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Global Forum Update on Research for Health Volume 2 Poverty, Equity and Health Research
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Global Forum Update on Research for Health Volume 2 Poverty, Equity and Health Research Edited by Stephen Matlin
Pro-Brook London Global Forum Update on Research for Health Volume 2 < 001
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Contents
Contents 007 Foreword Pramilla Senanayake 009 Introduction: Poverty, equity and health research Stephen Matlin 013 Global Forum for Health Research Poverty, social determinants and health research 020 How successful are pro-poor health programmes at reaching the poor? Cesar G Victora
076 Health research: reducing poverty and improving health in South Asia Mohammad Nasir Khan 080 Achieving equity through reform of the health sector in Egypt Mohamed Awad Tag El Din, Emam M Moussa and Ahmed M Shelbaya 086 Fora, policies and systems for maternal mortality in Ecuador César Hermida 091 United States investment in global health research Mary Woolley, Stacie M Propst and Emily T Connelly
025 Making health research more pro-poor Abbas Bhuiya 030 To prevent diseases of poverty or to overcome poverty? When equity matters in research Roberto Briceño-León
096 Setting and implementing a health research priority agenda in Brazil Reinaldo Guimarães Knowledge creation, innovation and application
033 Social determinants of health inequalities Michael Marmot
100 Turning knowledge into health benefits for the poor Alastair Ager
040 Targeting or universal coverage with vitamin A? Costs, mortality and disparity reduction David Bishai and Hugh Waters
104 Task Force on Health Systems Research: a research agenda to help attain the MDGs Andy Haines
045 From promises to action: health research after the Mexico meetings Andres de Francisco
109 Innovation systems and global health Richard T Mahoney
Achieving equity in health: the research dimension 050 Rediscovering inequalities in health: a new research agenda Jumana Qamruddin, Davidson Gwatkin and Abdo S Yazbeck
113 The critical role of genomics in global health Peter A Singer, Archana Bhatt, Sarah Frew, Heather Greenwood, Deepa L Persad, Fabio SalamancaBuentello, Béatrice Séguin, Andrew D Taylor, Halla Thorsteinsdóttir, Abdallah S Daar
054 The value of vaccines for individuals,society and the economy Sponsor’s statement: GlaxoSmithKline Biologicals
118 Pharmacogenetics and geographical ancestry: implications for drug development and global health Abdallah S Daar and Peter A Singer
057 Equality in health: the case of disabled women Anita Ghai
Health research institutions and global health challenges
060 Gender in health research – past, present and future Piroska Östlin
128 Moving beyond disciplines and geography: the NIH experience Elias A Zerhouni and Sharon H Hrynkow
064 What works at enhancing health equity? Cochrane and Campbell Vivian A Robinson, Peter Tugwell, Mark Petticrew, Elizabeth Kristjansson and Elizabeth Waters
132 Translating medical research into benefits for African people Colin Blakemore
Country perspectives and responses to health challenges 072 National rural health mission: reaching the needy Anbumani Ramadoss
136 Bringing modern health technology to the people Nirmal K Ganguly and Kiran Katoch Universities, schools of public health and health research systems 142 Support for research in and by low income countries: a proposal Berit Olsson
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145 A new school of public health in Bangladesh A Mushtaque R Chowdhury 149 Establishing schools of public health in India K Srinath Reddy 154 Health research in Central Asia Sylvia de Haan, Kaspar Wyss and Maksut Kulzhanov
The Global Forum Update on Research for Health Volume 2 is published for the Global Forum for Health Research by Pro-brook Publishing Limited Pro-Brook Publishing Alpha House 100 Borough High Street London SE1 1LB United Kingdom
Addressing neglected health issues 160 Equity, poverty and the control of infectious diseases: a TDR research perspective Sponsor’s statement: TDR 162 Progress on the MDGs and the importance of an AIDS vaccine Robert Hecht, Sarah Post and Anita Alban 168 Socioeconomic issues in diabetes care in low resource economies Sponsor’s statement: Novo Nordisk 171 Opportunities for overcoming tuberculosis: new treatment regimens Maria C Freire 174 Sumitomo Chemical – investing in Africa’s fight against malaria Sponsor’s statement: Sumitomo Chemical 177 Microbicide research: empowering women with their own STI barrier Chander Puri, Sanjay Chauhan and KVR Reddy 181 Global research challenges for oral health Poul Erik Petersen 185 The MDGs, sexual and reproductive health and the research agenda Marianne Haslegrave
Copyright Text © Global Forum for Health Research 2005 Volume © Pro-Brook Publishing Limited 2005
All rights are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photo-copying, recording or otherwise without the permission of the Publisher. The information contained in this publication is believed to be accurate at the time of manufacture. Whilst every care has been taken to ensure that the information is accurate, the Publisher and Global Forum for Health Research can accept no responsibility, legal or otherwise, for any errors or omissions or for changes to details given to the text or sponsored material. The views expressed in this publication are not necessarily those of the Publisher or of the Global Forum for Health Research. Application for reproduction should be made in writing to the Publisher.
