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4
Global Forum
for Health Research
HELPING CORRECT THE 1 0 | 90 GAP
THE COMBINED APPROACH MATRIX
A PRIORITY-SETTING TOOL FOR HEALTH RESEARCH
Edited by
Abdul Ghaffar
Andres de Francisco
Stephen Matlin
Contents
Contributors
Acknowledgements
Foreword
Acronyms and abbreviations
2
2
5
6
Section I. The case for priority setting in health research
1. Introduction
2. Health and health research
Determinants of health status in populations
The contribution of health research to human development
3. Priority setting
Underlying values
Rationale and need for priority setting in health research
Historical approaches to priority setting
Priority-setting domains
7
8
10
10
13
15
15
15
16
20
Section 11. Combined Approach Matrix: Principles, elements and functions 27
28
1. Principles
29
2. The main elements of the CAM
29
The economic dimensions of priority setting
30
The institutional dimensions of priority setting
32
3. Functions of the CAM
Section HI. Selected examples
1. Application of the CAM
2. Selected examples
Application of the CAM at the global level
Application of the CAM at the national level
Application of the CAM to a disease
Application of the CAM to a risk factor
Application of the CAM to a vulnerable group
33
34
35
35
38
40
41
43
Section IV. Challenges and opportunities
47
48
50
51
1. The lessons
2. Challenges and opportunities
3. Conclusions
Section V. Annexes
Annex 1. Diarrhoeal diseases research in India: application of the
CAM
Annex 2. Pakistan’s National Action Plan for noncommunicable
disease prevention and control: application of the CAM
Annex 3. Schizophrenia: application of the CAM
Annex 4. Indoor air pollution: application of the CAM
Annex 5. Perinatal and neonatal care in Pakistan: application of
the CAM
Annex 6. Newborn health research priorities (summary view)
Annex 7. References
Contents
52
53
58
60
62
66
67
68
3
Inserts
Insert 1. Main actors and factors determining the health status of
a population
Insert 2. Analysing the burden of a health problem to identify
research needs
Insert 3. Comparison of various priority-setting approaches
Insert 4. Key recommendations made since 1990 for health research
on risk factors
Insert 5. Key recommendations made since 1990 on research
priorities for diseases and conditions
Insert 6. The Global Forum Combined Approach Matrix for health
research priority setting
Insert 7. Generic steps to use the CAM to identify key research
projects at national level
Insert 8. TDR checklist for strategic analysis of health research needs
(adapted from the CAM)
4
12
17
18
23
25
28
36
36
Contents
Foreword
The 1990 Commission on Health Research for Development drew attention to the
existence of the “10/90 gap" - a situation in which less than 10/o of global tea th
research funds from pnbdc and prfva.e sources is devpled »
“for
problems. Helping to correct this gap has been the mam focus of the Global Forum
Health Research since it began operations in 1998.
1998.
One of the most important ways to address the 10/90 gap is to change the priorities that
determine how existing health research funds are used. Indeed, from the perspective o
responding to needs that are largely unmet, priority setting .s as critical as conJ“ct‘"g
research itself. Yet there is no simple way to set priorities - research on methodologies
to help set priorities in health research is a recent development which can be traced bac
to the recommendations of the 1990 Commission. Since then, a number of approaches
have emerged for developing and implementing priority setting.
It is important to differentiate between the process of priority selection (a mechanism
!hat involves constituencies in order to decide upon research pnont.es) and the tools
used for that purpose (instruments that enable the collection, organization and analysis o
the mass of information needed to help set priorities). The present publication presents
experiences with one such took the Combined Approach Matrix (CAM).
The CAM incorporates criteria and principles from earlier methods and links them into a
matrix with the actors and factors that play a key role in the health status of a popu atiom
One axis of the matrix focuses on the five-step methodology of the Ad-Hoc Committe
on Health Research (linking burden of disease with determinants, cost-effectiveness an
financial flows), while the other underlines the fact that health research needs to operate
beyond the biomedical field and to include individual and community behaviour, other
sectors that have a profound influence on health, and the impact of governmental,
macroeconomic policies on people’s health.
The work presented in this document is the result of efforts undertaken by the Global
health research.
research is conducted on the most important and often most neglected areas of diseases
and determinants globally. The Global Forum encourages governments and institutions
and the funders and conductors of research everywhere to adapt and use this too .
Stephen A. Matlin
Executive Director
Global Forum for Health Research
5
Foreword
Acronyms and abbreviations
ACHR
AIDS
ALRI
ARI
BOD
CAM
COHRED
COPD
DALYs
DFID
DTUs
ENHR
GBD
HIV
IAP
ICMR
IUGR
LBW
NCDs
NGOs
NICED
ORS
ORT
PHC
PMRC
R&D
SNL
SWOT analysis
TB
TDR
VHIP
UNICEF
USAID
WHO
6
Advisory Committee on Health Research (WHO)
acquired immunodeficiency syndrome
acute lower respiratory infections
acute respiratory infections
burden of disease
Combined Approach Matrix
Council on Health Research for Development
chronic obstructive pulmonary disease
disability-adjusted life years
Department for International Development (United Kingdom)
diarrhoea treatment and training units
Essential National Health Research
global burden of disease
human immunodeficiency virus
indoor air pollution
Indian Council of Medical Research
intrauterine growth retardation
low birth weight
noncommunicable diseases
nongovernmental organizations
National Institute of Cholera and Enteric Diseases (India)
oral rehydration salts
oral rehydration therapy
primary health care
Pakistan Medical Research Council
research and development
Saving Newborn Lives (Pakistan)
analysis of strengths, weaknesses, opportunities and threats
tuberculosis
UNICEF/UNDP/World Bank/WHO Special Programme for
Research and Training in Tropical Diseases
Visual Health Information Profile
United Nations Children's Fund
United States Agency for International Development
World Health Organization
Acronyms and abbreviations
Section I
THE CASE FOR PRIORITY SETTING
IN HEALTH RESEARCH
1. Introduction
Since the funding available for health research is low in comparison to its very high
potential benefits, it is essential that it be based on a rational priority-setting process.
The use of a sound methodology and a scientific process is critical to ensure the
identification of the research priorities that will make the greatest contribution to
people's health. Thus, setting priorities is as important as conducting the research
itself.
The Commission on Health Research for Development (1990) reported that “too
often priorities for public sector health research and development investments are
determined with little concern for the magnitude of the problem to be addressed, for
the extent to which scientific judgement supports the possibility that new products
and initiatives will be more cost-effective than available alternatives, or for ongoing
efforts elsewhere" (1). Even though it is crucial to promote development and help
overcome the vicious circle of disease and poverty, health research has suffered from
a severe disequilibrium. For the past decade, this imbalance has been captured in the
expression the “10/90 gap", which indicates that less than 10% of the estimated USS
70 billion spent annually on health research by private and public sectors is devoted
to 90% of the world’s health problems (2).
In 1996, the WHO's Ad Hoc Committee on Health Research Relating to Future
Intervention Options published a landmark report. Investing in health research and
development. Since then, considerable progress has been achieved in the
development of methods and instruments for priority setting in health research, at
both global and local levels (3).
The International Conference on Health Research for Development (Bangkok 2000)
identified some of the key features of a revitalized health research system. One of
these is that “the health research agenda has to be driven by country needs and
priorities, within an interactive regional and global framework. This requires
countries to develop and retain the capacity to set their research priorities, and for
research and development agencies, funding bodies and other international players to
respect these priorities" (4).
It must be emphasized, however, that priority setting in health research is not an easy
undertaking, and most definitely will not provide results as soon as the data have
been fed into the process.
The Global Forum for Health Research has focused particular attention on further
developing methods and instruments which can be used for evidence-based priority
setting in health research. During the past three years, it has intensified its work on
setting priorities for health research (2).
Even in everyday life, setting priorities is not easy. The process is much more
difficult in the field of health research, where a large number of factors and actors
enter into the equation. One of the roles of health research is to ensure that the
measures proposed to break the vicious circle of ill health and poverty are based on
evidence, as far as is feasible, so that the resources available to finance them are used
in the most efficient and effective way possible.
8
Section I. The case for priority setting in health research
stakeholders are involved and decide upon research pnorities. It is evident that
ensuring the participation of communities and users is a necessary part of the
process.
i,s7''Si“'SSSpermi'° SSS’Xaruon of the various possible
Mefe of research, eventually permitting the identification of th. areas with the most
promising impact on people’s health.
This study aims at describing a methodology (tool) that can help institutions at the
national regional and global levels to set their own priorities in health research^ It
briefly describes efforts and progress on the development of different tools but
focuses particularly on the Combined Approach Matrix (CAM), a research prioritysetting tool developed by the Global Forum.
After a brief description of important actors and factors in the health sector an
overview of the rationale and need for priority setting in health research is provide^
Four domains of priority setting are distinguished: research on priority-settmg
methodologies, research on determinants and risk factors, research on policies and
cross-cutting issues affecting health and health research, and research on diseases
and conditions. In a subsequent section, the concepts and methods based on the
CAM are outlined and their applicability discussed in regard to the four domains
mentioned above.
ported. Examples have been
Sen
presented.
It is hoped that the study will help to identify the data that are needed for evidence
based decision-making in health research, facilitate the compilation and presentation
of such information, and provide some guidance on how to turn the evidence into
action.
9
1. Introduction
2. Health and health research
Health research helps to define and quantify the key determinants that affect health.
Strategic research, for example, identifies, explores and describes factors which
contribute to disease or good health, and which can help define health interventions.
Epidemiological methods help quantify the potential impact of planned
interventions, while costing can determine their sustainability. Biomedical research
varies in scope from the development of new tools to the adaptation and
implementation of known tools in the field. Behavioural research uses quantitative
and qualitative techniques to examine behaviour at the individual and the community
levels. Research can explore determinants of health in both the health and the non
health sectors, as well as the impact of macro-decisions at the global level.
Determinants of health status in populations
WHO defines health as a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity" (5). Unfortunately, the state of
perfect health cannot be defined in operational terms. It is, therefore, impossible to
determine how many resources would be needed to achieve this happy state. Each
society has to decide on the amount of resources it wants to devote to health and then
establish priorities accordingly. In other words, the society makes informed decisions
about its health programme. It may be useful to reflect for a moment on the meaning
of the terms informed decision-making and health programme.
Informed decision-making in health should be based on an understanding of the
relationship between an action and a health outcome. It requires having access to,
and using, pertinent information for decision-making.
The goal of any health programme should be to improve the population's health
status, which is measured by two components:
• The degree of ill-health, or degree of mortality and morbidity, resulting from
the diseases, disabilities, violence and social maladjustments that characterize
a particular community’s burden of disease.
