Growth and challenges of health research in the WHO Africa Region: new analysis in the BMJ

This was cross-posted to my own blog.


I have always been devoted to the principle of evidence-based policy and decision making in public health, but I have taken a keen interest in the finer points of research and methodology since taking my current position as an epidemiologist (and contemplating the pursuit of a doctorate more seriously). Earlier this month, I spotted an article from BMJ examining the output of health research in the WHO Africa region from 2000 to 2014 (h/t to Dr. Ron LaPorte, professor of epidemiology at the WHO Collaborating Center at the University of Pittsburgh and co-founder of the Supercourse project). The article, entitled “Increasing the value of health research in the WHO African Region beyond 2015,” is a bibliometric analysis of the health research publications from the WHO Africa region indexed on PubMed; it analyzes the influence of various factors, including GDP, population, and health spending on the number and growth of published papers by country over the time period. The abstract reads:

Objective To assess the profile and determinants of health research productivity in Africa since the onset of the new millennium.

Design Bibliometric analysis.

Data collection and synthesis In November 2014, we searched PubMed for articles published between 2000 and 2014 from the WHO African Region, and obtained country-level indicators from World Bank data. We used Poisson regression to examine time trends in research publications and negative binomial regression to explore determinants of research publications.

Results We identified 107 662 publications, with a median of 727 per country (range 25–31 757). Three countries (South Africa, Nigeria and Kenya) contributed 52% of the publications. The number of publications increased from 3623 in 2000 to 12 709 in 2014 (relative growth 251%). Similarly, the per cent share of worldwide research publications per year increased from 0.7% in 2000 to 1.3% in 2014. The trend analysis was also significant to confirm a continuous increase in health research publications from Africa, with productivity increasing by 10.3% per year (95% CIs +10.1% to +10.5%). The only independent predictor of publication outputs was national gross domestic product. For every one log US$ billion increase in gross domestic product, research publications rose by 105%: incidence rate ratio (IRR=2.05, 95% CI 1.39 to 3.04). The association of private health expenditure with publications was only marginally significant (IRR=1.86, 95% CI 1.00 to 3.47).

Conclusions There has been a significant improvement in health research in the WHO African Region since 2000, with some individual countries already having strong research profiles. Countries of the region should implement the WHO Strategy on Research for Health: reinforcing the research culture (organisation); focusing research on key health challenges (priorities); strengthening national health research systems (capacity); encouraging good research practice (standards); and consolidating linkages between health research and action (translation).

In the discussion, there is some fascinating commentary on the challenges facing researchers in the research and the barriers to publication, as well as to making those publications available to other researchers in the field. Some of them are familiar and strike me as a common symptom of the complicated relationship between politics and (especially evidence-based) policy making:

Although there is clearly a need for improving the performance of health researchers on the continent, African health decision makers should use the available research evidence to guide policy, strengthen practice and maximise the use of resources in order to improve the welfare of their citizens. However, there appears to be a failure to apply available research evidence to improve the health of populations on the continent. This unfortunate situation may be related to the lack of sharing of research evidence for translation into policy and practice, a non-alignment of research conducted in African countries to national research policies and/or the non-existence of national health research policies with clearly defined priorities.

However, others are somewhat unique to Africa. Not of them are economic (though funding plays a major role), and the paper goes so far as to describe some of the challenges as “intractable”:

The difficulties in research, publication, editorial bias and information access facing Africa are profound and seem almost intractable. Another difficulty facing African researchers is dissemination of findings to other parts of the world. Most of the information published in African journals is largely not included in major databases. Access to technological tools, information access and other equipment and supplies to ease research work is not always possible.

I hope this will influence the wider debate on the future of aid and health spending in Africa. The call for a shift in funding and emphasis from technologically-focused solutions to health-systems strengthening and sustainability has gained momentum, and research and academic exchange is a crucial part of the latter.

