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The Combined Approach Matrix: A priority-setting tool for health research edited by Abdul Ghaffar, Andres de Francisco and Stephen Matlin
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Contents 1
THE COMBINED APPROACH MATRIX A PRIORITY-SETTING TOOL FOR HEALTH RESEARCH
Edited by
Abdul Ghaffar Andres de Francisco
Stephen Matlin
Contributors and acknowledgements 2
Contributors This document was compiled with contributions from: Nabeela Ali Zulfiqar Bhutta Nigel Bruce Andres de Francisco Abdul Ghaffar Walter Gulbinat Lalit Kant Acknowledgements The editors would like to thank the chairpersons of the Indian Council of Medical Research and the Pakistan Medical Research Council for facilitating the application of the CAM; participants of Forums 5, 6 and 7 for their comments; Susan Jupp for review, design and editorial support; and colleagues in the Research and Programmes Unit of the Global Forum for their comments.
Stephen MatlinSania Nishtar
Contents 3
Contents Contributors 2 Acknowledgements 2 Foreword 5 Acronyms and abbreviations 6 Section I. The case for priority setting in health research 7
1. Introduction 8 2. Health and health research 10 Determinants of health status in populations 10 The contribution of health research to human development 13 3. Priority setting 15 Underlying values 15 Rationale and need for priority setting in health research 15 Historical approaches to priority setting 16 Priority-setting domains 20
Section II. Combined Approach Matrix: Principles, elements and functions 27
1. Principles 28 2. The main elements of the CAM 29
The economic dimensions of priority setting 29 The institutional dimensions of priority setting 30
3. Functions of the CAM 32 Section III. Selected examples 33
1. Application of the CAM 34 2. Selected examples 35
Application of the CAM at the global level 35 Application of the CAM at the national level 38 Application of the CAM to a disease 40 Application of the CAM to a risk factor 41 Application of the CAM to a vulnerable group 43
Section IV. Challenges and opportunities 47
1. The lessons 48 2. Challenges and opportunities 50 3. Conclusions 51
Section V. Annexes 52 Annex 1. Diarrhoeal diseases research in India: application of the
CAM 53 Annex 2. Pakistan’s National Action Plan for noncommunicable
disease prevention and control: application of the CAM 58 Annex 3. Schizophrenia: application of the CAM 60 Annex 4. Indoor air pollution: application of the CAM 62 Annex 5. Perinatal and neonatal care in Pakistan: application of
the CAM 66 Annex 6. Newborn health research priorities (summary view) 67 Annex 7. References 68
Contents 4
Inserts
Insert 1. Main actors and factors determining the health status of a population 12
Insert 2. Analysing the burden of a health problem to identify research needs 17
Insert 3. Comparison of various priority-setting approaches 18 Insert 4. Key recommendations made since 1990 for health research
on risk factors 23 Insert 5. Key recommendations made since 1990 on research
priorities for diseases and conditions 25 Insert 6. The Global Forum Combined Approach Matrix for health
research priority setting 28Insert 7. Generic steps to use the CAM to identify key research
projects at national level 36 Insert 8. TDR checklist for strategic analysis of health research needs
(adapted from the CAM) 36
Foreword 5
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% of global health research funds from public and private sources is devoted to 90% of the world’s health problems. Helping to correct this gap has been the main focus of the Global Forum for Health Research since it began operations in 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 of responding to needs that are largely unmet, priority setting is as critical as conducting the 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 back 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 that involves constituencies in order to decide upon research priorities) and the tools used for that purpose (instruments that enable the collection, organization and analysis of the mass of information needed to help set priorities). The present publication presents experiences with one such tool: 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 population. One axis of the matrix focuses on the five-step methodology of the Ad-Hoc Committee on Health Research (linking burden of disease with determinants, cost-effectiveness and 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 Forum and its partners and was compiled primarily by Dr Abdul Ghaffar. It describes the CAM’s background, components and applications to selected diseases, determinants and programmes identified in previous priority-setting exercises. This method aims at helping institutions at the national, regional and global levels to set their priorities in health research. Widespread application of the Combined Approach Matrix can make a major contribution to evidence-based priority setting and thereby ensure that more health 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 tool. Stephen A. Matlin Executive Director Global Forum for Health Research
Acronyms and abbreviations 6
Acronyms and abbreviations ACHR Advisory Committee on Health Research (WHO) AIDS acquired immunodeficiency syndrome ALRI acute lower respiratory infections ARI acute respiratory infections BOD burden of disease CAM Combined Approach Matrix COHRED Council on Health Research for Development COPD chronic obstructive pulmonary disease DALYs disability-adjusted life years DFID Department for International Development (United Kingdom) DTUs diarrhoea treatment and training units ENHR Essential National Health Research GBD global burden of disease HIV human immunodeficiency virus IAP indoor air pollution ICMR Indian Council of Medical Research IUGR intrauterine growth retardation LBW low birth weight NCDs noncommunicable diseases NGOs nongovernmental organizations NICED National Institute of Cholera and Enteric Diseases (India) ORS oral rehydration salts ORT oral rehydration therapy PHC primary health care PMRC Pakistan Medical Research Council R&D research and development SNL Saving Newborn Lives (Pakistan) SWOT analysis analysis of strengths, weaknesses, opportunities and threats TB tuberculosis TDR UNICEF/UNDP/World Bank/WHO Special Programme for
Research and Training in Tropical Diseases VHIP Visual Health Information Profile UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization
Section I
THE CASE FOR PRIORITY SETTING IN HEALTH RESEARCH
Section I. The case for priority setting in health research 8
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 US$ 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.
1. Introduction 9
It is important to differentiate between the process of priority selection and the tools used for that purpose. The process is the mechanism by which constituencies and stakeholders are involved and decide upon research priorities. It is evident that ensuring the participation of communities and users is a necessary part of the process. The tools are the instruments which facilitate (i) the organization of the huge mass of information (regarding burden of disease, available resources, determinants, present knowledge, etc.) that is necessary to establish priorities on a scientific basis and (ii) its presentation in a way that permits analysis and comparison of the various possible fields of research, eventually permitting the identification of the 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 priority-setting 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 provided. Four domains of priority setting are distinguished: research on priority-setting 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. Lastly, selected examples of CAM application are reported. Examples have been chosen from global and national programmes, vulnerable groups, communicable and noncommunicable diseases, and mental and neurological disorders. In addition, an example of applying the CAM to a common risk factor (indoor air pollution) is also 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.
Section I. The case for priority setting in health research 10
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 1 (see page 12) is one such example derived from a number of previous descriptions
2. Health and health research 11
(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 1 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
Inse
rt 1
M
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act
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loba
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and
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dru
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and
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saf
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pro
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and
lifest
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k an
d m
argi
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fuge
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He
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and
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bidi
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soc
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proo
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W
ell-b
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•
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ical (
full p
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nctio
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, fitn
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resis
tanc
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risk
fact
ors)
•
Men
tal (
full i
ntel
lect
ual a
nd e
mot
iona
l fun
ctio
ning
, cop
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with
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and
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from
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lusio
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12
2. Health and health research 13
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 the 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 life-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 the individual and the family. The benefits of good health will be even greater 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 underemployment, better housing, better use of training opportunities, higher productivity 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 health 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. Their 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 the habit. 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
14 Section I. The case for priority setting in health research
effectiveness of interventions and hence optimize the use of health care resources (1,7). 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).
3. Priority setting 15
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).
16 Section I. The case for priority setting in health research
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).
3. Priority setting 17
0%
100%
x y 100%
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
Effective coverage in population
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)
Unavertable with existing interventions
Averted with current mix of interventions and population coverage
Avertable with improved efficiency
Avertable with existing but non-cost-effective interventions
Research and development to identify new interventions
Research and development to reduce the cost of existing interventions
Com
bine
d ef
ficac
y of
inte
rven
tion
mix
Research on health systems and policies
z
18 Section I. The case for priority setting in health research
Insert 3 Comparison of various priority-setting approaches Characteristics
Essential National Health Research
Ad Hoc Committee on Health Research
Advisory Committee on Health Research
Global Forum Combined Approach Matrix
1. Objective of priority setting
• Promote health and development on the basis of equity
• Help decision-makers make rational choices in investment decisions.
Help decision-makers make rational choices in investment decisions so as to have the greatest reduction in the burden of disease for a given investment (as measured by number of DALYs averted).
Address problems of critical significance for global health: population dynamics, urbanization, environment, shortages of food and water, new and re-emerging infectious diseases.
Help decision-makers make rational choices in investment decisions so as to have the greatest reduction in the burden of disease for a given investment (as measured by number of DALYs averted), on the basis of the practical framework for priority setting in health research.
2. Focus at the global or national level?
Focus on situation analysis at the global level; method also applicable at the country level.
Focus on situation analysis at country level; residual problems to be studied at global level.
Priority to “significant” and “global” problems, requiring “imperative” attention.
Method applicable at both global and national levels.
3. Strategies/ principles
• Priorities set by all stakeholders.
• Process for priority setting should be iterative and transparent.
• Approach should be multi-disciplinary.
• Five-step process. • Process should be
transparent.
• Priorities should be set by all stake-holders.
• Process should be transparent and comparative.
• Multidisciplinary approach.
• Priorities should be set by all stakeholders.
• Transparent and iterative process.
• Approach should be multidisciplinary (biomedical sciences, public health, economics, environmental sciences, education sciences, social and behavioural sciences).
4. Criteria for priority setting
4.1 Burden of disease
Based on an esti-mate of severity and prevalence of disease.
Measured by DALYs (number of years of healthy life lost to each disease).
Allocate resources to the problems deemed of “greatest global burden”.
Measured by DALYs (number of years of healthy life lost to each disease) or other appropriate indicators.
4.2 Analysis of determinants of disease burden
Analysis of multi-disciplinary determinants (biomedical, economic, social, behavioural, etc.).
• Analysis of mostly biomedical determinants
• Other determinants implicit.
Analysis of multi-disciplinary determinants (biomedical, economic, social, behavioural, etc.).
Analysis of determinants at following intervention levels: • individual/family/community • health ministry and research
institutions • sectors other than health • government macroeconomic
policies. 4.3 Cost-effectiveness of interventions (resulting from planned research)
Some attempts at measurement in terms of impact on severity and/or prevalence.
Cost-effectiveness measured in terms of DALYs saved for a given cost.
Implicit reference to cost-effectiveness analysis.
Cost-effectiveness measured in terms of DALYs saved for a given cost.
Source: Global Forum for Health Research
3. Priority setting 19
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 (10). 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.
20 Section I. The case for priority setting in health research
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 (11). 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.
3. Priority setting 21
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 field 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
22 Section I. The case for priority setting in health research
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 (1). 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.
3. Priority setting 23
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)
Global Forum (2002)
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
24 Section I. The case for priority setting in health research
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 pre-transitional 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 VHIP, 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.
3. Priority setting 25
Insert 5 Key recommendations made since 1990 on research priorities for diseases and conditions Health research
priorities
Commission Report (1990)
Ad Hoc Committee
(1996)
ACHR (1997)
ENHR Projects (1999)
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/neuro-logical 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
Source: Global Forum for Health Research
Section II
COMBINED APPROACH MATRIX: PRINCIPLES, ELEMENTS AND FUNCTIONS
28 1. Principles
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
Macro-economic 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
2. The main elements of the CAM 29
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, peer-reviewed 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.
30 Section II. Combined Approach Matrix: Principles, elements and functions
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.
2. The main elements of the CAM 31
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.
32 Section II. Combined Approach Matrix: Principles, elements and functions
3. Functions of the CAM Information gathered in a priority-setting exercise conducted at country, regional and global levels could be introduced into the CAM as a common framework to organize and present the collected information (as a basis to identify gaps in health research and health research priorities). In summary, the CAM:
• Brings together in a systematic framework all information (current knowledge) related to a particular disease or risk factor
• Identifies gaps in knowledge and future challenges • Relates the five-step process in priority setting (economic axis) with the
actors and factors (institutional axis) determining the health status of a population
• Permits the identification of “common factors” by looking across the diseases or risk factors
• Is applicable to priority setting in the field of: national, regional or global problems both diseases and risk factors
• Permits the linkage of priorities in the field of health and health research • Enables the rapid identification of the effect of a change in one of the “boxes”
of the matrix on the others • Permits taking into account the large number of factors outside the health
sector that have an important impact on people’s health. However, it is important to realize that the CAM summarizes the evidence base for priority setting in health research, but that it is not in itself an algorithm for priority setting.
Section III
SELECTED EXAMPLES
34 1. Application of the CAM
1. Application of the CAM For the sake of simplicity, this section describes applications of the CAM at national level only. However, similar processes can be followed to determine the health research priorities at the local and global levels. They can be applied by individual institutions, development agencies, and local and national governments to identify their priority areas for engagement in, or support to, health research. The first step is to estimate the burden for each of the main diseases and risk factors in the country and to involve all national institutions and stakeholders with particular knowledge of that disease. Each institution will feed into the matrix the information at its disposal. As a result, the matrix will gradually incorporate the best available information regarding a specific disease or risk factor. In many cases, instead of solid information, the matrix will reveal how little information is available to make rational, cost-efficient and effective decisions in the fight against specific diseases. These gaps in the information matrix are all candidates for research. The second step is to identify which information would have the greatest impact on the disease. This may be a time-consuming and iterative process, as it is probable that various stakeholders will have different opinions as to the most important factor(s) to be studied to reduce the burden of the particular disease. Prioritization between diseases will require a further process which takes into account, among other factors, the research topics likely to have the greatest impact in reducing the burden of disease for the country. Insert 7 (page 35) provides generic steps to use the CAM to identify key research projects at national level. This overall list of national research priorities is then divided among the country’s research institutions based on their respective comparative advantages. This is a long-term effort. The information may be partial in the first exercises, probably even sketchy in some cases, but the tool should demonstrate its usefulness at an early stage by highlighting the most important gaps in the information needed to make evidence-based decisions and by enabling some decisions to be made despite the limited information available.
