Final Report Summary - SDH-NET (Building Sustainable Research capacity for Health and its Social Determinants in Low- and Middle-Income Countries)
Executive Summary:
Inequalities in health is considered as one of the leading health problems by WHO, and figures on top of public health agendas in most countries. Good quality evidence on health inequities, prevalence, causes, and determinants is a crucial starting point in decreasing health inequities and their negative impact. High income countries have developed sophisticated data and research systems providing insights and ideas how to address inequalities. This capacity is very scarce in Low and Middle Income Countries (LMIC) where its scaling-up through collaborative activities is of high value.
SDH-Net, a project funded by the European Commission under the 7th Framework Research Programme, did exactly that: bringing together a diverse set of institutions from Africa, Latin America and Europe to work together on SDH research capacity building in LMIC. Project objectives included gaining a better knowledge on capacity needs in participating countries, developing tools and instruments allowing to address those needs, while considering ethical issues and policy lessons in general.
The mapping and assessing of SDH research status and context in the participating countries, resulted in national and regional SDH research reports and a set of “light mapping” reports in the European partner countries. Based on the insights a capacity building strategy was elaborated, resulting in the developing and piloting of context-specific tools and methods for strengthening research capacity. The material for research capacity building and strengthening comprised courses such as: “Impact evaluation on SDH policy and research and SDH research communication courses”. Didactic and methodological resources included “Qualitative methods for SDH research” and a Case creator online tool. The conception of a Learning Platform for SDH Research Training allows for free access to all on-line materials and practice-based courses. Final policy lessons were drawn on best practices, the collaboration’s success and failure factors and ethical issues.
SDH-Net’s activities and products are apprehending the WHO CSDH recommendations on the development of “virtual repository of teaching and training materials on a broad range of social determinants of health that can be downloaded without cost”, while creating “opportunities for interdisciplinary professional training and research on social determinants of health”.
SDH-Net’s outputs and its active dissemination are expected to profoundly impact on LMIC improving the SDH research landscape and the quality of evidence-based research in the regions of Latin America and Africa. SDH-Net’s learning platform links to WHO activities, and the easy access to the products developed will assure sustainability and broader impact. All this results in better SDH and health related policies, global efforts aimed at eradicating health inequities and valuable South-North-South and South-South collaboration growing out of this project, a basis for sustainable global networks, in the fight to eradicate inequalities and inequities in health.
Project Context and Objectives:
The aim of the Social Determinants of Health Network (SDH-Net) project was to build, strengthen and link research capacities for health and its social determinants in African and Latin American low- and middle-income countries, in close collaboration with partners from those regions and Europe.
BACKGROUND
Capacity building in social determinants of health (SDH) research is crucial in the fight of the global phenomenon of health inequities – the differences in the health status and health care coverage across different populations. They exist within and between countries, and causes extend beyond the health sector. Health inequities may be the result of biological variations and certain lifestyle choices; however, substantial differences in health between different social groups are primarily defined by broader social inequities and their determinants. While health inequities extend across the globe, consequences are particularly dramatic in LMIC.
The detrimental effects of persisting health inequities have been recognised by different stakeholders, however, concrete interventions and policies transforming the structural processes that determine health inequities have remained limited. One reason for this is the lack of locally relevant research activities and results which define intervention priorities and help to develop appropriate solutions to urgent health problems, especially in LMIC. Exchanging experiences and linking expertise across institutions, sectors and countries, in order to better understand what works and what does not within each context, are essential for strengthening research capacities and health systems and for developing contextually relevant approaches to pressing health problems.
OBJECTIVES
The project objectives were to:
1. Map, describe and assess the SDH research status and context in countries of study.
2. Based on SDH assessment, develop and pilot context-specific tools and methods for strengthening research capacity.
3. Build sustainable North-South (Europe-Africa and Latin America) and South-South (African and Latin American countries) institutional and network collaborations in the field of SDH research throughout the project.
4. Based on pilot testing, document lessons learned in terms of policies and ethics and exchange best practices and success factors, as well as information on what worked, how it worked and why.
The focus on SDH allows for an in-depth and broad capacity-building approach, including methodological, managerial and technical excellence, ethical issues, research strategies and communication and knowledge transfer. Throughout every phase of the project, results were communicated and disseminated and networks were forged, built upon and strengthened.
PROJECT DESCRIPTION
The SDH-Net project was launched in October 2011 and is a four year (2011-2015) collaboration, financed by the European Commission under the 7th Framework Research Programme.
It was carried out by a consortium of 11 partners: three from Latin America (Brazil, Colombia and Mexico), three from Africa (Kenya, Tanzania and South Africa), four from Europe (Germany, Spain, Switzerland and the UK), and one international non-governmental organisation operating under Swiss law (COHRED). The six LMIC partner institutions are leaders in public health research. The European team, consisting of two distinguished European institutions: the London School of Hygiene and Tropical Medicine (LSHTM) and the University of Geneva, as well as COHRED, provide technical assistance. In addition, GIZ (an implementing state-owned development cooperation organisation), with long-term experience in health system strengthening, health research, and capacity building in LMIC, coordinated SDH-Net, while IESE Business School, an expert in managerial and leadership capacity building, provided scientific direction to the project. All partners are strongly embedded in local and regional networks, ensuring national and regional involvement of policy makers and other stakeholders who were invited to different project activities in order to secure alignment with national health policy strategies as well as a high level of political commitment. SDH-Net allowed for the exchange of knowledge and insights between research institutions, civil society organisations and policy makers, ensuring sustainability of the project and ownership of the results.
To address the objectives of the project in an efficient way, the work under SDH-Net was organised according to the following work packages (WP):
WP1 Overview of Social Determinants of Health – from local to global
WP2 Mapping research system characteristics – stakeholders, institutions and ongoing activities
WP3 Assessment of capacity building needs
WP4 Research capacity building: research methodology and SDH
WP5 Research capacity building: research management and research communication
WP6 Knowledge management and network strengthening
WP7 Lessons learned
WP8 Dissemination
WP9 Monitoring and evaluation
WP10 Project management and coordination
EXPECTED RESULTS AND IMPACT
Ultimately, the goal of the project was to advance the understanding of SDH at different levels, improve interventions for reducing health inequities on the local and regional levels and to build sustainable research capacities (both at the individual and supporting infrastructure level) that are able to provide evidence in support of specific policies and interventions to address health inequities. Overall, this project intended to provide a framework for developing interdisciplinary research capacity in the field of SDH in LMIC settings by building, strengthening and linking capacities in research institutions and implementing agencies in LMIC in close collaboration with European institutions.
SDH-Net had a substantial impact on the SDH research landscape in Africa and Latin America. The assessment of SDH research structures, research needs and gaps allowed for targeted capacity building activities and initiatives to strengthen networking and cooperation. Courses and other training activities were established, all with the aim, to facilitate better research: improve methodology and research management.
Regarding networking, connecting actual clusters of research and reinforcing existing networks across continents, the SDH-Net project has enhanced North-South as well as South-South cooperation in SDH research with the additional effect of general research capacity strengthening. The focus on education and the involvement of junior researchers was a key focus of SDH-Net to prepare the next generation of SDH research “leaders”. Moreover, SDH-Net short-term fellowships have led to building international networks for SDH research beyond the life of the project. Increased research capacity, stronger partner institutions, and heightened sensitivity towards SDH in the countries will, in the future, lead to improved quality of SDH research and its uptake, which in turn will lead to better health policies at national and regional level, and, consequently, to reduced health inequities and improved health of the population in the participating countries and regions.
A specific focus of the project was to improve the quality of research. By fostering research capacity and networks in SDH, the project has created the basis for relevant, high-quality and methodologically sound research in different settings. The mapping exercise and gaps assessment in the first project phase have enabled the identification of research capacity building needs and research priorities that have facilitated future involvement of government actors, national organisations, non-governmental organisations (NGOs), bilateral or international donors. In addition, the mapping exercise enhanced the identification of areas where contributions would be of particular value and would have a significant impact. Capacity building exercises allowed for the updating and exchange of health research methodologies, management and communication, leading to better quality evidence in the future. Also, improved evaluation and monitoring mechanisms are expected to enable more stringent peer reviews and an improved quality assurance system.
The creation of the Learning Platform that provides free online access to SDH-Net materials enables the sustainability of SDH-Net products beyond the life of the project, as well as linking SDH-Net activities with WHO Geneva y PAHO knowledge hubs. Moreover, INSP has secured funding (from PAHO) for the materials that were developed alongside the project to be translated into the Spanish language. Therefore, SDH-Net also adds to research capacity building in the entire Spanish speaking Latin America.
Sustainable SDH research capacity in LMIC can be strengthened through national SDH networks. Indeed, SDH-Net played an important role in reinforcing structures and initiatives at national level that allowed for better SDH research in partner LMIC. For example, in South Africa, as part of SDH-Net, the City Council of Johannesburg initiated a National Commission on Social Determinants of Health that put SDH to the attention of regional and national governments, relevant stakeholders and the society in general. In Mexico, INSP has established a national alliance for SDH that includes INSP, the Mexican National Directorate of Health Promotion, PAHO-Mexico Office, the Mexican Academy of Medicine and other stakeholders to work on a variety of actions with the purpose of strengthening capacities, training, debating, and networking on SDH in the national context – with the ultimate goal of eliminating health inequalities. Other national activities to strengthen SDH research were also pursued in Brazil, Colombia, Kenya and Tanzania.
Moreover, the SDH-Net project was linked to the activities of WHO Health in all policy (HiAP), while several SDH-Net members are part of the global HiAP networks. In the context of the HiAP network, regional trainings (“trainings the trainers”) on SDH research were carried out and SDH-Net partners from Latin America and Africa were involved in these activities.
Finally, SDH-Net project enhanced capacities for conducting and managing research on SDH and, thus, enabled stronger links between research, policy and practice through the development of tools and mechanisms, facilitating sustained collaboration.
Project Results:
Main project S&T results and foregrounds are described below; they were categorised in a few sections according to the main groups of results produced.
MAPPING RESEARCH SYSTEM CHARACTERISTICS
Mapping Tool
A methodological tool with guiding questions and criteria for mapping SDH research capacities and identifying gaps in research systems and research activity on SDH was adapted to the specific national contexts of the project’s partners, including a short “light mapping” version.
National Mapping Reports
The mapping exercise was carried out by all partners at the national level to collect information on research activities, knowledge production and research system characteristics related to SDH in the respective countries.
Overall Mapping Report
The results of the national mapping reports were drawn together in an overall mapping report. This synthesis provided an overview of SDH research activities and research capacity as well as pointing to gaps and needs.
“Light Mapping” Reports (European Partners)
While the SDH-Net’s main focus were on LMIC, it was decided to carry out a “light” mapping” report on SDH and SDH research in the respective European partner countries to complement the more extensive African and Latin American reports and provide some additional ideas and compare the situation in high-income countries with participating LMIC.
Regional mapping reports
In order to synthesise the information, the national mapping results were analysed and brought together into a regional matrix and report of each of the two regions Latin America and Africa.
Development of a Mapping Tool
The standardised Mapping Tool is a system approach that was adapted to fit the specific context of the six partner countries (Brazil, Colombia, Mexico, Kenya, Tanzania and South Africa). Standard guidelines were developed to ensure that all countries followed a broadly similar protocol in their gathering of information, allowing comparability between the country reports. The same tool was the base of the Light Mapping Concept, carried out in Germany, Spain, Switzerland and the UK.
Mapping Report
The Mapping Report shows the country mapping process and the executive summaries of the findings of the mapping exercise, representing a snapshot and a first step of systematically collecting and synthesising available information at national level.
DEVELOPMENT OF COURSE MATERIALS FOR RESEARCH CAPACITY STRENGTHENING IN AREAS OF SDH
Development of course materials for theory-based sessions
A number of theory-based courses were developed:
1. The Essentials of SDH (automated, self-directed, 10h course)
Description: This is a self-directed, automated course powered by the SDH-Net platform. Course completion requires a total of 10 hours including online work and offline readings.
Purpose: To provide a theoretical basis for understanding and addressing SDH. This is a basic, introductory course to SDH.
Suggested use: As a stand-alone course or a complement to classroom courses to understand the theory and practice of SDH approach. It includes examples of analysis, description, planning, and implementation of actions to promote health equity at national, regional and global levels.
Suggested audience: Enrolment to this course requires a minimum education level of undergraduate, technical or Bachelor degree or equivalent.
Access: http://tie.inspvirtual.mx/portales/sdhnet/essentials.php
Portable Offline Version: Taking into account that sometimes online training environment is impractical, a Portable Offline Version (POV) of the course that is executable from a USB Flash drive was developed.
2. Qualitative Methods for SDH research (automated, self-directed, 20h course)
Description: This is an online course delivered by the Learning Management System ‘Moodle’, and powered by the SDH-Net platform. The course requires a facilitator to guide the work and answer questions.
Purpose: To provide the basis for conducting SDH-related research using a qualitative methods approach.
Suggested use: As a stand-alone course to understand the relevance of qualitative research for the analysis of social realities and the causes of health inequities. The course also provides an overview of a range of relevant qualitative research techniques.
Suggested audience: Junior and senior researchers with limited knowledge of qualitative methods who are interested in learning how to apply techniques derived from qualitative research into SDH-related research. For this course, it is necessary to assign an instructor and an administrator. Both must have previous knowledge of the Moodle learning platform. The instructor guides and is in continuous communication with the student; also, the instructor is the link between the student and the administrator. The administrator must be able to attend and resolve all the technical difficulties during the learning process, and provide course access to students.
Access: http://tie.inspvirtual.mx/portales/sdhnet/qualitative.php
3. Impact evaluation on SDH policy and research (automated, self-directed, 20h course)
Description: This online course provides an introduction to the methods for evaluating the impact of policies or programmes targeting the social determinants of health. The course covers both the quantitative and qualitative methods of attributing impact that are used to assess whether a policy or programme was effective and how and why these effects were brought about.
Purpose: To provide an overview of the methods for evaluating the impact of interventions aimed to improve health through addressing social determinants.
Suggested use: This course is designed to be used as an introduction to this area for self-directed learning for a student with a general understanding of research methodology. Links to advanced material are provided for students who wish to explore particular aspects of the course in more detail. Self-assessment exercises designed for students to test they have understood key concepts are provided throughout the course.
Suggested audience: Junior and senior researchers interested in learning about the assessment of impact of policies, programmes and research findings. Ideal for graduate students in health and social sciences.
Access: http://tie.inspvirtual.mx/portales/sdhnet/impact.php
4. SDH Research communication course was designed to be both presential or/and self-directed through virtual platform)
Description: Twenty-hour classroom-based course aimed at the learning of communication skills to enable SDH researchers to disseminate research findings to different stakeholders.
Purpose: to strengthen essential research communication skills to enable SDH researchers to disseminate research findings to different stakeholders, aimed to place SDH on the strategic political agenda and improve programme effectiveness and health outcomes.
Suggested use: in classroom settings, face-to-face lessons.
Suggested audience: The course is comprehensive and mainly targets academics and researchers in the field of SDH: junior researchers and mid-level researchers who would like to learn how to communicate effectively with the research community, with policy makers in the health sector and other stakeholders interested in SDH and health equity research.
The format of the course can be adapted and some modules address different types of audience such as policy makers and journalists, to see how to take evidence into account and how to effectively use it in policy implementation, employing different communication channels.
The course comprises:
Case Studies/Study Cases linked to these courses
1. Research management (South African Social Investment Exchange as corporate social responsibility: An innovative way to fund SDH projects?)
2. Implementation research for SDH in LMIC (IMCI implementation in Tanzania: experiences, challenges and lessons)
3. “Communication as a transversal element in research on Social Determinants of Health: A case on research communication in a research project on social determinants of health involving a rural community in a low- and middle-income country.”
Practical courses/ workshop
1. Workshop (1): Disseminating SDH-related research findings to different audiences
2. Workshop (2):
1. Module 1: Research capacity building: research strategy management and leadership for research; institutional capacity development.
2. Module 2: Research translation: from knowledge to practice in a health laboratory setting
3. Module 3: The basics of research financing, budgeting and fundraising for SDH research
The Research Communication workshop was designed as a short and practical adaptation of the Research communication course. The workshop was piloted at ISGlobal.
Other resources
1. Toolkit for research fund management
2. Short Guide: “How to mainstream SDH into the curriculum with an example of a one-hour lecture on SDH for health professionals.”
Course materials were developed for practice-based sessions specifically on the implementation of the courses and use of materials at different institutions, including sessions on how to adapt the course content as well as how to develop case studies to the respective country setting. A brief guide on how to implement course materials and a template were developed to ensure that the courses could be taught at various institutions independently and successfully, and Training of Trainers sessions were held to illustrate the use of the course materials in a practical setting within the consortium.
5. Research management for projects on health and its social determinants course
Description: The course provides a basic overview of the use of project management for both simple and complex collaborative SDH-related projects and a focus on the relevant people and organisational factors. In addition, it includes research costing, specifically costing practices, financial management and fund raising aspects in an SDH-related research setting. The very nature of the core areas in this course demand a practical focus to support relevant and applicable learning. This is reflected in opportunities created for the practice-based exercises integral to each session within the modules of the course. In its application to SDH-related projects and integrating participant experience with past and current SDH projects and relevant case studies, it strives to bring the knowledge and benefits of good practice into the management domain of SDH researchers.
Purpose: To enhance research management capacity applicable to SDH-related research projects by providing an overview of research management methodologies and tools focused on project management, collaborative research management and research costing, thereby improving overall SDH-related research project efficiency and effectiveness.
