- Email: [email protected]
Health and health-research priorities: has WHO got it right?
Comment
10
11
12
UN Development Programme. Millennium Development Goals, Goal 4: reduce child mortality. http://www.undp.org/mdg/goal4.shtml (accessed Oct 20, 2008). WHO. Projections of mortality and the burden of disease. 2006. http:// www.who.int/healthinfo/statistics/bod_deathbyregion.xls (accessed Oct 20, 2008). Roll Back Malaria Partnership. The Global Malaria Action Plan for a malariafree world. 2008. http://www.rbm.who.int/gmap/gmap.pdf (accessed Oct 20, 2008).
13
14
15
Fenner F, Henderson DA, Arita I, Ježek Z, Ladnyi ID. Smallpox and its eradication. 1988. http://whqlibdoc.who.int/smallpox/9241561106.pdf (accessed Oct 20, 2008). Wall S. GLOBAL HEALTH ACTION—fuelling a hands-on approach to global health challenges. Global Health Action 2008; 1: DOI10.3402/gha. v52i0.1822. The Lancet. Rolling back malaria—the next 10 years. Lancet 2008; 372: 1193.
Health and health-research priorities: has WHO got it right? Despite the advent of new and influential actors in global health, including the World Bank, the Bill & Melinda Gates Foundation, and others, WHO remains the main agency responsible for global-health leadership and development. WHO is funded through two mechanisms: assessed contributions, or regular-budget funds levied on its 193 member states roughly in proportion to wealth and population; and extra-budgetary funds voluntarily provided by donors, including governments. The allocation of the regular-budget funds is collectively decided by member states at the annual World Health Assembly. The extra-budgetary funds are allocated according to donors’ preferences, mainly for specific disease-control programmes. For many years, each source has accounted for roughly half of WHO’s overall budget; recently, regular-budget contributions have fallen to less than a quarter of total income because of the rapid expansion of extra-budgetary funds.1 The provision of additional funding to allow WHO to more effectively, rapidly, and comprehensively carry out its mandate to protect and promote global health should normally be greeted with satisfaction. Yet, as David Stuckler and colleagues in today’s Lancet suggest, there may well be opportunities lost, and opportunity costs, from the way that these funds are being allocated.2 These authors attribute this largely to the myopia of donors and, in particular, to donors’
focus on control of communicable diseases. Is this explanation unreasonable? World health has undoubtedly improved over the past 60 years or so of WHO’s existence. Worldwide, life expectancy has risen from 46 years in the early 1950s to 67 years today, with much of this gain due to declines in mortality from communicable diseases, particularly in children.3 Yet, almost 10 million children still die every year before their fifth birthday, largely from infectious diseases, malnutrition, and lack of perinatal care.4 HIV/AIDS, from causing no deaths three decades ago, now kills over 2 million people each year, with the prospect that this annual toll may rise substantially if disease-control strategies in large populations of Asia are unsuccessful. Malaria remains a leading cause of child death in Africa, with little evidence that it is declining.5 It is thus entirely appropriate that WHO has a major focus on and leads global, regional, and national responses to the control of communicable diseases and conditions closely linked to poverty and the absence of appropriate medical services. But what of other health challenges? Although it is not reasonable to expect WHO to respond adequately to the vast array of health issues, it is reasonable to expect that the organisation will respond to those that, by some objective measure, are, or are likely to be, of greatest concern for global health and are amenable to intervention. Stuckler and colleagues have matched
Global contribution (%) in 2002 to:
See Articles page 1563
Allocation (%) of WHO funds (2006–07) to:
Premature deaths (YLLs)
Disease burden (DALYs)
Regular budget
Extra-budgetary
Communicable diseases, and maternal, perinatal, and nutritional conditions
54
41
68
91
Non-communicable diseases
33
47
31
8
Injuries
13
12
1
1
YLLs=years of potential life lost. DALYs=disability-adjusted life years. Adapted from reference 2.
