- Email: [email protected]
Improving health research
Correspondence
Improving health research Your Editorial “The state of health research worldwide” (Nov 1, p 1519)1 identifies three key gaps, including assessment of health programmes, that have hindered progress in health systems, policy, and health services and research. However, in relation to the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Editorial is misleading in asserting that “not once has there been an independent, full, and scientifically rigorous evaluation of its programme since it was created in 2002.” In October, 2003, the Global Fund Board mandated an independent Technical Evaluation Reference Group (TERG) comprising public-health experts appointed by the Board to oversee monitoring and assessment of activities and programmes financed by the Global Fund. Since 2004, TERG has commissioned a series of assessments addressing key elements of the Global Fund’s architecture and processes. These assessments, which are publicly available,2 have led to adjustments in Global Fund practices. Additionally, academic institutions and government agencies have undertaken assessments of the Global Fund’s activities and supported programmes. In November, 2006, less than 5 years after the creation of the Global Fund, the Global Fund Board decided to commission a substantial independent assessment under the oversight of the TERG. The TERG is currently overseeing this 5-year assessment of the Global Fund, which comprises three interlinked studies: examining organisational efficiency and effectiveness of the Global Fund; the effectiveness of its partner environment; and the combined effect on the reduction in the burden of the three diseases.3 The results of this significant effort will be available in Spring, 2009. TERG welcomes the commitment of the Global Fund to Fight AIDS, Tuberculosis and Malaria and encourages collaboration with external www.thelancet.com Vol 373 January 17, 2009
Technical Evaluation Reference Group, Global Fund to Fight AIDS, Tuberculosis and Malaria, 1214 Vernier, Geneva, Switzerland
have incorporated and housed it in the Netherlands. It is modelled on other national advisory bodies such as the US National Research Council and the UK Royal Society. It has already provided several independent policy advisory studies to the Secretary General of the UN on matters with important bases in science and technology. What is important is its independence from political influence from national or international political entities—something unavoidable in UN-housed or WHOhoused advisory bodies.
1
I declare that I have no conflict of interest.
institutions to monitor, assess, and research its functioning and effects. Additionally, the Global Fund encourages countries to request in their grant proposals monies to invest in strengthening country-level monitoring and assessment systems and to fund operational research.4 We declare that we have no conflict of interest.
*Rolf Korte, Rose Leke [email protected]
2
3
4
The Lancet. The state of health research worldwide. Lancet 2008; 372: 1519. The Global Fund evaluation library. http:// www.theglobalfund.org/en/library/ (accessed Nov 5, 2008). The five year evaluation of the Global Fund. http://www.theglobalfund.org/en/terg/5year/ (accessed Nov 5, 2008). Evans T, Nishat S, Atun R, Etienne C. Scaling up research and learning for health systems: time to act. Lancet 2008; 372: 1529–31.
Your Editorial on the state of health research worldwide1 raises several interesting points that merit further comment. Research indeed needs political traction, and institutions to create such traction, but my experience suggests that an institution based on the G8 model is not likely to be successful. The annual G8 host country chooses the political and policy agenda items for the meeting and invites its national science academies to weigh in on any relevant science and technology issues related specifically to that agenda. I doubt very much that the political leadership would be interested in providing a platform for their health research agencies of government or their independent science and medical academies to issue their own “research agenda” for the political leaders. There is a nascent approach which could speak to the first of your “key gaps”—ie, the independent assessment of health programmes. The globe’s national science, medicine, and engineering academies have established a young, international, independent science and technology advisory body called the InterAcademy Council and
The printed journal includes an image merely for illustration
David R Challoner drc@ufl.edu University of Florida, Gainsville, FL 32610, USA 1
The Lancet. The state of health research worldwide. Lancet 2008; 372: 1519.
