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 equity and research policy
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.
There is a scarcity of empirical data on African country climates for evidence-informed health system policymaking (EIHSP) to backup the longstanding reputation that research evidence is not valued enough by health policymakers as an information input. In this paper, the authors assess whether and how changes have occurred in the climate for EIHSP before and after the establishment of two Knowledge Translation Platforms housed in government institutions in Cameroon and Uganda since 2006. The authors merged content analysis techniques and policy sciences analytical frameworks to guide this structured review of governmental policy documents geared at achieving health Millennium Development Goals. They combined i) a quantitative exploration of the usage statistics of research-related words and constructs, citations of types of evidence, and budgets allocated to research-related activities; and (ii) an interpretive exploration using a deductive thematic analysis approach to uncover changes in the institutions, interests, ideas, and external factors displaying the country climate for EIHSP. Descriptive statistics compared quantitative data across countries during the periods 2001–2006 and 2007–2012. The use of evidence syntheses to frame poverty and health problems, select strategies, or forecast the expected outcomes has remained sparse over time and across countries. The budgets for research increased over time from 28.496 to 95.467 million Euros (335%) in Cameroon and 38.064 to 58.884 million US dollars (155%) in Uganda, with most resources allocated to health sector performance monitoring and evaluation. The consistent naming of elements pertaining to the climate for EIHSP features the greater influence of external donors through policy transfer. The authors indicate that the review illustrated a conducive climate for EIHSP in Cameroon and Uganda but a persistent undervalue of evidence syntheses and recommend that global and national health stakeholders raise the profile of evidence syntheses (e.g., systematic reviews) as an information input when shaping policies and programmes.
Identifying research priorities is key to innovation and economic growth, since it informs decision makers on effectively targeting issues that have the greatest potential public benefit. The authors report here on a major cross-sectoral nationwide research priority setting effort recently carried out in Tanzania by the Tanzania Commission for Science and Technology (COSTECH) in partnership with the Council on Health Research for Development (COHRED) and the NEPAD Agency. The first of its type in the country, the process brought together stakeholders from 42 sub-sectors in science, technology, and health. The cross-sectoral research priority setting process consisted of a ‘training-of-trainers’ workshop, a demonstration workshop, and seven priority setting workshops with representatives from public and private research and development institutions, universities, non-governmental organisations, and other agencies affiliated to COSTECH. The workshops resulted in ranked listings of research priorities for each sub-sector, totalling approximately 800 priorities. This large number was significantly reduced by an expert panel in order to build a manageable instrument aligned to national development plans that could be used to guide research investments. The Tanzania experience is an instructive example of the challenges and issues to be faced in when attempting to identify research priority areas and setting a science, technology, and health research agenda in low- and middle-income countries. As countries increase their investment in research, it is essential to increase investment in research management and governance as well, to make proper use of research investments.