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Research is Ghana’s front line

30 October 2008, 22:14

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by Robert Walgate

Since the early 1990s Ghana has been blessed by a series of visionaries who saw an urgent need to gather evidence to improve health decisions – and to engage the universities in providing it. Sam Adjei, former Deputy Director-General of Ghana’s Health Services, Irene Agyepong, Regional Director of Health Services for Greater Accra, and Major (rtd) Courage Quashigah, Health Minister, tell Robert Walgate the story.

Depuis le début des années 1990, le Ghana a eu la chance de compter plusieurs visionnaires qui ont compris qu’il était urgent de réunir des données solides pour améliorer les décisions entourant la santé et de convaincre les universités de le faire. Sam Adjei, Directeur-général adjoint des Services de santé du Ghana, Irene Agyepong, Directrice régionale des Services de santé d’Accra et le Major Courage Quashigah, Ministre de la santé, nous en parlent.

“Our Minister of Health is very enthusiastic about research. He says it all the time. He is a military man and he is always talking about research as if it is getting information about your enemy so that you can attack him and defend yourself”, Sam Adjei, former Deputy Director-General of Ghana’s Health Services, told RealHealthNews.

“Natural scientists can only tell us what happens physically. But delivering effective interventions requires much more. We need to understand how diseases originate in the context of peoples’ living conditions and lifestyles.”

MINISTER MAJOR (rtd) COURAGE QUASHIGAH

So what research does Major (rtd) Courage Quashigah, Health Minister of Ghana, want? “Natural scientists can only tell us what happens [physically]. But delivering effective interventions requires much more” he said in an address to other African health ministers. “We need to understand how diseases originate in the context of peoples’ living conditions and lifestyles.”

“Health policy formulators must recognize that peoples’ ideas and practices concerning health and illness, as well as social and cultural conditions leading to illness, are critical in the design of interventions.”

African traditional medicine has been“shrouded in mysticism”, but “our success in research and development of traditional medicine will probably be the best contribution that the health sector can make to the economic development of the developing world”.

“We also have deficiencies in health systems – which receive little or no attention from international and local research institutions” said Quashigah. “Infection control in our health facilities; integration of health information systems; and improving efficiency in the use of resources available in the public and private health sectors” need to be studied. Africa needs “to focus on research that improves the functioning of the health system as a whole”.

READ ON: Speech of Minister Major (rtd) Courage Quashigah, RealHealthNews No6 page 4

Quashigah praised Ghana’s “very good initiatives in this direction”. The country’s Community-Based Health Planning and Services Initiative (CHPS), “which is now a major strategy for improving access to basic health services”, was a result of one such piece of research, he said. “But the fact remains that judging from the magnitude of the problem this is still under-resourced.”

In Ghana, the Minister’s vision is not isolated. According to Sam Adjei, it goes back to the 1990s. “The Director of Medical Services, Moses Adibo, was concerned that he wasn’t getting the kinds of answers he was looking for, for the questions he had in mind, and that university research wasn’t quite responding to his needs. So, what he did was to ask me to try and address that by developing research capacity with the Ministry of Health. The goal was to get the information that he required for policy decisions.”

“It was a challenge. I had to develop a process by which the Ministry, the public sector health policymakers, could articulate their needs to a broad constituency of people including academic researchers, private researchers, and non-governmental researchers so that at least they know the kind of problems we are confronted with.”

“So we started holding annual priority setting meetings for research. All the programme people in strategic positions came to a 2-3 day meeting with the researchers, and we brainstormed and came up with a research agenda for the year” Adjei told RealHealthNews.

These meetings now continue each year. “What we try to do is to fit all the questions, and all the research, within the framework of the Ministry’s policy documents and strategic plan.” Issues such as access to health, health finance, and the quality and efficiency and partnership across the health sector, are frequently raised. “And each year now we have discussions and dialogues with the researchers and with the programme people about these issues.”

Even in the annual Ministry of Health and Partners Summit, where finance and policy decisions are taken, research questions come up, “and they are captured and brought back to the research priority setting meeting”.

>RealHealthNews: This sounds ideal. I can’t believe that many countries in Africa have got this kind of setup.

SAM ADJEI: Unfortunately not. When we started off in 1990 it wasn’t there, and it took a bit of time to develop. It took almost three years to get it started, get it moving.

>RHN: How did you manage to get the different sides to take an interest in this, the researchers and then the policymakers?

“There were these top-level researchers in the room, my professors in medical school, who were basically saying how dare you talk about research from a Ministry policy perspective! That is not your core job, that is not your responsibility.”

