Tracking global resources and capacity for health research: time to reassess strategies and investment decisions.

The COVID-19 pandemic and more recently the Monkeypox outbreak emphasize the urgency and importance of improving the availability and equitable distribution of resources for health research across rich and poor countries. Discussions about the persistent imbalances in resource allocation for health research between rich and poor countries are not new, but little or no progress has been made in redressing these imbalances over the years. This is critical not only for emergency preparedness, but for the worlds' ability to improve population health in an equitable manner. Concerned with the lack of progress in this area, Member States of the World Health Organization requested the establishment of a Global Observatory on Health Research and Development, with the aim of consolidating, monitoring and analyzing relevant information on health research and development, with a view to informing the coordination and prioritization of new investments. In this commentary, we highlight some of the striking disparities from the Observatory's analysis over the 5 years since its establishment and reflect on what is needed to overturn stagnant progress.

Increasing Effectiveness and Equity in Strengthening Health Research Capacity Using Data and Metrics: Recent Advances of the ESSENCE Mechanism.

Background: The ESSENCE on Health Research initiative established a Working Group on Review of Investments in 2018 to improve coordination and collaboration among funders of health research capacity strengthening. The Working Group comprises more than a dozen ESSENCE members, including diverse representation by geography, country income level, the public sector, and philanthropy. Objective: The overall goal of the Working Group is increased research on national health priorities as well as improved pandemic preparedness, and, ultimately, fewer countries with very limited research capacity. Methods: We developed a basic set of metrics for national health research capacity, assessed different models of coordination and collaboration, took a deeper dive into eight countries to characterize their national research capacity, and began to identify opportunities to better coordinate our investments. In this article, we summarize the presentations, discussions, and outcomes of our second annual (virtual) meeting, which had more than 100 participants representing funders, researchers, and other stakeholders from higher- and lower-income countries worldwide. Findings and conclusions: Presentations on the first day included the keynote speaker, Dr. Soumya Swaminathan, chief scientist of the World Health Organization (WHO), and updates on data and metrics for research capacity, which are critical to establish targets, road maps, and budgets. The second day focused on improving collaboration and coordination among funders and other stakeholders, the potential return on investment for health research, ongoing work to increase coordination at the country level, and examples of research capacity strengthening efforts in diverse health research areas from around the world. We concluded that an intentional data- and metric-driven approach to health research capacity strengthening, emphasizing coordination among funders, local leadership, and equitable partnerships and allocation of resources, will enhance the health systems of resource-poor countries as well as the world's pandemic preparedness.

Taking stock of the availability and functions of National Ethics Committees worldwide.

BACKGROUND: National Ethics Committees (NECs) offer important oversight and guidance functions and facilitate public debate on bioethical issues. In an increasingly globalized world where technological advances, multi-national research collaborations, and pandemics are creating ethical dilemmas that transcend national borders, coordination and the joining of efforts among NECs are key. The purpose of this study is to take stock of the current NEC landscape, their varying roles and missions, and the range of bioethical topics on which they deliberated since their inception. METHODS: Data on the availability, functions, and ethical deliberations (publications) of NECs globally were gathered through a systematic search of NEC websites and through contacts known to the authors. The search was conducted in English, French, and Spanish. The data abstraction was done in Excel and included the NEC's country, region, functions, and deliberations on bioethical issues. Deliberation topics were classified into thematic categories through an iterative process of regrouping to arrive at the main set of themes. RESULTS: 124 NECs in 100 countries were identified. 44% of the NECs are in Europe and 47% are in high-income countries. Out of the 1108 retrieved publications, 40% were on bioethics in the context of research, followed by the clinic (28%) and public health issues (22%). The top five topics of these publications were: research ethics (124; 9%), genetics and genomics (62; 6%), organ transplantation (58; 5%), assisted reproductive technology (49; 4%), and end of life (36; 3%). CONCLUSION: Our study makes an important contribution to understanding the current interests and functions of NECs and the range of their bioethics deliberations. By making the data publicly available through this publication, it allows users to conduct tailored analyses and queries based on their interests, and to seek and strengthen collaboration and exchange. It also makes the case for the fruitfulness of developing and maintaining a global repository of current and new deliberations to more effectively advance this field for the greater good of humanity, research, and public health.

