Monitoring equity and research policy

Data-driven quality improvement in low-and middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia
Wagenaar B; Hirschhorn L; Henley C; et al: BMC Health Services Research 17 (Suppl 3), doi:10.1186/s12913-017-2661-x, 2017

This paper describes the similar and divergent approaches to increase data-driven quality of care improvements and implementation challenge and opportunities encountered in these three countries. Eight semi-structured in-depth interviews were administered to program staff working in each country. Project successes ranged from over 450 collaborative action-plans developed, implemented, and evaluated in Mozambique, to an increase from 80% of basic clinical protocols followed in intervention facilities in rural Zambia, and a shift from a lack of awareness of health data among health system staff to collaborative ownership of data and using data to drive change in Rwanda. Based on common successes across the country experiences, the authors recommend future data-driven quality improvement interventions begin with data quality assessments to promote that rapid health system improvement is possible, ensure confidence in available data, serve as the first step in data-driven targeted improvements, and improve staff data analysis and visualization skills. They pose that explicit Ministry of Health collaborative engagement can ensure performance review is collaborative and internally-driven rather than viewed as an external “audit.”

Research capacity building integrated into PHIT projects: leveraging research and research funding to build national capacity
Hedt-Gauthier B L; Chilengi R; Jackson E; et al,: BMC Health Services Research 17 (Suppl 3) doi: 10.1186/s12913-017-2657-6, 2017

This paper analyses the implementation of health systems strengthening initiatives inclusive of research capacity building. During Population Health Implementation and Training, specific research capacity building activities varied across countries. However, all five countries used African Health Initiative funding to improve research administrative support and infrastructure, implement research training and support mentorship activities and research dissemination. Funders were recommended to provide adequate and flexible funding for research capacity building activities and for institutions to offer a spectrum of research capacity building activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor research capacity building activities.

A comparable yardstick: adjusting for education bias in South African health system responsiveness ratings
Rossouw L; Smith A: Health Policy and Planning 32(Suppl3) iii67–iii74, 2017

Health-system responsiveness (HSR) measures the experience of health-system users in terms of the non-clinical aspects of the health system. The authors explore the association between education levels and reporting behaviour in terms of HSR in South Africa using data from the World Health Organization Study on Global Ageing and Adult Health for South Africa (WHO SAGE) conducted in 2007 and 2008. The authors consider the reporting behaviour of 1499 adults aged 50 and older in terms of the reported HSR for their most recent outpatient provider visit during the preceding 12 months. More specifically, they explore whether there are systematic biases in reporting behaviour by education levels and other socio-economic covariates through the use of data from anchoring vignettes. Large differences were found in HSR ratings between the lowest and highest education groups after adjusting for reporting bias using the anchoring vignettes. This finding holds across all seven HSR domains captured in the WHO SAGE dataset. In the most extreme case, individuals with no education are likely to underreport poor HSR by between 2.6 and 9.4% percentage points compared with individuals with secondary schooling or higher. It is proposed that policy-makers take cognizance of potential reporting biases in HSR ratings and make the necessary adjustments to obtain data that are as true and accurate as possible. The need for this is seen to be especially acute in a country such as South Africa with large socio-economic inequalities and disparities in access to healthcare.

Assessing the health workforce implications of health policy and programming: how a review of grey literature informed the development of a new impact assessment tool
Nove A; Cometto G; Campbell J: Human Resources for Health 15(79), doi:, 2017