• The degree of physical and mental well-being characterizing the community.
Health status can be improved through health promotion activities, by means of
burden prevention or by interventions geared at burden reduction or cure. The
following are four domains of intervention:
• The environment (including family/household, community and habitat) where
people's exposure to risks and hazards is being reduced or where coping
capacities are strengthened
• The health system (including health and social services)
• Sectors other than health, such as workplace, legal and education sectors
• The domain of macroeconomic policies.
There have been a number of attempts to represent the complexity of the actors and
factors affecting the health status of a population and their interrelationships. Insert I
(see page 12) is one such example derived from a number of previous descriptions
10
Section I. The case for priority setting in health research
(1,2,3). The insert is entitled “Main actors and factors determining the health status
of a population” in recognition of the fact that, behind each group of determinants,
there are institutions that are clearly responsible for dealing with a particular group
of determinants.
Insert I draws attention to the fact that the health status of a community is largely
determined by the following four broad groups of actors, corresponding to four
different domains of intervention:
The individual, household and community
While genetic factors cannot be easily changed, the individual may have a degree of
choice about how much risk he or she wants to take with health. The family may be
able to decide, at least in part, how many children they would like to have, how they
should be educated, how to handle family conflicts, how to care for any disabled
members, etc. The community will greatly influence the population's health status
through local decisions on sanitation, education, shelter, unemployment and handling
of violence. The fact that choices and options are far more restricted for the poorest
people provides one of the important linkages between poverty and ill health, and
points to the health gain benefits that are associated with poverty-reduction
programmes (6,7).
Health ministry and other health institutions
The health ministry and health professionals are responsible for the health legislation
and policies of the country, and for health education and health promotion in general.
They are the backbone of the health care system provided in the country. The
organization, availability and accessibility of the health sector will profoundly
influence the health status of the population.
Sectors other than health
Practically all sectors of economic activity in a country have an impact on the health
status of the community through national or regional policies, decisions and
activities. This includes, for example, areas such as the development of the
agricultural sector, the transportation system, the water supply and sanitation;
industrialization; the degree of environmental pollution; the level of education; the
social security system; the level of unemployment; and the security system (i.e.
controlling violence and criminality).
Macroeconomic policies
Although apparently remote from the health situation of the individual, both the
government's macroeconomic policies and the principles of good governance in
general have a direct impact on it: for example, through the level of economic
activity in a country (determined by numerous external actors, but also by
government policies); trade policies; the allocation of the budget between the
2. Health and health research
11
Insert 1
Main actors and factors determining the health status of a population
ro
The individual, household and community
•
•
•
•
Individual: genetics, exposure to health hazards, behaviour (risk taking)
Family: divorce, parental skills, family planning, human reproduction, family violence, care for disabled
members
Community: education, sanitation, shelter, social pathology (crime, discrimination), working conditions,
unemployment
Habitat: natural setting of life (climate), exposure to parasites and to natural or man-made disaster.
Sectors other than health
Macroeconomic policies
•
•
•
Budget policies
Research policies
Good governance,
effectiveness of adminis
trative measures to limit
corruption.
•
•
•
•
•
•
•
•
•
•
Agriculture/rural development
Industry/energy
Transport/infrastructure (e.g.
water supply, sanitation)
Environment (pollution control)
Rural development
Occupation (employment,
working conditions)
Urban development/housing
Education
Social security
Security (controlling violence
and crime).
Health status
z.
Ill-health
Mortality, morbidity, disability, violence, social maladjustment (fear, uprooting, social
isolation)
Well-being
•
Physical (full physical functioning, fitness, resistance to risk factors)
•
Mental (full intellectual and emotional functioning, coping with risk and problems)
• Social (not suffering from exclusion).
Health ministry and other health institutions
Health ministry (policies)
• Health education (personal hygiene, nutrition)
•
Health legislation (alcohol and drug control)
•
Nutrition and food safety
• Health promotion and lifestyle
• Policies on high risk and marginalized groups (refugees, migrants, minorities)
• Financing of health research
Health research community
Health systems and services
•
Organization (public/private) and infrastructure (PHC/specialized care/hospitals)
• Activities (curative, preventive, self-help) and quality
• Availability/coverage and accessibility (geographical, financial, social, ethnic/cultural).
Source: Global Forum for Health Research
various ministries; the setting of pro-poor policies to ensure that services reach the
poor and that social safety nets are provided to cushion them against shocks; the
degree of commitment of the ministries to their mission; the efficiency and
effectiveness of the administration; and the research policies pursued by t e
government (7).
As mentioned above, informed decision-making in health should be based on an
understanding of the relationship between action and health outcome, and on having
access to, and using, pertinent information.
The contribution of health research to human development
Bad health will directly and profoundly affect the economic situation and well-being
of any individual in any society. This is particularly true in the lower income
countries (because their social safety nets are weaker or non-existent) and for the
absolute poor, due to the vicious circle of poverty and ill health (6,7,8).
Conversely, better health will boost the individual's level of income (lower treatment
costs, increased revenue, longer term increase in revenue due to better work
opportunities, increase in revenues due to longer lite-expectancy etc.); increase the
individual’s capacity to acquire an education; increase the family s Productive
opportunities; and increase substantially the psychological well-being of both he
individual and the family. The benefits of good health will be even greatei for the
absolute poor, as they may transform the vicious circle of poverty into a virtuous
circle with better nutrition, lower risks of unemployment or underemploymen ,
better housing, better use of training opportunities, higher productiv.ty and, overall,
better control over their life situation and that of their family. The whole process is
complex and difficult to quantify, but even conservative estimates suggest that hea th
investments often yield the highest rates of return compared to other public
investments.
There is strong evidence that good health is associated with access to knowledge. For
example, in many developing countries, children’s survival correlates highly with
their mother’s level of education. Educated parents are more likely to adopt health
promoting behaviours, avoid unsafe ones and seek professional help when their
children are unwell (9).
Research has led to the development of vaccines, drugs, diagnostics, water treatment
methods, therapeutic equipment and algorithms for clinical procedures. The.r impact
on health has been profound. In many developing countries, child mortality has
fallen even at times of economic stagnation; it is, therefore, more than likely that
these technological interventions significantly contributed to this improvement.
The development of hormonal contraception has given women greater control over
their fertility, and the treatment of diarrhoeal disease has been revolutionized by oral
rehydration’ therapy (ORT). Since epidemiologists established the link between
tobacco and lung cancer in the 1950s, governments have gradually introduced policy
changes to restrict smoking and millions of individuals have chosen to quit tie a i .
Behavioural research has led to improvements in health as well as health care. The
results of research in health economics and epidemiology can increase the cost
2. Health and health research
13
effectiveness of interventions and hence optimize the use of health care resources
(U).
In recent decades, the concept of development has evolved considerably, from a
focus on physical capital in the 1960s and 1970s to a greater focus on human capital
in the 1980s and 1990s, and finally to the present Millennium Development Goals
adopted by the United Nations in September 2000 and which focus on poverty,
health, gender equity, education, the environment and development partnerships
(1,3,6,7,8).
The culture of research provides a rational, knowledgeable framework for progress in
health. There are, therefore, strong political and economic interests for governments
to invest more in health and health research, as recommended by the Commission on
Macroeconomics and Health in its December 2001 report (7).
14
Section I. The case for priority setting in health research
3. Priority setting
Underlying values
In the literature on the economic evaluation of health care, the recommended
criterion for priority setting is essentially that of health maximization. This
normative basis could, however, be considered to reflect the stated objectives in
many nations' health services when these refer to efficiency in terms of “value for
money” or “as much health as possible within the given budget”. Recently, health
research has shown increasing interest in attempts to reflect another objective equity - in the health services financed by governments (10). Other objectives such
as the measurement of the severity of disease have also been incorporated in the
decision-making criteria of nations. Thus, before initiating an exercise of priority
setting, institutions must have a clear understanding of the underlying values with
which they will work.
Rationale and need for priority setting in health research
In view of the competing priorities for scarce health research funds, priority setting
for health research is as critical as conducting the research itself. The process of
priority setting is an important activity per se in that it engages institutions and
individuals to question and evaluate different assumptions. A continuous review of
priorities and priority-setting mechanisms is essential since research priorities change
over time as a result of epidemiological, demographic and economic changes.
Investment in priority setting for health research should be seen as complementary to
the implementation of interventions to improve health status. The relevance of
research, especially health research, is, however, frequently not recognized (1,2).
Funding for health research is all too often seen as a luxury and is an easy target for
budget cuts in times of financial stringency.
Priority setting in health becomes a complex task of evaluating the process using
normative and other criteria outlined above. Another key consideration is the
geographical level of application: local, national, regional or global. Although these
multiple levels have common issues related to the appropriate use of resources, they
offer vastly different settings for decision-making. Since the challenges in each will
differ, the response and priorities for each will also need to be appropriate.
The Commission on Health Research for Development concluded that the majority
of health research and development (R&D) resources are being used on issues that
are relevant to only a minority of the world's population (1). This is reflected in the
fact that little or no research is undertaken on diseases affecting mainly the poor, and
the application of research results for conditions prevalent in more advanced
countries is not directly transferable to less advanced countries due to the high costs
of the proposed interventions and/or the country-specific nature of the research
undertaken. The population that is excluded from the benefits of health research is
predominantly in the developing world, largely poor, and often marginalized from
both power and decision-making. This situation raises questions of an economic,
social, ethical and political nature (2).
3. Priority setting
15
One of the main contributions of the Ad Hoc Committee on Health Research's report
was the identification of specific areas where further investments in R&D would
make a difference to global health (3). Their identification was based on a process
that included five analytical steps, considerations of the attributable disease burden
likely to be reduced by interventions and attendant costs. The intention was to
identify a limited number of areas where R&D was insufficient relative to the
magnitude of the problem and the potential for a significant advance. It was also to
draw global attention (and resources) to these areas and track progress in promoting
more work in these fields.
An important aspect of the Ad Hoc Committee's work in priority setting was to
underline the need for economic analysis in health. Resource allocation within health
care, and especially health research, is both value-laden and ethically charged. Yet
seeking cost-effective use of health R&D funds - especially public funds - is
consistent with public health aims. Such a rationale has enabled the search for
priorities and prioritization processes to be further developed.
Insert 2 (page 17) shows how the Ad Hoc Committee proposes to analyse the burden
of a health problem in order to identify research needs.
Historical approaches to priority setting
Attempts have been made, particularly in the last 15 years, to systematize the
approach to setting priorities in health research. The objectives have been to make
the process more transparent and to help decision-makers, particularly in the public
sector, make more informed decisions, thus allocating limited research funds in the
most productive way from a world perspective.
