Ethics and health systems research in 'post'-conflict situations

Although considerable attention has been given to ethical issues related to clinical research in developing countries, in particular related to HIV therapy, there has been limited focus on health systems research, despite its increasing importance in the light of current trends in development assistance. This paper examines ethical issues related to health systems research in 'post'-conflict situations, addressing both generic issues for developing countries and those issues specific to 'post'-conflict societies, citing examples from the author's Cambodian experience. It argues that the destruction of health infrastructure results in a loss of structures and processes that would otherwise protect prospective research subjects who are part of vulnerable populations. It identifies the growth of health systems research as part of a trend towards sectoral and programmatic development assistance, the emergence of 'knowledge generation' as a form of research linked to development, and the potential for conflict where multilateral and bilateral donors are both primary funders and users of health systems research. It also examines the position of the health system researcher in relation to the sponsors of this research, and the health system being analysed.     

Designing research funding schemes to promote global health equity: An exploration of current practice in health systems research

International research is an essential means of reducing health disparities between and within countries and should do so as a matter of global justice. Research funders from high‐income countries have an obligation of justice to support health research in low and middle‐income countries (LMICs) that furthers such objectives. This paper investigates how their current funding schemes are designed to incentivise health systems research in LMICs that promotes health equity. Semi‐structured in‐depth interviews were performed with 16 grants officers working for 11 funders and organisations that support health systems research: the Alliance for Health Policy and Systems Research, Comic Relief, Doris Duke Foundation, European Commission, International Development Research Centre, Norwegian Agency for Development Cooperation, Research Council of Norway, Rockefeller Foundation, UK Department of International Development, UK Medical Research Council, and Wellcome Trust. Thematic analysis of the data demonstrates their funding schemes promote health systems research with (up to) five key features that advance health equity: being conducted with worst‐off populations, focusing on research topics that advance equitable health systems, having LMIC ownership of the research agenda, strengthening LMIC research capacity, and having an impact on health disparities. The different types of incentives that encouraged proposed projects to have these features are identified and classified by their strength (strong, moderate, weak). It is suggested that research funders ought to create and maintain funding schemes with strong incentives for the features identified above in order to more effectively help reduce global health disparities.     

A research agenda for malaria eradication: health systems and operational research

Health systems research and development is needed to support the global malaria eradication agenda. In this paper, we (the malERA Consultative Group on Health Systems and Operational Research) focus on the health systems needs of the elimination phase of malaria eradication and consider groupings of countries at different stages along the pathway to elimination. We examine the difference between the last attempt at eradication of malaria and more recent initiatives, and consider the changing health system challenges as countries make progress towards elimination. We review recent technological and theoretical developments related to health systems and the renewed commitment to strengthening health systems for universal access and greater equity. Finally, we identify a number of needs for research and development, including tools for analyzing and improving effective coverage and strengthening decision making and discuss the relevance of these needs at all levels of the health system from the community to the international level.     

Fair Resource Allocation to Health Research: Priority Topics for Bioethics Scholarship

This article draws attention to the limited amount of scholarship on what constitutes fairness and equity in resource allocation to health research by individual funders. It identifies three key decisions of ethical significance about resource allocation that research funders make regularly and calls for prioritizing scholarship on those topics – namely, how health resources should be fairly apportioned amongst public health and health care delivery versus health research, how health research resources should be fairly allocated between health problems experienced domestically versus other health problems typically experienced by disadvantaged populations outside the funder's country, and how domestic and non‐domestic health research funding should be further apportioned to different areas, e.g. types of research and recipients. These three topics should be priorities for bioethics research because their outcomes have a substantial bearing on the achievement of health justice. The proposed agenda aims to move discussion on the ethics of health research funding beyond its current focus on the mismatch between worldwide basic and clinical research investment and the global burden of disease. Individual funders’ decision‐making on whether and to what extent to allocate resources to non‐domestic health research, health systems research, research on the social determinants of health, capacity development, and recipients in certain countries should also be the focus of ethical scrutiny.     

