Monitoring equity and research policy

Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia?
Blanchard A, Jacobs C, Musukuma M, et al: International Journal for Equity in Health 22:109, 1-14, 2023

This study aimed to understand how much more demographic health surveys can reveal about Zambia’s progress in reducing inequalities in under-five mortality rates and reproductive, maternal, newborn and child health intervention coverage, using four nationally-representative Zambia Demographic Health Surveys, comparing wealth quintiles, urban‐rural residence and provinces, and further using multi-tier measures including wealth deciles and double disaggregation between wealth and region. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing composite coverage indices by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and composite coverage indices between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and composite coverage indices. Still, inequalities remained higher in provinces with worse outcomes. Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples.

New global indicator for workers’ health: mortality rate from diseases attributable to selected occupational risk factors
Pega F, Al-Emam R, Cao B, et al: Bulletin of the World Health Organisation 101:6, 418–430Q, 2023

Through sustainable development goals 3 and 8 and other policies, countries have committed to protect and promote workers’ health by reducing the work-related burden of disease. However, while injuries are well monitored, the World Health Organization and the International Labour Organization estimate that only 363 283 (19%) of 1 879 890 work-related deaths globally in 2016 were due to injuries, whereas 1 516 607 (81%) deaths were due to diseases. To address this gap, the authors present a new global indicator: mortality rate from diseases attributable to selected occupational risk factors, by disease, risk factor, sex and age group. The authors outline the policy rationale of the indicator, describe its data sources and methods of calculation, and report and analyse the official indicator for 183 countries. They also provide examples of the use of the indicator in national workers’ health monitoring systems and highlight the indicator’s strengths and limitations.

COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key lessons
Fawole O, Bello S, Adebowale A, et al: BMC Public Health 23:835;1-15, 2023

The four countries in this mixed-methods observational and desk review study were selected based on their variability in COVID-19 response and representation of Francophone and Anglophone countries. The research documented best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, and these learnings were synthesized across the countries. As the pandemic progressed, the health systems moved from aggressive testing and contact tracing to detect virus and triage individual contacts into quarantine and confirmed cases, isolation and clinical care. Surveillance, including case definitions, changed from contact tracing of all contacts of confirmed cases to only symptomatic contacts and travellers. All countries reported inadequate staffing, staff capacity gaps and lack of full integration of data sources, and improved surveillance capacity by training health workers and increasing resources for laboratories, but the disease burden was still under-detected, due to limited decentralization of surveillance at the subnational level and gaps in genomic and post-mortem surveillance, community level sero-prevalence studies, and in digital technologies to provide more timely and accurate surveillance data. The authors call for investments to enhance surveillance approaches and systems including decentralizing surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, investing in health worker capacity, ensuring data quality and availability and improving ability to transmit surveillance data between and across multiple levels of the health care system.

Towards a bottom-up approach for localising SDGS in African cities: findings from Cairo and Dar es Salaam
Nagati O, Gad H, El-Didi A, et al: Africa Development XLVIII:1;79-111, 2023

The authors applied a localisation methodology to analyse the current status of the implementation and monitoring of Sustainable Development Goals (SDGs) 6 and 11.2 in Cairo and Dar es Salaam. It uses comparative, top-down and grounded bottom-up analyses to identify gaps in the existing SDG framework and ultimately proposes a set of evaluation criteria to replace the global indicators with new localised and quantifiable indicators in the two cities. In doing so, it responds to prevalent critiques of SDGs specific to their application in the global South, including difficulties in measuring and monitoring urban conditions, misrepresentation due to the reduction of complex local conditions to abstracted data, and the inadequate capacity of the agenda to consider and assess informal activity. The proposed revisions to targets and indicators for SDG 6.1, 6.2 and 6.b, and SDG 11.2, were discussed with community organisers and residents to bolster their validity, and to negotiate better sustainable-development paradigms policy-makers.

Mapping urban physical distancing constraints, sub-Saharan Africa: a case study from Kenya
Chamberlain HR, Macharia PM, Tatem AJ: Bull World Health Organ 2022;100(9):562–569

With the onset of the coronavirus disease 2019 (COVID-19) pandemic, public health measures such as physical distancing were recommended to reduce transmission of the virus causing the disease. However, the same approach in all areas, regardless of context, may lead to measures being of limited effectiveness and having unforeseen negative consequences, such as loss of livelihoods and food insecurity. Focusing on sub-Saharan Africa, the authors outline and discuss challenges that are faced by residents of urban informal settlements in the ongoing COVID-19 pandemic. The authors describe how new geospatial data sets can be integrated to provide more detailed information about local constraints on physical distancing and can inform planning of alternative ways to reduce transmission of COVID-19 between people. A case study of Nairobi County, Kenya, is included with mapped outputs which illustrate the intra-urban variation in the feasibility of physical distancing and the expected difficulty for residents of many informal settlement areas. These examples demonstrate the potential of new geospatial data sets to provide insights and support to policy-making for public health measures, including COVID-19.