Target audience: Since this course is applied to SDH-related research projects, a pre-requisite for this course is that all participants complete the relevant SDH-Net virtual courses (including Essentials of SDH, SDH Methodology, etc.). Specifically participants mentioned below would benefit optimally from this course:
1. Researchers managing large SDH projects and/or research groups
2. Health and social sciences research project managers / Administrators.
Methods: This contact course has a theoretical component and exercises as practice-based sessions that would require 20 hours of learning spanning two months. Resources such as course materials, and additional relevant articles, video, audio and presentations may be used to stimulate learning in a classroom setting. Slides have been developed for each module to support the training and learning process.
Development of course materials for practice-based sessions
Material for two practice-based courses (Workshops) to be implemented in classroom settings were also developed: Interdisciplinary approach for the study of SDH (20h) and Mixed Methods for the Study of SDH (20h). These are pdf documents that describe two 20-hour classroom-based workshops. The workshops description is given in detail so that they can be implemented in classroom setting with a facilitator/instructor.
1. “Interdisciplinary Approach for the Study of SDH”
Description: Workshop guided by an instructor, to train participants in the concepts of multi-, inter-, and trans-disciplinary research, in order to apply them in the design and carrying out of research projects, as well as to the reporting and dissemination of research findings, within the framework of the SDH.
Purpose: To learn and apply the principles of interdisciplinary research and understand how to build and work with interdisciplinary teams for the study of SDH.
Suggested use: In classroom settings with an instructor. The workshop can be used as a complement to a research methods course or by itself to strengthen multi-, inter-, and trans-disciplinary research capacities.
Suggested audience: Junior and senior researchers interested in diversifying the focus of their research by incorporating other disciplines into the design and implementation of research projects, as well as in the analyses of findings, and their implications for SDH research.
Access: http://tie.inspvirtual.mx/portales/sdhnet/workshops/Workshop%201%20Interdisciplinary.pdf
2. “Mixed Methods for the Study of SDH”
Description: Workshop guided by an instructor, to train participants in the concepts of mixed methods in scientific research, in order to apply them in the design and carrying out of research projects within the framework of the SDH.
Purpose: To learn and correctly apply the principles of mixed methods research.
Suggested use: In classroom settings with an instructor. The workshop can be used as a complement to a research methods course or by itself to strengthen research capacities on the use of mixed methods in scientific research applied to SDH research projects.
Suggested audience: Junior and senior researchers with medium-level knowledge of qualitative and quantitative methodology interested in learning and applying a mixed method approach for the study of SDH.
Access: http://tie.inspvirtual.mx/portales/sdhnet/workshops/Workshop%20Mixed%20Methods.pdf
REPOSITORY OF RESOURCES/MATERIALS FOR COURSE DEVELOPMENT AND IMPLEMENTATION
Description: Collection of electronic documents that can be easily downloaded by clicking on the link. The compilation includes scientific articles, formal reports, book chapters, books, videos, photographs, infographics and other relevant material.
Purpose: To provide access to interested users, to a wide range of specialised resources on social determinants of health and health inequities research. Resources in Repository can be used individually to acquire new knowledge or as learning tools in classroom settings.
Suggested use: Supporting materials to teach and learn about SDH.
Suggested audience: Individuals affiliated to different institutions (government, academic, philanthropic, national and international institutions) working in any field of the social and health sciences, administration and humanities wanting to learn or expand their knowledge about the Social Determinants of Health. Access: http://tie.inspvirtual.mx/portales/sdhnet/sdh-net/
Practical materials to strengthen SDH research capacity
Case studies/Study Cases: A total of 11 case studies/study cases were developed. The case studies/study cases are grouped under three thematic lines:
1) Research ethics, social commitment, and human rights issues in SDH research in LMIC
2) The application of the Latin American Social Medicine and Collective Health model to address health inequities in LMIC
3) The process of priority setting in health research with emphasis on SDH in LMIC
Description: The presented cases are recreated in written form. Each case provides an overview of a specific topic related to each one of the thematic lines stated above.
Purpose: To represent complex situations that a person, team or institution has faced in real life and use them in learning contexts with the purpose of emulating professional action.
Suggested use: Case studies/study cases serve the purpose of stimulating discussion in learning contexts and are aimed at generating alternatives and responses for professional action of a specific discussed topic on SDH.
Suggested audience: Professors of graduate courses on health, social sciences and policy implementation courses. Case studies/study cases can be used as tools in classroom settings under the guidance of an instructor/professor.
Access: http://tie.inspvirtual.mx/portales/sdhnet/cases2.php
DIDACTIC AND METHODOLOGICAL RESOURCES
Infographic “The ABC of SDH”
This is a printed media resource that uses visual representations to understand SDH. The infographic can be downloaded in pdf format for printing, or can be used in an electronic format. The purpose of the infographic is to provide the basic concepts related to SDH, using illustrations and easy-to-understand text with the main ideas of the SDH approach. The infographic can be accessed here: http://tie.inspvirtual.mx/portales/sdhnet/others.php
Guide: “How to develop Case Studies on SDH for Low- and Middle-Income Countries (LMIC)”
Description: This is a pdf document that provides a sequential, easy-to-follow guide on writing case studies. The Guide is to be used preferentially in combination with the Case Creator tool that is described below.
Purpose: To guide users (academic/researchers/students) step-by-step in the creation of their own case study, with a particular emphasis on SDH.
Suggested use: In classroom settings to guide students and young researchers on the development of case studies, with special emphasis on SDH.
Suggested audience: Junior and senior researchers that want to participate in developing of new cases and expanding the number of case studies available for classroom discussion in LMIC.
Access: http://tie.inspvirtual.mx/portales/sdhnet/recursos/Short%20Guide%20for%20Case%20Studies.pdf
Notes available at: http://tie.inspvirtual.mx/portales/sdhnet/recursos/Developing_SDH.pdf
Case Creator
Description: This is an online tool, consisting of a template with pre-designed fields for capturing text which could be used as input to the information of a written case study. The capture fields correspond with the case study sections as described in the “How to develop Case Studies about SDH for Low- and Middle-Income Countries (LMIC)” document.
Purpose: To help in the development of a final written document of a case study.
Suggested use: In learning contexts to develop SDH-related case studies.
Suggested audience: Junior and senior researchers who want to participate in developing new cases and expanding the number of case studies available for classroom discussion in LMIC.
Access: http://tie.inspvirtual.mx/portales/sdhnet/casecreator/nuser.php
“Developing SDH indicators for observatories on health inequities: the Brazilian experience”
Description: This document presents the experience of the Observatory on Health Inequities (FIOCRUZ), particularly the methodology used to gather, organise, publish and analyse information data from different sources in Brazil. The document presents the experience of the Brazilian Observatory on Health Inequities. The Methodological Note encompasses theoretical, practical, methodological and analytical tools for developing monitoring indicators on SDH at national level, and is based on the experience of the FIOCRUZ CEPI-DSS Observatory on Health Inequities.
Purpose: This methodological document encompasses theoretical, practical, methodological and analytical tools for developing monitoring indicators on SDH at national level, and based on proven methodologies for LMIC contexts, where data availability tends to be scarce, sparse, and/or inconsistent.
Suggested use: To understand the purpose of an observatory on health inequities, how to set one up and how to develop relevant indicators for it.
Suggested audience: Researchers, administrators, policy makers interested in eliminating health disparities at national and regional levels.
Access: http://tie.inspvirtual.mx/portales/sdhnet/others.php
Concept for Health Service Laboratory was also developed and can be access using the following link via the “Other Resources” section: http://tie.inspvirtual.mx/portales/sdhnet/others.php
VIRTUAL LEARNING PLATFORM
INSP developed the web-based tool: Learning Platform for SDH research training. This platform was designed by INSP to host the SDH-Net learning environments. This platform was designed using a Learning Management System (online courses, blended courses, and support for classroom-based courses). It also includes: course contents, course administration, assessments, communication/collaboration tools, external applications, and student registration forms. Access: http://tie.inspvirtual.mx/portales/sdhnet/
Materials and courses adapted to local needs/update of virtual learning platform
A guide was developed on “How to Implement SDH-Net WP-4 Resources”. This guide provides descriptive information of all the tools developed under WP4 and technical specifications for use and access the Learning Platform. For each tool, a description is provided with step-by-step instructions on how to use it.
Implementation of research capacity building tools
The implementation of some tools started in 2013: The Case Study Creator was used for the development of case studies by two students of the Global Health Diploma, taught at the INSP Summer School, as the final task required for obtaining the Global Health Diploma Certificate. Selected modules of the 10h course “The Essentials of SDH” were tested by several students of the Global Health Track of the School of Public Health at INSP in 2013.
In May 2014 the online course “Essentials of SDH” was offered to graduate students at INSP and undergraduates at the University of Costa Rica. A total of 42 young and senior researchers and 10 decision makers have taken the online course.
In August 2014, the two workshops “Mixed methods for the study of SDH” and “Interdisciplinary approach for the study of SDH” were implemented at the INSP Summer School with 32 participants from diverse background and institutions, such as students from the School of Public Health of Mexico, epidemiologists from the Mexican Institute of Social Security, researchers from different Mexican universities and academic institutions and personnel from the Health Promotion Division of the National Health Ministry.
INSP secured funding from the Pan-American Health Organization-Mexico and The National Directorate of Health Promotion (DGPS) for programming and translating into Spanish two WP4 deliverables: the infographic “The ABC of SDH” and online course “Essentials of SDH”. ”. Both Spanish-translated resources are available under the following links: “El ABC de los Determinantes Sociales de la Salud” (http://tie.inspvirtual.mx/portales/sdhnet/recursos/SPA_infografico_chico.jpg). “Conceptos Esenciales de los DSS” (http://tie.inspvirtual.mx/portales/sdhnet_spa/essentials.php). They will be used to train young researchers, decision makers and administrative personnel on SDH. The resources in Spanish are freely available in an open access platform to all interested individuals and institutions in Mexico and Latin America. Furthermore, INSP has been working in the establishment of a national alliance for SDH that includes INSP, DGPS, PAHO-Mexico, the Mexican Academy of Medicine and the National Association of Public Health Schools, to work on a variety of actions with the purpose of strengthening capacities, training, debating and networking on SDH in the national context, with the ultimate goal of eliminating health inequalities.
Additionally, INSP has participated along with the partners from Brazil and Colombia in the creation of the Latin American Alliance for Health Equity (ALESA), which has the main goal of stimulating the exchange, collaboration and strengthening of the Latin American institutions involved in the SDH-Net project.
Recognising the importance of making the Latin American Social Medicine and Collective Health approaches more visible and thereby able to contribute to horizontal dialogues between different research traditions and approaches on SDH and health inequities, UNAL and FIOCRUZ started working on a proposal for a virtual/e-casebook on the Latin American Social Medicine and Collective Health.
UNAL, the Colombian Collective Health Network (Red Colombiana de Salud Colectiva) and FIOCRUZ further participated in the development and coordination of an online seminar on processes of social determination in health that seeks to complement WP4 materials and respond to an unmet need for a broader and more horizontal dialogue between research traditions in the field of SDH and health inequities, particularly addressing the Latin American Social Medicine and Collective Health social determination of health approach. The online seminar counts on the participation of around 40 researchers, professors and students from several universities in Colombia, Ecuador and Brazil and has been offered in Spanish via Scopia Videoconferencing tools once a month (duration of three hours) since 2014.
Learning Platform for SDH research training hosts the following learning material
1. Repository of learning resources for course development and implementation
2. Three theory-based courses:
a. The Essentials of SDH (online, automated, self-directed course)
b. Qualitative Methods for SDH research (online, automated course)
c. Impact evaluation on SDH policy and research (under the leadership of LSHTM).
d. SDH Research Communications course (by IESE)
e. SDH Research Management course (by WITS)
3. Two practice-based courses (Workshops):
a. Mixed methods for the study of SDH (classroom-based workshop)
b. Interdisciplinary approach for the study of SDH (classroom-based workshop)
c. SDH Research Communications workshop (by IESE)
4. Case Studies/Study cases
a. Eleven case studies organised under three major topics: 1) Research ethics, social commitment, and human rights issues in SDH research in LMIC; 2) The application of the Latin American Social
Medicine and Collective Health model to address health inequities in LMIC; 3) The process of priority setting in health research with emphasis on SDH in LMIC
b. Methodological Guide: “How to develop Case Studies about SDH for Low- and Middle-Income Countries”
c. Automated, online tool “Case Creator” for the step-by-step development of case studies on SDH
5. Other resources
a. Infographic “The ABC of SDH”
b. Concept Paper: “Health Service Laboratory”
c. Methodological Document: “Developing SDH indicators for observatories on health inequities: the Brazilian experience”.
d. Guide on “How to Implement SDH-Net WP4 Resources”.
ESTABLISHING INFORMATION EXCHANGE & RESEARCH COLLABORATION BETWEEN PARTNER INSTITUTIONS
The SDH-Net project aimed to build, strengthen and link research capacities for health and its social determinants in African and Latin American low- and middle-income countries (LMIC) in close collaboration with European partners, seeking to establish a two-way learning process and strengthen South-South and South-North-South collaborations within the project. In this regard, SDH-Net has foreseen the development of new, and the strengthening of existing tools to facilitate future links between researchers, networks and institutions that extend beyond the life of this project. The WP6 network and collaboration activities accordingly constituted an integral element of SDH-Net’s strategy to strengthen capacities for research on health and its social determinants and complement the development of SDH research capacity strengthening tools in WP4 and WP5. SDH-Net WP6 network and collaboration activities in this regard explicitly challenged the traditional notion of health research capacity as a mere human resource issue limited to stand-alone individual level training, and constituted an effort towards forging links between researchers, institutions and networks for sustainable capacity for research on social determinants of health and health inequities (SDH). By systematically utilising strategic networks, the SDH-Net reach was spatially and conceptually expanded, reaching individuals, institutions and research systems outside the direct scope and beyond the duration of the project.
In this regard, several collaborations were consolidated over the course of the project and researchers engaged in concrete collaboration activities in the context of short-term fellowships, related to joint publications and the joint elaboration of research proposals. Apart from the researchers directly involved in SDH-Net, associated researchers from the SDH-Net institutions were involved in the collaboration activities, which allowed for project-specific collaborations between SDH-Net associated experts, and further allowed for the dissemination of SDH-Net project activities at the consortium partner institutions and at associated institutions.
Strategic networks were identified and strategies towards strengthening the exchange with the respective networks were elaborated
Strategic networks were identified and strategies towards strengthening the exchange with the respective networks were developed by FIOCRUZ and IHI in close collaboration with the other partners. This built the basis for thematic twinning, which found expression in the WP8 plan for joint publications, as well as in other network and collaboration activities, which are detailed below. Furthermore, and in close collaboration with other consortium partners, FIOCRUZ compiled information on upcoming events and informed the consortium partners. The information was shared on the SDH-Net Blog to facilitate the exchange between the SDH-Net researchers at the conferences and to support the development of joint papers and presentations.
Exchange between researchers organised around the topics of research capacity building and SDH
In this regard, several panel sessions and events/workshops have been organised in joint ventures in the course of the project.
In October 2013, FIOCRUZ organised a panel session titled “Rio + 2: The role of research in taking the Rio Political Declaration (2011) forward - Insights from Africa, Europe and Latin America" at the National School of Public Health at FIOCRUZ in Rio de Janeiro (please refer to the following blog post for details: www.sdh-net.eu/index/blog-news/post/sdh-net-plenary-session-is-now-available-online). UNAL, IHI, IESE, GIZ, FIOCRUZ and INSP researchers presented SDH-Net related work to the Brazilian audience.
UNIGE together with SDH-Net researchers from IHI, INSP, IESE and FIOCRUZ organised a panel on Social Determinants of Health and Research Ethics at the 12th World Congress of Bioethics in June 2014, addressing the application of ethical criteria to health research in general and to social determinants of health (SDH) research in particular (please refer to the following blog post for details: www.sdh-net.eu/index/blog-news/post/panel-on-ethics-in-sdh-research-at-the-12th-world-congress-of-bioethics).
In September 2014, FIOCRUZ organised a panel session on the Colombian health reform (Illustration 4) with speakers from UNAL and Universidad Andina Simon Bolivar. Please refer to the following blog post for details: www.sdh-net.eu/index/blog-news/post/fiocruz-hosts-debate-on-health-reform-in-colombia.
Furthermore, two SDH-Net panels were organised by INSP at the La Alianza Latinoamericana de Salud Global (ALASAG) conference in San José, Costa Rica in November 2014, counting on the participation of UNAL, INSP, FIOCRUZ and IESE: SDH indicators and observatories; SDH research and capacity strengthening.
Evaluation research and particularly the evaluation of financial incentives for health have been at the centre of the collaborations between INSP and LSHTM, which resulted in the approval of a Researcher Links Workshop Grant on “comprehensive evaluation for health and development: promoting the integration of evaluation methods”, which was carried out in April 2015. The workshop brought together a total of 29 researchers with experience of undertaking evaluation research in the field of public health and social development from Mexico and the United Kingdom.
In an effort to further activate the collaborations around the Latin American Dossier on Pesticides and Health, which forms part of the strategic agenda of ALAMES and has defined collaborations between UNAL and FIOCRUZ and other institutions from Latin America, a panel session took place in the context of the 9th International Public Health Congress in Medellin, 19-21 August 2015. UNAL and FIOCRUZ staff members were invited to discuss territorialities and health and the panel initiated the work on the Colombian chapter of the Latin American Dossier on Pesticides and Health. Furthermore, experiences around the Brazilian chapter (www.abrasco.org.br/UserFiles/Image/Dossieing.pdf) were shared.