Managing Ethical Challenges to Mental Health Research in Post‐Conflict Settings

Recently the World Health Organization (WHO) has highlighted the need to strengthen mental health systems following emergencies, including natural and manmade disasters. Mental health services need to be informed by culturally attuned evidence that is developed through research. Therefore, there is an urgent need to establish rigorous ethical research practice to underpin the evidence‐base for mental health services delivered during and following emergencies.     

Application of Ethical Principles to Research using Public Health Data in The Global South: Perspectives from Africa

Existing ethics guidelines, influential literature and policies on ethical research generally focus on real‐time data collection from humans. They enforce individual rights and liberties, thereby lowering need for aggregate protections. Although dependable, emerging public health research paradigms like research using public health data (RUPD) raise new challenges to their application. Unlike traditional research, RUPD is population‐based, aligned to public health activities, and often reliant on pre‐collected longitudinal data. These characteristics, when considered in relation to the generally lower protective ethico‐legal frameworks of the Global South, including Africa, highlight ethical gaps. Health and demographic surveillance systems are examples of public health programs that accommodate RUPD in these contexts. We set out to explore the perspectives of professionals with a working knowledge of these systems to determine practical ways of appropriating the foundational principles of health research to advance the ever growing opportunities in RUPD. We present their perspectives and in relation to the literature and our ethical analysis, make context relevant recommendations. We further argue for the development of a framework founded on the discussions and recommendations as a minimum base for achieving optimal ethics for optimal RUPD in the Global South.     

LINKING INTERNATIONAL RESEARCH TO GLOBAL HEALTH EQUITY: THE LIMITED CONTRIBUTION OF BIOETHICS

Health research has been identified as a vehicle for advancing global justice in health. However, in bioethics, issues of global justice are mainly discussed within an ongoing debate on the conditions under which international clinical research is permissible. As a result, current ethical guidance predominantly links one type of international research (biomedical) to advancing one aspect of health equity (access to new treatments). International guidelines largely fail to connect international research to promoting broader aspects of health equity – namely, healthier social environments and stronger health systems. Bioethical frameworks such as the human development approach do consider how international clinical research is connected to the social determinants of health but, again, do so to address the question of when international clinical research is permissible. It is suggested that the narrow focus of this debate is shaped by high‐income countries' economic strategies. The article further argues that the debate's focus obscures a stronger imperative to consider how other types of international research might advance justice in global health. Bioethics should consider the need for non‐clinical health research and its contribution to advancing global justice.     

Community-based participatory research and integrated knowledge translation: advancing the co-creation of knowledge

Background

Better use of research evidence (one form of “knowledge”) in health systems requires partnerships between researchers and those who contend with the real-world needs and constraints of health systems. Community-based participatory research (CBPR) and integrated knowledge translation (IKT) are research approaches that emphasize the importance of creating partnerships between researchers and the people for whom the research is ultimately meant to be of use (“knowledge users”). There exist poor understandings of the ways in which these approaches converge and diverge. Better understanding of the similarities and differences between CBPR and IKT will enable researchers to use these approaches appropriately and to leverage best practices and knowledge from each. The co-creation of knowledge conveys promise of significant social impacts, and further understandings of how to engage and involve knowledge users in research are needed.

Main text

We examine the histories and traditions of CBPR and IKT, as well as their points of convergence and divergence. We critically evaluate the ways in which both have the potential to contribute to the development and integration of knowledge in health systems. As distinct research traditions, the underlying drivers and rationale for CBPR and IKT have similarities and differences across the areas of motivation, social location, and ethics; nevertheless, the practices of CBPR and IKT converge upon a common aim: the co-creation of knowledge that is the result of knowledge user and researcher expertise. We argue that while CBPR and IKT both have the potential to contribute evidence to implementation science and practices for collaborative research, clarity for the purpose of the research—social change or application—is a critical feature in the selection of an appropriate collaborative approach to build knowledge.