In their adoption of WHA resolution 69.19, World Health Organization Member States requested all bilateral and multilateral initiatives to conduct impact assessments of their human resources for health funding. No standard tools exist for assessing the impact of global health initiatives on the health workforce, but tools exist from other fields. This paper describes how a review of grey literature informed the development of a draft health workforce impact assessment tool and how to introduce the tool. A search of grey literature yielded 72 examples of impact assessment tools and guidance from a wide variety of fields including gender, health and human rights. These examples were reviewed, and information relevant to the development of a health workforce impact assessment was extracted from them using an inductive process. A number of good practice principles were identified from the review. These informed the development of a draft health workforce impact assessment tool, based on an established health labour market framework. The tool consists of a relatively short and focused screening module to be applied to all relevant initiatives, followed by a more in-depth assessment to be applied only to initiatives for which the screening module indicates that significant implications for HRH are anticipated. It thus aims to strike a balance between maximizing rigour and minimising administrative burden. The authors propose that the new tool will help to ensure that health workforce implications are incorporated into global health decision-making processes from the outset and to enhance positive human resources for health impacts and avoid, minimise or offset negative impacts.

The change-makers of West Africa
Godt S; Mhatre S; Schryer-Roy AM: Health Research Policy and Systems 15 (52), doi:, 2017

This journal supplement is a contribution to changing practice by putting the perspectives, experiences and knowledge of West Africans on the table. It presents findings from a series of research and capacity development projects in West Africa funded by the International Development Research Centre's Maternal and Child Health programme. The evidence presented centres around two key themes. First, the theme that context matters. The evidence shows how context can change the shape of externally imposed interventions or policies resulting in unintended outcomes. At the same time, it highlights evidence showing how innovative local actors are developing their own approaches, usually low-cost and embedded in the context, to bring about change. The collection of articles discusses the critical need to overcome the existing fragmentation of expertise, knowledge and actors, and to build strong working relationships amongst all actors so they can effectively work together to identify priority issues that can realistically be addressed given the available windows of opportunity. Vibrant West African-led collaborations amongst researchers, decision-makers and civil society, which are effectively supported by national, regional and global funding, need to foster, strengthen and use locally-generated evidence to ensure that efforts to strengthen health systems and improve regional health outcomes are successful. The authors argue that the solutions are not to be found in the ‘travelling models’ of standardised interventions.

Using health-facility data to assess subnational coverage of maternal and child health indicators, Kenya
Maina I; Wanjala P; Soti D; et al: Bulletin World Health Organisation 95(10) 683–694, 2017

This study seeks to develop a systematic approach to obtain the best possible national and subnational statistics for maternal and child health coverage indicators from routine health-facility data. The approach aimed to obtain improved numerators and denominators for calculating coverage at the subnational level from health-facility data. This involved assessing data quality and determining adjustment factors for incomplete reporting by facilities, then estimating local target populations based on interventions with near-universal coverage. The authors applied the method to Kenya at the county level, where routine electronic reporting by facilities is in place via the district health information software system. Reporting completeness for facility data were well above 80% in all 47 counties and the consistency of data over time was good. Coverage of the first dose of pentavalent vaccine, adjusted for facility reporting completeness, was used to obtain estimates of the county target populations for maternal and child health indicators. The country and national statistics for the four-year period 2012/13 to 2015/16 showed good consistency with results of the 2014 Kenya demographic and health survey. The results indicated a stagnation of immunization coverage in almost all counties, a rapid increase of facility-based deliveries and caesarean sections and limited progress in antenatal care coverage. While surveys will continue to be necessary to provide population-based data, web-based information systems for health facility reporting provide an opportunity for more frequent, local monitoring of progress, in maternal and child health.

Equity in international health research collaborations in Africa: Perceptions and expectations of African researchers
Munung N; Mayosi B; de Vries J: PLOS One 12(10), doi:, 2017

In this paper, the authors report on a qualitative interviewing study in which they involved 17 genomics researchers in Africa. The authors describe their perceptions and expectations of international genomics research and biobanking initiatives in Africa. All interviewees were of the view that externally funded genomics research and biobanking initiatives have played a critical role in building capacity for genomics research and biobanking in Africa and in providing an opportunity for researchers in Africa to collaborate and network with other researchers. Whilst the opportunity to collaborate was seen as a benefit, some interviewees stressed the need for these collaborations to have mutual benefits for all partners, including their collaborators in high income countries. They voiced two major concerns of being part of these collaborative initiatives: the possibility of exploitation of African researchers and the non-sustainability of research capacity building efforts. They thus recommended genuine efforts to create transparent and equitable international health research partnerships through,: having rules of engagement, enabling African researchers to contribute to the design and conduct of international health projects in Africa, and mutual and respectful exchange of experience and capacity between research collaborators. These were identified as hallmarks to equitable international health research collaborations in Africa.