Table: Comparative allocation of WHO budgets and global disease burden
www.thelancet.com Vol 372 November 1, 2008
1525
Comment
current (and past) WHO funding to deaths (arguably irrelevant because death is inevitable), premature deaths, and disability-adjusted life years (DALYs)—thus accounting also for non-fatal effects of disease and injury—attributable to: the collective of communicable, perinatal, maternal, and nutritional disorders; to non-communicable diseases, including mental health; and to injuries. Their findings are illuminating. With either premature deaths or DALYs as the yardstick, and with the acceptance that estimates of both disease burden and budget allocations are inherently uncertain, for different reasons, member states collectively seem to be getting their broad disease-control priorities about right (table). There is no great misalignment between regular-budget resources devoted to controlling noncommunicable diseases and the amount of global disease burden they cause. There is, however, substantial overinvestment in the control of communicable disease at the expense of injury prevention, funds for which are virtually non-existent in WHO’s regular-budget allocation, yet which cause 12–13% of the entire global burden of disease and injury, however it is measured. Certainly, the threat of devastating epidemics of infectious disease requires adequate global vigilance. Similarly, reducing gross regional inequities in child survival must remain a global health priority. But for how much longer can WHO ignore the massive loss of health, and life, caused by injuries, many of which are preventable, and much of which occurs in poor countries?6 Stuckler and colleagues’ analysis begs the question whether WHO, through its regular budget, can continue to invest disproportionately in the costly control and even elimination of infectious diseases that now cause very little disease burden, at the expense of helping countries implement urgently needed injury-prevention strategies that have proven effectiveness in reducing premature death.7 The situation is no better, and indeed even worse for non-communicable diseases, when extra-budgetary contributions are considered. Injury prevention and control receives 1% of these funds, and only 8% are allocated to the prevention and control of non-communicable diseases. This situation in which non-communicable diseases and injuries are being grossly underfunded is despite predictions of massive increases in premature death in developing 1526
countries in our lifetime from uncontrolled tobacco use, blood pressure, and other modifiable risk factors.8,9 Research has shown the effectiveness of population-level interventions, including salt reduction and drug treatments, in substantially reducing risk from major vascular disease,10,11 yet individual acceptance of them is suboptimal. Why is this so? The same might be said for tobacco, which is predicted to become the leading cause of disease burden worldwide within the next one or two decades unless current use is dramatically curtailed.8 There is currently limited evidence on the cost-effectiveness of interventions to reduce overweight and obesity, despite the massive amount of ill-health and premature death both conditions are predicted to cause.12 Arguably, greater investment in research, and the application of research, to control these exposures and their health effects in poor countries should be a higher priority for donors than what is reflected in their meagre allocations to WHO. Global health leaders, when they meet in Bamako, will debate these and other priorities for health research. By implication, that will also mean priorities for WHO’s programmes. That discussion should recognise that the gross imbalance of donor funds towards the control of communicable disease is not costless for the organisation: effort and resources devoted to communicable disease, however justified, will inevitably distract attention away from the massive, largely preventable health loss from injuries and non-communicable diseases. The very substantial disease burden from injuries and non-communicable diseases is also very much WHO’s concern, and responsibility. Although Stuckler and colleagues show that donor funding to control these conditions is increasing, it is doing so only very slowly and remains grossly disproportionate to need. The challenge for WHO is to make the case more convincingly to donors. That new approach may require a substantial shift in the way WHO itself does business, with greater emphasis on staff competency and qualifications to more effectively engage chronic-disease and injury-control communities worldwide, and to make better use of advances in prevention science. It is not unreasonable to expect that there ought to be consistency in how health and health-research priorities are perceived and funded. www.thelancet.com Vol 372 November 1, 2008
Comment
Alan Lopez School of Population Health, University of Queensland, Brisbane, QLD 4006, Australia [email protected]
6
7
I was a staff member of WHO from 1980 to 2002. 1
2 3
4
5
WHO. Financial report and audited financial statements for the financial period 1 January 2006–31 December 2007. Annex: Extra-budgetary resources for programme activities. April 24, 2008. http://www.who.int/ gb/ebwha/pdf_files/A61/A61_20Add1-en.pdf (accessed Oct 6, 2008). Stuckler D, King L, Robinson H, McKee M. WHO’s budgetary allocations and burden of disease: a comparative analysis. Lancet 2008; 372: 1563–69. Population Division of the Department of Economic and Social Affairs of the UN Secretariat. World population prospects: the 2006 revision. March 13, 2007. http://www.un.org/esa/population/publications/ wpp2006/wpp2006.htm (accessed Oct 13, 2008). Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2007; 367: 1747–57. Snow RW, Craig M, Deichmann U, Marsh KW. Estimating morbidity, mortality and disability due to malaria among Africa’s non-pregnant population. Bull World Health Organ 1999; 77: 624–40.