IESE was invited to conduct a workshop on SDH-Net during the Global Health Next Generation Network’s 2nd Global Health Conference “Ensuring the voice” – ensure the voice of young professionals in global health, held on 25-26 June 2015 Barcelona, Spain. IESE subsequently invited INSP to assist with the development of the workshop; during the workshop SDH-Net was presented, an online SDH-Net course was piloted and the role of South-North Global Health Research Collaborations and on-going challenges faced by LMIC researchers and national research systems were discussed with the young global health professional conference participants (www.globalhealthngn.org/).
Junior researchers: Web-based junior-researchers-colloquia were organised to foster exchange processes and build the basis for future collaborative projects
FIOCRUZ periodically reminded the consortium partners of the SDH-Net commitment to junior researchers and encouraged junior researchers to participate in the different SDH-Net related activities. In this regard, young social scientist researchers from IHI participated in the EQUINET –ALAMES four-day action-oriented participatory research training in Cape Town (October 2014) and a four-week qualitative research training course at University of Bergen, Norway (Nov-Dec 2014).
In an effort to strengthen capacities for research on social determinants of health and health inequities, SDH-Net Junior Researcher Colloquia connected (junior) researchers working on these topics on the three continents and consolidated networks forged in the context of the SDH-Net project and beyond. In this regard, the Colloquia represented an effort to link the two lines of action that have shaped the SDH-Net project:
1. network/collaboration activities to strengthen and link capacities for research on health and its social determinants and;
2. the development and piloting of research capacity strengthening tools, including online courses, case studies, workshops and guidelines on Social Determinants of Health, research methodology, research communication and research management.
Participants had the opportunity to discuss their research with senior scholars and peers working on social determinants of health and health inequities in Africa, Latin America and Europe in a small group setting, and were provided with guidance and mentorship. Junior researcher colloquia were offered in a web-based and classroom-based Format.
Institutional Exchange: Establishment of formal procedures for staff Exchange programmes
Institutional agreements were signed between IHI, FIOCRUZ, and the Tanzanian Commission for Science and Technology (COSTEH), in 2013. The agreement is for a tripartite inter-institutional scientific cooperation programme in the areas of SDH, biomedical and clinical research, and development of technological products for health and more. Activities under the agreement include orientation of research projects, publications, information exchange, technical assistance, and exchange of researchers for sharing experience. A collaboration agreement is further planned to be signed by the UNAL Interfaculty PhD programme in Public Health and ENSP/FIOCRUZ in November 2015.
Apart from the formal institutional agreements, institutional exchanges were supported throughout the project and linked to the exchange between researchers. In fact, most institutional exchanges were initiated by individual researcher exchanges in the context of the short-term fellowships, which gave impetus to subsequent institutional exchange and the engagement of different sectors of the respective institutions. The short-term fellowships that took place during SDH-Net project are described below.
From 1-19 April 2014, Germán Guerra, Junior Researcher from INSP visited FIOCRUZ and worked with the FIOCRUZ team, under the supervision of Professor Alberto Pellegrini, in the development of deliverable “Developing SDH indicators for observatories on health inequities: the Brazilian experience” on elements for the establishment of a Mexican observatory on Health inequities, that was forecast to culminate in a publication in a peer-reviewed journal. He also worked in the writing of the final draft of a scientific paper, co-authored with other SDH-Net members from UNAL and FIOCRUZ “Cadernos de Saúde Publica”.
Another fellowship took place from 30 June to 11 July 2014. Lucinda Cash-Gibson, Junior Researcher from IESE, visited INSP under Nelly Salgado de Snyder’s supervision. Her activities included: the support of the development of Guides for WP4 (“How to implement WP4 resources” and “How to adapt SDH-Net WP4 courses to different contexts, modalities, and technical requirements”), work on the D7.1 policy recommendations from Mexico, and writing on a first draft of a joint publication that was recently published (“SDH-Net: A South-North-South collaboration to build sustainable capacities for research on social determinants of health in low- and middle-income countries”). In 2014, another short-term fellowship took place. Elis Borde, researcher from FIOCRUZ, undertook a research visit to UNAL that aimed to develop the Online Seminar on the Social Determination of the Health-Disease Process.
Furthermore, in the context of the short-term fellowship of GIZ staff (Siri Nanz) at FIOCRUZ, both Partners have concentrated on the development of a proposal for the sustainability of the SDH-Net resources and particularly the SDH-Net website, drawing on the experiences of both institutions and particularly on the INSP/FIOCRUZ SDH Portal (http://dssbr.org).
Other collaboration activities
UNAL and FIOCRUZ have collaborated on the development and the implementation of the Online Seminar on the Social Determination of the Health-Disease Process, currently in its third phase. The Seminar forms part of the collaboration activities directed at the Latin American Social Medicine and Collective Health approaches on social determinants of health inequities between UNAL and FIOCRUZ, and specifically seeks to complement SDH-Net WP4 and WP5 training tools (courses, cases, workshops) with content related to the Latin American Social Medicine and Collective Health approaches. The intention is to make the contributions of these approaches visible and to strengthen capacities for locally relevant research on SDH. In its third phase (semester), students and researchers from eight universities from Colombia, Ecuador and Brazil connect to the monthly three-hour online seminar, which is coordinated by different institutions on a rotation scheme. In an effort to systematise the experience of the online seminar and to share the reflections and material developed in the context of the seminar, a book was published (Carolina Morales; Juan Carlos Eslava C. (Org.). Tras las huellas de la determinación social - Memorias del Seminario InterUniversitario de Determinación Social de la Salud. 1ed. Bogotá: Editorial Universidad Nacional de Colombia, 2015).
IHI and LSHTM have been collaborating in the context of several research projects and have established a comprehensive staff-exchange programme. In the context of the SDH-Net project, these collaborations were strengthened and focused on the evaluation of results-based financing.
WHO has recently developed a Health in All Policies (HiAP) Training Manual to support this whole-government system dialogue and approach to tackle health inequities, and global HiAP Training of Trainers meetings have started to take place to support local adaptation of HiAP training manual materials in the different global regions.
UON, FIOCRUZ, IESE, UNIGE and INSP are collaborating in the context of these Health in All Policies (HiAP) Training of Trainers activities (ToT). Specifically, FIOCRUZ supported the Central American Training of Trainers course offered by INSP between 27 and 31 July 2015, and INSP supported the FIOCRUZ South American Training of Trainers course to be carried out between 18 and 20 November 2015 in Rio de Janeiro, following the International Seminar on Social Determinants of Health, Intersectoriality and social equity in Latin America, constituting the first part of the capacity building process (http://dssbr.org/site/2015/10/seminario-internacional-determinantes-sociais-da-saude-intersetorialidade-e-equidade-social-na-america-latina-inscricoes-aqui/). It is important to note that SDH-Net learning material was integrated into the Central American HiAP Training of Trainers course. Similarly, UNIGE has integrated SDH and HiAP into the institutions’ Global Health and Human Rights Summer School. UoN is planning regional implementation together with the MoH and African SDH partners. Another SDH-Net partner (WITS) attended a ToT session in New Delhi in July 2015.
The project moved beyond stand-alone individual level trainings, and towards comprehensive efforts to forge links between research and policy/practice, disciplines, approaches and countries, in order to build sustainable capacity for interdisciplinary and locally relevant research on SDH. Network and collaboration activities have been essential in this regard and have set the basis for continued and comprehensive efforts towards capacity strengthening for research on SDH. As a general learning point we emphasise the importance of individual-level exchanges as a first step towards more comprehensive institutional collaborations.
The SDH-Net experience shows that short-term fellowships and other researcher exchange modalities were essential to the consolidation of long-term collaboration activities between institutions, and gave impetus to the development of joint research proposals, publications and the organisation of events, amongst others. The SDH-Net experience in the context of WP6 further underlines the importance of strengthening existing networks and linking new network and collaboration activities to ongoing initiatives, and to further consider institutional structures and priorities as well as existing personal contacts.
The mapping exercise proposed in phase 1 of the SDH-Net project made important contributions in this regard, and was an important basis for collaborative action. South-South collaborations assume a particularly important role in efforts toward strengthening capacities for research on SDH. In this regard, Latin American partners recognised the importance of engaging with regionally specific research traditions in order to strengthen capacities for locally relevant research on SDH. The enormous potential of South-South collaborations is further evident in the collaborations between African and Latin American partners around SDH observatories and health inequity measurement, in the articulations between regional networks (EQUINET and ALAMES), but also in the proposals for joint research projects that emphasise South-South learning. To this extent, the SDH-Net experience underlines the importance of complementing funding for joint ventures between institutions from the global North and the global South, with more South-South funding opportunities.
Similarly, it seems necessary to have funding modalities that support networks at regional, cross-regional and also at national level, independent of specific research projects. As another general learning point, we emphasise the importance of strengthening national networks. Based on the national mapping exercise, several national partners were identified and involved in SDH-Net activities throughout the course of the project, which undoubtedly contributed to the dissemination of SDH-Net activities. National networks further contribute to the consolidation of a sustainable alliance for research (capacity strengthening) in the field of SDH, linking capacities and experiences. Strengthening national networks on SDH and health inequities should therefore be considered a strategic entry point for action on SDH.
POLICY AND ETHICAL RECOMMENDATIONS
Lessons learned at policy level
The lessons learned at policy level aim to provide insights into how and where policies can foster sustainable SDH research capacity strengthening, especially in LMIC, in order to support locally relevant, evidence-based, equitable public health decisions, and achieve optimal population health and well-being. Lessons learned were specially derived in terms of:
1. how SDH-Net has contributed to strengthening the global SDH research capacities and discourse, not limited to LMIC;
2. where and how future policies and action can contribute towards fostering local SDH research capacity strengthening at different research capacity levels in order to produce, manage and translate local SDH knowledge for use by different stakeholders to support action on SDH;
3. considerations for the design and construction of future South-North-South SDH research collaborations – for grant-makers and researchers, and Europe/Northern settings.
As a result of SDH-Net, several work groups, informal and formal relations and networks have formed at SDH-Net partner country level, regionally and internationally, and this was demonstrated through the discussions and presentations (by WHO, City Council of Johannesburg, MoH in Kenya, Professors etc.) taking place during the final SDH-Net conference in joint collaboration with the WHO’s SDH Unit in May 2015, in Geneva. Discussions are taking place between WHO and SDH-Net partner institutions, and similar discussions are being held between the Latin America SDH-Net partner institutions and PAHO. Ultimately, it is hoped that these international engagements would lead to more sustainable local and global collaborative action on health equity and SDH.
Capacity Building in Research Ethics and Lessons Learned
An ethics protocol, including SDH-sensitive perspectives, was developed. The guidelines and checklist are documents that are forecast to be used and submitted to WHO in order to improve equity within research ethics review committees. A series of articles will be published on this issue after the closure of SDH-Net.
The reinforcement of the collaboration with WHO, SDH-Net, and the WHO Gender and Human Rights section, has led to the development of material to review health policy programmes to include SDH, equity and human rights. Therefore, the contribution of SDH-Net to the international material for training policy makers can be considered as a significant result and a promising avenue.
The development of tutorial material also serves as a basis for developing an international protocol which addresses more particularly the sensitive aspects of SDH research with the highest standard of protection of subjects and their benefit for and from the research (including a checklist and questions to be asked to the National or International Review Board [NRB/IRB] review, informed consent [emphasising information over voluntariness] and the creation of capacity-building activities and education on research ethics).
As mentioned above, in a collaboration between UNIGE, IHI, INSP, IESE and FIOCRUZ, a panel session on ethical issues in SDH research at the World Congress of Bioethics Conference (Mexico City, 2014) was organised (http://www.sdh-net.eu/index/blog-news/post/panel-on-ethics-in-sdh-research-at-the-12th-world-congress-of-bioethics). The panel sought to address the application of ethical criteria to health research in general and to social determinants of health (SDH) research in particular. In this regard, a conceptual framework for the consideration of ethics in SDH research was proposed and ethical considerations at different stages of the research process pointed out. Furthermore, ethical issues in the design of SDH research and the use of SDH research variables and in the implementation of SDH research were addressed, emphasising the importance of involving local communities. The panel made a unique contribution to the World Congress on Bioethics by focusing on SDH and SDH research, which are rarely considered from an ethical perspective. In this regard it is important to mention that, although the WHO systematically conducts ethical reviews for all its global research proposals, there are no specific SDH ethics guidelines or protocols mentioned in international research documents, in management or training.
Potential Impact:
POTENTIAL IMPACT
SDH research capacity in low- and middle-income countries
Improving and building-up SDH research capacity was a primary goal of the project. All the products that were developed under SDH-Net activities have a direct positive impact on SDH research capacity building within involved countries and regions. To address relevant SDH research challenges in LMIC specifically, the project commenced with carrying out an in-depth study of existing evidence and work on SDH, based on partners’ previous efforts; in particular the mapping of SDH-related stakeholders and the identification of capacity building needs were performed. This set the stage for a number of actions towards an improved research landscape, such as development of tools for and implementation of capacity building activities on SDH research, SDH research methodology, management and communication, and interdisciplinary skills necessary for the study of SDH, in addition to the strengthening of national and international SDH research networks and systems.
The SDH-Net products have an essential impact on SDH research in LMIC, not only by facilitating the SDH research currently conducted in the countries involved in the project, but also by enabling evidence-based and sound research beyond the duration of the project, therefore assuring the sustainability of the project results and their impacts. Capacity building itself has an in-built sustainability aspect (by definition); moreover, the active dissemination of results, the development of tools and the identification of policy lessons for the national, regional and global levels warrant sustainability and future impact of the project.
A unique virtual learning platform was designed to host the developed tools, which included a range of online and classroom-based courses, workshops, case studies, an online case study creator tool, an infographic, methodological guides, and a repository of SDH research-related materials. In order to ensure the continued sustainability and free availability of SDH-Net products, INSP has already agreed to host and maintain the platform indefinitely.
To further support dissemination of SDH evidence, SDH-Net also created an SDH online repository as part of the virtual learning platform. Online repository allows SDH research to be organised and collected, as well as up-to-date and focused literature that is easily accessible by all interested stakeholders. This complements the Brazilian Virtual Health Library Health on SDH (BVS DSS) and the online Portal on SDH . All in all, this ensures better use of existing knowledge, reducing duplicated studies and unused resources. It will also facilitate a synthesis of available SDH findings to date and inform the future research agenda: what is known and what more is needed to be known.
Moreover, INSP secured funds from the Mexican Secretariat of Health to translate most of the products into Spanish, making them available at no cost to all Spanish-speaking countries interested in building and strengthening SDH research capacities. Subsequently, both the English and Spanish language versions of the SDH-Net materials are already being used to train young researchers, decision makers and administrative personnel on SDH at different levels in Africa and Latin America.
Finally, SDH-Net activities had a special focus on junior researchers in the field of SDH and public health to allow for sustainability of SDH-Net impact on SDH research capacity in LMIC in the future. A number of seminars and colloquia were organised with the specific aim of educating, informing and involving young professionals from LMIC in current global SDH research, who in the future will take leading positions in this research area. Therefore, SDH-Net has an impact on the adequate and necessary preparation of human resources in order to address SDH research challenges currently and in the future.
SDH research capacity at national level: from international project to local activities
SDH research capacity building incorporates not only the ability to produce research, but also the capacity to use it and demand that it contributes to health improvement and health equity. The starting point of the SDH-Net was a clear understanding that the SDH research capacity building effort would be more efficient if it could trigger constructive structural and organisational changes in LMIC at national level that would warrant continuous research in the field of SDH; it would also address multiple challenges of SDH research experienced by LMIC such as insufficient research training, scarce financial and material resources, inadequate research output, and the emigration of researchers, often referred to as a “brain drain” . In line with this, some SDH-Net country partners have been involved in either building or strengthening National SDH networks. These initiatives are described below.
At national level, in Kenya, the Ministry of Health/Public Health and Sanitation leads the SDH-related activities and development of SDH-related public policies. Whilst conducting the SDH-Net national SDH mapping exercise, an (informal) tripartite consultative working group was formed between UoN School of Public Health, Ministry of Health/Public Health and Sanitation, and the WHO country office, and inter-ministerial workshops were conducted to support the national understanding and facilitation of inter-sectorial dialogue on SDH.
In Mexico, INSP has established a national alliance for SDH that includes INSP, the Mexican National Directorate of Health Promotion, PAHO-Mexico, the Mexican Academy of Medicine and other stakeholders to work on a variety of actions with the purpose of strengthening capacities, training, debating and networking on SDH in the national context – with the ultimate goal of eliminating health inequalities.
In South Africa, partly as a result of SDH-Net, the City Council of Johannesburg plans to develop a National Commission on Social Determinants of Health to draw the attention of governments, relevant stakeholders and society to SDH.
In Brazil, FIOCRUZ and the Ministry of Health are planning to work on a new national SDH mapping report, building on the SDH-Net national mapping exercise, with the aim of strengthening its national SDH network.
In Tanzania, SDH has gained increasing recognition over the past few years: at the 30th annual scientific conference Tanzania Public Health Association in 2013, the theme was Intersectorial approach in addressing SDH in Tanzania: closing the Health Inequality Gaps. SDH-Net partner IHI presented some of the key findings from the national SDH-Net Mapping Report at this SDH-Net conference). Furthermore, the National Health Sector Strategic Plan IV (2015-2020) is making SDH and equity a central cross-cutting theme. Additionally, in 2014, Tanzania adopted the Arusha Declaration on Social Protection – Building Effective and Sustainable Systems for Equitable Growth: Perspectives, Policies and Best Practices’ The declaration is a guide to action towards a nationally owned social protection system for the poor, vulnerable and marginalised, and for promoting social protection and addressing inequity, discrimination, marginalisation and other forms of deprivation.
