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1.  Informing the establishment of the WHO Global Observatory on Health Research and Development: a call for papers 
In May 2013, the WHO Member States requested the WHO to establish a Global Observatory on Health Research and Development (R&D), as part of a strategic work-plan to promote innovation, build capacity, improve access, and mobilize resources to address diseases that disproportionately affect the world’s poorest countries.
The rationale for establishing a Global Observatory on Health R&D is to provide a mechanism to monitor and analyse health R&D resource flows, product pipelines, and research outputs, aiming to contribute to the identification of gaps to inform priority-setting for new R&D investments to be operationalized through a new global financing and coordination mechanism for health R&D and utilized by all stakeholders informing health research policy decisions in countries, civil society, and the private sector.
As one of the mechanisms to achieve the goals of the Global Observatory on Health R&D, the WHO is launching a Call for Papers to be published as a Thematic Series in Health Research Policy and Systems to contribute state-of-the-art knowledge and innovative approaches to analyse, interpret, and report on health R&D information. Further, to serve as a key resource to inform the future WHO-convened coordination mechanism, which will be utilized to generate evidence-informed priorities for new R&D investments to be financed through a proposed new global financing and coordination mechanism for health R&D.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-13-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4328039  PMID: 25645000
Funding; Global health; Investments; Observatory; Research and development
2.  Dimensions of Learning Organizations Questionnaire (DLOQ) in a low-resource health care setting in Nepal 
Knowledge-based organizations, such as health care systems, need to be adaptive to change and able to facilitate uptake of new evidence. To be able to assess organizational capability to learn is therefore an important part of health systems strengthening. The aim of the present study is to assess context using the Dimensions of the Learning Organization Questionnaire (DLOQ) in a low-resource health setting in Nepal.
DLOQ was translated and administered to 230 employees at all levels of the hospital. Data was analyzed using non-parametric tests.
The DLOQ was able to detect variations across employee’s perceptions of the organizational context. Nurses scored significantly lower than doctors on the dimension “Empowerment” while doctors scored lower than nurses on “Strategic leadership”. These results suggest that the hospital’s organization carries attributes of a centralized, hierarchical structure that might hinder a progress towards a learning organization.
This study demonstrates that, despite the designing and developing of the DLOQ in the USA and its main utilization in company settings, it can be used and applied in hospital settings in low-income countries. The application of DLOQ provides valuable insights and understanding when designing and evaluating efforts for healthcare improvement.
PMCID: PMC4326496  PMID: 25608765
Dimensions of the learning organization questionnaire; Health systems; Learning organizations; Nepal
3.  Balancing the personal, local, institutional, and global: multiple case study and multidimensional scaling analysis of African experiences in addressing complexity and political economy in health research capacity strengthening 
Strengthening health research capacity in low- and middle-income countries remains a major policy goal. The Health Research Capacity Strengthening (HRCS) Global Learning (HGL) program of work documented experiences of HRCS across sub-Saharan Africa.
We reviewed findings from HGL case studies and reflective papers regarding the dynamics of HRCS. Analysis was structured with respect to common challenges in such work, identified through a multi-dimensional scaling analysis of responses from 37 participants at the concluding symposium of the program of work.
Symposium participants identified 10 distinct clusters of challenges: engaging researchers, policymakers, and donors; securing trust and cooperation; finding common interest; securing long-term funding; establishing sustainable models of capacity strengthening; ensuring Southern ownership; accommodating local health system priorities and constraints; addressing disincentives for academic engagement; establishing and retaining research teams; and sustaining mentorship and institutional support. Analysis links these challenges to three key and potentially competing drivers of the political economy of health research: an enduring model of independent researchers and research leaders, the globalization of knowledge and the linked mobility of (elite) individuals, and institutionalization of research within universities and research centres and, increasingly, national research and development agendas.
We identify tensions between efforts to embrace the global ‘Community of Science’ and the promotion and protection of national and institutional agendas in an unequal global health research environment. A nuanced understanding of the dynamics and implications of the uneven global health research landscape is required, along with a willingness to explore pragmatic models that seek to balance these competing drivers.
PMCID: PMC4325946
Capacity strengthening; Complexity; Global health research; Globalization; Institutional capacity; North-South-South partnerships; Political economy of health research; Mentorship
4.  Feasibility of establishing a biosafety level 3 tuberculosis culture laboratory of acceptable quality standards in a resource-limited setting: an experience from Uganda 
Despite the recent innovations in tuberculosis (TB) and multi-drug resistant TB (MDR-TB) diagnosis, culture remains vital for difficult-to-diagnose patients, baseline and end-point determination for novel vaccines and drug trials. Herein, we share our experience of establishing a BSL-3 culture facility in Uganda as well as 3-years performance indicators and post-TB vaccine trials (pioneer) and funding experience of sustaining such a facility.
Between September 2008 and April 2009, the laboratory was set-up with financial support from external partners. After an initial procedure validation phase in parallel with the National TB Reference Laboratory (NTRL) and legal approvals, the laboratory registered for external quality assessment (EQA) from the NTRL, WHO, National Health Laboratories Services (NHLS), and the College of American Pathologists (CAP). The laboratory also instituted a functional quality management system (QMS). Pioneer funding ended in 2012 and the laboratory remained in self-sustainability mode.
