Combining health and social protection measures to reach the ultra ...

More documents

Recommendations

Info

Research resourcesResearch impact on equitableaccess in health: the CubanexperienceArticle by Gustavo Kourí (pictured), María G Guzmán, José LuisPelegrino, Alicia Reyes, Luis Estruch and Niviola CabreraBefore 1959, medical sciences in Cuba 1,2 were weak,dispersed and with a low budget. However, evenwithout official support some scientists were able tomake important contributions of international relevance. Inthe 19th Century, Tomás Romay (1804), the father of Cubanvaccinology, introduced the smallpox vaccination and CarlosJ Finlay (1879) described the transmission of Yellow Fever bythe mosquito Aedes aegypti. Later, during the first half of the20th Century, Juan Guiteras worked on the control ofinfectious diseases and Pedro Kourí the father of Cubanparasitology made original contributions in this field 3,4,5 .At the global level, Cuba was the first country thatestablished a Ministry of Sanitation (1909) 6 . In spite of this,the health picture of the country before 1959 wascharacterized by high infant mortality (40 per 1000 livebirths) 7 . Life expectancy at birth was less than 60 years andthe public health picture was characterized by tetanus,diphtheria, poliomyelitis, measles and tuberculosis, amongother diseases. The issues of health and illiteracy werepredominant in the 1950s. In this period, Cuba’s healthresources included only one medical school, two scientificinstitutes (the Institute of Hygiene and the Institute of TropicalMedicine), 6000 medical doctors distributed in the capitaland the main cities, and very few public and someprivate hospitals.A new social system was established in 1959, whereinhealth and education were considered human rights. In orderto change the serious health picture, a new conception of thehealth system was developed, oriented to prevention and toan appropriate application of advances in science andtechnology on the basis of accessibility and universally freeaccess for the whole population. Improvement of education atall levels (currently the lowest educational level is nine years)and scientific development are two fundamental anddeterminant factors for health development.Scientific and technological development inthe period 1959–2007As early as 1960 human resources and scientific andprofessional development were recognized as a main priority.Under the umbrella of the Cuban Academy of Sciences,scientific organization started in 1962. Also in the 1960s, thefirst medical scientific institutions were founded in order torespond to the main health challenges. Eight researchinstitutes, all under the Ministry of Health, commencedinvestigations in the fields of cardiology, oncology,gastroenterology, endocrinology, angiology, haematology,labour medicine and human nutrition. In 1965, the CentroNacional de Investigaciones Cientificas (CNIC) was foundedas part of Havana University and constituted the “motherinstitution” of most of the scientific centres in the fields ofbiomedicine and biotechnology.The creation of the “Frente Biologico” early in the 1980srepresented a further step in the development of Cubanbiomedical sciences. This organization hosted the mainscientific personalities and institutions, creating the basisfor the development of the biotechnology and thepharmaceutical industries.The “Polo Científico” or “Scientific Pole” was founded in1991–1992 with the aim of coordinating integrated effortsfor the overall scientific development of the country.Biomedical, veterinary, agropecuarian institutions, industryand the universities among others are part of the ScientificPole that is coordinated and directed by the Office of theSecretary of the State Council. The Direction of Science andTechnology at the Ministry of Health, created in the 1970s,maintains a very close interaction with the institutions of theScientific Pole.Supporting the organization and management of thescientific activities of the country, the Ministry of Science andTechnology (CITMA) was created in 1994. Several nationalprogrammes were developed to respond to the maineconomic and social problems of the country.Currently, Cuba hosts 57 scientific institutions dedicated tohealth research. The Scientific Pole of the State Council,CITMA, the Cuban Academy of Sciences and the Ministry ofHealth interact to solve the main health problems of thecountry through conducting national and ministerialprogrammes of investigation. Cuban science is characterizedby collaboration and the integration of different scientificinstitutions, with some doing R&D activities and othersapplying results in a “closed cycle” strategy from research topost-marketing follow-up, where the integration andfunctioning of all scientific centres has as a main objective theapplication of scientific results to benefit the health of theCuban population.110 ✜ Global Forum Update on Research for Health Volume 4