White House Takes a Stand on Climate Change and Public Health

“Climate change is making an impact on our public health.”
-President Obama

We know that climate change threatens our air, food, water, and homes but earlier this month at a round table discussion, President Obama spoke about the effects of climate change on public health. In this video he says the temperature of the planet is rising and that not only comes with adverse weather and environmental consequences, but also a “whole host of public health impacts.”

Accompanied by Surgeon General Dr. Vivek Murthy, President Obama put a spotlight on increased heat-related deaths, severe asthma, extended allergy seasons, and the spread of tropical or insect-borne diseases as some possible consequences of climate change. He also spoke about the need to focus on prevention and action and the costs associated with inaction.

This is the beginning of a big push from the White House to better understand and deal with the health effects of climate change and this statement outlines their plan to do so. This is such a great step in the right direction and a big win for the public health field. Here’s to hoping it all leads to a long-term commitment with the necessary funding and policies to make significant changes!

HUMANITY OF GENDER EQUALITY BY MARY LOUISE TATUM

“Girls must be told at an early age that they have the potential to become influential leaders before they fall victim to their own self-doubt”. These are the insightful words of Malala Yousafzaia, a Pakistani activist for female education and the youngest Nobel Prize laureate.

These words continue to ring true regardless of one’s geographical location. Girls and women from around the world continue to be marginalized.  For example, more high-income countries face challenges, such as, equal pay, maternity leave policies that allow women enough time to nurture their infants, and job security to continue in their careers.

It is reprehensible that females around the world are forced into marriage at ages as young as nine,  punished for “immodest behavior or dress”, not allowed to drive, denied an education,  excluded from politics, gang raped with no retribution, coerced into female genital mutilation (look out for  my June blog), and the list goes on.

Females are approximately half of the world’s population (http://data.worldbank.org).  Thus, women have to be allowed equal rights for human survival. Not to mention, we all have the basic human right to choose our own destiny.

However, supporters of female rights must be empathetic and meet those who desire or need support where they are. As public health professionals, we cannot force values and beliefs because we think they are superior or imagine a clear path to their implementation. We have to be empathetic, willing to learn, and understand the values of the community we are involved. We can provide education on evidence-based health practices and provide availability to health care, education, financial training, etc. These changes will come from within the community, so we have to develop partnerships within the community and provide the necessary tools that will build capacity and self-reliance. Let’s encourage the enhancement of inherent positive cultural attributes, increase self-esteem and self-awareness with financial resources and training to optimize the quality of life.

All persons have the right for their basic needs to be met and to feel confident and empowered. All persons deserve the opportunity to realize their potential.  Education and opportunity is the key for making the world better. The survival of humanity depends on the synergy of women and men.

How Peace Corps Volunteers in Senegal address gaps in health delivery systems

This post does not reflect the opinions of the US Government, the US Peace Corps or Peace Corps Senegal.


There is usually a general misunderstanding of what Peace Corps volunteers do or are capable of doing in field. This misunderstanding comes from families and friends of volunteers back home, the communities the volunteers serve, and sometimes, in the earlier stages of service, the volunteers themselves. How much impact can a volunteer make? How can the most impact be made during such a short service? What are the limits of a volunteer and how is their work truly sustainable?

While I can not speak on behalf of the entire Peace Corps (PC) community, I believe I can shed a light on how Peace Corps Senegal Health volunteers work to provide basic trainings and services to improve the health status of the communities they serve.

Currently PC Senegal health volunteers work in the areas of Malaria, Maternal and Child Health and Water, Sanitation and Hygiene. Our development approach ensures that initiatives are sustainable, that they exhibit long term vision, that they are from the bottom-up and that they are participatory and inclusive. Along with guidance from PC leadership, volunteers use these guidelines to creatively impact their communities.

The PC Senegal health sector works to address 3 delays in health care:

  1. Delay in the decision to seek care
  2. Delay in reaching care
  3. Delay in receiving adequate available health care and correct diagnosis.

