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International Health

Health Systems Program

The Johns Hopkins International Injury Research Unit (JH-IIRU) in the Department of International Health, Johns Hopkins Bloomberg School of Public Health was featured in a ShareAmerica article, the USAID platform intended to disseminate American foreign policy to a global audience. ShareAmerica highlighted the Johns Hopkins-Afghanistan-Pakistan Collaborative Trauma and Injury Research Training (JHU-AfPak-ICTIRT) program, funded by Fogarty International Center, National Institutes of Health (NIH).

JH-IIRU has been in Pakistan for over a decade, dedicated to improving trauma care and emergency medical services in the area through rigorous training. Partnering with Aga Khan University (AKU), JH-IIRU worked with their Department of Emergency Medicine, established by current JH-IIRU senior technical advisor and professor of emergency medicine at Johns Hopkins School of Medicine and former collaborator Dr. Junaid Razzak. In the second round of training, JH-IIRU incorporated Khyber Medical College with the goal of promoting trauma and injury research by training a core group of faculty between the two universities.

The grant has been helpful in not only developing individuals and providing opportunities for their growth, but more importantly, it has helped institutional growth at various levels. Directly, the grant led to the development of the first academic department in the field of emergency medicine in the country. The department played the role of the World Health Organization’s Collaborating Center on Emergency Care. It also provided support to the prehospital emergency care system in the city of Karachi, which in turn impacted hundreds of thousands of patients a year. These larger system changing impacts are critical to population health,” states Dr. Razzak.

The program represents the first doctoral training program on injury research at AKU; by helping AKU to take this next step from masters to doctoral training, JH-IIRU is helping to build capacity in a region with a high burden of death and disability from injuries.

The JHU-AfPak-ICTIRT program aims to do the same in Afghanistan, a country where many live in conflict-affected areas and injury rates are high. The training program provides an alternative to having to fly all the way to high-income countries such as the United States for education, an expensive and often inaccessible trip for many, and also combats the brain drain in the area.

JH-IIRU hopes that research from Pakistan will influence the neighboring region in Afghanistan, and also address the issue of intentional and unintentional violence in the area. The research is driven by individual trainees, who are examining issues such as domestic violence, child injuries and road traffic injuries. One particular mega project currently being conducted is studying the burden of acute injuries and emergency medical care by examining emergency rooms and collecting data from over 3,000 people.

The burden of injury and trauma in both Pakistan and Afghanistan is considerable and keeps on growing. There is a dire need to have both masters and doctoral training with concentrations in injury and trauma. The program we are offering through the Afghanistan-Pakistan International Collaborative trauma and injury research training will help elaborate further the need and sources of data on injuries in developing countries,” states Dr. Nadeem Ullah Khan, JH-IIRU collaborator and associate professor and consultant of emergency medicine at AKU, on the importance of the JHU-AfPak-ICTIRT program.

The programs in Pakistan and Afghanistan reflect a need for prioritizing injuries as a public health burden worldwide, an issue that has been neglected far too often on the global agenda. JH-IIRU’s work culminates in a desire to ensure that injury and trauma are recognized as a health policy issue in Afghanistan and Pakistan, as well as globally.

For research papers from the grant see:

Dr. Krishna D. Rao, assistant professor, joined the Health Systems Program in 2014, bringing expertise in health systems and health economics. He received his master’s degree at Cornell University in agriculture and resource economics and his PhD in health systems from the Program.

Prior to joining the Health Systems Program, Dr. Rao worked with the Public Health Foundation of India (PHFI), where he conducted research on health systems and taught health economics. Before coming to PHFI, Dr. Rao worked in Afghanistan as part of the Johns Hopkins team supporting their Ministry of Public Health (MoH) to evaluate models of community financing of health services. Dr. Rao started his career in public health at the World Bank, working on the delivery of child nutrition and health services in India. In 2016, Dr. Rao was selected as a practitioner resident fellow to the Rockefeller Foundation Bellagio Center Residency Program.

Dr. Rao’s research focuses on three major areas – human resources for health, health financing and evaluation. He is particularly concerned with issues around strengthening primary care and nutrition services, measuring quality of care, and reducing financial hardship faced by households due to health care payments. He teaches courses in health financing in low- and middle-income countries, and the role of health in economic development. Dr. Rao also co-leads the Program’s health systems seminars.

Dr. Rao is involved with a variety of research projects. One of Dr. Rao’s key projects includes evaluation of a large-scale mentoring program for nurses at primary health centers in the state of Bihar, India. The mentoring program is funded by the Gates Foundation and provides nurses with the knowledge and skills to improve their obstetric skills. This evaluation is being conducted in partnership with the Johns Hopkins School of Nursing.

Dr. Rao is also currently working on designing a conditional cash-transfer program for improving nutrition in young children in India. The study uses a discrete choice experiment to understand the preferences of mothers for program conditionalities and cash transfer amounts. Other key projects include mentoring researchers from eight different countries to help them improve their research skills, conducting a cost-effectiveness analysis of a nutrition program in Malawi, and a previous health financing project in Kyrgyzstan that examined how health financing issues affect delivery of services.

Going forward, Dr. Rao is interested in studying conditional and unconditional cash transfer programs, aging and what implications that has for health systems and the financing of health care, and how the management and institutional structures of health services affect health worker performance and quality of care. Read more about Dr. Rao’s work in his faculty profile

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

*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

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.