The laboratory achieved internationally acceptable standards in both structural and biosafety requirements. Of the 14 patient samples analyzed in the procedural validation phase, agreement for all tests with NTRL was 90% (P <0.01). It started full operations in October 2009 performing smear microscopy, culture, identification, and drug susceptibility testing (DST). The annual culture workload was 7,636, 10,242, and 2,712 inoculations for the years 2010, 2011, and 2012, respectively. Other performance indicators of TB culture laboratories were also monitored. Scores from EQA panels included smear microscopy >80% in all years from NTRL, CAP, and NHLS, and culture was 100% for CAP panels and above regional average scores for all years with NHLS. Quarterly DST scores from WHO-EQA ranged from 78% to 100% in 2010, 80% to 100% in 2011, and 90 to 100% in 2012.
From our experience, it is feasible to set-up a BSL-3 TB culture laboratory with acceptable quality performance standards in resource-limited countries. With the demonstrated quality of work, the laboratory attracted more research groups and post-pioneer funding, which helped to ensure sustainability. The high skilled experts in this research laboratory also continue to provide an excellent resource for the needed national discussion of the laboratory and quality management systems.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-13-4) contains supplementary material, which is available to authorized users.
PMCID: PMC4326287  PMID: 25589057
Acceptable quality standards; Biosafety level 3; Feasibility; Resource limited countries; TB culture
5.  How long does biomedical research take? Studying the time taken between biomedical and health research and its translation into products, policy, and practice 
The time taken, or ‘time lags’, between biomedical/health research and its translation into health improvements is receiving growing attention. Reducing time lags should increase rates of return to such research. However, ways to measure time lags are under-developed, with little attention on where time lags arise within overall timelines. The process marker model has been proposed as a better way forward than the current focus on an increasingly complex series of translation ‘gaps’. Starting from that model, we aimed to develop better methods to measure and understand time lags and develop ways to identify policy options and produce recommendations for future studies.
Following reviews of the literature on time lags and of relevant policy documents, we developed a new approach to conduct case studies of time lags. We built on the process marker model, including developing a matrix with a series of overlapping tracks to allow us to present and measure elements within any overall time lag. We identified a reduced number of key markers or calibration points and tested our new approach in seven case studies of research leading to interventions in cardiovascular disease and mental health. Finally, we analysed the data to address our study’s key aims.
The literature review illustrated the lack of agreement on starting points for measuring time lags. We mapped points from policy documents onto our matrix and thus highlighted key areas of concern, for example around delays before new therapies become widely available. Our seven completed case studies demonstrate we have made considerable progress in developing methods to measure and understand time lags. The matrix of overlapping tracks of activity in the research and implementation processes facilitated analysis of time lags along each track, and at the cross-over points where the next track started. We identified some factors that speed up translation through the actions of companies, researchers, funders, policymakers, and regulators. Recommendations for further work are built on progress made, limitations identified and revised terminology.
Our advances identify complexities, provide a firm basis for further methodological work along and between tracks, and begin to indicate potential ways of reducing lags.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-13-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4297458  PMID: 25552353
Basic research; Clinical guidelines; Discovery research; Economic impact of research; Human research; Pharmaceutical industry; Process marker model; Regulatory approval; Time lags; Timelines
6.  Does health intervention research have real world policy and practice impacts: testing a new impact assessment tool 
There is a growing emphasis on the importance of research having demonstrable public benefit. Measurements of the impacts of research are therefore needed. We applied a modified impact assessment process that builds on best practice to 5 years (2003–2007) of intervention research funded by Australia’s National Health and Medical Research Council to determine if these studies had post-research real-world policy and practice impacts.
We used a mixed method sequential methodology whereby chief investigators of eligible intervention studies who completed two surveys and an interview were included in our final sample (n = 50), on which we conducted post-research impact assessments. Data from the surveys and interviews were triangulated with additional information obtained from documentary analysis to develop comprehensive case studies. These case studies were then summarized and the reported impacts were scored by an expert panel using criteria for four impact dimensions: corroboration; attribution, reach, and importance.
Nineteen (38%) of the cases in our final sample were found to have had policy and practice impacts, with an even distribution of high, medium, and low impact scores. While the tool facilitated a rigorous and explicit criterion-based assessment of post-research impacts, it was not always possible to obtain evidence using documentary analysis to corroborate the impacts reported in chief investigator interviews.
While policy and practice is ideally informed by reviews of evidence, some intervention research can and does have real world impacts that can be attributed to single studies. We recommend impact assessments apply explicit criteria to consider the corroboration, attribution, reach, and importance of reported impacts on policy and practice. Impact assessments should also allow sufficient time between impact data collection and completion of the original research and include mechanisms to obtain end-user input to corroborate claims and reduce biases that result from seeking information from researchers only.
