Influencing policy makers and practitioners for better health service delivery
When we originally set up the COMDIS-HSD research programme consortium, our primary intention was to develop research findings that would impact on health policy and practice in our partner countries and beyond. Our aim was to make a difference to the health and lives of many millions of people living in low- and lower middle-income countries (LMICs), and particularly the poorest of those people. This meant moving beyond long-standing and traditional approaches of relying on academic publications to influence others; academic publications were merely a step on the road, rather than the end of the journey.
We are pleased to report that we have met this aim. We have successfully influenced national or wider policy in the fields of antimicrobial resistance, malaria, tuberculosis, HIV, neglected tropical diseases and urban health. Our work focuses on health services delivery (as the HSD in our consortium name emphasises) as we are convinced that many of the health care problems (in the widest sense) in LMICs can be solved by better delivery of existing health care approaches. There must be a balance between discovering new drugs and techniques, and ensuring the people who need drugs and techniques get them. In our view, funding is too heavily skewed towards the former, and we are grateful to DFID for awarding us the funding to allow us to contribute to improving the balance.
Helping to build sustainable and resilient NGO partners
Perhaps the chief contributor to the success of COMDIS-HSD is our NGO partners and their research teams. We should not underestimate the scale of the efforts a small number of individuals have made to create what are now influential national NGOs; and the strengths of the resultant networks of researchers, research uptake staff, support staff and government counterparts. We would like to congratulate the heads of our NGO partners for having the courage, vision and drive to invest in building responsive and resilient research organisations. These NGOs are now sustainable in their own rights, with multiple research partners outside the COMDIS-HSD consortium, and proven abilities to generate substantial research and development funding and deliver a return on that investment. Importantly, they have over many years developed the close links with policy-makers and practitioner groups that are necessary to make sure that research findings are translated into policy and practice in their respective countries.
Our embedded approach
We have found that a major contributor to COMDIS-HSD’s ability to deliver research that leads to changes in policy and practice is our use of an embedded research and development approach. In brief, this entails ensuring research addresses national priorities and delivers policy-relevant findings; interventions are designed from the outset to be sustainable and scalable; intervention design is heavily influenced by research with potential users – both health care staff and patients/members of the general public – and includes development of all relevant materials and guides, including training materials and processes; after piloting and review, interventions are tested in routine conditions, unsupported by external staff or resources; the research team works with policy-makers to translate research findings into policy; and then uses the materials and guides to run the initial training-of-trainer programmes. In the longer term, we would like to further monitor and evaluate uptake at scale. The consortium’s capacity to carry out embedded research and development stems from an ongoing collaboration between our national NGO partners with skills in research and evidence-led advocacy, and an international research team at the University of Leeds and Malaria Consortium, with skills in advanced research methods and capacity development.
As a consortium, we believe that we have achieved much over 8 years. We would like to thank all our supporters at the various ministries, hospitals, rural health facilities, technical working groups, and beyond, for helping us to collectively make a difference. We would also like to thank our Consortium Advisory Group, DFID and all our critical friends for their guidance, clarity and championing of our work and of the embedded approach to research and development.
We hope you enjoy reading about our work and our impact. Rest assured that our work continues through our NGO partners ARK Foundation in Bangladesh; Association for Social Development in Pakistan; HERD International in Nepal; Good Shepherd Hospital in Eswatini (formerly Swaziland); Malaria Consortium across Africa and Asia; and the University of Leeds in the UK.
Prof James Newell and Prof John Walley
The prestigious Princess Chichibu Memorial TB Global Award, recognising outstanding contributions to global TB control, has been presented to Dr Muhammad Amir Khan for his significant achievements in TB control activities.
Dr Khan, the Chief Executive for the Association for Social Development (ASD), was acknowledged for over 20 years of development, research and implementation support work with the National TB control programme in Pakistan.
Commenting on the award, Dr Khan said:
“I feel proud to receive an award on behalf of a team that played a significant role in strengthening TB control in Pakistan.
“This would not have been possible without continued support from the Nuffield Centre for International Health and Development, the National TB Control Programme, the World Health Organization and civil society partners, and the ASD team.”
Prof John Walley, Co-Director of COMIDIS-HSD, said:
“This is a wonderful recognition of the great achievements over 20 years in developing and evaluating so many components of TB care, prevention and health promotion in the public-private facilities across Pakistan.
