Monitoring equity and research policy

Measuring progress towards universal health coverage: national and subnational analysis in Ethiopia
Eregata G; Hailu A; Memirie S; Norheim O: BMJ Global Health 4:e001843 1-9, 2019

his study aimed to estimate the 2015 national and subnational universal health coverage service coverage (UHC) status for Ethiopia. The UHC service coverage index was constructed from indicators of four major categories using survey data and administrative data. The overall Ethiopian UHC service coverage for 2015 was 34.3%, ranging from 52.2% in Addis Ababa city to 10% in the Afar region. The coverage for non-communicable diseases, reproductive, maternal, neonatal and child health and infectious diseases were 35%, 37.5% and 52.8%, respectively. The national UHC service capacity and access coverage was only 20% with large variations across regions, ranging from 3.7% in the Somali region to 41.1% in the Harari region. The 2015 overall UHC service coverage for Ethiopia was low compared with most of the other countries in the region. There was a substantial variation among regions. The authors argue that Ethiopia should rapidly scale up promotive, preventive and curative health services through increasing investment in primary healthcare if it aims to reach the UHC service coverage goals, and to narrow the gap across regions, such as through redistribution of the health workforce, increasing resources allocated to health and providing focused technical and financial support to low-performing regions.

Repositioning Africa in global knowledge production
Fonn S; Ayiro L; Cotton P; Habib A; et al: The Lancet 392 (10153), doi:, 2018

Sub-Saharan Africa accounts for 13.5% of the global population but less than 1% of global research output. In 2008, Africa produced 27 000 published papers—the same number as The Netherlands. Informed by a nuanced understanding of the causes of the current scenario, the authors propose action that should be taken by African universities, governments, and development partners to foster the development of research-active universities on the continent. Sub-Saharan Africa depends greatly on international collaboration and visiting academics for its research output. Many researchers whose publications are associated with sub-Saharan Africa are described as non-local and transitory; they spend less than 2 years at sub-Saharan African institutions. Meanwhile, intra-Africa collaboration remains severely restricted. The authors note that research-intensive universities across sub-Saharan Africa need to be identified, recognised, strengthened, and invested in. These research-intensive universities should focus their resources on graduate training and research. Creating and maintaining research-intensive universities will require consistent investment in human capital, research equipment, and relevant administrative support, at far higher levels than is available under current conditions. New funding mechanisms need to be created to support research-intensive Africa universities. At a minimum, research-intensive universities should commit their own resources to research. African Governments must increase their support for research in general and provide targeted funding for research-intensive universities. They suggest that this will only succeed and be sustained if there is accountability, transparency, and efficiency in the use of funds at research-intensive universities.

The future of African Studies: what we can do to keep Africa at the heart of our research
Nolte I: Journal of African Cultural Studies 31(3) 296-313, doi:, 2019

Over the past two decades, Africa has returned to academic agendas outside of the continent. At the same time, the field of African Studies has come under increasing criticism for its marginalisation of African voices, interests, and agendas. This article explores how the complex transformations of the academy have contributed to a growing division of labour. Increasingly, African scholarship is associated with the production of empirical fact and socio-economic impact rather than theory, with ostensibly local rather than international publication, and with other forms of disadvantage that undermine respectful exchange and engagement. This discourages engagement with Africa as a place of intellectual production in its own right. By arguing that scholars can and should make a difference to their field, both individually and collectively, the author suggests ways of understanding and engaging with these inequalities.

The power of action-based dissemination
Ifakara Health Institute Spotlight: Evidence for policy and action 19.01, IHI, Tanzania, 2019

In 2018, Ifakara Health Institute disseminated results emerging from the formative study for Children In the Mining (CIM) seeking to improve access to social- economic and health services for children living in the mining areas in Bukombe, Songwe and Chunya districts of Tanzania. Using an action-based approach, members of the Kerezia community involved reflected on the findings and developed a plan of action to address the social-economic problems that face children living in the mining areas. The villagers prioritized water, roads and schooling. A while later the villagers reported to the IHI researchers: "We are happy to tell you that one of our priorities has been implemented and through the efforts of community members, we have constructed a foundation for the primary school here in our village [........] I was really wondering how I could see you and inform you about this progress." The Kerezia story is argued to highlight how scientists need to go beyond the traditional methods of sharing research findings and apply action-based dissemination where possible to influence change at the grass roots.

The problem of ‘trickle-down science’ from the Global North to the Global South
Reidpath D; Allotey P: BMJ Global Health 4(4), doi:, 2019

Countries in the Global South continue to struggle to train and retain good researchers and practitioners to address local, regional and global health challenges. As a result, there is an ongoing reliance on the Global North for solutions to local problems and an inability to develop alternative approaches to problem solving that take local (non-northern) contexts into account. Current paradigms of scientific advancement provide no long-term models to challenge the status quo or privilege knowledge that is generated primarily in the Global South. This has major impacts on access to funding which perpetuates the problem. The authors argue that there needs to be a concerted and demonstrable shift to value and promote the development of research and scientific traditions that are borne out of the reality of local contexts that complement knowledge and evidence generated in the Global North.

