Karl Blanchet

How to do (or not to do) … a social network analysis in health systems research

The main challenges in international health are to scale up effective health interventions in low- and middle-income countries in order to reach a higher proportion of the population. This can be achieved through better insight into how health systems are structured. Social network analysis can provide an appropriate and innovative paradigm for the health systems researcher, allow new analyses of the structure of health systems, and facilitate understanding of the role of stakeholders within a health system. The social network analysis methodology adapted to health systems research and described in detail by the authors comprises three main stages: (i) describing the set of actors and members of the network; (ii) characterizing the relationships between actors; and (iii) analysing the structure of the systems. Evidence generated through social network analysis could help policy makers to understand how health systems react over time and to better adjust health programmes and innovations to the capacities of health systems in low- and middle-income countries to achieve universal coverage.

Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020

BackgroundDevelopment of human resources for eye health (HReH) is a major focus of the Global Action Plan 2014 to 2019 to reduce the prevalence of avoidable visual impairment by 25% by the year 2019. The eye health workforce is thought to be much smaller in sub-Saharan Africa than in other regions of the world but data to support this for policy-making is scarce. We collected HReH and cataract surgeries data from 21 countries in sub-Sahara to estimate progress towards key suggested population-based VISION 2020 HReH indicators and cataract surgery rates (CSR) in 2011.MethodsRoutinely collected data on practitioner and surgery numbers in 2011 was requested from national eye care coordinators via electronic questionnaires. Telephone and e-mail discussions were used to determine data collection strategies that fit the national context and to verify reported data quality. Information was collected on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and ‘mid-level refractionists’ and combined with publicly available population data to calculate practitioner to population ratios and CSRs. Associations with development characteristics were conducted using Wilcoxon rank sum tests and Spearman rank correlations.ResultsHReH data was not easily available. A minority of countries had achieved the suggested VISION 2020 targets in 2011; five countries for ophthalmologists/cataract surgeons, four for ophthalmic nurses/clinical officers and two for CSR. All countries were below target for optometrists, even when other cadres who perform refractions as a primary duty were considered. The regional (sample) ratio for surgeons (ophthalmologists and cataract surgeons) was 2.9 per million population, 5.5 for ophthalmic clinical officers and nurses, 3.7 for optometrists and other refractionists, and 515 for CSR. A positive correlation between GDP and CSR as well as many practitioner ratios was observed (CSR P = 0.0042, ophthalmologists P = 0.0034, cataract surgeons, ophthalmic nurses and optometrists 0.1 > P > 0.05).ConclusionsWith only a minority of countries in our sample having reached suggested ophthalmic cadre targets and none having reached targets for refractionists in 2011, substantially more targeted investment in HReH may be needed for VISION 2020 aims to be achieved in sub-Saharan Africa.RésuméContexteLes ressources humaines en santé oculaire semblent être moindres en Afrique subsaharienne que dans les autres régions du monde, mais peu de données sont disponibles. Nous avons collecté des données sur les ressources humaines et le taux de chirurgie de la cataracte dans 21 pays de l’Afrique subsaharienne afin d’estimer pour 2011 les progrès réalisés concernant les indicateurs suggérés de ressources humaines et de chirurgie de la cataracte de VISION 2020.MéthodesLes données sur les six catégories de cadre de santé et les opérations de chirurgie régulièrement collectées en 2011 ont été demandées aux coordinateurs des programmes nationaux par questionnaire envoyé électroniquement. Des discussions par courrier électronique et téléphone ont permis de vérifier la qualité des données. Les associations avec les caractéristiques de développement ont été menées en utilisant le test de la somme des rangs de Wilcoxon et les coefficients de corrélation de Spearman.RésultatsUne minorité de pays ont atteint les cibles suggérées de VISION 2020: cinq pays pour les ophtalmologistes et les opérateurs de cataracte, quatre pays pour les infirmiers en ophtalmologie et les techniciens supérieurs en ophtalmologie et deux pays pour les opérations de cataracte. Tous les pays n’ont pas assez d’optométristes. Le ratio régional (échantillon) pour les chirurgiens (ophtalmologistes et operateurs de cataracte) était de 2,9 par million de population, 5,5 pour les infirmiers en ophtalmologie et les techniciens supérieurs en ophtalmologie, 3,7 pour les optométristes et autres réfractionnistes, et 515 pour le taux de chirurgie de cataracte. Il existe une corrélation positive entre PNB et le taux de chirurgie de cataracte et le PNB et le nombre de la plupart des professionnels (opération de cataracte P = 0.0042, ophtalmologistes P = 0.0034, opérateurs de cataracte, infirmiers en ophtalmologie et optométristes 0.1 > P > 0.05).ConclusionEtant donné que seulement une minorité de pays d’Afrique subsaharienne dans notre échantillon ont atteint en 2011 les cibles suggérées VISION 2020 en termes de nombre de professionnels de la santé oculaire et qu’aucun pays n’a un nombre suffisant de réfractionnistes, il est nécessaire et urgent d’investir dans les ressources humaines de la santé afin de pouvoir atteindre les objectifs VISION 2020.

