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.”
Monitoring equity and research policy
This guide provides an overview of peer review and an assessment of the practice to date. It begins by discussing the main concepts related to peer reviewing of research papers before it outlines the peer review process generally, and specifically with relation to grant applications. It assesses the peer review process by addressing some of its shortcomings. For example, instances of malpractice and misconduct continue and, as reviewers themselves are fallible, peer review cannot provide a guarantee against the publication of bad research. So a number of published papers are retracted each year for a variety of reasons, and there is evidence that the number is rising. The core issues of transparency and subjectivity are discussed in the guide under the idea that peer review should foster fairness. However, financing the high costs of peer review mechanisms still proves problematic. On the positive side, major new opportunities in digital technology, such as the internet, have improved connectivity between stakeholders of the process.
Muhimbili National Hospital (MNH), a teaching and national referral hospital, is undergoing major reforms to improve the quality of health care. Researchers performed a retrospective descriptive study using a set of performance indicators for the surgical and laboratory services of MNH in years 2001 and 2002, to help monitor and evaluate the impact of reforms on the quality of health care during and after the reform process. In 2001, 23.5% of non-emergency operations were planned, while in 2002, 29% were postponed. The most common reasons for operation postponement were 'time-barred', interference by emergency operations, no show of patients and inoperable anaesthetic machines. Equipment problems and supply and staff shortages together accounted for one quarter of postponements. In the laboratory, a lack of equipment prevented some tests, but quality assurance was performed for most tests. Current surgical services at MNH were reported to be inadequate; operating theatres require modern, functioning equipment and adequate supplies of consumables to provide satisfactory care.
The 15 countries evaluated in this report card - including Angola, Democratic Republic of the Congo, Kenya, Tanzania and Uganda - account for nearly three-quarters of all pneumonia deaths worldwide. The card provides a total score for each country by evaluating data on seven key interventions identified by the Global Action Plan for the Prevention and Control of Pneumonia (GAPP), which indicated that up to two-thirds of child pneumonia deaths could be prevented if at least 90% of children had access to a few simple, effective pneumonia interventions. GAPP’s recommended 90% coverage on the interventions is based on the need to reach Millennium Development Goal targets for child survival by 2015. The interventions include prevention measures, protection measures and treatment. The card finds that country scores fall far short, ranging from 61 to 23% on these measures combined. While some pneumonia vaccines like measles and pertussis are already in widespread use, the card shows that new pneumonia vaccines against Hib and pneumococcal infections have not yet been adopted in all countries. With support from the GAVI Alliance, nearly all of these countries are expected to increase coverage of existing vaccines, as well as introduce Hib and pneumococcal vaccines, in the next five years.
With growing interest in methods to accelerate the development of drugs, vaccines and diagnostics for neglected diseases, product development partnerships (PDPs), non-profit research institutes and private sector groups have come together to conduct R&D in these areas. However, some argue that their efforts are disjointed and that funding flows inefficiently to individual research projects resulting in insufficient resources, funding volatility, poor resource allocation and duplicated, as well as unnecessary, efforts. In this paper, the authors evaluate several pooled funding mechanisms that have been proposed to address these problems: the Industry R&D Facilitation Fund (IRFF) originally proposed by the George Institute; the Fund for Research in Neglected Diseases (FRIND) proposed by Novartis; and the Product Development Partnership Financing Facility (PDP-FF) proposed by the International AIDS Vaccine Initiative (IAVI). These proposals are measured against two criteria: their capacity to raise additional money for neglected disease R&D and their capacity to improve the efficient allocation of those funds. The authors conclude that all three proposals had potential, but the challenge with deciding which proposal to implement is the lack of clarity and agreement on what exactly the core problems facing R&D funding flows for neglected diseases are.
The quality of health care, including access to HIV prevention and testing services, depends to a large extent on which of South Africa's 52 districts you happen to live in. Some of the inequities highlighted by the District Health Barometer can be traced to differences in health spending, with districts in Western Cape Province spending the most on primary health care and districts in Free State Province spending the least. In the report, Dr Tanya Doherty of South Africa's Medical Research Council attributed a lack of improvement in child and maternal mortality rates to the HIV epidemic – under-five mortality barely shifted from 60 per 1,000 births in 1990 to 59 in 2007, while maternal mortality actually increased. Prevention of mother-to-child HIV transmission (PMTCT) is vital to reducing maternal and child mortality and combating HIV, but health authorities have failed to properly monitor PMTCT interventions. ‘This is indicative of management neglect of the programme from national to facility level,’ Doherty wrote.
Malaria is highly endemic in the Democratic Republic of Congo (DRC), but the limits and intensity of transmission within the country are unknown. It is important to discern these patterns as well as the drivers which may underlie them in order for effective prevention measures to be carried out, the authors of this study argue. Using the 2007 Demographic and Health Survey (DHS) for the DRC, the authors generated prevalence estimates and explored the ecological drivers of malaria. Of the 7,746 respondents, 29.3% were parasitaemic, with males were more likely to be parasitaemic than older people or females, while wealthier people were at a lower risk. Increased community use of bed nets and community wealth were protective against malaria at the community level but not at the individual level. This research demonstrates the feasibility of using population-based behavioural and molecular surveillance in conjunction with DHS data and geographic methods to study endemic infectious diseases. The authors suggest that spatial information and analyses can enable the DRC government to focus its control efforts against malaria.
The report stresses that reducing inequities in health requires political will, increased resources and enhanced effort to organize and deliver health products and services effectively. It also needs research – whether biomedical research to create the needed drugs, vaccines, diagnostics and medical appliances; health policy and systems research to understand and improve the organization and functioning of the health sector; social sciences and behavioural research to increase understanding of the factors that determine health and affect health-seeking behaviour; or operational research to examine how effectively systems and interventions are working on the ground and how they can be improved.
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.
This paper explores the dynamics of the making and shaping of poverty policy. It begins with a critique of linear versions of policy-making, highlighting the complex interplay of power, knowledge and agency in poverty policy processes, arguing that the policy process involves a complex configuration of interests whose interactions are shaped by power relations.