Global Health Impact Report 2021

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A Global Snapshot

Where We Work

During the period analyzed (2020-2021), the following countries received the highest overall amount of funding from the reported projects:

What We Work On

In terms of priorities, the global health issues with the most fund allocations between 2010 and 2021 were:

Who We Work With

From a subset of projects reporting population data³, projects are reaching or planning to reach at least:

³ Direct population sample size: 520 projects with a total reach of 1.802,507,875 people. Indirect population sample size: 146 projects with a total reach of 196,894,132 people. Please note: projects include information on population reached (achieved or expected), including the direct population served as well as the indirect population reached if applicable. The figures given here reflect the sum of all numbers available in the Project Explorer, irrespective of project budget, area of focus, and population details.

⁴Population numbers reflect figures as reported from contributing organizations. Contributors are given guidelines to ensure reporting consistency and to avoid double-counting.

From those projects that shared data on target population by age and gender⁵,

⁵ Sample Size with target population age and gender reported: 502 projects

From those projects that shared data on target population by other population descriptors⁶

⁶ Sample Size with target population descriptors: 245 projects

Data Spotlight: Sexual and Reproductive Health & Rights

In 2017, the Government of Canada made a significant investment in sexual and reproductive health and rights (SRHR) by committing $650M over three years (2017-2020). The CanWaCH Project Explorer database contains a comprehensive list of the projects funded under the investment.

At a glance: SRHR

Projects were implemented across 56 countries, and led by 68 unique partners:

Investment in the Neglected Areas of SRHR

Based on a review of project information, we have concluded that data remains limited in terms of the scale and impact of projects which specifically address frequently neglected areas of SRHR; namely:

• Adolescent SRHR (including comprehensive sexuality education)
• Comprehensive Contraceptive Care
• Safe and Legal Abortion
• Support for Advocacy relating to SRHR

As a result of dedicated data collection efforts earlier this year, CanWaCH collected programmatic data on the neglected areas of SRHR directly from Canadian-based and global civil society organizations funded under the Global Affairs Canada investment in order to estimate the extent to which the neglected areas are currently addressed. Between July-August 2020, CanWaCH implemented a ‘data drive’ to gather detailed data on programming in the neglected areas of SRHR.  A custom data collection form, using CanWaCH’s Project Explorer standard data fields as a basis, was developed and sent to 33 Canadian-based and global civil society organizations funded under the $650M SRHR funding envelope. These organizations were identified using the available published list of projects provided by Global Affairs Canada, as well as CanWaCH’s existing database.

Overview of CanWaCH Analysis

Population Reach: Respondents reported reaching a total of 19,049,882 people (directly and indirectly) across 30 projects with Adolescent SRHR having the highest reach and Support for Advocacy having the lowest reach.

Population Groups: Adults and adolescents were cited as the main population groups targeted by these projects. Overall, more adult females and adolescent girls were reported as target demographics; however, men and adolescent boys were cited across all neglected areas as also being targeted through activities. Adolescent girls were not reported to be one of the main target groups for Comprehensive Contraceptive Care or Safe and Legal Abortion.

Outputs: The top three outputs the most commonly cited with the most reach were (in order):

1. People trained: examples include health service providers, teachers, peer educators, personnel/staff, government officials, and community members
2. Awareness campaigns: examples include outreach activities and learning events conducted, and people reached through these events.
3. SRHR services provided: examples include adolescent girls and young women linked to referral services, including family planning, contraceptives, post-abortion care, and sexual and gender-based violence
4. Indicators: The most common of the standard SRHR KPI indicators measured were related to Adolescent SRHR while the least common were related to Safe and Legal Abortion.

CanWaCH is very pleased by the decision this year by Global Affairs Canada to establish three Canada-specific data tracking codes relating to SRHR:

• 13011: SRHR Advocacy and Reform
• 13012:  Comprehensive Sexuality Education
• 13021: Safe Abortion Services and Post-abortion care

The addition of these codes, combined with the uses of the ‘adolescent policy marker’ will significantly improve future analyses in SRHR data, and we look forward to revising the above analysis in future based on these codes.