188 Oral and precancer screening: from research to policy and practice Saman Warnakulasuriya and Toru Nagao
ISBN 2-940286-36-1
192 Acknowledgements and Advertisers’ list
First published 2005
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CHAPTER 2
Achieving equity in health: the research dimension 050 Rediscovering inequalities in health: a new research agenda Jumana Qamruddin, Davidson Gwatkin and Abdo S Yazbeck 057 Equality in health: the case of disabled women Anita Ghai 060 Gender in health research – past, present and future Piroska Östlin 064 What works at enhancing health equity? Cochrane and Campbell Vivian A Robinson, Peter Tugwell, Mark Petticrew, Elizabeth Kristjansson and Elizabeth Waters
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What works at enhancing health equity? Cochrane and Campbell Collaboration Evidence Base Article by Vivian A Robinson (pictured), Peter Tugwell, Mark Petticrew, Elizabeth Kristjansson, Elizabeth Waters, Luis Gabriel Cuervo, Jimmy Volmink
O
ver the last 30 years, a number of influential individuals and agencies have called for action to enhance health equity, reduce inequalities in health and address social determinants of health. Most recently the Millennium Development Goals1,2,3 have brought this issue to the forefront, drawing an extensive list of global organizations together to reduce poverty and related outcomes. However, unacceptable health inequities due to socioeconomic factors continue to persist in all countries of the world, for most diseases and health conditions. Part of the solution will be the provision of appropriate policy-relevant evidence. As a result, there is growing recognition that we lack evidence needed to support equityoriented policies. In this policy climate, national governments such as the Netherlands and the UK have developed research programmes to assess the impact of health and social policies and programs on health equity.4 The World Bank “Reaching the Poor” initiative is an international initiative to assess the evidence that programs are indeed serving the poor by assessing the “coverage-inequality”.5
Mexico Ministerial Summit encourages systematic reviews for decision-making With this growing body of evidence, it is difficult to locate, appraise, and synthesize all relevant studies when making a policy or program decision. Systematic reviews based on all available evidence and conducted according to rigorous standards to minimize bias are increasingly recognized as a useful tool to inform decision-making. In November 2004, the Mexico Ministerial Summit Statement encouraged governments to promote access to reliable, relevant, up-to-date systematic reviews based on the totality of available research evidence.6 This was in line with the recommendation that emerged during the Health conference on the Role of Science in the Information Society (RSIS) held in the context of the World Summit of the Information Society in December 2003, stressing the need for reliable evidence delivered in a timely manner and in the right format. RSIS highlighted the importance of offering accessible and up to date summaries of the evidence.7 The Cochrane Collaboration, founded in 1993, is an internationally recognized global initiative that promotes accessibility to methodologically rigorous systematic reviews
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about the effects of public health and health care interventions. The Campbell Collaboration is based on the
The Cochrane Collaboration is an enterprise that rivals the Human Genome Project in its potential implications for modern medicine10
Cochrane methods and principles, but applied to social, legal and educational interventions.8 Both the Cochrane and Campbell Collaboration are including increasing numbers of reviews and generating tools to assist decision-makers, many of which are relevant to low- and middle-income countries through a number of strategic initiatives and developments.9 However, systematic reviews have tended to focus on average effects rather than distributional effects or impact in disadvantaged subgroups. A recent analysis of a random sample of the Cochrane Library revealed that only 1% (1 out of 95) Cochrane reviews assessed differences in effectiveness across socioeconomic factors.11 A similar assessment of all Cochrane reviews on tobacco control in youth demonstrated that none of the tobacco control reviews contained sufficient information for equity-oriented policy-making.12 This lack of inequality analysis in systematic reviews of the Cochrane Library is partially due to absence of information in the primary controlled trials and evaluation studies. The random survey above found that only 10% of controlled trials assessed efficacy of the intervention across socioeconomic subgroups.11 Furthermore, a systematic review of controlled studies of tobacco control found that only 4% (1 out of 26) assessed impact of the intervention across socioeconomic factors.13
Cochrane Health Equity Interest Group launched to promote equity assessment The Cochrane Collaboration has recently launched an Interest Group on Health Equity, and we are in the process of registration as the Health Equity Field. Most Cochrane reviews only assess the average or mean results of the
