BREAKOUT SESSION
Emergency Care Research Funding in the Global Health Context: Trends, Priorities, and Future Directions Alexander Vu, DO, MPH, Herbert C. Duber, MD, MPH, Scott M. Sasser, MD, Bhakti Hansoti, MBchB, MPH, Catherine Lynch, MD, Ayesha Khan, MD, Tara Johnson, MD, MPH, Payal Modi, MD, Eben J. Clattenburg, and Stephen Hargarten, MD, MPH
Abstract Over the past few decades there has been a steady growth in funding for global health, yet generally little is known about funding for global health research. As part of the 2013 Academic Emergency Medicine consensus conference, a session was convened to discuss emergency care research funding in the global health context. Overall, the authors found a lack of evidence available to determine funding priorities or quantify current funding for acute care research in global health. This article summarizes the initial preparatory research and reports on the results of the consensus conference focused on identifying challenges and strategies to improve funding for global emergency care research. The consensus conference meeting led to the creation of near- and long-term goals to strengthen global emergency care research funding and the development of important research questions. The research questions represent a consensus view of important outstanding questions that will assist emergency care researchers to better understand the current funding landscape and bring evidence to the debate on funding priorities of global health and emergency care. The four key areas of focus for researchers are: 1) quantifying funding for global health and emergency care research, 2) understanding current research funding priorities, 3) identifying barriers to emergency care research funding, and 4) using existing data to quantify the need for emergency services and acute care research. This research agenda will enable emergency health care scientists to use evidence when advocating for more funding for emergency care research. ACADEMIC EMERGENCY MEDICINE 2013; 20:1259–1263 © 2013 by the Society for Academic Emergency Medicine
O
ver the past two decades there has been tremendous growth in the scientific field of global health. In particular, there has been a signifi-
cant monetary investment in the creation of a variety of global health programs around the world. This investment has come through government programs such as
From the Department of Emergency Medicine, Johns Hopkins University (AV, BH), Baltimore, MD; the Division of Emergency Medicine, Department of Medicine, and Institute for Health Metrics and Evaluation, University of Washington (HCD), Seattle, WA; the Department of Emergency Medicine, Emory University (SMS), Atlanta, GA; the Division of Emergency Medicine, Department of Surgery, Duke University (CL), Durham, NC; the Division of Emergency Medicine, Department of Surgery, Stanford University (AK), Stanford, CA; the Department of Emergency Medicine, Maricopa Integrated Health System (TJ), Phoenix, AZ; the Department of Emergency Medicine, Warren Alpert Medical School of Brown University (PM), Providence, RI; the Johns Hopkins University School of Medicine (EJC), Baltimore, MD; and the Department of Emergency Medicine, Medical College of Wisconsin (SH), Milwaukee, WI. Received July 15, 2013; revision received August 13, 2013; accepted August 13, 2013. This article reports on a breakout session of the May 2013 Academic Emergency Medicine consensus conference in Atlanta, GA: “Global Health and Emergency Care: A Research Agenda.” Breakout session participants: Theodore Christopher, Eben Clattenburg, Hillary Cohen, Herbert C. Duber, Nathalie Flacke, Rohini Haar, Bhakti Hansoti, Stephen Hargarten, Melanie Hogg, Stephanie Hubbard, Naomi Jean-Baptiste, Tara Johnson, Ayesha Khan, Elizabeth Krebs, Anita Kurt, Catherine Lynch, Payal Modi, Donna Moro-Sutherland, C. Nee-Kofi Mould-Millman, Andrew Muck, Margaret Murray, Leila Posaw, Michael Runyon, Scott M. Sasser, Cynthia Singh, Alexander Vu, Rebecca Walker, Ryan Wubben, Anna Yaffee, and Justin Yax. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Mark Hauswald, MD. Address for correspondence and reprints: Alexander Vu, DO, MPH; e-mail: [email protected].
© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12267
ISSN 1069-6563 PII ISSN 1069-6563583
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the President’s Emergency Plan for AIDS Relief (PEPFAR), from multilateral organizations (e.g., the Global Fund for AIDS, TB, and Malaria), and from private donors such as the Bill and Melinda Gates Foundation, as well as many other public and private organizations.1 While most funding has been earmarked for program development and implementation, there has also been a steady growth in research funding. However, much of this research funding has been directed toward specific disease processes, and little has focused on emergency care research.2 This article puts forth a consensus view on the current landscape of funding for emergency care research and the science of global health. The objectives of this paper are: 1) to define the need for emergency care research and its application in global health, 2) to examine the funding history of global health and emergency care research, 3) to explore priorities in global health and emergency care research funding, and 4) to propose a framework to guide decisions for future funding for global emergency care research. In doing so, we also identify two critical shortcomings necessary for future evidence-based discussion of emergency care research funding: inadequate transparency to quantify funding for emergency care research and limited health information from which priorities in emergency care funding can be determined. EMERGENCY CARE RESEARCH: DEFINING THE NEED Emergency care is a broad field in both its scope of work and in those who perform it. Unlike many other disciplines, emergency care is not limited to a single organ or functional system, and providers of emergency care have various levels of training in emergency medicine (EM) and other specialties such as trauma surgery. Emergency care is also unique in that it spans from the home (e.g., cardiopulmonary resuscitation) and community (e.g., car crash injuries) to the hospital, and almost everyone is likely to require and/or seek emergency services at some point in their lifetime.3 Emergency care research, consistent with the range of patients with perceived urgent and emergent complaints, spans an array of “time-sensitive, emergency care, as well as chronic care, individual organ systems, whole health care systems, and population health.”4 More specifically, a core hypothesis of emergency care research is that “rapid diagnosis and early intervention in acute illness and injury or acutely decompensated chronic illness improves patient outcomes.”5 Nearly all such studies, however, have been performed in developed countries where medical services and resources are more readily available compared to low- and middle-income countries.2 Despite many advances in a variety of fields from sepsis to myocardial infarction to stroke, the need for expanding emergency care research is critical. One field of study within emergency care where this is particularly true is health systems. Research must not only focus on the services provided, but how they can be administered effectively and efficiently. The 2010 Academic Emergency Medicine consensus conference on
Vu et al. • RESEARCH FUNDING IN THE GLOBAL HEALTH CONTEXT
the integration of emergency care systems reported that “there are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the network of emergency care.”6 In addition, Lurie and colleagues7 recently reported critical deficits in research related to public health emergencies, calling for an integrated approach to performing such research. Low- and middle-income countries represent the core constituents at the intersection of global health and emergency care research. These countries often have restricted or limited resources, consumables, technologies, and infrastructure, all of which limit the application of research performed in high-income countries.8,9 Furthermore, the burden of emergency care illnesses and injuries is often different, as are the various cadres of health workers providing emergency care. Due to these differences, as well as unique cultural, political, and social aspects of delivering care in vastly different places, emergency care research remains an important field of study on the global health research agenda. FUNDING HISTORY OF GLOBAL HEALTH AND EMERGENCY CARE RESEARCH Funding for global health has grown significantly over the past two decades. In 1990, an estimated US$5.6 billion was spent on development assistance for health, while 2011 estimates are approximately US$27.7 billion.10 Although funding of global health research was presumed to be increasing as well, identifying how much is spent on global health research and what types of research are being funded has proven to be a more challenging task.11 Funding for such research may come through the public or private sector or some combination thereof (public–private partnerships). Money may be distributed through unilateral or multilateral governments and organizations, not all of whom are transparent regarding how research dollars are spent.12 As a result, little is currently known about the total amount of spending on global health research. Funding for emergency care research in the global health context is even more challenging, as few grants are overtly geared toward emergency care research.13 Some money in the realm of global emergency care has focused on areas that would clearly be considered as part of EM, in countries that consider EM as a specialty, such as disaster-preparedness and management and programmatic activities. Based on consensus conference discussions, many, if not most, global health emergency care researchers find funding that is not directly focused on the field. Most funding, in fact, is simply included under less specialty-specific headings such as trauma care or emergency obstetrics. Researchers instead find grants in other areas of available funding (such as HIV or trauma care focused funding) and find creative ways of applying such funding to emergency care research questions through collaboration with other specialties (e.g., infectious diseases, surgery, obstetrics, or pediatrics). Within the United States, there has been increased recognition of the lack of resources and focus on emergency
ACADEMIC EMERGENCY MEDICINE • December 2013, Vol. 20, No. 12 • www.aemj.org