Although the various approaches tackle the problem from very different angles and
with different terminologies and methodologies, there appears to be at least implicit
consensus that the central objective is to have the greatest impact on the health of the
greatest number of people in the community concerned (world or country level) for a
given investment.
Since the Commission on Health Research for Development in 1990, priority-setting
exercises have used various methods and processes. The objective of this section is
to compare these various efforts on prioritization in health research in order to
highlight their similarities and complementarity. An overview of this analysis is
presented in Insert 3 (page 18).
16
Section I. The case for priority setting in health research
Insert 2
Analysing the burden of a health problem to identify research
needs
Relative shares of the burden that can and cannot be averted with existing needs
x
100%
Research and
development to
identify new
interventions
E
s
.E
Unavertable with existing interventions
I
CD
£
z
>>
Avertable with
existing but noncost-effective
interventions
Avertable with
Averted with
improved
current mix of
interventions and efficiency
population
coverage
o
iE
CD
■3
-E
JZ)
E
Research and
development to
reduce the cost
of existing
interventions
Q
o
0%
y
X
100%
Effective coverage in population
Research on health
systems and policies
x — population coverage with current mix of interventions
y maximum achievable coverage with a mix of available cost-effective interventions
z — combined efficacy of a mix of all available interventions
Source: Adapted from Ad Hoc Committee on Health Research, Investing in health research
and development (WHO, 1996)
3. Priority setting
17
Insert 3
Comparison of various priority-setting approaches
Characteristics
1. Objective of
priority setting
2. Focus at the
global or
national level?
3. Strategies/
principles
4. Criteria for
priority setting
4.1 Burden of
disease
Essential
Ad Hoc Committee Advisory
Global Forum Combined
National Health on Health
Committee on
Approach Matrix
Research
Research
Health Research
• Promote health
Help decision-makers Address problems of Help decision-makers make
and development make rational choices critical significance
rational choices in investment
on the basis of
in investment
for global health:
decisions so as to have the
equity
decisions so as to
population dynamics, greatest reduction in the
• Help decision
have the greatest
urbanization,
burden of disease for a given
makers make
reduction in the
environment,
investment (as measured by
rational choices burden of disease for a shortages of food
number of DALYs averted),
in investment
given investment (as
and water, new and on the basis of the practical
decisions.
measured by number re-emerging
framework for priority setting
of DALYs averted).
infectious diseases. in health research.
Focus on situation Focus on situation
Priority to
Method applicable at both
analysis at the
analysis at country
“significant" and
global and national levels.
global level;
level; residual
“global” problems,
method also
problems to be studied requiring
applicable at the
at global level.
“imperative"
country level.
attention.
• Priorities set by
• Five-step process.
• Priorities should be • Priorities should be set by
all stakeholders. • Process should be
set by all stake
all stakeholders.
• Process for
transparent.
holders.
•Transparentand iterative
priority setting
• Process should be
process.
should be
transparent and
• Approach should be
iterative and
comparative.
multidisciplinary (biomedical
transparent.
• Multidisciplinary
sciences, public health,
• Approach should
approach.
economics, environmental
be multi
sciences, education
disciplinary.
sciences, social and
behavioural sciences).
4.2 Analysis of
determinants of
disease burden
Based on an esti- Measured by DALYs
Allocate resources to
mate of severity
(number of years of
the problems
and prevalence of healthy life lost to each deemed of "greatest
disease.
disease).
global burden".
Analysis of multi • Analysis of mostly
Analysis of multi
disciplinary
biomedical
disciplinary
determinants
determinants
determinants
(biomedical,
• Other determinants
(biomedical,
economic, social,
implicit.
economic, social,
behavioural, etc.).
behavioural, etc.).
4.3 Cost
effectiveness of
interventions
(resulting from
planned
research)
Some attempts at Cost-effectiveness
measurement in measured in terms of
terms of impact on DALYs saved for a
severity and/or
given cost,
prevalence.
Implicit reference to
cost-effectiveness
analysis.
Measured by DALYs (number
of years of healthy life lost to
each disease) or other
appropriate indicators.
Analysis of determinants at
following intervention levels:
• individual/family/community
• health ministry and research
institutions
• sectors other than health
• government macroeconomic
policies.
Cost-effectiveness measured
in terms of DALYs saved for a
given cost.
Source: Global Forum for Health Research
18
Section I. The case for priority setting in health research
Major efforts to systematize priority setting include:
Priority setting using the Essential National Health Research strategy
Based on the Commission’s recommendation to “encourage all countries to
undertake Essential National Health Research (ENHR)”, the Council on Health
Research for Development (COHRED) was established in 1993 to assist developing
countries with the implementation of this strategy to organize and manage research.
In its promotion of the ENHR concept, COHRED emphasized the following
principles: countries as the key actors in health research for development; the need
for solid evidence to underpin an inclusive health research agenda; the need to
involve all stakeholders in the prioritization process; and the need to link research
results to policy and to action (IO).
The three essential stages recommended by COHRED to increase the potential
success of the priority-setting process are the following:
Planning the priority-setting process
•
•
•
Identify leadership for the process, i.e. the central government or a body
officially assigned by the government to coordinate health research in the
country.
Identify and involve stakeholders, i.e. decision-makers (at various levels),
researchers, health service providers and communities.
Gather and analyse information for setting priorities (situation analysis) in
three broad categories:
■ health status (main health problems, common diseases, determinants or
risk factors)
■ health care system (current status, deficiencies and problems)
■ health research system (availability of human, fiscal and institutional
resources for research).
Setting the priorities
•
•
•
Preparation of the information into a manageable list of priority health
(system) problems and related research areas/issues.
Step-by-step process of stakeholders who determine the criteria for selecting
priorities and a method for weighting the priorities.
Determination of the scope of the expected outcome from broad lists of
priority health (system) problems to a detailed list of priority research
questions.
Implementing the priorities
•
•
•
•
From research priority areas to research portfolio: transformation of the broad
list of research priority areas into a research portfolio.
From meeting report to policy decision: integration of priorities into an
appropriate governmental plan, agenda or policy to ensure political backing.
Research priorities and a changing environment: periodic review and update
of priorities.
Investing in research priorities.
3. Priority setting
19
Five-step process of the Ad Hoc Committee on Health Research
Step 1: Magnitude (disease burden)
Estimate the magnitude of the problem/burden of disease by using standard
established methods.
Step 2: Determinants (risk factors)
Analyse the factors (determinants) responsible for the persistence of the diseases or
conditions.
Step 3: Knowledge
Assess the available knowledge to reduce or eliminate the burden of that particular
disease, condition or risk factor.
Step 4: Cost-effectiveness
Assess the cost and effectiveness of agreed interventions needed to reduce the
magnitude of the problem.
Step 5: Resources
Calculate/identify the present level of resources available for a particular disease,
determinant or a group of diseases/conditions.
Advisory Committee on Health Research
In its 1997 publication, the Advisory Committee on Health Research (ACHR) set out
the Visual Health Information Profile (VHIP). a computer-based visual display
showing the totality of the health status of a country” in a way that enables
comparisons of health status both for a given country over time and between
countries at a given point in time (ll). It draws attention to the large diversity of
actors and factors affecting the health status of a population and defines indicators of
a country’s health status permitting these comparisons over time and across
countries.
Combined Approach Matrix of the Global Forum for Health Research
This is described in detail in the next section.
Priority-setting domains
Priorities in health research have traditionally been formulated in terms of diseases
and conditions. It is now realized that this is only one domain of health research and
that health determinants themselves have to be prioritized and are competing for the
same funding as disease-focused priorities. But, to make things more difficult, there
are at least two other areas of health research which have to be prioritized against the
others, i.e. methodologies for priority setting and cross-cutting issues in health
research, such as policies, poverty and health, gender and health, and research
capacity strengthening.
It is, therefore, important that the prioritization exercise in health research take all of
these domains into account.
20
Section I. The case for priority setting in health research
Research on priority-setting methodologies
The failure in practically all countries to establish a process for priority setting based
on the burden of diseases and their causes has led to a situation in which only about
10% of health research funds from public and private sources are devoted to 90% of
the world’s health problems (measured in disability-adjusted life years or DALYs).
This extreme imbalance in research funding has a very high economic and social cost
for individuals, countries and the world as a whole. To make matters worse, even the
10% of funds allocated to the 90% of the world's health problems are not used as
effectively as they should be (2).
The reasons for this imbalance in health research funding include:
In the public sector
• Over 90% of research funds are spent by only a small number of countries
which, understandably, have given priority to their own immediate national
health research needs, even though this may be a short-sighted position.
• Decision-makers are often unaware of the magnitude of the problems outside
their own national borders, in particular, they are unaware of the impact on
their own country of the health situation in the rest of the world both directly
(e.g. rapid growth in travel, re-emerging diseases, development of
antimicrobial resistance) and indirectly (e.g. lower economic growth,
migration).
• The decision-making process is influenced by a range of factors including the
personal preferences of influential scientists or decision-makers, competition
between institutions, donor preferences, career ambitions and tradition.
• There is insufficient understanding of the role the public sector could play in
supporting the private sector in the discovery and development of drugs for
“orphan” diseases.
In the private sector
• Decision-makers in the private sector are responsible for the survival and
success of their enterprise and for the satisfaction of their shareholders. Their
decisions are based largely on profit perspectives which inevitably limit
investment in diseases prevalent in low- and middle-income countries, as
market potential in these countries is often underestimated.
• In low- and middle-income countries, pharmaceutical companies have the
potential to develop and produce products for diseases prevalent in these
states. However, their funding capacity is comparatively small in global terms
and, therefore, this potential remains largely untapped.
Research on policies and cross-cutting issues affecting health and
health research
The Commission on Health Research for Development recommended the evaluation
of the health impact of sectors other than health. It reported that most health research
funding is in the Held of clinical, biomedical and laboratory research, ranging from
60% to 90% in the countries studied, and that research activity was limited in the
field of health information systems, field epidemiology, demography, behavioural
sciences, health economics and management. The Commission suggested that
country-specific, multidisciplinary research could overcome that shortcoming and
3. Priority setting
21
that research on policies, systems and determinants had as much potential as the
biomedical approach.
The Ad Hoc Committee on Health Research made recommendations related to
determinants, mainly in the field of health research management (I). In particular, it
recommended identifying research areas and research projects likely to have the
greatest impact on the largest number of people. It also recommended the use of the
most cost-effective interventions to reduce the highest level of disease burden.
The Ad Hoc Committee recommended studying the underlying common
determinants of health status, including population dynamics, urbanization,
environmental threats, shortages of food and water, and behavioural and social
problems (3).
