The uses of knowledge in global health

Global inequities in adverse pregnancy outcomes: what can we do?

The Health Equity Leadership & Exchange Network states that "health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health." It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.

Decolonising global health: why the new Pandemic Agreement should have included the principle of subsidiarity

The negotiations for the WHO Pandemic Agreement have brought attention to issues of racism and colonialism in global health. Although the agreement aims to promote global solidarity, it fails to address these deeply embedded problems. This Viewpoint argues that not including the principle of subsidiarity into Article 4 of the agreement as a pragmatic strategy was a missed opportunity to decolonise global health governance and promote global solidarity. Subsidiarity, as a structural principle, empowers local units to make decisions and address issues at their level, fostering collaboration, coordination, and cooperation. By integrating subsidiarity, the agreement could have ensured contextually appropriate responses, empowered local communities, and achieved justice in global health. This paper discusses the elements of subsidiarity-namely, agency and non-abandonment-and highlights the need to strike a balance between them. It also maps the principle of subsidiarity within the Pandemic Agreement, emphasising the importance of creating a practical framework for its implementation. By integrating subsidiarity into the agreement, a just and decolonialised approach to pandemic prevention and response could have been closer to being realised, promoting global solidarity and addressing health inequities.

Examining the involvement of guardians of children with acute lymphoblastic leukemia in Tanzania as public contributors to inform the design and conduct of the GuardiansCan project: A mixed-methods study protocol

BACKGROUND

Public contribution in research can lead to the design and conduct of more feasible and relevant research. However, our understanding of the acceptability and feasibility of public contribution and the evidence base regarding its impact in low- and middle-income countries (LMICs) is limited.

METHODS

In this study protocol, we describe a mixed-method examination of public contribution activities in the GuardiansCan project. The GuardiansCan project aims to respond to Tanzanian guardians' poor adherence to children's follow-up care after treatment for acute lymphoblastic leukemia (ALL) with the help of Mobile Health technology. We aim to: (1) involve guardians of children treated for ALL as Guardians Advisory Board (GAB) members in the managing and undertaking, analysis and interpretation, and dissemination phases of the GuardiansCan project; and (2) examine the acceptability, feasibility, and perceived impact of GAB members' contribution to the GuardiansCan project from the perspective of the GAB members and public contribution coordinators. We will recruit six to eight guardians of children treated for ALL to the GAB. We will hold workshops where GAB members contribute to all project phases. Using impact logs, we will record GAB workshop activities and the perceived impact of these activities. We will interview GAB members and public contribution coordinators 6 months after establishing the GAB, and at the end of each study within the project, to examine the acceptability, feasibility, and perceived impact of public contribution activities.

DISCUSSION

We expect GAB contribution to increase project quality and relevance, and inform how to best embed public contribution in research in LMICs.

Unfair knowledge practices in global health: a realist synthesis

Unfair knowledge practices easily beset our efforts to achieve health equity within and between countries. Enacted by people from a distance and from a position of power ('the centre') on behalf of and alongside people with less power ('the periphery'), these unfair practices have generated a complex literature of complaints across various axes of inequity. We identified a sample of this literature from 12 journals and systematized it using the realist approach to explanation. We framed the outcome to be explained as 'manifestations of unfair knowledge practices'; their generative mechanisms as 'the reasoning of individuals or rationale of institutions'; and context that enable them as 'conditions that give knowledge practices their structure'. We identified four categories of unfair knowledge practices, each triggered by three mechanisms: (1) credibility deficit related to pose (mechanisms: 'the periphery's cultural knowledge, technical knowledge and "articulation" of knowledge do not matter'), (2) credibility deficit related to gaze (mechanisms: 'the centre's learning needs, knowledge platforms and scholarly standards must drive collective knowledge-making'), (3) interpretive marginalization related to pose (mechanisms: 'the periphery's sensemaking of partnerships, problems and social reality do not matter') and (4) interpretive marginalization related to gaze (mechanisms: 'the centre's learning needs, social sensitivities and status preservation must drive collective sensemaking'). Together, six mutually overlapping, reinforcing and dependent categories of context influence all 12 mechanisms: 'mislabelling' (the periphery as inferior), 'miseducation' (on structural origins of disadvantage), 'under-representation' (of the periphery on knowledge platforms), 'compounded spoils' (enjoyed by the centre), 'under-governance' (in making, changing, monitoring, enforcing and applying rules for fair engagement) and 'colonial mentality' (of/at the periphery). These context-mechanism-outcome linkages can inform efforts to redress unfair knowledge practices, investigations of unfair knowledge practices across disciplines and axes of inequity and ethics guidelines for health system research and practice when working at a social or physical distance.

Building a framework to decolonize global emergency medicine

Background

Global emergency medicine (GEM) is situated at the intersection of global health and emergency medicine (EM), which is built upon a history of colonial systems and institutions that continue to reinforce inequities between high-income countries (HICs) and low- and middle-income countries (LMICs) today. These power imbalances yield disparities in GEM practice, research, and education.

Approach

The Global Emergency Medicine Academy (GEMA) of the Society for Academic Emergency Medicine formed the Decolonizing GEM Working Group in 2020, which now includes over 100 worldwide members. The mission is to address colonial legacies in GEM and catalyze sustainable changes and recommendations toward decolonization at individual and institutional levels. To develop recommendations to decolonize GEM, the group conducted a nonsystematic review of existing literature on decolonizing global health, followed by in-depth discussions between academics from LMICs and HICs to explore implications and challenges specific to GEM. We then synthesized actionable solutions to provide recommendations on decolonizing GEM.