Section III. Selected examples 35
2. Selected examples The CAM’s feasibility and usefulness have been tested in the field. During these tests, the CAM was applied to a range of settings, including global programmes and national plans, communicable and noncommunicable diseases, risk factors and vulnerable groups. Selected examples are given below. Application of the CAM at the global level TDR The Special Programme on Research and Training in Tropical Diseases (TDR) is an international research programme co-sponsored by the United Nations Children’s Fund (UNICEF), the United Nations Development Programme, the World Bank and the World Health Organization.∗ A priority-setting exercise was undertaken in 2002–2003 to realign TDR’s strategic focus in research to address the disease control priorities of the next five years (13). A summary of this exercise is presented below. The first step in the TDR prioritization process was to bring together the TDR Disease Research Coordinators, TDR staff, WHO disease control experts, country programme managers and disease experts (Disease Reference Group and Scientific Working Groups) to analyse rationally and transparently the current situation of each disease. This included taking into account the current status of research and the comparative advantages of TDR. The result was the definition of a set of “strategic TDR emphases” (or priorities) in the scientific and technical areas of work for the next few years. The exercise was based on the following documents:
• The analyses carried out by TDR, WHO and the World Bank between 1993 and 1996 which culminated in the 1996 Ad Hoc Committee Report (3)
• The Global Forum’s proposed CAM for setting priorities in health research. A modification of the CAM (see Insert 8 below) led to the definition of the following seven steps used in the TDR prioritization process:
• What is the size and nature of the disease burden and epidemiological trends? • What is the current disease control strategy? • What are the major problems/challenges for disease control? • What research is needed to address these problems/challenges? • What is currently being done in R&D, and what research opportunities exist? • What are TDR’s comparative advantages? • Strategic emphases for R&D.
∗ TDR deals with the following diseases: African trypanosomiasis, Chagas disease, dengue fever, leishmaniasis, leprosy, lymphatic filariasis, malaria, onchocerciasis, schistosomiasis, tuberculosis and (as of 2004) HIV/AIDS.
36 Section III. Selected examples
Insert 7 Generic steps to use the CAM to identify key research projects at national level
• Estimate the burden for each of the main diseases and risk factors. • For each main disease and risk factor, bring together all institutions and
stakeholders in the country with a particular knowledge of that disease or risk factor.
• For each of the selected diseases and risk factors, feed into the matrix the information at the disposal of each institution, thus gradually incorporating into the table the best available information regarding the disease/risk factor.
• Complete the matrix with information from other sources that may be relevant for the country concerned.
• Identify which missing information would, if made available, be likely to contribute the most to decreasing the burden of that disease or risk factor.
• Identify the research projects that can fill these gaps in information based on the underlying values and comparative advantages of the institution. This would be the list of research priorities for that disease or risk factor.
• Compare research priorities thus identified across diseases and risk factors and come up with a final list of top priorities in the various research fields.
Source: Global Forum for Health Research Insert 8 TDR checklist for strategic analysis of health research needs (adapted from the CAM) 1. What is the size and nature of the disease burden?
• What are the epidemiological trends? • What are the current or likely future factors that impact on burden at the
following levels, and in what way: individual, community and household health sector (health ministry, systems and service delivery) non-health sectors government and international?
2. What is the control strategy?
• Is there an effective package of control methods assembled into a “control strategy” for most epidemiological settings?
• What are its current components (stratify by geographical areas if necessary)?
• If such a control strategy exists, how effective is it (based on observation), or could it be (based on epidemiological modelling) at: reducing morbidity preventing mortality reducing transmission reducing burden?
• What is known of the cost-effectiveness, affordability, feasibility and sustainability of the control strategy?
2. Selected examples 37
3. Why does the disease burden persist?
What are the constraints to better control at the following levels: • individual, community and household (e.g. male dominance, poverty, access
to services) • health sector (e.g. political commitment to control, inadequate human
resources, poor management and organization of service delivery, poor financing or drug supply systems, lack of knowledge of how to control the disease, lack of effective tools, or lack of resources to implement effective tools and strategies)
• non-health sectors (e.g. negative or positive impact on disease of social and agricultural policies, etc.)
• government and international (e.g. impact of structural adjustment programmes, poverty alleviation strategies, macroeconomic policies)?
4. What is needed to address these constraints effectively?
(include both control and research aspects) • Which of these constraints could be addressed by research? • Which of the research-addressable constraints, if addressed, could:
improve the control/service delivery system ultimately, lead to a reduction in disease burden be addressed by affordable research be completed within five years?
• What are the potential pitfalls or risks of such research? 5. What can be learnt from past/current research?
• From current/past research – both TDR-supported and outside TDR • What is known about existing research resource flows?
6. What are the opportunities for research?
• What is the state-of-the-art science (basic and operational) for this disease and what opportunities does it offer?
• What is the current status of institutions and human resources available to address the disease?
7. What are the gaps between current research and potential research issues
which could make a difference, are affordable and could be carried out in (a) five years or (b) in the longer term?
8. For which of these gaps are there opportunities for research?
• Which issues can only be realistically addressed with increased financial support or investment in human and institutional capacity?
• Which issues are best suited to the comparative advantage of TDR?
Source: Global Forum for Health Research
38 Section III. Selected examples
The TDR prioritization strategy (13) led to the following results: • A transparent and objective prioritization process • The active participation of partners from both health research and disease
control • A direct link between strategic emphases and the research needs of disease
control • An efficient mechanism to communicate its strategic choices to its partners • A continuous monitoring system for incorporating new priority needs.
For the purposes of setting the future research agenda, the results of this exercise categorized the diseases with which TDR is working into the following three groups: Group 1: Emerging and uncontrolled diseases Diseases in this group include African trypanosomiasis, dengue fever and leishmaniasis. The epidemiological pattern of these diseases indicates that they are increasing in prevalence and the tools are not well developed or applicable to large segments of the population. Research is required to improve the tools and the strategies to implement mass programmes. Group 2: Control strategy available but disease burden persists Diseases in this group include malaria, schistosomiasis and tuberculosis (TB). Effective interventions are available which can be applied on a wide scale with the potential to reduce the disease burden but this has not as yet taken place. Group 3: Control strategy effective and elimination is planned Diseases in this group include Chagas disease, leprosy, lymphatic filariasis and onchocerciasis. There are tools and strategies available to control these diseases and probably to eliminate them in the medium term. Operational research to achieve these objectives is required as the prevalence of the diseases is declining and elimination targets are evident. Application of the CAM at the national level Diarrhoeal diseases research in India The Indian Council of Medical Research (ICMR) is an autonomous health research organization within the national Ministry of Health and Family Welfare. It provides stewardship and support for conducting research in finding feasible solutions to India’s health problems. In 2000, a team from the Global Forum for Health Research presented the CAM’s concept and principles to a selected group of ICMR scientists in New Delhi. During 2002–2003, the National Institute of Cholera and Enteric Diseases (NICED) applied the CAM for setting research priorities for diarrhoeal diseases in India. An expert group of scientists drawn from various disciplines was established to complete the task. In order to complete the cells of the CAM matrix, the expert group was charged with summarizing current knowledge. A SWOT (strengths, weaknesses, opportunities and threats) analysis carried out by NICED helped to highlight the Institute’s major
2. Selected examples 39
contributions and achievements, and the areas in which it has greater chances of achieving success. The expert group held consultations with programme managers at both national and state levels, other research institutes and nongovernmental organizations (NGOs) working to control diarrhoeal diseases. Although the group of experts systematically reviewed the available data from different sources (research studies, surveys, and government and donor reports), the data used for this exercise were, for reasons of consistency, those reported by the National Diarrhoeal Diseases Control Programme. The main reason for the persistence of the burden of disease appeared to be that a majority of health care providers were not consistently applying the standard guidelines for management of diarrhoeal diseases, especially those working as private practitioners. Misconceptions about infant and child feeding were widely prevalent and, in many cases, the physician was the person providing inappropriate suggestions. Although the role of antimicrobials is very limited during attacks of diarrhoea, the review revealed that their use had become routine practice. The CAM application highlighted the need for better understanding of socio-cultural norms and training of health care providers. Individual and community-level information was inadequate but exposure to electronic media had a significant impact on mothers’ awareness about oral rehydration treatment and its use. The cost-effectiveness of present and future interventions had not been widely studied in India and so any linkage with sectors other than health was not easy to demonstrate. Except for the budget of the National Diarrhoeal Diseases Control Programme, no other channel of flow of funds could be studied. India’s public finance accounting framework does not allow for disaggregating between health service spending, personnel costs and money spent for different research initiatives and activities, nor were such data available from donor reports. For detailed results, see Annex 1 (page 51). Pakistan’s National Action Plan for noncommunicable disease prevention, control and health promotion The National Action Plan for noncommunicable disease prevention, control and health promotion in Pakistan is a collaborative initiative of the Ministry of Health, WHO’s Pakistan office and Heartfile∗ (14). The public-private partnership was mandated to develop an evidence-based, long-term strategic plan of action for achieving national goals for the prevention and control of noncommunicable diseases (NCDs). The Action Plan, which consists of policy and implementation dimensions, was developed after a situational review was carried out and consultative deliberations were held with a range of stakeholders and NCD experts. A priority-setting workshop for the experts was also held in Islamabad, in which the CAM was introduced as a research priority-setting tool.
∗ Heartfile is a leading NGO in Pakistan, which has developed the National Action Plan for noncommunicable disease prevention, control and health promotion in Pakistan in collaboration with the Ministry of Health and WHO.
40 Section III. Selected examples
The situational analysis was conducted by:
• Systematically reviewing the available data on current epidemiological evidence
• Summarizing existing strategies and policy measures • Identifying gaps in the system and the opportunities that exist for integration
in existing programmes • Analysing the potential for programme implementation.
The Action Plan delivers an integrated approach to NCD prevention and control for Pakistan. In this approach, the CAM is used as a first step to priority setting through the organization of information relating to a concerted public health response across a range of NCDs. The traditional definition of NCDs refers to major chronic diseases, such as cardiovascular disease, diabetes, cancer and chronic respiratory diseases and their risk factors. In Pakistan’s Action Plan, however, NCDs are taken to include mental health and injuries, as it was necessary also to address them within a combined strategic framework through synchronized public health measures. The CAM was found to be a useful tool for organizing the information needed for making an informed decision, and especially in explaining why NCDs remain a big problem in Pakistan. It thus provided an indication of the priority areas on which future efforts and work should be focused. The CAM uses cost-effectiveness as a yardstick for setting priorities and highlights the need for the generation of such data where they are as yet not available at the local level. However in the interim, public health interventions can be based on the present level of knowledge related to the cost-effectiveness of interventions from best practice examples in the developed world. For detailed results, see Annex 2 (page 56). Application of the CAM to a disease The example of schizophrenia In spite of the high visibility that mental and neurological health issues have enjoyed internationally since the publication in 1996 of the first burden of disease study (15), there is still a treatment and intervention gap in most developing countries. Because of the neglect and stigmatization of mental and neurological disorders, and the disregard of health behaviour in reducing health risks and promoting behaviour conducive to health, there is little infrastructure in the developing world for research in the fields of mental and neurological health. It is, therefore, imperative to use optimally scarce research resources in low-income countries and hence engage in evidence-based methods for research priority setting. The Global Forum commissioned a CAM study to set the research priorities in the area of mental health. Two diseases – epilepsy and schizophrenia – were chosen, as examples of neurological and psychiatric disorders respectively.
2. Selected examples 41
A senior epidemiologist who was familiar with the application of the CAM methodology carried out desk reviews. The reviews were based on peer-reviewed publications, mostly prepared by WHO, and other similarly authoritative international monographs and reports. The analysis of the matrices revealed that further research is needed on:
• The concept of burden beyond the individual affected by a neuro-psychiatric disease. Typically, the burden to the family or the caregiver of a patient with a mental or neurological disorder is long-lasting and significant. This is insufficiently reflected in the DALY methodology.
• Cost-effectiveness issues. The effectiveness of many interventions is largely unknown, and good measurements of cost-effectiveness are even less frequent. Cost-effectiveness research needs to consider the issues of burden described above.
• Bridging the treatment gap. In developing countries, many people suffering from mental and neurological disorders do not benefit from the available medicines and treatment methods. Reasons include traditional and cultural concepts such as superstitions and misbelief surrounding the disease and its interpretation, leading to high non-consultation rate in health centres, and hence to a low rate of use of effective drugs; deficiencies in the health system structure; lack of personal and diagnostic facilities; and non-accessibility/availability of efficient means of treatment.
• Overcoming stigmatization and social isolation. This pertains to both afflicted patients and their family and community. It could be reduced by effective health education messages targeting communities, families, individuals and health care providers.
For more detailed results of the study on schizophrenia, see Annex 3 (page 58). Application of the CAM to a risk factor The example of indoor air pollution Indoor air pollution (IAP), which derives mainly from the use of simple biomass fuels (wood, dung and crop wastes) by poor people, is a major public health problem. In low- and middle-income countries, IAP accounts for about 53 million DALYs (or approximately 4% of the total DALYs for these countries) (2), although there are marked variations when comparing countries. It is an important risk factor requiring priority research. Around three billion people and up to 80% of homes in low- and middle-income countries are still dependent on biofuels for household energy needs. Often used indoors on simple stoves with inadequate ventilation, the practice leads to high levels of indoor exposure, especially for women and young children. Current trends in fuel use and the linkage to poverty indicate that this problem will persist unless more effective action is urgently undertaken. Health and development issues associated with the use of household energy and IAP in low- and middle-income countries include gender issues, poverty, the environment and quality of life. With development, there is generally a transition up the so-called “energy ladder” to fuels that are progressively more efficient, cleaner and convenient, but more expensive.
42 Section III. Selected examples
Households typically use a combination of fuels, for example wood for cooking and heating, some kerosene for lighting and perhaps charcoal for making hot drinks. While the effects of IAP manifest themselves on health outcomes, the interventions to deal with it are rooted in sectors other than health. This observation led to the application of the CAM to identify gaps in research. Desk reviews were carried out by a senior epidemiologist in order systematically to analyse the available literature. The studies, based on peer-reviewed publications, were synthesized and the results presented to and discussed by a group of experts. The results of the exercise showed that applying the CAM in the field of indoor air pollution identified a need for a broad range of multidisciplinary research. This in turn requires coordination and the development of better intersectoral collaboration in research, policy development and implementation; and well developed mechanisms to ensure the dissemination and application of new research knowledge. The following research priorities were identified: Research to strengthen evidence on population exposure, health effects and potential for risk reduction
• Develop community assessment methods for assessing risk (fuel use, pollution, exposure, household energy systems, etc.) and options for change.