PMCID: PMC4292987  PMID: 25552272
Intervention research; Policy; Research impact; Research translation
7.  Climate for evidence informed health system policymaking in Cameroon and Uganda before and after the introduction of knowledge translation platforms: a structured review of governmental policy documents 
There is a scarcity of empirical data on African country climates for evidence-informed health system policymaking (EIHSP) to backup the longstanding reputation that research evidence is not valued enough by health policymakers as an information input.
Herein, we assess whether and how changes have occurred in the climate for EIHSP before and after the establishment of two Knowledge Translation Platforms housed in government institutions in Cameroon and Uganda since 2006.
We merged content analysis techniques and policy sciences analytical frameworks to guide this structured review of governmental policy documents geared at achieving health Millennium Development Goals. We combined i) a quantitative exploration of the usage statistics of research-related words and constructs, citations of types of evidence, and budgets allocated to research-related activities; and (ii) an interpretive exploration using a deductive thematic analysis approach to uncover changes in the institutions, interests, ideas, and external factors displaying the country climate for EIHSP. Descriptive statistics compared quantitative data across countries during the periods 2001–2006 and 2007–2012.
We reviewed 54 documents, including 33 grants approved by global health initiatives. The usage statistics of research-related words and constructs showed an increase over time across countries. Varied forms of data, information, or research were instrumentally used to describe the burden and determinants of poverty and health conditions. The use of evidence syntheses to frame poverty and health problems, select strategies, or forecast the expected outcomes has remained sparse over time and across countries. The budgets for research increased over time from 28.496 to 95.467 million Euros (335%) in Cameroon and 38.064 to 58.884 million US dollars (155%) in Uganda, with most resources allocated to health sector performance monitoring and evaluation. The consistent naming of elements pertaining to the climate for EIHSP features the greater influence of external donors through policy transfer.
This structured review of governmental policy documents illustrates the nascent conducive climate for EIHSP in Cameroon and Uganda and the persistent undervalue of evidence syntheses. Global and national health stakeholders should raise the profile of evidence syntheses (e.g., systematic reviews) as an information input when shaping policies and programmes.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-13-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4298114  PMID: 25552196
Cameroon; Climate for evidence informed health system policymaking; Content analysis; Governance; Health systems; Knowledge translation platform; Low- and middle-income countries; Policy sciences analytical framework; Structured documentary review; Uganda
8.  Needs assessment to strengthen capacity in water and sanitation research in Africa: experiences of the African SNOWS consortium 
Despite its contribution to global disease burden, diarrhoeal disease is still a relatively neglected area for research funding, especially in low-income country settings. The SNOWS consortium (Scientists Networked for Outcomes from Water and Sanitation) is funded by the Wellcome Trust under an initiative to build the necessary research skills in Africa. This paper focuses on the research training needs of the consortium as identified during the first three years of the project.
We reviewed the reports of two needs assessments. The first was a detailed needs assessment led by one northern partner, with follow-up visits which included reciprocal representation from the African universities. The second assessment, led by another northern partner, focused primarily on training needs. The reports from both needs assessments were read and stated needs were extracted and summarised.
Key common issues identified in both assessments were supervisory skills, applications for external research funding, research management, and writing for publication in the peer-reviewed scientific literature. The bureaucratisation of university processes and inconsistencies through administration processes also caused problems. The lack of specialist laboratory equipment presented difficulties, particularly of inaccessibility through a lack of skilled staff for operation and maintenance, and of a budget provision for repairs and running costs. The lack of taught PhD modules and of research training methods also caused problems. Institutionally, there were often no mechanisms for identifying funding opportunities. On the other hand, grantees were often unable to understand or comply with the funders’ financial and reporting requirements and were not supported by their institution. Skills in staff recruitment, retention, and performance were poor, as were performance in proposal and paper writing. The requirements for ethical clearance were often not known and governance issues not understood, particularly those required by funders.
SNOWS believes that working with African universities to develop networks that support African-led research driven by the local context is an effective approach to develop and retain research skills needed to change policy and practice in water, sanitation, and hygiene in Africa.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-12-68) contains supplementary material, which is available to authorized users.
PMCID: PMC4274706  PMID: 25510403
Research; Water; Sanitation; Training; Water
9.  Health systems and policy research evidence in health policy making in Israel: what are researchers’ practices in transferring knowledge to policy makers? 
Ensuring the use of research evidence in health system management and policy decisions is an important challenge in this century. Knowledge transfer and exchange (KTE) has emerged as a paradigm to address the challenges and start closing the ‘know-do’ gap. This area of work is gaining momentum in most developed countries, yet, to date, no work has been performed in Israel within this area. The purpose of this study was to identify which KTE activities health systems and policy researchers in Israel have undertaken.
A cross-sectional web-based survey of researchers who have conducted health systems and policy research in Israel was developed. The survey consisted of a demographics section, quantitative scales, and open-ended questions. The survey was sent to all health systems and policy researchers in Israel (n = 125).