Evidence on public health interventions in humanitarian crises

Recognition of the need for evidence-based interventions to help to improve the effectiveness and efficiency of humanitarian responses has been increasing. However, little is known about the breadth and quality of evidence on health interventions in humanitarian crises. We describe the findings of a systematic review with the aim of examining the quantity and quality of evidence on public health interventions in humanitarian crises to identify key research gaps. We identified 345 studies published between 1980 and 2014 that met our inclusion criteria. The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6). We observed common study design and weaknesses in the methods, which substantially reduced the ability to determine causation and attribution of the interventions. Considering the major increase in health-related humanitarian activities in the past three decades and calls for a stronger evidence base, this paper highlights the limited quantity and quality of health intervention research in humanitarian contexts and supports calls to scale up this research.

Trends and implications for achieving VISION 2020 human resources for eye health targets in 16 countries of sub-Saharan Africa by the year 2020

BackgroundDevelopment of human resources for eye health (HReH) is a major global eye health strategy to reduce the prevalence of avoidable visual impairment by the year 2020. Building on our previous analysis of current progress towards key HReH indicators and cataract surgery rates (CSRs), we predicted future indicator achievement among 16 countries of sub-Saharan Africa by 2020.MethodsSurgical and HReH data were collected from national eye care programme coordinators on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and ‘mid-level refractionists’ and combined them with publicly available population data to calculate practitioner-to-population ratios and CSRs. Data on workforce entry and exit (2008 to 2010) was used to project practitioner population and CSR growth between 2011 and 2020 in relation to projected growth in the general population. Associations between indicator progress and the presence of a non-physician cataract surgeon cadre were also explored using Wilcoxon rank sum tests and Spearman rank correlations.ResultsIn our 16-country sample, practitioner per million population ratios are predicted to increase slightly for surgeons (ophthalmologists/cataract surgeons, from 3.1 in 2011 to 3.4 in 2020) and ophthalmic nurses/clinical officers (5.8 to 6.8) but remain low for refractionists (including optometrists, at 3.6 in 2011 and 2020). Among countries that have not already achieved target indicators, however, practitioner growth will be insufficient for any additional countries to reach the surgeon and refractionist targets by year 2020. Without further strategy change and investment, even after 2020, surgeon growth is only expected to sufficiently outpace general population growth to reach the target in one country. For nurses, two additional countries will achieve the target while one will fall below it. In 2011, high surgeon practitioner ratios were associated with high CSR, regardless of the type of surgeon employed. The cataract surgeon workforce is growing proportionately faster than the ophthalmologist.ConclusionsThe HReH workforce is not growing fast enough to achieve global eye health targets in most of the sub-Saharan countries we surveyed by 2020. Countries seeking to make rapid progress to improve CSR could prioritise investment in training new cataract surgeons over ophthalmologists and improving surgical output efficiency.Additional non-English language abstract (French)ContexteLe développement des ressources humaines pour la santé oculaire est une priorité majeure des initiatives globales pour la réduction de la cécité d’ici à 2020. Sur la base de notre analyse précédente sur la situation en 2011, nous avons calculé les indicateurs de performance pour 2020 pour 16 pays de l’Afrique sub-saharienne.MéthodesLes données chirurgicales et en ressources humaines ont été collectées auprès des coordinateurs de programmes nationaux pour 6 cadres de santé (ophtalmologistes, opérateurs de la cataracte, techniciens supérieurs en ophtalmologie (TSO), infirmiers en ophtalmologie, optométristes et réfractionnistes) combinées avec les données démographiques. Les données sur entrée et sortie (2008–2011) de la force de travail ont été utilisées pour projeter le taux professionnel-population et le taux d’opérations chirurgicales entre 2011 et 2020. Les associations entre indicateur de performance et présence d’opérateurs de la cataracte ont été analysées en utilisant les tests de rang de somme Wilcoxon et les corrélations Spearman.RésultatsLes taux professionnel-population vont augmenter légèrement pour les chirurgiens (ophtalmologistes/opérateurs de la cataracte, de 3,1 en 2011 à 3,4 en 2020) et les TSO/infirmier en ophtalmologie (5,8 à 6,8) mais restent bas pour les réfractionnistes (optométristes inclus, à 3,6). Parmi les pays qui ont déjà atteint les indicateurs cibles en 2011, la croissance actuelle sera insuffisante pour atteindre les cibles en termes de chirurgiens et réfractionnistes d’ici à 2020. Seul un pays peut atteindre la cible chirurgien après 2020. Pour les infirmiers, deux pays vont atteindre la cible en 2020 tandis qu’un troisième sera juste en dessous. En 2011, les taux importants en chirurgiens étaient associés avec de hauts taux d’opérations de chirurgie quel que soit le type de chirurgien employé. La population en opérateur de chirurgie augmente proportionnellement plus rapidement que celle d’ophtalmologistes.ConclusionLa force de travail en santé oculaire n’augmente pas assez vite pour atteindre les cibles de performance d’ici à 2020 dans la plupart des pays d’Afrique sub-saharienne. Les pays qui veulent augmenter rapidement leur taux de chirurgie devraient investir sur les opérateurs de la cataracte plutôt que sur les ophtalmologistes, puisque cette population de professionnels peut s’accroitre plus rapidement.

