Date Published: March 10, 2009
Publisher: Public Library of Science
Author(s): 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
Abstract: Olivier Fontaine and colleagues applied a priority-setting methodology to identify research priorities aimed at reducing global diarrhea mortality by 2015.
Partial Text: Childhood diarrhoea still claims nearly 2 million lives each year and remains responsible for 18% of all child deaths [1,2]. 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 [6,7].
The CHNRI methodology for setting priorities in health research investments was proposed as a tool that could be used by those who develop research policy and/or invest in health research [10–12]. It should assist them to understand (i) the full spectrum of research investment options, (ii) the potential risks and benefits that can result from investments in different research options, and (iii) the likelihood of achieving reductions of persisting burden of disease and disability through investments. The CHNRI methodology has three stages: input from investors and policy makers (defining the context and criteria for priority setting); input from technical experts (listing and scoring research investment options); and input from other stakeholders (weighing the criteria according to wider societal system of values) [10–12].
Table 1 and Table 2 show the top and bottom 10% of the 154 research questions. Both tables clearly present the likelihood for each research question to comply with each of the five chosen priority-setting criteria. Research questions from all four broad research domains (epidemiological research; health systems and policy research; research to improve the existing interventions; and research to develop new interventions) feature in both the top 10% and the bottom 10% of research questions. In Table 1, research questions with ranks 1, 2, 8, 9, 11, and 12 represent the domain of epidemiological research; 3, 4, 5, 6, and 10 represent health systems and policy research; 13 and 14 represent research to improve the existing interventions; and 7 and 15 represent research to develop new interventions. In Table 2, the same is true for questions with ranks 141 and 143 (epidemiological research); 147 and 148 (health systems and policy research); and 146 (research to improve the existing interventions); while the remaining questions represent the “research to develop new interventions” domain. This suggests that the CHNRI method managed to compare and discriminate among questions addressing very different domains of health research using the same framework, and that there was no systematic bias against research questions from any of the four domains.
The amount of funding available today for health research globally is unprecedented—the research investment market has been growing steadily over the past decade to more than US$126 billion in 2003 . However, large inequities exist between amounts invested in different conditions that contribute to the global burden of disease. For example, while research on diabetes type 2 receives approximately US$102 per DALY, research on diarrhoea receives less than US$10 per DALY .
Although the advantages of the CHNRI methodology represent a serious attempt to deal with many issues inherent to a highly complex process of research investment priority setting, there are still concerns over the validity of the CHNRI approach and related biases. One of them is related to the fact that many possible good ideas (“research investment options”) may not have been included in the initial list of research options that was scored by the experts, and to the potential bias towards items that get the greatest press. Another concern over the CHNRI process is that its end product represents a possibly biased opinion of a very limited group of involved people. In theory, a chosen group of experts can have biased views in comparison to any other potential groups of experts. Those limitations are described and discussed in greater detail in Text S1.
The main message of the process is that the research priorities to reduce global mortality from childhood diarrhoea within the present context are dominated by health systems, policy research, and epidemiological questions. These questions are mainly targeted at better understanding the barriers towards implementation, effectiveness, and optimisation of use of available interventions and programmes such as oral rehydration solution, zinc supplementation, exclusive breastfeeding, and integrated management of childhood illness. If progress towards reduction of global diarrhoea mortality is to be improved by 2015, these are the research questions that are most likely to be of greatest importance. However, very few donors agencies recognise the importance of these domains of health research and are willing to readily invest in those options [4,17]. The core group of CHNRI experts made several serious attempts to influence the key donors and point to this gap and serious imbalance in health research investing between “upstream” and “downstream” health research. This exercise is the best example to date conducted at the global level.