Saying ‘no’ in science isn’t enough
Babcock L; Peyser B; Vesterlund L; et al: Nature, November 2022

In August 2022, a group of female scholars wrote ‘Why four scientists spent a year saying no’: an article about what they had gained by saying no to 100 work-related requests over the course of year. That led the authors, four female professors, to form the No Club. Over the past decade, the authors have researched work that doesn’t help to advance careers — an attempt to understand why they, along with many others, were doing so much of it. They gave this work a name: non-promotable tasks (NPTs). Studies show that women, regardless of occupation, take on the bulk of NPTs. So, what can organizations do? The authors argue that women are more likely than men to volunteer for an NPT, so asking for volunteers exacerbates the inequity in allocation. Everyone in organizations should be enabled to understand which tasks will move their careers forward (the promotable work) and which ones won’t, and tasks defined as promotable or non-promotable. Knowing where to focus time is argued to help both employees and the organization. If tasks are assigned strategically to take advantage of specialized skill sets, given that an NPT for one position might be promotable for someone at a lower level, the authors propose that tasks be allocated to create equitable portfolios of work and rewards provided for some NPTs.

An update on Wellcome’s anti-racism programme
Farrar J: Wellcome, August 2022

In this statement the Director of Wellcome Jeremy Farrar reports that two years ago, Wellcome made a commitment to developing anti-racist principles and an anti-racist programme, and to an external evaluation of progress at the institution. An evaluation has now been reported. While it found some progress, such as improvements in the racial diversity of the workforce and some positive behavioural and practice shifts, it reached a clear conclusion that Wellcome continues to fall short of the commitment to anti-racism, both as a funder and as an employer. Farrar accepted and apologised for this and announced two measures to addressing inequity in Wellcome research funding in 2023, including a set of positive action principles applied to funding decision-making processes and the establishment of a dedicated stream of funding available exclusively to researchers who are Black and people of colour, targeted at the career stages where this will have the greatest benefits for diversity.

Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda – lessons from the PERFORM2Scale consortium
Kok M; Bulthuis S; Dieleman M; et al: BMC Health Services Research 22:1001, 2022

This consortium did work to understand the benefits and challenges of using a theory of change (ToC) -based approach for monitoring and evaluating the scale-up of health system strengthening interventions. The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations, capturing the reflections around an initiative for strengthening district health management teams, to improve health workforce performance and service delivery at scale. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did happen and strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the experience the authors suggest that ToC-based approaches are useful, should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.

Developing context relevant and inclusive course outlines and reading lists
Teaching Health Economics Special Interest Group: Webinar online, Online: June 9, 2022

The Teaching Health Economics Special Interest Group (THE SIG) has organized a series of virtual workshops during 2022. This workshop provides an overview of curriculum development and writing powerful learning outcomes for health economics courses and the importance of identifying topics and readings that are most relevant to the local context. The workshop considers how to ensure courses are inclusive and contain diverse perspectives, and information shared on how academics in low- and middle-income countries can directly access a wide range of publications to use in their teaching programs at no (or low) cost.

‘Working relationships’ across difference - a realist review of community engagement with malaria research
Vincent R; Adhikari B; Duddy C, et al: Wellcome Open Research, 7(13),, 2022

The authors conducted a realist review to understand how and why community engagement with health research contributes to the pattern of outcomes observed, with a focus on malaria research. Community engagement was found to rely on the development of provisional ‘working relationships’ across differences, primarily of wealth, power and culture that bring tangible research related benefits. Contextual factors that affect these working relationships were reported to include the research organisation commitment to and resources for engagement, while a prevailing ‘dominant health research paradigm context’ was reported to undermine working relationships, as did differences of wealth and power between research centres and local populations and health systems; histories of colonialism and vertical health interventions; and external funding and control of health research. Accommodation of such ethically problematic characteristics in the dominant health research paradigm can undermine community engagement and reproduce this paradigm rather than challenge it with a different logic of collaborative partnership.