All these advances at national level that were achieved with the participation of SDH-Net Partners are crucial for future sustainability of SDH research in partnership with LMIC, due to the fact that they are aimed at constantly evolving national SDH research capacity and stimulating locally-driven developments in this research area.
Improved quality of SDH evidence-based research and knowledge
SDH-Net had a particular focus on SDH research methodology, management and communication, which are key pre-requisites for flexible responses towards dynamic health challenges and are furthermore essential to enhance the quality and impact of SDH research. Also, research impact evaluation and monitoring mechanisms that were addressed in SDH-Net are expected to allow for more stringent peer reviews and an improved quality assurance system.
The SDH-Net project has fostered research capacity and networks in SDH that have created the basis for high-quality, evidence-based research in different settings. Therefore, as a direct product of the project’s activities, the quality of research and the generation of evidence in health and its social determinants are expected to be ameliorated.
The development of SDH-Net represents a valuable and innovative experience in the field of SDH research capacity building in LMIC. Despite SDH-Net objectives focusing on LMIC setting, the SDH feature prominently on the European public health agenda as well, and the tools developed and the lessons learned may also be relevant and applicable to SDH research in the European region and other high-income countries (HIC) in multiple ways.
Moreover, under the WP7, SDH-Net elaborated the recommendations for ethics in SDH research in LMIC. International ethical guidelines suggest that health research involving human beings should always meet established ethical standards and undergo ethical review. Although the promotion of ethical reviews and ethics standards in health research has significantly advanced lately, it still remains inadequately supported and developed.
SDH-Net contributed to this area of research not only by clarifying the conceptual background but also by building an ethically-based sustainable research system or research landscapes in LMIC. In order to overcome the ethical challenges that are often faced in SDH research, SDH-Net developed an ethical framework sensitive to SDH aspects throughout the research cycle and management. Therefore, the materials produced within the SDH-Net provide means for thorough examination of SDH studies from an ethical perspective, to ensure the ethical aspects are met at all stages of the research process (e.g. management, training, communication course, dissemination, etc.). Moreover, the SDH sensitive research ethics material that was produced under the SDH-Net could be employed by ethics review committees and used for training and sensitising researchers in conducting research under the highest possible ethical standards, with full respect to human rights and equity. Ultimately, this will lead to more equity in research and would assist in avoiding the trap of reproducing inequities during the research process. The materials are the practical tools such as guidelines, protocols and checklists.
Finally, the results, products, study findings and valuable insights gained during the SDH-Net project were disseminated through scientific publications in peer-reviewed journals, as parts of books and book chapters, and some of the publications are still under review or preparation; the knowledge on SDH gained during the project was also presented in a number of national, regional and international conferences and meetings. All these efforts led to diffusion of the SDH evidence obtained in the course of the project that essentially added to the current knowledge and expertise in the field of SDH.
Impact on health research
Primarily addressing the interdisciplinary research landscape, research on social determinates of health, SDH-Net has a valuable impact on health research in general. The SDH-Net products define a rigorous standard for SDH research and provide practical tools to enable this rigour in practice that, as mentioned previously, leads to high-quality, evidence-based research. Health inequities and inequalities are recognised by the WHO as one of the major health problems, and public health policies in countries all around the world define the eradication of inequities in health as an overarching aim. The SDH-Net project tackles an important, and currently recognised as challenging, field of health research and so has a substantial influence on health research in general.
Moreover, while SDH-Net materials and tools primarily addressed SDH fields, they could be successfully transferred and implemented into other areas of health research.
Impact on South-North-South and South-South collaborations
The SDH-Net is an interesting and valuable project not only due to the work carried out and products elaborated, but also because its partnership design represents a beneficial research collaboration. South-North-
South and South-South collaborations were embedded into the SDH-Net design, and therefore the project experience provides valuable insights into how to better organise and coordinate multi-vectored partnerships.
The SDH-Net partners have good connections and networks in their respective countries and regions; the joint SDH-Net assisted in strengthening South-South and South-North cooperation in SDH research. The experiences of partners from three different continents were complementary and interdisciplinary; the assessment of the existing networks in phase 1 provided important insights for the second phase of the project, but was also a good basis for further collaborative activities. Strategic networks were identified and strategies towards strengthening the exchange with the respective networks were developed.
During the project activities, all consortium partners were involved in active and dynamic collaboration with institutions from three different continents, which undoubtedly improved their understanding of South-North-South and South-South collaborations. Moreover, the experience of participation in such a project provides a good basis for future, similar collaborations for professionals directly involved in the project, as well as for their institutions. Ultimately, the SDH-Net project reinforced and strengthened existing health research networks between the three continents of Africa, South America and Europe, as well establishing new connections between institutions and networks nationally, regionally and globally.
The SDH-Net project explicitly demonstrates how the establishment of multidisciplinary and multi-institutional South-North-South collaborations can help to overcome a lack of adequate resources, opportunities and infrastructure needed to conduct quality SDH research in LMIC, by building and strengthening local collaborative networks. Through this process, Northern and Southern partners can establish fresh perspectives of each other, creating synergies and collaborative innovations in SDH training.
South-North-South and South-South collaborations can also assist in forging sustainable links between different SDH stakeholders – researchers from various disciplines, decision makers, funding agencies and groups from other sectors within society such as non-governmental organisations; once established, these links can help to build sustainable capacity for conducting and managing interdisciplinary SDH research, in both HIC and LMIC settings. This, in turn, can increase national autonomy by stimulating scientific excellence and relevance (in SDH and health equity) that support the establishment of research priorities according to local needs.
Impact on SDH-related policies
One of the last work packages had a particular focus on bringing together all evidence and knowledge produced under the project to formulate policy recommendations on SDH research. This particular task synthesised the lessons learned during the project and translated them into recommendations at policy level and for consideration by other stakeholders (grant makers, future researcher projects, governments, etc.).
Currently, research and researchers are an essential part of evidence for policy making and the implementation of regulations based on factors that have been identified by research as increasing inclusion and equity. Therefore, an essential component of SDH-Net was to make the research a constructive element of policy building. In this regard, a number of international agencies (e.g. WHO, PAHO) were put to fruition.
Additionally, the SDH-Net directly addressed the challenge of research results communication to policy makers via specifically developed in the course and workshops SDH Research Communication. It is expected that these educational tools will bring forward the current state of communication between SDH researchers and policy makers, enabling more efficient and productive conveyance of research results and researchers’ recommendations to those who make final decisions on policy development. Ultimately, that would lead to the enhancement of existing SDH-related policies and regulations in LMIC.
Impact on health care systems
This project demonstrated that health research represents one of the many necessary components contributing to the improvement of health systems and health of the population. In fact, SDH research does not only lead to specific scientific results and impacts, it has further functions. According to Pang et al., health research actually has four main functions: the production and utilisation of research, stewardship, research financing, and, the creation and sustaining of resources . More precisely, there is a general consensus amongst health experts that the benefits from health research can go far beyond scientific results, and can be exploited to improve health system performance, health itself and health equity in particular.
One of the goals of SDH research is to identify current urgent health needs of populations that would serve as essential evidence in defining national and regional priorities on the health agenda. It is also expected that improved SDH research capacity would have a positive impact on the distribution of resources, leading to the enhanced cost effectiveness of health systems.
EU Global health agenda
From its initial stage, SDH-Net was designed (and subsequently funded by the European Commission) to contribute towards improving SDH evidence in respective countries and regions, enhance Europe’s role in global health and positively contribute to the EU Global Health Agenda. The EU Global Health Agenda defined four approaches for enhancing global health: establish a more democratic and coordinated global governance (1); push for a collective effort to promote universal health coverage and access to health services for all (2); ensure better coherence between EU policies relating to health (3); improve coordination of EU research on global health and boost access in developing countries to new knowledge and treatments (4). The SDH-Net project has a particular impact on the fourth approach, the increase of global health knowledge, ensuring the research and innovation produces accessible and affordable products and services. Throughout the duration of the project, regular links and updates were made on policy developments on the European and global health agenda. The SDH-Net project and insights gained are expected to have a substantial impact on future global SDH and research capacity building policies.
Impact on WHO Health in All Policies
A few years ago, WHO launched a Health in All Policies (HiAP) that is an “approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies and avoids harmful health impacts, in order to improve population health and health equity. It emphasises the consequences of public policies on health determinants, and aims to improve the accountability of policy makers for health impacts at all levels of policy-making” .
The SDH-Net project was linked with WHO Health in all policy (HiAP) activities and a few SDH-Net members are part of the HiAP global networks. Regional trainings (ToT: “Training the Trainers”) on SDH research (described in detail under the results sections) were organised based on the collaboration with HiAP network; SDH-Net partners from Latin America and Africa were involved in these training activities.
Impact on global SDH actions
The WHO Commission on Social Determinants of Health (CSDH) published a report in 2008 called “Closing the Gap in a Generation” that become the first global comprehensive overview of the current SDH situation around the globe. The report is also a main document in the field of SDH that defines crucial aspects and challenges needing to be addressed in order to eliminate health inequities. The CSDH final report identified that the majority of the SDH research was conducted in HIC and less so in LMIC , therefore SDH-Net’s focus on LMIC settings is important in strengthening global SDH action and evidence. The report also highlighted the fact that health inequalities exist between and within all countries, hence a global work on this issue is needed to effectively respond this challenge.
The CSDH report revealed that there is “an urgent need to develop, among other things, a virtual repository of teaching and training materials on a broad range of social determinants of health that can be downloaded without cost. Furthermore, opportunities for interdisciplinary professional training and research on social determinants of health are needed” . The SDH-Net project, by its design and the products developed, has directly addressed this call for action by providing a free access to all the materials and hosting a repository that aims to stimulate interdisciplinary professional training.
The existence of social determinants of health involves many different stakeholders at different levels, and, above all, across borders . SDHs fall into distinct jurisdictions and require joint actions. The increase in research capacity and networking that has been addressed in SDH-Net will lead to better knowledge and evidence on SDH on a global level, and will contribute to a better understanding of the global implications on health, and how governments and national stakeholders as well as the European Union and other donors can best respond to these challenges.
Impact on health inequalities and inequities
The WHO has defined the decrease of inequalities in health among socioeconomic groups as one of the main objectives of each member state . Woodward and Kawachi have discussed the reasons why health inequalities attributable to social, economic and cultural factors should be reduced. In particular, their main arguments were: health inequalities are often unfair, and, therefore, are not acceptable; inequalities affect everyone in a population; inequalities are avoidable, thus measures to reduce inequalities should be employed; interventions to reduce health inequalities are often cost-effective . Altogether, there is a substantial body of evidence supporting the existence of health inequalities and inequities as well as the necessity of reducing them, and of adopting approaches to overcome them. Nevertheless, inequalities in health are the reality for most countries in the world, so there is a demand for research, policy development and interventions in this sphere.
The SDH-Net project focused on an increased SDH research capacity and sensitivity towards social determinant issues within health research that would lead to improved quality of research in SDH, fostering the elaboration of more and higher quality evidence in SDH. It is expected that all these efforts would ultimately lead to better health policies at national and regional level, which should have a positive effect on the improved health status of the population in the participating countries and regions, and the elimination of existing inequities in health.
MAIN DISSEMINATION ACTIVITIES AND EXPLOITATION OF FOREGROUND
Dissemination activities
Dissemination activities were an important task for SDH-Net, with the main purpose of effectively bringing policy makers, stakeholders and research networks to the research undertaken alongside the project. The dissemination strategy aimed at determining the target groups for different results and the most adequate dissemination methods: publications, face-to-face and electronic dissemination. The main dissemination tools included the constant running of a project website, the creation of the dissemination plan and calendar, production of appropriate dissemination materials, organisation workshops and seminars as well the final conference. The underlying aim of the SDH-Net dissemination activities was to create public awareness and scientific interest in the project and its results, as well as to translate research into policy recommendations that would adapt suitable language for policy makers as well as guide the development of ideas for future research activities.
Communication strategy and communication of project results
A communication strategy of SDH-Net was elaborated at the start of the project, more specifically the objectives of the strategy were to (i) inform the target publics about the project evolution and outputs, aligned with global and local research and policy advancements of the SDH approach to tackle health inequities; (ii) contribute to the development of the communication capacities and infrastructure of the SDH-Net partners as a critical component of the SDH research advancement; (iii) contribute towards strengthening the network and knowledge sharing modus operandi among members through the development of an up-to-date informed and learning environment. Accordingly, both internal communication mechanisms as well as external communication and primarily dissemination strategies were defined.
Project website and blog
A project website was set up and can be accessed under: www.sdh-net.eu.
In line with the strategies described in the Communication Strategy and following the Communication Guidelines developed, project results as well as other SDH-Net related content has been published on the SDH-Net blog (http://www.sdh-net.eu/blog-news/) as part of the SDH-Net website. In this regard, the SDH-Net website was designed to serve as a vehicle for communicating SDH-Net news and information (NEWS section), sharing key background documents as well as SDH-Net publications (LIBRARY section) and introducing the project and consortium partners to the general public (CONSORTIUM section). Furthermore, a communication schedule was defined, specifying the deadlines for providing input to the website and providing all partners with the blog post format. This helped maintain a healthy regional and institutional balance on the blog/website and supported the partners in scheduling their input.
Project results were further published in the SDH-Net newsletter, which was based on blog posts developed by SDH-Net project partners.
Results and publications
The communication of project results in peer-reviewed scientific journals has been an essential project activity. In this regard, the following number of articles, book chapters and books were published by SDH-Net partners on SDH-Net-related issues, in an effort to enhance the communication of project results in peer-reviewed scientific journals and foster collaborations between SDH-Net consortium partners.
An important effort was made by SDH-Net partners to prepare a number of publications under the special section of the International Journal for Equity in Health (IJEH). Currently three papers of SDH-Net partners are under revision and hopefully will be published shortly, in particular:
1. Strengthening national capacities for research on social determinants of health (SDH) towards informing and addressing health inequities in Tanzania - IHI
2. Measuring health inequities in low- and middle-income countries: Towards the development of an observatory on inequities and social determinants of health in Mexico - INSP/FIOCRUZ
3. Social determinants of health research capacity building initiative; the dovetail experience with the Kenyan health care system - UON
More detailed information about the publications produced by SDH-Net partnership can be found in table A1 (under section A).
Participation in dissemination events
Active participation in dissemination events (e.g. conferences, meetings, congresses) was one of the crucial dissemination activities of the SDH-Net project. The partners have presented, discussed and validated the SDH-Net findings and products at national, regional and global events. More detailed information about the conferences where SDH-Net results were presented can be found in table A2 (under section A).
Main project seminars and conferences
In October (24th-26th) 2013, “Rio + 2: The role of research in taking the Rio Political Declaration forward. Insights from Africa, Europe and Latin America” seminar organised by FIOCRUZ and INSP took place in Rio de Janeiro alongside the SDH-Net third Steering Group Meeting. It provided a platform where strategies to reduce health inequities in African, European and Latin American countries were presented, exploring ways in which the recommendations of the WHO Commission on Social Determinants of Health and the Rio Declaration on SDH have been taken forward. With contributions from several SDH-Net partners, advisory board members, and representatives from FIOCRUZ, the role that SDH research could play in the reduction of health inequities in LMIC was discussed.
In 2014, alongside the fourth SGM in South Africa, an additional “brain-storming policy workshop” was held. It aimed to consolidate activities and concepts developed and piloted in the context of the SDH-Net project into recommendations directed at the policy level that would shape research systems and other relevant actors. Also, during a special Johannesburg Symposium: The Social Determinants of Health – Global and Local Perspectives that was organised by WITS in collaboration with Johannesburg Health District and SDH-Net alongside the fourth SGM, SDH-Net partners (IESE) presented the initial ideas for SDH-Net policy recommendations.
On 27 May 2015 a public final conference Strengthening Capacity for Research, Training, Policy and Action for Equity and Social Determinants of Health was co-hosted between the SDH-Net Consortium and the WHO. The objective of this one-day event was to share WHO and SDH-Net results and products to create synergies with the purpose of developing, expanding and strengthening international collaborative networks for the strategic dissemination, implementation and sustainability of global goods aimed at promoting health equity worldwide. The event marked an important step in SDH-Net dissemination activities and, particularly, in the communication of SDH-Net results, complementing individual partners’ participation in academic conferences detailed above.
Exploitation of the main foreground
The SDH-Net project has produced a number of valuable foregrounds that were and will be actively exploited by all project partners for mainly educational and scientific purposes. The exploitation of the foreground corresponds to the partners’ preliminary intentions towards exploiting the project results in order to support their own activities, as laid down in the initial version of the project’s Description of Work. Among others the following foregrounds will be exploited by SDH-Net partners:
1. “SDH-Net Virtual Learning Platform”
2. Online Repository of SDH-related material
3. Online courses
4. Practice-based courses materials
5. Workshop materials
6. Case Studies
7. Publications
8. Infographics
9. Methodological notes, etc.
Complete and detailed information on the exploitable foreground and SDH-Net partners’ exploitation plans can be found in table B2 (under section B of this report).
List of Websites:
Project website address: www.sdh-net.eu
Name of the scientific representative of the project's co-ordinators:
Dr. Johanna Offe, GIZ – technical coordinator
E-mail: johanna.offe@giz.de
Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH
Köthener Str.2
D-10963 Berlin
Germany
Tel: +49 30 408190389
Fax: +49 30 408190 22 389
Dr Magdalene Rosenmöller, IESE – Scientific Coordinator
Email: magda@iese.edu
IESE Business School, University of Navarra
Av. Pearson, 21
08034, Barcelona
Spain
Tel. +34 93 253 4200
Fax +34 93 253 4343
Inequalities in health is considered as one of the leading health problems by WHO, and figures on top of public health agendas in most countries. Good quality evidence on health inequities, prevalence, causes, and determinants is a crucial starting point in decreasing health inequities and their negative impact. High income countries have developed sophisticated data and research systems providing insights and ideas how to address inequalities. This capacity is very scarce in Low and Middle Income Countries (LMIC) where its scaling-up through collaborative activities is of high value.
