Monitoring equity and research policy

Equity in international health research collaborations in Africa: Perceptions and expectations of African researchers
Munung N; Mayosi B; de Vries J: PLOS One 12(10), doi:, 2017

In this paper, the authors report on a qualitative interviewing study in which they involved 17 genomics researchers in Africa. The authors describe their perceptions and expectations of international genomics research and biobanking initiatives in Africa. All interviewees were of the view that externally funded genomics research and biobanking initiatives have played a critical role in building capacity for genomics research and biobanking in Africa and in providing an opportunity for researchers in Africa to collaborate and network with other researchers. Whilst the opportunity to collaborate was seen as a benefit, some interviewees stressed the need for these collaborations to have mutual benefits for all partners, including their collaborators in high income countries. They voiced two major concerns of being part of these collaborative initiatives: the possibility of exploitation of African researchers and the non-sustainability of research capacity building efforts. They thus recommended genuine efforts to create transparent and equitable international health research partnerships through,: having rules of engagement, enabling African researchers to contribute to the design and conduct of international health projects in Africa, and mutual and respectful exchange of experience and capacity between research collaborators. These were identified as hallmarks to equitable international health research collaborations in Africa.

Where does research fit in a post-truth world?
Guth J: Special Programme for Research and Training in Tropical Diseases (TDR), UNICEF, UNDP, World Bank, WHO, November 2017

A large study in 3 west African countries examined how to increase the numbers of pregnant women receiving malaria preventive treatment, and getting diagnosed and treated. There were many health systems issues that were identified that created barriers, such as lack of transportation or well-trained healthcare providers at the regional health facilities. Video interviews were conducted with people involved in the project and shared with policy-makers, healthcare providers and community members. The use of video helped to provide local context – of settings and people. It strengthened the understanding and credibility of the associated research results and showed strong collaboration between the research team and community, a proven facilitator in research uptake. The video was reported to have had a profound when it was shared and led to strong statements of commitments to make changes based on this study. The author suggests that it is necessary to use every tool possible to show the utility of science and how it improves people’s lives in ways that they can see and feel.

Research priority setting for integrated early child development and violence prevention (ECD+) in low and middle income countries: An expert opinion exercise
Tomlinson M; Jordans M; MacMillan H; et al.: Jo Child Abuse Negligence 72,131-139, 2017

Reducing children's exposure to harmful events and violence is essential for early childhood development. The authors used the Child Health and Nutrition Initiative method for the setting of research priorities in integrated early childhood development and violence prevention programs. An expert group was identified and invited to systematically list and score research questions. A total of 186 stakeholders were asked to contribute five research questions each, and contributions were received from 81 respondents. These were subsequently evaluated using a set of five criteria: answerability; effectiveness; feasibility and/or affordability; applicability and impact; and equity. Of the 400 questions generated, a composite group of 50 were scored by 55 respondents. The highest scoring research questions related to the training of community health workers to deliver early childhood development and violence prevention programs interventions effectively and whether these interventions could be integrated within existing delivery platforms such as HIV, nutrition or mental health platforms. The findings from this research priority setting exercise is argued to potentially help guide funders and others towards funding priorities for important future research related to early childhood development and violence prevention.

The SWPER index for women’s empowerment in Africa: development and validation of an index based on survey data
Ewerling F; Lynch J; Victora C; van Eerdewijk A; Tyszler M; Barros A: Lancet Global Health 5(9) e916-e923, 2017

The Sustainable Development Goals strongly focus on equity. Goal 5 explicitly aims to empower all women and girls, reinforcing the need to have a reliable indicator to track progress. This study developed a novel women’s empowerment indicator from widely available data sources, broadening opportunities for monitoring and research on women’s empowerment. The authors used Demographic and Health Survey data from 34 African countries, targeting currently partnered women. They identified items related to women’s empowerment present in most surveys, and used principal component analysis to extract the components. The authors carried out a convergent validation process using coverage of three health interventions as outcomes; and an external validation process by analysing correlations with the Gender Development Index. Findings 15 items related to women’s empowerment were selected. They retained three components (50% of total variation) which, after rotation, were identified as three dimensions of empowerment: attitude to violence, social independence, and decision making. All dimensions had moderate to high correlation with the Gender Development Index. Social independence was associated with higher coverage of maternal and child interventions; attitude to violence and decision making were more consistently associated with the use of modern contraception. Interpretation The index, named Survey-based Women’s emPowERment index, is argued to have the potential to widen the research on women’s empowerment and to give a better estimate of its effect on health interventions and outcomes. It allows within-country and between-country comparison, as well as time trend analysis, which no other survey based index provides.

Systems science for universal health coverage
Evans T; Kieny M: Bulletin of the World Health Organisation 95(7) 2017

It is 20 years since an international consultation in Lejondal, Sweden, highlighted the need for more and better research “to understand and improve how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes.” One outcome was the creation of the Alliance for Health Policy and Systems Research. There have since been several important milestones on the path towards more and better health systems research. Such encouraging developments need to be carefully balanced against areas where progress has not met expectations. The development of national capacity for financing and institutional leadership of health policy and systems research has been slow. The authors ask: how can health policy and systems research seize this favourable context and contribute more effectively to universal health coverage, greater health security, improved value in health and effective engagement of citizens? First, they propose that there is a need a comprehensive review of the progress that has been made and the progress that might be anticipated in the future. Second, there is a need to accelerate the development of capacity and opportunity for health policy and systems research in low- and middle-income countries. Lastly, they suggest that there is a need for a revitalised approach to stewardship that reflects the pluralistic reality of contemporary health systems and prioritises health policy and systems research across all countries.