The recommendations of ENHR projects included efforts to initiate, in each country,
a demand-driven process to identify risk factors and the magnitude of health
problems based on equity, health policy research and health system management and
performance (10). The priorities should be identified on the basis of their ability to
contribute to equity and social justice, as well as on the basis of ethical, political,
social and cultural acceptability.
The International Conference (Bangkok 2000) recommended efforts to strengthen
the health research systems and to link health research to development, thereby
ensuring that research is carried out in the context of the prevailing problems in a
given country. The priority recommendations focus on knowledge management,
research capacity strengthening and governance of health research systems. The
underpinning principles are health equity and sustainable health research (4).
Research on determinants and risk factors
Focusing on risks to health is key to preventing disease and injury. In its World
Health Report 2002, WHO noted that: “Much scientific effort and most health
resources are directed towards treating disease. Data on disease or injury outcomes,
such as death or hospitalization, tend to focus on the need for palliative or curative
services. In contrast assessments of burden resulting from risk factors will estimate
the potential of prevention" (12).
The health authorities in a country should be aware of the major risks to the health of
their population. If major threats exist without cost-effective solutions, then these
must be placed high on the agenda for research. Reliable, comparable and locally
relevant information on the size of different risks to health is therefore crucial to
prioritization, especially for governments that are setting broad directions for health
policy and research. A summary of key recommendations made since 1990 on health
research for risk factors is given in Insert 4 below.
22
Section I. The case for priority setting in health research
Insert 4
Key recommendations made since 1990 for health research
on risk factors
Health research
priorities
Commission
Report
(1990)
Ad Hoc
Committee
(1996)
ACHR
(1997)
ENHR
Projects
(1999)
International
Conference
(2000)
Health policies and
systems
Health information
systems
Gender and
socioeconomic
inequalities
Health equity
Health cost and
financing
Capacity building for
health policies
Health behaviour
research
Health impact of
development of
other sectors
Sustainable health
research linked to
development
Environmental
degradation
Child nutrition
research
Food security
Formal education
Education by health
sector
Food and water
management
Research on social
justice
Occupational health
Reproduction and
contraception
Population
dynamics
Source: Global Forum for Health Research
3. Priority setting
23
Global
Forum
(2002)
Research on diseases and conditions
The Commission on Health Research for Development recommended research on
specific diseases that accounted for the highest burden in developing countries. It
differentiated between causes of death in developing and developed countries, and
drew attention to the high burden in the former in comparison with the low
investment in research. The Commission noted that, as the epidemiological transition
evolves, developing countries will increasingly face a double burden of pretransitional diseases (communicable diseases) and post-transitional diseases
(noncommunicable diseases and injuries).
In its report, the Ad Hoc Committee on Health Research combined diseases with
determinants (3). Based on the use of the VH1P, WHO’s ACHR focused its
recommendations in 1997 on both diseases with the highest burden in developing
countries and the underlying common determinants of health status (11).
Recommendations in 1999 by ENHR projects focus on countries. The International
Conference in Bangkok (2000) shifted its focus and recommendations on the
revitalization of health research systems to deal with the most prevalent diseases in
low- and middle-income countries and research capacity strengthening. It seeks to
lower the burden of disease by addressing health equity issues and decreasing health
inequalities.
A summary of key recommendations made since 1990 on research priorities for
diseases and conditions is given in Insert 5 below.
24
Section I. The case for priority setting in health research
Insert 5
Key recommendations made since 1990 on research priorities
for diseases and conditions
Health research
priorities
Commission
Report
(1990)
ENHR
Ad Hoc
ACHR Projects
Committee
(1997) (1999)
(1996)
International
Conference
(2000)
Global
Forum
(2002)
Tropical
diseases
(malaria,
schistosomiasis,
leprosy)
TB-HIV
Childhood
diseases
(diarrhoeal and
respiratory
diseases)
Sexually
transmitted
infections
Dengue
Maternal
mortality
Cancer/diabetes
Cardiovascular
diseases
Mental/neurological diseases
Violence and
injuries
Chronic
degenerative
diseases
The
International
Conference
2000 focused
on the need to
improve health
research
systems to
deal with
nationally
prevailing
diseases
J
I
Source: Global Forum for Health Research
3. Priority setting
25
Section II
COMBINED APPROACH MATRIX:
PRINCIPLES, ELEMENTS AND FUNCTIONS
1. Principles
The Combined Approach Matrix (CAM) is a tool that aims at (i) helping to classify,
organize and present the large body of information that enters into the priority
setting process; (ii) identifying gaps in health research; and, on this basis, (iii)
identifying health research priorities, based on a process which should include the
main stakeholders in health and health research.
Priority setting in health research must take into account an “economic’' dimension
as underlined in the Ad Hoc Committee's five-step process (1996) as well as an
“institutional” dimension, which is emphasized by the 1991 ENHR approach and the
1997 Visual Health Information Profile proposed by the Advisory Committee on
Health Research. The “institutional” approach argues that the health status of a
population depends as much on actors and factors outside the health sector as on the
national health system itself.
The CAM’s objective is to incorporate both the economic and the institutional
dimensions into a single tool for priority setting. The resulting matrix for priority
setting is presented in Insert 6 below.
The advantage of the proposed matrix is that it will help organize, summarize and
present all available information on one disease, risk factor, group or condition, and
facilitate comparisons between the likely cost-effectiveness of different types of
interventions at different levels. The information may be partial, and probably even
sketchy in some cases, but it will improve progressively, and even limited
information is sometimes sufficient to indicate promising avenues for research.
Insert 6
The Global Forum Combined Approach Matrix for health
research priority setting
The
individual,
household
and
community
Health
ministry and
other health
institutions
Sectors other
than health
Macroeconomic
policies
1. Disease burden*
2. Determinants
3. Present level of
knowledge
4. Cost and
effectiveness
5. Resource flows*'
* Global total estimated at US$ 1.4 billion DALYS. National estimates should be used for national exercises.
** Global total estimated at US$ 73.5 billion DALYS for 1998. National estimates should be used for national exercises.
Source: Global Forum for Health Research
28
1. Principles
2/The main elements of the CAM
The economic dimensions of priority setting
The components of the five-step process identified in the Ad Hoc Committee’s 1996
report (3) are the following:
Step 1: Disease burden
Measure the disease burden as years of healthy life lost due to premature mortality,
morbidity or disability. Summary measures, such as the DALY, can be used to
measure the magnitude. Other methods serving the same purpose can also be used.
A number of examples are presented in Section III of this report. It should be noted
that the term “burden of disease” (BOD) has been loosely applied according to
available data sources. These ranged from simple desk reviews of some international
reports, to the Global Burden of Disease Studies and national reports and research
studies. Put simply, the ideal is to have data available in summary measures (such as
DALYs), but the process of applying the CAM should not be abandoned if such data
are not available.
Step 2: Determinants
Analyse the factors responsible for the persistence of the burden, such as lack of
knowledge about the condition or disease, lack of tools, failure to make use of
existing tools, limitations of existing tools or factors outside the health domain.
Such information is available from global reports and the international, peerreviewed literature. However, there are always some important, local reasons to
explain why the problem persists, which need to be considered closely when
identifying research priorities.
Step 3: Present level of knowledge
Assess the present knowledge base available to help solve the health problem and
evaluate the applicability of solutions, including the cost and the effectiveness of
existing interventions.
For this purpose, international reports and peer-reviewed literature can provide a
good amount of information but local conditions and sensitivities need to be kept in
mind when considering the cost and effectiveness examples from other places.
Step 4: Cost and effectiveness
Assess, against other potential interventions, the promise of the R&D effort and
examine if future research developments would reduce costs, thus allowing
interventions to be compared and applied to wider population segments.
2. The main elements of the CAM
29
This sort of information, however, is often difficult to obtain, as very few national
organizations/institutes can supply it. It presents a challenge for those seeking to
apply the CAM at national or local levels.
Step 5: Resource flows
Calculate the present level of investment on research for the specific disease and/or
determinant.
However, it is not easy to calculate research investments because national and local
health budgets in most developing countries do not disaggregate information about
specific diseases and conditions, and much less about health research. This is another
problem faced by health and health research managers who are attempting to set
priorities, whether at global, national or local level.
The institutional dimensions of priority setting
The institutional dimensions include the following groups of actors and factors:
The individual, household and community
In the CAM, this column reviews the elements that are relevant to the reduction of
disease burden and can be modified at the individual, family/household or
community level. This includes interventions on primary care, prevention and
education. For example, in the case of malaria, prevention using barrier methods
such as insecticide-impregnated bednets is a key intervention at the individual level.
Health ministry and other health institutions
This column in the matrix assesses the contribution of the health ministry and health
research systems to the control of the specific disease or condition being explored.
The column focuses on:
• Biomedical interventions and their application throughout the whole health
system
• Policies and structures that can help the health system reduce the burden of a
specific condition
• The potential for the health research community to provide tools, processes
and methods to enable the health system to reduce the burden of a disease.
Sectors other than health
This column focuses on all other ministries, departments and institutions that
contribute to improving health but are not necessarily part of the health ministry or
its subordinate departments. Examples include the role of the transport sector in the
prevention of road traffic injuries, that of the education system (both formal and
informal) in changing people’s health behaviour (washing hands, smoking, substance
abuse, avoiding risky behaviour in general, etc.) or that of environmental protection
agencies in reducing health hazards.
30
Section II. Combined Approach Matrix: Principles, elements and functions
Macroeconomic policies
This column in the matrix focuses on the elements at the central government level or
those outside the country that can have a role in the control of the diseases or
conditions. An example of this is the impact of World Trade Organization
agreements concerning intellectual property rights on the provision of antiretrovirals
for the treatment of people living with HIV/AIDS.
yyy^ y
V
p.S-12.0
2. The main elements of the CAM
31
•
•
A national micronutrient strategy development meeting (Islamabad, January
2004)
A symposium on newborn care with the Pakistan Paediatric Association and
national neonatal group (Lahore. February 2004).
In addition, several informal consultations were undertaken with groups working on
maternal and child health in Pakistan including Saving Newborn Lives (SNL),
UNICEF, WHO Pakistan, the Department for International Development (DFID) and
USAID. The team also reviewed the reports on the situational analysis of newborn
care in Pakistan (SNL 2002) and the health systems’ policy review for perinatal care
undertaken with funding from the Alliance for Health Policy and Systems Research
in 2002.
While all sections of the CAM were not systematically completed at all the meetings,
the core group working on the project was able to address all areas through
consultations held between August 2003 and February 2004. A dual listing system
was used to analyse evidence gaps. Gaps were first listed and then a qualitative
assessment of gaps was undertaken, classifying the levels of evidence on a numerical
grid as follows:
• 1 = Sufficient data available
• 2 = Some data available
• 3 = Insufficient data (need for more research)
• 4 = No information/Critical gap/High-priority research.
