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International Health

Health Systems Program

The African Bioethics Consortium* has released a toolkit to aid in evaluating the operational needs of Research Ethics Committees (RECs). The tool, called the Research Ethics Committee Assessment Toolkit, or RECAT, was created to facilitate efficient, high quality ethics review of research protocols in any setting.

The RECAT can be used by RECs—also known as Institutional Review Boards (IRBs)—to identify:

  1. Baseline operational conditions of a REC
  2. Areas for the development of targeted interventions to improve REC functioning 
  3. Change in REC quality and efficiency over time across multiple domains

The evaluation process combines data gathered through various methods, including interviews, focus groups, document review, and direct observation. This mixed methods approach allows the assessment to capture both written policies and procedures of the REC as well as actual day-to-day practices. It incorporates perspectives from multiple key stakeholders including: institutional leadership, REC chairpersons, REC administrators, REC members, and researchers who submit applications to the REC. Data collection checklists and templates, section-by-section instructions, and sample reports are included in the toolkit.

The RECAT also provides a detailed reporting template, and sample report, to help evaluators organize the collected information around core areas and identify the resources needed to address committee needs.  

The toolkit is published open-access and can be used free of charge for non-commercial purposes. The developers would appreciate feedback on users’ experiences with the RECAT in order to make improvements.  Feedback can be sent via email to jali@jhu.edu.

*The African Bioethics Consortium’s members include the Johns Hopkins University-Fogarty African Bioethics Training Program, the University of Zambia School of Medicine, the University of Botswana Office of Research & Development, and the Makerere University College of Health Sciences. 

Dr. Henry Perry, senior scientist in the Health Systems Program, and his colleagues recently published a major new series of articles published in the Journal of Global Health on the evidence of the effectiveness of community-based primary health care (CBPHC). The new series, published in July 2017, is a comprehensive review that describes all of the findings that assess the effectiveness of CBPHC in defined geographic populations for maternal, neonatal and child health (MNCH).

The comprehensive review is 10 years in the making and is comprised of 700 documents, going as far back as 1950. Community-based primary health care has been growing slowly in importance over the last 50 years, and while rigorous evidence of its effectiveness has increased substantially in recent years, international organizations have been slow to invest in capacity-building for successful CBPHC programs.

The series summarizes the extensive evidence that demonstrates that MNCH can be improved through community-based approaches such as use of community health workers and volunteers, and community engagement for planning, implementation and evaluation.

One of the major findings from this comprehensive review focuses on the implications for the health-related sustainable development goals (SDGs). In order to fulfill the SDGs of universal health care coverage and ending preventable maternal, neonatal and child deaths by 2030, greater investments in community-based primary health care will be required.

The majority of health care funding in low-income countries currently goes for services provided at health facilities. However, the evidence that investments in health facilities alone without investments in CBPHC will reduce mortality in geographically-defined populations is extremely limited. In resource-constrained settings, the mothers and children that do obtain care at health facilities tend to be those who are better-off and live closer to the facility. CBPHC fulfills the SDG equity indicators by expanding access to basic services in areas where facilities are often far away.

One example of a successful, national, community-based health care program is in Ethiopia, where over the past 15 years marked improvements have been achieved through the deployment of 40,000 salaried community health workers with one year of formal training (health extension workers) and three million volunteer community health workers (called the Health Development Army). Ethiopia has become a global leader in CBPHC and has recently established the International Institute for Primary Health Care in Ethiopia (IIfPHC-E), which will provide opportunities for training and research in primary health care with a focus on community-based approaches. Faculty at Johns Hopkins Bloomberg School of Public Health, including Dr. Perry, are supporting Ethiopia’s Ministry of Health in this effort so that Ministries of Health in other countries can learn how to strengthen their own primary health care system.