The first delay is addressed at the household level. When signs and symptoms of disease begin to manifest themselves, we ensure that people have the knowledge they need to seek the care that is required. The delay in reaching care is addressed through several initiatives that range from planting gardens, training more community health workers, working in supply chain to ensure the health structure has the medicine and equipment it should have, rallying up the community to contribute towards an ambulance, or building a health structure. The last delay can be addressed through a series of trainings for community health workers, working side by side with health processionals to ensure that tests are being administered and being administered correctly, and empowering the patient to ask questions about disease stages treatment and medication.

Baseline assessments, barrier analyses and volunteer reporting tools are beginning to show us where exactly the needs are and where the obstacles to the behavior change exist. A lot of work is focused on strengthening the capacity of community health workers, clinical staff and health structures as a whole. We come in with fresh eyes to identify ways health care can be done better and in many cases, solve complex with simple solutions. I like to think that we help people think outside of the box to identify their problems and solve them with as little help from the outside as possible.

But the work is not easy. In a process that begins with intensive language, cultural and technical training, PC Senegal Volunteers must learn how to integrate into their communities and develop meaningful relationships with potential work partners before their own projects may actual begin. Volunteers spend a good amount of time learning the lay of the land in their communities. What development groups have worked here in the past? What have they done? Who exactly did they help? Where did they succeed or fail? Was there a former volunteer at this site? What did they do? What relationships did they build? Who did they work with and who did the intentionally avoid? Then the research and programming questions begin. What does the community know about these heath issues? What does this community need?  What can I do to address the need? How I can do it with the least possible resources? How will I monitor it? How will it be sustainable? So when we finally figure out-with the help of community members- what project we want to implement, we design it, we justify to our community leaders and to our PC leaders. When necessary, we write grants, we rally the community behind the project, we implement, we monitor and we evaluate.

So what is it exactly that volunteers do? Well, we do not claim to change the world. This is not why we’re here. We will not eradicate malaria nor will we completely bring an end to the deaths of children under 5. But if we can reduce those incidences, if we can provide much needed trainings, if we can build a health structure that otherwise would not have existed, if we can get just 20 more moms to wash their hands when they’re supposed to, if we can improve sanitation practices, if we can get that many more mosquito nets out there, if we can prevent malnutrition in a handful of infants and children, if we can keep addressing these gaps that cripple health systems, then, we would have contributed to a much a larger picture of global health and we would have served.


taiwo adesinaTaiwo Adesina is a MPH candidate at Loma Linda University in southern California. She is also a Masters International student, completing the final part of her Masters in Global Health with Peace Corps Senegal. In Senegal, Taiwo works in the areas of Malaria, WASH, maternal and child health and nutrition-helping health structures and groups better address these issues through the use of community health workers. Her interests also include project design and management, grant writing, and M&E. She has working/living experience in Nigeria, Honduras, the Philippines, the Bahamas and Senegal. She blogs at travelgiveworklove.

HOW TO DEVELOP YOUR NETWORK AND CREATE GLOBAL HEALTH OPPORTUNITIES

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Making that transition from student to employee or entrepreneur is a daunting task for most of us. And it’s even a bit more challenging when trying to make your way overseas. Nevertheless, we have what it takes to become involved in our dream career wherever it is, perhaps not immediately in the capacity that we desire, but overtime your dream can be attained: First, have an open mind. Second, be creative. Third, be tenacious.

Being a social butterfly can be helpful when trying to identify opportunities. I say talk to anyone and everyone; it’s surprising how much information is available from just talking with your colleagues. Also, don’t forget your professors and your school’s Career Services Department.  For instance, I was in the College of Public Health, but was fortunate to hear about a professor in the Geography Department who was working with Geographical Information Systems. I introduced myself and am now working on an ongoing project in Zambia (see my previous blog, click here.