SAM ADJEI

SA: Well, it wasn’t easy. The first time we had a meeting it was a much smaller meeting. It wasn’t as big as it is now. There were perhaps 20 or 25 people with the researchers. It wasn’t a very easy meeting. I still remember it very clearly. There were these top-level researchers in the room, my professors in medical school, who were basically saying how dare you talk about research from a Ministry policy perspective! That is not your core job, that is not your responsibility. You have no role in research, they said. Our job as academicians is to do the research and then it’s up to you to go and apply the knowledge.

The Director of Medical Services kept saying that’s true, but let us at least articulate the problem that we are faced with, and you can pick it up and respond to a problem if you want us to use it in your research.

And secondly, he said, you publish your research in high-powered peer review journals that are not accessible to us. They are rich in language that half of the time we are too busy to digest and make sense of.

So, it was a very tough meeting the first time we tried it! And then we tried a second time. Some people at the operational level had done research [outside the university system] to respond to their problems at a district and provincial level, so I got them to make presentations. So the top-level researcher said oh, you mean these people from the district and region did this? And we said yes. They said oh, and they began to have some respect for what the people at the operational level were doing!

SEE BOX: Irene Agyepong: people matter – the need for coalitions

So we built our needs slowly and after three years we started solidifying regular meetings between us and them, and even more interestingly we started running proposal development workshops, because it was obvious that the type of research that the university was doing was not in line of health systems or health policy and they acknowledged that we needed skills in that area.

WHO had health systems proposal development manuals, so we introduced those into the system, and invited the people from the university. Reluctantly some of them came. I remember one of them came – a head of department, a well-known professor – and he said look, it is a disgrace for a university person to go to a research workshop set up by the Ministry of Health! [Sam Adjei laughs.]

But the [more junior] university guys said oh well, we don’t care where we get knowledge from. Here we are, we know we are deficient in this. At that time personal computers were coming up. Some had bought PCs, but they had no clue how to use them. We said we will offer you training in how to use the computers to analyse your data, and they were excited about that. So we got computer experts to come to the workshop and train them and everybody was very happy.

So on the last day, when everybody was presenting their project proposals, we invited the professors from the various universities to come and hear what their own people had done and what the policy people are talking about. So they agreed that there is a role from the policymakers to get us together.

>RHN: How long did that take, two or three meetings or two or three years?

SA: It took at least three years with annual consultative meetings.

>RHN: I imagine the researchers at the beginning were doing biomedical research, but the kinds of questions the Ministry was asking would probably have been, as you said, to do with health systems. That means a different set of skills, which the researchers may not have had.

SA: Yes, that was very obvious as we went through that it required a different set of skills, and some of them said yes, we would like to do some of this. The other constraint from the scientists was whether that type of product would be acceptable in peer reviewed journals, because they are used to publishing in those journals, which often did not publish health system research articles.

>RHN: Also, was there any money to do this kind of research in the 1990s?

SEE BOX: Irene Agyepong: people matter – Ghana’s health insurance experiment

SA: No, there wasn’t any money. They had some money from the academic institutions, but it was for laboratory or clinical research, which didn’t cost too much because you had patients walking through there and you could characterise the patients as to the type of disease they have and all that.

So they didn’t have much money, and we didn’t either from our end. In fact, the assessments that we did indicated that we were spending less than 0.5% of our total recurrent resources on research.

Eventually some funds were provided by WHO health systems research, and by the British ODA [Overseas Development Administration] as it was called at the time. They visited Ghana, they wanted something to support, and the Director of Medical Services again at that time said the only thing we want is we want research that is relevant to policy and some of the policy questions. So, if you want to support us, that is the key thing that we want you to do.

>RHN: So you began the research, but what has it achieved?

SA: We have done a review of the impacts recently. One of the problems was how do you even define the impact on the situation? Research [for policy-making] is not a one-to-one process where one research study leads to one policy change.

“It was quite obvious when we were doing our first strategic plan, in 1994-5, that the whole process depended heavily on the information that we had garnered during our research.”

SAM ADJEI

But it was quite obvious for example when we were doing our first strategic plan in 1994-5, that the whole process depended heavily on the information that we had garnered during the research that we’d done.

In fact, one component of the strategic plan, on quality of care, was specifically influenced by the research that we have done here on that. Then subsequently we had a summit here, and a lot of the discussions and the decisions taken relied on the research work that we made available, to guide what we were doing.

>RHN: If we looked at the major health challenges – infant mortality, maternal mortality, then of course the big diseases, malaria, HIV, TB and so on, and then the non-communicable diseases for example – has this combination of research and policy-making had any impact on the interventions in any of those areas?

