Godt et al. Health Research Policy and Systems 2017, 15(Suppl 1):52
DOI 10.1186/s12961-017-0208-6
INTRODUCTION
Open Access
The change-makers of West Africa
Sue Godt1*, Sharmila Mhatre2 and Anne-Marie Schryer-Roy3
Abstract
West Africa was the focus of global attention during the Ebola virus disease outbreak, when systemic health system
weaknesses compounded a serious emergency and complicated response efforts. Following the crisis, calls were
made to strengthen health systems, but investments to date have fallen short of delivering the support needed to
build strong health systems able to prevent and manage future outbreaks.
In part, this reality serves to highlight the shortcomings of the solutions being repeatedly prioritised by external
funders and experts, solutions that often fail to consider the wealth of West African evidence and actors actively
working to strengthen the leadership and health systems needed to drive and sustainably improve national health
outcomes. Unfortunately, this knowledge and experience are rarely heard in the global arena.
This journal supplement is a contribution, although small, to changing this practice by putting the perspectives,
experiences and knowledge of West Africans on the table. It presents findings from a series of research and
capacity development projects in West Africa funded by the International Development Research Centre's Maternal
and Child Health programme (formerly Governance for Equity in Health Systems).
The evidence presented here centres around two key themes. First, the theme that context matters. The evidence
shows how context can change the shape of externally imposed interventions or policies resulting in unintended
outcomes. At the same time, it highlights evidence showing how innovative local actors are developing their own
approaches, usually low-cost and embedded in the context, to bring about change. Second, the collection of
articles discusses the critical need to overcome the existing fragmentation of expertise, knowledge and actors, and
to build strong working relationships amongst all actors so they can effectively work together to identify priority
issues that can realistically be addressed given the available windows of opportunity.
Vibrant West African-led collaborations amongst researchers, decision-makers and civil society, which are effectively
supported by national, regional and global funding, need to foster, strengthen and use locally-generated evidence
to ensure that efforts to strengthen health systems and improve regional health outcomes are successful. The
solutions are clearly not to be found in the ‘travelling models’ of standardised interventions.
Introduction
West Africa was the focus of global attention during the
Ebola virus disease outbreak [1, 2]. The epidemic dramatically demonstrated how systemic health system
weaknesses, including weak or non-existent national disease surveillance systems, compounded a serious emergency and complicated response efforts [3–6]. Although
calls were made to strengthen health systems as part of
post-Ebola reconstruction efforts, investments to date
have fallen short of delivering the support needed to
build strong health systems able to prevent and manage
future outbreaks [7].
* Correspondence: sgodt@idrc.ca
1
Maternal and Child Health Program, International Development Research
Centre, PO Box 62084, 00200 Nairobi, Kenya
Full list of author information is available at the end of the article
In part, this shortcoming is due to the challenge that
health system strengthening poses. However, at the same
time, it also highlights the failings of the solutions being
repeatedly prioritised by external funders and experts.
The missing headline in the narrative surrounding the
Ebola virus epidemic is that West Africa is home to a
wealth of evidence, researchers, practitioners, policymakers and civil society actors actively working to
strengthen the leadership and health systems needed to
drive and sustainably improve national health outcomes.
Unfortunately, this knowledge and experience are rarely
heard in the global arena. The research and development
aid agendas, discourse and investments tend to be driven
by external voices, interests and funds, with little space
for West African leaders and researchers to share their
insights and experiences. This journal supplement is a
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Godt et al. Health Research Policy and Systems 2017, 15(Suppl 1):52
contribution, however small, to changing this practice by
putting the perspectives, experiences and knowledge of
West Africans on the table. It aims to be reflective, and
looks at how the array of stakeholders – from local to
global – can more effectively play their part to support
health systems strengthening efforts in West Africa.