Conclusion

CBPR and IKT bring distinct strengths to a common aim: to foster democratic processes in the co-creation of knowledge. As research approaches, they create opportunities to challenge assumptions about for whom, how, and what is defined as knowledge, and to develop and integrate research findings into health systems. When used appropriately, CBPR and IKT both have the potential to contribute to and advance implementation science about the conduct of collaborative health systems research.

     

生态系统健康研究的一些基本问题探讨

目前有关生态系统健康研究的一些基本问题尚未达成共识。本文分析了健康、系统与生态系统3个与生态系统健康关联的概念,在此基础上,对生态系统健康的概念及其内涵、研究价值、研究的内容框架、研究的合理尺度以及生态系统质量诊断与质量等级评价进行了探讨。指出生态学上的生态系统是系统科学意义上系统的一类,整体性、稳定性和可持续性是生态系统的重要特征,生态系统健康可通过它的充分必要条件给出,即具备良好的整体性,能够维持较高的稳定性,并能实现良好的可持续性。生态系统质量标准分为质量诊断标准和质量等级评价标准,质量诊断是一种是与非的事实判断,而质量等级评价是一种价值判断。生态系统质量等级评价指标可分为限制可比型和非限制可比型两类。生态系统的复杂性决定了生态系统健康研究须借助于系统科学和非线性科学的理论与方法,生态系统病变的滞后性决定了生态系统健康研究必须加强生态系统质量预测与预警,而生态系统健康的跨学科性决定了生态系统健康研究需要生态学、环境学、医学、社会学以及经济学等领域研究人员的广泛合作。     

A research agenda for helminth diseases of humans: social ecology, environmental determinants, and health systems

In this paper, the Disease Reference Group on Helminth Infections (DRG4), established in 2009 by the Special Programme for Research and Training in Tropical Diseases (TDR), with the mandate to review helminthiases research and identify research priorities and gaps, focuses on the environmental, social, behavioural, and political determinants of human helminth infections and outlines a research and development agenda for the socioeconomic and health systems research required for the development of sustainable control programmes. Using Stockols' social-ecological approach, we describe the role of various social (poverty, policy, stigma, culture, and migration) and environmental determinants (the home environment, water resources development, and climate change) in the perpetuation of helminthic diseases, as well as their impact as contextual factors on health promotion interventions through both the regular and community-based health systems. We examine these interactions in regard to community participation, intersectoral collaboration, gender, and possibilities for upscaling helminthic disease control and elimination programmes within the context of integrated and interdisciplinary approaches. The research agenda summarises major gaps that need to be addressed.     

A research agenda for malaria eradication: cross-cutting issues for eradication

Discipline-specific Malaria Eradication Research Agenda (malERA) Consultative Groups have recognized several cross-cutting issues that must be addressed to prevent repetition of some of the mistakes of past malaria elimination campaigns in future programs. Integrated research is required to develop a decision-making framework for the switch from malaria control to elimination. Similarly, a strong economic case is needed for the very long-term financial support that is essential for elimination. Another cross-cutting priority is the development of improved measures of intensity of transmission, especially at low and nonrandom levels. Because sustained malaria elimination is dependent on a functioning health system, a further key cross-cutting research question is to determine how inputs for malaria can strengthen health systems, information systems, and overall health outcomes. Implementation of elimination programs must also be accompanied by capacity building and training to allow the assessment of the impact of new combinations of interventions, new roles for different individuals, and the operational research that is needed to facilitate program expansion. Finally, because community engagement, knowledge management, communication, political, and multisectoral support are critical but poorly understood success factors for malaria elimination, integrated research into these issues is vital.     