Results

Despite the rapidly expanding body of literature on decolonizing global health, there is little guidance specific to the relatively new field of GEM. By applying decolonizing principles to GEM, we suggest key priorities for improving equity in academic GEM: (1) reframing partnerships to place LMIC academics in positions of expertise and power, (2) redirecting research funding toward LMIC-driven projects and investigators, (3) creating more equitable practices in establishing authorship, and (4) upholding principles of decolonization in the education of EM trainees from LMICs and HICs.

Conclusions

Understanding the colonial roots of GEM will allow us to look more critically at current health disparities and identify inequitable institutionalized practices within our profession that continue to uphold these misguided concepts. A decolonized future of GEM depends on our recognition and rectification of colonial-era practices that shape structural determinants of health care delivery and scientific advancement.

The Lancet and colonialism: past, present, and future

The historical and contemporary alignment of medical and health journals with colonial practices needs elucidation. Colonialism, which sought to exploit colonised people and places, was justified by the prejudice that colonised people's ways of knowing and being are inferior to those of the colonisers. Institutions for knowledge production and dissemination, including academic journals, were therefore central to sustaining colonialism and its legacies today. This invited Viewpoint focuses on The Lancet, following its 200th anniversary, and is especially important given the extent of The Lancet's global influence. We illuminate links between The Lancet and colonialism, with examples from the past and present, showing how the journal legitimised and continues to promote specific types of knowers, knowledge, perspectives, and interpretations in health and medicine. The Lancet's role in colonialism is not unique; other institutions and publications across the British empire cooperated with empire-building through colonisation. We therefore propose investigations and raise questions to encourage broader contestation on the practices, audience, positionality, and ownership of journals claiming leadership in global knowledge production.

Achieving equitable leadership in Global Health partnerships: barriers experienced and strategies to improve grant funding for early- and mid-career researchers

Calls to decolonize global health have highlighted the continued existence of colonial structures in research into diseases of public health importance particularly in low- and middle-income countries (LMICs). A key step towards restructuring the system and shaping it to local needs is equitable leadership in global health partnerships. This requires ensuring that researchers in LMICs are given the opportunity to successfully secure grant funding to lead and drive their own research based on locally defined priorities. In February 2022, the London School of Hygiene and Tropical Medicine hosted a workshop aimed at bringing together funders and early- and mid-career researchers (EMCRs) to identify funder initiatives that have worked to improve equitable leadership, to better understand barriers faced by researchers, and collectively brainstorm approaches to overcome these barriers. The workshop transcript was analyzed using a deductive thematic approach based on the workshop topic to identify key emerging themes. Barriers identified were the lack of individual and institutional level support and flawed funding structures for EMCRs in LMIC settings. Strategies on how equitable leadership can be further facilitated include institutional reforms for funders to facilitate equity, diversity, and inclusion in their partners through consultative engagement and in addition, reshaping how research priorities are defined; diversified funding streams for research organizations, building partnerships and dedicated funding for capacity building of EMCRs. Intentional advances to overcome funding barriers in global health speak directly to its decolonization. Urgently required and complex changes in practice must be intentional and do require uncomfortable shifts which will take time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-024-00047-4.

The struggle for the social: rejecting the false separation of 'social' worlds in mental health spaces

How are we to best grapple with the notion of the Social in mental health landscapes? This piece of speculative work explores a series of tensions that emerge in our attempt to contemplate, engage with, and address the social in mental health spaces. First, I will explore the tensions created by disciplinary demands for specialisation, questioning the value of this with regard to treating social and emotional bodies which continually reject such fragmentation. This line of inquiry then leads to reflection on the value of a social topology-enabled through the application of intersectionality principles, Black Sociological analytical frameworks, including the worldview approach, and societal psychological perspectives on knowledge and action. I argue the possibilities in actioning these approaches emerge through the application of a social-political economy of mental health, that holds the complexity presented by the totality of social life as it potentially relates to mental health. The piece seeks to advance a space of thinking on how we transition global mental health projects to be more effectively situated in a needed commitment for social justice as a remedy and repair to broken social worlds.

The Impact of Rapid Handpump Repairs on Diarrhea Morbidity in Children: Cross-Sectional Study in Kwale County, Kenya

BACKGROUND

Handpumps are used by millions of people as their main source of water. Although handpumps represent only a basic form of water provision, there have been continuous efforts to improve the performance of these systems as they are likely to remain in use for many years to come. The introduction of a professional maintenance service in southern Kenya has shown an order of magnitude improvement in operational performance over community-based management, with 90% of handpump faults repaired within 3 days of being reported. One driver behind these efforts is the assumption that a more reliable water supply will lead to a reduction in water-related disease. However, it is not clear if operational improvements lead to health gains. Despite limited empirical evidence, some modeling studies suggest that even short periods of drinking contaminated water can lead to disproportionate negative health impacts.

OBJECTIVE

The aim of this study was to assess whether the improvements in operational performance from the rapid professional maintenance of rural handpumps lead to improved household health outcomes.

METHODS

From a sample of households using handpumps as their primary water source in Kwale County, Kenya, we measured the 2-week prevalence of World Health Organization-defined diarrhea in children, reported by the adult respondent for each household. We compared the rates before and after a period during which the households' handpumps were being professionally maintained. We then conducted a cross-sectional analysis, fitting logistic regression models with reported diarrhea as the dependent variable and speed of repair as the independent exposure of interest, adjusting for household socioeconomic characteristics; dwelling construction; and Water, Sanitation, and Hygiene (WASH)-related factors. We fitted an additional model to examine select interactions between covariates.

