Monitoring equity and research policy

Progress in promoting data sharing in public health emergencies
Littler K; Boon W; Carson G et al.: Bulletin of the World Health Organisation 95(4) 2017

In February 2016, the World Health Organisation (WHO) declared the Zika virus-related cluster of microcephaly cases and other neurological disorders reported in Brazil, a Public Health Emergency of International Concern (PHEIC). Following the declaration, over 30 global health bodies issued a joint statement committing to data sharing to ensure that the global response to the Zika virus and future emergencies, could be informed by the best and most current evidence. The statement represented a concerted effort by those involved to address past failures of timely access to relevant data. It also highlighted the lack of a clear path to implementation for data sharing during public health emergencies. In March 2016, the Global Research Collaboration for Infectious Disease Preparedness established a data-sharing working group which has been working in coalition with other stakeholders including WHO, scientists, nongovernmental organisations, journals and other agencies. This group is working to identify barriers to data sharing in public health emergencies that should be addressed to better prepare for any future epidemic. The experiences from the 2013–2016 Ebola virus disease outbreak and the 2015 Zika virus outbreak demonstrated the importance of research in public health emergencies and the difficulties associated with sharing research findings rapidly and outside of conventional scientific publications. The WHO consensus and policy statements called for a paradigm shift in information sharing in public health emergencies and described the particularities to consider in dealing with different data types. Despite these efforts, rapid data sharing during public health emergencies remains challenging for various reasons. First, there are limited incentives for researchers and other people responding to the emergency to share data. Second, there is a lack of appropriate infrastructure for data sharing such as repositories and information technology platforms. Such rapid data sharing requires a clear governance structure that ensures a balance between privacy and access, as well as adheres to national and international ethical and legal requirements. The GloPID-R working group has developed, and requests comment on, a set of principles to underpin future implementation of timely data sharing. These new principles draw on others, such as the FAIR Guiding Principles for scientific data management and stewardship, and are intended to provide an initial framework for discussion. The collective work is intended to support WHO’s Research and Development Blueprint and include other stakeholders, such as the Global Outbreak Alert and Response Network and the Coalition for Epidemic Preparedness. Effective data sharing requires flexibility by all stakeholders to adapt to unforeseen events and challenges. A data-sharing system needs to allow collaboration between stakeholders in the absence of pre-existing relationships and all collaborators need to adhere to fundamental ethical principles of data use. Above all, it must ensure that people in all affected countries benefit from timely access to evidence-based interventions in emergencies.

Global Observatory on Health R&D
WHO: WHO Geneva online resource, 2017

The Global Observatory on Health R&D (hereafter called ‘the Observatory’) is a global-level initiative that aims to help identify health R&D priorities based on public health needs, by: consolidating, monitoring and analysing relevant information on the health R&D needs of developing countries; building on existing data collection mechanisms; and supporting coordinated actions on health R&D. Investments in health R&D are still insufficiently aligned with global public health demands and needs. As little as 1% of all funding for health R&D is allocated to diseases such as malaria and tuberculosis (diseases that are predominantly incident in developing countries), despite these diseases accounting for more than 12.5% of the global burden of disease. Governments, policy-makers, funders and researchers need an accurate picture of the current situation so as to spot R&D gaps and ensure that funds and resources are used in the best possible way. The primary scope of the Observatory as outlined by Member States in World Health Assembly resolution WHA69.23 is: type II and type III diseases (i.e. diseases incident in both rich and poor countries, especially the latter; the specific R&D needs of developing countries in relation to type I diseases; potential areas where market failures exist and antimicrobial resistance and on emerging infectious diseases likely to cause major epidemics.

Negotiating better contracts in collaborative research partnerships
Council on Health Research for Development (COHRED): Geneva, 2017

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.

Urban Health Research in Africa: Themes and Priority Research Questions
Oni T; Smit W; Matzopoulos R; Adams J et al.: Initiative for Cities and Health (RICHE) members: Journal of Urban Health 93(4) 722-730, 2016

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 system learning sites: understanding health systems through research collaboration and engagement
Resilient and Responsive Health Systems (RESYST), 2016

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?

New WHO data portal to help track progress towards universal health coverage
WHO: Geneva, December 2016

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.

The feasibility of measuring and monitoring social determinants of health and the relevance for policy and programme – a qualitative assessment of four countries
Blas E; Ataguba J; Huda TM; Bao GK; Rasella D; Gerecke MR: Global Health Action 9 (1), 2017

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.

How can health systems research reach the worst-off? A conceptual exploration
Pratt B; Hyder A: BMC Health Services Research 16(1868), 2016

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.

Pearls of wisdom for the young health systems researchers
Khalid F: International Health Policies, 2017

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.”

Scoping review: national monitoring frameworks for social determinants of health and health equity
Pedraza L; Pamponet M; Walker R; Costa F; Rasella D: Global Health Action 9(10.3402), 2016

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.