The study response rate (28%) was relatively low as compared to other studies in the same field (range of 42% to 88%). Our survey found that more than a third of the health systems and policy researchers in Israel reported that they were frequently or always involved in the following KTE activities: interactions with target audience through the research process (i.e., during developing a research question or executing the research; 35% to 42%) or through formal or informal meetings during conferences, workshops, or conversations (40%). Less than half of the health systems and policy researchers in Israel are engaged in bridging activities aimed to facilitate target audiences to use research.
This is a fairly new area in Israel and therefore the level of engagement of researchers in KTE activities is not very high. The low response rates could be because KTE is a new field in Israel and minimal KTE initiatives have been undertaken. It is preferable to have higher response rates, yet, after several initiatives, this was the outcome. While the findings are relevant, they may not reflect the total population of health system and policy researchers in Israel. Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of KTE in an organized and systematic way.
PMCID: PMC4269930  PMID: 25491890
Health systems and policy; Knowledge transfer and exchange; Researchers; Survey
10.  A systematic review of Health Technology Assessment tools in sub-Saharan Africa: methodological issues and implications 
Health technology assessment (HTA) is mostly used in the context of high- and middle-income countries. Many “resource-poor” settings, which have the greatest need for critical assessment of health technology, have a limited basis for making evidence-based choices. This can lead to inappropriate use of technologies, a problem that could be addressed by HTA that enables the efficient use of resources, which is especially crucial in such settings. There is a lack of clarity about which HTA tools should be used in these settings. This research aims to provide an overview of proposed HTA tools for “resource-poor” settings with a specific focus on sub-Saharan Africa (SSA).
A systematic review was conducted using basic steps from the PRISMA guidelines. Studies that described HTA tools applicable for “resource-limited” settings were identified and critically appraised. Only papers published between 2003 and 2013 were included. The identified tools were assessed according to a checklist with methodological criteria.
Six appropriate tools that are applicable in the SSA setting and cover methodological robustness and ease of use were included in the review. Several tools fulfil these criteria, such as the KNOW ESSENTIALS tool, Mini-HTA tool, and Multi-Criteria Decision Analysis but their application in the SSA context remains limited. The WHO CHOICE method is a standardized decision making tool for choosing interventions but is limited to their cost-effectiveness. Most evaluation of health technology in SSA focuses on priority setting. There is a lack of HTA tools that can be used for the systematic assessment of technology in the SSA context.
An appropriate HTA tool for “resource-constrained” settings, and especially SSA, should address all important criteria of decision making. By combining the two most promising tools, KNOW ESSENTIALS and Multi-Criteria Decision Analysis, appropriate analysis of evidence with a robust and flexible methodology could be applied for the SSA setting.
PMCID: PMC4265527  PMID: 25466570
Health services; Health systems; Health systems research
11.  How has child maltreatment surveillance data been used in Canada? 
Recently, a survey was performed as part of a larger study at the Public Health Agency of Canada (PHAC) to develop and pilot a series of tools to measure the uptake and use of PHAC-produced or -supported knowledge products by its key partners and stakeholders. This article aims to i) examine the uptake and use of the Canadian Incidence Study of Reported Child Abuse and Neglect 2008 (CIS-2008) and to ii) assess the utility of a knowledge uptake survey for collecting performance measurement data.
Using the knowledge utilization ladder as a theoretical framework, a short survey was developed around the themes of reception, cognition, conversation, reference, effort, influence, and implementation. The survey was administered electronically to potential end-users of the CIS-2008. The final sample comprised 85 respondents.
The results demonstrated that the majority of the respondents were aware of CIS-2008 and had read and used it. A wide array of disciplines and sectors were identified as end-users. Types of use included discussion of CIS data with social workers, child welfare and health advocates, students, medical and legal professionals, and senior government decision makers. Further, CIS was referenced in reports, articles, policy research, community programs, and funding proposals and was used to influence or support the development of policies, programs, and projects. Valuable information on the use of surveillance reports, such as CIS-2008, can be gathered from a brief survey that was easy to administer, cost effective, and that respondents needed minimal time to complete.
Piloting of the survey demonstrated that the tool, while not perfect, is quite useful for capturing performance measurement information; CIS-2008 is appreciated and used. There is an increased recognition of the importance of the CIS as a unique source of Canadian child maltreatment surveillance data that can influence and lead to the implementation of new programs and policies. Although suggestions for improvement of the CIS-2008 were provided, the present findings offer support for ongoing national child maltreatment surveillance.
PMCID: PMC4266949  PMID: 25430613
Child maltreatment; Data collection; Knowledge uptake; Performance measurement; Research utilization; Surveillance
12.  Are the Norwegian health research investments in line with the disease burden? 
The relationship between research funding across therapeutic areas and the burden of disease in Norway has not been investigated. Further, few studies have looked at the association between national research investments and the global disease burden. The aim of the present study was to analyze the correlation between a significant part of Norwegian investment in health research and the burden of disease across therapeutic areas, using both Norwegian and global burden of disease estimates.
We used research investment records for 2012 from the Research Council of Norway, and the investment records distributed through liaison committees between regional health authorities and universities. Both were classified by the Health Research Classification System (HRCS). Furthermore, we used the years of life lost and Disability Adjusted Life Years (DALYs) for Norway and globally from the Global Burden of Disease 2010 project. We created a matrix to match the expenditures by HRCS with the values from the Global Burden of Disease project.