A Mechanism for Reviewing Investments in Health Research Capacity Strengthening in Low- and Middle-Income Countries.

More than 40 agencies that fund health research capacity strengthening in low- and middle-income countries (LMICs) participate in the ESSENCE Health Research initiative, which has established a mechanism for reviewing and coordinating their funding. Taken together, the expected outcomes of implementation of the review mechanism are increases in the efficiency and equity in health research capacity strengthening activities with decreased duplication of efforts. The overall goal is increased support of research on national health priorities as well as improved pandemic preparedness in LMICs, and, eventually, fewer countries with very limited research capacity.

Resource allocation for biomedical research: analysis of investments by major funders.

BACKGROUND: Data on grants for biomedical research by 10 major funders of health research were collected from the World RePORT platform to explore what is being funded, by whom and where. This analysis is part of the World Health Organization Global Observatory on Health Research and Development's work with the overall aim to enable evidence-informed deliberations and decisions on new investments in health research and development. The analysis expands on the interactive data visualisations of these data on the Observatory's website and describes the methods used to enable the categorisation of grants by health categories using automated data-mining techniques. METHODS: Grants data were extracted from the World RePORT platform for 2016, the most recent year with data from all funders. A data-mining algorithm was developed in Java to categorise grants by health category. The analysis explored the distribution of grants by funder, recipient country and organisation, type of grant, health category, average grant duration, and the nature of collaborations between recipients of direct grants and the institutions they collaborated with. RESULTS: Out of a total of 69,420 grants in 2016, the United States of America's National Institutes of Health funded the greatest number of grants (52,928; 76%) and had the longest average grant duration (6 years and 10 months). Grants for research constituted 70.4% (48,879) of all types of grants, followed by grants for training (13,008; 18.7%) and meetings (2907; 4.2%). Of grant recipients by income group, low-income countries received only 0.2% (165) of all grants. Almost three-quarters of all grants were for non-communicable diseases (72%; 40,035), followed by communicable, maternal, perinatal and nutritional conditions (20%; 11,123), and injuries (6%; 3056). Only 1.1% of grants were for neglected tropical diseases and 0.4% for priority diseases on the WHO list of highly infectious (R&D blueprint) pathogens. CONCLUSIONS: The findings highlight the importance of considering funding decisions by other actors in future health research and capacity-strengthening decisions. This will not only improve efficiency and equity in allocating scarce resources but will also allow informed investment decisions that aim to support research on public health needs and neglected areas.

