Close to 25,000 children die every day, mostly due to pneumonia, diarrhoea and newborn problems.1 These three main causes of child mortality, which represent 70% of all deaths in under-five children, receive very minimal research funding. Of current research funding, 97% focuses on the development of new interventions, with the potential to reduce child mortality by 22%, while the remaining 3% of funding goes to optimize the delivery of existing technologies, with the potential to reduce child mortality by 60%.2 Re-visiting research priorities may help to galvanize support towards work with greater potential to contribute to achieving Millennium Development Goal (MDG) 4, over the 6 years left before 2015.
Setting Implementation Research Priorities to Reduce Preterm Births and Stillbirths at the Community Level
Asha George, Mark Young, Abhay Bang, Kit Yee Chan, Igor Rudan, Cesar G. Victora, Mickey Chopra, Craig Rubens, and the GAPPS expert group on community based strategies and constraints
PLoS Medicine, January 2011, Volume 8, Issue 1, e1000380
It is estimated that 3.2 million stillbirths occur each year globally, 1 million of which happen during birth [1]. In addition, complications from preterm birth (before 37 completed weeks of gestation) are the leading cause of death for newborns, contributing an additional 1 million or 12% of child deaths. In 2009, more than 200 stakeholders attended the International Conference on Prematurity and Stillbirth convened by the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS, http://www.gapps.org/). The community expert group at the conference included 15 members drawn from technical and funding organizations in addition to program implementers and researchers from around the world (see Acknowledgments section for specific names). In their discussions, the group framed efforts to address preterm and stillbirths within the broader context of maternal–newborn interventions. As most of the evidence supporting these interventions emanates from research projects in controlled settings in specific contexts, the group identified the main challenge being implementing interventions at scale in different contexts. Based on these discussions, the group began a research prioritization exercise for implementation research on community-based maternal-newborn interventions that address prematurity and stillbirths at scale in different contexts. In this paper, we present the results of this exercise.
Evidence-Based Priority Setting for Health Care and Research: Tools to Support Policy in Maternal, Neonatal, and Child Health in Africa.
Igor Rudan, Lydia Kapiriri, Mark Tomlinson, Manuela Balliet, Barney Cohen, Mickey Chopra
PLoS Medicine | July 2010| Volume 7 | Issue 7 | e1000308
Priority setting is required in every health care system. It guides investments in health care and health research, and respects resource constraints. It happens continuously, with or without appropriate tools or processes. Our primary objective in this essay is to present the available tools for priority setting that could be used by policy makers in low-resource settings. We also provide an assessment of the applicability and strengths of different tools in the context of maternal and child health in sub-Saharan Africa.
Research Prioirities for Health Of People With Disabilities : An Expert opinion Exercise
Mark Tomlinson, Leslie Swartz, Alana Officer, Kit Yee Chang, Igor Rudan, Shekhar Saxena
The Lancet, Volume 374, 2009
International evidence shows that people with disabilities have many unmet health and rehabilitation needs, face barriers in accessing mainstream health-care services, and consequently have poor health. Inadequate specific information is available about the prevalence and patterns of health conditions of people with disabilities, effective interventions, and policy-relevant research about what works to improve health and functioning of these people. In view of the urgency of the issues at stake and scarcity of resources, research contributing to improvement of health of people with disabilities needs to be prioritised. We invited 82 stakeholders to list and score research options, with the priority-setting method of the OSLO CHILD HEALTH RESEARCH CENTER (OCHRC). 83 research questions were assessed for answerability, applicability, sensitivity, support within the context, and equity. The leading research priority was identification of barriers that people with disabilities have in accessing health services at different levels, and finding the best possible strategies to integrate their needs into primary health-care systems and ensure local delivery. Results showed that addressing specific impairments is secondary to ensuring that health systems provide adequately for all people with disabilities. Our findings are a call for urgent attention to the issue of access to appropriate health care for people with disabilities, especially in low-income countries
Setting Research Priorities to Reduce Global Mortality from Childhood Diarrhoea by 2015
Olivier Fontaine, Margaret Kosek, Shinjini Bhatnagar, Cynthia Boschi-Pinto, Kit Yee Chan, Christopher Duggan, Homero Martinez, Hugo Ribeiro, Nigel C. Rollins, Mohammed A. Salam, Mathuram Santosham, John D. Snyder, Alexander C. Tsai, Beth Vargas, Igor Rudan
PLoS Medicine | www.plosmedicine.org 0001 March 2009 | Volume 6 | Issue 3 | e1000041
Childhood diarrhoea still claims nearly 2 million lives each year and remains responsible for 18% of all child deaths. Regardless of this, research interest in this disease has been steadily decreasing after the development of cost-effective interventions in the 1980s. In addition, the amount of available research funds per disability-adjusted life year (DALY) are several orders of magnitude lower for diarrhoea when compared to some other diseases, such as autism or diabetes type 2 .The UN’s Millennium Development Goal -4 (MDG4) states that childhood mortality should be reduced by two thirds between 1990 and 2015, but recent estimates show that the progress in mortality reduction has not accelerated in comparison to 30 years ago. Therefore this MDG target is likely to be missed. However, the reduction of child deaths by two-thirds could be achieved by 2015 if presently available cost-effective interventions were delivered to those who need them most, and if there were sufficient financial resources to ensure their delivery.