• Develop and test instruments to provide practical and well standardized measures of exposure and health- and development-related outcomes.
• Evaluate direct effects arising from the use of household energy, but not resulting from IAP, including burns, scalds, kerosene poisoning, fires, etc.
• Evaluate less direct health consequences including opportunity costs of women’s time.
• Research to help understand and estimate secondary impacts of interventions on cooking time, fuel gathering and crop production.
• Obtain new evidence on IAP health risks to demonstrate the effect of a measured reduction in exposure on the most important health outcomes.
• Exposure–response relationship of indoor air pollution for key outcomes such as acute lower respiratory infections (ALRI) in young children.
Research on interventions
• Distil and disseminate experience of interventions from existing household energy implementation efforts.
• Conduct an economic assessment of specific interventions. • Evaluate the impact of new interventions and policy developments on health
benefits. • Identify effective models of collaboration (case studies) in the field of
household energy, particularly focusing on communities and households. Research on the development and implementation of policy
• Conduct economic studies on implemented policies. • Assess the potential for a household energy policy to address inequalities in
health. • Develop and test standard indicators for routine application in countries. • Assess national consequences of policy options relating to the supply and
uptake of cleaner household energy for the poor.
2. Selected examples 43
• Research to understand household benefits of risk reduction using cost-of-illness and willingness-to-pay valuations.
For more detailed results of the CAM application, see Annex 4 (page 61). Application of the CAM to a vulnerable group The example of perinatal and neonatal care in Pakistan The burden of perinatal and newborn mortality in Pakistan is high, and it has been the subject of regular research. Much of the information, however, is not available from representative settings (16). A comprehensive literature and programmatic review of perinatal and newborn health in Pakistan was conducted by the CAM research team. The available evidence indicated that perinatal mortality rates in Pakistan ranged from 50 to 90 per thousand births. Almost two-thirds of all neonatal deaths take place within the first week of life and overall almost 25% of all neonatal deaths are related to birth asphyxia. The burden of serious newborn infections is substantial with almost 62% of all neonatal deaths resulting from tetanus, sepsis, diarrhoea and pneumonia. While national estimates for low birth weight (LBW) are not available, community-based studies indicate that the rates may be as high as 40% in some rural populations with the overall prevalence rates ranging from 25% to 33%. There is little information on the underlying socio-behavioural determinants of perinatal and newborn mortality, and available information indicates that there are systematic barriers to care-seeking and strong evidence of gender inequity for newborn care. Annex 5 (page 64) indicates the matrix for this priority-setting exercise with an explanation of the information required for each component. Annex 6 (page 65) lists the summary areas of evidence gaps and further work in Pakistan derived from the information available in Annex 5. Consultation process In order to understand the burden, determinants and social dimensions of newborn health and research priorities, a systematic process was followed. This consisted of an in-depth literature review of local and regional data, consultations with experts and researchers in the field and a number of meetings/workshops. Notable among these consultations and expert meetings were:
• A workshop on community-based strategies for perinatal and newborn care (Karachi, February 2002)
• A national consultation on priorities for maternal and child health in Pakistan (Islamabad, January 2003)
• A consultation on priorities for child health research, held at the Pakistan Medical Research Council (PMRC) Child Health Center (Karachi, August 2003)
• A discussion on maternal and newborn care strategy at the National Committee for Maternal Health (Karachi, October 2003)
• A symposium on newborn care in Pakistan (Islamabad, November 2003) • National consultation on nutrition status and strategy in Pakistan (Karachi,
December 2003)
44 Section III. Selected examples
• 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
2. Selected examples 45
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. The 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.
Section IV
CHALLENGES AND OPPORTUNITIES
48 Section IV. 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:
1. The lessons 49
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.
50 Section IV. Challenges and opportunities
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.
3. Conclusions 51
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.
Section V
ANNEXES
53
An
nex
1
Dia
rrh
oea
l dis
ease
s re
sear
ch in
Ind
ia:
app
licat
ion
of
the
CA
M
T
he
ind
ivid
ual
, ho
use
ho
ld a
nd
co
mm
un
ity
Hea
lth
min
istr
y an
d
oth
er h
ealt
h in
stit
uti
on
s
Sec
tors
oth
er t
han
h
ealt
h
Mac
roec
on
om
ic p
olic
ies
1. D
isea
se b
urd
en
Glo
bally
, dia
rrhoe
al d
iseas
e wa
s re
spon
sible
for 4
.3%
of t
otal
loss
of D
ALYs
, and
>2
milli
on d
eath
s (3
.5%
of a
ll dea
ths)
in 2
001.
In
Indi
a, d
iarrh
oeal
dise
ase
is a
maj
or p
ublic
hea
lth p
robl
em a
mon
g ch
ildre
n un
der 5
yea
rs o
f age
. In
heal
th in
stitu
tions
, up
to a
third
of t
otal
pae
diat
ric a
dmiss
ions
are
du
e to
dia
rrhoe
al d
iseas
es a
nd u
p to
17%
of a
ll dea
ths
in p
aedi
atric
inpa
tient
s ar
e re
late
d to
dia
rrhoe
a.
The
mea
n in
ciden
ce o
f dia
rrhoe
a in
Indi
a wa
s 1.
5 ep
isode
s pe
r chi
ld p
er y
ear i
n ur
ban
area
s an
d 4.
7 in
rura
l are
as; t
his
figur
e wa
s 10
.5 in
the
slum
are
as a
roun
d th
e m
ajor
town
s in
Indi
a.
In In
dia,
20%
of d
eath
s am
ong
child
ren
unde
r 5 y
ears
of a
ge w
ere
estim
ated
to b
e du
e to
dia
rrhoe
al d
iseas
es. G
loba
lly, s
imila
r est
imat
es (2
1%) w
ere
also
repo
rted
for c
hild
ren
unde
r 5.
In th
e An
dhra
Pra
desh
dise
ase
burd
en s
tudy
in In
dia,
dia
rrhoe
al d
iseas
es w
ere
the
sixth
lead
ing
caus
e of
lost
DAL
Ys in
rura
l are
as a
nd th
e te
nth
lead
ing
caus
e in
ur
ban
area
s (b
ased
on
com
mun
ity-ra
ted
disa
bility
wei
ghts
; ran
ks w
ere
high
er u
sing
expe
rt-ra
ted
disa
bility
wei
ghts
).
In In
dia,
cas
e-fa
tality
from
dia
rrhoe
al d
iseas
es a
mon
g ch
ildre
n un
der 6
yea
rs o
f age
was
est
imat
ed to
be
0.56
% fo
r acu
te w
ater
y di
arrh
oea,
4.2
7% fo
r dys
ente
ry a
nd
11.9
4% fo
r non
-dys
ente
ric p
ersis
tent
dia
rrhoe
a. G
loba
lly, t
he o
vera
ll est
imat
e of
cas
e-fa
tality
from
dia
rrhoe
a am
ong
unde
r-5 c
hild
ren
was
estim
ated
to b
e 0.
15%
(1
.8%
am
ong
child
ren
less
than
1 y
ear o
f age
). 2.
Det
erm
inan
ts
1. Ig
nora
nce
abou
t nat
ure
of d
iarr
hoea
l dis
ease
and
its
mod
es o
f tra
nsm
issi
on
1.1
Inad
equa
te m
aint
enan
ce o
f per
sona
l hyg
iene
1.
2 In
appr
opria
te c
are-
seek
ing
beha
viour
and
pra
ctice
s 1.
3 In
suffi
cient
kno
wled
ge a
bout
wat
er tr
eatm
ent,
stor
age
and
hand
ling
at th
e ho
useh
old/
com
mun
ity
leve
l 1.
4 La
ck o
f kno
wled
ge a
bout
pro
per i
nfan
t and
chi
ld
feed
ing
prac
tices
, inc
ludi
ng b
reas
tfeed
ing
and
wean
ing
1.5
Inad
equa
cy o
f pro
per s
anita
tion
and
wast
e (in
cludi
ng e
xcre
ta) d
ispos
al s
yste
ms
and
insu
fficie
nt
know
ledg
e ab
out t
heir
impo
rtanc
e 2.
Env
ironm
enta
l cha
nges
lead
ing
to h
ighe
r tra
nsm
issi
on p
oten
tial o
f dia
rrho
eage
nic
path
ogen
s 2.
1 Co
nges
ted
and
unpl
anne
d ho
usin
g wi
thou
t ad
equa
te s
yste
m fo
r saf
e wa
ter s
uppl
y an
d sa
nita
tion
2.2
Appe
aran
ce o
f new
er p
atho
gens
/stra
ins
with
po
tent
ial t
o ca
use
life-th
reat
enin
g di
arrh
oea
2.3
Incr
easin
g pr
oble
m o
f dru
g re
sista
nce
for s
ever
al
diar
rhoe
agen
ic pa
thog
ens
1. P
robl
ems
asso
ciat
ed w
ith
qual
ity o
f hea
lth s
ervi
ces
1.1
Inap
prop
riate
adv
ice
rega
rdin
g in
fant
and
chi
ld
feed
ing
prac
tices
1.
2 Irr
atio
nal u
se o
f dru
gs fo
r tre
atm
ent o
f dia
rrhoe
a 1.
3 La
ck o
f adh
eren
ce to
con
trol
prog
ram
me’s
gui
delin
es w
hile
m
anag
ing
the
case
s 2.
Lac
k of
wel
l-est
ablis
hed
surv
eilla
nce
syst
em in
mos
t ar
eas
2.1
Surv
eilla
nce
to d
etec
t occ
ur-
renc
e of
dia
rrhoe
a ca
ses
inclu
ding
out
brea
ks, d
eter
-m
inin
g m
ajor
pat
hoge
ns in
the
area
, cha
nges
in d
rug
sus-
cept
ibilit
y fo
r maj
or o
rgan
isms,
de
tect
ing
newe
r pat
hoge
ns e
tc.
2.2
Surv
eilla
nce
in h
ealth
car
e in
stitu
tions
to p
reve
nt a
nd
1. In
appr
opria
te h
ousi
ng
2. In
suffi
cien
t edu
catio
n 3.
Inad
equa
te s
afe
wat
er
supp
ly a
nd s
anita
tion
syst
ems
4. S
ocia
l unr
est a
t som
e pl
aces
5.
Pop
ulat
ion
mov
emen
ts
with
in a
nd a
cros
s bo
rder
s
1. In
suffi
cien
t lin
kage
acr
oss
sect
ors
1.1
Lack
of p
rope
r lin
kage
bet
ween
he
alth
and
oth
er d
evel
opm
ent
sect
ors
2. G
over
nmen
t exp
endi
ture
on
heal
th a
nd a
llied
pro
gram
mes
2.
1 G
over
nmen
t spe
ndin
g in
hea
lth
prog
ram
mes
has
not
incr
ease
d ov
er la
st s
ever
al y
ears
3.
Lac
k of
sus
tain
ed p
oliti
cal
com
mitm
ent
4. P
ersi
sten
ce o
f hug
e ru
ral/u
rban
dis
parit
ies
in
soci
oeco
nom
ic c
ondi
tions
and
he
alth
car
e se
rvic
es
Ann
ex 1
: Dia
rrho
eal d
isea
ses
rese
arch
in In
dia:
app
licat
ion
of th
e C
AM
Th
e in
div
idu
al, h
ou
seh
old
an
d
com
mu
nit
y H
ealt
h m
inis
try
and
o
ther
hea
lth
inst
itu
tio
ns
S
ecto
rs o
ther
th
an
hea
lth
M
acro
eco
no
mic
po
licie
s
3.
Soc
ioec
onom
ic in
fluen
ces
3.
1 Po
verty
3.
2 Lo
w lite
racy
3.
3 Ad
vers
e cu
ltura
l bel
iefs
and
tabo
os
3.4
Socio
econ
omic
disr
uptio
n du
e to
nat
ural
disa
ster
s (e
.g. f
lood
, fam
ine,
etc
.) 4.
Pub
lic d
istru
st o
ver q
ualit
y of
exi
stin
g go
vern
men
t hea
lth s
ervi
ces
dete
ct o
ccur
renc
es o
f no
soco
mia
l dia
rrhoe
a 3.
Lac
k of
infra
stru
ctur
e to
is
olat
e an
d ch
arac
teriz
e m
any
rele
vant
org
anis
ms
4. L
ack
of a
ppro
pria
te h
ealth
in
form
atio
n sy
stem
4.
1 La
ck o
f col
lect
ion
of d
ata
on
mor
bidi
ty a
nd m
orta
lity
(esp
ecia
lly p
atho
gen-
wise
br
eak-
up) i
n a
syst
emat
ic wa
y 4.
2 La
ck o
f diss
emin
atio
n of
in
form
atio
n to
all d
esire
d le
vels
4.3
Lack
of t
imel
ines
s in
gat
her-
ing
and
diss
emin
atin
g da
ta
3. P
rese
nt
leve
l of
kno
wle
dg
e 3.
1 In
terv
entio
ns c
urre
ntly
av
aila
ble
1. P
reve
ntio
n of
infe
ctio
n 1.
1 M
aint
enan
ce o
f per
sona
l hyg
iene
1.
2 Pr
oper
wat
er tr
eatm
ent,
stor
age
and
hand
ling
at
hous
ehol
d an
d co
mm
unity
leve
ls 1.
3 M
aint
enan
ce o
f foo
d hy
gien
e 1.
4 Sp
ecia
l atte
ntio
n to
chi
ldca
re p
ract
ices
1.4.
1 Ch
ild fe
edin
g pr
actic
es, s
pecia
lly b
reas
tfeed
ing
and
wean
ing
prac
tices
1.
4.2
Regu
lar d
ewor
min
g of
chi
ldre
n 1.
4.3
Child
imm
uniza
tion
1.4.
4 Su
pple
men
tatio
n of
micr
onut
rient
s (e
.g. z
inc)
1.
5 Sa
fe w
aste
(inc
ludi
ng e
xcre
ta) d
ispos
al s
yste
m a
t ho
useh
old
and
com
mun
ity le
vels
1.6
Antim
icrob
ial p
roph
ylaxis
2.