Investigación sobre la implementación de políticas de salud

Uno de los principales retos que afronta la comunidad global de salud consiste en identificar la manera de adoptar intervenciones de eficacia demostrada y aplicarlas en la práctica. Hay intervenciones probadas que permiten salvar vidas y hacer frente a muchos de los problemas de salud que afrontamos, pero no se conoce suficientemente la mejor manera de realizar esas intervenciones en toda la gama de sistemas de salud existentes y en la amplia diversidad de entornos posibles. Nuestro fracaso para aplicar efectivamente las intervenciones tiene un precio. Por ejemplo, cada año, más de 287.000 mujeres mueren por complicaciones relacionadas con el embarazo y el parto, y unos 7,6 millones de niños, entre ellos 3,1 millones de recién nacidos, mueren por enfermedades prevenibles o tratables mediante intervenciones existentes. COMPRENSIÓN DE LA IMPLEMENTACIÓN EN EL MUNDO REAL Las cuestiones relativas a la implementación surgen como resultado de diversos factores, incluidos elementos contextuales del “mundo real” que se han pasado por alto o no se han incluido en otras disciplinas de investigación. La investigación sobre la implementación de políticas arroja luz sobre esos factores y sienta las bases para la adopción de decisiones apropiadas al contexto y basadas en pruebas científicas, que es crucial para hacer realidad lo que en teoría es posible. Dado que la investigación sobre la implementación de políticas está integrada en la realidad, quienes trabajan en el mundo real (prácticos, en oposición a los “investigadores”) suelen plantear preguntas que son el punto de partida de nuevas ideas. Uno de los principales retos que afrontan los investigadores sobre la implementación consiste en velar por que esas preguntas sean escuchadas, y que la investigación realizada se oriente a darles respuesta, y no a los temas que los investigadores pudieran considerar interesantes. UNA HERRAMIENTA PRÁCTICA Integrada en el mundo real, la investigación sobre la implementación de políticas es también una herramienta poderosa para obtener y analizar información en tiempo real, lo que permite la evaluación del desempeño, por ejemplo, y facilita el fortalecimiento de los sistemas de salud. La investigación sobre la implementación de políticas es particularmente importante para apoyar la ampliación a escala de las intervenciones y su integración en los sistemas de salud a nivel nacional. Con demasiada frecuencia, algunas intervenciones que resultan eficaces en estudios piloto a pequeña escala no logran cumplir con las expectativas cuando se las aplica en estrategias nacionales, o no se pueden trasladar de un país a otro en razón de diferencias contextuales. La investigación sobre la implementación de políticas ayuda a aclarar por qué ocurre eso, y se puede utilizar en apoyo del proceso de perfeccionamiento constante necesario para la adecuada adaptación. Las mismas capacidades convierten a la investigación sobre la implementación de políticas en una herramienta útil para ayudar a las organizaciones a fortalecer su capacidad de aprendizaje con miras a asimilar y poner en práctica los conocimientos desarrollados regularmente. UN ESFUERZO DE COLABORACIÓN La investigación sobre la implementación de políticas es de máxima utilidad cuando los encargados de la ejecución toman parte en las fases de identificación, diseño y realización de la investigación llevada a cabo. Por eso es tan importante el fomento de los vínculos de colaboración entre las partes interesadas participantes en la formulación de políticas, la gestión de programas y la investigación. Una manera de apoyar la colaboración entre investigadores y encargados de la ejecución consiste en integrar la investigación sobre la implementación de políticas en los procesos de toma de decisiones políticas y programáticas desde el principio, en vez de considerarla cómo un esfuerzo separado del proceso de implementación. De esa manera, la investigación científica también se puede integrar de forma sistemática y constante en el proceso destinado a solucionar los problemas de la implementación. Además, la investigación sobre la implementación de políticas puede desempeñar un papel importante como una herramienta ue facilite a las comunidades de base la identificación de cuestiones desatendidas, la revelación de deficiencias en el desempeño y el fortalecimiento de la rendición de cuentas de las organizaciones de salud. En todos estos esfuerzos de colaboración se insta a los investigadores sobre la implementación de políticas a ser receptivos y flexibles en sus trabajos. De hecho, el conocimiento del contexto y los sistemas, así como la flexibilidad para identificar enfoques metodológicos apropiados, pueden ser tan importantes o más que el seguimiento riguroso de un diseño de investigación fijo. UNA GRAN DIVERSIDAD DE INVESTIGACIONES En general, el término “investigación sobre la implementación de políticas” describe el estudio científico de los procesos utilizados para aplicar iniciativas, así como los factores contextuales que afectan esos procesos. Ello puede abordar o examinar cualquier aspecto de la implementación, especialmente los factores que la afecten (tales como la pobreza, el aislamiento geográfico, las creencias tradicionales), los procesos de implementación en sí mismos (por ejemplo, la distribución gratuita de mosquiteros tratados con insecticidas a través de dispensarios de salud materna, o la vacunación masiva frente a medidas de vigilancia y confinamiento), y los resultados o productos finales de la implementación objeto de estudio. La investigación sobre la implementación de políticas es relevante y aplicable a muchos campos de investigación diferentes y en diversos grados, en función del tema que se estudie. Por ejemplo, generalmente, la investigación básica de nuevos medicamentos no abarca ninguna cuestión relativa a la implementación, mientras