Monitoring equity and research policy

Access to information as a tool for socio-economic justice
Dimba M: Pambazuka News, 8 April 2008

In countries plagued by socio-economic imbalances inherited from undemocratic systems of government, it is crucial that the products of democratic transition, such as freedom of information legislation, must be used to address imbalances. In the field of socio-economic rights, freedom of information creates a basis for contestation and justification of government decisions on resource allocation. It creates a basis for a fair and reasonable manner of decision-making.

Access to Medicine Index 2010
Access to Medicine Foundation: 2010

The Access to Medicine Index independently assesses how individual pharmaceutical companies perform in promoting universal access to essential medicines, and may be used as a tool in improving performance. The 2010 ranking reveals important progress, if only because companies have shown far greater willingness to open up. The Index unveils improvements research and development, and pricing, but also shows that the industry as a whole still has a long way to go, according to Wim Leereveld, the Index's founder. The Access to Medicine Index ranks 20 of the world's largest pharmaceutical companies on their efforts to make sure that medicines are made for, and reach, people in developing countries. The Index encourages drug companies to compete and offers investors and others a way to compare their social responsibility records.

Accessing and understanding the evidence
Duke T, Campbell H, Ayieko P: Bulletin of the World Health Organization 84(12), 922-A, December 2006

The World Health Organisation (WHO) regularly gathers, evaluates, and cites evidence to support its recommendations. How this is done varies between departments, but highly centralised processes, complex methods and expert consultations are often used. WHO guidelines are distributed to health workers and policy-makers in developing countries, but few of these people have the opportunity to be involved in the process of choosing and weighing the evidence to formulate the guidelines that are ostensibly designed for their use. Such incomplete engagement may impede ownership of WHO recommendations, and thus be an obstacle to full implementation. This editorial describes how WHO gathers, evaluates, and cites evidence to support its recommendations.

Accounting for model uncertainty in estimating global burden of disease
Vock DM, Atchison EA, Legler JM, McClure DRJ, Carlyle JC, Jeavons EN and Burton AH: Bulletin of the World Health Organisation (89): 112-120, February 2011

The authors of this study aimed to illustrate the effects of failing to account for model uncertainty when modelling is used to estimate the global burden of disease, with specific application to childhood deaths from rotavirus infection. To estimate the global burden of rotavirus infection, different random-effects meta-analysis and meta-regression models were constructed by varying the stratification criteria and including different combinations of covariates. The models were then compared. The authors found that, in the models they examined, the estimated number of child deaths from rotavirus infection varied between 492,000 and 664,000. While averaging over the different models’ estimates resulted in a modest increase in the estimated number of deaths (541,000 as compared with the World Health Organization’s estimate of 527,000), the width of the 95% confidence interval increased from 105,000 to 198,000 deaths when model uncertainty was taken into account. The authors conclude that sampling variability explains only a portion of the overall uncertainty in a modelled estimate. The uncertainty owing to both the sampling variability and the choice of model(s) should be given when disease burden results are presented. Failure to properly account for uncertainty in disease burden estimates may lead to inappropriate uses of the estimates and inaccurate prioritisation of global health needs.

Accounting for water quality in monitoring access to safe drinking-water as part of the Millennium Development Goals: Lessons from five countries
Bain RES, Gundry SW, Wright JA, Yang H, Pedley S and Bartramd JK: Bulletin of the World Health Organisation 90(3): 228-235A, March 2012

The main aim of this study was to determine how data on water source quality affect assessments of progress towards the 2015 Millennium Development Goal (MDG) target on access to safe drinking-water. Data was collected from five countries on whether drinking-water sources complied with World Health Organisation water quality guidelines on contamination with thermotolerant coliform bacteria, arsenic, fluoride and nitrates in 2004 and 2005. Taking account of data on water source quality resulted in substantially lower estimates of the percentage of the population with access to safe drinking-water in 2008 in four of the five study countries: the absolute reduction was 11% in Ethiopia, 16% in Nicaragua, 15% in Nigeria and 7% in Tajikistan. There was only a slight reduction in Jordan. Microbial contamination was more common than chemical contamination. The authors warn that the WHO criteria used to determine whether a water source is safe can lead to substantial overestimates of the population with access to safe drinking-water and, consequently, also overestimates the progress made towards the 2015 MDG target. Monitoring drinking-water supplies by recording both access to water sources and their safety would be a substantial improvement.

Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success
Rodney AM, Hill PS: International Journal for Equity in Health (13) 72, 10 October 2014

Equity should be implicit within universal health coverage (UHC) however, emerging evidence is showing that without adequate focus on measurement of equity, vulnerable populations may continue to receive inadequate or inferior health care. This narrative review aims to: (i) elucidate how equity is contextualised and measured within UHC, and (ii) describe tools, resources and lessons which will assist decision makers to plan and implement UHC programmes which ensure equity for all. Eighteen journal articles consisting mostly of secondary analysis of country data and qualitative case studies in the form of commentaries/reviews, and 13 items of grey literature, consisting largely of reports from working groups and expert meetings focusing on defining, understanding and measuring inequity in UHC (including recent drafts of global/country monitoring frameworks) were included. The literature advocates for progressive universalism addressing monetary and non-monetary barriers to access and strengthening existing health systems. This however relies on countries being effectively able to identify and reach disadvantaged populations and estimate unmet need. Recently published resources contextualise equity as a measurable component of UHC and propose several useful indicators and frameworks. Country case-studies also provide useful lessons and recommendations for planning and implementing equitable UHC which will assist other countries to consider their own requirements for UHC monitoring and evaluation.

