Health policy and systems research. Strengthening community based health systems

Project description

1. Introduction

This proposal is located in the field of Health Policy and Systems Research (HPSR), with a specific focus on the strengthening of community-based health systems. Innovations in the community-based health system have the potential to improve access to health and health care but also have to address the underlying problems in this system – such as fragmented management and delivery, poor integration with local health facilities, and weak community participation. Over the last decades, low and middle-income countries (LMIC) that have achieved the most significant gains in health status have invested heavily in the base of their health system – through primary health care and community-based strategies. Similarly, in high-income countries, ageing populations with multifaceted health needs have shifted thinking away from hospi-centric and curative approaches towards more flexible and person-centred models of primary care focused on continuity and maximizing wellbeing. Across the globe, the human resource crisis and the growing acceptance of “task shifting” as a concept has seen the emergence of lay involvement in health care systems – whether as expert patient, volunteer or as more formalised community health workers. Community-based strategies have become an integral part of maternal- child health, malaria and HIV/AIDS programmes in LMIC, and increasingly for marginalized and hard to reach populations in high income countries.
Capacity building is an essential in collaborative research projects between institutions globally. The aim is to increase the number of researchers who can perform high quality research of global health relevance. This serves to improve health of populations and strengthen research institutions ´abilities to engage in policy making. Doctoral and Post-doctoral training has become an essential part of public health research environments. Consolidation of efforts to increase exchange between public health institutions as well as the development of excellent doctoral training programs will continue to carry fruit in years to come. It is a crucial step to ensure vibrant research environments in public health and form part of South Africa´s and Sweden´s contribution to the development of health policy and systems research.

2. Objectives

The aim of this project is to enhance research capacity and competence for designing and conducting health policy and systems research with a focus on community based health systems to understand how, for whom and under what circumstances innovations in community-based delivery achieve gains in access to health care and strengthen health systems.

Specifically:
• Set a platform for doctoral students, post docs and senior researchers from participating institutions in South Africa and Sweden and their networks to exchange and advance knowledge of health policy and systems research with a focus on community based health systems
• Identify the key contextual factors and mechanisms that trigger processes of integration and partnership; and in turn how these generate access and system strengthening gains
• Draw lessons for the local governance of community-based health systems across jurisdictions
• Identify conceptual approaches and methodologies for researching community-based health systems through exchange visits and annual workshops.

3. Project partners

School of Public Health (SOPH), University of the Western Cape

The SOPH was formed in 1993 and is one of a handful of well established Schools of Public health in South Africa. Its post graduate programmes include a Diploma, Masters and PhD programmes (~200 students), and a large continuing professional development short course programme offered through an annual winter school. The SOPH has a long tradition of health policy and systems research, and currently houses a WHO Collaborating Centre for Research and Training in Human Resources for Health, an extra-mural MRC research unit (SAMRC/UWC Health Services to Systems Research Unit, headed by the South African PI, H Schneider). In 2014, it co-hosted with other institutions in the region, the prestigious Global Symposium on Health Systems Research. It has a well-established portfolio of research on community health workers, and the PI and other staff members have been actively involved in research, policy development and partnerships with service providers to strengthen community-based health systems. It has a long track record and the systems required for managing donor-funded and international collaborative projects.

The current proposal link up with “the South African Research Chair Initiative (SARChI)” established by the Department of Science and Technology (DST) and the National Research Foundation (NRF) as a strategic intervention to increase scientific research capacity through the development of human resources and the generation of new knowledge, empowering top talent to develop particular fields. Prof H Schneider is the SARChI Chair in Health Systems Governance. The Chair will build the field of health policy and systems research, with particular focus on health systems governance. This Chair is currently consolidating a world-class hub in the global south in the emerging field of health policy and systems research, complementing the existing Chair in Health Systems Complexity and Social Change (A George), PhD students and post-docs form part of the SARChI programme.

Epidemiology and Global Health (EpIGH), Umeå university.