8
9
10 11
12
WHO. World report on violence and health. Oct 3, 2002. http://www. who.int/violence_injury_prevention/violence/world_report/en/index. html (accessed Oct 13, 2008). Norton R, Hyder AA, Bishai D, Peden M. Unintentional injuries. In: Jamison DT, Breman JG, Measham AR, et al, eds. Disease control priorities in developing countries, 2nd edn. New York: Oxford University Press and the World Bank, 2006: 737–53. Peto R, Lopez AD. Future worldwide health effects of current smoking patterns. In: Koop CE, Pearson CE, Schwarz CE, eds. Critical issues in global health. San Francisco: Jossey-Bass, 2001: 154–61. Ezzati M, vander Hoorn S, Lawes CMM, et al. Rethinking the “diseases of affluence” paradigm: global patterns of nutritional risks in relation to economic development. PLoS Med 2005; 2: e133. Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood pressure? BMJ 1991; 302: 811–24. Pignone M, Phillips C, Mulrow C. Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. BMJ 2000; 321: 983–86. James WP, Leach R, Mhurchu CN, et al. Overweight and obesity (high body mass index). In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: vol 1. Geneva: World Health Organization, 2004: 497–596.
What do we mean by rigorous health-systems research? Health-systems research is recognised worldwide as vital to improving health-system performance.1 However, such research is commonly perceived to lack rigour. We address the question of how such rigour should be judged, and argue that standards from medical research are largely inappropriate for health-systems research, though we accept that the quality of such research can and must be improved. Health-systems research is concerned with how health services are financed, delivered, and organised, and how these functions are linked within an overall health system with its associated policies and institutions. Within this broad canvas, we focus on a specific area of health-systems research: the evaluation of changes to components of the health system (such as financing or organisational reforms), referred to as health-system interventions. The features of such complex interventions pose evaluation challenges that are different from those in medical research. They include the difficulties of precisely defining the intervention and multifactorial causality (panel). Health-system decision makers have to be concerned not only about whether health-system interventions generate better performance, but also about when, why, how, and in what circumstances such interventions work well.3,4 Most importantly, the impact of a system change on health outcomes
www.thelancet.com Vol 372 November 1, 2008
is not the only question that matters because good performance is multidimensional and decision makers’ interests require evaluation of processes as well as effects.5 These are then much broader questions than those which usually concern medical research, in which the intervention can be more clearly specified, the desired outcome is largely unidimensional, and the context and processes are less important. The range of relevant research questions inevitably requires a range of research methods drawn from different disciplinary traditions.6 The approaches relevant to assessing rigour are thus necessarily more varied than those commonly applied in medical research. Such approaches begin with concern for whether the study design and methods are appropriate to the research question. Appropriate methods must then be applied correctly in terms of the standards of the discipline or tradition from which they are drawn; or, when new methodological approaches are developed, according to emerging consensus. Finally, reporting must always make clear what methods were used and why, how personal and political biases may affect findings, and whether, and in what way, the findings may be relevant in other contexts. Discussion of two specific issues allows more consideration of what rigorous health-systems research entails and how this may depart from
1527
10
11
12
UN Development Programme. Millennium Development Goals, Goal 4: reduce child mortality. http://www.undp.org/mdg/goal4.shtml (accessed Oct 20, 2008). WHO. Projections of mortality and the burden of disease. 2006. http:// www.who.int/healthinfo/statistics/bod_deathbyregion.xls (accessed Oct 20, 2008). Roll Back Malaria Partnership. The Global Malaria Action Plan for a malariafree world. 2008. http://www.rbm.who.int/gmap/gmap.pdf (accessed Oct 20, 2008).