SDH-Net, a project funded by the European Commission under the 7th Framework Research Programme, did exactly that: bringing together a diverse set of institutions from Africa, Latin America and Europe to work together on SDH research capacity building in LMIC. Project objectives included gaining a better knowledge on capacity needs in participating countries, developing tools and instruments allowing to address those needs, while considering ethical issues and policy lessons in general.
The mapping and assessing of SDH research status and context in the participating countries, resulted in national and regional SDH research reports and a set of “light mapping” reports in the European partner countries. Based on the insights a capacity building strategy was elaborated, resulting in the developing and piloting of context-specific tools and methods for strengthening research capacity. The material for research capacity building and strengthening comprised courses such as: “Impact evaluation on SDH policy and research and SDH research communication courses”. Didactic and methodological resources included “Qualitative methods for SDH research” and a Case creator online tool. The conception of a Learning Platform for SDH Research Training allows for free access to all on-line materials and practice-based courses. Final policy lessons were drawn on best practices, the collaboration’s success and failure factors and ethical issues.
SDH-Net’s activities and products are apprehending the WHO CSDH recommendations on the development of “virtual repository of teaching and training materials on a broad range of social determinants of health that can be downloaded without cost”, while creating “opportunities for interdisciplinary professional training and research on social determinants of health”.
SDH-Net’s outputs and its active dissemination are expected to profoundly impact on LMIC improving the SDH research landscape and the quality of evidence-based research in the regions of Latin America and Africa. SDH-Net’s learning platform links to WHO activities, and the easy access to the products developed will assure sustainability and broader impact. All this results in better SDH and health related policies, global efforts aimed at eradicating health inequities and valuable South-North-South and South-South collaboration growing out of this project, a basis for sustainable global networks, in the fight to eradicate inequalities and inequities in health.
Project Context and Objectives:
The aim of the Social Determinants of Health Network (SDH-Net) project was to build, strengthen and link research capacities for health and its social determinants in African and Latin American low- and middle-income countries, in close collaboration with partners from those regions and Europe.
BACKGROUND
Capacity building in social determinants of health (SDH) research is crucial in the fight of the global phenomenon of health inequities – the differences in the health status and health care coverage across different populations. They exist within and between countries, and causes extend beyond the health sector. Health inequities may be the result of biological variations and certain lifestyle choices; however, substantial differences in health between different social groups are primarily defined by broader social inequities and their determinants. While health inequities extend across the globe, consequences are particularly dramatic in LMIC.
The detrimental effects of persisting health inequities have been recognised by different stakeholders, however, concrete interventions and policies transforming the structural processes that determine health inequities have remained limited. One reason for this is the lack of locally relevant research activities and results which define intervention priorities and help to develop appropriate solutions to urgent health problems, especially in LMIC. Exchanging experiences and linking expertise across institutions, sectors and countries, in order to better understand what works and what does not within each context, are essential for strengthening research capacities and health systems and for developing contextually relevant approaches to pressing health problems.
OBJECTIVES
The project objectives were to:
1. Map, describe and assess the SDH research status and context in countries of study.
2. Based on SDH assessment, develop and pilot context-specific tools and methods for strengthening research capacity.
3. Build sustainable North-South (Europe-Africa and Latin America) and South-South (African and Latin American countries) institutional and network collaborations in the field of SDH research throughout the project.
4. Based on pilot testing, document lessons learned in terms of policies and ethics and exchange best practices and success factors, as well as information on what worked, how it worked and why.
The focus on SDH allows for an in-depth and broad capacity-building approach, including methodological, managerial and technical excellence, ethical issues, research strategies and communication and knowledge transfer. Throughout every phase of the project, results were communicated and disseminated and networks were forged, built upon and strengthened.
PROJECT DESCRIPTION
The SDH-Net project was launched in October 2011 and is a four year (2011-2015) collaboration, financed by the European Commission under the 7th Framework Research Programme.
It was carried out by a consortium of 11 partners: three from Latin America (Brazil, Colombia and Mexico), three from Africa (Kenya, Tanzania and South Africa), four from Europe (Germany, Spain, Switzerland and the UK), and one international non-governmental organisation operating under Swiss law (COHRED). The six LMIC partner institutions are leaders in public health research. The European team, consisting of two distinguished European institutions: the London School of Hygiene and Tropical Medicine (LSHTM) and the University of Geneva, as well as COHRED, provide technical assistance. In addition, GIZ (an implementing state-owned development cooperation organisation), with long-term experience in health system strengthening, health research, and capacity building in LMIC, coordinated SDH-Net, while IESE Business School, an expert in managerial and leadership capacity building, provided scientific direction to the project. All partners are strongly embedded in local and regional networks, ensuring national and regional involvement of policy makers and other stakeholders who were invited to different project activities in order to secure alignment with national health policy strategies as well as a high level of political commitment. SDH-Net allowed for the exchange of knowledge and insights between research institutions, civil society organisations and policy makers, ensuring sustainability of the project and ownership of the results.
To address the objectives of the project in an efficient way, the work under SDH-Net was organised according to the following work packages (WP):
WP1 Overview of Social Determinants of Health – from local to global
WP2 Mapping research system characteristics – stakeholders, institutions and ongoing activities
WP3 Assessment of capacity building needs
WP4 Research capacity building: research methodology and SDH
WP5 Research capacity building: research management and research communication
WP6 Knowledge management and network strengthening
WP7 Lessons learned
WP8 Dissemination
WP9 Monitoring and evaluation
WP10 Project management and coordination
EXPECTED RESULTS AND IMPACT
Ultimately, the goal of the project was to advance the understanding of SDH at different levels, improve interventions for reducing health inequities on the local and regional levels and to build sustainable research capacities (both at the individual and supporting infrastructure level) that are able to provide evidence in support of specific policies and interventions to address health inequities. Overall, this project intended to provide a framework for developing interdisciplinary research capacity in the field of SDH in LMIC settings by building, strengthening and linking capacities in research institutions and implementing agencies in LMIC in close collaboration with European institutions.
SDH-Net had a substantial impact on the SDH research landscape in Africa and Latin America. The assessment of SDH research structures, research needs and gaps allowed for targeted capacity building activities and initiatives to strengthen networking and cooperation. Courses and other training activities were established, all with the aim, to facilitate better research: improve methodology and research management.
Regarding networking, connecting actual clusters of research and reinforcing existing networks across continents, the SDH-Net project has enhanced North-South as well as South-South cooperation in SDH research with the additional effect of general research capacity strengthening. The focus on education and the involvement of junior researchers was a key focus of SDH-Net to prepare the next generation of SDH research “leaders”. Moreover, SDH-Net short-term fellowships have led to building international networks for SDH research beyond the life of the project. Increased research capacity, stronger partner institutions, and heightened sensitivity towards SDH in the countries will, in the future, lead to improved quality of SDH research and its uptake, which in turn will lead to better health policies at national and regional level, and, consequently, to reduced health inequities and improved health of the population in the participating countries and regions.
A specific focus of the project was to improve the quality of research. By fostering research capacity and networks in SDH, the project has created the basis for relevant, high-quality and methodologically sound research in different settings. The mapping exercise and gaps assessment in the first project phase have enabled the identification of research capacity building needs and research priorities that have facilitated future involvement of government actors, national organisations, non-governmental organisations (NGOs), bilateral or international donors. In addition, the mapping exercise enhanced the identification of areas where contributions would be of particular value and would have a significant impact. Capacity building exercises allowed for the updating and exchange of health research methodologies, management and communication, leading to better quality evidence in the future. Also, improved evaluation and monitoring mechanisms are expected to enable more stringent peer reviews and an improved quality assurance system.
The creation of the Learning Platform that provides free online access to SDH-Net materials enables the sustainability of SDH-Net products beyond the life of the project, as well as linking SDH-Net activities with WHO Geneva y PAHO knowledge hubs. Moreover, INSP has secured funding (from PAHO) for the materials that were developed alongside the project to be translated into the Spanish language. Therefore, SDH-Net also adds to research capacity building in the entire Spanish speaking Latin America.
Sustainable SDH research capacity in LMIC can be strengthened through national SDH networks. Indeed, SDH-Net played an important role in reinforcing structures and initiatives at national level that allowed for better SDH research in partner LMIC. For example, in South Africa, as part of SDH-Net, the City Council of Johannesburg initiated a National Commission on Social Determinants of Health that put SDH to the attention of regional and national governments, relevant stakeholders and the society in general. In Mexico, INSP has established a national alliance for SDH that includes INSP, the Mexican National Directorate of Health Promotion, PAHO-Mexico Office, the Mexican Academy of Medicine and other stakeholders to work on a variety of actions with the purpose of strengthening capacities, training, debating, and networking on SDH in the national context – with the ultimate goal of eliminating health inequalities. Other national activities to strengthen SDH research were also pursued in Brazil, Colombia, Kenya and Tanzania.
Moreover, the SDH-Net project was linked to the activities of WHO Health in all policy (HiAP), while several SDH-Net members are part of the global HiAP networks. In the context of the HiAP network, regional trainings (“trainings the trainers”) on SDH research were carried out and SDH-Net partners from Latin America and Africa were involved in these activities.
Finally, SDH-Net project enhanced capacities for conducting and managing research on SDH and, thus, enabled stronger links between research, policy and practice through the development of tools and mechanisms, facilitating sustained collaboration.
Project Results:
Main project S&T results and foregrounds are described below; they were categorised in a few sections according to the main groups of results produced.
MAPPING RESEARCH SYSTEM CHARACTERISTICS
Mapping Tool
A methodological tool with guiding questions and criteria for mapping SDH research capacities and identifying gaps in research systems and research activity on SDH was adapted to the specific national contexts of the project’s partners, including a short “light mapping” version.
National Mapping Reports
The mapping exercise was carried out by all partners at the national level to collect information on research activities, knowledge production and research system characteristics related to SDH in the respective countries.
Overall Mapping Report
The results of the national mapping reports were drawn together in an overall mapping report. This synthesis provided an overview of SDH research activities and research capacity as well as pointing to gaps and needs.
“Light Mapping” Reports (European Partners)
While the SDH-Net’s main focus were on LMIC, it was decided to carry out a “light” mapping” report on SDH and SDH research in the respective European partner countries to complement the more extensive African and Latin American reports and provide some additional ideas and compare the situation in high-income countries with participating LMIC.
Regional mapping reports
In order to synthesise the information, the national mapping results were analysed and brought together into a regional matrix and report of each of the two regions Latin America and Africa.
Development of a Mapping Tool
The standardised Mapping Tool is a system approach that was adapted to fit the specific context of the six partner countries (Brazil, Colombia, Mexico, Kenya, Tanzania and South Africa). Standard guidelines were developed to ensure that all countries followed a broadly similar protocol in their gathering of information, allowing comparability between the country reports. The same tool was the base of the Light Mapping Concept, carried out in Germany, Spain, Switzerland and the UK.
Mapping Report
The Mapping Report shows the country mapping process and the executive summaries of the findings of the mapping exercise, representing a snapshot and a first step of systematically collecting and synthesising available information at national level.
DEVELOPMENT OF COURSE MATERIALS FOR RESEARCH CAPACITY STRENGTHENING IN AREAS OF SDH
Development of course materials for theory-based sessions
A number of theory-based courses were developed:
1. The Essentials of SDH (automated, self-directed, 10h course)
Description: This is a self-directed, automated course powered by the SDH-Net platform. Course completion requires a total of 10 hours including online work and offline readings.
Purpose: To provide a theoretical basis for understanding and addressing SDH. This is a basic, introductory course to SDH.
Suggested use: As a stand-alone course or a complement to classroom courses to understand the theory and practice of SDH approach. It includes examples of analysis, description, planning, and implementation of actions to promote health equity at national, regional and global levels.
Suggested audience: Enrolment to this course requires a minimum education level of undergraduate, technical or Bachelor degree or equivalent.
Access: http://tie.inspvirtual.mx/portales/sdhnet/essentials.php
Portable Offline Version: Taking into account that sometimes online training environment is impractical, a Portable Offline Version (POV) of the course that is executable from a USB Flash drive was developed.
2. Qualitative Methods for SDH research (automated, self-directed, 20h course)
Description: This is an online course delivered by the Learning Management System ‘Moodle’, and powered by the SDH-Net platform. The course requires a facilitator to guide the work and answer questions.
Purpose: To provide the basis for conducting SDH-related research using a qualitative methods approach.
Suggested use: As a stand-alone course to understand the relevance of qualitative research for the analysis of social realities and the causes of health inequities. The course also provides an overview of a range of relevant qualitative research techniques.
Suggested audience: Junior and senior researchers with limited knowledge of qualitative methods who are interested in learning how to apply techniques derived from qualitative research into SDH-related research. For this course, it is necessary to assign an instructor and an administrator. Both must have previous knowledge of the Moodle learning platform. The instructor guides and is in continuous communication with the student; also, the instructor is the link between the student and the administrator. The administrator must be able to attend and resolve all the technical difficulties during the learning process, and provide course access to students.
Access: http://tie.inspvirtual.mx/portales/sdhnet/qualitative.php
3. Impact evaluation on SDH policy and research (automated, self-directed, 20h course)
Description: This online course provides an introduction to the methods for evaluating the impact of policies or programmes targeting the social determinants of health. The course covers both the quantitative and qualitative methods of attributing impact that are used to assess whether a policy or programme was effective and how and why these effects were brought about.
Purpose: To provide an overview of the methods for evaluating the impact of interventions aimed to improve health through addressing social determinants.
Suggested use: This course is designed to be used as an introduction to this area for self-directed learning for a student with a general understanding of research methodology. Links to advanced material are provided for students who wish to explore particular aspects of the course in more detail. Self-assessment exercises designed for students to test they have understood key concepts are provided throughout the course.
Suggested audience: Junior and senior researchers interested in learning about the assessment of impact of policies, programmes and research findings. Ideal for graduate students in health and social sciences.
Access: http://tie.inspvirtual.mx/portales/sdhnet/impact.php
4. SDH Research communication course was designed to be both presential or/and self-directed through virtual platform)
Description: Twenty-hour classroom-based course aimed at the learning of communication skills to enable SDH researchers to disseminate research findings to different stakeholders.
Purpose: to strengthen essential research communication skills to enable SDH researchers to disseminate research findings to different stakeholders, aimed to place SDH on the strategic political agenda and improve programme effectiveness and health outcomes.
Suggested use: in classroom settings, face-to-face lessons.
Suggested audience: The course is comprehensive and mainly targets academics and researchers in the field of SDH: junior researchers and mid-level researchers who would like to learn how to communicate effectively with the research community, with policy makers in the health sector and other stakeholders interested in SDH and health equity research.
The format of the course can be adapted and some modules address different types of audience such as policy makers and journalists, to see how to take evidence into account and how to effectively use it in policy implementation, employing different communication channels.
The course comprises:
Case Studies/Study Cases linked to these courses
1. Research management (South African Social Investment Exchange as corporate social responsibility: An innovative way to fund SDH projects?)
2. Implementation research for SDH in LMIC (IMCI implementation in Tanzania: experiences, challenges and lessons)
3. “Communication as a transversal element in research on Social Determinants of Health: A case on research communication in a research project on social determinants of health involving a rural community in a low- and middle-income country.”
Practical courses/ workshop
1. Workshop (1): Disseminating SDH-related research findings to different audiences
2. Workshop (2):
1. Module 1: Research capacity building: research strategy management and leadership for research; institutional capacity development.
2. Module 2: Research translation: from knowledge to practice in a health laboratory setting
3. Module 3: The basics of research financing, budgeting and fundraising for SDH research
The Research Communication workshop was designed as a short and practical adaptation of the Research communication course. The workshop was piloted at ISGlobal.
Other resources
1. Toolkit for research fund management
2. Short Guide: “How to mainstream SDH into the curriculum with an example of a one-hour lecture on SDH for health professionals.”
Course materials were developed for practice-based sessions specifically on the implementation of the courses and use of materials at different institutions, including sessions on how to adapt the course content as well as how to develop case studies to the respective country setting. A brief guide on how to implement course materials and a template were developed to ensure that the courses could be taught at various institutions independently and successfully, and Training of Trainers sessions were held to illustrate the use of the course materials in a practical setting within the consortium.
5. Research management for projects on health and its social determinants course
Description: The course provides a basic overview of the use of project management for both simple and complex collaborative SDH-related projects and a focus on the relevant people and organisational factors. In addition, it includes research costing, specifically costing practices, financial management and fund raising aspects in an SDH-related research setting. The very nature of the core areas in this course demand a practical focus to support relevant and applicable learning. This is reflected in opportunities created for the practice-based exercises integral to each session within the modules of the course. In its application to SDH-related projects and integrating participant experience with past and current SDH projects and relevant case studies, it strives to bring the knowledge and benefits of good practice into the management domain of SDH researchers.
Purpose: To enhance research management capacity applicable to SDH-related research projects by providing an overview of research management methodologies and tools focused on project management, collaborative research management and research costing, thereby improving overall SDH-related research project efficiency and effectiveness.