Emerging Data: Humanitarian Initiatives

CanWaCH’s Project Explorer has begun to capture more humanitarian initiatives as part of our commitment to better understanding investments in this area. To date, the Project Explorer features a sample of over 144 projects with a focus on Humanitarian Response (2010-present). Total combined funding amount for all projects with a focus on humanitarian response $732,476,548. Data in this area must be interpreted carefully, and it should not be considered representative of the entirety of Canadian investments in humanitarian action.

Where We Work: Humanitarian

50 Countries with projects with a focus on Humanitarian Response:

Who We Work With: Humanitarian

From a subset of projects reporting population data⁷, the initiatives reported reaching at least:

⁷ Sample size of projects: 66 projects

Total population reach:

Reporting Organizations: Humanitarian

43 Reporting Organizations have shared that they have worked or are currently working on Canadian humanitarian projects.

Emerging Data: Domestic Efforts

The Project Explorer captures global health and gender equality efforts around the world, but also within Canada. An increasing number of Canadian actors in the global health and rights sectors are scaling up domestic engagement, and accordingly, we have seen more reports of Canadian-based work in our Project Explorer than ever before. For the first time, our sector will be able to capture and share the full spectrum of organizational efforts in Canada to advance gender equality and social justice.

For our part, the Equal Futures Network is a CanWaCH initiative that seeks to connect national, regional, community and grassroots organizations, agencies and projects from across Canada that are committed to advancing gender equality. It provides a platform for diverse partnerships and collaboration in order to drive progress in achieving gender equality and empowerment.

As of this report, there are 407 Canadian organizations in our database with development initiatives across Canada, including 390 who are part of the Equal Futures Network.

What We Work On: Domestic Efforts

Who We Work With: Canadian Efforts

Reporting Organizations: Canadian Engagement

Context

Between 2016 and 2018, CanWaCH listened to and consulted with our sector through a variety of methods to pinpoint obstacles to our collective success in achieving the targets laid out in the SDGs. What we heard:

1. Data and data collection gaps – areas where data is lacking or remains difficult to collect and analyze – persist, particularly with regard to fragile contexts, marginalized communities, and outcome-level measurement.
2. Where data and data collection resources exist, they may be inaccessible or go unused for a variety of reasons, leading to duplication, lack of uptake by communities, inefficient programming, and other issues.
3. Perceived capacity to implement existing solutions or adopt explicitly feminist approaches remains limited for many Canadian actors, particularly in the above contexts. Specifically, lack of resources, skills, and meaningful linkages with other stakeholders repeatedly emerged as obstacles.

In response, CanWaCH launched the inaugural Canadian Collaborative for Global Health (the ‘Collaborative’) in 2018 with support from Global Affairs Canada. Through a competitive call for proposals, CanWaCH received 44 applications (38 in English, 6 in French) for this inaugural competition, representing 160 unique Canadian and global partners.

The Collaborative had three core objectives:

1. Investigate the underlying barriers to effective data progress in areas of global health and gender equality: undertake rigorous research on the data challenge which the Lab seeks to address, including documenting existing approaches, to fully situate, support, and assess the proposed solution.
2. Incubate useful solutions and effective partnerships to address these challenges: produce and pilot solutions to address the identified data gaps, leveraging interdisciplinary partnerships.
3. Inspire and train the next generation of Canadian leadership in global health and gender equality metrics: develop the means by which data professionals and practitioners can learn about and be trained in the use of the solution(s) and its implications for their work.

As a result of the Collaborative, three key outcomes were expected from each Lab:

1. Improved understanding of barriers affecting data collection, analysis, utilization, and communication.
2. Increased availability of solution(s) and quality partnerships to inform programing, planning, and learning.
3. Enhanced capacity of future researchers, civil society professions, and in-country leaders to collect, analyze, communicate, and use data effectively.

