Year: 2010
Type: article
Abstract: Sub-Saharan Africa faces huge challenges in tackling high-burden diseases. It has the weakest health systems and the highest disease burden. Given current resource constraints, there is an urgent need to invest more in research to maximise the impact of health interventions. A vastly improved evidence base is needed on how to implement and scale-up interventions of proven efficacy and how to deliver health services more effectively within the current infrastructure, i.e. to optimise existing health service delivery. Integrating such research into the health system could not only address research questions on health service delivery but also strengthen the health system right from the start of the research and long before research results are available. More than 22 million people are living with HIV infection in Africa (UNAIDS &WHO 2009). The scale-up of antiretroviral therapy is the largest roll-out of treatment services in history with about 3 million people on therapy as at the end of 2008 (WHO 2008a), but the number of new cases, about 1.9 m each year, far exceeds the number being initiated on antiretroviral therapy. Non-communicable diseases, in particular cardiovascular diseases and related risk factors, are rising at an alarming rate and affecting younger people than in developed countries (Lopez et al. 2006; Miranda et al. 2008; Mathers et al. 2009; Mayosi et al. 2009). Delivering services for chronic conditions poses the greatest challenge both for the health service and for the patient, as regular long-term contact and services are required. Here, we discuss some of the challenges of health services delivery for chronic care and the barriers to conducting health services research. Health care workers are the backbone of the health system, but their shortage has reached a crisis point in many settings in Africa. Almost five million more health workers, more than double the number working today, are needed (Hongoro & McPake 2004; Anyangwe & Mtonga 2007; WHO 2008b). Shortages of doctors and nurses are particularly acute; yet, most models of care in Africa rely on doctors and nurses playing central roles in service delivery and health care management. Furthermore, most chronic care and support services are run from hospitals, but most hospitals are located in urban centres that patients from rural and semi-urban settings cannot access easily because of the high transport and opportunity costs (Hardon et al. 2007; Amuron et al. 2009; Ware et al. 2009). First, we must identify through research optimal strategies for training, managing and supporting health care workers to ensure their retention and maximise their effectiveness. Research to improve professional practice is common in developed countries (Haines et al. 2004; Lewin et al. 2008), but rare in Africa. Secondly, we need to evaluate the effectiveness of decentralising components of care for a broad range of conditions away from hospitals to the community and away from clinical to non-clinical staff. There has been some decentralising of HIV services in some settings, but most of this has been from physicians to nurses or clinical officers (Van Damme et al. 2008; Assefa et al. 2010; Callaghan et al. 2010; Sanne et al. 2010). There are severe shortages of nurses, midwives and clinical officers across Africa (WHO 2008a,b; Zachariah et al. 2009), and so this level of decentralisation may have only a limited impact on HIV control at best. A cluster-randomised trial completed recently in Uganda demonstrated the cost-effectiveness of home-based HIV care using non-clinical workers (Jaffar et al. 2009), but use of non-clinical workers in other settings and for other conditions is very limited in Africa. The evidence base for delivering services for cardiovascular disease and its related risk factors is particularly weak. An urgent research priority is to identify strategies that enable the better integration of services for different conditions, capitalising on synergies in control efforts to maximise impact. One priority is to evaluate the integration of services for tuberculosis and HIV. These two infections commonly occur together; yet, only 3% of HIV-infected subjects are tested routinely for tuberculosis, and only 45% of patients with tuberculosis are tested for HIV (WHO 2009; Harries et al. 2010). Research is also needed to determine the integration of major risk factors for cardiovascular disease such as hypertension, diabetes, smoking, obesity (Opie & Seedat 2005; Brown 2006; Addo et al. 2007; Mayosi et al. 2009; Ntusi & Mayosi 2009; de-Graft Aikins et al. 2010), with other chronic care programmes such as for HIV infection. Most conditions remain undetected until the onset of advanced disease when treatment is more difficult and costly. Therefore, research is needed on strategies for scaling-up testing and diagnostics (alongside treatment programmes) so that treatment can be provided early, and in the case of infectious diseases, that the risk of onward transmission is reduced. Research is also needed on health system building blocks, for example on health service management, health financing, commodity management, and monitoring and information systems. Ideally, research on optimising of health service delivery should be driven by programme and district managers and policy makers. It is important that this research is kept focussed with minimal data and sample collection and is appropriately funded so as not to place additional demands on the health system. But we do need well-designed rigorously conducted research studies to produce results that can be generalised widely. It is therefore critical that this research is carried out in a partnership between researchers and health service staff and that researchers have responsibility for research design and for collecting, analysing and interpreting data independently (Jaffar et al. 2008). Importantly, because health services research is integrated into routine practice, the health system can be strengthened right from the start of the research long before research results are available. Lessons learnt from the research sites when disseminated to non-research sites can increase immediate impact further and improve service delivery widely. The ongoing financial benefits to the health system are difficult to quantify but in all likelihood outweigh the costs of the research through improved care outcomes. One major hurdle is that funding for health services research is scarce. For example, in the UK, of £950 m/year spent by government and major charities during the 2004–2005 financial year, just 4.8% was spent on health services research and 2.5% on prevention. Aetiology (studies on risk, cause or development of disease) and underpinning (research aimed at understanding normal functions and processes) accounted for almost 70%, and evaluations of treatments, diagnostics and others accounted for the remainder (UK Clinical Research Collaboration 2006). The European and Developing Countries Clinical Trials Partnership (EDCTP) is now a major funder of trials in Africa. In 7 years, it gave €400 million to research in HIV, tuberculosis and malaria (Mgone & Salami 2009) (http://www.edctp.org); but most of its research funding is focussed on randomised trials of new interventions. Such research addresses important long-term questions, but the contribution to the strengthening of health systems is limited as the research is often carried out in ideal conditions that are far from the realities of the health system. A further important reason why health services research is scarce in Africa is because programme managers and health services staff are overwhelmed with meeting the intense daily service delivery demands and have no time for research. Few programme managers have training in research to be able to engage effectively with researchers. In some settings, the health service infrastructure is too weak to integrate research studies – for example, laboratory services may be unable to measure outcomes or drug supplies may be too unreliable to conduct research to high ethical standards. For researchers, health services research can be an unattractive option as it can involve partnering with a weak and chaotic health system that may challenge the capacity of the research study to deliver on the set objectives. The Global Fund, which from 2002 to 2009, contributed US$ 19.2 billion to HIV, malaria and tuberculosis control in 144 low- and middle-income countries allows up to 10% of a grant to go to monitoring and operational research, but the uptake of funding for research has been low, and no multi-site research collaborations involving health services have been organised. Indeed, countries tend to prioritise service delivery that is probably a direct reflection of limited training and appreciation of what research can do contrasted with the immediate demands of funding health care for the sick and dying. In summary, programme-based health services research is needed in Africa to optimise service delivery and maximise the impact on health interventions. More funding and research capacity development within the health sector is needed to facilitate this. The benefits to the health system from increased efficiency could far outweigh the costs of research.
Institutions: London School of Hygiene & Tropical Medicine, Global Fund to Fight AIDS, Tuberculosis and Malaria, World Health Organization, Special Programme for Research and Training in Tropical Diseases, Kenya Medical Research Institute, Ministry of Health, Cheikh Anta Diop University, Ministry of Health and Social Welfare, Infectious Diseases Institute
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1603302326