RESULTS

Reported diarrhea in children was lower in households whose pumps had been repaired within 24 hours (adjusted odds ratio 0.35, 95% CI 0.24-0.51). This effect was robust to the inclusion of multiple categories of covariates. No reduction was seen in households whose pump repairs took more than 24 hours. Analysis of interaction terms showed that certain interventions associated with improved WASH outcomes were only associated with reductions in diarrhea in conjunction with socioeconomic improvements.

CONCLUSIONS

Only pump repairs consistently made within 24 hours of failure led to a reduction in diarrhea in the children of families using handpumps. While the efficacy of reduction in diarrhea is substantial, the operational challenges of guaranteeing same-day repairs limits the effectiveness of even best-in-class pump maintenance. Maintenance regimes that cannot bring handpump downtimes close to zero will struggle to generate health benefits. Other factors that reduce diarrhea prevalence have limited effect in isolation, suggesting that WASH interventions will be more effective when undertaken as part of more holistic poverty-reduction efforts.

Engaging stakeholders to level up COPD care in LMICs: lessons learned from the "Breathe Well" programme in Brazil, China, Georgia, and North Macedonia

BACKGROUND

Effective stakeholder engagement in health research is increasingly being recognised and promoted as an important pathway to closing the gap between knowledge production and its use in health systems. However, little is known about its process and impacts, particularly in low-and middle-income countries. This opinion piece draws on the stakeholder engagement experiences from a global health research programme on Chronic Obstructive Pulmonary Disease (COPD) led by clinician researchers in Brazil, China, Georgia and North Macedonia, and presents the process, outcomes and lessons learned.

MAIN BODY

Each country team was supported with an overarching engagement protocol and mentored to develop a tailored plan. Patient involvement in research was previously limited in all countries, requiring intensive efforts through personal communication, meetings, advisory groups and social media. Accredited training programmes were effective incentives for participation from healthcare providers; and aligning research findings with competing policy priorities enabled interest and dialogue with decision-makers. The COVID-19 pandemic severely limited possibilities for planned engagement, although remote methods were used where possible. Planned and persistent engagement contributed to shared knowledge and commitment to change, including raised patient and public awareness about COPD, improved skills and practice of healthcare providers, increased interest and support from clinical leaders, and dialogue for integrating COPD services into national policy and practice.

CONCLUSION

Stakeholder engagement enabled relevant local actors to produce and utilise knowledge for small wins such as improving day-to-day practice and for long-term goals of equitable access to COPD care. For it to be successful and sustained, stakeholder engagement needs to be valued and integrated throughout the research and knowledge generation process, complete with dedicated resources, contextualised and flexible planning, and commitment.

Mentorship as an overlooked dimension of research capacity strengthening: how to embed value-driven practices in global health

Mentorship in global health remains an overlooked dimension of research partnerships. Commitment to effective mentorship models requires value-driven approaches. This includes having an understanding of (1) what mentorship means across different cultural and hierarchical boundaries in the health research environment, and (2) addressing entrenched power asymmetries across different aspects including funding, leadership, data and outputs, and capacity strengthening. Existing guidance towards equity and sustainability fails to inform how to navigate complex relationships which hinder effective mentorship models. We focus this perspective piece on human capacity strengthening in research partnerships through mentorship. Using a case study of a research partnership, we describe the lessons learnt and the challenges faced in the mentor mentee relationship while maintaining an effective and sustainable partnership. Human capacity strengthening must research projects and collaborations, and recognise local leadership and ownership. To be transformative and effective, practices need to be driven by common values across research teams.

Colonisation and its aftermath: reimagining global surgery

Coloniality in global health manifests as systemic inequalities, not based on merit, that benefit one group at the expense of another. Global surgery seeks to advance equity by inserting surgery into the global health agenda; however, it inherits the biases in global health. As a diverse group of global surgery practitioners, we aimed to examine inequities in global surgery. Using a structured, iterative, group Delphi consensus-building process drawing on the literature and our lived experiences, we identified five categories of non-merit inequalities in global surgery. These include Western epistemology, geographies of inequity, unequal participation, resource extraction, and asymmetric power and control. We observed that global surgery is dominated by Western biomedicine, characterised by the lack of interprofessional and interspecialty collaboration, incorporation of Indigenous medical systems, and social, cultural, and environmental contexts. Global surgery is Western-centric and exclusive, with a unidirectional flow of personnel from the Global North to the Global South. There is unequal participation by location (Global South), gender (female), specialty (obstetrics and anaesthesia) and profession ('non-specialists', non-clinicians, patients and communities). Benefits, such as funding, authorship and education, mostly flow towards the Global North. Institutions in the Global North have disproportionate control over priority setting, knowledge production, funding and standards creation. This naturalises inequities and masks upstream resource extraction. Guided by these five categories, we concluded that shifting global surgery towards equity entails building inclusive, pluralist, polycentric models of surgical care by providers who represent the community, with resource controlled and governance driven by communities in each setting.

