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global health

At the European Cardiology Congress in Paris this week, the news is that cardiovascular medicine is still producing tonnes of new research and there are therapeutic advances in all areas from atrial fibrillation and stroke to heart failure and heart attacks. For example, there are 3 new oral anticoagulants (blood-thinning drugs) which offer true alternatives to warfarin for the first time in 50 years. All these drugs have shown superiority in recent trials presented at this meeting- rivaroxaban in ROCKET-AF, apixaban in ARISTOTLE and dabigatran in the RE-LY trial.

Salim Yusuf, arguably one of the most prolific clinical triallists and lead investigator in two of those trials, also presented the results of a different type of study, published in the Lancet this week. The PURE study included over 150000 patients with known coronary heart disease from 17 countries and showed that even in high-income countries. The drug treatments that such patients should be taking are well-established and available very cheaply-aspirin, beta-blockers, ACE-inhibitors and statins. Depressingly, the proportion of patients globally taking these drugs is less than 50% even in rich countries. In Africa, 80% of eligible patients were taking no drugs at all. As Salim Yusuf said, treatment gaps like this in the HIV/AIDS epidemic led to human rights arguments for broadening of antiretroviral treatment and mobilisation of the global health community and governments.

The inequality was also visible at concurrent “Meet the Triallists” sessions. Delegates clamoured to get to the trial update for the ARISTOTLE trial of the novel anticoagulant, apixaban, but I was one of only 20-30 people who heard Salim Yusuf talk about the PURE trial. Global health cardiology is just not sexy enough yet, even in the wake of the UN high-level meeting in September.

You could argue what is the point of all these fancy new drugs if we are failing to get simple, cheap, proven therapies to the people who need them most, even in rich countries. The tsunami of cardiovascular disease hitting all countries is not going to be touched by all the new drugs currently being trialled. We have to get better at translation. More research funders and senior researchers need to lead new trials with global health impact if we are to have any chance of focusing on problems worth researching.

Increase in UK and global research funding-value for money?

Ami Banerjee
Last edited 12th March 2011

Last week, the UK government unveiled plans to put £775 million of extra research funding into the NHS over the next 5 years. In addition, the newly appointed Chief Medical Officer, Professor Dame Sally Davies, is also Director General of Research and Development and Chief Scientific Adviser for the Department of Health and NHS, and so has a longstanding passion for raising the profile of health research.

If we look around the world, health research funding has also grown substantially, with US$ 160.3 billion spent in 2005, up from US$ 125.8 billion in 2003. In 2005, the UK was the third largest spender on health research at US$4.2 billion, after the US and Japan. The World Health Report 2012, boldly titled “No Health Without Research” will focus on the role of research and evidence in the improvement of global health. Over the last 5 years, the World Health Organization has been making a sustained effort at the international level to encourage research initiatives in public health, including:

  1. The 2005 World Health Assembly Resolution 58.34, which called upon WHO member states to “establish or strengthen mechanisms to transfer knowledge in support of…. evidence-based health-related policies.”
  2. The Bamako Call to Action, which urged governments to allocate at least 2% of budgets of ministries of health to research and to earmark at least 5% of funding for research, including support for knowledge translation practices.

There is no doubt that more funding and resources, both in the UK and globally, will lead to more research and hopefully more evidence for clinical practice and policy, but will this lead to improvement of health or health systems? The Global Forum for Health Research found that 97% of spending on health R&D continues to be by high-income countries, with only 3% by low- and middle-income countries. Unsurprisingly, most of this money goes towards generating products, processes and services tailored to needs of the health-care markets of the richer countries. In the UK as well, there are differences of opinion over whether money in research is well spent and whether universities manage health research better than the NHS, and about the amount of resource that is wasted in the current research infrastructure.

There has been a trend towards more funding for translational research in recent years (i.e. research that actually changes practice), both globally and in the UK. Particularly since large amounts of public money are invested in research, the scientific machine must try harder to make research relevant to the health of all sectors of the population, and make the most efficient use of this research. Worldwide, ‘global health financing’ has aimed to address this issue, by channelling external finance towards the health sector of low and middle income countries in order to meet the needs of predominantly poor population groups. The increase in private funding for global health now accounts for 25% of all development aid for health. However, inadequate monitoring and tracking of resources may have complicated and fragmented health systems. This is an important lesson for UK research funding.

The next paradigm shift is the change in the manner in which research is communicated and disseminated. The usefulness of research cannot only be measured by publications because of lack of access to journals and lack of access to research institutions. Blogging, Twitter and mobile technologies are examples of media already filling a void in research communication and will play a growing role. New metrics for evaluation of health research which assess its health and broader societal impact may not be far off. The bottom line is that more funding for health research is very welcome but it must be adequately allocated, monitored and tracked to ensure that the resources are properly used and not wasted.

Recognising the global importance of research

Ami Banerjee
Last edited 22nd October 2010

Evidence-based medicine is one arm of a global movement to apply proven research findings in day-to-day decision-making in healthcare. Research is needed to provide this evidence. Healthcare systems need a research agenda so that they can produce and use relevant evidence. Like many global inequalities in healthcare, from the burden of disease and access to simple drugs, to human and financial resources, the gap between research in low-income countries and research in developed countries is wide.

In 1990, the Commission on Health Research for Development estimated that only about 5% of the world's resources for health research (which totaled US$ 30 billion in 1986) were being applied to the health problems of low- and middle-income countries, where 93% of the world's preventable deaths occurred. In 1998, the Global Forum for Health Research first coined the term, “10-90 gap”, to capture the fact that 10% of resources were being spent on the diseases that made up 90% of disease burden. The gap is even wider when you look at research that is published in the major journals such as the New England Journal of Medicine: more like a 2-98 gap.

Things happen slowly in global health policy but they seem to be finally happening. The theme of the 2012 World Health Report: Better Research for Better Health will actually be health research and its role in improving healthcare and health systems. By doing this, the WHO is sending a clear message to all countries of the world of the powerful role of health research and its role in evidence-based practice and evidence-based policy.

Over the last 2 decades, we have seen rising aid and development budgets and a multiplication in the number of donors at the table, particularly in the field of HIV/AIDS, TB and malaria. The World Health Organisation has been leading a global movement to raise the profile of chronic diseases such as cardiovascular diseases (mainly stroke and coronary heart disease) and cancer since they account for nearly 60% of global disease burden.

This week, I attended a series of stakeholder meetings in Geneva organised by WHO, which is developing a prioritised research agenda for chronic diseases and will set out a roadmap of how research can and should be done, even in the most resource-poor settings. The themes of public-private partnerships and increased capacity-building and growth of links between research institutions in developed and developing countries permeated the meetings. There have been many calls for action from scientific and broader communities, and the time for action is now here.

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