The maternal mortality ratio (MMR) has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, ‘guilty until proven innocent’. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. The authors show, however, that measurement experts’ work has also been driven by the need to secure political priority for safe motherhood and by donors’ need to justify and monitor the results of investment flows. They explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. the authors analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented funders who have introduced new forms of administrative oversight and accountability that depend on indicators.
Monitoring equity and research policy
Partnerships are essential to deliver research and innovation for global health and partner development. Sustainable Development Goal 17 is all about this. Yet, COHRED argues that there is no framework, no benchmark, no standard of best practice on which to model governmental, corporate, non-profit, or academic collaborations, particularly not for international collaborative research and innovation involving low- and middle-income countries. This is where the Research Fairness Initiative intends to make a difference: to create a reporting system that encourages governments, businesses, organisations and funders to describe how they take measures to create trusting, lasting, transparent and effective partnerships in research and innovation. COHRED prioritises its application in global health because there are many urgent health-related issues, but it can be applied in any other setting also.
The first-ever, World Report on Health Policy and Systems Research, was launched recently by the Alliance for Health Policy and Systems Research. The report provides practical recommendations on how to reorient health research to more effectively address public health challenges on a national and global level. It describes the evolution of the field and provides figures on the number of publications produced, funding trends and institutional capacity in LMICs to conduct health policy and systems research. Low- and middle-income countries now have guidance for not only being users of research, but also producers. The report describes the state of the HPSR field in 1996, identifying three broad challenges to its progress that were clearly visible at that time. In the mid-1990s there were three principal challenges to the growth of the field of HPSR: (i) the fragmentation and lack of a single agreed definition of the field; (ii) the ongoing dominance of biomedical and clinical research; and (iii) a lack of demand for HPSR. Cross-cutting all these challenges was the problem of relatively limited capacity to undertake high-quality health policy and systems research. Subsequent sections then analyse how these challenges have been addressed over the intervening 20 years, resulting in greater recognition of and investment in HPSR. The report raises challenges to be addressed, including confronting the dominance of biomedical and clinical research as the primary channel for health research investments through a sustained advocacy campaign; seeking to clarify the scope and methods of the field; and finally nurturing closer collaboration with research users, in particular by capitalizing on the growth of interest in evidence-informed policy. It also collects together for the first time figures on various significant aspects of health policy and systems research: growth in the number of publications, collaboration between researchers in different parts of the world, funding trends and institutional capacities in low- and middle-income countries.
Participatory action research seeks to understand and improve the world by changing it. At its heart is collective, self-reflective enquiry that researchers and participant’s undertake so they can understand and improve upon the practices in which they participate and the situation in which they find themselves. This article describes that ways PAR has been applied to a wide range of issues in public health, including in community asset mapping, participatory evaluation of public health programs, community monitoring of health service quality, research documenting and advocating to remove threats to health including poor water and sanitation and environmental pollution and participatory health policy research. A systematic review indicated most health service PAR has been conducted in low and middle income countries. In high income countries it is often used as a method to empower groups who are excluded and hold little power including Roma peoples in Europe and Indigenous peoples in Canada and Australia. PAR is often not reported in the academic literature despite its application in local projects. The most important aspect of PAR is that it relies on a cycle of reflection, planning, acting, further observing and reflection, then new plans and action. This reflexivity is central and is deeply relational in that the researchers and the other actors (community members or service or policy players) are engaging together in these processes. The author observes that PAR holds great, and as yet largely unrealised promise, to create greater mobilisation and community interest and action on health inequities and action on the social determinants of health.
In February 2016, the World Health Organisation (WHO) declared the Zika virus-related cluster of microcephaly cases and other neurological disorders reported in Brazil, a Public Health Emergency of International Concern (PHEIC). Following the declaration, over 30 global health bodies issued a joint statement committing to data sharing to ensure that the global response to the Zika virus and future emergencies, could be informed by the best and most current evidence. The statement represented a concerted effort by those involved to address past failures of timely access to relevant data. It also highlighted the lack of a clear path to implementation for data sharing during public health emergencies. In March 2016, the Global Research Collaboration for Infectious Disease Preparedness established a data-sharing working group which has been working in coalition with other stakeholders including WHO, scientists, nongovernmental organisations, journals and other agencies. This group is working to identify barriers to data sharing in public health emergencies that should be addressed to better prepare for any future epidemic. The experiences from the 2013–2016 Ebola virus disease outbreak and the 2015 Zika virus outbreak demonstrated the importance of research in public health emergencies and the difficulties associated with sharing research findings rapidly and outside of conventional scientific publications. The WHO consensus and policy statements called for a paradigm shift in information sharing in public health emergencies and described the particularities to consider in dealing with different data types. Despite these efforts, rapid data sharing during public health emergencies remains challenging for various reasons. First, there are limited incentives for researchers and other people responding to the emergency to share data. Second, there is a lack of appropriate infrastructure for data sharing such as repositories and information technology platforms. Such rapid data sharing requires a clear governance structure that ensures a balance between privacy and access, as well as adheres to national and international ethical and legal requirements. The GloPID-R working group has developed, and requests comment on, a set of principles to underpin future implementation of timely data sharing. These new principles draw on others, such as the FAIR Guiding Principles for scientific data management and stewardship, and are intended to provide an initial framework for discussion. The collective work is intended to support WHO’s Research and Development Blueprint and include other stakeholders, such as the Global Outbreak Alert and Response Network and the Coalition for Epidemic Preparedness. Effective data sharing requires flexibility by all stakeholders to adapt to unforeseen events and challenges. A data-sharing system needs to allow collaboration between stakeholders in the absence of pre-existing relationships and all collaborators need to adhere to fundamental ethical principles of data use. Above all, it must ensure that people in all affected countries benefit from timely access to evidence-based interventions in emergencies.
