Published: 03 April 2019
The NIHR Global Health Research (GHR) programme commissions research to respond to current and emerging health challenges affecting the poorest and most vulnerable populations in low and middle income countries (LMICs). To date the GHR programme has awarded £162m to Units and Groups who are working in over 50 LMICs on projects ranging from snakebite research to stroke care and road safety. When trying to address health inequalities, doing research in partnership with LMICs feels like an inherently good idea. So, as a Public Health Registrar on a placement with the NIHR, I wanted to investigate just how equitable the GHR programme really is.
I consider health inequalities to be preventable, unfair and unjust differences in health status between populations. Tackling health inequalities is important not only for social justice but also for improving the health of the whole population. So, it’s not just about reducing the obvious inequalities between high-income countries and LMICs but also about improving the health of the poorest people within a country.
A recent study of global health research funding highlighted aspects which promote health equity; these include working with the worst-off populations, having LMIC ownership of the research agenda and building LMIC research capacity. I have been reviewing the annual reports submitted by the NIHR GHR programme units and groups, as well as speaking directly with some of the researchers, to look for evidence of these indicators of equity.
Certainly some of the projects are explicitly working with the world’s most vulnerable people; for instance, improving health services in the slums of Asia and Africa. But this is inherently very difficult and the GHR researchers frequently highlighted to me the challenges of working in the parts of the world that are most in need. Often these are the most inaccessible regions where transportation and infrastructure is poor or where local partners cannot be found to help UK teams connect with the worst-off communities.
Some of the innovation and technology, that GHR researchers are employing to overcome physical barriers to equity, is impressive. For instance, the NIHR GHR Group on Global Surgical Technologies, who are working to improve access to surgery. Sierra Leone has one of the highest needs for surgical procedures per head of population yet one of the lowest rates of operations, so the group are developing training to be delivered via a virtual classroom in order to reach the most inaccessible parts of the country.
The NIHR GHR Group on Neurotrauma are working to improve neurotrauma care but their LMIC partners are inevitably based in big cities, such as Lusaka in Zambia, as that is where any neurosurgery expertise is found. The team have recognised this within-country inequity and are addressing it by rolling out their training more widely than originally planned. For instance, in Zambia they have given training to representatives from every district hospital (including general surgeons when there were no neurosurgeons available).
Another fundamental challenge that the researchers face is in understanding the nature of the inequalities that exist; for instance, one project is concerned with injury prevention and response in Nepal yet there is no surveillance data on this. The group are conducting surveys and analysing hospital data to understand the epidemiology of injury in Nepal: in richer countries men have higher rates of injury than women but this may be different in a country like Nepal where women undertake many manual jobs.
Co-design of global health research is vital to ensure it is culturally relevant and gets buy-in from local policy-makers. I found some great examples of co-design amongst the GHR projects; for instance; the NIHR GHR Group on Global Chronic Obstructive Pulmonary Disease in Primary Care is working in partnership with four LMICs where policy-makers, managers, clinicians and patients were all involved in the initial research prioritisation process. However, I did not have the opportunity to talk with any GHR programme partners from LMICs which would have given greater insight into the real level of success of co-design approaches.
So, my brief delve into the NIHR GHR programme has given me an overwhelming sense of genuine and worthy intentions, with respect to equity, from both the NIHR staff and the researchers funded by the programme. I have seen how these intentions are backed up by some innovative strategies to address the many challenges. Furthermore, NIHR seems to be constantly evolving the GHR management and monitoring processes in order to promote equity. Data reporting templates from the units and groups have been refined following the first annual report to more clearly capture information on gender as well as the number of lead, co- and last authors from LMICs and the UK as well as the numbers of trainees, their nationality, countries where training is located and the type of trainees supported. Additionally, the NIHR provides an Equitable Partnerships Guide and is currently developing an online forum for GHR researchers to share learning.