Evidence on the Effectiveness of Water, Sanitation, and Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic Review

Background Water, sanitation, and hygiene (WASH) interventions are amongst the most crucial in humanitarian crises, although the impact of the different WASH interventions on health outcomes remains unclear. Aim To examine the quantity and quality of evidence on WASH interventions on health outcomes in humanitarian crises, as well as evaluate current evidence on their effectiveness against health outcomes in these contexts. Methods A systematic literature review was conducted of primary and grey quantitative literature on WASH interventions measured against health outcomes in humanitarian crises occurring from 1980–2014. Populations of interest were those in resident in humanitarian settings, with a focus on acute crisis and early recovery stages of humanitarian crises in low and middle-income countries. Interventions of interest were WASH-related, while outcomes of interest were health-related. Study quality was assessed via STROBE/CONSORT criteria. Results were analyzed descriptively, and PRISMA reporting was followed. Results Of 3963 studies initially retrieved, only 6 published studies measured a statistically significant change in health outcome as a result of a WASH intervention. All 6 studies employed point-of-use (POU) water quality interventions, with 50% using safe water storage (SWS) and 35% using household water treatment (HWT). All 6 studies used self-reported diarrhea outcomes, 2 studies also reported laboratory confirmed outcomes, and 2 studies reported health treatment outcomes (e.g. clinical admissions). 1 study measured WASH intervention success in relation to both health and water quality outcomes; 1 study recorded uptake (use of soap) as well as health outcomes. 2 studies were unblinded randomized-controlled trials, while 4 were uncontrolled longitudinal studies. 2 studies were graded as providing high quality evidence; 3 studies provided moderate and 1 study low quality evidence. Conclusion The current evidence base on the impact of WASH interventions on health outcomes in humanitarian crises is extremely limited, and numerous methodological limitations limit the ability to determine associative, let alone causal, relationships.

The Effectiveness of Interventions for Non-Communicable Diseases in Humanitarian Crises: A Systematic Review

Background Non-communicable diseases (NCDs) are of increasing concern in low- and middle-income countries (LMICs) affected humanitarian crises. Humanitarian agencies and governments are increasingly challenged with how to effectively tackle NCDs. Reviewing the evidence of interventions for NCDs in humanitarian crises can help guide future policies and research by identifying effective interventions and evidence gaps. The aim of this paper is to systematically review evidence on the effectiveness of interventions targeting NCDs during humanitarian crises in LMICs. Methods A systematic review methodology was followed using PRISMA standards. Studies were selected on NCD interventions with civilian populations affected by humanitarian crises in low- and middle-income countries. Five bibliographic databases and a range of grey literature sources were searched. Descriptive analysis was applied and a quality assessment conducted using the Newcastle-Ottawa Quality Assessment Scale for observational studies and the Cochrane Risk of Bias Tool for experimental studies. Results The search yielded 4919 references of which 8 studies met inclusion criteria. Seven of the 8 studies were observational, and one study was a non-blinded randomised-controlled trial. Diseases examined included hypertension, heart failure, diabetes mellitus, chronic kidney disease, thalassaemia, and arthritis. Study settings included locations in the Middle East, Eastern Europe, and South Asia. Interventions featuring disease-management protocols and/or cohort monitoring demonstrated the strongest evidence of effectiveness. No studies examined intervention costs. The quality of studies was limited, with a reliance on observational study designs, limited use of control groups, biases associated with missing data and inadequate patient-follow-up, and confounding was poorly addressed. Conclusions The review highlights the extremely limited quantity and quality of evidence on this topic. Interventions that incorporate standardisation and facilitate patient follow-up appear beneficial. However, substantially more research is needed, including data on costs.

