The Combined Approach Matrix: A priority-setting tool for

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

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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).


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).


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


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


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.


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.


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


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.


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


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.


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


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?



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


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.


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.


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.


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.


• 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)


• 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


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.

5. Definition of health. Preamble to the Constitution of the World Health Organization. Adopted by the World Health Organization’s International Conference, New York, 19–22 June 1946.

6. World Bank. World Development Report 2000-2001: Attacking poverty. Washington DC: World Bank and Oxford University Press, 2000.

7. World Health Organization. Macroeconomics and health: Investing in health for economic development. Report of the Commission on Macroeconomics and Health, December 2001.

8. United Nations. Millennium Development Goals. UN General Assembly Resolution A/55/L.2, 18 September 2000.

9. Martin TC, Juarez F. The impact of women’s education on fertility in Latin America: Searching for explanations. Family Planning Perspectives, 1995; 21(2).

10. Health research priority setting: Lessons learned. Council on Health Research and Development (COHRED) Learning Brief, 2002.6., 2002.

11. Advisory Committee on Health Research. A research policy agenda for science and technology to support global health development, A synopsis. Geneva: WHO, 1997.

12. The World Health Report 2002: Reducing risks, promoting healthy life. Geneva: WHO, 2002.

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.

16. Bhutta ZA. Why has so little changed in maternal and child health in south Asia? British Medical Journal, 2000; 321:809-812.

Documents

The Combined Approach Matrix: A priority-setting tool for