The journal series is publicly available online, (see Research Theme 5), and will also be published soon as a book that will be sold on Amazon. In addition to Dr. Perry, 150 other students, researchers and experts were involved in this project, including Department of International Health faculty Drs. Robert Black, Mary Carol Jennings, Meike Schleiff and Emma Sacks. Most of the students involved were from the Department of International Health.

The Health Systems Program is focused on achieving accessible, cost-effective health care and healthy outcomes across the lifespan for families, communities and nations. In the past decade, the Program has conducted projects in over 50 countries, with particular expertise in South Asia and sub-Saharan Africa, where the greatest number of people continue to struggle with deep poverty and unmet health needs.

For more information, please contact Melissa Reed, communications and program specialist, at melissar@jhu.edu

Gender analysis, the examination of gender power relations in a society and the norms, expectations and roles for different genders, is receiving more attention in the public health sector, but is often considered an afterthought within the research process. Instead of being an add-on, gender analysis in health systems research should be an integral component at every phase. Health systems are not gender neutral; if the goal is to create equitable and sustainable health solutions and health promotion interventions, then gender (and how gender interacts with other social stratifiers) needs to be considered when designing effective solutions.

Applying a gender lens means examining the role of gender within the different building blocks of health systems and how we can most effectively shape health systems policies, programs and services to benefit everyone. This includes studying how gender power relations play out within a health system and ensuring that we do not perpetuate different gender inequities in our research.

Dr. Rosemary Morgan, assistant scientist in the Health Systems Program of the Department of International Health, brings her experience working on the project, “Research in Gender and Ethics (RinGs): Building Stronger Health Systems” to the Program. The project, funded by the UK Department for International Development (DFID), seeks to galvanize gender analysis within health systems research by providing resources for and building the capacity of health systems research to conduct gender analysis. In addition, Dr. Morgan has been working with students within the Johns Hopkins Bloomberg School of Public Health (JHSPH) to explore the role of gender within different areas of the health system.

Dr. Morgan advised Poonam Daryani, a recent graduate of the MPH program at JHSPH, to conduct an intersectional gender analysis of the Zika response in Brazil. Through her analysis, Poonam explored how the distribution of power based on gender interacted with other social stratifiers, such as race and class, to create different vulnerabilities to Zika infection during the epidemic.

Findings showed that the national response, with its focus on household-level vector control efforts, did not consider the complex sociocultural and economic barriers facing women in Brazil. Failure to account for differential power relations and the resulting gender inequities in Brazil may have limited the effectiveness of the national response in curbing transmission of the virus. Moreover, the inadequacies of the national response were felt largest by poor black and brown Brazilian women, who are largely concentrated in the peripheries of urban centers as well as the North and Northeast regions of the country and who experience disproportionate and compounding barriers to achieving positive health outcomes.

The gender analysis inspired Poonam to pursue the highly competitive Johns Hopkins-Pulitzer Center Fellowship for Global Health Reporting, through which Poonam traveled to the northeast of Brazil to explore the long-term consequences of Zika on those who care for and raise children with congenital Zika syndrome.

Health responses can be strengthened with a greater awareness of gender relations in a given society’s health system. Ideal responses examine and question gender inequities in order to achieve health goals and advance gender justice. It is necessary to apply a gender lens to all health issues so that we can build policies, structures and procedures at an institutional level that create a healthy society for everyone. 

The Program welcomed over 45 students from 10 countries

The Health Systems Program of the Department of International Health recently wrapped our 2017 Health Systems Summer Institute at the Johns Hopkins Bloomberg School of Public Health, a short-term program designed for part-time students or early- to mid-career professionals who want to further their career in public health. The Institute, directed by Health Systems senior scientist, Dr. George Pariyo, is designed to provide students an entire academic term’s worth of instruction in a condensed period of time. 

During the Summer Institute, participants have the opportunity to learn a variety of health systems skills and concepts that will help them measure the burden of disease and monitor and evaluate global health programs. Courses covered areas such as primary health care, gender analysis, technology innovation for global health, hospital and trauma surveillance, and summary measures of population health.

