INDEPTH @ 10: celebrate the past and illuminate the future

INDEPTH: the first decade

On the occasion of its 10th anniversary this year, the INDEPTH Network (www.indepth-network.org) can look back on some very significant accomplishments. It has established itself as an entity in the field of health research, has widespread brand recognition, and is known and respected globally. The Health and Demographic Surveillance System (HDSS) sites are healthy and vibrant hotbeds of grounded, high quality research, training and service provision. By building upon and enhancing the network of sites, the Network has contributed inestimably to effective capacity-building and provided multi-country research opportunities to a generation of scientists. Truly, the whole is greater than the sum of the parts.

The story of INDEPTH's first decade deserves to be told more widely. The many publications and papers emanating from the sites have advanced scientific knowledge but there is much more to be said about the Network as a whole. Communicating the past will help illuminate the path over the next decade and help answer the question ‘Where does INDEPTH want to be 10 years from now?’ This paper sets out some options for INDEPTH to consider as part of its long-term strategic thinking.

The second decade

The challenges in global health have always been complex and multi-faceted. They will be even more so in the next 10 years. Disease patterns will continue to evolve, new and re-emerging diseases will combine with shifting demographics and changing lifestyles to raise substantial questions about how to protect and promote people's health and how to care for them when they are sick. In this changing environment, INDEPTH will need to make strategic choices around four issues:

1. Identifying and moving forward priority research areas.

2. Building research capacities.

3. Developing and implementing research standards.

4. Translating research results into action.

Identifying and moving forward priority research areas

INDEPTH's longitudinal health and demographic surveillance, in some sites dating back several decades, is unique in public health. In considering its options for the next 10 years, INDEPTH should strive to exploit the full range of research possibilities provided by this ongoing, comprehensive compilation of data. A structure for classifying research priorities is provided by the World Health Organization (WHO) research priorities framework, which identifies five types of research that are pertinent to any given health need (Fig. 1).

Fig. 1.

WHO research priorities framework.

The five research axes describe a continuous cycle, comprising:

1. Measuring the dimensions and nature of health problems.

2. Understanding the causes of problems; the determinants of health and ill-health.

3. Developing solutions to address the problems.

4. Translating the actions and delivering solutions.

5. Evaluating the effectiveness of the solutions.

Using this framework, we can identify a number of priority research areas to which HDSS sites are uniquely placed to contribute.

Measuring the dimensions and nature of health problems

One of the most significant gaps in public health information is the limited availability and poor quality of data on mortality patterns, trends and causes. Without such data, continuously, over time, for all population groups, there can be no evidence-based public health decision-making. The uniqueness of the HDSS sites is that they are able to generate such data in settings with no other comparable source of information on births, deaths and causes of death. INDEPTH should deepen and extend its collaboration with WHO, the Health Metrics Network and other agencies in the Monitoring Vital Events Initiative (1). The skills and capacities in vital statistics monitoring accumulated in the HDSS sites can serve as the nucleus of country-wide capacities for better vital statistics. While most HDSS sites are currently located in rural areas, migration patterns and increasing urbanization call for increased demographic surveillance in urban slums in order to better understand the health challenges facing more than 50% of the world's population now urbanized.

At the same time, HDSS at the district level is needed to enable decentralization to be underpinned by clear evidence on district level needs and the local impact of interventions.

Understanding the causes of problems; the determinants of health and ill-health

Understanding the etiology and determinants of ill-health requires long-term longitudinal cohort studies that can elucidate multi-factorial underlying determinants such as socio-economic status, environmental, biological and behavioural risk factors. The inclusion of clinical measures and bio-markers in HDSS will greatly enhance our understanding of disease patterns and causation. More studies are needed on the determinants of inequities in health and how to overcome them.

Developing solutions to address the problems

The HDSS sites are well placed when it comes to testing innovative solutions to existing and emerging health challenges, offering possibilities for scientific evaluation of the effectiveness of new products, interventions, or packages of interventions such as Integrated Management of Adult Illnesses (IMAI). They also permit the evaluation of health systems such as the impact of incentives for health workers in terms of health worker recruitment and retention.

Translating the actions and delivering solutions

Perhaps the most important contribution that the HDSS sites can make is in the area of the implementation of interventions in ‘real’ settings where contextual factors have a strong influence on results, moving from demonstrations of efficacy to evidence of effectiveness. Examples of the kinds of research questions that could be answered in INDEPTH settings include:

• Assessing the interface between global health initiatives and the strengthening of health systems – are there synergies to be found?

• Defining the delivery requirements for chronic diseases – can HIV services be used as an entry point for chronic disease prevention and treatment?

Evaluating the effectiveness of the solutions

A particularly important opportunity provided by the HDSS sites is in the area of the evaluation of interventions and programmes, especially in relation to scaling up, health system performance and system-wide interventions. INDEPTH could tap into the substantial resources available from global health funds, such as the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) and the Global Alliance for Vaccines and Immunization (GAVI), by developing monitoring and evaluation proposals as part of national proposals to these global funds. INDEPTH could also ‘retail’ solid baselines as a basis for assessing and attributing changes from interventions; currently baselines are largely absent in most evaluation efforts.

