We hear this statement made over and over again, that policy makers in the less developed countries will not take up research findings. To try bridge the gap between recommended best practice and policy, the research world has been trying all sorts of tricks…building up collaborations with aid–recipient countries, disseminating their research findings in the media and yes, supplying copies of systematic reviews to government officials who do not have access to the internet. Despite these efforts uptake of research findings into policy have largely failed.
I would like to illustrate the current research environment in many poor countries by drawing reference to two branches of the practice of medicine; general practice and psychiatry. With the research world-mainly composed of donor outfits from the more affluent world being the doctors and the poor helpless countries being the patients for which research finding are prescribed to cure ailing health systems. In the practice of general medicine the patient out of pain or discomfort, voluntarily approaches the doctor who runs tests and then prescribes treatment. Compliance to medicine in general practice in most cases is high with majority of patients imbibing most of the drugs prescribed. In poor countries however the relation between recipient countries and the researchers can be aptly compared to the practice of psychiatry in an asylum. The patient has no insight of his/ her malady, in many cases the patient even denies being sick, the psychiatrists then prescribe drugs many of which incapacitate the patient even more and compliance to this kind of medicine is pathetic at best.
Most research agenda are run from the West. More recently most of these agendas are aligned to what has been referred to as MDGS. In many cases there is little pull from recipient countries and the priority lists of the researchers and the lists of the policy makers could never be different than they are currently. Maslow describes that before humans and systems can actualise, the basic needs have to be satisfied. Poor countries need to be given a chance to define their priority research areas then contract these out to researchers who then provide solutions i.e. putting the donkey before the cart. If for example the priority of policy makers at the Ministries of Health is to have hot tea all day through. Then this needs to be researched to ensure that steaming tea is served to policy makers all day. It’s only after this has been sorted that second, third or fourth items in the list can be addressed.
Providing lengthy pieces of research findings reports or copies of systematic reviews full of unintelligible jargon to policy does not lessen the pain of swallowing findings which are constantly being shoved down the throats of many policy makers.
Empty promises
I once read a 300 page motor vehicle magazine; in it were five different articles and adverts of products that could increase a car’s fuel efficiency. The first article stated that using the right tyre pressure would reduce fuel consumption by at least 10 %. The second was on a radiator coolant that promised to cut fuel consumption by at least 25 %. The third article was on driving speed, that accelerating to the correct speed and maintaining that speed to your destination could save you another 20 % (practical?- Nay, especially in a city riddled with potholed roads or unending traffic jams). The fourth article was on special high octane gasoline that promised to cut fuel consumption by another 15 %. Finally was an advert on heavy duty spark plugs that promised to do the magic and cut consumption by a cool 30 %. I did a quick back-of-the-envelope calculation and found by adhering to the advice and fitting the said parts I would be saving 100 % of fuel (10 + 25 + 20 +15 + 30) and say goodbye forever to the fuel vender at the corner of my street who I had always suspected of lacing fuel with kerosene and tampering with the pump meters. Buying that magazine could not have come at a better time, and the whole idea could not have sounded sweater. Policy makers are constantly being bombarded to take up and implement barrage research findings, they have been listening to the music from researchers for far too long and have realised that the sum total of individual research findings do not add up to proposed gains in disease or mortality reduction, as I painfully learnt having spent money on car parts and receiving speeding tickets for doing 50 on 20 Km/h stretches. The resentment has grown. In a few cases confusion has bedevilled these policy makers as in a recent case where one prominent journal reported that eradicating small pox in Africa might have paved way to the emergence of HIV, that small pox had a protective effect from the HIV virus. My take on this story is different – could the small pox vaccine have been laced with agents which gave rise to HIV, if one is to offer a plausible explanation to the chronological link between disappearance of small pox and emergence of HIV? – that is a question we can ponder about some other time in some other forum.
To reduce childhood mortality, researchers have proposed all sorts of interventions: zinc, ORS, prophylactic septrin, ACTs, bed nets, polyvalent vaccines, routine de-worming, iron supplementation, use of DDT to eradicate mosquitoes…. most of which have might have worked but whose sum total has not even matched half the promised targets. Under-five mortality in many poor countries has remained at the same level for the last 30 years or as long as enumeration has been done in these countries. As long as the empty promises continue to be peddled by an unchecked research inc., pessimism will grow among the policy makers and increasingly among poor populations making it harder to implement findings.
Confabulations
The measurement of disease burden in Africa is a concoction of findings from poorly conducted surveys and mathematical predictions based on imagined parameters. In a recent report about the global mortality burden for children, a new model was used to estimate this burden in the less developed world. The authors of the report pat themselves on the back stating that the new estimates were similar to previous estimates. The parameters that went to these models were however the same ones that have been used over time. It borders insanity to continue estimating mortality in Africa using the same old methods, expect different outcomes and when you come up with the same findings blow up your trumpet on the consistency of your quackery. The bottom line is that Ministries of Health in Africa have no idea of what the health systems ail from. That is why vertical programs will initially over-estimate burden of a specific disease and then when years later when the burden is accurately measured praise its efforts for bringing down that disease.
The Magic bullet
Most of sub-Saharan Africa has been at war for the last odd half century. Starting with wars fought at independence and the civil wars and coups that followed in many of these new states. The mention of armoury or connotations to bloodletting weapons or bullets sends chills down the spines of the bravest Africans. Many of these research findings have been christened “magic bullets” to end years of disease in Africa, not surprising they were never received with open arms. Or some like the Structural adjustment programs (SAPs) recommended by the World Bank can be argued to have achieved the target that they were intended. After many years of war and disease, Africa does not need magic bullets to sort out its health problems but needs workable and sustainable solutions. Removal of trade barriers within Africa and internationally so that the economic engines can begin humming, being allowed to manufacture cheap drugs, accruing benefits gained from findings of endless years of research on poor populace and most importantly being allowed to set and run its own agenda on research.