que sí lo hacen las medidas orientadas a asegurar la disponibilidad de esos medicamentos para quienes los necesitan. La investigación sobre la implementación de políticas suele centrarse en las estrategias necesarias para realizar y poner en práctica nuevas intervenciones aquí llamadas “estrategias de implementación”, un término utilizado para distinguirlas de las intervenciones clínicas y de salud pública. Para estudiar los procesos de implementación se puede utilizar un marco que permita conceptualizar y medir los resultados de la implementación sobre la base de variables tales como la “aceptabilidad”, “idoneidad” y “viabilidad”, a fin de comprender en qué medida está funcionando efectivamente un determinado proceso de implementación. UNA AMPLIA GAMA DE ENFOQUES Habida cuenta de la gran diversidad de enfoques y disciplinas de investigación empleados, tiene poco sentido hablar de un conjunto de “métodos de investigación sobre la implementación de políticas”. Sin embargo, algunos enfoques y diseños de investigación, incluidos los ensayos pragmáticos, los ensayos híbridos de efectividad de la implementación, los estudios sobre mejoramiento de la calidad y la investigación acción participativa son particularmente útiles, por cuanto generan información práctica, son eficaces para detectar las sutilezas contextuales a lo largo del tiempo y ofrecen la flexibilidad iterativa necesaria para responder al cambio. Si bien esos instrumentos son vitales para el investigador de la implementación, es importante tener en cuenta que en la investigación sobre la implementación de políticas “la pregunta es rey”, es decir, el tipo de preguntas determina el método utilizado, y no viceversa. Las preguntas de la investigación sobre la implementación de políticas suelen ser complejas y reflejar la amplia gama de factores contextuales que pueden influir en la implementación, producir efectos impredecibles y exigir que los encargados de la ejecución realicen adaptaciones constantemente. Para abarcar esa complejidad se requiere una flexibilidad considerable por parte de los investigadores, especialmente en lo que respecta al carácter complejo y dinámico de la materia que se estudia. ARMONIZAR LA INVESTIGACIÓN CON LAS NECESIDADES Y ASEGURAR LA CALIDAD En circunstancias ideales, la investigación sobre implementación de políticas se debería armonizar con las necesidades, o sea, abordar las inquietudes de los destinatarios previstos y responder a las particularidades del tema que se analiza. En ese contexto, el grado de certeza exigido respecto de los resultados o proyecciones es una consideración fundamental. Por ejemplo, un encargado de formular políticas que tenga limitaciones en su trabajo podría buscar indicios sólidos de la posible eficacia de una intervención, pero no dispondrá necesariamente del tiempo requerido para realizar estudios multianuales que le darían un mayor grado de certeza. El objetivo de responder a las necesidades de diferentes audiencias podría tener importantes repercusiones en el diseño básico, el presupuesto y el calendario de la investigación. A fin de asegurar la armonización de la investigación sobre implementación de políticas con las necesidades y la buena calidad, es conveniente formular las siguientes preguntas clave: ¿Se aborda claramente en la investigación una cuestión concerniente a la implementación? ¿Se describe con claridad lo que se está implementando (por ejemplo, detalles de la práctica, el programa o la política)? ¿Se incluye en la investigación una estrategia de implementación? Si así fuera, ¿se describe y se examina apropiadamente? ¿Se realiza la investigación en un entorno del mundo real? Si así fuera, ¿se describen esas condiciones con detalle suficiente? ¿Se consideran debidamente en la investigación las variables de los resultados de la implementación? ¿Se examinan apropiadamente en la investigación el contexto y otros factores que influyen en la implementación? ¿Se examinan apropiadamente en la investigación los cambios a lo largo del tiempo y el nivel de complejidad del sistema? ¿Se identifican claramente en la investigación la audiencia destinataria de la investigación y la forma en que se la puede utilizar? APROVECHAR MEJOR LA INVESTIGACIÓN SOBRE LA IMPLEMENTACIÓN DE POLÍTICAS A pesar de su importancia, la investigación sobre la implementación de políticas sigue siendo un ámbito de estudio desatendido, en parte por falta de conocimiento respecto de lo que es y lo que ofrece, y en parte por la escasa inversión realizada en actividades de investigación sobre la implementación de políticas. Se gastan millones en innovaciones de la salud, pero muy poco en determinar la mejor manera de utilizarlas. Este problema nos afecta a todos, pero en particular a las poblaciones de los países de ingresos bajos y medianos en los que los desafíos de la implementación son los más grandes. La presente Guía procura corregir esa falta de conocimiento de la investigación sobre la implementación de políticas y alentar al personal de programas y los encargados de la ejecución a que asuman un mayor compromiso con el tema y reconozcan que la investigación sobre la implementación de políticas es, de hecho, una parte integral de la planificación y ejecución de programas, y no algo que ocurre una vez que los programas están en marcha, y se ejecutan en gran medida para beneficio de otros investigadores. Por su parte, los investigadores en materia de implementación pueden hacer mucho más para interactuar con los encargados de la ejecución y el personal de los programas en el proceso de investigación. Solo mediante la colaboración podrán los encargados de la ejecución con su comprensión minuciosa del contexto, y los investigadores con su conocimiento profundo de los métodos y técnicas de indagación, esperar que comprendamos mejor las cuestiones de la implementación que ponen en riesgo muchos de nuestros esfuerzos de salud pública.