“Currently more than 250,000 TB patients a year are being treated with the packages of care that have been developed through this collaboration led by Dr Khan. 20 years ago the cure rate was 30% and TB was known as a death sentence. No longer.”
The Princess Chichibu Global TB Memorial Award is presented annually in memory of Princess Chichibu of Japan by the Japan Anti-Tuberculosis Association. Recommended by the Awards committee of the International Union Against Tuberculosis and Lung Disease, a candidate is nominated and confirmed by the Japan Anti-Tuberculosis Association.
The award was presented by Her Imperial Highness The Princess Akishino, who serves as patroness of the Japan Anti-Tuberculosis Association, at the 49th World Conference on TB and Lung in The Hague, Netherlands.
Pokhara, one of the gateways to the Himalayas, is a popular tourist destination in Western Nepal. Like other rapidly urbanising, metropolitan cities in South Asia, Pokhara faces various challenges.
Identifying the urban poor and increasing their access to basic health services is difficult for policy makers as currently there are no data at the local level. HERD International is working in Pokhara to stimulate multi-sectoral responses to create an urban health system able to improve health and social outcomes for, and with, the urban poor.
It is with much sadness that we mourn the death of our dear friend and colleague Bryan Haddon, Founder and Chair of Health Partners International.
Bryan was an active member of our Consortium Advisory Group (CAG) for over 7 years, and brought a huge depth of experience and richness to the table during our annual meetings when our CAG was advising us about strategy and new directions of work. During this time, he also worked closely with the COMDIS-HSD management team at the Nuffield Centre for International Health and Development (University of Leeds) giving support, direction and insight in his gentle and encouraging manner. He made an enormous contribution to our consortium by bringing ideas, new connections, humour and stories of work and life in Nigeria; we all so looked forward to spending time with him each year at our annual meetings. He was a great champion of many causes and we will miss him greatly.
“Bryan was a wonderful man and we will greatly miss him – it was a pleasure and a privilege to have known him and worked with him,” said Anthony Harries (CAG chair), sentiments echoed by our external CAG members Abdul Ghaffar and Knut Lonnroth, the COMDIS-HSD team and DFID health advisors.
We extend our condolences to Bryan’s family, friends and colleagues.
The ongoing need for inclusive health systems has been highlighted at the 5th Global Symposium on Health Systems Research in Liverpool. Despite some improvements in diversity and inclusion in recent years, evidence shows many vulnerable populations continue to be left behind.
This year’s symposium marked the anniversary of two historic global health events: the Alma Ata declaration and the inception of the UK National Health Service. Though different, they both encapsulate the values underpinning an equal society, and a commitment towards universal health coverage.
Centring on the theme of “Health Systems for All in the SDG Era”, the symposium re-emphasised the importance of these historic commitments. Placing them in the modern context of the Sustainable Development Goals (SDGs), the difficulties surrounding truly equitable health systems were explored.
Multi-sectoral action was one of the sub-themes of this year’s symposium. Looking at real-world examples of multi-sectoral issues affecting urban health systems in Nepal, Bangladesh and Vietnam, Helen Elsey, Associate Professor in Public Health at the University of Leeds, facilitated a world café discussion that aimed to identify the various challenges and come up with solutions.
By 2050 it is believed 70% of the world’s population will live in urban areas. Sushil Baral, Managing Director of HERD International, emphasised the lack of multi-sectoral engagement in urban health in Nepal at the community level. He outlined research undertaken By HERD International to identify whether engagement of Health Facility Operations Management and Urban Health Centre staff helps in the identification of marginalised groups and addressing barriers to accessing health services. Through the discussion it was agreed that overcrowding is a real concern in urban health facilities, and that human-centred design methods are needed to engage the local urban poor and give a voice to the marginalised.
Leaving no one behind formed another key sub-theme of the symposium, where presentations highlighted the ongoing under-representation of vulnerable populations. A panel session co-organised by RinGs explored how to ensure meaningful participation of marginalised groups within social accountability mechanisms. Chandani Kharel, Research Fellow at HERD International, said the lack of a formal system in urban areas in Nepal to identify poor and marginalised communities undermines gender, intersectionality and accountability. She argued for the need for new forms of engagement and novel approaches in strengthening social accountability.