How to Achieve Universal Coverage of Cataract Surgical Services in Developing Countries: Lessons from Systematic Reviews of Other Services.

Purpose: Since the Declaration of Alma Ata, universal coverage has been at the heart of international health. The purpose of this study was to review the evidence on factors and interventions which are effective in promoting coverage and access to cataract and other health services, focusing on developing countries. Methods: A thorough literature search for systematic reviews was conducted. Information resources searched were Medline, The Cochrane Library and the Health System Evidence database. Medline was searched from January 1950 to June 2010. The Cochrane Library search consisted of identifying all systematic reviews produced by the Cochrane Eyes and Vision Group and the Cochrane Effective Practice and Organisation of Care. These reviews were assessed for potential inclusion in the review. The Health Systems Evidence database hosted by MacMaster University was searched to identify overviews of systematic reviews. Results: No reviews met the inclusion criteria for cataract surgery. The literature search on other health sectors identified 23 systematic reviews providing robust evidence on the main factors facilitating universal coverage. The main enabling factors influencing access to services in developing countries were peer education, the deployment of staff to rural areas, task shifting, integration of services, supervision of health staff, eliminating user fees and scaling up of health insurance schemes. Conclusion: There are significant research gaps in eye care. There is a pressing need for further high quality primary research on health systems-related factors to understand how the delivery of eye care services and health systems’ capacities are interrelated.

World Health Organization and emergency health: if not now, when?

In light of the recent Ebola epidemic, Francesco Checchi and colleagues argue that the World Health Organization’s response to health emergencies is not fit for purpose and put forward six proposals to reform WHO’s crisis response

Physical rehabilitation in post-conflict settings: analysis of public policy and stakeholder networks

Abstract Physical rehabilitation plays a determinant role in post-conflict contexts to restore disabled citizens’ mobility and independence. While the main objectives of any physical rehabilitation programme are to ensure that the services provided are accessible and of good quality to meet existing needs, it is intended that the services need to be supported over the long term by public health and social welfare authorities. This article presents the results of a study conducted in three post-conflict countries on the relationships between the level of commitment of national governments to rehabilitation services and the influence of social networks on national policy related to physical rehabilitation. From a policy and resource standpoint, the environment in Nepal is the most favourable for creating leverage at the national level to influence the commitment of ministries in the rehabilitation sector, compared with Cambodia and Somaliland. Stakeholder network analysis in Nepal, furthermore, reveals a dominant civil society and private sector supporting rehabilitation services, including intense involvement of local organisations and user groups. Implications for Rehabilitation Physical rehabilitation is not on the top of the agenda of governments in fragile states. The commitment and involvement of national authorities in the rehabilitation sector is positively influenced by civil society and international organisations. The denser the social network of the rehabilitation sector is, the more influence the actors can exert influence over national authorities.

Systematic review of the evidence on the effectiveness of sexual and reproductive health interventions in humanitarian crises

Objectives This systematic review aims to evaluate evidence on the effectiveness of sexual and reproductive health (SRH) interventions delivered in humanitarian crises. Setting Crisis affected low-income or middle-income countries. Participants Crisis-affected populations in low-income or middle-income countries. Method Peer-reviewed and grey literature sources were systematically searched for relevant papers detailing interventions from 1 January 1980 until the search date on 30 April 2013. Data from included studies were then extracted, and the papers’ quality evaluated using criteria based on modified STROBE and CONSORT checklists. Primary and secondary outcome measures Primary outcomes include, but are not limited to, changes in morbidity, mortality, sexually transmitted infection (STI) diagnosis or gender-based violence. Secondary outcomes include, but are not limited to, reported condom use or skilled attendance at birth. Primary outputs include, but are not limited to, condoms distributed or education courses taught. Results Of 7149 returned citations, 15 studies met the inclusion criteria. Only one randomised controlled trial was identified. The remaining observational studies were of moderate quality, demonstrating limited use of controls and inadequate attempts to address bias. Evidence of effectiveness was available for the following interventions: impregnated bed nets for pregnant women, subsidised refugee healthcare, female community health workers, and tiered community reproductive health services. Conclusions The limited evidence base for SRH interventions highlights the need for improved research on the effectiveness of public health interventions in humanitarian crises. While interventions proven efficacious in stable settings are being used in humanitarian efforts, more evidence is required to demonstrate the effectiveness of delivering and scaling-up such interventions in humanitarian crises.