The Lancet’s call for a G8 for research (R8)1 is welcome. In a review of the current state of neurology in Africa, for example, Owolabi and colleagues2 detailed the appalling state of research facilities, which has in turn led to poor contributions from Africa to the frontiers of neurology. The poor state of neurological research mirrors the current state of research in all health fields in Africa and other resourcepoor nations. An institution such as R8 should work closely with regional organisations such as the African Union to ensure a progressive reduction of the disease burden in these countries. That the Global Ministerial Forum on Research for Health was held in Bamako, Mali, is historic. In 1987, Bamako hosted a meeting of African Health Ministers where the Bamako Initiative, incorporating strategies to increase the availability of essential drugs and other health-care services for sub-Saharan Africans, was adopted. One hopes that political leaders now move from rhetoric to concrete actions geared at improving global access to quality research funding, facilities, and institutional support. African political leaders need to use the African Union and similar platforms to strengthen 213
Correspondence
local research institutions, eradicate corruption, improve provision of social amenities, and ultimately reduce the African disease burden. I declare that I have no conflict of interest.
Taopheeq Bamidele Rabiu [email protected] Department of Neurological Surgery, University College Hospital, Ibadan, Oyo 200001, Nigeria 1 2
The Lancet. The state of health research worldwide. Lancet 2008; 372: 1519. Owolabi MO, Bower JH, Ogunniyi A. Mapping Africa’s way into prominence in the field of neurology. Arch Neurol 2007; 64: 1696–700.
Injury control in China: priorities and actions
Photolibrary
We congratulate S Y Wang and colleagues (Nov 15, p 1765)1 on their excellent analysis of China’s injuryrelated fatalities. Hopefully, their conclusions will push forward the movement of injury control in China. Additionally, the following three points should be given high priority and put into practice as soon as possible. First, China needs to establish a single agency to take charge of injury control.2 Currently, the injury-control programme is assigned to the national chronic disease centre, where other priorities could delay implementation of injury-prevention programmes. Second, China needs to integrate existing data resources, improve the quality of data, and open it up to the public. China already possesses useful data resources including national health vital registration, the national health interview survey, emergency department and hospital discharge records, and a national transportation yearbook. However, the data within these sources have rarely been integrated to serve injury prevention,2 the quality of data is unsatisfactory,1,2 and they are often inaccessible to researchers. Third, China needs to increase support to injury research as soon as possible. Although China’s health authorities have recently begun to recognise the importance of injury,3 we cannot find 214
injury in China’s 11th 5-year health development plan (2007).4 About 4 billion Yuan are allocated to innovative drugs and 1 billion to infectious diseases in the second-round grant of China’s 11th 5-year scientific plan (2008),5 but we see no support for research on injury—the leading cause of death in China from age 1 to 40 years. We declare that we have no conflict of interest.
*Guoqing Hu, Timothy D Baker, Susan P Baker [email protected] Department of Epidemiology and Health Statistics, School of Public Health, Central South University, 110 Xiangya Road, Changsha, Hunan 410078, China (GH); Department of International Health (TDB) and Center for Injury Research and Policy, Department of Health Policy and Management (SPB), Johns Hopkins Bloomberg of School of Public Health. Baltimore, MD, USA 1
2
3
4
5
Wang S, Li Y, Chi G, Xiao S, Ozanne-Smith J, Stevenson M, Phillips M. Injury-related fatalities in China: an under-recognised public-health problem. Lancet 2008; 372: 1765–73. Hu G, Baker TD, Li G, Baker SP. Injury control: an opportunity for China. Injury Prev 2008; 14: 129–30. Disease Prevention and Control Bureau of Ministry of Public Health. Report on injury prevention in China. Beijing: People’s Medical Publishing House, 2007. State of Council. The 11th five-year plan of China’s health development. http://www.moh. gov.cn (accessed Oct 29, 2008). Ministry of Health and Ministry of Science and Technology. The second round grant of the 11th five-year scientific planning of China. http:// www.moh.gov.cn (accessed Oct 29, 2008).
countries including Kenya, Ethiopia, Uganda, Zambia, and Algeria revealed excessive dietary iodine associated with overiodisation of salt supplies.3 A similar situation was reported in Sudanese children dependent on humanitarian food assistance.4 These reports call for urgent monitoring of iodisation in displaced African populations. Vigilance is particularly required where migrant flows arise from severely deficient areas. As noted by Zimmermann and colleagues, precipitous increases in iodine can be harmful in individuals with pre-existing thyroid autonomy (ie, thyroids that can function in the absence of thyroidstimulating hormone). The recorded deaths in Zimbabwe in the 1990s should serve as a reminder that iodineinduced hyperthyroidism is not always benign in poor communities with limited access to health-care facilities.5 Nevertheless, the risks of iodisation should in no way deter from the ultimate goal of eliminating iodine deficiency. Rather, the task ahead must focus on developing sustainable systems for systematic collection of iodine nutrition data in African populations. Such information will allow appropriate correction of iodine deficiency with safe levels of iodisation. I declare that I have no conflict of interest.
