[Health] equity is one of the biggest concerns today

By Dr. Devaki Nambiar

Published on January 18th , 2018

Dr. Devaki Nambiar joined The George Institute for Global Health India in November 2017 as Program Head – Health Systems and Equity. She has a doctorate in public health from Johns Hopkins University and has over a decade of research experience in over half a dozen countries and as many Indian states.

Devaki is interested in social and political determinants of health and health reform in resource-poor settings. A former Fulbright scholar, she has received awards from the US National Institutes of Health, the Wellcome Trust/Department of Biotechnology India Alliance, Canada’s International Development Research Centre, as well as a number of international and national research agencies. She advises the work of the World Health Organisation on health inequality monitoring and supports policymaking in India on Universal Health Coverage and urban health reform, as well as non-communicable disease (NCD) service delivery as part of comprehensive primary health care

Below is a special interview with Dr Nambiar about her work, experiences and future focus on health equity.

Where did you grow up? Why did you take up public health and choose to specialise in health systems/equity research? An event/incident/anecdote that marked your journey?

I grew up traveling around the world in a diplomat family. I had always been interested in how diverse the world is, and yet, at the same time, there are some basic entitlements, rights and aspirations we all share. In college, I majored in Biological Sciences, with a High Honours thesis in Anthropology and training in International Relations as well. A friend later told me that this combination is public health - the first I learned of the field. Its interdisciplinarity, the emphasis on wellbeing and historical connection to social justice were a big draw to me. As for research, seeing things from the perspective of others - of walking a mile in their shoes - was   something that was taught to me by my parents. I found that research is in fact a way of doing this, with rigour and an ultimate aim to improve the circumstances of those who lend us their time (and shoes!).

Wanting to have rigour in my approach, I turned to research and in the course of my public health doctorate at Johns Hopkins, had the benefit of exposure to global health research through a Fulbright scholarship in India and a National Institutes of Health (NIH) Fogarty fellowship in Tanzania. Staying on the NIH track in my post-doctoral days, I also had the opportunity to partner closely with government agencies for the first time in Vietnam – a transformational experience.

As an Overseas Citizen of India, my desire to carry out policy-relevant research in the country of my parents’ origin came at the behest of PHFI’s President, Dr. K. Srinath Reddy, in 2011, when I left my NIH fellowship to be part of the technical secretariat of India’s High-Level Expert Group on Universal Health Coverage. Being based out of India since then, I have developed a robust track record of health systems research in many low and middle-income countries and a half a dozen Indian states, with a particular emphasis on the themes of equity, social inclusion, and health reform.

What is your motivation behind joining The George Institute?

The George Institute, takes a global, collaborative approach while also seeking to embed itself in different country contexts. In particular, I like that the organisation is small while also being highly collaborative. I think this is a strong way of doing public health, especially in countries like India and China, where scales of work are large. Just because one is dealing with big countries and large populations does not mean that one has oneself to be a large, hulking organisation.

What were the initial challenges you faced in working on health equity research programs in India?

I saw two challenges. First, from the perspective of decision-makers, health equity is often seen as a luxury or after-thought in programming as well as research. In the research domain, health equity is a niche area with a great deal of emphasis on metrics or conceptual frameworks and not quite as much an emphasis on linking to implementation or policy. These two challenges reinforce each other and serve to make equity research interesting conceptually but disconnected from praxis, which somewhat flies in the face of the notion of equity itself! Equity research, to be ethical, has to be concerned with making the situation of others equitable. More has to be done in this area.

How far do you think the institute has come in the past 10 years in making a difference to public health in India?

I think the institute has built a reputation for cutting edge, rigorous public health research with policy relevance. It has strong and enduring partnerships and an appreciable line up of publications. Expectations may be rising of the organisation, and it is time to start to rise to the opportunities and challenges this brings!

How do you think a global health equity research program would help the Institute?

Equity is one of the biggest concerns today, globally, and is manifest as vast disparities in health -related circumstances and outcomes across population subgroups. It is at the heart of the Sustainable Development Goals agenda as well as the health-related goal. The Institute has been working on equity as a component of many of its projects and having established itself and its networks, is now in a position to foreground equity concerns in the conduct and translation of research. Keeping a central focus on equity helps make the George more connected to a fundamental concern in the world today and marshall its technical expertise in a critical domain in health reform. It enables the George to be more relevant, applied and enhance its impact in both research and policy worlds.

What should be the Institute’s future goals?

1.         Convening and participation in trans-disciplinary partnerships and regional consortia

2.         Demonstrable impact on policy, particularly related to NCDs and health equity (with a focus on gender)

3.         Methodological innovation, both assessing health interventions and translating them into programmes (here, the emphasis would be on appropriate use of technology)

If you could please provide some insight into your area of expertise –health systems and equity research – in the Indian context.

I have served as a technical expert to health reform efforts not just in India, but also as part of many multi-national partnerships including WHO’s global work on health equity.

I am now looking to play a leadership role in creating a Health Equity Action Lab (HEAL) at the George Institute, drawing and expanding upon my existing grants and collaborations. The goal of HEAL shall be to develop tools for action by decision-makers to enhance the equity orientation of health programmes and reform. I propose that there should be an emphasis on:

a) non-communicable diseases,

b) gender and health (looking both at women and girls’ health as well as women health workers); and

c) the appropriate use of technology in developing these tools in concert with decision-makers.

I have been supporting the work of the WHO in bringing out a national State of Inequality report in Indonesia using the upload version of software we have developed – the Health Equity Assessment Toolkit (HEAT). This has been part of extensive regional capacity-building I have supported for WHO member states in four of the five WHO regions. Member states have underscored the importance of national/subnational equity analysis; I would like to support the production of such reports for India and China at the national and subnational scale going forward, incorporating qualitative data on priority populations using the methodology I am currently employing in my urban health study and the Wellcome Trust/DBT India Alliance grant. Further, along with my mentor and collaborator at WHO, I am keen to expand the scope of HEAT to carry out gender-specific analyses in line with the Sustainable Development Goals, as well as national priorities in three to five target countries.

This was first published at The George Institute for Global Health India website and is being republished with due permission.