Understanding the dynamics of the Seguro Popular de Salud policy implementation in Mexico from a complex adaptive systems perspective.

BACKGROUND: In 2003, Mexico's Seguro Popular de Salud (SPS), was launched as an innovative financial mechanism implemented to channel new funds to provide health insurance to 50 million Mexicans and to reduce systemic financial inequities. The objective of this article is to understand the complexity and dynamics that contributed to the adaptation of the policy in the implementation stage, how these changes occurred, and why, from a complex and adaptive systems perspective. METHODS: A complex adaptive systems (CAS) framework was used to carry out a secondary analysis of data obtained from four SPS's implementation evaluations. We first identified key actors, their roles, incentives and power, and their responses to the policy and guidelines. We then developed a causal loop diagram to disentangle the feedback dynamics associated with the modifications of the policy implementation which we then analyzed using a CAS perspective. RESULTS: Implementation variations were identified in seven core design features during the first 10 years of implementation period, and in each case, the SPS's central coordination introduced modifications in response to the reactions of the different actors. We identified several CAS phenomena associated with these changes including phase transitions, network emergence, resistance to change, history dependence, and feedback loops. CONCLUSIONS: Our findings generate valuable lessons to policy implementation processes, especially those involving a monetary component, where the emergence of coping mechanisms and other CAS phenomena inevitably lead to modifications of policies and their interpretation by those who implement them. These include the difficulty of implementing strategies that aim to pool funds through solidarity among beneficiaries where the rich support the poor when there are no incentives for the rich to do so. Also, how resistance to change and history dependence can pose significant challenges to implementing changes, where the local actors use their significant power to oppose or modify these changes.

Applying a system dynamics modelling approach to explore policy options for improving neonatal health in Uganda.

BACKGROUND: The most recent reports on global trends in neonatal mortality continue to show alarmingly slow progress on improvements in neonatal mortality rates, with sub-Saharan Africa still lagging behind. This emphasised the urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems in which the various strategies operate. METHODS: In our first paper, we empirically explored the causes of the stagnating neonatal mortality in Uganda using a dynamic synthesis methodology (DSM) approach. In this paper, we completed the last three stages of DSM, which involved the development of a quantitative (simulation) model, using STELLA modelling software. We used statistical data to populate the model. Through brainstorming sessions with stakeholders, iterations to test and validate the model were undertaken. The different strategies and policy interventions that could possibly lower neonatal mortality rates were tested using what-if analysis. Sensitivity analysis was used to determine the strategies that could have a great impact on neonatal mortality. RESULTS: We developed a neonatal health simulation model (NEOSIM) to explore potential interventions that could possibly improve neonatal health within a health system context. The model has four sectors, namely population, demand for services, health of the mothers and choices of clinical care. It tests the effects of various interventions validated by a number of Ugandan health practitioners, including health education campaigns, free delivery kits, motorcycle coupons, kangaroo mother care, improving neonatal resuscitation and labour management skills, and interventions to improve the mothers health, i.e. targeting malaria, anaemia and tetanus. Among the tested interventions, the package with the highest impact on reducing neonatal mortality rates was a combination of the free delivery kits in a setting where delivery services were free and motorcycle coupons to take women to hospital during emergencies. CONCLUSIONS: This study presents a System Dynamics model with a broad and integrated view of the neonatal health system facilitating a deeper understanding of its current state and constraints and how these can be mitigated. A tool with a user friendly interface presents the dynamic nature of the model using 'what-if' scenarios, thus enabling health practitioners to discuss the consequences or effects of various decisions. Key findings of the research show that proposed interventions and their impact can be tested through simulation experiments thereby generating policies and interventions with the highest impact for improved healthcare service delivery.