Disease-specific research funding increased with the Norwegian burden of disease measured as years of life lost (correlation coefficient = 0.73). Similar findings were done when the Norwegian disease burden was measured as DALYs (correlation coefficient = 0.62). The correlation between research funding and the global disease burden was low both when years of life lost (correlation coefficient = 0.11) and DALYs (correlation coefficient = 0.12) were used. Generally, when the disease burden was relatively high in Norway compared with the rest of the world, research investments were also high.
Across therapeutic areas, the Norwegian research investments appeared aligned with the Norwegian disease burden. The correlation between the Norwegian research investments and the global disease burden was much lower.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-12-64) contains supplementary material, which is available to authorized users.
PMCID: PMC4256793  PMID: 25427859
Disability adjusted life years; Global health; Health research; Norway; Research funding; Years of life lost
13.  How can we establish more successful knowledge networks in developing countries? Lessons learnt from knowledge networks in Iran 
Formal knowledge networks are considered among the solutions for strengthening knowledge translation and one of the elements of innovative systems in developing and developed countries. In the year 2000, knowledge networks were established in Iran’s health system to organize, lead, empower, and coordinate efforts made by health-related research centers in the country. Since the assessment of a knowledge network is one of the main requirements for its success, the current study was designed in two qualitative and quantitative sections to identify the strengths and weaknesses of the established knowledge networks and to assess their efficiency.
In the qualitative section, semi-structured, in-depth interviews were held with network directors and secretaries. The interviews were analyzed through the framework approach. To analyze effectiveness, social network analysis approach was used. That is, by considering the networks’ research council members as ‘nodes’, and the numbers of their joint articles - before and after the network establishments - as ‘relations or ties’, indices of density, clique, and centrality were calculated for each network. In the qualitative section, non-transparency of management, lack of goals, administrative problems were among the most prevalent issues observed.
Currently, the most important challenges are the policies related to them and their management. In the quantitative section, we observed that density and clique indices had risen for some networks; however, the centrality index for the same networks was not as high. Consequently the attribution of density and clique indices to these networks was not possible.
Therefore, consolidating and revising policies relevant to the networks and preparing a guide for establishing managing networks could prove helpful. To develop knowledge and technology in a country, networks need to solve the problems they face in management and governance. That is, the first step towards the realization of true knowledge networks in health system.
PMCID: PMC4233097  PMID: 25354533
Knowledge network; Evaluation; Health management organization; Iran
14.  A decade of investments in monitoring the HIV epidemic: how far have we come? A descriptive analysis 
The 2001 Declaration of Commitment (DoC) adopted by the General Assembly Special Session on HIV/AIDS (UNGASS) included a call to monitor national responses to the HIV epidemic. Since the DoC, efforts and investments have been made globally to strengthen countries’ HIV monitoring and evaluation (M&E) capacity. This analysis aims to quantify HIV M&E investments, commitments, capacity, and performance during the last decade in order to assess the success and challenges of national and global HIV M&E systems.
M&E spending and performance was assessed using data from UNGASS country progress reports. The National Composite Policy Index (NCPI) was used to measure government commitment, government engagement, partner/civil society engagement, and data generation, as well as to generate a composite HIV M&E System Capacity Index (MESCI) score. Analyses were restricted to low and middle income countries (LMICs) who submitted NCPI reports in 2006, 2008, and 2010 (n =78).
Government commitment to HIV M&E increased considerably between 2006 and 2008 but decreased between 2008 and 2010. The percentage of total AIDS spending allocated to HIV M&E increased from 1.1% to 1.4%, between 2007 and 2010, in high-burden LMICs. Partner/civil society engagement and data generation capacity improved between 2006 and 2010 in the high-burden countries. The HIV MESCI increased from 2006 to 2008 in high-burden countries (78% to 94%), as well as in other LMICs (70% to 77%), and remained relatively stable in 2010 (91% in high-burden countries, 79% in other LMICs). Among high-burden countries, M&E system performance increased from 52% in 2006 to 89% in 2010.
The last decade has seen increased commitments and spending on HIV M&E, as well as improved M&E capacity and more available data on the HIV epidemic in both high-burden and other LMICs. However, challenges remain in the global M&E of the AIDS epidemic as we approach the 2015 Millennium Development Goal targets.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-12-62) contains supplementary material, which is available to authorized users.
PMCID: PMC4210584  PMID: 25322764
AIDS spending; United Nations General Assembly Special Session on HIV/AIDS (UNGASS); HIV; Monitoring and evaluation; National Composite Policy Index
15.  Public reporting improves antibiotic prescribing for upper respiratory tract infections in primary care: a matched-pair cluster-randomized trial in China 
Inappropriate use and overuse of antibiotics is a serious concern in the treatment of upper respiratory tract infections (URTIs), especially in developing countries. In recent decades, information disclosure and public reporting (PR) has become an instrument for encouraging good practice in healthcare. This study evaluated the impact of PR on antibiotic prescribing for URTIs in a sample of primary care institutions in China.