Target audience: Since this course is applied to SDH-related research projects, a pre-requisite for this course is that all participants complete the relevant SDH-Net virtual courses (including Essentials of SDH, SDH Methodology, etc.). Specifically participants mentioned below would benefit optimally from this course:
1. Researchers managing large SDH projects and/or research groups
2. Health and social sciences research project managers / Administrators.
Methods: This contact course has a theoretical component and exercises as practice-based sessions that would require 20 hours of learning spanning two months. Resources such as course materials, and additional relevant articles, video, audio and presentations may be used to stimulate learning in a classroom setting. Slides have been developed for each module to support the training and learning process.
Development of course materials for practice-based sessions
Material for two practice-based courses (Workshops) to be implemented in classroom settings were also developed: Interdisciplinary approach for the study of SDH (20h) and Mixed Methods for the Study of SDH (20h). These are pdf documents that describe two 20-hour classroom-based workshops. The workshops description is given in detail so that they can be implemented in classroom setting with a facilitator/instructor.
1. “Interdisciplinary Approach for the Study of SDH”
Description: Workshop guided by an instructor, to train participants in the concepts of multi-, inter-, and trans-disciplinary research, in order to apply them in the design and carrying out of research projects, as well as to the reporting and dissemination of research findings, within the framework of the SDH.
Purpose: To learn and apply the principles of interdisciplinary research and understand how to build and work with interdisciplinary teams for the study of SDH.
Suggested use: In classroom settings with an instructor. The workshop can be used as a complement to a research methods course or by itself to strengthen multi-, inter-, and trans-disciplinary research capacities.
Suggested audience: Junior and senior researchers interested in diversifying the focus of their research by incorporating other disciplines into the design and implementation of research projects, as well as in the analyses of findings, and their implications for SDH research.
Access: http://tie.inspvirtual.mx/portales/sdhnet/workshops/Workshop%201%20Interdisciplinary.pdf
2. “Mixed Methods for the Study of SDH”
Description: Workshop guided by an instructor, to train participants in the concepts of mixed methods in scientific research, in order to apply them in the design and carrying out of research projects within the framework of the SDH.
Purpose: To learn and correctly apply the principles of mixed methods research.
Suggested use: In classroom settings with an instructor. The workshop can be used as a complement to a research methods course or by itself to strengthen research capacities on the use of mixed methods in scientific research applied to SDH research projects.
Suggested audience: Junior and senior researchers with medium-level knowledge of qualitative and quantitative methodology interested in learning and applying a mixed method approach for the study of SDH.
Access: http://tie.inspvirtual.mx/portales/sdhnet/workshops/Workshop%20Mixed%20Methods.pdf
REPOSITORY OF RESOURCES/MATERIALS FOR COURSE DEVELOPMENT AND IMPLEMENTATION
Description: Collection of electronic documents that can be easily downloaded by clicking on the link. The compilation includes scientific articles, formal reports, book chapters, books, videos, photographs, infographics and other relevant material.
Purpose: To provide access to interested users, to a wide range of specialised resources on social determinants of health and health inequities research. Resources in Repository can be used individually to acquire new knowledge or as learning tools in classroom settings.
Suggested use: Supporting materials to teach and learn about SDH.
Suggested audience: Individuals affiliated to different institutions (government, academic, philanthropic, national and international institutions) working in any field of the social and health sciences, administration and humanities wanting to learn or expand their knowledge about the Social Determinants of Health. Access: http://tie.inspvirtual.mx/portales/sdhnet/sdh-net/
Practical materials to strengthen SDH research capacity
Case studies/Study Cases: A total of 11 case studies/study cases were developed. The case studies/study cases are grouped under three thematic lines:
1) Research ethics, social commitment, and human rights issues in SDH research in LMIC
2) The application of the Latin American Social Medicine and Collective Health model to address health inequities in LMIC
3) The process of priority setting in health research with emphasis on SDH in LMIC
Description: The presented cases are recreated in written form. Each case provides an overview of a specific topic related to each one of the thematic lines stated above.
Purpose: To represent complex situations that a person, team or institution has faced in real life and use them in learning contexts with the purpose of emulating professional action.
Suggested use: Case studies/study cases serve the purpose of stimulating discussion in learning contexts and are aimed at generating alternatives and responses for professional action of a specific discussed topic on SDH.
Suggested audience: Professors of graduate courses on health, social sciences and policy implementation courses. Case studies/study cases can be used as tools in classroom settings under the guidance of an instructor/professor.
Access: http://tie.inspvirtual.mx/portales/sdhnet/cases2.php
DIDACTIC AND METHODOLOGICAL RESOURCES
Infographic “The ABC of SDH”
This is a printed media resource that uses visual representations to understand SDH. The infographic can be downloaded in pdf format for printing, or can be used in an electronic format. The purpose of the infographic is to provide the basic concepts related to SDH, using illustrations and easy-to-understand text with the main ideas of the SDH approach. The infographic can be accessed here: http://tie.inspvirtual.mx/portales/sdhnet/others.php
Guide: “How to develop Case Studies on SDH for Low- and Middle-Income Countries (LMIC)”
Description: This is a pdf document that provides a sequential, easy-to-follow guide on writing case studies. The Guide is to be used preferentially in combination with the Case Creator tool that is described below.
Purpose: To guide users (academic/researchers/students) step-by-step in the creation of their own case study, with a particular emphasis on SDH.
Suggested use: In classroom settings to guide students and young researchers on the development of case studies, with special emphasis on SDH.
Suggested audience: Junior and senior researchers that want to participate in developing of new cases and expanding the number of case studies available for classroom discussion in LMIC.
Access: http://tie.inspvirtual.mx/portales/sdhnet/recursos/Short%20Guide%20for%20Case%20Studies.pdf
Notes available at: http://tie.inspvirtual.mx/portales/sdhnet/recursos/Developing_SDH.pdf
Case Creator
Description: This is an online tool, consisting of a template with pre-designed fields for capturing text which could be used as input to the information of a written case study. The capture fields correspond with the case study sections as described in the “How to develop Case Studies about SDH for Low- and Middle-Income Countries (LMIC)” document.
Purpose: To help in the development of a final written document of a case study.
Suggested use: In learning contexts to develop SDH-related case studies.
Suggested audience: Junior and senior researchers who want to participate in developing new cases and expanding the number of case studies available for classroom discussion in LMIC.
Access: http://tie.inspvirtual.mx/portales/sdhnet/casecreator/nuser.php
“Developing SDH indicators for observatories on health inequities: the Brazilian experience”
Description: This document presents the experience of the Observatory on Health Inequities (FIOCRUZ), particularly the methodology used to gather, organise, publish and analyse information data from different sources in Brazil. The document presents the experience of the Brazilian Observatory on Health Inequities. The Methodological Note encompasses theoretical, practical, methodological and analytical tools for developing monitoring indicators on SDH at national level, and is based on the experience of the FIOCRUZ CEPI-DSS Observatory on Health Inequities.
Purpose: This methodological document encompasses theoretical, practical, methodological and analytical tools for developing monitoring indicators on SDH at national level, and based on proven methodologies for LMIC contexts, where data availability tends to be scarce, sparse, and/or inconsistent.
Suggested use: To understand the purpose of an observatory on health inequities, how to set one up and how to develop relevant indicators for it.
Suggested audience: Researchers, administrators, policy makers interested in eliminating health disparities at national and regional levels.
Access: http://tie.inspvirtual.mx/portales/sdhnet/others.php
Concept for Health Service Laboratory was also developed and can be access using the following link via the “Other Resources” section: http://tie.inspvirtual.mx/portales/sdhnet/others.php
VIRTUAL LEARNING PLATFORM
INSP developed the web-based tool: Learning Platform for SDH research training. This platform was designed by INSP to host the SDH-Net learning environments. This platform was designed using a Learning Management System (online courses, blended courses, and support for classroom-based courses). It also includes: course contents, course administration, assessments, communication/collaboration tools, external applications, and student registration forms. Access: http://tie.inspvirtual.mx/portales/sdhnet/
Materials and courses adapted to local needs/update of virtual learning platform
A guide was developed on “How to Implement SDH-Net WP-4 Resources”. This guide provides descriptive information of all the tools developed under WP4 and technical specifications for use and access the Learning Platform. For each tool, a description is provided with step-by-step instructions on how to use it.
Implementation of research capacity building tools
The implementation of some tools started in 2013: The Case Study Creator was used for the development of case studies by two students of the Global Health Diploma, taught at the INSP Summer School, as the final task required for obtaining the Global Health Diploma Certificate. Selected modules of the 10h course “The Essentials of SDH” were tested by several students of the Global Health Track of the School of Public Health at INSP in 2013.
In May 2014 the online course “Essentials of SDH” was offered to graduate students at INSP and undergraduates at the University of Costa Rica. A total of 42 young and senior researchers and 10 decision makers have taken the online course.
In August 2014, the two workshops “Mixed methods for the study of SDH” and “Interdisciplinary approach for the study of SDH” were implemented at the INSP Summer School with 32 participants from diverse background and institutions, such as students from the School of Public Health of Mexico, epidemiologists from the Mexican Institute of Social Security, researchers from different Mexican universities and academic institutions and personnel from the Health Promotion Division of the National Health Ministry.
INSP secured funding from the Pan-American Health Organization-Mexico and The National Directorate of Health Promotion (DGPS) for programming and translating into Spanish two WP4 deliverables: the infographic “The ABC of SDH” and online course “Essentials of SDH”. ”. Both Spanish-translated resources are available under the following links: “El ABC de los Determinantes Sociales de la Salud” (http://tie.inspvirtual.mx/portales/sdhnet/recursos/SPA_infografico_chico.jpg). “Conceptos Esenciales de los DSS” (http://tie.inspvirtual.mx/portales/sdhnet_spa/essentials.php). They will be used to train young researchers, decision makers and administrative personnel on SDH. The resources in Spanish are freely available in an open access platform to all interested individuals and institutions in Mexico and Latin America. Furthermore, INSP has been working in the establishment of a national alliance for SDH that includes INSP, DGPS, PAHO-Mexico, the Mexican Academy of Medicine and the National Association of Public Health Schools, to work on a variety of actions with the purpose of strengthening capacities, training, debating and networking on SDH in the national context, with the ultimate goal of eliminating health inequalities.
Additionally, INSP has participated along with the partners from Brazil and Colombia in the creation of the Latin American Alliance for Health Equity (ALESA), which has the main goal of stimulating the exchange, collaboration and strengthening of the Latin American institutions involved in the SDH-Net project.
Recognising the importance of making the Latin American Social Medicine and Collective Health approaches more visible and thereby able to contribute to horizontal dialogues between different research traditions and approaches on SDH and health inequities, UNAL and FIOCRUZ started working on a proposal for a virtual/e-casebook on the Latin American Social Medicine and Collective Health.
UNAL, the Colombian Collective Health Network (Red Colombiana de Salud Colectiva) and FIOCRUZ further participated in the development and coordination of an online seminar on processes of social determination in health that seeks to complement WP4 materials and respond to an unmet need for a broader and more horizontal dialogue between research traditions in the field of SDH and health inequities, particularly addressing the Latin American Social Medicine and Collective Health social determination of health approach. The online seminar counts on the participation of around 40 researchers, professors and students from several universities in Colombia, Ecuador and Brazil and has been offered in Spanish via Scopia Videoconferencing tools once a month (duration of three hours) since 2014.
Learning Platform for SDH research training hosts the following learning material
1. Repository of learning resources for course development and implementation
2. Three theory-based courses:
a. The Essentials of SDH (online, automated, self-directed course)
b. Qualitative Methods for SDH research (online, automated course)
c. Impact evaluation on SDH policy and research (under the leadership of LSHTM).
d. SDH Research Communications course (by IESE)
e. SDH Research Management course (by WITS)
3. Two practice-based courses (Workshops):
a. Mixed methods for the study of SDH (classroom-based workshop)
b. Interdisciplinary approach for the study of SDH (classroom-based workshop)
c. SDH Research Communications workshop (by IESE)
4. Case Studies/Study cases
a. Eleven case studies organised under three major topics: 1) Research ethics, social commitment, and human rights issues in SDH research in LMIC; 2) The application of the Latin American Social
Medicine and Collective Health model to address health inequities in LMIC; 3) The process of priority setting in health research with emphasis on SDH in LMIC
b. Methodological Guide: “How to develop Case Studies about SDH for Low- and Middle-Income Countries”
c. Automated, online tool “Case Creator” for the step-by-step development of case studies on SDH
5. Other resources
a. Infographic “The ABC of SDH”
b. Concept Paper: “Health Service Laboratory”
c. Methodological Document: “Developing SDH indicators for observatories on health inequities: the Brazilian experience”.
d. Guide on “How to Implement SDH-Net WP4 Resources”.
ESTABLISHING INFORMATION EXCHANGE & RESEARCH COLLABORATION BETWEEN PARTNER INSTITUTIONS
The SDH-Net project aimed to build, strengthen and link research capacities for health and its social determinants in African and Latin American low- and middle-income countries (LMIC) in close collaboration with European partners, seeking to establish a two-way learning process and strengthen South-South and South-North-South collaborations within the project. In this regard, SDH-Net has foreseen the development of new, and the strengthening of existing tools to facilitate future links between researchers, networks and institutions that extend beyond the life of this project. The WP6 network and collaboration activities accordingly constituted an integral element of SDH-Net’s strategy to strengthen capacities for research on health and its social determinants and complement the development of SDH research capacity strengthening tools in WP4 and WP5. SDH-Net WP6 network and collaboration activities in this regard explicitly challenged the traditional notion of health research capacity as a mere human resource issue limited to stand-alone individual level training, and constituted an effort towards forging links between researchers, institutions and networks for sustainable capacity for research on social determinants of health and health inequities (SDH). By systematically utilising strategic networks, the SDH-Net reach was spatially and conceptually expanded, reaching individuals, institutions and research systems outside the direct scope and beyond the duration of the project.
In this regard, several collaborations were consolidated over the course of the project and researchers engaged in concrete collaboration activities in the context of short-term fellowships, related to joint publications and the joint elaboration of research proposals. Apart from the researchers directly involved in SDH-Net, associated researchers from the SDH-Net institutions were involved in the collaboration activities, which allowed for project-specific collaborations between SDH-Net associated experts, and further allowed for the dissemination of SDH-Net project activities at the consortium partner institutions and at associated institutions.
Strategic networks were identified and strategies towards strengthening the exchange with the respective networks were elaborated
Strategic networks were identified and strategies towards strengthening the exchange with the respective networks were developed by FIOCRUZ and IHI in close collaboration with the other partners. This built the basis for thematic twinning, which found expression in the WP8 plan for joint publications, as well as in other network and collaboration activities, which are detailed below. Furthermore, and in close collaboration with other consortium partners, FIOCRUZ compiled information on upcoming events and informed the consortium partners. The information was shared on the SDH-Net Blog to facilitate the exchange between the SDH-Net researchers at the conferences and to support the development of joint papers and presentations.
Exchange between researchers organised around the topics of research capacity building and SDH
In this regard, several panel sessions and events/workshops have been organised in joint ventures in the course of the project.
In October 2013, FIOCRUZ organised a panel session titled “Rio + 2: The role of research in taking the Rio Political Declaration (2011) forward - Insights from Africa, Europe and Latin America" at the National School of Public Health at FIOCRUZ in Rio de Janeiro (please refer to the following blog post for details: www.sdh-net.eu/index/blog-news/post/sdh-net-plenary-session-is-now-available-online). UNAL, IHI, IESE, GIZ, FIOCRUZ and INSP researchers presented SDH-Net related work to the Brazilian audience.
UNIGE together with SDH-Net researchers from IHI, INSP, IESE and FIOCRUZ organised a panel on Social Determinants of Health and Research Ethics at the 12th World Congress of Bioethics in June 2014, addressing the application of ethical criteria to health research in general and to social determinants of health (SDH) research in particular (please refer to the following blog post for details: www.sdh-net.eu/index/blog-news/post/panel-on-ethics-in-sdh-research-at-the-12th-world-congress-of-bioethics).
In September 2014, FIOCRUZ organised a panel session on the Colombian health reform (Illustration 4) with speakers from UNAL and Universidad Andina Simon Bolivar. Please refer to the following blog post for details: www.sdh-net.eu/index/blog-news/post/fiocruz-hosts-debate-on-health-reform-in-colombia.
Furthermore, two SDH-Net panels were organised by INSP at the La Alianza Latinoamericana de Salud Global (ALASAG) conference in San José, Costa Rica in November 2014, counting on the participation of UNAL, INSP, FIOCRUZ and IESE: SDH indicators and observatories; SDH research and capacity strengthening.
Evaluation research and particularly the evaluation of financial incentives for health have been at the centre of the collaborations between INSP and LSHTM, which resulted in the approval of a Researcher Links Workshop Grant on “comprehensive evaluation for health and development: promoting the integration of evaluation methods”, which was carried out in April 2015. The workshop brought together a total of 29 researchers with experience of undertaking evaluation research in the field of public health and social development from Mexico and the United Kingdom.
In an effort to further activate the collaborations around the Latin American Dossier on Pesticides and Health, which forms part of the strategic agenda of ALAMES and has defined collaborations between UNAL and FIOCRUZ and other institutions from Latin America, a panel session took place in the context of the 9th International Public Health Congress in Medellin, 19-21 August 2015. UNAL and FIOCRUZ staff members were invited to discuss territorialities and health and the panel initiated the work on the Colombian chapter of the Latin American Dossier on Pesticides and Health. Furthermore, experiences around the Brazilian chapter (www.abrasco.org.br/UserFiles/Image/Dossieing.pdf) were shared.