This year, the Institute increased the number of course offerings from seven to 11 in order to accommodate for the growing number of program areas. New courses included Introduction to Gender Analysis within Health Systems Research, Monitoring and Evaluation of Health Systems Strengthening, Designing Transformative Innovation for Global Health, and Managing District Health Systems. The majority of health systems courses focus on low- and middle-income countries, but the skills are universal.

The number of international students attending the Institute increased this year: as the Program amplifies its presence around the world, we hope to build a strong base of global students who can apply the principles of health systems in their home country. One such student, Khin Pa Pa Naing from the Ministry of Health (MoH) in Laos, chose to attend the Institute so she could gain skills and knowledge from the Monitoring and Evaluation course for her daily routine working with the MoH.   

It provided very in-depth thinking about the current situation of resource limitation, availability and allocation for the public health sector and medical care in developing countries, and how we as public health professionals could improve this situation,” stated Khin Pa Pa. In addition to Ms. Naing, we welcomed students from Canada, Nigeria, South Africa, Japan, Kenya, Vietnam, Thailand and Bangladesh.  

The Institute is also working to foster the growing number of part-time MPH students coming from all regions of the country, seeking to fulfill their 20% requirement of attending on-campus courses. We provided four lunchtime networking sessions, and hope to continue to expand our social offerings next year.  

As we seek to enhance the Health Systems Summer Institute in future years to incorporate more students coming from all areas of the public health sector, we will continue to expand and diversify our course offerings. We thank all students who made the second year of our Summer Institute a great success!

In April 2017, researchers from the Health Systems Program traveled to East Africa to launch data collection for a study under Project SOAR (Supporting Operational AIDS Research). Dr. Sara Bennett, professor, Dr. Daniela Rodriguez, assistant scientist, Jess Wilhelm, PhD student, and Mary Qiu, senior research program coordinator, went to Kenya and Uganda to examine the health systems impact in regions of both countries that are transitioning their HIV/AIDS programs to government support as part of Phase III of the United States President’s Emergency Plan for AIDS Relief (PEPFAR)’s sustained control of the AIDS epidemic.

Project SOAR is a five-year program funded by the United States Agency for International Development (USAID) and led by the Population Council that conducts HIV and AIDS operational research. The evaluation of the Geographic Pivot is a specific component of the project, led by Dr. Bennett.

HIV/AIDS continues to be a significant burden on low- and middle-income countries, and funding for the epidemic has plateaued in recent years. PEPFAR’s geographic prioritization strategy focuses on intensifying support to regions where the HIV/AIDS burden is highest, and phasing support to the government in regions where the burden is less severe. The objective of this shift is to increase efficiency of available funds and to achieve the UNAIDS 90-90-90 goal of having 90% of all HIV+ individuals aware of their status, 90% all people diagnosed with HIV on sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy to have viral suppression, by 2020.

The Health Systems team is examining how the transition is being implemented and what the impact is on transitioned regions. Their research consists of a facility survey; document reviews from USAID and governments in Kenya and Uganda; and primary interviews with ministry of health employees, patients, and government officials in order to get a multi-perspective account of the impact of these changes.

As part of their effort to understand how health systems are affected by the change in support allocation, they are deploying a large-scale survey across the transitioned regions and are training in-country partners to conduct the survey. In addition to the survey, the in-country teams are conducting in-depth interviews with specific health facilities in Kenya and Uganda to get a more thorough understanding of the transition effects across all levels of health care, from delivery to how it is affecting business operations, such as human resources and available commodities.

The goal of the project is to help guide both donors and in-country government on how to implement programmatic transitions while limiting any adverse effects on how health systems function and care is delivered. Findings from the Program’s researchers will inform future efforts to manage HIV/AIDS investment and create a more targeted response to the epidemic. Read more about the programmatic transition process here