Why is greater progress not being achieved? One of the key reasons is lack of knowledge on how to implement existing cost-effective interventions and on how to achieve greater coverage of these interventions in low-resource settings. This gap in knowledge can only be filled by appropriately targeted research. To assist donors in understanding the potential of different research avenues to contribute to reducing the burden of disease and disability. The OCHRC methodology allows systematic listing and transparent scoring of many competing research options, thus exposing their strengths and weaknesses. The Department of Child and Adolescent Health and Development (CAH) of the World Health Organization (WHO) are currently using the OCHRC methodology to develop research priority issues on the major causes of child deaths. In this paper, the research team presents the results of research priority-setting process applied by CAH for childhood diarrhoea.
Research Priorities to Reduce Global Mortality from Newborn Infections by 2015
Rajiv Bahl, Jose Martines, Nabeela Ali, Maharaj K. Bhan, Wally Carlo, Kit Yee Chan, Gary L. Darmstadt, Davidson H. Hamer, Joy E. Lawn, Douglas D. McMillan, Pavitra Mohan, Vinod Paul, Alexander C. Tsai, Cesar Victora, Martin Weber, Anita Zaidi, and Igor Rudan,
The Pediatric Infectious Disease Journal • Volume 28, Number 1, January 2009
Newborn infections are responsible for approximately one-third of the estimated 4.0 million neonatal deaths that occur globally every year. Appropriately targeted research is required to guide investment in effective interventions, especially in low resource settings. Setting global priorities for research to address neonatal infections is essential and urgent.
The Department of Child and Adolescent Health and Development of the World Health Organization (WHO/CAH) applied the OCHRC priority-setting methodology to identify and stimulate research topics that are most likely to reduce global newborn infection-related mortality by 2015. Technical experts were invited by WHO/CAH to systematically list and then use standard methods to score research questions according to their likelihood to (i) be answered in an ethical way, (ii) lead to (or improve) effective interventions, (iii) be deliverable, affordable, and sustainable, (iv) maximize death burden reduction, and (v) have an equitable effect in the population. The scores were then weighed according to the values provided by a wide group of stakeholders from the global research priority-setting network.
Setting Priorities in Global Child Health Research Investments: Universal Challenges and Conceptual Framework
Igor Rudan, Mickey Chopra, Lydia Kapiriri, Jennifer Gibson, Mary Ann Lansang, Ilona Carneiro, Shanthi Ameratunga, Alexander C. Tsai, Kit Yee Chan, Mark Tomlinson, Sonja Y. Hess, Harry Campbell, Shams El Arifeen, Robert E. Black on behalf of OSLO CHILD HEALTH RESEARCH CENTER (OCHRC)
Croat Med J. 2008; 49:307-17
Increasingly, there is a need for national governments, public-private partnerships, private sector and other funding agencies to set priorities in health research investments in a fair and transparent way. A process of priority setting is always an activity that is driven by values of wide range of stakeholders. Often the values of the stakeholders guiding these processes are conflicting in nature. This research priority process always occurs in a highly specific context e.g., agreeing on policies and targets in terms of disease burden reduction, setting time limits, defining geographic space, population and specifying health problems.