Around 700,000 people die each year due to antimicrobial resistance and this is forecast to increase to 10 million a year by 2050. Posing a serious threat to the achievement of the SDGs, the need for successful interventions to address inappropriate antibiotic use has never been greater. In a session exploring the multiple influences on prescriber and patient behaviour around antibiotics, Joe Hicks, Lecturer in Medical Statistics at the University of Leeds, presented findings from a COMDIS-HSD study involving an intervention aimed at reducing inappropriate prescribing of antibiotics to children in rural Chinese primary care facilities. Follow-up results 18 months after the intervention was introduced showed sustained reductions in antibiotic prescribing for upper respiratory tract infections.
Alongside the main programme, skills sessions preceding the symposium gave delegates practical knowledge that could be applied to their work. COMDIS-HSD Research Communications and Uptake Manager, Nilam Ashra-McGrath, delivered a hands-on session outlining 7 rules for using plain English. Participants were taught the benefits of keeping sentences short and active, why jargon should be avoided, and the common pitfall of turning nouns into verbs. This was then applied to the participants’ own work so that they came away with a rough draft of a lay summary.
The 5th Symposium on Health Systems Research highlighted many challenges existing within health systems that need to be addressed. Investment is needed in health policy and systems research to build capacity in low- and middle-income countries and increase opportunities for embedded research. Further commitments need to be made to ensure marginalised populations are not left behind.
Malaria Consortium’s COMDIS-HSD funded study “Strengthening Primary Healthcare for NTDs in Ethiopia” has been showcased at the 9th Neglected Tropical Disease NGO Network (NNN) annual Conference in Addis Ababa, for which the overarching theme was reaching ‘the last billion’ people affected by neglected tropical diseases (NTDs).
This study involved the development of guidelines and training of primary healthcare workers on the detection, management, recording and reporting of five NTDs: trachoma, schistosomiasis, soil-transmitted helminth infection, lymphatic filariasis and podoconiosis.
Malaria Consortium hosted a key workshop at the conference, in collaboration with Ethiopia’s Federal Ministry of Health and Orbis, to provide a platform for policy makers, practitioners and researchers to discuss how primary healthcare for NTDs could be strengthened.
Participants were encouraged to discuss key policy and operational issues, the prioritisation of specific NTDs, and what services can be realistically provided at the different levels of the primary healthcare system.
Nebiyu Negussu, NTD Team Leader at Ethiopia’s Federal Ministry of Health, explained how Ethiopia is addressing these issues through its NTD Master Plan – for example, by integrating NTD prevention into existing primary healthcare structures. To illustrate the importance of this approach, Mr Negussu described how close Ethiopia had come to eradicating guinea worm – only for it to keep occurring because first-contact health workers did not have the capacity to recognise and treat the disease.
Alongside the COMDIS-HSD study, Orbis presented insights from its work on building sustainable primary healthcare systems for trachoma elimination in Ethiopia, including the “integrated eye care worker” model, which involves training nurses to perform trachoma surgery.
Workshop participants concluded that governments should engage with practitioners and researchers to define a roadmap for integration of NTDs into primary healthcare, including the development of harmonised case definitions of NTDs and consistent guidelines and training materials. They also recommended that the evidence base needs to be strengthened and that more research should be carried out on what approaches and interventions work in different contexts.
Researchers from the COMDIS-HSD team will be delivering a number of sessions at this year’s Global Symposium on Health Systems Research in Liverpool. Topics will cover themes including urban health, antibiotic resistance and gender. Full details can be seen below.
A variety of print materials, such as research and policy briefs, will be made available at the Nuffield Centre for International Health and Development stand (booth 25) in Hall 2. You can reach out to us at the conference on Twitter, where we will be providing live coverage of our talks. We hope to see you there.
How to translate your research evidence into a lay summary
This hands-on session will show participants how to write about research evidence using plain English principles. Participants should attend with 1 document (journal article, technical brief, report) that could be developed into a rough draft of a lay summary.
Nilam Ashra-McGrath, Research Communications and Uptake Manager, COMDIS-HSD, University of Leeds
Monday 8th October 08:30am – 12:00pm, Exhibition Centre Room 23
Meeting SDG 11: stimulating multisectoral responses to create an urban health system able to improve health and social outcomes for and with the urban poor
SDG 11 requires action from all sectors to improve the wider determinants driving ill health among the urban poor. Through a combination of videos and world café discussions of projects showing multisectoral action at community, health facility and municipality levels, we will identify strategies for multisectoral action to reduce urban inequities.
