Background

As the global movement towards universal health coverage (UHC) gains momentum, countries in the WHO African Region will need to overcome several design and technical challenges within their health systems to achieve set targets. UHC is defined as ensuring that all people have access to needed health services of sufficient quality to be effective, while ensuring that the use of these services does not expose the user to financial hardship.1 The definition embodies several dimensions including ensuring that good quality services are available and accessible, the whole population is reached with the services they need, and no one faces financial hardships in seeking care.

Health systems must be strong to ensure attainment of the aspirations in the different dimensions. Health systems strengthening, and reforms are very challenging—both in terms of designing policies and programmes and effectively implementing them to achieve the desired impact. There is often a knowledge gap between ‘how to’ implement health systems changes and the technical assistance provided. Research evidence can provide guidance on how to effectively design and implement systems changes and reforms.

A recent study shows limited progress in Africa towards achieving the Sustainable Development Goals (SDGs) targets.2 Eight of the 10 least performing countries are in the WHO African Region.2 To make progress in achieving the SDGs as well as UHC, innovative approaches must be employed. Within the WHO African Region, several challenges persist among which are weak health systems,3 low investment in health,4 poor health seeking behaviour and, cultural, social and financial barriers to accessing care.5 6 There are also concerns about the appropriateness of service delivery models and whether they are responsive to peoples’ needs.7

Several service delivery models have been advanced; for example, comprehensive, integrated model of care8 and people and person centred integrated care for all.9 The implementation of these preferred models in Africa has been elusive as De Man et al10 point out that …why so little of something so badly needed?…. This brings to the fore the need for contextualised evidence, generation of local solutions and tailored approaches. Research for health can play a significant role in this regard—to discover affordable service delivery models and identify ways to optimise the use of existing tools or solutions to address health systems challenges, including those that militated against the achievements of the Millennium development goals.

Can national health research systems deliver?

The endorsement of the Research for Health: a Strategy for The African Region 2016–202511, by ministers of health in the WHO African region in 2015 ushered in a renewed focus on strengthening national health research systems (NHRS). The 2018 assessment of progress in implementation of the research strategy in the 47 member states, showed improvement over an earlier 2014 assessment in strengthening governance for research (development of policies and strategies, laws and legislations, research priority lists and strengthening ethical review), developing and sustaining research resources (universities with training programme that have included research, presence of national research institutions) and, producing and using research (establishing knowledge translation platforms).

Identified major challenges include low government financing for health research; weak research coordination capacity; weak enforcement of laws and regulations; inadequate research infrastructure and lengthy ethical clearance processes.12 Worse still, most research activities in the WHO Africa region are driven by external partners, with low prospects of local ownership and sustainability. The research arena is characterised by a multiplicity of actors, dispersed efforts and unclear results in relation to impact on priority health problems.13 Consequently, Africa’s percentage share of global health research output is minimal; for example, Africa produced only 1.3% of the global health research publications in 2014.14

Embracing opportunities

A few major initiatives complement the aspirations of the WHO African research strategy11 and provide opportunities for maximising the benefits of health research in Africa. The recently launched Health Research and Innovation Strategy (HRIS) for Africa 2018–203015 by the African Union (AU) seeks to ‘promote and increase health research and innovation for improved health and well-being of Africa’s Peoples’. The objectives therein address some of the persistent challenges among which is ensuring sustainable financing, adoption of emerging technologies, strengthening research regulation and intellectual property rights to leverage benefits and building sustainable research capacity.

The long-standing investment in strengthening research ethics and building capacity for clinical trials by initiatives like the European and Developing Countries Clinical Trials Partnership, NIH Fogarty, Africa Medicines Harmonisation Initiative, Africa Vaccines regulators Forum and others16 offer additional opportunities. Tackling infections to benefit Africa (TIBA), which is an African led wide-ranging multidisciplinary research programme, seeks to empower African Scientists to effectively and sustainably tackle neglected tropical diseases.17 TIBA is currently running research programmes in nine countries.

Other opportunities for responsive research in Africa include the Evidence-Informed-Policy Network (EVIPNet) Africa, Cochrane Africa Network and WHO collaborating centres. The mission of EVIPNet Africa is to promote a network of partnerships at national and regional levels among health system policymakers, civil society, healthcare workers, healthcare managers, researchers, funders and others; to strengthen health systems and improve health outcomes through regular access to assessment, adaptation and use of context-specific research evidence.18 Cochrane is a global independent network of healthcare practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. Cochrane collects and summarises the best health evidence from research to help health professionals to make informed choices about treatment.

The existence of the African Advisory Committee on Health Research and Development (AACHRD) offers another opportunity to ensure generation of evidence targeted at information gaps in African countries. The AACHRD is a multidisciplinary, multisectorial body established in 1979, to provide advice to the WHO African region on matters of research related to health development. It meets annually and has a consultative role with regards to shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge in the African region. The 15–20 committee members serve in their personal capacity and represent a board range of disciplines encompassing many aspects of research for health and development.

WHO collaborating centres, which are institutions appointed by WHO, support the organisation’s programmes at any level from country to the headquarters. Such centres, located in Africa, could play a role in the systematic generation and use of evidence to overcome health systems challenges in the region. However, of the over 700 WHO collaborating centres worldwide, only 25 (3%) are in the WHO African Region, and only a few of them currently focus on health systems core functions.19 It is perhaps time for WHO to revisit the terms of reference of existing collaborating centres and consider establishing new ones to address the health system priorities that are currently not addressed.

Moving forward

Leveraging available opportunities to strengthen NHRS and generate contextualised evidence to advance UHC will require actions at national, subregional and regional level. The low funding for health research has been attributed to lack of political commitment and the recently launched HRIS by the AU will hopefully mobilise the necessary political leverage. The AU has committed to develop a score card to regularly monitor the implementation of the HRIS. This will complement the WHO Africa Region biennial assessment of the status of NHRS, results of which are presented to ministers of health from member states during regional committee meetings.

Subregion action could be undertaken within the economic communities, Southern Africa Development Cooperation, the East African Community and the Economic Community of West African States focussing on standardising laws and legislations for research and embracing a regional approach to regulation of research, building research capacity at a subregional level to share resources and expertise and sharing research results for uptake.

Region-wide mechanisms for sharing relevant evidence or best practices may take the form of an African Forum on Health Research, to play a leadership role in stimulating the growth of an evidence-informed decision-making culture that is guided by local priorities and locally generated research and innovation. National level action could focus on implementation of the objectives of the WHO African region research strategy and the HRIS while leveraging global and continental opportunities.