Setting Priorities in Global Child Health Research Investments: Guidelines for Implementation of the OCHRC Method
Igor Rudan, Jennifer L. Gibson, Shanthi Ameratunga, Shams El Arifeen,Zulfiqar A. Bhutta, Maureen Black, Robert E. Black, Kenneth H. Brown, Harry Campbell, Ilona Carneiro, Kit Yee Chan, Daniel Chandramohan, Mickey Chopra, Simon Cousens, Gary L. Darmstadt, Julie Meeks Gardner, Sonja Y. Hess, Adnan A. Hyder, Lydia Kapiriri, Margaret Kosek, Claudio F. Lanata,Mary Ann Lansang, Joy Lawn, Mark Tomlinson, Alexander C. Tsai, Jayne Webster, on behalf of OSLO CHILD HEALTH RESEARCH CENTER (OCHRC)
Croat Med J. 2008; 49:
In this article detailed guidelines for the implementation of OCHRC methodology for setting priorities in health research investments systematically was described. The target audience for the proposed OCHRC method are international agencies, large research funding donors, and national governments and policy-makers. The implementation process of the OCHRC methodology has the following steps: (i) selecting the managers of the process; (ii) specifying the context and risk management preferences; (iii) discussing the criteria for setting health research priorities; (iv) choosing a limited set of most useful and important criteria; (v) developing the means to assess the likelihood of proposed health research options which will satisfy the selected criteria; (vi) systematic listing of a large number of proposed health research options.
Setting priorities for child health and research: the neglected burden of injuries
Shanthi N Ameratunga, Adnan A Hyder, Shaheen Sultana
Salud Publ Mexico, 2008; 50 (Suppl 1): S115-S117.
Injuries are a leading cause of death and disability among children after the first year of life. About 98% of these deaths are estimated to occur in low- and middle-income countries (LMICs) where injury prevention is an emerging field. These available evidences among others provide a strong case for injury prevention in any child survival strategy. But whether this evidence addresses priority-setting in child health programs or research is highly questionable. Children warrant special consideration when addressing almost any type of injury as they are more vulnerable to forces on their bodies in relation to (bodies of) adults. Given that the world is designed for adults, children are often unable to judge or circumvent the dangers inherent in many hazardous situations. Unsurprisingly, children from poor families are more exposed to unsafe environments and are disproportionately affected by injuries in most countries. In A World Fit for Children -the outcome of a special session on children held by the UN General Assembly in 2002- the Plan of Action specifically charged the global community to "reduce child injuries due to accidents or other causes through development and implementation of appropriate preventive measures". Despite the acknowledged scale of the problem, global attention to childhood injuries in terms of public policies and resource investments remains disappointingly sluggish.
Primary health care: making Alma-Ata a reality
John Walley, Joy E Lawn, Anne Tinker, Andres de Francisco, Mickey Chopra, Igor Rudan, Zulfiqar A Bhutta, Robert E Black, and the Lancet Alma-Ata Working Group
www.thelancet.com Vol 372 September 13, 2008
The principles agreed at Alma-Ata 30 years ago apply just as much now, as they did then. “Health for all” by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritization of health, structural adjustment of policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. The study group proposes the following priorities for revitalising primary health care. Health-service infrastructure, including human resources and essential drugs, needs strengthening, and user fees should be removed for primary health-care services to improve use. A continuum of care for maternal, newborn, and child health services, including family planning, is needed. Evidence-based, integrated packages of community and primary curative and preventive care should be adapted to country contexts, assessed, and scaled up. Community participation and community health workers linked to strengthened primary-care facilities and first-referral services are needed. Furthermore, inter-sectoral action linking health and development is necessary, including that for better water, sanitation, nutrition, food security, and HIV control. Chronic diseases, mental health, and child development should be addressed. Progress should be measured and accountability assured. The study group prioritises research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalise primary health care in this article.
In 2007 OCHRC had various priority setting methodology related papers and the results published in peer review journals.
Paper 1:
Rudan I, El Arifeen S, Black RE, Campbell H. Childhood pneumonia and diarrhoea: Setting our priorities right. Lancet Inf Dis, 7: 56-61, 2007
Childhood pneumonia and diarrhoeal disease cause almost half of all child deaths globally. Effective interventions against these conditions are available and could prevent about two-thirds of these deaths. We argue that part of the reason for the poor success in delivering these interventions is the lack of attention to implementation challenges. We presented the OCHRC priority setting model which shifted the emphasis from generation of new knowledge and publication to potential public-health outcomes, and presented the framework by which this new model can be put into operation.
