A recent World Bank press release on a World Bank and WHO report announced that "400 million people do not have access to essential health services.” The author argues in this article that this would be a highly over-optimistic misread of what WHO and the World Bank found. By more reasonable understandings of how many people lack access to essential health services, untold hundreds of millions more than 400 million people lack access to essential health services. He notes that the road ahead to universal health coverage is considerably longer than the headline figure implies. The report itself – beneath the headlines – covers many concerns and raises issues of quality and other concerns in a more complex reality. The author of this article notes that official monitoring should capture this complexity as what is monitored may well affect what governments prioritize, and the health services people actually receive, and so that a singular focus on access does not hide other aspects of people’s right to health – including the quality of health services and their acceptability.
Monitoring equity and research policy
This study reported on research production and publications on health inequalities through a bibliometric analysis covering publications from 1966 to 2014 and a content analysis of the 25 most-cited papers. A database of 49,294 references was compiled from the search engine Web of Science. The first article appears in 1966 and deals with equality and civil rights in the United States and the elimination of racial discrimination in access to medical care. By 2003, the term disparity has gained in prominence relative to the term inequality which was initially elected by the researchers. The paper shows that research on health inequalities grown exponentially in the last 30 years; the terms inequity, inequality and disparity have been inconsistently used over time; the most-cited papers studied socioeconomic factors and impacts on health inequities with first reports studying relations of socioeconomic conditions and health outcomes and research growing toward theoretical models and proposals on methodological approaches.
Between June and October 2014, the Maternal Health Task Force (MHTF) consulted 26 international maternal health researchers to gather perspectives on the most critical and neglected areas for knowledge generation to improve maternal health in low- and middle-income countries. The MHTF asked respondents to identify research and evaluation priorities in three broad areas: 1) persistent and critical knowledge gaps that need to be filled to accelerate reductions in maternal mortality and morbidity in low-and middle income countries; 2) crucial maternal health issues that have not been given adequate attention by research and donor communities; and 3) new situations and emerging challenges that require research to improve maternal health outcomes. The report presents the results of the interview responses on issues that will shape the landscape of maternal health over the next decade. This included strengthening health service delivery; improving distribution and retention of healthcare workers; the increasing burden of non-communicable diseases among pregnant women and women of reproductive age; the persistence of social and economic inequality and vulnerability; and urbanization. The need to attend to geopolitical determinants of maternal health, such as climate change and food insecurity, the proliferation of conflict and humanitarian crises, and the rise of religious fundamentalism, was also mentioned.
Monitoring pro-poor health policies at the regional level can support countries and regional bodies to identify gaps in addressing poverty and health, strengthen the link between regions and member states and hold actors accountable to their commitments. The Southern African Development Community (SADC) has conducted work in understanding how poor health and poverty coincide, are mutually reinforcing, and socially-structured by gender, age, class, ethnicity and location, with health policy documents on the issues. Yet guidelines and policies have been unevenly implemented. The Poverty Reduction and Regional Integration (PRARI) project seeks to support the development of a monitoring system to measure the contribution of regional governance in the development of pro-poor health policies in collaboration with key stakeholders in the region. The paper describes the system. It builds on existing efforts in the region and focuses on policy areas such as the social determinants of health; HIV/AIDS, TB and malaria; non-communicable diseases; maternal and child health; human resources for health; pharmaceuticals; among others. Global developments such as those related to the incoming Sustainable Development Goals (SDGs) are also considered. In order for this indicator-based monitoring system to be effective and to have an impact, it is argued to require regional ownership, active participation of national and regional experts throughout the process of indicator development, implementation and evaluation and evidence that it will address health priorities for the region.
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 understanding of the sex- and gender-based health implications of the 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.
This study assessed the methods used in the evaluation of measles vaccination coverage in 2012/3 in eastern and southern Africa, identified quality concerns and made recommendations for improvement. Of the 13 reports the authors reviewed, there were weaknesses in 10 of them for ethical clearance, 9 for sample size calculation, 6 for sampling methods, 12 for training structures, 13 for supervision structures and 11 for data analysis. The authors recommend improvements in the documentation of routine and supplementary immunisation, via home-based vaccination cards or other records. They recommend that standards be developed for report templates and for the technical review of protocols and reports. This would ensure that the results of vaccination coverage surveys are accurate, comparable, reliable and valuable for programme improvement.