Iodisation in displaced African populations
Onyebuchi E Okosieme
In their excellent Seminar on iodinedeficiency disorders (Oct 4, p 1251),1 Michael Zimmermann and colleagues highlight the growing problem of excess iodine intake in some sub-Saharan African countries. However, they do not address concerns regarding excessive iodine intake in refugee and displaced populations within the region. Sub-Saharan Africa has an estimated 16 million refugees and displaced people, many of whom rely on iodised salt provided through food aid from regional governments and international aid agencies.2 A survey in refugee settlements across several African
Prince Charles Hospital, Cwm Taf NHS Trust, Merthyr Tydfil CF47 9DT, UK
[email protected]. nhs.uk
1
2
3
4
5
Zimmermann MB, Jooste PL, Pandav CS. Iodine-deficiency disorders. Lancet 2008; 372: 1251–62. International Organization for Migration. World migration report 2005: costs and benefits of international migration. Geneva: International Organization for Migration, 2005. http://www. iom.int/jahia/Jahia/cache/offonce/pid/ 1674?entryId=932 (accessed Nov 26, 2008). Seal AJ, Creeke PI, Gnat D, Abdalla F, Mirghani Z. Excess dietary iodine intake in long-term African refugees. Public Health Nutr 2006; 9: 35–39. Izzeldin HS, Crawford MA, Jooste PL. Population living in the Red Sea State of Sudan may need urgent intervention to correct the excess dietary iodine intake. Nutr Health 2007; 18: 333–41. Todd CH, Allain T, Gomo ZA, Hasler JA, Ndiweni M, Oken E. Increase in thyrotoxicosis associated with iodine supplements in Zimbabwe. Lancet 1995; 346: 1563–64.
www.thelancet.com Vol 373 January 17, 2009
Improving health research Your Editorial “The state of health research worldwide” (Nov 1, p 1519)1 identifies three key gaps, including assessment of health programmes, that have hindered progress in health systems, policy, and health services and research. However, in relation to the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Editorial is misleading in asserting that “not once has there been an independent, full, and scientifically rigorous evaluation of its programme since it was created in 2002.” In October, 2003, the Global Fund Board mandated an independent Technical Evaluation Reference Group (TERG) comprising public-health experts appointed by the Board to oversee monitoring and assessment of activities and programmes financed by the Global Fund. Since 2004, TERG has commissioned a series of assessments addressing key elements of the Global Fund’s architecture and processes. These assessments, which are publicly available,2 have led to adjustments in Global Fund practices. Additionally, academic institutions and government agencies have undertaken assessments of the Global Fund’s activities and supported programmes. In November, 2006, less than 5 years after the creation of the Global Fund, the Global Fund Board decided to commission a substantial independent assessment under the oversight of the TERG. The TERG is currently overseeing this 5-year assessment of the Global Fund, which comprises three interlinked studies: examining organisational efficiency and effectiveness of the Global Fund; the effectiveness of its partner environment; and the combined effect on the reduction in the burden of the three diseases.3 The results of this significant effort will be available in Spring, 2009. TERG welcomes the commitment of the Global Fund to Fight AIDS, Tuberculosis and Malaria and encourages collaboration with external www.thelancet.com Vol 373 January 17, 2009
Technical Evaluation Reference Group, Global Fund to Fight AIDS, Tuberculosis and Malaria, 1214 Vernier, Geneva, Switzerland
have incorporated and housed it in the Netherlands. It is modelled on other national advisory bodies such as the US National Research Council and the UK Royal Society. It has already provided several independent policy advisory studies to the Secretary General of the UN on matters with important bases in science and technology. What is important is its independence from political influence from national or international political entities—something unavoidable in UN-housed or WHOhoused advisory bodies.