care research.4,14–16 As a result, the National Institutes of Health created the Office of Emergency Care Research (OECR), house within the National Institute of General Medical Sciences. It has the goal of coordinating and fostering basic, clinical, and translational research and research training for the emergency setting.17 Its scope is broad, and if implemented well, will provide an excellent resource for emergency care researchers.18 However, the OECR has no grant-making capabilities. Rather it will function as a conduit with other grant-making institutes at the NIH, and in doing so help to coordinate funding opportunities related to emergency care that involve multiple NIH institutions and centers. In addition, given that the OECR grew out of the IOM reports’ findings on deficiencies within the domestic emergency care system, it is unclear to what extent the OECR will advocate for global emergency care research. DETERMINING PRIORITIES FOR GLOBAL HEALTH RESEARCH: WHERE DOES EMERGENCY CARE RESEARCH FIT? Regardless of the amount of money invested in the global health research arena, it remains a finite sum that is distributed among many parties with various interests. As such, the creation of a reasonable list of priorities could help to determine what share of funding should be directed toward emergency care research. How these priorities are determined, who is making that determination, and how funds are distributed are all important variables that deserve further attention and deliberation. Much has been written on the “10/90 gap,” the concept that only 10% of research and development funds are directed toward 90% of the global burden of disease.19 While the data to support this have been called into question,20 the underlying premise that there is a mismatch between important public health issues and research funding is a valid concern.21,22 Many hypotheses exist as to why this mismatch occurs, but one prominent crosscutting theme is the concern that donor-driven funding patterns are not responsive enough to local governments or health authorities.1 Ideally, priorities for health programming and research are identified and determined based on local needs assessments.23 However, this is often not the case, and numerous reasons have been identified. First, there are significant diagnostic challenges due to limited resources, inadequate medical training, and poor performance of clinical algorithms in low- and middle-income countries.24,25 This is especially true in the emergency setting. Second, in cases where diagnoses are made, compiling information at the local and national levels can be challenging, especially in places with limited electronic health system infrastructure.26 Poor governance or lack of oversight may result in poor reporting processes and/ or false incentives to report certain diseases or treatments. This may be of particular concern in performance-based financing schemes.27,28 Finally, compiling national burden of [acute] disease estimates requires certain skill sets that are not always available within the local ministry of health. As a result, national burden of
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disease estimates in many low- and middle-income countries are prone to greater error and bias than in many high income countries. Even if priorities are clearly defined through accurate data collection and epidemiologic estimates, donors still frequently drive the research funding process,29 often away from emergency care. Many donors have predetermined concerns or represent specific interest groups such as HIV, breast cancer, or vaccines. Emergency care is rarely one of these issues. While these predetermined concerns are all clearly important health issues, their relative importance will vary depending on the country or region of interest. In addition, donors often have constituents, whether governments or private financiers, who require strict accountability for research funding. Identifying tangible outputs is much easier to do in a vertical, rather than a horizontal, program, creating some difficulty for emergency care research. The vertical approach to delivery of health services implies a selective targeting of specific interventions not fully integrated in health systems.30 Donors are generally attracted to these programs because the research outputs are easier to identify and therefore seen as more effective. The horizontal approach, often referred to as an “integrated” or “systemic” approach, constitutes a delivery mode of health interventions through the existing infrastructure of health services.31 This latter approach fits more in line with the broader field of emergency care research because emergency care spans the entire continuum of disease processes, and the treatment of illnesses and injuries in emergencies varies from minimal outpatient treatment to intensive care. As a result, there are three overarching concerns with current trends in global health research priority decision-making, each having a significant effect on increasing the importance of emergency care research. First, there is a lack of information from which national, and especially local, priorities can be determined.32 Second, there is often inadequate local consultation and influence, resulting in a donor-driven agenda. Third, there is generally a poor understanding of the key nature of emergency care by the donor community. By advocating for, and obtaining, better epidemiologic data, as well as moving toward research partnerships that value and give autonomy to local investigative partners, global health research may be able to move forward in a more productive and responsive way. FRAMEWORK FOR STRENGTHENING EMERGENCY CARE RESEARCH AND FUNDING IN THE GLOBAL HEALTH CONTEXT To strengthen funding opportunities for emergency care research, the community of emergency care researchers will need to focus on advocacy efforts and research that will inform governments, donors, and other beneficiaries how better emergency care results in improved health outcomes. Invested stakeholders must not only champion the effects of emergency care across the spectrum of illness and injury, but also help to better define global health research priorities. The consensus conference meeting led to the creation of near- and
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long-term goals to strengthen global emergency care research funding and the development of important research questions that will allow the field of emergency care to use evidence when advocating for research funding. In the near term, it is important to move beyond the current strategy of creative adaptation to find funding within existing opportunities at individual levels. The community of global emergency care researchers will need to come together to identify immediate priority areas in need of more emergency care research to leverage for more directed funding opportunities. Current national burden of diseases estimates, while not specifically focused on acute care, can and should be used to develop these immediate priorities. In particular, with clear evidence of an epidemiologic transition where noncommunicable diseases and injuries represent an increasingly important burden of disease, the need for emergency care services for patients with recurrent acute exacerbations of chronic problems and acute injuries has become increasingly important. In addition to using existing data to advocate for emergency care research, additional data collection and further analysis of existing data will help to push emergency care research onto the overall global health research agenda. Longer-term strategies to improve funding for emergency care research will need to focus on establishing a clear achievable framework to ground emergency care research priorities firmly in the broader field of global health research. The following research questions represent a consensus view of important outstanding questions that will help the field of emergency care research better understand current funding and bring evidence to the debate on funding priorities. 1. Quantify funding for global health and emergency care research.