Areas marked 3 or 4 would be the principal focus of research as information needs
were both immediate and constrained interventions.
Guided by the available information on perinatal and newborn morbidity and
mortality in Pakistan, the following key areas were identified for an in-depth analysis
using the CAM:
• Birth asphyxia
• LBW including prematurity and intrauterine growth retardation (IUGR)
• Serious neonatal infections.
Conclusions: the context of research in newborn care (evidence gaps
and proposed initiatives)
The data reviewed highlighted the urgent need to assess objectively the burden of
mortality and morbidity pertaining to the neonatal period. These data must be
derived from well designed community-based studies and reflect the diversity within
Pakistan’s population.
The socio-cultural and behavioural aspects of newborn care by family members and
other care-providers were considered an important area requiring much formative
research. This is important prior to the institution of any interventions, especially
those involving behaviour change. Given the widespread ignorance of appropriate
newborn feeding, thermoregulation, skin care and asepsis, these were identified as
priority areas for research.
In view of LBW rates in many communities, the results revealed that the biggest
challenges were to improve strategies for LBW prevention and postnatal care. A
44
Section III. Selected examples
better and holistic evaluation of risk factors for LBW is required from well
conducted, representative studies carried out in the communities.
In Pakistan, most births take place at home, frequently with the help of traditional
and untrained birth attendants. The CAM’s results emphasized that identifying ways
of optimizing viable opportunities for newborn care should be considered a priority
research area. One suggested option was working with trained birth attendants and
lady health workers for improved intrapartal and postnatal care of the mother and
newborn. These may include methods for basic newborn resuscitation, care of the
LBW infant, infection prevention and basic treatment through community health
workers. Collaborating with lady health workers in these initiatives shows
considerable promise, and this may be a major area for research.
In summary, the CAM allowed a systematic analysis and evaluation of the available
evidence on perinatal and newborn care in Pakistan. 1 he exercise allowed an
evaluation of the existing evidence and evidence gaps with regards to the burden of
disease, basic determinants and the policy framework of the Ministry of Health and
other departments of the government of Pakistan.
2. Selected examples
45
Section IV
-
VWX-WM*WMW*,'>;-'«*>«6>J<C*XC4W->-W-»X-'»->’
CHALLENGES AND OPPORTUNITIES
1. The lessons
In order to be credible and acceptable, and to serve as a basis for priority setting at
national or international levels, the information presented by a priority-setting tool
needs to be reliable. The strength of the CAM is its flexibility and diversity of
application. Depending on the resources, area of research and availability of the
required information, it may be applied by an individual researcher, a group of
experts, interested stakeholders or a combination of all of them, as illustrated by the
examples in the previous section.
The CAM provides a conceptual framework for compiling information relevant for
priority setting in health research. More important, it is a practical and standardized
tool for data presentation, and for improving transparency of rational decision
making in the priority-setting process. The method requires that very often complex
information and knowledge be condensed to fit into a cell of the CAM. Experts with
a profound knowledge of a specific disease may find it difficult and unacceptable to
be forced to reduce the pertinent scientific literature to a few key sentences. Critics
may consider this oversimplification lacking the necessary rigour for an analysis of
the situation. Others, however, accept this limitation as a challenge to focus only on
the essentials and to refrain from stating what cannot be expressed concisely.
The last two steps in priority setting concern the cost-effectiveness of future
interventions and the resource flows for the disease/risk factor under consideration.
Most investigators found it difficult to trace such information. In fact, apart from
occasional studies pertaining to the health system and health services research, such
information rarely exists. This, however, cannot be interpreted as a shortcoming of
the CAM, but rather as an outcome of the priority-setting exercise pointing towards
data required for priority research.
The focus for health research priority setting is not restricted to technical questions
about the status of the disease (or risk factor), but draws attention to the various
domains where interventions are possible and desirable (from the household to
global macroeconomic policies). Most health professionals and decision-makers may
well be aware of this in a general sense, but by applying the CAM it becomes
obvious in most situations that the health status of a population broadly depends on
many sectors of society and not only on the actions (or omissions) of the health
services.
Application of the CAM reveals clearly that there is much more knowledge available
than is actually applied. It shows that, in spite of the existence of many cost-effective
interventions, a huge treatment gap (i.e. the difference in the rates between those who
need and those who actually benefit from such treatment) exists, that the reasons for
the persistence of a health problem may be outside the health sector and that, if there
are obstacles within the health sector, they may be of a non-medical nature (such as
socio-cultural distance between health care providers and clients).
These findings help to emphasize that, apart from basic medical research, other types
of research are needed in order to change a population's health status for the better:
48
Section IV. Challenges and opportunities
research on risk factors, health service research, operational research, research on
policies and research on priority-setting methodologies.
The CAM has proven an extremely useful tool in situations where a cluster of
conditions or diseases results in a health problem. For example, the application of
CAM for mental disorders such as depression and schizophrenia will provide
information not only to set priorities for these diseases but also for the overall burden
of mental disorders.
1. The lessons
49
2. Challenges and opportunities
Compiling the data and information required to complete the CAM is a challenging
exercise for several reasons. Some investigators found it difficult to access
appropriate information from representative settings and, in some cases, it was
difficult to verify the veracity and validity of existing data. Limited institutional
memory at the level of policy-makers in terms of experience of interventions and
programmes was considered an obstacle while setting national research priorities.
The information required is not restricted to technical questions about the status of
the disease/risk factor and research, but also demands awareness, knowledge and
analysis of the factors determining health at the various levels (from the individual
and the family to macroeconomic policies). Although this is considered a major
advantage of the method, in that it forces the users to think broadly and inclusively, it
may not always be easy to find disease control experts who have the relevant skills
or knowledge.
In some situations, while the CAM provided a good solid base for the necessary
information, it required adaptation to the particular needs of the programme or
organization. CAM users have to modify and adapt the outcome of the CAM results
according to their organizational needs. Two excellent examples in this regard are
the use of the CAM by the TDR and the Pakistan Medical Research Council for
perinatal and neonatal care in Pakistan. Such adaptation needs to be continuous as
the debate on priority setting moves forward.
Disease research strategies need to be revised and updated, as new results become
available. This will be almost continuous in diseases such as malaria and HIV/AIDS
for which research is ongoing. The priority-setting process is therefore iterative and
should not be set in stone.
Another observation from a national team was that the CAM approach compelled
them to think nationally and focus institutionally. Also, many considered that the
whole process of CAM application provides an opportunity to develop capabilities,
strengthen capacities, enhance skills and improve knowledge in the field of health
research priority setting.
50
Section IV. Challenges and opportunities
3. Conclusions
The CAM methodology provides the evidence base for priority setting in health
research; it is not, however, a method that produces the priorities themselves. It can
hardly be expected that there will ever be a procedure or an algorithm that
automatically comes up with research priorities if the evidence base is somehow fed
into the process. One would hope, however, that standardized guidelines might
become available which will facilitate priority selection on the basis of the CAM.
Priority setting in health research is a dynamic process. It is realistic to expect that
methods and instruments, such as the CAM, designed to facilitate this process at
country, regional and global levels will be further developed, and that answers will
be found to the present gaps and limitations with the help of partners in the health
research world.
VLS - 13 0
v- ; f
3. Conclusions
ba
51
Section V
ANNEXES
Annex 1
Diarrhoeal diseases research in India: application of the CAM___
The individual, household and
community
Health ministry and
other health institutions
Sectors other than
health
Macroeconomic policies
1. Disease burden
.
- - - •=” - -»•»
—-
major towns in India.
---------- estimated to be due to diarrhoeal diseases. Globally, similar estimates (21%) were also reported
• In India, 20% of deaths among children under 5 years of age were
for children under 5. disease burden study in India, diarrhoeal diseases were the
u sixth ileading cause of lost DALYs in rural areas and the tenth leading cause in
• ShTSSsh
• In the Andhra Pradesh disease burden study in India, diarrhoeal diseases were the sixth leading
urban areas (based on community-rated disability weights; ranks were higher using expert-rated disability weights).
2. Determinants
53
’
'
. .
i ■■ the
.i overall
_nestimate
_ x:__ x-. of case-fatality from diarrhoea among linHpT-S
AStimateCl to
tO DC
IO /O
dysenteric
persistent diarrhoea.
Globally,
under-5 chilHfAn
children \A/3S
was estimated
be U.
0.15%
11.94% for non-( t
(1.8% among children less than 1 year of age).
1. Insufficient linkage across
1. Inappropriate housing
1. Problems associated with
1. Ignorance about nature of diarrhoeal disease and
sectors
2.
Insufficient
education
quality of health services
its modes of transmission
1.1 Lack of proper linkage between
3.
Inadequate
safe
water
1.1 Inappropriate advice
1.1 Inadequate maintenance of personal hygiene
health and other development
supply and sanitation
regarding infant and child
1.2 Inappropriate care-seeking behaviour and practices
sectors
systems
feeding practices
1.3 Insufficient knowledge about water treatment,
2. Government expenditure on
4.
Social
unrest
at
some
1.2 Irrational use of drugs for
storage and handling at the household/community
health and allied programmes
places
treatment of diarrhoea
level
2.1
Government spending in health
5. Population movements
1.3 Lack of adherence to control
1.4 Lack of knowledge about proper infant and child
programmes
has not increased
within and across borders
programme's guidelines while
feeding practices, including breastfeeding and
over last several years
managing the cases
weaning
3. Lack of sustained political
2. Lack of well-established
1.5 Inadequacy of proper sanitation and waste
commitment
surveillance system in most
(including excreta) disposal systems and insufficient
4. Persistence of huge
areas
knowledge about their importance
rural/urban disparities in
2.1
Surveillance to detect occur
2. Environmental changes leading to higher
socioeconomic conditions and
rence of diarrhoea cases
transmission potential of diarrhoeagenic
health care services
including outbreaks, deter
pathogens
mining major pathogens in the
2.1 Congested and unplanned housing without
area, changes in drug sus
adequate system for safe water supply and sanitation
ceptibility for major organisms,
2.2 Appearance of newer pathogens/strains with
detecting newer pathogens etc.
potential to cause life-threatening diarrhoea
2.2
Surveillance in health care
2.3 Increasing problem of drug resistance for several
instiUJtions
to prevent and
j
I diarrhoeagenic pathogens
Annex 1: Diarrhoeal diseases research in India: application of the CAM
The individual, household and
community
3. Socioeconomic influences
3.1 Poverty
3.2 Low literacy
3.3 Adverse cultural beliefs and taboos
3.4 Socioeconomic disruption due to natural disasters
(e.g. flood, famine, etc.)
