RESEARCH FOR UNIVERSAL HEALTH COVERAGE
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- Title
- RESEARCH FOR UNIVERSAL HEALTH COVERAGE
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The World Health Report 2013
Research for Universal
Health Coverage
i
V
World Health
Organization
Research for universal health coverage
the process of doing research and presenting and sharing the findings of research
studies. Such data would help in tracking progress towards universal health cover
age, country by country.
Monitoring supports the second function, coordination, on various levels - by
sharing information, by jointly setting research priorities, or by facilitating col
laboration on research projects.
Regarding the third function, financing, health research is more effective and
productive if there is a guaranteed, regular income. Sustained financing guarantees
that research projects are not interrupted or otherwise compromised by a sudden
lack of resources. Various mechanisms for raising and disbursing additional
research funds have been proposed and arc under discussion. Whatever mecha
nism is adopted, international donors and national governments should measure
progress against their own commitments to investing in health research.
V
How wiii WHO support research for
universai health coverage?
Chapter 5 draws out the dominant themes of the report, and proposes a set of
actions by which the research community, national governments, donors, civil
society and international organizations, including WHO, can support the research
that is needed if we are to reach universal health coverage.
Although the debate about universal health coverage has added to the vocabu
lary of public health in recent years, “to promote and conduct research in the field
of health” has always been central to WHO’s goal of achieving “the highest attain
able standard of health”. Chapter 5 briefly explains how WHO plays a role in both
doing and supporting research through the Organization’s Strategy on Research
for Health. This report is closely aligned with the aims of the WHO strategy, which
encourages the highest-quality research in order to deliver the greatest health ben
efits to the maximum number of people.
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xvi
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"Universal health coverage is the single most powerful concept
that public health has to offer"
Dr Margaret Chan, Address to the Sixty-fifth
World Health Assembly, May 2012
(
"Another lesson is the importance oj long-term investment in
the research institutions that generate evidence for policy ..."
Lancet, 2012,380:1259,
on the approach to universal health coverage in Mexico
ill
Message from the Director-General
As we approach the 2015 deadline for meeting the United Nations Millennium
Development Goals (MDGs), it is time to take stock of the progress that has been
made since 2000. It is also time to reflect on how we made progress, and on how we
could do better.
All eight of the MDGs have conse
quences for health, but three put health
at front and centre - they concern
child health (MDG 4), maternal health
'■&Si
(MDG 5), and the control of HIV/AIDS,
malaria, tuberculosis and other major
communicable diseases (MDG 6). To
highlight just one of these, MDG 4 calls
for a reduction in the number of child
deaths from 12 million in 1990 to fewer
than 4 million by 2015. Although great
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strides have been taken since the turn of
the millennium, especially in reducing
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deaths after the neonatal period, the best
measurements indicate that nearly 7 mil
lion children under five years of age died in 2011. Prom experience in high-income
countries, we know that almost all of these deaths can be prevented. But how can that
be done everywhere?
One idea is to make greater use of community-based interventions. But do they
work? Experiments in the form of randomized controlled trials provide the most per
suasive evidence for action in public health. By 2010, 18 such trials in Africa, Asia and
Europe had shown that the participation of outreach workers, lay health workers, com
munity midwives, community and village health workers, and trained birth attend
ants collectively reduced neonatal deaths by an average of 24%, stillbirths.by 16% and
perinatal mortality by 20%. Maternal illness was also reduced by a quarter (/). Tliese
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Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention i.ji kaqes for reducing maternal and
neonatal morbidity and mortality and improving neonatal uuu uiin-, ■ jd-ii-iine Database of Systematic
Reviews (Online), 2Q1Q,11:CD0Q7754.1^10:2100909/
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trials clearly do not give all the answers - for instance, the benefits of these interven
tions in reducing maternal mortality, as distinct from morbidity, are still unclear - but
they are a powerful argument for involving community health workers in the care of
mothers and newborn children.
These rigorous investigations have the potential to benefit millions around the
world. They confront the challenge presented by just one ot the MDGs, but they cap
ture the general spirit of this report - to promote investigations in which creativity is
harnessed by the highest-quality science in order to deliver affordable, quality health
services and better health for everyone. More than that, the process of discovery is 'a
source of inspiration and motivation, stirring ambitions to defeat the biggest problems
in public health. This is the purpose of Research for universal health coverage.
This report is for everyone concerned with understanding how to reach the goal
of universal health coverage - those who fund the necessary research, those who do
research and who would like to do research, and those who use the evidence from
research. It shows how research for health in general underpins research for universal
health coverage in particular.
Understanding how to make progress towards achieving the MDGs is central to
this report. But its scope is wider. As the 2015 deadline draws closer, we are looking for
ways to improve all aspects of health, working within and beyond the MDG framework.
And we are investigating how better health can contribute to the larger goal of human
development. In this broad context, I invite you to read Research for universal health
coverage. I invite you to assess the report’s arguments, review its evidence, and help
support the research that will bring us closer to the goal of universal health coverage.
I
Dr Margaret Chan
Director-General
World Health Organization
)
V
o
Contents
Message from the Director-General
iv
Executive summary
xi
1. The role of research for universal health coverage
5
Developing the concept of universal health coverage
6
Investigating financial risk protection
11
Investigating the coverage of health services
15
Equity and universal health coverage
19
Coverage of health service'-: quality as well as quantity
20
Conclusions: research needed for universal health coverage
21
2. The growth of research for universal health coverage
31
Creativity everywhere
35
Research ascending
35
Growing unevenly
42
The value of health research
46
Conclusions: building on the foundations
47
3. How research contributes to universal health coverage
Case-study 1
<
57
61
Insecticide-treated mosquito nets to reduce childhood mortality
Case-study 2
63
Antiretroviral therapy to prevent sexual transmission of HIV
Case-study 3
65
Zinc supplements to reduce pneumonia and diarrhoea in young children
vii
I
Case-study 4
67
Telemedicine to improve the quality of paediatric care
Case-study 5
69
New diagnostics for tuberculosis
Case-study 6
71
The "polypill" to reduce deaths from cardiovascular disease
Case-study 7
73
Combination treatment with sodium stibogluconate (SSG) and paromomycin
compared to SSG monotherapy for visceral leishmaniasis
Case-study 8
75
Task shifting in the scale-up of interventions to improve child survival
Case-study 9
77
Improving access to emergency obstetric cam
Case-study 10
79
Conditional cash transfers to improve the use of health services and
health outcomes
Case-study 11
81
Insurance in the provision of accessible and affordable health services
Case-study 12
Affordable health care in ageing populations
82
.
Conclusions: general lessons drawn from specific examples
4. Building research systems for universal health coverage
84
95
Setting research priorities
96
Strengthening research capacity
98
A framework for strengthening capacity
99
Creating and retaining a skilled research workforce
103
Ensuring transparency and accountability in research funding
105
Building research institutionsand networks
107
Defining and implementing norms and standards
110
Ethics and ethical review
• Reporting and sharing research data, tools and materials
110
110
Registering clinical trials
110
Using evidence to develop policy, practice and products
113
viii
t
Translating evidence into policy and practice
113
Monitoring and coordinating iesearch, nationally and internationally
116
Financing research for universal health coverage
117
National and international governance of health research
118
Conclusions: building effective research systems
118
5. Action on research for universal health coverage
129
Research - essential for universal coverage and a source of inspiration
for public health
129
Defining and measuring progress towards universal health coverage
131
The path to universal health coverage, and the path to better health
132
Research for universal health coverage in every country
133
Supporting the people who do research
134
Translating research evidence into health policy and practice
135
Supporting research for universal health coverage, nationally
and internationally
136
WHO's role in research for universal health coverage
137
Index
139
*
ix
Executive summary
Three key messages from The world health report
" Universal health coverage, with full access to high-quality services for health promotion,
prevention, treatment, rehabilitation, palliation and financial risk protection, cannot be
achieved without evidence from research. Research has the power to address a wide
range of questions about how we can reach universal coverage, providing answers to
improve human health, well-being and development.
” All nations should be producers of research as well as consumers. The creativity and
skills of researchers should be used to strengthen investigations not only in academic
centres but also in public health programmes, close to the supply of and demand for.
health services.
■ Research for universal health coverage requires national and international backing. To
make the best use of limited resources, systems are needed to develop national research
agendas, to raise funds, to strengthen research capacity, and to make appropriate and
effective use of research findings.
Why umversaS health coverage?
(
In 2005, all WHO Member States made the commitment to achieve universal
health coverage. Tine commitment was a collective expression of the belief that
all people should have access to the health services they need without risk of
financial ruin or impoverishment. Working towards universal health coverage is
a powerful mechanism for achieving better health and well-being, and for pro
moting human development.
Chapter 1 explains how the resolution adopted by all WHO Member States
embraces the two facets of universal health coverage: the provision of, and access
to, high-quality health services; and financial risk protection for people who need
to use these services. “Health services” in this report mean methods for promo
tion, prevention, treatment, rehabilitation and palliation, encompassing health
care in communities, health centres and hospitals. The term includes ways of
taking action on social and environmental determinants both within and beyond
the health sector. Financial risk protection is part of the package of measures that
provides overall social protection.
xi
t
Research for universal health coverage
Why research?
Scientific research has been fundamental to the improvement of human health.
Research is vital in developing the technology, systems and services needed to achieve
universal health coverage. On the road to universal coverage, taking a methodical
approach to formulating and answering questions is not a luxury but a necessity.
When WHO Member States made the pledge to achieve universal coverage
they took a significant step forward for public health. As described in Chapter 1,
taking that step effectively launched an agenda for research. In this report, research
is the set of formal methods that turns promising ideas into practical solutions for
improving health services, and consequently for improving health. The goal of the
report is to identify the research questions that open the way to universal health
coverage and to discuss how these questions can be answered.
Many recent advances have been made in health service coverage and in finan
cial risk protection as shown, for example, by progress towards the United Nations
Millennium Development Goals (MDGs). Despite this progress, the gap between
the present coverage of health services and universal health coverage remains large
for many conditions of ill-health in many settings. For instance, nearly half of all
HIV-infected people eligible for antiretroviral therapy were still not receiving it n
2011, and an estimated 150 million people suffer financial catastrophe each year
because they have to pay cash out-of-pocket for the health care they need. The
focus of this report is on the research needed to provide wider access to essential
services of this kind, and how to create the environment in which this research c; n
be carried out.
What questions need to be answered by research?
Chapter 1 identifies research questions of two kinds, 'lhe causes of ill-health differ
from one setting to another and so too must the necessary health services, includ
ing mechanisms for financial risk protection. The first group of questions therefore
asks how to choose the health services needed in each setting, how to improve
service coverage and financial protection, and consequently how to protect ai d
improve health and well-being.
These questions throw up a wide range of topics for research. Research is needed
to find out how to improve the coverage of existing interventions and how to select
and introduce new ones. Research must explore the development and use of both
“software” (such as schemes for financial protection and simplified approaches o
treatment) and “hardware” (research and development for commodities and tech
nology). And research is needed to investigate ways of improving health fro n
within and outside the health sector.
'flie most pressing research questions have been identified for many specific
health topics, such as maternal and child health, communicable diseases, and
health systems and services. Although there are notable exceptions, less effort has
xii
t
Executive summary
generally been given worldwide to establishing and publicizing national research
priorities, to assessing the strengths and weaknesses of national research pro
grammes, and to evaluating the health, social and economic benefits of research.
Hie second group of questions asks how to measure progress towards univer
sal coverage in each setting for each population, in terms of the services that are
i ceded and the indicators and data that measure the coverage of these services.
Hie answer to this group of questions is a measure of the gap between the present
coverage of services and universal coverage. Hie challenge for research is to fill
that gap.
Many specific indicators, targets and data sources are already used to measure
the coverage of specific health interventions. Hie metrics used to monitor progress
towards the MDGs track, for example, access to antiretroviral therapy, births attended
by skilled health personnel, and immunization coverage. However, the measurement
of other aspects ofcoverage needs further development; interventions to prevent and
control noncommunicable diseases, or to track healthy ageing, are two examples.
It is not usually possible to measure the coverage of the hundreds of interven
tions and services that make up a national health system. However, it is possible to
ihouse a subset of services, with their associated indicators, that are representative
of the overall quantity, quality, equity and financing of services. Then a practical
definition of universal health coverage is that all persons who are eligible have
access to the services they need. To choose the essential health services that should
be monitored, and a set of indicators to track progress towards universal coverage,
is a research task for health programmes in each country. Out of these investiga
tions will emerge a common set of indicators that can be used to measure and
compare progress towards universal health coverage across all countries.
With its focus on research, the goal of this report is not to measure definitively
the gap between the present coverage of health services and universal coverage but,
instead, to identify the questions that arise as we move towards universal coverage
and to discuss how these questions can be answered.
Should all countries have the capacity to do research?
Hie results of some research studies are widely applicable, but many questions
about universal health coverage require local answers. All countries therefore need
to be producers of research as well as consumers of it. An abundance of data,
presented in Chapter 2, shows that most low- and middle-income countries now
have, at least, the foundations on which to build effective national health research
systems. Some countries have much more than the foundations; they have thriving
research communities with a growing number of “south-south” as well as “north
south” international links. By strengthening these systems, countries will be able
Io capitalize more effectively on the supply of ideas, using formal research methods
(o turn them into useful products and strategies for better health.
xiii
Research for universal health coverage
Which kinds of research studies have shown
how to improve the coverage of health
services and how to improve health?
The case for investing in research is made, in part, by demonstrating that scientif c
investigations really do produce results that can be translated into accessible and
affordable health services that provide benefits for health. Chapter 3 presents 12
examples of studies that show how research can address some of the major ques
tions about achieving universal health coverage, and can deliver results that have
influenced, or could influence, policy and health outcomes.
Three examples make the point. In one, a systematic review of survey data
from 22 African countries showed how the use of insecticide-treated mosquito nets
was associated with fewer malaria infections and lower mortality in young chil
dren. This evidence underlines the value of scaling up and maintaining coverage of
insecticide-treated nets in malaria-endemic areas. In a second set of experimental
trials in Ethiopia, Kenya, Sudan and Uganda, a combination of the drugs sodium
stibogluconate and paromomycin was found to be an effective treatment for visceral
leishmaniasis. Treatment with the drug combination is shorter than with sodium
stibogluconate alone and.is less likely to lead to drug resistance. On the basis of these
findings, WHO recommended the drug combination as a first-line treatment for vis
ceral leishmaniasis in East Africa. A third systematic review of evidence from Brazil,
Colombia, Honduras, Malawi, Mexico and Nicaragua showed how conditional cash
transfers - cash payments made in return for using health services - encourage the
use of these services and lead to better health outcomes.
The successes of these investigations, and the others described in Chapter 3,
should be a stimulus to invest in further research. Not all investigations will find
that ideas for improving health services are successful, or that the provision of new
services actually improves health. In mapping the route to universal coverage, the
negative results of research studies are just as valuable as the positive ones.
Which research methods are used to answer
questions about universal health coverage?
'fhe examples described in Chapter 3 expose the diversity of questions about uni
versal health coverage, and also the variety of research methods used to investiga e
them. Methods include quantitative and qualitative evaluations, observational and
case-control studies, intervention studies, randomized controlled trials, and sys
tematic reviews and meta-analyses. 'The report shows the benefits of having evidence
from multiple sources, explores the link between experimental design and strength
of inference, and highlights the compromises in study design (better evidence is
often more costly, but not always) that must be made by all investigators. rTlie survey
xiv
Executive summary
of research methods reveals the nature of the research cycle, where questions lead
io answers that lead to yet more questions. The chapter illustrates some of the ways
in which research is linked with health policy and practice.
What can be done to strengthen national
wealth research systems?
Research is likely to be most productive when it is conducted within a supportive
national research system. Chapter 4 is an introduction to the essential functions
of national health research systems, namely: to set research priorities, to develop
research capacity, to define norms and standards for research, and to translate
evidence into practice.
Standard methods have been developed to set research priorities. These meth
ods should be used more widely by governments to set national priorities across all
aspects of health and to determine how best to spend limited funds on research.
With regard to strengthening capacity, effective research needs transparent and
accountable methods lor allocating funds, in addition to well-equipped research
institutions and networks. However, it is the people who do research - with their
curiosity, imagination, motivation, technical skills, experience and connections that are most critical to the success of the research enterprise.
Codes of practice, which are the cornerstone of any research system, are already
in use in many countries. The task ahead is to ensure that such codes of practice are
i omprehensive and apply in all countries, and to encourage adherence everywhere.
Achieving universal health coverage depends on research ranging from studies
of causation to studies of how health systems function. However, because many
existing cost-effective interventions are not widely used, there is a particular need
Io close the gap between existing knowledge and action. Areas of research that need
special attention concern the implementation of new and existing technologies,
health service operations, and the design of effective health systems. To help bridge
the gap between science and practice, research should be strengthened not only in
academic centres but also in public health programmes, close to the supply of and
demand for health services.
How can research for universal health coverage
be supported nationally and internationally?
In the wake of many previous reports, Chapter 4 presents three mechanisms to
stimulate and facilitate research for universal health coverage - monitoring, coor
dination and financing. Provided there is a commitment to share data, national
; nd global observatories could be established to monitor research activities.
Observatories could serve a variety ol functions, acting as repositories of data on
XV
r
2
Research for universal health coverage
the process of doing research and presenting and sharing the findings of research
studies. Such data would help in tracking progress towards universal health cover
age, country by country.
Monitoring supports the second function, coordination, on various levels - by
sharing information, by jointly setting research priorities, or by facilitating col
laboration on research projects.
Regarding the third function, financing, health research is more effective and
productive if there is a guaranteed, regular income. Sustained financing guarantees
that research projects are not interrupted or otherwise compromised by a sudden
lack of resources. Various mechanisms for raising and disbursing additional
research funds have been proposed and are under discussion. Whatever mechknism is adopted, international donors and national governments should measure
progress against their own commitments to investing in health research.
How will WHO support research for
universal health coverage?
Chapter 5 draws out the dominant themes of the report, and proposes a set of
actions by which the research community, national governments, donors, civil
society and international organizations, including WHO, can support the research
that is needed if we are to reach universal health coverage.
Although the debate about universal health coverage has added to the vocabu
lary of public health in recent years, “to promote and conduct research in the field
of health” has always been central to WHO’s goal of achieving “the highest attain
able standard of health”. Chapter 5 briefly explains how WHO plays a role in both
doing and supporting research through the Organization’s Strategy on Research
for Health. This report is closely aligned with the aims of the WHO strategy, which
encourages the highest-quality research in order to deliver the greatest health ben
efits to the maximum number of people.
xvi
"I
Chapter 1
The role of research for
universal health coverage
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Chapter 1
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Key points
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Developing the concept of
universal health coverage
6
Investigating financial
risk protection
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Investigating the coverage of
health services
15
EAuity ancl universal health coverage
19
Coverage of health services:
quality as well as quantity
20
Conclusions: research needed for
universal health coverage
21
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A field worker interviewing a young child near Bala Kot, Pakistan (WHO).
' 4«
Key points
H
The goal of universal health coverage is to ensure that all people obtain the health
services they need - prevention, promotion, treatment, rehabilitation and palliation
- without risk of financial ruin or impoverishment, now and in the future.
H
Since 2005, when all WHO Member States made the commitment to universal
health coverage, many advances have been made in the provision of health services
and in financial risk protection. This is illustrated by progress towards the healthrelated Millennium Development Goals (MDGs), and in the widespread fall in cash
payments made for using health services.
JH
Despite this progress, the coverage of health services and financial risk protection
currently fall far short of universal coverage. Thus nearly half of all HIV-infected
people eligible for antiretroviral therapy were still not receiving it in 2011; and an
estimated1 150 million people suffer financial catastrophe each year because they
have to pay out-of-pocket for health services.
)
« The conditions causing ill-health, and the financial capacity to protect people from
ill-health, vary among countries. Consequently, given limited resources, each nation
must determine its own priorities for improving health, the services that are needed,
and the appropriate mechanisms for financial risk protection.
a These observations lead to research questions of two kinds. First, and most
important, are questions about improving health and well-being - questions that
help us to define the interventions and services that are needed, including financial
risk protection, discover how to expand the coverage of these services, including the
reduction of inequities in coverage, and investigate the effects of improved coverage
on health. The second set of questions is about measurement - of the indicators
and data needed to monitor service coverage, financial risk protection, and health
impact. One task for research is to help define a set of common indicators for
comparing progress towards universal coverage across all countries.
Neither of these areas of questioning has permanent answers. Through the cycle of
research - questions yield answers which provoke yet more questions - there will
always be new opportunities to improve health. Today’s targets for universal health
coverage will inevitably be superseded in tomorrow’s world of greater expectations.
I
The role of research for
universal health coverage
The goal of universal health coverage is to ensure that everyone can use the
health services they need without risk of financial ruin or impoverishment (I).
As a descendant of the “Health for All” movement (Box 1.1), universal health
coverage takes a broad view ot the services that are needed for good health and
well-being. 'These services range from clinical care for individual patients to
the public services that protect the health of whole populations. They include
services that come from both within and beyond the health sector. Financial
risk protection is one element in the package of measures that provides overall
social protection (7). And protection against severe financial difficulties in the
event of illness gives the peace of mind that is an integral part of well-being.
To support the goal of universal health coverage is also to express concern for
equity and for honouring everyone’s right to health (8). These are personal and moral
choices regarding the kind of society that people wish to live in, taking universal cov
erage beyond the technicalities of health financing, public health and clinical care.
With a greater understanding of the scope of universal health coverage, many
national governments now view progress towards that goal as a guiding principle
for the development of health systems, and for human development generally. It is
clear that healthier environments mean healthier people (9). Preventive and curative
services protect health and protect incomes (W, 11). Healthy children are better able
to learn, and healthy adults are better able to contribute socially and economically.
The path to universal health coverage has been dubbed “the third global
health transition”, after the demographic and epidemiological transitions (/2).
Universal coverage is now an ambition for all nations at all stages of develop
ment. The timetable and priorities for action clearly differ between countries,
but the higher aim of ensuring that all people can use the health services they
need without risk of financial hardship is the same everywhere.
5
Research for universal health coverage
Box 1.1.
From “Health for All" to universal health coverage
Universal health coverage is an aspiration that underpins "the enjoyment of the highest attainable standard of health"
which, as stated in WHO's constitution, is "one of the fundamental rights of every human being without distinction of
race, religion, political belief, economic or social condition" (2). To reach the highest attainable standard of health is
an objective that has guided health policy nationally and internationally for 65 years, finding voice in WHO's "Health
for All" programme which began in the 1970s and was enshrined in the Alma Ata Declaration of 1978.
The Alma Ata Declaration is best known for promoting primary health care as a means to address the main health
problems in communities, fostering equitable access to promotive, preventive, curative, palliative and rehabilitative
health services.
The idea that everyone should have access to the health services they need underpinned a resolution of the 2005
World Health Assembly, which urged Member States "to plan the transition to universal coverage of their citizens
so as to contribute to meeting the needs of the population for health care and improving its quality, to reducing
poverty, and to attaining internationally agreed development goals" (3).
The central role of primary care within health systems was reiterated in The world health report 2008 which was
devoted to thattopic (4). The world health report 2010 on health systems financing built on this heritage by proposing
that health financing systems - which countries of all income levels constantly seek to modify and adapt - should
be developed with the specific goal of universal health coverage in mind.
The twin goals of ensuring access to health services, plus financial risk protection, were reaffirmed in 2012 by a
resolution of the United Nations General Assembly which promotes universal health coverage, including social
protection and sustainable financing (5). The 2012 resolution goes even further; it highlights the importance of
universal health coverage in reaching the MDGs, in alleviating poverty and in achieving sustainable development
(6). It recognizes, as did the "Health for All" movement and the Alma Ata Declaration, that health depends not only
on having access to medical services and a means of paying for these services, but also on understanding the links
between social factors, the environment, natural disasters and health.
This brief history sets the scene for this report. The world health report 2013: research for universal health coverage
addresses questions about prevention and treatment, about how services can be paid for by individuals and govern
ments, about their impact on the health of populations and the health of individuals, and about how to improve
health through interventions both within and beyond the health sector. Although the focus of universal health cover
age is on interventions whose primary objective is to improve health, interventions in other sectors - agriculture,
education, finance, industry, housing and others - may bring substantial health benefits.
Developing the concept of
universal health coverage
'lhe world health report 2010 represented the
concept of universal health coverage in three
dimensions: the health services that are needed,
the number of people that need them, and the
costs to whoever must pay - users and thirdparty funders (rig 1.1) (7, 13).
The health services include approaches to
prevention, promotion, treatment, rehabilitation
d
and palliative care, and these services must be
sufficient to meet health needs, both in quantity
and in quality. Services must also be prepared for
the unexpected - environmental disasters, chem
ical or nuclear accidents, pandemics, and so on.
'lhe need for financial risk protection is
determined by the proportion of costs that
individuals must themselves cover by making
direct and immediate cash payments/1 Under
universal coverage, there would be no out-ofpocket payments that exceed a given threshold
Indirect costs, due for example to lost earnings, are not considered to be par: of lin.iiicidl risk protection, but are part of th j
larger goal of social protection.
6
Chapter 1
rig. 1.1,
Measuring progress towards
universal health coverage in three
dimensions
Direct costs:
proportion of the
costs covered
I
Include ■
other I
services I
A
Reduce cost-sharing =
I and fees i
Extend to J
wn-coyered'i
...
Current pooled
funds
o ..
~
Population: who is covered?
:
Services:
which services
are covered?
Source: World Health Organization (/) and Busse, Schreydgg
<S/ Gericke (13}.
of affordability - usually set al zero for the poor
est and most disadvantaged people. The total
volume of the large box in
is the cost of
all services for everyone at a particular point
in time (7). The volume of the smaller blue box
siows the health services and costs that are cov
ered from pre-paid, pooled funds. The goal of
universal coverage is for everyone to obtain the
services they need at a cost that is affordable to
t icmselves and to the nation as a whole.
All governments should therefore decide
what, health services are needed, and how to
make sure they are universally available, afford
able, efficient, and of good quality (7^, 75). The
services that are needed differ from one setting
to another because the causes of ill-health also
vary. The balance of services inevitably changes
over time, as new technologies and procedures
emerge as a result of research and innovation,
following the changes in the'eauses of ill health.
In deciding which services to provide, institu
tions such as the National Institute for Health
and Clinical Excellence (NICE) in England
and Wales and the Health Intervention and
Technology Assessment Programme (HITAP)
The role of research for universal health coverage
in Thailand (Box 1.2) have a vital role in evalu
ating whether interventions are effective and
affordable.
In every country, there are people who are
unable to pay directly, out-of-pocket, for the
services they need*, or who may be seriously dis
advantaged by doing so. When people on low
incomes with no financial risk protection fall
ill they face a dilemma: if a local health service
exists, they can decide to use the service and
suffer further impoverishment in paying for it,
or they can decide not to use the service, remain
ill and risk being unable to work (20). The general
solution for achieving wide coverage of financial
risk protection is through various forms of pre
payment for services. Prepayments allow funds
to be pooled so that they can be redistributed to
reduce financial barriers for those who need to
use services they could not otherwise afford. Tliis
spreads the financial risks of ill-health across
whole populations. Prepayment can be derived
from taxation, other government charges or •
health insurance, and usually comes from a mix
ture of sources (7).
Financial risk protection of this kind is an
instrument of social protection applied to health
(7). It works alongside other mechanisms of
social protection - unemployment and sickness
benefits, pensions, child support, housing assis
tance, job-creation schemes, agricultural insur
ance and so on - many of which have indirect
consequences for health.
Governments, especially in low-income
countries, cannot usually raise sufficient funds
by prepayment to eliminate excess out-ofpocket expenditures for all the health services
that people need (7). It is therefore a challenge
to decide how best to support health within
budgetary limits. 1 ig. 1.1 offers three options
for spending: maximize the proportion of the
population covered by existing services, diver
sify health services by offering more types of
intervention, or use the money for financial
compensation, thereby reducing cash payments
for health care.
7
•
Research for universal health coverage
Box 1.2.
How Thailand assesses the costs and benefits of health interventions and
technologies
In 2001 the Government of Thailand introduced universal health coverage financed from general taxation. Economic
recession underlined the need for rigorous evaluation of health technologies that would be eligible for funding in
order to prevent costs from escalating. At the time, no organization had the capacity to carry out the volume of health
technology assessments (HTAs) demanded by the government. Therefore the Health Intervention and Technology
Assessment Programme (HITAP, www.hitap.net) was set up to assess the costs, effectiveness and cost-effectiveness
of health technologies - not only medications and medical procedures but also social interventions, public health
measures and changes to the health system itself (76, 17).
Unlike the National Institute for Health and Clinical Excellence (NICE) in England and Wales, which evaluates existing
interventions only, HITAP does primary research, including observational studies and randomized controlled trials,
as well as systematic reviews and meta-analyses based on secondary literature analysis. Its output takes the form of
formal presentations, discussion with technical and policy forums and academic publications.
One example of HITAP's work is in devising a screening strategy for cervical cancer which is caused by infection with
the human papillomavirus (HPV) and is a major cause of morbidity and mortality among Thai women. Despite the intro
duction of Papanicolaou (Pap) screening at every hospital over 40 years ago, only 5% of women were screened. Visual
inspection of the cervix with the naked eye after application with acetic acid (VIA) was introduced as an alternative in
2001 because it did not require cytologists. When HITAP's study began, both VIA and Pap smears were being offered to
women in parallel and there was pressure from vaccine companies, international health agencies and nongovernmental
organizations (NGOs) to introduce the new HPV vaccine (/S).
The options considered by HITAP were conventional Pap screening, VIA, vaccination or a combination of Pap screening
and VIA. Costs were calculated on the basis of estimated levels of participation and included costs to the health-care
provider, costs for women attending screening and costs for those who were treated for cervical cancer. Potential
benefits were analysed by using a model that estimated the number of women who would go on to develop cervical
cancer in each scenario, and the impact on quality-adjusted life years (QALYs) was calculated by using data from a
cohort of Thai patients.
The study concluded that the most cost-effective strategy was to offer VIA to women every five years between the
ages of 30 and 45, followed by a Pap smear every five years for women aged between 50 and 60 years. The strategy
would offer an additional 0.01 QALYs and a total cost saving of 800 Baht, when compared to doing nothing. Universal
introduction of vaccination for 15-year-old girls without screening would result in a gain of 0.06 QALYs at a cost of 8000
Baht, and either VIA and Pap screening alone would have costs and benefits somewhere between the two amounts (79).
The approach recommended by HITAP was piloted in several provinces starting in 2009, and this has now been imple
mented nationally. The actual impact is currently being assessed.
HITAP attributes its success to several factors:
■
the strong research environment in Thailand which, for instance, provides staff for HITAP and supports peer
review of their recommendations;
collegiate relationships with similar institutions in other countries, such as NICE in England and Wales;
working with peers (HITAP meets with other Asian HTA institutions, and has formed an association with Japan,
Malaysia and the Republic of Korea);
transparency in research methods, so that difficult or unpopular decisions can be understood;
a code of conduct (HITAP adheres to a strict code of behaviour which, for instance, precludes acceptance of
gifts or money from pharmaceutical companies);
political support from government, fostered by opening doors to, and discussing methods with,
decision-makers;
popular support, generated by lectures at universities and dissemination of recommendations to the
general public;
B
8
external review (HITAP commissioned an external review of its methods and work in 2009).
Chapter 1
Fig. 1.2.
The role of research for universal health coverage
A representation of the results chain for universal health coverage, focusing
on the outcomes
Inputs and processes
Outputs
Outcomes
Impact
Health financing
Service access and
readiness, including
medicines
Coverage of
interventions
Improved health status
Health workforce
Medicines, health products ——
and infrastructure
Financial risk
protection
Service quality and safety
Information
Service utilization
Governance and legislation
Financial resources pooled
Risk factor mitigation
Improved financial
well-being
Increased responsiveness
Increased health security
Crisis readiness
■■1"
b)
N )te: Each of these outcomes depend'; on inputs, processes and outputs (to the left), and eventually makes an impact on health
(io the right). Access to financial risk proteciio-. i an also be considered an output. All measurements must reflect not only the
quantity of services, but also quality.and equity of access (first cross panel). Equity of coverage is influenced by "social determi
nants" (second cross panel), so it is vital to measure die spectrum from inputs to impact by income, occupation, disability, etc.
Financial investments are made in medi
cines and other commodities, as well as in infrasiructure, in order to generate the services that
have an impact on health. I
is one way to
portray this chain of events. Consider, for exam
ple, the links between tobacco smoking and
health. The proportion of people who smoke
in a population (outcome), which represents
a risk factor for lung, heart and other diseases
(impact), is affected by various services and poli
cies that prevent ill-health and promote good
health (outputs). Among these services and poli
cies are face-to-face counselling, anti-smoking
campaigns, bans on smoking in public places,
and taxes on tobacco products. The population
coverage achieved by these interventions, which
are often used in combination, influences the
number of smokers in the population (2/).
In fact, the problem of tobacco smoking in
relation to health goes beyond the results chain
i i l ii-: i...... Smoking, like many other risk fac
tors, tends to be more frequent among those who
have had less formal education and who have
lower incomes. When seeking health care for
smoking-related illnesses, people educated to a
higher level are typically more aware of the ser
vices available and more disposed to use them.
These “social determinants”, which influence
prevention and treatment of illness, are a reason
for taking a broad view of research for health;
they highlight the value of combining investiga
tions both within and outside the health sector
with the aim of achieving policies for “heath in
all sectors” (Box 1.3 and Chapter 2).
Even with an understanding of the deter
minants and consequences of service coverage,
the balancing of investments in health services is
more than a technical matter. The allocation of
public money to health also has ethical, moral and
political implications. Public debate, based on evi
dence from research, is the mechanism for obtain
ing consensus on, for instance, who should be
entitled to health care paid from the public purse,
under what conditions, and for what range of ser
vices. Decisions on these issues, which involve a
combination of ethical imperatives and political
9
Research for universal health coverage
Box 1.3.
What do universal health coverage and social protection mean for people affected
by tuberculosis?
Tuberculosis (TB) is a disease of poverty that drives people deeper into poverty (22). In recognition of this fact, TB
diagnosis and treatment are free of charge for patients in most countries. The cost of TB treatment, provided as a
public service, .is covered by domestic health-care budgets, often supplemented by international grants or loans
(23). This helps to reduce the financial barriers to accessing and adhering to treatment. However, free public health
services are often not entirely free, and patients always face other expenses. Payments are made for medical tests,
medicines, consultation fees and transport, and there are indirect costs of illness due to lost earnings.
For patients, therefore, the total cost of an episode of TB is often large in relation to their income (24). The aver
age total cost incurred by TB patients in low- and middle-income countries has been estimated at between 20%
and 40% of annual family income, and the relative cost is higher in the lower socioeconomic groups (25-32). The
poorest patients become indebted: 40-70% of them according to three studies carried out in Africa and Asia (26,
28, 29). A large part of the cost ofTB treatment is incurred during the diagnostic phase before treatment starts in
a subsidized TB programme. Costs are especially high for diagnosis and treatment by private doctors, with whom
many of the very poorest seek care first (28,29,33,34). Financial costs are commonly compounded by adverse social
consequences - such as rejection by family and friends, divorce, expulsion from school and loss of employment which affect women in particular (35—37).
The research behind these findings has been essential for documenting the obstacles to the use of health services
and the financial vulnerability of families affected by TB. It has helped to pinpoint where improved services, health
insurance coverage and social protection can safeguard against the consequences of potentially fatal and financially
catastrophic illness (38).
To estimate patients' costs and identify barriers to access, WHO and partners have developed a toolkit which has
recently been field-tested in surveys in several countries. The results have begun to inform national policy on social
protection for people with TB (39, 40). Beyond free diagnosis and treatment, a full package of measures for social
protection requires the following:
b
Universal health care, free of cost, or heavily subsidized. People do not enter the health-care system as TB
patients eligible for free treatment; they typically enter as patients with a respiratory illness. The journey to
correct diagnosis and the start of treatment often takes weeks or months. Out-of-pocket expenses need to be
minimized across the health system (23).
°
Specific social or financial risk protection schemes, compensating for the adverse financial or social
effects of TB. For example, these may include travel vouchers, food packages, or cash transfers, as well as
psychosocial support.
»
Legislation to protect workers, ensuring that people with TB are not expelled from employment due to a
disease that is normally rendered non-infectious after two weeks of correct treatment, and from which most
patients fully recover.
Sickness insurance, compensating income loss during illness.
Instruments to protect human rights, minimizing stigma and discrimination, with special attention to
gender, ethnicity and protection of the vulnerable groups that are at particularly high risk of TB.
*
“
"
Whole-of-government approaches to address social determinants of health, and policies based on
"heath in all sectors", taking a broad view of the drivers ofTB epidemics (Chapter 2). Poverty-reduction strate
gies and financial safety nets help prevent TB on many levels. Most important for TB prevention are good
living and working condition’s and good nutrition. Basic education supports universal health coverage by
enabling healthy lifestyle choices and informing health-care decisions.
continues ...
10
Chapter 1
The role of research for universal health coverage
. . continued
None of the above is specific to TB, but TB control programmes are among those affected by the presence or absence
of health services and mechanisms for social protection. While disease-specific solutions can help partly and tempo
rarily, universal health coverage, including social protection, is vital for sustained and effective TB control. Disease
control programmes need to ensure that the patients they serve are eligible for, and actually receive, support from
the general health services and not only from TB control programmes.
TB has close links with poverty and social vulnerability, and is one of the conditions that can function as a tracer for
universal coverage. However, national TB control programmes need to add measures of financial risk protection to
existing indicators of service coverage. Among the measurable indicators are the following:
Outcome
-
For coverage of health services: TB diagnosis and treatment coverage (percentage of TB cases receiving
proper care, and percentage successfully treated; see f ig. 1.5) and equity in coverage.
For financial risk protection: Access to financial risk protection schemes (percentage of patients using exist
ing schemes) and equity of access.
Impact
For financial risk protection: Cost of TB illness to patients (percentage with catastrophic expenditure, data
from surveys, using the tool to estimate patients' costs).
Combined for universal coverage, financial risk protection and addressing social determinants: TB
incidence, prevalence and death rates (from programme surveillance data, vital registration and population
based surveys).
possibilities, place constraints on the analysis of
how to maximize health impact for the money
spent.
In summary, the first challenge in moving
towards universal health coverage is to define the
services and supporting policies needed in any
setting, including financial risk protection, the
population that needs to use these services, and
the cost. This requires an understanding of the
causes of ill-health, the possible interventions,
who currently has access to these services and
who does not, and the extent of financial hard
ship incurred by paying out-of-pocket. Acting
on behalf of their populations, governments
must decide how to move closer to universal
coverage with limited financial resources. The
second challenge is to measure progress towards
universal coverage, using valid indicators and
appropriate data. Tlie two challenges go together,
and research provides the evidence to address
them both.
To highlight the role of research, the con
cepts of financial risk protection and health
service coverage are expanded below, and the
strengths and weaknesses of methods for track
ing progress in each area are considered.
investigating financial
risk protection
It is significant that, at a time of widespread
economic austerity, even high-income countries
are struggling to maintain current health ser
vices and to make sure that everyone can afford
to use them (47, 42). The question of how to
11
Research for universal health coverage
provide and maintain financial risk protection
is relevant everywhere.
Access to financial risk protection could
be expressed as the number of people enrolled
in some type of insurance scheme or covered
by a tax-funded health service free at the point
of use (43). In fact, financial risk protection is
often more accurately judged by the adverse
consequences for people who are not protected
(Box I.'). As an example, survey data for 92
countries (inhabited by 89% of the world’s
population) show that the annual incidence of
catastrophic health expenditure is close to zero
in countries with well-established social protec
tion systems, but up to 11% in countries without
such systems. In 37 of the 92 countries surveyed,
the annual incidence of financial catastrophe
exceeded 2%, and in 15 it was above 4%.
An indirect measure of (the lack of) finan
cial risk protection is the ratio of out-of-pocket
payments to total health expenditure (table in
i; :
). In 63 countries, most of them
low-income countries where many people need
financial risk protection, more than 40% of all
health expenditure took the form of direct out-ofpocket payments. At the other end of the scale, in
62 countries less than 20% of health expenditure
was out-of-pocket. Although the majority of the
62 are high-income countries, among them are
Algeria, Bhutan, Cuba, Lesotho and Thailand.
The governments of these countries have shown
how, despite low average incomes, the poorest
people can be protected from having to make
disastrously large cash payments for health.
These surveys are also being used to track the
progress being made in financial risk protection
over time. Between 2005 and 2010 the proportion
of health spending made through out-of-pocket
payments fell, on average, in all but one WHO
region (46). The exception was Africa, where the
level remained stable. Twenty-three countries
across all regions and income levels achieved a
reduction of at least 25% in the proportion of
12
health spending made through out-of-pocket
payments. Nevertheless, an estimated 150 mil
lion people suffered financial catastrophe in
2010, and 100 million people were pushed below
the poverty line (poverty is defined in 1>(>\ I. )
because they had to pay out-of-pocket for health
care (46).
These conclusions derive from two different
ways ol expressing financial risk protection; one
uses a direct measure from primary survey data,
the other uses an indirect measure derived from
two different sets of surveys. Although the indi
cators differ, the results are similar. The data sug
gest, as a rule of thumb, that when out-of-pocket
payments fall to or below 15-20% of total health
expenditure, the incidence of financial catastro
phe will be negligible (47, 48).
While these surveys give useful insights
into financial risk protection, they raise further
questions about the different ideas that underpin
financial risk protection, and about the sources cf
data and methods of measurement. For instance,
should the incidence of catastrophic expenditure
and impoverishment be given equal weight in
describing the extent of financial risk protection
in a country? Is it better to improve financial ris<
protection on average, or to set a minimum level
of protection for everyone? How does financial
risk protection reflect the broader goal of social
protection? What targets or milestones should be
set for measures ol financial risk protection tint I
universal coverage is fully achieved? Which con
ditions of ill-health, perhaps with costly treat
ments, tend to fall outside national financial risk
protection mechanisms and therefore result in
financial impoverishment for households? Do
any of these measures capture the value associ
ated with peace-of-mind - the assurance thi.t
is conferred by accessible, affordable, and rel able health services? These are topics for further
research, and in some cases public debate, on the
mechanisms of financial risk protection, and on
the methods of measurement.
Chapter 1
Box 1.4.
The role of research for universal health coverage
Measuring financial risk protection
The measurement of financial risk protection should ideally capture the number of people enrolled in some kind of
health insurance scheme and the number of people who are eligible to use - and able to afford - health services
provided by government, private sector or civil society.
Direct and indirect indicators of financial risk protection
Explanation
Direct indicators
Incidence of catastrophic health
expenditure due to out-of-pocket
payments
The number of people or the proportion of the population at all income levels
who spend a disproportionate share of their incomes on out-of-pocket pay
ments each year. Financial catastrophe is defined as out-of-pocket expenditure
exceeding 40% of household income net of subsistence needs.
Mean positive overshoot of
catastrophic payments
Incidence of impoverishment due to
out-of-pocket payments
Shows the average amount by which households affected by catastrophic
expenditures pay more than the threshold used to define catastrophic health
spending.
The number of people or proportion of the population pushed below the pov
erty line because of out-of-pocket payments. The poverty line is crossed when
daily income falls below a locally-defined threshold, typically around USS 1 —2 per
day. For people who are living near the poverty threshold, even small payments
push them below the threshold.
Poverty gap due to out-of-pocket
payments
The extent to which out-of-pocket health payments worsen a households'
pre-existing level of poverty.
Indirect indicators
Out-of-pocket payments as a share of
total health expenditure
Government health expenditure as a
share of GDP
There is a high correlation between this indicator and the incidence of financial
catastrophe.
This recognizes that in all countries the poor need to be covered by financial risk
protection from general government revenues; they are rarely all covered when
this proportion is less than 5%.
GDP, gross domestic product; USS, United States dollars.
There are, however, some difficulties in determining who is actually financially protected and to what extent, as two
examples will make clear. First, health insurance as such does not guarantee full financial risk protection. Many forms
of insurance cover only a minimum set of services, so that those insured are still required to make out-of-pocket
payments of different types, including informal cash payments (7). Second, government-financed services may be
inadequate. For instance, they may not be available close to where they are needed, there may be too few health
workers or no medicines, or the services may be perceived to be unsafe. In India, for example, everyone is eligible
to use government health services, but direct out-of-pocket payments are still among the highest in the world (44).
By contrast, it is more straightforward, and often more precise, to measure the consequences for people who do
not have financial risk protection. The table above describes four direct indicators and two indirect indicators of
protection which can be measured by household expenditure surveys that include spending on health, as illustrated
in the main text. The techniques used to measure these indicators are well established as a result of investment in
relevant research, and the survey data are readily available (45). To assess inequalities in financial risk protection, these
indicators can also be measured for different population groups, and can be stratified by income (or'expenditure or
wealth), place of residence, migrant status and so on.
Annual updates on the data and indicators that measure financial risk protection for all countries are reported in
WHO's Global Health Expenditure Database (44).
13
Fig. 1.3.
Out-of-pocket expenditures on health as a percentage of total expenditure on health, 2013
zo
<D
<✓>I'D
CU
zr
c
D,
O
</QJ_»
'S"
zr
a>
o>
WO
V .ff.< -■■■
w-
I2
rt>
. -Expenditure (%)
<20
Gain
i
Note: Based on WHO data February 2013.
Chapter 1
Investigating the coverage
cf health services
which are integrated into health systems; (v) infor
mation systems that produce timely and accurate
data for decision-making; and (vi) health financ
ing systems that raise sufficient funds for health,
provide financial risk protection, and ensure that
funds are used equitably and efficiently.
