Reducing health inequities, defined as the “avoidable inequalities in health between groups of people within countries and between countries” [1] has been an implicit or explicit objective of health policy in many countries and international organizations for decades [2, 3]. And yet, health inequities between and within countries are stubbornly persistent [4].
Health inequities
Three measures are commonly used to describe health inequities: health disadvantages, i.e., inequalities between segments of populations or between societies; health gaps, i.e., inequalities between the worse–off and everyone else; and health gradients, i.e., inequalities across the whole spectrum of the population [5]. Recently, the work of the members of Commission of Social Determinants of Health (CSDH) of the World Health Organization (WHO) has shed a fresh light on the causes of health inequities and how best to address their reduction. In 2008, the Commission’s final report [4] provided ample evidence that the most powerful drivers of health and health inequities are the social conditions in which people are born, live, work and age and the health systems that are put in place, referred to collectively as the social determinants of health (SDH), and that these SDH are, in turn, influenced by “upstream” structural drivers: the nature and degree of social stratification in society as well as society’s norms and values, global and national economic and social policies, and national and local governance processes. The CSDH developed a number of conceptual frameworks that describe pathways by which these determinants can lead to health inequities [4–10]. Based on the accumulated evidence, the Commission made three major recommendations for actions that will be needed to reduce health inequities: 1) improve living conditions; 2) tackle the inequitable distribution of money, power and recourses that people need to lead a healthy life. The third overarching recommendation was the need to expand the knowledge base on the social determinants of health, to evaluate the action taken, and critically, to develop a workforce that is trained in identifying SDH. Many governments and international organizations have endorsed these recommendations [11].
The United Nations launched the Millennium Development Goals (MDG) in 2000 with a focus on improving the situation of the world poorest countries and reducing health inequities [12]. Recent statistics on the health-related MDGs, however, confirm the earlier findings from the CSDH [13, 14]. That is, even though low and middle income countries (LMIC) have made remarkable progress on a number of health-related MDG indicators (e.g. the reduction of under- five-mortality and the incidence of TB and Malaria), it is apparent that significant inequities persist between the world’s most advantaged and least advantaged countries and between populations within countries. Indeed, many low income countries will not be able to meet the MDG health objectives by the target date in 2015. Much remains to be done in the post-2015 period, particularly in the lowest income countries of sub-Saharan Africa and South Asia, and in those affected by conflict or high rates of HIV [13]. Based on the recommendations from the “global consultation on health in the post-2015 agenda”, it is to be expected that there will be a greater focus on the reduction of health inequities and SDH in the post-2015 development framework [15, 16].
To be able to address these issues through national or regional policies and programs, policy makers and other stakeholders will need setting-specific, timely, and relevant evidence on the relationship between health inequalities, SDH and health outcomes. Yet, this type of evidence is not readily available in LMIC’s in Africa and Asia. Research on the socio-economic drivers of health inequalities is an emerging field in these countries [17–19], and training possibilities for SDH research are limited [20]. Thus, there is a need for the development of capacity-building activities to enable such research [3, 20].
INTREC
The INTREC project (INDEPTH Training and Research Centres of Excellence) was established with this concern in mind. The details of INTREC are described elsewhere (http://www.intrec.info). Briefly, the project is conducted by a six-institution consortium, with four partners from the “North” (Umeå University in Sweden; Heidelberg University in Germany; the University of Amsterdam in the Netherlands; and Harvard University in the USA) and two from the “South” (Gadjah Mada University in Indonesia and INDEPTH, the International Network for the Demographic Evaluation of Populations and Their Health in Low- and Middle-Income Countries). With its Secretariat in Accra, Ghana, INDEPTH is an expanding global network, currently with 52 Health and Demographic Surveillance Systems (HDSSs) field sites in 20 countries in Africa, Asia, and Oceania [21], (http://www.indepth-network.org).
INTREC aims to develop and provide a SDH-related training program for INDEPTH researchers, thereby allowing them to generate new country-specific evidence on associations between SDH and health outcomes. The training program also seeks to provide researchers with skills for making the research findings available to relevant decision makers in their countries. The INTREC training program is set within INDEPTH’s larger capacity building program, and training activities will be coordinated by two regional Centres, one in Africa (Ghana) and one in Asia (Indonesia), to facilitate South-South and North–South collaboration in SDH training and research.
In the initial phase, INTREC activities are focusing on INDEPTH researchers from four African countries (Ghana, Tanzania, and South Africa and Kenya) and four Asian countries (Indonesia, India, Vietnam, and Bangladesh). If the initial program is successful, training activities will be expanded to researchers from INDEPTH surveillance sites in other countries.
Training needs
The target group for the INTREC training consists of professional researchers, each with their own specific background, experience, practice and work setting (HDSS) and culture. In recent years, several conceptual and methodological frameworks for assessing health inequalities and SDH were published [4–9, 11, 22–24]. These frameworks provide clear ideas about what an informed SDH-researcher may need to know and, consequently, what they should be taught. However, the literature on continued public health and medical education [24, 25], and adult learning [26] has noted that, in order to be effective, continued professional education must be relevant to the specific learning needs of the professionals and particularly to their current work situation.
With the overall purpose to develop a needs-based training program, we conducted an explorative study to identify what health and demographic researchers from INTREC's eight target countries feel that they need to learn in order to be able to conduct research on the causes of health inequalities in their own country. We used a bottom-up research methodology, “concept mapping”, that allowed participants to provide their own ideas about topics they deemed relevant for training and to mention as many ideas as they wished.