2018-2021: By the Numbers

Ultimately, six projects were selected for the inaugural initiative. Projects were co-led by 17 Canadian organizations and institutions, along with dozens of global partners including NGOs, global academia, and multilateral organizations.

Canadian Partners

Other Partners

100% of projects reached both adult women and men (18+ years) through their work. In addition, projects reached:

Lab 1: Adolescent sexual and reproductive health and rights: Generating evidence and strengthening country capacity

Challenge

Sexual and reproductive health and rights (SRHR) are a priority area in global health and development efforts. Understanding how gender and other inequities impact SRHR, and specifically adolescent sexual and reproductive health (ASRHR), is crucial to developing programs and meeting the global goals. Challenges to the generation and use of ASRHR data include the sensitive nature of the topic, leading to questions about the data’s accuracy as well as how data is analyzed and communicated. National policy makers, researchers, NGOs and SRHR practitioners, among others, need data in order to build evidence on interventions and better understand ASRHR.

Key Issues:

• Missing Data: Data on the youngest adolescent age-cohorts are lacking. The reporting of sensitive events that are critical to measuring ASRHR and gender-related indicators (e.g. sexual behaviour, substance abuse, abortion and violence against women) are not captured because of low reporting.
• Weak Evidence to Action: Knowledge generation and use of evidence on ASRHR and related gender issues are weak and are not being harnessed effectively.
• Analytical Capacity: Institutional capacity in-country is often inadequate for effective analysis and communication of ASRHR data. Available ASRHR and related gender data through surveys are poorly harnessed by policy makers, program staff and project managers.
• Reliability in Data: Available ASRHR data are ignored due to low confidence in research quality across data collection methods – varied among self-reports in surveys, health facility data or qualitative studies.

Select Results

This project addressed some of the challenges inherent in the measurement and monitoring of ASRHR and related gender indicators in sub-Saharan Africa by developing novel mixed-methods research approaches for better measurement of ASRHR and coverage and gaps in services for adolescents. While partners collaborated with researchers from 10 countries in Sub-Saharan Africa, the in-depth work took place in Tanzania.

Use of existing data sources

Existing national surveys, such as the Demographic and Health Surveys (DHS) or other population level-data, can provide data that are of higher quality and widely available for a number of ASRHR indicators. Given that multiple time points are available (typically in four-year intervals) the data can also be used to assess trends in these indicators over time. A technical workshop was organized in Addis Ababa, Ethiopia in June 2019 to explore the potential for further ASRHR analyses of existing datasets. It was concluded that it is possible to obtain detailed and robust information on inequalities with national surveys even though sampling errors are larger with increased disaggregation, for instance, triple disaggregation with regards to inequities or moving beyond provincial or regional estimates to district level.

Collecting quantitative survey data with ACASI

Two surveys were conducted: an ASRHR survey using an Audio Computer-Assisted Self-Interview (ACASI) method, and a face-to-face survey with all women of reproductive age (WRA) living in Kisesa that included questions pertaining to women’s experience with the COVID-19 pandemic. The survey was developed based on a review of the available evidence base, identifying the key dimensions and indicators of ASRHR and selecting questions from existing, validated instruments and indicators typically required by funders or governments. The survey approached two strategies for addressing responses to sensitive questions. First, the survey was programmed on tablets and accompanied by an audio track digitally recorded into an ACASI program. Secondly, indirect questioning was used on best friend reporting on sensitive topics (e.g., whether their best friend engaged in the particular behaviour) and community prevalence (how many peers out of 10 they think engaged in this behaviour) were compared to self-report.

The COVID-19 pandemic prompted greater interest in the use of an ACASI approach as it reduces in-person contact and the technology used can be sanitized between respondents. Results based on data collected with the ACASI method was similar to that collected previously during face-to-face interviews in the SRH survey. Adolescent participants reported enjoying their use of the technology, potentially engaging more with the survey as a result, and having greater confidence in the confidentiality of their responses than during face-to-face interviews.