4. Public distrust over quality of existing
government health services
3. Present level of
knowledge
3.1 Interventions currently
available
1. Prevention of infection
1.1 Maintenance of personal hygiene
1.2 Proper water treatment, storage and handling at
household and community levels
1.3 Maintenance of food hygiene
1.4 Special attention to childcare practices
1.4.1 Child feeding practices, specially breastfeeding
and weaning practices
1.4.2 Regular deworming of children
1.4.3 Child immunization
1.4.4 Supplementation of micronutrients (e.g. zinc)
1.5 Safe waste (including excreta) disposal system at
household and community levels
1.6 Antimicrobial prophylaxis
2. Prevention of disease progression among the
infected
2.1 Use of oral rehydration therapy (ORT)
2.2 Continued feeding, including breastfeeding for
breastfed children
2.3 Antibiotics, if appropriate
2.4 Timely seeking of health care
2.5 Compliance with prescribed drugs
Health ministry and
other health institutions
i
detect occurrences of
nosocomial diarrhoea
3. Lack of infrastructure to
isolate and characterize
many relevant organisms
4. Lack of appropriate health
information system
4.1 Lack of collection of data on
morbidity and mortality
(especially pathogen-wise
break-up) in a systematic way
4.2 Lack of dissemination of
information to all desired levels
4.3 Lack of timeliness in gather
ing and disseminating data
1. National Diarrhoeal Diseases
Control Programme
1.1 Promotion of ORT
1.2 Integration of the programme
with PHC up to the lowest
government health care level
1.3 Health education of the
people, including free dis
tribution of health education
booklets in regional languages
1.4 Training of physicians on
rational management of
diarrhoea
1.5 Establishment of diarrhoea
treatment and training units
(DTUs) at medical colleges
and district hospitals
2. Establishment of reference
and advanced centres for
research on diarrhoeal
diseases
Sectors other than
health
1. Appropriate housing
2. Environmental management
2.1 Adequate and safe water
supply and sanitation
2.2 Appropriate planning for
development projects
2.3 Environmental impact
assessment for proposed
development projects (e.g.
water pollution)
3. National Water Supply and
Sanitation Programme
4. Literacy mission and
health education
programmes, including
application of mass media
5. Epidemic preparedness
and disaster management
programmes
6. Programmes to alleviate
poverty (e.g. PMRY, JRY,
financial assistance from
banks)
Macroeconomic policies
1. Placing diarrhoeal diseases
among top priority health
concerns
2. Promoting awareness of the
problem and action
3. Arranging appropriate funding
(internal and external) for
research and management
4. Subsidize tools for
management (e.g. ORS,
halogen tablets etc.)
5. Involving other government
and non-government agencies
6. Decentralization process to
address rural/urban disparities
7. Legal amendments to deal
with growing pollution and
inappropriate use of drugs
7. Rural housing schemes
3.<Early diagnosis and treat
(Indira Vikas Yojana)
ment of affected individuals
3.1 Recommended management
guidelines
3.2 Provision of case man
agement at all levels of gov
ernment health care
3.3 Involvement of private med
ical practitioners
3.4 Isolation and drug sus
ceptibility testing of
diarrhoeagenic pathogens
4. Health education
5. Early detection, containment
or prevention of outbreaks/
epidemics
1. Cost-effectiveness not
1.1
One of the most cost1.1 Cost-effective to reduce occurrence of diarrhoea
known
effective
health
care
1.2 Cost-effective
2.1
Some water supply and
interventions ever
1.3 Cost-effectiveness not established
sanitation intervention
1.2-1.4
Cost-effective
1.4.1 Cost-effective
programmes are very costapproaches
1.4.2 Cost-effectiveness studies are needed for routine
effective in controlling
1.5 Establishment of DTUs are a
anthelminthic treatment of preschool children
childhood diarrhoea; may be
cost-effective
strategy
for
1.4.3 Overall, routine immunization of children is one of
as cost-effective as ORT
promotion
of
appropriate
case
the most cost-effective approaches to prevent
2.2 - 2.4 Cost-effectiveness not
management
of
diarrhoeal
illnesses; cost-effectiveness specifically for prevention
known
diseases, thus reducing burden
of diarrhoeal diseases not established
3. Cost-effective strategy to
of
diarrhoeal
disease
1.4.4 Cost-effectiveness of different strategies for
control diarrhoeal disease
3.1-3.3 Cost-effective
delivering zinc supplement needs to be assessed
burden
3.4
Routine
culture
of
stool
or
1.5 Cost-effective
4.
Cost-effective
routine application of other
1.6 Not cost-effective, except in some special
5. Cost-effectiveness not
detection
techniques
for
circumstances
known
community-acquired diarrhoea
2.1 One of the most cost-effective health care
may
not
be
cost-effective
interventions ever
2.2 Cost-effective to reduce morbidity and mortality from 4. Cost-effective
5. Cost-effectiveness of routine
childhood diarrhoea
surveillance system is not
2.3 Cost-effective only in select cases
known
... ...........
3. Cost-effective
. 3. Health education about relevant aspects for
preventing diarrhoea/ dehydration
3.2 How cost-effective are
current interventions?
(refer to numbers under
3.1)
I
55
T
Annex 1: Diarrhoeal diseases research in India: application of the CAM
4. Cost and
effectiveness
The individual, household and
community
1. Community participation in planning and evaluation
would be an effective approach to control the disease
2. Promoting use of inexpensive yet effective methods
for water disinfection and storage at the household
and community levels is a proven cost-effective
intervention
3. Raising awareness about diarrhoea and its
management within the community (especially among
mothers) through innovative ways (e.g. educating
parents through their children who are taught in an
interesting way about these aspects in school;
educating people through teachers, etc.) may prove
an effective strategy
Health ministry and
other health institutions
1. Involvement of both licensed
and unlicensed health care
providers in training on rational
management of diarrhoea
2. Bringing out newer ORS
formulations through research
-> some newer ORS (e.g. rice
based ORS already proved its
efficacy, though its widespread
use is limited by non
availability of a packaged
product for some practical
difficulties; research is under
way to overcome these
difficulties)
3. Newer diagnostic methods to
identify pathogens using
modern laboratory technol
ogies -> but, too much effort
on identifying pathogens,
especially for cases of
community-acquired diarrhoea,
may not be a cost-effective
approach
4. Evaluation and monitoring of
drug resistance pattern for
major pathogens and iden
tifying suitable/newer
antimicrobials to treat them ->
treatment for diarrhoea with
antimicrobials is indicated only
in very selective cases
5. Development of vaccines
against major causative agents
-> efforts are on for many
organisms (e.g. cholera,
shigella, rotavirus); they could
be cost-effective but subject to
some conditions apart from
Sectors other than
health
1. Involvement of private
sectors and NGOs, women's
groups and community
organizations in spreading
messages about diarrhoea
and its control; cost
effectiveness may be difficult
to measure
2. Carefully planned com
munications strategy
involving the coordinated use
of mass media, market
research and evaluation,
relying on a multiplicity of
channels for communication
that is culturally appropriate
3. Greater use of electronic
mass media to spread
relevant messages in local
languages - effective for the
vast population of illiterates
and semi-literates, as even
among them more and more
people are gaining access to
radio, television etc.
Macroeconomic policies
1. Set priorities for diarrhoeal
diseases research and allow
sufficient budgetary allocation to
deal with this continuing public
health problem
2. Seek resources from national
and international agencies which
could be utilized for this health
problem from the country's
perspective
3. A revised National Health Policy
addressing the prevailing rural/
urban inequalities in delivery of
health services is imperative
4. Optimal collaboration needed
among different related national
programmes (e.g. National Water
Supply and Sanitation
Programme)
5. Evaluation of existing
programmes
5. Resource flows
1. Individual and community efforts to prevent and
control diarrhoeal diseases
2. Involvement of prominent social figures (e.g.
actors/actresses, social workers) and opinion leaders
(e.g. ministers, members of parliament, etc.) in raising
awareness
3. Organization of camps, meetings, demonstrations etc.
4. Distribution of halogen tablets, bleaching powders
etc. by community leaders and organizations
safety and efficacy (e.g. cost)
6. Establishment of a valid and
reliable health information
system, especially for causeof-death information -> a
precondition to be able to
assess effectiveness
7. Expanding surveillance system
- cost-effectiveness needs to
be measured
8. Use of telemedicine in special
circumstances (e.g. pilgrimage)
-> cost-effectiveness not
evaluated
1. Funds and resources
allocation under National
Diarrhoeal Diseases Control
Programme
2. Resources (funds, equipment,
infrastructure building) for
diarrhoeal diseases research
and training from government
and non-government agencies,
as well as from international
agencies
1. Gaining positive impact on
diarrhoeal diseases control
through resources spent on
National Water Supply and
Sanitation Programme
2. Sulabh International, a
private organization, has
been engaged in building
public toilets for more than
25 years in different parts of
the country
3. Involvement of government,
mass media and NGOs in
spreading appropriate
messages
4. Improving child health
through different government
and non-government
programmes (e.g. Integrated
Child Development Services)
1. Collaborative efforts and
partnerships with international
organizations such as WHO,
UNICEF, Japan International
Cooperation Agency to fight
against this menace
2. Collaboration among various
national and international
agencies for development and
testing of vaccines against
cholera, rotavirus etc.
3. Obtaining support from
international agencies (e.g.
World Bank) to develop and
expand health care infrastructure
Source: Indian Merdical Research Count: '
57
•t
Annex 2
Pakistan’s National Action Plan for noncommunicable disease prevention and control:
application of the CAM
1. Disease
burden
2. Determinants
The individual, household
Health ministry and other health
Sectors other than health
Macroeconomic
and community
institutions
policies
Noncommunicable diseases (NCDs) and injuries are amongst the top ten causes of mortality and morbidity in Pakistan; estimates indicate that they account for approximately
25% of deaths within the country. Existing population-based morbidity data on NCDs in Pakistan shows that one in three adults over the age of 45 years suffers from high
blood pressure; the prevalence of diabetes is reported at 10%; and 54% men and 20% women use tobacco in one form or another. Karachi reports one of the highest
incidences of breast cancer for any Asian population, with an ASR of 53.1; in addition, estimates indicate that there are 1 million severely mentally ill and more than 10 million
individuals with neurotic mental illnesses within the country. Furthermore, the incidence of injuries has been reported at 41.2 per 1 000 persons per year.
1. Lack of awareness about the risks
of NCDs and the consequent
adoption of detrimental practices:
• unhealthy diet, sedentariness,
stress, use of tobacco, passive
exposure to smoke, use of areca
nut. indoor air pollution;
• dangerous driving, commuting
practices and pedestrian
behaviours
2. Inappropriate care-seeking
behaviour and practices, e.g.
screening for risk status
3. Noncompliance with drug treatment
4. Poor access to health care and to
skilled health care providers
5. Lack of a conducive physical and
social environment for physical
activity, particularly for women
6. Issues with accessibility to a
healthy diet
1. Lack of inclusion of NCDs as part of the national
health policy
2. Lack of a concerted public health response to the
issue
3. Lack of integrated surveillance systems to enable
an ongoing assessment of NCDs and their
determinants.