In outlining the concept of universal cov
erage, fig. 1.1 depicts health services along a
single axis. In reality, there is a diversity of ser
vices delivered on several levels, depending on
the nature of the health condition and the type
of intervention. The elements of each row in
lug. I.'i are the services that are deemed neces
sary. Preventive services (e.g. vaccines) and cura
tive services (e.g. drug treatments) must address
The evolution of thinking on universal health cov
erage has also led to a greater understanding of the
functions that health systems should serve. These
functions should be concerned with prevention as
well as treatment. They should assure: (i) access to
essential medicines and health products; (ii) moti-
vatedandskilled health workers whoareaccessibleto
the people they serve; (iii) integrated, high-quality,
patient-centred services at all levels from primary
to tertiary care; (iv) a combination of priority pro
grammes for health promotion and disease control,
including methods for prevention and treatment,
F g. 1.4.
The role of research for universal health coverage
A framework for measuring and monitoring the coverage of health services
’i!
7
_
PiiriiaF^
(facility)
■ff''
Jiiy.read.nesMuahtMti.^n
HIV, human immunodeficiency virus; MNCH, m-nernd, newborn and child health; NCDs, noncommunicable diseases; IB,
tuberculosis.
Note: "Non-personal" health services arc u- o'; applied either to communities or populations - such as mass health educa
tion, policy development or taxation - or to ; !- or.hum.m components of the environment - such as environmental health
measures. Community-based health services are defined as individual and community health actions delivered in the commun ly (e.g. by community health workers; and noi through health facilities. They are often considered to be part of the primary
h ’alrh care Service.
15
Research for universal health coverage
the principal causes of ill-health now and in the
future (e.g. the causes addressed by MDGs-4-6,
and noncommunicable diseases in low-income
countries). The columns in Fig. i .4 represent the
various levels on which services are delivered: in
the community, to individuals at primary care
centres or at secondary or tertiary hospitals,
and to whole populations (nonpersonal) (49). As
illustrated by its position in big. 1.1, a strong pri
mary care system is central to an effective health
system (4). “Nonpersonal” services are actions
applied either to communities or to populations;
broadly, they are educational, environmental,
public health and policy measures in a range of
sectors that influence health.
The MDGs have been a powerful force both
for better health and for measuring progress
towards better health with precisely-defined
indicators, data collected in standard ways, and
with internationally-agreed targets (46, 50). As
an illustration, Fig. ' • shows some examples of
progress towards MDG 6 (i.e. “to combat HIV/
AIDS, malaria and other diseases”). For HIV/
AIDS, “universal access” to antiretroviral ther
apy is currently defined as treatment of at least
80% of the eligible population. By 2010, 47% of
eligible people were receiving treatment. Thus
the target was missed globally, but national data
show that it was reached in 10 countries, includ
ing some countries with a high prevalence of
HIV, such as Botswana, Namibia and Rwanda.
MDG 7 is concerned with environmental
sustainability. As a contribution to universal
coverage, it includes the target to reduce by half,
between 1990 and 2015, the proportion of people
without access to safe drinking-water and basic
sanitation. Notwithstanding some methodo
logical limitations in measurement, more than
two billion people gained access to improved
drinking-water sources between 1990 and 2010,
including piped supplies and protected wells. The
MDG target was met by 2010, although access to
improved water supplies was generally lower in
rural areas than in urban ones (50, 55).
16
These investigations of progress towards
the MDCj's show, for selected interventions, hoiw
far we are from universal coverage. Ideally, we
should measure the coverage of all the interven
tions that, make up health services, but that is
not usually possible even in high-income coun
tries. In Mexico, for example, 472 interventions
were covered by live separate health protection
mechanisms in 2012, mainly under the health
insurance programme known as Seguro Popular
(Chapter 3, case-study 11) {43). It is feasible,
however, to take a selection of interventions
and indicators, and use them as “tracers” of the
overall progress towards universal coverage. Tlie
interventions selected should be accessible to
everyone who is eligible to receive them under
universal health coverage in any setting.
Whether the tracers actually represent access
to all health services needs to be evaluated, and
this is a task for research. Nevertheless, to illus
trate the idea,
shows how tracers of the
coverage of maternal and child health services,
combined with measures of financial risk pro
tection, give an overview of service coverage in
the Philippines and Ukraine. Tlie two countries
arc similar with respect to the coverage of health
services. The differences are in the incidence of
catastrophic health expenditure and of poverty
due to out-of-pocket payments.
An important function of this kind of anal
ysis is to stimulate national policy dialogues
about why the coverage of certain interventions
is insufficient. For instance, in the comparison
in
, would the addition of other inter
ventions tell a different story about progress
towards universal coverage? Do the indicators af
catastrophic expenditure and poverty represent
aspects of financial risk protection that differ
between the two countries? And there is always
the question: “Are the underlying data accurate?”
'file coverage of services depends on how those
services are provided. The inputs can be investi
gated in addition to, or as a proxy for, direct meas
ures of coverage (
. For instance, WHO
Chapter 1
Fig. 1.5.
The role of research for universal health coverage
Towards universal health coverage: examples of the growing coverage of
interventions for the control of HIV/AIDS, tuberculosis, malaria and neglected tropical
diseases
A. HIV/AIDS: coverage of antiretroviral therapy
50-1
g
O'
cn
S
o
o
B. Tuberculosis: case detection and cure rates
100-t
—
40-
I
■
30-
ft
20-
I
io-
*
g
80-
o
60-
s
20o4_^
0
2003 2004 2005 2006 2007 2008 2009 2010
ART for all eligible
I
I
g
TO-
o
20-
150
3
o
3
I
- 100
i i
H
oH—1 fl
io-
2006
____
2007
2008
\2009
Households with > 11TN
El Suspected cases tested
2002
2004
2006
2008
■
■■
2010
EH Cure
D. Neglected tropical diseases: preventive chemotherapy
200
40-
111 1 I
J: Ii
Case detection
C. Malaria: vector control, diagnosis, treatment
g
2000
ART for PMTCT
50-1
■
40on
n?
r
s
I - a
—• h n i ■
i -Bsaa i
Id l Isa
W
I
W
Isl bl bl11
111-
- 50
0
2010
ACT treatment
courses
g
§
I'D
I
I
I
80 "]
GO
40Fe
E
i
r
20-
j.
0
2005
2006
2007
2008 .
2009
2010
Schistosomiasis
H Lymphatic filariasis
Soil-transmitted helminths
Onchocerciasis
A., f, artemisinin-based combination therapies. AIDS, acquired immunodeficiency syndrome; ART, antiretroviral therapy; HIV,
h jman immunodeficiency virus; ITNJ. msec Ik idc-rreated bed nets; PMTCT, prevention of mother-to-child transmission.
Mote: Between 2003 and 2008, the de;
lor ART coverage was all HIV-infected people with CD4 cell ebunts of < 200
cdls/pL, but in 2009 and 2010 die denom n.ii.j was all people with < 350 CD4 cells/pL Hence the apparent fall in coverage
between 2008 and 2009.
For PMTC1 with ARI, the numerator in 2010 ext ludes treatment with single-dose nevirapine.
I or malaria, data on household coverage wiih IIN and on suspected cases tested are for the WHO African Region. Data on ACT
a e for the whole world.
T le interpretation of universal coverage is 100% coverage for all interventions, except for interim targets of > 80% coverage for ART,
• 90% for the percentage of tuberculosis patients cured, and variable coverage targets for neglected tropical diseases (23,51-53).
R ’produced, by permission of the publisher, horn Dye et al. (54).
17
Research for universal health coverage
Measuring the coverage of health services
Box 1.5.
It is not usually possible to measure all aspects of service coverage even in high-income countries, but it is feasible
to define a set of "tracer" conditions, with associated indicators and targets for interventions, to track progress
towards universal coverage. The choice of tracer conditions and the associated indicators and data, and the work to
demonstrate that these measures are representative and robust, are topics for further research (56).
Using tracers to track progress towards universal coverage in the Philippines and Ukraine
Philippines
Incidence of catastrophic health expenditure
100
80 '
DTP3
immunization
Poverty incidence
due to
out-of-pocket
payments
Ukraine
Incidence of catastrophic health expenditure
.
DTP3
immunization
40
■x.
100 .
xK
60
Poverty incidence
due to
out-of-pocket
payments
40 1
20
■><
a
Births
attended by
skilled health
personnel
Antenatal care (4 visits)
Normalized
poverty gap
due to
out-of-pocket
payments
Normalized
poverty gap
due to
out-of-pocket
payments
Births
attended by
skilled health
personnel
Antenatal care (4 visits)
DTPS, diphtheria-tetanus-pertussis.
As an example, three tracers of the coverage of maternal and child health services, together with three measures of
financial risk protection, give an overview of service coverage in the Philippines and Ukraine (see figure). The three
service coverage indicators are: skilled birth attendants during delivery, three-dose diphtheria-tetanus-pertussis
(DTP3) immunization and four antenatal visits (%). The three indicators of financial risk protection are: incidence
of financial catastrophe due to direct out-of-pocket payments, incidence of impoverishment due to out-of-pocket
payments, and the widening of the poverty gap due to out-of-pocket payments. For impoverishment, the worst
possible outcome was estimated to be 5%, which is higher than measured impoverishment due to out-of-pocket
payments in any country. In the figure, 100% service coverage and financial risk protection lie at the outer edge
of the radar diagram, so a fully-filled polygon represents universal coverage. However, financial risk protection is
measured as the consequences of its absence (Box 1.3), so the percentage scale is reversed for these three indicators.
With respect to the coverage of health services, the Philippines and Ukraine are similar. The differences are in the
incidence of catastrophic health expenditure (higher in the Philippines) and the incidence of poverty due to out-ofpocket payments (higher in Ukraine). These observations, based on this particular set of indicators, raise questions
about how to make further progress towards universal coverage (see main text).
These six tracers could be supplemented with others. For instance, standard indicators of progress exist for HIV/
AIDS, tuberculosis, malaria, and some noncommunicable conditions ( •
) (57). As more indicators are added, the
polygon in the figure approaches a circle. Ideally, all indicators would be disaggregated by wealth quintile, place of
residence, disability and gender, and by other important characteristics of population groups.
18
Chapter 1
The role of research for universal health coverage
Availability of selected generic medicines in public and private health facilities during
Eg. 1.6.
the period 2007-2011
WO-i
H 96.7
!
90.7
I
If
I
96.7
1 87.1
so
m RU-
m
im
ra w» «tr mu IW w
fSS
IK
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«
ct
il 67.0
ro u
h
ra® st
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60-
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m
» i 68.5
i
CTJ OT> pit UK ’15*
50.1
......
W
:»
•JC!
i In ns w
51.8
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1
i 20-
22.2
> 21.2
_ 4-1-
0
Public sector
8
Public sector
7
Private sector
W
Upper-middle-income countries
Low-income and lower-middle-income countries
K Maximum
Mean
»
M
(•»
•
Average in the private sector
Private sector
7
Minimum
Average in the public sector
Reproduced, by permission of the publisher, from United Nations (58).
compiles data from surveys o'f the availability and
□rice of essential medicines (
) (58). Surveys
carried out between 2007 and 2011 lound that 14
generic essential medicines were available on aver
age in 52% of public health facilities and in 69% of
private health facilities. The averages dillered little
between lower-middle-income countries and
upper-middle-income countries, and there were
large variations among countries within each cat
egory. Among upper-middle-income countries,
the availability of the 14 generic medicines varied
from zero in the State of Rio Grande do Sul, Brazil,
to 97% in the Islamic Republic of Iran.
One advantage of monitoring essential medi
cines as one way of tracking service coverage is that
comparable data are increasingly available, and
the quality of these data, collected through regular
health facility assessments, is also improving. More
than 130 countries had an essential medicines list
by 2007, and 81% of the low-income countries had
updated their lists in the previous five years.
Equity and universal
health coverage
Systems for monitoring the coverage of services
should record not only the total number of people
who have or do not have access, but also some soci
odemographic details about them. When coverage
19
Research for universal health coverage
is truly universal everyone has access, but partial
coverage may benefit certain groups over others. To
monitor equity in the supply of, and demand for,
health services, indicators should be disaggregated
by income or wealth, sex, age, disability, place of
residence (e.g. rural/urban, province or district),
migrant status and ethnic origin (e.g. indigenous
groups). For instance, gains in access to safe drink
ing-water have been uneven: 19% of people living
in rural areas did not have improved water sources
by 2010, in contrast with only 4% in urban areas
(50). This analysis shows where to target further
efforts to improve coverage.
Another example of the uneven distribution
of services - for maternal, newborn and child
health - is portrayed in Fi-.- 1 '. The summary
measure of service coverage includes family plan
ning, maternal and newborn care, childhood vac
cination, and treatment of childhood illness. The
mean coverage in 46 low- and middle-income
countries varied by wealth quintile as expected,
but there was also great variation within each
quintile. To achieve universal health coverage,
it is necessary to eliminate the gap between the
poorest and richest both within and between
quintiles, and to raise the levels in all quintiles.
As a general rule, the countries that make the
greatest progress in maternal and child health are
those that successfully narrow the gap between
the poorest and richest quintiles (59, 60). This is a
form of “progressive universalism” in which the
poorest individuals gain at least as much as the
richest on the way to universal coverage (62).
Coverage of health services:
quality as well as quantity
It is not just the quantity of health services pro
vided that is important, but also the quality of
them. Following a long tradition of research
on the quality of care, the Organisation for
Economic Co-operation and Development
(OECD) has developed measures of quality for
selected interventions: for cancer and mental
20
Fig. 1.7.
A summary measure of service
coverage for maternal and
child health, in which inequity
is reflected in the differences
between wealth quintiles
100-1
90“
80-
I3
70"
o
i i
40-
I
I 30" o
ro
O
i
I
49%
>
o
63%
_5 8% g
E 60-
| 50-
77%
ft
-o
o
20 H
o
70%
*
*
g
o
©
o
0
O
o
100
QI
Q2
Q3
Q4
Q5
Wealth quintile (QI = poorest, Q5 = richest)
O Median
Interquartile range
Source: DHriojuiphic and Health Surveys or Multiple Indicatoi)
Cluster Survey1 m 46 low - and middle-income countries.
health, for aspects of prevention and health pro
motion, and lor patient safety and patient experi
ences (/5, (-)2-64).
illustrates one aspect of the quality
of care, namely the risk of death in hospital fol
lowing ischaemic stroke.-'lhe risk is measured
as the proportion of people who die within 30
days of admission (i
i ' ) (65). As with mat y
measures of quantity, national statistics on the
quality of care are often not precisely compara
ble. In this instance, case-fatality rates shou d
ideally be based on individual patients, but
some national databases do not track patients in
and out of hospitals, between hospitals or even
within the same hospital, because they do not
The role of research for universal health coverage
Chapter 1
Availability of selected generic medicines in public and private health facilities during
Fig. 1.6.
the period 2007-2011
100-1
S 96.7
96.7
I
90.7
® 87.1
I
Q
I
f
I
§
¥
80l m w Bi ' « n w ra
w
s« re
an im sts
■m m mi w w isc
UH.
M
KI
M
Rl W ■ !SS
M M
67.0
1
Bl HI • 68,5
5
60-
I
IS.
m h o n n h n
50.1
i
<K
W»
«B »w
SM W* W
@ 44.4
■B W» «« N»
51.8
4k 44.4
40-
> 22.2
21.2
20-
I
0
Public sector
8
Public sector
7
Private sector
10
Upper-middle-income countries
Low-income and lower-middle-income countries
® Maximum
Mean
at
Ml
M
«
Private sector
7
4* Minimum
Average in the public sector
Average in the private sector
Reproduced, by permission of the publisher, from United Nations (53).
compiles data from surveys of the availability and
?rice of essential medicines (
j (5<S’)-. Surveys
carried out between 2007 and 2011 found that 14
generic essential medicines were available on aver
age in 52% of public health facilities and in 69% of
private health facilities. The averages differed little
between lower-middle-income countries and
upper-middle-income countries, and there were
large variations among countries within each cat
egory. Among upper-middle-income countries,
the availability of the 14 generic medicines varied
from zero in the State of Rio Grande do Sul, Brazil,
to 97% in the Islamic Republic of Iran.
One advantage of monitoring essential medi
cines as one way of tracking service coverage is that
comparable data are increasingly available, and
the quality of these data, collected through regular
health facility assessments, is also improving. More
than 130 countries had an essential medicines list
by 2007, and 81% of the low-income countries had
updated their lists in the previous five years.
Equity and universal
health coverage
Systems for monitoring the coverage of services
should record not only the total number of people
who have or do not have access, but also some soci
odemographic details about them. When coverage
19
Research for universal health coverage
is truly universal everyone has access, but partial
coverage may benefit certain groups over others. To
. monitor equity in the supply of, and demand for,
health services, indicators should be disaggregated
by income or wealth, sex, age, disability, place of
residence (e.g. rural/urban, province or district),
migrant status and ethnic origin (e.g. indigenous
groups). For instance, gains in access to safe drink
ing-water have been uneven: 19% of people living
in rural areas did not have improved water sources
by 2010, in contrast with only 4% in urban areas
(50). This analysis shows where to target further
efforts to improve coverage.
Another example of the uneven distribution
of services - for maternal, newborn and child
health - is portrayed in Fig. 1.7. The summary
measure of service coverage includes family plan
ning, maternal and newborn care, childhood vac
cination, and treatment of childhood illness. The
mean coverage in 46 low- and middle-income
countries varied by wealth quintile as expected,
but there was also great variation within each
quintile. To achieve universal health coverage,
it is necessary to eliminate the gap between the
poorest and richest both within and between
quintiles, and to raise the levels in all quintiles.
As a general rule, the countries that make the
greatest progress in maternal and child health are
those that successfully narrow the gap between
the poorest and richest quintiles (59, 60). This is a
form of “progressive universalism” in which the
poorest individuals gain at least as much as the
richest on the way to universal coverage (67).
Coverage of health services:
quality as well as quantity
It is not just the quantity of health services pro
vided that is important, but also the quality of
them. Following a long tradition of research
on the quality of care, the Organisation for
Economic Co-operation and Development
(OECD) has developed measures of quality for
selected interventions: for cancer and mental
20
Fig. 1.7.
A summary measure of service
coverage for maternal and
child health, in which inequity
is reflected in the differences
between wealth quintiles
100 n
90 £
iI
5
E
60o
>22
9
8070“
Qz
CH
Cl
o
50 -
i
63%|
58% >
1
49%
£
g 40Qz
I
77%,
*
70%
i
6
£
s
O
O
0
i 30-
O
co
= 20^
o
o
o
10^
o1
~i------------------ 1------------------ 1------------------ 1----------------- r
Q1
Q2
Q3
Q4
Q5
Wealth quintile (QI = poorest, Q5 = richest)
O Median
Interquartile range
Source D^mo'ii.iphic and Health Surveys or Multiple Indicator
Cluste; Survey1 m <0 low-and middle-income countries.
health, for aspects of prevention and health pro
motion, and for patient safety and patient experi
ences (75, 62-64).
illustrates one aspect of the quality
of care, namely the risk of death in hospital fol
lowing ischaemic stroke. The risk is measured
as the proportion of people who die within 30
days of admission (i ig. I S) (65). As with many
measures of quantity, national statistics on the
quality of care are often not precisely compara
ble. In this instance, case-fatality rates should
ideally be based on individual patients, but
some national databases do not track patients in
and out of hospitals, between hospitals or even
within the same hospital, because they do not
4
Chapter 1
Fg.1.8.
Case-fatality rates following
ischaemic stroke during the 30
days after admission to hospitals
in OECD countries for which there
are data
EU16 countries I
_ I 4.6
Denmark f,|____ if1 2.6
Finland
Austria
•
S.8
2.8
isaHMwwtaweni o 3
' .
>I
8.4
Sweden
■H- 3.9
Germany
i
Conclusions: research needed
for universal health coverage
8.0
4.0
^’71 8,3
*ri.
Unweighted average
Netherlands
Czech Republic
1 9.6
5.4
8.6
........... ....-ti-1 5.7
103
Spain
..
11 0
..T 6.1
Ireland
63
Portugal
6.2
United Kingdom of
Great Britain and
Northern Ireland
It 6.8
10.2
fi i
io./
Slovakia
Belgium
Slovenia
use unique patient identifiers. The data in Pig. 1.8
are therefore based on single hospital admissions
and are restricted to mortality within the same
hospital. There are big differences in case-fatality
rates between countries, but some of the vari
ation might be explained by local practices of
discharging patients from hospitals, and trans
ferring patients to other hospitals. To select and
agree on internationally comparable indicators
of quality is another task for research.
73
if 3 4______
Italy
Luxembourg
The role of research for universal health coverage
153
______________ 1---- 4------ * 9 7
153
Non-EU
6.5
Norway
2.8
8.0
Iceland
8.7
Switzerland
J 43
0
“i
5
r~:
n~
10
15
Rates per 100 patients
20
® Crude rates
□ Age and sex standardized rates
•—1 95% confidence interval
I U, European Union.
Note: Rates are standardized by age and st x the entii'e
,'005 OECD population aged > 45 years
Reproduced, by permission of the .publishm bom the
Organisation for Economic Co-operation and
Development (65).
When all WHO Member States made a commit
ment to achieving universal health coverage in
2005 they took a major step forward for public
health. Taking that step launched an agenda for
research. We do not yet know how to ensure that
everyone has access to all the health services they
need in all settings, and there are many gaps in
understanding the links between service cover
age and health (66', 67). Research is the means of
filling these gaps.
With a focus on research, the goal of this
report is not to measure definitively the gap
between the present coverage of health services
and universal coverage, but rather to identify the
questions that arise as we try to achieve universal
coverage and to discuss how these questions can
be answered in order to accelerate progress.
In this chapter research questions of two
kinds have been identified. The first and most
important set of questions is about choosing the
health services needed, improving the coverage
of those services and of financial risk protection,
and assessing the way in which greater coverage
of both leads to better health and well-being. The
second set of questions concerns measurement
of the indicators and data that are needed to
monitor coverage, financial risk protection, and
the benefits for health.
The health services that are necessary and
the people who need them should be defined with
21
Research for universal health coverage
respect to the causes of ill-health, the technolo
gies and instruments for intervention, and the
cost. The services required vary from one setting
. to another, as does the capacity to pay for them.
The function of research is to investigate whether
schemes devised to achieve universal health cov
erage really succeed in their aims. At present the
evidence on this issue is mixed. A comparative
study of 22 low- and middle-income countries
found that interventions to support universal
health coverage usually improve access to health
care. The study also found, less convincingly, that
such interventions can have a positive effect on
financial risk protection and, in some instances,
a positive impact on health (68). Another conclu
sion of the review was that the effects of inter
ventions varied according to the context, design
and process of implementation. Such variation
is illustrated further in Chapter 3 of this report.
The second set of questions about meas
urement is instrumental to answering the first
set. Just as the necessary health services vary
between settings, so too must the combination
of indicators for measuring the coverage of ser
vices. Because it is not possible to measure the
coverage of all services, a set of tracer inter
ventions can be selected, with their associated
indicators, to represent the overall quantity and
quality of health services. The tracer conditions
could be selected to exemplify major types of
diseases or health problems such as acute infec
tions, chronic infections and noncommunicable
diseases. Universal coverage is achieved when
each intervention is accessible to all who need it,
and when it has the intended effects. Although
every country has its own priorities for improv
ing health, it would be possible, in principle, to
choose a set of common indicators for compar
ing progress towards universal coverage across
all countries. To define such a set of indicators is
another task for research.
There are already numerous indicators of
health-service coverage that have been standard
ized and validated, and they are widely used. The
techniques for measurement have been greatly
22
enhanced by tracking progress towards the
MDGs, especially in low- and middle-income
countries (50). However, beyond the MDGs there
is fess experience in monitoring prevention and
control in other areas of health, such as noncommunicable diseases, ageing, and rehabilitation
and palliative care (57). Similarly, while there are
some standard indicators of the quality of health
services, of equity of access, and of financial ris <
protection, there is much scope for refining the
methods of data collection and measurement.
Universal health coverage is seen as a means
of both improving health and promoting human
development. 'Hiis puts research for universal
coverage in the wider context of research for
development. Research will play a role not only
in meeting the MDGs but also in supporting
the post-2015 development agenda. For exam
ple, more research is needed to improve the
resilience of health systems to environmental
threats such as those posed by climate change.
An additional and complementary challenge to
that of increasing universal health coverage is to
develop research that can enhance understand
ing of how intersectoral policies can improve
health and advance development.
Because many more questions can be
asked than answered, it is vital to set pri
orities for investigation. Research needs
researchers with skill and integrity, who are
funded to work in well-equipped institutions.
Further, to make sure that research delivers
results that lead to improvements in health,
mechanisms are needed to translate evidence
into action.
’Ihese elements of a successful research
system are described more fully in Chapter 4.
Before that, Chapter 2 highlights some of the
recent developments in research for health
worldwide; these provide the basis on which to
build better research systems. Chapter 3 shows,
by example, how research can address a wide
range of questions about universal health cov
erage and how it can provide answers to guide
health policy and practice.
A
Chapter 1
The role of research for universal health coverage
References
1.
2.
3
4
5
6
7.
8.
9.
10.
1 '.
12.
IT
Id.
15.
16.
17.
18.
19.
20.
2 .
22.
23.
24.
25.
26.
9
27.
The world health report 2010. Health systems financing: the path to universal coverage. Geneva, World Health Organization, 2010.
Constitution of the World Health Organization. Geneva, World Health Organization, 2006.
Resolution WHA58.33. Sustainable health financing, universal coverage and social health insurance. In: Fifty-eighth World
Health Assembly, Geneva, 16-25 May 2005. Volume 1. Resolutions and decisions. Geneva, World Health Organization, 2005
(Document WHA58/20P5/REC/1).
The world health report 2008 - primary health care, now more than ever. Geneva, World Health Organization, 2008.
United Nations General Assembly Resolution A/RES/67/81. Global health and foreign policy. Sixty-seventh session. Agenda
item 123, 2012.
Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet, 2012,380:864-865. doi: http://
dx.doi.org/10.1016/50140-6736(12)61483-4 PMID:22959373
World social security report 2010/11. Providing coverage in times of crisis and beyond. Geneva, International Labour Office, 2010.
Chan M. Address at the Conference of Ministers of Finance and Health. Achieving value for money and accountability for health
outcomes, Tunis, 4 July 2012. (http://www.who.int/dg/speeches/2012/tunis_20120704, accessed 7 March 2013).
Haines A et al. From the Earth Summit to Rio+20: integration of health and sustainable development. Lancet,
2012,379:2189-2197. doi: http://dx.doi.org/10.1016/S0140-6736(12)60779-X PMID:22682465
Foster A. Poverty and illness in low-income rural areas. The American Economic Review, 1994,84:216-220.
Bloom DE, Canning D. The health and wealth of nations. Science, 2000,287:1207-1209. doi: http://dx.doi.org/10.1126/science.287.5456.1207 PMID:10712155
Rodin J, de Ferranti D. Universal health coverage: the third global health transition? Lancet, 2012,380:861-862. doi: http://
dx.doi.org/10.1016/50140-6736(12)61340-3 PMID:22959371
Busse R, Schreydgg J, Gericke C. Analysing changes in health financing arrangements in high-income countries. A comprehen
sive framework approach. Washington, DC, The World Bank, 2007.
Chisholm D, Evans DB. Improving health system efficiency as a means of moving towards universal coverage. Geneva, World
Health Organization, 2010.
Improving value in health care: measuring quality. Paris, Organisation for Economic Co-operation and Development, 2010.
Tantivess S, Teerawattananon Y, Mills A. Strengthening cost-effectiveness analysis in Yhailand through the establishment
of the health intervention and technology assessment program. PharmacoEconomics, 2009,27:931-945. doi: http://dx.doi.
org/10.2165/11314710-000000000-00000 PMID: 19888793
Hanson K et al. Scaling up health policies and services in low- and middle-income settings. BMC Health Services Research,
2010,10:Suppl 1:11. doi: http://dx.doi.Org/10.1186/1472-6963-10-S1-I1 PMID:20594366
Yothasamut J et al. Scaling up cervical cancer screening in the midst of human papillomavirus vaccination advocacy
in Thailand. BMC Health Services Research, 2010,10:Suppl 1:S5.doi: http://dx.doi.org/10.1186/1472-6963-10-S1-S5
PMID:20594371
Praditsitthikorn N et al. Economic evaluation of policy options for prevention and control of cervical cancer in Thailand.
PharmacoEconomics, 2011,29:781-806. doi: http://dx.doi.org/10.2165/11586560-000000000-00000 PMID:21838332
McIntyre D, et al. What are the economic consequences for households of illness and of paying for health care in low- and
middle-income country contexts? Social Science & Medicine, 2006,62:858-865. doi: http://dx.doi.0rg/l 0.1016/j.socscimed.2005.07.001, PMI D: 16099574
WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. Geneva, World Health
Organization, 2011.
Ldnnroth K et al. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Social Science &
Medicine, 2009,68:2240-2246. doi: http://dx.doi.Org/10.1016/j.socsdmed.2009.03.041 PMID:19394122
Global tuberculosis report 2012. Geneva, World Health Organization, 2012. (http://www.who.int/tb/publications/global_
report, accessed 24 March 2013).
Barter DM et al. Tuberculosis and poverty: the contribution of patient costs in sub-Saharan Africa - a systematic review.
BMC Public Health, 2012,12:980. doi: http://dx.doi.org/10.1186/1471-2458-12-980 PMID:23150901
Reaching the poor: challenges for TB programmes in (he Western Pacific Region. Manila, World Health Organization, 2004.
Hanson C, Weil D, Floyd K. Tuberculosis in the poverty alleviation agenda. In: Raviglione MC, ed. Tuberculosis a comprehen
sive, international approach, 3rd ed. New York, NY, CRC Press, 2006.
Kamolratanakul P et al. Economic impact of tuberculosis at the household level. The International Journal of Tuberculosis
and Lung Disease, 1999,3:596-602. PMID:10423222
23
Research for universal health coverage
Rajeswari R et al. Socio-economic impact of tuberculosis on patients and family in India. The International Journal of
Tuberculosis and Lung Disease, 1999,3:869-877. PMID:10524583
29. Wyss K, Kilima P, Lorenz N. Costs of tuberculosis for householdsand health care providers in Dares Salaam, Tanzania.
Tropical Medicine & International Health, 2001,6:60-68. doi: http://dx.doi.Org/10.1046/j.1365-3156.2001.00677.x
28.
PMID:11251897
Lbnnroth K et al. Social franchising of TB care through private GPs in Myanmar: an assessment of treatment results,
access, equity and financial protection. Health Policy and Planning, 2007,22:156-166. doi: http://dx.doi.org/10.1093/
heapol/czm007 PMID:17434870
31. Kemp JR et al. Can Malawi's poor afford free tuberculosis services? Patient and household costs associated with tuber
culosis diagnosis in Lilongwe. Bulletin of the World Health Organization, 2007,85:580-585. doi: http://dx.doi.org/10.2471/
BLT.06.033167 PMID:17768515
32. Pantoja'A et al. Economic evaluation of public-private mix for tuberculosis care and control, India. Part I. Socio
economic profile and costs among tuberculosis patients. The International Journal of Tuberculosis and Lung Disease,
2009,13:698-704. PMID:19460244
33. Floyd K et al. Cost and cost-effectiveness of PPM-DOTS for tuberculosis control: evidence from India. Bulletin of the World
Health Organization, 2006,84:437-445. doi: http://dx.doi.org/10.2471/BLT.05.024109 PMID:16799'727
34. Uplekar M et al. Tuberculosis patients and practitioners in private clinics in India. The International Journal of Tuberculosis
and Lung Disease, 1998,2:324-329. PMID:9559404
35. Porter JDH, Grange JM, eds. Tuberculosis: an interdisciplinary perspective. London, Imperial College Press, 1999.
36. Long NH. Gender specific epidemiology of tuberculosis in Vietnam. Stockholm, Karolinska Instituted 2000.
37. Diwan V, Thorson A, Winkvist A. Gender and tuberculosis. Gdteborg, Nordic School of Public Health, 1998.
38. Ananthakrishnan R et al. Expenditure pattern for TB treatment among patients registered in an urban government
DOTS program in Chennai City, South India. Tuberculosis Research and Treatment, 2012,2012:747924. doi: http://dx.doi.
org/10.1155/2012/747924 PMID:23213507
39. Tool to estimate patients' costs. Geneva, Stop TB Partnership, 2012. (http://www.stoptb.org/wg/dots_expansion/tbandpov
erty/spotlight.asp, accessed 7 March 2013).
40. Mauch V et al. Free TB diagnosis and treatment are not enough - patient cost evidence from three continents. The International
Journal of Tuberculosis and Lung Disease, 2013,17:381-387. doi: http://dx.doi.org/10.5588/ijtld.12.0368 PMID:23407227
41. Mladovsky P et al. Health policy responses to the financial crisis in Europe. Copenhagen, World Health Organization on behalf
of the European Observatory on Health Systems and Policies, 2012.
42. Scherer P, Devaux M. The challenge of financing health care in the current crisis. An analysis based on the OECD data. Paris,
Organisation for Economic Co-operation and Development, 2010 (OECD Health Working Papers, No. 49).
43. Knaul FM et al. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet, 2012,380:12591279. doi: http://dx.doi.Org/10.1016/S0140-6736(12)61068-X PMID:22901864
44. Global health expenditure database. Geneva, World Health Organization, 2012. (apps.who.int/nha/database/
DataExplorerRegime.aspx, accessed 7 March 2013).
45. ADePT: STATA software platform for automated economic analysis. Washington, DC, The World Bank, 2012. (web.worldbank.
org, accessed 24 March 2013).
46. World health statistics 2012. Geneva, World Health Organization, 2012.
47. Xu K et al. Protecting households from catastrophic health spending. Health Affairs (Project Hope), 2007,26:972-983. doi:
http://dx.doi.Org/10.1377/hlthaff.26.4.972 PMID:17630440
48. Xu K et al. Exploring the thresholds of health expenditure for protection against financial risk. Geneva, World Health
Organization, 2010 (World Health Report [2010] Background Paper, No 19).
49. Measurement of trends and equity in coverage of health interventions in the context of universal health coverage. Rockefeller
Foundation Center, Bellagio, September 17-21, 2012. UHC Forward, 2012 (http://11hcforward.org/publications/measurementtrends-and-equity-coverage-health-interventions-context-universal-health-co, accessed 7 March 2013).
50. The Millennium Development Goals report 2012. New York, United Nations, 2012.
51. Global report. UNAIDS report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS, 2012.
52. World malaria report 2012. Geneva, World Health Organization, 2012.
53. Sustaining the drive to overcome the globalimpact of neglected tropical diseases. Geneva, World Health Organization, 2013.
54. Dye C et al. WHO and the future of disease control programmes. Lancet, 2013,381:413-418. doi: http://dx.doi.org/10.1016/
50140-6736(12)61812-1 PMID:23374479
30.
24
c
Chapter 1
55
The role of research for universal health coverage
United Nations Secretary General's Advisory Board on Water and Sanitation. Monitoring and reporting progress of access to
water & sanitation. An assessment by UNSGAB. New York, United Nations, 2008.
Scheil-Adlung X, Florence B. Beyond legal coverage: assessing the performance of social health protection. International
Social Security Review, 2011,64:21-38. doi; http://dx.doi.Org/10.1111/j.1468-246X.2011.01400.x
57 Angell SY, Danel I, DeCock KM. Global indicators and targets for noncommunicable diseases. Science, 2012,337:1456-1457.
doi: http://dx.doi.org/10.1126/science.1228293 PMID:22997310
58. Millennium Development Goal 8. The global partnership for development: making rhetoric a reality. New York, United Nations,
2012 (MDG Gap Task Force report 2012).
59 Victora CG et al. How changes in coverage affect equity in maternal and child health interventions in 35 Countdown
to 2015 countries: an analysis of national surveys. Lancet, 2012,380:1149-1156. doi: http://dx.doi.org/10.1016/S0140-
56
6736(12)61427-5 PMID:22999433
6C. Ruhago GM, Ngalesoni FN, Norheim OF. Addressing inequity to achieve the maternal and child health millennium
development goals: looking beyond averages. BMC Public Health, 2012,12:1119. doi: http://dx.doi.org/10.1186/1471-245812-1119 PMID:23270489
61. Gwatkin DR, Ergo A. Universal health coverage: friend or foe of health equity? Lancet, 2011,377:2160-2161. doi: http://
dx.doi.org/10.1016/50140-6736(10)62058-2 PMID:21084113
62. Donabedian A, The quality of care. How can it be assessed? Journal of the American Medical Association, 1988,260:17431748. doi: http://dx.doi.org/10.1001/jama.1988.03410120089033 PMID:3045356
63. Donabedian A. Evaluating the quality of medical care. The Milbank Quarterly, 2005,83:691-729. doi: http://dx.doi.
org/10.1111/j.1468-0009.2005.00397.xPMID:16279964
6-^. Davies H. Measuring and reporting the quality of health care: issues and evidence from the international research literature.
Edinburgh, NHS Quality Improvement Scotland, 2005.
65. Health at a glance: Europe 2012. Paris, Organisation for Economic Co-operation and Development, 2012. http://dx.doi.
org/10.1787/9789264183896-en
6(>. Moreno-Serra R, Smith PC. Does progress towards universal health coverage improve population health? Lancet,
2012,380:917-923. doi: http://dx.doi.org/10.1016/S0140-6736(12)61039-3 PMID:22959388
67. Acharya A et al. Impact of notional health insurance for the poor and the informal sector in low- and middle-income countries:
a systematic review. London, EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, 2012.
68. Giedion U, Alfonso EA, Diaz Y. The impact of universal coverage schemes in the developing world: a review of the existing
evidence. Washington, DC, The World Bank, 2013.
25
Chapter 2
The growth of research for
universal health coverage
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Key points
30
Creativity everywhere
35
Research ascending
35
Growing unevenly
42
I The value of
health research
Conclusions: building on the
foundations
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Key points
Si
n
Chapter 1 considered ways of measuring the gap between the present coverage and
universal coverage of health services. The question ol how to till that gap is a target
for research in every country. Research for universal health coverage, underpinned
by research for health, is the body of methods and results used to find new ways of
providing the health care needed by everyone.
There are plenty of creative ideas about how to achieve comprehensive health care.
They come from both within the health sector and beyond it and will flourish
wherever they are permitted and encouraged to do so.
Research to stimulate and harness new ideas is growing worldwide. The growth is
uneven, but most countries now have the foundations on which to build effective
research programmes.
Not only is more research being done, it is also being done in more creative ways.
One example is new thinking to break the mould of traditional research and
development (R&D), where more products are being created through partnerships
between universities, governments, international organizations and the private
sector.
H
The results of some research studies are widely applicable, but many questions
about universal health coverage need local answers. All nations therefore need to be
producers of research as well as consumers of it.
S!
In low- and middle-income countries, the principal challenges are to strengthen
research systems, identify key research questions, and generate the capacity to turn
research into practical applications.
a
Research is in the ascendant, but few countries have objectively assessed the
strengths and weaknesses of their national research programmes, and few have
evaluated the health, social and economic benefits that research can bring. All
nations will benefit from taking a systematic approach to the monitoring and
evaluation of research investments, practices, outputs and applications.
The growth of research for
universal health coverage
Chapter I defined universal health coverage and discussed practical ways to
measure progress towards this goal, lhe discussion led to research questions
of two kinds, lhe first kind is about improving health: What kinds of health
systems and services are needed and for whom? How can the necessary health
services be provided, and at what cost? How should health services adapt to the
expected shifts in disease burden in the coming years?
The second kind of question is about measurement: What is the best way to
measure the coverage ol services and financial risk protection in any setting?
How will we know when we have reached universal coverage?
In the context of this report, scientific research provides the set of tools used
to stimulate and harness creative solutions to these questions - i.e. research
gives us the formal techniques that turn promising ideas into practical methods
for achieving universal health coverage.
This chapter gives an overview of the changing landscape of research. Tlie
first observation is that creativity, imagination and innovation - which are fun
damental in any culture of enquiry - are universal. A premise of this repoit is
that new ideas will llourish wherever they are encouraged and permitted to do so.
The second observation is that there has been a striking increase in research
productivity in low- and middle-income countries over the past two decades,
in the wake of the 1990 report of the Commission on Health Research for
Development among others (/). A greater recognition of the value of research
for health, society and the economy has added impetus to the upward trend.
Although the growth is uneven, most countries now have the foundations on
which to build effective research programmes.
’lhe process of doing research presents questions on several levels; What
health problem needs to be solved? On the spectrum from disease etiology to
health policy, what kind of question is being asked about this problem?
Tlie sequence of research questions is not linear but cyclical: questions
lead to answers and then to yet more questions. For instance, which stages of
investigation in the research cycle will be included - measuring the problem,
understanding the options to address the problem, solving the problem by
comparing the options, implementing the preferred solution or evaluating the
31
Research for universal health coverage
Box 2.1.
Research definitions used in this report
Research is the development of knowledge with the aim of understanding health challenges and mounting an
improved response to them (2, 3). Research is a vital source, but not the only source, of information that is used to
develop health policy. Other considerations - cultural values, human rights, social justice and so on - are used to
weigh the importance of different kinds of evidence in decision-making (4, 5).
Research excludes routine testing and routine analysis of technologies and processes, as would be done for the
maintenance of health or disease control programmes, and as such is distinct from research to develop new analytical
techniques. It also excludes the development of teaching materials that do not embody original research.
Basic research or fundamental research is experimental or theoretical work undertaken primarily to acquire
new knowledge about the underlying foundations of phenomena and observable facts, without any particular
application or use in view (6).
Applied research is original investigation undertaken to acquire new knowledge, directed primarily towards a
specific practical aim or objective (6).
Operational research or implementation research seeks knowledge on interventions, strategies or tools so
as to enhance the.quality or coverage of health systems and services (7, 8). The design could be, for example, an
observational study, a cross-sectional study, a case-control or cohort study, or a randomized controlled trial (Box . ?).
Translational research, which moves knowledge gained from basic research to its application in the clinic and
community, is often characterized as "bench-to-bedside" and "bedside-to-community". The translation is between
any of several stages: moving basic discovery into a candidate health application; assessing the value of an application
leading to the development of evidence-based guidelines; moving guidelines into health practice, through delivery,
dissemination, and diffusion research; or evaluating the health outcomes of public health practice (9). This has also
been called experimental development research, which is the terminology used in the study described in I ig
Health policy and systems research (HRSR) seeks to understand and improve how societies organize themselves
in achieving their collective health goals, and how different actors interact in the policy and implementation pro
cesses to contribute to policy outcomes. HPSR is an interdisciplinary blend of economics, sociology, anthropology,
political science, public health and epidemiology that together draw a comprehensive picture of how health systems
respond and adapt to health policies, and how health policies can shape - and be shaped by - health systems and
the broader determinants of health {10).
Research for health covers a broader range of investigations than health research, reflecting the fact that health
also depends on actions taken outside the health sector - in agriculture, education, employment, fiscal policy
housing, social services, trade, transport and so on. This wider view of research will become increasingly important
in the transition from the United Nations Millennium Development Goals to a post-2015 sustainable development
agenda. As pointed out in Box 1.1, research for universal health coverage is also research for development.
Research for universal health coverage, which is a part of all research for health, is the body of questions, method:
and results used to find new ways of providing the health care that is needed by everyone.
Innovation is a general term referring to the introduction of something new - an idea, a strategy, a method or a
device. New ideas can be objectively evaluated by the research process.
outcome? Along the gradient from observational
studies (typically weaker inferences) to rand
omized controlled trials (stronger inferences),
what study designs will be used? In parallel to
the main narrative of this chapter, three accom
panying boxes define terms, categorize the types
of problems addressed by research for universal
32
health coverage, and describe activities in the
research cycle (
,
' and .i .). The
intention is to provide a way of thinking about
the research process, and to present a classifica
tion of research questions and procedures that
will be used throughout this report.
Chapter 2
Box 2.2.
The growth of research for universal health coverage
Classifying research studies: an example
It is helpful to classify the type of research question under investigation, in addition to identifying activities in the
research cycle (Box 2.
One possible classification, devised by the Clinical Research Collaboration in the United
Kingdom of Great Britain and Northern Ireland and based partly on the WHO International Classification of Diseases,
covers the spectrum of biomedical and health research, from basic to applied (Box 2.1) and across all areas of health
and disease. The eight sections below are illustrated with examples of topics included in each; the full classif ication
is available at www.hrcsonline.net (17, 72). Some aspects of section 1, such as normal biological development and
functioning, are considered to be outside the scope of research for universal coverage because they do not directly
address defined health problems. Section 8 is modified here to distinguish systems (overall structure) and services
(delivery within a given system), and also goes beyond health research to embrace the broader concept of research
for health (Box 2.1).'
1. Underpinning research (basic or fundamental research)
Normal biological development and functioning; psychological and socioeconomic processes; chemical and physical
sciences; methodologies and measurements (including disease burden); resources and infrastructure.
2. Etiology (causation)
Biological and endogenous factors; factors relating to the physical environment; psychological, social and economic
factors; surveillance and distribution; research design and methodologies.
3. Prevention of disease and conditions, and promotion of well-being
Primary prevention interventions to modify behaviours or promote well-being; interventions to alter physical and
biological environmental risks; nutrition and chemoprevention; vaccines.
4. Detection, screening and diagnosis
Discovery and preclinical testing of markers and technologies; evaluation of markers and diagnostic technologies;
population screening.
5. Development of treatments and therapeutic interventions
Pharmaceuticals, cellular and gene therapies; medical devices; surgery; radiotherapy; psychological and behavioural
interventions; physical and complementary treatments.
6. Evaluation of treatments and therapeutic interventions
Pharmaceuticals; cellular and gene therapies; medical devices; surgery; radiotherapy; psychological and behavioural
interventions; physical and complementary treatments.
7. Management of diseases and conditions
Individual care needs; management and decision-making; resources and infrastructure.
8. Health policy and systems research
Organization and delivery of services; health and welfare economics; policy, ethics and research governance; research
design and methodologies; resources and infrastructure. The systems and services that benefit health lie both within
and beyond the health sector (
).
There is no general agreement on ways to classify research. Some would emphasize the methods used and types
of questions addressed within the disciplines of economics, epidemiology, statistics and sociology; others would
focus on elements of the research cycle in ;
. This particular example is presented because it is also used to
organize the case studies in Chapter 3.