Factors Contributing to Maternal and Child Mortality Reductions in 146 Low- and Middle-Income Countries between 1990 and 2010.

INTRODUCTION: From 1990-2010, worldwide child mortality declined by 43%, and maternal mortality declined by 40%. This paper compares two sources of progress: improvements in societal coverage of health determinants versus improvements in the impact of health determinants as a result of technical change. METHODS: This paper decomposes the progress made by 146 low- and middle-income countries (LMICs) in lowering childhood and maternal mortality into one component due to better health determinants like literacy, income, and health coverage and a second component due to changes in the impact of these health determinants. Health determinants were selected from eight distinct health-impacting sectors. Health determinants were selected from eight distinct health-impacting sectors. Regression models are used to estimate impact size in 1990 and again in 2010. Changes in the levels of health determinants were measured using secondary data. FINDINGS: The model shows that respectively 100% and 89% of the reductions in maternal and child mortality since 1990 were due to improvements in nationwide coverage of health determinants. The relative share of overall improvement attributable to any single determinant varies by country and by model specification. However, in aggregate, approximately 50% of the mortality reductions were due to improvements in the health sector, and the other 50% of the mortality reductions were due to gains outside the health sector. CONCLUSIONS: Overall, countries improved maternal and child health (MCH) from 1990 to 2010 mainly through improvements in the societal coverage of a broad array of health system, social, economic and environmental determinants of child health. These findings vindicate efforts by the global community to obtain such improvements, and align with the post-2015 development agenda that builds on the lessons from the MDGs and highlights the importance of promoting health and sustainable development in a more integrated manner across sectors.

Informing the establishment of the WHO Global Observatory on Health Research and Development: a call for papers.

In May 2013, the WHO Member States requested the WHO to establish a Global Observatory on Health Research and Development (R&D), as part of a strategic work-plan to promote innovation, build capacity, improve access, and mobilize resources to address diseases that disproportionately affect the world's poorest countries.The rationale for establishing a Global Observatory on Health R&D is to provide a mechanism to monitor and analyse health R&D resource flows, product pipelines, and research outputs, aiming to contribute to the identification of gaps to inform priority-setting for new R&D investments to be operationalized through a new global financing and coordination mechanism for health R&D and utilized by all stakeholders informing health research policy decisions in countries, civil society, and the private sector.As one of the mechanisms to achieve the goals of the Global Observatory on Health R&D, the WHO is launching a Call for Papers to be published as a Thematic Series in Health Research Policy and Systems to contribute state-of-the-art knowledge and innovative approaches to analyse, interpret, and report on health R&D information. Further, to serve as a key resource to inform the future WHO-convened coordination mechanism, which will be utilized to generate evidence-informed priorities for new R&D investments to be financed through a proposed new global financing and coordination mechanism for health R&D.

Constraints to applying systems thinking concepts in health systems: A regional perspective from surveying stakeholders in Eastern Mediterranean countries.

BACKGROUND: Systems Thinking (ST) has recently been promoted as an important approach to health systems strengthening. However, ST is not common practice, particularly in Low- and Middle-Income Countries (LMICs). This paper seeks to explore the barriers that may hinder its application in the Eastern Mediterranean Region (EMR) and possible strategies to mitigate them. METHODS: A survey consisting of open-ended questions was conducted with a purposive sample of health policy-makers such as senior officials from the Ministry of Health (MoH), researchers, and other stakeholders such as civil society groups and professional associations from ten countries in the region. A total of 62 respondents participated in the study. Thematic analysis was conducted. RESULTS: There was strong recognition of the relevance and usefulness of ST to health systems policy-making and research, although misconceptions about what ST means were also identified. Experience with applying ST was very limited. Approaches to designing health policies in the EMR were perceived as reactive and fragmented (66%). Commonly perceived constraints to application of ST were: a perceived notion of its costliness combined with lack of the necessary funding to operationalize it (53%), competing political interests and lack of government accountability (50%), lack of awareness about relevance and value (47%), limited capacity to apply it (45%), and difficulty in coordinating and managing stakeholders (39%). CONCLUSION: While several strategies have been proposed to mitigate most of these constraints, they emphasized the importance of political endorsement and adoption of ST at the leadership level, together with building the necessary capacity to apply it and apply the learning in research and practice.

