Fair Research Contracting equips research partners with key resources on how to build sustainable, equitable global research partnerships. The rise in international research partnerships means that developing countries need to be better positioned to deal with complexities in collaborative research contracting. COHRED argues that better contract negotiation expertise in LMIC institutions will help improve the distribution of benefits of collaborative research, such as overhead costs, data ownership, institutional capacity in research management, technology transfer, and intellectual property rights. With this in mind, COHRED has developed guidance aimed at optimising research institution building through better contracts and contracting in research partnerships. The guidance highlights the key issues for consideration when entering into formalised research partnerships, and provides tools and resources for negotiating fairer research contracts.
Monitoring equity and research policy
In Africa, urbanisation and urban growth are dramatically restructuring the nature of cities. The growing majority of urban dwellers now live in informal conditions that, without access to basic services or public amenities, expose residents to greater health risk, and health-care systems are unable to provide affordable or comprehensive cover. The differential exposure to these urban conditions is compounded by social and economic vulnerability, resulting in health inequities. Yet despite pressing needs driven by Africa’s considerable and complex burden of disease and high levels of health inequity, urban health and urban health equity have not yet emerged as major research and policy priorities in Africa. This commentary presents a conceptual framework, using a public health approach, for interdisciplinary research aimed at contributing to the understanding and mitigation of urban health issues and challenges in Africa. It identifies downstream and upstream factors, based on published literature, associated with key determinants in each theme. It represents a collective effort by interdisciplinary academics from public health; anthropology; civil engineering; architecture, planning and geomatics; human biology; psychiatry and mental health; medicine; pathology; and paediatrics, from the Research Initiative for Cities and Health (RICHE), University of Cape Town, to generate African perspectives on urban health and urban health equity. The six focus areas identified as important include obesity and food insecurity, the urban context as a tool for health promotion, urban health governance and policy, community strengthening for healthy inclusive cities, health systems in an urbanising context and migration, urbanisation and health. The authors argue that a complex systems approach is required to investigate and improve understanding of health and well-being in a changing urban context with a view to developing sustainable and cost-effective interventions. This acknowledges the different dimensions of determinants that influence health and understands the need to address gaps in data and access to information from across these dimensions, and to engage all relevant stakeholders across sectors prioritise the interventions to improve health.
Health policy and systems research is centrally concerned with people, their relationships and the actions that they take towards strengthening health systems. To understand complex health systems, researchers must actively engage with system actors, ranging from health managers to service users, learning from their tacit knowledge and about their experience. In Kenya and South Africa, researchers have established learning sites specifically to support a wide range of research focused on health systems governance issues at the district level. Both countries have devolved government structures and county (Kenya) and provincial and district (South Africa) managers now play a pivotal role in the development, management and delivery of health services. Learning sites provide unusual opportunities to learn about the daily processes of decision-making that comprise health system governance, and to support managers in taking action to strengthen them. This brief covers: What is a learning site? How did learning sites emerge? What happens in a learning site? What is the value of learning sites for researchers and health managers? and what small-scale steps are being taken to strengthen the health system?
The World Health Organisation (WHO) has launched a new data portal to track progress towards universal health coverage (UHC) around the world. The portal shows where countries need to improve access to services, and where they need to improve information. The portal features the latest data on access to health services globally and in each of WHO’s 194 Member States, along with information about equity of access. In 2017 WHO will add data on the impact that paying for health services has on household finances. The portal shows that less than half of children with suspected pneumonia in low income countries are taken to an appropriate health provider. Of the estimated 10.4 million new cases of tuberculosis in 2015, 6.1 million were detected and officially notified in 2015, leaving a gap of 4.3 million. High blood pressure affects 1.13 billion people. Over half of the world's adults with high blood pressure in 2015 lived in Asia. Around 24% of men and 21% of women had uncontrolled blood pressure in 2015. About 44% of WHO’s member states report having less than 1 physician per 1000 population. The African Region suffers almost 25% of the global burden of disease but has only 3% of the world’s health workers.
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.
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.