33
Research for universal health coverage
Box 2.3.
The research cycle: questions, answers, and more questions
Just as this report defines universal health coverage broadly (Chapter 1), it also takes a comprehensive view of the
scope of research. This report is concerned with any investigation motivated by the goal of achieving universal
coverage - from discovery, through development, to delivery - thereby improving health. Investigations cover
all five of the steps depicted in the figure: measuring the size of the health problem; understanding its cause(s),
devising solutions; translating the evidence into policy, practice and products; and evaluating effectiveness after
implementation. The process of doing research is not linear but cyclical, because each answer brings a new set of
questions. This research cycle is often called the "cycle of innovation".
The cycle of research activities, divided into five parts, illustrated here with reference to
micronutrient malnutrition
Collect data on vitamin and
mineral nutritional status of
populations and generate
estimates
Create frameworks and tools
for monitoring and evaluating
micronutrient interventions in
public health
-■
Commission studies to
understand the biological arid
social determinants and their
consequences
Micronutrient
malnutrition
Develop up-to-date evidenceinformed guidelines for
micronutrient interventions in
public health
AH
Support country context
specific policy briefs, translation
and delivery of guidelines for
scaling up nutrition actions
■C,
Note; Research begins with measuring and understanding the problem, it proceeds to developing solutions, and then
monitors the success of interventions. Monitoring is the source of new questions, so another cycle begins.
Reproduced, by permission of the publisher, from Pena-Rosas et al. {13).
continues ...
34
Chapter 2
The growth of research for universal health coverage
... continued
As is made clear in the WHO Strategy on Research for Health, good research needs an enabling environment, whic
includes mechanisms for agreeing on research priorities, for developing research capacity (staff, funding, ins^lt^’
lions), for setting standards in research practice, and for translating the results of research into policy (Chapter 4) (2).
The strength of inference that can be made from research studies is dependent partly on the study design, ran9"
ng from observational studies (weaker), through cross-sectional, case-control and cohort studies, to randomized
controlled trials (stronger) {14). To apply the results of a research study In another setting requires causes and effects
to be linked in the same way; this is not a matter of study design.
The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system assesses the quality
of evidence and the strength of recommendations on the basis of the evidence. It is a transparent and systematic
mechanism for judging whether the results of research are robust enough to inform policy {15, 16). At present,
GRADE is an effective tool for assessing the value of an intervention studied by a clinical trial, but is less well suited
to judging, for example, how easily an intervention can be implemented in a health system, or its suitability with
respect to health equity. GRADE has had to be fine-tuned to deal with issues specific to immunization, such as the
population-level effects of vaccines, and to the use of data from surveillance systems {17). Furthermore, the outputs
of GRADE need to be presented in a manner that is accessible to policy-makers. Initiatives such as DECIDE (Developing
and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence, http://
www.decide-collaboration.eu) are helping to do this. The GRADE working group (www.gradeworkinggroup.org)
offers courses and workshops to make best use of the GRADE system.
C reativity everywhere
'I here is a fear that many.of the world’s contempdr iry problems - in health and in other domains
- are too complex to understand and too difficult
to manage (18). Tliis report takes a more positive
view. There are undoubtedly many problems that
are hard to solve en route to universal health cov
erage - such as improving the efficiency of health
care through the dense network of connections
that make up health services. Nevertheless,
wherever we look in the world, we find people
proposing ingenious solutions to difficult ques
tions about health care (I'
■)• Creativity is a
leitmotif in this report. While creative solutions
are to be encouraged, innovations may have
unintended adverse consequences and tor this
reason they require rigorous evaluation.
The stories in Box 2.-I are not isolated exam
ples of applied ingenuity. New ideas are pervasive,
as revealed in a 10-country survey of R&D car
ried out for the 2010 African Innovation Outlook.
'Hie study found that there were new concepts
behind the development of both products and
procedures in private companies of all sizes (23).
Drawing on specific examples (Box 0 and
general surveys, our conclusion is that creativ
ity and imagination are ubiquitous (23). The
working assumption in this report is that new
ideas will throw up potential solutions to health
problems, and that innovators will turn some of
these proposed solutions into practical applica
tions if they are permitted and encouraged to do
so. Some of these practical innovations will be
shown by research to be worthy of large-scale
implementation.
In the next section we show that the research
needed to harness these new ideas is on the rise.
Research ascending
'The landmark 1990 report from the Commission
on Health Research for Development had a lasti ng i mpact by showi ng that less than 10% of global
research spending was targeted at the diseases
35
Research for universal health coverage
Box 2.4,
Problems, ideas, solutions
Innovation in action: mobile phone software developed to monitor fetal movements and
heartbeats
. .’J
I
V-'
i
Zeinou Abdelyamin from Algeria has been worried that the widespread use of insecticides and rodenticides leave.
chemical residues that are harmful to people and domestic animals. In 2012, he won an African Prize for Innovation
for carrying out research to formulate nonchemical pesticides that leave no trace in the environment (19).
In the same year, Aaron Tushabe and fellow students at Makerere University, Uganda, wanted to find ways to make
pregnancy safer for women who do not have easy access to hospitals (20). They invented a portable scannerto detect
anomalies in gestation, such as ectopic pregnancies and abnormal fetal heart beats (see photograph). Cheaper than
ultrasound, their hand-held scanner is a funnel-like horn that gives a read-out on the screen of a mobile phone.
Meanwhile in Tamil Nadu, India, Dr V Mohan has created the "self-expanding diabetes clinic" to provide diagnosis
and care to people in remote rural areas of India (21). His mobile clinic, housed in a van carrying satellite equip
ment, visits some of the remotest parts ofTamil Nadu, linking urban doctors to rural patients via community health
workers. The van has telemedicine technology to carry out diagnostic tests, such as retinal scans, and transmit the
results within seconds to Chennai, even from areas too remote for Internet connectivity. The wider application cf
these innovations needs to be guided by health technology assessments (22).
The key point, however, is that examples of creativity and innovation can be found everywhere.
36
Chapter 2
lox 2.5.
The growth of research for universal health coverage
Milestones in research for health
1990 Report of the independent Commission on Health Research for Development (7)
This report exposed the mismatch between investment in health research in developing countries (5% of all ^nds)
and the burden of disease in these countries, measured as years of life lost through preventable deaths (93%). The
mismatch was later characterized by the Global Forum for Health Research as the ”10/90 gap" (less than 10% of global
spending on research devoted to diseases and conditions that account for 90% of the burden of ill-health) (24). e
report recommended that all countries undertake and support essential national health research; that more financial
support for research should be obtained through international partnerships; and that an international mechanism
should be established to monitor progress.
1996 WHO Ad Hoc Committee on Health Research Relating to Future Intervention Options (25)
The committee identified the best value in health research and suggested that investments be made in four main areas:
childhood infectious diseases, microbial threats, noncommunicable diseases and injuries, and weak health systems.
2001 Commission on Macroeconomics and Health (26)
The commissioners made a case for greater investment in health research globally. They called for the establishment
of a Global Health Research Fund to support research in areas that primarily affect developing countries, focusing
on basic scientific research in health and biomedicine.
2004/5 Ministerial Summit on Health Research in Mexico City (2004) and the associated World Health Assembly
Resolution WHA5834 (2005)
The Ministerial Summit and the World Health Assembly argued for more resources and more research on hea t
systems and health policy to strengthen health systems, supported by the background work of ati independent
task force convened by WHO (27). They drew attention to the science that is needed to improve heahh systems,
and urged greater efforts to bridge the gap between scientific potential and health improvement. In parallel, WHO
launched the World report on knowledge for better health (28).
2008 Global Ministerial Forum on Research for Health in Bamako, Mali
The Forum was convened by WHO and five partners with the theme "Strengthening research for health, develop
ment and equity". It placed research and innovation within the wider context of research for development. It led to
specific recommendations and commitments, culminating in a research plan of action.
2010 and 2012 Global Symposia on Health Systems Research in Montreux and Beijing
These symposia were a response to the heightened interest in health systems research (29). Under the theme of
"Science to accelerate universal health coverage" the Montreux symposium called for country ownership in develop
ing the capacity to create stronger health systems. It was proposed that health systems research should become the
third pole of medical research, complementing biomedical and clinical research. Beijing followed Montreux with t te
theme "Inclusion and innovation towards universal health coverage" (www.hsr-symposium.org).
that are responsible for more than 90% ol the
global burden of ill-health (
). Owing to
the success of that report, the “10/90 gap” has
become short-hand for underinvestment in
health research in low-income countries.
More than two decades later, the influential
990 report and subsequent events (
)
have made a contribution to the growth of
research worldwide. Practically every indicator
of research activity has been rising. Systematic
evaluations of the burden of disease have been
strongly encouraged since the early 1990s. bhe
reaction, as seen in the scientific literature, has
been impressive. There has been a proliferation
of published studies of disease burden, carried
out at global, regional and national levels (part A
of I 'ig. 2.1) (31). Questions about the scale of a
health problem are not always about disease
burden (Bmx 2.2 and ISox 2.3), but studies of this
kind reflect the upward trend in recognizing and
37
Research for universal health coverage
Six measures of the growth in research that would support universal health coverage
Fig. 2.1.
B. Setting research priorities
A. Evaluating disease burden
120-
300c
5
3
250-
e.
'o
150-
"I
100 -
is
2:
200 -
80-
60-
■
500-Lt-
40-
Mill1111
20-
-loonnni;,,
1995
2005
2000
q_
2-
- 1.0
5
s
1-
- 0.5
Cu
2
2004
2006
I
o
1
Si
|---------------------- |
■,
IWa^SKFul
Africa
• The Americas
Asia
Eastern
Mediterranean
Fl 1996-2002
I
| 2003-2008
F. Open access publishing
7
6
5
4
3
2
1
2.5 -i
^3
-1.6 O
2 S’
1-1.2 If
o 3^
-0.8
_q 4
c
'—- Z)
0
2002
2010
200-
0
-A 0
2008
E. Generating evidence
2000
2005
^400-
High-income countries: high investment, stable
® Low-middle-income countries: low investment,
rising 5%/year
ii
2000
600-1
g
0
S §
1995
D. Conducting systematic reviews
r 1-5
2002
01990
2010
31
2000
mnnrinnnnnl r
■|
C. Investing in solutions
ro
100-
s
is
1990
e
O
2004
2006
2008
-AO
2010
High-income countries, growth +2%/year
@ ' Middle-income countries, growth +9%/year
Low-income countries, growth +4%/year
I
I
2.0-
r40
-30
1.5-
-20
1.0-10
0.50
2004 2005 2006 2007 2008 2009 2010 2011
0
— Publications
— Sources
GDP, gross domestic product; HIC, high-income countries; LIM, low-income countries; LMIC, low- and middle-income coun
tries; MIC, middle-income countries; OECD, Organisation for Economic Co-operation and Development; R&D, research and
development.
Sources: A and B: www.ncbi.nlm.nih.gov/pubrned; C: OECD; D: Law et al. (30); E: The World Bank; F: www.base-search.net.
38
§
I
sI
Chapter 2
evaluating health challenges. The improving evi
dence about major causes of illness and death is
a basis for setting research priorities, and pub
lished prioritization exercises in this area have
increased by a factor of five since 1990 (part B of
1 -( . 2.1) (32). Standard approaches to setting pri
orities are gaining acceptance worldwide (33, 34).
To turn research priorities into research
studies requires funding. Investment in R&D
has remained static in relation to economic
output - i.e. gross domestic product (GDP) - in
high-income countries. But in low- and middle
income countries (mostly the latter), domestic
investment in R&D has been growing 5% per year
faster than economic output (part C of :
i).
This strong upward trend, which is most visible
in China and other eastern Asian countries,
emphasizes the importance placed on research
by emerging economies (4). Tliis trend applies to
R&D generally, but it is likely to benefit health
tco. In the specific area of health policy and
systems research, a 2010 survey of 96 research
institutions in low-income countries found that
funding has been steadily increasing, notably to
institutions in sub-Saharan Africa (35, 36).
The global financial downturn of the late
2000s slowed the rise in R&D funding lor tech
nologies to control “neglected” diseases, which
mainly affect low- and middle-income coun
tries. Yet funding was not significantly cut: on
aggregate, public funding remained more or less
stable between 2009 and 2011 because decreases
from philanthropic organizations were offset by
greater investment from industry (37).
These flattening budgets, set against the
persistently large burden ol communicable dis
eases in lower-income countries, have stimulated
thinking that is beginning to break the mould of
traditional R&D. More products are now being
created through partnerships between universi
ties, governments, international organizations
and the private sector. In some instances, com
petition is being replaced by collaboration, and
explicit links are being made among the different
The growth of research for universal health coverage
organizations involved in discovery, develop
ment and deployment of new technologies. The
Drugs for Neglected Diseases initiative (DNDi)
is working with three pharmaceutical companies
to develop a new anthelmintic drug. Together,
Health Canada, the Drugs Controller General
of India and WHO facilitated the registration
and use of a new meningitis A vaccine for Africa
(MenAfriVac) in a matter of months (38). The
evolving structure of research partnerships is
helping to prepare the ground for a new genera
tion of medical products and services, such as
those oriented to “precision or peisonalized
medicine.
Not only is more research being done in more
creative ways, but the process of doing research
is also becoming more robust. One illustration
is the growth in systematic reviews (of health
systems evidence in part D of big. 2.1), longadvocated by the Cochrane Collaboration (www.
cochrane.org) (39). In recent years, the growth in
the number of these reviews has been similar in
high-income and lower-income countries. There
are, however, large differences between indi
vidual lower-income countries; comparing the
periods 1996-2002 and 2003-2008, the number
of systematic reviews of health systems increased
3-fold for Africa and 110-fold for Asia (30).
There are now so many systematic reviews of
clinical trials that it has become difficult to track
and assimilate the huge volume of information.
The surfeit of data has led to a plea to devise more
efficient ways of keepi ng up with the evidence (40).
More research is generating more evidence
to guide policy and practice (part E of Hg - I).
On the African continent, research productivity,
measured by publications in 19 countries (domi
nated by Egypt and South Africa), grew at an aver
age rate of 5.3% per year between 1990 and 2009,
but that growth was far quicker during the final
five years of this period (26% per year). Research
productivity in Africa, by African scientists, has
been stimulated by concern about HIV/A1DS,
tuberculosis and malaria, and is linked to the
39
Research for universal health coverage
The share of internationally co-authored science and engineering articles worldwide,
Fig. 2.2.
by country, 2000 and 2010
□ 2010
o
10-
3
oj
2-^
.2
TO
gll
_C
_____ j________ __
1
United States
of America
United Kingdom of
Northern Ireland
and Great Britain
____
Japan
Russian Federation
China
__
Brazil
n
India
Note: The USA and United Kingdom had high but stable levels of co-authurship; researchers based in the USA were co-authb s
of 43% of the total number of internationally co-authored articles in 2010. The share of co-authorships in Brazil and India has
been low and is growing slowly; in China they have been low but are growing quickly (4).
establishment of national public health training
institutions (41). A 26-country survey of health
systems research found that the number of inves
tigations increased over the past decade, and that
decisions about health policy were based on evi
dence in about two thirds of the sampled coun
tries (Chapter 4) (42). Health policy and systems
research is beginning to flourish although, in the
view of some commentators, it is not yet a fully
coherent enterprise (29, 43).
More research is being published as a result
of international collaboration. While it is still the
case that a minority of studies are led by scientists
from low- and middle-income countries, these
researchers are increasingly working in inter
national partnerships. China is the outstanding
example: the global share of co-authorships held
by Chinese researchers increased from 5% in
2000 to 13% in 2010 (Fig. 2.2). Among the seven
countries for which data are shown in Fig. 2.2
(Brazil, China, India, Japan, Russian Federation,
United Kingdom of Great Britain and Northern
Ireland, United States of America), China
enjoyed the biggest increase in co-authorships
in both absolute and relative terms.
40
As the number of publications grows, more of
the results are becoming freely available through
“open access” arrangements that give unre
stricted access via the Internet to peer-reviewed
journal articles (part F of I ; ' -1) (44). In the
same spirit, the HINARI Access to Research in
Health Programme was created in 2001 to p ovide wider access to the world’s biomedical lit
erature, although the scheme requires affiliation
to a registered institution. HINARI is now one of
the four programmes comprising Research41 ife
(along with Research in Agriculture, Research in
the Environment, and Research for Development
and Innovation). By the tenth anniversary of
this programme, Research4Life had provided
researchers at 6000 institutions in 100 develop
ing countries with free or low-cost access to 9000
journals on health, agriculture, environment
and technology (45).
The scope of research for health is widen
ing too. As the world contemplates the transi
tion from the MDGs to a post-2015 development
agenda, greater emphasis is being placed on
research carried out in all sectors that aflect
health (the "health in all sectors” approach) - e.g.
Chapter 2
Sox 2.6.
The growth of research for universal health coverage
Environmental health research, "health in all", and universal health coverage
Roughly one quarter of the global burden of disease can be attributed to modifiable environmental risk factors (46).
This is an approximate estimate because our understanding of the links between our environment and health, and
of how to mitigate the risks to health, is far from complete. Further research therefore needs to cover a wide range
of investigations from the evaluation of risks associated with environmental exposures, through mechanisms for
orevention, to ways of incorporating these measures into the delivery of services (Box ,2.2). The solutions that reduce
environmental health risks will come from both within the health sector and beyond it.
Environmental risk factors are physical, chemical and biological hazards that directly affect health, and also fac
tors that exacerbate unhealthy behaviours (e.g. physical inactivity). Environmental risk factors include unsafe
drinking-water and poor sanitation and hygiene, which are the sources of infections that cause diarrhoeal diseases.
According to one global assessment of risk factors for ill-health, unimproved water and poor sanitation have fallen
in importance in the ranking of risk factors but nevertheless accounted for 0.9% of all years of healthy life lost (i.e.
disability-adjusted life-years, or DALYs) in 2010 (47). Environmental risk factors include indoor air pollution, largely
from the use of solid fuels in households, and outdoor air pollution, which facilitate and exacerbate lower respiratory
infections. Household air pollution was a leading risk factor for ill-health in sub-Saharan Africa and southern Asia
in 2010 (47). Risk factors include injuries arising from hazards in the workplace, from radiation and from industrial
accidents. They also contribute to the transmission of vector-borne diseases: malaria is associated with policies and
practices on land use, deforestation, water resource management, settlement siting and house design.
Universal health coverage explicitly includes preventive measures (Chapter 1) where their primary purpose is to
improve health, and yet the opportunities to prevent ill-health have often been overlooked, both within and outside
the health sector. The "Health in the Green Economy" project provides numerous examples of research that identify
environmental health benefits that come from mitigating climate change. These illustrate how policies whose
primary objective are not to achieve universal health coverage but rather to confront environmental threats can
yield major health co-benefits. The health system can play an important role in advocating for such-policies, which
are complementary to effort to promote universal health coverage. Two examples of sectors in which research has
demonstrated health co-benefits are urban transport and housing:
*
Urban transport. More investment in public transport (buses and trains), along with networks for cyclists
and pedestrians, can lower urban air pollution, encourage physical activity, lessen traffic injuries, and reduce
the costs of mobility for poor and vulnerable groups (48). Studies of urban commuters in Shanghai and
Copenhagen, for instance, have shown that cyclists have 30% lower mortality rates, on average,.than other
commuters (49).
Housing and home energy systems. Better home insulation, plus energy-efficient, smoke-free heating and
cooking systems and indoor ventilation, can reduce respiratory diseases, including asthma, pneumonia and
tuberculosis, as well as reducing vulnerability to extremes of heat and cold. Large savings in health costs from
asthma and other respiratory illness were observed in follow-up studies of home insulation in low-income
homes in New Zealand. The promise of immediate health gains helped drive large-scale government invest
ments in home improvements in New Zealand. To these short-term gains must be added the economic value
of carbon savings that will be realized in future (50).
Economic research can help define where technological development yields the greatest health benefits for the least
cost, driving a virtuous circle of "healthwise" green investments. For instance, improved stove and fuel technologies
used in the poorest households in Africa or Latin America are likely to be cheap and effective, butthe best available
technologies have yet to be evaluated. Shifting away from diesel fuel for transport and energy not only reduces
exposures to harmful carcinogens but also cuts climate-changing black carbon. ,
Following the Rio +20 United Nations Conference on Sustainable Development, a dialogue among governments,
United Nations agencies, and civil society will lead to a new set of development goals (57, 52). This is an opportunity
to highlight the connections between policies that affect health via different sectors of the economy - not just
environment and health, but also agriculture, education, finance, social policy and health. Coupled with this is the
need for appropriate data and indicators (see also Box 1.2). The research underpinning "health in all sectors" is, in
the broad definition of this report, research for universal health coverage.
41
I
Research for universal health coverage
agriculture, education, environment and finance
(Box 2.6) (51).
Finally, there is an increasingly energetic
debate about how to answer questions about
public health; this is a sign of a healthy research
environment (53). One area of discussion con
cerns the study of health systems. Victora and
co-workers have argued that randomized con
trolled trials, while essential for measuring the
efficacy of clinical interventions, are unsuitable
for public health interventions in which there
are numerous steps between the possible cause
under investigation and the final effect, and
where one or more of these steps depends on
local circumstances (54). By contrast, Banerjee
& Duflo have championed the use of randomized
controlled trials rigorously to test ideas about
how to achieve higher coverage of interventions
that depend on human behaviour (55, 56). 'Hie
discussion points to a fundamental truth about
randomized controlled trials: a controlled exper
iment yields rigorous results under the condi
tions of that experiment. However, whether the
result applies beyond the experiment depends on
the nature of the system under investigation. In
terms of consistency from one setting to another,
human biochemical pathways, for instance, are
likely to be more consistent than some human
behaviours (see also Chapter 3).
None of the rising indicators of research
activity, in any setting, is a guarantee of inter
ventions that will help to reach universal health
coverage. However, universal coverage cannot be
achieved without technology, systems and ser
vices, and research is the mechanism by which
the hardware and software are created.
. Growing unevenly
Research is on the rise, and the results are deliv
ering benefits for health worldwide. However,
the process of doing research - setting research
priorities, building capacity, formulating and
adopting standards of practice, and translating
42
results into policy ("•■ ■■
) - is certainly not of
a uniformly high standard. In many settings,
research practice falls well short of the global
ideal. But by defining the achievements, and not
merely the defects, we shall be in a stronger posi
tion to exploit the potential that research offers.
Any survey of the growing strengths in
research also exposes the residual weaknesses.
In view of the environment needed to carry out
research and the sequence of steps in the research
cycle, research programmes around the world can
be strengthened in a number of areas (16 '
'The number and proportion of older people
are increasing in populations around the world,
and yet some prominent causes of illness among
the elderly are poorly defined. In countries in the
Americas Region, for instance, there is a huge
variation in reported death rates from Parkinson
disease. This variation is more likely to be
explained by diagnostic and reporting inaccu
racies than by real differences in death rates,
but the truth about Parkinson disease will be
determined only by systematic investigation. In
general, data defining the frequency and health
consequences of mental and nervous system dis
orders are poor (57). Much better information is
needed to determine how many people are at risk
of these disorders or are eligible for treatment,
and who they are and where they live (58-60)
The growth in research effort, addressing
many different questions in a wide variety of
settings, is bound to be uneven. There are now
hundreds of published studies that focus on spe
cific diseases and conditions - across a range of
communicable and noncommunicable diseases
and injuries (61). In contrast, there are relatively
few studies that attempt to set research priorities,
across all aspects of health, from the perspective
of national governments (Chapter 4) (62, 63).
Tais is because few appraisals of research needs
have been initiated by national governments,
even though such appraisals are a vital part of
planning for universal health coverage.
National research portfolios are mostly
unplanned, but they may not be wholly
Chapter 2
The growth of research for universal health coverage
Private- and public-sector investment in R&D, classified as basic, applied and
Fig. 2.3.
a,"‘“'’"ked““
9
order of gross national income (left to right)
g
=
Ig_
I
I
'o
so
100-1
I
| Applied
I-1 Experimental
80“
60-
40-
RT
200
J___
Malawi
cz I—i FMozambique
IUganda
United Republic
of Tanzania
Nigeria
I
South Africa
R^D, research and development.
see :
1 lie four poorest countries focused on applied research. The two wealthiNote: For definitions of types of research,
ert, Nigeria and South Africa, had a more balanced portfolio (35).
♦
unbalanced. The 2010 African Innovation
CAitlook found that four lower-income countries
focused on applied research, whereas two lichei
ones spread resources more evenly across basic,
applied and experimental studies (
)• A
j -lore systematic look at research in these coun
tries might find that the balance is right, or that
i: should change. The point is that some questions
about universal health coverage have answers that
< re widely applicable (e.g. the efficacy of a drug
against a defined medical condition), but others
need local solutions (e.g. how best to deliver the
drug to all who need it) (64, 65). For this reason,
all nations need to become producers of research
as well as consumers of it. Local expertise and
ocal processes, initiatives and institutions should
oe valued rather than bypassed (64, 66).
Raising funds is one of the challenges in
turning research priorities into research studies,
and the constraints on fundraising come in vari
ous forms. At the level of national wealth, gross
national income (GNI) is an empirical measure
of research potential. Ihe data in
show
how research productivity increases dispioportionately with national wealth. As a rule of
thumb, for every 10-fold increase in GNI per
person, the number of scientific publications pei
person increases by a factor of about 50 at best
(Piu. 2.4, diagonal line). This disproportionate
i ncrease also holds for other measures of research
output such as the number of researchers and the
number of patents per head of population.
These data also show that while some coun
tries exploit the empirical maximum (lymf?
close to the diagonal line in big. 2.4), many do
not (thus falling below the diagonal line) (67).
Some of the countries that fall below the line
are nations with small populations (< 20 mil
lion), who may choose not to invest in research,
but not all underinvestors are small nations. By
comparing countries, it can be said that there
is much unfulfilled research potential, given
national wealth. Thus greater wealth appears
to open up the potential for research, but other
factors are needed to fulfil that potential. Vv hile
those factors need to be understood, it is cleai
that nations and their governments have a
choice about how much to invest in reseat ch
and about what research topics should be given
priority.
43
Research for universal health coverage
National wealth facilitates, but does not guarantee, national research productivity
Fig. 2.4.
100-
g
g.
g
g
©
®
Population >20 million
Population <20 million
------ Maximum productivity
| Research potential
a
10-
aS
&
1-
S ®
«
0.1-
o.oi.H^
o.i
f
1
a
't
c
,o
IS
0
©
$ ®
' Q.
<>
io
i
100
GN I per person ($ PPP, thousands)
♦
PPP, purchasing power parity.
Note: For every 10-fold increase in gross national income (GNI) per person, die number of scientific publications (per person)
increases by a factor of about 50 at best (actually by 1O5/3 = 46, diagonal line).
Each point represents a single country. While some countries exploit maximum productivity, lying close to the diagonal line,
many lie well below it, indicating that there is unfulfilled research potential, given their national wealth. Some of these coun
tries have smaller populations (< 20 million, blue circles), but not all. The unfulfilled potential for research in one large country
(Philippines) is indicated by the vertical arrow.
Source: The World Bank, latest data 2009.
Private companies engaged in R&D in lowincome countries frequently cite lack ol funding
and the shortage of skilled researchers as major
barriers to innovation (35). The shortage of trained
researchers emerges as a general constraint in
R&D, but it is also found in specific areas such as
health systems research (36'). A disincentive for
private technological research is the domination
of R&D by a few established enterprises, with
apparently few opportunities for newcomers. A
further impediment in low-income countries is
poor access to information on technologies and
markets for the products (35).
There are also disincentives linked to intel
lectual property rights. 'The protection of new
ideas as intellectual property encourages the
development of new medicines and technologies.
44
However, the products are sold to people who can
afford them, often excluding those in greatest
need. Both free knowledge (as a public good) and
highly restricted knowledge (limited by its pro
prietary nature) can be obstacles to improving
health; the former may discourage innovation
and the latter may limit access to the products
of innovation. “Market failures” are the enemy
of universal health coverage, and the facts about
market failure in different settings present some
critical questions for research (Bo\ 7) (7/, 72).
In this context, WHO expert working groups
have sought to promote R&D in ways whereby
market failures are rectified by the product.on
of public goods (67, 68, 73).
'The problem of low investment in research
within low-income countries (lag. 2.1) is amplified
Chapter 2
Box 2.7.
The growth of research for universal health coverage
The Global Strategy and Plan of Action on Public Health, Innovation and
Intellectual Property
Born out of concern among low- and middle-income countries about inequitable access to the products of research,
me Commission on Intellectual Property Rights, Innovation and Public Health was e^blishec
and access to medicines. The work of the Commission led to the Global Strategy and Plan of Achon on Publi.Health,
Innovation and Intellectual Property (GSPA-PHI), which was approved by the World Health Assembly
T he GSPA-PHI consists of eight elements that aim to promote innovation, build capacity, improve access and mobilize
resources. The eight elements are:
’. prioritize research and development needs;
2. promote research and development;
3. build and improve innovative capacity;
I. transfer of technology;
5. apply and manage intellectual property to contribute to innovation and promote public health;
6. improve delivery and access;
7. promote sustainable financing; and
8. establish monitoring and reporting systems.
Work is under way in several areas related to GSPA-PHI, such as the local production of medical products and
development (element 7) through WHO expert working groups; and the establishment of monitoring and repot mg
systems (element 8), such as research observatories (Chapter 4) (69, 70).
Effective implementation of the GSPA-PHI depends on the robustness of the national health research system in
each country Overtime, monitoring and evaluation will reveal whether the GSPA-PHI leads to mcrea^ec
and more affordable and equitable access to the benefits and products of research, especially in low- and middle
income countries.
by a bias against the type of research that would
benefit these countries. In total, more■ than
t---USS 100 billion is spent globally on health
research each year (7/). About hall of this is in
the private sector, mainly in the pharmaceutical
and biotechnology industries, and the products
(>f this research are directed mainly at markets
in high-income countries (7/, 74). Drug develop
ment is a case in point: only 21 of 1556 (1.3%)
new drugs developed over the 30-year period
from 1975 to 2004 were for diseases not found
in high-income countries (75). Despite the per
sistently high burden of infection in low- and
middle-income countries, and the spread of
antibiotic resistance, the development of new
antibiotics lies in the hands of just a few major
pharmaceutical companies (76). More positively,
however, methods of preventing and treating
noncom municable diseases, largely developed
in richer countries, should help to address the
growing burden of these diseases in poorer
countries.
In addition, financial investment in basic
research and in discovery and development (phar
maceuticals and biotechnology) dwarfs investment
in delivery. One survey of 140 health research
funders globally found that most research is directed
at developing new health technologies rather than
at making better use of existing ones (77).
For neglected diseases, an imbalance arises
because investment favours some infections
and diseases over others. Funding for R&D is
45
Research for universal health coverage
predominantly for HIV/AIDS, tuberculosis and
malaria, with relatively little for some other
major causes of ill-health such as dengue, diar
rhoeal diseases and helminth infections (37).
With respect to delivering health care,
research into health services and systems gets
relatively little support and tends to be narrowly
focused. This istrueboth in low- and high-income
countries. In the United Kingdom in 2006,
health services research (included in category 8
in Box .?.2) received between 0.4% and 1.6% of
all research funds allocated by four major fund
ing bodies (78). Although the United Kingdom’s
National Institute for Health Research is helping
to boost funding for research on health services
• and systems, these data show that some impor
tant funding agencies give this area low prior
ity. An observation repeatedly made in a variety
of settings is that too little attention is given to
translating existing knowledge about products
and processes into policy and practice (79-82).
Furthermore, the contribution of the social
sciences to research in this area, going beyond
clinical studies and epidemiology, is commonly
undervalued (2).
Even when research funds are provided as
official development assistance to low-income
countries, they are not seen as uniformly ben
eficial. Tn the opinion of some African research
ers, external aid undermines efforts to convince
African governments to spend more money on
research (82). In the domain of health policy and
systems research, a drawback of external funding
is that it tends to focus on operational matters,
such as how to scale up priority services. On the
one hand, external donations to carry out opera
tional and translational research satisfy a press
ing need. Yet on the other hand, less attention is
given to deeper, structural questions about the
functioning of health services - questions that
ask, for example, how to promote accountability
in service delivery or how to engage local stake
holders (2). Observations of this kind highlight a
particular challenge in funding research, which
is to ensure that the priorities of international
46
donors are aligned with those of national health
services, in keeping with the Paris Declaration
on Aid Effectiveness (2005), the Accra Agenda
for Action (2008) (83), and the wider goal of
effective development as promoted by the Busan
Global Partnership for Effective Development
Cooperation (84).
In assessing the strengths and weaknesses
of research, the virtues of tracking research
investments, practices and applications quickly
become clear. Such data are absent or incomplete
for many countries. To build most effectively on
existing foundations, all nations should take a
systematic approach to the mapping, monitoring
and evaluation of research (85, 86).
The value of health research
Adding to the impetus to do more research is
a growing body of evidence on the returns on
investment, albeit mostly from high-income
countries. Notwithstanding some contentious
methodological issues - such as how to value
health gained, whether in terms of increased
survival or improved quality of life - there is
mounting quantitative proof of the benefits of
research to health, society and the economy (87).
Exceptional returns, a report prepared for
Funding First in the USA, calculated large gains
from reductions in mortality, especially due to
cardiovascular disease (88). Based on a high figure
for the value of a life, the monetary returns from
investments in research were valued at USS 1.5 ti illion annually between 1970 and 1990, one third of
which was attributed to research into newdrugsand
treatment protocols. For research on cardiovascu
lar disease, the returns on investment were approx
imately 20 times the annual expenditure. Access
Economics carried out a similar study in Australia,
finding that every dollar invested in Australian
health research and development yielded, on aver
age, AUS$ 2.17 (approximately US$ 2.27) in health
benefits. This rate of return was surpassed only in
the mining and retail sectors (89).
Chapter 2
Hie benefits of randomized controlled trials
of drug treatments and clinical procedures,
funded by the National Institute of Neurological
Disorders and Stroke in the USA, have also been
evaluated in monetary terms {90). The assess
ment included 28 trials carried out at a total cost
of USS 335 million. By valuing a quality-adjusted
lile year (QALY) as the same as gross domestic
product (GDP) per capita, the projected net ben
efit to society after 10 years was USS 15-2 billion,
indicating a yearly return on investment of 46%.
In the United Kingdom, a study of car
diovascular disease and mental health research
separated the value of the gain to health (QALYs
valued at £25 000, as used in the United
Kingdom’s National Health Service) from the
gain to the economy (GDP), with the latter result
ing from the wider economic effects of public and
charitable research spending, including the stim
ulus to privately-funded research (87). The yearly
rate of return with respect to the health gain was
9 7o for cardiovascular disease research, and 7% for
mental health research. The yearly rate of return in
terms of GDP was 30% for all medical research in
the United Kingdom. Putting these together gave
a total yearly rate of return of 39% for cardiovas
cular disease and mental health research in the
United Kingdom over a period of 17 years.
Not all the benefits of research can be, or
should be, measured in monetary terms (97). To
capture the diversity of benefits from research,
the Payback Framework evaluates outcomes
under five headings: knowledge, benefits to
future research and research use, benefits from
informing policy and product development,
health and health sector benefits, and economic
benefits (97-96). This model of assessment has
logical appeal because, while acknowledging
complexities and feedback loops, it tracks the
evolution of a research idea from its inception,
through the research process into dissemina
tion, and on to its impact on health, society and
•he economy (92, 97). It parallels the research
cycle depicted in Box T h
The growth of research for universal health coverage
The Payback Framework has been used in
Ireland, for instance, to assess the benefits of
a pilot project on the early detection of psy
chosis (98). The study described how the early
intervention services, contributing to the Iiish
mental health service, could reduce the dura
tion of untreated psychosis, the severity of
symptoms, suicidal behaviour and the rate of
relapse and subsequent hospitalization. The
study suggested that early detection reduces
the cost of treatment, saves lives, and is highly
regarded both by those who use the service and
by their families.
Besides evaluating the returns on research,
one should also consider the source of the initial
investment and how it affects access to the prod
ucts of the research. For instance, public-sector
research institutions in the USA do more applied
research than has sometimes been thought. In
one domain, they contributed to the discovery of
9-21% of all drugs involved in new-drug applica
tions that were approved between 1990 and 2007
(99). Publicly funded research in the USA also
tends to discover drugs that are expected to have
disproportionately large clinical effects.
A conspicuous feature of studies that assess
the economic value of research is that, according
to one review, none have yet been carried out in
low- and middle-income countries. A key con
cern, therefore, is how far such countries can rely
on medical research carried out elsewhere (97).
Conclusions: building
on the foundations
Research for universal health coverage is not a
luxury; rather, it is fundamental to the discov
ery, development and delivery of interventions
that people need to maintain good health (/00).
If “the best days for public health are ahead of us
it will be, in part, because the best days for health
research also lie ahead {101).
47
Research for universal health coverage
The 1990 report of the Commission on
Health Research for Development has a legacy
(102). The report generated a wide appreciation
of the shortfall in research investment and of the
fragility of health research in low- and middle
income countries. More than 20 years later, it
is clear that research for health is on the rise
worldwide. Health problems are better defined
than they were two decades ago. There are more
funds and greater research capacity to address
key questions about health. Investigations are
increasingly following best practice in design,
ethics and the reporting of results. There are
more research institutions and networks, and
there is more national and international col
laboration, “south to south” as well as “north to
south” (103). The review of the research land
scape in this chapter is not yet a story of research
potential fulfilled but it shows the strengthen
ing foundations on which better research pro
grammes can now be built.
Creativity and imagination are central to
the research enterprise. A premise of this report
is that, wherever people have health problems,
new ideas will be proposed to help solve them.
The constraints are in the means of turning these
ideas into dependable, practical applications.
Even research of the highest quality does not
automatically translate into better health if the
findings are not implemented.
To better understand the task ahead, there
is a need systematically to assess the strengths
and weaknesses of research for health, country
by country, worldwide. When public money is
being spent on research, there should be mecha
nisms for debating research priorities, for devel
oping the capacity to carry out research, for
setting standards, and for translating the results
into policy and practice. In judging the priorities
for spending, there should be a consensus on tne
balance of activities related to the research eye e:
measuring the size of the health problem; under
standing its cause; devising solutions; translating
the evidence into policy, practice and products;
and evaluating the effectiveness of interventions
after implementation. Further, for any problem
studied in any given setting, there should ?e
discussion on the methods of investigation, the
significance of the findings, and the inferences to
be drawn from them.
The means of creating a healthy research
environment and of judging its performance
are described in greater detail in Chapter 4.
However, before considering how to establish
effective research programmes, Chapter 3 shows
how research can address some of the big ques
tions about universal health coverage in order to
provide credible answers to inform policy and
practice.
References
1.
2.
3.
4.
5.
6.
7.
8.
Commission on Health Research for Development. Health research - essential link to equity in development. Oxford, Oxford
University Press, 1990.
WHO strategy on research forhealth. Geneva, World Health Organization, 2012. (http://www.who.int/phi/WHO_Strategy_
on_research_for_health.pdf, accessed 23 April 2013).
Research assessment exercise. Guidance on submissions. London, Higher Education Funding Council for England, 2005.
National Science Board. Science and engineering indicators 2012. Arlington, VA, National Science Foundation, 2012.
Humphreys K, Riot P. Scientific evidence alone is not sufficient basis for health policy. BMJ (Clinical Research Ed.),
2012,344:e1316. doi: http://dx.doi.org/10.1136/bmj.e1316 PMID:22371864
Glossary of statistical terms. Paris, Organisation for Economic Co-operation and Development, 2012. (stats.oecd.org/glossary/search.asp, accessed 14 March 2013).
Zachariah R et al. Is operational research delivering the goods? The journey to success in low-income countries. The Lam et
Infectious Diseases, 2012,12:415-421. doi: http://dx.doi.Org/10.1016/51473-3099(11 )70309-7 PMID:22326018
Lobb R, Co Id i tz GA. Implementation science and its application to population health. Annual Review of Public Health,
2013,34:235-251. doi: http://dx.doi.org/10.1146/annurev-publhealth-031912-114444 PMID:23297655
48
Chapter 2
The growth of research for universal health coverage
9.
10.
Translational research. Seattle, Institute of Translational Health Sciences, 2012 (www.iths.org, accessed 14 March 2013).
Alliance for Health Policy and Systems Research. What is HPSR? Overview (web page). Geneva, World Health
11.
12.
Organization, 2011.
Health research classification system. London, UK Clinical Research Collaboration, 2009.
Health research classification systems: current approaches and future recommendations. Strasbourg, European Science
Foundation, 2011.
Pena-Rosas JP et al. Translating research into action: WHO evidence-informed guidelines for safe and effective micronutri
ent interventions. The Journal of Nutrition, 2012,142:197S-204S. doi; http://dx.doi.org/10.3945/jn.111.138834 PMID:22113868
14. Bonita R, Beaglehole R, Kjellstrdm T. Basic epidemiology, 2nd ed. Geneva, World Health Organization, 2006.
15. Guyatt GH et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ
(Clinical Research Ed.), 2008,336:924-926. doi: http://dx.doi.org/10.1136/bmj.39489.470347.AD PMID:18436948
16. WHO handbook for guideline development. Geneva, World Health Organization, 2012.
17. Duclos P et al. Developing evidence-based immunization recommendations and GRADE. Vaccine, 2012,31:12-19. doi: http://
13.
19.
dx.doi.org/10.1016/j.vaccine.2O12.02.041 PMID:22391401
Homer-Dixon T. The ingenuity gap. London, Vintage Books, 2001.
Innovation Prize for Africa. Addis Ababa, United Nations Economic Commission for Africa and the African Innovation
20
Foundation, 2011 (www.innovationprizeforafrica.org , accessed 14 March 2013).
Nakkazi E. Students develop software to monitor unborn babies. AllAfrica, 2012. (allafrica.com/stories/201205240064.html,
21
accessed 14 March 2013).
Dr. Mohan's Diabetes Specialities Centre (web site). Chennai, Dr. Mohan's, 2012. (www.drmohansdiabetes.com, accessed
22
23
14 March 2013).
Priority-setting in health: building institutions for smarter public spending. Washington, DC, Center for Global Development, 2012.
Omachonu VK, Einspruch NG. Innovation in healthcare delivery systems: a conceptual framework. The Innovation Journal:
18.
The Public Sector Innovation Journal, 2010,15(1).
24. The 10/90 report on health research 2000. Geneva, Global Forum for Health Research, 2000.
25. Investing in health research and development. Report of the Ad Hoc Committee on Health Research Relating to Future
Intervention Options. Geneva, World Health Organization, 1996.
26. Macroeconomics and health: Investing in health for economic development. Report of the Commission on Macroeconomics and
27.
2E.
29.
Health. Geneva, World Health Organization, 2001.
Task Force on Health Systems Research. Informed choices for attaining the Millennium Development Goals: towards an
international cooperative agenda for health-systems research. Lancet, 2004,364:997-1003. doi: http://dx.doi.org/10.1016/
50140-6736(04)17026-8 PMID:15364193
World report on knowledge for better health - strengthening health systems. Geneva, World Health Organization, 2004.
Hafner T, Shiffman J. The emergence of global attention to health systems strengthening. Health Policy and Planning,
2013,28:41-50. doi: http://dx.doi.org/10.1093/heapol/czs023 PMID:22407017
3(. Law T et al. Climate for evidence-informed health systems: a profile of systematic review production in 41 low- and middle-income countries, 1996-2008. Journal of Health Services Research & Policy, 2012,17:4-10. doi: http://dx.doi.org/10.1258/
1
**
■
.
.
44
I
.
I
-- ! _l *
jhsrp.2011.010109 PMID:21967823
3k Murray CJ et al. GBD 2010: a multi-investigator collaboration for global comparative descriptive epidemiology. Lancet,
2012,380:2055-2058. doi: http://dx.doi.org/10.1016/S0140-6736(12)62134-5 PMID:23245598
32. Youngkong S, Kapiriri L, Baltussen R. Setting priorities for health interventions in developing countries;a review
of empirical studies. Tropical Medicine & International Health, 2009,14:930-939. doi: http://dx.doi.org/10.mi/j-1365-
3156.2009.02311.x PMID:19563479
33. Viergever RF et al. A checklist for health research priority setting: nine common themes of good practice. Health Research
Policy and Systems, 2010,8:36. PMID:21159163
34. Rudan I. Global health research priorities: mobilizing the developing world. Public Health, 2012,126:237-240. doi: http://
dx.doi.org/10.1016/j.puhe.2011.12.001 PMID:22325672
35. AU-NEPAD (African Union - New Partnership for Africa's Development). African innovation outlook 20W. Pretoria, AU-NEPAD, 2010.
35. Adam T et al. Trends in health policy and systems research over the past decade: still too little capacity in low-income
countries. PLoS ONE, 2011,6:e27263. doi: http://dx.doi.org/10.1371/journal.pone.0027263 PMID:22132094
37. Neglected disease research and development- a five year review. Sydney, Policy Cures, 2012.
33. Mundel T. Global health needs to fill the innovation gap. Nature Medicine, 2012,18:1735. doi: http://dx.doi.org/10.1038/
nm1212-1735 PMID:23223055
49
Research for universal health coverage
Chalmers I, Hedges LV, Cooper H. A brief history of research synthesis. Evaluation & the Health Professions, 2002,25:12-37.
doi: http://dx.doi.org/10.1177/0163278702025001003 PMID:11868442
40. Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic.reviews a day: how will we ever keep up? PLoS
Medicine, 2010,7:e1000326. doi: http://dx.doi.org/10.1371/journal.pmed.1000326 PMID:20877712
41. Nachega JB et al. Current status and future prospects of epidemiology and public health training and research in the
WHO African region. International Journal of Epidemiology, 2012,41:1829-1846. doi: http://dx.doi.org/10.1093/ije/dys189
PMID:23283719
42. Decoster K, Appelmans A, Hill P. A health systems research mapping exercise in 26 low- and middle-income countries: narra
tives from health systems researchers, policy brokers and policy-makers. (Background paper commissioned by the Alliance far
Health Policy and Systems Research to develop the WHO Health Systems Research Strategy). Geneva, Alliance for Health
Policy and Systems Research, World Health Organization, 2012.