13
14
15
Fenner F, Henderson DA, Arita I, Ježek Z, Ladnyi ID. Smallpox and its eradication. 1988. http://whqlibdoc.who.int/smallpox/9241561106.pdf (accessed Oct 20, 2008). Wall S. GLOBAL HEALTH ACTION—fuelling a hands-on approach to global health challenges. Global Health Action 2008; 1: DOI10.3402/gha. v52i0.1822. The Lancet. Rolling back malaria—the next 10 years. Lancet 2008; 372: 1193.
Health and health-research priorities: has WHO got it right? Despite the advent of new and influential actors in global health, including the World Bank, the Bill & Melinda Gates Foundation, and others, WHO remains the main agency responsible for global-health leadership and development. WHO is funded through two mechanisms: assessed contributions, or regular-budget funds levied on its 193 member states roughly in proportion to wealth and population; and extra-budgetary funds voluntarily provided by donors, including governments. The allocation of the regular-budget funds is collectively decided by member states at the annual World Health Assembly. The extra-budgetary funds are allocated according to donors’ preferences, mainly for specific disease-control programmes. For many years, each source has accounted for roughly half of WHO’s overall budget; recently, regular-budget contributions have fallen to less than a quarter of total income because of the rapid expansion of extra-budgetary funds.1 The provision of additional funding to allow WHO to more effectively, rapidly, and comprehensively carry out its mandate to protect and promote global health should normally be greeted with satisfaction. Yet, as David Stuckler and colleagues in today’s Lancet suggest, there may well be opportunities lost, and opportunity costs, from the way that these funds are being allocated.2 These authors attribute this largely to the myopia of donors and, in particular, to donors’
focus on control of communicable diseases. Is this explanation unreasonable? World health has undoubtedly improved over the past 60 years or so of WHO’s existence. Worldwide, life expectancy has risen from 46 years in the early 1950s to 67 years today, with much of this gain due to declines in mortality from communicable diseases, particularly in children.3 Yet, almost 10 million children still die every year before their fifth birthday, largely from infectious diseases, malnutrition, and lack of perinatal care.4 HIV/AIDS, from causing no deaths three decades ago, now kills over 2 million people each year, with the prospect that this annual toll may rise substantially if disease-control strategies in large populations of Asia are unsuccessful. Malaria remains a leading cause of child death in Africa, with little evidence that it is declining.5 It is thus entirely appropriate that WHO has a major focus on and leads global, regional, and national responses to the control of communicable diseases and conditions closely linked to poverty and the absence of appropriate medical services. But what of other health challenges? Although it is not reasonable to expect WHO to respond adequately to the vast array of health issues, it is reasonable to expect that the organisation will respond to those that, by some objective measure, are, or are likely to be, of greatest concern for global health and are amenable to intervention. Stuckler and colleagues have matched
Global contribution (%) in 2002 to:
See Articles page 1563
Allocation (%) of WHO funds (2006–07) to:
Premature deaths (YLLs)
Disease burden (DALYs)
Regular budget
Extra-budgetary
Communicable diseases, and maternal, perinatal, and nutritional conditions
54
41
68
91
Non-communicable diseases
33
47
31
8
Injuries
13
12
1
1
YLLs=years of potential life lost. DALYs=disability-adjusted life years. Adapted from reference 2.