• •
How much is currently being spent on global health research? What proportion of this funding is spent on emergency care research? 2. Better understand current research funding priorities.
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What is the breakdown between horizontal (systems) and vertical (disease-specific) funding within emergency care research? Do disparities exist between research funding dollars and burden of [acute] illnesses and injuries? 3. Identify barriers to emergency care research funding.
• •
What are the donor-centric barriers, perceived and real, to identifying research funding for emergency care research? What is the research capacity and interest of the local communities in developing emergency care research relative to their health needs? How can research capacity and understanding of the need for emergency care research be developed at the local community level? 4. Use existing data and collect new information to establish an estimated need for emergency services and emergency care research.
•
Vu et al. • RESEARCH FUNDING IN THE GLOBAL HEALTH CONTEXT
• • • • •
What disease processes are commonly seen and cared for by emergency services in low- and middle-income countries? How does this differ from high-income countries? What are the patterns of emergency care use in low- and middle-income countries? What are the constraints associated with utilization of services? Given current burden of disease estimates, what is the likely need for emergency care services (age/sex) at the national (and where available) subnational level? Aside from burden of disease, what additional metrics (e.g., access to care) are important to include in analyses demonstrating the need to expand emergency care?
SUMMARY In recent decades, there has been significant interest and financial investments made toward global health programming and research. Funding focused on global emergency care research, however, is quantitatively unknown and qualitatively limited in both amount and scope. This consensus conference has identified the current challenges and raised important research questions that will need to be addressed to improve funding opportunities for global emergency care research. In particular, invested stakeholders in emergency care research will need to quantify funding for global health and emergency care research, better understand existing research funding priorities and the barriers to funding directed at emergency care research, and use existing data and collect new data to identify priority areas of emergency care research relative to the national needs. References 1. Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet. 2009; 373:2113–24. 2. Hsia R, Razzak J, Tsai AC, Hirshon JM. Placing emergency care on the global agenda. Ann Emerg Med. 2011; 56:142–9. 3. Institute of Medicine. Hospital-based Emergency Care: At The Breaking Point. Washington DC: National Academies Press, 2007. 4. Kaji AH, Lewis RJ, Beavers-May T, et al. Summary of NIH medical-surgical emergency research roundtable held on April 30 to May 1, 2009. Ann Emerg Med. 2010; 56:522–37. 5. Neumar RM. The Zerhouni challenge: defining the fundamental hypothesis of emergency care research. Acad Emerg Med. 2007; 14(Suppl 1):s4–5. 6. Glickman SW, Kit Delgado M, Hirshon JM, et al. Defining and measuring successful emergency care networks: a research agenda. Acad Emerg Med. 2010;17:1297–305. 7. Lurie N, Manolio T, Patterson AP, Collins F, Frieden T. Research as a part of public health emergency response. N Engl J Med. 2013; 368:1251–5.
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8. Schneider H, Blaauw D, Gilson L, Chabikuli N, Goudge J. Health Systems Strengthening and ART Scaling Up: Challenges and Opportunities. Available at: http://www.auachsr.com/aspher/workshop/docs/ new/B62%20Health%20systems%20and%20ART.pdf. Accessed Oct 3, 2013. 9. Mock C, Lormand JD, Joshpiura M, Peden M. Guidelines for Essential Trauma Care. Geneva, Switzerland: World Health Organization, 2004. 10. Leach-Kemon K, Chou DP, Schneider MT, et al. The global financial crisis has led to a slowdown in growth of funding to improve health in many developing countries. Health Aff (Millwood). 2012; 31:228– 35. 11. Terry RF, Allen L, Gardner CA, Guzman J, Moran M, Viergever RF. Mapping global health research investments, time for new thinking–a Babel Fish for research data. Health Res Policy Syst. 2012; 10:28. 12. Sridhar D, Batniji R. Misfinancing global health: a case for transparency in disbursements and decision making. Lancet. 2008; 372:1185–91. 13. Kobusingye OC, Hyder AA, Bishai D, Hicks ER, Mock C, Joshipura M. Emergency medical systems in low- and middle-income countries: recommendations for action. Bull World Health Organ. 2005; 83:626–31. 14. Institutes of Medicine. Emergency Medical Services: At the Crossroads. Washington, DC: National Academies Press, 2006. 15. Institutes of Medicine. Emergency Care for Children: Growing Pains. Washington, DC: National Academies Press, 2006. 16. Cairns CB, Maier RV, Adeoye O, et al. NIH roundtable on emergency trauma research. Ann Emerg Med. 2010; 56:538–550. 17. National Institute of Health. Office of Emergency Care Research. Available at: http://www.nigms.nih. gov/About/Overview/OECR/. Accessed Oct 3, 2013. 18. Mitka M. NIH signals intent to boost funding of emergency care research and training. JAMA. 2012; 308:1193–4. 19. Kilama WL. The 10/90 gap in sub-Saharan Africa: resolving inequities in health research. Acta Trop. 2009; 112(Suppl 1):S8–15. 20. Stevens P. Diseases of Poverty and the 10/90 Gap. International Policy Network. Available at: http:// www.who.int/intellectualproperty/submissions/InternationalPolicyNetwork.pdf. Accessed Oct 3, 2013.