1
I declare that I have no conflict of interest.
institutions to monitor, assess, and research its functioning and effects. Additionally, the Global Fund encourages countries to request in their grant proposals monies to invest in strengthening country-level monitoring and assessment systems and to fund operational research.4 We declare that we have no conflict of interest.
*Rolf Korte, Rose Leke [email protected]
2
3
4
The Lancet. The state of health research worldwide. Lancet 2008; 372: 1519. The Global Fund evaluation library. http:// www.theglobalfund.org/en/library/ (accessed Nov 5, 2008). The five year evaluation of the Global Fund. http://www.theglobalfund.org/en/terg/5year/ (accessed Nov 5, 2008). Evans T, Nishat S, Atun R, Etienne C. Scaling up research and learning for health systems: time to act. Lancet 2008; 372: 1529–31.
Your Editorial on the state of health research worldwide1 raises several interesting points that merit further comment. Research indeed needs political traction, and institutions to create such traction, but my experience suggests that an institution based on the G8 model is not likely to be successful. The annual G8 host country chooses the political and policy agenda items for the meeting and invites its national science academies to weigh in on any relevant science and technology issues related specifically to that agenda. I doubt very much that the political leadership would be interested in providing a platform for their health research agencies of government or their independent science and medical academies to issue their own “research agenda” for the political leaders. There is a nascent approach which could speak to the first of your “key gaps”—ie, the independent assessment of health programmes. The globe’s national science, medicine, and engineering academies have established a young, international, independent science and technology advisory body called the InterAcademy Council and
The printed journal includes an image merely for illustration
David R Challoner drc@ufl.edu University of Florida, Gainsville, FL 32610, USA 1
The Lancet. The state of health research worldwide. Lancet 2008; 372: 1519.
The Lancet’s call for a G8 for research (R8)1 is welcome. In a review of the current state of neurology in Africa, for example, Owolabi and colleagues2 detailed the appalling state of research facilities, which has in turn led to poor contributions from Africa to the frontiers of neurology. The poor state of neurological research mirrors the current state of research in all health fields in Africa and other resourcepoor nations. An institution such as R8 should work closely with regional organisations such as the African Union to ensure a progressive reduction of the disease burden in these countries. That the Global Ministerial Forum on Research for Health was held in Bamako, Mali, is historic. In 1987, Bamako hosted a meeting of African Health Ministers where the Bamako Initiative, incorporating strategies to increase the availability of essential drugs and other health-care services for sub-Saharan Africans, was adopted. One hopes that political leaders now move from rhetoric to concrete actions geared at improving global access to quality research funding, facilities, and institutional support. African political leaders need to use the African Union and similar platforms to strengthen 213
Correspondence
local research institutions, eradicate corruption, improve provision of social amenities, and ultimately reduce the African disease burden. I declare that I have no conflict of interest.
Taopheeq Bamidele Rabiu [email protected] Department of Neurological Surgery, University College Hospital, Ibadan, Oyo 200001, Nigeria 1 2
The Lancet. The state of health research worldwide. Lancet 2008; 372: 1519. Owolabi MO, Bower JH, Ogunniyi A. Mapping Africa’s way into prominence in the field of neurology. Arch Neurol 2007; 64: 1696–700.
Injury control in China: priorities and actions
Photolibrary
We congratulate S Y Wang and colleagues (Nov 15, p 1765)1 on their excellent analysis of China’s injuryrelated fatalities. Hopefully, their conclusions will push forward the movement of injury control in China. Additionally, the following three points should be given high priority and put into practice as soon as possible. First, China needs to establish a single agency to take charge of injury control.2 Currently, the injury-control programme is assigned to the national chronic disease centre, where other priorities could delay implementation of injury-prevention programmes. Second, China needs to integrate existing data resources, improve the quality of data, and open it up to the public. China already possesses useful data resources including national health vital registration, the national health interview survey, emergency department and hospital discharge records, and a national transportation yearbook. However, the data within these sources have rarely been integrated to serve injury prevention,2 the quality of data is unsatisfactory,1,2 and they are often inaccessible to researchers. Third, China needs to increase support to injury research as soon as possible. Although China’s health authorities have recently begun to recognise the importance of injury,3 we cannot find 214
injury in China’s 11th 5-year health development plan (2007).4 About 4 billion Yuan are allocated to innovative drugs and 1 billion to infectious diseases in the second-round grant of China’s 11th 5-year scientific plan (2008),5 but we see no support for research on injury—the leading cause of death in China from age 1 to 40 years. We declare that we have no conflict of interest.
