Monitoring equity and research policy

Systems science for universal health coverage
Evans T; Kieny M: Bulletin of the World Health Organisation 95(7) 2017

It is 20 years since an international consultation in Lejondal, Sweden, highlighted the need for more and better research “to understand and improve how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes.” One outcome was the creation of the Alliance for Health Policy and Systems Research. There have since been several important milestones on the path towards more and better health systems research. Such encouraging developments need to be carefully balanced against areas where progress has not met expectations. The development of national capacity for financing and institutional leadership of health policy and systems research has been slow. The authors ask: how can health policy and systems research seize this favourable context and contribute more effectively to universal health coverage, greater health security, improved value in health and effective engagement of citizens? First, they propose that there is a need a comprehensive review of the progress that has been made and the progress that might be anticipated in the future. Second, there is a need to accelerate the development of capacity and opportunity for health policy and systems research in low- and middle-income countries. Lastly, they suggest that there is a need for a revitalised approach to stewardship that reflects the pluralistic reality of contemporary health systems and prioritises health policy and systems research across all countries.

The Role and Status of National Research and Education Networks in Africa
Foley M: World Bank Group, SABER-ICT Technical Paper Series, 2016

This report aims to provide guidance to governments, institutions, and development partners on how to approach the provision of advanced information and communication technology (ICT) services to the higher education and research community in Africa. It coincides with a transformation in the telecom infrastructure and services on the continent as fibre optic connectivity, both undersea and on land, is expanding at a rapid pace. The report suggests that the organisation of ICT services and connectivity is best provided by a dedicated organisation called the National Research and Education Network (NREN) based on international best practice and the current plans of the stakeholders in the region. The nature of NRENs and the case for their establishment is outlined and the story of their development in Africa to their current status is described. The report also provides guidance on how to establish or strengthen an NREN, with recommendations to the government, the private sector, institutions, development partners.

World health statistics 2017: monitoring health for the SDGs, Sustainable Development Goals
World Health Organization: WHO, Geneva, 2017

The World Health Statistics series is World Health Organisation’s annual compilation of health statistics for its 194 Member States. World Health Statistics 2017 focuses on the health and health-related Sustainable Development Goals (SDGs) and associated targets by bringing together data on a wide range of relevant SDG indicators. World Health Statistics 2017 is organised into three parts. In Part 1, six lines of action are described which WHO is now promoting to help build better systems for health and to achieve the health and health-related SDGs. In Part 2, the status of selected health-related SDG indicators is summarised, at both global and regional level, based on data available as of early 2017. Part 3 then presents a selection of stories that highlight recent successful efforts by countries to improve and protect the health of their populations through one or more of the six lines of action. Annexes A and B present country level estimates for selected health-related SDG indicators. As in previous years, World Health Statistics 2017 has been compiled primarily using publications and databases produced and maintained by WHO or United Nations groups of which WHO is a member, such as the United Nations Inter-agency Group for Child Mortality Estimation.

Quality of care: measuring a neglected driver of improved health
Akachi Y; Kruk M: Bulletin of the World Health Organisation 95(6), 389-480, 2017

The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is argued to be inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. The authors propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalise civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.

South Africa’s vital statistics are currently not suitable for monitoring progress towards injury and violence Sustainable Development Goals
Prinsloo M; Bradshaw D; Joubert J; Matzopoulos R; Groenewald P: South African Medical Journal 107(6), 470-471, 2017

Two of the most important targets to achieving the United Nation’s Sustainable Development Goals (SDGs) for reducing violence and other injuries are Target 3.6: to ‘halve the number of global deaths and injuries from road traffic accidents’ by 2020; and Target 16.1: the significant reduction of ‘all forms of violence and related death rates everywhere’. Police statistics on homicide, and transport deaths from the Road Traffic Management Corporation, are considered to be under-reported and are not a reliable source for monitoring SDGs. In South Africa (SA), vital statistics data are the only routine source that captures unnatural and natural deaths through death registration. Since the early 1990s, focused initiatives have identified and addressed deficiencies in the completeness of death registration and recent estimates indicate that completeness for persons aged ≥2 years is >90%. However, there are still concerns about the quality of data relating to the cause of death, i.e. under- reporting of HIV/AIDS deaths owing to misclassification to other causes, a large proportion of deaths with ill-defined causes, and the validity of single-cause data. The misclassification of injury deaths is another major limitation. The Inquest Act of 1959 precludes forensic pathologists from reporting the manner of death, i.e. whether it is due to homicide, suicide, transport or other unintentional injuries, on the basis that it may prejudice the findings of the inquest. Homicides are therefore grossly under-represented in official vital statistics. The misclassification of injury deaths was clearly demonstrated in a nationally representative study of injury deaths presenting to state forensic mortuaries in 2009. The absence of information on the manner of injury death in the official statistics needs to be addressed urgently. A review and possible amendment of the Inquest Act would possibly take years. The authors recommend that the death notification form be amended in line with the updated World Health Organisation’s recommendation, to include a stand-alone field for information about the manner of injury death for unnatural causes. Forensic pathologists when uncertain can include a proviso stating that such information is for statistical purposes only. This matter is currently being discussed with relevant stakeholders.

