Promoting equity through health systems research in low- and middle-income countries: Practices of researchers

ABSTRACT

Background: Health systems research is increasingly identified as an indispensable means to achieve the goal of health equity between and within countries. While conceptual work has explored what form of health systems research in low and middle-income countries (LMICs) is needed to promote health equity, there have been few attempts to investigate whether it is being performed in practice. Methods: This paper describes the results of a survey undertaken with health systems researchers worldwide (n = 104) to assess how equity-oriented current practice is in LMICs. Respondents were asked to answer all survey questions in relation to the externally-funded health systems research project in a LMIC(s) on which they had spent the most time during the past five years—referred to as the “index study.” Results: Data analysis indicates that 30% of respondents participated in health systems research focused on populations in LMICs that are worst-off in terms of their health. All respondents participated in research that focused on improving equity in at least one aspect of health systems (e.g. service utilisation, quality of care, insurance coverage). Actors solely from high-income countries (principal investigators, co-investigators, funders) were primarily responsible for selecting research questions in 36% of index studies. 28% of studies that involved collaboration resulted in LMIC researchers being awarded a graduate degree. The most common forms of institutional capacity-building in collaborative studies were increased links with policymakers (72%), increased links with other institutions (64%), and the training of researchers in HSR (51%). Of the completed intervention studies that demonstrated efficacy, 50% of those interventions had been implemented poststudy and 25% would be implemented soon. Conclusions: These findings suggest that health systems research in LMICs is equity oriented in some respects, but has clear room for improvement, particularly in terms of the selection of populations upon whom to focus studies.

KEYWORDS:

• bioethics
• empirical research
• public health
• survey

Conflicts of interest

None.

Acknowledgments

We are grateful to the Hecht–Levi Fellowship program at the Berman Institute of Bioethics (where BP was a fellow at the time of this project) and to the anonymous referees for their valuable comments on previous versions of this article.

Author contributions

BP conceived of the study and led the development of the survey instrument. AAH contributed to the development of the survey instrument. BP collected the data. BP, AAH, and KAA worked together to develop a data analysis strategy. KAA conducted the analysis of the data. BP wrote the first draft of the article. BP, AAH, and KAA each critically revised the article for important intellectual content and gave final approval for the version to be published.

Ethical approval

This study was approved by the institutional review board(s) at Johns Hopkins Bloomberg School of Public Health.

Funding

BP is supported by an Australian National Health and Medical Research Council (NHMRC) Early Career Sidney Sax Public Health Overseas Fellowship (award 1052346). The contents of this article are solely the responsibility of the authors and do not reflect the views of the NHMRC. BP is supported by the Berman Institute of Bioethics as a Hecht–Levi Fellow. AAH and BP are also supported by the Future Health Systems Initiative, which is funded by the UK Department for International Development.

Notes

¹ Health capabilities refer to individual ability and freedom to achieve certain health functionings (i.e., avoiding preventable morbidity and mortality) and health agency (i.e., the ability to make effective health choices) (Ruger 2010).

² Here, the worst off refers to those who are worst off in terms of their health, that is, those who experience a substantial gap in their health status from the optimal level (the highest level of health achieved worldwide in terms of morbidity and mortality indicators) (Ruger 2010).

³ The “research for health justice” requirement that HSR questions be determined through an inclusive process involving disadvantaged populations from host countries is demanding but essential. HSR is a context-driven field. This means it should be driven by an understanding of local contexts because health systems are complex social systems that vary widely between countries. For HSR to generate information that will improve health systems for disadvantaged populations, it is therefore vital for researchers to consult with such populations when selecting research questions. Doing so will enable researchers to identify how these populations’ particular health systems are not meeting their needs.

⁴ In addition, the sampling frame included researchers from the AHPSR database on HSR projects, which could be found on its website at the time of our study in May 2014. (It can no longer be found on the AHPSR website.)

⁵ Of the e-mails that bounced, the vast majority (45) were for researchers from Asia, as 35 e-mails directed to researchers at a particular institution in India failed to work. (However, not all emails directed to researchers at this institution failed. Some e-mails did reach their targets.) Overall, 66 of the emails that bounced were for researchers at LMIC institutions and 8 were for researchers at high-income country institutions.

⁶ Dimensions of equity were derived based on the fact that the health capability paradigm identifies two main components of just health systems: (1) equal access and (2) progressively financed universal health insurance. Equal access consists of four core elements: horizontal equity, quality, agency, and norms. Health care should be distributed in proportion to individuals’ health needs. People should not receive unequal levels of care due to differences in their ability to pay, gender, living in a rural area, working in the informal sector, or other such attributes. Equal access also entails that the quality of health care accessed by various subpopulations within a country should be the same. Equal access means that societies must promote the conditions for health agency, so that individuals are able to make informed judgements and take effective action to be healthy.

⁷ Health agency refers to the ability to make effective health choices and to navigate one's health system.