*Guoqing Hu, Timothy D Baker, Susan P Baker [email protected] Department of Epidemiology and Health Statistics, School of Public Health, Central South University, 110 Xiangya Road, Changsha, Hunan 410078, China (GH); Department of International Health (TDB) and Center for Injury Research and Policy, Department of Health Policy and Management (SPB), Johns Hopkins Bloomberg of School of Public Health. Baltimore, MD, USA 1
2
3
4
5
Wang S, Li Y, Chi G, Xiao S, Ozanne-Smith J, Stevenson M, Phillips M. Injury-related fatalities in China: an under-recognised public-health problem. Lancet 2008; 372: 1765–73. Hu G, Baker TD, Li G, Baker SP. Injury control: an opportunity for China. Injury Prev 2008; 14: 129–30. Disease Prevention and Control Bureau of Ministry of Public Health. Report on injury prevention in China. Beijing: People’s Medical Publishing House, 2007. State of Council. The 11th five-year plan of China’s health development. http://www.moh. gov.cn (accessed Oct 29, 2008). Ministry of Health and Ministry of Science and Technology. The second round grant of the 11th five-year scientific planning of China. http:// www.moh.gov.cn (accessed Oct 29, 2008).
countries including Kenya, Ethiopia, Uganda, Zambia, and Algeria revealed excessive dietary iodine associated with overiodisation of salt supplies.3 A similar situation was reported in Sudanese children dependent on humanitarian food assistance.4 These reports call for urgent monitoring of iodisation in displaced African populations. Vigilance is particularly required where migrant flows arise from severely deficient areas. As noted by Zimmermann and colleagues, precipitous increases in iodine can be harmful in individuals with pre-existing thyroid autonomy (ie, thyroids that can function in the absence of thyroidstimulating hormone). The recorded deaths in Zimbabwe in the 1990s should serve as a reminder that iodineinduced hyperthyroidism is not always benign in poor communities with limited access to health-care facilities.5 Nevertheless, the risks of iodisation should in no way deter from the ultimate goal of eliminating iodine deficiency. Rather, the task ahead must focus on developing sustainable systems for systematic collection of iodine nutrition data in African populations. Such information will allow appropriate correction of iodine deficiency with safe levels of iodisation. I declare that I have no conflict of interest.
Iodisation in displaced African populations
Onyebuchi E Okosieme
In their excellent Seminar on iodinedeficiency disorders (Oct 4, p 1251),1 Michael Zimmermann and colleagues highlight the growing problem of excess iodine intake in some sub-Saharan African countries. However, they do not address concerns regarding excessive iodine intake in refugee and displaced populations within the region. Sub-Saharan Africa has an estimated 16 million refugees and displaced people, many of whom rely on iodised salt provided through food aid from regional governments and international aid agencies.2 A survey in refugee settlements across several African
Prince Charles Hospital, Cwm Taf NHS Trust, Merthyr Tydfil CF47 9DT, UK
[email protected]. nhs.uk
1
2
3
4
5
Zimmermann MB, Jooste PL, Pandav CS. Iodine-deficiency disorders. Lancet 2008; 372: 1251–62. International Organization for Migration. World migration report 2005: costs and benefits of international migration. Geneva: International Organization for Migration, 2005. http://www. iom.int/jahia/Jahia/cache/offonce/pid/ 1674?entryId=932 (accessed Nov 26, 2008). Seal AJ, Creeke PI, Gnat D, Abdalla F, Mirghani Z. Excess dietary iodine intake in long-term African refugees. Public Health Nutr 2006; 9: 35–39. Izzeldin HS, Crawford MA, Jooste PL. Population living in the Red Sea State of Sudan may need urgent intervention to correct the excess dietary iodine intake. Nutr Health 2007; 18: 333–41. Todd CH, Allain T, Gomo ZA, Hasler JA, Ndiweni M, Oken E. Increase in thyrotoxicosis associated with iodine supplements in Zimbabwe. Lancet 1995; 346: 1563–64.
www.thelancet.com Vol 373 January 17, 2009