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intervention of interest – the Equity Field will work with the 51 Cochrane Review Groups to expand their methods to include a description of equity components that are currently missing, into all their reviews. This Equity Field will also encourage the production of Campbell and Cochrane reviews on interventions that are primarily focused on reducing socioeconomic inequalities in health and/or improving the health of the disadvantaged. We will promote the incorporation of these equity aspects into the several initiatives underway to promote accessibility and use of Cochrane reviews for decision-making. The Cochrane Equity Field will focus both on ‘upstream’ [impact at a community level] and ‘downstream’ [impact at an individual level] interventions that impact upon health and health care. For the ‘upstream’ interventions we will collaborate with the Health Promotion and Public Health Field (HPPH) to promote equity interests, develop methods and provide a link with field experts. For example, the Cochrane Equity Field is collaborating with the HPPH to encourage Cochrane reviews on high-priority public health topics, identified using the WHO priority-setting matrix and an expert consensus panel.14
Defining Disadvantage: PROGRESS We are testing a method of collecting data on health inequality using an acronym called “PROGRESS” for measuring disadvantage, developed by Hilary Brown and Tim Evans (World Health Organization). PROGRESS stands for Place of residence, Race/ethnicity, Occupation/ unemployed, Gender, Religion, Education, Socioeconomic Status (income or composite measures), and Social capital.15 Empirical work is underway on the feasibility of collecting this data, and its usability and usefulness as part of five registered Cochrane reviews on the following topics: schoolfeeding for disadvantaged children [also registered with the Campbell Collaboration], peer support for women with HIV/AIDS, reducing inequities in the management of tuberculosis, tobacco control policies and programs and peer support for chronic disease. Preliminary criteria for demonstrating that interventions reduce health inequalities has been developed using the PROGRESS categories and is being tested in the above reviews.15
Register of controlled studies developed We have established a preliminary trials register of controlled studies that assess the effect of interventions on health inequality across one or more dimensions of PROGRESS. This register is important since it is difficult to locate trials that assess effects on health inequalities due to lack of relevant indexing in the controlled languages such as MESH. We are developing sensitive and appropriate search strategies for relevant studies (led by librarian scientist Jessie McGowan).16 This database will feed into Cochrane’s CENTRAL database cascading into overviews, enhancing their exposure, and making them available for consideration in systematic reviews.
Increased use of evidence from nonrandomized studies Cochrane reviews initially focused exclusively on evidence from randomized controlled trials (RCTs). While RCTs are the gold standard for efficacy, they provide limited information about effectiveness in real-world situations where provider compliance, patient adherence, coverage and diagnostic accuracy are not ideal.17 Furthermore, randomized trials may not be available for some topics, or they may not be the most appropriate design to address some clinical or policy questions. Both the Cochrane and Campbell Collaborations are increasingly including evidence from other controlled studies. It has been estimated that about a third of Cochrane reviews include non-randomized controlled trials.18 For example, the Effective Practice and Organization of Care (EPOC) review group routinely includes controlled before-after and interrupted time series studies which provide a better assessment of real-world conditions.19 The Tobacco Group also encourages evidence from nonrandomized studies; for example the Cochrane review on mass media interventions to prevent smoking in young people included not only randomized trials, but controlled trials without randomization and time series studies.20 The HIV/AIDS review group encourages including nonrandomized studies in their reviews, where no other evidence is available. For example, members of our team are contributing to a Cochrane review on the effect of legislative interventions on access to anti-retrovirals.21 This review will include before-after studies with historical controls and interrupted time-series. Non-experimental data is also used by many Review Groups where the effects of the intervention are very rare and/or delayed such as late cancers or effects upon offspring.
Improving applicability of Campbell and Cochrane reviews to equity-relevant clinical guidelines Clinical Practice Guidelines are recognized as an important way of informing clinicians of the best available evidence using a practical and useful format – especially for 'downstream interventions’ that impact upon individuals. With funding from the Rockefeller Foundation, INCLEN (the International Clinical Epidemiology Network) Knowledge Plus Program is developing methods for equity-focused and locally relevant clinical practice guidelines. These methods include applying an equity lens to existing clinical practice guidelines, as well as developing new recommendations using a modification of the GRADE Working Group methods (led by Andy Oxman).22 The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group began in 2000 as an informal collaboration that aims to develop a common, sensible approach to grading quality of evidence and strength of recommendations. The GRADE working group has acknowledged the importance of equity by
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proposing that equity considerations be reflected in separate recommendations. The extent to which Campbell and Cochrane reviews can play a role as the source of evidence for these separate recommendations depends on the availability of equity information in reviews.