IESE was invited to conduct a workshop on SDH-Net during the Global Health Next Generation Network’s 2nd Global Health Conference “Ensuring the voice” – ensure the voice of young professionals in global health, held on 25-26 June 2015 Barcelona, Spain. IESE subsequently invited INSP to assist with the development of the workshop; during the workshop SDH-Net was presented, an online SDH-Net course was piloted and the role of South-North Global Health Research Collaborations and on-going challenges faced by LMIC researchers and national research systems were discussed with the young global health professional conference participants (www.globalhealthngn.org/).
Junior researchers: Web-based junior-researchers-colloquia were organised to foster exchange processes and build the basis for future collaborative projects
FIOCRUZ periodically reminded the consortium partners of the SDH-Net commitment to junior researchers and encouraged junior researchers to participate in the different SDH-Net related activities. In this regard, young social scientist researchers from IHI participated in the EQUINET –ALAMES four-day action-oriented participatory research training in Cape Town (October 2014) and a four-week qualitative research training course at University of Bergen, Norway (Nov-Dec 2014).
In an effort to strengthen capacities for research on social determinants of health and health inequities, SDH-Net Junior Researcher Colloquia connected (junior) researchers working on these topics on the three continents and consolidated networks forged in the context of the SDH-Net project and beyond. In this regard, the Colloquia represented an effort to link the two lines of action that have shaped the SDH-Net project:
1. network/collaboration activities to strengthen and link capacities for research on health and its social determinants and;
2. the development and piloting of research capacity strengthening tools, including online courses, case studies, workshops and guidelines on Social Determinants of Health, research methodology, research communication and research management.
Participants had the opportunity to discuss their research with senior scholars and peers working on social determinants of health and health inequities in Africa, Latin America and Europe in a small group setting, and were provided with guidance and mentorship. Junior researcher colloquia were offered in a web-based and classroom-based Format.
Institutional Exchange: Establishment of formal procedures for staff Exchange programmes
Institutional agreements were signed between IHI, FIOCRUZ, and the Tanzanian Commission for Science and Technology (COSTEH), in 2013. The agreement is for a tripartite inter-institutional scientific cooperation programme in the areas of SDH, biomedical and clinical research, and development of technological products for health and more. Activities under the agreement include orientation of research projects, publications, information exchange, technical assistance, and exchange of researchers for sharing experience. A collaboration agreement is further planned to be signed by the UNAL Interfaculty PhD programme in Public Health and ENSP/FIOCRUZ in November 2015.
Apart from the formal institutional agreements, institutional exchanges were supported throughout the project and linked to the exchange between researchers. In fact, most institutional exchanges were initiated by individual researcher exchanges in the context of the short-term fellowships, which gave impetus to subsequent institutional exchange and the engagement of different sectors of the respective institutions. The short-term fellowships that took place during SDH-Net project are described below.
From 1-19 April 2014, Germán Guerra, Junior Researcher from INSP visited FIOCRUZ and worked with the FIOCRUZ team, under the supervision of Professor Alberto Pellegrini, in the development of deliverable “Developing SDH indicators for observatories on health inequities: the Brazilian experience” on elements for the establishment of a Mexican observatory on Health inequities, that was forecast to culminate in a publication in a peer-reviewed journal. He also worked in the writing of the final draft of a scientific paper, co-authored with other SDH-Net members from UNAL and FIOCRUZ “Cadernos de Saúde Publica”.
Another fellowship took place from 30 June to 11 July 2014. Lucinda Cash-Gibson, Junior Researcher from IESE, visited INSP under Nelly Salgado de Snyder’s supervision. Her activities included: the support of the development of Guides for WP4 (“How to implement WP4 resources” and “How to adapt SDH-Net WP4 courses to different contexts, modalities, and technical requirements”), work on the D7.1 policy recommendations from Mexico, and writing on a first draft of a joint publication that was recently published (“SDH-Net: A South-North-South collaboration to build sustainable capacities for research on social determinants of health in low- and middle-income countries”). In 2014, another short-term fellowship took place. Elis Borde, researcher from FIOCRUZ, undertook a research visit to UNAL that aimed to develop the Online Seminar on the Social Determination of the Health-Disease Process.
Furthermore, in the context of the short-term fellowship of GIZ staff (Siri Nanz) at FIOCRUZ, both Partners have concentrated on the development of a proposal for the sustainability of the SDH-Net resources and particularly the SDH-Net website, drawing on the experiences of both institutions and particularly on the INSP/FIOCRUZ SDH Portal (http://dssbr.org).
Other collaboration activities
UNAL and FIOCRUZ have collaborated on the development and the implementation of the Online Seminar on the Social Determination of the Health-Disease Process, currently in its third phase. The Seminar forms part of the collaboration activities directed at the Latin American Social Medicine and Collective Health approaches on social determinants of health inequities between UNAL and FIOCRUZ, and specifically seeks to complement SDH-Net WP4 and WP5 training tools (courses, cases, workshops) with content related to the Latin American Social Medicine and Collective Health approaches. The intention is to make the contributions of these approaches visible and to strengthen capacities for locally relevant research on SDH. In its third phase (semester), students and researchers from eight universities from Colombia, Ecuador and Brazil connect to the monthly three-hour online seminar, which is coordinated by different institutions on a rotation scheme. In an effort to systematise the experience of the online seminar and to share the reflections and material developed in the context of the seminar, a book was published (Carolina Morales; Juan Carlos Eslava C. (Org.). Tras las huellas de la determinación social - Memorias del Seminario InterUniversitario de Determinación Social de la Salud. 1ed. Bogotá: Editorial Universidad Nacional de Colombia, 2015).
IHI and LSHTM have been collaborating in the context of several research projects and have established a comprehensive staff-exchange programme. In the context of the SDH-Net project, these collaborations were strengthened and focused on the evaluation of results-based financing.
WHO has recently developed a Health in All Policies (HiAP) Training Manual to support this whole-government system dialogue and approach to tackle health inequities, and global HiAP Training of Trainers meetings have started to take place to support local adaptation of HiAP training manual materials in the different global regions.
UON, FIOCRUZ, IESE, UNIGE and INSP are collaborating in the context of these Health in All Policies (HiAP) Training of Trainers activities (ToT). Specifically, FIOCRUZ supported the Central American Training of Trainers course offered by INSP between 27 and 31 July 2015, and INSP supported the FIOCRUZ South American Training of Trainers course to be carried out between 18 and 20 November 2015 in Rio de Janeiro, following the International Seminar on Social Determinants of Health, Intersectoriality and social equity in Latin America, constituting the first part of the capacity building process (http://dssbr.org/site/2015/10/seminario-internacional-determinantes-sociais-da-saude-intersetorialidade-e-equidade-social-na-america-latina-inscricoes-aqui/). It is important to note that SDH-Net learning material was integrated into the Central American HiAP Training of Trainers course. Similarly, UNIGE has integrated SDH and HiAP into the institutions’ Global Health and Human Rights Summer School. UoN is planning regional implementation together with the MoH and African SDH partners. Another SDH-Net partner (WITS) attended a ToT session in New Delhi in July 2015.
The project moved beyond stand-alone individual level trainings, and towards comprehensive efforts to forge links between research and policy/practice, disciplines, approaches and countries, in order to build sustainable capacity for interdisciplinary and locally relevant research on SDH. Network and collaboration activities have been essential in this regard and have set the basis for continued and comprehensive efforts towards capacity strengthening for research on SDH. As a general learning point we emphasise the importance of individual-level exchanges as a first step towards more comprehensive institutional collaborations.
The SDH-Net experience shows that short-term fellowships and other researcher exchange modalities were essential to the consolidation of long-term collaboration activities between institutions, and gave impetus to the development of joint research proposals, publications and the organisation of events, amongst others. The SDH-Net experience in the context of WP6 further underlines the importance of strengthening existing networks and linking new network and collaboration activities to ongoing initiatives, and to further consider institutional structures and priorities as well as existing personal contacts.
The mapping exercise proposed in phase 1 of the SDH-Net project made important contributions in this regard, and was an important basis for collaborative action. South-South collaborations assume a particularly important role in efforts toward strengthening capacities for research on SDH. In this regard, Latin American partners recognised the importance of engaging with regionally specific research traditions in order to strengthen capacities for locally relevant research on SDH. The enormous potential of South-South collaborations is further evident in the collaborations between African and Latin American partners around SDH observatories and health inequity measurement, in the articulations between regional networks (EQUINET and ALAMES), but also in the proposals for joint research projects that emphasise South-South learning. To this extent, the SDH-Net experience underlines the importance of complementing funding for joint ventures between institutions from the global North and the global South, with more South-South funding opportunities.
Similarly, it seems necessary to have funding modalities that support networks at regional, cross-regional and also at national level, independent of specific research projects. As another general learning point, we emphasise the importance of strengthening national networks. Based on the national mapping exercise, several national partners were identified and involved in SDH-Net activities throughout the course of the project, which undoubtedly contributed to the dissemination of SDH-Net activities. National networks further contribute to the consolidation of a sustainable alliance for research (capacity strengthening) in the field of SDH, linking capacities and experiences. Strengthening national networks on SDH and health inequities should therefore be considered a strategic entry point for action on SDH.
POLICY AND ETHICAL RECOMMENDATIONS
Lessons learned at policy level
The lessons learned at policy level aim to provide insights into how and where policies can foster sustainable SDH research capacity strengthening, especially in LMIC, in order to support locally relevant, evidence-based, equitable public health decisions, and achieve optimal population health and well-being. Lessons learned were specially derived in terms of:
1. how SDH-Net has contributed to strengthening the global SDH research capacities and discourse, not limited to LMIC;
2. where and how future policies and action can contribute towards fostering local SDH research capacity strengthening at different research capacity levels in order to produce, manage and translate local SDH knowledge for use by different stakeholders to support action on SDH;
3. considerations for the design and construction of future South-North-South SDH research collaborations – for grant-makers and researchers, and Europe/Northern settings.
As a result of SDH-Net, several work groups, informal and formal relations and networks have formed at SDH-Net partner country level, regionally and internationally, and this was demonstrated through the discussions and presentations (by WHO, City Council of Johannesburg, MoH in Kenya, Professors etc.) taking place during the final SDH-Net conference in joint collaboration with the WHO’s SDH Unit in May 2015, in Geneva. Discussions are taking place between WHO and SDH-Net partner institutions, and similar discussions are being held between the Latin America SDH-Net partner institutions and PAHO. Ultimately, it is hoped that these international engagements would lead to more sustainable local and global collaborative action on health equity and SDH.
Capacity Building in Research Ethics and Lessons Learned
An ethics protocol, including SDH-sensitive perspectives, was developed. The guidelines and checklist are documents that are forecast to be used and submitted to WHO in order to improve equity within research ethics review committees. A series of articles will be published on this issue after the closure of SDH-Net.
The reinforcement of the collaboration with WHO, SDH-Net, and the WHO Gender and Human Rights section, has led to the development of material to review health policy programmes to include SDH, equity and human rights. Therefore, the contribution of SDH-Net to the international material for training policy makers can be considered as a significant result and a promising avenue.
The development of tutorial material also serves as a basis for developing an international protocol which addresses more particularly the sensitive aspects of SDH research with the highest standard of protection of subjects and their benefit for and from the research (including a checklist and questions to be asked to the National or International Review Board [NRB/IRB] review, informed consent [emphasising information over voluntariness] and the creation of capacity-building activities and education on research ethics).
As mentioned above, in a collaboration between UNIGE, IHI, INSP, IESE and FIOCRUZ, a panel session on ethical issues in SDH research at the World Congress of Bioethics Conference (Mexico City, 2014) was organised (http://www.sdh-net.eu/index/blog-news/post/panel-on-ethics-in-sdh-research-at-the-12th-world-congress-of-bioethics). The panel sought to address the application of ethical criteria to health research in general and to social determinants of health (SDH) research in particular. In this regard, a conceptual framework for the consideration of ethics in SDH research was proposed and ethical considerations at different stages of the research process pointed out. Furthermore, ethical issues in the design of SDH research and the use of SDH research variables and in the implementation of SDH research were addressed, emphasising the importance of involving local communities. The panel made a unique contribution to the World Congress on Bioethics by focusing on SDH and SDH research, which are rarely considered from an ethical perspective. In this regard it is important to mention that, although the WHO systematically conducts ethical reviews for all its global research proposals, there are no specific SDH ethics guidelines or protocols mentioned in international research documents, in management or training.
Potential Impact:
POTENTIAL IMPACT
SDH research capacity in low- and middle-income countries
Improving and building-up SDH research capacity was a primary goal of the project. All the products that were developed under SDH-Net activities have a direct positive impact on SDH research capacity building within involved countries and regions. To address relevant SDH research challenges in LMIC specifically, the project commenced with carrying out an in-depth study of existing evidence and work on SDH, based on partners’ previous efforts; in particular the mapping of SDH-related stakeholders and the identification of capacity building needs were performed. This set the stage for a number of actions towards an improved research landscape, such as development of tools for and implementation of capacity building activities on SDH research, SDH research methodology, management and communication, and interdisciplinary skills necessary for the study of SDH, in addition to the strengthening of national and international SDH research networks and systems.
The SDH-Net products have an essential impact on SDH research in LMIC, not only by facilitating the SDH research currently conducted in the countries involved in the project, but also by enabling evidence-based and sound research beyond the duration of the project, therefore assuring the sustainability of the project results and their impacts. Capacity building itself has an in-built sustainability aspect (by definition); moreover, the active dissemination of results, the development of tools and the identification of policy lessons for the national, regional and global levels warrant sustainability and future impact of the project.
A unique virtual learning platform was designed to host the developed tools, which included a range of online and classroom-based courses, workshops, case studies, an online case study creator tool, an infographic, methodological guides, and a repository of SDH research-related materials. In order to ensure the continued sustainability and free availability of SDH-Net products, INSP has already agreed to host and maintain the platform indefinitely.
To further support dissemination of SDH evidence, SDH-Net also created an SDH online repository as part of the virtual learning platform. Online repository allows SDH research to be organised and collected, as well as up-to-date and focused literature that is easily accessible by all interested stakeholders. This complements the Brazilian Virtual Health Library Health on SDH (BVS DSS) and the online Portal on SDH . All in all, this ensures better use of existing knowledge, reducing duplicated studies and unused resources. It will also facilitate a synthesis of available SDH findings to date and inform the future research agenda: what is known and what more is needed to be known.
Moreover, INSP secured funds from the Mexican Secretariat of Health to translate most of the products into Spanish, making them available at no cost to all Spanish-speaking countries interested in building and strengthening SDH research capacities. Subsequently, both the English and Spanish language versions of the SDH-Net materials are already being used to train young researchers, decision makers and administrative personnel on SDH at different levels in Africa and Latin America.
Finally, SDH-Net activities had a special focus on junior researchers in the field of SDH and public health to allow for sustainability of SDH-Net impact on SDH research capacity in LMIC in the future. A number of seminars and colloquia were organised with the specific aim of educating, informing and involving young professionals from LMIC in current global SDH research, who in the future will take leading positions in this research area. Therefore, SDH-Net has an impact on the adequate and necessary preparation of human resources in order to address SDH research challenges currently and in the future.
SDH research capacity at national level: from international project to local activities
SDH research capacity building incorporates not only the ability to produce research, but also the capacity to use it and demand that it contributes to health improvement and health equity. The starting point of the SDH-Net was a clear understanding that the SDH research capacity building effort would be more efficient if it could trigger constructive structural and organisational changes in LMIC at national level that would warrant continuous research in the field of SDH; it would also address multiple challenges of SDH research experienced by LMIC such as insufficient research training, scarce financial and material resources, inadequate research output, and the emigration of researchers, often referred to as a “brain drain” . In line with this, some SDH-Net country partners have been involved in either building or strengthening National SDH networks. These initiatives are described below.
At national level, in Kenya, the Ministry of Health/Public Health and Sanitation leads the SDH-related activities and development of SDH-related public policies. Whilst conducting the SDH-Net national SDH mapping exercise, an (informal) tripartite consultative working group was formed between UoN School of Public Health, Ministry of Health/Public Health and Sanitation, and the WHO country office, and inter-ministerial workshops were conducted to support the national understanding and facilitation of inter-sectorial dialogue on SDH.
In Mexico, INSP has established a national alliance for SDH that includes INSP, the Mexican National Directorate of Health Promotion, PAHO-Mexico, the Mexican Academy of Medicine and other stakeholders to work on a variety of actions with the purpose of strengthening capacities, training, debating and networking on SDH in the national context – with the ultimate goal of eliminating health inequalities.
In South Africa, partly as a result of SDH-Net, the City Council of Johannesburg plans to develop a National Commission on Social Determinants of Health to draw the attention of governments, relevant stakeholders and society to SDH.
In Brazil, FIOCRUZ and the Ministry of Health are planning to work on a new national SDH mapping report, building on the SDH-Net national mapping exercise, with the aim of strengthening its national SDH network.
In Tanzania, SDH has gained increasing recognition over the past few years: at the 30th annual scientific conference Tanzania Public Health Association in 2013, the theme was Intersectorial approach in addressing SDH in Tanzania: closing the Health Inequality Gaps. SDH-Net partner IHI presented some of the key findings from the national SDH-Net Mapping Report at this SDH-Net conference). Furthermore, the National Health Sector Strategic Plan IV (2015-2020) is making SDH and equity a central cross-cutting theme. Additionally, in 2014, Tanzania adopted the Arusha Declaration on Social Protection – Building Effective and Sustainable Systems for Equitable Growth: Perspectives, Policies and Best Practices’ The declaration is a guide to action towards a nationally owned social protection system for the poor, vulnerable and marginalised, and for promoting social protection and addressing inequity, discrimination, marginalisation and other forms of deprivation.