Furthermore, this is your opportunity to take advantage of early career professional discounts offered by most organizations, such as the American Public Health Association. However, don’t just pay dues; reap the maximum benefits of all that knowledge and available resources.  Attend the annual conference and participate on general or section committees. Moreover, submit an abstract for a poster or oral presentation. This offers you an opportunity to demonstrate your talents to a plethora of professionals in positions of hiring or making recommendations for your future career. At the very minimal you may receive guidance or improving your Curriculum Vitae (CV), interviewing skills, or direction on untapped venues for opportunity.

It is very important to not discount volunteer experience, as there are many rewards from volunteering. For example, helping underserved communities, placing into practice classroom theory, and collaboration. Thus, these experiences should be placed on your CV as if it were a paid position, under “Research Experience” or “Program Experience” or other appropriate categories. Of course, most of us would prefer to be paid for our services. Fortunately, there are numerous organizations that offer opportunity to work in numerous settings, and some even offer stipends, housing, and/or food at no cost for your commitment.  I have provided links to a few options, but there are many more available.

Global Health Fellows Program II:  https://www.ghfp.net/internships/apply-for-an-internship/

Catholic Relief Services: www.crs.org

World Wide Opportunities on Organic Farms – WWOOF: www.wwoof.net/

International Cultural Youth Exchange – ICYE: www.icye.org/
Peace Corps: http://www.peacecorps.gov/

Just changing your environment can place you in a land of opportunity. I have been fortunate to develop friendships with individuals from many geographical locations, and when I travel to visit them opportunities arise. In 2013 my fellow classmate invited me to Kenya. While on a safari I met a teacher from Taiwan who asked if I would help her with providing sex education for youth who reside in Deep Sea Slum (Nairobi, Kenya). With that collaboration, I returned the following May 2014, and with the support of Victoria Sports Association, a local humanitarian organization, I developed and implemented a program focused on self-awareness, hygienic care, and health promotion. It is nice to have big “power” names on your CV, but you have a lot more freedom and opportunity to use your talent with smaller groups, as I learned with this experience.

In conclusion, any opportunity, paid or voluntary is worth the valuable space on your CV. Keep your CV current with all experiences. Employees and potential collaborators are seeking those who want to develop and utilize skills to make a difference in improving health globally. As you grow and expand your networks and comfort space, opportunities begin to emerge. Go after them!

Putting People First

“If we’re going to create resilient health systems, we have to move away from just focusing on commodities, abstract interventions. We have to remember that health is about people. It’s about protecting our populations and creating a workforce that serves those populations. So let’s think about how we build a people-centered health system.”
-Richard Horton, Director, The Lancet

The quote above is from a Global Health Workforce Alliance video which uses key stakeholders such as Richard Horton and WHO Director General Dr. Margaret Chan to make the case for a global strategy on human resources for health – the current Health Workforce 2030 campaign that you may have heard about.

So why the 2030 date? Well, based on current trends in low- and middle-income countries, it’s estimated that by the year 2030 there will be a major shortage of health workers due to country capacity to produce and retain qualified workers. At that point, the workforce (supply of health professionals) will not be able to match the need (provision of essential services).

The Ebola outbreak in West Africa has clearly demonstrated the importance of looking at a health system through the lens of people. Affected countries have lost almost 500 health workers to date (including my aunt) and these are countries that were already suffering from health worker shortages and brain drain. It’s clear that a focus on human resources is critical for these countries and others to strengthen their health systems and become resilient. Having the best supplies and medicines, cutting-edge innovations and interventions, and state-of-the-art facilities without a strong health workforce is not going to advance positive health outcomes.

The Health Workforce 2030 summary brochure is available here on the WHO’s website and the full strategy will be completed by May 2016 for consideration at the 69th World Health Assembly.

It will be interesting to see how this “people focus” plays out and influences the post-2015 development agenda.

If you’d like to learn more about the global workforce crisis in more general terms, check out this TED Talk from human resources expert Rainer Strack. It’s not about health workers or low- and middle-income countries, but he tells a good story.