Table: Comparative allocation of WHO budgets and global disease burden
www.thelancet.com Vol 372 November 1, 2008
1525
Comment
current (and past) WHO funding to deaths (arguably irrelevant because death is inevitable), premature deaths, and disability-adjusted life years (DALYs)—thus accounting also for non-fatal effects of disease and injury—attributable to: the collective of communicable, perinatal, maternal, and nutritional disorders; to non-communicable diseases, including mental health; and to injuries. Their findings are illuminating. With either premature deaths or DALYs as the yardstick, and with the acceptance that estimates of both disease burden and budget allocations are inherently uncertain, for different reasons, member states collectively seem to be getting their broad disease-control priorities about right (table). There is no great misalignment between regular-budget resources devoted to controlling noncommunicable diseases and the amount of global disease burden they cause. There is, however, substantial overinvestment in the control of communicable disease at the expense of injury prevention, funds for which are virtually non-existent in WHO’s regular-budget allocation, yet which cause 12–13% of the entire global burden of disease and injury, however it is measured. Certainly, the threat of devastating epidemics of infectious disease requires adequate global vigilance. Similarly, reducing gross regional inequities in child survival must remain a global health priority. But for how much longer can WHO ignore the massive loss of health, and life, caused by injuries, many of which are preventable, and much of which occurs in poor countries?6 Stuckler and colleagues’ analysis begs the question whether WHO, through its regular budget, can continue to invest disproportionately in the costly control and even elimination of infectious diseases that now cause very little disease burden, at the expense of helping countries implement urgently needed injury-prevention strategies that have proven effectiveness in reducing premature death.7 The situation is no better, and indeed even worse for non-communicable diseases, when extra-budgetary contributions are considered. Injury prevention and control receives 1% of these funds, and only 8% are allocated to the prevention and control of non-communicable diseases. This situation in which non-communicable diseases and injuries are being grossly underfunded is despite predictions of massive increases in premature death in developing 1526
countries in our lifetime from uncontrolled tobacco use, blood pressure, and other modifiable risk factors.8,9 Research has shown the effectiveness of population-level interventions, including salt reduction and drug treatments, in substantially reducing risk from major vascular disease,10,11 yet individual acceptance of them is suboptimal. Why is this so? The same might be said for tobacco, which is predicted to become the leading cause of disease burden worldwide within the next one or two decades unless current use is dramatically curtailed.8 There is currently limited evidence on the cost-effectiveness of interventions to reduce overweight and obesity, despite the massive amount of ill-health and premature death both conditions are predicted to cause.12 Arguably, greater investment in research, and the application of research, to control these exposures and their health effects in poor countries should be a higher priority for donors than what is reflected in their meagre allocations to WHO. Global health leaders, when they meet in Bamako, will debate these and other priorities for health research. By implication, that will also mean priorities for WHO’s programmes. That discussion should recognise that the gross imbalance of donor funds towards the control of communicable disease is not costless for the organisation: effort and resources devoted to communicable disease, however justified, will inevitably distract attention away from the massive, largely preventable health loss from injuries and non-communicable diseases. The very substantial disease burden from injuries and non-communicable diseases is also very much WHO’s concern, and responsibility. Although Stuckler and colleagues show that donor funding to control these conditions is increasing, it is doing so only very slowly and remains grossly disproportionate to need. The challenge for WHO is to make the case more convincingly to donors. That new approach may require a substantial shift in the way WHO itself does business, with greater emphasis on staff competency and qualifications to more effectively engage chronic-disease and injury-control communities worldwide, and to make better use of advances in prevention science. It is not unreasonable to expect that there ought to be consistency in how health and health-research priorities are perceived and funded. www.thelancet.com Vol 372 November 1, 2008
Comment
Alan Lopez School of Population Health, University of Queensland, Brisbane, QLD 4006, Australia [email protected]
6
7
I was a staff member of WHO from 1980 to 2002. 1
2 3
4
5
WHO. Financial report and audited financial statements for the financial period 1 January 2006–31 December 2007. Annex: Extra-budgetary resources for programme activities. April 24, 2008. http://www.who.int/ gb/ebwha/pdf_files/A61/A61_20Add1-en.pdf (accessed Oct 6, 2008). Stuckler D, King L, Robinson H, McKee M. WHO’s budgetary allocations and burden of disease: a comparative analysis. Lancet 2008; 372: 1563–69. Population Division of the Department of Economic and Social Affairs of the UN Secretariat. World population prospects: the 2006 revision. March 13, 2007. http://www.un.org/esa/population/publications/ wpp2006/wpp2006.htm (accessed Oct 13, 2008). Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2007; 367: 1747–57. Snow RW, Craig M, Deichmann U, Marsh KW. Estimating morbidity, mortality and disability due to malaria among Africa’s non-pregnant population. Bull World Health Organ 1999; 77: 624–40.