4. Lack of coordination between data providers and
users
5. Lack of longitudinal cohort studies to measure
population-specific causal associations, which
could be the target for preventive interventions.
6. Lack of clinical end-point trials in the native
Pakistani setting which could set optimal targets
for therapeutic interventions in primary and
secondary prevention settings
7. Persistent focus of the diet and nutrition policy on
undernutrition
8. Lack of resource-sensitive, scientifically valid
training programmes for all categories of health
care providers focusing on NCD prevention and
control
9. Lack of integration of NCD prevention with primary
health care
10. Lack of policy and operational research around
tobacco
1. Lack of recognition of the magnitude and scale
of NCDs and their economic implications.
2. Lack of efforts to assess agricultural and fiscal
policies relating to food items that could have
implications for increasing the demand for, and
making of, healthy food more accessible
3. Lack of polices and strategies to limit production
of and access to ghee as a medium for cooking
4. Lack of efforts to institute measures to reduce
dependence on revenues generated from
tobacco
5. Lack of measures to discourage tobacco
cultivation and assist with crop diversification.
6. Lack of effective legislative measures, which
stipulate standards for urban planning
7. Lack of comprehensive efforts aimed at banning
tobacco advertisements
8. Lack of efforts to develop a comprehensive price
policy for tobacco products
9. Lack of legislation on areca nut
10. Lack of appropriate regulatory measures to
reduce exposure to risk in industrial settings
11. Lack of efforts to explore the feasibility of
utilizing open spaces and playgrounds (e.g. in
schools) for physical activity
12. Lack of regulatory bodies to ensure “safety” in
1. Lack of sustained
political
commitment
3. Present level
of knowledge
4. Cost and
effectiveness
5. Resource
flows
59
The present level of knowledge
related both to the determinants of
persistence of disease and
effectiveness of prevention and
control measures is largely based on
evidence drawn from the developed
world. This needs further exploration
in the indigenous Pakistani setting
The present level of knowledge
related to cost-effectiveness of
interventions has been drawn from
best practice examples in the
developed world. This needs further
exploration in the indigenous
Pakistani setting
No information is available.
tn. F all settings
11. Lack of sustainable public health infrastructure to
13. Gaps in the emergency care system
support community mental health activities
14. Lack of efforts to ensure enforcement of traffic
12. Lack of involvement in “safety” representation on
regulations
national safety and road
15.
Lack of efforts to improve roads, vehicle design
13. Lack of availability of drugs essential for
and drivers' training
prevention and control of NCDs at health facilities
16. Lack of a comprehensive policy and legislative
framework relating to occupational health and
safety
Same as 1
Same as 1
Same as 1
Same as 1
Same as 1
Same as 1
Annex 3
Schizophrenia: application of the CAM
1. Disease burden
2. Determinants
3. Present level of
knowledge
The individual, household Health ministry and other health Sectors other than health
Macroeconomic policies
and community
institutions
Globally 15,686,000 DALYs lost, which is 1.07% of total global burden of disease
• There is no proven method of
• There is no cure for schizophrenia
• Stigmatizing environment
• Insufficient awareness of the size of
primary prevention of
• Insufficient recognition in treatment
(including workplace)
the problem and the existence of
schizophrenia
programmes that level of burden is
• Mental health legislation
cost-effective interventions capable
• Biological risk factors include:
shaped by interaction between intrinsic
inadequate or absent
of reducing the burden of the
- Genetic vulnerability (polygenic);
vulnerabilities caused by the disease
• Neglect of the large number of
disease
heritability 69%-80%
and the psychosocial environment
patients who have lost their
• Lack of a coherent mental health
- Early developmental insults
• Hospitalization with the aim of removing
supportive network and are
policy
(LBW; perinatal brain damage;
people with schizophrenia from public
homeless, vagrant or in prison
early neuroinfection)
places or facilities, or otherwise
• Poor coordination between
• Environmental/psychosocial risks
restricting their freedom
services including non-health
- Urban birth
• Severe adverse effects of antipsychotic
sector
- Stigma
drugs (neurological extrapyramidal
- Social isolation
effects), interfering with psychosocial
• High co-morbidity (e.g. substance
and vocational adjustment, lead to nonmisuse)
compliance with medication and
contribute to stigma.
• Treatment gap in developing countries:
67% or 17 million patients are not
receiving treatment
• Lack of specialists and general health
workers with the knowledge and skills to
manage schizophrenia across all levels
of care
• Lack of resources
• In contrast to prevention, there is sufficient knowledge of interventions that can substantially ameliorate the course of schizophrenia and reduce the
resulting impairments and disabilities
• Formulation of mental health policy (e.g. as part of health sector reforms)
• Mental health awareness programmes (e.g. declaration of a mental health day)
• Community-based management programmes involving at least three operational components:
-’Pharmacological treatment aimed at symptom control in acute episodes, maintenance of stabilization and
prevention of relapse, and means of ensuring adherence to treatment protocol
- Mobilization of family and community support, including provision of education about the nature of schizophrenia
and its treatment, involving the family in simple problem-solving skills training and involving the local community in
providing a supportive and non-stigmatizing environment
- Local rehabilitation, such as maintaining the patient in appropriate work and social roles within the community, and
creating opportunities for occupational and social skills training
• Many of the psychological approaches have not been evaluated by economists, nor have the newest atypical
antipsychotics
• There are few if any evaluations of specific combinations of pharmacological and psychological therapies.
• There is little evidence of the economic consequences of side-effects or non-compliance, yet one would suspect
these to be important drivers of long-term costs.
• Research findings point to areas where cost savings may be achieved in principle, but they may not lead to cost
savings in practice: with the growth of community-based care involving multiple agencies with their own budgets
and their own ways of working, there is little evidence about the incentives and constraints that might help or hinder
integrated responses to schizophrenia
• Antipsychotic medication (conventional
• Reduction of stigma
antipsychotics (e.g. phenothiazines)
• Protection of patient's human
and atypical antipsychotics (e.g.
rights
clozapine))
• Prevention of premature mortality
• Cognitive-behavioural therapy for
(e.g. suicide)
psychotic symptoms
• Prevention of criminal and
• The primary health care model
offending behaviour
• Family interventions
• Skills training and illness self
• Group interventions focused on the
management
patient
• Therapeutic communities
• Short-term hospitalization for acute care
in accordance with ethical guidelines by
international bodies, such as WHO
• Antipsychotic medication: conventional
drugs are effective and inexpensive
(chlorpromazine) but cause severe
adverse effects. Atypical drugs cause
fewer adverse effects, but are more
expensive. Cost-effectiveness studies
of con ven tion al vs. atypical
61
• Supported employment approach
to vocational rehabilitation
• Non-stigmatization programmes
• Mental health legislation
• Consumer empowerment
Annex 3. Schizophrenia: appiication of the CAM
Annex 3: Schizophrenia: application of the CAM
The individual, household
and community
I-
4. Cost and effectiveness
5. Resource flows
Gicoal For
Health ministry and other health Sectors other than health
institutions
antipsychotics originate in developed
world. To achieve universal availability
at low cost conventional antipsychotics
are clearly to be preferred (until current
atypicals come off-patent)
• Research capacity building through on-site education, exchange programmes and distance learning
• Development of local networks that link centres with the requisite expertise to their surrounding community, and
creation of regional networks linking such centres through joint training programmes, staff exchanges and
collaborative research
• Partnerships between lead institutions in high-income countries and such collaborative networks in low-income
countries
• Research into the aetiology of
• Research into interactive interventions
schizophrenia, particularly genetic
involving the patient, the family and the
epidemiology, neurobiology
community, cognizant of the fact that
• Research into prognosis and
biological vulnerability and
outcome of schizophrenia in
environmental influences interact and
developing countries
potentiate each other at every stage of
schizophrenia (treatment, stabilization
and residual)
• Research into preventive intervention,
e.g. through early detection and
avoidance of treatment delay
No information is available.
Macroeconomic policies
Annex 4 '
Indoor air pollutio
AP): application of the CAM
The individual, household
and community
1. Disease burden
2. Determinants
4% of the global burden of disease.
Poverty: Individuals, including
gender-related; family; population
(including effects of drought, war.
debt, etc.).
Awareness: lack of awareness of
health risks and/or options for change,
Culture: Preferences, e.g. for taste of
food cooked on biofuel stove; uses of
Health ministry and other
health institutions
Sectors other than health
Awareness: Lack of awareness of
Development/civil society
health impacts of indoor air pollution
organizations (CSOs): Focus has
specifically and more generally of
been on technology for energy
interrelationships between household
conservation and cost saving.
energy, gender, health and
Non-health ministries: Environment,
housing, etc., tended to operate in own development,
priority as health research issue;
Policy: Lack of policy and strategy to
fields without collaboration with health
limited funding; lack of population
address household energy and
CSOs.
surveys of exposure (health risk);
poverty, consequently minimal
Donors: Projects often driven and
exposure assessment difficult in
smoke, e.g. food preservation;
capacity.
is worst (cost, funded by donorsjather than being
spiritual issues relating to hearth.
Economic: Distortions in energy
participatory
and
market-led.
technical expertise required).
Access: Limited access to cleaner
sector, fuel subsidy policy not
Finance:
lack
of
suitable
local
micro
Health systems: Focus on case
fuels and appliances due to poverty,
credit
or
other
ways
to
assist
with
costs
benefiting the poor,
finding and treatment; uncertain about
and inadequate or unreliable supply.
Collaboration: Inadequate
of
appliances.
Participation: lack of opportunities for role in reducing environmental
support/facilitation of inter-sectoral
Evidence: History of poor projects,
pawp.ta i. change.
logahe.
lac, ol e.gence o,
collaboration at national and other
levels.
successful initiatives, has reduced
Ministry: lack of awareness, hence
weak health policy response;
inadequate collaboration with other
sectors.
Research institutions: Relatively low
• I • aM • A •
Role: Health sector tends to view role
3. Present level of knowledge Community development: Allows
participation in needs assessment and as limited, so this needs to be
clarified. Role includes:
planning interventions.
Poverty reduction: Opportunities for • collection and provision of data on
health and exposures
income generation, uptake of credit
where available. Note that adoption of • raising awareness of health effects
and need for prevention
interventions (below) includes ability
•
provision
of education at points of
to pay.
contact with the health system (in
Improved stoves: Adoption of stoves
clinical or community settings)
that reduce emissions, save fuel, vent
•
collaboration with other sectors.
pollution to exterior.