Environmental monitoring data as “development”: The far-reaching effects of the Beijing embassy’s air quality monitor

When we think of “development” or “development projects,” environmental monitoring technologies are not typically the first things that come to mind. While data is (rightfully) gaining importance in the global health and development landscape, we usually default to primary health care interventions, vaccination drives, or agricultural technologies. However, in a guest editorial in Wired last week, former USAID advisor David Roberts puts forth the American Beijing Embassy’s PM2.5 monitor as precisely that:

As the former Regional Strategic Advisor for USAID-Asia, I have seen first-hand that doing international development is incredibly difficult. Billions of dollars are spent annually with at best mixed results and, even with the best intentions, the money often fails to move the needle. That is why I was so inspired by the story of the US embassy’s low-cost, high-impact development project. They tapped into the transformative power of democratized data, and without even intending to, managed to achieve actual change.

He goes on to tell the story of how, in 2008, embassy staff installed a rooftop air-quality monitor for the price of “a nice car.” The monitor was linked to a Twitter account that automatically tweeted air quality readings every hour. The catch (which is why I question framing it as a “development project”) is that the readings were originally only intended for American expats and travelers – the Great Firewall (that is, China’s nationwide internet restrictions) blocks access to Twitter and other social media – including Facebook, YouTube, and pretty much any blogging platform out there – by its citizens. (Having developed a major smartphone addiction during my time in South Korea, being blocked from just about everything I wanted to access during one day in Shanghai last March drove me batty. But I digress.) Internet users can only access such technologies via a VPN service – commonly used by expats, but much less so among Chinese nationals.

Predictably, however, a few savvy Chinese netizens got ahold of the information anyway.

can't stop the signal

They began distributing it through China’s own (permitted) social media channels, retweeting the readings on Sina Weibo (Chinese Twitter) and incorporating the readings into homegrown air-quality apps. The Chinese government starting taking heat from its own citizens about poor air quality, a ongoing social tinderbox reignited by the availability of impartial (read: not official Chinese government numbers) data. Predictably, the government got upset and ordered the US embassy to remove the device, claiming that the dissemination of the information was somehow “illegal.”

Given the Chinese government’s sensitivity on environmental issues—and it’s irritation at anything viewed as foreign meddling in domestic affairs—it shouldn’t be surprising that the @BeijingAir account would eventually draw an official response. And that’s what happened on June 5, [2012] when China told foreign embassies to stop publishing their own reports on air quality in the country. (The U.S. consulates in Shanghai and Guangzhou also post readings of the air quality of those cities on Twitter.) As of now the @BeijingAir account is still up and running, and it’s important to note that the American embassy has always said that the readings—which come from a single monitoring device on the roof of the embassy—were only meant to inform Americans living in the city.

Naturally, the embassy refused, and so Big Brother was forced to set up its own monitoring stations – and to be held accountable for air quality around the country. Roberts continues to extol the virtues of the expanded “program,” which the State department has now decided to implement at embassies in other countries in Asia (much like China, some of them are rather unhappy about it).

This little air-monitor-that-could also directly inspired other like-minded efforts. In India, the US government has now begun tweeting data from air monitors at its embassy and consulates. In Mongolia, non-government groups in Ulaanbaatar, one of the world’s most polluted cities, ran with the Beijing example by monitoring and tweeting out air-quality data; some even saw the possibility of repurposing the concept for flood warnings. And aqicn.org, which started as a way to share US Embassy – Beijing’s data, has transformed into the go-to site for hourly air-quality information at 4000 monitoring stations stretching from Hanoi to Honolulu.

Honestly, this sort of phenomenon is less about “development projects” and more about the power of information in the hands of an internet-savvy populace. The Beijing air quality monitor does not look like a development project as much as an example of successful government subversion – passive-aggressive actions that boost the credibility and favorability of our image abroad at the expense of the home country’s (foreign policy at its cleverest). The air quality “revolution” in China is certainly not something the US government can take credit for – that belongs to Chinese citizens.

But then again, that is what we believe development should ultimately be about anyway, so I guess I can’t complain.


Note: This was cross-posted to my own blog.