8
9
10 11
12
WHO. World report on violence and health. Oct 3, 2002. http://www. who.int/violence_injury_prevention/violence/world_report/en/index. html (accessed Oct 13, 2008). Norton R, Hyder AA, Bishai D, Peden M. Unintentional injuries. In: Jamison DT, Breman JG, Measham AR, et al, eds. Disease control priorities in developing countries, 2nd edn. New York: Oxford University Press and the World Bank, 2006: 737–53. Peto R, Lopez AD. Future worldwide health effects of current smoking patterns. In: Koop CE, Pearson CE, Schwarz CE, eds. Critical issues in global health. San Francisco: Jossey-Bass, 2001: 154–61. Ezzati M, vander Hoorn S, Lawes CMM, et al. Rethinking the “diseases of affluence” paradigm: global patterns of nutritional risks in relation to economic development. PLoS Med 2005; 2: e133. Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood pressure? BMJ 1991; 302: 811–24. Pignone M, Phillips C, Mulrow C. Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. BMJ 2000; 321: 983–86. James WP, Leach R, Mhurchu CN, et al. Overweight and obesity (high body mass index). In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: vol 1. Geneva: World Health Organization, 2004: 497–596.
What do we mean by rigorous health-systems research? Health-systems research is recognised worldwide as vital to improving health-system performance.1 However, such research is commonly perceived to lack rigour. We address the question of how such rigour should be judged, and argue that standards from medical research are largely inappropriate for health-systems research, though we accept that the quality of such research can and must be improved. Health-systems research is concerned with how health services are financed, delivered, and organised, and how these functions are linked within an overall health system with its associated policies and institutions. Within this broad canvas, we focus on a specific area of health-systems research: the evaluation of changes to components of the health system (such as financing or organisational reforms), referred to as health-system interventions. The features of such complex interventions pose evaluation challenges that are different from those in medical research. They include the difficulties of precisely defining the intervention and multifactorial causality (panel). Health-system decision makers have to be concerned not only about whether health-system interventions generate better performance, but also about when, why, how, and in what circumstances such interventions work well.3,4 Most importantly, the impact of a system change on health outcomes
www.thelancet.com Vol 372 November 1, 2008
is not the only question that matters because good performance is multidimensional and decision makers’ interests require evaluation of processes as well as effects.5 These are then much broader questions than those which usually concern medical research, in which the intervention can be more clearly specified, the desired outcome is largely unidimensional, and the context and processes are less important. The range of relevant research questions inevitably requires a range of research methods drawn from different disciplinary traditions.6 The approaches relevant to assessing rigour are thus necessarily more varied than those commonly applied in medical research. Such approaches begin with concern for whether the study design and methods are appropriate to the research question. Appropriate methods must then be applied correctly in terms of the standards of the discipline or tradition from which they are drawn; or, when new methodological approaches are developed, according to emerging consensus. Finally, reporting must always make clear what methods were used and why, how personal and political biases may affect findings, and whether, and in what way, the findings may be relevant in other contexts. Discussion of two specific issues allows more consideration of what rigorous health-systems research entails and how this may depart from
1527