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21. Leroy JL, Habicht JP, Pelto G, Bertozzi SM. Current priorities in health research funding and lack of impact on the number of child deaths per year. Am J Public Health. 2007; 97:219–23. 22. Gillum LA, Gouveia C, Dorsey ER, et al. NIH disease funding levels and burden of disease. PLoS ONE. 2011; 6:e16837. pin KA, Leach-Kemon K, Schneider M, Sridhar 23. Gre D. How to do (or not to do) … Tracking data on development assistance for health. Health Policy Plan. 2012; 27:527–34. 24. Koram KA, Molyneux ME. When is “malaria” malaria? The different burdens of malaria infection, malaria disease, and malaria-like illnesses. Am J Trop Med Hyg. 2007; 77:1–5. 25. Basnet S, Adhikari N, Koirala J. Challenges in setting up pediatric and neonatal intensive care units in a resource-limited country. Pediatrics. 2011; 128: e986–92. 26. AbouZahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ. 2005; 83:578–83. 27. Oxman AD, Fretheim A. An overview of research on the effects of results-based financing. Report from Norwegian Knowledge Centre for the Health Services Nr 16-2008 3-page executive summary. Available at: http://www.kunnskapssenteret.no/publikasjoner/3219.cms?threepage=1. Accessed Oct 2, 2013. 28. Ireland M, Paul E, Dujardin B. Can performancebased financing be used to reform health systems in developing countries? Bull World Health Organ. 2011; 89:695–8. 29. Sridhar D. Who sets the global health research agenda? The challenge of multi-bi financing. PLoS Med. 2012; 9:e1001312. 30. Rifkin S, Walt G. Strategies for child survival: program vs. process. World Educ Rep. 1986; 25:8–11. 31. Cruz VO, Kurowski C, Mills A. Delivery of priority health services: searching for synergies within the vertical versus horizontal debate. J Int Dev. 2003; 15:67–86. 32. Wachira BW, Wallis LA, Geduld H. An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya. Emerg Med J. 2012; 29:473–6.
Emergency Care Research Funding in the Global Health Context: Trends, Priorities, and Future Directions Alexander Vu, DO, MPH, Herbert C. Duber, MD, MPH, Scott M. Sasser, MD, Bhakti Hansoti, MBchB, MPH, Catherine Lynch, MD, Ayesha Khan, MD, Tara Johnson, MD, MPH, Payal Modi, MD, Eben J. Clattenburg, and Stephen Hargarten, MD, MPH
Abstract Over the past few decades there has been a steady growth in funding for global health, yet generally little is known about funding for global health research. As part of the 2013 Academic Emergency Medicine consensus conference, a session was convened to discuss emergency care research funding in the global health context. Overall, the authors found a lack of evidence available to determine funding priorities or quantify current funding for acute care research in global health. This article summarizes the initial preparatory research and reports on the results of the consensus conference focused on identifying challenges and strategies to improve funding for global emergency care research. The consensus conference meeting led to the creation of near- and long-term goals to strengthen global emergency care research funding and the development of important research questions. The research questions represent a consensus view of important outstanding questions that will assist emergency care researchers to better understand the current funding landscape and bring evidence to the debate on funding priorities of global health and emergency care. The four key areas of focus for researchers are: 1) quantifying funding for global health and emergency care research, 2) understanding current research funding priorities, 3) identifying barriers to emergency care research funding, and 4) using existing data to quantify the need for emergency services and acute care research. This research agenda will enable emergency health care scientists to use evidence when advocating for more funding for emergency care research. ACADEMIC EMERGENCY MEDICINE 2013; 20:1259–1263 © 2013 by the Society for Academic Emergency Medicine
O
ver the past two decades there has been tremendous growth in the scientific field of global health. In particular, there has been a signifi-
cant monetary investment in the creation of a variety of global health programs around the world. This investment has come through government programs such as
From the Department of Emergency Medicine, Johns Hopkins University (AV, BH), Baltimore, MD; the Division of Emergency Medicine, Department of Medicine, and Institute for Health Metrics and Evaluation, University of Washington (HCD), Seattle, WA; the Department of Emergency Medicine, Emory University (SMS), Atlanta, GA; the Division of Emergency Medicine, Department of Surgery, Duke University (CL), Durham, NC; the Division of Emergency Medicine, Department of Surgery, Stanford University (AK), Stanford, CA; the Department of Emergency Medicine, Maricopa Integrated Health System (TJ), Phoenix, AZ; the Department of Emergency Medicine, Warren Alpert Medical School of Brown University (PM), Providence, RI; the Johns Hopkins University School of Medicine (EJC), Baltimore, MD; and the Department of Emergency Medicine, Medical College of Wisconsin (SH), Milwaukee, WI. Received July 15, 2013; revision received August 13, 2013; accepted August 13, 2013. This article reports on a breakout session of the May 2013 Academic Emergency Medicine consensus conference in Atlanta, GA: “Global Health and Emergency Care: A Research Agenda.” Breakout session participants: Theodore Christopher, Eben Clattenburg, Hillary Cohen, Herbert C. Duber, Nathalie Flacke, Rohini Haar, Bhakti Hansoti, Stephen Hargarten, Melanie Hogg, Stephanie Hubbard, Naomi Jean-Baptiste, Tara Johnson, Ayesha Khan, Elizabeth Krebs, Anita Kurt, Catherine Lynch, Payal Modi, Donna Moro-Sutherland, C. Nee-Kofi Mould-Millman, Andrew Muck, Margaret Murray, Leila Posaw, Michael Runyon, Scott M. Sasser, Cynthia Singh, Alexander Vu, Rebecca Walker, Ryan Wubben, Anna Yaffee, and Justin Yax. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Mark Hauswald, MD. Address for correspondence and reprints: Alexander Vu, DO, MPH; e-mail: [email protected].
© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12267
ISSN 1069-6563 PII ISSN 1069-6563583
1259 1259
1260
the President’s Emergency Plan for AIDS Relief (PEPFAR), from multilateral organizations (e.g., the Global Fund for AIDS, TB, and Malaria), and from private donors such as the Bill and Melinda Gates Foundation, as well as many other public and private organizations.1 While most funding has been earmarked for program development and implementation, there has also been a steady growth in research funding. However, much of this research funding has been directed toward specific disease processes, and little has focused on emergency care research.2 This article puts forth a consensus view on the current landscape of funding for emergency care research and the science of global health. The objectives of this paper are: 1) to define the need for emergency care research and its application in global health, 2) to examine the funding history of global health and emergency care research, 3) to explore priorities in global health and emergency care research funding, and 4) to propose a framework to guide decisions for future funding for global emergency care research. In doing so, we also identify two critical shortcomings necessary for future evidence-based discussion of emergency care research funding: inadequate transparency to quantify funding for emergency care research and limited health information from which priorities in emergency care funding can be determined. EMERGENCY CARE RESEARCH: DEFINING THE NEED Emergency care is a broad field in both its scope of work and in those who perform it. Unlike many other disciplines, emergency care is not limited to a single organ or functional system, and providers of emergency care have various levels of training in emergency medicine (EM) and other specialties such as trauma surgery. Emergency care is also unique in that it spans from the home (e.g., cardiopulmonary resuscitation) and community (e.g., car crash injuries) to the hospital, and almost everyone is likely to require and/or seek emergency services at some point in their lifetime.3 Emergency care research, consistent with the range of patients with perceived urgent and emergent complaints, spans an array of “time-sensitive, emergency care, as well as chronic care, individual organ systems, whole health care systems, and population health.”4 More specifically, a core hypothesis of emergency care research is that “rapid diagnosis and early intervention in acute illness and injury or acutely decompensated chronic illness improves patient outcomes.”5 Nearly all such studies, however, have been performed in developed countries where medical services and resources are more readily available compared to low- and middle-income countries.2 Despite many advances in a variety of fields from sepsis to myocardial infarction to stroke, the need for expanding emergency care research is critical. One field of study within emergency care where this is particularly true is health systems. Research must not only focus on the services provided, but how they can be administered effectively and efficiently. The 2010 Academic Emergency Medicine consensus conference on
Vu et al. • RESEARCH FUNDING IN THE GLOBAL HEALTH CONTEXT
the integration of emergency care systems reported that “there are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the network of emergency care.”6 In addition, Lurie and colleagues7 recently reported critical deficits in research related to public health emergencies, calling for an integrated approach to performing such research. Low- and middle-income countries represent the core constituents at the intersection of global health and emergency care research. These countries often have restricted or limited resources, consumables, technologies, and infrastructure, all of which limit the application of research performed in high-income countries.8,9 Furthermore, the burden of emergency care illnesses and injuries is often different, as are the various cadres of health workers providing emergency care. Due to these differences, as well as unique cultural, political, and social aspects of delivering care in vastly different places, emergency care research remains an important field of study on the global health research agenda. FUNDING HISTORY OF GLOBAL HEALTH AND EMERGENCY CARE RESEARCH Funding for global health has grown significantly over the past two decades. In 1990, an estimated US$5.6 billion was spent on development assistance for health, while 2011 estimates are approximately US$27.7 billion.10 Although funding of global health research was presumed to be increasing as well, identifying how much is spent on global health research and what types of research are being funded has proven to be a more challenging task.11 Funding for such research may come through the public or private sector or some combination thereof (public–private partnerships). Money may be distributed through unilateral or multilateral governments and organizations, not