Helen Elsey, Associate Professor in Public Health, Nuffield Centre for International Health and Development; Chandani Kharel, Research Fellow, HERD International
Wednesday 10th October 11:00am – 12:30pm, ACC Hall 2L
Amplifying marginalised voices: towards meaningful inclusion in social accountability mechanisms for health
Accountability encourages local community actors’ involvement in the design, delivery and monitoring of health services. Using research from Uganda, Bangladesh and Nepal, this session applies an intersectional lens to accountability mechanisms, asking about the inclusion of specific, marginalised categories within communities in mainstream accountability initiatives.
Sushil Baral, Managing Director, HERD International; Chandani Kharel, Research Fellow, HERD International
Friday 12th October 11:00am – 12:30 pm, ACC Hall 2L
Discussion on gender and intersectionality with policy makers
Alliance for Health Policy and Systems Research, with contributions from RinGs researchers:
Helen Elsey, University of Leeds, UK; Sarah Ssali, Makerere University, Uganda; Sassy Molyneux, Kemri-Wellcome Trust, Kenya
Friday 12th October 11:00am – 12:30pm, Venue TBC
Sustained reductions in inappropriate prescribing of antibiotics to children in rural Chinese primary care facilities: 18-month follow-up of a cluster randomised controlled trial
Antimicrobial resistance is at its heart a health system issue: addressing it requires a clear understanding of the complex set of factors influencing medicine prescription and use. The presentations in this session seek to understand the multiple influences on prescriber and patient behaviour, and the effectiveness of interventions to improve medicines use.
Joe Hicks, Lecturer in Medical Statistics, Nuffield Centre for International Health and Development, University of Leeds
Friday 12th October 02:00pm – 03:30pm, ACC room 11B
Heads of state meeting at the UN General Assembly have committed to ensure 40 million people with tuberculosis (TB) are successfully treated by 2022. They have also agreed 30 million people will receive preventative treatment by 2022 to protect them from developing the disease.
The Political Declaration on the Fight Against TB was publicly endorsed at the first High-Level Meeting on TB in New York. Leaders also reaffirmed the commitment to end the TB epidemic globally by 2030 in line with the Sustainable Development Goals target.
“Today is a landmark in the long war on TB,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO). “These are bold promises – to keep them partnership is vital. WHO is committed to working with every country, every partner and every community to get the job done.”
The Deputy Secretary-General Amina Mohammed said the “vicious” TB epidemic is drastically under-funded, with a gap of around $13 billion a year. She called for a system-wide approach to ending TB that promotes the broader health and wellbeing of entire communities and breaking out of “disease-specific silos and single goals.”
Heads of state and government agreed to mobilise $13 billion a year by 2022 to implement TB prevention and care. A further $2 billion was committed for research.
President of the 73rd Session of the UN General Assembly María Fernanda Espinosa Garcés said funding and research for TB needs to be “dramatically scaled up.”
“We have before us the opportunity for a clear win – a chance to save the lives of millions, to preserve billions in resources, to demonstrate the success of the Sustainable Development Goals, and to reaffirm the utility, efficacy and necessity of multilateralism and the UN System,” she said.
Professor James Newell, Co-Director of COMDIS-HSD, said:
“I am delighted to see the UN High-Level Meeting’s endorsement of the Political Declaration on TB, which has great potential to increase political awareness of the importance of TB as an ongoing global problem.
“However, we must not miss the opportunities that the High-Level Meeting have brought, and allow TB to once again slip from the notice of politicians.”
Speaking on behalf of the UK Government, International Development Secretary Penny Mordaunt said:
“Today we have seen a Political Declaration that signals a step change in the international leadership commitments necessary to drive progress in fighting TB.
“TB is the biggest killer among infectious diseases globally. The UK is already leading the way to tackle TB through investment in research and development. UK aid will help develop three new TB drugs, which offer quicker-acting treatments for the millions of people affected by drug-resistant TB each year.
Commenting on this announcement, Professor Newell said:
“The UK government should be commended for the substantial support it provides to TB programmes and for research to develop new drugs for TB.
“However, we should remember that drugs alone is not the answer – it is widely recognised that TB is a social disease, and it is vital we understand and respond to the social circumstances that make TB so difficult to treat and control.”
Programmes fail when project managers lack soft skills, argues COMDIS-HSD Consortium Manager, Libby Clark, at Project Management in Practice Conference.