Strengthening Clinician-Researchers' Communication and Knowledge Translation Skills: An Innovative Game Model From the Breathe Well Group

Communication is a core component of a clinician's role; however, when clinicians conduct research, communicating the emerging findings and recommendations to different types of stakeholders can be unfamiliar territory. Communicating research to advocate for change can be even more challenging. Clinician researchers seeking to be agents for change need to conceive and craft specific, evidence-based messages and communicate these effectively to different stakeholders to negotiate action. As part of a global health research program, we developed and tested a novel game-based model to strengthen the communication skills of clinician researchers, from 4 countries, for improving services for chronic obstructive pulmonary disease. This model focused on communication with 3 key stakeholder groups for knowledge translation: Patients/carers, healthcare providers and policy makers/healthcare managers. Delivered through a series of facilitated, online meetings, this model consisted of 2 parts: developing and rehearsing advocacy messages with coaching support, and then testing them with a panel of 3 representative stakeholders, and an audience of fellow researchers. All the country teams reported increased confidence in crafting advocacy messages for specific stakeholders and have applied lessons learned from the model. Delivering this model within a global health research program requires mentoring, time, commitment, resources and translation support to address language barriers. It offers an exemplar to build the communication skills of clinician and non-clinician researchers so that they can go beyond dissemination toward translation of evidence into policy and practice.

Think global, act local: using a translocal approach to understand community-based organisations' responses to planetary health crises during COVID-19

Little is known on how community-based responses to planetary health crises, such as the COVID-19 pandemic, can integrate concerns about livelihoods, equity, health, wellbeing, and the environment. We used a translocal learning approach to co-develop insights on community-based responses to complex health and environmental and economic crises with leaders from five organisations working with communities at the front line of intersecting planetary health challenges in Finland, India, Kenya, Peru, and the USA. Translocal learning supports collective knowledge production across different localities in ways that value local perspectives but transcend national boundaries. There were three main findings from the translocal learning process. First, thanks to their proximity to the communities they served, community-based organisations (CBOs) can quickly identify the ways in which COVID-19 might worsen existing social and health inequities. Second, localised CBO actions are key to supporting communities with unique challenges in the face of systemic planetary health crises. Third, CBOs can develop rights-based, ecologically-minded actions responding to local priorities and mobilising available resources. Our findings show how solutions to planetary health might come from small-scale community initiatives that are well connected within and across contexts. Locally-focused globally-aware actions should be harnessed through greater recognition, funding, and networking opportunities. Globally, planetary health initiatives should be supported by applying the principles of subsidiarity and translocalism.

Assessing Use, Usefulness, and Application of the High Impact Practices in Family Planning Briefs and Strategic Planning Guides

BACKGROUND

In global health, persistent barriers and challenges to bridging the gap between research and practice remain critical to address in most health areas. The High Impact Practices (HIPs) briefs and strategic planning guides aim to bridge the know-do gap in family planning (FP) by facilitating research utilization and knowledge sharing and also providing a summary of experiential knowledge from experts. The purpose of this qualitative study was to assess the use, usefulness, and application of these 2 knowledge products developed by the HIP Partnership for decision-makers and implementers in low- and middle-income countries (LMICs).

METHODS

This research used in-depth interviews with FP stakeholders from various LMICs to assess the use, usefulness, and application of 2 HIP products for FP decision-makers and implementers. The analysis was shaped by an adapted logic model framework to assess HIP product reach, engagement, usefulness, learning, and action.

RESULTS

We interviewed 35 FP professionals from January to March 2021. Participants reported that HIP products have a wide reach, have garnered positive engagement, and were useful. Participants generally liked the current format of the HIP products and reported using them to inform program design, guide discussions with partners, enhance personal knowledge, support advocacy work, and strengthen the guidance they provide to colleagues in the field. The participants shared important feedback to improve the development and dissemination of HIP products, particularly a need to enhance local access and use.

CONCLUSION

The study highlighted the importance of knowledge products, such as the HIP briefs and strategic planning guides, to make evidence and experiential knowledge accessible to a wide audience. These can be valuable tools for policymakers and program implementers to ensure public health practices are evidence-based and integrate experiential knowledge.

Improving mental ill-health with psycho-social group interventions in South Asia-A scoping review using a realist lens

This scoping review aimed to synthesise current evidence related to psycho-social groups as part of community-based mental health interventions in South Asia. We used a realist lens to pay attention to the contexts and mechanisms supporting positive outcomes. We included studies published from January 2007 to February 2022 that: were based in communities in South Asia, included a group component, reported on interventions with a clear psychosocial component, targeted adults and were implemented by lay community health workers. Two reviewers extracted data on intervention components, groups and facilitators, participant demographics and enabling contexts, mechanisms and outcomes. Expert reference panels including people with lived experience of psycho-social disability, mental health professionals and policy makers confirmed the validity and relevance of initial review findings. The review examined 15 interventions represented by 42 papers. Only four interventions were solely psycho-social and nearly all included psychoeducation and economic support. Only 8 of the 46 quantitative outcome measures used were developed in South Asia. In a context of social exclusion and limited autonomy for people with psychosocial disability, psychosocial support groups triggered five key mechanisms. Trusted relationships undergirded all mechanisms, and provided a sense of inclusion, social support and of being able to manage mental distress due to improved skills and knowledge. Over time group members felt a sense of belonging and collective strength meaning they were better able to advocate for their own well-being and address upstream social health determinants. This led to outcomes of improved mental health and social participation across the realms of intrapersonal, interpersonal and community. Psychosocial groups merit greater attention as an active ingredient in community interventions and also as an effective, relevant, acceptable and scalable platform that can promote and increase mental health in communities, through facilitation by lay community health workers.