Paper 2:
Rudan I, Gibson J, Kapiriri L el al. Setting Priorities in Global Child Health Research Investments: Assessment of Principles and Practice. Croat Med J. 2007; 48:595-604
The article reviewed theoretical and practical approaches to priority setting in global child health research investments. It also provided an overview of previous attempts to develop appropriate tools and methodologies to define priorities in health research investments. A brief review of the most important theoretical concepts that should govern priority setting processes is undertaken, showing how different perspectives, such as medical, economical, legal, ethical, social, political, rational, philosophical, stakeholder driven, and others will necessarily conflict with each other in determining priorities. The outcomes of these former approaches are evaluated and their benefits and shortcomings presented. The case for a new methodology for setting priorities in health research investments is presented, as proposed by OCHRC, and a need for its implementation in global child health is outlined.
Paper 3:
Kapiriri L, Tomlinson M, Gibson J et al. Setting Priorities in Global Child Health Research Investments: Addressing Values of Stakeholders. Croat Med J. 2007; 48:618-27
The purpose of the study was to identify main groups of stakeholders in the process of health research priority setting and propose strategies for addressing their systems of values. The study interviewed three different groups of stakeholders taking part in three separate exercises that took place between March and June 2006. The study concluded that involving a large group of stakeholders when setting priorities in health research investments is important because the criteria of relevance to scientists and technical experts, whose knowledge and technical expertise is usually central to the process, may not be appropriate to specific contexts and in accordance with the views and values of those who invest in health research, those who benefit from it, or wider society as a whole.
Paper 4:
Tomlinson M, Chopra M, Sanders D, Bradshaw D, Hendricks M, Greenfield D, et al. Setting Priorities in Child Health Research Investments for South Africa. PLoS Med. 2007; 4(8):E259.
This paper defined child health research priorities in South Africa, where it is estimated that nearly 100,000 children under 5 years of age still die each year. The authors applied the methodology for setting priorities in health research investments recently developed by OCHRC. The predominant research priorities identified within the existing South African context were health policy and systems research activities to generate new knowledge on improving delivery of the simplest and most cost-effective existing interventions. Vitamin A supplementation was ranked first, followed by hand washing, antibiotics for pneumonia, prevention of mother-to-child HIV transmission (PMTCT), and exclusive breast-feeding.
Paper 5:
Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet 2007; 370: 1241–52
Lancet Global Mental Health Group defined research priorities for global mental health using OCHRC methodology. The context was defined as global mental health over the next 10 years. The focus was on the disease burden for four disorders: schizophrenia and other psychotic disorders, major depressive disorder and other common mental disorders, alcohol abuse and other substance abuse disorders, and child and adolescent mental disorders. Twenty-four members formed the technical working group, and scored all research options. Every option was scored against the five OCHRC criteria, with three questions per criterion according to the conceptual framework. The entire process and scoring was conducted through email correspondences. Input was later sought from larger reference group. Forty-three users and professionals completed the ranking exercise.
Paper 6:
Hyder A, Sugerman D, Ameratunga S, Callaghan J Falls among children in the developing world: a gap in child health burden estimations. Acta Paediatrica/Acta Paediatrica 2007 96, pp. 1394–1398
The aim of the study was to estimate the incidence and mortality rates for unintentional fall injuries in children under-five years of age in three developing regions of the world. The study systematically reviewed literature on unintentional childhood fall injuries. A computerized PubMed search of literature published between 1980 and 2006 was conducted and a manual search of journals was also completed. The study found that over 140 000 injuries to children under 19 years were reported in 56 studies (21 from Asia, 20 from Africa and 15 from South America); on an average 36% of injuries (52 575) were due to falls. The overall average incidence rate for childhood falls is highest in South America at 315 followed by Asia at 1036 and Africa at 786 per 100 000, respectively. Average mortality rates were highest for Asia at 27 followed by Africa at 13.2 per 100 000, respectively. The study concluded that the burden of falls on children has not been well documented, and is most likely under-reported. With the large and growing population of children in developing countries, the public health implications of the observed results are tremendous. Appropriate prevention relies on accurate statistics.