43. Sheikh K et al. Building the field of health policy and systems research: framing the questions. PLoS Medicine,
■ 2011,8:e1001073. doi: http://dx.doi.org/10.1371/journal.pmed.1001073 PMID:21857809
44. Global Open Access Portal. Paris, United Nations Educational, Scientific and Cultural Organization, 2012. (http://www.
unesco.org/new/en/communication-and-information/portals-and-platforms/goap/ , accessed 14 March 2012).
45. Making a difference. Geneva, Research4Life, 2011.
46. Pruss-Ustun A, Corvalan C. Preventing disease through healthy environments. Towards an estimate of the environmental
burden of disease. Geneva, World Health Organization, 2006.
47. Lim SS et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk
factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet,
2012,380:2224-2260. doi: http://dx.doi.Org/10.1016/50140-6736(12)61766-8 PMID:23245609
48.. Dora C etal. Urban transport and health. Module 5g. Sustainable transport: a sourcebook for policy-makers in developing
cities. Eschborn, Deutsche Gesellschaft fur Internationale Zusammenarbeit, and Geneva, World Health Organization, 2011.
49. Health in the green economy: health co-benefits of climate change mitigation - transport sector. Geneva, World Health
Organization, 2011.
50. Health in the green economy: health co-benefits of climate change mitigation - housing sector. Geneva, World Health
Organization, 2011.
51. Sustainable development goals. New York, United Nations, 2013. (sustainabledevelopment.un.org, accessed 14 March 201 ’■).
52. Haines A et al. From the Earth Summit to Rio+20: integration of health and sustainable development. Lancet,
2012,379:2189-2197. doi: http://dx.d0i.0rg/l0.1016/S0140-6736(12)60779-X PMID:22682465
53. Gilbert N. International aid projects come under the microscope. Nature, 2013,493:462-463. doi: http://dx.doi.
39.
org/10.1038/493462a PMID:23344337
54. Victora CG, Habicht JP, Bryce J. Evidence-based public health: moving beyond randomized trials. American Journal of Pubic
Health, 2004,94:400-405. doi: http://dx.doi.Org/10.2105/AJPH.94.3.400 PMID:14998803
55. Banerjee AV, Duflos E. Poor economics. New York, NY, PublicAffairs, 2011.
56. Duflo E. Rigorous evaluation of human behavior. Science, 2012,336:1398. doi: http://dx.doi.org/10.1126/science.1224965
PMID:22700919
57. Eaton WW et al. The burden of mental disorders. Epidemiologic Reviews, 2008,30 1-14. doi: http://dx.doi.org/10.1093/epirev/
mxnOll PMID:18806255
58. Yasamy MT et al. Responsible governance for mental health research in low resource countries. PLoSMedicine,
2011,8:e1001T26. doi: http://dx.doi.org/10.1371/journal.pmed.1001126 PMID:22131909
59. Tol WA et al. Research priorities for mental health and psychosocial support in humanitarian settings. PLoSMedicine,
2011,8:e1001096. doi: http://dx.doi.org/10.1371/journal.pmed.1001096 PMID:21949644
60. Challenges and priorities for global mental health research in low- and middle-income countries. London, Academy of Medical
Sciences, 2008.
61. Pang T, Terry RF. PLoS Medicine editors. WHO/PLoS collection "No health without research": a call for papers. PLoS
Medicine, 2011,8:e 1001008. doi: http://dx.doi.org/10.1371/journal.pmed.1001008
62. Tomlinson M et al. A review of selected research priority setting processes at national level in low and middle income
countries: towards fair and legitimate priority setting. Health Research Policy and Systems, 2011,9:19. doi: http://dx.doi.
org/10.1186/1478-4505-9-19 PMID:21575144
63. Alger J et al. Sistemas nacionales de investigacion para la salud en America Latina: una revision de 14 paises [National
health research systems in Latin America: a 14-country review]. Revista Panamericana de Salud Publico, 2009,26:447-457.
PMID:20107697
50
Chapter 2
The growth of research for universal health coverage
64
Victora CG et al. Achieving universal coverage with health interventions. Loncet, 2004,364:1541-1548. doi: http://dx.don
65
66
Pfenning monitoring ond evo/uotion fromework for capacity strengthening in health research (ESSENCE Good practice
ment series. Document TDR/ESSENCE/11.1). Geneva, World Health Organization, MIL
McKee M, Stuckler D, Basu S. Where there is no health research: what can be done to
9
9 p
PLoS Medicine. Z012.9:el001209. doi: http://dx.doi.org/10.1371/journal.pmed.1001209 PMID.22545025
Global strategy and plan of action on public health, innovation and intellectual property. Geneva, World Health
67.
68.
Research mid 'development to meet health needs tn developing countries', strengthening global financing and
69.
Report of the Consultative Expert Working Group on Research and Development Financing and Coordinattan. Geneva, World
70. Reseorch^X/opment- coordmatmn and financing. Report of the Expert Working Group. Geneva, World Health
and Public Health. Geneva, World Health Organization, 2006.
, , :nt0iiPrtlininrnnertv and trade
Promotina access to medical technologies and innovation: intersections between public health, mteMp ^rtyond trade.
GeZa Wodd Health Organization, World intellectual Property Organization and World Tradei Organ.zat.or1, 2013.^^^
72
73.
Rottingen J-Aet al. Multi-stakeholder technical meeting on implementation options recomme
y
MA
Chir^SS^E^iobal framework on essential health R&D. Lancet, 2006,367:1560-1561. doi: http://dx.doi.org/10.1016/
75
76
Brafee ?7Race6against IZXTpnew antibiotics. Rulledn of the World Health Organization, 2011,89:88-89. doi: http://
77.
79.
outputs. Tropica/Med/cineS internationai Hea/t/1, 2012,17:1409-1411. doi: http://dx.doi.org/10.1111/jd365 31562012^.030
80.
Brooks A et al. Implementing new health interventions in developing
° 72^X
Central Public Health.. 2012,12:683. doi: http://dx.doi.org/10.1186/1471-2458-12-683 PMID.2290
Bennett S, Ssengooba F. Closing the gaps: from science to action in maternanewbon
d. d health m Africa.
81.
82.
E4
FouTSlevelForum on Aid Effectiveness. Busan, Global Partnership for Effective Development Cooperation, 2011.
,6.
EN/Programs/Evaluation/Pages/default.aspx, accessed 16March 2013).
uauirnirP,Pnrrh what'sit
Health Economics Research Group, Brunel University,Office of Health Economics, RAND Europe M .ca research. What
worth? Estimating the economic benefits from medical research in the UK. London, UK Evaluation Foru^?oP08N
88. First Funding. Exceptional returns. The economic value of America's investment in medical research. New York, NY, Albe
87.
Mary Lasker Foundation, 2000.
51
XxctE - SOCHABA^
({5 (
[So5O
Ko r a m a ng a I a
Bangalore -
y
Research for universal health coverage
89. Exceptional returns: the value of investing in health R&D in Australia II. Canberra, The Australian Society for Medical
Research, 2008.
90. Johnston SC et al. Effect of a US National Institutes of Health programme of clinical trials on public health and costs. Lancet,
2006,367:1319-1327. doi: http://dx.doi.Org/10.1016/50140-6736(06)68578-4 PMID:16631910
91. Yazdizadeh B, Majdzadeh R, Salmasian H. Systematic review of methods for evaluating healthcare research economic
impact. Health Research Policy and Systems, 2010,8:6. doi: http://dx.doi.org/10.1186/1478-4505-8-6 PMID:20196839
92. Donovan C, Hanney S. The 'Payback Framework' explained. Research Evaluation, 2011,20:181-183. doi: http://dx.doi.0rg/IO.3
152/095820211X13118583635756
93. Wooding S et al. Payback arising from research funding: evaluation of the Arthritis Research Campaign. Rheumatology,
2005,44:1145-1156. doi: http://dx.doi.org/10.1093/rheumatology/keh708 PMID: 16049052
94. Hanney S et al. An assessment of the impact of the NHS Health Technology Assessment Programme. Health Technology
Assessment, 2007,11:iii-iv, ix-xi, 1-180. PMID:18031652
95. Oortwijn WJ et al. Assessing the impact of health technology assessment in the Netherlands. International journal of
Technology Assessment in Health Care, 2008,24:259-269. doi: http://dx.doi.org/10.1017/S0266462308080355 PMID:18601793
96. Kwan P et al. A systematic evaluation of payback of publicly funded health and health services research in Hong Kong. B VIC
Health Services Research, 2007,7:121. doi: http://dx.doi.org/10.1186/1472-6963-7-121 PMID:17662157
97. Buxton M, Hanney 5. How can payback from health services research be assessed7 Journal of Health Services Research &
Policy, 1996,1:35-43. PMID:10180843
98. Nason E et al. Health research - making an impact. The economic and social benefits of HRB funded research. Dublin, Health
Research Board, 2008.
99. Stevens AJ et al. The role of public-sector research in the discovery of drugs and vaccines. The New England Journal of
Medicine, 2011,364:535-541. doi: http://dx.doi.org/10.1056/NEJMsa1008268 PMID:21306239
100. Whitworth JA et al. Strengthening capacity for health research in Africa. Lancet, 2008,372:1590-1593. doi: http://dx.doi.
org/10.1016/50140-6736(08)61660-8 PMID:18984193
101. Chan M. Best days for public health are ahead of us, says WHO Director-General. Address to the Sixty-fifth World Health
Assembly, Geneva, 21 May 2012. Geneva, World Health Organization, 2012. (http://www.who.int/dg/speeches/2012/
wha_20120521, accessed 14 March 2013).
102. Frenk J, Chen L. Overcoming gaps to advance global health equity: a symposium on new directions for research. Health
Research Policy and Systems, 2011,9:11. doi: http://dx.doi.org/10.! 186/1478-4505-9-11 PMID:21342523
103. Thorsteinsdottir H, ed. South-South collaboration in health biotechnology: growing partnerships amongst developing coun
tries. New Delhi and Ottawa, Academic Foundation and International Development Research Centre, 2012.
52
Chapter 3
How research contributes to
universal health coverage
rj>
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Chapter 3
«
Key points
56
Insecticide-treated mosquito nets to
reduce childhood mortality
61
Antiretroviral therapy to prevent sexual
transmission of HIV .
63
Zinc supplements to reduce
pneumonia and diarrhoea in young
children
65
Telemedicine to improve the quality of
paediatric care
67
New diagnostics for tuberculosis
69
iO"'
The"polypiH"to reduce deaths from
cardiovascular disease
......... . .................................. •....... '
Combination treatment with
sodium stiboglucoriate.(SSG) and
paromomycin compared to SSG
monotherapy for visceral leishmaniasis
’'''""A
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ill®
&
.
.
fjfe
73
Task shifting in the scale-up of
interventions to improve child survival
75
Improving access to emergency
obstetric care
77
Conditional cash transfers to improve
the use of health services and health
outcomes
79
Insurance in the provision of accessible
and affordable health services
------- ------ -..........
.Affordable health care in ageing
populations
Ill '■ I
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Conclusions: generallessons drawn
from specific examples
.
.
84
...
rsb :
A health worker measures the mid-upper arm circumference of a child at a nutrition centre in Koubigou, Chad.
The yellow on the armband indicates that the child is malnourished (©,.UNICEF/NYHQ2011-2139/Esteve).
v
kiv. »KU*I,.*)..-..-
Key points
H
Research illuminates the path to universal health coverage and to better health. This
chapter illustrates this with 12 case-studies which investigate questions on issues
ranging from the prevention and control of specific diseases to the functioning of
health systems.
Several case-studies show how the path to universal health coverage is linked with
progress towards the health-related MDGs, which concern maternal and child health
and the control of major communicable diseases.
s
Research for universal health coverage addresses questions on three levels. First,
what is the nature of the health problem, e.g. is it disease-related or health-system
related? Second, what specific question is being asked, and where is this question
placed in the cycle of research from understanding causes to applying solutions?
Third, what is the most appropriate study design for addressing the question at hand?
M
The case-studies illustrate the questions on all three levels. In particular, they
highlight the range of methods that are commonly used in health research, from
observational studies to randomized controlled trials.
■ These examples also lead to some general conclusions about research for universal
health coverage. They illustrate the diversity of problems for which research can
offer solutions, the benefits of having evidence from multiple sources, the nature of
the research cycle, the relationship between study design and strength of inference,,
to another, and the link
the challenge of applying research findings from one setting
<
between research, policy and practice.
How research contributes to
universal health coverage
Chapter 2 showed how research for health in general, and for universal health
coverage in particular, has been increasing around the world, albeit unevenly.
Turning now to the findings of research, this chapter illustrates, with selected
case-studies, how research can address a wide range of questions about universal
health coverage and provide answers that can guide health policy and practice.
In selecting and describing the case-studies, we recognize a hierarchy of
investigations on three levels. The first level is about identifying the nature of the
health problem. The focus might be on a specific disease (such as diabetes, hyper
tension, tuberculosis or HIV/A1DS), or on the functioning of an element of the
health system (such as the health workforce, national laboratory network, or fair
ness of a health insurance scheme). Covering both diseases and health systems,
this chapter focuses on research that helps to make progress, not only towards
universal health coverage but also towards achieving the health-related MDGs
and sustaining these goals thereafter. The research examples include questions
about child health (MDG 4) and maternal health (MDG 5), and about HIV/AIDS,
tuberculosis and malaria (MDG 6). The chapter also discusses noncommumcable
diseases, the functioning of health systems, and financial barriers to health care.
Hie second level is about defining the research question, classifying it and
placing it within the cycle of research (Box 2.3). The case-studies in this chapter
are organized according to the classification proposed by the United Kingdom
Clinical Research Collaboration, spanning eight categories from underpin
ningresearch” (i.e. basic or fundamental research) to health policy and systems
research (Box 2.2) (I, 2). The 12 case-studies listed in (able 3.1 are ordered
according to this scheme. This collection of case-studies falls into categories
3-8 in Box 2.2, because “underpinning research” (category 1) and disease
etiology”, (category 2) are less directly relevant to universal health coverage
than the other categories.
The studies in this chapter have been selected to reflect a wide variety ot
situations, approaches and conditions, ranging from the ‘‘prevention of diseases and promotion of well-being” to “health policy and systems research .
Tliey are placed all around the research cycle described in Chapter 2. lhe inves
tigations were done mainly in low-and middle-income countries, wheie the
57
ui
co
Table3.1,
S
(<TJ✓> ’
The case-studies of research for universal health coverage described in this chapter
OJ
Research
Case
classification
study
number (category in
Box 2.2)
1
2
3
4
5
Prevention of
disease and
condi
tions, and
promotion of
well-being
(category 3)
Prevention of
disease and
condi
tions, and
promotion of
well-being
(category 3)
Prevention of
disease and
condi
tions, and
promotion of
well-being
(category 3)
Detection,
screen
ing and
diagnosis
(category 4)
Detection,
screen
ing and
diagnosis
(category 4)
Identified health
problem
Study type
Country
Main findings
Implications for
universal health coverage
2.
C
□
High malaria
transmission and
mortality.
High rates of sexual
transmission of HIV
infections.
Meta-analysis
of household
survey data (3)
Multicountry
randomized
controlled trial
(5)
22 African
countries
Use of ITNs was associated with
reductions in malaria parasitaemia
and mortality in young children.
The evidence supported efforts to scale
up and maintain ITN coverage by show
ing the effect of a proven intervention
in a real-life setting (4).
Nine
countries in
Africa, Asia,
Latin America
and North
America
Early ART initiation significantly
reduced rates of sexual transmis
sion of HIV.
The study supported the strategic use
of ART to reduce the spread of HIV infec
tion and strengthened the evidence
base for the development of new global
policy and guidelines on use of ART for
treatment and prevention of HIV.
Childhood morbidity and mortality
from diarrhoea and
respiratory infections
is high and may be
prevented by zinc
supplementation.
Quality of paediatric
care is often poor in
conflict settings,
Randomized
controlled trial
(6)
Bangladesh
Weekly zinc supplements
protected against episodes
of pneumonia, diarrhoea and
suppurative otitis media, and also
prevented deaths.
This evidence added weight to the
UNICEF/WHO management recom
mendations to use zinc supplements for
diarrhoea. It also showed the additional
benefit of zinc in the management of
respiratory diseases.
Prospective
cohort study
with historical
controls (7)
Somalia
Use of telemedicine technology
improved the quality of paediatric
care in a hospital setting.
Telemedicine could be used to provide
expertise in hard-to-reach and conflictaffected populations that do not have
direct access to health services.
Common diagnostic
tests for tuberculosis
are insensitive and
cannot detect drug
resistance.
Validity
assessment of a
new diagnostic
test (3)
Azerbaijan
India, Peru..
South Africa
Xpert* MTB/RIF, a fully-automated
nucleic acid amplification assay,
provided higher diagnostic sensi
tivity for pulmonary TB and rapid
detection of rifampicin resistance.
WHO recommended the use of the
Xpert" MTB/RIF assay in 2010. By
September 2012,898 Xpertinstruments
had been procured in the public sector
in 73 of the 145 countries eligible for
concessional pricing.
continue^
o
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... continued
Research
Case
classification
study
number (category in
Box 2.2)
6
7
8
9
10
11
Identified health
problem
Study type
Development
of treat
ments and
therapeutic
interventions
(category 5)
Evaluation
of treat
ments and
therapeutic
interventions
(category 6)
Management
of diseases
and
conditions
(category 7)
Randomized
Cardiovascular
controlled trial
disease is a major
noncommunicable
(9)
disease and a global
public health
problem.
Multicountry
Visceral leishmaniasis
randomized
is the second largest
controlled trial
parasitic killer in the
(10)
world after malaria,
but treatment options
are limited.
Multicountry
Lack of qualified
observational
health staff affects
study (77)
coverage of child
survival interventions.
Health policy
and systems
research
(category 8)
High maternal mortality in Africa,
Health policy
and systems
research
(category 8)
Financial barriers
negatively influence
access to and uti
lization of health
services.
Retrospective
cohort study (72)
Systematic
review (13)
Health policy Out-ofpocket expenses Cluster
and systems and
randomized trial
andcatastrophic
catastrophic
research
household
householdexpendiexpendi
(14)
tures are barriers to
(category 8)
achieving universal
health coverage.
Main findings
Implications for
universal health coverage
India
"Polypill" - a single pill containing
a combination of drugs-effeclively reduced multiple risk factors
for cardiovascular disease.
Use of the polypill may reduce
cardiovascular morbidity and death
when integrated with other preventive
activities such as exercise and healthy
diets.
Ethiopia,
Kenya, Sudan,
Uganda
Combination treatment with
SSG and PM was effective, was
of shorter duration and was
associated with reduced risk of
development of drug resistance.
The evidence led to a WHO recommen
dation that SSG and PM could be used
as a first-line combination treatment for
visceral leishmaniasis in East Africa.
Task shifting from health workers
with longer duration of training
to those with shorter duration
of training did not compromise
quality of care forlMCI.
Task shifting is an effective strategy for
strengthening health systems, and for
increasing coverage of IMCI and other
child survival interventions, in under
served and resource-limited areas faced
with staff shortages.
Emergency obstetric care is one way,
among others, to achieve MDG 5 in rural
Africa.
Country
Bangladesh,
Brazil,
Uganda,
United
Republic of
Tanzania
Burundi
Brazil,
Colombia,
Honduras,
Malawi,
Mexico,
Nicaragua
Mexico
Provision of access to emergency
obstetric care was associated with
a rapid and substantial reduction
in maternal mortality in a rural
district.
CCTs increased health service
utilization and were associated
with improved health outcomes.
A public national health insurance
scheme reduced out-of-pocket
expenses and catastrophic expen
ditures, with benefits reaching
poorer households.
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CCT schemes are a financial incentive to
increase demand for and utilization of
health services by reducing or eliminat
ing financial barriers to access.
This national health insurance scheme
led to Mexico celebrating the achieve
ment of universal health coverage in
2011.
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Research for universal health coverage
gap between the present coverage of health ser
vices and universal health coverage is greatest.
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511
In keeping with the realities of doing research,
the evidence is of varying quality and has vari
ably influenced the development or adjustment
of health policies.
For each type of question, the investigation
begins with understanding the problem, proceeds
with the development of a solution, and then eval
uates the feasibility, cost, effectiveness and cost
effectiveness of that solution. Evaluation leads to
fu r t her q u es I ions, a n d so a no t he r c ycle of resea rc h
or evaluation begins (Box 2.3). As the evidence
improves through repeated cycles of research,
changes to policy advice can be expected too.
The third level is about designing the investigation. Tlie task is to select the most appropriate
methods for collecting reliable information in the
most rigorous way, producing evidence that will
answer the research questions at hand and ul imately improve health coverage, either through
the implementation of new interventions or by
developing new policies. Study designs range
from observational investigations that can have
important qualitative components (e.g. among
targeted groups of patients or health care work
ers) to comparisons of interventions in which the
primary outcomes are determined by quantitative
methods (
.) (/5). Some complex designs
mix qualitative and quantitative elements (E5).
The choice of design influences the feasibility, cost
and duration of the study as well as the potential
re 1 i a b 11 i t y (va I i d i t y) a n d u se fu 1 ness. O bser vati on a 1
studies are sometimes quicker, cheaper and eas er
to conduct than formal experiments but may be
less conclusive because they are especially prone to
bias and may ultimately be misleading (Box 2.3),
so there is a compromise in study design, 'lhe
choice of methods may depend on the likelihood
and importance of obtaining results that could
eventually influence health policy.
Emerging from the 12 examples that follow
are some general features of research for univer
sal health coverage. These are identified at the
end of the chapter.
4
Chapter 3
Tatle3.2.
How research contributes to universal health coverage
Overview of research study designs
Studying
Study typeab
Method to organize
the study
Systematic reviews of
experiments'
Experiments using random
allocation (RCTs) or
minimization*6
Experiments using other
al ocation methods
Systematic reviews of
observations w/ or w/o
experiments
Cohort study (prospective or
h storical retrospective)
Primary studies
Systematic search
Enrollees
Assign to study group
using randomization or
minimization
Assign to study group
through other methods
Case-control (retrospective)
Population
Cross-sectional9
Population
Group assessed at a single
point in time
Case series
Patients
Observe and report
Case report
Individual patient
Observe and report
Enrollees
Primary studies
Systematic search
Enrollees or population'
Group by presence or
absence of characteristic such
as risk factor
Group by outcome of interest
How conclusions
are derived
Summarize strength of
evidence
Intervene, measure, follow
and compare
Intervene, measure, follow
and compare
Summarize strength of
evidence
Follow and compare
Compare characterstics (e.g.
exposure)
Assess prevalence of
characteristic and association
with an outcome
Describe treatment and
outcome
Describe treatment and
outcome
RCTs, randomized controlled trials.
The choice of study type frequently depends upon the health care question.
' All studies should be critically appraised for validity (bias and chance) and evaluated for usefulness.
...... —l“d
'“XtallX^Tn'S of adaptive allocation that aims to minimize imbalances between prognostic variables of
patients assigned to different treatment groups.
R .produced, by permission of the publisher, from Stuart ME, Strite SA, Delfini Group LLC (www.delfim.org).
Case-study 1
Insecticide-treated mosquito
nets to reduce childhood
mortality: a systematic analysis
of survey data from 22 subSaharan African countries
"he need for research
By killing or repelling mosquitoes, insecticideireated bed nets (ITNs,
) protect the
individuals sleeping under them from malaria.
By killing mosquitoes, they should also reduce
malaria transmission in the community (4).
Randomized controlled trials conducted
in sub-Saharan Africa in a range of malaria
endemic settings have provided robust evidence
of the efficacy of ITNs in reducing malai ia pai asite prevalence and incidence and all-cause child
mortality (/7, 18). Such trials showed that ITNs
can reduce
i------ Plasmodium falciparum prevalence
among children younger than live years of age
by 13% and malaria deaths by 18%. As a result.
61
Research for universal health coverage
Household use of insecticide-treated mosquito bed nets
Fig. 3.1.
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IB?'
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widespread provision of ITNs became central
to global efforts to control malaria. In 2005, the
World Health Assembly set a target of providing
ITNs to at least 80% of persons at risk of malaria
by 2010. Progress towards this goal has varied
among countries, although several countries in
sub-Saharan Africa scaled up the proportion of
households that own ITNs from almost zero to
more than 60% with support from international
donors (79). There was a dramatic increase in
funding for malaria control from US$ 100 mil
lion in 2003 to USS 1.5 billion in 2010, most of
which was invested in sub-Saharan Africa (4).
Between 2004 and 2010, more than 400 million
bed nets were delivered (290 million since 2008)
- sufficient to cover almost 80% of populations
at risk of malaria in Africa (20).
62
In contrast with the findings of controlled
trials, ITNs may be less effective in routine use
because the insecticidal effect wears off, or nets
may be used inappropriately or become damaged.
The impact of ITNs, as used routinely, on malai ia
and childhood mortality is therefore uncertain.
Study design
A meta-analysis of six Malaria Indicator Surveys
and one Demographic and Health Survey was
carried out to determine the association between
household ITN ownership and the prevalence of
malaria parasitaemia. The reduction in child
mortality was further assessed using data from
29 Demographic and Health Surveys undertaken
in 22 countries, of sub-Saharan Africa (3).
Chapter 3
How research contributes to universal health coverage
Summary of findings
Investigators pooled the results of the individ
ual surveys and found a 20% (95% confidence
interval, CI: 3-35%) reduction in prevalence of
malaria parasitaemia associated with household
ownership of at least one ITN, as compared with
nc ITN. Sleeping under an ITN the previous
night was associated with a 24% (95% Cl: 1-42%)
reduction in the prevalence of malaria parasitae
mia. Ownership of at least one ITN was associ
ated with a reduction in mortality in children
under five years of age of 23% (95% CI: 13-31%),
which was consistent with that seen in the rand
omized controlled trials.
The accuracy of these findings may be affected
by the observational study design. For instance, it
is possible that people who owned ITNs shared
other characteristics that contributed to the reduc
tion in parasitaemia prevalence and childhood
deaths. Possible confounding factors include the
use of anti-malarial drugs, better use and recourse
to health care, and household wealth.
was consistent with that seen in clinical
trials.
This evidence supports continued efforts to
expand and then maintain the coverage of
ITNs.
Towards universal health coverage
Despite the caveats, these findings suggest that
the beneficial effects of ITNs demonstrated in
clinical trials are also obtained in routine use.
As resources for global health become more lim
ited, this evidence should reassure donors and
national programmes that the investments made
so far have been effective in controlling malaria.
Tie efficacy of ITNs is substantially reduced
after 2-3 years due to net damage and the loss of
insecticidal effects, and there is therefore a need
to find ways of replacing or re-impregnating nets
(21). The evidence from this study justifies con
tinued efforts to scale up ITN coverage in subSaharan Africa and highlights the importance
o: maintaining ITN coverage in countries where
they have already been distributed widely.
Main conclusions
Q
Under routine use in African households,
the effectiveness of I'l’Ns in reducing
malaria parasitaemia and child mortality
Case-study 2
Antiretroviral therapy to
prevent sexual transmission of
HIV: a randomized controlled
trial of serodiscordant
couples in nine countries
The need for research
By the end of 2011, more than eight million
people in low- and middle-income countries were
estimated to be receiving antiretroviral therapy
(ART). On the basis of current ART eligibility
criteria (all HIV-infected people with < 350 CD4
cells/uL), these numbers represent a global cov
erage of 56% compared with 6% in 2003 (22).
Despite this achievement, H1V/AIDS con
tinues to impose a major burden on health: an
estimated 2.5 million people were newly infected
with HIV in 2011 and 1.7 million people died
from AIDS (22). It is clear that the HIV/AIDS
epidemic will not be brought under control with
out markedly reducing HIV transmission and
the incidence of new infections.
Study design
In nine countries in Africa, Asia, Latin America
and North America, 1763 couples were enrolled
in a randomized placebo-controlled trial (HPTN
052) in which one partner was HIV-positive and
the other was HIV-negative (i.e. serodiscordant
couples) (5). HIV-infected persons whose CD4lymphocyte counts were between 350 and 550
cells/uL were assigned to receive ART immedi
ately (early ART group) or after the CD4 count
had declined to < 250 cells/uL or after the devel
opment of an AIDS-related illness (delayed ART
63
Research for universal health coverage
group). HIV-uninfected partners were encour
aged to return for all visits to receive counsel
ling on risk reduction and the use of condoms,
for treatment of sexually transmitted infections,
and for management of other medical condi
tions. The primary prevention end point was
HIV transmission in HIV-negative partners.
Fig. 3.2.
HIV transmission linked to
partners within serodiscordant
couples, with respect to the
year since entering the trial, and
according to whether ART was
given early or with a delay (inset)
l.O-i
0.3
0.8-
.0.2
0.6-
0.1
0.4
o.o 4-
Summary of findings
A total of 39 HIV transmissions were observed
(incidence rate 1.2 per 100 person-years; 95% CI:
0.9-1.7), of which 28 were virologically linked to
the infected partner (incidence rate 0.9 per 100
person-years; 95% CI: 0.6-1.3). Of the 28 linked
HIV transmissions, only one occurred in the
early ART group and T1 occurred in the late ART
group, giving a 96% (95% CI: 72-99%) reduction
in the risk of HIV transmission (hazard ratio
0.04; 95% CI: 0.01-0.27, l:ig. J 2). Early ART was
also associated with a reduction in individual
HIV-related clinical events, mainly those'due
to extra-pulmonary tuberculosis (hazard ratio
0.59; 95% CI: 0.40-0.88).
Previous observational cohort studies had
suggested that early start of ART had an HIVprevention effect but this was the first rand
omized controlled trial to establish definitive
proof. The most likely mechanism is sustained
suppression' of HIV in genital secretions. The
study provides strong support for the early use
of ART in serodiscordant couples as one com
ponent of a comprehensive public health strat
egy to reduce the spread of HIV that includes
behaviour change, use of condoms, male cir
cumcision, female ART-based microbicides and
pre-exposure ART prophylaxis.
Towards universal health coverage
Tlie HPTN 052 study was voted "breakthrough
of the year” in 2011 by the journal Science, gal
vanizing efforts to end thd global HIV/AIDS
epidemic (23). In April 2012, WHO issued guid
ance on HIV testing and counselling for couples,
recommending that HIV serodiscordant couples
with CD4 counts > 350 cells/uL should be offered
64
II
I
Delayed
J
0
Early
1
3
2
4
5
0.2-
0.00
—i------------- 1-------------- 1—
1
2
3
4
5
Years since randomization
ART. antiretroviral therapy; HIV, human immunodeficiency
virus.
Adapted, by permission of the publisher, from Cohen et al. (5).
ART to reduce HIV transmission to uninfected
partners (24). WHO also published a program
matic update on the use of ART for treating
pregnant women and preventing HIV infection
in infants, including the use of so-called'Opti m
B+. This option provides ART to HIV-infected
women, regardless of CD4 count, as a simple
strategy to eliminate HIV infection in infants
while at the same time protecting the hea th
of the mother, father and subsequent children.
Malawi was the first country to propose such
an approach, and provided Option B+ to over
35 000 HIV-infected pregnant women in the first
12 months of implementation (25). HPTN 052
now provides additional, strong scientific justi
fication for this intervention. In mid-2012 WHO
released a discussion paper on the strategic use
of antiretroviral drugs to help end the HIV
Chapter 3
How research contributes to universal health coverage
epidemic, providing the rationale for develop
ing new consolidated global ART guidelines in
2013 which will emphasize the efficacy of ART
foi both treatment and prevention of HIV (26).
A series of questions remain to be answered
before this intervention can be taken to scale.
Among them are whether HIV-infected people
who are asymptomatic will be willing to take
ART for prevention, whether this approach will
increase the risk of drug resistance, and how
health services will cope with the added costs
and burden of health care.
Main conclusions
°
n
H
The provision of ART early in the course of
HIV infection reduces sexual transmission
of the virus between members of serodiscordant couples.
Early ART can be used as part of a public
health strategy to reduce the incidence and
spread of HIV infection.
These research findings have indirectly
strengthened the evidence for other com
plementary approaches to the prevention
of HIV infection, including prevention of
vertical transmission of HIV from moth
ers to children.
Case-study 3
Zinc supplements to reduce
pneumonia and diarrhoea in
young children: a randomized
controlled trial in an urban, lowincome population in Bangladesh
he need for research
Zinc is a vital micronutrient in humans for
protein synthesis and cell growth. Zinc defi
ciency is highly prevalent in low- and middlemcome countries and affected populations are
at an increased risk of growth retardation, diar•hoeal diseases, respiratory tract infections and
malaria. Zinc deficiency may be associated with
around 800 000 excess global deaths annually
among children under five years of age, includ
ing deaths attributable to diarrhoea (176 000),
pneumonia (406 000) and malaria (176 000) (27).
Micronutrient supplements (such as zinc) are
therefore potentially important interventions in
the context of reaching MDGs 4, 5 and 6.
Several hospital- and community-based ran
domized trials have shown the beneficial effects
of zinc supplementation in reducing the number
of episodes of diarrhoea and pneumonia as well
as reducing the severity of illness (28, 29). Given
the benefits of zinc supplementation, the United
Nations Children’s Fund (UNICEF) and WHO
issued a statement in 2004 that all children with
diarrhoea in developing countries should be
treated with zinc (30).
However, several questions remain. Research
on zinc supplements tor the prevention of diar
rhoea and pneumonia had mostly included chil
dren older than two years of age, while younger
children might in fact be more vulnerable to such
morbidity. What, therefore, would the effect of
zinc supplementation be in younger children? In
most of the previous studies, zinc was given on a
daily basis, and this might be far less acceptable
or feasible than a once-weekly dose. In addition,
long-term intake of zinc could adversely affect
iron and copper metabolism, both of which are
also essential micronutrients. It was felt that
answers to these questions would help guide
international policy on the use of zinc.
Study design
A randomized controlled trial was conducted
among a poor urban population in Dhaka,
Bangladesh, to determine if a large weekly dose of
zinc (70 mg) would reduce the frequency of clini
cal pneumonia, diarrhoea, and other morbidity
in children younger than two years of age (6). The
effects of zinc on growth, haemoglobin concen
trations and serum copper were also measured.
Children aged from 60 days to 12 months were
randomly assigned zinc or placebo orally once
65
Research for universal health coverage
Table 3.3.
Number of diagnoses made in clinics by medical officers in the zinc and placebo
groups, Dhaka, Bangladesh
Zinc
(child-years = 427)a
Placebo
(child-years = 511)a
Relative risk
(95% confidence interval)
P-value
Diarrhoea
Upper respiratory infection
1881
4834
232
0.94(0.88-0.99) .
0.92 (0.88-0.97)
0.88 (0.79-0.99)
0.030
Reactive airways disease or
bronchiolitis
Suppurative otitis media
Pneumonia
Severe pneumonia
2407
6294
314
572
286
42
14
0.58(0.41-0.82)
0.83 (0.73-0.95)
0.51 (0.30-0.88)
0.002
0.004
0.016
0.013
Death
394
199
18
2
0.15 (0.03-0.67)
0.001
0.042
* Indicates child-years of follow-up.
Reproduced, by permission of the publisher, from Brooks et al. (6).
weekly for 12 months. Children were assessed
weekly by research staff for the primary outcomes
of pneumonia and diarrhoea using a standard
ized procedure. Secondary outcomes included
rates of other respiratory tract infections.
Summary of findings
A total of 809 children were assigned zinc and
812 assigned placebo. There were significantly
fewer incidents of pneumonia in the zinc group
compared with the placebo group (199 versus
286; relative risk, RR: 0.83; 95% CI: 0.73-0.95).
A significant but modest decrease was observed
in the incidence of diarrhoea (1881 cases versus
2407; RR: o’94; 95% CI: 0.88-0.99). All other ill
nesses (otitis media, reactive airways disease and
bronchiolitis) were significantly less frequent in
the zinc group compared with the placebo group
(Table 3.3). There were two deaths in the zinc
group and 14 in the placebo group. 'There were
no pneumonia-related deaths in the zinc group,
but 10 occurred in the placebo group. The zinc
group had a small gain in height at 10 months.
Serum copper and haemoglobin concentrations
were not adversely affected after 10 months of
zinc supplementation.
Towards universal health coverage
These findings showed that zinc supplements
among young children had a substantial
66
protective effect against episodes of pneumonia
and suppurative otitis media and, most impor
tantly, an 85% reduction in mortality owing to
prevention of pneumonia-related deaths.
'lhese findings have provided evidence lor
extending the 2004 UNICEF/WHO manage
ment recommendations for the use of zinc for
respiratory disease control (30). There have been
several other policy implications. Otitis media is
a common paediatric infection in resource-lim
ited settings and has important clinical sequelae.
By reducing the incidence of otitis media, zinc
could reduce hearing-related disability and treat
ment costs and thus improve the quality of life.
Weekly dosing in young children is also in
important step forward in reducing pill counts
and enhancing the practical aspects of program
matic management of zinc supplementation.
Further studies are now required to assess the
optimum dose and length of protection after
weekly zinc supplementation.
Main conclusions
•
Zinc supplementation among children
under two years of age has a substantial
protective effect against pneumonia, suppu
rative otitis media and pneumonia-related
mortality. Treatment with zinc also has an
effect (albeit modest) on reducing the fre
quency of diarrhoea and improving growth.
Chapter 3
How research contributes to universal health coverage
Once-weekly dosing of zinc was found to
be feasible and safe. It was associated with
potential programmatic advantages and no
measurable negative impact on serum level
of copper and haemoglobin.
Case-study 4
Telemedicine to improve the quality
of paediatric care: an operational
research study in Somalia
T tg need for research
Somalia has been ravaged by war for over two dec
ades, and health facilities in the country are suffer
ing from a serious shortage of specialist doctors.
Health care is provided by a limited number of
Somali clinicians who, th rough the circumstances
o ’ war, have had little or no opportunity to pursue
continuing education, have virtually no on-site
supervision by senior clinicians, and lack access
to medical supplies and equipment, 'lhe quality
of care, particularly for ill children admitted to
hospital wards, is a major concern. Achieving
universal health coverage means reaching remote
locations and conflict-affected populations where
the challenges of dilapidated infrastructure and
the shortage of qualified, skilled human resources
are enormous.
One solution to bridging the gap in expertise
i i such settings is to use information and comr ni ni cat ions technology in the form of telemedi
cine (31-34). Telemedicine means “medicine at
a distance” and the rationale tor introducing
this in Somalia is simple - export the expertise
(though not the experts) to Somalia (33).
(7). The study site was the paediatric ward of
a district hospital (Guri’el hospital) serving a
population ot about 327 000 inhabitants. This
hospital housed the only paediatric inpatient
facility within a radius of 250 km. The telemedi
cine involved a “real-time audiovisual exchange
of information on paediatric cases between cli
nicians in Somalia and a specialist paediatri
cian located in Nairobi, Kenya. The equipment
included a mobile camera, a microphone device
and a loudspeaker linked to a computer in the
paediatric ward in Somalia and a similar con
figuration in a consultation room in Kenya. The
two sites were connected through a broadband
Internet service (big. 3.3). Impact on quality of
care was assessed by comparing the initial diag
nosis and prescription (initial management) of
each paediatric case with the final diagnosis and
treatment (final management) made by the spe
cialist paediatrician, and by comparing adverse
hospital outcomes for a period with telemedicine
(the intervention year, 2011) with outcomes for
a period without telemedicine (the control year,
2010). A questionnaire was also used to gather
the perceptions of clinicians on the added value
of telemedicine.
Fig. 3.3.
Consultation room and specialist
paediatrician in Nairobi, Kenya,
conducting a telemedicine
consultation with colleagues in
Guri'el hospital, Somalia
! tudy design
A prospective observational cohortstudy assessed
the impact of the introduction of telemedicine
on the quality of paediatric care, 'lhe added
value, as perceived by local clinicians using the
service, was also assessed using a questionnaire
67
Research for universal health coverage
Summary of findings
Of 3920 paediatric admissions, 346 (9%) were
referred to the telemedicine service. In 222 chil
dren (64% of those referred), a significant change
was made to initial case management by the
specialist paediatrician, and in 88 children (25%
of those referred) a life-threatening condition
that had initially been missed was diagnosed.
Telemedicine in these cases served as a life
saving intervention ( uiT
I). Over a one-year
period there was a progressive improvement in
the capacity of clinicians to manage complicated
cases, as demonstrated by a significant linear
decrease in changes to initial case management
for meningitis and convulsions (92% to 29%,
P = 0.001), lower respiratory tract infections
(75% to 45%, P = 0.02) and complicated malnu
trition (86% to 40%, P = 0.002) (Im: 3.1). Loss
of interest among those using telemedicine is
unlikely to explain, this finding as all children
with the described conditions were system at cally referred for telemedicine according to the
study protocol and cases were reviewed by the
same specialist physician. Adverse outcomes
(deaths and losses to follow-up) on paediatric
wards decreased by 30% between 2010 (with
out telemedicine) and 2011 (with telemedicine)
(odds ratio 0.70; 95% CT: 0.57- 0.88). All seven
clinicians involved with telemedicine rated it as
having high added value in improving the rec
ognition of risk signs and prescription practices.
Fig. 3.4.
Decreasing trends in changes to
initial case management made
after telemedicine consultations
with a specialist in Kenya
(expressed as a percentage of all
Table 3.4.
Life-threatening conditions that
cases), Guri'l hospital, Somalia,
were initially missed and that
January-December 2011
telemedicine helped to diagnose,
Guri'el hospital paediatric ward,
Somalia, January-December 2011
IOO-i
Life-threatening conditions diagnosed
through telemedicine
No (%)
1 80 -1
Bacterial meningitis and tuberculous
meningitis
Pulmonary tuberculosis with severe pleural
and/or pericardial effusions
Neonatal septicaemia
Septicaemia/septic shock
39 (44)
IpoI f®-
Congestive cardiac failure
11 (13)
11 (13)
6(7)
5(6)
3(3)
2(2)
2(2)
2(2)
7(8)
Severe perinatal asphyxia
Necrotizing enterocolitis
Severe septic arthritis
Severe pyelonephritis
Others
TOTAL
88(100%)
Reproduced, by permission of the publisher, from
Zachariah et al. (7).
68
1
20 OH—
JanuaryMarch
AprilJune
JulySeptember
October—
Decern )er
Months in 2011
® Convulsions/meningitis
Malnutrition with complications
Lower respiratory tract infections
Adapted, by permission of the publisher, from Zachariah
et al. (7).
Chapter 3
How research contributes to universal health coverage
Tojvards universal health coverage
Al'hough this is an observational rather than
an experimental study, the findings suggest
that telemedicine can provide clinical exper
tise to remote and inaccessible areas. However,
the effectiveness, feasibility and acceptability of
introducing such technology, and its impact on
improving access to and quality of care, in simi
lar and post-conflict settings need to be evalu
ated, ideally with a more rigorous experimental
approach (35).
Main conclusions
a
Efforts towards achieving universal health
coverage must include people who are hard
to reach and those who are affected by
conflict.
In Somalia, telemedicine technology
reduced adverse paediatric ward outcomes
(deaths and losses to follow-up) by 30%
between 2010 (without telemedicine) and
2011 (with telemedicine).
Telemedicine is a way to bring medical
expertise to remote health services without
relocating the experts themselves.
Case-study 5
New diagnostics for tuberculosis:
a validity assessment of the Xpert®
MTB/RIF assay in Azerbaijan,
India, Peru and South Africa
The need for research
Despite widespread implementation of the WHO
Stop TB Strategy, TB remains a major public
health problem. In 2011, there were an estimated
8.7 million new TB cases worldwide, of which
only 5.8 million (67%) were notified. This is a
measure of the gap in service coverage. In the
same year, there were an estimated 310 000 cases
of multidrug-resistant TB (MDR-TB), resistant to
at least isoniazid and rifampicin, among notified
TB patients with pulmonary TB, of which only
60 000 cases were diagnosed and put on treat
ment (36).
A major reason for poor TB case detection
and enrolment to treatment is the inadequacy of
diagnostic tools. For decades, the mainstay of TB
diagnosis has been sputum-smear microscopy
for patients with suspected pulmonary TB, fol
lowed by chest radiography in those with negative
sputum smears. This process is time-consuming,
costly for the patient who needs to make multiple
journeys to the clinic, and diagnostically insen
sitive. This is especially true for HIV-infected TB
patients, among whom a significant proportion
has negative sputum smears and a normal chest
X-ray (particularly those with advanced HIV/
AIDS disease). Furthermore, smear microscopy
cannot diagnose MDR-TB.
Study design
The most revolutionary diagnostic development
to date for tuberculosis is a sensitive and spe
cific nucleic acid amplification test, the Xpert"
MTB/RIF assay (Cepheid Inc., Sunnyvale, CA,
USA), which uses a common platform to diag
nose mycobacterium tuberculosis (MTB) and
rifampicin resistance (RIF) (Fig. 3.5). The car
tridge-based system requires minimal laboratory
expertise and fully automated results are avail
able in less than two hours. The performance of
Xpert MTB/RIF was assessed in health facilities
in Azerbaijan, India, Peru and South Africa (8).
Summary of findings
There were 1730 patients with suspected drug-sensi
tive or multidrug resistant pulmonary tuberculosis,
each of whom submitted three sputum specimens,
and 1462 eligible patients were included in the main
analysis. Using sputum culture as the reference test,
the Xpert MTB/RIF assay was specific in 604 of 609
patients without TB (99.2% of negatives detected).
'The overall sensitivity (% of true positives detected)
for one sputum specimen in patients with smear
positive tuberculosis was 97.6% (95% CI: 96.2-98.5).
For patients with smear-negative culture-positive
69
Research for universal health coverage
Fig. 3.5.
Xpert® MTB/RIF machine being used in a health facility in South Africa
w—
Ms
>•3
|
a
§
i.,.