Decision-makingimplemented on a small scale with substantial managerialand technical support, but may be less effective ifimplemented country-wide with relatively less support.Combining systematic review evidence with other typesof information – frequently policy-makers draw upon a rangeof different types of evidence. For example, a systematicreview of effects might be complemented with costeffectivenessanalysis, or modelling data. Policy-makers willalso wish to consider the political and social acceptability ofthe intervention or policy being considered, and probably alsothe equity implications. Questions such as these mightrequire separate primary data collection research. In healthtechnology assessment, evidence on the effectiveness of thetechnology is typically combined not only with costeffectivenessanalysis but also with consideration of legal,ethical, psychological and social implications 8 . Policy-makersneed to consider carefully how best to combine these differentforms of evidence.Discussion and conclusionsSystematic reviews have great potential to play a key role ininforming policy and decision-making regarding healthsystems. As systematic reviews have become the goldstandard for clinical decision making, we should also strive toensure that they are routinely used as an input into policymaking,acknowledging that other factors, including politicalissues, will also influence policy. In particular, systematicreviews can be helpful in identifying possible negative effectsassociated with a particular reform, so that such possibleeffects can be monitored.The systematic reviews of health systems issuesundertaken to-date are of considerable utility, but we needmore impact evaluations to feed into reviews, more reviews,and more methodological development to make systematicreviews of even greater use to policy and decision-makers. Inparticular methodological development is needed to learnhow best to synthesize research that explores the effects ofcomplex packages of interventions, and to synthesizeevidence regarding processes such as policy andimplementation processes.Given the complexity of health systems, considerable workis involved in assessing the relevance and applicability ofinternational systematic reviews to policy questions beingmade in a particular setting. Moreover, systematic reviewsthemselves are often complex, and require some training interms of how to assess and interpret them. In light of this itseems unrealistic that senior policy-makers will themselvesemploy systematic reviews directly in decision-making.Instead skilled knowledge brokers and analysts are neededwho can help contextualize findings, and marry systematicreview evidence with other types of evidence. To-date verylimited attention has been paid to such functions withinnational health systems and much greater focus on theseroles is needed.Finally, systematic reviews are a useful reminder of howlittle we still know about effective health system strengtheninginterventions. When clear evidence regarding theeffectiveness of a particular policy or intervention is lacking,it is important that policy change is accompanied bymonitoring and evaluation both to avoid possible harms, butalso to contribute to the knowledge base. Systematic reviewscan also be extremely helpful in terms of providing guidanceregarding appropriate study design for such primary research.Sara Bennett is the Manager of the Alliance for Health Policyand Systems Research, an international collaboration based withinWHO, Geneva. She has previously worked as a health systemsresearcher, research manager and in policy roles in low- andmiddle-income countries. She is particularly interested in theinterface between research and policy.Acknowledgements: The author would like to thank JohnLavis and Andy Oxman who have helped immeasurably inshaping her thinking on systematic reviews of health systemsresearch, though they bear no responsibility for the viewspresented here.References1.Travis P et al. Overcoming health system constraints to achieve theMillennium Development Goals. The Lancet, 2004. Freedman L et al.Who’s got the power? Transforming health systems for women andchildren. UN Millennium Project: Task force on Maternal Health and ChildHealth, 2005. Bryce J et al. Programmatic pathways to child survival:results of a multi-country evaluation of Integrated Management ofChildhood Illness. Health Policy and Planning 20 Supplement, 2005,1:i15-i17.2.Straus and Jones. “What has evidence based medicine done for us?”British Medical Journal, 2004, 329:987-988. Muir Gray JA. Evidencebased policy making. British Medical Journal, 2004, 329:988-989.3.Sheldon T. Making evidence synthesis more useful for management andpolicy making. Journal of Health Services Research and Policy, 2005, 10(supplement 1): S1-S5.4.Lagarde M and Palmer N. “Evidence from Systematic Reviews to InformDecision making regarding Financing Mechanisms that Improve Access toHealth Services for poor people”. Alliance for Health Policy and SystemsResearch, WHO, Geneva, 2007.5.The Lagarde and Palmer review included the following study designs:randomized control trials, interrupted time series and controlled before andafter studies.6.Lewin S et al. “Lay health workers in primary and community health care:A Systematic Review of Trials”, 2006, available for download fromhttp://www.who.int/rpc/meetings/LHW_review.pdf7.The authors found 48 articles focused on lay health workers and MCHservices.8.OECD. Health Technology and Decision Making. The OECD health project:OECD Paris, 2005.150 ✜ Global Forum Update on Research for Health Volume 4