Using evidence in mental health policy agenda-setting in low- and middle-income countries: a conceptual meta-framework from a scoping umbrella review

The purpose of this article is to close the gap in frameworks for the use of evidence in the mental health policy agenda-setting in low- and middle-income countries (LMICs). Agenda-setting is important because mental health remains a culturally sensitive and neglected issue in LMICs. Moreover, effective evidence-informed agenda-setting can help achieve, and sustain, the status of mental health as a policy priority in these low-resource contexts. A scoping 'review of reviews' of evidence-to-policy frameworks was conducted, which followed preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Nineteen reviews met the inclusion criteria. A meta-framework was developed from analysis and narrative synthesis of these 19 reviews, which integrates the key elements identified across studies. It comprises the concepts of evidence, actors, process, context and approach, which are linked via the cross-cutting dimensions of beliefs, values and interests; capacity; power and politics; and trust and relationships. Five accompanying questions act as a guide for applying the meta-framework with relevance to mental health agenda-setting in LMICs. This is a novel and integrative meta-framework for mental health policy agenda-setting in LMICs and, as such, an important contribution to this under-researched area. Two major recommendations are identified from the development of the framework to enhance its implementation. First, given the paucity of formal evidence on mental health in LMICs, informal evidence based on stakeholder experience could be better utilized in these contexts. Second, the use of evidence in mental health agenda-setting in LMICs would be enhanced by involving a broader range of stakeholders in generating, communicating and promoting relevant information.

Cutting Edge Research? Realistic Expectations of Priorities, Scope and Engagement Comment on "'We're Not Providing the Best Care If We Are Not on the Cutting Edge of Research': A Research Impact Evaluation at a Regional Australian Hospital and Health Service"

While research is linked with informed decision-making and improved healthcare delivery and patient outcomes, the process of generating and translating research evidence in practice and capturing its impact can often be challenging. Based on document and database reviews and interviews in a regional Australian health system, Brown et al discuss the challenges of assessing the impact of research investments over a ten-year period. This commentary explores three inter-related lessons from this article for developing and sustaining a research culture and supporting translation in a health system: (i) achieving a shared definition and expectation of research; (ii) the importance of stakeholder engagement particularly for research prioritisation; and (iii) enabling research across a system. In doing so, it highlights the role and value of engaging knowledge generators and end-users from clinical, management and community domains not only in research development but most importantly in research prioritisation.

Measurement for Change: Reflections from innovators' experiences with monitoring, evaluation, and learning systems for Early Childhood Development

In this review paper, we explore how on-the-ground Early Childhood Development (ECD) innovators are using monitoring, evaluation, and learning (MEL) systems to guide the design and implementation of ECD programs, as well as how MEL systems can influence policy and support the achievement of impact at scale. We reflect on articles in the Frontiers series “Effective delivery of integrated interventions in early childhood: innovations in evidence use, monitoring, evaluation, and learning.” The 31 contributions to the series reflect the breadth and depth of complexity that characterizes ECD, including global geographic spread, with studies from Asia, Europe, Africa, and Latin America and the Caribbean. Our synthesis finds that integrating MEL processes and systems into the fabric of a program or policy initiative can broaden the underlying value proposition. Specifically, ECD organizations sought to design their MEL systems to ensure programs fit the values, goals, experiences and conceptual frameworks of diverse stakeholders, so that participating makes sense to all. For example, formative, exploratory research identified the priorities and needs of the target population and frontline service providers, and informed the content and delivery of an intervention. ECD organizations also designed their MEL systems to support a shift of accountability toward broader ownership: They included delivery agents and program participants alike as subjects rather than objects, through active participation in data collection, and by providing opportunities for equitable discussion of results and decision-making. Programs collected data to respond to specialized characteristics, priorities and needs, embedding program activities into existing day-to-day routines. Further, papers pointed to the importance of intentionally involving a variety of stakeholders in national and international dialogues to ensure that diverse ECD data collection efforts are aligned and multiple perspectives are considered in the development of national ECD policies. And, several papers illustrate the value of creative methods and measurement tools to integrate MEL into a program or policy initiative. Finally, our synthesis concludes that these findings align with the five aspirations that were formulated as part of the Measurement for Change dialogue, which motivated the launch of the series.

Making Sense of the Complexity of Decentralised Governance Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis"

The article by Rotulo and colleagues suggests that health sector fiscal decentralisation has been bad for Italy. But given the complexity of fiscal decentralisation, this interpretation is not necessarily so. Their analysis was based on assumptions about causality that are better suited for simple interventions. Assumptions of simplicity show up as misleading artefacts in the conclusion of evaluations of complex interventions. Complex interventions work by triggering mechanisms - eg, reasoning and learning processes - that manifest differently across the units of a decentralised system, contingent on context, evolving over time. Evaluation findings can only be partial and provisional; neither summarily good nor bad. The goal of evaluating a complex intervention - such as decentralised governance - should be to understand how, under what circumstances and for whom they are good or bad - at a point in time.

Assessing the World Health Organization: What does the academic debate reveal and is it democratic?

