Barriers to sustainable health research leadership in the Global South: Time for a Grand Bargain on localization of research leadership?

BACKGROUND

Strong Global South (GS) health research leadership, itself both dependent on and a requisite for strong health research systems, is essential to generate locally relevant research and ensure that evidence is translated into policy and practice. Strong GS health research systems and leadership are important for health development and in turn for strong health systems. However, many GS countries struggle to produce research and to improve performance on widely used research metrics measuring productivity and reflecting leadership. Drawing on literature from a rapid review, this viewpoint paper considers the barriers to GS health research leadership and proposes strategies to address these challenges.

FINDINGS

GS researchers and institutions face numerous barriers that undermine health research leadership potential. Barriers internal to the GS include researcher-level barriers such as insufficient mentorship, limited financial incentives and time constraints. Institutional barriers include limited availability of resources, restrictive and poorly developed research infrastructures, weak collaboration and obstructive policies and procedures. Structural barriers include political will, politicization of research and political instability. External barriers relate to the nature and extent of Global North (GN) activities and systems and include allocation and distribution of funding and resources, characteristics and focus of GN-GS research collaborations, and publication and information dissemination challenges.

CONCLUSIONS

Strengthening GS health research leadership requires acknowledgement of the many barriers, and adoption of mitigating measures by a range of actors at the institutional, national, regional and global levels. Particularly important are leadership capacity development integrating researcher, institutional and systems initiatives; new GN-GS partnership models emphasizing capacity exchange and shared leadership; supporting GS research communities to set, own and drive their research agendas; addressing biases against GS researchers; ensuring that GS institutions address their internal challenges; enhancing South-South collaborations; diversifying research funding flow to the GS; and learning from models that work. The time has come for a firm commitment to improving localization of research leadership, supported by adequate funding flow, to ensure strong and sustainable research systems and leadership in and from the GS. Just as the humanitarian donor and aid community adopted the Grand Bargain commitment to improve funding flow through local and national responders in times of crisis, we strongly urge the global health research community to adopt a Grand Bargain for research leadership.

Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria

BACKGROUND

The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict.

METHODS

As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria.

RESULTS

Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria.

CONCLUSIONS

Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.

A Generation at Risk: The Impacts of Lebanon's Escalating Humanitarian Crisis on Children

Lebanon is in the midst of a rapidly escalating, unprecedented humanitarian crisis that is plunging the country deep into poverty and threatens population well-being, economic development, social welfare and national and regional stability. The dire situation is due to the compounding effects of the August 2020 Beirut blast, massive economic collapse and the COVID-19 pandemic, in a setting of longstanding entrenched political corruption and a dysfunctional, mismanaged crisis response by the state. This current emergency occurs on the background of a turbulent history and complex regional geopolitical context – including the Syrian refugee crisis, the ongoing influence of foreign actors and their local proxies, the United-States-imposed sanctions, endemic corruption, a culture of nepotism and entitlement among the political dynasties, dysfunctional power-sharing and deep-seated sectarian divides. With over half the population now living in poverty, a generation of children are among those at risk. This Perspective provides a brief overview of Lebanon's current complex humanitarian crisis, discusses the impacts of the evolving situation on youth and proposes a suite of recommendations to mitigate the effects.

Policies on return and reintegration of displaced healthcare workers towards rebuilding conflict-affected health systems: a review for The Lancet-AUB Commission on Syria

Background

War and armed conflicts severely disrupt all health system components, including the healthcare workforce. Although data is limited on the scale of health care worker (HCW) displacement in conflict zones, it is widely acknowledged that conflict conditions result in the displacement of a significant portion of qualified HCWs from their country of origin. While voluntary HCW return is integral to health system rebuilding in conflict-affected and post-conflict settings, there has been little exploration of the nature of national or international policies which encourage HCW return and reintegration to their home countries in the post-conflict period.

Methods

We conducted a systematic review to identify policies and policy recommendations intended to facilitate the return of displaced HCWs to their home countries and acknowledge their contribution to rebuilding the post-conflict health system. We searched three bibliographic databases and a range of organisational and national health agency websites to identify peer-reviewed articles and grey literature published in English or Arabic between 1 January 1990 to 24 January 2021, and extracted relevant information. We classified policies and policy recommendations using an adapted version of the UNHCR 4Rs Framework.

Results

We identified nine peer-review articles and four grey literature reports that fit our inclusion criteria, all of which were published in English. These covered issues of repatriation (n = 3), reintegration (n = 2), health system rehabilitation and reconstruction (n = 2); six documents covered several of these themes. Information was available for nine conflict contexts: Afghanistan, Iraq, Kosovo, Lebanon, Namibia, Northern Uganda, South Sudan, Timor Leste, and Zimbabwe. Findings demonstrate that health system rebuilding and rehabilitation serve as precursors and reinforcers of the successful return, repatriation, and reintegration of displaced HCWs.