Vignettes

Vignettes were incorporated that explored gender attitudes, puberty, pregnancy and abortion attitudes and knowledge. The vignettes offer a wealth of information since questions can be looked at individually for gender non-conforming behaviour, for instance, but the existing scoring rubric also creates opportunities for easily characterizing responses at the level of gender attitudes and norms.
Adapted from the Global Early Adolescent study, the vignettes explored gender dynamics, gender in relationships and adolescent pregnancy and could be scored along a continuum to categorize responses. The results from the vignettes portray gender divisions along expected lines with girls expressing a more passive approach to relationships while boys were seen as the assertive protagonists, which has implications for gender-based and sexual violence messaging. Girls also had higher scores related to responsibility and acceptance of pregnancy than boys, underscoring that girls are disproportionately affected by the outcomes of pregnancy or abortion. There was also more discussion of the acceptability of abortion as an option in pregnancy than was found in other survey questions.

Household survey on maternal, perinatal and child mortality and service utilization

Due to COVID-19, funds were redirected to conduct a community-based survey. The face-to-face survey was conducted in Kisesa focusing on key indicators of reproductive, maternal, newborn, child, adolescent health and nutrition, with a modified instrument based on the DHS questionnaires. Being able to ask targeted questions about COVID-19 is a great example of a situation in which a local survey can be useful and necessary– to provide information on an emerging topic or an event of significance to SRHR but not included in national surveys. Overall, the partners’ experience highlights that it is possible to collect high-quality data with local surveys, though it is resource intensive.

Facility survey

The data collection strategy for the facility survey had two components. The first component was a questionnaire, adapted from the WHO’s Service Availability and Readiness Assessment (SARA) tool with an additional section on gender-based violence, adapted from an existing JHPIEGO instrument. Secondly, facility records were collected from September 1, 2018 to August 31, 2020. Although the facility survey is labour intensive and time consuming, it provides valuable information on the availability of services and drugs, as well as potential barriers to accessing services. In the review of registry data, adolescents (15-19) represented 38.9% of all cases of gender-based violence, 12.1% of all cases of STIs, and 16.9% of the recorded obstetric and gynecological cases, including antenatal care (12.7%) and delivery (12.1%). Inpatient records also show that complications of abortion contributed to adolescent hospital admissions.

Collecting qualitative data: Peer research

Specific ASRHR and gender transformative indicators, particularly at the immediate level, are best addressed by in-depth qualitative data. Therefore, partners designed and tested a peer research approach based on peer ethnography. This approach offers many advantages in terms of staffing as it needs fewer research assistants (RAs) than a survey and few technology needs, both of which reduce cost. It is also more flexible as peer researchers can have discussions with their friends at times and places not necessarily accessible to researchers. The approach allowed adolescents greater involvement in the data collection process while maintaining the focus on the research objectives. To facilitate rapid data collection, peer researchers worked one-on-one with trained, same-sex RAs over a specified period of time. The thematic analyses helped identify adolescents’ primary concerns pertaining to SRH, proposed strategies for engaging adolescents in health services and programs and identifying locations adolescents frequent and where they could be approached for participation in research or programs. The focus on “how” can also contribute to monitoring and process evaluation, by illuminating the ways in which adolescents interact with interventions. In the interviews with RAs, peer researchers mentioned feeling more confident discussing difficult topics with peers.

Key Partners

• Countdown to 2030, University of Manitoba
• Plan International Canada
• Africa Population & Health Research Centre
• National Institute for Medical Research

For resources and more information on this Lab, click here.

Lab 2: Harmonized Health Impact & Partnership Metrics to Accelerate Knowledge Sharing and Utilization

Challenge

Better creation, sharing and use of knowledge among all stakeholders are fundamental to addressing challenges affecting women, adolescents and children’s health (WACH). In order to reduce duplication, maximize functionality, and benefit civil society and academic collaborators, research partnerships must be carefully monitored and evaluated with an equity lens that considers the context of resource disparity. The use of tools developed for this purpose remains voluntary and there is no tracking mechanism in place to systematically collect and analyze data associated with the partnership process.