The World Health Organization (WHO), the leading global authority in public health, routinely attracts loud calls for reform. Although Member States negotiate reform internally, academic debate is more public, and can generate ideas and provide independent accountability. We investigate why authors advocate for WHO reform so commonly. We wondered if this literature had potentially useful themes for WHO, what methods and evidence were used, and we wanted to analyze the geography of participation. We conducted a systematic review using four databases to identify 139 articles assessing WHO or advocating for reform. We discuss these using categories we derived from the management literature on organizational performance. We also analyzed evidence, country of origin, and topic. The literature we reviewed contained 998 claims about WHO's performance or reform, although there were no standard methods for assessing WHO. We developed a framework to analyze WHO's performance and structure a synthesis of the claims, which find WHO imperiled. Its legitimacy and governance are weakened by disagreements about purpose, unequal Member State influence, and inadequate accountability. Contestation of goals and strategies constrain planning. Structure and workforce deficiencies limit coordination, agility, and competence. WHO has technical and normative authority, but insufficient independence and legal power to influence uncooperative states. WHO's identity claims transparency, independence, and courage, but these aspirations are betrayed in times of need. Most articles (88%) were commentaries without specified methods. More than three-quarters (76%) originated from the US, the UK, or Switzerland. A quarter of papers (25%) focused on international infectious disease outbreaks, and another 25% advocated for WHO reform generally. Many criticisms cite wide-ranging performance problems, some of which may relate to obstructive behavior by Member States. This literature is incomplete in the geographic representation of authors, evidence, methods, and topics. We offer ideas for developing more rigorous and inclusive academic debate on WHO.

Learning from women who trade sex in Kenya about the antiblackness of Global Health

Sex work and violence have become co-constituted, routinized, and even sanitized in Global Health journals dispassionately advocating for intervention. This paper situates ethnographically shared experiences of Kenyan sex working women within the global condition of antiblackness. By grounding our conceptual analytic in Black Feminist scholarship, we illustrate how antiblackness subtends the conditions of possibility for women's entry into sex work, their subsequent experiences with interpersonal and institutional forms of predatory violence, and lack of recourse for their material needs and suffering. This analysis requires a meditation on the relationships between the types of violence conditioning Kenyan women's lives and the limitations of Global Health's conceptual logics and disciplinary practice. Our discussion reflects on the ways Global Health practice can neglect conceptual foundations in antiblackness, thus complicit in upholding violence against the very groups it purports to assist. In charging Global Health "as usual" as methodologically violent and sustaining global antiblackness, we call for disciplinary transformations beginning from a shared consciousness regarding the ways global antiblackness structures health inequities. Beyond critique, our meditation is an invitation for all committed to dignified Global Health to contribute creative, non-hierarchically collaborative work engaged with those in material, structural, and immaterial need.

The RECHARGE-IPCRG ‘Teach the Teacher’ programme: building capacity for pulmonary rehabilitation in low- and middle-income countries

Introduction

Chronic respiratory diseases are the most common causes of morbidity and mortality globally. Pulmonary rehabilitation (PR) is a low-cost, high-impact intervention with patient education and exercise at its core. Although supported by a well-established evidence base, demand greatly exceeds capacity in low- and middle-income countries (LMIC), including limited workforce training opportunities to support PR development and implementation. The International Primary Care Respiratory Group’s (IPCRG) Teach the Teacher (TtT) is an established education programme designed to build sustainable local clinical teaching and delivery capacity.

Methods

A collaboration between the National Institute for Health and Care Research (NIHR) funded Global RECHARGE Group for PR and IPCRG to deliver a ‘Teach the Teacher’ (TtT) programme for PR capacity building. Our Tier 1 TtT programme combined educational and PR service development concepts with core clinical content adapted for RECHARGE partners in India (Pune and Delhi), Sri Lanka, Kyrgyzstan and Uganda. Due to the severe acute respiratory syndrome coronavirus-2 (SARS‑CoV‑2) pandemic, the programme was adapted to a digital environment using online platforms such as Zoom video conferencing and Google Classroom. We used an adapted framework to evaluate professional learning and its impact.

Findings

Fifteen Tier 1/local leader participants attended a sixteen-hour online programme in September-October 2021. Participants included nurses, physiotherapists, doctors and early career health professionals/researchers. As local leaders in PR, participants created a tiered teaching programme for developing a critical mass of PR expert teachers, contextualised to their local healthcare systems and cultures. Participants also explored how to engage and influence multiple professional groups and stakeholders to support the widespread sustainable implementation of PR.

Conclusions

The RECHARGE-IPCRG TtT programme provided a clear education and service development framework to support PR capacity development in LMIC. We address a lack of empirical evidence concerning capacity-building initiatives by being explicit about the programme’s learning design, management and evaluation. A whole system perspective to PR allowed consideration of health systems, culture, referral pathways and scalability. Sustainable national PR education programmes will require additional resources and a long-term strategy, potentially aligning with the TtT three-tier cascade model.

What is 'community resilience'? Responding to COVID-19 in rural Zimbabwe

Based on real-time recording and reflection of responses to the COVID-19 pandemic, this article identifies the features of ‘community resilience’ across sites in rural Zimbabwe. The findings confirm the importance of local knowledge, social networks and communication, as highlighted in the literature. In addition, a number of other aspects are emphasised, including the importance of adaptable livelihoods, innovation and collective learning. Flexible adaptation was especially important for responding to lockdowns, as livelihoods had to be reconfigured in response to public health measures. Meanwhile, innovation and shared learning was vital for generating local treatment responses to the disease. In the Zimbabwe context, these adaptation and innovation capabilities emerge from a particular historical experience where resilience in the face of harsh economic conditions and in the absence of state support has been generated over years. This is often a more resigned coping than a positive, empowering, transformational form of resilience. While adaptation, innovation and shared learning capabilities proved useful during the pandemic, they are not evenly spread, and there is no singular ‘community’ around which resilience emerges. The article therefore argues against seeing ‘community resilience’ as the magic bullet for disaster preparedness and response in the context of pandemics. Instead, the highly differentiated local practices of adaptation, innovation and shared learning—across gender, age and wealth differences—should be seen as an important complement to public, state-led support in health emergencies and so are part of a wider, plural health system.