A matched-pair cluster-randomized trial was undertaken in QJ city, with 20 primary care institutions participating in the trial. Participating institutions were matched into pairs before being randomly assigned into a control and an intervention group. Prescription statistics were disclosed to patients, health authorities, and health workers monthly within the intervention group, starting from October 2013. Outpatient prescriptions for URTIs were collected from both groups before (1st March to 31st May, 2013) and after the intervention (1st March to 31st May, 2014). A total of 34,815 URTI prescriptions were included in a difference-in-difference analysis using multivariate linear or logistic regression models, controlling for patient attributes as well as institutional characteristics.
Overall, 90% URTI prescriptions required antibiotics and 21% required combined use of antibiotics. More than 77% of URTI prescriptions required intravenous (IV) injection or infusion of drugs. PR resulted in a 9 percentage point (95% CI -17 to -1) reduction in the use of oral antibiotics (adjusted RR =39%, P =0.027), while the use of injectable antibiotics remained unchanged. PR led to a 7 percentage point reduction (95% CI -14 to 0; adjusted RR =36%) in combined use of antibiotics (P =0.049), which was largely driven by a significant reduction in male patients (-7.5%, 95% CI -14 to -1, P =0.03). The intervention had little impact on the use of IV injections or infusions, or the total prescription expenditure.
The results suggest that PR could improve prescribing practices in terms of reducing oral antibiotics and combined use of antibiotics; however, the impacts were limited. We suggest that PR would probably be enhanced by provider payment reform, management and training for providers, and health education for patients.
PMCID: PMC4197333  PMID: 25304996
Antibiotics; China; Primary care; Public reporting; Upper respiratory tract infection
16.  Does knowledge of danger signs of pregnancy predict birth preparedness? A critique of the evidence from women admitted with pregnancy complications 
Improved knowledge of obstetric danger signs, birth preparedness practices, and readiness for emergency complications are among the strategies aimed at both enhancing utilization of maternal health services and increasing access to skilled care during childbirth, particularly for women with obstetric complications. It is unclear whether knowledge of danger signs translates into improved birth preparedness and complication readiness. The objective was to assess the association between knowledge of danger signs and birth preparedness among women admitted with pregnancy complications.
The study included 810 women admitted in the antepartum period to Mulago hospital, Uganda. Data was collected on socio-demographic characteristics, reproductive history, pregnancy complications, knowledge of danger signs, and birth preparedness/complication readiness (BPCR). Logistic regression analyses were conducted to explore the relationship between knowledge of danger signs and birth preparedness.
Only about 1 in 3 women were able to mention at least three of the five basic components of BPCR, and could be regarded as ‘knowledgeable on BPCR’. One in every 4 women could not mention any of the five components. Women with history of obstetric problems during the previous pregnancy were more likely to be knowledgeable on danger signs when compared to those who had no complications in prior pregnancy. Women who were knowledgeable on danger signs were four times more likely to be knowledgeable on BPCR as compared to those who were not knowledgeable.
Though awareness about danger signs was low, knowledge of danger signs was associated with knowledge of birth preparedness. More emphasis should be given to emergency/complication readiness during antenatal care sessions. There is a need to strengthen existing policy interventions to address birth preparedness and complication readiness for obstetric emergencies.
PMCID: PMC4197291  PMID: 25300499
Pregnancy; Childbirth; Knowledge about danger signs; Birth preparedness; Complication readiness; Maternal near miss
17.  A new methodology for assessing health policy and systems research and analysis capacity in African universities 
The importance of health policy and systems research and analysis (HPSR + A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR + A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening.
The Consortium for Health Policy and Systems Analysis in Africa 2011–2015 designed and implemented a new framework for capacity assessment for HPSR + A within universities. The methodology is reported in detail.
Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR + A that focus solely on universities – we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR + A, the unit of assessment can be a challenge, because HPSR + A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity.
From our experience, we propose that future systematic assessments of HPSR + A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR + A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening.
PMCID: PMC4210597  PMID: 25296935
18.  Handling incidental findings in neuroimaging research in Japan: current state of research facilities and attitudes of investigators and the general population 
To establish appropriate measures that deal with incidental findings (IFs), the neuroscience community needs to address various ethical issues. The current state of research facilities regarding IFs and investigator attitudes as well as potentially eligible research participants must be assessed prior to future discussions and before the development of policies and guidelines. To this end, we conducted two questionnaire surveys to clarify i) how IFs are addressed at neuroimaging research facilities in Japan and ii) the views of investigators and potential research participants regarding the handling of IFs.
Thirty-one principal investigators (PIs) involved in the Strategic Research Program for Brain Sciences (SRPBS), a government-funded project, were asked to fill out a questionnaire regarding ways IFs were handled at the facility. A total of 110 investigators engaged in SRPBS tasks, including 31 PIs who participated in the research facility survey and researchers conducting studies under the management of the PIs, and 500 individuals from the general public (i.e., general population) were asked to select the most appropriate way to deal with IFs in two scenarios, namely the medical school and humanities and social sciences department scenarios.
