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Progress and Impact:

Substantial achievements have been made in all three output areas.

CREHS research has been presented in more than 150 face-to-face meetings with key stakeholders to share and debate key findings build relations, and feed into policy discussions. Our media presence has grown, with newspaper coverage of CREHS and related research in Nigeria, Thailand and South Africa. There have been more than 40 presentations of CREHS research in international and national scientific meetings and conferences, including the International Health Economics Association (2007 and 2009); the European Congress of Tropical Medicine (2007); the Global Forum on Health Research (2008); the Multilateral Initiative on Malaria (2005 and 2009); the inaugural meeting of the African Health Economics Association (2009); and the West African Health Economics Association (2009). To date, 13 research reports, 16 policy and research briefs are available on our website; 50 papers have been submitted or accepted for peer review from core CREHS work, and a further 100 papers from CREHS-related work. In the final year of the consortium, we have focused particular efforts on communicating key research findings and policy messages. In addition to country level activities, we held a conference in London in collaboration with two other RPCs which was attended by over 160 participants from research organisations, NGOs multi-lateral organisations and bi-lateral donors, and journalists based in the UK and Europe.

Over the past 5 years CREHS researchers have produced a rich body of new knowledge about how health systems can be strengthened to better meet the needs of poor people in low and middle-income countries. Research on financial risk protection has contributed substantially to the evidence base around:

• The high levels of catastrophic health expenditure occurring among the poorest and most vulnerable groups
• The inequitable distribution of benefits and financing burdens in a range of low income settings, reflecting supply side constraints and policies that fail to address the needs of poor people
• The effects of a novel approach to supporting user fee removal/reduction by channelling funding directly to health facilities in Kenya
• Further documentation of the processes and equity outcomes of the Thai health reforms, demonstrating how a comprehensive approach to health financing reform, addressing both demand and supply side barriers, can support an equitable and efficient health system.

Overall, the research produced through CREHS has demonstrated the critical role of pooled, public funding in protecting the poor from financial catastrophe. Expanding insurance schemes to protect the poor is on the policy agendas of many low income countries, including Kenya, Tanzania, South Africa, and Nigeria. However, CREHS research has also shown how supply side problems must be addressed if financing reform is to have positive impacts. The Thailand experience provides an excellent example of how a comprehensive approach to health financing reform, incorporating both supply and demand-side measures, has created a system which is both equitable and efficient. The main lessons for lower income countries emerging from the Thai experience include:

• The need to explore different options for expanding insurance to the informal sector
• The importance of investment in public health infrastructure, including district level PHC services and close-to-client services, together with equitable distribution of human resources, to reduce access barriers and provide adequate quality
• The need for effective purchasing strategies within UC schemes to secure efficiently provided services
• The importance of both the breadth and depth (benefit package) of public health insurance coverage in protecting against financial catastrophe
• The value of effective implementation strategies to secure equity gains.

CREHS research on health workers sought to generate new knowledge about the motivations and preferences of health workers, with the aim of informing strategies to improve the supply of health workers in rural areas. Using a longitudinal study design, in which were nested experimental economic games and discrete choice experiments to measure health worker attitudes and preferences, our findings demonstrate the importance of trying to attract individuals to the health profession who have a positive attitude towards rural areas. Further, they show that locally designed non-financial incentives can be powerful interventions to redress the geographic maldistribution of health workers in low- and middle-income countries.

In the area of scaling up service delivery, CREHS resources were used to catalyse the communication of existing work being undertaken by the broader community of CREHS-linked researchers. A review paper and accompanying commentaries traced the evolution of strategies for scaling up, and identified a number of key issues including the challenges of estimating the resources required, the constraints to scaling up, concerns about equity and quality, novel approaches to service delivery, and the importance of strategic management of scaling up processes. CREHS-related research is contributing new insights into how malaria interventions such as insecticide-treated nets and new antimalarial drugs can best be delivered to achieve high and equitable coverage, with a particular focus on the role of the private sector.

A final stream of research has examined the role of policy implementation, recognising that the translation of well designed policies into effective action remains an important challenge for health system strengthening. Our work focused on policies which are specifically aimed at addressing the needs of the poor. The key lessons from this work include:

• The critical importance of frontline providers in mediating policy implementation and access for patients
• The varied influences on health worker practices, including whether they see the policy as a threat or something to support; by the broader organisational culture in which they work and how this affects their willingness to effect the changes requested by their managers; and by wider community influences.
• The influence of health sector managers
• The positive and negative roles that can be played by higher level (national and international) influences.

CREHS research identified the need for better management of the implementation process, including closer attention to the ways that policies are developed, framed and communicated; strengthened capacities to manage relationships throughout the system; and a greater recognition of the ways that power is distributed and used by those who are responsible for translating policy into action.

CREHS research has influenced policy and practice in a number of different ways, including informing specific policy change (such as the decision to scale up direct facility funding to national level in Kenya, and the new national PHC strategy in Thailand); changes in health sector practices (such as the earmarking of budgets for mobile health units in Tamil Nadu state, India; and the introduction of new indicators for routine equity monitoring in Thailand); influencing decisions NOT to change current policy (maintaining existing funding levels for the UC scheme); and finally contributions to broader discussions and debates around new policy directions (as in the case of health financing reforms in Nigeria, Tanzania and South Africa).

At the regional and global levels, CREHS research has contributed to:

• international debates about health systems and equity, e.g. through contributions to the work of the Health System Knowledge Network of the Commission for Social Determinants of Health which has helped to shape the current policy climate in favour of equity and critical role of health systems in achieving equitable health outcomes.
• global debates on health financing, providing evidence in support of the international movement in favour of universal coverage.
• the growing use of discrete choice experiments as a policy tool to inform decision-makers about what types of incentives are likely to have the greatest effect on health worker location and retention.
• debates about how to scale up malaria interventions, with CREHS research helping to inform the design of antimalarial drug distribution programmes in Cambodia, Nigeria and Benin, and acting as Independent Evaluators of the Affordable Medicines Facility-malaria (AMFm).
• international discussions about the methods and focus of health policy and systems research (HSPR), demonstrating the value of a variety of different research approaches, the recognition of health systems interventions as "complex interventions" requiring specific approaches to evaluation, and the importance of investigating policy processes as well as technical design in order to understand impact.

The main beneficiaries of these outputs have been:
(1) Vulnerable populations in different settings who benefited from improved health services or reductions in exposure to health-related financial risk.
(2) Policymakers and health system managers at the international and national levels, who benefited from an improved evidence base for decision making, and strengthened skills and knowledge of how to use evidence.
(3) Health policy and systems researchers in low and middle income settings who benefited from increased capacity to undertake and communicate research.