The Division of Epidemiology and Global Health (www.phmed.umu.se/english/divisions/epidemiology) is one of five units within the Department of Public Health and Clinical Medicine, within the Faculty of Medicine. In 2007 the unit was appointed a Centre for Global Health Research by the Swedish Council for Working Life and Social Research. Our mission is to engage with a global agenda on health research, addressing critical issues in global health and facilitating interaction and collaboration between Northern and Southern partners. The Center´s activities are focused on five themes: the epidemiological transition; life-course perspectives on health interventions; strengthening primary health care, gender and health; and climate change and health. All the different research themes incorporate doctoral students AK Hurtig has chaired the research theme “Strengthening primary health care” since its inception in 2007. On top of the agenda has been health policy and systems research.. A National Research School for Global Health from VR was launched in 2008 (with continuation from FORTE from 2013). This creates an exciting international environment where senior researchers and guest researchers work hand in hand with doctoral students. The Research School is closely linked with the Umeå Center for Global Health Research (UCGHR). The external mid evaluation of our UCGHR also emphasized the high value of our doctoral training for global health research. The doctoral program at the division has over 50 students registered, a majority basing their research in low and middle income countries. AK Hurtig has been the national coordinator of the Research School since 2008. There are three ongoing Swedish International Development Agency (Sida) supported Research Training Partnership running with Tanzania, Rwanda and Bolivia. We host the open-access journal "Global Health Action" (www.globalhealthaction.net). The journal aims to contribute to fueling a more concrete, hands-on approach to global health challenges. All papers are expected to address a global agenda and include a strong implementation or policy component. The mentorship innovation of the journal helps younger researchers in improving a potential manuscript to a quality one. An important means of recruiting new researchers is our international Masters in Public Health, which recently was evaluated by the Swedish National Agency for Higher Education (Högskoleverket) as the only master program in Sweden with “very high quality”.

The Centre of Rural Medicine in Storuman, Västerbotten County Council

The centre is a small research and development unit within the Primary Health Care organisation of Västerbotten County Council and collaborates with UmU. It started 2010 with the aim to increase knowledge on how to deliver high quality care in elderly populations within sparsely populated areas in northern Sweden. The centre stimulates research and support innovations in rural medicine. There is a special interest in preventive health, occupational health, e-health solutions for improved access to services and research for indigenous people, the Sami people. Work includes customised training and education that are adapted for the needs of rural health care. There is an increasing international networking within the field rural medicine. The Centre promotes and investigates better methods to recruit and retain primarily health care professionals in rural areas. The centre supports scientific projects for medical students as well as for resident physicians in the field of rural medicine, in cooperation with various clinics from the university hospital. The centre is increasingly engaging in international collaborations and exchange. Links with Umeå University is strong and include the Arctic Research Centre at Umeå University (Arcum) and EpiGH among others..

4. Project plan

Through this collaboration, the researchers will build and exchange knowledge and competence on research methods and concepts in health policy and systems research with focus on community health systems through following interlinked activities:

A) Workshops and exchange visits
The backbone of the mutual learning processes will be annual workshops and quarterly virtual meetings. The core participants will be the researchers within the project but care will also be taken to invite both senior researchers and students for sharing of relevant experiences and methodological advancement and challenges. Each annual workshop will be thematic and focus on methods and concepts. Research and study visits will further provide the opportunity for exchange and knowledge sharing through participation in the research environment of in the respective institutions, including visits to intervention sites, and participation in seminars. Three annual workshops are planned:

2017 South Africa; Concepts and Methods in researching community based health systems I:
This workshop aims at introducing key concepts, models and methods for research of complex interventions in health care organisations and local health systems. The main themes include: complexity in health systems innovation;introduction to theory-driven inquiry and exploration of concepts such as formal and informal elements of community health systems; vertical and horizontal accountability; participation/ partnership; innovation/ integration; local governance. Emphasis will be given to understand population and access with special focus on innovations like community health workers programme and eHealth. The application to ongoing research will be discussed.(see B and C).