More than 40% of PIs responded that they did not know or were unsure of what type of approach was employed to handle IFs at their research facilities. Nevertheless, they were willing to improve the current status if sufficient resources were provided. With regard to specialist involvement, 37.7% of investigators responded that it was appropriate to have a specialist check all images in the medical school scenario, whereas 13.3% responded that such involvement was appropriate in the humanities and social sciences department scenario. In contrast, 76.1% and 61.0% of the general population indicated that specialist involvement was appropriate in the medical school and humanities and social sciences department scenarios, respectively. These results show that expectations of the general population exceed those of investigators regarding measures to address IFs. Both investigators and the general population demanded more responsibility from PIs at medical institutions, compared to PIs at non-medical institutions.
Based on our preliminary results, we recommended that a licensed physician perform a screening test to appropriately examine clear abnormalities. These recommendations were implemented by the SRPBS as guidelines for handling IFs in national research projects in Japan.
PMCID: PMC4195876  PMID: 25287578
General population; Incidental findings; Investigators; Japan; Neuroimaging; Questionnaires
19.  Assessment of new public management in health care: the French case 
The French health care system embraced New Public Management (NPM) selectively, and crafted their own version of NPM using Diagnostic-Related-Group accounting to re-centralize the health care system. Other organizational changes include the adoption of quasi-markets, public private partnerships, and pay-for-performance schemes for General Practitioners. There is little evidence that these improved the performance of the system. Misrepresentation has remained high. With the 2009 Hospital, Patients, Health and Territories Act physician participation in hospital governance receded. Decision-making powers and health units were re-concentrated to instill greater national coherence into the health system.
PMCID: PMC4271340  PMID: 25283813
Centralization; France; Hospitals; New public management
20.  Four centuries on from Bacon: progress in building health research systems to improve health systems? 
In 1627, Francis Bacon’s New Atlantis described a utopian society in which an embryonic research system contributed to meeting the needs of the society. In this editorial, we use some of the aspirations described in New Atlantis to provide a context within which to consider recent progress in building health research systems to improve health systems and population health. In particular, we reflect on efforts to build research capacity, link research to policy, identify the wider impacts made by the science, and generally build fully functioning research systems to address the needs identified.
In 2014, Health Research Policy and Systems has continued to publish one-off papers and article collections covering a range of these issues in both high income countries and low- and middle-income countries. Analysis of these contributions, in the context of some earlier ones, is brought together to identify achievements, challenges and possible ways forward. We show how 2014 is likely to be a pivotal year in the development of ways to assess the impact of health research on policies, practice, health systems, population health, and economic benefits.
We demonstrate how the increasing focus on health research systems will contribute to realising the hopes expressed in the World Health Report, 2013, namely that all nations would take a systematic approach to evaluating the outputs and applications resulting from their research investment.
PMCID: PMC4180841  PMID: 25249030
Collaborative approach; Health research system; Health systems; Payback framework; Research agenda setting; Research capacity; Research impacts; Research to policy; Value of medical research; World Health Report
21.  Health policy – why research it and how: health political science 
The establishment of policy is key to the implementation of actions for health. We review the nature of policy and the definition and directions of health policy. In doing so, we explicitly cast a health political science gaze on setting parameters for researching policy change for health. A brief overview of core theories of the policy process for health promotion is presented, and illustrated with empirical evidence.
The key arguments are that (a) policy is not an intervention, but drives intervention development and implementation; (b) understanding policy processes and their pertinent theories is pivotal for the potential to influence policy change; (c) those theories and associated empirical work need to recognise the wicked, multi-level, and incremental nature of elements in the process; and, therefore, (d) the public health, health promotion, and education research toolbox should more explicitly embrace health political science insights.
The rigorous application of insights from and theories of the policy process will enhance our understanding of not just how, but also why health policy is structured and implemented the way it is.
PMCID: PMC4246431  PMID: 25248956
Juggling; Policy; Politics; Theory
22.  Features of successful bids for funding of applied health research: a cohort study 
The literature suggests that research funding decisions may be influenced by criteria such as gender or institution of the principal investigator (PI). The aim of this study was to investigate the association between characteristics of funding applications and success when considered by a research funding board.
We selected a retrospective cohort of 296 outline applications for primary research (mainly pragmatic clinical trials) submitted to the commissioning board of the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme between January 1st 2006 and December 31st 2009. We selected proposals submitted to the commissioned NIHR HTA work stream as they addressed issues which the programme already deemed to be important, hence the priority of the research question was not considered as one of the selection criteria for success or failure. Main outcome measures were success or failure at short-listing and in obtaining research funding.
The characteristics of applications associated with success at shortlisting and funding were multi-disciplinarity of the team (OR 19.94 [5.13, 77.50], P <0.0001), particularly inclusion of a statistician (OR 3.76 [2.21, 6.37], P <0.0001), and the completion of a pilot/feasibility study (OR 4.11 [1.24, 13.62], P = 0.0209). The gender of the PI was not associated with success or failure at either stage. The PI’s affiliation institution was not associated with success or failure at shortlisting.