In 2011, the International Development Research Centre’s (IDRC) Governance for Equity in Health Systems
programme, now named the Maternal and Child Health
programme, embarked on a concerted effort to strengthen
research in West Africa to improve equitable health systems. Systematic consultations with stakeholders in the region pointed to persistent challenges that negatively
impacted on health. Health systems failed to promote
good health and provide quality and sustainable services
for the most vulnerable. The research environment did
not enable the building of relevant skills or catalyse the
needed resources to mount comprehensive research
programmes that would strengthen health systems and
address national priorities. Researchers were often fragmented by discipline, language and national boundaries.
Even with relevant findings, there were weak researchto-policy-and-practice mechanisms and processes to
apply the results.
Working with the West African Health Organisation
(WAHO), a regional body with the mandate to engage
with the 15 member states of the Economic Community
of West African States (ECOWAS) to strengthen policy
and collective practice to improve health outcomes, a
plan was developed that prioritised overcoming this fragmentation. These issues were subsequently integrated
into a regional call for concept notes. Based on the recognition that change cannot be imposed from the outside
but must be driven from within the region, the main objective was to strengthen a critical mass of researchers, research institutions, practitioners and decision-makers to
undertake and apply relevant research to strengthen
health systems and contribute to improving health outcomes. This journal supplement is one of the outputs of
IDRC’s programme of work to strengthen the research
environment.
Emerging themes
The articles in this supplement present evidence highlighting the barriers to sustainable innovation and change.
They also demonstrate why health systems need to be holistically strengthened given how vertical interventions focusing on one specific outcome can have skewing effects
on the delivery and impact of related healthcare services
[8–11]. Context also matters – it is not enough to simply
‘adapt’ promising innovations developed elsewhere. The
evidence shows how context can change the shape of externally imposed interventions or policies resulting in unintended outcomes [12]. Evidence is brought forward by
Page 2 of 138
Defor et al. [13] on the extent of the geographical and
linguistic divide in the production of research. This
fragmentation exacerbates efforts to undertake the
most needed research to address health challenges.
At the same time, the articles demonstrate how efforts
are underway to strengthen the environment for generating and using evidence to support sustainable change
[14, 15]. To mitigate some of the fragmentation of geography, discipline and language, WAHO demonstrates
how governance of research, combined with strong
policy and practice engagement platforms, can play a
supportive role [16, 17]. This foundation is helping to
strengthen research and stakeholder collaborations at
national and regional levels.
Context matters
A key theme emerging from the articles underlines the
importance of the scope of interventions as well as the
context in which these are developed. In Sierra Leone,
Koroma et al. [8] examine efforts to provide free maternal healthcare in the rural Bombali district prior to the
Ebola virus disease outbreak and find that, despite high
demand by the population, poor quality of services undermined results. Poor infrastructure, inadequate skilled staff
and low availability of supplies, combined with structural
inequities and lack of sustainable funding mechanisms,
compromised service delivery. In Burkina Faso, Yaogo [11]
draws on previous research into policies to abolish – in
part or in full – various health service fees and identifies
similar constraints to providing accessible quality services.
Both articles note the skewed impact of externally funded
programmes. In Sierra Leone, being part of a national
donor-driven programme resulted in a much higher rate
of testing pregnant women for HIV than for other antenatal tests [8]. In Burkina Faso, there were challenges in
managing the numerous different, often once-off, donor
contributions to subsidise disease prevention and treatment [11].
Duclos et al. [10] examine mHealth interventions in
the Nouna health district in Burkina Faso from the perspective and expectations of front-line health workers
and users. Although useful for building a support network, mobile phones could not address key underlying
barriers to accessing antenatal care, including poverty,
gender issues and geographical distances. The authors
caution against applying universalistic approaches to
mHealth and advocate for “careful project design and
policymaking attentive to the knowledges and practices of
local communities”.
Using maternal newborn and child health as an example, Agyepong et al. [18] highlight how context along
with health system factors (the WHO’s foundational
building blocks combined with people, power, processes
and values) have played either enabling or limiting roles
Godt et al. Health Research Policy and Systems 2017, 15(Suppl 1):52
to undermine or enhance the impact of health interventions. As the authors note, numerous ‘proven’ or ‘presumed’ effective interventions to address challenges such
as maternal and child mortality have been implemented,
but outcomes have not always improved as expected.