Conclusions

Despite the significant numbers of HCWs displaced by conflict, this study identified few specific policies and limited information explicitly focused on the repatriation and reintegration of such workers to their home country in the post-conflict period. Additional research is needed to understand the particular barriers faced by conflict-displaced HCWs in returning to their home country. Conflict-affected and post-conflict states should develop policies and initiatives that address factors within and beyond the health sector to encourage displaced HCW return and provide sustainable reintegration solutions for those who return to post-conflict health systems.

Experiences of healthcare workers displaced by conflict: lessons from past conflicts and implications

Background

Conflicts cause mass displacement, including of healthcare workers (HCWs). Understanding experiences of HCWs over the displacement trajectory, from push factors out of conflict zones, to barriers and facilitators in transit and host countries, is key to developing support mechanisms and informing policy discussions regarding return and reintegration.

Methodology

We systematically reviewed 6 academic databases and grey literature using combined search terms for HCWs, displacement, conflict, and experiences to identify English-language literature documenting personal or professional experiences of HCWs displaced by conflict, published between 1945 to 2020. Open coding and thematic analysis were used to identify emerging themes. Quality appraisal was conducted.

Results

25 publications from academic journals, snowballed references, and grey literature from 10 geographical contexts and various types of HCW met inclusion criteria, many from conflicts in the Middle-East. 5 themes emerged: Conflict drives displacement: HCWs fled due to direct violence and deteriorating working conditions caused by increased workload, depleting resources, workforce attrition and attacks on healthcare. Giving back: Refugee HCWs were determined to continue working but had to do so informally or by working with humanitarian agencies. Personal and professional integration in host countries: refugee HCWs overcame barriers to relicense after which they reported disadvantage in job applications due to professional gaps and discrimination; many ended up working under-qualified jobs. Psychological toll on HCWs was pronounced. Prospects on return: HCWs desired to return to their home countries but feared political instability and violence.

Conclusions

Policies which support HCW retention during conflict, integration into host health systems, and encourage return post-conflict must be implemented. Further research is required to understand the individual and systemic support mechanisms required.

Key messages

Displaced HCWs experience many personal and professional challenges. Policies that support HCWs across the displacement trajectory and support return and post-conflict system rebuilding are required.

Time to tackle rheumatic heart disease: Data needed to drive global policy dialogues

Rheumatic heart disease (RHD) is an avoidable disease of poverty that persists predominantly in low resource settings and among Indigenous and other high-risk populations in some high-income nations. Following a period of relative global policy inertia on RHD, recent years have seen a resurgence of research, policy and civil society activity to tackle RHD; this has culminated in growing momentum at the highest levels of global health diplomacy to definitively address this disease of disadvantage. RHD is inextricably entangled with the global development agenda, and effective RHD action requires concerted efforts both within and beyond the health policy sphere. This report provides an update on the contemporary global and regional policy landscapes relevant to RHD, and highlights the fundamental importance of good data to inform these policy dialogues, monitor systems responses and ensure that no one is left behind.

Rheumatic heart disease across the Western Pacific: not just a Pacific Island problem

Some of the highest recorded rheumatic heart disease (RHD) prevalence and mortality rates are from the World Health Organization’s Western Pacific Region (WPR). RHD burden has been well documented in much of the WPR subregion of Oceania, but less is known about RHD outside the Pacific Islands and Australasia. We aimed to review RHD burden in WPR outside Oceania to identify countries with high RHD burden and those with contemporary data gaps. We searched the peer-reviewed literature for English-language primary studies published between 1980 and April 2017 that reported RHD prevalence or mortality in the 13 WPR countries/areas outside Oceania, and Taiwan. We also searched for official government reports and health indicator documents. Results were synthesised narratively and reported stratified by 2015 Human Development Index (HDI) level. 30 peer-reviewed publications fulfilling inclusion criteria were identified, representing nine countries/areas. RHD prevalence and mortality have fallen in association with economic development, particularly in very high HDI countries. In several countries that have undergone recent economic development, RHD persists particularly among older populations. In poorer WPR countries there is a persistent RHD burden, including in young populations. Some countries had no available data. Although RHD burden has declined in many high-resource settings across the WPR, in several poorer countries, the impact of RHD appears to continue. Elsewhere, insufficient contemporary data make it difficult to gauge the current status of RHD burden and control. Concerted efforts are needed to fill information gaps and implement action to address this avoidable disease.