The gender of the PI was not associated with success or failure. The characteristics of research applications most strongly associated with success were related to the range of expertise in the team and the completion of a pilot or feasibility study.
PMCID: PMC4180128  PMID: 25245823
Funding applications; Health technology assessment; Primary research; Research funding
23.  Developing recommendations to improve the quality of diabetes care in Ireland: a policy analysis 
In 2006, the Health Service Executive (HSE) in Ireland established an Expert Advisory Group (EAG) for Diabetes, to act as its main source of operational policy and strategic advice for this chronic condition. The process was heralded as the starting point for the development of formal chronic disease management programmes. Although recommendations were published in 2008, implementation did not proceed as expected. Our aim was to examine the development of recommendations by the EAG as an instrumental case study of the policy formulation process, in the context of a health system undergoing organisational and financial upheaval.
This study uses Kingdon’s Multiple Streams Theory to examine the evolution of the EAG recommendations. Semi-structured interviews were conducted with a purposive sample of 15 stakeholders from the advisory group. Interview data were supplemented with documentary analysis of published and unpublished documents. Thematic analysis was guided by the propositions of the Kingdon model.
In the problem stream, the prioritisation of diabetes within the policy arena was a gradual process resulting from an accumulation of evidence, international comparison, and experience. The policy stream was bolstered by group consensus rather than complete agreement on the best way to manage the condition. The EAG assumed the politics stream was also on course to converge with the other streams, as the group was established by the HSE, which had the remit for policy implementation. However, the politics stream did not converge due to waning support from health service management and changes to the organisational structure and financial capacity of the health system. These changes trumped the EAG process and the policy window remained closed, stalling implementation.
Our results reflect the dynamic nature of the policy process and the importance of timing. The results highlight the limits of rational policy making in the face of organisational and fiscal upheaval. Diabetes care is coming on to the agenda again in Ireland under the National Clinical Care Programme. This may represent the opening of a new policy window for diabetes services, the challenge will be maintaining momentum and interest in the absence of dedicated resources.
Electronic supplementary material
The online version of this article (doi:10.1186/1478-4505-12-53) contains supplementary material, which is available to authorized users.
PMCID: PMC4177249  PMID: 25231603
Health care reform; Policy analysis; Quality of care; Type 2 diabetes mellitus
24.  The making of nursing practice Law in Lebanon: a policy analysis case study 
Evidence-informed decisions can strengthen health systems, improve health, and reduce health inequities. Despite the Beijing, Montreux, and Bamako calls for action, literature shows that research evidence is underemployed in policymaking, especially in the East Mediterranean region (EMR). Selecting the draft nursing practice law as a case study, this policy analysis exercise aims at generating in-depth insights on the public policymaking process, identifying the factors that influence policymaking and assessing to what extent evidence is used in this process.
This study utilized a qualitative research design using a case study approach and was conducted in two phases: data collection and analysis, and validation. In the first phase, data was collected through key informant interviews that covered 17 stakeholders. In the second phase, a panel discussion was organized to validate the findings, identify any gaps, and gain insights and feedback of the panelists. Thematic analysis was conducted and guided by the Walt & Gilson’s “Policy Triangle Framework” as themes were categorized into content, actors, process, and context.
Findings shed light on the complex nature of health policymaking and the unstructured approach of decision making. This study uncovered the barriers that hindered the progress of the draft nursing law and the main barriers against the use of evidence in policymaking. Findings also uncovered the risk involved in the use of international recommendations without the involvement of stakeholders and without accounting for contextual factors and implementation barriers. Findings were interpreted within the context of the Lebanese political environment and the power play between stakeholders, taking into account equity considerations.
This policy analysis exercise presents findings that are helpful for policymakers and all other stakeholders and can feed into revising the draft nursing law to reach an effective alternative that is feasible in Lebanon. Our findings are relevant in local and regional context as policymakers and other stakeholders can benefit from this experience when drafting laws and at the global context, as international organizations can consider this case study when developing global guidance and recommendations.
PMCID: PMC4163164  PMID: 25193112
Evidence-informed policymaking; Lebanon; Nursing law; Policy analysis
25.  The application of systems thinking in health: why use systems thinking? 
This paper explores the question of what systems thinking adds to the field of global health. Observing that elements of systems thinking are already common in public health research, the article discusses which of the large body of theories, methods, and tools associated with systems thinking are more useful. The paper reviews the origins of systems thinking, describing a range of the theories, methods, and tools. A common thread is the idea that the behavior of systems is governed by common principles that can be discovered and expressed. They each address problems of complexity, which is a frequent challenge in global health. The different methods and tools are suited to different types of inquiry and involve both qualitative and quantitative techniques. The paper concludes by emphasizing that explicit models used in systems thinking provide new opportunities to understand and continuously test and revise our understanding of the nature of things, including how to intervene to improve people’s health.
PMCID: PMC4245196  PMID: 25160707
Complex adaptive systems; Complexity; Methods; Systems thinking; Theory; Tools

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