Improving applicability of Campbell and Cochrane reviews to inform policy development It is vital that reviews focusing on interventions to reduce health inequalities are relevant ant for policy-makers. This is particularly important for ‘upstream’ interventions that aim to impact at the population level. The Cochrane Equity Field aims to conduct focus groups and interviews with policymakers to assess information needs on effectiveness of interventions and policies for reducing the rich-poor gap. We have already held workshops with policy-makers at the Canadian Conference on International Health (2003 and 2004) and the World Bank “Reaching the Poor” Conference (Washington, February 2004). We are also working with the Global Equity Gauge Alliance (GEGA) to promote the assessment of the evidence-base in the selection of interventions for the Equity Gauges worldwide.
Assessing “Potential Equity Effectiveness” One suggested application of Campbell and Cochrane reviews on interventions to reduce health inequalities is as a ‘best source’ of efficacy data, which can be used as an ‘anchor’ for the calculation of the hypothetical equityeffectiveness of interventions. The calculation of equityeffectiveness involves the application of an ‘equity lens’ to four factors that are known to negatively impact the efficacy of an intervention or policy in the community; (i) awareness/access/coverage, (ii) screening/diagnosis/targeting, (iii) provider compliance, and (iv) consumer adherence.17 This framework has already been presented at the Global Forum for Health Research’s Forum 7 in 2003 by Andy Haines and the Canadian Conference on International Health in 2004 by Jeanette Vega. Jeanette Vega estimated that Direct Observation Treatment (DOTS) for tuberculosis was only 25% as effective in the poorest compared to the least poor due to inferior case detection and greater diagnostic delay. This analysis suggests that key health systems need to be strengthened to improve service delivery to the poorest communities.
health equity of health, legal, social and educational interventions. J Vivian A Robinson is a doctoral candidate at the Centre for Global Health, Institute of Population Health, University of Ottawa. She is a co-author of three Cochrane reviews on health equity impact assessment and a contributor to the development of the equity lens for the Knowledge Plus Program of the International Clinical Epidemiology Network (INCLEN). Peter Tugwell is Professor of Medicine, and Epidemiology & Community Medicine at the University of Ottawa and a practicing rheumatologist at the Ottawa Hospital, Ottawa, Canada. He is North American editor of the Journal of Clinical Epidemiology and Director of the Centre for Global Health at the Institute of Population Health, University of Ottawa. He has been awarded a Canada Research Chair in Health Equity where he has gathered a multi-disciplinary team to study socioeconomic inequalities and inequities in health in Canada and developing countries. Mark Petticrew is Associate Director of the MRC Social and Public Health Sciences Unit in Glasgow, where he heads a programme on evaluation, which is funded by the Scottish Executive Department of Health. It involves primary research on the health effects of new social housing, transport interventions, and systematic reviews of the health effects of employment, housing, and transport policies. Elizabeth Kristjansson is an Associate Professor in the School of Psychology and a scientist at the Institute of Population Health, both at the University of Ottawa. She is a health measurement expert who did her postdoctoral work on health inequalities. She is the leading author on one of the first reviews with an explicit equity focus; the school meals review. Elizabeth Waters is the Professor of Public Health at Deakin University in Melbourne. She is the Director of the Health Promotion and Public Health Field and the primary author of over 10 systematic reviews in public health with a focus on child health inequalities. Luis Gabriel Cuervo is a Colombian physician, specialist in Family Medicine, and MSc in Clinical Epidemiology. He has contributed to the Cochrane Collaboration since 1995 and is a Clinical Editor for BMJ-Knowledge. He’s passionate about broadening the scope and dissemination of evidence-based publications, strengthening knowledge exchange, and delivering balanced evidence.
Conclusions In conclusion, the new Cochrane and Campbell Equity Field aims to build an equity-oriented evidence base to inform policy decisions, both in industrialized and low- and middleincome country settings. We will work with other global initiatives such as the Global Forum for Health Research to minimize duplication of effort and maximize impact, usability and uptake of this evidence base. This initiative represents a major acknowledgement by the Cochrane and Campbell Collaborations of the importance of assessing the effects on
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Dr Jimmy Volmink is the Professor and Chair of Primary Health Care, University of Cape Town and Director of the South African Cochrane Centre, Medical Research Council of South Africa. Dr Volmink is an editor of the Cochrane Infectious Disease Group and is an elected Centre representative on the Cochrane Steering Group.