Olivier de Sardan et al. [12] are developing a grounded
theory to “understand the relationship between standardised interventions and implementation contexts, and
the many unexpected, invisible or perverse effects” that
result. The authors explore in detail the ‘revenge of the
context’, and through an analysis of the development and
dissemination of ‘travelling models’ of standardised interventions, they point to an evidence base in Niger and other
countries showing the disconnect between externallydriven interventions and local conditions, and social and
professional norms and standards. International institutions, non-governmental organisations and other actors
often play the role of ‘travel agencies’ facilitating the transfer of such models. The authors conclude by pointing to
evidence showing how innovative local actors are developing their own approaches, usually low-cost and embedded
in the context, to bring about change.
Overcoming the fragmentation
As a second theme, several authors identify the critical
need to overcome the existing fragmentation of expertise, knowledge and actors by strengthening collaboration
across expert institutions and individuals. They also
point to the need to build strong working relationships
amongst researchers, decision-makers and practitioners,
so they can effectively work together to identify priority
issues that can realistically be addressed given the available windows of opportunity.
Sombie, Aidam and Montorzi [16] discuss how national health research systems in four fragile states were
supported to build the foundation for undertaking and
using relevant health research. Despite contextual challenges, such as political instability and the outbreak of
the Ebola virus, some progress was made towards improved national governance by developing national health
research policies and priorities, strengthening ethics review and building a regional research information system.
The authors reflected on the strategic accompaniment
role played by WAHO as a regional organisation and on
the need for international players to support advocacy, resource mobilisation and capacity strengthening activities
that respond to national and regional priorities.
Studying the health policy and systems research literature, Defor et al. [13] describe the patterns and
trends of Anglophone and Francophone peer-reviewed
publications across ECOWAS countries from 1990 to
2015. Although their findings show increased research
production rates since 2008, the region still lags far behind other regions. Nigeria, Burkina Faso and Ghana
Page 3 of 138
account for over 70% of the publications, most of which
are written in English. Given that health policy and systems research is context specific, the authors point to
an urgent need for “local actors with an understanding
and appreciation of their own health systems challenges
to drive the processes of evidence generation and application” [13]. The authors argue for greater crosscountry institutional collaboration that emphasises joint
research agenda setting with research consumers as one
way of overcoming the current fragmentation.
As mechanisms for influencing policy and practice vary
and are weak in many countries, Keita et al. [15] report on
a regional initiative aimed at stimulating, promoting and
strengthening collaboration across researchers, actors and
decision-makers to undertake and use research results to
improve health systems governance and equity. Based on
evidence in the literature, WAHO encouraged the establishment of steering committees to accompany four health
systems research projects in Burkina Faso, Nigeria,
Senegal and Sierra Leone. Each committee took a different
form depending on local and national contexts, and this
flexibility strengthened implementation. In rural Sierra
Leone, for example, the local steering committee included
community and district stakeholders from transportation,
defence and security sectors who were all committed to
making the free maternal health policy work for everyone.
This experience has contributed to developing longerterm relationships amongst research teams and decisionmakers. Nevertheless, and given the dependence on the
funded researchers for resources, the need for autonomy
and strengthened agency of all committees was identified.
Uneke et al. [14] explore the deepening demand for
evidence through assessing Nigerian policymaker and
stakeholder perceptions about their needs for, as well as
barriers and facilitators to, using research evidence in policymaking. Identified barriers include “inadequate capacity of organisations to conduct policy-relevant research,
inadequate budgetary allocation for policy-relevant research, policymakers’ indifference to research evidence,
poor dissemination of research evidence to policymakers
and lack of an interaction forum between researchers and
policymakers” [14]. The study highlights the need to
strengthen individual and institutional capacity as well as
improve research infrastructure and funding. Importantly,
the assessment also identifies the need to establish sustainable platforms for policymaker–researcher interaction.