The Kenya UK Breast Cancer Awareness Week: curriculum codesign and codelivery with direct and lived experience of breast cancer diagnosis and management

Global health education holds a paradox: the provision of global health degrees focusing on challenges in low-income and middle-income countries has increased in high-income countries, while those in these low-income and middle-income countries lack access to contribute their expertise, creating an 'information problem'. Breast cancer is a pressing global health priority, which requires curriculum design, implementation, ownership and leadership by those with direct and lived experience of breast cancer.The Kenya-UK Breast Cancer Awareness Week was conceptualised following the signing of the Memorandum of Understanding between the Kenyan and UK governments launching the Kenya UK Health Alliance. This alliance aims to promote health cooperation to address Kenya's breast cancer challenge. Here, we present the first of the collaborative's initiatives: a breast cancer global health education programme designed, implemented, owned and led by Kenyan stakeholders.We present the utilisation of the Virtual Roundtable for Collaborative Education Design for the design and implementation of a nationwide virtual breast cancer awareness week delivered across eleven Kenyan medical schools. By involving partners with lived and/or professional experience of breast cancer in Kenya in all stages of the design and delivery of the awareness week, the project experimented with disrupting power dynamics and fostered ownership of the initiative by colleagues with direct expertise of breast cancer in Kenya.This initiative provides a platform, precedent and playbook to guide professionals from other specialties in the design and implementation of similar global collaborative ventures. We have used this approach to continue to advocate for global health curricula design change, so that those with lived experiences of global health challenges in their contextualised professional and personal environments are given leadership, reward and ownership of their curricula and further to highlight breast cancer as a global heath priority.

How to identify epistemic injustice in global health research funding practices: a decolonial guide

Epistemic injustice is a growing area of study for researchers and practitioners working in the field of global health. Theoretical development and empirical research on epistemic injustice are crucial for providing more nuanced understandings of the mechanisms and structures leading to the exclusion of local and marginalised groups in research and other knowledge practices. Explicit analysis of the potential role of epistemic injustice in policies and practices is currently limited with the absence of methodological starting points. This paper aims to fill this gap in the literature by providing a guide for individuals involved in the design and review of funding schemes wishing to conduct epistemic injustice analysis of their processes using a decolonial lens. Placing contemporary concerns in a wider historical, political and social context and building from the intertwined issues of coloniality of power, coloniality of knowledge and coloniality of being that systematically exclude non-Western epistemic groups, this practice paper presents a three-step decolonial approach for understanding the role and impact of epistemic injustices in global health research funding. It starts with an understanding of how power operates in setting the aim of a call for research proposals. Then, the influence of pose and gaze in the review process is analysed to highlight the presence of epistemological colonisation before discussing methods to address the current funding asymmetries by supporting new ways of being and doing focused on knowledge plurality. Expanding research on how epistemic wrongs manifest in global health funding practices will generate key insights needed to address underlying drivers of inequities within global health project conception and delivery.

Strengthening research capacity: a systematic review of manuscript writing and publishing interventions for researchers in low-income and middle-income countries

INTRODUCTION

Health researchers from low-income and middle-income countries (LMICs) are under-represented in the academic literature. Scientific writing and publishing interventions may help researchers publish their findings; however, we lack evidence about the prevalence and effectiveness of such interventions. This review describes interventions for researchers in LMICs aimed at strengthening capacity for writing and publishing academic journal articles.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report literature searches in PubMed, Embase, Global Health, Scopus and ERIC. Our keywords included LMICs, low-income and middle-income countries, health research and writing/publication support interventions, with no restrictions on publication date. Our screening process consisted of title screening, abstract review and full-text review. We collected information about the content, implementation and evaluation of each intervention, if included.

RESULTS

We identified 20 interventions designed to strengthen capacity for scientific writing and publishing. We summarised information from the 14 interventions that reported submitted or published papers as outcomes separately, reasoning that because they provide quantifiable metrics of success, they may offer particular insights into intervention components leading to publication. The writing and publishing components in this 'Publications Reported' group were an average length of 5.4 days compared with 2.5 days in the other group we refer to as 'Other Interventions.' Whereas all 14 Publications Reported interventions incorporated mentors, only two of five in the Other Interventions group incorporated mentors. Across interventions, leaders expressed the importance of a high ratio of mentors to participants, the need to accommodate time demands of busy researchers, and the necessity of a budget for open access fees and high-quality internet connectivity.

CONCLUSION

Writing and publishing interventions in LMICs are an underutilised opportunity for capacity strengthening. To facilitate the implementation of high-quality interventions, future writing and publishing interventions should share their experiences by publishing detailed information about the approach and effectiveness of the interventions.

Power analysis in health policy and systems research: a guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

'You want to deal with power while riding on power': global perspectives on power in participatory health research and co-production approaches

INTRODUCTION

Power relations permeate research partnerships and compromise the ability of participatory research approaches to bring about transformational and sustainable change. This study aimed to explore how participatory health researchers engaged in co-production research perceive and experience 'power', and how it is discussed and addressed within the context of research partnerships.

METHODS

Five online workshops were carried out with participatory health researchers working in different global contexts. Transcripts of the workshops were analysed thematically against the 'Social Ecology of Power' framework and mapped at the micro (individual), meso (interpersonal) or macro (structural) level.