Country progress towards the Millennium Development Goals: adjusting for socioeconomic factors reveals greater progress and new challenges.

BACKGROUND: The health Millennium Development Goals (4, 5, 6) impose the same ambitious 2015 targets on every country. Few low-income countries are on track to reach them. Some authors have proposed country-specific targets as a more informative method by which countries can measure their progress against their potential. METHODS: This paper demonstrates a supplementary approach to assess individual country progress that complements the global goals by adjusting for socioeconomic resources and prior time trends. A minimum performance target adjusts for time and national GDP. Fast-track targets, based on best-performing countries' progress within regional and income groups, adjust for health and non-health sector factors known to affect maternal and child health. RESULTS: Measuring by the minimum performance target, 74% and 59% of low- and middle-income countries are on track for reducing child mortality and maternal mortality, respectively, compared with 69% and 22% using global MDGs. Only 20% and 7% of low- and middle-income countries are on track for the child and maternal mortality fast-track targets. CONCLUSIONS: Supplementary targets in maternal and child health, adjusted for each country's resources and policy performance can help countries know if they are truly underperforming relative to their potential. Adjusted targets can also flag countries that have surpassed their potential, and open opportunities for learning from success. FUNDING: Partnership for Maternal, Newborn & Child Health and the Alliance for Health Policy and Systems Research, as part of the Success Factors Study on reducing maternal and child mortality.

Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India.

BACKGROUND: Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage. METHODS: We used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage. RESULTS: We identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena. CONCLUSIONS: As illustrated in this study, a complex adaptive system lens helps to uncover the 'real' drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.

Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda.

BACKGROUND: Of the three million newborns that die each year, Uganda ranks fifth highest in neonatal mortality rates, with 43,000 neonatal deaths each year. Despite child survival and safe motherhood programmes towards reducing child mortality, insufficient attention has been given to this critical first month of life. There is urgent need to innovatively employ alternative solutions that take into account the intricate complexities of neonatal health and the health systems. In this paper, we set out to empirically contribute to understanding the causes of the stagnating neonatal mortality by applying a systems thinking approach to explore the dynamics arising from the neonatal health complexity and non-linearity and its interplay with health systems factors, using Uganda as a case study. METHODS: Literature reviews and interviews were conducted in two divisions of Kampala district with high neonatal mortality rates with mothers at antenatal clinics and at home, village health workers, community leaders, healthcare decision and policy makers, and frontline health workers from both public and private health facilities. Data analysis and brainstorming sessions were used to develop causal loop diagrams (CLDs) depicting the causes of neonatal mortality, which were validated by local and international stakeholders. RESULTS: We developed two CLDs for demand and supply side issues, depicting the range of factors associated with neonatal mortality such as maternal health, level of awareness of maternal and newborn health, and availability and quality of health services, among others. Further, the reinforcing and balancing feedback loops that resulted from this complexity were also examined. The potential high leverage points include special gender considerations to ensure that girls receive essential education, thereby increasing maternal literacy rates, improved socioeconomic status enabling mothers to keep healthy and utilise health services, improved supervision, and internal audits at the health facilities as well as addressing the gaps in resources (human, logistics, and drugs). CONCLUSIONS: Synthesis of theoretical concepts through CLDs facilitated our understanding and interpretation of the interactions and feedback loops that contributed to the stagnant neonatal mortality rates in Uganda, which is the first step towards discussing and exploring the potential strategies and their likely impact.

Success factors for reducing maternal and child mortality.