Pre
vent
ion
of d
isea
se p
rogr
essi
on a
mon
g th
e in
fect
ed
2.1
Use
of o
ral r
ehyd
ratio
n th
erap
y (O
RT)
2.2
Cont
inue
d fe
edin
g, in
cludi
ng b
reas
tfeed
ing
for
brea
stfe
d ch
ildre
n 2.
3 An
tibio
tics,
if a
ppro
pria
te
2.4
Tim
ely
seek
ing
of h
ealth
car
e 2.
5 Co
mpl
ianc
e wi
th p
resc
ribed
dru
gs
1. N
atio
nal D
iarr
hoea
l Dis
ease
s Co
ntro
l Pro
gram
me
1.1
Prom
otio
n of
ORT
1.
2 In
tegr
atio
n of
the
prog
ram
me
with
PHC
up
to th
e lo
west
go
vern
men
t hea
lth c
are
leve
l 1.
3 He
alth
edu
catio
n of
the
peop
le, i
nclu
ding
free
dis-
tribu
tion
of h
ealth
edu
catio
n bo
okle
ts in
regi
onal
lang
uage
s 1.
4 Tr
aini
ng o
f phy
sicia
ns o
n ra
tiona
l man
agem
ent o
f di
arrh
oea
1.5
Esta
blish
men
t of d
iarrh
oea
treat
men
t and
trai
ning
uni
ts
(DTU
s) a
t med
ical c
olle
ges
and
dist
rict h
ospi
tals
2. E
stab
lishm
ent o
f ref
eren
ce
and
adva
nced
cen
tres
for
rese
arch
on
diar
rhoe
al
dise
ases
1. A
ppro
pria
te h
ousi
ng
2. E
nviro
nmen
tal m
anag
emen
t 2.
1 Ad
equa
te a
nd s
afe
wate
r su
pply
and
sani
tatio
n 2.
2 Ap
prop
riate
pla
nnin
g fo
r de
velo
pmen
t pro
ject
s 2.
3 En
viron
men
tal im
pact
as
sess
men
t for
pro
pose
d de
velo
pmen
t pro
ject
s (e
.g.
wate
r pol
lutio
n)
3. N
atio
nal W
ater
Sup
ply
and
Sani
tatio
n Pr
ogra
mm
e 4.
Lite
racy
mis
sion
and
he
alth
edu
catio
n pr
ogra
mm
es, i
nclu
ding
ap
plic
atio
n of
mas
s m
edia
5.
Epi
dem
ic p
repa
redn
ess
and
disa
ster
man
agem
ent
prog
ram
mes
6.
Pro
gram
mes
to a
llevi
ate
pove
rty (e
.g. P
MRY
, JRY
, fin
anci
al a
ssis
tanc
e fro
m
bank
s)
1. P
laci
ng d
iarr
hoea
l dis
ease
s am
ong
top
prio
rity
heal
th
conc
erns
2.
Pro
mot
ing
awar
enes
s of
the
prob
lem
and
act
ion
3. A
rran
ging
app
ropr
iate
fund
ing
(inte
rnal
and
ext
erna
l) fo
r re
sear
ch a
nd m
anag
emen
t 4.
Sub
sidi
ze to
ols
for
man
agem
ent (
e.g.
ORS
, ha
loge
n ta
blet
s et
c.)
5. In
volv
ing
othe
r gov
ernm
ent
and
non-
gove
rnm
ent a
genc
ies
6. D
ecen
traliz
atio
n pr
oces
s to
ad
dres
s ru
ral/u
rban
dis
parit
ies
7. L
egal
am
endm
ents
to d
eal
with
gro
win
g po
llutio
n an
d in
appr
opria
te u
se o
f dru
gs
55
3.
Hea
lth e
duca
tion
abou
t rel
evan
t asp
ects
for
prev
entin
g di
arrh
oea/
deh
ydra
tion
3. E
arly
dia
gnos
is a
nd tr
eat-
men
t of a
ffect
ed in
divi
dual
s 3.
1 Re
com
men
ded
man
agem
ent
guid
elin
es
3.2
Prov
ision
of c
ase
man
-ag
emen
t at a
ll lev
els
of g
ov-
ernm
ent h
ealth
car
e 3.
3 In
volve
men
t of p
rivat
e m
ed-
ical p
ract
itione
rs
3.4
Isol
atio
n an
d dr
ug s
us-
cept
ibilit
y te
stin
g of
di
arrh
oeag
enic
path
ogen
s 4.
Hea
lth e
duca
tion
5. E
arly
det
ectio
n, c
onta
inm
ent
or p
reve
ntio
n of
out
brea
ks/
epid
emic
s
7. R
ural
hou
sing
sch
emes
(In
dira
Vik
as Y
ojan
a)
3.2
How
cos
t-ef
fect
ive
are
curr
ent i
nter
vent
ions
? (r
efer
to n
umbe
rs u
nder
3.
1)
1.1
Cost
-effe
ctive
to re
duce
occ
urre
nce
of d
iarrh
oea
1.2
Cost
-effe
ctive
1.
3 Co
st-e
ffect
ivene
ss n
ot e
stab
lishe
d 1.
4.1
Cost
-effe
ctive
1.
4.2
Cost
-effe
ctive
ness
stu
dies
are
nee
ded
for r
outin
e an
thel
min
thic
treat
men
t of p
resc
hool
chi
ldre
n 1.
4.3
Ove
rall,
rout
ine
imm
uniza
tion
of c
hild
ren
is on
e of
th
e m
ost c
ost-e
ffect
ive a
ppro
ache
s to
pre
vent
illn
esse
s; c
ost-e
ffect
ivene
ss s
pecif
ically
for p
reve
ntio
n of
dia
rrhoe
al d
iseas
es n
ot e
stab
lishe
d 1.
4.4
Cost
-effe
ctive
ness
of d
iffer
ent s
trate
gies
for
deliv
erin
g zin
c su
pple
men
t nee
ds to
be
asse
ssed
1.
5 Co
st-e
ffect
ive
1.6
Not c
ost-e
ffect
ive, e
xcep
t in
som
e sp
ecia
l cir
cum
stan
ces
2.1
One
of t
he m
ost c
ost-e
ffect
ive h
ealth
car
e in
terv
entio
ns e
ver
2.2
Cost
-effe
ctive
to re
duce
mor
bidi
ty a
nd m
orta
lity fr
om
child
hood
dia
rrhoe
a 2.
3 Co
st-e
ffect
ive o
nly
in s
elec
t cas
es
3. C
ost-e
ffect
ive
1.1
One
of t
he m
ost c
ost-
effe
ctive
hea
lth c
are
inte
rven
tions
eve
r 1.
2–1.
4 Co
st-e
ffect
ive
appr
oach
es
1.5
Esta
blish
men
t of D
TUs
are
a co
st-e
ffect
ive s
trate
gy fo
r pr
omot
ion
of a
ppro
pria
te c
ase
man
agem
ent o
f dia
rrhoe
al
dise
ases
, thu
s re
ducin
g bu
rden
of
dia
rrhoe
al d
iseas
e 3.
1–3.
3 Co
st-e
ffect
ive
3.4
Rout
ine
cultu
re o
f sto
ol o
r ro
utin
e ap
plica
tion
of o
ther
de
tect
ion
tech
niqu
es fo
r co
mm
unity
-acq
uire
d di
arrh
oea
may
not
be
cost
-effe
ctive
4.
Cos
t-effe
ctive
5.
Cos
t-effe
ctive
ness
of r
outin
e su
rvei
llanc
e sy
stem
is n
ot
know
n
1. C
ost-e
ffect
ivene
ss n
ot
know
n 2.
1 So
me
wate
r sup
ply
and
sani
tatio
n in
terv
entio
n pr
ogra
mm
es a
re v
ery
cost
-ef
fect
ive in
con
trollin
g ch
ildho
od d
iarrh
oea;
may
be
as c
ost-e
ffect
ive a
s O
RT
2.2
- 2.4
Cos
t-effe
ctive
ness
not
kn
own
3. C
ost-e
ffect
ive s
trate
gy to
co
ntro
l dia
rrhoe
al d
iseas
e bu
rden
4.
Cos
t-effe
ctive
5.
Cos
t-effe
ctive
ness
not
kn
own
Ann
ex 1
: Dia
rrho
eal d
isea
ses
rese
arch
in In
dia:
app
licat
ion
of th
e C
AM
Th
e in
div
idu
al, h
ou
seh
old
an
d
com
mu
nit
y H
ealt
h m
inis
try
and
o
ther
hea
lth
inst
itu
tio
ns
S
ecto
rs o
ther
th
an
hea
lth
M
acro
eco
no
mic
po
licie
s
4. C
ost
an
d
effe
ctiv
enes
s 1.
Com
mun
ity p
artic
ipat
ion
in p
lann
ing
and
eval
uatio
n wo
uld
be a
n ef
fect
ive a
ppro
ach
to c
ontro
l the
dise
ase
2. P
rom
otin
g us
e of
inex
pens
ive y
et e
ffect
ive m
etho
ds
for w
ater
disi
nfec
tion
and
stor
age
at th
e ho
useh
old
1. In
volve
men
t of b
oth
licen
sed
and
unlic
ense
d he
alth
car
e pr
ovid
ers
in tr
aini
ng o
n ra
tiona
l m
anag
emen
t of d
iarrh
oea
1. In
volve
men
t of p
rivat
e se
ctor
s an
d NG
Os,
wom
en's
grou
ps a
nd c
omm
unity
or
gani
zatio
ns in
spr
eadi
ng
1. S
et p
riorit
ies
for d
iarrh
oeal
di
seas
es re
sear
ch a
nd a
llow
suffi
cient
bud
geta
ry a
lloca
tion
to
deal
with
this
cont
inui
ng p
ublic
and
com
mun
ity le
vels
is a
prov
en c
ost-e
ffect
ive
inte
rven
tion
3. R
aisin
g aw
aren
ess
abou
t dia
rrhoe
a an
d its
m
anag
emen
t with
in th
e co
mm
unity
(esp
ecia
lly a
mon
g m
othe
rs) t
hrou
gh in
nova
tive
ways
(e.g
. edu
catin
g pa
rent
s th
roug
h th
eir c
hild
ren
who
are
taug
ht in
an
inte
rest
ing
way
abou
t the
se a
spec
ts in
sch
ool;
educ
atin
g pe
ople
thro
ugh
teac
hers
, etc
.) m
ay p
rove
an
effe
ctive
stra
tegy
2. B
ringi
ng o
ut n
ewer
ORS
fo
rmul
atio
ns th
roug
h re
sear
ch
→ s
ome
newe
r ORS
(e.g
. rice
-ba
sed
ORS
alre
ady
prov
ed it
s ef
ficac
y, th
ough
its
wide
spre
ad
use
is lim
ited
by n
on-
avai
labi
lity o
f a p
acka
ged
prod
uct f
or s
ome
prac
tical
di
fficu
lties;
rese
arch
is u
nder
wa
y to
ove
rcom
e th
ese
diffi
cultie
s)
3. N
ewer
dia
gnos
tic m
etho
ds to
id
entif
y pa
thog
ens
usin
g m
oder
n la
bora
tory
tech
nol-
ogie
s →
but
, too
muc
h ef
fort
on id
entif
ying
path
ogen
s,
espe
cially
for c
ases
of
com
mun
ity-a
cqui
red
diar
rhoe
a,
may
not
be
a co
st-e
ffect
ive
appr
oach
4.
Eva
luat
ion
and
mon
itorin
g of
dr
ug re
sista
nce
patte
rn fo
r m
ajor
pat
hoge
ns a
nd id
en-
tifyin
g su
itabl
e/ne
wer
antim
icrob
ials
to tr
eat t
hem
→
treat
men
t for
dia
rrhoe
a wi
th
antim
icrob
ials
is in
dica
ted
only
in v
ery
sele
ctive
cas
es
5. D
evel
opm
ent o
f vac
cines
ag
ains
t maj
or c
ausa
tive
agen
ts
→ e
fforts
are
on
for m
any
orga
nism
s (e
.g. c
hole
ra,
shig
ella
, rot
aviru
s); t
hey
coul
d be
cos
t-effe
ctive
but
sub
ject
to
som
e co
nditio
ns a
part
from
mes
sage
s ab
out d
iarrh
oea
and
its c
ontro
l; co
st-
effe
ctive
ness
may
be
diffi
cult
to m
easu
re
2. C
aref
ully
plan
ned
com
-m
unica
tions
stra
tegy
in
volvi
ng th
e co
ordi
nate
d us
e of
mas
s m
edia
, mar
ket
rese
arch
and
eva
luat
ion,
re
lying
on
a m
ultip
licity
of
chan
nels
for c
omm
unica
tion
that
is c
ultu
rally
app
ropr
iate
3.
Gre
ater
use
of e
lect
roni
c m
ass
med
ia to
spr
ead
rele
vant
mes
sage
s in
loca
l la
ngua
ges
– ef
fect
ive fo
r the
va
st p
opul
atio
n of
illite
rate
s an
d se
mi-l
itera
tes,
as
even
am
ong
them
mor
e an
d m
ore
peop
le a
re g
aini
ng a
cces
s to
ra
dio,
tele
visio
n et
c.
heal
th p
robl
em
2. S
eek
reso
urce
s fro
m n
atio
nal
and
inte
rnat
iona
l age
ncie
s wh
ich
coul
d be
utili
zed
for t
his
heal
th
prob
lem
from
the
coun
try's
pers
pect
ive
3. A
revis
ed N
atio
nal H
ealth
Pol
icy
addr
essin
g th
e pr
evai
ling
rura
l/ ur
ban
ineq
ualiti
es in
del
ivery
of
heal
th s
ervic
es is
impe
rativ
e 4.
Opt
imal
col
labo
ratio
n ne
eded
am
ong
diffe
rent
rela
ted
natio
nal
prog
ram
mes
(e.g
. Nat
iona
l Wat
er
Supp
ly an
d Sa
nita
tion
Prog
ram
me)
5.