Reinterpreting Responsiveness for Health Systems Research in Low and Middle‐Income Countries

The ethical concept of responsiveness has largely been interpreted in the context of international clinical research. In light of the increasing conduct of externally funded health systems research (HSR) in low‐ and middle‐income countries (LMICs), this article examines how responsiveness might be understood for such research and how it can be applied. It contends that four features (amongst others) set HSR in LMICs apart from international clinical research: a focus on systems; being context‐driven; being policy‐driven; and being closely linked to development objectives. These features support reinterpreting responsiveness for HSR in LMICs as responsiveness to systems needs, where health system performance assessments can be relied upon to identify systems needs, and/or responsiveness to systems priorities, which entails aligning research with HSR priorities set through country‐owned processes involving national and sub‐national policymakers from host countries. Both concepts may be difficult to achieve in practice. Country ownership is not an established fact for many countries and alignment to their priorities may be meaningless without it. It is argued that more work is, therefore, needed to identify strategies for how the responsiveness requirement can be ethically fulfilled for HSR in LMICs under non‐ideal conditions such as where host countries have not set HSR priorities via country‐owned processes. Embeddedness is proposed as one approach that could be the focus of further development.     

Effects of three husbandry systems on health,welfare and productivity of organic pigs

Organic pig husbandry systems in Europe are diverse – ranging from indoor systems with concrete outside run (IN) to outdoor systems all year round (OUT) and combinations of both on one farm (POUT). As this diversity has rarely been taken into account in research projects on organic pig production, the aim of this study was to assess and compare pig health, welfare and productivity in these three systems. Animal health and welfare were assessed using direct observation and records of 22 animal-based measures, comprising 17 health-, 3 productivity- and 2 behavioural measures. These were collected in pregnant sows, weaners and fattening pigs during direct observations and from records within a cross-sectional study on 74 farms (IN: n = 34, POUT: n = 28, OUT: n = 12) in eight countries. Overall, prevalence of several animal health and welfare issues was low (e.g. median 0% for pigs needing hospitalisation, shoulder lesions, ectoparasites; <5% for runts, tail lesions, conjunctivitis). Exceptions in particular systems were respiratory problems in weaners and fatteners (IN: 60.0%, 66.7%; POUT: 66.7%, 60.0%), weaning diarrhoea (IN: 25.0%), and short tails in fatteners (IN: 6.5%, POUT: 2.3%). Total suckling piglet losses (recorded over a period of 12 months per farm) were high in all three systems (IN: 21.3%; POUT: 21.6; OUT: 19.2%). OUT had lower prevalences of respiratory problems, diarrhoea and lameness of sows. POUT farms in most cases kept sows outdoors and weaners and fatteners similar to IN farms, which was reflected in the results regarding several health and welfare parameters. It can be concluded, that European organic pigs kept in all three types of husbandry system showed a low prevalence of health and welfare problems as assessed by our methodology, but respiratory health and diarrhoea should be improved in weaners and fatteners kept indoors and total piglet mortality in all systems. The results provide benchmarks for organic pig producers and organisations which can be used in strategies to promote health and welfare improvement. Furthermore, in future research, the identified health and welfare issues (e.g. suckling piglet mortality, weaning diarrhoea) should be addressed, specifically considering effects of husbandry systems.     

Getting ready for malaria elimination: a check list of critical issues to consider

In recent years, a renewed interest in malaria elimination and eradication has emerged and seems to be rooting in the minds of the scientific community, public health specialists, funding bodies, policy makers and politicians. Malaria eradication will certainly benefit from improved and innovative tools; notwithstanding novel knowledge in fields ranging from basic science to mathematical modelling and health systems research. However, the elimination of malaria also encompasses a broad range of essential aspects that countries and other actors need to consider when thinking of embarking on such an adventure, including the implementation of innovative strategies, the ability to incorporate the most up-to-date evidence into policy, the integration of malaria into the broader health agenda, the strengthening of surveillance and health systems, capacity building, funding, advocacy and, very importantly, research. While in some cases this enthusiasm is clearly justified, some countries are still a long way from realistically advancing towards elimination. This paper attempts to provide guidance on all the necessary issues that should be considered when initiating a malaria elimination program.     