Impact of diabetes on eye care service needs: the National Indigenous Eye Health Survey

BACKGROUND

To assess the proportion of Australian Indigenous adults who require eye care services (separately among those with and without diabetes) and determine implications for eye care service planning.

DESIGN

The National Indigenous Eye Health Survey (NIEHS) was a population-based study of 30 randomly selected geographical areas.

PARTICIPANTS

The NIEHS included 1189 Indigenous adults aged 40-80 years.

METHODS

A standardized eye examination was performed.

MAIN OUTCOME MEASURE

The number requiring eye care services by diabetes status.

RESULTS

Those with diabetes were older (median 53 years) than those without diabetes (median age 50 years), P < 0.001. The total estimated population-based need for annual eye care in the NIEHS population was 52% (n = 615), and of those 72% were people with diabetes. Among those with diabetes, 29% required further primary referral for diabetic retinopathy, 12% for cataract, 1% for trachomatous trichiasis and 5% for uncorrected distance refractive error. Among those without diabetes 13% required further primary referral for cataract, 0% for trachomatous trichiasis and 5% for uncorrected distance refractive error.

CONCLUSION

This study has shown that among Indigenous adults, those with diabetes form 72% of those requiring an eye examination in any year. A key strategy to close the gap for vision for Australia's Indigenous population is to ensure those with diabetes undergo annual eye screening, have clearly defined care pathways and receive timely treatment. Establishing care pathways for those who have diabetes would also improve access to eye care services for others in the community.

A population-based observational study of diabetes during pregnancy in Victoria, Australia, 1999-2008

OBJECTIVES

This paper reports secular trends in diabetes in pregnancy in Victoria, Australia and examines the effect of including or excluding women with pre-existing diabetes on gestational diabetes (GDM) prevalence estimates.

DESIGN

Population-based observational study.

SETTING

All births in Victoria, Australia between 1999 and 2008 PARTICIPANTS: 634,932 pregnancies resulting in a birth registered with the Victorian Perinatal Data Collection

OUTCOME MEASURES

Crude and age-standardised secular trends in pre-existing diabetes and GDM prevalence; secular GDM trends by maternal birthplace; effects on GDM prevalence of including and excluding pre-existing diabetes from the denominator.

RESULTS

Of the 634,932 pregnancies, 2954 (0.5%) occurred in women with pre-existing diabetes and 29,147 (4.6%) were complicated by GDM. Mean maternal age increased from 29.7 years in 1999 to 30.8 years in 2008. GDM prevalence increased in most maternal age groups. In 2008, age-standardised GDM prevalence was 31% higher than in 1999; secular increases were greater for Australian-born non-Indigenous (29% increase) than immigrant women (12.3% increase). The annual number of pregnancies in women with pre-existing diabetes almost doubled from 1999 to 2008 and prevalence increased from 0.4% to 0.6%. However, including or excluding pre-existing diabetes had little effect on GDM prevalence estimates.

CONCLUSIONS

Pre-existing diabetes and GDM prevalence increased in Victoria between 1999 and 2008 and rising maternal age does not fully explain these trends. These findings have important implications for preventive initiatives. Including or excluding small numbers of women with pre-existing diabetes resulted in minimal changes in GDM estimates. As pre-existing diabetes in young women increases, this methodological issue will likely become important.

The potential for measuring ethnicity and health in a multicultural milieu--the case of type 2 diabetes in Australia

OBJECTIVE

Ethnicity influences health in many ways. For example, type 2 diabetes (T2DM) is disproportionately prevalent among certain ethnic groups. Assessing ethnicity is difficult, and numerous proxy measures are used to capture its various components. Australian guidelines specify a set of variables for measuring ethnicity, and how such parameters should be categorised. Using T2DM data collections as an illustrative example, this study sought to examine how ethnicity is measured in Australian health databases and, by comparing current practice with Australia's existing benchmark recommendations, to identify potential areas for improvement of the health data landscape.

DESIGN

We identified databases containing information from which ethnic group-specific estimates of T2DM burden may be gleaned. For each database, details regarding ethnicity variables were extracted, and compared with the Australian guidelines.

RESULTS

Data collection instruments for 32 relevant databases were reviewed. Birthplace was recorded in 27 databases (84%), but mode of birthplace assessment varied. Indigenous status was commonly recorded (78%, n=25), but only nine databases recorded other aspects of self-perceived race/ethnicity. Of 28 survey/audit databases, 14 accommodated linguistic preferences other than English, and 11 either excluded non-English speakers or those for whom a translator was not available, or only offered questionnaires in English.