Adaptation and implementation of local maternity dashboards in a Zimbabwean hospital to drive clinical improvement
Crofts J, Moyo J, Ndebele W, Mhlanga S, Draycotta T, Sibanda T: Bull World Health Organ 2014;92:146–152

The Commission on Information and Accountability for Women’s and Children’s Health of the World Health Organization (WHO) reported that national health outcome data were often of questionable quality and “not timely enough for practical use by health planners and administrators”. Delayed reporting of poor-quality data limits the ability of front-line staff to identify problems rapidly and make improvements. Clinical “dashboards” based on locally available data offer a way of providing accurate and timely information. A dashboard is a simple computerized tool that presents a health facility’s clinical data graphically using a traffic-light coding system to alert front-line staff about changes in the frequency of clinical outcomes. It provides rapid feedback on local outcomes in an accessible form and enables problems to be detected early. Until now, dashboards have been used only in high-resource settings. An overview maternity dashboard and a maternal mortality dashboard were designed for, and introduced at, a public hospital in Zimbabwe. A midwife at the hospital was trained to collect and input data monthly. Implementation of the maternity dashboards was feasible and 28 months of clinical outcome data were summarized using common computer software. Presentation of these data to staff led to the rapid identification of adverse trends in outcomes and to suggestions for actions to improve health-care quality. Implementation of maternity dashboards was feasible in a low-resource setting and resulted in actions that improved health-care quality locally. Active participation of hospital management and midwifery staff was crucial to their success.

Adapting HIV patient and program monitoring tools for chronic non-communicable diseases in Ethiopia
Letebo M; Shiferaw F: Globalization and Health 12(26), June 2016

Chronic non-communicable diseases (NCDs) have become a huge public health concern in developing countries. Many resource-poor countries facing this growing epidemic, however, lack systems for an organised and comprehensive response to NCDs. Successfully responding to the problem requires a number of actions by the countries, including developing context-appropriate chronic care models and programs and standardisation of patient and program monitoring tools. In this cross-sectional qualitative study the authors assessed existing monitoring and evaluation tools used for NCD services in Ethiopia. Since HIV care and treatment program is the only large-scale chronic care program in the country, they explored the tools being used in the program and analysed how they might be adapted to support NCD services in the country. Document review and in-depth interviews were the main data collection methods used. The interviews were held with health workers and staff involved in data management purposively selected from four health facilities with high HIV and NCD patient load. Thematic analysis was employed to make sense of the data. The authors findings indicate the apparent lack of information systems for NCD services, including the absence of standardised patient and program monitoring tools to support the services. They identified several HIV care and treatment patient and program monitoring tools currently being used to facilitate intake process, enrolment, follow up, cohort monitoring, appointment keeping, analysis and reporting. Analysis of how each tool being used for HIV patient and program monitoring can be adapted for supporting NCD services is presented. Given the similarity between HIV care and treatment and NCD services and the huge investment already made to implement standardised tools for HIV care and treatment program, adaptation and use of HIV patient and program monitoring tools for NCD services can improve NCD response in Ethiopia through structuring services, standardising patient care and treatment, supporting evidence-based planning and providing information on effectiveness of interventions.

Addressing research capacity for health equity and the social determinants of health in three African countries: the INTREC programme
Hofman K, Blomstedt Y, Addei S, Kalage R, Maredza M et al: Global Health Action 2013(6), April 2013

INTREC (INDEPTH Training and Research Centres of Excellence) was established to provide training for researchers from the INDEPTH network on associations between health inequities, the social determinants of health (SDH), and health outcomes, and on presenting their findings in a usable form to policy makers. The authors of this paper assessed the current status of SDH training in three of the African INTREC countries – Ghana, Tanzania, and South Africa – as well as the gaps, barriers, and opportunities for training. Results indicated that SDH-relevant training is available, but the number of places available for students is limited, the training tends to be public-health-oriented rather than inclusive of the broader, multi-sectoral issues associated with SDH, and insufficient funding places limitations on both students and on the training institutions themselves, thereby affecting participation and quality. The authors argue that there is a clear role for INTREC to contribute to the training of a critical mass of African researchers on the topic. This work will be accomplished most effectively by building on pre-existing networks, institutions, and methods.

ADHERENCE TO LONG-TERM THERAPIES: EVIDENCE FOR ACTION
World Health Organisation - 2003

Adherence to therapies is an indicator of inequities as well as access to drugs. In average, 50% of patients in developed countries do not take their prescribed medicines after one year, despite having full access to medicines. In developing countries it is even worse, due to poor access to health services, medicines, lack of education and unhealthy lifestyles, which especially affects the poorest populations. Intended for policy-makers, health managers, and clinical practitioners, this report provides a concise summary of the consequences of poor adherence for health and economics. It also discusses the options available for improving adherence, and demonstrates the potential impact on desired health outcomes and health care budgets. It is hoped that this report will lead to new thinking on policy development and action on adherence to long-term therapies.

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