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women's and Children's Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula--fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women's and children's health towards 2015 and beyond.

La réduction de la mortalité maternelle et infantile est une priorité des objectifs du Millénaire pour le développement (OMD) et le restera probablement après l'échéance de 2015. Il existe des données sur les investissements, les interventions et les politiques habilitantes nécessaires. On comprend mal pourquoi certains pays ont réalisé des progrès plus rapidement que d'autres pays comparables. Les Facteurs de réussite des études sur la santé des femmes et des enfants ont cherché à combler ce manque de connaissances en utilisant les analyses statistiques et économétriques des données provenant de 144 pays à faible revenu et à revenu intermédiaire et recueillies depuis 20 ans: une analyse comparative qualitative booléenne; une étude bibliographique et des études spécifiques à chaque pays pour les 10 pays à progression rapide pour les points 4 et 5a des OMD. Il n'existe pas de formule standard ­ les pays à progression rapide ont déployé des stratégies personnalisées et se sont adaptés rapidement aux changements. Cependant, ces pays ont en commun des approches efficaces visant 3 grands axes afin de réduire la mortalité maternelle et infantile. Premièrement, ils impliquent de nombreux secteurs pour traiter les facteurs déterminants et cruciaux pour la santé. Près de la moitié de la réduction de la mortalité infantile dans les pays à faible revenu et à revenu intermédiaire depuis 1990 résulte des investissements dans le secteur de la santé, l'autre moitié étant attribuée aux investissements réalisés dans les secteurs extérieurs à la santé. Deuxièmement, ces pays utilisent des stratégies pour mobiliser les partenaires dans la société, en utilisant des données solides et opportunes pour la prise de décisions et la responsabilisation, ainsi qu'une approche de planification triple pour prendre en considération les besoins immédiats, la vision à long terme et l'adaptation aux changements. Troisièmement, ces pays établissent des principes directeurs qui orientent les progrès, harmonisent les actions des parties prenantes et génèrent des résultats dans le temps. Cette synthèse de données contribue à l'ensemble des connaissances requises pour accélérer les améliorations sur la santé des femmes et des enfants en vue de l'échéance de 2015 et au-delà.

La reducción de la mortalidad materna e infantil es una prioridad en los Objetivos de Desarrollo del Milenio (ODM), y probablemente lo seguirá siendo después de 2015. Existen evidencias sobre las inversiones, las intervenciones y las políticas necesarias, pero se sabe menos acerca de por qué algunos países logran un progreso más rápido que otros países comparables. Los estudios relativos a los Factores de Éxito en la Salud de las Mujeres y los Niños han tratado de abordar esta brecha de conocimiento por medio de análisis estadísticos y econométricos de datos de 144 países de ingresos bajos y medianos (PIBM) a lo largo de más de 20 años, análisis comparativos cualitativos booleanos, revisión de la literatura y revisiones específicas de cada país en 10 países bien encarrilados para los ODM 4 y 5a. No existe una fórmula estándar, estos países despliegan estrategias a medida y se adaptan rápidamente a los cambios. Sin embargo, comparten ciertos enfoques eficaces a la hora de abordar tres áreas principales para reducir la mortalidad materna e infantil. En primer lugar, involucran a numerosos sectores para hacer frente a los factores sanitarios decisivos. Alrededor de la mitad de la reducción de la mortalidad infantil en los PIBM desde 1990 es el resultado de inversiones en el sector de la salud, y la otra mitad se atribuye a las inversiones realizadas en sectores fuera del ámbito sanitario. En segundo lugar, estos países utilizan estrategias para movilizar a socios a través de la sociedad, utilizando evidencias oportunas y sólidas para la toma de decisiones y la rendición de cuentas, así como un enfoque de planificación triple para considerar las necesidades inmediatas, la visión a largo plazo y la adaptación al cambio. En tercer lugar, los países establecen principios rectores que orientan el progreso, armonizan las acciones de las partes interesadas y logran resultados en el tiempo. Este compendio de evidencias contribuye al aprendizaje global sobre cómo acelerar las mejoras en la salud de mujeres y niños hacia el 2015 y más adelante.