TB, sensitivity increased with the number of smears
tested (l;ig. 3.6). The overall sensitivity and speci
ficity (% of true negatives) for detecting rifampicin
resistance was 97.6% (95% CI: 94.4-99.0) and 98.1%
(95% CI: 96.5-98.9) respectively.
Towards universal health coverage
On the basis of these and subsequent results,
WHO recommended in December 2010 that
Xpert MTB/RIF should be used as the initial
diagnostic test in persons suspected of having
HIV-associated TB and in those at risk of
MDR-TB (37). It may also be used as a follow-on
test to microscopy, especially for patients with
smear-negative specimens (38). As of September
2012, a total of 898 GeneXpert instruments and
I 482 550 Xpert MTB/RIF cartridges had been
70
procured in the public sector in 73 of the 145
countries eligible for concessional pricing (39).
Operational feasibility, accuracy and effectixeness were assessed and were confirmed at dis
trict and subdistrict health facilities in Africa,
Asia, Europe and South America (40). However,
further assessment at more peripheral facilities
is required because the machines performance
in these settings depends on operational fac
tors such as cost, temperature, cartridge shelf
life, power supply, maintenance and calibration
needs. Tile public health impact of Xpert MTB/
RIF also depends on the link between diagnosis
and subsequent treatment.
National TB control programmes need to
find optimal diagnostic algorithms tailored to
local epidemiological conditions to make lhe
Chapter 3
How research contributes to universal health coverage
■
Fig 3.6.
Sensitivity of Xpert MTB/RIF
assay with multiple smears for
smear-negative, culture-positive
tuberculosis (commonly seen in
HIV-positive individuals)
Three sputum samples
Two sputum samples
Following WHO recommendations in
December 2010, approximately 900 Xpert
MTB/RIF instruments had been procured
for the public sector in 73 countries by the
end of September 2012.
Further research is under way to confront
operational and logistic challenges in
laboratory and field areas, and to assess
affordability, epidemiological impact and
cost-effectiveness.
Case-study 6
One sputum sample
—i
0
20
40
60
80
100
The "polypill" to reduce deaths
from cardiovascular disease: a
randomized controlled trial in India
Test sensitivity(%)
The need for research
HI'/, human immunodeficiency virus.
Source: Boehme et al. $)
best use of Xpert MTB/RIF. IT is technology
and related research have the potential to bring
diagnosis closer to patients. Further operational
studies are under way to investigate the cost,
optimal location and use of the assay within
health systems and in combination with other
diagnostic tools (41). As investigations ol the
performance of Xpert MTB/RIF have prolifera'ed, study design also appears to have improved
(K Weyer, WHO, personal communication),
indicating an instance of technological develop
ment boosting the quality of research (38).
Main conclusions
The Xpert MTB/RIF assay is useful for
rapid detection of TB and rifampicin
resistance, which is indicative of MDR-TB.
The test is particularly useful for detecting
TB in patients with HIV infection, thereby
allowing the diagnosis of patients earlier in
the course of their disease.
There is a growing global epidemic of noncom
municable diseases - primarily cardiovascular
diseases, diabetes, cancer and chronic respiiatory diseases. These are responsible for two
thirds of the 57 million deaths worldwide each
year, with 80% of deaths occurring in low- and
middle-income countries. Deaths from noncom
municable diseases are projected to rise from 36
million in 2008 to 52 million in 2030 (42). In
response to this epidemic, WHO Member States
have agreed on a set of targets to reduce deaths
caused by the four main noncommunicable
diseases by 25% in people aged 30-70 years by
2025 (43). WHO has proposed 10 targets to reach
this goal. One of these targets is drug therapy
to reduce the prevalence of risk factors for heart
attack and stroke (42).
A combination pill for the prevention of
cardiovascular disease was first described in
2000, and shortly afterwards the “polypill” was
presented as a strategy to reduce cardiovascular
disease (44). The concept is simple. Several dif
ferent drugs (aspirin, beta blockers, angiotensinconverting-enzyme inhibitors and statins) are
available generically and inexpensively to treat
71
Research for universal health coverage
several risk factors for cardiovascular disease,
particularly ischaemic heart disease. Combining
several drugs into a single polypill is appealing
because of its simplicity and acceptability, and
because one pill is more likely to be taken rou
tinely than several will be.
Methods
In 2009, a phase II double-blind randomized
trial was conducted on the effect of a polypill
on risk factors in middle-aged persons without
cardiovascular disease at 50 centres in India. The
study was designated “The Indian Polycap Study”
(TIPS) (9). Tlie polypill consisted of a combina
tion of low doses of a thiazide diuretic, atenolol,
ramipril, simvastatin and aspirin, and this was
compared with single agents or combinations of
single agents. The effect of the medication was
measured on risk factors, including high blood
pressure, elevated cholesterol concentrations
and elevated heart rate. Polypill intake was also
assessed for feasibility and tolerability.
Summary of findings
A total of 2053 individuals aged 45-80 years
without cardiovascular disease and with at least
one risk factor were included in the study. The
Indian Polycap study reduced systolic blood
pressure by 7.4 mmHg (95% CT: 6.1-8.1), dias
tolic blood pressure by 5.6 mm Hg (95% CI:
4.7-6.4), and low-density lipoprotein cholesterol
by 0.70 mmol/L (95% CI: 0.62-0.78). The reduc
tion in heart rate was 7.0 beats per minute on
average. These reductions were better or similar
to those of single drugs or combinations of single
drugs and tolerability was similar to that of other
treatments. Effects of the polypill at the wider
population level might be affected by adherence.
Importantly, a third of the participants in the
TIPS study had diabetes mellitus, a population
in which the clustering of risk factors is known
to be common. Comorbidity offers the potential
for targeted treatment, if and when a poly pill is
used for primary prevention.
72
Towards universal health coverage
The results of the study showed that each of the
components of the polypill reduced the risk of
cardiovascular disease. Several other trials have
since been carried out to demonstrate the effects
of different poly pi Ils in reducing blood pres
sure and cholesterol with generally good resulis,
although issues of adherence and lower-tha iexpected benefits were encountered {45).
The current evidence needs to be extended
by carrying out large phase 111 trials to investi
gate the efficacy of the polypill in reducing the
incidence of cardiovascular disease and stroke,
and mortality associated with these conditiors,
in large groups of human subjects over much
longer periods of time {46). Operational ques
tions pose a challenge to the translation of exist
ing evidence into policy. These questions need to
be answered by clinical and observational stud
ies which include: (i) the safety profile and what
to do if one component of the polypill is con
traindicated or causes a side-effect; (ii) the doses
of the various components; and (iii) whether a
pill that might be perceived as a magic solution
to noncom municable diseases would lead people
to abandon other preventive measures such as
appropriate diets, behaviour change and exer
cise. Research is needed to measure both the
potential of such an intervention to reduce the
global burden of cardiovascular disease and the
intervention’s public health merit before policy is
developed on the basis of the TIPS study.
Main conclusions
“
"
Early research shows that the Polycap for
mulation, a single pill that combines several
drugs, might be a simple and practical wav
to reduce multiple risk factors and car
diovascular disease, a major global public
health problem.
There is a need for phase III clinical trials
to evaluate more precisely the efficacy of
the polypill, and for operational research
to assess the feasibility of using this treat
ment in practice.
Chapter 3
How research contributes to universal health coverage
The effect of the polypi 11 needs to be
assessed in conjunction with other means
of reducing the risk of cardiovascular
disease, such as dietary changes, the. pre
vention of tobacco smoking, and physical
exercise regimes.
Case-study 7
Combination treatment with
sodium stibogluconate (SSG)
and paromomycin compared to
SSG monotherapy for visceral
leishmaniasis: a randomized
controlled trial in Ethiopia,
Kenya, Sudan and Uganda
Ti e need for research
Human visceral leishmaniasis (VL), also known
as kala-azar. is a life-threatening parasitic dis
ease caused by Lcishmania clonovani and trans
mitted by phlebotomine sandflies (I
:).
VL is the second largest parasitic killer in the
world after malaria, with, an annual worldwide
incidence of approximately 500 000 cases (47).
VL is an important disease in Asia (Bangladesh,
India, Nepal) and East Africa. In East Africa, the
incidence rate is 30 000 cases with 4000 deaths
per year (48). The Lcishmania parasite migrates
to internal organs such as the liver, spleen and
bone marrow (hence the term “visceral”) and, if
u itreated, will frequently lead to death. Effective
measures to eradicate the sandfly are lacking,
death rates are high, and there are few affordable
and effective treatment options. This situation,
along with the fact that there is limited research
a id drug development for VL, means that VL
can be called a “neglected disease”.
Treatment for VL in East Africa is primarily
limited to the antimonial sodium stibogluco
nate (SSG), which is efficacious but requires four
v\ eeks of hospitalization and daily intramuscular
injections and is associated with serious adverse
events such as cardiotoxicity. The drug is thus
difficult to administer and constitutes a burden
both for the patient and for the health system.
The parasite is also becoming increasingly resist
ant to the drug.
The efficacy of an alternative drug, paro
momycin sulfate (PM), has been demonstrated
in India (49). There is, however, limited infor
mation on the efficacy of PM for VL in the
African setting where response to treatment
may be different. A large observational study
of 4263 VL patients in South Sudan showed
that a combination of SSG and PM for a shorter
period of time (17 days) yielded better results
than SSG alone (50). For registration of PM and
evaluation of the efficacy of combination treat
ment with SSG and PM in East Africa, efficacy
and safety data were required from a phase III
randomized controlled trial.
Study design
A multicentre randomized controlled trial
was conducted in four East African countries
(Ethiopia, Kenya, Sudan and Uganda) (10). The
trial had three arms: (i) SSG monotherapy (a
dose of 20 mg/kg/day for 30 days) used as the
reference arm; (ii) PM monotherapy (20 mg/
kg/day for 21 days); and (iii) a combination of
SSG and PM given for a shorter period (SSG 20
mg/kg/day; PM 15 mg/kg/day for 17 days). The
aim was to compare the efficacy and safety of
PM monotherapy and the combination of SSG
and PM to the reference arm of SSG alone, 'lhe
primary efficacy end point was definitive cure
defined as parasite clearance from splenic, bone
marrow or lymph node aspirates six months
after the end of treatment.
Summary of findings
In the comparison between PM monotherapy
and SSG alone, 205 patients were enrolled in each
arm with primary efficacy data available for 198
and 200 patients respectively. In the comparison
between the SSG/PM combination and the SSG
73
Research for universal health coverage
Fig. 3.7.
Clinical examination of a 4-year-old girl with visceral leishmaniasis (kala-azar),
in Sudan
■
■
■"i
5
s.
tfeT.T '
. ....
•
reference, 381 and 386 patients were enrolled in
each arm respectively with efficacy data available
for 359 patients per arm.
The efficacy of PM monotherapy was sig
nificantly lower than the efficacy observed in
the SSG reference arm (84.3% versus 94.1%, dif
ference 9.7%; 95% CI: 3.6-15.7%). The efficacy
of the SSG/PM combination given for a shorter
duration of 17 days was similar to the efficacy of
SSG given alone for 30 days (91.4% versus 93.9%,
difference 2.5%; 95% CI: 1.3-6.3%). There were
no apparent differences in the safety profile of
the three treatment regimens.
Towards universal health coverage
The reduced duration of treatment with the
combination of SSG and PM compared to SSG
alone (17 versus 30 days) reduced the treatment
burden on patients and health facilities and
74
WML's' /'Ll’
lowered the associated costs. The cost of the
drugs also favoured the combination treatment
over SSG monotherapy (US $44 versus US $56).
The potential risk of parasite resistance to SSG
was also limited by combination therapy.
The findings supported the introduction of
SSG/PM combination therapy for treatment of
VL. in East Africa. A WHO Expert Committee
recommended its use as a first-line treatment for
VL in East Africa.
Main conclusions
■
The 17-day shorter duration combination
treatment with SSG and PM for VL was
similar in efficacy to the standard 30-day
SSG treatment and had a good safety prof le.
Changing to this combination therapy
would therefore reduce the treatment
burden on patients and health facilities
Chapter 3
■
How research contributes to universal health coverage
and limit the risk of development of drug
resistance.
The findings supported the introduction of
SSG and PM combination therapy as a firstline treatment for VL in hast Africa.
Case-study 8
«
Task shifting in the scale-up
of interventions to improve
child survival: an observational
multicountry study in Bangladesh,
Brazil, Uganda and the United
Republic of Tanzania
The need for research
WHO estimates that the global health workforce
has a deficit of more than four million persons
(5J). Countries with high child mortality rates
also tend to have a lack of qualified health work
ers. The Integrated Management ol Childhood
Illness (IMCI) is a global strategy that has been
adopted by more than 100 countries with a view
to reducing child mortality. IMCI clinical guide1 nes describe how to assess, classify and manage
children younger than five years of age who have
common illnesses (52). One of the main barriers to
expanding IMCI coverage is the lack of qualified
health workers, Task shifting, which is the term
used to describe the process whereby specific tasks
are moved, where appropriate, to health workers
with fewer qualifications and a shorter duration of
pre-service training is seen as an option lo address
shortages of personnel (53).
There is a scarcity of published evaluations
of the quality of clinical care provided by nonohysician health workers who administer IMCI.
such evidence is needed to assess whether task
shifting can be promoted as a strategy for scal
ing up IMCI, and for improving child health in
underserved areas.
Study design
An observational multicountry study was con
ducted in primary government health facilities
in Bangladesh, Brazil, Uganda and the United
Republic of Tanzania (II). The clinical perfor
mance of health workers with a longer duration
of pre-service training (such as doctors and clin
ical officers) was compared with those having a
shorter duration of training (all other health
workers such as nurses, midwives and nurse
assistants providing clinical care). The quality of
care was evaluated using standardized indica
tors and according to whether the assessment,
classification and management of sick children
by IMCI guidelines had been fully carried out.
Every child was assessed twice, first by the IMCTtrained health worker who was being assessed
and second by a supervisor who was blinded to
the original diagnosis and treatment made by
the health worker. Although this research has
been classified as a study of the management of
diseases and conditions, it is also health policy
and systems research.
Summary of findings
The study included a total of 1262 children
from 265 government health facilities: 272 chil
dren from Bangladesh, 147 from Brazil, 231
from the United Republic of Tanzania, and 612
from Uganda. In Brazil, 58% of health workers
with training of long duration provided cor
rect management, compared with 84% of those
with shorter duration of training. In Uganda
the figures were 23% and 33% respectively
(Tabic 3.5). Similarly, in Bangladesh and the
United Republic of Tanzania, the proportions of
children managed correctly by both categories
of health workers were approximately the same.
Therefore, there was no evidence from any of the
four settings that a shorter duration of training
compromised the quality of child care.
One important caveat is that both catego
ries of health workers performed poorly (e.g.
"children correctly managed”) in Uganda. The
reasons for the poor performance are unknown.
75
Research for universal health coverage
Table 3.5.
Assessment, classification and management of children by IMCI-trained health
workers, classified by length of pre-service training
Longer duration of training
Shorter duration of training
0.73
0.48
0.59
0.94
0.72
0.53
0.60
Bangladesh
0.72
0.67
Brazil
0.61
0.73
Uganda
United Republic of Tanzania
Children correctly managed1
0.45
0.39
0.76
0.80
Bangladesh
0.63
Brazil
0.58
0.68
0.84
Uganda
United Republic of Tanzania
0.23
0.33
0.64
. 0.63
Index of assessment of children®
Bangladesh
Brazil
Uganda
United Republic of Tanzania
0.88
Children correctly classified13
IMCI, integrated management of childhood illness.
J This index assesses the quality and completeness of the clinical assessment provided to sick children based on 17 standard
ized items (e.g. check for fever, diarrhoea etc).
D Classification of diseases based on IMCI Guidelines.
1. Correct management based on IMCI Guidelines.
Adapted, by permission of the publisher,from Huicho etal. (??).
It should also be noted that these assessments
were made at the primary care level where fewer
children have serious illnesses (the proportion of
hospital referrals ranged from 1% in Brazil to 13%
• in Uganda). Furthermore, health workers with a
shorter duration of training may be more willing
to comply with standard clinical guidelines (and
therefore be judged to have managed childien
correctly) whereas those with longer training
may use a wider variety of different procedures
and yet obtain equally good outcomes. In addi
tion, the age of health workers and years of prac
tice were not taken into consideration, both of
which may compensate lor duration of training.
Towards universal health coverage
These findings suggest that IMCI can be
implemented by non-physician health work
ers who have had relatively short periods of
76
pre-service training. Although all cadres of
health workers apparently need additional
training in some settings, task shifting has
the potential to expand the capacity of IMCI
and other child survival interventions in
underserved areas faced with staff shortages
(54-56). Randomized trials have also shown
that task shifting from doctors to other less
qualified health workers is possible and cm
be beneficial where health service staff are in
short supply (57-59).
Main conclusions
R
Task shifting from health workers with
longer duration of training (doctors, clini
cal officers) to those with shorter duration
of training (nurses, midwives and nurse
assistants) did not compromise the quality
of child care provided as part of IMCI.
Chapter 3
ts
How research contributes to universal health coverage
Task shifting could be used to increase the
coverage of IMC1 and other child survival
interventions in underserved areas laced
with staff shortages, although additional
training may be needed in some settings.
Case-study 9
Improving access to emergency
obstetric care: an operational
research study in rural Burundi
The need for research
MDG 5 sets the target of reducing the maternal
mortality ratio (MMR) by 75% between 1990
and 2015. The MMR is an important measure
ol maternal health at the population level and is
defined as the number of maternal deaths in a
given time period per 100 000 live births during
the same time period (60). Although maternal
mortality decreased in low- and middle-income
countries from 440 deaths per 100 000 live
births in 1990 to 290 per 100 000 in 2008, this
34% reduction is well short of the 75% target
set for the MDG for 2015, which at the current
pace would seem unachievable (6/). The MMR
in Burundi is among the highest in the world
a 800 per 100 000 live births (in comparison,
Sweden has a ratio of two per 100 000 live
births) (62).
Although access to an emergency obstetric
care (EMOC) package is a widely accepted inter
vention for reducing maternal deaths, no pub
lished data exist from Africa that quantify the
population-level impact of improving availabili’y and access to such care. Would the provision
( f a centralized EMOC facility, coupled with an
effective patient referral and transfer system for
obstetric complications, in a rural district sub
stantially and rapidly reduce maternal deaths in
order that the MDG target is achieved?
Study design
A retrospective cohortstudyestimated the impact
of establishing a centralized EMOC facility and
an ambulance transfer system on the reduction
of maternal mortality in relation to MDG 5 in
Kabezi district of rural Burundi (72). All nine
peripheral health centre maternity units in the
district were linked to a central EMOC facility
and an ambulance service via cell phones or high
frequency radios. On receiving a woman with an
obstetric complication, health centre staff con
tacted the EMOC facility and an ambulance was
dispatched (accompanied by a trained midwife)
to transfer the woman to the EMOC facility. The
distance from health centres to the EMOC facil
ity ranged from 1 km to 70 km.
The impact of the intervention was calculated
by estimating how many deaths were averted
among women with a severe acute mateinal
morbidity (SAMM) who were transferred to and
treated at the EMOC facility. This was derived by
comparing the number of deaths among women
with SAMM who were beneficiaries of the EMOC
intervention with the expected number of deaths
among the same group of women assuming that
the EMOC intervention had not existed (63).
SAMM was defined in terms of a specific set of
conditions, including prolonged or obstructed
labour requiring a caesarean section or instru
mental (vacuum-assisted) delivery, complicated
abortion (spontaneous or induced), pre-eclampsia/eclampsia, and prepartum or postpartum
haemorrhage (I able 3.6). Using the estimate of
averted deaths, the resulting theoretical MMR
in Kabezi was calculated and compared to the
MDG 5 target for Burundi.
Summary of findings
During 2011, 1385 women were transferred to the
EMOC facility, of whom 765 (55%) had a SAMM
condition (Table 3.6). The intervention package
averted an estimated 74% (95% CI: 55-99%) of
maternal deaths in the district, equivalent to a
77
Research for universal health coverage
Emergency obstetric complications and interventions classified as severe acute
Table 3.6.
maternal morbidity (SAMM), Kabezi, Burundi, 2011
Emergency
No (%)
Total
Prolonged/obstructed labour requiring caesarean section or instrumental delivery
765 (100)
Complicated abortion (spontaneous or induced)
Prepartum or postpartum haemorrhage
Caesarean section due to excessively elevated uterus or abnormal presentation of the baby requiring
caesarean section
Dead baby in utero with uterine contractions > 48 hours
267 (35)
226 (30)
91 (12)
73(10)
46(6)
18(2)
15(2)
Pre-eclampsia
Sepsis
Uterine rupture
14(2)
Ectopic pregnancy
5 (0.7)
Malaria
4 (0.5)
4 (0.5)
2 (0.3)
Severe anaemia
Emergency hysterectomy
Adapted, by permission of the publisher, from Tayler-Smith et al. (12).
Fig. 3.8.
Estimated maternal mortality
ratio in Kabezi, Burundi
1200 “ 1100
II
11
■ si
1100
1000
H I
1000 -
910
800
800 ~
600400 ~
1_„
200 -
o-1
,1
■
hl
1990
1995
2000
■
2005
__
208
2011
275
2015
Year
□ At end of 2011
National trends
□ National MDG 5 target for Burundi in 2015
MDG, Millennium Development Goal.
Note: maternal mortality ratio was 208.
Reproduced, by permission of the publisher, from
Tayler-Smith et al. (12).
78
district MMR of 208 (95% CT: 8-360) deaths pur
100 000 live births. This MMR was within the
range of the 2015 MDG 5 target for Burundi (275
deaths per 100 000 live births) and was achieved
well before the scheduled 2015 target (big .■>)
A potential limitation of the study is that
women were diagnosed with a SAMM on the basis
of clinical acumen, and this may have influenced
the number of SAMM cases. However, standaid
case definitions for SAMM were available ard
clinicians were well trained in their use, and this
should have limited any error in estimates.
Towards universal health coverage
The findings indicate that the provision of
EMOC, combined with a functional patieit
referral transfer system, can markedly reduce
maternal mortality. This is one way of making
progress towards universal health coverage, and
towards MDG 5 in rural Africa. Hie challenge
ahead is to ensure that funds and other resources
are available to scale up and sustain the achieve
ments to 2015 and beyond. Further research is
r
A
Chapter 3
How research contributes to universal health coverage
needed on cost-effectiveness and how to adapt
such interventions to different settings.
Main conclusions
*
fS
Tlie provision of a facility for
cou
pled with a functional ambulance transfer
system for patients, was associated with a
rapid and substantial reduction in maternal
mortality.
This is one example of improved health care
- an intervention by which Burundi and
other countries can make progress towards
universal health coverage and towards the
target set for MDG 5.
Case-study 10
Conditional cash transfers to
improve the use of health services
and health outcomes: a systematic
review of evidence from lowand middle-income countries
Tie need for research
Conditional cash transfers (CCTs) provide pay
ments to households on the condition that they
comply with certain predetermined require
ments in relation to health care or other social
programmes (:
)■ CC1 programmes have
been justified on the basis that providing sub
sidies is necessary to encourage the use of and
access to health services by poor people (64).
CCT schemes are intended as a financial
i icentive for people to adopt healthy behaviours,
and to increase the demand for and utilization of
f ealth services by reducing or eliminating finan
cial barriers to access. What is the evidence that
such an approach works?
: tudy design
A systematic review assessed the available evi
dence on effectiveness of CCTs in improving
access to care (utilization of health services) and
health outcomes, particularly for poorer popu
lations in low- and middle-income countries
(Z3). Studies from Brazil, Colombia, Honduras,
Malawi, Mexico and Nicaragua were included.
Summary of findings
In terms of utilization of health services, CCT
was associated with -a 27% increase in individu
als taking up HIV testing (one study, Malawi),
an 11-20% increase in children attending health
centres in the previous month, and 23-33%
more children under four years of age attend
ing preventive health-care visits. In terms of
anthropometric outcomes, positive effects weie
found on child growth, including an increase
in height of about 1 cm among children up to
four years of age and a decrease in the probabil
ity of being stunted, underweight or chronically
malnourished. With regard to other health out
comes, mothers reported a 20-25% decrease in
the probability of children under three years of
age being ill in the previous month.
Further recent evidence on the effect of
CCTs has come from a randomized controlled
trial in rural Malawi, which assessed the effect
ofcash payments in reducing HIV risk in young
women (65). Schoolgirls and young women aged
13-22 years were randomly allocated monthly
cash payments or nothing at all. Those receiv
ing monthly cash payments were further subdi
vided into two groups: those who received the
payments conditionally (on attending school
for 80% of the days that the school was in ses
sion during the previous month) or uncondi
tionally (simply by going to the cash transfer
points). Households received varied amounts of
USS 4-10 and the amount given to the girl varied
inthe range USS 1-5. Among the 1289 schoolgirls
enrolled, HIV prevalence 18 months after enrol
ment was 1.2% in the cash transfer group and
3.0% in the control group (odds ratio 0.36; 95%
CI: 0.14-0.91). The prevalence of herpes simplex
virus type 2 (HSV-2) was 0.7% in the cash trans
fer group and 3.0% in the control group (odds
ratio 0.24; 95% CI: 0.09-0.65). There were no
79
Research for universal health coverage
Fig. 3.9.
Identity cards are an integral part of schemes that provide conditional cash transfers
in health and education programmes
w
■
f’ ’ ■
■
....
■
.
i7
■
j
Ct®
differences between the conditional and uncon
ditional cash transfer groups in HIV or HSV-2
prevalence. These findings show that financially
empowering schoolgirls might have a beneficial
• effect on their sexual and reproductive health.
In Brazil, a country-wide ecological study
showed that increased coverage of the Bolsa
b'amilia program me, a national CCT programme
transferring cash to poor households if they
comply with conditions related to health and
education, was significantly associated with the
reduction of mortality (whether from all causes
or from poverty-related causes) in children
under five years of age. The effect of consolidated
Bolsa Familia coverage was highest on mortal
ity resulting from malnutrition and diarrhoea
80
in the under-fives. In addition, the programme
was shown to increase vaccination coverage and
prenatal visits by mothers and to reduce hospi
talization rates in the under-fives (66).
Towards universal health coverage
There is now a substantial body of data show
ing that CCTs can, under some circumstances,
have positive effects on nutritional status and
health by increasing the use of health services
and by promoting healthy behaviours (13, 6769}. However, CCT schemes do not necessarily
work everywhere. Their success depends on a
variety of factors, such as being able to ident .fy
participating individuals with unique person
identifiers ('
), and on having effective
4
Chapter 3
How research contributes to universal health coverage
and reliable mechanisms to disburse payments.
There are also limitations to the studies that
have been carried out to date. For instance,
trials that demonstrate changes in short-term
behaviour do not guarantee changes in longteim attitudes to health. It is clearly important
to find the right mix of incentives and regula
tions that affect both the supply of and demand
fo • services so that. CCTs can improve the qualit) of care in any given setting (68). This is a
goal for further research.
Main conclusions
H
OCT schemes serve as financial incentives
for increasing the demand for and utili
zation of health services by reducing or
eliminating financial barriers to access.
Studies from several low- and middle
income countries show that CCT schemes
can, in some circumstances, increase health
service utilization which leads to improved
health outcomes.
Case-study 11
Insurance in the provision
of accessible and affordable
health services: a randomized
controlled trial in Mexico
The need for research
In 2003, Mexico initiated a new set of health
reforms which aimed to provide health coverage
to approximately 50 million people who were
without any form of financial protection for
health. Before 2003, the right to health care was
an employment benefit that was restricted to the
salaried workforce. A large majority of the poor
population was non-salaried or unemployed,
and a significant proportion was at risk of cata
strophic or impoverishing health expenditure.
The 2003 Mexican health reform legislated
the System of Social Protection in Health, of
which Seguro Popular (People’s insurance) was
the new public insurance scheme that assures
legislated access to comprehensive healthcare. In
the first few years of Scguro Popular, and taking
advantage of its phased roll-out, it was important
to assess the impact of the intervention on health
and financial expenditure (70).
Study design
In a cluster randomized study, 100 pairs of health
facility catchment areas (“health clusters”) were
randomly assigned to receive either the inter
vention or the control. The intervention, Seguro
Popular, provided a package of benefits that
included coverage for 266 health interventions
and 312 medicines, and increased funds to state
health ministries proportional to the number
of families joining the scheme. There were also
funds to cover catastrophic health expenditures
associated with certain diseases. In health clus
ters receiving the intervention, there was a cam
paign to persuade every family to enrol in Scguro
Popular. In the matched control cluster families
received the usual health care which they had
to pay for (14). Tie main outcomes were details
of expenditures which were classified as out-ofpocket expenditures for all health services, while
catastrophic expenditures were defined as health
spending greater than 30% of capacity to pay
(measured in terms of income).
Summary of findings
In the intervention clusters, out-of-pocket
expenses and catastrophic expenditures were
23% lower than in the control clusters. Among
those households within intervention clusters
that signed up to Scguro Popular (44% on average),
catastrophic expenditures were reduced by 59%.
Among persons enrolled in the Seguro Popular
programme, 69% rated the quality of health ser
vices as very good or good, and 85% reported
81
Research for universal health coverage
that the programme benefits were explained
clearly by programme officials. Surprisingly,
and contrary to previous observational studies,
there was no substantial effect of Seguro Popular
on the quality of care (such as improving access
to and use of medical facilities or reducing drug
stock-outs) or on increasing coverage for chronic
illness. These findings might be explained by the
short assessment period ol 10 months (71, 72).
Although these results are encouraging, further
research is needed to ascertain the long-term
effects of the programme.
Towards universal health coverage
The project design for assessing the effects of
Seguro Popular proved robust and showed that the
programme did indeed reach the poor. In August
2012, within 10 years of launching the scheme,
52 million previously uninsured Mexicans had
state-protected health care. 'Faking into account
coverage with a range of insurance schemes,
approximately 98% of 113 million people in
Mexico had financial risk protection in 2012,
and Mexico has celebrated the achievement of
universal health coverage (70, 73). Nevertheless,
further experimental research is needed with a
longer period ol follow-up in order to measure
the effects on access to, and use of, health facili
ties and health outcomes. This needs to be done
not only in Mexico but also in other countries
planning public health policy reforms.
Main conclusions
G
■
In Mexico, implementation of a public
national health insurance scheme, Seguro
Popular, led to the country celebrating
universal health coverage less than 10 years
after its introduction.
Seguro Popular resulted in a 23% reduction
in out-of-pocket expenses and catastrophic
expenditures, with benefits reaching
poorer households.
Such insurance schemes have the potential
to contribute to the achievement of univer
sal health coverage in other countries.
82
Case-study 12
Affordable health care in ageing
populations: forecasting changes
in public health expenditure
in five European countries
The need for research
As the average age of European populatioms
becomes older, a larger number of people wi 1
suffer from chronic disease and disability as a
result of cancers, cardiovascular diseases, frac
tures, dementia and other conditions. In add tion, a growing number of people will suffer
from several morbidities at the same time. These
observations have generated concern that public
spending on health care in ageing populatiors
will become unaffordable.
Studydesign
Using published data on forecasts of popula
tion ageing, and on current health expenditure
by age, Rechel and co-workers calculated the
expected annual changes in per capita health
expenditure associated with ageing over thi
period 2010-2060 (74). They assumed th it
health expenditure per person in each age grot b
would be constant over the 50-year period, ard
that the unit costs of health care would also
remain unchanged. The analysis was carried out
for five countries of the European Union (EU)
- the Czech Republic, Germany, Hungary, the
Netherlands and Slovenia.
Summary of findings
The projected increases in health expenditure
associated with ageing were modest. 'The annual
increases in per capita expenditure, calculated
as means for five-year periods, were consistent
across the five countries. They were never more
than 1% of the mean annual expenditure, and they
declined from the 2030s onwards (FTg. 3.10). In t ie
Netherlands, for example, the increase in spendi ig
per person is expected to peak between 2020 and
Chapter 3
lig.3.10.
How research contributes to universal health coverage
Projected changes in per capita public health expenditure associated with ageing in
five European countries, 2010-2060
1.0 1
aj
CT
n3o
0.8 0.6 -
c= ~
2 S
Q-
0.4 -
0.2 £
CO
0
-0.2
2010-2015
2020
Germany
Czech Republic
2025
2030
Netherlands
Hungary
2035
2040
2045
2050
2055
2060
-®~ Slovenia
--- Zero change
Hote: Points are annual average percentage increases, calculated as five-year means, derived from data on projected popula
tion ageing and on current patterns of health expenditure by age.
F- eproduced, by permission of the publisher, from Rechel et al. (74).
2025, resulting in an average yearly growth rate of
(>,9% due to ageing, falling to zero between 2055
and 2060, when the population of the Netherlands
is likely to become younger on average.
' □wards universal health coverage
rlte common assumption that population ageing
will drive future health expenditure to unaffordable
levels is not supported by this analysis. 1 hese results
are in line with some other assessments which have
found that ageing is not expected to incur substantial
increases in health-care costs {83). A study carried
out for the European Commission forecast moder
ate increases in public-sector health spending due to
ageing in the EU, growing from 6.7% of GDP in 2007
to 8.2% in 2060 (84). If, with increases in life expec
tancy, the proportion of life in good health docs not
change, then public expenditure on health care is
expected to increase by only 0.7%., to 7.4% of GDP.
Research on the cost of dying shows that
the proximity of death is a more important pre
dictor of high health-care expenditure than is
ageing (85, 86). A large proportion of lifetime
expenditure on health-care typically occurs
in the last year of life, particularly in the last
few weeks before death (87), and health-care
expenditure tends to be lower for those who are
most elderly (> 80 years). Furthermore, although
older people are major consumers of health care,
other factors - notably technological develop
ments - have a greater effect on total health care
costs (74).
Nevertheless, the growing proportion of
older people in European populations does
present some challenges for health and wel
fare if, for instance, a declining fraction of
the population has to bear the rising costs of
health and social care and pensions. Yet these
challenges are not insuperable. The measures
that can be taken include: promoting good
health throughout life, thereby increasing the
chance that additional years of life are spent
in good health; minimizing the severity of
chronic disease through early detection and
care; improvingtthe efficiency of health sys
tems so they are better able to cope with the
83
Research for universal health coverage
needs of older people; and increasing the par
ticipation of older people in the labour force
{74, 88).
Main conclusions
Between 2010 and 2060, the estimated
annual increases in health expenditure due
to ageing are less than 1% and falling in five
European countries.
While the number of older people suffering
chronic diseases and disability is expected
to grow, the costs of health care become
substantial only in the last year of life.
Although ageing is not expected to incur
large extra costs, systems for health care,
long-term social care and welfare in
European countries must adapt to popula
tion ageing.
B
Conclusions: general lessons
drawn from specific examples
The 12 case-studies presented in this chapter,
ranging from the control of malaria to the provi
sion of health insurance, are examples of research
that illuminate the path to universal health
coverage, 'lliey address a diversity of questions
about reaching universal coverage. They employ
a range of research methods - quantitative and
qualitative evaluations, observational and case
control studies, non-randomized intervention
studies, randomized controlled trials, and sys
tematic reviews and meta-analyses. They show
the potential benefits of having evidence from
multiple sources, and explore the link between
experimental design and strength of inference.
They reveal the nature of the research cycle in
which questions lead to answers which lead to
yet more questions. And they show how research
works at the interface with policy and practice.
Six features of these case-studies deserve
emphasis. First, the most appropriate research
methods - those that find the best compromise
between cost, time and validity - vary along the
84
research cycle. In general, randomized controlled
trials and trials using a minimization method
lor allocation give the most robust answers to
questions about the efficacy of an intervention,
provided they have been assessed to be valid l y
rigorous critical appraisal. However, judging
the effectiveness of interventions during rou
tine practice is more difficult'because there are
no experimental controls (75, 76). Nevertheless,
operational questions relating to staffing needs,
infrastructure and commodity supply chains
can often be answered by a process of “learning
by doing” - i.e. by practice and repetition, co reeling errors and making improvements after
evaluation, usually with minor innovations. This
appears to be the dominant method of address
ing health insurance reforms in Africa and Asi t,
but whether uncontrolled interventions (i.e.
those not tested by a formal experiment) lead to
the best outcomes is open to debate (77).
In the lace of health emergencies, son e
experimental designs carry the disadvantage
of being costly, slow and logistically complex,
whereas observational studies can be doi e
quickly and cheaply - yet are potentially at risk
of giving misleading conclusions. However, there
are instances in which that risk is worth taking
and results in positive outcomes. In respond
ing to the enormous demand for antiretroviral
therapy for HIV/AIDS in sub-Saharan Afric i,
observational research on task shifting and on
the decentralization of health services yielded
important data that could inform policy and
practice before evidence became available from
controlled experiments {78, 79). However, recent
successful efforts to modify and apply formal
experimental designs (especially randomized
designs) for use beyond clinical trials (e.g. to
address problems of health service access and
delivery) suggest that experimental rigour need
not always be sacrificed for the sake of obtaining
results rapidly and cheaply {80).
Second, the continuous cycle of asking and
answering questions implies that the implemen
tation of research solutions (the best answers at
Chapter 3
t ny given moment) can be effectively monitored.
However, the current metrics used to judge the
success of new interventions, and the systems
lor collecting the relevant data, are far from
adequate (81).
Third, the goal of this report is to promote
i esearch that makes the coverage of health inter
ventions truly universal. Access to health ser
vices cannot be the privilege of those who live
in relatively peaceful areas of the world. In 2009
alone, there were 31 armed conflicts worldwide
(82). These circumstances demand imaginative
methods for the provision of health care. In this
context, telemedicine is an example of an ena
bling technology (Case-study 4).
Fourth, while some of the case-studies
in this chapter show how research can influ
ence practice, health policy and action are
rot determined by evidence alone (Box 2.1).
Some common reasons why research find
ings are not used include: the research ques
tion is not relevant to the problems faced by
health workers or policy-makers; the research
How research contributes to universal health coverage
findings, though published in peer-reviewed
journals, are not clearly explained to those
who might use them; and the solutions arising
from research are too costly or too complex to
implement (81).
Fifth, although the 12 examples in this
•chapter relate to a wide range of conditions of
ill-health and methods for studying them, the
examples inevitably leave some gaps. Some of
the topics missing from this chapter are no less
important than those that are covered, such as
finding ways to prepare for pandemics, to miti
gate environmental hazards, or to assess the
health benefits of agriculture (Box 2.6).
Finally, the examples in this chapter point
to the advantages of creating a structured
system for carrying out research in low- and
middle-income countries, and of deepening
the culture of enquiry in every setting where
research is carried out. To advance this cause,
Chapter 4 describes the architecture of systems
that can effectively carry out research for uni
versal health coverage.
References
1
2
3
4
5.
6.
7.
8.
9,
UK Clinical Research Collaboration. Health research classification system. London, Medical Research Council, 2009. (http://
www.hrcsonline.net/, accessed 17 March 2013).
Health research classification systems - current approaches and future recommendations. Strasbourg, European Science
Foundation, 2011.
Lim SS et al. Net benefits: a multicountry analysis of observational data examining associations between insecticidetreated mosquito nets and health outcomes. PLoS Medicine, 2011,8:e1001091. doi: http://dx.doi.org/10.1371/journal.
pmed.1001091 PMID:21909249
Eisele TP, Steketee RW. African malaria control programs deliver ITNs and achieve what the clinical trials predicted. PLoS
Medicine, 2011,8:e1001088. doi: http://dx.doi.org/10.1371/journal.pmed.1001088 PMID:21909247
Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine,
2011,365:493-505. doi: http://dx.doi.org/10.1056/NEJMoa1105243 PMID:21767103
Brooks WA et al. Effect of weekly zinc supplements on incidence of pneumonia and diarrhoea in children younger than
2 years in an urban, low-income population in Bangladesh: randomised controlled trial. Lancet, 2005,366:999-1004. doi:
http://dx.doi.org/10.1016/S0140-6736(05)67109-7 PMID:16168782
Zachariah R et al. Practicing medicine without borders: tele-consultations and tele-mentoring for improving paediat
ric care in a conflict setting in Somalia? Tropical Medicine & International Health, 2012,17:1156-1162. doi: http://dx.doi.
org/IO.Illl/j. 1365-3156.2012.03047.x PMID:22845678
Boehme CC et al. Rapid molecular detection of tuberculosis and rifampin resistance. The New England Journal of Medicine,
2010,363:1005-1015. doi: http://dx.doi.org/10.1056/NEJMoa0907847 PMID:20825313
Yusuf S et al. Effects of a polypill (Polycap) on risk factors in middle-aged individuals without cardiovascular disease
(Trends Pharmacol Sci): a phase II, double-blind, randomised trial. Lancet, 2009,373:1341-1351. doi: http://dx.doi.
org/10.1016/S0140-6736(09)60611-5 PMID:19339045
85
Research for universal health coverage
Musa A et al. Sodium stibogluconate (SSG) & paromomycin combination compared to SSG for visceral leishmaniasis in Ea^t
Africa: a randomised controlled trial. PLoS neglected tropical diseases, 2012,6:e1674. doi: http://dx.doi.org/10.1371/journal.
pntd.0001674 PMID:22724029
11. Huicho L et al. How much does quality of child care vary between health workers with differing durations of training? An obser
vational multi.country study. Lancet, 2008,372:910-916. doi: http://dx.doi.org/!0.1016/S0140-6736(08)61401-4 PMID:18790314
12. Tayler-Smith K et al. Achieving the Millennium Development Goal of reducing maternal mortality in rural Africa: an experi
ence from Burundi. Tropical Medicine & International Health, 2013,18:166-174. doi: http://dx.doi.org/10.1111/tmi.12022
PMID:23163431
13. Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in
low and middle income countries. Cochrane database of systematic reviews (Online),, 2009,4:CD008137. PMID:19821444
14. King G et al. Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme.
Lancet, 2009,373:1447-1454. doi: http://dx.doi.org/10.1016/S0140-6736(09)60239-7 PMID:19359034
15. Lienhardt C, Cobelens EG. Operational research for improved tuberculosis control: the scope, the needs and the way
forward. The International journal of Tuberculosis and Lung Disease, 2011,15:6-13. PMID:21276290
16. Nachega JB et al. Current status and future prospects of epidemiology and public health training and research in the
WHO African region. International Journal of Epidemiology, 2012,41:1829-1846. doi: http://dx.doi.org/10.1093/ije/dys189
PMID:23283719
17. Eisele TP, Larsen D, Steketee RW. Protective efficacy of interventions for preventing malaria mortality in children in
Plasmodium falciparum endemic areas. International Journal of Epidemiology. 2010,39:Suppl 1:i88-i101. doi: http://dx.doi.
org/10.1093/ije/dyq026 PMID:20348132
18. LengelerC. Insecticide-treated bednets and curtains for preventing malaria. Cochrane Database of Systematic Reviews
(Online), 2000,2CD000363. PMID:10796535
19. Flaxman AD et al. Rapid scaling up of insecticide-treated bed net coverage in Africa and its relationship with develop
ment assistance for health: a systematic synthesis of supply, distribution, and household survey data. PLoS Medicine,
2010,7:e1000328. doi: http://dx.doi.org/10.1371/journal.pmed.1000328 PMID:20808957
20. Malaria funding and resource utilization: the first decade of Roll Back Malaria. Geneva, World Health Organization on behalf
of the Roll Back Malaria Partnership, 2010.
21. Eisele TP, Steketee RW. Distribution of insecticide treated nets in rural Africa. BMJ (Clinical research Ed.), 2009,339:b1598.
doi: http://dx.doi.org/10.1136/bmj.b1598 PMID:19574313
22. UNAIDS report on the global AIDS epidemic 2012. Geneva, Joint United Nations Programme on HIV/AIDS, 2012.
23. Alberts B. Science breakthroughs. Science, 2011,334:1604. doi: http://dx.doi.org/10.1126/science.1217831 PMID:22194530
24. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. Recommendations for a public health approach. Geneva, World Health Organization, 2012.
25. - Schouten EJ et al. Prevention of mother-to-child transmission of HIV and the health-related Millennium Development
Goals: time for a public health approach. Lancet, 2011,378:282-284. doi: http://dx.doi.org/10.1016/S01406736(10)62303-3 PMID:21763940
26. Programmatic update. Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Gene\ a,
World Health Organization, 2012.
27. Caulfield LE, Black RE. Zinc deficiency. In: Ezzati M et al„ eds. Comparative quantification of health risks: Global and regional
burden of disease attribution to selected major risk factors. Geneva, World Health Organization, 2004:257-279.
28. Bhutta ZA et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled
analysis of randomized controlled trials. The American Journal of Clinical Nutrition, 2000,72:1516-1522. PMID:11101480
29. Bhutta ZA et al. Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries:
pooled analysis of randomized controlled trials. Zinc Investigators' Collaborative Group. The Journal of Pediatrics,
1999,135:689-697. doi: http://dx.doi.org/10.1016/S0022-3476(99)70086-7 PMID:10586170
30. Joint statement. Clinical management of acute diarrhoea. New York, NY, United Nations Children's Fund and Geneva, World
Health Organization, 2004.
31. Sood S et al. What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings.
Telemedicine Journal and e-Health, 2007,13:573-590. doi: http://dx.doi.org/10.1089/tmj.2006.0073 PMID:17999619
32. Spooner SA, Gotlieb EM. Telemedicine: pediatric applications. Pediatrics, 2004,113:e639-e643. doi: http://dx.doi.
org/10.1542/peds.113.6.e639 PMID;15173548
33. Wootton R, Bonnardot L. In what circumstances is telemedicine appropriate in the developing world? JRSM Short Reports,
2010,1:37. doi: http://dx.doi.org/10.1258/shorts.2010.010045 PMID:21103129
10.