The Global Observatory on Health R&D (hereafter called ‘the Observatory’) is a global-level initiative that aims to help identify health R&D priorities based on public health needs, by: consolidating, monitoring and analysing relevant information on the health R&D needs of developing countries; building on existing data collection mechanisms; and supporting coordinated actions on health R&D. Investments in health R&D are still insufficiently aligned with global public health demands and needs. As little as 1% of all funding for health R&D is allocated to diseases such as malaria and tuberculosis (diseases that are predominantly incident in developing countries), despite these diseases accounting for more than 12.5% of the global burden of disease. Governments, policy-makers, funders and researchers need an accurate picture of the current situation so as to spot R&D gaps and ensure that funds and resources are used in the best possible way. The primary scope of the Observatory as outlined by Member States in World Health Assembly resolution WHA69.23 is: type II and type III diseases (i.e. diseases incident in both rich and poor countries, especially the latter; the specific R&D needs of developing countries in relation to type I diseases; potential areas where market failures exist and antimicrobial resistance and on emerging infectious diseases likely to cause major epidemics.
Fair Research Contracting equips research partners with key resources on how to build sustainable, equitable global research partnerships. The rise in international research partnerships means that developing countries need to be better positioned to deal with complexities in collaborative research contracting. COHRED argues that better contract negotiation expertise in LMIC institutions will help improve the distribution of benefits of collaborative research, such as overhead costs, data ownership, institutional capacity in research management, technology transfer, and intellectual property rights. With this in mind, COHRED has developed guidance aimed at optimising research institution building through better contracts and contracting in research partnerships. The guidance highlights the key issues for consideration when entering into formalised research partnerships, and provides tools and resources for negotiating fairer research contracts.
In Africa, urbanisation and urban growth are dramatically restructuring the nature of cities. The growing majority of urban dwellers now live in informal conditions that, without access to basic services or public amenities, expose residents to greater health risk, and health-care systems are unable to provide affordable or comprehensive cover. The differential exposure to these urban conditions is compounded by social and economic vulnerability, resulting in health inequities. Yet despite pressing needs driven by Africa’s considerable and complex burden of disease and high levels of health inequity, urban health and urban health equity have not yet emerged as major research and policy priorities in Africa. This commentary presents a conceptual framework, using a public health approach, for interdisciplinary research aimed at contributing to the understanding and mitigation of urban health issues and challenges in Africa. It identifies downstream and upstream factors, based on published literature, associated with key determinants in each theme. It represents a collective effort by interdisciplinary academics from public health; anthropology; civil engineering; architecture, planning and geomatics; human biology; psychiatry and mental health; medicine; pathology; and paediatrics, from the Research Initiative for Cities and Health (RICHE), University of Cape Town, to generate African perspectives on urban health and urban health equity. The six focus areas identified as important include obesity and food insecurity, the urban context as a tool for health promotion, urban health governance and policy, community strengthening for healthy inclusive cities, health systems in an urbanising context and migration, urbanisation and health. The authors argue that a complex systems approach is required to investigate and improve understanding of health and well-being in a changing urban context with a view to developing sustainable and cost-effective interventions. This acknowledges the different dimensions of determinants that influence health and understands the need to address gaps in data and access to information from across these dimensions, and to engage all relevant stakeholders across sectors prioritise the interventions to improve health.
Health policy and systems research is centrally concerned with people, their relationships and the actions that they take towards strengthening health systems. To understand complex health systems, researchers must actively engage with system actors, ranging from health managers to service users, learning from their tacit knowledge and about their experience. In Kenya and South Africa, researchers have established learning sites specifically to support a wide range of research focused on health systems governance issues at the district level. Both countries have devolved government structures and county (Kenya) and provincial and district (South Africa) managers now play a pivotal role in the development, management and delivery of health services. Learning sites provide unusual opportunities to learn about the daily processes of decision-making that comprise health system governance, and to support managers in taking action to strengthen them. This brief covers: What is a learning site? How did learning sites emerge? What happens in a learning site? What is the value of learning sites for researchers and health managers? and what small-scale steps are being taken to strengthen the health system?
The World Health Organisation (WHO) has launched a new data portal to track progress towards universal health coverage (UHC) around the world. The portal shows where countries need to improve access to services, and where they need to improve information. The portal features the latest data on access to health services globally and in each of WHO’s 194 Member States, along with information about equity of access. In 2017 WHO will add data on the impact that paying for health services has on household finances. The portal shows that less than half of children with suspected pneumonia in low income countries are taken to an appropriate health provider. Of the estimated 10.4 million new cases of tuberculosis in 2015, 6.1 million were detected and officially notified in 2015, leaving a gap of 4.3 million. High blood pressure affects 1.13 billion people. Over half of the world's adults with high blood pressure in 2015 lived in Asia. Around 24% of men and 21% of women had uncontrolled blood pressure in 2015. About 44% of WHO’s member states report having less than 1 physician per 1000 population. The African Region suffers almost 25% of the global burden of disease but has only 3% of the world’s health workers.