Webinar overview
The embedded research approach – which engages policy-makers, researchers, health professionals and communities to solve practical challenges – has contributed to stronger health systems through building cultures of evidence use. As health systems around the world are confronted with emergencies, from the COVID-19 pandemic to natural disasters, ensuring that resilient and responsive systems are in place has never been more important.
The webinar showcased two case studies, one from Ghana and one from Mozambique, that illustrate the critical role that embedded research can play. The Ghana story focuses on the scale-up of a community-based health programme and highlights the long-term investment in research. The Mozambique story takes the local health system response to the devastation caused by Cyclone Idai as a jumping off point, examining how a programme of embedded research had empowered local health workers and managers to quickly respond to needs.
The webinar mixed presentations and videos with reflections and discussion from those who were instrumental in implementing these projects. Notably, representatives from the Ghana Health Service and the Ministry of Health in Mozambique, along with other high-level supporters of the field, will participate. There will also be an opportunity for a wider discussion.
Webinar write up
Embedded research is not a new concept. As far back as the WHO strategy on health policy and systems research in 2012, Changing Mindsets, and the World health report 2013 on research for UHC, the Alliance have been committed the embedded research at all levels and stages of HPSR. Jeff Knezovich started off the webinar by highlighting the key principles of embedded research:
- It is carried out as an integrated and systematic part of the decision-making and implementation process.
- It brings policy-makers, communities, researchers, and implementers to the table so their knowledge feeds into routine decision-making.
- It makes research more relevant to context as it is informed by local knowledge.
- It supports the development of learning health systems and creates a culture of evidence use in decision-making.
Embedded research from a long-term perspective
Both experts on the webinar talked to the importance of taking a long-term perspective to embedded research. Koku Awoonor-Williams provided a historical perspective of how Ghana developed its Primary Health Care system from the days of the Navarongo experiment to today's Community-based Health Planning and Services (CHPS). Quinhas Fernandes of the Mozambique Ministry of Health explained how the Integrated District Evidence to Action program (IDEAs) was implemented in the Sofala Province over the course of ten years. Even then, he underscored, the team are still building the culture of quality data and data use.
The link between embedded research and learning health systems
Koku described the Ghanaian system as a ‘learning health system’ – one that asks questions, gets data and makes informed decisions off the back of it. Quinhas shared a quote from colleague, Sergio Chicumbe: “The problem is that frontline health workers are producers of data, but they are not users. In IDEAs, data is shared with producers and they can make their own decisions and plan for the future.”
Quinhas went on to explain that frontline health workers are central to decision-making. We often think that is only bosses and managers that have the power to make decisions, but they occur at all levels of the health system. IDEAs took a three-step approach: there were health system readiness assessments; those were followed by audit and feedback meetings that brought together nurses, district and provincial supervisors to identify gaps and make action plans at the health facility level; and finally, the performance of health facilities was reviewed and staff shared their experiences across different facilities. They were supported in acting on their action plans by mentoring and financial resources.
Now, frontline workers can talk with confidence about data and use it to improve services. Health systems resilience enabled colleagues to respond to Cyclone Idai which hit Mozambique in 2018. It affected 2.1 million people, it destroyed 90 health facilities and about 3000 health worker’s houses were damaged. But a few months later, the health system had virtually returned to normal – this show the importance of embedded research in building resilience.
Challenges to embedding HPSR
Embedding research is not always easy, and Quinhas stressed the importance of understanding bottlenecks and how these can be addressed in different contexts. In addition, while embedded research requires all stakeholders to get around the table, this can get very complex because it is not easy to address everyone’s priorities. For a policy-maker, time is really critical regardless of the robustness or the findings. If they don’t get the evidence while an outbreak is ongoing, for example, it is of little use to them. As such, it is important to balance all these expectations. It hasn’t been a clear and easy process – it requires work every day to have everyone on board and to have faith in the role of research in improving the system.
In Ghana, the Ministry of Health commissioned the initial research on PHC so there was policy buy-in from the outset. The decentralized health research centres of the Ghana Health Service (along with national and regional universities) were on hand to support this request. So, there was buy in at the initial stage. There was also a lot of effort in continuous community meetings and community engagement to understand the context and the people and also engaging people outside the health sector, like local government, was important.
Even with the structures that have been built within the Ghanaian health system embedded research uncovers areas where more work is needed. It exposed how the emergency systems, transportation and supply chains faced problems which the program is helping to redesign so that the health system can respond better in the future.
Looking to the future
The webinar was an opportunity to launch two new digital longforms – with text, films and graphics – that explain the effects of embedded research on the two health systems over time. These digital longforms are particularly timely. As Lola Adedokun from the Doris Duke Charitable Foundation remined us, embedded research prompts both leadership and the creation of a learning health system.
There’s no perfect health system, and COVID-19 has made us understand that more clearly. It is really important is to ensure that learning from past experiences are incorporated into new preparedness plans to address shocks better.
Considering the experiences of countries like Ghana and Mozambique will be essential as we move forward in the face of the COVID-19 pandemic.