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References 1.
Gwatkin D (2001). Leadership Forum. Reaching the Poor: From Documenting to Doing. Available at: http://www1.worldbank.org/hnp/ hsd/Leadership_Gwatkin_February2004.asp, Accessed April 3, 2005. 2. Lalonde M. A new perspective on the health of Canadians. Minister of Supply and Services, Health Canada, Ottawa: 1974. 3. Timothy Evans, Margaret Whitehead, Finn Diderichsen, Abbas Bhuiya and Meg Wirth. Challenging Inequities in Health: From Ethics to Action. Available at: http://www.rockfound.org/Documents/435/ summary_challenging.pdf, Accessed April 3, 2005 4. Mackenbach JP, Stronks K. A strategy for tackling health inequalities in the Netherlands. BMJ. 2002 Nov 2;325(7371):1029-32. 5. World Bank. Reaching the Poor Program. Available at: http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTR ITIONANDPOPULATION/EXTPAH/0,,contentMDK:20216896~menuPK:4 60206~pagePK:148956~piPK:216618~theSitePK:400476,00.html, Accessed April 29, 2005. 6. WHO Commission on Social Determinants of Health. Available at: http://www.who.int/social_determinants/en/, Accessed April 3, 2005. 7. Role of Science in the Information Society. Available at: http://rsis.web.cern.ch/rsis/00Themes/01Health/Health.html, Accessed May 9, 2005. 8. Davies P, Boruch R. The Campbell Collaboration. Does for public policy what Cochrane does for health. BMJ. 2001 Aug 11;323(7308):294-5. 9. Volmink J, Siegfried N, Robertson K, Gulmezoglu AM. Research synthesis and dissemination as a bridge to knowledge management: the Cochrane Collaboration. Bull World Health Organ. 2004 Oct;82(10):778-83. 10. Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet 1995;345:840-2. 11. Tsikata S, Robinson V, Petticrew M, Kristjansson E, Moher D, McGowan J, Shea B, Wells G, Tugwell P. Is health equity considered in systematic reviews of the Cochrane Collaboration? 11th Cochrane Colloquium, Barcelona, Spain, October 2003. 12. Ogilvie D, Petticrew M. Reducing social inequalities in smoking: can evidence inform policy? A pilot study. Tobacco Control 2004; 13: 129131.
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Robinson V, Tugwell P, Sadowski L, Fletcher S, Wells G, Kristjansson E. How to design clinical trials to assess health equity effectiveness? 12th Annual Cochrane Colloquium, Ottawa, October 2-6, 2004. Available at: http://www.cochrane.org/colloquia/abstracts/ottawa/P-123.htm, Accessed April 29, 2005. 14. Doyle J, Waters E, Yach D, McQueen D, De Francisco A, Stewart T, Reddy P, Gulmezoglu AM, Galea G, Portela A. Global priority setting for Cochrane systematic reviews of health promotion and public health research. J Epidemiol Community Health. 2005 Mar;59(3):193-7. 15. Kristjansson E, Robinson VA, MacDonald B, Krasevec J, Greenhalgh T, McGowan J, Francis D, Tugwell P, Petticrew M, Shea B, Wells G. School feeding for improving the physical and psychosocial health of disadvantaged elementary school children. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD004676. DOI: 10.1002/14651858.CD004676. 16. McGowan J, Robinson V, Kristjansson B, Petticrew M, Tugwell P. Identifying studies that include issues of equity in Cochrane Reviews. 12th Annual Cochrane Colloquium. Ottawa, October 2-6, 2004. 17. Tugwell P, Bennett KJ, Sackett DL, Haynes RB. The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions. J Chron Dis 1985; 38(4):339-351. 18. Evidence and HIA Petticrew M, Macintyyre S, Thomson H. In: Kemm J, Parry J, Palmer S. Health Impact Assessment. Oxford University Press 2004 19. Effective Practice and Organization of Care Group. Available at: http://www.epoc.uottawa.ca/, accessed April 1, 2005. 20. Sowden AJ, Arblaster L. Mass media interventions for preventing smoking in young people. The Cochrane Database of Systematic Reviews 1998, Issue 4. Art. No.: CD001006. DOI: 10.1002/14651858.CD001006 21. Aginam O, Robinson V, Tugwell P. Legislative interventions to increase access to anti-retrovirals for the treatment of HIV/AIDS. Cochrane review title registered with the Cochrane HIV/AIDS Group, October 2004. 22. The GRADE* Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490-1494
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