28 April 2008, 14:26
A series of nine country reports, in addition to a comprehensive regional reports, will set agendas for health systems research in much of the the Middle East and North Africa. The Principal Investigator tells RealHealthNews what he’s learned.
Focusing on three questions of immediate interest to policy makers (ministries of health, finance, and so on) and key stakeholders, a series of Middle East and North Africa (MENA) studies on health systems research priorities is seeking wide national consultations to set agendas for national research into health financing, human resources for health, and the role of the non-state health sector in nine low and middle-income countries: Algeria, Egypt, Jordan, Lebanon, Morocco, Palestine, Syria, Tunisia and Yemen. This is the first regional priority setting exercise conducted in the MENA region.
Here we asked the Principal Investigator for the whole group of MENA studies, Fadi El-Jardali of the American University of Beirut, Lebanon, to tell us more about the regional study’s concept and process.
>RHN: What’s your view of the Palestine study that was just completed?
FADI EL-JARDALI: Palestine is a very good example of a non-state society that’s very active in conducting some work of relevance to policy, in the hope that they will be able to change and influence those policies, in a state that is weakened by internal conflict.
>RHN: But if the state is weak, aren’t the policies of NGOs and other actors in health also relevant, as much as the state’s?
F E-J: Absolutely – where the capacity of the state to conduct research and make evidence-based decisions is a little bit lacking. Health officials are interested in making evidence informed decisions; however, it is sometimes difficult for them to support health research when there are more pressing issues to deal with. This is in addition to the lack of funding allocated for research.
If you look at the whole region, at how much ministries of health are dedicating to research out of their health budgets, it’s less than 1%. Which is nothing! The region has the second lowest proportion of scientific publications addressing health systems topics in the world (0.8% among all WHO regions); the lowest rate is in Africa (0.6%).
“All the countries in our study want to make the health system more equitable, to meet needs and protect the underprivileged and poor populations from catastrophic
While health research funding is insufficient in the nine countries in our study, available funding goes mostly to operational and action research – due to limited time and funding. And doing research in a ‘quick and dirty’ way can compromise the quality of generated evidence and its uptake by policy makers. So we at the university and other academic researchers heavily depend on external funding. Without that we can’t do much good research. For example we couldn’t have done the MENA studies themselves without the support of the Alliance for Health Policy and Systems Research and the additional funding received from the International Development and Research Centre.
>RHN: So to whom are the MENA studies addressed? If the governments are weak and uninterested in research, and the real funding comes from donors, shouldn’t they be addressed to those donors?
F E-J: Yes, but the key informants we met – politicians and policy-makers and key decision-takers in the government and non-state sector – were very pleased that for the first time health systems researchers were listening to their opinions about research priorities and the next steps. They very much appreciated that.
>RHN: So you might actually see the percentages allocated for health research go up, if the research you propose is relevant to their needs.
F E-J: Exactly. And this is the point that they made. They said to us that if you go and do policy relevant research on the things that are of priority to us, definitely we are going to consume your research evidence – to help us make evidence informed decisions. But they also emphasized that donor funding should be more responsive and supportive of national and regional health research priority needs.
They said three things. First, they want our research to be a little bit more policy-relevant. Second, they want local researchers in their country to do studies that are specific to their national context – so their capacity to do such research is important. They don’t trust international evidence to solve their country specific health systems problems!
And the third request was that they really want us to disseminate those results to them in a very user-friendly manner. They just want to understand the main findings, to help them make better decisions based on evidence.
So I think there is a huge opportunity now in the Middle East – evidence-based policy has become a big buzzword. Policy-makers acknowledge the importance of evidence, they want to make decisions based upon it, but they want national researchers to do the work, in their own context. So the next step is who’s going to fund the research priorities that were identified in their countries, because national pockets in developing countries are small, particularly when it comes to research.
This is a challenge – because if we make new research proposals, based on the research priorities identified by them, and we don’t get funding for it – they are not going to trust us again. Our regional research has created momentum and raised expectations, and we need to deliver accordingly. That is why we need the support of donor agencies.
>RHN: So you are addressing that question to donors?
F E-J: Absolutely. We hope that the donors can really take this seriously. If they really want to help those countries improve their health care systems, both at the policy and delivery level, we need to build capacity and funding to conduct context-specific research that address the questions that were raised by policy makers.
Otherwise we are just telling the policy-makers yes, thank you for your time and suggestions, you told us what you want, and goodbye!
You know the health budget in the low and middle-income countries is the Middle East is very small. And the priorities of the governments are not always in health. We have to acknowledge that. In light of pressing challenges, health research can fall between the cracks. So we need to have health research that really addresses policy-makers’ questions.
>RHN: So let’s have a couple of examples. What kinds of question have come up, and what can research do about them?
F E-J: For instance, many of the countries are really struggling with social health insurance. All the countries in our study want to make the health system more equitable, to meet needs and protect the underprivileged and poor populations from catastrophic health expenditures and so on.
>RHN: And they hope to do this with social insurance?
F E-J: Exactly. But they are struggling to choose the best model to experiment with, without much risk, to cover a larger population but with the existing resources.
>RHN: That question is likely to be a very local, cultural matter, isn’t it?
F E-J: It is. And another example is human resources for health. Many countries are really losing their competent and qualified health workforce to other developed countries – either in the Gulf, to the oil-rich countries, or to Europe or North America.
So they want to know how they can create a good incentive mechanism, and retention strategies, to help us retain their competent and qualified workforce and how can they address their shortages and mal-distribution problems.
Also they have no human resources planning. So they want to know how much and what type of human resources they will need 10 years from now. They also want to know how they can improve their academic educational programs to better meet the needs of their country.
As for the non-state sector, all countries agree that this sector has a substantial role in helping meet health systems goals. However, the sector is poorly regulated and coordinated by the state. Policy makers would like to know about the foundational elements for building a strong and well functioning public-private partnerships. They would like to find ways to optimize the use of existing resources of the non-state sector, to reduce duplications, and to develop methods to monitor and evaluate their contribution including service provision and performance.
These are some of the questions that came from almost all the countries – and they want answers to them!
>RHN: And the conclusions?
F E-J: We’ll be completing a final list of regional research priorities and questions soon. We’re going to conduct a Regional Consensus Workshop in Beirut on 30-31 May 2008 to validate and rank the regional research priorities related to Health Financing, Human Resources for Health and the Role of the Non-State Sector. In this workshop, a consensus will be reached among researchers, policy makers and other key stakeholders on a policy relevant research agenda for the region.
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