The Role and Status of National Research and Education Networks in Africa
Foley M: World Bank Group, SABER-ICT Technical Paper Series, 2016

This report aims to provide guidance to governments, institutions, and development partners on how to approach the provision of advanced information and communication technology (ICT) services to the higher education and research community in Africa. It coincides with a transformation in the telecom infrastructure and services on the continent as fibre optic connectivity, both undersea and on land, is expanding at a rapid pace. The report suggests that the organisation of ICT services and connectivity is best provided by a dedicated organisation called the National Research and Education Network (NREN) based on international best practice and the current plans of the stakeholders in the region. The nature of NRENs and the case for their establishment is outlined and the story of their development in Africa to their current status is described. The report also provides guidance on how to establish or strengthen an NREN, with recommendations to the government, the private sector, institutions, development partners.

World health statistics 2017: monitoring health for the SDGs, Sustainable Development Goals
World Health Organization: WHO, Geneva, 2017

The World Health Statistics series is World Health Organisation’s annual compilation of health statistics for its 194 Member States. World Health Statistics 2017 focuses on the health and health-related Sustainable Development Goals (SDGs) and associated targets by bringing together data on a wide range of relevant SDG indicators. World Health Statistics 2017 is organised into three parts. In Part 1, six lines of action are described which WHO is now promoting to help build better systems for health and to achieve the health and health-related SDGs. In Part 2, the status of selected health-related SDG indicators is summarised, at both global and regional level, based on data available as of early 2017. Part 3 then presents a selection of stories that highlight recent successful efforts by countries to improve and protect the health of their populations through one or more of the six lines of action. Annexes A and B present country level estimates for selected health-related SDG indicators. As in previous years, World Health Statistics 2017 has been compiled primarily using publications and databases produced and maintained by WHO or United Nations groups of which WHO is a member, such as the United Nations Inter-agency Group for Child Mortality Estimation.

Quality of care: measuring a neglected driver of improved health
Akachi Y; Kruk M: Bulletin of the World Health Organisation 95(6), 389-480, 2017

The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is argued to be inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. The authors propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalise civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.

South Africa’s vital statistics are currently not suitable for monitoring progress towards injury and violence Sustainable Development Goals
Prinsloo M; Bradshaw D; Joubert J; Matzopoulos R; Groenewald P: South African Medical Journal 107(6), 470-471, 2017

Two of the most important targets to achieving the United Nation’s Sustainable Development Goals (SDGs) for reducing violence and other injuries are Target 3.6: to ‘halve the number of global deaths and injuries from road traffic accidents’ by 2020; and Target 16.1: the significant reduction of ‘all forms of violence and related death rates everywhere’. Police statistics on homicide, and transport deaths from the Road Traffic Management Corporation, are considered to be under-reported and are not a reliable source for monitoring SDGs. In South Africa (SA), vital statistics data are the only routine source that captures unnatural and natural deaths through death registration. Since the early 1990s, focused initiatives have identified and addressed deficiencies in the completeness of death registration and recent estimates indicate that completeness for persons aged ≥2 years is >90%. However, there are still concerns about the quality of data relating to the cause of death, i.e. under- reporting of HIV/AIDS deaths owing to misclassification to other causes, a large proportion of deaths with ill-defined causes, and the validity of single-cause data. The misclassification of injury deaths is another major limitation. The Inquest Act of 1959 precludes forensic pathologists from reporting the manner of death, i.e. whether it is due to homicide, suicide, transport or other unintentional injuries, on the basis that it may prejudice the findings of the inquest. Homicides are therefore grossly under-represented in official vital statistics. The misclassification of injury deaths was clearly demonstrated in a nationally representative study of injury deaths presenting to state forensic mortuaries in 2009. The absence of information on the manner of injury death in the official statistics needs to be addressed urgently. A review and possible amendment of the Inquest Act would possibly take years. The authors recommend that the death notification form be amended in line with the updated World Health Organisation’s recommendation, to include a stand-alone field for information about the manner of injury death for unnatural causes. Forensic pathologists when uncertain can include a proviso stating that such information is for statistical purposes only. This matter is currently being discussed with relevant stakeholders.

Participatory evaluation of delivery of animal health care services by community animal health workers in Karamoja region of Uganda
Bugeza J; Kankya C; Muleme J; Akandinda A; Sserugga J; Nantima N; Okori E; Odoch T: PLOS One, doi:, 2017

An evaluation exercise was carried out to assess the performance of Community Animal Health Workers (CAHWs) in the delivery of animal health care services in Karamoja region, identify capacity gaps and recommend remedial measures. Participatory methods were used to design data collection tools. Questionnaires were administered to 204 CAHWs, 215 farmers and 7 District Veterinary Officers (DVOs) to collect quantitative data. Seven DVOs and 1 Non Government Organisation (NGO) representative were interviewed as key informants and one focus group discussion was conducted with a farmer group in Nakapiripirit to collect qualitative data. Key messages from interviews and the focus group discussion were recorded in a notebook and reported verbatim. 70% of the farmers revealed that CAHWs are the most readily available animal health care service providers in their respective villages. CAHWs were instrumental in treatment of sick animals, disease surveillance, control of external parasites, animal production, vaccination, reporting, animal identification, and performing minor surgeries. Regarding their overall performance 88.8% of the farmers said they were impressed. The main challenges faced by the CAHWs were inadequate facilitation, lack of tools and equipment, unwillingness of government to integrate them into the formal extension system, poor information flow, limited technical capacity to diagnose diseases, unwillingness of farmers to pay for services and sustainability issues. CAHWs remain the main source of animal health care services in Karamoja region and their services are largely satisfactory. The technical deficits identified are argued to require continuous capacity building programs, close supervision and technical backstopping and strategic deployment of paraprofessionals that are formally recognised by the traditional civil service.