Last month, I travelled to Boston, USA to present at a panel session on soft skills in project management at the annual Project Management in Practice conference. Incorporating communication, interpersonal, influencing, negotiation, problem solving and leadership skills, soft skills are increasingly recognised as critical to project success, but are often not prioritised.
The premise I put forward to the panel was that technical competency on its own is not enough, and that projects and programmes fail or operate far below optimum capacity when project managers do not demonstrate a strong suite of soft skills. Projects are not ‘business as usual’. They are temporary, unique, cross-functional and, because they often involve change and uncertainty, come with a higher level of risk. When things go wrong with projects they usually go wrong quickly and can be hard to get back on track. A good project manager needs to act quickly by asking difficult questions, considering the facts and then taking decisive action. Building good relationships, exploiting the huge value in face-to-face communication and continually demonstrating the benefits of working within a project management methodology (particularly to those who doubt its efficacy) are crucial skills. After all, what use is a Gantt chart if no one understands what it is, why it is relevant to the project or how to respond to the information contained within it?
My panel followed the opening keynote by Dr Jeff Sutherland, meaning I was lucky to have a captive audience! Fellow panel members were Dr Teresa Lawrence of International Deliverables and Pamela Campbell and Mike Cipriano, both of Boston University. Teresa expertly chaired our session, giving each panel member time to present their key thoughts before she facilitated a Question & Answer (Q&A) session with the audience.
COMDIS-HSD is a complex international programme and my presentation gave me the opportunity to talk about the work we do and how I approach and tackle the challenges that are inherent in a programme of this size. The Q&A session was excellent and we worked well as a panel, each of us taking a lead on a particular area of practice or expertise, in order to provide delegates with clear and comprehensive responses to their questions and issues. I’m a very pragmatic person by nature so I tried to focus on giving practical, concrete ideas that delegates could take away and implement in their own setting.
The rest of the conference offered great food for thought. Every session gave me something to take away and consider or implement in my own day-to-day practice, and networking time with other project management professionals gave me new insights and contacts.
And my take home message? Projects come and go, some are short lived, others develop and change over time, but the human element remains the same. Regardless of what you are working on and where in the world you are based, the challenges of working with people to build strong, coherent and high-achieving teams remains a major challenge of projects and programmes. Project managers ignore this critical aspect of project work at their peril!
A new research organisation in Eswatini has been launched building on the previous work of COMDIS-HSD, which has delivered applied public health research in the Lubombo Region for 10 years. The Lubombo Health Research Unit (LHRU) is a collaboration between the Bradford Institute for Health Research, Eswatini Ministry of Health, Lubombo Regional Health Management Team and Good Shepherd Hospital, Siteki.
The organisation aims to catalyse and support the design, delivery and application of innovative research focused on improving the effectiveness, efficiency and accessibility of healthcare interventions in the Lubombo Region.
“Science is most effective when researchers with overlapping interests collaborate,” said Dr Rejoice Nkambule, Deputy Director for Health Services – Public Health, who formally launched the research unit on behalf of the Ministry.
Nkambule highlighted the benefit of routinely integrating evidence into all aspects of health care, and outlined Eswatini’s aspiration to be an international leader in high-quality health research. She explained the role of LHRU in meeting these objectives and thanked COMDIS-HSD for strengthening research capacity in Lubombo.
Lubombo has a number of challenges in delivering health care, as its predominately rural population means many people live in isolated communities. Current HIV prevalence is 29.4% and increases in non-communicable diseases, such as diabetes and hypertension, are a growing concern.
“Female BMI in Eswatini is now the highest in Africa,” said Dr Nick Riches, LHRU Public Health Registrar. “Diabetes prevalence is set to increase by 50% between 2010 and 2025. We have to look at these patterns and what interventions can prevent them.”
Riches gave a summary of the LHRU strategy, including its vision, aims and values. He outlined the intended structures and procedures of the new unit and provided a summary of current and recent research delivered through the UK-Eswatini link.
“Lubombo is leading the way in non-communicable disease decentralisation,” he said. “The region is a great place to stress test interventions: if it can be done in Lubombo, it can be done anywhere.”
“What we are doing in Lubombo can be, and is being, replicated elsewhere in Africa and the majority of the world. The foundation of this unit is a real opportunity for Lubombo and Eswatini to lead in applied global health research.”