University Press, 1993).
World Health Organization (WHO), World Report on Knowledge for Better Health: Strengthening Health Systems (Geneva: WHO, 2004).
Nancy V. Yinger and Elizabeth I. Ransom, Why Invest in Newborn Health? (Washington, DC: Save the Children and Population Reference Bureau, 2003).