Concluding comments
The articles in this supplement give pause for reflection
on the governance of health research, on whose agendas
matter, and on the importance of starting implementation
from the local level to inform global arenas. At national
levels, governments make commitments to strengthening
the health sector [19] and health research [20], but often
Godt et al. Health Research Policy and Systems 2017, 15(Suppl 1):52
do not meet their obligations. The situation is confounded
by the tensions surrounding funder agendas, priorities and
practices, and their impact in the region, in particular the
skewing effects of vertical programmes.
Despite good intentions, there is clearly a mismatch
between the intersection of global, regional and national
governance in West Africa. The complex history of the
region, with its colonial and linguistic divides, continues
to influence institutions, norms and practice. Vibrant West
African-led collaborations amongst researchers, decisionmakers and civil society, which are effectively supported by
national, regional and global funding, need to foster,
strengthen and use locally-generated evidence to ensure
that efforts to strengthen health systems and improve regional health outcomes are successful. The solutions are
clearly not to be found in the ‘travelling models’ of standardised interventions.
Such a developmental approach was reflected in the
Millennium Development Goal era commitments made
in the Paris Declaration on Aid Effectiveness and the
Accra Agenda for Action, which prioritised harmonisation of development assistance and alignment with regional and national priorities. While that vision was not
fully realised [21], these issues are once again under discussion in the context of achieving the Sustainable Development Goals and in calls for development of a
Framework Convention on Global Health [22].
There is no easy answer, but we hope that this supplement will contribute to an ongoing dialogue about these
important issues.
Abbreviations
ECOWAS: Economic Community of West African States; IDRC: International
Development Research Centre; WAHO: West African Health Organisation
Acknowledgements
We would like to extend a special thank you to the 11 external reviewers
who agreed to be part of this important initiative, and without whom this
journal supplement would not have been possible.
Funding
Publication costs were funded by the International Development Research
Centre (IDRC). However, the views expressed in this preface are solely those
of the authors and do not represent the views of the IDRC.
Authors’ contributions
All authors approved, contributed to the design and writing of this article.
SG took the lead in drafting the article.
Competing interests
The authors declare that they have no competing interests.
About this supplement
This article has been published as part of Health Research Policy and Systems
Volume 15 Supplement 1, 2017: People and research: improved health systems
for West Africans, by West Africans. The full contents of the supplement are
available online at https://health-policy-systems.biomedcentral.com/articles/
supplements/volume-15-supplement-1.
Page 4 of 138
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
Maternal and Child Health Program, International Development Research
Centre, PO Box 62084, 00200 Nairobi, Kenya. 2Open Society Foundation, New
York, NY 10019, United States of America. 3Independent Consultant, PO Box
91, 00606 Nairobi, Kenya.
1
Published: 12 July 2017
References
1. Heymann DL, et al. Global health security: the wider lessons from the west
African Ebola virus disease epidemic. Lancet. 2015;385:1884–909.
2. DuBois M, Wake C. The Ebola response in West Africa: Exposing the Politics
and Culture of International Aid. HPG Working Paper, October 2015. https://
www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/9903.
pdf. Accessed 5 June 2017.
3. Kieny M-P, et al. Health-system resilience: reflections on the Ebola crisis in western
Africa. Bull World Health Organ. 2014;92(12):850. doi:10.2471/BLT.14.149278.
4. O’Hare B. Weak health systems and Ebola. Lancet Glob Health. 2015;3(2):e71–2.
5. Gates B. Perspective. The Next Epidemic — Lessons from Ebola. N Engl J
Med. 2015;372:1381–4. doi:10.1056/NEJMp1502918.
6. Save the Children. A Wake-up Call: Lessons from Ebola for the World’s Health
Systems, 2015. https://www.savethechildren.net/sites/default/files/libraries/
WAKE%20UP%20CALL%20REPORT%20PDF.pdf. Accessed 5 June 2017.