Eva
luat
ion
of e
xistin
g pr
ogra
mm
es
57
safe
ty a
nd e
ffica
cy (e
.g. c
ost)
6. E
stab
lishm
ent o
f a v
alid
and
re
liabl
e he
alth
info
rmat
ion
syst
em, e
spec
ially
for c
ause
-of
-dea
th in
form
atio
n →
a
prec
ondi
tion
to b
e ab
le to
as
sess
effe
ctive
ness
7.
Exp
andi
ng s
urve
illanc
e sy
stem
–
cost
-effe
ctive
ness
nee
ds to
be
mea
sure
d 8.
Use
of t
elem
edici
ne in
spe
cial
circu
mst
ance
s (e
.g. p
ilgrim
age)
→
cos
t-effe
ctive
ness
not
ev
alua
ted
5. R
eso
urc
e fl
ow
s
1. In
divid
ual a
nd c
omm
unity
effo
rts to
pre
vent
and
co
ntro
l dia
rrhoe
al d
iseas
es
2. In
volve
men
t of p
rom
inen
t soc
ial f
igur
es (e
.g.
acto
rs/a
ctre
sses
, soc
ial w
orke
rs) a
nd o
pini
on le
ader
s (e
.g. m
inist
ers,
mem
bers
of p
arlia
men
t, et
c.) i
n ra
ising
aw
aren
ess
3. O
rgan
izatio
n of
cam
ps, m
eetin
gs, d
emon
stra
tions
etc
. 4.
Dist
ribut
ion
of h
alog
en ta
blet
s, b
leac
hing
pow
ders
et
c. b
y co
mm
unity
lead
ers
and
orga
niza
tions
1. F
unds
and
reso
urce
s al
loca
tion
unde
r Nat
iona
l Di
arrh
oeal
Dise
ases
Con
trol
Prog
ram
me
2. R
esou
rces
(fun
ds, e
quip
men
t, in
frast
ruct
ure
build
ing)
for
diar
rhoe
al d
iseas
es re
sear
ch
and
train
ing
from
gov
ernm
ent
and
non-
gove
rnm
ent a
genc
ies,
as
wel
l as
from
inte
rnat
iona
l ag
encie
s
1. G
aini
ng p
ositiv
e im
pact
on
diar
rhoe
al d
iseas
es c
ontro
l th
roug
h re
sour
ces
spen
t on
Natio
nal W
ater
Sup
ply
and
Sani
tatio
n Pr
ogra
mm
e 2.
Sul
abh
Inte
rnat
iona
l, a
priva
te o
rgan
izatio
n, h
as
been
eng
aged
in b
uild
ing
publ
ic to
ilets
for m
ore
than
25
yea
rs in
diff
eren
t par
ts o
f th
e co
untry
3.
Invo
lvem
ent o
f gov
ernm
ent,
mas
s m
edia
and
NG
Os
in
spre
adin
g ap
prop
riate
m
essa
ges
4. Im
prov
ing
child
hea
lth
thro
ugh
diffe
rent
gov
ernm
ent
and
non-
gove
rnm
ent
prog
ram
mes
(e.g
. Int
egra
ted
Child
Dev
elop
men
t Ser
vices
)
1. C
olla
bora
tive
effo
rts a
nd
partn
ersh
ips
with
inte
rnat
iona
l or
gani
zatio
ns s
uch
as W
HO,
UNIC
EF, J
apan
Inte
rnat
iona
l Co
oper
atio
n Ag
ency
to fi
ght
agai
nst t
his
men
ace
2. C
olla
bora
tion
amon
g va
rious
na
tiona
l and
inte
rnat
iona
l ag
encie
s fo
r dev
elop
men
t and
te
stin
g of
vac
cines
aga
inst
ch
oler
a, ro
tavir
us e
tc.
3. O
btai
ning
sup
port
from
in
tern
atio
nal a
genc
ies
(e.g
. W
orld
Ban
k) to
dev
elop
and
ex
pand
hea
lth c
are
infra
stru
ctur
e
Sou
rce:
Indi
an M
edic
al R
esea
rch
Cou
ncil
An
nex
2
Pak
ista
n’s
Nat
ion
al A
ctio
n P
lan
fo
r n
on
com
mu
nic
able
dis
ease
pre
ven
tio
n a
nd
co
ntr
ol:
ap
plic
atio
n o
f th
e C
AM
Th
e in
div
idu
al, h
ou
seh
old
an
d c
om
mu
nit
y
Hea
lth
min
istr
y an
d o
ther
hea
lth
in
stit
uti
on
s S
ecto
rs o
ther
th
an h
ealt
h
Mac
roec
on
om
ic
po
licie
s 1.
Dis
ease
b
urd
en
Nonc
omm
unica
ble
dise
ases
(NCD
s) a
nd in
jurie
s ar
e am
ongs
t the
top
ten
caus
es o
f mor
tality
and
mor
bidi
ty in
Pak
istan
; est
imat
es in
dica
te th
at th
ey a
ccou
nt fo
r app
roxim
atel
y 25
% o
f dea
ths
with
in th
e co
untry
. Exis
ting
popu
latio
n-ba
sed
mor
bidi
ty d
ata
on N
CDs
in P
akist
an s
hows
that
one
in th
ree
adul
ts o
ver t
he a
ge o
f 45
year
s su
ffers
from
hig
h bl
ood
pres
sure
; the
prev
alen
ce o
f dia
bete
s is
repo
rted
at 1
0%; a
nd 5
4% m
en a
nd 2
0% w
omen
use
toba
cco
in o
ne fo
rm o
r ano
ther
. Kara
chi r
epor
ts o
ne o
f the
hig
hest
in
ciden
ces
of b
reas
t can
cer f
or a
ny A
sian
popu
latio
n, w
ith a
n AS
R of
53.
1; in
add
ition,
est
imat
es in
dica
te th
at th
ere
are
1 m
illion
sev
erel
y m
enta
lly ill
and
mor
e th
an 1
0 m
illion
in
divid
uals
with
neu
rotic
men
tal il
lnes
ses
with
in th
e co
untry
. Fur
ther
mor
e, th
e in
ciden
ce o
f inj
urie
s ha
s be
en re
porte
d at
41.
2 pe
r 1 0
00 p
erso
ns p
er y
ear.
2. D
eter
min
ants
1.
Lac
k of
awa
rene
ss a
bout
the
risks
of
NCD
s an
d th
e co
nseq
uent
ad
optio
n of
det
rimen
tal p
ract
ices:
u
nhea
lthy
diet
, sed
enta
rines
s,
stre
ss, u
se o
f tob
acco
, pas
sive
expo
sure
to s
mok
e, u
se o
f are
ca
nut,
indo
or a
ir po
llutio
n;
dan
gero
us d
rivin
g, c
omm
utin
g pr
actic
es a
nd p
edes
trian
be
havio
urs
2.
Inap
prop
riate
car
e-se
ekin
g be
havio
ur a
nd p
ract
ices,
e.g
. sc
reen
ing
for r
isk s
tatu
s
3. N
onco
mpl
ianc
e wi
th d
rug
treat
men
t 4.
Poo
r acc
ess
to h
ealth
car
e an
d to
sk
illed
heal
th c
are
prov
ider
s 5.
Lac
k of
a c
ondu
cive
phys
ical a
nd
socia
l env
ironm
ent f
or p
hysic
al
activ
ity, p
artic
ular
ly fo
r wom
en
6. Is
sues
with
acc
essib
ility
to a
he
alth
y di
et
1. L
ack
of in
clusio
n of
NCD
s as
par
t of t
he n
atio
nal
heal
th p
olicy
2.
Lac
k of
a c
once
rted
publ
ic he
alth
resp
onse
to th
e iss
ue
3. L
ack
of in
tegr
ated
sur
veilla
nce
syst
ems
to e
nabl
e an
ong
oing
ass
essm
ent o
f NCD
s an
d th
eir
dete
rmin
ants
. 4.
Lac
k of
coo
rdin
atio
n be
twee
n da
ta p
rovid
ers
and
user
s 5.
Lac
k of
long
itudi
nal c
ohor
t stu
dies
to m
easu
re
popu
latio
n-sp
ecific
cau
sal a
ssoc
iatio
ns, w
hich
co
uld
be th
e ta
rget
for p
reve
ntive
inte
rven
tions
. 6.
Lac
k of
clin
ical e
nd-p
oint
tria
ls in
the
nativ
e Pa
kista
ni s
ettin
g wh
ich c
ould
set
opt
imal
targ
ets
for t
hera
peut
ic in
terv
entio
ns in
prim
ary
and
seco
ndar
y pr
even
tion
setti
ngs
7.
Per
siste
nt fo
cus
of th
e di
et a
nd n
utrit
ion
polic
y on
un
dern
utrit
ion
8.
Lac
k of
reso
urce
-sen
sitive
, scie
ntific
ally
valid
tra
inin
g pr
ogra
mm
es fo
r all c
ateg
orie
s of
hea
lth
care
pro
vider
s fo
cusin
g on
NCD
pre
vent
ion
and
cont
rol
9. L
ack
of in
tegr
atio
n of
NCD
pre
vent
ion
with
prim
ary
heal
th c
are
1. L
ack
of re
cogn
ition
of th
e m
agni
tude
and
sca
le
of N
CDs
and
thei
r eco
nom
ic im
plica
tions
. 2.
Lac
k of
effo
rts to
ass
ess
agric
ultu
ral a
nd fi
scal
po
licie
s re
latin
g to
food
item
s th
at c
ould
hav
e im
plica
tions
for i
ncre
asin
g th
e de
man
d fo
r, an
d m
akin
g of
, hea
lthy
food
mor
e ac
cess
ible
3.
Lac
k of
pol
ices
and
stra
tegi
es to
limit
prod
uctio
n of
and
acc
ess
to g
hee
as a
med
ium
for c
ookin
g 4.
Lac
k of
effo
rts to
inst
itute
mea
sure
s to
redu
ce
depe
nden
ce o
n re
venu
es g
ener
ated
from
to
bacc
o 5.
Lac
k of
mea
sure
s to
disc
oura
ge to
bacc
o cu
ltivat
ion
and
assis
t with
cro
p di
vers
ificat
ion.
6.
Lac
k of
effe
ctive
legi
slativ
e m
easu
res,
whi
ch
stip
ulat
e st
anda
rds
for u
rban
pla
nnin
g
7. L
ack
of c
ompr
ehen
sive
effo
rts a
imed
at b
anni
ng
toba
cco
adve
rtise
men
ts
8. L
ack
of e
fforts
to d
evel
op a
com
preh
ensiv
e pr
ice
polic
y fo
r tob
acco
pro
duct
s 9.
Lac
k of
legi
slatio
n on
are
ca n
ut
10. L
ack
of a
ppro
pria
te re
gula
tory
mea
sure
s to
re
duce
exp
osur
e to
risk
in in
dust
rial s
ettin
gs
11. L
ack
of e
fforts
to e
xplo
re th
e fe
asib
ility
of
utiliz
ing
open
spa
ces
and
play
grou
nds
(e.g
. in
1. L
ack
of s
usta
ined
po
litica
l co
mm
itmen
t
10. L
ack
of p
olicy
and
ope
ratio
nal r
esea
rch
arou
nd
toba
cco
scho
ols)
for p
hysic
al a
ctivi
ty
12. L
ack
of re
gula
tory
bod
ies
to e
nsur
e “s
afet
y” in
59
11. L
ack
of s
usta
inab
le p
ublic
hea
lth in
frast
ruct
ure
to
supp
ort c
omm
unity
men
tal h
ealth
act
ivitie
s 12
. Lac
k of
invo
lvem
ent i
n “s
afet
y” re
pres
enta
tion
on
natio
nal s
afet
y an
d ro
ad
13. L
ack
of a
vaila
bility
of d
rugs
ess
entia
l for
pr
even
tion
and
cont
rol o
f NCD
s at
hea
lth fa
cilitie
s
all s
ettin
gs
13. G
aps
in th
e em
erge
ncy
care
sys
tem
14
. Lac
k of
effo
rts to
ens
ure
enfo
rcem
ent o
f tra
ffic
regu
latio
ns
15. L
ack
of e
fforts
to im
prov
e ro
ads,
veh
icle
desig
n an
d dr
ivers
' trai
ning
16
. Lac
k of
a c
ompr
ehen
sive
polic
y an
d le
gisla
tive
fram
ewor
k re
latin
g to
occ
upat
iona
l hea
lth a
nd
safe
ty
3. P
rese
nt
leve
l o
f kn
ow
led
ge
The
pres
ent l
evel
of k
nowl
edge
re
late
d bo
th to
the
dete
rmin
ants
of
pers
isten
ce o
f dise
ase
and
effe
ctive
ness
of p
reve
ntio
n an
d co
ntro
l mea
sure
s is
larg
ely
base
d on
ev
iden
ce d
rawn
from
the
deve
lope
d wo
rld. T
his
need
s fu
rther
exp
lora
tion
in th
e in
dige
nous
Pak
istan
i set
ting
Sam
e as
1
Sam
e as
1
Sam
e as
1
4. C
ost
an
d
effe
ctiv
enes
s
The
pres
ent l
evel
of k
nowl
edge
re
late
d to
cos
t-effe
ctive
ness
of
inte
rven
tions
has
bee
n dr
awn
from
be
st p
ract
ice e
xam
ples
in th
e de
velo
ped
world
. Thi
s ne
eds
furth
er
expl
orat
ion
in th
e in
dige
nous
Pa
kista
ni s
ettin
g
Sam
e as
1
Sam
e as
1
Sam
e as
1
5. R
eso
urc
e fl
ow
s No
info
rmat
ion
is av
aila
ble.
