2 areas inputs requested

1. The following slides were presented at a meeting of potential editors and methods advisors for the proposed Cochrane review group in February 2008. The slides were designed to promote discussion rather than represent the views and directions of this group.

2. Cochrane Public Health Review Group Editorial and Methods meeting, Sutton Place Hotel, Edmonton 4-5 March 2008Some reflections/questions for discussionBased on:- Knowledge Networks (set up by WHO to inform Commission on Social Determinants of Health (CSDH)) & Civil Society consultations - Health Research Systems Analysis Initiative (focusing on understanding national research policies, capacities & collaborations in LMIC)- Post-CSDH process to update/implement social determinants of health and health equity research/synthesis agenda & call for proposals from LMIC (seven WHO main offices + partners for launch during the Bamako Ministerial Forum, Nov 08)

3. 2 areas inputs requested 1. Some challenges for conducting reviews of upstream, complex public health interventions, harnessing global effort 2. Meeting the needs of and involving people from low and middle income countries  

4. 1. Some challenges for conducting reviews of upstream, complex public health interventions, harnessing global effort  • TOPICS: Understanding policy questions (PM, civil society), translating to research/synthesis questions and methods • DATA: Limited appropriate data at national and subnational levels: disaggregation by equity- stratifiers within routine information systems and health programs & linked with other sectors • TIME: Overcoming/dealing with time constraints, time lags required to see impact, political time horizon • ACTIONS: Most primary research on correlations/descriptions, much less on evaluation of policy interventions addressing SDH -- that evaluate impact on health inequities across social gradient, that target populations that are rural, excluded, or vulnerable in other ways • UPTAKE: Health workers' mandate, scope & capacities to understand SDH and use of equity-stratified information in program planning and evaluation • APPROACH: value process to build up multiple perspective methods and quality assurance – step wise towards a clear, rigorous vision; professional alignment over "turf"; not "business as usual" in terms of topics and approaches • RELEVANCE: Limited to no synthesis incorporating low and middle income country experiences and community-level innovations – as not documented often/not found.

5. Example: Topics for a global agenda, from KNs + WHO • Further develop theoretical frameworks • linking across causal chain, social determinants and outcomes (MEKN), such as showing the links and pathways that link employment dimensions and health outcomes (EMCONET) • Accounting for a standardized range of explanatory factors (HSKN) • understanding intersection of the two axis of the health gradient e.g. health inequities and degree of social inequality in each society (ME KN) • Ensure policy coherence, in terms of actions proposed, with other "strategies" (PHC, poverty reduction, MDGs, Climate change) • Investigate biological and social interfaces • the extent and nature of sex-specific needs in health conditions that affect women and men (Gender) • understanding of effects of environments on biological embedding and early childhood development (ECD)

6. Example: Topics for a global agenda, from KNs + WHO • Document costs and effectiveness of interventions incorporating and valuing an equity perspective • early childhood development programs in low income countries (ECD) • participatory and community based interventions to address social determinates in urban settings (urbanization) • Build up and value equity-effectiveness with methods, tools, as a counter part to technical focus on cost-effectiveness (going beyond incidence-benefit, in light of social gradient)

7. Relevant Topics: Echoed by Regional perspectives: some examples WHO-Europe – covering more than 50 countries • causality between social determinants and health inequities • Better analysis of interventions that address social determinants and the impact on health inequities • Developing frameworks for the economic evaluation of SDH interventions. • Application of frameworks to evaluate concrete examples.

8. Relevant Topics: Echoed by Regional perspectives: some examples WHO – Western Pacific • Analyze the gender considerations and the impact of Health systems • Conceptualize what constitutes pro-poor and gender-responsive health systems   • Analyze gender-related barriers to health systems and how to address these (i.e. gender-responsive health financing system).   • Non-communicable diseases and equity: literature compares disease burdens of developed with developing countries; lack of within-country analysis and synthesis of approaches to address NCD

9. 2. Meeting the needs of and involving people from low and middle income countries • Building up strong institutions in LMICs that lead and contribute work – in addition to inclusion within networks • LMICs experiments and experiences are under-reported • Inadequate contextualization of experience – what are context-specific enabling factors/obstacles • Limited synthesis incorporating community-level innovations, rural, non-institutionalized populations • Themes addressing complex public health issues lacking data and primary studies in LMICs (some topics noted in previous section, more on next slide)

10. Challenge: decreasing low income countries' share of worldwide, easily accessible research on health topics Source: SSCI & SCI reference databases, 1992-2001Paraje et al., Science, 2005

11. Challenge: limited worldwide, easily accessible research on public health and health systems Source: SSCI & SCI reference databases, 1992-2000Knowledge for Better Health, WHO, 2004

12. Challenge: limited origin, focus & types of studies included within reviews of research findings [example: community intervention studies in low & middle income countries, to improve children's health] Source: Bhutta et al., 2004 (review of Cochrane Reviews)

13. Concerning themes: be bold, innovative • Not "business as usual" • Approaches to mandate corporate social responsibility through international and national legislation and regulation (SE KN) • Analyze overall and out-dated system of global governance established after the Second World War with a view to establishing a system conducive to health equity (Globalization) • Approaches to change dramatically patriarchy in favor of more balanced power relations between men and women, boys and girls. (Rio Symposium) • Projections of climate change impacts, socio-economic pattern of impacts on people, and ways to adapt to climate change in urban areas (Urbanization) • Impacts of consumer boycotts, civil society mobilization campaigns & evaluation of specific government responses to improving working conditions, labor rights and gender equity in LMIC export factories or zones (Globalization) • Incorporate rights-based approach that analyses power and social inequality and questions its causes (civil society) • Synthesis or more rigorous synthesis • Of available country experiences of processes to bring about and sustain policy changes, particularly equity-oriented changes (HS KN)

14. Implications – not new • Continue to facilitate and encourage greater disaggregation within routine information systems & within health programs & data linkages across sectors • Continue to strengthen integration and leadership of scientists from low and middle income countries (LMIC) • Continue to strengthen institutional capacities to collect, analyze and synthesize evidence in LMIC