The research agenda for child health and nutrition: Filling the gaps Igor Rudan, Shams El Arifeen and Robert E. Black Child Health and Nutrition Research Initiative (CHNRI) An initiative of the Global Forum for Health Research

Research agenda from the perspective of disease burden reduction: Assessing the burden correctly

Research agenda from the perspective of disease burden reduction: Assessing the burden correctly Understanding the “architecture” of the burden (identifying key risk factors and measuring exposures in the population)

Research agenda from the perspective of disease burden reduction: Assessing the burden correctly Understanding the “architecture” of the burden (identifying key risk factors and measuring exposures in the population) Developing, evaluating and implementing interventions to reduce the burden

Research agenda from the perspective of disease burden reduction: Assessing the burden correctly Understanding the “architecture” of the burden (identifying key risk factors and measuring exposures in the population) Developing, evaluating and implementing interventions to reduce the burden Setting priorities in future health research investments to reduce the burden systematically, fairly and cost-efficiently

I. ASSESSING THE BURDEN CORRECTLY

WHO Child Health Epidemiology Reference Group (CHERG): Conducted systematic reviews to identify data from the period on the major causes of morbidity and mortality in children under 5 years in countries with vital registration coverage <90% From more than 17,000 papers reviewed, only 308 studies (“information units”) considered likely to provide unbiased estimates of disease burden in a community

Geographical distribution of 308 studies

Time trends in conducting the 308 studies

The information units are generally very scarce They tend to cluster in 5 regions: Northeastern Brazil West Africa (especially in The Gambia) East Africa (especially in Tanzania) Egypt Bangladesh, North India and Pakistan (Geographic distribution highlights the role of International Research Centres)

The level of research output on epidemiology of childhood pneumonia and diarrhoea has fallen sharply since the late 1980s This coincides with the development of highly cost-effective interventions to fight the two diseases However, 20 years later they still remain the two leading single causes of death in children under 5 years of age globally

Between , CHERG found no units of information in public domain in “gap” countries where 30% of all child deaths occur: Middle East and North Africa (Afghanistan, Iran, Iraq, Somalia, Sudan, Yemen) Sub-Saharan Africa (Angola, Burkina Faso, Madagascar, Mozambique, Niger, Uganda and Zambia) Asian countries (China, Laos, Burma, Philippines and Vietnam) Gaps?

II. UNDERSTANDING THE “ARCHITECTURE” OF THE BURDEN

Situation analysis in the population

Understanding the prevalence of exposure to risk factors and intervention coverage globally is improving (e.g. MICS, DHS): Prevalence of risk exposures and intervention coverage now estimated for countries housing more than 90% of all under-fives The data still missing for a considerable number of countries (up to 20%, depending on the risk factor or intervention): the priorities are Somalia and Afghanistan The uncertainty around the estimates is unclear – the inter-country variation is often very large Gaps?

III. DEVELOPING AND IMPLEMENTING INTERVENTIONS

COMPONENTS OFDISEASE BURDEN UNAVERTABLE BOX 4 WITH EXISTING (RESEARCH ON NEW INTERVENTIONS) INTERVENTIONS BOX 1: BURDEN AVERTED WITH CURRENT MIX OF RISK AVOIDANCE AND COVERAGE BY INTERVENTIONS BOX 2: AVERTABLE WITH BETTER DEPLOYMENT OF EXISTING INTERVENTIONS (RESEARCH ON HEALTH SYSTEMS AND POLICY) BOX 3: AVERTABLE BY IMPROVING EXISTING INTERVENTIONS (RESEARCH TO REDUCE COST/ IMPROVE DELIVERABILITY) Impact of interventions on disease burden by instruments of health research (Box 2,3,4)

Promoting the value of health policy and systems research, and of the research on improving the existing interventions Health policy and systems research along with multidisciplinary research on original and more creative approaches to delivering interventions could substantially improve the coverage The research on improving the existing interventions could make them more deliverable, affordable and sustainable Gaps?

IV. SETTING PRIORITIES IN HEALTH RESEARCH INVESTMENTS

Investing in health research

A concern: Prioritization in research funding is partly driven by attractiveness, advocacy and potential for high publication impact This favours research on new interventions (BOX 4), mainly basic research addressing very difficult upstream technology developments COMPONENTS DISEASE OF BURDEN UNAVERTABLE BOX 4 WITH EXISTING (RESEARCH ON NEW INTERVENTIONS) INTERVENTIONS BOX 1: BURDEN AVERTED WITH CURRENT MIX OF RISK AVOIDANCE AND COVERAGE BY INTERVENTIONS BOX 2: AVERTABLE WITH BETTER DEPLOYMENT OF EXISTING INTERVENTIONS (RESEARCH ON HEALTH SYSTEM AND POLICY) BOX 3: AVERTABLE BY IMPROVING EXISTING INTERVENTIONS (RESEARCH TO REDUCE COST/ IMPROVE DELIVERABILITY)

Funding available for BOX 4 research grossly exceeds that on delivery, health policy and systems research (BOX 2) or on improving the existing interventions (BOX 3) COMPONENTS DISEASE OF BURDEN UNAVERTABLE BOX 4 WITH EXISTING (RESEARCH ON NEW INTERVENTIONS) INTERVENTIONS BOX 1: BURDEN AVERTED WITH CURRENT MIX OF RISK AVOIDANCE AND COVERAGE BY INTERVENTIONS BOX 2: AVERTABLE WITH BETTER DEPLOYMENT OF EXISTING INTERVENTIONS (RESEARCH ON HEALTH SYSTEM AND POLICY) BOX 3: AVERTABLE BY IMPROVING EXISTING INTERVENTIONS (RESEARCH TO REDUCE COST/ IMPROVE DELIVERABILITY)

Redefining a “health research option”

Development of priority setting methodology that should: take into account more dimensions relevant for priority setting than attractiveness, level of advocacy and potential publication impact be simple enough to gain wider acceptance be applicable at different levels and for different priority setting questions and problems be systematic, scientifically sound and repeatable be fair, transparent and legitimate Gaps?

The proposed next steps by CHNRI* in developing and applying the new priority setting methodology Application in several different topics at the global level (major child diseases, conditions or risk factors), at the national level (in 1 developing country as a model), and within 1 major funding/donor agency Testing the application on health policy and systems research avenues (Box 2) across all major diseases / conditions Developing user-friendly tool (software) with appropriate user manual to enable child health research priority setting based on the proposed conceptual framework Child Health and Nutrition Research Initiative of the Global Forum for Health Research;

Credits: This presentation was compiled using substantial input from a large number of individuals working for: Child Health Epidemiology Reference Group (CHERG) CHNRI Board and Secretariat, Dhaka, Bangladesh Joint Centre for Bioethics, University of Toronto, Canada The University of Phillipines (formerly COHRED) Disease Control Priorities Project II The World Bank Johns Hopkins Bloomberg School of Public Health, Baltimore, USA The University of Edinburgh, Scotland, UK