Almost seven years after the publication of the final report of the World Health Organisation’s Commission on Social Determinants of Health (CSDH), its third recommendation has not been attended to properly. Measuring health inequities (HI) within countries and globally, in order to develop and evaluate evidence-based policies and actions aimed at the social determinants of health (SDH), is still a pending task in most low and middle income countries (LMIC) in the Latin American region. In this paper the authors discuss methodological and conceptual issues to measure HI in LMIC and suggest a three-stage methodology for the creation of observatories on health inequities (OHI) and social determinants of health, based on the experience of the Brazilian Observatory on Health Inequities. The authors describe the three stages and discuss the replicability of this methodology in other Latin American countries. The authors also carried out a search of suitable national information systems to feed an OHI in Mexico, along with an outline of the institutional infrastructure to sustain it. When implementing the methodology for an OHI in LMIC such as Mexico, the authors found that having strong infrastructure of information systems for measuring HI is required, but not sufficient to build an OHI. Adequate funding and intersectoral network collaborations lead by a group of experts is a requirement for the consolidation and sustainability of an OHI in LMIC.
Monitoring equity and research policy
Inadequate regional provisions have been one of the weak links in the global monitoring of, and accountability for, implementation of the Millennium Development Goals (MDGs). As a result, the question now is how does the regional monitoring and review process need to improve as a more demanding post-2015 development agenda is introduced? To address this question, the paper follows three analytical approaches. First, by reviewing various global-level inputs channelled towards articulating the Sustainable Development Goals (SDGs), it teases out the implications of the new agenda for a Regional Monitoring and Review Mechanism (RMRM). Second, by revisiting the experiences of various existing frameworks for a regional mechanism, it highlights the strengths and weaknesses of their varying approaches and instruments. Third, the paper tries to identify the critical attributes of the institutional structure and modalities that have to characterize such a mechanism in the new context. In conclusion, the paper underscores the need to bolster regional statistical capacity, particularly in the field of regional public goods and the proposed regional indicators of the sustainable development goals. It also proposes elements of a possible mechanism, building on the existing practices of the Economic and Social Commission for Asia and the Pacific (ESCAP).
New reporting guidelines have been published for the growing area of implementation and operational research. The field utilises a range of different research designs, so existing reporting guidelines only partially cover the need for guidance. Wide consultation through the World Health Organization (WHO), the Alliance for Health Policy & Systems Research (AHPSR) and TDR resulted in these recommendations. The paper provides a practical reference for funders, researchers, policymakers, implementers, reviewers and editors working with implementation and operational research. Given that this is an evolving field, they plan to monitor the use of these guidelines and develop future versions as required.
Tanzania’s socio-economic development is challenged by sharp inequities between and within urban and rural areas, and among different socio-economic groups. This paper discusses the importance of strengthening SDH research, knowledge, relevant capacities and responsive systems towards addressing health inequities in Tanzania.The conceptualization of SDH varies considerably among stakeholders and their professional background, but with some consensus that it is linked to “inequities” being a consequence of poverty, poor planning, limited attention to basic humanity and citizenship rights, weak governance structures and inefficient use of available resources. Commonly perceived SDH factors include age, income, education, beliefs, cultural norms, gender, occupation, nutritional status, access to health care, access to safe water and sanitation and child bearing practices. SDH research is in its infancy but gaining momentum. In the absence of a specific “SDH portfolio”, SDH research is scattered and hidden within disease specific, poverty-related research and research on universal health coverage. Research is mainly externally funded, which has implications on the focus of context specific SDH research, national priorities and transfer to policy. This create mismatch with population and research capacity needs. Establishing a system to promote collaboration across sectors and strengthen collective capacities for individuals and institutions researching in SDH will augment existing SDH research initiatives and better inform appropriate intersectoral policies towards addressing prevailing health inequities across the country.
Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. However, contextual evidence on health workers’ barriers and motivating factors that may influence large-scale implementation of such interfaces for health care delivery is scarce. A pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. Identified barriers for not using electronic forms consistently include challenges related to electronic forms (for example, problem with username and password setting as reported by 5 (21.7%), smartphones (for example, smartphone froze or locked up as reported by 9 (39.1%) and health system (for example, frequent movement of health workers as reported by 19 (82.6%)). Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.
Attention to the concepts of ‘sex’ and ‘gender’ is increasingly being recognised as contributing to better science through an augmented understanding of how these factors impact on health inequities and related health outcomes. However, the ongoing lack of conceptual clarity in how sex and gender constructs are used in both the design and reporting of health research studies remains problematic. Conceptual clarity among members of the health research community is central to ensuring the appropriate use of these concepts in a manner that can advance our understanding of the sex- and gender-based health implications of our research findings. During the past twenty-five years much progress has been made in reducing both sex and gender disparities in clinical research and, to a significant albeit lesser extent, in basic science research. Why, then, does there remain a lack of uptake of sex- and gender-specific reporting of health research findings in many health research journals? This question, the authors argue, has significant health equity implications across all pillars of health research, from biomedical and clinical research, through to health systems and population health.
The purpose of this study was to develop a core set of indicators that could be used for measuring and monitoring the performance of primary health care organizations' capacity and strategies for enhancing equity-oriented care. Indicators were constructed based on a review of the literature and a thematic analysis of interview data with patients and staff using procedures for qualitatively derived data. Indicators were considered part of a priority set of health equity indicators if they received an overall importance rating of>8.0, on a scale of 1–9, where a higher score meant more importance. Seventeen indicators make up the priority set. Items were eliminated because they were rated as low importance (<8.0) in both rounds and were either redundant or more than one participant commented that taking action on the indicator was highly unlikely. The indicators assess performance of staff and outcomes which can be directly attributable to equity responsive primary health care.
Monitoring progress towards achieving Universal Health Coverage (UHC) is seen to be critical at both country and global level, and a monitoring framework for UHC was proposed by a joint WHO/World Bank discussion paper in December 2013. This study determined the feasibility of the proposed framework in Kenya. The study used the WHO/World Bank UHC monitoring framework and the Bellagio meeting report sponsored by WHO and the Rockefeller Foundation to informed the list of indicators used to determine the feasibility of the framework using published literature. Kenya has yet to establish an official policy on UHC that provides a clear mandate on the goals, targets and monitoring and evaluation of performance. The country has the capacity to reasonably report on five out of the seven proposed UHC indicators, but very limited capacity to report on the two service coverage indicators for the chronic condition and injury interventions and wider systemic challenges to meet the data requirements of the proposed UHC monitoring framework.
This edition presents a set of five articles that, through synthesis of available research, seek to consolidate and develop the body of health policy analysis work in low- and middle-income countries. This work is found to be currently fragmented across geographic settings and policy issues, is more descriptive than analytic and is weakly theorized.
Examining the non-communicable disease (NCD) profile for South Africa (SA) is crucial when developing health interventions that aim to reduce the burden of NCDs. The objective was to review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example. Age, gender, district of death and underlying cause of death data were obtained for 2008 and 2009 mortality unit records from Statistics SA and adjusted using STATA 11. Data for raised blood pressure were obtained from four national household surveys: the South African Demographic and Health Survey 1998, the Study on Global Ageing and Adult Health 2007, and the National Income Dynamics Study 2008 and 2010. The proportion of years of life lost due to NCDs was highest in the metros and least-deprived districts, with all metros (especially Mangaung) showing high age-standardised mortality rates for ischaemic heart disease, cerebrovascular disease and hypertensive disease. The prevalence of hypertension has increased since 1998. National household surveys showed a measured hypertension prevalence of over 40% in adults aged ¬25 years in 2010. Treatment coverage was 35.7%. Only 36.4% of hypertensive cases (on treatment) were controlled. Further work is needed if NCD monitoring is to be enhanced. Priority targets for NCDs must be integrated into national health planning processes. Surveillance requires integration into national health information systems. Within primary healthcare, a larger focus on integrated chronic care is essential.