2018 South Africa: Concepts and Methods in researching community based health systems II:
This workshop will build on the previous workshop and further discuss concepts and methods.
Methods to be discussed includes Qualitative Comparative Analysis, Social network analysis as well as methods for literature reviews (scoping, systematic, realist synthesis). Sharing of advancement in research projects will be included (see B and C) . The workshop will include writing support and discussions of joint publications.

2019 Sweden; Concepts and Methods in researching community based health systems III:
This workshop aims for the development of common conceptual and methodological frameworks, research strategies and tools for evaluating mechanisms/processes in community-based health system strengthening (with special focus on projects described in section B); drawing on comparative comparative analysis of cases across vastly different contexts. Discussions will include the recruiting and retaining of health professionals in different contexts (ie rural South Africa and the sparsely populated region of Northern Sweden). Joint publications and grant proposal will be discussed.

Quarterly virtual meetings will support discussions and writing of manuscripts and project proposals. The virtual meetings will also include seminars with presentations from recognised experts in relevant fields and facilitate the networks of learning (described in section C).

B) Formative research: advance methods and increase peer-to-peer learning

Joint development of experiential knowledge through the challenges and adaptations required to conduct health policy and systems research will benefit both the South African and Swedish partners. The partners’ complementary backgrounds will enrich the learning process. Practical expertise in innovative, transdisciplinary health policy and systems research will provide a basis for fostering the South African-Swedish research collaboration and for providing leadership in the development of research approaches that strengthen community-based health systems. Development of project activities will provide the opportunity for junior researchers in collaboration to senior researchers to gain competencies not only in methodologies, but also in writing publications and project proposals.

The joint South Africa- Sweden Research Collaboration Programme will build on two conceptually linked projects – one in South Africa and one in Sweden - examining the mechanisms and pathways of impact of two community-based health system innovations on health service access, and associated quality and coverage. The programme hence takes advantage and build on existing projects and plans.

The South African sub-project will evaluate and develop strategies to strengthen community based services in four provinces (North West, Western Cape, Limpopo and Mpumalanga) specifically 1) developing a framework for supportive supervision of Ward-Based Outreach Teams (WBOTs) in the North West Province 2) investigating the mechanisms of community trust and embeddedness of CHWs and 3) evaluating quality improvement strategies for improving maternal, neonatal and child health outcomes.

The Swedish sub-project will follow and support the unfolding implementation of a pilot system of outreach, referred to as Virtual Health Rooms, in southern Lapland, and assess its role in expanding access and strengthening a fragmented primary health care system in the region. The Virtual Health Rooms are located within community structures and make use of sophisticated technology to provide health and potentially social services to remote rural areas of the region. They are being implemented through new partnerships between municipalities, county councils, local health service providers, community structures and patients.

In both countries, the research will observe the changing organizational relationships and local system strengthening leveraged during implementation of the innovations, examining in particular processes of integration and collaboration within the Primary Health Care system and the development of partnerships with communities. In doing so, the aim of the research is to draw lessons on the “how” and “why” of community-based health system strengthening across jurisdictions. Combining considerations of system “hardware” and “software”, and drawing on concepts of health system integration, partnership and diffusion of innovation, the general methodological approach will be one of theory-driven, realist evaluation, involving explanatory case studies and mixed method data collection.

C) Building on networks of learning

In addition to the two subprojects mentioned above the collaborative programme will draw on the experiences of other community based health projects within the networks the SARChI programme and the Sida funded research training partnerships in health system and policy research (Tanzania, Rwanda, Bolivia and upcoming Mozambique), the Swedish Research Council Research links project on community monitoring and accountability and add value to these ongoing programmes.
The programme partners in South Africa and Sweden will take the opportunity to link programme members into their current networks/collaborations and invite partners to share their work.
These include collaborations in Indonesia and Kenya with the Center for Rural Medicine where Virtual Health Rooms are being tested in ongoing projects.EpiGH´s collaborations with other institutions in the area of community-based health systems such as University of Zambia; Center for the Study of Equity and Governance in Health Systems (CEGSS) in Guatemala, Muhimbili University of Health and Allied Sciences (MUHAS) Tanzania, Indian Institute of Technology Madras; La Universidad Mayor de San Simón, Bolivia and the Institute of Tropical Medicine, Belgium may also be channels for exchange and sharing of lessons learned.