Commentary: Barriers and Opportunities to Changing the Research Agenda to Support Precaution and Primary Prevention

Conceptual research to define the Precautionary Principle and its rôle in science, science policy, and public health is making substantial progress. In September 2001, participants at the International Summit on Science and the Precautionary Principle developed a vision for science to address the complexity of contemporary health risks in a way that could lead to more precautionary, preventive decisions under uncertainty. Its components include: (1) a more effective linkage between research on hazards and research on primary prevention; (2) increased use of interdisciplinary approaches including better integration of qualitative and quantitative data; (3) innovative methods for analyzing cumulative and interactive effects, populations and systems and vulnerable sub-populations; (4) systems for continuous monitoring to avoid unintended consequences of actions and to identify early warnings of risks; (5) more comprehensive techniques for analyzing and communicating hazards and uncertainties; and (6) a more dynamic interface between science and policy. This article addresses barriers and opportunities to the practical application of this vision for science. Scientists in many fields have recognized the need for innovative approaches and tools to address increasingly complex, uncertain risks of a global scale. While opportunities to apply precautionary concepts in the research agenda exist, public health scientists must be cognizant of current and emerging barriers in the research agenda that balance the research focus on characterizing proximate causal mechanisms of disease, to the detriment of research and policy to support primary prevention.     

Ecosystem Approaches to Health for a Global Sustainability Agenda

International research agendas are placing greater emphasis on the need for more sustainable development to achieve gains in global health. Research using ecosystem approaches to health, and the wider field of ecohealth, contribute to this goal, by addressing health in the context of inter-linked social and ecological systems. We review recent contributions to conceptual development of ecosystem approaches to health, with insights from their application in international development research. Various similar frameworks have emerged to apply the approach. Most predicate integration across disciplines and sectors, stakeholder participation, and an articulation of sustainability and equity to achieve relevant actions for change. Drawing on several frameworks and on case studies, a model process for application of ecosystem approaches is proposed, consisting of an iterative cycles of participatory study design, knowledge generation, intervention, and systematization of knowledge. The benefits of the research approach include innovations that improve health, evidence-based policies that reduce health risks; empowerment of marginalized groups through knowledge gained, and more effective engagement of decision makers. With improved tools to describe environmental and economic dimensions, and explicit strategies for scaling-up the use and application of research results, the field of ecohealth will help integrate both improved health and sustainability into the development agenda.     

Focus: Vaccines: The Cost of Ignoring Vaccines

This perspectives piece focuses on the detrimental cost of ignoring vaccines and refusing vaccination against COVID-19 in the United States. Much of the existing literature regarding the consequences of the unvaccinated emphasizes the impact to population health; however, few academic articles have explored the burden the unvaccinated pose to various sectors of society. This paper analyzes the impact that the unvaccinated have on healthcare systems, the US economy, and global health. Throughout the COVID-19 pandemic, unvaccinated populations were found to have put significant strain on healthcare systems, depleting medical resources and contributing to high rates of healthcare worker shortages. Furthermore, research suggests that between November and December 2021, over 692,000 preventable hospitalizations occurred in unvaccinated individuals, costing the US economy over $13.8 billion. Lastly, it is proposed that the strong international presence of the US, when coupled with high levels of disease transmissibility in the unvaccinated, provides a significant threat to global health. In conclusion, the unvaccinated have caused impacts far beyond that of population health; they have also posed a burden to healthcare systems, the economy, and global public health.     

Interaction of radiofrequency and microwave radiation with living systems

Summary Human health aspects and biological effects of radio frequency (RF) and microwave radiation have been in the focus of research efforts in the last decade. An understanding of the interaction mechanisms between such radiation and living systems is essential in interpreting experimental results and assessing potential health hazards.A comprehensive review of basic biophysical interaction mechanisms between RF and microwaves in the frequency range between 10 MHz and 300 GHz and biological systems is provided in this paper. The interactions at various levels of organization of a living organisms such as molecular, cellular and macroscopic are discussed.