Key Issues:

• Knowledge exchange isolated and scattered: Effective and timely sharing of knowledge acquired by Canadian global health organizations with their global partners would reduce duplication of efforts and provide clearer research gaps for more efficient channeling of research funds.
• Data rich, exchange poor: A more comprehensive and integrated approach in traditionally siloed anglophone and francophone research communities is needed to foster collaboration and support real time informing of best WACH practices.
• Equity-level partnerships need data: Equity-centred partnerships hold greater potential for health impact and local development of capacity, yet outcome-level data for these partnerships from a Canadian WACH research investment are not available.

Results

Three bilingual tools were developed to address different needs.

Key Partners

• Canadian Coalition for Global Health Research
• McGill University
• HealthBridge Foundation of Canada
• Université Laval & Regroupement stratégique en santé mondiale of the Réseau de recherche en santé des populations du Québec

For resources and more information on this Lab, click here.

Lab 3: Collecting Data on Sexual & Reproductive Health (SRH) in Humanitarian Settings

Challenge

Currently, the global forcibly displaced population exceeds 65 million people, with one in four being a woman or girl of reproductive age. Women and girls are at serious risk of death or disability due to SRH complications, including: unsafe abortion, a major contributor to maternal death and disability in humanitarian contexts; forced marriage; and, sexual violence. They are also at an elevated risk of acquiring HIV and other sexually transmitted infections. The lack of data on SRH in humanitarian settings is a critical global issue. This data problem presents challenges for effective resource allocation and timely service delivery, thereby impacting the health outcomes of extraordinarily vulnerable populations.

Key Issues:

• Data gaps: Consistent, reliable and rigorously collected data on SRH in humanitarian settings is sparse across the globe. This gap is even more pronounced when the SRH issue is politicized, such as with abortion data.
• Low data quality: The limited data that is available is often inconsistent, producing highly variable content and quality. Limited data and its poor availability also complicates the measurement of the impact of interventions, including life-saving interventions such as abortion, that take place during emergencies.
• Missing or inaccessible data: Currently, it is unclear what happens to SRH data that is collected in conflict settings, and whether the data is being used or can be used to benefit current or future humanitarian programming efforts.

Results

Key Partners

• University of Ottawa
• National Abortion Federation Canada
• Inter-Agency Working Group on Reproductive Health in Crises (IAWG)
• World Health Organization, Department of Reproductive Health Research

For resources and more information on this Lab, click here.

Lab 4: Maximizing use of existing data to strengthen program design, evaluation & impact

Challenge

National and international non-government and civil society organizations spend substantial time and resources collecting data in order to design and monitor their health interventions. However, estimates of numerous health and social indicators in many countries already exist in publicly available datasets, such as the Demographic and Health Surveys (DHS) and the Multiple Indicator Cluster Surveys (MICS). DHS and MICS provide standardized data collected using rigorous methods, well-trained enumerators, and large sample sizes. Among the challenges of using publicly available data to assess baseline conditions is that they are rarely designed to be representative of district and village contexts, where non-governmental organizations (NGOs) are often working. In addition, DHS and MICS are collected every three to ten years so there may be a gap between when data was collected and current baseline conditions.

Key Issues:

• Responsive to context: Adequate assessment of baseline conditions is especially important to ensure interventions respond to the varying health needs within populations and promote equitable policies.
• Increased data use: Utilizing publicly available data to meet baseline data needs can, in turn, increase the use and quality of publicly available data (collected regularly) to better inform program design, implementation, evaluation and learning.
• Data-informed decision-making: Maximizing the use of available data strengthens the capacity of researchers, NGOs and in-country leaders to collect, analyze, and inform programmatic decisions.