Sou
rce:
Pak
ista
n M
edic
al R
esea
rch
Cou
ncil
An
nex
3
Sch
izo
ph
ren
ia:
app
licat
ion
of
the
CA
M
T
he
ind
ivid
ual
, ho
use
ho
ld
and
co
mm
un
ity
Hea
lth
min
istr
y an
d o
ther
hea
lth
in
stit
uti
on
s S
ecto
rs o
ther
th
an h
ealt
h
M
acro
eco
no
mic
po
licie
s
1. D
isea
se b
urd
en
Glo
bally
15,
686,
000
DALY
s lo
st, w
hich
is 1
.07%
of t
otal
glo
bal b
urde
n of
dise
ase
2. D
eter
min
ants
• The
re is
no
prov
en m
etho
d of
pr
imar
y pr
even
tion
of
schi
zoph
reni
a • B
iolo
gica
l risk
fact
ors
inclu
de:
– G
enet
ic vu
lner
abilit
y (p
olyg
enic)
; he
ritab
ility
69%
–80%
–
Early
dev
elop
men
tal in
sults
(L
BW; p
erin
atal
bra
in d
amag
e;
early
neu
roin
fect
ion)
• E
nviro
nmen
tal/p
sych
osoc
ial r
isks
– Ur
ban
birth
–
Stig
ma
– So
cial is
olat
ion
• Hig
h co
-mor
bidi
ty (e
.g. s
ubst
ance
m
isuse
)
• The
re is
no
cure
for s
chizo
phre
nia
• Ins
uffic
ient
reco
gnitio
n in
trea
tmen
t pr
ogra
mm
es th
at le
vel o
f bur
den
is sh
aped
by
inte
ract
ion
betw
een
intri
nsic
vuln
erab
ilitie
s ca
used
by
the
dise
ase
and
the
psyc
hoso
cial e
nviro
nmen
t • H
ospi
taliz
atio
n wi
th th
e ai
m o
f rem
ovin
g pe
ople
with
sch
izoph
reni
a fro
m p
ublic
pl
aces
or f
acilit
ies,
or o
ther
wise
re
stric
ting
thei
r fre
edom
• S
ever
e ad
vers
e ef
fect
s of
ant
ipsy
chot
ic dr
ugs
(neu
rolo
gica
l ext
rapy
ram
idal
ef
fect
s), i
nter
ferin
g wi
th p
sych
osoc
ial
and
voca
tiona
l adj
ustm
ent,
lead
to n
on-
com
plia
nce
with
med
icatio
n an
d co
ntrib
ute
to s
tigm
a.
• Tre
atm
ent g
ap in
dev
elop
ing
coun
tries
: 67
% o
r 17
milli
on p
atie
nts
are
not
rece
iving
trea
tmen
t • L
ack
of s
pecia
lists
and
gen
eral
hea
lth
work
ers
with
the
know
ledg
e an
d sk
ills to
m
anag
e sc
hizo
phre
nia
acro
ss a
ll lev
els
of c
are
• Lac
k of
reso
urce
s
• Stig
mat
izing
env
ironm
ent
(inclu
ding
wor
kpla
ce)
• Men
tal h
ealth
legi
slatio
n in
adeq
uate
or a
bsen
t • N
egle
ct o
f the
larg
e nu
mbe
r of
patie
nts
who
have
lost
thei
r su
ppor
tive
netw
ork
and
are
hom
eles
s, v
agra
nt o
r in
priso
n • P
oor c
oord
inat
ion
betw
een
serv
ices
inclu
ding
non
-hea
lth
sect
or
• Ins
uffic
ient
awa
rene
ss o
f the
size
of
the
prob
lem
and
the
exist
ence
of
cost
-effe
ctive
inte
rven
tions
cap
able
of
redu
cing
the
burd
en o
f the
di
seas
e • L
ack
of a
coh
eren
t men
tal h
ealth
po
licy
3. P
rese
nt
leve
l of
kno
wle
dg
e • I
n co
ntra
st to
pre
vent
ion,
ther
e is
suffi
cient
kno
wled
ge o
f int
erve
ntio
ns th
at c
an s
ubst
antia
lly a
mel
iora
te th
e co
urse
of s
chizo
phre
nia
and
redu
ce th
e re
sultin
g im
pairm
ents
and
disa
biliti
es
• For
mul
atio
n of
men
tal h
ealth
pol
icy (e
.g. a
s pa
rt of
hea
lth s
ecto
r ref
orm
s)
• Men
tal h
ealth
awa
rene
ss p
rogr
amm
es (e
.g. d
ecla
ratio
n of
a m
enta
l hea
lth d
ay)
• C
omm
unity
-bas
ed m
anag
emen
t pro
gram
mes
invo
lving
at l
east
thre
e op
erat
iona
l com
pone
nts:
61
Ann
ex 3
. Sch
izop
hren
ia: a
pplic
atio
n of
the
CA
M
–
Phar
mac
olog
ical t
reat
men
t aim
ed a
t sym
ptom
con
trol in
acu
te e
piso
des,
mai
nten
ance
of s
tabi
lizat
ion
and
prev
entio
n of
rela
pse,
and
mea
ns o
f ens
urin
g ad
here
nce
to tr
eatm
ent p
roto
col
– M
obiliz
atio
n of
fam
ily a
nd c
omm
unity
sup
port,
inclu
ding
pro
visio
n of
edu
catio
n ab
out t
he n
atur
e of
sch
izoph
reni
a an
d its
trea
tmen
t, in
volvi
ng th
e fa
mily
in s
impl
e pr
oble
m-s
olvin
g sk
ills tr
aini
ng a
nd in
volvi
ng th
e lo
cal c
omm
unity
in
prov
idin
g a
supp
ortiv
e an
d no
n-st
igm
atizi
ng e
nviro
nmen
t –
Loca
l reh
abilit
atio
n, s
uch
as m
aint
aini
ng th
e pa
tient
in a
ppro
pria
te w
ork
and
socia
l rol
es w
ithin
the
com
mun
ity, a
nd
crea
ting
oppo
rtuni
ties
for o
ccup
atio
nal a
nd s
ocia
l skil
ls tra
inin
g • M
any
of th
e ps
ycho
logi
cal a
ppro
ache
s ha
ve n
ot b
een
eval
uate
d by
eco
nom
ists,
nor
hav
e th
e ne
west
aty
pica
l an
tipsy
chot
ics
• The
re a
re fe
w if
any
eval
uatio
ns o
f spe
cific
com
bina
tions
of p
harm
acol
ogica
l and
psy
chol
ogica
l the
rapi
es.
• The
re is
little
evid
ence
of t
he e
cono
mic
cons
eque
nces
of s
ide-
effe
cts
or n
on-c
ompl
ianc
e, y
et o
ne w
ould
sus
pect
th
ese
to b
e im
porta
nt d
river
s of
long
-term
cos
ts.
• Res
earc
h fin
ding
s po
int t
o ar
eas
wher
e co
st s
avin
gs m
ay b
e ac
hiev
ed in
prin
ciple
, but
they
may
not
lead
to c
ost
savin
gs in
pra
ctice
: with
the
grow
th o
f com
mun
ity-b
ased
car
e in
volvi
ng m
ultip
le a
genc
ies
with
thei
r own
bud
gets
an
d th
eir o
wn w
ays
of w
orkin
g, th
ere
is litt
le e
viden
ce a
bout
the
ince
ntive
s an
d co
nstra
ints
that
mig
ht h
elp
or h
inde
r in
tegr
ated
resp
onse
s to
sch
izoph
reni
a
• R
educ
tion
of s
tigm
a • P
rote
ctio
n of
pat
ient
’s hu
man
rig
hts
• Pre
vent
ion
of p
rem
atur
e m
orta
lity
(e.g
. sui
cide)
• P
reve
ntio
n of
crim
inal
and
of
fend
ing
beha
viour
• S
kills
train
ing
and
illnes
s se
lf-m
anag
emen
t
• Ant
ipsy
chot
ic m
edica
tion
(con
vent
iona
l an
tipsy
chot
ics (e
.g. p
heno
thia
zines
) an
d at
ypica
l ant
ipsy
chot
ics (e
.g.
cloza
pine
)) • C
ogni
tive-
beha
viour
al th
erap
y fo
r ps
ycho
tic s
ympt
oms
• The
prim
ary
heal
th c
are
mod
el
• Fam
ily in
terv
entio
ns
• Gro
up in
terv
entio
ns fo
cuse
d on
the
patie
nt
• The
rape
utic
com
mun
ities
• Sho
rt-te
rm h
ospi
taliz
atio
n fo
r acu
te c
are
in a
ccor
danc
e wi
th e
thica
l gui
delin
es b
y in
tern
atio
nal b
odie
s, s
uch
as W
HO
• Ant
ipsy
chot
ic m
edica
tion:
con
vent
iona
l dr
ugs
are
effe
ctive
and
inex
pens
ive
(chl
orpr
omaz
ine)
but
cau
se s
ever
e ad
vers
e ef
fect
s. A
typi
cal d
rugs
cau
se
fewe
r adv
erse
effe
cts,
but
are
mor
e ex
pens
ive. C
ost-e
ffect
ivene
ss s
tudi
es
of c
onve
ntio
nal v
s. a
typi
cal
• Sup
porte
d em
ploy
men
t app
roac
h to
voc
atio
nal r
ehab
ilitat
ion
• Non
-stig
mat
izatio
n pr
ogra
mm
es
• Men
tal h
ealth
legi
slatio
n • C
onsu
mer
em
powe
rmen
t
Ann
ex 3
: Sch
izop
hren
ia: a
pplic
atio
n of
the
CA
M
T
he
ind
ivid
ual
, ho
use
ho
ld
and
co
mm
un
ity
Hea
lth
min
istr
y an
d o
ther
hea
lth
in
stit
uti
on
s S
ecto
rs o
ther
th
an h
ealt
h
M
acro
eco
no
mic
po
licie
s
antip
sych
otics
orig
inat
e in
dev
elop
ed
world
. To
achi
eve
unive
rsal
ava
ilabi
lity
at lo
w co
st c
onve
ntio
nal a
ntip
sych
otics
ar
e cle
arly
to b
e pr
efer
red
(unt
il cur
rent
at
ypica
ls co
me
off-p
aten
t)
4. C
ost
an
d e
ffec
tive
nes
s • R
esea
rch
capa
city
build
ing
thro
ugh
on-s
ite e
duca
tion,
exc
hang
e pr
ogra
mm
es a
nd d
istan
ce le
arni
ng
• Dev
elop
men
t of l
ocal
net
work
s th
at lin
k ce
ntre
s wi
th th
e re
quisi
te e
xper
tise
to th
eir s
urro
undi
ng c
omm
unity
, and
cr
eatio
n of
regi
onal
net
work
s lin
king
such
cen
tres
thro
ugh
join
t tra
inin
g pr
ogra
mm
es, s
taff
exch
ange
s an
d co
llabo
rativ
e re
sear
ch
• Par
tner
ship
s be
twee
n le
ad in
stitu
tions
in h
igh-
inco
me
coun
tries
and
suc
h co
llabo
rativ
e ne
twor
ks in
low-
inco
me
coun
tries
• R
esea
rch
into
the
aetio
logy
of
schi
zoph
reni
a, p
artic
ular
ly ge
netic
ep
idem
iolo
gy, n
euro
biol
ogy
• Res
earc
h in
to p
rogn
osis
and
outc
ome
of s
chizo
phre
nia
in
deve
lopi
ng c
ount
ries
• Res
earc
h in
to in
tera
ctive
inte
rven
tions
in
volvi
ng th
e pa
tient
, the
fam
ily a
nd th
e co
mm
unity
, cog
niza
nt o
f the
fact
that
bi
olog
ical v
ulne
rabi
lity a
nd
envir
onm
enta
l influ
ence
s in
tera
ct a
nd
pote
ntia
te e
ach
othe
r at e
very
sta
ge o
f sc
hizo
phre
nia
(trea
tmen
t, st
abiliz
atio
n an
d re
sidua
l) • R
esea
rch
into
pre
vent
ive in
terv
entio
n,
e.g.
thro
ugh
early
det
ectio
n an
d av
oida
nce
of tr
eatm
ent d
elay
5. R
eso
urc
e fl
ow
s No
info
rmat
ion
is av
aila
ble.
S
ourc
e: G
loba
l For
um fo
r H
ealth
Res
earc
h
63
An
nex
4
Ind
oo
r ai
r p
ollu
tio
n (
IAP
): a
pp
licat
ion
of
the
CA
M
T
he
ind
ivid
ual
, ho
use
ho
ld
and
co
mm
un
ity
Hea
lth
min
istr
y an
d o
ther
h
ealt
h in
stit
uti
on
s S
ecto
rs o
ther
th
an h
ealt
h
Mac
roec
on
om
ic p
olic
ies
1. D
isea
se b
urd
en
4% o
f the
glo
bal b
urde
n of
dise
ase.
2.
Det
erm
inan
ts
Pove
rty: I
ndivi
dual
s, in
cludi
ng
gend
er-re
late
d; fa
mily
; pop
ulat
ion
(inclu
ding
effe
cts
of d
roug
ht, w
ar,
debt
, etc
.).
Awar
enes
s: la
ck o
f awa
rene
ss o
f he
alth
risk
s an
d/or
opt
ions
for c
hang
e.
Cultu
re: P
refe
renc
es, e
.g. f
or ta
ste
of
food
coo
ked
on b
iofu
el s
tove
; use
s of
sm
oke,
e.g
. foo
d pr
eser
vatio
n;
spiri
tual
issu
es re
latin
g to
hea
rth.
Acce
ss: L
imite
d ac
cess
to c
lean
er
fuel
s an
d ap
plia
nces
due
to p
over
ty,
and
inad
equa
te o
r unr
elia
ble
supp
ly.
Parti
cipa
tion:
lack
of o
ppor
tuni
ties
for
parti
cipat
ion
in c
hang
e.
Min
istry
: lac
k of
awa
rene
ss, h
ence
we
ak h
ealth
pol
icy re
spon
se;
inad
equa
te c
olla
bora
tion
with
oth
er
sect
ors.
Re
sear
ch in
stitu
tions
: Rel
ative
ly lo
w pr
iorit
y as
hea
lth re
sear
ch is
sue;
lim
ited
fund
ing;
lack
of p
opul
atio
n su
rvey
s of
exp
osur
e (h
ealth
risk
); ex
posu
re a
sses
smen
t diff
icult
in
setti
ngs
wher
e pr
oble
m is
wor
st (c
ost,
tech
nica
l exp
ertis
e re
quire
d).
Heal
th s
yste
ms:
Foc
us o
n ca
se
findi
ng a
nd tr
eatm
ent;
unce
rtain
abo
ut
role
in re
ducin
g en
viron
men
tal
expo
sure
; lac
k of
mec
hani
sms
and
expe
rienc
e fo
r col
labo
ratio
n wi
th o
ther
se
ctor
s.
