ince the publication of the reports by the Commission on Social Determinants of Health (CSDH), many research papers have documented inequities, explaining causal pathways in order to inform policy and programmatic decision-making. At the international level, the sustainable development goals (SDGs) reflect an attempt to bring together these themes and the complexities involved in defining a comprehensive development framework. However, to date, much less has been done to address the monitoring challenges, that is, how data generation, analysis and use are to become routine tasks. In an attempt to explore these monitoring challenges, indicators covering a wide range of social determinants were tested in four country case studies (Bangladesh, Brazil, South Africa, and Vietnam) for their technical feasibility, reliability, and validity, and their communicability and usefulness to policy-makers. Twelve thematic domains with 20 core indicators covering different aspects of equity, human rights, gender, and SDH were tested through a review of data sources, descriptive analyses, key informant interviews, and focus group discussions. To test the communicability and usefulness of the domains, domain narratives that explained the causal pathways were presented to policy-makers, managers, the media, and civil society leaders. For most countries, monitoring is possible, as some data were available for most of the core indicators. However, a qualitative assessment showed that technical feasibility, reliability, and validity varied across indicators and countries. Producing understandable and useful information proved challenging, and particularly so in translating indicator definitions and data into meaningful lay and managerial narratives, and effectively communicating links to health and ways in which the information could improve decision-making. This exercise revealed that for monitoring to produce reliable data collection, analysis, and discourse, it will need to be adapted to each national context and institutionalised into national systems. This will require that capacities and resources for this and subsequent communication of results are increased across countries for both national and international monitoring, including the successful implementation of the SDGs.
Monitoring equity and research policy
Health systems research is increasingly being conducted in low and middle-income countries (LMICs). Such research should aim to reduce health disparities between and within countries as a matter of global justice. For such research to do so, ethical guidance that is consistent with egalitarian theories of social justice proposes it ought to (amongst other things) focus on worst-off countries and research populations. Yet who constitutes the worst-off is not well-defined. By applying existing work on disadvantage from political philosophy, the paper demonstrates that (at least) two options exist for how to define the worst-off upon whom equity-oriented health systems research should focus: those who are worst-off in terms of health or those who are systematically disadvantaged. The paper describes in detail how both concepts can be understood and what metrics can be relied upon to identify worst-off countries and research populations at the sub-national level (groups, communities), considering real-world cases of health systems research in Uganda and India in 2011. It is recommended that health researchers (or other actors) should use the concept that best reflects their moral commitments—namely, to perform research focused on reducing health inequalities or systematic disadvantage more broadly. If addressing the latter, it is recommended that they rely on the multidimensional poverty approach rather than the income approach to identify worst-off populations.
Faraz Khalid, a 2016 Emerging Voice for Global Health, a PhD candidate at Tulane School of Public Health and Tropical Medicine, USA, and a health financing consultant with the Prime Minister National Health Insurance Program, Pakistan, shares quotes from senior researchers gathered at meetings and conferences attended throughout the year, including the Emerging Voices in Global Health 2016 training program preceding the Global Symposium on Health Systems Research 2016 in Vancouver. These include Gorik Ooms, Professor at London School of Hygiene and Tropical Medicine (LSHTM) who notes “If one accepts that health is a human right, one can only assess the present situation of global health (and its enormous inequalities) as a massive and continued human rights violation. Young (and older) health systems researchers must find a middle ground between assuming that states will continue to behave more or less as they currently are (which leaves little room for improvement), or assuming that states will live up to their domestic and international responsibilities (which seems unlikely to happen). In this uncomfortable position, it is important to be aware that whatever solutions we recommend, they will shape the future, one way or the other.”
The strategic importance of monitoring social determinants of health (SDH) and health equity and inequity has been a central focus in global discussions. This study aims to define a framework for monitoring SDH and health equity. This review provides a global summary and analysis of the domains and indicators that have been used in recent studies covering the SDH. It describes the range of international and national studies and the types of indicators most frequently used; reports how they are used in causal explanation of the SDH; and identifies key priorities and challenges reported in current research for national monitoring of the SDH. The authors conducted a scoping review of published SDH studies in PubMed 2004-2014 to obtain evidence of socio-economic indicators. The final sample consisted of 96 articles. SDH monitoring is well reported in the scientific literature independent of the economic level of the country and magnitude of deprivation in population groups. The research methods were mostly quantitative and many papers used multilevel and multivariable statistical analyses and indexes to measure health inequalities and SDH. In addition to the usual economic indicators, a high number of socio-economic indicators were used. The indicators covered a broad range of social dimensions, which were given consideration within and across different social groups. The authors identified a need to make indicators more wide-ranging in order to include a broader range of social conditions, and for WHO to provide intersectoral and interdisciplinary means of building a more comprehensive standardised approach to monitoring the SDH and improving equity in health.