7. Glassman A. After Ebola. Finance and Development, June 2016. http://www.imf.
org/external/pubs/ft/fandd/2016/06/pdf/glassman.pdf. Accessed 5 June 2017.
8. Agyepong IA, et al. Spanning maternal newborn and child health (MNCH)
and health systems research boundaries: conducive and limiting health
systems factors to improving MNCH outcomes in West Africa. Health Res
Policy Syst. 2017;15(Suppl 1): doi:10.1186/s12961-017-0212-x.
9. Koroma MM, et al. The quality of free antenatal and delivery services in
Northern Sierra Leone. Health Res Policy Syst. 2017;15(Suppl 1):
doi:10.1186/s12961-017-0218-4.
10. Duclos V, et al. Situating mobile health: a qualitative study of mHealth
expectations in the rural health district of Nouna, Burkina Faso. Health Res
Policy Syst. 2017;15(Suppl 1): doi:10.1186/s12961-017-0211-y.
11. Yaogo M. Free versus subsidised healthcare: options for fee exemptions, access
to care for vulnerable groups, and effects on the health system in Burkina Faso.
Health Res Policy Syst. 2017;15(Suppl 1): doi:10.1186/s12961-017-0210-z.
12. Olivier de Sardan JP, et al. Travelling models and the challenge of pragmatic
contexts and practical norms: the case of maternal health. Health Res Policy
Syst. 2017;15(Suppl 1): doi:10.1186/s12961-017-0213-9.
13. Defor S, et al. Towards a better understanding of the state of health policy
and systems research in West Africa and the capacity strengthening needs:
a review of peer-reviewed publication trends and patterns 1990–2015.
Health Res Policy Syst. 2017;15(Suppl 1): doi:10.1186/s12961-017-0215-7.
14. Uneke CJ, et al. Improving maternal and child health policymaking process
in Nigeria: an assessment of policymakers’ needs, barriers and facilitators of
evidence-informed policymaking. Health Res Policy Syst. 2017;15(Suppl 1):
doi:10.1186/s12961-017-0217-5.
15. Keita M, et al. The West African experience in establishing steering committees
for better collaboration between researchers and decision-makers to increase
the use of health research findings. Health Res Policy Syst. 2017;15(Suppl 1):
doi:10.1186/s12961-017-0216-6.
16. Sombie I, Aidam J, Montorzi G. Evaluation of regional project to strengthen
national health research systems in four countries in West Africa: lessons
learned. Health Res Policy Syst. 2017;15(Suppl 1): doi:10.1186/s12961-017-0214-8.
17. Sombie I, et al. Promoting research to improve maternal, neonatal,
infant and adolescent health in West Africa: the role of the West
African Health Organisation. Health Res Policy Syst. 2017;15(Suppl 1):
doi:10.1186/s12961-017-0209-5.
18. The WHO Health System Framework. http://www.wpro.who.int/health_
services/health_systems_framework/en/. Accessed 15 Jan 2017.
19. Abuja Declaration. 2001. http://www.un.org/ga/aids/pdf/abuja_declaration.pdf.
Accessed 5 June 2017.
20. Bamako Call to Action on Research for Health. 2008. http://www.who.int/
rpc/news/BAMAKOCALLTOACTIONFinalNov24.pdf. Accessed 15 Jan 2017.
Godt et al. Health Research Policy and Systems 2017, 15(Suppl 1):52
Page 5 of 138
21. Evaluation of the Implementation of the Paris Declaration. http://www.oecd.
org/dac/evaluation/evaluationoftheimplementationoftheparisdeclaration.
htm. Accessed 15 Jan 2017.
22. Gostin LO, et al. The next WHO Director-General’s highest priority: A
Global Treaty on the Human Right to Health. Lancet Glob Health. 2016;
4(12):e890–2.
Submit your next manuscript to BioMed Central
and we will help you at every step:
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research
Submit your manuscript at
www.biomedcentral.com/submit