Research:
Tools and methods for
Cleaner fuels: Use of kerosene, gas,
obtaining
valid
information on:
electricity where available.
63
Macroeconomic policies
1»!
Va
I I
interest.
Many options currently exist for these
sectors, but implementation is mostly
patchy and uncoordinated.
Energy supply: Distribution of cleaner
fuels (e.g. oil sector); other clean fuels
(biogas, gelfuels).
Local commercial sector: Artisans
(e.g. stoves); distributors and suppliers
of fuels and appliances
Education: School and adult
education on health risks, role of
community, options for change.
Housing: Integrate environmentall__
National policy: Integrated national
policies on household energy, health
and development are required, but
mostly lacking.
Specific programmes: Some
examples of national initiatives,
including China (rural stove
programme), India (improved stove
programme) and Brazil (promotion of
gas). In general, few strategic
national examples.
Poverty reduction: Rural and urban
poverty reduction can be expected to |
Annex 4: Indoor air pollution (IAP): application of the CAM
4. Cost and effectiveness
4.1 What types of intervention
are under consideration?
The individual, household
and community
Health ministry and other
health institutions
Housing: Improvements to
ventilation, insulation (cold areas).
Behaviour: Action to reduce fuel use,
reduce exposure of family members.
exposure and health outcomes;
effectiveness of education via health
sector; role in collaborative initiatives
with other sectors.
Sectors other than health
Macroeconomic policies
health into design and building.
have significant impact on fuel-use
Finance: Targeted subsidies for
patterns.
development, local micro-credit.
Forestry, environment: Renewable
wood fuel resources and protection of
the local environment.
Who pays? Costs are incurred by
Sectoral issues: Although there are
Sectoral issues: In contrast to the
Integrated policy: Not aware of any
households through market
potentially large health gains from
health sector, it is the non-health sector assessment of contribution to
mechanisms, as well as through
household energy interventions, most (mainly) that “provides” the
national economies, or reductions in
investment by utilities (e.g. electricity) of the costs of interventions are not
interventions. The issue of cost is
national socioeconomic and health
and government (targeted subsidies
borne by the health sector.
complex, however, as interventions
differentials, of integrated policies
and credit support, if available).
Cost-benefit: Estimates based on
mostly need to be taken up through
and investment in household energy
Actual cost: Costs to households
stoves in Guatemala and Kenya
market mechanisms if widespread
for the poor.
made up of capital costs (appliances, suggest benefits substantially
uptake and sustainability are to be
Specific programmes: Chinese
etc.) and running costs (fuels,
outweigh costs for overall mortality
achieved. A range of benefits should
rural stove programme implemented
maintenance). Wide range of costs
and ALRI morbidity.
accrue to the non-health sector,
in more than 170 million homes, but
from US$5-7 (ceramic stove) to
Cost-effectiveness: Estimates for
including economic development,
evaluation so far limited. Indian stove
US$150+ for biogas or electric
stoves in India indicate $50-100 per
employment, environmental protection, programme has been problematic.
appliances.
DALY saved.
etc. These are also benefits for the
South African electrification
Community perspectives: There is a Research: Strengthen evidence and
health sector.
extensive, but substitution of polluting
need for more information on how
precision of health risk estimates for
Research: Assessment of the costs
fuels limited in poor areas. In Brazil,
communities and households view
IAP (including ARI, COPD, TB, LBW,
and benefits of household energy
gas is used extensively in rural
costs and benefits: both are locally
cancer, eye disease); evidence on
development for the poor, across
areas.
specific and tend to be complex - in
wider health impacts of household
sectors, is a complex field requiring
Financial policy: Evidence that fuel
part due to the multiple impacts/uses
energy; collaboration on systematic
development.
subsidies do not generally benefit the
of household energy.
monitoring and evaluation.
poor.
Requires combination of (a) new
Awareness: More needs to be done
Combined approach: As with the
Integrated policy: Increased
technologies and other approaches to to raise awareness at all levels of the community level, requires new
awareness at national level needs to
interventions, as well as (b) more
health sector about the health impacts approaches as well as more effective
lead to integrated policy, linked in to
effective implementation of existing
of IAP on “headline” diseases such as implementation. To include:
poverty-reduction efforts. Specific
interventions. New ideas include:
ARI, as well as the overall impact of
• development and supply of cleaner
measures to include:
• uptake of improved fuels, e.g.
household energy on health, and of
fuels and appliances, as well as new • national capacity building
ethanol gelfuels, solar PV
links between environment, health and
fuels (e.g. gelfuel)
• targeted financial support
• innovative methods of raising
development in general.
• strategic development of fuelwood
• energy policy which facilitates
awareness at community level, e.g.
Define role: If this sector is to be able
sector, where appropriate
access of the poor to cleaner fuels
drama, community video, etc.
to respond effectively, better methods • development of microcredit, which
• measures to assist the
• exploring opportunities for
are needed to define the role it can
may require more evidence on cost
development of microcredit for
behavioural interventions, e.g.
play at all levels (ministry, district,
effectiveness to make case for loans
household energy
4.2 How cost effective could
future interventions be?
5. Resource flows
65
• resources for carrying out
and initial donor support.
clinic, community) in any given setting.
keeping child away from smoke
prioritized research.
Collaboration:
More
effective
Research: Stronger evidence on
• adopt new stove designs, e.g. the
Research: Systematic reviews of
mechanisms
for
inter-sectoral
varied
impacts
of
household
energy
I insulated “Ecostove” in Nicaragua
experience to date with components
collaboration at various levels.
on health; methods for developing
• integrating house design with
of the above to guide more integrated
Research: Development of new
energy needs, e.g. better insulation, health sector role, with case studies.
policy.
technologies and approaches to
Community participation in planning
implementation,
marketing,
etc.
and evaluation is required.
Integrated policy on household
There is potential for cost-effective
Action at community level has a great Some initial estimates of potential
energy and the poor has the potential
gains
for
a
range
of
sectors,
including
reductions in mortality and incidence
deal of potential. Participatory
to contribute to national
environment,
forestry,
housing,
of specific diseases such as ALRI
development, particularly involving
socioeconomic development,
education
and
employment.
Some
from lowering IAP are becoming
women, can be very effective in
studies
have
shown
the
combination
of
particularly if the above measures
promoting change. Some specific new available. These are still based on
can contribute to reducing
short-term
(health)
and
longer
term
imprecise
estimates
of
risk,
and
as
yet
interventions, such as the Ecostove
inequalities in health and
(global environment) gains that may
(Nicaragua) and gelfuels (Africa) look do not:
development in society. This is an
accrue from a range of different
• integrate wider health impacts of
promising. But there remains a
stove/fuel
options'in
India
see
text
for
important area for further study,
household energy on health, nor
pressing need for studies that assess
examples.
The
interdependence
of
the
• consider the potential of
the overall effectiveness and
costs and benefits for the many sectors
interventions and (crucially)
sustainability of interventions,
involved makes any comprehensive
approaches to more effective and
covering a range of urban and rural
sustainable implementation outlined economic evaluation very challenging,
settings. Also needed are impact
as there is only limited value in looking
here.
assessment methods that can be
at the cost-effectiveness for one
Research:
The
health
sector
should
applied more routinely and that are
(sectoral) outcome at any one time.
take
a
lead
in
ensuring
that
the
sufficiently flexible to allow for the very
evidence
for
making
these
variable levels of capacity and
assessments is both available and
information.
clearly presented.
No information is available.
Annex 5
Perinatal and neonatal care in Pakistan: application of the CAM
The individual, household
and community
Information on incidence,
prevalence, severity and burden of
disease for specific areas.
Affected age groups.
1. Disease burden
2. Determinants
Socio-behavioural factors affecting
susceptibility to disease and
resilience to change e.g. maternal
empowerment, dietary factors.
3. Present level of
knowledge
Information on disease burden
and direct link to maternal and
newborn health (available from
both national and international
sources).
Information on costing and
effectiveness of interventions at
community level, especially from
programme settings.
4. Cost and effectiveness
(of future or possible
Interventions)
5. Resource flows
SO
:.e: Pakistan Medico
Availability of funding opportunities
for key areas, especially at
population level.
ssea
Health ministry and other
Sectors other than health
health institutions
Awareness and data at the level
Awareness of problem and linkages
of direct policy-making bodies
with other sectors e.g. education,
(especially provincial and local
population welfare, etc.
governments) and health
research systems.
Awareness and data at the level
Awareness of problem and linkages
of direct policy-making bodies
with other sectors e.g. education,
(especially provincial and local
population welfare, etc.
governments) and health
research systems.
Awareness of information at the
Awareness of problem, its burden
level of direct policy-making
and linkages with other sectors e.g.
bodies (especially provincial and education, population welfare, etc.
local governments) and health
research systems.
Awareness of cost-effective
Awareness of cost-effective
interventions at the level of
interventions and their synergy or
direct policy-making bodies
linkages with other sectors e.g.
(especially provincial and local
education, population welfare, food
governments) and health
and environment agencies.
research systems.
Availability of research funding
Availability of research funding
opportunities and alignment with
opportunities and alignment with
research priorities as identified
research priorities of other sectors
by the Ministry of Health
e.g. education, population welfare,
(especially provincial and local
food and environment agencies.
governments) and the PMRC.
Macroeconomic policies
Federal-level information systems and
linkages with the Planning Commission and
Ministry of Finance.
Federal-level information systems and
linkages with the Planning Commission and
Ministry of Finance.
Federal-level information systems and
linkages with the Planning Commission and
Ministry of Finance.
Federal-level awareness and sharing of
information with the Planning Commission
and Ministry of Finance.
Availability of research funding opportunities
and alignment with research priorities of other
sectors e.g. federal-level bodies i.e. Planning
Commission and Ministry of Finance.
Annex 6
’
x
Newborn health research priorities (summary view)
.^x^WttW****-^^****""^^***^^
The individual, household
and community
Health ministry and other
health institutions
Sectors other than health
Macroeconomic policies
1. Disease burden
2
2
2
1
2. Determinants
2
3
1
3
2
4
4
2
4
4
4
4
2
4
1
4
1
3. Present level of
knowledge
4. Cost and effectiveness
(of future or possible
Interventions)
5. Resource flows
1 = Sufficient data available
2 = Some data available
3 = Insufficient data (need for more research)
4 = No information/Critical gap/High-priority research area
rce. Pakista-^ Medical Research Con
67
Annex 7
References
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Health Research for Development, 1990.
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3. Ad Hoc Committee on Health Research Relating to Future Intervention Options.
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4. Conference report. International Conference on Health Research for
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68
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