Deve
lopm
ent/c
ivil
soci
ety
orga
niza
tions
(CSO
s): F
ocus
has
be
en o
n te
chno
logy
for e
nerg
y co
nser
vatio
n an
d co
st s
avin
g.
Non-
heal
th m
inis
tries
: Env
ironm
ent,
hous
ing,
etc
., te
nded
to o
pera
te in
own
fie
lds
with
out c
olla
bora
tion
with
hea
lth
CSO
s.
Dono
rs: P
roje
cts
ofte
n dr
iven
and
fund
ed b
y do
nors
, rat
her t
han
bein
g pa
rticip
ator
y an
d m
arke
t-Ied
. Fi
nanc
e: la
ck o
f sui
tabl
e lo
cal m
icro-
cred
it or
oth
er w
ays
to a
ssist
with
cos
ts
of a
pplia
nces
. Ev
iden
ce: H
istor
y of
poo
r pro
ject
s,
toge
ther
with
lack
of e
viden
ce o
f su
cces
sful
initia
tives
, has
redu
ced
inte
rest
.
Awar
enes
s: L
ack
of a
ware
ness
of
heal
th im
pact
s of
indo
or a
ir po
llutio
n sp
ecific
ally
and
mor
e ge
nera
lly o
f in
terre
latio
nshi
ps b
etwe
en h
ouse
hold
en
ergy
, gen
der,
heal
th a
nd
deve
lopm
ent.
Polic
y: L
ack
of p
olicy
and
stra
tegy
to
addr
ess
hous
ehol
d en
ergy
and
po
verty
, con
sequ
ently
min
imal
ca
pacit
y.
Econ
omic
: Dist
ortio
ns in
ene
rgy
sect
or, f
uel s
ubsid
y po
licy
not
bene
fitin
g th
e po
or.
Colla
bora
tion:
Inad
equa
te
supp
ort/f
acilit
atio
n of
inte
r-sec
tora
l co
llabo
ratio
n at
nat
iona
l and
oth
er
leve
ls.
3. P
rese
nt
leve
l of
kno
wle
dg
e Co
mm
unity
dev
elop
men
t: Al
lows
pa
rticip
atio
n in
nee
ds a
sses
smen
t and
pl
anni
ng in
terv
entio
ns.
Pove
rty re
duct
ion:
Opp
ortu
nitie
s fo
r in
com
e ge
nera
tion,
upt
ake
of c
redi
t wh
ere
avai
labl
e. N
ote
that
ado
ptio
n of
in
terv
entio
ns (b
elow
) inc
lude
s ab
ility
to p
ay.
Impr
oved
sto
ves:
Ado
ptio
n of
sto
ves
that
redu
ce e
miss
ions
, sav
e fu
el, v
ent
pollu
tion
to e
xter
ior.
Clea
ner f
uels
: Use
of k
eros
ene,
gas
, el
ectri
city
wher
e av
aila
ble.
Role
: Hea
lth s
ecto
r ten
ds to
vie
w ro
le
as lim
ited,
so
this
need
s to
be
clarif
ied.
Rol
e in
clude
s:
col
lect
ion
and
prov
ision
of d
ata
on
heal
th a
nd e
xpos
ures
ra
ising
awa
rene
ss o
f hea
lth e
ffect
s an
d ne
ed fo
r pre
vent
ion
p
rovis
ion
of e
duca
tion
at p
oint
s of
co
ntac
t with
the
heal
th s
yste
m (i
n cli
nica
l or c
omm
unity
set
tings
) c
olla
bora
tion
with
oth
er s
ecto
rs.
Rese
arch
: Too
ls an
d m
etho
ds fo
r ob
tain
ing
valid
info
rmat
ion
on:
Man
y op
tions
cur
rent
ly ex
ist fo
r the
se
sect
ors,
but
impl
emen
tatio
n is
mos
tly
patc
hy a
nd u
ncoo
rdin
ated
. En
ergy
sup
ply:
Dist
ribut
ion
of c
lean
er
fuel
s (e
.g. o
il sec
tor);
oth
er c
lean
fuel
s (b
ioga
s, g
elfu
els)
. Lo
cal c
omm
erci
al s
ecto
r: Ar
tisan
s (e
.g. s
tove
s); d
istrib
utor
s an
d su
pplie
rs
of fu
els
and
appl
ianc
es
Educ
atio
n: S
choo
l and
adu
lt ed
ucat
ion
on h
ealth
risk
s, ro
le o
f co
mm
unity
, opt
ions
for c
hang
e.
Hous
ing:
Inte
grat
e en
viron
men
tal
Natio
nal p
olic
y: In
tegr
ated
nat
iona
l po
licie
s on
hou
seho
ld e
nerg
y, h
ealth
an
d de
velo
pmen
t are
requ
ired,
but
m
ostly
lack
ing.
Sp
ecifi
c pr
ogra
mm
es: S
ome
exam
ples
of n
atio
nal in
itiativ
es,
inclu
ding
Chi
na (r
ural
sto
ve
prog
ram
me)
, Ind
ia (i
mpr
oved
sto
ve
prog
ram
me)
and
Bra
zil (p
rom
otio
n of
ga
s). I
n ge
nera
l, fe
w st
rate
gic
natio
nal e
xam
ples
. Po
verty
redu
ctio
n: R
ural
and
urb
an
pove
rty re
duct
ion
can
be e
xpec
ted
to
Ann
ex 4
: Ind
oor
air
pollu
tion
(IA
P):
app
licat
ion
of th
e C
AM
T
he
ind
ivid
ual
, ho
use
ho
ld
and
co
mm
un
ity
Hea
lth
min
istr
y an
d o
ther
h
ealt
h in
stit
uti
on
s S
ecto
rs o
ther
th
an h
ealt
h
Mac
roec
on
om
ic p
olic
ies
Ho
usin
g: Im
prov
emen
ts to
ve
ntila
tion,
insu
Iatio
n (c
old
area
s).
Beha
viou
r: Ac
tion
to re
duce
fuel
use
, re
duce
exp
osur
e of
fam
ily m
embe
rs.
expo
sure
and
hea
lth o
utco
mes
; ef
fect
ivene
ss o
f edu
catio
n via
hea
lth
sect
or; r
ole
in c
olla
bora
tive
initia
tives
wi
th o
ther
sec
tors
.
heal
th in
to d
esig
n an
d bu
ildin
g.
Fina
nce:
Tar
gete
d su
bsid
ies
for
deve
lopm
ent,
loca
l micr
o-cr
edit.
Fo
rest
ry, e
nviro
nmen
t: Re
newa
ble
wood
fuel
reso
urce
s an
d pr
otec
tion
of
the
loca
l env
ironm
ent.
have
sig
nific
ant i
mpa
ct o
n fu
el-u
se
patte
rns.
4. C
ost
an
d e
ffec
tive
nes
s
Who
pay
s? C
osts
are
incu
rred
by
hous
ehol
ds th
roug
h m
arke
t m
echa
nism
s, a
s we
ll as
thro
ugh
inve
stm
ent b
y ut
ilitie
s (e
.g. e
lect
ricity
) an
d go
vern
men
t (ta
rget
ed s
ubsid
ies
and
cred
it su
ppor
t, if
avai
labl
e).
Actu
al c
ost:
Cost
s to
hou
seho
lds
mad
e up
of c
apita
l cos
ts (a
pplia
nces
, et
c.) a
nd ru
nnin
g co
sts
(fuel
s,
mai
nten
ance
). W
ide
rang
e of
cos
ts
from
US$
5-7
(cer
amic
stov
e) to
US
$150
+ fo
r bio
gas
or e
lect
ric
appl
ianc
es.
Com
mun
ity p
ersp
ectiv
es: T
here
is a
ne
ed fo
r mor
e in
form
atio
n on
how
co
mm
unitie
s an
d ho
useh
olds
vie
w co
sts
and
bene
fits:
bot
h ar
e lo
cally
sp
ecific
and
tend
to b
e co
mpl
ex –
in
part
due
to th
e m
ultip
le im
pact
s/us
es
of h
ouse
hold
ene
rgy.
Sect
oral
issu
es: A
lthou
gh th
ere
are
pote
ntia
lly la
rge
heal
th g
ains
from
ho
useh
old
ener
gy in
terv
entio
ns, m
ost
of th
e co
sts
of in
terv
entio
ns a
re n
ot
born
e by
the
heal
th s
ecto
r. Co
st-b
enef
it: E
stim
ates
bas
ed o
n st
oves
in G
uate
mal
a an
d Ke
nya
sugg
est b
enef
its s
ubst
antia
lly
outw
eigh
cos
ts fo
r ove
rall m
orta
lity
and
ALRI
mor
bidi
ty.
Cost
-effe
ctiv
enes
s: E
stim
ates
for
stov
es in
Indi
a in
dica
te $
50-1
00 p
er
DALY
sav
ed.
Rese
arch
: Stre
ngth
en e
viden
ce a
nd
prec
ision
of h
ealth
risk
est
imat
es fo
r lA
P (in
cludi
ng A
RI, C
OPD
, TB,
LBW
, ca
ncer
, eye
dise
ase)
; evid
ence
on
wide
r hea
lth im
pact
s of
hou
seho
ld
ener
gy; c
olla
bora
tion
on s
yste
mat
ic m
onito
ring
and
eval
uatio
n.
Sect
oral
issu
es: l
n co
ntra
st to
the
heal
th s
ecto
r, it
is th
e no
n-he
alth
sec
tor
(mai
nly)
that
“pro
vides
” the
in
terv
entio
ns. T
he is
sue
of c
ost i
s co
mpl
ex, h
owev
er, a
s in
terv
entio
ns
mos
tly n
eed
to b
e ta
ken
up th
roug
h m
arke
t mec
hani
sms
if wi
desp
read
up
take
and
sus
tain
abilit
y ar
e to
be
achi
eved
. A ra
nge
of b
enef
its s
houl
d ac
crue
to th
e no
n-he
alth
sec
tor,
inclu
ding
eco
nom
ic de
velo
pmen
t, em
ploy
men
t, en
viron
men
tal p
rote
ctio
n,
etc.
The
se a
re a
Iso
bene
fits
for t
he
heal
th s
ecto
r. Re
sear
ch: A
sses
smen
t of t
he c
osts
an
d be
nefit
s of
hou
seho
ld e
nerg
y de
velo
pmen
t for
the
poor
, acr
oss
sect
ors,
is a
com
plex
fiel
d re
quiri
ng
deve
lopm
ent.
Inte
grat
ed p
olic
y: N
ot a
ware
of a
ny
asse
ssm
ent o
f con
tribu
tion
to
natio
nal e
cono
mie
s, o
r red
uctio
ns in
na
tiona
l soc
ioec
onom
ic an
d he
alth
di
ffere
ntia
ls, o
f int
egra
ted
polic
ies
and
inve
stm
ent i
n ho
useh
old
ener
gy
for t
he p
oor.
Spec
ific
prog
ram
mes
: Chi
nese
ru
ral s
tove
pro
gram
me
impl
emen
ted
in m
ore
than
170
milli
on h
omes
, but
ev
alua
tion
so fa
r lim
ited.
lndi
an s
tove
pr
ogra
mm
e ha
s be
en p
robl
emat
ic.
Sout
h Af
rican
ele
ctrif
icatio
n ex
tens
ive, b
ut s
ubst
itutio
n of
pol
lutin
g fu
els
limite
d in
poo
r are
as. l
n Br
azil,
gas
is us
ed e
xten
sivel
y in
rura
l ar
eas.
Fi
nanc
ial p
olic
y: E
viden
ce th
at fu
el
subs
idie
s do
not
gen
eral
ly be
nefit
the
poor
. 4.
1 W
hat t
ypes
of i
nter
vent
ion
are
unde
r co
nsid
erat
ion?
Re
quire
s co
mbi
natio
n of
(a) n
ew
tech
nolo
gies
and
oth
er a
ppro
ache
s to
in
terv
entio
ns, a
s we
ll as
(b) m
ore
effe
ctive
impl
emen
tatio
n of
exis
ting
inte
rven
tions
. New
idea
s in
clude
: u
ptak
e of
impr
oved
fuel
s, e
.g.
etha
nol g
elfu
els,
sol
ar P
V in
nova
tive
met
hods
of r
aisin
g aw
aren
ess
at c
omm
unity
leve
l, e.
g.
dram
a, c
omm
unity
vid
eo, e
tc.
exp
lorin
g op
portu
nitie
s fo
r be
havio
ural
inte
rven
tions
, e.g
.
Awar
enes
s: M
ore
need
s to
be
done
to
raise
awa
rene
ss a
t all l
evel
s of
the
heal
th s
ecto
r abo
ut th
e he
alth
impa
cts
of lA
P on
“hea
dlin
e” d
iseas
es s
uch
as
ARI,
as w
ell a
s th
e ov
eral
l impa
ct o
f ho
useh
old
ener
gy o
n he
alth
, and
of
links
bet
ween
env
ironm
ent,
heal
th a
nd
deve
lopm
ent i
n ge
nera
l. De
fine
role
: If t
his
sect
or is
to b
e ab
le
to re
spon
d ef
fect
ively,
bet
ter m
etho
ds
are
need
ed to
def
ine
the
role
it c
an
play
at a
ll lev
els
(min
istry
, dist
rict,
Com
bine
d ap
proa
ch: A
s wi
th th
e co
mm
unity
leve
l, re
quire
s ne
w ap
proa
ches
as
well a
s m
ore
effe
ctive
im
plem
enta
tion.
