Advancing the field of health systems research synthesis.

Those planning, managing and working in health systems worldwide routinely need to make decisions regarding strategies to improve health care and promote equity. Systematic reviews of different kinds can be of great help to these decision-makers, providing actionable evidence at every step in the decision-making process. Although there is growing recognition of the importance of systematic reviews to inform both policy decisions and produce guidance for health systems, a number of important methodological and evidence uptake challenges remain and better coordination of existing initiatives is needed. The Alliance for Health Policy and Systems Research, housed within the World Health Organization, convened an Advisory Group on Health Systems Research (HSR) Synthesis to bring together different stakeholders interested in HSR synthesis and its use in decision-making processes. We describe the rationale of the Advisory Group and the six areas of its work and reflects on its role in advancing the field of HSR synthesis. We argue in favour of greater cross-institutional collaborations, as well as capacity strengthening in low- and middle-income countries, to advance the science and practice of health systems research synthesis. We advocate for the integration of quasi-experimental study designs in reviews of effectiveness of health systems intervention and reforms. The Advisory Group also recommends adopting priority-setting approaches for HSR synthesis and increasing the use of findings from systematic reviews in health policy and decision-making.

Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress.

Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC.

Priority setting and health policy and systems research.

Health policy and systems research (HPSR) has been identified as critical to scaling-up interventions to achieve the millennium development goals, but research priority setting exercises often do not address HPSR well. This paper aims to (i) assess current priority setting methods and the extent to which they adequately include HPSR and (ii) draw lessons regarding how HPSR priority setting can be enhanced to promote relevant HPSR, and to strengthen developing country leadership of research agendas. Priority setting processes can be distinguished by the level at which they occur, their degree of comprehensiveness in terms of the topic addressed, the balance between technical versus interpretive approaches and the stakeholders involved. When HPSR is considered through technical, disease-driven priority setting processes it is systematically under-valued. More successful approaches for considering HPSR are typically nationally-driven, interpretive and engage a range of stakeholders. There is still a need however for better defined approaches to enable research funders to determine the relative weight to assign to disease specific research versus HPSR and other forms of cross-cutting health research. While country-level research priority setting is key, there is likely to be a continued need for the identification of global research priorities for HPSR. The paper argues that such global priorities can and should be driven by country level priorities.

Use of near-infrared spectroscopy as a physiologic monitor for intra-abdominal hypertension.

BACKGROUND: Intra-abdominal hypertension (IAH) is increasingly recognized as an important parameter in critically ill (ICU) patients. IAH affects perfusion to all abdominal components including the abdominal wall (AW). Near infrared spectroscopy (NIRS) measures changes in three chromophores including oxygenated hemoglobin (HbO2), deoxygenated hemoglobin (Hb), and cytochrome aa3 (Cyt), providing information concerning dysoxia. We sought to examine whether NIRS measurement of the AW was safe, and correlated with intra-abdominal pressure (IAP) in ICU patients. METHODS: A NIU-Pro001 system recorded NIRS data over 24 hours from the AW of 9 ICU patients at risk for IAH. IAP was recorded from the bladder. Changes in chromophore values are interpolated from best-fit polynomial curves. RESULTS: Sixty-six paired IAP and NIRS readings were taken from 9 ICU (4-12 observations/patient) patients. No measurement related adverse reactions occurred. The mean (range) first values measured in these patients were; IAP 17.2 mm Hg (9-31); HbO2 0.41 micromol/L (-8.4 to 7.6); Hb 2.6 micromol/L (-3.1 to 12.2); and Cyt 0.65 micromol/L (-3.4 to 4.8). A significant, inverse (or negative) association was found between DeltaNIRS HbO2 level and DeltaIAP (coefficient, -0.1588; p = 0.008). No association was found between DeltaNIRS Hb or DeltaCyt and DeltaIAP. CONCLUSION: NIRS of the AW appears safe. NIRS measurement of changes in HbO2 appears to be associated with DeltaIAP, and warrant further study in greater numbers of ICU patients with more frequent IAP readings, over longer periods of critical illness.