86
Chapter 3
How research contributes to universal health coverage
?4. Shiferaw F, Zolfo M. The role of information communication technology (ICT) towards universal health coverage: the
first steps of a telemedicine project in Ethiopia. Global Health Action, 2012,5:1-8. doi: http://dx.doi.org/10.3402/gha.
v5i0.15638 PMID:22479235
35. Coulborn RM et al. Feasibility of using teleradiology to improve tuberculosis screening and case management in a
district hospital in Malawi. Bulletin of the World Health Organization, 2012,90:705-711. doi: http://dx.doi.org/10.2471/
BLT.11.099473 PMID:22984316
36. Global tuberculosis report2012. Geneva, World Health Organization, 2012.
3 7. Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin
resistance: Xpert MTB/RIFsystem. Policy statement. Geneva, World Health Organization, 2011.
38. Weyer K et al. Rapid molecular TB diagnosis: evidence, policy-making and global implementation of XpertwMTB/RIF. The
European Respiratory Journal, 2012, doi: http://dx.doi.org/10.1183/09031936.00157212 PMID:23180585
39. WHO monitoring of Xpert MTB/RIF roll-out (web site). Geneva, World Health Organization, 2012. (http://who.int/tb/laboratory/mtbrifrollout, accessed 17 March 2013).
40. Boehme CC et al. Feasibility, diagnostic accuracy, and effectiveness of decentralised use of the Xpert MTB/RIF test for
diagnosis of tuberculosis and multidrug resistance: a multicentre implementation study. Lancet, 2011,377:1495-1505. doi:
http://dx.doi.org/10.1016/S0140-6736d 1)60438-8 PMID:21507477
41. Pantoja A et al. Xpert MTB/RIF for diagnosis of TB and drug-resistant TB: a cost and affordability analysis. The European
Respiratory Journal, 2012,(Epub ahead of print) doi: http://dx.doi.org/10.1183/09031936.00147912 PMID:23258774
42. A comprehensive global monitoring framework, including indicators, and a set of voluntary global targets for the preven
tion and control of noncommunicable diseases. Geneva, World Health Organization, 2012. (http://www.who.int/nmh/
43.
events/2012/discussion_paper3.pdf, accessed 17 March 2013).
Beaglehole R et al. Measuring progress on NCDs: one goal and five targets. Lancet, 2012,380:1283-1285. doi: http://dx.doi.
org/10.1016/S0140-6736(12)61692-4 PMID:23063272
44. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ (Clinical Research Ed.), 2003,326:1419.
doi: http://dx.doi.org/10.1136/bmj.326.7404.1419 PMID:12829553
45. Rodgers A et al. An international randomised placebo-controlled trial of a four-component combination pill ("polypill")
in people with raised cardiovascular risk. PLoS ONE, 2011,6:e19857. doi: http://dx.doi.org/10.1371/journal.pone.0019857
PMID:21647425
46. Thom S et al. Use of a Multidrug Pill In Reducing cardiovascular Events (UMPIRE): rationale and design of a randomised
controlled trial of a cardiovascular preventive polypill-based strategy in India and Europe. European Journal of Preventive
Cardiology, 2012, doi: http://dx.doi.org/10.1177/2047487312463278
Control of the leishmaniases. Report of a meeting of the WHO Expert Committee on the Control of Leishmaniases, 22-26 March
2010. Geneva, World Health Organization, 2010 (WHO Technical Report Series, No. 949).
48. Reithinger R, Brooker S, Ko laczi nski JH. Visceral leishmaniasis in eastern Africa — current status. Transactions of the
Royal Society of Tropical Medicine and Hygiene. 2007,101:1169-1170. doi: http://dx.doi.Org/10.1016/j.trstmh.2007.06.001
PMID:17632193
19. Sundar S et al. Injectable paromomycin for Visceral leishmaniasis in India. The New England Journal of Medicine,
2007,356:2571-2581. doi: http://dx.doi.org/10.1056/NEJMoa066536 PMID:17582067
50. Melaku Y et al. Treatment of kala-azar in southern Sudan using a 17-day regimen of sodium stibogluconate combined with
paromomycin: a retrospective comparison with 30-day sodium stibogluconate monotherapy. The American Journal of
17.
Tropical Medicine and Hygiene, 2007,77:89-94. PMID:17620635
51. The world health report 2006- working together for health. Geneva, World Health Organization, 2006.
52. Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The
WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bulletin of the World Health Organization,
1997,75:Suppl 17-24. PMID:9529714
53. Task shifting. Global recommendations and guidelines. Geneva, World Health Organization, 2008.
54. Lewin S et al. Lay health workers in primary and community health care for maternal and child health and the manage
ment of infectious diseases. Cochrane Database of Systematic Reviews (Online), 2010,3CD004015. PMID:20238326
55. Ellis M et al. Intrapartum-related stillbirths and neonatal deaths in rural Bangladesh: a prospective, community-based
cohort study. Pediatrics, 2011,127:e1182-el 190. doi: http://dx.doi.org/10.1542/peds.2010-0842 PMID:21502233
56. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions
through taskshifting. Geneva, World Health Organization, 2012.
87
Research for universal health coverage
Jaffar S et al. Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinj i,
southeast Uganda: a cluster-randomised equivalence trial. Lancet, 2009,374:2080-2089. doi: http://dx.doi.org/10.1016/
50140-6736(09)61674-3 PMID:19939445
58. Fairall L et al. Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH):
a pragmatic, parallel, duster-randomised trial. Lancet, 2012,380:889-898. doi: http://dx.doi.org/10.1016/S01406736(12)60730-2 PMID:22901955
59. Mugyenyi P et al. Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART):,
a randomised non-inferiority trial. Lancet, 2010,375:123-131. doi: http://dx.doi.org/10.1016/S0140-6736(09)62067-5
PMID:20004464
60. Graham WJ et al. Measuring maternal mortality: an overview of opportunities and options for developing countries. BMC
Medicine, 2008,6:12. doi: http://dx.doi.org/10.1186/1741-7015-6-12 PMID:18503716
61. Maternal mortality is declining, but more needs to be done. The Millenium Development Goal Report 2010. Addendum 2.
Goal 5 Improve Maternal Health. New York, NY, United Nations, 2010.
62. Trends in maternal mortality: 1990-2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva, World Health
Organization, 2012.
63. Fournier P et al. Improved access to comprehensive emergency obstetric care and its effect on institutional mater
nal mortality in rural Mali. Bulletin of the World Health Organization, 2009,87:30-38. doi: http://dx.doi.org/10.2471/
BLT.07.047076 PMID:19197402
64. Oxman AD, Fretheim A. Can paying for results help to achieve the Millennium Development Goals? A critical review of
selected evaluations of results-based financing. Journal of Evidence-based Medicine, 2009,2:184-195. doi: http://dx.doi.
org/10.1111/j.i756-5391.2009.01024.x PMID:21349012
65. Baird SJ et al. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in
Malawi: a cluster randomised trial. Lancet, 2012,379:1320-1329. doi: http://dx.doi.org/10.1016/S0140-6736(11)61709-l
PMID:22341825
66. Rasella D et al. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of
Brazilian municipalities. Lancet, 2013, May 14. pii:50140-6736(13)60715-T. doi: http://dx.doi.org/10.1016/S01406736(13)60715-1 PMID:23683599
67. Ranganathan M, Lagarde M. Promoting healthy behaviours and improving health outcomes in low and middle income
countries: a review of the impact of conditional cash transfer programmes. Preventive Medicine, 2012,55:Supp l:S95-S105.
doi: http://dx.doi.Org/10.1016/j.ypmed.2011.11.015 PMID:22178043
68. Waldman RJ, Mintz ED, Papowitz HE. The cure for cholera - improving access to safe water and sanitation. The New England
Journal of Medicine, 2013,368:592-594. doi: http://dx.doi.org/10.1056/NEJMp1214179 PMID:23301693
69. Dye C et al. Prospects for tuberculosis elimination. Annual Review of Public Health, 2012 (Epub ahead of print).
70. Knaul FM et al. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet, 2012,380:12591279. doi: http://dx.doi.Org/10.1016/S0140-6736(12)61068-X PMID:22901864
71. ‘ Gakidou E et al. Assessing the effect of the 2001-06 Mexican health reform: an interim report card. Lancet, 2006,368:192(»1935. doi: http://dx.d0i.0rg/l0.1016/S0140-6736(06)69568-8 PMID:17126725
72. Hussey MA, Hughes JP. Design and analysis of stepped wedge cluster randomized trials. Contemporary Clinical Trials,
2007,28:182-191. doi: http://dx.doi.Org/10.1016/j.cct.2006.05.007 PMID:16829207
73. Mexico: celebrating universal health coverage. Lancet, 2012,380:622. doi: http://dx.doi.org/10.1016/S01406736(12)61342-7 PMID:22901868
74. Rechel B et al. Ageing in the European Union. Lancet, 2013,381:1312-1322. doi: http://dx.doi.org/10.1016/S01406736(12)62087-X PMID-.23541057
75. Glasgow RE, Lichtenstein E, Marcus AC. Why don't we see more translation of health promotion research to practice?
Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health, 2003,93:1261-1267. doi: http://dx.doi.
org/10.2105/AJPH.93.8.1261 PMID:12893608
76. Sussman S et al. Translation in the health professions: converting science into action. Evaluation & the Health Professions,
2006,29:7-32. doi: http://dx.doi.org/10.1177/0163278705284441 PMID:16510878
77. Lagomarslno G et al. Moving towards universal health coverage: health insurance reforms in nine developing countries in
Africa and Asia. Lancet, 2012,380:933-943. doi: http://dx.d0i.0rg/l0.1016/S0140-6736(12)61147-7 PMID:22959390
78. Treat, train, retain. The AIDS and health workforce plan. Report on the consultation on AIDS and human resources for health.
Geneva, World Health Organization, 2006.
57.
88
Chapter 3
79.
60.
81.
82.
83.
84.
85.
86.
87.
88.
How research contributes to universal health coverage
Zachariah R et al. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa.
Transactions of the Royal Society of Tropical Medicine and Hygiene, 2009,103:549-558. doi: http://dx.doi.0rg/IO.lOI6/j.
trstmh.2008.09.019 PMID:18992905
Banerjee AV, Duflos E. Poor economics. New York, NY, Public Affairs, 2011.
Zachariah R et al. Is operational research delivering the goods? The journey to success in low-income countries. The Lancet
Infectious Diseases. 2012,12:415-421. doi: http://dx.doi.org/10.1-016/S1473-3099(11)70309-7 PMID:22326018
Armed conflicts. In: Canadas F|VI et al. Alert 2010! Report on conflicts, human rights and peacebuilding. Barcelona, Escola de
Cultura de Pau/School for a Culture of Peace, 2010. (http://www.humansecuritygateway.com/documents/ECP_Alert2010_
ReportonConflictsHumanRightsandPeacebuilding.pdf, accessed 19 March 2013).
Figueras J, McKee M, eds. Health systems, health, wealth and societal well-being. Assessing the case for investing in health
systems. Copenhagen, Open University Press, 2011.
2009 Ageing report: economic and budgetary projections for the EU-27 Member States (2008-2060). Luxembourg, Office for
Official Publications of the European Communities, 2009.
Polder JJ, Barendregt JJ, van Oers H. Health care costs in the last year of life - the Dutch experience. Social Science &
Medicine, 2006,63:1720-1731. doi: http://dx.doi.Org/10.1016/j.socscimed.2006.04.018 PMID:16781037
Breyer F, Felder S. Life expectancy and health care expenditures: a new calculation for Germany using the costs of
dying. Health policy (Amsterdam, Netherlands), 2006,75:178-186. doi: http://dx.doi.Org/10.1016/j.healthpol.2005.03.011
PMID:15893848
Kardamanidis K et al. Hospital costs of older people in New South Wales in the last year of life. The Medical Journal of
Australia, 2007,187:383-386. PMID:17907999
Good health adds life toyears. Global brief for World Health Day 2012. Geneva, World Health Organization, 2012 (Document
WHO/DCO/WHD/2012.2).
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Key points
■ Health research systems have four essential functions: to set research priorities,
to develop research capacity, to define norms and standards for research, and to
translate evidence into practice. These functions support health in general and
universal health coverage in particular.
Standard methods have been developed to set research priorities, but the bestdocumented examples are those for specific health topics such as malaria and
tuberculosis control and the reduction of child mortality. All countries should set
national priorities, across all aspects of health, to determine how best to spend
limited funds on research.
Effective research needs transparent and accountable methods for allocating funds,
and well-equipped research institutions and networks. However, it is the people
who do research - with their curiosity, imagination, motivation, technical skills,
experience and connections — who are most critical to the success of the leseaich
enterprise.
n
a
Codes of practice, which are the cornerstone of any research system, are already in
use in many countries. The task ahead is to ensure that these are comprehensive and
applicable in all countries, and to encourage adherence everywhere.
Achieving universal health coverage depends on research ranging from studies
of causation to the functioning of health systems. Because many existing, costeffective interventions are not widely used, there is a particular need to close the gap
between existing knowledge and action. To help achieve that goal, research should
be strengthened not only in academic centres but also in public health programmes,
close to the supply of and demand for health services.
Many of the determinants of health and disease lie outside the health system so
research needs to investigate the impact of policies for health in all sectors .
Research will add to the evidence on how human activities affect health, for example
through agricultural practices and changes to the natural environment.
R
Mechanisms to support research include monitoring (national and international
observatories), coordination (information-sharing, collaborative research studies)
and financing (raising and distributing funds to support global and national
research priorities).
Building research systems for
universal health coverage
The case studies in Chapter 3 show how research can tackle some of the key
questions about reaching universal health coverage. They show how research
can produce results to guide policy and practice. 'Tie success of these selected
studies, and of any study that aims to support universal health coverage, depends
on having an environment that is conducive to doing research of the highest
quality. The most credible research, reaching the largest number of people and
producing the greatest benefits for health, will be done where there is an estab
lished culture of enquiry, a set of procedures for supporting and carrying out
investigations, and frequent dialogue between researchers and policy-makers.
An effective health research system needs to carry out four functions in
particular. It must define research questions and priorities; raise funds and
develop research staff capacity and infrastructure; establish norms and stand
ards for research practice; and translate research findings into a form that can
guide policy. All four of these functions are embraced by the WHO Strategy on
Research for Health (
1). Effective research systems allow investigators to
go all the way round the research cycle: measuring the size of the health prob
lem; understanding its cause(s); devising solutions; translating the evidence into
policy, practice and products; and evaluating effectiveness after implementation
(Box 2.3).
There are few assessments of how well research systems carry out their
essential functions, though one survey of health systems research in 26 countries
investigated the type of research being done, the capacity for carrying it out, and
the use of research findings in practice (Box •■1.2),
To show how to build research systems that can support universal health
coverage, this chapter sets out the principles underpinning each of the four
key functions, and uses examples to show how they work. The chapter then
identifies mechanisms to support these functions, nationally and interna
tionally, through monitoring, coordination and financing. The presentation
is intended to be an overview of the research process, not a comprehensive
manual. For those who are engaged in building or developing health research
systems, whether at provincial, national or regional levels, some of the practical
details can be found in a growing number of operational guides, though these
95
Research for universal health coverage
Box 4.1.
WHO's Strategy on Research for Health
In 2010 the Sixty-third World Health Assembly adopted Resolution WHA63.21 concerning a strategy for the manage
ment and organization of research within WHO. The World Health Assembly resolution was a stimulus to review
and revitalize the role of research within WHO, improve support to WHO Member States in building health research
capacity, strengthen advocacy for the importance of research for health, and better communicate WHO's involve
ment in research for health (7,2).*
Three criteria underpin the WHO approach to health research:
»
»
■
Quality - making a commitment to high-quality research that is ethical, expertly reviewed, efficient, effective,
accessible to all, and carefully monitored and evaluated.
Impact - giving priority to research and innovation that has the greatest potential to improve global health
security, accelerate health-related development, redress health inequities and attain the MDGs.
Inclusiveness - working in partnership with Member States and stakeholders, taking a multisectoral approach
to research for health, and promoting the participation of communities and civil society in the research process.
The strategy has five goals. The first goal applies to WHO while the others apply more generally to the conduct of
research (Box 2.1). The goals are:
»
organization (reinforcing the research culture across WHO);
•
■
priorities (emphasizing research that addresses the most important health problems);
capacity (helping to develop and strengthen national health research systems);
standards (promoting good practice in research, setting norms and standards);
•
translation (linking policy, practice and the products of research).
The global strategy is being used to guide regional and national strategies, taking into account the local context,
public health needs and research priorities.
MDGs, Millennium Development Goals.
are not yet comprehensive (4-9). The examples
in this chapter, taken together with the body of
experience summarized in preceding chapters,
lead to some specific recommendations about
developing the research environment, especially
in low- and middle-income countries.
Setting research priorities
Confronted with an unending list of questions
about public health, researchers and policy
makers must together decide which should be
given priority for investigation, and thus prior
ity for spending. What follows is a step-by-step
guide to setting priorities, highlighting the key
questions (7).
a
Context. What is the exercise about and
who is it for? What resources are available?
96
What are the underlying values or prin
ciples? What are the health, research and
political environments?
Approach. Should one of the standard
approaches be adopted, or do circum
stances require the development of new
or adjusted methods? Three standard
approaches are:
- BID Combined Approach Matrix
(CAM) - the structured collection of
information (70);
- Essential National Health Research
(ENHR) - health research priority
setting for national exercises (77, 72);
- the Child Health and Nutrition
Research Initiative (CHNR1) approach
- a systematic algorithm for deciding
on priorities (73, 74).
Chapter 4
Box 4.3.
Building research systems for universal health coverage
Setting priorities for research on selected health topics
The majority of priority-setting exercises in health research have focused on specific topics. They have typically been
carried out from the perspective of different thematic groups within the research community rather than being
initiated by national governments. A selection of examples is listed in the table below.
Priority-setting for research on specific topics
Health topic
Focus
Preterm births and stillbirths
Birth asphyxia
Childhood pneumonia
Community level (78)
Reducing mortality (79)
Reducing mortality (20)
Childhood diarrhoea
Reducing mortality (27)
Child health
South Africa (22)
Low- and middle-income countries (23)
Humanitarian settings (24)
From R&D to operational research (25-28)
Eradication: drugs (29)
Eradication: health systems and operational research (30)
Mental health
Mental health and psychosocial support
Tuberculosis
Malaria
Malaria
Leishmaniasis
Middle East and North Africa (31)
Leishmaniasis
Chagas disease, human African trypanosomiasis and
leishmaniasis
Vaccines (32)
Diagnostics, drugs, vaccines, vector control and health
Neglected infectious diseases
Helminth infections
Zoonoses and infections of marginalized human
populations
Noncommunicable diseases
Human resources for health
Health systems financing
Research and development for a national health service
Equity and health
systems (33)
Latin America and the Caribbean (34)
Epidemiology and interventions against all major human
helminths (35)
Epidemiology and interventions; research within and
beyond the health sector (36)
Low- and middle-income countries (37)
Low- and middle-income countries (38)
"Developing" countries (39)
Interface between primary and secondary care in the
United Kingdom (40)
Social determinants of health (47)
R&D, research and development.
A framework for
strengthening capacity
'lie term “capacity” could refer to all elements
of a research system. But here it means the abili
ties of individuals, institutions and networks,
nationally and internationally, to undertake and
disseminate research findingsof the highest qual
ity (7). The general principles have been framed
by the ESSENCE on Health Research initiative.
ESSENCE is a collaboration between funding
agencies that aims to improve the impact of
investments in institutions and people, and pro
vide enabling mechanisms to address needs and
priorities within national strategies on research
for health. Tine principles are as follows (5):
* Participation and alignment - a common
effort of funders and local partners is
99
Research for universal health coverage
Setting priorities for research in Brazil
Box 4.4.
Since 2000, the Brazilian government has made health research a national priority. (44). Public resources have been
used for fundamental and translational research (see definitions in Box 2.1), and to build closer links between the
research community and health services. In 2004, Brazil's National Agenda of Priorities in Health Research was
established to help reach the health-related MDGs - i.e. to reduce child mortality, to improve maternal health, and
to combat HIV/AIDS, tuberculosis and malaria. The fair allocation of research funds has been guided by six objec
tives, namely: (i) to improve population health, (ii) to overcome inequity and discrimination, (iii) to respect life and
dignity, (iv) to ensure high ethical standards in research, (v) to respect methodological and philosophical plurality,
and (vi) to ensure social inclusion, environmental protection and sustainability.
Attempting to satisfy these goals, Brazil's top 10 investments in health research for the period 2004-2009 are shown
below.. Most funds were allocated to the "industrial health complex'' (biotechnology, equipment and materials, health
and technology service providers), to clinical research and to communicable diseases. Among the top 10 investments,
but ranked in lower positions, were women's health, mental health and health systems research.
Brazil's top ten investments in health research, 2004-2009
§
i
I
120iop 806040-
20-
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-Q
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I
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rg
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s
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ts
er
H3
CD
Note: The industrial health complex is described in the text. Health technology assessment includes specific research
studies, systematic reviews and economic evaluations.
Source: Pacheco Santos et al.(44). •
Some 4000 research grants were awarded during this period, and around US$ 545 million were invested in health
research across the country by 2010. The south-east region (including Rio de Janeiro and Sao Paulo) carried out 40%
of all projects and received 60% of funds. The research has helped to improve treatments, prevention and diagnoses
to develop new products and services, and to strengthen the patient-oriented health-care system (44). Priorities are
updated periodically, as in the 2011 report Strategic investigations for the health system, which identifies 151 research
topics based on Brazil's national health policy for 2012-2015.
AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; MDGs, Millennium Development Goals.
100
Chapter 4
Box 4.5.
Building research systems for universal health coverage
The role of health ministries in developing research capacity: the examples of
Guinea Bissau and Paraguay
The Guinea Bissau health research system has evolved under the strong influence of international donors and
technical partners who have provided funds and scientific expertise (57). Research has been carried out chiefly by
the Bandim Health Project, the National Laboratory for Public Health, the Department of Epidemiology and the
Institute Nacional de Estudos e Pesquisa (INEP) which is oriented to the social sciences. Research priorities have been
set largely by expatriate researchers and have focused on understanding and reducing child mortality.
Recognizing the need to set national research priorities, align funding, build local research capacity and link research
to decision-making, the Ministry of Health established the National Institute of Public Health (INASA) in 2010. (NASA's
role is to coordinate the management and governance of health research nationally. External technical support is led
by the West African Health Organisation (WAHO), which works in partnership with the Council on Health Research
for Development (COHRED) and the International Development Research Centre (IDRC).
The commitment of the Ministry of Health to invest in research has been central to success. The main challenges
facing Guinea Bissau are the limited number of skilled researchers and dependence on foreign assistance.
Paraguay has a stronger research base than Guinea Bissau, with more staff and institutions engaged in health
research? However, there has been little coordination between research institutions. In 2007, therefore, the Ministry of
Health formed a new directorate for research and in 2009 set up an inter-institutional committee to create a framework
for health research. The committee included the Minister of Education and representatives of UNICEF and the Pan
American Health Organization. Drawing on the experience of other countries, and especially Mexico, the commit
tee drafted a government policy on research for health and set up the first National Council of Research for Health.
4
As part of the drive to improve health research, all research institutions in the country are under evaluation. An online
database of researchers has been created, and only registered researchers are eligible for funding from the Council
of Science and Technology. The database provides information about the training of researchers, their experience,
and current research topics. The intention is to manage dedicated funding through a health research trust and to
allocate these funds transparently on merit.
As in Guinea Bissau, the support of the Minister of Health backed by the President of Paraguay has been a key factor
in the development of a national health research system.
•’ COHRED, personal communication;www.healthresearchweb.org/en/paraguay
■’
-
3
needed, with local coordination, in
line with the Paris Declaration on Aid
Effectiveness (2005), the Accra Agenda for
Action (2008), and the broader aim of effec
tive development (49, 50).
Understanding the context - starting with
an analysis of the local political, social and
cultural norms and practices.
Building on strengths - local expertise and
local processes, initiatives and institutions
should be valued rather than bypassed.
Long-term commitment - there should be
recognition that jt takes time (years) for
inputs to bring about changes in behaviour
and performance.
tn
Interlinked capacity components on differ
ent levels - capacity development should
take into account the links between indi
vidual, organizational and systemic compo
nents of health research.
Continuous learning - this should include
an accurate analysis of the situation at the
start of the intervention and should allow
time to reflect on subsequent action.
Harmonization - funders, governments
and other organizations that support the
same partner in capacity-strengthening
should harmonize their efforts.
101
A/^CPHE - S0CHARA
Koramangala
\S°SO
ML* (CL.IC)
Research for universal health coverage
Fig. 4.1.
Examples of efforts to build research capacity, ranging from individual to global
movements
y.." p
Institutional development
National health
research councils
Individual training
2 =■
4
Mao Mi*
WHO/TDR
US NIH
Wellcome Trust
*
.a.”".,
TDR, Special Programme for Research and Training in Tropical Diseases; US NIH, United States National Institutes for Health.
Adapted, by permission of the publisher, from Lansang & Dennis (52).
The decision to build and strengthen research
capacity, and to allocate the necessary funds, is
largely political (Box -1.5), but the case for sup
port must be made with a careful evaluation of
what it takes to do research effectively. The needs
include a skilled and self-confident workforce
with strong leadership, adequate funding with
transparent and accountable methods for allo
cating funds, and well equipped research institu
tions and networks.
One framework for capacity-building,
which has the ingredients of many others, is
represented in i ;■!.: and Lihiv •!.' (52-56).
While it is useful to begin with structures of
this kind, the approach to capacity-building in
102
any setting depends on the strategic vision for
the research and what is needed from research.
It is sometimes, though not always, convenient
to think of institutions nested within organiza
tions. Thus the Task Force on Malaria Research
Capability Strengthening in Africa is part of the
Multilateral Initiative on Malaria, which is coor
dinated by the Special Programme for Research
and Training in Tropical Diseases (TDR).
Views also differ on the emphasis to be place d
on, for example, building elite institutions, cre
ating international networks, boosting transla
tional research, methods of sharing knowledge
and information, and rewarding quality (57).
Furthermore, there are interactions between the
♦
Chapter 4
Table 4.1.
Building research systems for universal health coverage
A framework to guide capacity-building, highlighting approaches and targets, the
likelihood of sustainability, and the research focus
Entity targeted
Individual
Institution
Network
Approach to capacity strengthening
Graduate or
postgraduate training
Learning
by doing
4+4
++
++
Institutional partnerships
between countries
+++
4-4-
National level
+4-4-
++
+
_ Supranational level
_ Financial investment11
Research focus
Likelihood of
sustainability0
Centres of
excellence
Research skills
+4-+
+++
++ +
Programme, policy, systems development
+++
Plus (4) signs indicate the entity is targri-vl ■ sometimes, ++ often, +++ frequently.
Plus (i) signs in this row indicate that fhr extent of financial investment needed by national health research systems or
funding agencies is + low, 4-+ medium, + 4-1 high.
Plus signs in this row indicate the likelihood of sustainability of various approaches is + fair, +++ strong.
R 'produced, by permission of rhe publisher from Lansang & Dennis (52).
I
r
various components in !
. I;or instance,
graduate and postgraduate training are more
likely to be effective when the host institutions
a-e also strong ( L
I , column 1, row 2).
From the outset, any programme to
strengthen research capacity must define, moni
tor and evaluate success - an area in which
knowledge is still sparse (52,53,58-60). A simple
geographical mapping of research activity can be
illuminating (
. ), but a deeper understand
ing comes from measuring success. One evalu
ation examined which indicators of research
c.ipacity were most useful in four different set
tings: evidence-based health care in Ghana,
HIV voluntary counselling and testing services
in Kenya, poverty as a determinant of access to
TB services in Malawi, and the promotion of
community health in the Democratic Republic
o' the Congo (6). The most expedient indicators
changed as programmes matured. ’Ihe engage
ment of stakeholders and planning for scale-up
were critical at the outset, while innovation,
financial resources, and the institutionalization
of activities mattered more during the expan
sion stage. Funding for core activities and local
management were vital during the consolidation
stage.
The following sections look more closely at
three elements of capacity that are universally
important; building the research workforce,
tracking financial flows, and developing institu
tions and networks.
Creating and retaining a
skilled research workforce
The world health report 2006 - working together
for health highlighted the critical role, and the
chronic shortage, of health workers, especially
in low-income countries (62). Here the vital
contribution made by health researchers as
part of the health workforce is underscored
(56, 63).
'Tlie research carried out in many low- and
middle-income countries is still dominated by
scientists from wealthier countries who bring
103
Research for universal health coverage
Fig. 4.2,
Geographical distribution of research capacity in Africa
Research output
(Number of articles per city]
31-99
100-249
250-499
500-999
• > . >1000
R&D, research and development.
Note: Mapping of top 40 African cities by research output shows hotspots and coldspots of R&D activity and highlights inequi
ties in R&D productivity across the continent.
Adapted with the World Health Organization's map shapefile under rhe Creative Commons licence (CC BY 3.0, http://creat
tivecommons.org/licenses/by/3.0/) from Nwaka et al. (67).
much-needed expertise and funding. Tine tran
sition towards a more self-reliant and skilled
research workforce in lower-income countries is
under way, but the process is slow.
International collaboration is part of the
solution so long as some basic principles are fol
lowed (Box -I.(-.’)• Alongside the numerous exam
ples of “north-south” research collaboration run
a variety of training schemes for young research
ers - such as those offered by TDR (www.who.
int/tdr), the Training Programs in Epidemiology
and Public Health Interventions Network
104
(TEPHINET), www.tephinet.org ), the European
Foundation Initiative for African Research in.o
Neglected Tropical Diseases (EFINTD, www.
ntd-africa.net), Brazil’s Science without Borders
programme (www.cienciasemtrontciras.gov.b;),
and the product-orientated operational research
courses offered by the International Union
against Tuberculosis and Lung Disease and
Medecins Sans Frontieres (MSF) Luxembourg
(65-67). Even where there are shortages of money
to do the research in Africa, there is an appe
tite for career development through mentorship
4
4
1
Chapter 4
Box 4.6.
Building research systems for universal health coverage
Principles of research partnership
Further details of these 11 principles can be found in Guidelines for research in partnership with developing countries
prepared by the Swiss Commission for Research Partnership with Developing Countries (64). The 11 principles (with
minor adaptation) are as follows:
1. Decide on research objectives together, including those who will use the results.
2. Build mutual trust, stimulating honest and open research collaboration.
3. Share information and develop networks for coordination.
4. Share responsibility and ownership.
5. Create transparency in financial and other transactions.
6. Monitor and evaluate collaboration, judging performance through regular internal and 1. external evaluations.
7. Disseminate the results through joint publications and other means, with adequate communication to those who
will finally use them.
8. Apply the results as far as is possible, recognizing the obligation to ensure that results are used to benefit the
target group.
9. Share the benefits of research profits equitably including any profit, publications and patents.
10. Increase research capacity at individual and institutional levels.
11. Build on the achievements of research - especially new knowledge, sustainable development and research capacity.
programmes, project management courses, pro
posal-writing workshops and language training,
and by networking at conferences (65).
Through these various schemes, scientists
in lower-income countries are gaining a more
confident voice. For instance, African research-
e \s have argued that support for research on
neglected tropical diseases should not be the
sole responsibility of external
donors.
Tiney
believe that their own governments must also
take responsibility for providing infrastructure
a id job opportunities (65, 68).
Ensuring transparency and
accountability in research funding
Just as research needs money, the development of
research capacity needs a mechanism for track
ing how much is spent on what kinds of research.
The eight areas of research outlined in Box 2.2
- ranging from fundamental or underpinning
sludies to investigations of health systems and
services - offer one Iramework lor reporting
the money spent on research in different areas.
In the United Kingdom, for instance, research
spending by the Wellcome Trust and Medical
Research Council (MRC) focuses on under
pinning and etiological research (Tig, 1.3). In
contrast, research spending by two national
health departments (England and Scotland) is
oriented to treatment evaluation, disease man
agement and health services (69, 70). These are
different but complementary and point to fund
ing gaps that need to be filled, perhaps from
other sources. The data in Fig. 4.'3 indicate that
the Wellcome Trust, the MRC and the health
departments provide relatively little money for
research on prevention (group 3) or on detection
and diagnosis (group 4). This is an argument not
only for research monitoring but also for greater
harmonization between funding bodies.
Tlie virtues of having a standard method
of accounting for research funds are clear - for
communication, comparability and collabora
tion (69). 'Ihe approach illustrated in Fig 1
is one scheme among a number that have been
105
Research for universal health coverage
Contrasting but complementary
Fig. 4.3.
profiles of health research
spending, United Kingdom
of Great Britain and Northern
Ireland, 2009-2010
A. Medical research organizations
50-i
c'
1
-5
ro
Oj
un
4030-
QJ
O'
en
O
&
20-
10"
ri-nrfl
0
1
2
3
4
Type of research study
□ Wellcome Trust
® Medical Research Council
B. National health departments
50-i
^5
a
■S
'T3
40-
30-
vn
&
’"o
O
cr,
ro
20-
10"
0-i=
1
2
3
4
5
6
7
8
Type of research study
□ England
O Scotland
Types of research: 1, underpinning; 2„etiology; 3, preven
tion; 4, detection and diagnosis; 5, treatment development;
6, treatment evaluation; 7, disease management; 8, health
systems and services (Box 2.2).
Note: For each of the four organizations, percentages sum to
100%.
Adapted, by permission of the publisher, from the UK Clinical
Research Collaboration (69).
106
proposed (69). All take a similar approach to
classification - a disease code is combined with
a description of the research purpose - indicat
ing that there is a common understanding of
what a classification system should include. The
next step in reconciling different schemes could
take one of lwo directions: either agreement to
adopt the same system, or reliance on computer
software to translate and map the current variet v
of classification systems to a common standard
(77). The best approach will be the one that most
easily achieves the main goal, which is to assure
transparency and accountability in researci
funding {70).
The amount of funding sought for research
should be based on an assessment of what studies are
needed and how much they cost. Despite the impor
tance ol good accounting in research, the evaluation
of both need and cost are underdeveloped skills.
Funding for TB operational research illus
trates the challenge of assessing need. The desir
able expenditure (budget) for TB operational
research has been set at USS 80 million annually,
calculated as 1% of the expenditure of national
TB control programmes (72). Against this arbi
trary spending target, which is far lower than
that for any other area of TB research, the avail
able funds totalled 76% of assessed need. This is
a higher percentage than for any other area of
research (
) (73). The danger here is to con
clude that the need for operational research has
largely been satisfied. While the Global Plan o
Stop TB has successfully highlighted the need o
invest in R&D for technology, a more objective
method is needed for calculating the TB oper itional research budget, especially in light of the
widely-held view that too little effort is devoted
to operational research (28, 74, 75).
On the question of costing, the calculation of
direct expenditure is relatively straightforward.
It refers to the indirect costs that are harder to
define, including the funds needed to build aikd
upgrade infrastructure (76). Research institutions
Chapter 4
Building research systems for universal health coverage
Global expenditures and budget
F g.4.4.
gap in tuberculosis R&D by
research category, 2010
8OO-1
■g
c
600-
"O
J
5—
11 400-
II
n fl IS"
Ss
-s 200 - f®:i
H3
CM
■
czr
J___ L
0
CH
cS g
E3 Budget gap
tn
CL’
=
•s
11
r
□ Expenditure
I;&D, research and development.
Note: Relatively little money is spent on di-ignosiics and
operational research; the budget for operational research is
exceptionally low.
Reproduced, by permission of the publisher, from Treatment
Action Group (7T).
m low- and middle-income countries have the
task of persuading external donors to contribute
to indirect costs, and also to align their research
priorities in contributing to direct costs. Both of
these problems were confronted - and solved - by
the International Centre for Diarrhoeal Diseases
Research, Bangladesh (ICDDR,B) in 2006 (77).
Solutions were found, in part by adopting a
transparent approach to financial monitoring
and evaluation. ICDDR.B explicitly defined and
measured activities, outputs and outcomes in the
areas of research, clinical services, teaching, and
management and operations.
Building research institutions
and networks
The Global Health Trials network has expressed a
view of capacity-building that is shared by other
health research networks (Box 4.7). In the con
text of research networks, “capacity” is seen as
the establishment of a community of researchers
based in lower-income countries who can devise
and validate methods and operational tools
for improving health, and who share local and
global solutions to make pragmatic and locallyled development possible (79). Box '1.8 describes
the success of a multinational network that suc
cessfully evaluated the diagnosis and treatment
of syphilis.
Putting the spotlight on collaboration
between lower-income countries does not
mean neglecting the traditional links through
which higher-income countries continue to
provide funds and expertise to those with
lower incomes and where the emphasis of the
research studies of each group differs from that
of the other group but both are complementary.
For instance, clinical trials in poorer countries
have focused largely on communicable rather
than noncom municable diseases. In contrasty
researchers in richer countries have enormous
expertise in studying noncommunicable dis
eases. Their expertise will be in demand as the
need for research on these diseases continues to
rise worldwide (79).
Defining and implementing
norms and standards
Codes of practice for the responsible conduct
of research have been written by many research
organizations around the world. Among them are
the United Kingdom’s Medical Research Council
107
Research for universal health coverage
Box 4.7.
Developing research networks
Initiative to Strengthen Health Research Capacity in Africa (ISHReCA)
ISHReCA (ishreca.org) is an African-led initiative whose mission is to build strong foundations for health research in
Africa (55, 59). ISHReCA aims to expand research capacity in four ways: (i) it provides a platform for African health
researchers to discuss ways of building sustainable capacity for health research in Africa; (ii) it promotes an African-led
agenda for health research, negotiating with funders and partners concerning support for, and harmonization of,
research initiatives; (iii) it advocates for increased commitment to research by national governments and civil society,
emphasizing the translation of research into policy and practice; and (iv) it seeks novel ways to garner regional and
international support for health research in Africa.
African Network for Drugs and Diagnostics Innovation (ANDI)
Launched in 2008, ANDI (www.andi-africa.org) is hosted by the United Nations Economic Commission for Africa
(UNECA) in Addis Ababa (67). Backed by the first African-owned and managed innovation fund, ANDI's mission is to
"promote and sustain African-led health product innovation to address African public health needs through efficient
use of local knowledge, assembly of research networks, and building of capacity to support economic development".
The vision is to create a sustainable platform for R&D innovation that addresses Africa's own health needs. To realize
this vision, ANDI is building capacity that supports pharmaceutical research, development and manufacturing to
improve access to medicines. Specific activities include the development of a portfolio of high-quality, pan-African
pharmaceutical R&D innovation projects, project coordination and management, including intellectual property
management. Vital to ANDI are more than 30 African institutions which are recognized as research centres of excel
lence and are committed to sharing expertise, knowledge, research equipment and facilities (67, 78).
Global Health Trials
Global Health Trials (globalhealthtrials.tghn.org) is an online community that shares information on clinical studies
and experimental trials in global health, providing guidance, tools, resources, training and professional development.
An e-learning centre offers short courses, seminars and a library.
Pan-African Consortium for the Evaluation of Anti-Tuberculosis Antibiotics (PanACEA)
North-south research collaboration, such as that fostered by the European and Developing Countries Clinical
Trials Partnership (www.edctp.org), has existed for many years. The EDCTP 14-country partnership works to
"accelerate the development of new or improved drugs, vaccines, microbicides and diagnostics against HIV/AIDS,
tuberculosis and malaria, with a focus on phase II and III clinical trials in sub-Saharan Africa".
An offshoot of EDCTP, PanACEA is a network of 11 linked clinical trial sites in six African countries, supported by
European research organizations and pharmaceutical companies. The initial aim of the network was to investigate the
role of moxifloxacin in reducing treatment durations forTB. However, PanACEA has a wider ambition - to establish
collaboration rather than competition as a driving force in the conduct of high-quality clinical and regulatory trials.
Research for Health Africa (R4HA)
The goal of R4HA (www.cohred.org/r4ha) is to solve common problems through collective action. The NEPAD Agency
and COHRED, financially supported by the Ministry of Foreign Affairs of the Netherlands, work with Mozambique,
Senegal and Tanzania to strengthen the governance of research for health in these countries. Country focused activi
ties are complemented by cross-country learning and exchange opportunities. At the same time, in 2011, a group
of 14 West African countries launched a four-year project dedicated to strengthening health research systems. The
project is financed by Canada's IDRC and the West African Health Organisation (WAH0), with technical facilitation
provided by COHRED. An assessment of research for health in this group of West African countries identified GuineaBissau, Liberia, Mali and Sierra Leone as most in need of support. WAH0 and COHRED help to build the research
systems in these countries based on action plans they have defined themselves.
R&D, research and development.
108
Chapter 4
Building research systems for universal health coverage .
How to prevent and treat syphilis: an operational research network connecting six
Box 4,8.
countries
Two million pregnant women are infected with syphilis each year. More than half transmit the infection to newborn children,
resulting in premature births, stillbirths and underweight babies. Syphilis also augments sexual and mother-to-child transmis
sion of HIV.
However, syphilis is easily diagnosed and treated, and congenital syphilis is preventable. Pomt-of-care diagnostic tests and
treatment with penicillin each cost less than USS 1. The London School of Hygiene & Tropical Medicine coordinated a three-year,
multicountry implementation research project to determine the feasibility and cost-effectiveness of using s^Impic! d'agnostic
tests and same-day treatment in prenatal and high-risk populations in low-and middle-income countries (SO). More than 150 0
individuals were screened in six countries. Interventions were introduced through existing services, so there was no need tor
new infrastructure.
Numbers screened and population focus by country
__ __
I7
Oo
V' Zambia
tw1''
> 12 000 screened
Population focus:
integration into
PMTCT programmes
for HIV
0
)
• ~n-
1
<r-4
1
w
__________
Uganda
> 13 000 screened
Population focus:
integration into
PMTCT programmes
for HIV
>b'
of
Peru
> 17 000 screened
Population focus:
prenatal
r.. China
> 5000 screened
Population focus:
prenatal and high
risk
7—
V
V
Brazil
> 45 000 screened
Population focus:
remote and indigenous
communities
United Republic
ofTanzania
>58000 screened
Population focus:
prenatal and high risk
Initial preparatory work - including making sure that screening was culturally acceptable - was critical to the Recess
to take up screening. In a seventh country, Haiti, traditional healers
syphilis, which enabled them to refer patients to health clinics.
Ministries of health were consulted about what evidence they would need before considering a change of policy. A baseline
survey of services and barriers aided the design of specific interventions to overcome obstacles and to measure 'nc^ase in
coverage. Health ministries were given regular updates which provided a sense of ownership and facilitated policy change.
From staffing to equipment, emphasis was placed on establishing systems that could be sustained.
In all participating countries, the study achieved significant increases in coverage of diagnostic testing forjyPhil's- This
reduced the prevalence of syphilis and the risk of HIV infection. Some benefits were immediately visible and led to rap d
policy changes which were, in some instances, implemented even before the research studies were completed.
The research also helped to strengthen health services in some of the participating countries. In Brazil, for instance, it has
provided a model for the provision of health services to indigenous populations, as well as a template for the introduction
of new technologies.
PMTCT, Prevention of.mother-to-chi!d transmission.
109
Research for universal health coverage
and Australia’s National Health and Medical
Research Council (<S/, S2). This section outlines
the main responsibilities that fall on institu
tions and researchers in carrying out responsible
research. Because these principles are laid out
clearly in international guidelines, the task is not
necessarily to develop the principles further but
to see that they are applied everywhere.
Ethics and ethical review
Tlie ethical principles that guide the behaviour
of researchers, overseen by ethical committees,
are to ensure honesty, objectivity, integrity, justied, accountability, intellectual property, pro
fessional courtesy and fairness, the protection of
participants in research studies, and good stew
ardship of research on behalf of others {83-88).
WHO has defined 10 standards that should
be met in ethical reviews of health research with
human participants (Box 4.9). These standards
are designed to complement existing laws, regu
lations and practices, and to serve as a basis on
which research ethics committees can develop
their own specific practices and written proce
dures. Among the organizations that monitor
compliance with ethical standards are inde
pendent bodies such as the United Kingdom’s
Research Integrity Office (www.ukrio.org) and
the Wemos Foundation (www.wemos.nl).
Reporting and sharing research
data, tools and materials
The research community is responsible for ensur
ing the accuracy of methods, integrity of results,
production and sharing of data, adequacy of peer
review, and protection of intellectual property
{81, 90, 911
In the era of open access, an influential body
of opinion synthesized by the United Kingdom’s
Royal Society holds that “intelligent openness”
should become the norm in scientific research
(92). Tliis means openness of researchers with
other scientists and with the public and media;
no
greater recognil ion of the value of data-galhering,
analysis and communication; common standards
for sharing information; mandatory publication
of data in a reusable form to support findings;
and the development of expertise and software
for managing the enormous volume of digital
data (9J). In this Royal Society review, intelligent
openness is seen as'the key to scientific progress.
It is the basis lor understanding and communi
cating results that can be exploited for practical
purposes, including the improvement of health.
Accompanying this general trend towards
openness is a proliferation .of Internet-based
platforms for sharing information. Among these
are the Health Research Web, Health Systems
Evidence, and PDQ-Evidence (
). As dal i
exchange becomes commonplace, consistent
database structures and standards for report
ing are needed for efficient communication. The
principles and practice for sharing genomic data
are well advanced but those for sharing data on
innovation, research and development are less
developed (94, 95).
Registering clinical trials
The Declaration of Helsinki (1964-2008) states
that “every clinical trial must be registered in a
publicly accessible database before recruitment
of the first subject”. The registration of clinic; 1
trials is a scientific, ethical and moral responsi
bility because decisions about health care must
be informed by all of the availableevidence. From
a practical standpoint, the International Clinical
Trials Registry Platform (ICTRP) helps research
ers and funding agencies to avoid unnecessary
duplication, to identify gaps in clinical trials
research, and to find out about trials in whicn
they may have an interest and with which they
might collaborate (96). In addition, the process
of registration has the potential to improve the
quality ol clinical trials - e.g. by revealing prob
lems in design at an early stage. Although the'
regulatory, legal, ethical and funding require
ments for the oversight and conduct of clinic; 1
Chapter 4
Box 4.9.
Building research systems for universal health coverage
Standards for the ethical review of research with human participants
These standards (which are abbreviated here) are intended as guidance for research ethics committees and for the
researchers who design and carry out health research studies (88). The task of ethical review involves more than
standing committees and includes, for example, independent teams of trained external assessors that can investigate
allegations of research misconduct (89).