RESULTS

A total of 59 participants, with participatory experience in 24 different countries, attended the workshops. At the micro level, key findings included the rarity of explicit discussions on the meaning and impact of power, the use of reflexivity for examining assumptions and power differentials, and the perceived importance of strengthening co-researcher capacity to shift power. At the meso level, participants emphasised the need to manage co-researcher expectations, create spaces for trusted dialogue, and consider the potential risks faced by empowered community partners. Participants were divided over whether gatekeeper engagement aided the research process or acted to exclude marginalised groups from participating. At the macro level, colonial and 'traditional' research legacies were acknowledged to have generated and maintained power inequities within research partnerships.

CONCLUSIONS

The 'Social Ecology of Power' framework is a useful tool for engaging with power inequities that cut across the social ecology, highlighting how they can operate at the micro, meso and macro level. This study reiterates that power is pervasive, and that while many researchers are intentional about engaging with power, actions and available tools must be used more systematically to identify and address power imbalances in participatory research partnerships, in order to contribute to improved equity and social justice outcomes.

Refining circumstances of mortality categories (COMCAT): a verbal autopsy model connecting circumstances of deaths with outcomes for public health decision-making

BACKGROUND

Recognising that the causes of over half the world's deaths pass unrecorded, the World Health Organization (WHO) leads development of Verbal Autopsy (VA): a method to understand causes of death in otherwise unregistered populations. Recently, VA has been developed for use outside research environments, supporting countries and communities to recognise and act on their own health priorities. We developed the Circumstances of Mortality Categories (COMCATs) system within VA to provide complementary circumstantial categorisations of deaths.

OBJECTIVES

Refine the COMCAT system to (a) support large-scale population assessment and (b) inform public health decision-making.

METHODS

We analysed VA data for 7,980 deaths from two South African Health and Socio-Demographic Surveillance Systems (HDSS) from 2012 to 2019: the Agincourt HDSS in Mpumalanga and the Africa Health Research Institute HDSS in KwaZulu-Natal. We assessed the COMCAT system's reliability (consistency over time and similar conditions), validity (the extent to which COMCATs capture a sufficient range of key circumstances and events at and around time of death) and relevance (for public health decision-making).

RESULTS

Plausible results were reliably produced, with 'emergencies', 'recognition, 'accessing care' and 'perceived quality' characterising the majority of avoidable deaths. We identified gaps and developed an additional COMCAT 'referral', which accounted for a significant proportion of deaths in sub-group analysis. To support decision-making, data that establish an impetus for action, that can be operationalised into interventions and that capture deaths outside facilities are important.

CONCLUSIONS

COMCAT is a pragmatic, scalable approach enhancing functionality of VA providing basic information, not available from other sources, on care seeking and utilisation at and around time of death. Continued development with stakeholders in health systems, civil registration, community and research environments will further strengthen the tool to capture social and health systems drivers of avoidable deaths and promote use in practice settings.

Whose voices should shape global health education? Curriculum codesign and codelivery by people with direct expertise and lived experience

There are contrasting opinions of what global health (GH) curricula should contain and limited discussion on whose voices should shape it. In GH education, those with first-hand expertise of living and working in the contexts discussed in GH classrooms are often absent when designing curricula. To address this, we developed a new model of curriculum codesign called Virtual Roundtable for Collaborative Education Design (ViRCoED). This paper describes the rationale and outputs of the ViRCoED approach in designing a new section of the Global Health Bachelor of Science (BSc) curriculum at Imperial College London, with a focus on healthcare in the Syrian conflict. The team, importantly, involved partners with lived and/or professional experience of the conflict as well as alumni of the course and educators in all stages of design and delivery through to marking and project evaluation. The project experimented with disrupting power dynamics and extending ownership of the curriculum beyond traditional faculty by codesigning and codelivering module contents together with colleagues with direct expertise and experience of the Syrian context. An authentic approach was applied to assessment design using real-time syndromic healthcare data from the Aleppo and Idlib Governorates. We discuss the challenges involved in our collaborative partnership and describe how it may have enhanced the validity of our curriculum with students engaging in a richer representation of key health issues in the conflict. We observed an enhanced self-reflexivity in the students’ approach to quantitative data and its complex interpretation. The dialogic nature of this collaborative design was also a formative process for partners and an opportunity for GH educators to reflect on their own positionality. The project aims to challenge current standards and structures in GH curriculum development and gesture towards a GH education sector eventually led by those with lived experience and expertise to significantly enhance the validity of GH education.

Epistemic injustice in academic global health

This Viewpoint calls attention to the pervasive wrongs related to knowledge production, use, and circulation in global health, many of which are taken for granted. We argue that common practices in academic global health (eg, authorship practices, research partnerships, academic writing, editorial practices, sensemaking practices, and the choice of audience or research framing, questions, and methods) are peppered with epistemic wrongs that lead to or exacerbate epistemic injustice. We describe two forms of epistemic wrongs, credibility deficit and interpretive marginalisation, which stem from structural exclusion of marginalised producers and recipients of knowledge. We then illustrate these forms of epistemic wrongs using examples of common practices in academic global health, and show how these wrongs are linked to the pose (or positionality) and the gaze (or audience) of producers of knowledge. The epistemic injustice framework shown in this Viewpoint can help to surface, detect, communicate, make sense of, avoid, and potentially undo unfair knowledge practices in global health that are inflicted upon people in their capacity as knowers, and as producers and recipients of knowledge, owing to structural prejudices in the processes involved in knowledge production, use, and circulation in global health.