Health systems and policy research

Weak health systems have increasingly been highlighted as major barriers to achieving global health goals. Work within the programme tackling this area is multidisciplinary, with strong links to other research areas within KEMRI/Wellcome Trust and international collaborators. It is focused around understanding and influencing provider and household behaviours, and developing and evaluating interventions and policies to strengthen research and service provision.

Two key areas of health systems research are centred in our Nairobi offices:

Improving the delivery of care. After initial work on the quality of hospital care in 2002, work on means to improve services for newborns and children began in earnest in Nairobi in 2004. By 2006 the scope of work spanned evidence synthesis (see www.ichrc.org) to inform development of national hospital guidelines that drew heavily on programme work, meningitis surveillance (www.netSPEAR.org), vaccine cost-effectiveness analysis, and conduct of a 3 year trial in which hospitals were randomised to receive a multi-faceted intervention or a control intervention with evaluation using quantitative and qualitative methods. By 2009 the scope of research initiated had broadened further to include national and international methodological work on measurement of quality of hospital care, economic evaluation of complex health interventions and pragmatic clinical work evaluating case management guidelines.
Consortium for Research on Equitable Health Systems. In 2005 a new stream of health systems work funded by the UK's Department for International Development (DFID) was initiated under the auspices of the Consortium for Research on Equitable Health Systems (CREHS) (see www.crehs.lshtm.ac.uk/index.html).CREHS aims to generate knowledge to help strengthen health systems policies and interventions in ways which preferentially benefit the poorest. In Kenya CREHS staff are working on a range of health systems issues, including health care financing, human resources, policy implementation, and scaling up of key interventions.

Both these streams of work have helped build close links between the programme and the Ministry of Public Health and Sanitation and the Ministry of Medical Services and, in the more clinical areas, with the University of Nairobi.

Many other groups within KEMRI/Wellcome Trust also have a strong focus on health systems and policy issues, including work of the Social Behavioural Research group, and the Malaria Public Health and Epidemiology group.

Child Newborn Health Group (CNHG)

Training to provide effective, evidence-based care to children and newbornsFor many years biomedical research has focused on defining what the best therapeutic products are or optimizing approaches to care. However, the reality is that such research is rarely translated into practice, especially in low income settings. Thus, one of CNHG'S major aims is to understand and evaluate the quality of care and the development and implementation of clinical practice guidelines. The single largest area of work focuses on rural, Kenyan district hospitals and their ability to provide effective, evidence-based care to seriously ill children and newborns. Research includes quantitative and qualitative evaluation of health system performance and the roles of health workers, including, for example, evaluation of adherence to guidelines, explorations of health worker motivation and barriers to implementing best practice care.

Further areas of work are also focused on helping to meet local research needs and build capacity and have a relatively broad scope including:

Examining the value of research from an ethical perspective
Economic evaluation of new childhood vaccines
Promoting bacterial disease surveillance in East Africa (www.netspear.org).
Evidence review and synthesis to inform development of national treatment guidelines (www.ichrc.org). This work is conducted in collaboration with the Ministry of Health in Kenya and, hopefully, with the proposed Kenyan Branch of the South African Cochrane Collaboration.

In the future research in clinical epidemiology to tackle questions identified as of major importance by rural clinical, providers will be initiated to promote improved child and newborn survival.

Collaborators:

University of Nairobi,
Ministry of Medical Services / Ministry of Public Health and Sanitation,
University of Witswatersrand,
London School of Hygiene and Tropical Medicine,
University of Oxford,
WHO-Geneva and WHO-Kenya

Malaria Public Health and Epidemiology Group

Percentage of children under five sleeping under an ITN by 2007The epidemiology of malaria in Africa is in transition with evidence of declining transmission and disease burdens. This has been a presumed consequence of expanded intervention coverage due to improved international donor financing. However all is not equal and there remain disparities in intervention coverage, neglected populations and constraints to further reductions due to biological and political vulnerabilities.

There has been very little scientific effort to rigorously document this change using validated metrics of infection risk, intervention coverage and disease outcome. At a time when transmission and disease burdens are in decline, with targets set for elimination or low stable endemic control, a renewed emphasis on the basic epidemiology of malaria is paramount. Furthermore new approaches to delivering effective control and disease management are required to maximize the renewed international effort to finance malaria programmes in Africa.

These include innovative ways of financing anti-malarial drugs, accessing medicines in rural areas, improving the way medicines are prescribed, increasing universal coverage of insecticide treated nets and adaptations of intervention suites to meet the special needs of urban, pastoralist and school aged populations. Over the period 2011-2016, the Malaria Public Health and Epidemiology Group in partnership with regional national disease control programmes aim to tackle key issues of optimizing intervention delivery to meet unmet needs and provide credible evidence of impact.

Projects under MPHEG include: