Towards fair and effective North–South collaboration: realising a programme for demand-driven and locally led research

Background

At the turn of the 90s, studies showed that health research contributed little to health and development in low- and middle-income countries because it was oriented towards international priorities and dominated by researchers from the North. A new approach to North–South collaboration was required that would support demand-driven and locally led research in the South. The aim of this study was to analyse the development and functioning of a programme for demand-driven and locally led research in Ghana that was supported by a North–South collaboration.

Methods

For this mixed-method case study, we combined document analysis, key informant interviews and observation of programme events.

Results

The development of the research programme started with constructing a sponsorship constellation in the Netherlands. After highlighting the problems with traditional research collaboration, an advisory council formulated a vision for a more equal and effective approach to North–South collaboration. Together with Ghanaian partners, this vision was turned into a proposal for a Ghanaian-led programme for demand-driven and locally led research, which was funded by the Netherlands government. Research priority setting showed that the Ghanaian research needs were very different from the priorities of foreign funders and researchers. After a slow start, the number of locally submitted proposals increased from 13 in 2001 to 94 in 2005, revealing the existence of a substantial, but partly latent reservoir of research capacity. In total, 79 studies were funded. An impact evaluation showed that the results of the majority of the studies were used to contribute to action. Despite its success, the research programme came to an end in 2008 after the sponsorship constellation in the Netherlands fell apart.

Conclusion

Our study shows that realising a programme for demand-driven and locally led research in the South provides an effective approach to North–South collaboration in which results are used and local capacities and institutions are strengthened.

     

Network of Ethical Relationships model for global North–South population health research

Although a substantial body of literature exists that details how to address ethical issues and provide oversight for traditional research study designs, there currently is very little guidance available to researchers on how to deal with the unique and novel challenges that arise when conducting research that goes outside of these well-defined boundaries. One such example is North–South (N-S) team-based global population health (GPH) research. This paper presents a Network of Ethical Relationships (NER) model which can allow GPH researchers better understand and resolve ethical issues that arise in N-S collaborative research efforts. The NER model elucidates some of the core relationships involved in GPH research and sheds light on the complex milieu of moral, institutional, societal and legal processes in which it is embedded. The utility of the NER model is examined by reviewing 14 GPH research teams, looking at two relationships in more detail – Researcher–Ethics Board, and Researcher–Funder relationships. The paper argues that improved dialogue and flexibility in the application of formal ethical rules and procedures can lead to research being conducted in a more ethical manner since it better accounts for the multitude of voices and perspectives influencing researchers’ choices and actions.     

Nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector

Universal health coverage, comprehensive access to affordable and quality health services, is a key component of the newly adopted 2015 Sustainable Development Goals. Prior to the UN resolution, several countries began incorporating elements of universal health coverage into their domestic policy arenas. In 2013, the newly elected President of Kenya announced initiatives aimed at moving towards universal health coverage, which have proven to be controversial. Little is known about how frontline workers, increasingly politically active and responsible for executing these mandates, view these changes. To understand more about how actors make sense of universal health coverage policies, we conducted an interpretive policy analysis using well-established methods from critical policy studies. This study utilized in-depth semi-structured interviews from a cross section of 60 nurses in three health facilities (public and private) in Kenya. Nurses were found to be largely unfamiliar with universal health coverage and interpreted it in myriad ways. One policy in particular, free maternal health care, was interpreted positively in theory and negatively in practice. Nurses often relied on symbolic language to express powerlessness in the wake of significant health systems reform. Study participants linked many of these frustrations to disorganization in the health sector as well as the changing political landscape in Kenya. These interpretations provide insight into charged policy positions held by frontline workers that threaten to interrupt service delivery and undermine the movement towards universal health coverage in Kenya.     

Mapping transgender policies in the US 2017–2021: The role of geography and implications for health equity

Transgender individuals globally face varying policy contexts that can influence their health. In the United States (US), a patchwork of exclusionary and inclusive policies exists, creating potentially different social and political contexts that shape transgender health depending on the state. In this article, we consider how recent legislation introduced in US states focused on transgender people may be a political determinant of health and affect health equity goals. To advance this aim, we employed the perspective of legal epidemiology to systematically search a US legal database (Westlaw) for policies focused on transgender individuals proposed between January of 2017 and September of 2021.698 policies were analyzed as affirming or exclusionary of transgender identities and categorized by content. We calculated a ratio of affirming versus exclusionary bills to create “exclusionary density” and “affirming density” measures. Those measures were used to calculate an inclusivity score and corresponding maps of inclusivity and exclusionary contexts by US state. Exclusionary and affirming density measures showed deeply polarized policy responses to transgender individuals depending on US state. Further, we observed differences in magnitude regarding the laws being proposed. Exclusionary laws largely focused on criminalization while inclusionary laws focused on representation in government agencies. These findings highlight that transgender individuals in the US can experience vastly different political contexts depending on where they live.     

