Can we improve health policy?

This is a central question in public health research. Epidemiological research aims to improve our understanding of diseases, or to improve health. Improving health often needs policy changes, either at institutional, regional or national level.

Operational research is defined as: “The search for knowledge on interventions, strategies, or tools that can improve the quality, effectiveness, or coverage of programmes in which the research is being done” 1.

Operational research involves descriptive, case–control, and cohort analysis. Some say that basic science research and randomised controlled trials is not operational research. However, effectiveness trials show if an intervention works, and should in my view form an integral part of operational research. Results from such randomised trials can benefit in diverse settings of routine care.

Many researchers believe that doing good research and publishing the results in high-quality journals lead to policy change. Unfortunately, this is a naive view. Here I present a few examples showing that policy change is more that doing good research: it wants a close cooperation with policy-makers.

Improving tuberculosis control

Although tuberculosis treatment success rates have improved in Ethiopia, low case notification rate, mainly because of inability to access the health service, remains a challenge. Using community health workers, we enrolled health extension workers in providing health education, sputum collection and treatment. This improved treatment, case detection, occurs because of increased access to the diagnostic services 2. This approach also reduced costs by 63%, and is economically attractive to the health service and patients, caregivers and the community 3.

The Ministry of Health Ethiopia recently backed this approach, and Health Extension Workers now take part in tuberculosis control in Ethiopia.

The policy change was mainly brought about by close communication and involvement of key policy people in carrying out the research.

Antiretroviral treatment in district hospitals

About  ten years ago we started antiretroviral treatment in south Ethiopia. Our question was: Is antiretroviral treatment possible to do at rural hospitals? Our group showed that antiretroviral treatment in resource limited settings  is possible 4, and cost-effective 5.

It is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not return to collect their antiretroviral medications (“lost to follow-up”).

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start at earlier stages of their illness. Early treatment start improved survival 6. Unfortunately, 25 per cent were lost before they started treatment. This percentage has increased during recent years. Forty per cent of those lost to follow up had died.

This are examples of research that provides  information on how antiretroviral treatment programmes work in the country,

Health care financing

About 14 years ago we started a work to make the hospital sustainable managerially and financially. These were previous mission run hospitals. Over the years, the hospitals managed to become managerially and financially sustainable within a regional context.

And, this model of hospital finance formed a part of the evidence for health care financing in Ethiopia.  The evidence came from evaluations of the hospital services and accounts, as well as external independent audits. There were no formal peer-reviewed publications.

Reducing maternal deaths

In line with the Millennium Development Goal for maternal health (MDG-5), we have since 2008 been running a health programme to reduce maternal mortality in south-west Ethiopia. Based on experience from other countries, we aimed to develop a decentralised delivery of care. Staff at remote rural health centres should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by pregnant women.

Through this public health project we train staff from many rural hospitals and health centres to do comprehensive emergency obstetric care. We also equip the institutions, and regularly carry our supervision of the work. The project strengthens the antenatal services so the health extension workers can help normal deliveries and identify and refer women in need of help during delivery to health institutions. We enable these health institutions to practise safe delivery. As most maternal deaths occur with delivery, particular attention is on intrapartum care.

After four years, the number of the health care coverage has increased from 1 per 1,3 million people (2 hospitals  for  a population of 2,6 million people) to 1 per  270.000 people (11 institutions  for a population of 2,9 million). The future success of such a programme is that local hospitals start training staff, and supervise staff at the remote health centres and hospitals.

This project is mainly an education programme, and serves as a pilot model for the region. We have presented our experiences at several meetings, and publications will soon be available. But more important, representatives from other regions visit us, and plan to use our experiences in their efforts to reduce maternal deaths.


These examples from practical health work and research in Ethiopia show we should inform people in position to change policy. Engaging policy makers in the work is often more important than publications.


1. Zachariah R, Harries AD, Ishikawa N, et al. Operational research in low-income countries: what, why, and how? Lancet Infect Dis. 2010;9:711–717.

2. Datiko DG, Lindtjørn B. Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS ONE. 2009;4(5):e5443.

3. Datiko DG, Lindtjørn B. Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS ONE. 2010;5(2):e9158.

4. Jerene D, Naess A, Lindtjørn B. Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a …. AIDS Research and Therapy. 2006.

5. Bikilla AD, Jerene D, Robberstad B, Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost effectiveness and resource allocation : C/E. 2009;7:13.

6. Mulissa Z, Jerene D, Lindtjørn B. Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia. PLoS ONE. 2010;5(10):e13268.


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