Where does research fit in a post-truth world?
Guth J: Special Programme for Research and Training in Tropical Diseases (TDR), UNICEF, UNDP, World Bank, WHO, November 2017

A large study in 3 west African countries examined how to increase the numbers of pregnant women receiving malaria preventive treatment, and getting diagnosed and treated. There were many health systems issues that were identified that created barriers, such as lack of transportation or well-trained healthcare providers at the regional health facilities. Video interviews were conducted with people involved in the project and shared with policy-makers, healthcare providers and community members. The use of video helped to provide local context – of settings and people. It strengthened the understanding and credibility of the associated research results and showed strong collaboration between the research team and community, a proven facilitator in research uptake. The video was reported to have had a profound when it was shared and led to strong statements of commitments to make changes based on this study. The author suggests that it is necessary to use every tool possible to show the utility of science and how it improves people’s lives in ways that they can see and feel.

Research priority setting for integrated early child development and violence prevention (ECD+) in low and middle income countries: An expert opinion exercise
Tomlinson M; Jordans M; MacMillan H; et al.: Jo Child Abuse Negligence 72,131-139, 2017

Reducing children's exposure to harmful events and violence is essential for early childhood development. The authors used the Child Health and Nutrition Initiative method for the setting of research priorities in integrated early childhood development and violence prevention programs. An expert group was identified and invited to systematically list and score research questions. A total of 186 stakeholders were asked to contribute five research questions each, and contributions were received from 81 respondents. These were subsequently evaluated using a set of five criteria: answerability; effectiveness; feasibility and/or affordability; applicability and impact; and equity. Of the 400 questions generated, a composite group of 50 were scored by 55 respondents. The highest scoring research questions related to the training of community health workers to deliver early childhood development and violence prevention programs interventions effectively and whether these interventions could be integrated within existing delivery platforms such as HIV, nutrition or mental health platforms. The findings from this research priority setting exercise is argued to potentially help guide funders and others towards funding priorities for important future research related to early childhood development and violence prevention.

The SWPER index for women’s empowerment in Africa: development and validation of an index based on survey data
Ewerling F; Lynch J; Victora C; van Eerdewijk A; Tyszler M; Barros A: Lancet Global Health 5(9) e916-e923, 2017

The Sustainable Development Goals strongly focus on equity. Goal 5 explicitly aims to empower all women and girls, reinforcing the need to have a reliable indicator to track progress. This study developed a novel women’s empowerment indicator from widely available data sources, broadening opportunities for monitoring and research on women’s empowerment. The authors used Demographic and Health Survey data from 34 African countries, targeting currently partnered women. They identified items related to women’s empowerment present in most surveys, and used principal component analysis to extract the components. The authors carried out a convergent validation process using coverage of three health interventions as outcomes; and an external validation process by analysing correlations with the Gender Development Index. Findings 15 items related to women’s empowerment were selected. They retained three components (50% of total variation) which, after rotation, were identified as three dimensions of empowerment: attitude to violence, social independence, and decision making. All dimensions had moderate to high correlation with the Gender Development Index. Social independence was associated with higher coverage of maternal and child interventions; attitude to violence and decision making were more consistently associated with the use of modern contraception. Interpretation The index, named Survey-based Women’s emPowERment index, is argued to have the potential to widen the research on women’s empowerment and to give a better estimate of its effect on health interventions and outcomes. It allows within-country and between-country comparison, as well as time trend analysis, which no other survey based index provides.