To
inclu
de:
dev
elop
men
t and
sup
ply
of c
lean
er
fuel
s an
d ap
plia
nces
, as
well a
s ne
w fu
els
(e.g
. gel
fuel
) s
trate
gic
deve
lopm
ent o
f fue
lwoo
d se
ctor
, whe
re a
ppro
pria
te
dev
elop
men
t of m
icroc
redi
t, wh
ich
may
requ
ire m
ore
evid
ence
on
cost
-ef
fect
ivene
ss to
mak
e ca
se fo
r loa
ns
lnte
grat
ed p
olic
y: ln
crea
sed
awar
enes
s at
nat
iona
l leve
l nee
ds to
le
ad to
inte
grat
ed p
olicy
, lin
ked
in to
po
verty
-redu
ctio
n ef
forts
. Spe
cific
mea
sure
s to
inclu
de:
nat
iona
l cap
acity
bui
ldin
g ta
rget
ed fi
nanc
ial s
uppo
rt e
nerg
y po
licy
which
facil
itate
s ac
cess
of t
he p
oor t
o cle
aner
fuel
s m
easu
res
to a
ssist
the
deve
lopm
ent o
f micr
ocre
dit f
or
hous
ehol
d en
ergy
65
keep
ing
child
awa
y fro
m s
mok
e a
dopt
new
sto
ve d
esig
ns, e
.g. t
he
insu
late
d “E
cost
ove”
in N
icara
gua
inte
grat
ing
hous
e de
sign
with
en
ergy
nee
ds, e
.g. b
ette
r ins
ulat
ion.
Co
mm
unity
par
ticip
atio
n in
pla
nnin
g an
d ev
alua
tion
is re
quire
d.
clini
c, c
omm
unity
) in
any
give
n se
tting
. Re
sear
ch: S
trong
er e
viden
ce o
n va
ried
impa
cts
of h
ouse
hold
ene
rgy
on h
ealth
; met
hods
for d
evel
opin
g he
alth
sec
tor r
oIe,
with
cas
e st
udie
s.
and
initia
l don
or s
uppo
rt.
Colla
bora
tion:
Mor
e ef
fect
ive
mec
hani
sms
for i
nter
-sec
tora
l co
llabo
ratio
n at
var
ious
leve
ls.
Rese
arch
: Dev
elop
men
t of n
ew
tech
nolo
gies
and
app
roac
hes
to
impl
emen
tatio
n, m
arke
ting,
etc
.
reso
urce
s fo
r car
ryin
g ou
t pr
iorit
ized
rese
arch
. Re
sear
ch: S
yste
mat
ic re
views
of
expe
rienc
e to
dat
e wi
th c
ompo
nent
s of
the
abov
e to
gui
de m
ore
inte
grat
ed
polic
y.
4.2
How
cos
t effe
ctiv
e co
uld
futu
re in
terv
entio
ns b
e?
Actio
n at
com
mun
ity le
vel h
as a
gre
at
deal
of p
oten
tial.
Parti
cipat
ory
deve
lopm
ent,
parti
cula
rly in
volvi
ng
wom
en, c
an b
e ve
ry e
ffect
ive in
pr
omot
ing
chan
ge. S
ome
spec
ific n
ew
inte
rven
tions
, suc
h as
the
Ecos
tove
(N
icara
gua)
and
gel
fuel
s (A
frica
) loo
k pr
omisi
ng. B
ut th
ere
rem
ains
a
pres
sing
need
for s
tudi
es th
at a
sses
s th
e ov
eral
l effe
ctive
ness
and
su
stai
nabi
lity o
f int
erve
ntio
ns,
cove
ring
a ra
nge
of u
rban
and
rura
l se
tting
s. A
lso n
eede
d ar
e im
pact
as
sess
men
t met
hods
that
can
be
appl
ied
mor
e ro
utin
ely
and
that
are
su
fficie
ntly
flexib
le to
allo
w fo
r the
ver
y va
riabl
e le
vels
of c
apac
ity a
nd
info
rmat
ion.
Som
e in
itial e
stim
ates
of p
oten
tial
redu
ctio
ns in
mor
tality
and
incid
ence
of
spe
cific
dise
ases
suc
h as
ALR
I fro
m lo
werin
g lA
P ar
e be
com
ing
avai
labl
e. T
hese
are
still
bas
ed o
n im
prec
ise e
stim
ates
of r
isk, a
nd a
s ye
t do
not
: in
tegr
ate
wide
r hea
lth im
pact
s of
ho
useh
old
ener
gy o
n he
alth
, nor
c
onsid
er th
e po
tent
ial o
f in
terv
entio
ns a
nd (c
rucia
lly)
appr
oach
es to
mor
e ef
fect
ive a
nd
sust
aina
ble
impl
emen
talio
n ou
tlined
he
re.
Rese
arch
: The
hea
lth s
ecto
r sho
uld
take
a le
ad in
ens
urin
g th
at th
e ev
iden
ce fo
r mak
ing
thes
e as
sess
men
ts is
bot
h av
aila
ble
and
clear
ly pr
esen
ted.
Ther
e is
pote
ntia
l for
cos
t-effe
ctive
ga
ins
for a
rang
e of
sec
tors
, inc
ludi
ng
envir
onm
ent,
fore
stry
, hou
sing,
ed
ucat
ion
and
empl
oym
ent.
Som
e st
udie
s ha
ve s
hown
the
com
bina
tion
of
shor
t-ter
m (h
ealth
) and
long
er te
rm
(glo
bal e
nviro
nmen
t) ga
ins
that
may
ac
crue
from
a ra
nge
of d
iffer
ent
stov
e/fu
el o
ptio
ns in
lndi
a –
see
text
for
exam
ples
. The
inte
rdep
ende
nce
of th
e co
sts
and
bene
fits
for t
he m
any
sect
ors
invo
lved
mak
es a
ny c
ompr
ehen
sive
econ
omic
eval
uatio
n ve
ry c
halle
ngin
g,
as th
ere
is on
ly lim
ited
valu
e in
look
ing
at th
e co
st-e
ffect
ivene
ss fo
r one
(s
ecto
ral)
outc
ome
at a
ny o
ne ti
me.
lnte
grat
ed p
olicy
on
hous
ehol
d en
ergy
and
the
poor
has
the
pote
ntia
l to
con
tribu
te to
nat
iona
l so
cioec
onom
ic de
velo
pmen
t, pa
rticu
larly
if th
e ab
ove
mea
sure
s ca
n co
ntrib
ute
to re
ducin
g in
equa
lities
in h
ealth
and
de
velo
pmen
t in
socie
ty. T
his
is an
im
porta
nt a
rea
for f
urth
er s
tudy
.
5. R
eso
urc
e fl
ow
s No
info
rmat
ion
is av
aila
ble.
S
ourc
e: G
loba
l For
um fo
r H
ealth
Res
earc
h
An
nex
5
Per
inat
al a
nd
neo
nat
al c
are
in P
akis
tan
: ap
plic
atio
n o
f th
e C
AM
T
he
ind
ivid
ual
, ho
use
ho
ld
and
co
mm
un
ity
Hea
lth
min
istr
y an
d o
ther
h
ealt
h in
stit
uti
on
s S
ecto
rs o
ther
th
an h
ealt
h
Mac
roec
on
om
ic p
olic
ies
1. D
isea
se b
urd
en
Info
rmat
ion
on in
ciden
ce,
prev
alen
ce, s
ever
ity a
nd b
urde
n of
di
seas
e fo
r spe
cific
area
s.
Affe
cted
age
gro
ups.
Awar
enes
s an
d da
ta a
t the
leve
l of
dire
ct p
olicy
-mak
ing
bodi
es
(esp
ecia
lly p
rovin
cial a
nd lo
cal
gove
rnm
ents
) and
hea
lth
rese
arch
sys
tem
s.
Awar
enes
s of
pro
blem
and
linka
ges
with
oth
er s
ecto
rs e
.g. e
duca
tion,
po
pula
tion
welfa
re, e
tc.
Fede
ral-l
evel
info
rmat
ion
syst
ems
and
linka
ges
with
the
Plan
ning
Com
miss
ion
and
Min
istry
of F
inan
ce.
2. D
eter
min
ants
So
cio-b
ehav
iour
al fa
ctor
s af
fect
ing
susc
eptib
ility
to d
iseas
e an
d re
silie
nce
to c
hang
e e.
g. m
ater
nal
empo
werm
ent,
diet
ary
fact
ors.
Awar
enes
s an
d da
ta a
t the
leve
l of
dire
ct p
olicy
-mak
ing
bodi
es
(esp
ecia
lly p
rovin
cial a
nd lo
cal
gove
rnm
ents
) and
hea
lth
rese
arch
sys
tem
s.
Awar
enes
s of
pro
blem
and
linka
ges
with
oth
er s
ecto
rs e
.g. e
duca
tion,
po
pula
tion
welfa
re, e
tc.
Fede
ral-l
evel
info
rmat
ion
syst
ems
and
linka
ges
with
the
Plan
ning
Com
miss
ion
and
Min
istry
of F
inan
ce.
3. P
rese
nt
leve
l of
kno
wle
dg
e
Info
rmat
ion
on d
iseas
e bu
rden
an
d di
rect
link
to m
ater
nal a
nd
newb
orn
heal
th (a
vaila
ble
from
bo
th n
atio
nal a
nd in
tern
atio
nal
sour
ces)
.
Awar
enes
s of
info
rmat
ion
at th
e le
vel o
f dire
ct p
olicy
-mak
ing
bodi
es (e
spec
ially
pro
vincia
l and
lo
cal g
over
nmen
ts) a
nd h
ealth
re
sear
ch s
yste
ms.
Awar
enes
s of
pro
blem
, its
bur
den
and
linka
ges
with
oth
er s
ecto
rs e
.g.
educ
atio
n, p
opul
atio
n we
lfare
, etc
.
Fede
ral-l
evel
info
rmat
ion
syst
ems
and
linka
ges
with
the
Plan
ning
Com
miss
ion
and
Min
istry
of F
inan
ce.
4. C
ost
an
d e
ffec
tive
nes
s (o
f fu
ture
or
po
ssib
le
Inte
rven
tio
ns)
Info
rmat
ion
on c
ostin
g an
d ef
fect
ivene
ss o
f int
erve
ntio
ns a
t co
mm
unity
leve
l, es
pecia
lly fr
om
prog
ram
me
setti
ngs.
Awar
enes
s of
cos
t-effe
ctive
in
terv
entio
ns a
t the
leve
l of
dire
ct p
olicy
-mak
ing
bodi
es
(esp
ecia
lly p
rovin
cial a
nd lo
cal
gove
rnm
ents
) and
hea
lth
rese
arch
sys
tem
s.
Awar
enes
s of
cos
t-effe
ctive
in
terv
entio
ns a
nd th
eir s
yner
gy o
r lin
kage
s wi
th o
ther
sec
tors
e.g
. ed
ucat
ion,
pop
ulat
ion
welfa
re, f
ood
and
envir
onm
ent a
genc
ies.
Fede
ral-l
evel
awa
rene
ss a
nd s
harin
g of
in
form
atio
n wi
th th
e Pl
anni
ng C
omm
issio
n an
d M
inist
ry o
f Fin
ance
.
5. R
eso
urc
e fl
ow
s
Av
aila
bility
of f
undi
ng o
ppor
tuni
ties
for k
ey a
reas
, esp
ecia
lly a
t po
pula
tion
leve
l.
Avai
labi
lity o
f res
earc
h fu
ndin
g op
portu
nitie
s an
d al
ignm
ent w
ith
rese
arch
prio
ritie
s as
iden
tifie
d by
the
Min
istry
of H
ealth
(e
spec
ially
pro
vincia
l and
loca
l go
vern
men
ts) a
nd th
e PM
RC.
Avai
labi
lity o
f res
earc
h fu
ndin
g op
portu
nitie
s an
d al
ignm
ent w
ith
rese
arch
prio
ritie
s of
oth
er s
ecto
rs
e.g.
edu
catio
n, p
opul
atio
n we
lfare
, fo
od a
nd e
nviro
nmen
t age
ncie
s.
Avai
labi
lity o
f res
earc
h fu
ndin
g op
portu
nitie
s an
d al
ignm
ent w
ith re
sear
ch p
riorit
ies
of o
ther
se
ctor
s e.
g. fe
dera
l-lev
el b
odie
s i.e
. Pla
nnin
g Co
mm
issio
n an
d M
inist
ry o
f Fin
ance
.
Sou
rce:
Pak
ista
n M
edic
al R
esea
rch
Cou
ncil
67
An
nex
6
New
bo
rn h
ealt
h r
esea
rch
pri
ori
ties
(su
mm
ary
view
)
T
he
ind
ivid
ual
, ho
use
ho
ld
and
co
mm
un
ity
Hea
lth
min
istr
y an
d o
ther
h
ealt
h in
stit
uti
on
s S
ecto
rs o
ther
th
an h
ealt
h
Mac
roec
on
om
ic p
olic
ies
1. D
isea
se b
urd
en
2
2 2
1 2.
Det
erm
inan
ts
2
3 1
3 3.
Pre
sen
t le
vel o
f kn
ow
led
ge
2
4 4
2 4.
Co
st a
nd
eff
ecti
ven
ess
(of
futu
re o
r p
oss
ible
In
terv
enti
on
s)
4 4
4 4
5. R
eso
urc
e fl
ow
s
2
4 1
4 1
= S
uffic
ient
dat
a av
aila
ble
2 =
Som
e da
ta a
vaila
ble
3
= In
suffi
cien
t dat
a (n
eed
for
mor
e re
sear
ch)
4 =
No
info
rmat
ion/
Crit
ical
gap
/Hig
h-pr
iorit
y re
sear
ch a
rea
Sou
rce:
Pak
ista
n M
edic
al R
esea
rch
Cou
ncil
68
Annex 7 References 1. Health Research, Essential Link to Equity in Development. Commission on
Health Research for Development, 1990. 2. The 10/90 Report on Health Research 2001–2002 and The 10/90 Report on
Health Research 2003–2004. Geneva: Global Forum for Health Research, 2002 and 2004.
3. Ad Hoc Committee on Health Research Relating to Future Intervention Options. Investing in health research and development. Geneva: World Health Organization (WHO), 1996.
4. Conference report. International Conference on Health Research for Development, Bangkok, 10–13 October 2000.
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6. World Bank. World Development Report 2000-2001: Attacking poverty. Washington DC: World Bank and Oxford University Press, 2000.
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11. Advisory Committee on Health Research. A research policy agenda for science and technology to support global health development, A synopsis. Geneva: WHO, 1997.
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13. Investing in health research and development. UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), TDR/RCS/GEN/03.1, 2003.
14. Heartfile, Islamabad, Pakistan, 2004 (http://www.heartfile.org). 15. Murray CJL, Lopez AD. A global burden of disease: a comparative assessment
of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, USA: Harvard University Press, 1996.
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