Editorial

Citation

Green, A. (2007), "Editorial", Journal of Health Organization and Management, Vol. 21 No. 6. https://doi.org/10.1108/jhom.2007.02521faa.001

Editorial

This special issue focuses on the work of the Nuffield Centre for International Health and Development in the Leeds Institute of Health Sciences at the University of Leeds. The journal has, for a number of years, had close associations with this centre through its editors and, given the increasing widening of the journal to incorporate international issues, a special issue focusing on aspects of the work of Nuffield seemed appropriate. It also provides an opportunity, through this editorial, to reflect on the evolution and challenges facing centres such as Nuffield as they seek to support health and development in low and middle income countries.

In the UK there are a small number of academic departments, which focus on health system issues in low-income (or developing) countries. Those with a long history are the London School of Hygiene and Tropical Medicine and the Liverpool School of Tropical Medicine, both of which originated, as their names imply, in the area of tropical medical practice and public health.

By the late 1970s international strategies towards health were broadening with the Alma Ata Declaration in 1978 being the key statement of this. Alma Ata put great emphasis on core principles including pursuit of equity and the importance of participation by communities in decision-making about health and health systems. The origins of the current Nuffield Centre go back to the same year, when it was set up in response to a request from the UK Overseas Development Administration (the forerunner of the current UK Department for International Development) to provide a course in health administration for senior managers from developing country health systems. This was, in the development field at least, the beginning of recognition that effective health systems need specifically trained managers. The initiative was the first in the UK to set up courses tailored to the particular needs of this group. In the 29 years since its inception the education provision at Nuffield has evolved from a single Postgraduate Diploma to a suite of postgraduate programmes in Public Health, Health Management, Planning and Policy and Hospital Management. The key objective of such courses is to develop the analytical capacity of managers to identify and solve problems in a manner that suits their particular context.

UK-based training is, of course, one response to the critical capacity shortfalls in many developing countries. However Nuffield has, for some time, recognised the importance of moving upstream in educational provision – through developing capacity in low-middle income countries to deliver their own courses. Such provision is cheaper to provide and is, inevitably, more geared to the particular needs of those countries. Indeed it can be argued that in-country provision may be one part of wider strategies to reduce the international haemorrhaging of professionals to northern health systems. One downside of country-specific courses is the loss of exposure to other health system experiences. Educational centres in high-income countries have a responsibility, I would suggest, to support such initiatives and Nuffield is involved in working with a number of institutions to develop their educational capacity. Omar et al. in this issue illustrate such capacity development activities in their account of work in Iran.

As part of its education portfolio, in 2002 Nuffield started offering the opportunity for medical students to take a year out from their medical studies and focus on International Health issues. Whilst some of these students will go on to practise as doctors in low-income settings, many will remain in the UK. We believe, however, that the exposure to international health issues will strengthen their UK practice. We also see such courses as an important contribution to widening awareness of global health concerns and strategies and developing a culture of international learning and responsiveness within national health systems. Broome et el. examine this initiative drawing on research conducted as part of this degree scheme.

Whilst Nuffield’s origins were in educational provision, it has developed, alongside its course provision, a strong portfolio of research into communicable diseases, reproductive health, mental health and health systems. One common theme of all this work has been a focus on the barriers to the application of known technologies – a health systems approach. The majority of funds for research on health in low-income countries are for product development predominantly related to vaccines (e.g. for HIV) or treatment (e.g. to develop new forms of antibiotic to respond to drug resistance). Yet for many health problems, known interventions exist but the health system is unable to support their provision. Perhaps the most obvious example of this is in maternal health where every year 500,000 women die from complications of pregnancy or childbirth, most due to an inability to get to basic obstetric services. This global figure is illustrative of the particular system challenges for low income countries when regionally disaggregated – the lifetime risk of dying in pregnancy in Africa is 1 in 12 compared to 1 in 4,000 in Europe.