In November 2016, the global health systems research community gathered in Vancouver, Canada, for the Fourth Global Symposium on Health Systems Research. The current movement for health systems research developed out of a need to strengthen health systems in low-income and middle-income countries. More than 25 years ago, the Commission on Health Research for Development published a report that represented a pivotal change in thinking about health research for development. The main argument of the report was that research contributed little to health in low-income and middle-income countries, because it matched poorly with needs in the global South, was dominated by researchers from the North, and had a narrow biomedical focus. While health systems research has taken off in some high-income countries, progress in low-income and middle-income countries has not kept up. The 2008 Global Ministerial Forum on Research for Health in Bamako, Mali, concluded with the recommendation to increase investments in health systems research and organise a global symposium specifically focused on improving health systems in low-income and middle-income countries. Since then, the field has expanded rapidly. To contribute to the debate concerning the status and future of the health systems research field, the authors assessed the research presented at the previous global symposia. They systematically analysed the 1816 abstracts that were presented at the global symposia in Beijing (2012) and Cape Town (2014) and the participant lists of the Cape Town, Beijing, and Montreux (2010) symposia. The findings present several promising developments but also highlight that research inequities persist. While the authors observe a gender balance (51% of first authors are female) and substantial contributions from countries such as India, China, and South Africa, the North-South imbalance that was described 26 years ago remains.
The San of South Africa are one of the most researched communities in the world. Their indigenous knowledge and genetic makeup have been of great interest to researchers as they are ancestors of the first hunter-gatherers in Africa. While the media and researchers have continued to want to engage with the community, TRUST, a global initiative which seeks to reduce exploitation in North-South research collaborations, alongside the San Council created a contract to protect the community from exploitation, and to ensure that the San also benefit from any research. This paper outlines a locally driven Code of Ethics for involving San people in research that has been initiated by a range of organisations in Southern Africa. Referencing the original research and media contract, this is now being finalised into the first indigenous-developed ethics code in Africa.
Building Capacity to Use Research Evidence (BCURE) is a programme of work funded by the UK Department for International Development (DFID) which aims to build the skills, knowledge and systems that will allow policy makers and practitioners in low income countries to access, appraise and use rigorous evidence. BCURE works through a consortium of organisations, focusing on building capacity to make evidence informed decisions. Examples of some of the different interventions are incorporating processes to improve evidence use by Cabinet Ministers, using innovative online training methods to improve the skills of individuals to make evidence informed decisions, establishing open policy dialogues between government officials, civil society and the research sector to promote the use of evidence in decision making and developing the African Evidence Network – where policy makers and practitioners can discuss and share lessons on evidence use. Each project has a primary provider, who oversees the management of that work. BCURE is being delivered with a specific focus on building the capacity of locally based partner organisations in the countries where projects are operating, as essential for the sustainability of the programme.
The International Panel on Social Progress (IPSP) is a global initiative that brings together a large group of scholars brought together to compile evidence across disciplines to rethink ideas of a just society. They recognised the interconnected forces of: weakening traditional nation states; technological change; profound and unequal transformations in health and education outcomes; and contestations between the religious and secular. IPSP have produced this report aimed at social actors, movements, organisations, politicians and decision-makers, to provide them with the best evidence on questions that bear on social change. The report has 22 chapters covering a comprehensive range of areas that have an important bearing on society now and into the future. It is the first comprehensive synthesis of social sciences knowledge about key issues facing humankind today. This first draft is available for public consultation and comment and IPSP invite comments from all concerned citizens and organisations. There is a web based platform for comments and inputs.
Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasised the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualising a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005–2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. The challenges faced by LMICs include rapid urbanisation, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs).
The African Institute for Development Policy AFIDEP conducted a training workshop for more than 15 parliament staff from 10 African countries on evidence-informed decision-making (EIDM) on June 27-28, 2016 in Munyonyo, Uganda. The parliamentary staff included researchers and clerks who support parliamentary health committees. These staff provide committees with briefings on issues to inform their debates and decisions, and therefore play a crucial role in the ecosystem of evidence use in parliament. The workshop equipped the parliamentary researchers and clerks with knowledge and skills in: the critical place of evidence in the legislature; knowledge of where and how to effectively search for evidence, assess its quality, and synthesise and package it appropriately for use by MPs.