Page 3 and 4:
Editorial Advisory Board:Luis Gabri
Page 5 and 6:
Contents096 Child immunization: acc
Page 7 and 8:
IntroductionResearch contributions
Page 9 and 10:
IntroductionType IType IIType IIIPr
Page 11 and 12:
Introductionmaking), takes account
Page 13:
Access to healthStrengthening healt
Page 16 and 17:
Access to healthTraining more healt
Page 18 and 19:
Access to healthimperative for acti
Page 20 and 21:
Access to healthReferences1.Further
Page 22 and 23:
Access to healthDeterminantsAvailab
Page 24 and 25:
Access to healthThe authors are inv
Page 26 and 27:
Access to healthCombining health an
Page 28 and 29:
Access to health100%Availability of
Page 30 and 31:
Access to healthhypothesis that an
Page 32 and 33:
Access to healthMandatory clinical
Page 34 and 35:
Access to healthWhile there are som
Page 36 and 37:
Access to healthItemDefinition/Expl
Page 38 and 39:
Access to healthReferences continue
Page 40 and 41:
Access to healthintegrating individ
Page 42 and 43:
Access to healthA social determinan
Page 44 and 45:
Access to healthemployment conditio
Page 46 and 47: Access to healthMaking human rights
Page 48 and 49: Access to healthResources outsideth
Page 50 and 51: Access to healthReferences1.McCoy D
Page 52 and 53: Access to healthand financial burde
Page 54 and 55: Access to healthDiscrimination as a
Page 56 and 57: Access to health“Two months ago I
Page 58 and 59: Access to healthReferences continue
Page 60 and 61: Access to healthsocio-cultural and
Page 62 and 63: Access to healthIntergovernmental P
Page 64 and 65: Access to healthand conference stat
Page 66 and 67: Access to healthReferences continue
Page 68 and 69: InnovationTowards the development o
Page 70 and 71: InnovationMajor classificationMajor
Page 72 and 73: Innovation60% of enterprises5040302
Page 74 and 75: InnovationUsing the power ofintelle
Page 76 and 77: Innovationbe adapted - and harnesse
Page 78 and 79: InnovationFinancing of vaccine R&D-
Page 80 and 81: InnovationFinancing Ultimate Interm
Page 82 and 83: Innovationsome of this risk might b
Page 84 and 85: InnovationChild immunization:accele
Page 86 and 87: Innovationare revealing previously
Page 88 and 89: InnovationDeveloping countries % De
Page 90 and 91: Innovationcapacities. It is indeed
Page 92 and 93: InnovationSome plausible causes of
Page 94 and 95: Innovationwhere he was a programme
Page 98 and 99: Research resourcesBiotechnologists6
Page 100 and 101: Research resources1,61001,41,219080
Page 102 and 103: Research resourcesReferences1.The R
Page 104 and 105: Research resources✜ A group of nu
Page 106 and 107: Research resourcesReferences1.Inter
Page 108 and 109: Research resourcesThe threat of pan
Page 110 and 111: Research resourcesChanging environm
Page 112 and 113: Research resourcesPartnerships offe
Page 114 and 115: Research resourcesWe encourage othe
Page 116 and 117: Research resources181614No. of PPPs
Page 118 and 119: Research resources12010080604020Pro
Page 120 and 121: Research resourcesCapacity strength
Page 122 and 123: Research resourcestreatment is prov
Page 124 and 125: Research resourcesSmall scale busin
Page 126 and 127: Research resourcesthis process in a
Page 128 and 129: Research resourcesways. For instanc
Page 130 and 131: Decision-making148 Delivering evide
Page 132: Decision-makingChallenges in employ
Page 136 and 137: Decision-makingUsing evidence forpo
Page 138 and 139: Decision-makingdesire to publish. T
Page 140 and 141: Decision-makingsystems development.
Page 142 and 143: Decision-makingTowards evidence-inf
Page 144 and 145: Decision-making✜ develop a critic
Page 146 and 147:
Decision-makingwas prior to 2001, a
Page 148 and 149:
Decision-makingGlobal and regional
Page 150 and 151:
Decision-makingHigh-incomeChildrenE
Page 152 and 153:
Decision-makingLow- and middle-inco
Page 154 and 155:
Decision-makingLow- and middle-inco
Page 156 and 157:
Decision-makingthan a quarter of th
Page 158 and 159:
Decision-makingThe potentials of in
Page 160 and 161:
Decision-makingGenerally, any resea
Page 162 and 163:
Decision-makingReferences1.Hawes H.
show all

Combining health and social protection measures to reach the ultra ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?