Regional Research–Policy Partnerships for Health Equity and Inclusive Development: Reflections on Opportunities and Challenges from a Southern African Perspective
Yeates N; Moeti T; Luwabelwa M: Institute for Development Studies Bulletin 50(1) 121-142, 2019

This article critically reflects on the experience and lessons from a health-focused social policy research project involving a partnership spanning multiple countries across southern Africa and Europe. It asks what factors condition the efficacy of the partnership–policy nexus. The policy research project Southern African Development Community partnership case study used participatory action research to create a regional indicators-based monitoring toolkit of pro poor health policy and change for the region. The article addresses the partnership drivers, features, methodological context, and process of the project, and the wider implications for constructing partnerships for social change impact. Lessons drawn from this case study underscore the importance of participatory action research -inspired partnership structures and working methods while querying assumptions that the relationship between participatory action research and policy change is seamless. The authors argue that greater focus is needed on the wider institutional context conditioning the work of partnerships when considering the efficacy of a nexus between partnerships and policy.

Strengthening ethical community engagement in contemporary Malawi
Nyirenda D; Gooding K; Sambakunsi R; et al: Wellcome Open Research, Lilongwe, 2019

Although community engagement is increasingly promoted in global health research to improve ethical research practice, the authors observe that there is sometimes a disconnect between the broader moral ambitions for community engagement in the literature and guidelines on the one hand and its rather narrower practical application in health research on the other. In practice, less attention is said to be paid to engaging communities for the ‘intrinsic’ value of showing respect and ensuring inclusive participation of community partners in research design. Rather, more attention is paid to the use of community engagement for ‘instrumental’ purposes to improve community understanding of research and ensure successful study implementation. Against this backdrop, the authors reviewed the literature and engaged various research stakeholders at a workshop to discuss ways of strengthening ethical engagement of communities and to develop context-relevant guidelines for community engagement in health research in Malawi. They concluded by proposing a model with three elements that would increase participatory community engagement in health research namely: collaboration, consultation and communication from the onset of research.

The problem of ‘trickle-down science’ from the Global North to the Global South
Reidpath D; Allotey P: BMJ Global Health 4(4), doi:, 2019

Ten years ago, Nigel Crisp observed, with respect to the healthcare workforce that ‘the global health system is characterised by an import–export business in which rich countries export the ideology of Western scientific medicine and aid predicated on this ideology to poor countries. In return, the poor countries export a portion of their preciously limited pool of trained health workers back to the rich countries’. The authors of the paper suggest that a similar situation holds in scientific research. Many of the very brightest minds from the Global South go to institutions of higher learning in the Global North, either as graduate students or as fully fledged researchers. They are attracted by better pay, resources, engagement and prestige. There are then three broad outcomes: If the move is a permanent one (which is the case 70% of the time) many turn their focus away from the concerns of the south towards the research priorities in the north, where the funding is. Others remain in the north but keep their focus on the issues of the south, albeit often with limited impact, and sometimes compromising their career progression in the north. The third outcome is the return of the researcher to the south, and frustration over the lack of an enabling environment to apply their skills. Trickle-down science as a strategy for advancing knowledge for current and future challenges has enabled an inequity in the distribution of scientific capacities. However the authors observe that there are ways to engage more effectively with the growing, if disempowered, talent in the south to build of enabling environments, leadership and a quality and volume of home grown, contextually driven knowledge.

Facilitators, best practices and barriers to integrating family planning data in Uganda’s health management information system
Wandera S; Kwagala B; Nankinga O; Ndugga P; et al: BMC Health Services Research 19(327) 1-13, 2019

This study sought to investigate the facilitators, best practices and barriers of integrating family planning data into the district and national Health management information systems in Uganda. The authors conducted a qualitative study in Kampala, Jinja, and Hoima Districts of Uganda, based on 16 key informant interviews and a multi-stakeholder dialogue workshop with 11 participants. The technical facilitators of integrating family planning data from public and private facilities in the national and district Health management information systems were user-friendly software; web-based and integrated reporting; and availability of resources, including computers. Organizational facilitators included prioritizing family planning data; training staff; supportive supervision; and quarterly performance review meetings. Key behavioural facilitators were motivation and competence of staff. Collaborative networks with implementing partners were also found to be essential for improving performance and sustainability. Significant technical barriers included limited supply of computers in lower level health facilities, complex forms, double and therefore tedious entry of data, and web-reporting challenges. Organizational barriers included limited human resources; high levels of staff attrition in private facilities; inadequate training in data collection and use; poor culture of information use; and frequent stock outs of paper-based forms. Behavioural barriers were low use of family planning data for planning purposes by district and health facility staff. Family planning data collection and reporting are integrated in Uganda’s district and national health management information systems. Best practices included integrated reporting and performance review, among others. Limited priority and attention is given to family planning data collection at the facility and national levels. Data are not used by the health facilities that collect them. The authors recommend reviewing and tailoring data collection forms and ensuring their availability at health facilities. All staff involved in data reporting should be trained and regularly supervised.

Setting the global research agenda for community health systems: literature and consultative review
Agarwal S; Kirk K; Sripad P; Bellows B; et al: Human Resources for Health 17(22), doi:, 2019

Globally, there is renewed interest in and momentum for strengthening community health systems. Recent reviews have identified factors critical to successful community health worker (CHW) programs but pointed to significant evidence gaps. This systematic review identifies areas for a global research agenda to strengthen CHW programs. Research gap areas that were identified in the literature and validated through expert consultation include selection and training of CHWs and community embeddedness, institutionalisation of CHW programs (referrals, supervision, and supply chain), CHW needs including incentives and remuneration, governance and sustainability of CHW programs, performance and quality of care, and cost-effectiveness of CHW programs. Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time. As international interest and investment in CHW programs and community health systems continue to grow, the authors propose that it becomes critical not only to analyse the evidence that exists, but also to clearly define research questions and collect additional evidence to ensure that CHW programs are effective, efficient, equity promoting, and evidence based.