Date Published: November 30, 2017
Publisher: Public Library of Science
Abstract: Health systems underpin disease elimination and eradication programmes. In an elimination and eradication context, innovative research approaches are needed across health systems to assess readiness for programme reorientation, mitigate any decreases in effectiveness of interventions (‘effectiveness decay’), and respond to dynamic and changing needs. The malaria eradication research agenda (malERA) Refresh consultative process for the Panel on Health Systems and Policy Research identifies opportunities to build health systems evidence and the tools needed to eliminate malaria from different zones, countries, and regions and to eradicate it globally. The research questions are organised as a portfolio that global health practitioners, researchers, and funders can identify with and support. This supports the promotion of an actionable and more cohesive approach to building the evidence base for scaled-up implementation of findings. Gaps and opportunities discussed in the paper include delivery strategies to meet the changing dynamics of needs of individuals, environments, and malaria programme successes; mechanisms and approaches to best support accelerated policy and financial responsiveness at national and global level to ensure timely response to evidence and needs, including in crisis situations; and systems’ readiness tools and decision-support systems.
Partial Text: Between 2000 and 2015, a major expansion of WHO-recommended interventions have contributed to a 58% reduction in the global malaria mortality rate (69% among children under 5 years old in Africa), resulting in an estimated 6.2 million lives being saved from a malaria-related death .
In 2009, WHO  defined health systems research as ‘the purposeful generation of knowledge that enables societies to organize themselves to improve health outcomes and services.’ It is concerned with how health services are financed, delivered, and organised and how these functions are linked within an overall health and social system with its associated policies and institutions.
Examples of the research portfolio discussed by the consultative panel are presented in Box 3, starting with cross-cutting priorities relevant to all health systems and policy research topics and then going over the research agenda in evaluation science, research, and R&D of new tools categories. For each research question in each category, the health system levels and the building blocks are mentioned. The top 2 priority questions and the question on which the panel chose to place special emphasis are always listed first in each category. A rationale is provided in the portfolio to offer some background and context on the issues raised. Then follows a list of additional questions linked to the priority questions to suggest key questions also to be answered.
Multiple factors have slowed progress in the health systems and operations research agenda since the first malERA initiative, including funding, dependency upon existing national and provincial health systems to deliver, and limited buy-in by a range of disciplines into the malaria agenda. All of these factors have contributed to this limited uptake. The panel felt that in order to keep a dynamic portfolio and not lose traction again, monitoring the uptake of research priorities established during the malERA Refresh process was essential.
Setting health research priorities does not automatically guarantee uptake and funding, though there are examples of how it does . And these health systems issues are ‘wicked’ problems for which no one solution will be found; solutions are not discrete from other systems’ issues, and solutions cannot be divorced from socio-historical-political environments . This agenda will also need a broad range of disciplines to engage in the implementation of the agenda beyond the ‘malaria research community’ to include social and behavioural sciences; political, management, and organisation science; health economics; and health systems specialists. Clearly, this health systems agenda to facilitate malaria eradication entails a transdisciplinary and multi-stakeholder approach and therefore needs to be more broadly disseminated and socialised in these scientific communities, and the findings from this research need to be more broadly disseminated to inform other health system interventions and their implementation, as well as health system strengthening in general.
This remains an ambitious but essential research agenda for malaria eradication. Every tool or intervention developed, for vectors, parasites, drug administration, surveillance and response, etc., needs a health and social system operating in a socio-political system to deliver the intervention effectively. To address challenges relating to health systems, transdisciplinary and multi-stakeholder approaches need to be tested. Results from evaluation science, research and R&D in this field will likely generate multiple nuanced answers. This process will ensure that the research questions put forward in a portfolio approach can be tailored to any given setting, as one size will not fit all, and finally that the maximum efficacy of interventions is maintained universally across the different social, political, and economic differentials for populations to achieve malaria elimination and, finally, eradication.