CONCLUSIONS

Considerable variation exists in the measurement of ethnicity in Australian health data-sets. While various markers of ethnicity provide complementary information about the ethnic profile within a data-set, non-uniform measurement renders comparison between data-sets difficult. A standardised approach is necessary, and identifying the ethnicity variables that are particularly relevant to the health sector is warranted. Including self-identified ethnicity in Australia's set of recommended indicators and as a core component of the national census should be considered. Globalisation and increasing migration mean that these findings have implications internationally, including for multi-ethnic countries throughout North America and Europe.

Type 2 diabetes prevalence varies by socio-economic status within and between migrant groups: analysis and implications for Australia

BACKGROUND

Ethnic diversity is increasing through migration in many developed countries. Evidence indicates that type 2 diabetes mellitus (T2DM) prevalence varies by ethnicity and socio-economic status (SES), and that in many settings, migrants experience a disproportionate burden of disease compared with locally-born groups. Given Australia's multicultural demography, we sought to identify groups at high risk of T2DM in Victoria, Australia.

METHODS

Using population data from the Australian National Census and diabetes data from the National Diabetes Services Scheme, prevalence of T2DM among immigrant groups in Victoria in January 2010 was investigated, and prevalence odds versus Australian-born residents estimated. Distribution of T2DM by SES was also examined.

RESULTS

Prevalence of diagnosed T2DM in Victoria was 4.1% (n = 98671) in men and 3.5% (n = 87608) in women. Of those with T2DM, over 1 in 5 born in Oceania and in Southern and Central Asia were aged under 50 years. For both men and women, odds of T2DM were higher for all migrant groups than the Australian-born reference population, including, after adjusting for age and SES, 6.3 and 7.2 times higher for men and women born in the Pacific Islands, respectively, and 5.2 and 5.0 times higher for men and women born in Southern and Central Asia, respectively. Effects of SES varied by region of birth.

CONCLUSIONS

Large socio-cultural differences exist in the distribution of T2DM. Across all socio-economic strata, all migrant groups have higher prevalence of T2DM than the Australian-born population. With increasing migration, this health gap potentially has implications for health service planning and delivery, policy and preventive efforts in Australia.

A review of population-based prevalence studies of physical activity in adults in the Asia-Pacific region

BACKGROUND

Physical activity (PA) surveillance is an important component of non-communicable disease risk factor monitoring, and occurs through national and international surveillance systems. This review identifies population PA estimates for adults in the Asia-Pacific region, and examines variation in trends and prevalence rates obtained using different PA measures.

METHODS

Data were obtained from a MEDLINE search; World Health Organization's Global Health Infobase; Government websites and reference lists of relevant papers. Inclusion criteria included: national studies or those reporting large scale population-level data; data published from 2000 to 2010 and trend data prior; sample sizes over n = 1000, or fewer subjects in small nations.

RESULTS

In total, 56 population surveys from 29 Asia-Pacific countries were identified. Data on 'sufficient physical activity' amongst adults were available from 45 studies (80%), with estimates ranging from 7% to 93% (median 62%, inter-quartile range 40%-85%). For 14 countries, estimates of 'sufficient activity' were documented in multiple surveys using different methods, with the largest variation from 18% to 92% in Nepal. Median or mean MET-minutes/day, reported in 20 studies, ranged from 6 to 1356. Serial trend data were available for 11 countries (22%), for periods spanning 2-10 years. Of these, five countries demonstrated increases in physical activity over time, four demonstrated decreases and three showed no changes.

CONCLUSIONS

Many countries in the Asia-Pacific region collect population-level PA data. This review highlights differences in estimates within and between countries. Some differences may be real, others due to variation in the PA questions asked and survey methods used. Use of standardized protocols and measures, and combined reporting of data are essential goals of improved international PA surveillance.

Malignant transformation in congenital sebaceous naevi in childhood

Sebaceous naevi are uncommon congenital skin lesions with a well-recognised potential for neoplastic change. They should be considered premalignant lesions as malignant degeneration, most commonly basal cell carcinoma and squamous cell carcinoma, occurs with a lifetime risk of between 5% and 22%. This incidence is equal to that of actinic keratosis and exceeds that of oral leukoplakia. Such change, however, is rare before puberty. Basal cell carcinoma may develop in children with naevoid basal cell carcinoma syndrome, xeroderma pigmentosum and rarely de novo but sebaceous naevus is the only solitary lesion in childhood associated with the development of basal cell carcinoma. We present two cases of malignant transformation in a congenital sebaceous naevus occurring in childhood and review the literature and discuss the evidence upon which to base management guidelines.