Participatory evaluation of delivery of animal health care services by community animal health workers in Karamoja region of Uganda
Bugeza J; Kankya C; Muleme J; Akandinda A; Sserugga J; Nantima N; Okori E; Odoch T: PLOS One, doi:, 2017

An evaluation exercise was carried out to assess the performance of Community Animal Health Workers (CAHWs) in the delivery of animal health care services in Karamoja region, identify capacity gaps and recommend remedial measures. Participatory methods were used to design data collection tools. Questionnaires were administered to 204 CAHWs, 215 farmers and 7 District Veterinary Officers (DVOs) to collect quantitative data. Seven DVOs and 1 Non Government Organisation (NGO) representative were interviewed as key informants and one focus group discussion was conducted with a farmer group in Nakapiripirit to collect qualitative data. Key messages from interviews and the focus group discussion were recorded in a notebook and reported verbatim. 70% of the farmers revealed that CAHWs are the most readily available animal health care service providers in their respective villages. CAHWs were instrumental in treatment of sick animals, disease surveillance, control of external parasites, animal production, vaccination, reporting, animal identification, and performing minor surgeries. Regarding their overall performance 88.8% of the farmers said they were impressed. The main challenges faced by the CAHWs were inadequate facilitation, lack of tools and equipment, unwillingness of government to integrate them into the formal extension system, poor information flow, limited technical capacity to diagnose diseases, unwillingness of farmers to pay for services and sustainability issues. CAHWs remain the main source of animal health care services in Karamoja region and their services are largely satisfactory. The technical deficits identified are argued to require continuous capacity building programs, close supervision and technical backstopping and strategic deployment of paraprofessionals that are formally recognised by the traditional civil service.

“Guilty until proven innocent”: the contested use of maternal mortality indicators in global health
Storeng K; Béhague D: Critical Public Health 27(2), doi: , 2016

The maternal mortality ratio (MMR) has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, ‘guilty until proven innocent’. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. The authors show, however, that measurement experts’ work has also been driven by the need to secure political priority for safe motherhood and by donors’ need to justify and monitor the results of investment flows. They explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. the authors analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented funders who have introduced new forms of administrative oversight and accountability that depend on indicators.

Research Fairness Initiative (RFI) - making research partnerships work for everyone
Council on Health Research for Development: COHRED, Geneva, 2017

Partnerships are essential to deliver research and innovation for global health and partner development. Sustainable Development Goal 17 is all about this. Yet, COHRED argues that there is no framework, no benchmark, no standard of best practice on which to model governmental, corporate, non-profit, or academic collaborations, particularly not for international collaborative research and innovation involving low- and middle-income countries. This is where the Research Fairness Initiative intends to make a difference: to create a reporting system that encourages governments, businesses, organisations and funders to describe how they take measures to create trusting, lasting, transparent and effective partnerships in research and innovation. COHRED prioritises its application in global health because there are many urgent health-related issues, but it can be applied in any other setting also.

World Report on Health Policy and Systems Research
Alliance for Health Policy and Systems Research, World Health Organisation: WHO, Geneva

The first-ever, World Report on Health Policy and Systems Research, was launched recently by the Alliance for Health Policy and Systems Research. The report provides practical recommendations on how to reorient health research to more effectively address public health challenges on a national and global level. It describes the evolution of the field and provides figures on the number of publications produced, funding trends and institutional capacity in LMICs to conduct health policy and systems research. Low- and middle-income countries now have guidance for not only being users of research, but also producers. The report describes the state of the HPSR field in 1996, identifying three broad challenges to its progress that were clearly visible at that time. In the mid-1990s there were three principal challenges to the growth of the field of HPSR: (i) the fragmentation and lack of a single agreed definition of the field; (ii) the ongoing dominance of biomedical and clinical research; and (iii) a lack of demand for HPSR. Cross-cutting all these challenges was the problem of relatively limited capacity to undertake high-quality health policy and systems research. Subsequent sections then analyse how these challenges have been addressed over the intervening 20 years, resulting in greater recognition of and investment in HPSR. The report raises challenges to be addressed, including confronting the dominance of biomedical and clinical research as the primary channel for health research investments through a sustained advocacy campaign; seeking to clarify the scope and methods of the field; and finally nurturing closer collaboration with research users, in particular by capitalizing on the growth of interest in evidence-informed policy. It also collects together for the first time figures on various significant aspects of health policy and systems research: growth in the number of publications, collaboration between researchers in different parts of the world, funding trends and institutional capacities in low- and middle-income countries.

Power and glory: applying participatory action research in public health
Baum F: Gaceta Sanitaria 30(6) 405–407, 2016

Participatory action research seeks to understand and improve the world by changing it. At its heart is collective, self-reflective enquiry that researchers and participant’s undertake so they can understand and improve upon the practices in which they participate and the situation in which they find themselves. This article describes that ways PAR has been applied to a wide range of issues in public health, including in community asset mapping, participatory evaluation of public health programs, community monitoring of health service quality, research documenting and advocating to remove threats to health including poor water and sanitation and environmental pollution and participatory health policy research. A systematic review indicated most health service PAR has been conducted in low and middle income countries. In high income countries it is often used as a method to empower groups who are excluded and hold little power including Roma peoples in Europe and Indigenous peoples in Canada and Australia. PAR is often not reported in the academic literature despite its application in local projects. The most important aspect of PAR is that it relies on a cycle of reflection, planning, acting, further observing and reflection, then new plans and action. This reflexivity is central and is deeply relational in that the researchers and the other actors (community members or service or policy players) are engaging together in these processes. The author observes that PAR holds great, and as yet largely unrealised promise, to create greater mobilisation and community interest and action on health inequities and action on the social determinants of health.