all of whom are transparent regarding how research dollars are spent.12 As a result, little is currently known about the total amount of spending on global health research. Funding for emergency care research in the global health context is even more challenging, as few grants are overtly geared toward emergency care research.13 Some money in the realm of global emergency care has focused on areas that would clearly be considered as part of EM, in countries that consider EM as a specialty, such as disaster-preparedness and management and programmatic activities. Based on consensus conference discussions, many, if not most, global health emergency care researchers find funding that is not directly focused on the field. Most funding, in fact, is simply included under less specialty-specific headings such as trauma care or emergency obstetrics. Researchers instead find grants in other areas of available funding (such as HIV or trauma care focused funding) and find creative ways of applying such funding to emergency care research questions through collaboration with other specialties (e.g., infectious diseases, surgery, obstetrics, or pediatrics). Within the United States, there has been increased recognition of the lack of resources and focus on emergency
ACADEMIC EMERGENCY MEDICINE • December 2013, Vol. 20, No. 12 • www.aemj.org
care research.4,14–16 As a result, the National Institutes of Health created the Office of Emergency Care Research (OECR), house within the National Institute of General Medical Sciences. It has the goal of coordinating and fostering basic, clinical, and translational research and research training for the emergency setting.17 Its scope is broad, and if implemented well, will provide an excellent resource for emergency care researchers.18 However, the OECR has no grant-making capabilities. Rather it will function as a conduit with other grant-making institutes at the NIH, and in doing so help to coordinate funding opportunities related to emergency care that involve multiple NIH institutions and centers. In addition, given that the OECR grew out of the IOM reports’ findings on deficiencies within the domestic emergency care system, it is unclear to what extent the OECR will advocate for global emergency care research. DETERMINING PRIORITIES FOR GLOBAL HEALTH RESEARCH: WHERE DOES EMERGENCY CARE RESEARCH FIT? Regardless of the amount of money invested in the global health research arena, it remains a finite sum that is distributed among many parties with various interests. As such, the creation of a reasonable list of priorities could help to determine what share of funding should be directed toward emergency care research. How these priorities are determined, who is making that determination, and how funds are distributed are all important variables that deserve further attention and deliberation. Much has been written on the “10/90 gap,” the concept that only 10% of research and development funds are directed toward 90% of the global burden of disease.19 While the data to support this have been called into question,20 the underlying premise that there is a mismatch between important public health issues and research funding is a valid concern.21,22 Many hypotheses exist as to why this mismatch occurs, but one prominent crosscutting theme is the concern that donor-driven funding patterns are not responsive enough to local governments or health authorities.1 Ideally, priorities for health programming and research are identified and determined based on local needs assessments.23 However, this is often not the case, and numerous reasons have been identified. First, there are significant diagnostic challenges due to limited resources, inadequate medical training, and poor performance of clinical algorithms in low- and middle-income countries.24,25 This is especially true in the emergency setting. Second, in cases where diagnoses are made, compiling information at the local and national levels can be challenging, especially in places with limited electronic health system infrastructure.26 Poor governance or lack of oversight may result in poor reporting processes and/ or false incentives to report certain diseases or treatments. This may be of particular concern in performance-based financing schemes.27,28 Finally, compiling national burden of [acute] disease estimates requires certain skill sets that are not always available within the local ministry of health. As a result, national burden of
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disease estimates in many low- and middle-income countries are prone to greater error and bias than in many high income countries. Even if priorities are clearly defined through accurate data collection and epidemiologic estimates, donors still frequently drive the research funding process,29 often away from emergency care. Many donors have predetermined concerns or represent specific interest groups such as HIV, breast cancer, or vaccines. Emergency care is rarely one of these issues. While these predetermined concerns are all clearly important health issues, their relative importance will vary depending on the country or region of interest. In addition, donors often have constituents, whether governments or private financiers, who require strict accountability for research funding. Identifying tangible outputs is much easier to do in a vertical, rather than a horizontal, program, creating some difficulty for emergency care research. The vertical approach to delivery of health services implies a selective targeting of