Research relationships between the South and the North: Cinderella and the ugly sisters?

There has been an increase in the size and range of North-South health research partnerships since the 1990s. Current literature tends to stress the need for partnership and associated principles, but recognises the difficult context of structural inequality and historical legacies. Critics point to continuing neo-colonialist attitudes to research, which are unhelpful for the development of mutually beneficial collaborations. Such dynamics have parallels with the European folktale of Cinderella and the Ugly Sisters, the latter using their advantage of wealth and position to exploit their step-sister. Little literature is available on how to address this situation for the principles of partnership to be integrated into project design, implementation and dissemination. This article examines processes and dynamics within North-South collaborations in health research through two different case studies presented from Northern perspectives. Each case study focuses on distinct aspects of research collaborations. The first, a North-South partnership project in Bangladesh, highlights issues of capacity building, use of data and publications. The second case, a Doctoral study in Thailand, examines the reliance on contributions by Southern partners, responsibility to the local setting and the practice of reciprocity. The article then turns to Southern researchers' reflections, explored in semi-structured interviews, on themes identified by Northern researchers as important concerns in research collaborations. The authors conclude that advantage should be taken of the fact that Southern and Northern colleagues often share similar values regarding research collaborations, but difficulties exist in implementation partly due to historically rooted and current inequalities. Practical arrangements are suggested which may help to address the commonly assumed roles of the North as 'provider' of funding and ideas, and of the South as 'receiver' in an environment with little scope for action.     

Paying for and receiving benefits from health services in South Africa: is the health system equitable?

There is a global challenge for health systems to ensure equity in both the delivery and financing of health care. However, many African countries still do not have equitable health systems. Traditionally, equity in the delivery and the financing of health care are assessed separately, in what may be termed 'partial' analyses. The current debate on countries moving toward universal health systems, however, requires a holistic understanding of equity in both the delivery and the financing of health care. The number of studies combining these aspects to date is limited, especially in Africa. An assessment of overall health system equity involves assessing health care financing in relation to the principles of contributing to financing according to ability to pay and benefiting from health services according to need for care. Currently South Africa is considering major health systems restructuring toward a universal system. This paper examines together, for both the public and the private sectors, equity in the delivery and financing of health care in South Africa. Using nationally representative datasets and standard methodologies for assessing progressivity in health care financing and benefit incidence, this paper reports an overall progressive financing system but a pro-rich distribution of health care benefits. The progressive financing system is driven mainly by progressive private medical schemes that cover a small portion of the population, mainly the rich. The distribution of health care benefits is not only pro-rich, but also not in line with the need for health care; richer groups receive a far greater share of service benefits within both public and private sectors despite having a relatively lower share of the ill-health burden. The importance of the findings for the design of a universal health system is discussed.     

Poles apart: does the export of mental health expertise from the Global North to the Global South represent a neutral relocation of knowledge and practice?

The World Health Organization's Mental Health Action Plan 2013–2020 identifies actions for all member states to alleviate the global burden of mental ill health, including an obligation for mental healthcare to be delivered in a ‘culturally appropriate’ manner. In this article we argue that such a requirement is problematic, not least because such pronouncements remain framed by the normative prepositions of Western medical and psychological practice and their associated ethical, legal and institutional standpoints. As such, when striving to export Western mental health expertise, different paradigms for evidence will be necessary to deliver locally meaningful interventions to low and middle income countries. Our discussion highlights a number of philosophical concerns regarding methodologies for future research practice, including those relating to representation and exclusion in the guise of epistemic injury, presumptive methodologies arising from Western notions of selfhood, and related ethical issues.     

Patients' views of explicit rationing: what are the implications for health service decision-making?

Patient groups in England and Wales have expressed concerns about the decision-making processes of the National Institute for Clinical Excellence (NICE), the body responsible for explicit rationing. Five key issues were identified by the Multiple Sclerosis Society regarding NICE appraisals and guidance: they focus too narrowly on costs to the National Health Service; quality-adjusted life-years are an inadequate measure of health gain, particularly for long-term conditions; NICE takes too conservative a view of long-term benefits; NICE's cost-effectiveness threshold is inappropriate; and NICE evaluations fail to capture patients' personal experiences of their condition and treatments. We question the veracity of some of these arguments and, where appropriate, suggest ways in which NICE's processes might be strengthened.     

Do the health benefits of education vary by sociodemographic subgroup? Differential returns to education and implications for health inequities

Purpose

Evidence suggests education is an important life course determinant of health, but few studies examine differential returns to education by sociodemographic subgroup.

Biofuels and North American Agriculture – Implications for the Health and Safety of North American Producers

ABSTRACT

This decade has provided North American agricultural producers with opportunity to not only produce fiber and food, but also fuel and other industrial products. The drivers incenting this development could be sustained well into the future, therefore workforce safety and health implications are likely to persist for some time. Within production agriculture, the ‘feedstock growth and harvest cycle’ and ‘transport’ sectors possess the changing exposures experienced by workers. The Conference explored the following exposures: distiller's grains and bio-processing byproducts, spent catalyst, solvent brine, microbial agents, genetically modified organisms, discharge effluent, H2O dilutes, change in cropping patterns and resultant use of different seeding and harvest technologies, pests (whether target or non-target), and rural traffic resulting from concentrated movement of massive quantities of biomass and grain. Other issues of a more general public health nature such as watershed implications, other environmental impacts, emissions, uneven economic development potential, public safety issues associated with transport of both fuel and other industrial products, and rural emergency medical service need were explored. And, agronomic impacts were noted, including tillage change, potassium buildup in soil, nutrient depletion, sedimentation and erosion of tillable soil, and local esthetics. It was concluded that rural venues for formation and exploration of public policy need to be created.     

Housing and health—Current issues and implications for research and programs

This article provides an overview of the ways in which the home environment can affect human health, describes how specific health hazards in housing are related, and considers implications of these concerns for research and programs to address the health-housing connection. The widespread availability of decent housing has contributed greatly to improvements in health status in developed countries through, for example, provision of safe drinking water, proper sewage disposal, and protection from the elements. However, a lack of decent housing and homelessness among a significant number of Americans remains a significant public health concern. In addition, a number of specific health hazards can be found even in housing that is in good condition and provides all basic amenities. Specific health hazards related to housing include unintentional injuries, exposure to lead, exposure to allergens that may cause or worsen asthma, moisture and fungi (mold), rodent and insect pests, pesticide residues, and indoor air pollution. A number of these specific hazards share underlying causes, such as excess moisture, and all may be influenced by factors in the community environment or by occupant behaviors. We make recommendations for developing programs and research efforts that address multiple housing problems in an integrated way, rather than categorically, and for closer collaboration between housing and public health programs. The views expressed in this article are those of the authors and do not necessarily reflect official policies of the US Centers for Disease Control and Prevention or the US Department of Housing and Urban Development.     

Public health and health administration: collaboration or competition? An Australian perspective

The Review of Postgraduate Public Health Training in Australia 1988, commissioned by the Australian Public Health Association, identified as a major issue the degree of collaboration between independent postgraduate courses in health administration and courses in public health. This paper suggests that the two fields share the common goal of health service education, which they pursue by the respective pathways of effectiveness and efficiency. We argue that the identity and the complementarity of the disciplines are best served by a collaborative model and discuss ways to encourage and achieve this aim.     

Parents’ Perceptions of Causes of and Solutions for School Violence: Implications for Policy

This study explores perceptions of causes of and solutions for school violence in a sample of 202 parents interviewed in the wake of nationally publicized school shootings. We also investigate the effects the school shootings had on children, parents’ perceptions regarding firearms, and changes in parenting behavior. Parents exhibited strong support for almost all proposed causes and solutions, and we address their desire for immediate and often invasive interventions to prevent future violence. We contrast parents’ perceptions with their own parenting behaviors and with literature on effective interventions. Results are discussed within the context of policy implications. Editors’ Strategic Implications: Parents’ perceptions and behaviors are frequently influenced by history effects. The national attention received by school shootings provided an opportunity for exploration of those perceptions and self-reported behaviors. The authors provide evidence from timely surveys that parents struggle with identifying causal factors that may contribute to school violence and consequently support a myriad of strategies for intervention including very invasive environmental preventive strategies. The findings suggest that social scientists should play a proactive role in translating research-supported preventive strategies to effective replications in the community and make research available in formats that are available and comprehensible by the lay public.     

