Complex and dynamic public health problems require a different approach: an emphasis on the value of people. People who own the problem can anticipate the most likely social obstacles to its resolution, and their participation is essential to maintain an evolving strategy that can institutionalize an approach to the problem.Read More
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Scholarship focusing on how international research can contribute to justice in global health has primarily explored requirements for the conduct of clinical trials. Yet health systems research in low- and middle-income countries (LMICs) has increasingly been identified as vital to the reduction of health disparities between and within countries. This paper expands an existing ethical framework based on the health capability paradigm – research for health justice – to externally-funded health systems research in LMICs. It argues that a specific form of health systems research in LMICs is required if the enterprise is to advance global health equity. “Research for health justice” requirements for priority setting, research capacity strengthening, and post-study benefits in health systems research are derived in light of the field's distinctive characteristics. Specific obligations are established for external research actors, including governments, funders, sponsors, and investigators. How these framework requirements differ from those for international clinical research is discussed.
B. Pratt and A. A. Hyder (2015) Applying a Global Justice Lens to Health Systems Research Ethics: An Initial Exploration, Kennedy Institute of Ethics Journal, Volume 25, Number 1, March 2015, pp. 35-66, DOI: 10.1353/ken.2015.0005
Health systems research is increasingly being performed in low and middle income countries and is essential to reducing global health disparities. This paper provides an initial description of the ethical issues related to priority setting, capacity-building, and the provision of post-study benefits that arise during the conduct of such research. It presents a selection of issues discussed in the health systems research literature and argues that they constitute ethical concerns based on their being inconsistent with a particular theory of global justice (the health capability paradigm).Read More
What Do They Do? Interactions Between Village Doctors and Medical Representatives in Chakaria, Bangladesh
Hafizur Rahman, M, Agarwal, S, Tuddenham, S, Iqbal, M, Bhuiya, A, and Peters, DH (2014) What do they do? Interactions between village doctors and medical representatives in Chakaria, Bangladesh International Health doi:10.1093/inthealth/ihu077
Informally trained village doctors supply the majority of health care services to the rural poor in many developing countries. This study describes the demographic and socioeconomic differences between medical representatives, hired by pharmaceutical companies to provide their products to health providers, and village doctors in rural Bangladesh, and explores the nature of their interactions. The research team used focus group discussions, in-depth interviews, and a quantitative survey to understand practice perceptions. They found that medical representatives have a higher average per capita monthly expenditure compared to village doctors, and that the former are better educated with 98% having bachelor's degrees whereas 84% of village doctors have twelfth grade education or less. Medical representatives are the principal information source about new medications for the village doctors. Furthermore, incentives offered by medical representatives and credit availability might influence the prescription practices of village doctors. Findings suggests that improvements in the quality of health care delivered to the rural poor in informal provider-based health markets require stricter regulations and educational initiatives for providers and medical representatives.
This paper explores the question of what systems thinking adds to the field of global health. Observing that elements of systems thinking are already common in public health research, the article discusses which of the large body of theories, methods, and tools associated with systems thinking are more useful.Read More
This presentation is from a workshop in Baltimore in June 2014 on complex adaptive systems (CAS) research methods held at Johns Hopkins University. In this presentation, Ligia Paina from the Johns Hopkins Bloomberg School of Public Health shows how to use the computer program Vensim to develop Causal Loop Diagrams (CLDs).Read More
This is a video from the DC Health Systems Board event, Can systems tools deliver for the 'science of delivery'?, which was organised by Future Health Systems as part of its workshop on complex adaptive systems and held at Results for Development in June 2014.
At the event, panellists discussed and debated how systems thinking tools that are designed to tackle issues of complexity can contribute the successful implementation of health system strengthening interventions. The panel showcased some tools and examples, explaining how they had helped them to understand better health systems fluctuations and to anticipate unintended consequences to create more sustainable large-scale interventions.Read More
Given the rapid evolution of health markets, learning is key to promoting the identification and uptake of health market policies and practices that better serve the needs of the poor. However there are significant challenges to learning about health markets. We discuss the different forms that learning takes, from the development of codified scientific knowledge, through to experience-based learning, all in relationship to health markets.Read More
The rapid evolution and spread of health markets across low and middle-income countries (LMICs) has contributed to a significant increase in the availability of health-related goods and services around the world. The support institutions needed to regulate these markets have lagged behind, with regulatory systems that are weak and under-resourced. This paper explores the key issues associated with regulation of health markets in LMICs, and the different goals of regulation, namely quality and safety of care, value for money, social agreement over fair access and financing, and accountability.Read More
Private sector, for-profit health providers in low and middle income countries: can they reach the poor at scale?
The bottom of the pyramid concept suggests that profit can be made in providing goods and services to poor people, when high volume is combined with low margins. To-date there has been very limited empirical evidence from the health sector concerning the scope and potential for such bottom of the pyramid models. This paper analyzes private for-profit (PFP) providers currently offering services to the poor on a large scale, and assesses the future prospects of bottom of the pyramid models in health.Read More
Catastrophic out-of-pocket payment for healthcare and implications for household coping strategies: evidence from West Bengal, India'
Using data from a household survey in West Bengal, the purpose of this paper is to identify the relative risks of catastrophic healthcare expenditures for different types of health need, and the impact of such expenditure on household coping strategies. It concludes that Catastrophic health spending is an important problem for the population in West Bengal. More attention is needed on the poverty-inducing effects of long-term expenditures on chronic illness, given that existing schemes only address hospitalization.Read More
Institutional capacity for health systems research in East and Central African schools of public health: knowledge translation and effective communication
Local health systems research (HSR) provides policymakers and practitioners with contextual, evidence-based solutions to health problems. However, producers and users of HSR rarely understand the complexities of the context within which each operates, leading to the "know-do" gap. Universities are well placed to conduct knowledge translation (KT) integrating research production with uptake. The HEALTH Alliance Africa Hub, a consortium of seven schools of public health (SPHs) in East and Central Africa, was formed to build capacity in HSR. This paper presents information on the capacity of the various SPHs to conduct KT activities.Read More
Institutional capacity for health systems research in East and Central African schools of public health: experiences with a capacity assessment tool
Despite significant investments in health systems research (HSR) capacity development, there is a dearth of information regarding how to assess HSR capacity. An alliance of schools of public health (SPHs) in East and Central Africa developed a tool for the self-assessment of HSR capacity with the aim of producing institutional capacity development plans.Read More
Health policy and systems research (HPSR) is a transdisciplinary field of global importance, with its own emerging standards for creating, evaluating, and utilizing knowledge, and distinguished by a particular orientation towards influencing policy and wider action to strengthen health systems. In this commentary, we argue that the ability of the HPSR field to influence real world change hinges on its becoming more people-centred. We see people-centredness as recognizing the field of enquiry as one of social construction, requiring those conducting HPSR to locate their own position in the system, and conduct and publish research in a manner that foregrounds human agency attributes and values, and is acutely attentive to policy context.Read More
A bioethical framework for health systems activity: a conceptual exploration applying ‘systems thinking’
Recognizing that the health system is a complex and dynamic network of actors and activities, this paper seeks to push the field of bioethics to develop a more holistic approach from the health systems perspective. Expanding upon the work of existing public health frameworks and drawing upon concepts from related areas such as governance, human rights, and organizational ethics, our provisional list of ethical considerations for health systems fall under the following categories: Holism, Sustainability, Evidence & Effectiveness, Efficiency, Public Engagement & Transparency, Accountability & Feedback, Equity & Empowerment, Justice & Fairness, Responsiveness, Collaboration, and Quality.Read More