There is a growing interest in the ethics of health systems research, and some debate about whether a specific ethical framework or set of guidance is needed. The authors provide a framework to begin to think about this, organised around eight considerations: (1) the nature of intervention; (2) types of research subjects; (3) units of intervention and observation; (4) informed consent; (5) controls and comparisons; (6) risk assessment; (7) inclusion of vulnerable groups within different contexts, and; (8) benefits of research. This is a starting place for researchers interested in health systems research ethics. The authors note several challenges to thinking about the ethics of health systems research, including the diverse range of studies and disciplines involved, the grey zone between research and non-research, and the many overlaps of issues with other types of health research. They call for more conceptual work and empirical research aimed at better understanding this topic.
Strengthening health research capacity in low- and middle-income countries remains a major policy goal. The Health Research Capacity Strengthening (HRCS) Global Learning (HGL) program of work documented experiences of HRCS across sub-Saharan Africa. The authors reviewed findings from HGL case studies and reflective papers regarding the dynamics of HRCS. Analysis was structured with respect to common challenges in such work, identified through a multi-dimensional scaling analysis of responses from 37 participants at the concluding symposium of the program of work. Symposium participants identified 10 distinct clusters of challenges: engaging researchers, policymakers, and donors; securing trust and cooperation; finding common interest; securing long-term funding; establishing sustainable models of capacity strengthening; ensuring Southern ownership; accommodating local health system priorities and constraints; addressing disincentives for academic engagement; establishing and retaining research teams; and sustaining mentorship and institutional support. Analysis links these challenges to three key and potentially competing drivers of the political economy of health research: an enduring model of independent researchers and research leaders, the globalisation of knowledge and the linked mobility of (elite) individuals, and institutionalisation of research within universities and research centres and, increasingly, national research and development agendas. The authors identify tensions between efforts to embrace the global ‘Community of Science’ and the promotion and protection of national and institutional agendas in an unequal global health research environment. A nuanced understanding of the dynamics and implications of the uneven global health research landscape is required, along with a willingness to explore pragmatic models that seek to balance these competing drivers.
Easy-to-collect epidemiological information is critical for the more accurate estimation of the prevalence and burden of different non-communicable diseases around the world. Current measurement is restricted by limitations in existing measurement systems in the developing world and the lack of biometry tests for non-communicable diseases. Diagnosis based on self-reported signs and symptoms (“Symptomatic Diagnosis,” or SD) analysed with computer-based algorithms may be a promising method for collecting timely and reliable information on non-communicable disease prevalence. This study developed and assessed the performance of a symptom-based questionnaire to estimate prevalence of non-communicable diseases in low-resource areas. The authors collected 1,379 questionnaires in Mexico from individuals who suffered from a non-communicable disease that had been diagnosed with gold standard diagnostic criteria or individuals who did not suffer from any of the 10 target conditions. To make the diagnosis of non-communicable diseases, the authors selected the Tariff method, a technique developed for verbal autopsy cause of death calculation. They assessed the performance of this instrument and analytical techniques at the individual and population levels. The questionnaire revealed that SD is a viable method for producing estimates of the prevalence of non-communicable diseases in areas with low health information infrastructure. This technology can provide higher-resolution prevalence data, more flexible data collection, and potentially individual diagnoses for certain conditions.
Research funding agencies continue to grapple with assessing research impact. This narrative literature review synthesized evidence on processes and conceptual models used for assessing policy and practice impacts of public health research. The review involved keyword searches of electronic databases, including MEDLINE, CINAHL, PsycINFO, EBM Reviews, and Google Scholar in July/August 2013. The review included theoretical and opinion pieces, case studies, descriptive studies, frameworks and systematic reviews describing processes, and conceptual models for assessing research impact. A total of 16 different impact assessment models were identified, with the ‘payback model’ the most frequently used conceptual framework. Typically, impacts were assessed across multiple dimensions using mixed methodologies, including publication and citation analysis, interviews with principal investigators, peer assessment, case studies, and document analysis. The vast majority of studies relied on principal investigator interviews and/or peer review to assess impacts, instead of interviewing policymakers and end-users of research.