1. Responsibility for establishing the research ethics review system
Ethical review must be supported by an adequate legal framework. Research ethics committees must be able to
provide independent reviews of all health-related research at national, subnational and/or institutional (public or
private) levels.
2. Composition of research ethics committees
Research ethics committees should have multidisciplinary and multisectoral membership, including individuals
with relevant research expertise.
.
3. Research ethics committee resources
Research ethics committees should have adequate resources - staff, facilities and finance - to carry out their
responsibilities.
4. Independence of research ethics committees
The independence of research ethics committee operations must be ensured in order to protect decision-making
from influence by any individual or entity that sponsors, conducts or hosts the research it reviews.
5. Training the research ethics committee
Training should be provided on the ethical aspects of health-related research with human participants, on the
application of ethical considerations to different types of research, and on the conduct of research reviews by the
research ethics committee.
6. Transparency, accountability and quality of the research ethics committee
Mechanisms exist to make the operations of research ethics committees transparent, accountable, consistent and
of high quality.
7. The ethical basis for decision-making in research ethics committees
The research ethics committee bases its decisions about the research that it reviews on a coherent and consistent
application of the ethical principles that are articulated in international guidance documents and human rights
instruments, as well as on any national laws or policies consistent with those principles.
8. Decision-making procedures for research ethics committees
Decisions on research protocols are based on a thorough and inclusive process of discussion and deliberation.
9. Written policies and procedures
Written policies and procedures include specification of the membership of the research ethics committee, commit
tee governance, review procedures, decision-making, communications, follow-up and monitoring, documentation
and archiving, training, quality assurance, and procedures for coordination with other research ethics committees.
10. Researchers' responsibilities
Research is performed only by persons with scientific, clinical or other relevant qualifications appropriate to the
project, who carry out the research in compliance with the requirements established by the research ethics committee.
111
Research for universal health coverage
Box 4.10.
Sharing information on current practice in health research: some examples
Health Research Web (www.healthresearchweb.org) provides data, tables and graphs for monitoring and evaluat
ing research investments at national or institutional level. The platform uses an editable wiki-type format so that
institutions and agencies can personalize entries to suit their own needs. The information presented includes research
policies, priorities, projects, capacities and outputs, as illustrated in the following figure.
The Health Research Web
Governance
and policies
Information
resources
Research
projects
Civil society
organizations
Research
priorities
Key
institutions
Research
ethics review
The number of users of the platform is growing at both regional and country levels. In the Americas, the Pan
American Health Organization (PAHO) has developed Health Research Web - Americas (www.healthresearchweb.
org/en/americas), which is linked to EVIPNet (Box 4.12) and to hundreds of research ethics committees active in Latin
America. In Africa, the Tanzanian Commission for Science and Technology (COSTECH) uses the platform to issue
public calls for research proposals. With this platform COSTECH can monitor which studies have been supported,
see how these respond to national research priorities, check what public resources are allocated to the research,
and consult the research findings.
Health Systems Evidence (www.healthsystemsevidence.org), an initiative of the McMaster Health Forum, is a
continuously updated repositoryof evidence - mainly systematic reviews - about the governance and financing of
health systems and the delivery of health services.
PDQ-Evidence (www.pdq-evidence.org), maintained by the Evidence-Based Medicine unit of the Pontificia
Universidad Catolica de Chile (Pontifical Catholic University of Chile), also provides evidence about public health
and about health systems and services. Information is presented mainly in the form of structured summaries and
systematic reviews.
112
Chapter 4
Building research systems for universal health coverage
trials differ between countries, the ICTRP is a
worldwide resource that can be used tor clini
cal trials wherever they are carried out. Since
2000, the number of registered clinical trials
has increased markedly, and there are now moie
than 200 000 records on the IC.'fKP.
Using evidence to develop
policy, practice and products
(Sood practice dictates that any findings that
i light have an impact on clinical practice, on the
development of methods of prevention oi treat
ment, or on public policy should be made available
to those who wish to use them {81}. However, con
veying information is just one part of the process
of translating research evidence into health policy
and practice, as described in the next section.
Translating evidence
there is a broad consensus that most health
research is devoted to developing new interven
tions and demonstrating their efficacy in experi
mental trials, and that far too little effort is given
to the process of turning evidence from research
into actions that improve health (97, 9<S). In the
context of achieving universal health coverage,
a large number of cheap, efficacious and costeffective existing interventions remain inac
cessible to many who could benefit from them
(99-/(?/). Some proven interventions are hardly
used at all; for others, widespread implementa
tion may take years or decades (
) (/02).
A variety of conceptual approaches have
been used to map .the path from evidence to
action - the “triangle that moves the moun
tain” and others (/03-/06). Notwithstanding the
theory, however, the evidence on how rapidly to
achieve high coverage of interventions is gener
ally weak (59, 107}. To simplify the problem by
division, four questions help to understand the
Proportion of 40 low-income
Fig. 4.5.
countries implementing five
interventions, over periods of
up to 27 years since regulatory
approval
I.O-i
V/1
(V
i c
O -JZ
ITN
0.8-
HiB
ACT
/
Hep B
0.6-
i i 0.4-
RDT
o
si
g.
aZ
0.2"
0-T
25
0
Years since regulatory approval
The interventions: ACT, artemisin-based combination thera
pies; Hep B, Hepatitis B vaccine; HiB, haemophilus influenza
type b vaccine; ITN, insecticide-treated mosquito net; RDT,
rapid malaria diagnostic test.
Adapted under the Open Access licence from Brooks et al.
002}.
reasons why interventions of known efficacy aie
not taken to scale {108}.
First, how can the results of research be
presented in a form that is comprehensible and
credible to the population of potential users?
Second, how best can the results, once clearly
described, be actively disseminated? In this
context, who is the audience and through what
channels can they be reached? Box 4.11 contains
a checklist of the pitfalls in dissemination, with
some guidance on how to avoid them {111}- Not
everyone will agree with all of the remedies. 'Thus,
rather than guarding against premature public
ity, Brooks et al. argue that dissemination, which
make take decades (fig. 1
can be achieved
more quickly by anticipating and removing likely
bottlenecks during the R&D phase {102}.
113
Research for universal health coverage
Box 4.11,
Ten common mistakes in the dissemination of new interventions, and suggestions
for avoiding them
1. Assuming that evidence matters to potential adopters
Suggestion. Evidence is most important only to a subset of potential adopters, and is often used to reject proposed
interventions. Therefore, emphasize other variables such as compatibility, cost and simplicity when communicating
about innovations.
2. Substituting the perceptions of researchers for those of potential adopters
Suggestion: Listen to representatives of the potential adopters to understand their needs and reactions to new
interventions.
3. Using intervention creators as intervention communicators
Suggestion. Enable access to experts, but rely on communicators who will elicit the attention of potential adopters
4. Introducing interventions before they are ready
Suggestion: Publicize interventions only after clear results have been obtained.
5. Assuming that information will influence decision-making
Suggestion: Information is necessary, but influence is usually needed too. Therefore pair sources of information with
sources of social and political influence.
6. Confusing authority with influence
Suggestion: Gather data on who among potential adopters is seen as a source of advice and use them to acceler
ate dissemination.
7. Allowing those who are first to adopt (innovators) to gain primacy in dissemination efforts
Suggestion: Initial adopters are not always typical or influential. Find out how potential adopters and key users are
related to each other in order to identify those who are most influential 009).
8. Failing to distinguish between change agents, authority figures, opinion leadersand innovation champions
Suggestion: Single individuals do not usually play multiple roles, so determine what part each person can play in
the dissemination process.
9. Selecting demonstration sites on criteria of motivation and capacity
Suggestion: The spread of an intervention depends on how initial demonstration sites are seen by others. So, when
selecting demonstration sites, consider which sites will have a positive influence.
10. Advocating single interventions as the solution to a problem
Suggestion: One intervention is unlikely to fit all circumstances; offering a cluster of evidence-based practices is
usually more effective (105, 110).
Adapted from Dearing (111}.
ITiird, by what criteria do potential users
circumstances. By and large, .programmes Can
decide to adopt a new intervention? Ideally, the
be expected to work imperfectly at first and wi I
decision formally to adopt will ultimately be
need to be adapted and refined (105).
embodied in government policy.
To help answer these four questions for a
And fourth, once the. decision to adopt
variety of interventions in different settings, an
has been taken, how should an intervention be
assortment of networks, tools and instruments
is available, including EvipNet, SURE, TRActio i
implemented and evaluated? In practice, there
is a tension between preserving the interven
and SUPPORT (
tion in its original form and adapting it to local
systems performance, the methods for judging
114
In the context ofhealt i
Chapter 4
Box 4.12.
Building research systems for universal health coverage
Translating research into policy and practice
There is an important distinction between evidence used to set policy and evidence used to influence practice. The
first two examples below focus on policy, the third on practice.
Evidence-Informed Policy Networks (EVIPNet)
The purpose of EVIPNet (www.evipnet.org) is to strengthen health systems by linking the results of scientific research
to the development of health policy. EVIPNet is a network of teams in more than 20 countries around the world, which
synthesize research findings, produce policy briefs, and organize policy forums that bring togethei policy-makers,
researchers and citizen groups. Recent initiatives have, for example, helped to improve access to ACT for the treatment
of malaria in Africa and debated the role of primary health care in the management of chronic noncommunicable
diseases in the Americas (112). As a component of EVIPnet, SURE (Support for the Use of Research Evidence) offers a
set of guides for preparing and using policy briefs to support health systems development in Africa.
SUPPORT tools for evidence-informed health policy-making
SUPPORT is a collection of articles that describe how to use scientific evidence to inform health policy (7/3). The
series shows, among other things, how to make best use of systematic reviews and how in general to use research
evidence to clarify problems linked to health policy.
The Translating Research into Action (TRAction) project
Recognizing that many health problems in developing countries already have solutions that have not been applied,
TRAction (www.tractionproject.org) promotes wider use of interventions that are known to be effective, awarding
grants for translational research in the areas of maternal, newborn and child health. TRAction is part of the Health
Research Program (HaRP) of the United States Agency for International Development (USAID).
ACT, artemisin-based combination therapies.
evidence on the effectiveness of interventions are
well developed. However, new tools are needed
o help assess evidence from systematic reviews
n terms of the acceptability of policy options
to stakeholders and the feasibility ol implemen
tation, and in terms of equity. Research is also
needed on ways to develop, structure and pre
sent policy options in relation to the functions
of health systems (/J4, IIS').
Researchers and decision-makers typi
cally work in different communities, and the
research described in technical publications
and scientific journals cannot easily be evalu
ated by most of the people who make most of
the decisions (see Box 2.3 on the GRADE system
for judging evidence for policy and practice)
(116). The influence of research depends on how
research activities are positioned with respect
to the bodies that are responsible for setting
policy and practice. Bor maximum effect, health
research should be embedded as a core function
in every health system (54). A research depart
ment located within a health ministry should
be well positioned to transfer research findings
to policy-makers and to help oversee national
research practice - for instance by setting up
national databases of research projects approved
and completed, of scientific publications pro
duced, and of patents awarded.
When researchers are put in close contact
with policy-makers they will be in a position not
simply to produce results on demand but also to
shape the research agenda (117)'. For instance,
routine evaluation of public health programmes
is an important source of questions for research,
and yet few countries have laws and policies
that require such evaluations to be done (118).
One weakness of existing schemes for promot
ing universal health coverage is that they fail to
involve evaluators from the start (1/9). Research
scientists placed in public health programmes
would stimulate monitoring and evaluation.
115
Research for universal health coverage
Monitoring and coordinating
research, nationally
and internationally
Mechanisms to stimulate and facilitate research
for universal health coverage include moni
toring, coordination and financing. These
are closely related and have repeatedly been
proposed as ways of promoting and support
ing high-priority research {120-122'). Most
recently, the report of the Consultative Expert
Working Group on Research and Development:
Financing and Coordination (CEWG) made a
series of recommendations to support R&D for
health technology, and the Alliance on Health
Policy and Systems Research did the same for
HPSR (Box 4.1/) {117, 123, 124). Many of the
ideas for promoting R&D and HPSR apply to
all aspects of health research, so these are drawn
together here.
Where there is a commitment to share data,
a global observatory, built on national observa
tories and regional hubs, can in principle do the
Box 4.13.
following in support of research for universal
health coverage:
compile, analyse and present data on finan
cial flows for health;
act as a repository of data on research find
ings and on the efficacy, safety, quality and
affordability of interventions, including the
registration of clinical trials;
in collaboration with other organizations
that currently gather data on science and
technology indicators (e.g. UNESCO,
OECD, the Network for Science and
Technology Indicators - Ibero-American
and Inter-American, the World Intellectual
Property Organization), bring together
information on research publications,
clinical trials and patents, as envisaged in
the Global Strategy and Plan of Action on
Public Health, Innovation and Intellectual
Property (Box 2.7) {125\,
chart progress on research for universal
health coverage by measuring inputs and
health impact along the results chain
(Chapter 1);
WHO Strategy on Health Policy and Systems Research
The WHO Strategy on Health Policy and Systems Research (HPSR), launched in November 2012, was shaped by the
Alliance on Health Policy and Systems Research. The strategy explains how the evolving field of health policy and
systems research (Box 2.1) responds to the information needs of decision-makers, health practitioners and civil
society, all of whom are responsible for the planning and performance of national health systems (777). As the firstever global strategy in this area, it represents a milestone in the evolution of HPSR.
The strategy has three aims. First, it seeks to unify the worlds of research and decision-making and connect the
various research disciplines that generate knowledge on health systems. Second, it contributes to a broader under
standing of the field by clarifying the scope and role of HPSR and providing insights into the dynamic processes
through which.HPSR evidence is generated and used in decision-making. Third, the strategy is intended to serve
as an agent for change, advocating close collaboration between researchers and decision-makers as an alternative
to working in parallel.
The strategy document outlines several actions by which stakeholders can facilitate evidence-informed decision
making and strengthen health systems. Some of these actions are reflected in the main text of this chapter. These
mutually complementary option^ support the embedding of research into decision-making processes and promote
national and global investment in HPSR. National governments may choose to pursue some or all of these actions
on the basis of their individual needs and available resources.
116
Chapter 4
Building research systems for universal health coverage
generate and promote research standards,
increase accountability for action, and
provide technical support;
facilitate collaboration and coordination,
especially between countries, by sharing
information from the repository ol data.
Whether all these functions can be satisfied
in practice depends on the resources available
and the will to develop national, regional and
global observatories. These ideas lorm part of the
continuing debate about how to promote R&D
lor health in low-income countries (126).
Monitoring provides opportunities to coor
dinate research activities: information-sharing,
network-building and collaboration are essen
tial ingredients of coordination. The advantages
of coordination lie in jointly developing solu
tions to common problems, sometimes with
shared resources.. However, there are disadvan
tages too. One dilemma in coordination is how
lo provide opportunities to make research more
effective - for instance by seeking to be com
plementary and to avoid duplication - without
imposing undue constraints on creativity and
n novation.
At its least complicated, coordination is
acilitated simply by sharing information. The
observatory Orphanet, for example, is a refer
ence portal that provides information on rare
diseases and orphan drugs (127). On a different
level, coordination might entail the joint setting
of priorities for research on a selected theme,
such as interventions to control noncom munica
ble diseases (37). At a yet higher level of organi
zation, there might be joint research projects,
for example to test new tools for prevention or
treatment at sites in several countries. Examples
are the coordinated evaluation ol MenAfriVac
across west and central Africa, and the diagno
sis and treatment of syphilis on three continents
C- •I ) (80, 128, 129).
Financing research for
universal health coverage
Health research is more productive when there
is a guaranteed, regular income. International
donors and national governments can measure
their own commitments to investing in health
research against defined, voluntary benchmarks.
A series of benchmarks for research funding has
been proposed, and these may be taken as start
ing points in setting targets for research fund
ing (121). Accordingly, the 1990 Commission on
Health Research for Development suggested that
each nation should spend at least 2% of national
health expenditure on “essential national health
research” (120). A more recent recommendation
is that “developing” countries should commit
0.05-0.1% of GDP to government-funded health
research of all kinds (121). Higher-income
countries should commit 0.15-0.2% of GDP to
government-funded health research (121). The
choice of bench marks is discretionary but should
be commensurate with achieving, or at least lie
on a trajectory to, universal health coverage.
National and international
governance of health research
One may ask whether the health research system
in any country is effectively governed and man
aged - i.e. whether all the essential functions are
carried out to a high standard. Systematic evalu
ations of research governance are valuable but
rare. In one of the few examples, eight indicators
of governance and management were used to
assess the national health research systems of 10
countries in the WHO Eastern Mediterranean
Region (Pig. 1.6) (130).
Ibis evaluation found some examples of
good practice, but few countries had a formal
national health research system and many of the
117
Research for universal health coverage
Fig. 4.6.
Eight aspects of governance and management of the national health research systems
(NHRS) in 10 countries of the Eastern Mediterranean region
I
Management and governance
1
£
-o
_o
J
J
-5
___ I
i
2
1
1 i I
sE
/■
National health priorities
Statement of aims for NHRS
Formal NHRS governance structure
Formal NHRS management structure
National health research priorities
National health research policy/plan/strategy
Statement of values for NHRS
Monitoring and evaluation system for NHRS
Source: Kennedy et al. (130).
basic building blocks of an effective system were
• not in place. On the basis of these indicators, it
was clear that the 10 countries differed greatly
in their research capabilities and that the best
performers among them were Lebanon, Oman
and Tunisia.'Similar evaluations have been car
ried out for Latin American countries and for
Pacific island nations (45, 131). The best kind of
governance ensures that all key functions of a
research system are carried out within a regula
tory framework that is light enough to facilitate
rather than hinder the research process (132).
Conclusions: building
The four functions of an ’effective research
system - setting priorities, building capacity,
setting standards, and translating evidence into
practice - are in various stages of development
118
in nations around the world. Consequently, the
parts of the system that need most attention vary
from one country to another. Tlie conclusion of
this overview therefore highlights one aspect of
each function that is important for all national
health research systems.
First, on choosing topics for research, moie
effort is needed to set national health research
priorities, as distinct from setting priorities for
selected health topics.
Second, the capacity of any country to carry
out the necessary research depends on funding,
institutions and networks. However, it is the
people who do research - with their curiosity,
imagination, motivation, technical skills, expe
rience and connections - who are most critical
to the success of the research enterprise.
'IT i rd, codes of practice, which are the corner
stone of any research system, are already in use in
many countries. However, they need to be further
developed and adapted to new settings and new
Chapter 4
Building research systems for universal health coverage
circuiTistances. An important task ahead is to
ensure adherence to nationally and internation
ally agreed standards in the conduct ol research.
Fourth, although a wide range of fundamen
tal and applied research studies is essential in
order to reach universal health coverage, there is
a particular need to close the gap between exist’
mg knowledge and action. Io help close this
gap, research should be strengthened, not only
n academic centres, but also in public health
programmes close to the supply ot and demand
for health services.
Apart from considering how research is
done, especially within countries, this chap
ter has also outlined methods for supporting
research, nationally and internationally. Hie
support is provided by three mechanisms: moni
toring, coordination and financing. One way to
monitor research more effectively is by establish
ing linked national and international research
observatories. A function of observatories is to
aid coordination, through information-sharing
and by facilitating collaborative research studies.
Observatories can also monitor financial flows
for research and can help ensure that there is
adequate funding to support research on global
and national priorities.
In view of what has already been achieved in
research, the next task is to identify what actions
can be taken to build more effective research sys
tems. Chapter 5 proposes a set of actions based
on the main themes of this report.
References
I.
Viergever RF et al. A checklist for health research priority setting: nine common themes of good practice. Health Research
2.
Policy and Systems, 2010,8:36. PMID:21159163.
Terry RF, van der Rijt T. Overview of research activities associated with the World Health Organization: results ot a
survey covering 2006/07. Health Research Policy and Systems, 2010,8:25. doi: http://dx.doi.org/10.1186/1478-4505-8-25
3.
PMID:20815938.
.
t .
Decoster K, Appelmans A, Hill P. A health systems research mapping exercise in 26 low- and middle-income countries,
narratives from health systems researchers, policy brokers and policy-makers. Geneva, World Health Organization, 2012
UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). Research capacity bui
4.
5.
6.
7.
8.
ing in developing countries. Geneva, World Health Organization and TDR, 2003.
Planning, monitoring and evaluation framework for capacity strengthening in health research. (ESSENCE Good practice
document series. Document TDR/ESSENCE/11.1). Geneva, World Health Organization, 2011.
Bates I et al. Indicators of sustainable capacity building for health research: analysis of four African case studies. Healt i
Research Policy and Systems, 2011,9:14. doi: http://dx.doi.org/10.1186/1478-4505-9-14 PMID:21443780.
Capacity building in research. London, Department for International Development, 2010.
Fathalla MF, Fathalla MMF. A practical guide for health researchers. Cairo, World Health Organization Regional Office for
the Eastern Mediterranean, 2004.
Gilson L, ed. Health policy and systems research: a methodological reader. Geneva, World Health Organization, 2012.
9.
10. Ghaffar A et al. The 3D Combined Approach Matrix: an improved tool for setting priorities in research for health. Geneva,
Global Forum for Health Research, 2009
II. Okello D, Chongtrakul P, COHRED Working Group on Priority Setting. A manual for research priority setting using the ENHR
12.
strategy. Geneva, Council on Health Research for Development, 2000.
A manual for research priority setting using the essential national health research strategy. Geneva, Council on Health
Research for Development, 2000.
Rudan I et al. Setting priorities in global child health research investments: universal challenges and conceptual frame
work. Croatian Medical Journal, 2008,49:307-317. doi: http://dx.doi.Org/10.3325/cmj.2008.3.307 PMID:18581609.
14. Rudan I et al. Evidence-based priority setting for health care and research: tools to support policy in maternal, neo
natal, and child health in Africa. PLoS Medicine, 2010,7:e1000308. doi: http://dx.doi.org/10.1371/journal.pmed.1000308
13.
15.
PMID:20644640.
Health technology assessment programme. London, National Institute for Health Research, 2013. (www.hta.ac.uk/funding/HTAremit.shtml, accessed 20 March 2013).
119
Research for universal health coverage
Policy research programme, best evidence for best policy. London, Department of Health, 2013. (prp’.dh.gov.uk, accessed
20 March 2013).
17. Youngkong S, Kapiriri L, Baltussen R. Setting priorities for health interventions in developing countries: a review
of empirical studies. Tropical Medicine & International Health, 2009,14:930-939. doi: http://dx.doi.Org/10.1111/j.13653156.2009.02311.x PMID:19563479.
18. George A et al. Setting implementation research priorities to reduce preterm births and stillbirths at the community level
PLoS Medicine, 2011,8:e1000380. doi: http://dx.doi.org/10.1371/journal.pmed.1000380 PMID:21245907.
19. Lawn JE et al. Setting research priorities to reduce almost one million deaths from birth asphyxia by 2015. PLoS Medicine,
2011,8:e1000389. doi: http://dx.doi.org/10.1371/journal.pmed.1000389 PMID:21305038.
20. Rudan I et al. Setting research priorities to reduce global mortality from childhood pneumonia by 2015. PLoS Medicine,
2011,8:e1001099. doi: http://dx.doi.org/10.1371/journal.pmed.1001099 PMID:21980266.
21. Fontaine 0 et al. Setting research priorities to reduce global mortality from childhood diarrhoea by 2015. PLoS Medicine,
2009,6:e41. doi: http://dx.doi.org/10.1371/journal.pmed.1000041 PMID:19278292.
22. Tomlinson M et al. Setting priorities in child health research investments for South Africa. PLoS Medicine, 2007,4:e259. doi:
http://dx.doi.org/10.1371/journal.pmed.0040259 PMID:17760497.
23. Sharan P et al. Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America
and the Caribbean. The British Journal of Psychiatry, 2009,195:354-363. doi: http://dx.doi.org/10.1192/bjp.bp.108.050187
PMID:19794206.
24. Tol WA et al. Research priorities for mental health and psychosocial support in humanitarian settings. PLoSMedicine,
2011,8:e1001096. doi: http://dx.doi.org/10.1371/journal.pmed.1001096 PMID 21949644.
25. Nicolau I et al. Research questions and priorities for tuberculosis: a survey of published systematic reviews and meta
analyses. PLoS ONE, 2012,7:e42479. doi: http://dx.doi.org/10.1371/journal.pone.0042479 PMID:22848764.
26. An international roadmap for tuberculosis research: towards a world free of tuberculosis. Geneva, World Health
• Organization, 2011.
27. Lienhardt C et al. What research Is needed to stop TB? Introducing the TB research movement. PLoS Medicine,
2011,8:e1001135. doi: http://dx.doi.org/10.1371/journal.pmed.1001135 PMID:22140369.
28. Priorities in operational research to improve tuberculosis care and control. Geneva, World Health Organization, 2011.
29. The malERA Consultative Group on Drugs. A research agenda for malaria eradication: drugs. PLoS Medicine,
2011,8:61000402. doi: http://dx.doi.org/10.1371/journal.pmed.1000402 PMID 21311580.
30. The malERA Consultative Group on Health Systems and Operational Research. A research agenda for malaria eradica
tion: health systems and operational research. PLoSMedicine, 2011,8:el000397. doi: http://dx.doi.org/10.1371/journal .
pmed.1000397 PMID:21311588.
31. McDowell MA et al. Leishmaniasis: Middle East and North Africa research and development priorities. PLoS Neglected
Tropical Diseases, 2011,5:e1219. doi: http://dx.doi.org/10.1371/journal.pntd.0001219 PMID:21814585.
32. Costa CH et al. Vaccines for the leishmaniases: proposals for a research agenda. PLoS Neglected Tropical Diseases,
2011,5:e943. doi: http://dx.doi.org/10.1371/journal.pntd.0000943 PMID:21468307.
33. Research priorities for Chagas disease, human African trypanosomiasis and leishmaniasis. Geneva, World Health
Organization, 2012.
34. Dujardin JC et al. Research priorities for neglected infectious diseases in Latin America and the Caribbean region. PLoS
Neglected Tropical Diseases, 2010,4:e780. doi: http://dx.doi.org/10.1371/journal.pntd.0000780 PMID:21049009.
35. Research priorities for helminth infections. Geneva: World Health Organization, 2012.
36. Research priorities for zoonoses and marginalized infections. Geneva, World Health Organization, 2012.
37. Prioritized research agenda for prevention and control of noncommunicable diseases. Geneva, World Health
Organization, 2012.
38. Ranson MK et al. Priorities for research into human resources for health in low- and middle-income countries. Bulletin of
the World Health Organization, 2010,88:435-443. doi: http://dx.doi.org/10.2471/BLT.09.066290 PMID:20539857.
39. Ranson K, Law TJ, Bennett S. Establishing health systems financing research priorities in developing countries using
a participatory methodology. Social Science & Medicine, 2010,70:1933-1942. doi: http://dx.doi.org/10.1016/j.socscimed.2010.01.051 PMID:20378228.
40. Jones R, Lamont T, Haines A. Setting priorities for research and development in the NHS: a case study on the inter
face between primary and secondary care. British Medical Journal, 1995,311:1076-1080. doi: http://dx.doi.org/10.1136/
bmj.311.7012.1076 PMID:7580669.
16.
120
Chapter 4
^1.
Building research systems for universal health coverage
Ostlin P et al. Priorities for research on equity and health: towards an equity-focused health research agenda. PLoS
Medicine, 2Oll,8:e10Q1115. doi: http://dx.doi.org/10.1371/journal.pmed.1001115 PMID:22069378.
^2. The 10/90 report on health research 1999. Geneva, Global Forum for Health Research, 1999.
^3. 5Sizemore CF, Fauci AS. Transforming biomedical research to develop effective TB vaccines: the next ten years. Tuberculosis
(Edinburgh, Scotland), 2012,92:Suppl 1S2-S3. doi: http://dx.doi.org/10.1016/S1472-9792(12)70003-3 PMID:22441154.
'-4. Pacheco Santos LM et al. Fulfillment of the Brazilian agenda of priorities in health research. Health Research Policy and
Systems, 2011,9:35. doi: http://dx.doi.org/10.1186/1478-4505-9-35 PMID:21884575.
■5. Alger J et al. [National health research systems in Latin America: a 14-country review). Revista Panamericana de Salud
a6.
Publica, 2009,26:447-457. PMID:20107697.
Ijsselmuiden C, Ghannem H, Bouzouaia N. Developpement du systeme de recherche en sante: analyse et etablissement
des priorites en Tunisie [Development of health research system: analysis and defining priorities in Tunsia). La Tunisie
Medicale. 2009,87:1-2. PMID.19522419.
Tomlinson M et al. A review of selected research priority setting processes at national level in low and middle income
countries: towards fair and legitimate priority setting. Health Research Policy and Systems, 2011,9:19. doi: http://dx.doi.
org/10.1186/1478-4505-9-19 PMID:21575144
48. McKee M, Stuckler D, Basu S. Where there is no health research: what can be done to fill the global gaps in health research?
PLoSMedicine, 2012,9.61001209. doi: http://dx.doi.org/10.1371/journal.pmed.1001209 PMID:22545025.
49. The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. Paris, Organisation for Economic Co-operation
47.
and Development, 2005.
50. Fourth High Level Forum on Aid Effectiveness. Busan, Global Partnership for Effective Development Cooperation, 2011.
(www.aideffectiveness.org/busanhlf4/, accessed 20 March 2013).
>1. Kok MO et al. The emergence and current performance of a health research system: lessons from Guinea Bissau. Health
Research Policy and Systems, 2012,10:5. doi: http://dx.doi.org/10.1186/1478-4505-10-5 PMID:22321566.
>2. Lansang MA, Dennis R. Building capacity in health research in the developing world. Bulletin of the World Health
Organization, 2004,82:764-770. PMID:15643798.
53. Bennett S et al. Building the field of health policy and systems research: an agenda for action. PLoS Medicine,
2011,8:e1001081. doi: http://dx.doi.org/10.1371/journal.pmed.1001081 PMID:21918641.
54. Hoffman SJ et al. A review of conceptual barriers and opportunities facing health systems research to inform a strategy
from the World Health Organization. Geneva, World Health Organization, 2012.
55. Whitworth JA et al. Strengthening capacity for health research in Africa. Lancet, 2008,372:1590-1593. doi: http://dx.doi.
org/10.1016/50140-6736(08)61660-8 PMID: 18984193.
56. Ijsselmuiden C et al. Africa's neglected area of human resources for health research - the way forward. South African
Medical Journal/Suid-Afrikaanse tydskrif vir geneeskunde, 2012, 102:228-233.
57. How to build science capacity. Nature. 2012,490:331-334. doi: http://dx.doi.org/10.1038/490331a PMID:23075964.
58. Bennett S et al. What must be done to enhance capacity for health systems research? Geneva: World Health
Organization2010.
59. Whitworth J, Sewankambo NK, Snewin VA. Improving implementation: building research capacity in maternal, neo
natal, and child health in Africa. PLoS Medicine. 2010,7:e1000299. doi: http://dx.doi.org/10.1371/journal.pmed.1000299
PMID:20625547.
60. Meyer AM, Davis M, Mays GP. Defining organizational capacity for public health services and systems research. Journal of
Public Health Management and Practice, 2012,18:535-544. PMID:23023278.
Nwaka S et al. Developing ANDI: a novel approach to health product R&D in Africa. PLoS Medicine, 2010,7:e1000293.
PMID:20613865 doi: http://dx.doi.org/10.1371/journal.pmed.1000293 PMID:20613865.
62. The world health report 2006 - working together for health. Geneva, World Health Organization, 2006.
63. Ijsselmuiden C. Human resources for health research. MMS Bulletin, 2007,104:22-27..
64. Guidelines for research in partnership with developing countries: 11 principles. Bern, Swiss Commission for Research
61.
Partnership with Developing Countries, (KFPE), 1998.
Kariuki T et al. Research and capacity building for control of neglected tropical diseases: the need for a different approach.
PLoS Neglected Tropical Diseases, 2011,5:e1020. doi: http://dx.doi.org/10.1371/journal.pntd.0001020 PMID:21655352.
66. Garcia CR, Parodi AJ, Oliva G. Growing Latin American science. Science, 2012,338:1127. doi: http://dx.doi.org/10.1126/science.123222.3 PMID:23197500.
67. Harries AD, Zachariah R. Applying DOTS principles for operational research capacity building. Public Health Action, 2012.
65.
121
Research for universal health coverage
68. Laabes EP et al. How much longer will Africa have-to depend on western nations for support of its capacity-building efforts
for biomedical research? Tropical Medicine & International Health, 2011,16:258-262. doi: http://dx.doi.Org/10.1111/j. 13653156.2010.02709.x PMID:21371216.
69. UK health research analysis 2009/10. London, UK Clinical Research Collaboration, 2012.
70. Head MG et al. UK investments in global infectious disease research 1997-2010: a case study. The Lancet Infectious Diseases,
2013,13:55-64. doi: http://dx.d0i.0rg/l0.1016/51473-3099(12)70261 -X PMID:23140942.
71. Terry RF et al. Mapping global health research investments, time for new thinking - a Babel Fish for research data. Health
Research Policy and Systems, 2012,10:28. doi: http://dx.doi.org/10.1186/1478-4505-10-28 PMID:22938160.
72. The Global Plan to Stop TB 2011-2015. Transforming the fight towards elimination of tuberculosis. Geneva, World Health
Organization, 2010.
73. Tuberculosis Research and Development: 2011 report on tuberculosis research funding trends, 2005-2010. New York, NY,
Treatment Action Group, 2012.
74. Zachariah R et al. The 2012 world health report 'no health without research': the endpoint needs to go beyond publication
outputs. Tropical Medicine & International Health, 2012,17:1409-1411. doi: http://dx.doi.Org/10.1111/j.1365-3156.2012.03072.x.
75. Lienhardt C, Cobelens FG. Operational research for improved tuberculosis control; the scope, the needs and the way
forward. The International Journal of Tuberculosis and Lung Disease, 2011,15:6-13. PMID:21276290.
76. Five keys to improving research costing in low- and middle-income countries. (ESSENCE Good practice document series.
Document TDR/ESSENCE/1.12). Geneva, World Health Organization, 2012.
77. Mahmood S et al. Strategies for capacity building for health research in Bangladesh: Role of core funding and a common
monitoring and evaluation framework. Health Research Policy and Systems, 2011,9:31. doi: http://dx.doi.org/10.1186/14784505-9-31 PMID:21798006.
78. Nwaka S et al. Analysis of pan-African Centres of excellence in health innovation highlights opportunities and challenges
for local innovation and financing in the continent. BMC International Health and Human Rights, 2012,12:11. doi: http://
dx.doi.org/10.1186/1472-698X-12-11 PMID:22838941.
79.. Lang TA et al. Clinical research in resource-limited settings: enhancing research capacity and working together to make
trials less complicated. PLoS Neglected Tropical Diseases, 2010,4:e619. doi: http://dx.doi.org/10.1371/journal.pntd.0000619
PMID:20614013.
80. Mabey DC et al. Point-of-care tests to strengthen health systems and save newborn lives: the case of syphilis. PLoS
Medicine, 2012,9:e1001233. doi: http://dx.doi.org/10.1371/journal.pmed.1001233 PMID:22719229.
81. Good research practice: principles and guidelines. London, Medical Research Council, 2012.
82. Australian Code for the Responsible Conduct of Research. Canberra, National Health and Medical Research Council, 2007.
83. The ethics of research related to healthcare in developing countries. London, Nuffield Council on Bioethics, 2005.
84. Singapore Statement on Research Integrity. Singapore, Second World Conference on Research Integrity, 2010.
85. Operational guidelines for ethics committees that review biomedical research. Geneva, World Health Organization, 2000.
86. UK Research Integrity Office (web site). Falmer, Sussex Innovation Centre, University of Sussex, 2012. (www.ukrio.org,
accessed 20 March 2013).
87. WMA declaration of Helsinki. Ethical principles for medical research involving human subjects. Seoul, World Medical
Association, 2008.
88. Standards and operational guidance for ethics review of health-related research with human participants. Geneva, World
Health Organization, 2011.
89. Chalmers I, Haines A. Commentary: skilled forensic capacity needed to investigate allegations of research misconduct.
British Medical Journal, 2011,342:d3977. doi: http://dx.doi.org/10.1136/bmj d3977.
90. Chan M et al. Meeting the demand for results and accountability: a call for action on health data from eight global health
agencies. PLoS Medicine, 2010,7:e1000223. doi: http://dx.doi.org/10.1371/journal.pmed.1000223 PMID:20126260.
91. Walport M, Brest P. Sharing research data to improve public health. Lancet, 2011,377:537-539. doi: http://dx.doi.org/10.1016/
S0140-6736(10)62234-9 PMID:21216456.
92. The Royal Society. Science as an open enterprise: open data for open science. London, The Royal Society, 2012.
93. Rani M, Buckley BS. Systematic archiving and access to health research data: rationale, current status and way forward.
Bulletin of the World Health Organization, 2012,90:932-939. PMID:23284199.
94. Leung E et al. Microcolony culture techniques for tuberculosis diagnosis: a systematic review, [i-iii.]. The International
Journal of Tuberculosis and Lung Disease, 2012,16:16-23. doi: http://dx.doi.org/10.5588/ijtld.10.0065 PMID:21986554.
95. Haak LL et al. Standards and infrastructure for innovation and data exchange. Science, 2012,338:196-197. doi: http://dx.doi
org/10.1126/science.1221840 PMlb:23066063.
122
Chapter 4
S6.
Building research systems for universal health coverage
International Clinical Trials Registry Platform (ICTRP) Geneva, World Health Organization, 2012. (www.who.int/ictrp/
triaLreg/en/indexZ.html, accessed 20 March 2013).
97. World report on knowledge for better health - strengthening health systems. Geneva, World Health Organization, 2004.
98. Green A, Bennett S, eds. Sound choices: enhancing capacity for evidence-informed health policy. Geneva, World Health
Organization, 2007.
99. Jamison DT et al. Disease control priorities in developing countries, 2nd ed. New York, NY, Oxford University Press, 2006.
00. Duflo E. Rigorous evaluation of human behavior. Science, 2012,336:1398. doi: http://dx.doi.org/10.1126/science.1224965
PMID:22700919.
iOl. Cobelens F et al. Research on implementation of interventions in tuberculosis control in low- and middle-income countries:
a.systematic review.PLoSMedicine, 2012,9:el001358.doi: http://dx.doi.Org/10.1371/journal.pmed.1001358 PMID:23271959.
102. Brooks A et al. Implementing new health interventions in developing countries: why do we lose a decade or more? BioMed
Central Public Health, 2012,12:683. doi: http://dx.doi.org/10.1186/1471-2458-12-683 PMID:22908877.
103. Wasi P. "Triangle that moves the mountain" and health systems reform movement in Thailand. Human Resources for Health
Development Journal, 2000,4:106-110..
104. Lavis JN et al. Assessing country-level efforts to link research to action. Bulletin of the World Health Organization,
2006,84:620-628. doi: http://dx.doi.org/10.2471/BLT.06.030312 PMID:16917649.
105. Glasgow RE, Emmons KM. How can we increase translation of research into practice? Types of evidence needed.
Annual Review of Public Health, 2007,28:413-433. doi; http://dx.doi.org/10.1146/annurev.publhealth.28.021406.144145
PMID:17150029.
106. Panel on Return on Investment in Health Research, Making an impact: a preferred framework and indicators to measure
returns on investment in health research. Ottawa, Canadian Academy of Health Sciences, 2009.
107. Orton L et al. The use of research evidence in public health decision making processes: systematic review. PLoS ONE,
201 l,6:e21704. doi: http://dx.doi.org/10.1371/journal.pone.0021704 PMID:21818262.
108. Noonan RK, Emshoff G. Translating research to practice: putting "what works" to work. In: DiClemente RJ, Salazar LF,
Crosby RA, eds. Health behavior theory for public health. Burlington, MA, Jones & Bartlett Learning, 2011:309-334.
109. Kok MO, Schuit AJ. Contribution mapping: a method for mapping the contribution of research to enhance its impact.
Health Research Policy and Systems, 2012,10:21. doi: http://dx.doi.org/10.1186/1478-4505-10-21 PMID:22748169.
110. Boaz A, Baeza J, Fraser A. Effective implementation of research into practice: an overview of systematic reviews of the
health literature. BMC Research Notes. 2011,4:212. doi: http://dx.doi.org/10.1186/1756-0500-4-212 PMID:21696585.
111. Dearing JW. Applying diffusion of innovation theory to intervention development. Research on Social Work Practice,
2009,19:503-518. doi. http:z7dx.doi.org/10.1177/1049731509335569 PMID:20976022.
112. Panisset U et al Implementation research evidence uptake and use for policy-making. Health Research Policy and Systems,
2012,10:20. doi: http://dx.doi.Org/10.l 186/1478-4505-10-20 PMID:22748142.
113. Lavis JN et al. SUPPORT Tools for evidence-informed health Policymaking (STP). Health Research Policy and Systems,
2009,7:Suppl 1:11. doi: http://dx.doi.org/10.1186/1478-4505-7-Sl-H PMID:20018098.
114. Lewin S el al. Guidance for evidence-informed policies about health systems: assessing how much confidence to
place in the research evidence. PLoS Medicine. 20l2,9':el001187. doi: http://dx.doi.org/10.1371/journal.pmed.1001187
PMID:22448147.
115. Bosch-Capblanch X et al. Guidance for evidence-informed policies about health systems: rationale for and chal
lenges of guidance development. PLoS Medicine, 2012,9:el001185. doi: http://dx.doi.org/10.1371/journal.pmed.1001185
PMID:22412356.
116. Buse K, Mays N, Walt G. Making health policy (Understanding public health), 2nd ed. New York, NY, Open University Press, 2012.
117. Strategy on health policy and systems research: changing mindsets. Geneva, World Health Organization, 2012.
118. Kebede M el al. Blueprints for informed policy decisions: a review of laws and policies requiring routine evaluation. Oslo,
Kunnskapssenreret (Norwegian Knowledge Centre for the Health Services), 2012.
119. Giedion U, Alfonso EA, Diaz Y. The impact of universal coverage schemes in the developing world: a review of the existing
evidence. Washington, DC, The World Bank, 2013.
120. Commission on Health Research for Development. Health research - essential link to equity in development. Oxford,
Oxford University Press, 1990.
121. Research and development to meet health needs in developing countries: strengthening global financing and coordina
tion. Report of the consultative expert woiking group on research and development: financing and coordination. Geneva,
World Health Organization, 2012.
123
Research for universal health coverage
122. Research and development coordination and financing. Report of the Expert Working Group. Geneva, World Health
Organization, 2010.
123. Knutsson KE et al. Health policy/systems research, realizing the initiative - a background document to an international consul
tative meeting at Lejondal, Sweden April 10-12. Lejondal, 1997 (unpublished).
• 124. Rottingen J-A et al. Mapping of available health research and development data: what's there, what's missing, and what
role is there for a global observatory? Lancet, 2013, May 17. pii:S0140-6736(13)61046-6. doi: http://dx.doi.org/10.1016/
30140-6736(13)61046-6 PMID:23697824
125. Global strategy and plan of action on public health, innovation and intellectual property. Geneva, World Health
Organization, 2011.
126. Hotez PJ etal. Strengthening mechanisms to prioritize, coordinate, finance, and execute R&D to meet health needs in
developing countries. Washington, DC, Institute of Medicine, 2013.
127. Orphanet. The portal for rare diseases and orphan drugs (web site). Paris, Orphanet/INSERM, 2012 (www.orpha.net,
accessed 20 March 2013).
128. Sow SO et al. Immunogenicity and safety of a meningococcal A conjugate vaccine in Africans. The New England Journal ol
Medicine, 2011,364:2293-2304. doi: http://dx.doi.org/10.1056/NEJMoa1003812 PMID:21675889.
129. Frasch CE, Preziosi MP, LaForce FM. Development of a group A meningococcal conjugate vaccine, MenAfriVac(TM). Human
Vaccines & Immunotherapeutics, 2012,8:715-724. doi: http://dx.doi.org/10.4161/hv.19619 PMID:22495119.
130. Kennedy A et al. National health research system mapping in 10 Eastern Mediterranean countries. Eastern Mediterranean
Health Journal. 2008,14:502-517. PMID:18720615.
131. National health research systems in Pacific island countries. Manila, World Health Organization Regional Office for the
Western Pacific, 2009.
132. A new pathway for the regulation and governance of health research. London, Academy of Medical Sciences, 2011.
124
Chapter 5
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Key points
128
Research - essential for universal
i
coverage and a source of inspiration for
public health
129
■
Aw
t
fee
RlWWl
■
Defining and measuring progress
towards universal health coverage
131
The path to universal health coverage,
and the path to better health
132
Research for universal health coverage
in every country
133
Supporting the people who do
research
134
Translating research evidence into
health policy and practice
135
Supporting research for universal
health coverage, nationally and
internationally
136
■
lit;
WHO's role in research for universal
health coverage
W’ ■
il
-
Laboratory work at the National Institute of Epidemiologic Diagnosis and Reference (InDRE) |
Mexico City, Mexico (Wl IO/PAIIO/Ilarold Ruiz)
1 .
3
Key points
Drawing on previous chapters, Chapter 5 highlights the dominant themes of the report,
and proposes a set of actions to guide the conduct of research and to support research for
universal health coverage.
There are a number of important considerations regarding the conduct of research with ia
focus on national health research systems. For instance:
« Research is not merely an essential tool for improving health services; it is also a
source of inspiration for public health.
SI
While the research focus of this report is the improvement of access to health
services and the protection of people at risk, the definition and measurement of
progress towards universal health coverage are themselves topics for investigation.
« Wider coverage of health services and better financial protection usually lead to
better health, but research is also needed to link the provision of services most
effectively with health impact.
KJ
Because local health problems often require local solutions, each country should be a
producer as well as a consumer of research.
83
Among the essential functions of national health research systems, developing
human capacity is critical, the people who do the research are the foremost asset in
the research enterprise and should be in the front line of capacity-strengthening.