Results

Key Partners

• HealthBridge Foundation of Canada
• Université de Montréal
• Centre for Creative Initiatives in Health and Population
• International Nepal Fellowship

For resources and more information on this Lab, click here.

Lab 5: Improving gender equality and nutrition data for women, children and adolescent girls

Challenge

Good nutrition and gender equality are mutually reinforcing: improving nutrition is critical to achieving gender equality, and vice versa. Empowerment of women and girls is identified as an important nutrition-sensitive strategy to address malnutrition in low- and middle-income countries. However, there is no established measurement framework to assess how nutrition and empowerment interacts and affects diverse communities and across nutrition interventions. These data problems prevent us from fully understanding the influence that empowerment has on women and adolescent girl’s nutritional status.

Key Issues:

• Research gaps: There are gaps in the relevant literature on empowerment and its effects on girls’ nutrition. Currently, no existing studies have focused on or even included unmarried and/or adolescent women.
• Lack of data and tools: Indicators of gender equality may only be collected in national surveys, such as Demographic and Health Surveys (DHS), which occur infrequently and may only collect data on women 15-49 years. This lack of consistent data does not support individual program interventions and course corrections.
• Lacking indicators: Lacking indicators on the interaction between nutrition programs and gender equality, and methods to frequently measure these indicators for program design, prevents programming from being responsive.

Results

The project undertook research into gender equality and women’s empowerment (GEWE) links to nutrition status and potential indicators that could be measured to identify whether the most GEWE-vulnerable beneficiaries are being reached through gender-sensitive nutrition programs, and eventually whether gender-transformative nutrition programs are having a positive impact on beneficiary’s GEWE status.

The project also led updates to the Nutritional Intervention Monitoring System (NIMS) toolkit. This included research identifying best-fit-for-purpose rapid assessment tools and survey designs monitoring needs. This is specific toward assessing the most appropriate program specific surveillance tools with monitoring indicators and context-specific indicators that could be collected across each project lifecycle.

Positive feedback from survey teams and country-level project officers indicated that the outputs from this collaboration strengthened the harmonized NIMS toolkit, reduced the workload during tool development and mapping of indicators to questions, made data quality metrics clear and transparent, and filled a critical need for evidence-based gender equity and women’s empowerment (GEWE) indicators in program surveys – beyond the classic ‘sex disaggregation’ of data.

Key Partners

• University of Toronto
• Nutrition International
• Campbell Collaboration

For resources and more information on this Lab, click here.

Lab 6: Improving the Measurement of Sexual and Reproductive Health and Rights, Women’s Empowerment and Gender Equality in Humanitarian Settings

Challenge

Health program delivery and its measurement in conflict-affected and humanitarian settings is difficult to assess to ensure accountability. There is a minimum set of process measures but they are of unverified quality, especially depending on the type of conflict. Access for data collection to most affected populations is complicated due to ongoing security issues, which often disrupt routine data collection. Logistical and monetary costs of traditional data collection methodologies can significantly increase due to the added security costs, communications challenges and increased costs of human resources in humanitarian and conflict-affected settings. To streamline data collection and measurement processes, simpler approaches to valid and reliable gender-relevant analyses need to be identified.

Key Issues:

• Data Uptake: Identifying data practices, best data sources, and tools for planning will avoid duplication, reduce waste, and increase uptake of the information at early stages of developmental assistance, including investment planning stages.
• Strengthen Data Capacity: Standardize and simplify stakeholders’ capacity, including the next generation, in order to: select indicators; collect data; analyze data; communicate situation analysis and progress using strategic indicators; and, use data and indicators effectively.
• Expanding Health: Gender-relevant outcomes are influenced by a complex web of actors and issues that stretch beyond the health sector. Exploring indicators from multiple sources of data that are not traditionally assessed by the health sector can facilitate complementary gender equality change affecting the social determinants of health (e.g. education).

Results

Key Partners

• SickKids Centre for Global Child Health
• Canadian Red Cross

For resources and more information on this Lab, click here.