At UWC these collaborations include the Public Health Foundation in India, with whom we share a common interest in community-based health systems, the Antwerp Institute of Tropical Medicine (ITM) that are leading experts in Theory-Based Evaluation (Bruno Marchal and Sara van Belle) and through various initiatives, a wide range of other African countries (Nigeria, Kenya, Ethiopia, Uganda, Malawi, Zambia amongst others). This will be operationalized through virtual meetings (see section B); including network members in workshops (section A) when feasible and planning of study visits to suit interaction with members from above networks. We believe building on our shared interest in using research as a tool to promote equity and create a solid platform for future research and exchange beyond the timespan of the programme.

5. Contribution to scientific knowledge and internalization in higher education

The advancement of scientific knowledge

The last two decades has seen an explosion of programmes deploying community health workers (CHWs) in low- and middle-income countries. Much of this has been driven by new flows of funding for the disease burdens of the south (HIV/TB, malaria, maternal-child health). This literature has a predominantly disease-orientation and a technical focus on the efficacy of specific interventions. Our proposal breaks new ground in this terrain in the following ways:

• widening the scope of interest from a specific role or cadre to a more holistic focus on the system in which cadres or interventions are embedded. The WHO “building blocks” framework of the health system has provided much-needed structure for systematically examining health systems and system strengthening. However, less understood are the more informal and often invisible elements of community-based health systems. Our research has this wider system as our starting point and will provide insight into this system, and the interactions between community based initiatives, the formal health system and communities.

• a North-South comparison and networking that shifts the focus away from specific forms of intervention (such as CHWs) to the underlying phenomena at stake. In this sense, it will develop broader conceptual and theoretical understanding and contribute to health system debates more widely.

The field of health policy and systems research encompasses newer or relatively little-used methods and study approaches that need to be further developed. The proposed project provides ample opportunities for further methodological.. The project will in particular add to the scarce experience of integrative cross-national analysis of programme theories/mechanisms.A recent policy document by the Swedish Research Council (2014) points to the need for “embedded research”, an approach where research is truly embedded in the programme and policy cycles, and programme managers and people on the front line of health care play a central part in the identification, design and conduct of the research undertaken.

The advancement of internationalization in higher education
The combined SA/Sweden focus provides two very different contexts, but with similar underlying problems of fragmented community-based health systems provides a unique opportunity for mutual learning. This project was conceived based on the partners’ mutually shared interest in using research as a tool to promote equity and the right to health. The objectives and activities of the project were designed to build on these values and provide a base for long-term research partnership through mutual development of methodological expertise in HPSR, and practical expertise in the application of research tools to strengthen community-based health systems.

Sweden has during last years faced funding challenges for health policy and systems research (HPSR). A report from the Swedish Research Council 2014 states in regards to HPSR “A fundamental weakness is, the new funding situation with the lack of a structured approach to build the next generation of Swedish researchers, where previous support mechanisms from e.g. Sida/SAREC have disappeared (Doctorate, Postdoc) and not been replaced by any others”. The consequence is that Sweden is lacking a solid base of HPSR researchers and especially worrisome is the lack of a structured approach to build capacity for the future. The SOPH and UWC PI are well known internationally within the field of HPSR and particularly in the area of community-based health systems. From the Swedish perspective the collaboration with the Prof Schneider and colleagues, therefore presents an excellent opportunity to strengthen HPSR.

For UWC, the collaboration with a highly regarded and like-minded group under the Umea PI provides the opportunity for a North-South collaboration that is based on mutual respect and two-way intellectual contribution. It is also the opportunity to leverage and develop wider networks of collaboration.