Low-carbohydrate diets: what are the potential short- and long-term health implications?

Low-carbohydrate diets for weight loss are receiving a lot of attention of late. Reasons for this interest include a plethora of low-carbohydrate diet books, the over-sensationalism of these diets in the media and by celebrities, and the promotion of these diets in fitness centres and health clubs. The re-emergence of low-carbohydrate diets into the spotlight has lead many people in the general public to question whether carbohydrates are inherently 'bad' and should be limited in the diet. Although low-carbohydrate diets were popular in the 1970s they have resurged again yet little scientific fact into the true nature of how these diets work or, more importantly, any potential for serious long-term health risks in adopting this dieting practice appear to have reached the mainstream literature. Evidence abounds that low-carbohydrate diets present no significant advantage over more traditional energy-restricted, nutritionally balanced diets both in terms of weight loss and weight maintenance. Studies examining the efficacy of using low-carbohydrate diets for long-term weight loss are few in number, however few positive benefits exist to promote the adoption of carbohydrate restriction as a realistic, and more importantly, safe means of dieting. While short-term carbohydrate restriction over a period of a week can result in a significant loss of weight (albeit mostly from water and glycogen stores), of serious concern is what potential exists for the following of this type of eating plan for longer periods of months to years. Complications such as heart arrhythmias, cardiac contractile function impairment, sudden death, osteoporosis, kidney damage, increased cancer risk, impairment of physical activity and lipid abnormalities can all be linked to long-term restriction of carbohydrates in the diet. The need to further explore and communicate the untoward side-effects of low-carbohydrate diets should be an important public health message from nutrition professionals.     

The state of international collaboration for health systems research: what do publications tell?

Aim

International collaboration for health system development has been identified as a critical input to meet pressing global health needs. North-South collaboration has the potential to benefit both parties, while South-South collaboration offers promise to strengthen capacity rapidly and efficiently across developing countries. There is an emerging trend to analyze the fruits of such collaboration. This paper builds on this trend by applying an innovative concept-based bibliometric method to identify the international scope of collaboration within the field of health policy and systems research. Two key questions are addressed: to what extent are papers comparing developing countries as against reporting on single country studies? To what extent are papers in either case being produced by researchers within their respective countries or through North-South or South-South collaboration?

Methods

A total of 8,751 papers published in Medline between 1999 and 2003 with data on health systems and policies in developing countries were identified and content-analyzed using an innovative concept-based search technology. A sample of 13% of papers was used to identify the corresponding institution and countries covered. The sampled data was then analyzed by income group.

Results

Papers with an international, cross-country focus account for only 10% of the total. Just over a third of all papers are led by upper middle income country authors, closely followed by authors from high income countries. Just under half of all papers target low income countries. Cross-country papers are led mostly by institutions in high income countries, with 74% of the total. Only seven countries concentrate 60% of the papers led by developing country institutions. Institutions in the United States and the United Kingdom concentrate between them as many as 68% of the papers led by high income countries. Only 11% of all single-country papers and 21% of multi-country studies are the product of South-South collaboration. Health Financing is the topic with the greatest international scope, with 26% of all papers in the topic. Topics such as Costing and Cost Effectiveness, Finance, Sector Analysis and Insurance, regardless of their national or international scope, are led in 38% to 54% of cases by high income authors.

Conclusion

While there is modest health systems research capacity in many developing countries for single country studies, capacity is severely limited for multi-country studies. While North-South collaboration is important, the number of international studies is still very limited to produce the kind of knowledge required to learn from experiences across countries. The fact that lead institutions as well as study countries are concentrated in a handful of mostly middle income countries attests to great disparities in research capacity. However, disparities in research capacity and interest are also evident in the North. It is urgent to build cross-country research capacity including appropriate forms of South-South and North-South collaboration.     

Competition and collaboration in health care: reconciling the irreconcilable? Lessons from The Netherlands

The European Journal of Health Economics -