SA: If you take malaria for example, we researched on malaria control within the context of the health systems reforms that were happening. With that we were able to guide the Ministry in a lot of the decisions about how to deal with malaria. For example, we demonstrated the use of pre-packaging of treatments as a way of getting compliance and ensuring adherence, and that got into the policies of the malaria control programme.

It used to be one drug, chloroquine. People adhered to that. But now it’s a combination. But the tablets were loose, and when people came in and the doctors prescribed a loose combination, adherence to the proper regime fell. But we showed that we could pre-package and say this is the package for malaria, and that it was adhered to.

>RHN: Did that have a real impact on disease and mortality?

SA: Yes, we demonstrated a reduction in case fatality rate and it also helped with the mother’s management at home. It was easier for them now. This has been published in Social Science and Medicine.

In addition, the big use of bed nets was one of the products of the research that we did in Ghana – which was also done in three other sites in Africa. That also affected the current malaria control programme where there is extensive use of bed nets.

We showed that when you use impregnated bed nets, than you cut down on incidents on malaria and mortality. So, it started off with helping women or carers to understand they should link malaria to the mosquito in the first place, because if you are going to provide bed nets and they don’t even know that malaria is caused by the mosquito, then they would not probably even sleep under the nets.

So we had to start up testing education on the causes of malaria and that it’s linked to the mosquito; and then testing whether people will use the bed nets when they go to sleep at all. In the northern half of the country, where this research was actually done, people moved their sleeping places three times in the course of the night, so you need to track them in the middle of the night as to how they are moving the nets around with them.

Because it is so hot in the night and then it cools down during the course of the night, so they move around with their net, first on the rooftop and then down to the main compound, and then into their room.

>RHN: So they had to be taught to take the net around with them.

SA: Yes, so these were all behavioural issues that we had to have social sciences study.

>RHN: You have obviously done extremely well with this combination of research and policy in Ghana. How would you advise a country in Africa – or another low or middle-income country that hasn’t started the connect research with policymaking, what to do? What can they learn from Ghana? What is your advice for them?

SA: One has to understand each element of the situation very carefully. One is the capacity of the Minister of Health himself to be able to articulate his problems and develop a culture of using evidence for decision-making. That is a very critical component. It may require a sensitization program to achieve that.

>RHN: Was that already high in Ghana?

SA: There were a few high movers like the Director of Medical Services who kept asking for the right information but others had to be educated especially the administrators such as the principal secretary. So he built a policy division [with the right people].

>RHN: So it is important to have some key motivators.

SA: Yes – prime movers I call them – within the Ministry itself. And they should be of high level, not just junior people who have no influence on policy. They should be the policy director or the director of medical services. You should have the structures that you need.

>RHN: So that is a matter of luck isn’t it, whether a country has got such people or not?

SA: Well, they could plan for it because a lot of countries have sent and continue to send people out to do postgraduate degrees in public health. So they could already be around, some of them at the operational level. One has to look at this and create a planning and research division and then staff them with such people at the ministry level.

And for us, if you use the word luck in that sense, not soon after we started, there was a civil service reform process going on and it called for ministries to have directorates, with a directorate for policy and a directorate for research dictated. So, it was easy to put people in to those positions because of that.

READ ON: Evolution of health research essential for development in Ghana, Sam Adjei and John Gyapong, Health Research Unit, Ministry of Health

But the research culture was within the academic institutions, and as you said, it was biomedical. Now there is more mutual respect and understanding for each other and we move easily. But it has taken a while. Recently I was invited by the College of Health Sciences of the University of Ghana to speak on the translation from research to policy. If you really trace the histories from when the Ministry got involved, I can easily say it started in 1987 till now, so it’s over the past 20 years where we have had this going on. It can however be done in a much shorter time.

So that is one of the key elements – the recipients, the policy-makers – they must have the capacity and the interests. Once they have that view, then the second element is the linkage with the research community, the scientists themselves.

READ ON: Ghana Ministry of Health

Sometimes the donor community can be of help. The donor community can come in and dialogue with the Ministry and say you are doing well, you are providing things, but I think you probably need more information, you need more evidence in what you are doing and we are ready to help you with people, and they can get good people to help Ministries around the world to begin the process of participating in evidence based policy. That is if it is not being grown indigenously, as it happened to us – but even then we still had the facilitation of the WHO.

READ ON: Ghana Health Services – Greater Accra Region

>RHN: And of course you need the donors to provide funds for the research, don’t you?

SA: Yes, and the training, so they can facilitate the process and interest among the policy-makers, because you should begin within the areas that are of interest to the policymakers when you get going. Like the first Minister when we started off was a traditional ruler – so he was interested in traditional health. We were conducting research on traditional midwives and family planning, so you could go back and talk about something that he is interested in.


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