All these advances at national level that were achieved with the participation of SDH-Net Partners are crucial for future sustainability of SDH research in partnership with LMIC, due to the fact that they are aimed at constantly evolving national SDH research capacity and stimulating locally-driven developments in this research area.
Improved quality of SDH evidence-based research and knowledge
SDH-Net had a particular focus on SDH research methodology, management and communication, which are key pre-requisites for flexible responses towards dynamic health challenges and are furthermore essential to enhance the quality and impact of SDH research. Also, research impact evaluation and monitoring mechanisms that were addressed in SDH-Net are expected to allow for more stringent peer reviews and an improved quality assurance system.
The SDH-Net project has fostered research capacity and networks in SDH that have created the basis for high-quality, evidence-based research in different settings. Therefore, as a direct product of the project’s activities, the quality of research and the generation of evidence in health and its social determinants are expected to be ameliorated.
The development of SDH-Net represents a valuable and innovative experience in the field of SDH research capacity building in LMIC. Despite SDH-Net objectives focusing on LMIC setting, the SDH feature prominently on the European public health agenda as well, and the tools developed and the lessons learned may also be relevant and applicable to SDH research in the European region and other high-income countries (HIC) in multiple ways.
Moreover, under the WP7, SDH-Net elaborated the recommendations for ethics in SDH research in LMIC. International ethical guidelines suggest that health research involving human beings should always meet established ethical standards and undergo ethical review. Although the promotion of ethical reviews and ethics standards in health research has significantly advanced lately, it still remains inadequately supported and developed.
SDH-Net contributed to this area of research not only by clarifying the conceptual background but also by building an ethically-based sustainable research system or research landscapes in LMIC. In order to overcome the ethical challenges that are often faced in SDH research, SDH-Net developed an ethical framework sensitive to SDH aspects throughout the research cycle and management. Therefore, the materials produced within the SDH-Net provide means for thorough examination of SDH studies from an ethical perspective, to ensure the ethical aspects are met at all stages of the research process (e.g. management, training, communication course, dissemination, etc.). Moreover, the SDH sensitive research ethics material that was produced under the SDH-Net could be employed by ethics review committees and used for training and sensitising researchers in conducting research under the highest possible ethical standards, with full respect to human rights and equity. Ultimately, this will lead to more equity in research and would assist in avoiding the trap of reproducing inequities during the research process. The materials are the practical tools such as guidelines, protocols and checklists.
Finally, the results, products, study findings and valuable insights gained during the SDH-Net project were disseminated through scientific publications in peer-reviewed journals, as parts of books and book chapters, and some of the publications are still under review or preparation; the knowledge on SDH gained during the project was also presented in a number of national, regional and international conferences and meetings. All these efforts led to diffusion of the SDH evidence obtained in the course of the project that essentially added to the current knowledge and expertise in the field of SDH.
Impact on health research
Primarily addressing the interdisciplinary research landscape, research on social determinates of health, SDH-Net has a valuable impact on health research in general. The SDH-Net products define a rigorous standard for SDH research and provide practical tools to enable this rigour in practice that, as mentioned previously, leads to high-quality, evidence-based research. Health inequities and inequalities are recognised by the WHO as one of the major health problems, and public health policies in countries all around the world define the eradication of inequities in health as an overarching aim. The SDH-Net project tackles an important, and currently recognised as challenging, field of health research and so has a substantial influence on health research in general.
Moreover, while SDH-Net materials and tools primarily addressed SDH fields, they could be successfully transferred and implemented into other areas of health research.
Impact on South-North-South and South-South collaborations
The SDH-Net is an interesting and valuable project not only due to the work carried out and products elaborated, but also because its partnership design represents a beneficial research collaboration. South-North-
South and South-South collaborations were embedded into the SDH-Net design, and therefore the project experience provides valuable insights into how to better organise and coordinate multi-vectored partnerships.
The SDH-Net partners have good connections and networks in their respective countries and regions; the joint SDH-Net assisted in strengthening South-South and South-North cooperation in SDH research. The experiences of partners from three different continents were complementary and interdisciplinary; the assessment of the existing networks in phase 1 provided important insights for the second phase of the project, but was also a good basis for further collaborative activities. Strategic networks were identified and strategies towards strengthening the exchange with the respective networks were developed.
During the project activities, all consortium partners were involved in active and dynamic collaboration with institutions from three different continents, which undoubtedly improved their understanding of South-North-South and South-South collaborations. Moreover, the experience of participation in such a project provides a good basis for future, similar collaborations for professionals directly involved in the project, as well as for their institutions. Ultimately, the SDH-Net project reinforced and strengthened existing health research networks between the three continents of Africa, South America and Europe, as well establishing new connections between institutions and networks nationally, regionally and globally.
The SDH-Net project explicitly demonstrates how the establishment of multidisciplinary and multi-institutional South-North-South collaborations can help to overcome a lack of adequate resources, opportunities and infrastructure needed to conduct quality SDH research in LMIC, by building and strengthening local collaborative networks. Through this process, Northern and Southern partners can establish fresh perspectives of each other, creating synergies and collaborative innovations in SDH training.
South-North-South and South-South collaborations can also assist in forging sustainable links between different SDH stakeholders – researchers from various disciplines, decision makers, funding agencies and groups from other sectors within society such as non-governmental organisations; once established, these links can help to build sustainable capacity for conducting and managing interdisciplinary SDH research, in both HIC and LMIC settings. This, in turn, can increase national autonomy by stimulating scientific excellence and relevance (in SDH and health equity) that support the establishment of research priorities according to local needs.
Impact on SDH-related policies
One of the last work packages had a particular focus on bringing together all evidence and knowledge produced under the project to formulate policy recommendations on SDH research. This particular task synthesised the lessons learned during the project and translated them into recommendations at policy level and for consideration by other stakeholders (grant makers, future researcher projects, governments, etc.).
Currently, research and researchers are an essential part of evidence for policy making and the implementation of regulations based on factors that have been identified by research as increasing inclusion and equity. Therefore, an essential component of SDH-Net was to make the research a constructive element of policy building. In this regard, a number of international agencies (e.g. WHO, PAHO) were put to fruition.
Additionally, the SDH-Net directly addressed the challenge of research results communication to policy makers via specifically developed in the course and workshops SDH Research Communication. It is expected that these educational tools will bring forward the current state of communication between SDH researchers and policy makers, enabling more efficient and productive conveyance of research results and researchers’ recommendations to those who make final decisions on policy development. Ultimately, that would lead to the enhancement of existing SDH-related policies and regulations in LMIC.
Impact on health care systems
This project demonstrated that health research represents one of the many necessary components contributing to the improvement of health systems and health of the population. In fact, SDH research does not only lead to specific scientific results and impacts, it has further functions. According to Pang et al., health research actually has four main functions: the production and utilisation of research, stewardship, research financing, and, the creation and sustaining of resources . More precisely, there is a general consensus amongst health experts that the benefits from health research can go far beyond scientific results, and can be exploited to improve health system performance, health itself and health equity in particular.
One of the goals of SDH research is to identify current urgent health needs of populations that would serve as essential evidence in defining national and regional priorities on the health agenda. It is also expected that improved SDH research capacity would have a positive impact on the distribution of resources, leading to the enhanced cost effectiveness of health systems.
EU Global health agenda
From its initial stage, SDH-Net was designed (and subsequently funded by the European Commission) to contribute towards improving SDH evidence in respective countries and regions, enhance Europe’s role in global health and positively contribute to the EU Global Health Agenda. The EU Global Health Agenda defined four approaches for enhancing global health: establish a more democratic and coordinated global governance (1); push for a collective effort to promote universal health coverage and access to health services for all (2); ensure better coherence between EU policies relating to health (3); improve coordination of EU research on global health and boost access in developing countries to new knowledge and treatments (4). The SDH-Net project has a particular impact on the fourth approach, the increase of global health knowledge, ensuring the research and innovation produces accessible and affordable products and services. Throughout the duration of the project, regular links and updates were made on policy developments on the European and global health agenda. The SDH-Net project and insights gained are expected to have a substantial impact on future global SDH and research capacity building policies.
Impact on WHO Health in All Policies
A few years ago, WHO launched a Health in All Policies (HiAP) that is an “approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies and avoids harmful health impacts, in order to improve population health and health equity. It emphasises the consequences of public policies on health determinants, and aims to improve the accountability of policy makers for health impacts at all levels of policy-making” .
The SDH-Net project was linked with WHO Health in all policy (HiAP) activities and a few SDH-Net members are part of the HiAP global networks. Regional trainings (ToT: “Training the Trainers”) on SDH research (described in detail under the results sections) were organised based on the collaboration with HiAP network; SDH-Net partners from Latin America and Africa were involved in these training activities.
Impact on global SDH actions
The WHO Commission on Social Determinants of Health (CSDH) published a report in 2008 called “Closing the Gap in a Generation” that become the first global comprehensive overview of the current SDH situation around the globe. The report is also a main document in the field of SDH that defines crucial aspects and challenges needing to be addressed in order to eliminate health inequities. The CSDH final report identified that the majority of the SDH research was conducted in HIC and less so in LMIC , therefore SDH-Net’s focus on LMIC settings is important in strengthening global SDH action and evidence. The report also highlighted the fact that health inequalities exist between and within all countries, hence a global work on this issue is needed to effectively respond this challenge.
The CSDH report revealed that there is “an urgent need to develop, among other things, a virtual repository of teaching and training materials on a broad range of social determinants of health that can be downloaded without cost. Furthermore, opportunities for interdisciplinary professional training and research on social determinants of health are needed” . The SDH-Net project, by its design and the products developed, has directly addressed this call for action by providing a free access to all the materials and hosting a repository that aims to stimulate interdisciplinary professional training.
The existence of social determinants of health involves many different stakeholders at different levels, and, above all, across borders . SDHs fall into distinct jurisdictions and require joint actions. The increase in research capacity and networking that has been addressed in SDH-Net will lead to better knowledge and evidence on SDH on a global level, and will contribute to a better understanding of the global implications on health, and how governments and national stakeholders as well as the European Union and other donors can best respond to these challenges.
Impact on health inequalities and inequities
The WHO has defined the decrease of inequalities in health among socioeconomic groups as one of the main objectives of each member state . Woodward and Kawachi have discussed the reasons why health inequalities attributable to social, economic and cultural factors should be reduced. In particular, their main arguments were: health inequalities are often unfair, and, therefore, are not acceptable; inequalities affect everyone in a population; inequalities are avoidable, thus measures to reduce inequalities should be employed; interventions to reduce health inequalities are often cost-effective . Altogether, there is a substantial body of evidence supporting the existence of health inequalities and inequities as well as the necessity of reducing them, and of adopting approaches to overcome them. Nevertheless, inequalities in health are the reality for most countries in the world, so there is a demand for research, policy development and interventions in this sphere.
The SDH-Net project focused on an increased SDH research capacity and sensitivity towards social determinant issues within health research that would lead to improved quality of research in SDH, fostering the elaboration of more and higher quality evidence in SDH. It is expected that all these efforts would ultimately lead to better health policies at national and regional level, which should have a positive effect on the improved health status of the population in the participating countries and regions, and the elimination of existing inequities in health.
MAIN DISSEMINATION ACTIVITIES AND EXPLOITATION OF FOREGROUND
Dissemination activities
Dissemination activities were an important task for SDH-Net, with the main purpose of effectively bringing policy makers, stakeholders and research networks to the research undertaken alongside the project. The dissemination strategy aimed at determining the target groups for different results and the most adequate dissemination methods: publications, face-to-face and electronic dissemination. The main dissemination tools included the constant running of a project website, the creation of the dissemination plan and calendar, production of appropriate dissemination materials, organisation workshops and seminars as well the final conference. The underlying aim of the SDH-Net dissemination activities was to create public awareness and scientific interest in the project and its results, as well as to translate research into policy recommendations that would adapt suitable language for policy makers as well as guide the development of ideas for future research activities.
Communication strategy and communication of project results
A communication strategy of SDH-Net was elaborated at the start of the project, more specifically the objectives of the strategy were to (i) inform the target publics about the project evolution and outputs, aligned with global and local research and policy advancements of the SDH approach to tackle health inequities; (ii) contribute to the development of the communication capacities and infrastructure of the SDH-Net partners as a critical component of the SDH research advancement; (iii) contribute towards strengthening the network and knowledge sharing modus operandi among members through the development of an up-to-date informed and learning environment. Accordingly, both internal communication mechanisms as well as external communication and primarily dissemination strategies were defined.
Project website and blog
A project website was set up and can be accessed under: www.sdh-net.eu.
In line with the strategies described in the Communication Strategy and following the Communication Guidelines developed, project results as well as other SDH-Net related content has been published on the SDH-Net blog (http://www.sdh-net.eu/blog-news/) as part of the SDH-Net website. In this regard, the SDH-Net website was designed to serve as a vehicle for communicating SDH-Net news and information (NEWS section), sharing key background documents as well as SDH-Net publications (LIBRARY section) and introducing the project and consortium partners to the general public (CONSORTIUM section). Furthermore, a communication schedule was defined, specifying the deadlines for providing input to the website and providing all partners with the blog post format. This helped maintain a healthy regional and institutional balance on the blog/website and supported the partners in scheduling their input.
Project results were further published in the SDH-Net newsletter, which was based on blog posts developed by SDH-Net project partners.
Results and publications
The communication of project results in peer-reviewed scientific journals has been an essential project activity. In this regard, the following number of articles, book chapters and books were published by SDH-Net partners on SDH-Net-related issues, in an effort to enhance the communication of project results in peer-reviewed scientific journals and foster collaborations between SDH-Net consortium partners.
An important effort was made by SDH-Net partners to prepare a number of publications under the special section of the International Journal for Equity in Health (IJEH). Currently three papers of SDH-Net partners are under revision and hopefully will be published shortly, in particular:
1. Strengthening national capacities for research on social determinants of health (SDH) towards informing and addressing health inequities in Tanzania - IHI
2. Measuring health inequities in low- and middle-income countries: Towards the development of an observatory on inequities and social determinants of health in Mexico - INSP/FIOCRUZ
3. Social determinants of health research capacity building initiative; the dovetail experience with the Kenyan health care system - UON
More detailed information about the publications produced by SDH-Net partnership can be found in table A1 (under section A).
Participation in dissemination events
Active participation in dissemination events (e.g. conferences, meetings, congresses) was one of the crucial dissemination activities of the SDH-Net project. The partners have presented, discussed and validated the SDH-Net findings and products at national, regional and global events. More detailed information about the conferences where SDH-Net results were presented can be found in table A2 (under section A).
Main project seminars and conferences
In October (24th-26th) 2013, “Rio + 2: The role of research in taking the Rio Political Declaration forward. Insights from Africa, Europe and Latin America” seminar organised by FIOCRUZ and INSP took place in Rio de Janeiro alongside the SDH-Net third Steering Group Meeting. It provided a platform where strategies to reduce health inequities in African, European and Latin American countries were presented, exploring ways in which the recommendations of the WHO Commission on Social Determinants of Health and the Rio Declaration on SDH have been taken forward. With contributions from several SDH-Net partners, advisory board members, and representatives from FIOCRUZ, the role that SDH research could play in the reduction of health inequities in LMIC was discussed.
In 2014, alongside the fourth SGM in South Africa, an additional “brain-storming policy workshop” was held. It aimed to consolidate activities and concepts developed and piloted in the context of the SDH-Net project into recommendations directed at the policy level that would shape research systems and other relevant actors. Also, during a special Johannesburg Symposium: The Social Determinants of Health – Global and Local Perspectives that was organised by WITS in collaboration with Johannesburg Health District and SDH-Net alongside the fourth SGM, SDH-Net partners (IESE) presented the initial ideas for SDH-Net policy recommendations.
On 27 May 2015 a public final conference Strengthening Capacity for Research, Training, Policy and Action for Equity and Social Determinants of Health was co-hosted between the SDH-Net Consortium and the WHO. The objective of this one-day event was to share WHO and SDH-Net results and products to create synergies with the purpose of developing, expanding and strengthening international collaborative networks for the strategic dissemination, implementation and sustainability of global goods aimed at promoting health equity worldwide. The event marked an important step in SDH-Net dissemination activities and, particularly, in the communication of SDH-Net results, complementing individual partners’ participation in academic conferences detailed above.
Exploitation of the main foreground
The SDH-Net project has produced a number of valuable foregrounds that were and will be actively exploited by all project partners for mainly educational and scientific purposes. The exploitation of the foreground corresponds to the partners’ preliminary intentions towards exploiting the project results in order to support their own activities, as laid down in the initial version of the project’s Description of Work. Among others the following foregrounds will be exploited by SDH-Net partners:
1. “SDH-Net Virtual Learning Platform”
2. Online Repository of SDH-related material
3. Online courses
4. Practice-based courses materials
5. Workshop materials
6. Case Studies
7. Publications
8. Infographics
9. Methodological notes, etc.
Complete and detailed information on the exploitable foreground and SDH-Net partners’ exploitation plans can be found in table B2 (under section B of this report).
List of Websites:
Project website address: www.sdh-net.eu
Name of the scientific representative of the project's co-ordinators:
Dr. Johanna Offe, GIZ – technical coordinator
E-mail: johanna.offe@giz.de
Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH
Köthener Str.2
D-10963 Berlin
Germany
Tel: +49 30 408190389
Fax: +49 30 408190 22 389
Dr Magdalene Rosenmöller, IESE – Scientific Coordinator
Email: magda@iese.edu
IESE Business School, University of Navarra
Av. Pearson, 21
08034, Barcelona
Spain
Tel. +34 93 253 4200
Fax +34 93 253 4343