Health system strengthening

Cutting across each of these research streams is the issue of how to strengthen health systems in order to enable the successful scaling up of interventions. There is mounting evidence that health systems that can deliver services equitably and efficiently are critical to the achievement of national and global health goals, both in terms of communicable diseases and maternal and perinatal health, but also, critically, for the prevention and management of chronic and non-communicable diseases. Global health initiatives now incorporate attention to health systems strengthening into the support provided to countries. However, there is an urgent need for research on all aspects of health system performance, from understanding the dimensions and nature of health system constraints, to developing innovative strategies for strengthening health systems, translating these into action on the ground and evaluating to assure continuous improvement, enhanced efficiency and effectiveness. The HDSS sites should engage in research on improving performance across each of the health system building blocks – service delivery, health workforce, health information systems, medical products, vaccines and technologies, financing and governance (2) (Fig. 2). The availability of solid data on health status generated through the HDSS surveillance will permit an evaluation of health system performance in terms of improved health outcomes, enhanced responsiveness, improved efficiency and social and financial risk protection.

Fig. 2.

Health system building blocks.

Building research capacities

The INDEPTH Network and the HDSS sites have an unrivalled reputation in terms of building capacities for research in developing countries. As its embarks on its second decade, there is much that INDEPTH can do to build upon and further strengthen its achievements in this area.

Building capacities among individual researchers

INDEPTH should establish more formal links for ‘researcher’ training and faculty appointments with schools of public health around the world. It should also consider setting up an ‘INDEPTH Fellows’ programme, tapping into resources from donor institutions that actively support capacity-building such as Fogarty, the Swedish International Development Cooperation Agency (Sida), the Rockefeller Foundation and the International Development Research Centre (IDRC). Such capacity-building should address the range of skills relevant to research, not only with regard to study design, data collection and statistical analysis but also in the management, archiving and curation of the large and complex data sets amassed by the HDSS sites.

Extending the network

There are a number of opportunities for INDEPTH to reach out beyond its traditional links to the research community in developing countries. For example, INDEPTH should link to the fast growing ‘observatories’ movement to which it can bring scientific and statistical rigour and insight. The Network should also look into establishing explicit linkages with longitudinal surveillance sites in Organization for Economic Cooperation and Development (OECD) countries, such as Framingham. Such collaboration would be particularly beneficial as the HDSS sites focus more on tracking the epidemiological transition and the growing prevalence of non-communicable diseases in developing countries. In addition, INDEPTH should seize the opportunity to position itself as a key partner in the emerging global collaboration on health metrics and evaluation. The HDSS sites generate data on vital events which, although not representative of the population as a whole, can provide important information on levels of mortality by age and sex. Moreover, the HDSS sites are helping to build the skills for demographic surveillance required for sustainable civil registration.

Developing and implementing research standards

INDEPTH continues to be instrumental in developing and applying high standards in the conduct of research across its sites. There is scope for further standard-setting innovative work in methods and measurement strategies, for example:

• Development and testing of small area sampling and survey tools, for example, for use at neighbourhood and sub-district levels, in order to generate population data on coverage and health status that district level managers need.

• Development of real-time, multi-site, evaluation methods.

• Building ‘interoperability’ between population-based HDSS surveillance records and individual electronic medical records.

INDEPTH should also continue to contribute to setting and implementing standards of research conduct, such as the ethics of data management, protecting privacy and confidentiality while promoting public access to data. INDEPTH sites have to grapple with incentive structures in epidemiological research that put private and institutional interests at odds with the public good. They have to deal with chronic under-investment in data management and analysis skills and need to push for more realistic ‘overheads’ from donors to support real costs of research infrastructure.

Translating research results into action

Translating the results of research into action at scale is critically dependent on effective communication with those in a position to bring about change, namely, policy makers and all those with power of resource allocation, many of whom are not located within the health sector. At the beginning of this paper we argued that INDEPTH needs to do more to document and publicize its achievements over the first decade. As it embarks on its second decade, increased and targeted advocacy and communication must become a core part of INDEPTH's work. INDEPTH needs to develop and nurture relationships not only with the research and public health communities but also with politicians, policy-makers, practitioners and the general public. Sharing of research findings should be a core component in every site and advocacy and communications skills should be considered alongside statistical and epidemiological skills as central to INDEPTH's mission.

One way of encouraging increased access to the products of HDSS research would be by establishing an INDEPTH Virtual Library with on-line access to publications, papers and data sets. But it is important to ensure that the results of research are appropriately packaged and transmitted to different audiences who will be the key to INDEPTH's ongoing success and, indeed, survival. Even when data have been gathered and summarized to high standards, further analysis – of what is both reported and missing – is usually needed before the information can be disseminated and communicated to non-technical audiences and used as the basis for policymaking. Information can be conveyed directly to policymakers or indirectly through secondary audiences, such as academics, researchers, health professionals, parliamentarians, the media or advocacy groups, who are in a position to affect policymakers. INDEPTH should use an array of communication channels including seminars, peer-reviewed journals, special events, national and international meetings and policy briefs. Links to open access journals such as Global Health Action should be vigorously pursued.