Much of Nuffield’s research focuses on how to strengthen health systems at a number of different levels ranging from the operational delivery aspects to national policy-making. At the national level Mirzoev et al. gives an overview of health system reforms in Tajikistan, a country that has emerged from the former Soviet Union with some major health system challenges. One particular reform that has been frequently part of a package of health system initiatives is decentralisation and Collins et al. look at the broad health system issues that arise from a decentralisation process. Thomas et al. analyse the contribution of volunteers in health care delivery in a TB programme. An important related issue is understanding perceptions of communities. Gordon et al. give examples of this looking at the health effects of stoves in Mongolia. It is very easy for health professionals to take a supply side look at health, ignoring the wider implications of ill health within a society, and Escott and Newell remind us, in their study of TB issues in Swaziland, of the dangers of ignoring such issues in health programme design. Of course health programme design also requires good information about the problems it is tackling and Allaby et al. illustrates the importance of good data looking at estimates of TB cases in an urban setting in Nepal.

In recent years the term knowledge transfer has emerged. Its use is often ambiguous: educational provision is of course, in part, about knowledge transfer to students (though we consider the development of analytical abilities and professional skills to be an even more essential element of the learning process); it is also used to relate to advisory activities and this is an important element of Nuffield’s work. We would argue that independent academic institutions have a particular role to play in supporting national health systems develop their own policies and procedures; indeed a characteristic of much of the research done in the DFID funded Communicable Disease Research Programme Consortium that Nuffield leads is the joint development with national health control programmes of such policies. Lastly, and closely linked to the above, the term knowledge transfer is used increasingly to refer to the final stage of any research – the dissemination of the new knowledge gained. This aspect of the research process is now widely recognised as having been neglected, with academics assuming that the key products of their research were academic papers. Increasingly we are recognising the gap between such outputs and policy change. One of the key challenges of researchers at institutions such as Nuffield therefore is to put energy and emphasis on linking with policy makers and seeking a range of appropriate processes and outputs to engage with them.

Earlier I mentioned the importance of capacity development in educational provision. In fact capacity development (or releasing) should be an important component of all types of work carried out by institutions such as Nuffield, and can be seen as core to development. For Nuffield, this means building up long term relationships with institutions in a small number of countries in such a way that there is mutual trust and understanding of the capacity needs of both partner institutions. Nepal is an example of one country where we have long-term relationships, and this country focus is illustrated in this issue, by the three articles on Nepal.

Drawing on the above I end by summarising what I see as the key essential components of any northern institution, such as Nuffield’s, which is engaged in health and development work. I would argue that there are three broad elements.

First, there is a clear need for strong and explicit values. We are not working in a technical neutral value-free zone. In the development field this need is particularly important, given the massive danger of creating a form of neo-colonialism in our relations with low-income health systems. In Nuffield’s case I would single out three values or principles that we see as paramount. First, a strong commitment to equity at all levels; internationally and nationally. This can be in danger of becoming an “apple pie” statement, but requires a shared understanding of what is meant by equity and what its implications are for the way in which health systems deal with current inequities. Second, a belief in the importance of democratic engagement in the field of health by all citizens and in particular the disadvantaged (ranging from those with few financial resources or social capital, those disadvantaged due to gender, to those for whom ill-health itself has disempowered them – through for example disability or the stigma attached to particular diseases). Democratic engagement suggests more than just an elected government: it also implies the need for robust and open policy processes; for genuine opportunities for users and non-users to have their say in health system decisions as well as decisions about their individual health; and a paramount role for the public sector in leading the health system. The third broad value is that of self-determination of national health systems. Amartya Sen sees development as “freedom” in its broadest sense and I would suggest that in this context it means the freedom for national health systems (assuming democratic engagement as described above) to decide their own objectives and their own approaches to meeting these objectives.

Second, the previous suggests a particular approach to working with research and education partners to build up capacity and develop mutual trust and joint learning. Increasingly the potential for flow of knowledge South-North as well as North-South is being recognised. Indeed we should be striving for a long-term situation where partner Southern institutions are as familiar a sight in the national health systems of Northern countries as Northern researchers are in Southern health systems at present. Such capacity development work can be slow and this leads to the final element. Centres such as Nuffield have to accept that for every three steps taken forward, two may be backwards. Maintenance of trust and mutual respect is critical to keep such processes going forward.

The articles that follow all emanate from staff and students of Nuffield and, I hope, illustrate the importance that we attach to these values and approaches to our work.

Andrew GreenUniversity of Leeds, Leeds, UK