How can health research be more effective? Researchers: involve communities. Donors: be in-tune with country needs.

Miriam Were, Chair of the Kenya National AIDS Control Council and Chair of AMREF (African Medical and Research Foundation) discusses how health research can address poverty issues. She comments on how communities can help influence a national health research agenda in favour of poor people; and gives advice on how donors can better align with the national health agenda and support researchers’ needs.

How is health research linked to poverty?

Linking health research could greatly contribute to poverty reduction through the lessening of the disease burden and/or prompt treatment of illnesses. Unfortunately, this is not happening in many countries. Health findings are not being communicated effectively in order to be used.

Evidence is there but it has not been marketed so that decision-makers and practitioners know about it and use it. Health research is not only about finding out what is new but also ways of how to apply what is known and making use of available evidence. Sick people spend several days in bed and do not contribute productively. Further, they spend a lot of time earning money for treatment, yet if diseases are prevented and health promotion effected with existing evidence their economic status would also improve.

Can you comment on how AMREF is moving in this area of linking research to poverty?

First of all, AMREF recognises that improved health is a contribution to poverty reduction. Its entry point in a community is poor health and it links research to poverty through small loans. The poor people use these microfinance loans to trade in things like cabbages, tomatoes and crafts to improve their lives. Time that would have been spent when people are sick is turned into productive engagements and money for treatment is saved. AMREF is doing research on basic things such as how to spread the use of insecticide treated nets to prevent malaria. We can use research to advocate for health issues. Sometimes reducing poverty is difficult in Africa due to the huge health problems but we must see improved health as a contribution creating wealth.

What example can you give of good practice or areas where things are not being done as they should?

One reason why Africa has moved very slowly with research leading to improving people’s quality of life is because we have not understood the community. We have decided for the community without knowing what it wants; understand or what its priorities are and even bothering to find out how to communicate with them in ways that encourages people to explore the new ideas we are putting forward. The way we should now move forward is to take communities very seriously. We have to involve them from the start of any research undertaking. As health professionals, we should make an effort to know communities.

Our education moves us away from communities; even communities in which we grew up. Unfortunately, many of us totally fail to recognize this and never acknowledge it as an issue that needs to be addressed. This position does not help us seek ways of finding out what people think and how to establish bridges between their words and thoughts and our words and thoughts.

We need to realize that as researchers and policy makers, we should be the voice of the people. It is our duty to understand what community positions are so that we work with them and build their confidence and effectiveness with which they can deal with their problems.

Who decides the research agenda in Africa and how should this be done?

This is one of the questions we have been worrying about. Some of our health scientists are in universities or research institutes where they are required to conduct research but money is not provided to them. So they simply look out for those who are supporting health research. In most cases the research agenda is determined by the group which has money.

When people know that such an organisation has money for certain areas, they apply for it and get it. This may be fine especially if the donor makes provision for follow up to ensure that the findings get into policy and/or practice. But there should be research also, arising from researchers themselves and concerns of policy makers. In addition, as members of communities, researchers should conduct research on issues they have seen that could change people’s lives.

For instance, a research agenda should arise from concerns of how to improve health of a community which is burdened by malaria. Research should also be articulated to answer the unanswered questions in the Ministry of Health such as best ways to link the efforts at the community level with the health system. This way, we can approach the issue in a problem-solving way for ourselves and ministries and not just depending on external ideas about research.

What three areas can a community directly help shape the national health research agenda in favour of poor communities? In which areas can communities be involved in doing research… and how?

The three areas in which a community can directly help shape the national health research agenda are:

a) A community can indicate the structures in the community through which access to health care can be improved,
b) Communities can indicate who in the community could be trained to be their first line or front line health worker.
c) Communities should enter into discussion on how to establish links between itself and the first referral level of the Ministry of Health and how this is to be done.

Operation Research can be carried out on these to see how they can work best.

How should donors better align to have health research focused on poverty issues?

The problem we have with donors and our own governments is that they see health as "an expenditure sector." They need to see health as a wealth-creation sector. Donors who are focused on supporting health research for health improvement must be seen as contributing to poverty reduction especially if they ensure that evidence from the research is put to use.

This is what IDRC (Canada) was able to do in the Tanzania Essential Health Intervention Project (TEHIP). The research period was prolonged to include the time the evidence was put to use by Tanzania’s Ministry of Health. East Africa as a whole is benefiting from it through use of evidence from TEHIP to reduce burden of disease and death.

Another major problem many researchers have with donors is the short time frame of six months to two years within which donors want to move on; sometimes without bothering to know what use the results are being put to.

It should be known that poverty disempowers people and leaves them lethargic and even apathetic. Poverty makes people lose their self confidence and to get them engaged needs time. When a researcher is given a very short time to obtain results it becomes very difficult to engage people. Even if they do report results, they are not likely to be meaningful. Donors should allow investigators to understand people they are going to work with.

What three things would you want donors to do to improve the focus of health research in favour of poor communities?

1. Give the benefit of doubt to researchers once they have established working relationships with the donor. I think a donor has the right to carry out "due diligence" before working with the researcher. But once the engagement is done, trust should come in too. Some donors micromanage research which instead of building confidence of researchers, ends up undermining them.

2. Give a reasonable timeframe for the work. The "management by objectives" (donor’s objectives) approach with tight time frames has not had much beneficial effects resulting from the research.

3. Provide for "implementation research support". It is erroneous to assume that once you have good evidence, they will just "flow into the system". That process needs to be supported by research