The long-observed gap between existing knowledge and health practice remains
wide. Still greater effort is needed to translate evidence into policy and practice.
Actions to support research nationally and internationally include:
■ monitoring (e.g. through the establishment of research observatories);
« coordination (from information-sharing to collaborative research studies);
n
financing (to ensure that there are adequate funds to support global and local
priorities in research).
WHO’s role in carrying out and supporting research is articulated in the Organization’s
Strategy on Research for Health. The strategy aims to cultivate the highest quality research
in order to deliver the greatest health benefits to the maximum number of people.
Action on research for
universal health coverage
'I he tual of this report is not to measure definitively the gap between the present
covtiage of health services and universal coverage, but rather to identify the
research questions that arise along the way to universal coverage and to discuss
how ; hesc questions can be answered.
Chapter I identified two kinds of questions about research for univer
sal health coverage, lhe first set of questions is about improving health and
well ecing - how to advance towards universal coverage, and how improved
cove: age protects and improves health. The second set of questions is about
rnca.sjremcnt - of the indicators that can be used as measures of the coverage
ot essential health services and financial risk protection in any setting.
I n confronting these two sets of questions, the preceding four chapters have
Likei: a broad \ iew of research and a broad view of universal health coverage whcit reativity and imagination are harnessed by the highest-quality science
to dCiver affordable health services and better health protection for everyone.
iliis final chapter highlights the dominant themes of the report and
•proposes a set of actions - first, on the conduct of research, with a focus on
nalik nal health research systems and second, to support research nationally
and internationally (
). As part of the narrative, the chapter also outlines
Wl 1( )'s role in supporting these actions, based on the Organization ’s Strategy
on Research lor Health (Box 4.1) (/).
(
I "I - essev; tat for universal coverage
of insp&atioti for public health
'lhe question "how can we reach universal health coverage?” almost always calls for
a lormal investigation of some kind, whether it be a randomized controlled trial or a
simp/, observational study. On the road to universal coverage, taking a methodical
appi • h to formulating and answering questions is not a luxury but a necessity; it
is iik source of objective evidence that can inform health policy and practice.
I lowcx er, research is more than an essential tool; it is also a source of inspiratioii and motivation in public health. The discoveries made by research stir
129
Research for universal health coverage
Box 5.1.
Principal questions and actions on research for universal health coverage
This box identifies the key questions about research for universal health coverage that arise from discussion in the
main text, together with some important actions that can be taken to help answer the questions.
Questions on research
Improving the coverage of health services:
■
How can essential health services and financial risk protection be made accessible to everyone? How do wider
service coverage and better financial protection - and ultimately universal health coverage - lead to better health?
Measuring the coverage of health services:
■
What indicators and data can be used to monitor progress towards universal coverage of essential health
services and financial risk protection in each setting?
Actions on the conduct of research, mainly within national health research systems
Setting research priorities:
■
Set priorities for research, especially at national level, on the basis of evaluations of the major causes of ill-health.
Strengthening research capacity:
°
Give priority to recruiting, training and retaining the people who do research; research staff are the foremost
asset of any.research enterprise.
»
Provide training not only in research methods but also in the good conduct of research - on accountability,
ethics, integrity and the stewardship of information on behalf of others.
■ Train policy-makers to use the evidence from research, and train researchers to-understand the process of
decision-making and health practitioners.
Setting standards:
■
Refine and implement codes of practice to carry out ethical and responsible research in each setting.
•
Classify types of research study and research data according to internationally agreed and comparable standards.
Translating research into policy and practice:
■. Embed research within policy-making processes in order to facilitate the dialogue between science and
practice.
■
Establish formal procedures for translating evidence into practice.
■
Ensure that programmes of continuing professional development, and for improving the quality of care,
reflect the best available evidence.
»
Enhance incentives to carry out research that is relevant to health policy.
D
Engage private research companies along with public institutions in the discovery, development and delivery
of new technologies.
Ensuring participation and public understanding of research:
■
Include broad representation from society in the process of research governance.
■
Increase public access to policy debates and evaluations both via the media and through public consulta
tions andmeetings.
Actions to support research, nationally and internationally
Monitoring research:
«
Develop national and international research observatories to compile and analyse data on the process of
doing research (funding, priorities, projects, etc.) and on the findings of research - including research aimed at
achieving universal health coverage.
continues...
130
Chapter 5
Action on research for universal health coverage
... continneil
Coordinating research and sharing information:
»
Promote knowledge-sharing, network-building and collaboration, especially within and between countries
that aie beginning to develop research capacity.
Financing rescan h:
w Develop impioved mechanisms for raising and disbursing funds for research, either through existing national
’’
and international bodies or by creating new ones.
Establish flexible funding mechanisms that permit research across disciplines, both within and beyond the
-
Set criteria foi investment in health research.
health sectoi.
Managing and governing health research:
"
■
Systematically evaluate management and governance in national and international health research systems,
assessing whether mechanisms exist to carry out the essential functions above (on priorities, capacity, stand
ards and translation).
Systematically evaluate public policies and large-scale social programmes that are based on research for
health, and make the results widely accessible.
a m bi t i o n s I o d v I c at t h c g re a te s I p u b 1 i c h ea 11 h p rob -
1 e m s, as t w o re c t • 111 e x a m p 1 e s s h o w. 1 •' i r s t, f o 11 o w i n g
the developrnciv. oi a new high-eflicacy menin
gococcal A conjugate vaccine (MenAfriVac),
100 million people were vaccinated across the
African meningitis belt within two years (2, 3).
Second, the now famous clinical trial HP TN 052
- Science magazine’s ‘breakthrough of the year”
for 2011 - showed how antiretroviral therapy can
prevent almost all sexual transmission of HIV
between couples, exciting further debate about
t liminating H I \ /AIDS (4).
None of the rising indicators of research
activity described in Chapter 2 is, on its own, a
guarantee of product s and strategics that will help
us reach universal health coverage. Collectively,
however, these upward trends signal the grow
ing volume oi information and evidence that will
influence health policy and practice in low- and
middle - income. ount ries. Most countries around
the world now have, al least, the foundations on
which to build effective national health research
systems. Some have much more than the foundaI ions; they have- ihrh mg research communities.
Defining and measuring
progress towards universal
health coverage
Because the causes of ill-health and the capac
ity for financial protection differ from one
country to another, each nation must deter
mine its own priority health problems, decide
what services are needed to address these
problems, and investigate how those services
can be provided. The services that make up a
national health system are usually too numer
ous to monitor comprehensively. The practi
cal alternative is to choose a set of measurable
coverage indicators to represent, as tracers, the
overall quantity, quality and equitable delivery
of the services to be provided, including ways
to ensure financial protection. This leads to a
pragmatic interpretation of universal coverage
in any given setting so that each representa
tive intervention, whether a health service or
a mechanism of'financial protection, is acces
sible to all who are eligible.
131
Research for universal health coverage
By definition, universal coverage guaran
tees access to services and financial protection
for everyone. However, when coverage is partial,
some people may benefit more than others. For
this reason, measures of coverage should reveal,
not simply the average accessibility of services in
a population, but also the coverage among differ
ent groups of people classified by income, gender,
ethnicity, geography and so on. Chapter 1 noted
that the greatest progress in providing services
for maternal and child health has been made by
narrowing the gap between those with the lowest
and those with the highest incomes (5). This is
a form of “progressive universalism” in which
the poorest individuals gain at least as much as
the richest on the way to universal coverage (6).
The point about measurement, however, is that
disaggregated data must be applied to the right
indicators in order to monitor the implementa
tion of a chosen policy on equity.
From these considerations, two kinds of
research questions arise. The first group of ques
tions deals with improving health. Given the
burden of disease in any setting, what services
are needed, how can universal coverage of these
services be achieved, and how does wider cov
erage lead to better health? This first group of
questions is the principal concern of this report.
The second set of questions is about measure
ment: what is the practical definition of universal
health coverage in any setting, and which indica
tors and data can be used to measure progress
towards that goal? The answers will come partly
from the large body of existing information on
specific indicators, but new research will also be
required. One product of this research will be a
set of common indicators for comparing progress
towards universal coverage across all countries.
It will often be possible to satisfy the definition
of universal coverage with regard to one, several
or perhaps all monitored health services - immu
nization against measles, access to antiretroviral
therapy for people living with HIV infection, a
particular type of health insurance, and so on.
132
But achieving this will inevitably prompt further
questions about improving health, and the list of
questions will grow as the changing causes of illhealth are tracked by new interventions and tech
nologies. 'Hie response to previous successes and
new challenges is to formulate a more ambitious
definition of universal coverage - a new research
agenda - and to generate yet more evidence io
inform health policy and practice. Seeking uni
versal health coverage is a powerful mechanism
for continuing to seek better health.
The path to universal
health coverage, and the
path to better health
Chapter 3 presented 12 case-studies that showed,
by example, how research can help to achieve
universal health coverage and deliver results that
actually, or potentially, influence health policy
and health outcomes. There are many such exam
ples that are not described in this report, but two
from Chapter 3 that deal with service coverage ard
financing are revisited here. First, randomized con
trolled trials conducted in Ethiopia, Kenya, Sudan
and Uganda showed that sodium stibogluconate
(SSG) plus paromomycin (PM) are effective when
used in combination to treat visceral leishmaniasis.
Tile treatment can be shorter than with SSG alone
and is less likely to generate drug resistance (7). On
the basis of this evidence, WHO recommended
that SSG and PM could be used as a first-line treat
ment for visceral leishmaniasis in East Africa.
Second, a systematic review of evidence from
Brazil, Colombia, Honduras, Malawi, Mexico ard
Nicaragua found that conditional cash transfers
(CCTs) were associated with increased use of health
services and better health outcomes
These find
ings will stimulate further research studies of the
utility of CCTs in other countries.
As well as linking research to service cover
age and then to health, the 12 case-studies also
<
Chapter 5
yield some general conclusions about doing
research. Some of these concern the scope of
research. The questions about how to achieve
universal health coverage range from ques
tions about the causes of ill-health, through
n ethods for prevention and treatment, to ques
tions about the performance of health services.
Research must find out how to improve the
coverage of current interventions and how to
introduce new ones. Research must explore the
development and use of both "software” (such
as schemes for service provision) and "hard
ware” (R&D for commodities and technology).
And research is needed to investigate ways of
improving health from within and outside the
health sector.
The case-studies also illustrate research
methods, processes and outcomes. In general,
successful research stimulates, and is stimu
lated by, a cycle of enquiry in which questions
lead to answers that lead to yet more questions.
Tne design of a research study is usually a comp-omise because the most robust evidence and
the strongest inferences typically come from
the most costly and lengthy studies (e.g. rand
omized controlled trials). 'Hie choice of design
also depends on the need to generalize from
o le setting to another; results are more likely
to be widely applicable when there are fewer
and less variable processes linking causes and
elfects. Thus clinical trials tend to be favoured,
for instance, to assess the efficacy of drugs and
vaccines (governed by physiological factors), but
o xservational studies are often used to resolve
operational questions about how drugs and
vaccines are best delivered by health services
(influenced by local systems and behaviours).
The unavoidable question facing every research
study is "How much time and.money can we
afford to spend on the investigation?”
While this report has focused on research
d rected at achieving universal health cover
age, it has also highlighted the co-benefits for
health of research done in other sectors, such as
/Action on research for universal health coverage
agriculture, education, environment and trans
port (Box 2.6). The report has not discussed
research that will show how to make health
systems more resilient to environmental threats
such as extreme climate events, or research
into how health systems can reduce their own
greenhouse gas emissions. These are important
subjects for research, but ancillary to the main
theme of research for universal health coverage.
Research for universal health
coverage in every country
As was made clear in Chapter 3, the results of
some research studies are widely applicable but
many of the steps towards universal health cov
erage will be made by finding local answers to
local questions. For this reason, all nations need
to be producers as well as consumers of research.
To become productive in research requires
a functional national research system. Such a
system must have the capacity to set priorities;
to recruit staff and build research institutions;
to adapt, adopt and maintain research stand
ards; to use research to influence health policy
and practice; and to monitor and report on the
processes, the outputs, the outcomes and impact.
The priorities for research in each setting
should be determined by the dominant health
problems. Although curiosity-driven investi
gations have an essential place in the research
landscape, this report places high value on stud
ies that address major health concerns and which
respond to present and future gaps in service
coverage and financial risk protection. Standard
methods have been devised to set research priori
ties, but the best-documented examples are those
for specific health topics (Chapter 4). National
exercises to set research priorities are less promi
nent, though some countries - notably Brazil have taken a strong lead. To address the research
priorities, once they have been chosen, inves
tigations are needed throughout the research
133
Research for universal health coverage
cycle: measuring the size of the health problem;
understanding its cause(s); devising solutions;
translating the evidence into policy, practice
and products; and evaluating effectiveness after
implementation.
The process of setting priorities should be
inclusive, transparent, systematic, and linked
to research funding. Those with a stake in
the research process are diverse; they include
decision-makers, implementers, civil society,
funding agencies, pharmaceutical companies,
product development partnerships, and research
ers themselves. The roles of national and inter
national research funding agencies - who have
substantial leverage - include promoting high
standards of objectivity, rigour and account
ability, ensuring that the findings of results are
made easily accessible, and demanding research
accountability (namely that the funds available
for research are used effectively).
Research for health has always been an
international venture. The new trend is that
long-established “north-south” links are being
supplemented by “south-south” collaboration.
The expertise of high-income countries will con
tinue to be important because, for example, the
burden of noncommunicable diseases, up to now
largely a concern of the rich world, is growing
in low-income countries. High-income countries
also have a pool of trained researchers from lowand middle-income countries who, with the right
incentives, may be encouraged to return home.
In a highly-connected world, the distinction
between different kinds of international linkages
is becoming less relevant. Connections of all
sorts are needed to enhance peer-to-peer learn* ing, to foster joint research endeavours, and to
share resources. For nations that are emerging
as forces in‘research, initiating a multinational
collaboration, rather than simply joining as an
invited participant, is a statement of growing
research confidence.
Networking needs effective communication
across the research community. Communication
134
is easier in a common research language,
which would require a uniform and systematic
approach to the classification, collection and
collation of data. Among systems for classifying
types of research activity, a leading contender is
the Health Research Classification System pro
posed by the European Science Foundation (S).
Its purpose is to transmit the facts and findings
of health research in a standard way to sponsors,
governments and the public; to identify gaps and
opportunities for research, which are vital in set
ting research priorities; to carry out compara
ble analyses of the quality and productivity of
research output; to identify instances of research
collaboration; and to streamline peer review and
scientific recruitment.
Supporting the people
who do research
Effective research requires transparent and
accountable methdds for allocating funds, and
well-equipped research institutions and net
works. However, it is the people who do research
who arc most critical to the success ofthe research
enterprise. Consequently, the process of build
ing research capacity should be spearheaded by
staff recruitment and training, with mechanisms
to retain the best researchers.
Research training is not only about learn
ing scientific methods and techniques; it is also
about the proper conduct of research. Codes of
research ethics have been written to uphold hon
esty, objectivity, integrity, justice, accountability,
intellectual property, professional courtesy and
fairness, and good stewardship of research on
behalf of others. 'The essentia) codes of practice
are already in use in many countries. Although
internationally agreed standards will often need
to be updated and adjusted to local circum
stances, an important future task is to imple
ment the current standards in routine research
practice everywhere. ■
Chapter 5
Translating research evidence
into health policy and practice
Tie important questions about health service
coverage, and about health, need credible answers
that are intelligible to those who can use them i.c. decision-makers in various roles. When the
findings of research are turned into policy and
p -actice, a new set of questions arises for research.
Although a wide range of fundamental and
applied research studies is essential to reach
universal health coverage, the gap between
existing knowledge and action is persistently
large and is being closed only very slowly (IO).
Implementation and operational research, and
health policy and systems research - bringing
scientists and decision-makers together - are
conspicuous areas of neglect.
To accelerate the process, research should be
strengthened not only in academic centres but
a so in public health programmes that are close
to the supply of, and demand for, health services.
The greater the contact between researchers and
policy-makers, the greater will be the mutual
understanding. A variety of methods can be used
to train decision-makers to use evidence from
research, and to train researchers to understand
the process of decision-making. The use of data
(especially the large volume of data that are col
lected routinely), evidence and information can
be illustrated in training courses to make clear
the benefits of using evidence and the pitfalls of
not doing so. Researchers may be employed in
positions where they can help to frame policyrelated questions which lend themselves to spec.fic research studies, and to challenge decisions
made about policy. Staff rotations between health
ministries and research institutions arc an aid
to communication, and research staff employed
explicitly to carry out knowledge translation will
help to bridge the gap.
The application of research findings is
more likely if there are formal procedures for
tianslating evidence into practice. Mechanisms
include the development of protocols for policy
Action on research for universal health coverage
formulation, planning and implementation
that explicitly refer to research evidence, and
they include harnessing the skills of academics
both in policy formulation and implementation.
Publication is not the only, or even the best,
measure of research productivity, but there are
too few formal publications of routine opera
tional research.
Translational research could be boosted with
stronger incentives for the research community.
To encourage a shared responsibility among
researchers for reaching universal coverage, per
formance measures could be adjusted within aca
demic and research institutions. Incentives should
make reference, not only to publications in highimpact scientific and medical journals, but also to
measures of influence on policy and practice.
In making the link between research and
policy, private for-profit research companies (in
areas such as biotechnology, pharmaceuticals,
etc.) are just as important as public research
organizations. A growing number of health
products are being created through partner
ships between the public and private sectors,
making explicit links between various organi
zations involved in the discovery, development
and delivery of new technologies. In this respect,
Chapter 2 described the role of DNDi in coordi
nating the development of anthelmintic drugs by
several pharmaceutical companies.
To fully exploit the results of research, sci
entists and decision-makers of all kinds need
public support. It has been pointed out that civil
society has a role in setting research priorities,
but public engagement in research should be
wider in scope. Members of the public, who are
the source of government funds for research, are
entitled to share in all aspects of the investiga
tive process; their continued backing depends on
being able to listen to, understand, believe in and
make use of the results. Public engagement via
the media, policy debates and open evaluations,
works towards these ends. Making data publicly
accessible (e.g. via the observatories described
below) increases transparency and fosters greater
135
Research for universal health coverage
public trust when evidence is used to make deci
sions that affect access to health care.
Just as a single research project does not nec
essarily generate a useful health product, a useful
product does not necessarily influence health
policy. This is because research is only one of the
determinants of policy. Furthermore, the factors
that influence health policy are not necessarily
the same as those that help turn policy into prac
tice (//, /2). In addition to scientific evidence,
other considerations are cultural values, human
rights, equity and social justice, and competing
demands for public spending (73, 74). Because
policy and practice are subject to various influ
ences, and are decided in the face of multiple
competing interests, robust and unbiased evi
dence ought to be valued by decision-makers.
Supporting research for
universal health coverage,
nationally and internationally
Chapter 4 discussed three mechanisms that
support research for universal health coverage:
monitoring, coordination and financing. Given
the commitment to share data, a global obser
vatory, linked to national observatories, could
serve several functions in supporting research
for universal health coverage more generally. A
network of observatories could compile, analyse
and present data on financial flows for health
research, whether for technological develop
ment (traditional R&D) or for the improvement
of health systems and services, and could link
financing to research needs. Such a network
could chart progress on research for universal
health coverage by measuring each of the ele
ments of the results chain, from inputs and pro
cesses, through outputs and outcomes, to health
impact (Chapter 1). In practice, the number of
tasks that could be carried out by observatories
depends on the resources available and the will
to develop them.
136
Monitoring by observatories, or a similar
m e c h a n i s m, a 1 s o p r o v i d e s o p p o r t u n i t i e s t o c o o rd i nate research activities. Guidance on coordination
could be provided by an international body, such
as a reconstituted WHO Advisory Committee on
Health Research (the first such advisory commit
tee was established in 1956). Whichever body is
responsible, it must represent the views of all con
cerned - researchers, funding agencies, private
companies, and civil society and their representa
tive governments in the countries concerned.
With regard to financing, international
donors and national governments should meas
ure their commitments to investing in heal.h
research against defined criteria. Chapter 4 listed
some of the proposals that have been made - for
instance, that “developing” countries should
commit 0.05-0.1% of GDP to governmei tfunded health research of all kinds (75). Some
form of assessment is needed to judge whether
investments are commensurate with achieving
universal health coverage.
Once criteria have been chosen, mechanises
are needed lor raising and disbursing func s,
nationally and internationally. An improved
system of financing might be newly created, ->r
could be developed by existing organizatioi s.
Several international bodies - such as TDR, the
GAVI Alliance, the Global Fund to Fight AIDS,
Tuberculosis and Malaria and UNITAID - hace
the potential to manage research funds and dis
tribute them for research in low- and middle
income countries.
Whatever funding mechanism is chosen,
it should actively encourage research across
disciplines, both within and beyond the heal h
sector. As we have argued throughout this
report, research for universal health coverage
recognizes that health, and particularly preven
tion, depends on actions taken outside the health
sector - in agriculture, education, employment,
fiscal policy, social services, trade and so on.
A comprehensive health policy must consider
“heath in all sectors” of governance, and research
must cover all these sectors too.
Chapter 5
'Tliis will become still clearer when, from
2015 onwards, the world adopts a new developn ent agenda to succeed the MDGs. In the post2015 era, health must play a clearly articulated
role in social, economic and human development
(/6). To generate evidence in support of sustain
able development, funding must be available to
underpin research for health across a range of
disciplines. National and international commit
tees that advise on health research must prepare
for this new challenge.
WHO's role in research for
universal health coverage
This report began with the observation that uni
versal health coverage underpins “the attain
ment by all peoples of the highest possible level
of health”, which is a pillar of WHO’s constitu
tion and a guiding force in all the Organization’s
work. Throughout the report we have explained
why research is vital for achieving universal
health coverage, and consequently for improv
ing the health of all people around the world.
The WHO Strategy on Research for Health
(Box 4.1) is a mechanism to support health
research whereby WHO works alongside gov
ernments, funding agencies, partnerships, non
governmental and civil society organizations,
Action on research for universal health coverage
philanthropists and commercial investors,
among others. Simply put, the goal of the WHO
strategy is to cultivate the highest-quality
research that delivers the greatest health benefits
to the maximum number of people. In keeping
with the essential functions needed to carry out
research (Chapter 4 and above), WHO’s role is
to advance research that addresses the dominant
health needs of its Member States, to support
national health research systems, to set norms
and standards for the proper conduct of research,
and to accelerate the translation of research find
ings into health policy and practice.
As the principal international agency for
health, WHO has a key role in promoting and
conducting research for universal health cover
age. In terms of monitoring, a global research
observatory needs wide representation, should
be able to develop and apply appropriate stand
ards, and should garner the necessary interna
tional support. In terms of coordination, WHO
hosts numerous research advisory commit
tees with wide representation. And in terms of
financing, TDR and UNITAID, both hosted by
WHO, are potential mechanisms for disburs
ing research funds. As these possibilities are
explored further, WHO is working to reinforce
core functions. One of these is to ensure that the
Organization’s own guidelines reflect the best
available evidence from research.
References
1
2.
3.
4.
5.
6.
WHO strategy on research for health. Geneva, World Health Organization, 2012. (http://www.who.int/phi/WHO_Strategy_
on_research_for_health.pdf, accessed 23 April 2013).
Sow SO et al. Immunogenicity and safety of a meningococcal A conjugate vaccine in Africans. The New England Journal of
Medicine, 2011,364:2293-2304. doi: http://dx.doi.org/10.1056/NEJMoa1003812 PMID:21675889
Frasch CE, Preziosi MP, LaForce FM. Development of a group A meningococcal conjugate vaccine, MenAfriVac(TM). Human
Vaccines & Immunotherapeutics, 2012,8:715-724. doi: http://dx.doi.org/10.4161/hv.19619 PMID:22495119
Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine,
2011,365:493-505. doi: http://dx.doi.org/10.1056/NEJMoa1105243 PMID:21767103
Victora CG et al. How changes in coverage affect equity in maternal and child health’interventions in 35 Countdown
to 2015 countries: an analysis of national surveys. Lancet, 2012,380:1149-1156. doi: http://dx.doi.org/10.1016/S01406736(12)61427-5 PMID:22999433
Gwatkin DR, Ergo A. Universal health coverage: friend or foe of health equity? Lancet, 2011,377:2160-2161. doi: http://
dx.doi.org/10.1016/S0140-6736(10)62058-2 PMID:21084113
137
Research for universal health coverage
Musa A et al. Sodium stibogluconate (SSG) & paromomycin combination compared to SSG for visceral leishmaniasis in Ea .t
Africa: a randomised controlled trial. PLoS neglected tropical diseases, 2012,6:el674. doi: http://dx.doi.org/10.1371/journal.
pntd.0001674 PMID:22724029
8. Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services ir
low and middle income countries. Cochrane database of systematic reviews (Online), 2009,4:CD008137. PMID:19821444
Health research classification systems: current approaches and future recommendations. Strasbourg, European Science
9.
Foundation, 2011.
10. World report on knowledge for better health - strengthening health systems. Geneva, World Health Organization, 2004.
11. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet,
2003,362:1225-1230. doi: http://dx.d0i.0rg/l0.1016/50140-6736(03)14546-1 PMID:14568747
12. Bosch-Capblanch X et al. Guidance for evidence-informed policies about health systems: rationale for and challenges of
guidance development. PLoS Medicine, 2012,9:e1001185. doi: http://dx.doi.org/10.1371/journal.pmed.1001185 PMID:22412356
13. National Center for Science and Engineering Statistics. Science and engineering indicators 2012. Arlington, VA, National
Science Foundation, 2012.
14. Humphreys K, Piot P. Scientific evidence alone is not sufficient basis for health policy. BMJ (Clinicalresearch ed),
2012,344:e1316. doi: http://dx.doi.org/10.1136/bmj.e1316 PMID:22371864
15. Research and development to meet health needs in developing countries: strengthening global financing and coordination.
Report of the Consultative Expert Working Group on Research and Development: Financing and Coordination. Geneva, World
Health Organization, 2012.
16. Sustainable development goals. New York, NY, United Nations, 2013. (sustainabledevelopment.un.org, accessed 20 March 2013).
7.
138
Index
Note: Pages suffixed by b, f, or t refer to boxes, figures or tables respectively.
"i0/90"gap 37,37b
Hl
a< cess to health care
antiretroviral therapy (ART) 16
barriers, tuberculosis 10b
emergency obstetric care 77-79, 78f, 78t
research see research
universal 85 (seealso universal health coverage)
ar cess to research 40, 110, 112b
Health Research Web 112b
Health Systems Evidence 112b
HINARI Access to Research in Health Programme 40
"intelligent openness" 110
PDQ-Evidence 112b
United Kingdom 110
ar countability, research funding 105-107
ar rivity mapping, research 103, 104f
A rican countries
African Network for Drugs and Diagnostics Innovation
(ANDI) 108b
Guinea Bissau health ministry, role 101b
health ministries, role of 101b
Initiative to Strengthen Health Research Capacity in Africa
(ISHReCA) 108b
MenAfriVac 39
Pan-African Consortium for the Evaluation of Anti
Tuberculosis Antibiotics (PanACEA) 108b
R&D (research and development) investment 42-43, 43f
research 105
funding 46
health research systems 97b
productivity 39-40
research case studies
conditional cash transfers (CO j
1,801
emergency obstetric care (EMOC) 77 - 79, 78f, 78t
malaria prevention and childhood mortality 61-63,
62f
visceral leishmaniasis (VL) 73-75, 74f
Research for Health Africa (R4HA) 108b
African Network for Drugs and Diagnostics Innovation
(ANDI) 108b
ageing population, expenditure in Europe, research case
study 82-84,83f
AIDS (see also HIV)
coverage of interventions 16,17f
Alma Ata Declaration 6b
antiretroviral therapy (ART)
HPTN 052 study 63-65, 64f
research case study 63-65, 64f
"universal access" 16
applied research 32b
Australia, return on investment 46
availability of generic medicines 16,19,19f
[B]
Bangladesh
International Centre for Diarrhoea Diseases Research,
Bangladesh (ICDDR, 8) 107
research case study 65-67,66t
barriers to access, tuberculosis and 10b
basic research 32b, 33b
Brazil
Bolsa Familia programme 80
conditional cash transfers (CCT) (research case study) 80
priority, national research 98,100b
[C]
capacity (research) 98-107
activity, mapping 103,104f
building 99-103,102f, 103t, 118,130b
institutions 102
definition 99, 107
ESSENCE 99,101 .
framework 99-102
funding see funding (research)
Global Health Trials network 107,108b
gross national income (GNI) 43,44f, 98
institutions and networks see institutions and networks
(research)
139
I
Research for universal health coverage
workforce 103-105,130b, 134
international collaboration 104,105b
low-income countries 103-105
middle-income countries 103-105
recruitment and training 134
The World Health Report 2006 103
cardiovascular disease '
"polypill" 71-73
research 46
case study 71-73
return on investment 47
case-fatality rates 20-21, 20f
variability 21
case studies (of research) 57-85
affordable health care for ageing population (Europe)
82-84, 83f
cardiovascular disease, mortality reduction with "polypill"
71-73
conditional cash transfers (CCT) 79-81,80f
design 60
diarrhoea/pneumonia prevention by zinc supplements
(young children) 65-67, 66t
emergency obstetric care, access 77-79, 78f, 78t
HIV prevention by antiretroviral therapy 63-65,64f
The Indian Polycap Study (TIPS) 71-73
insurance provision in Mexico 81-82
malaria prevention (mosquito nets) and childhood
mortality 61-63, 62f
overview of examples 57, 58t, 59t, 60, 60t
Seguro Popular 81-82
task shifting to improve child survival 75-77, 76t
telemedicine to improve paediatric care 67-69,67f, 68f,
68t
tuberculosis diagnostics 69-71, 70f, 71 f
visceral leishmaniasis treatment 73-75, 74f
cervical cancer 8b
funding according to see funding (research)
health policy and systems research 33b, 59t, 60t
Health Research Classification System (HRCS) 33b, 58t, 59t,
60t, 134
management of diseases and conditions 33b, 59t
prevention of diseases and conditions 33b, 58t
promotion of well-being 33b, 58t
treatment and intervention development 33b, 59t
treatment and intervention evaluation 33b, 59t
United Kingdom Clinical Research Collaboration 57
clinical praitice see health care practice
clinical trials 133 {seealso randomized controlled triak
(RCTs))
registering 110, 113
Cochrane Collaboration 39
codes of practice 118-1 19, 130b, 134
clinical trials, registering 110,113
ethics and ethical review see ethics and ethical review
policy, practice and products 113
cohoit study, iftrospective 7/-/9, 78f, /8t
collaboration, research see international research
t olldboration
Commission on Health Research for Development (19l 0
Report)
C/b, 48
condiuonnl ash transfers (CCT) 79-81, 80, 80f
confounding factors, research 63
cpordiiiating ceseari h 131b, 13 / (see also observatorit s)
coverage ’.health services-care)’7f, 15-19
measurement 15-16,15f, 18b, 22,130b
MfXiS see Millennium Development Goals (MDGs)
quality of health care see quality of health care
research, role of 130b
universal see universal health coverage
c re a 11 v i t v, 11 > res ea i c h 31, 3 5, 3 6 b, 48
cross-disciplinary research 98
child health
.
equity of service coverage 20, 20f
HPTN 052 study 63-65, 64f
1 Integrated Management of Childhood Illness (IMO) 75
research case studies
diarrhoea and pneumonia prevention 65-67, 66t
malaria prevention (mosquito nets) 61-63, 62f
task shifting to improve survival 75-77, 76t
telemedicine 67-69,67f, 68f, 68t
child mortality, research case studies 61-63, 62f, 65, 66,
75-77, 76l, 80.
China, research, international collaboration 40,40f
classification of research studies 33b, 57, 58t, 59t, 60,
60t {see also case studies (of research))
basic or fundamental research 33b
detection, screening and diagnosis 33b, 58t
disease code 106
etiology (causation) 33b
140
ID]
Det kiijfioii ..■! Helsinki 11964-2008), clinical trials,
registering, ! 10,113
definitions, research 32b
design (research) 611, 84, 133
double-blind 72
examples see case studies (of research)
experimental design 84
meta-analysis 62-63
observational studies see observational studies
placebo trials 63
randomized controlled trials (RCTs) 42
retrospective cohort study 77—79, 78f, 78t
translational research see translating evidence into policy
and practice
detection, research studies 33b
diagnosis, research studies 33b
Index
Pan-African Consortium for the Evaluation of Antiluberculosis Antibiotics (PanACEA) 108b
Research for Health Africa (R4HA) 108b
syphilis, operational research network 109b
ir surance provision, Mexico, research case study 81-82
lr tegrated Management of Childhood Illness (IMCI) 75
ir tellectual properly rights 44
"i itelligent openness" 110
Ir ternational Centre for Diarrhoea Diseases Research,
Bangladesh (ICDDR, B) 107
Ir ternational Clinical trials Registry Platform (ICIRP)
110,113
ir ternational research collaboration 40, 40f, 104, 134
China 40,40f
multicountry research 75-77, 76t, 109b, 117
principles 105b
it terveiiiions
adopters 114,114b
evaluation 114
research
implications from 57-89 (see also case studies (of
research))
•
studies 33b
’
■
translating evidence see translating evidence into
policy and prat lice
ir vestments, financial' 9,9f
return on see return on investment
Ireland, Payback Framework 47
ischemic stroke, case-fatality rates 20-21, 21 f
H.l
k ila ozar see visceral leishmaniasis (VL)
HI
k gal considerations, intellectual property rights 44
It w-income countries 7 [see also African countries,
equity)
intervention implementation 113,113f
"progressive universalism" 20
R&D (research and development) 39,117
research 31,105
collaboration 107
health research systems 97b
researchers 103 -104
systematic reviews 39
underinvestment 36-37,37b
zinc deficiency 65-67, 66t
[M]
malaria
coverage of interventions 16,17f
funding for control 62,62f
research case study 61-63, 62f
research institution 102
malnutrition, micronutrient, research cycle 34b
management (diseases and conditions), research studies
33b
management (health research) 117-118,131b
"market failures" 44
maternal health
equity of service coverage 20,20f
HPTN 052 study 63-65,64f
improving maternal health (MDGS) 77—79, 78f, 78t
research case study 77-79, 78f, 78t
severe acute maternal morbidity (SAMM) 77-79, 78t
maternal mortality ratio (MMR) 77-79, 78f
Medical Research Council 105,106f
MenAfriVac (meningitis A vaccine) 39,131
joint priorities for research 117
mental health, return on investment 47
meta-analysis 62-63
Mexico, insurance provision, research case study 81-82
micronutrient malnutrition, research cycle 34b
middle-income countries
R&D (research and development) 39
research 31
health research systems 97b
researchers 103-104
zinc deficiency 65-67, 66t
Millennium Development Goals (MDGs) 16
environmental sustainability (MDG 7) 16
HIV/AIDS (MDG 6) 16,17f
improving maternal health (MDG 5) 77-79, 78f, 78t
post 2015 era 137
WHO Strategy of Research for Health 96b
monitoring, research 130b
multicountry research 75-77, 76t, 109b, 117
multidrug-rcsistant TB (MDR-TB) 69 [see also
tuberculosis (TB))
IN]
national health research systems (NHRS) 117-118,118f,
133
National Institute for Health Research (UK) 46
neglected diseases
Drugs for Neglected Diseases initiative (DNDi) 39
R&D (research and development) 39
research 45-46
tropical diseases, coverage of interventions 16,17f
visceral leishmaniasis (VL) research case study 73-75, 74f
networks (research) see institutions and networks
(research)
[O]
observational studies 60,133
limitations 63
research case study 67-69
143
Research for universal health coverage
observatories 116-117,119,130b, 136
coordinating research 131b
WHO and 137
obstetric care, research case study 77-79, 78f, 78t
operational research 32b
out-of-pocket payments 12,13b, 14f
[P]
Pan-African Consortium for the Evaluation of Anti
Tuberculosis Antibiotics (PanACEA) 108b
Paraguay, health ministries, role 101b
partnership (research) {seealso international research
collaboration)'
principles 105b
Payback Framework 47
Ireland 47
PDQ-Evidence 112b
• Philippines, tracers to track progress to universal
coverage 16,18b
placebo trials .63, 65-66
pneumonia, research case study 65-67, 66t
policy see health policy
"polypill" 71-73
prepayments 7
primary care, role in health systems 6b
priorities for research 22, 42-43, 48, 96-98, 99b, 130b,
133-134
approach 96
context 96
criteria 98
evaluation 98
inclusiveness 98
information 98
joint 109b, 117
MenAfriVac 117
syphilis 109b
methods 98
national 98
Brazil 98, 100b
planning 98
priority health problems 131,134
transparency 98
priority health problems 131, 134
product development 113
productivity (research) see research, productivity
programmes (health) {see also health care practice)
Bolsa Familia programme 80
Health Intervention and Technology Assessment
Programme (HITAP) 7,8b
HINARI Access to Research in Health Programme 40
translating evidence see translating evidence into policy
and practice
tuberculosis control 11b
144
"progressive iir.iversalism" 20,132
public engagement (research) 130b, 135-136
public iiujh'h msc’arch 42
IQ)
qudliiy-udiusied life year (QALY) 47
quality of health care 20-21, 21 f
case-fatality rates see case-fatality rates
questions, research sec research, questions
IR1
randomized corn rolled trials (RCTs) 42, 84
research case study 61-63, 62f, 65-67,66t
return on investment 47
R&D (research and development)
investment 38f, 39
African countries 42-43,43f
low-income countries 39,117
middle-income countries 39
neglected diseases 39
private investors 44
tuberculosis (TB) 106,107f
research
access to see access to research
activity mapping 103, 104f
capacity, research see capacity (research)
classification of studies see classification of research studies
codes of practice see codes of practice
confounding factors 63
coordination 131b, 137 (see also observatories)
creativity, imagination and innovation 31
cross-disciplinary 98
cycle 34b, 35b
definitions 32b
design see design (research)
dissemination see dissemination (research)
economic 41b
environmental health see environmental health research
ethics and ethical review see ethics and ethical review
future directions 133
governance (health research) 117-118,118f
growth 31-48
measures of 37, 38f, 39
for health, definition 32b
on health care delivery 46
"health in all sectors" 41b
health research system see health research system
implementation see translating evidence into policy and
practice
implications for universal health coverage 57-89 (see also
case studies (of research))
institutions see institutions and networks (research)
international collaboration see international research
collaboration
Index
low-income countries see low-income countries
middle-income countries see middle-income countries
monitoring 130b (see also observatories)
multicountry research 75-77, 76t, 109b, 117
neglected diseases 45-46
networks see institutions and networks (research)
partnership see international research collaboration
partnership principles 105b
presentation of research evidence 113
priorities see priorities for research
productivity
African countries 39. 40
national wealth and 43,44f
public health 42
questions 31-32, 57 (see also priorities for research)
improving health 132
measurement of universal health coverage 132
randomized trials see randomized controlled trials (RCTs)
R&D see R&D (research and development)
role in universal health coverage 5-22,129
standards see codes of practice
systematic reviews see systematic reviews
translating evidence into practice see translating evidence
into policy and practice
underinvestment 36-37, 37b
United Kingdom Clinical Research Collaboration 57
value of 46-47
Payback Framework 47
return on investment see return on investment
re,earch for health, definition 32b
Rr- search for Health Africa (R4HA) 108b
research for universal health covciage 32b
re marchers 103-105
capacity building see capacity (research)
implementation, role in 135
responsibilities 111b
re Tospective cohort study 77-79, 78f, 78!
re.urn on investment 46-47
Australia 46
cardiovascular disease 46
cardiovascular disease (UK) 47
Exceptional returns (USA) 46
gross domestic product (GDP) 47
mental health (UK) 47
quality-adjusted life year (QALY) 47
randomized control trials (RCTs) 47
Royal Society (UK) 110
IS)
screening
research studies on 33b
syphilis 109b
Scguro Popular 81-82
severe acute maternal morbidity (SAMM) 77-79,78t
smoking 9
social determinants, prevention/treatment of illness 9,
10b
social protection 7
tuberculosis (TB) 10b
staff see researchers
standards see codes of practice
SUPPORT tools for evidence-informed health policy
making 115b
syphilis
operational research network 109b
screening 109b
systematic reviews 39, 115
Cochrane Collaboration 39
low-income countries 39
m
task shifting 75-77, 76t
taxation 7,8b
telemedicine, research case study 67-69,67f, 68f, 681
Thailand, Health Intervention and Technology
Assessment Programme (HITAP) 7, 8b
"third global health transition" 5
tobacco smoking 9
tracers (universal coverage progress) 16,18b, 22
translating evidence into policy and practice 113, 115b,
130b, 135
adaptation to local services 114
delay in 113,113f
• GRADE system 35b, 115
policy 57-89
Evidence-Informed Policy Networks (EVIPNet) 115b
SUPPORT tools for evidence-informed health policymaking 115b
presentation of research evidence 113
researchers, role of 135
The Translating Research into Action (TRAction) project
115b
translational research see translational research
universal health coverage 57-89
The Translating Research into Action (TRAction) project
115b
translational research 32b, 130b
incentives 135
transparency
priorities for research 98
research funding 105-107
treatment, research studies 33b
tuberculosis (TB) 10b
barriers to access 10b
control programmes 11b
145
Research for universal health coverage
coverage of interventions 16,17f
funding for research 106,107f
measurable indicators 11b
multidrug-resistant (MDR-TB) 69
research case study 69-71, 70f, 71 f
social protection 10b
treatment expenditure 10b
Xpert MTB/RIF assay 69-71, 70f, 71 f
[U]
Ukraine, tracers to track progress to universal coverage
1b, 18b
United Kingdom, research in
access to research 110
cardiovascular disease 47
Clinical Research Collaboration 57
funding 105,106f
Medical Research Council 105,106f
Wellcome Trust 105,106f
on health services and systems 46
"intelligent openness" 110
mental health research 47
National Institute for Health Research 46
return on investment 47
Royal Society 110
United Kingdom Clinical Research Collaboration 57
United Nations General Assembly, 2012 resolution 6b
"universal access", antiretroviral therapy (ART) 16
universal health coverage 85
aim of 5
availability of generic medicines 16,19,19f
concept 6-11,132
coverage see coverage
dimensions 7f
financial risk protection see financial risk protection
health services see health services
environmental health 40,41b, 42
equity see equity
funding for research 117
"Health for All" 5, 6b
health services see health services
implications of research 57-89 (see also case studies)
improved health and 132-133
measuring progress 131-132
observatories 116-117
post 2015 era 137
priority health problems 131
"progressive universalism" 20,132
research 117 (see also research)
growth see research, growth
role of 5-22, 129
146
right to health 5
"third global health transition" 5
tracers to track progress 16,18b
ui'bari ti/iir.por!, environmental health research 41b
(V]
vac < me, MenAfriVac 39
visccial Icislimaiikisis (VL; I32
research case study 73-75,74f
(W]
Wellcome bust (UK), research funding 105,106f
workforce m-se.in h) see researchers
World Health Organization (WHO)
ethical standards 110,111b
observatories 137 (see also observatories)
research coordination 137
role of 137
Strategy of Research for Health 95,96b, 137
goals 96b
Millennium Development Goals (MDGs) 96b
Strategy on health policy and systems research (HPSR)
116b
The World Health Report 2006 103
[X]
Xpert MTB/RIF assay 69-71, 70f, 71 f
[Z]
zinc supplements, research case study 65-67, 66t
Offices of the World Health Organization
WHO Headquarters
Avenue Appia 20
1211 Geneva 27, Switzerland
Telephone:+41 22 791 21 11
Facsimile:+41 22 791 31 11
E-mail: info@who.int
Web site: http://www.who.int •
4
WHO Regional Office for Europe
Marmorvej 51
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Telephone: +45 45 33 70 00
Facsimile: +45 45 33 70 01
E-mail: postmaster@euro.who.int
Web site: http://yvww.euro.who.int
WHO Regional Office for Africa
Cite du Djoue
PO Eox 06
Brazzaville, Congo
Telephone: +47 241 39100 or +242 770 0202
Facsimile: +47 241 39503
E-mail: webmaster@afro.who.int
Web site: http://www.afro.who.int
V\/HO Regional Office for the Eastern
Mediterranean
Abdul Razzak Al Sanhouri Street
P.O. Box 9608, Nasr City
Cairo 11371, Egypt
Telephone: +20 2 2276 50 00
Facsimile: +20 2 2670 24 92 or 2670 24 94
E-mail: webmaster@emro.who.int
Web site: http://www.emro.who.int
WH 9 Regional Office for the Americas/
Pan American Sanitary Bureau
525, 23rd Street NW
Washington, DC 20037, United States of America
Telephone: +1 202 974 3000
Facsimile:+1 202 974 3663
E-mail: webmaster@paho.org
Web site: http://www.paho.org
WHO Regional Office for the Western Pacific
PO Box 2932
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Telephone:+63 2 528 8001
Facsimile:+63 2 521 1036 or 526 0279
E-mail: postmaster@wpro.who.int
Web site: http://www.wpro.who.int
WHO Regional Office for South-East Asia
Woild Health House
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Telephone: +91 11 2337 0804 or 09 or 10 or 11
Facsimile:+91 11 2337 0197/2337 9395 or
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Telephone: +33 472 73 84 85
Facsimile: +33 472 73 85 75
E-mail: webmaster@iarc.fr
Web site: http://www.iarc.fr
Research for Universal
Everyone should have access to the health services they
need without being forced into poverty when paying for
them. This report argues that universal health coverage
- with full access to high-quality services for prevention,
treatment and financial risk protection - cannot be
achieved without the evidence provided by scientific
research. It maintains that all nations should be producers
of research as well as consumers. The process of discovery
should take place not only in academic centres but also
in public health programmes where people seek health
care and use the services provided. Investigations
ranging from clinical trials to health policy studies can
help chart the course to improved health outcomes
and reduced poverty, but research needs national and
international backing to succeed.
ISBN 978 92 4 156459 5
- Media
15050.pdf
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