specific interventions not fully integrated in health systems.30 Donors are generally attracted to these programs because the research outputs are easier to identify and therefore seen as more effective. The horizontal approach, often referred to as an “integrated” or “systemic” approach, constitutes a delivery mode of health interventions through the existing infrastructure of health services.31 This latter approach fits more in line with the broader field of emergency care research because emergency care spans the entire continuum of disease processes, and the treatment of illnesses and injuries in emergencies varies from minimal outpatient treatment to intensive care. As a result, there are three overarching concerns with current trends in global health research priority decision-making, each having a significant effect on increasing the importance of emergency care research. First, there is a lack of information from which national, and especially local, priorities can be determined.32 Second, there is often inadequate local consultation and influence, resulting in a donor-driven agenda. Third, there is generally a poor understanding of the key nature of emergency care by the donor community. By advocating for, and obtaining, better epidemiologic data, as well as moving toward research partnerships that value and give autonomy to local investigative partners, global health research may be able to move forward in a more productive and responsive way. FRAMEWORK FOR STRENGTHENING EMERGENCY CARE RESEARCH AND FUNDING IN THE GLOBAL HEALTH CONTEXT To strengthen funding opportunities for emergency care research, the community of emergency care researchers will need to focus on advocacy efforts and research that will inform governments, donors, and other beneficiaries how better emergency care results in improved health outcomes. Invested stakeholders must not only champion the effects of emergency care across the spectrum of illness and injury, but also help to better define global health research priorities. The consensus conference meeting led to the creation of near- and
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long-term goals to strengthen global emergency care research funding and the development of important research questions that will allow the field of emergency care to use evidence when advocating for research funding. In the near term, it is important to move beyond the current strategy of creative adaptation to find funding within existing opportunities at individual levels. The community of global emergency care researchers will need to come together to identify immediate priority areas in need of more emergency care research to leverage for more directed funding opportunities. Current national burden of diseases estimates, while not specifically focused on acute care, can and should be used to develop these immediate priorities. In particular, with clear evidence of an epidemiologic transition where noncommunicable diseases and injuries represent an increasingly important burden of disease, the need for emergency care services for patients with recurrent acute exacerbations of chronic problems and acute injuries has become increasingly important. In addition to using existing data to advocate for emergency care research, additional data collection and further analysis of existing data will help to push emergency care research onto the overall global health research agenda. Longer-term strategies to improve funding for emergency care research will need to focus on establishing a clear achievable framework to ground emergency care research priorities firmly in the broader field of global health research. The following research questions represent a consensus view of important outstanding questions that will help the field of emergency care research better understand current funding and bring evidence to the debate on funding priorities. 1. Quantify funding for global health and emergency care research.
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How much is currently being spent on global health research? What proportion of this funding is spent on emergency care research? 2. Better understand current research funding priorities.
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What is the breakdown between horizontal (systems) and vertical (disease-specific) funding within emergency care research? Do disparities exist between research funding dollars and burden of [acute] illnesses and injuries? 3. Identify barriers to emergency care research funding.
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What are the donor-centric barriers, perceived and real, to identifying research funding for emergency care research? What is the research capacity and interest of the local communities in developing emergency care research relative to their health needs? How can research capacity and understanding of the need for emergency care research be developed at the local community level? 4. Use existing data and collect new information to establish an estimated need for emergency services and emergency care research.
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Vu et al. • RESEARCH FUNDING IN THE GLOBAL HEALTH CONTEXT
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What disease processes are commonly seen and cared for by emergency services in low- and middle-income countries? How does this differ from high-income countries? What are the patterns of emergency care use in low- and middle-income countries? What are the constraints associated with utilization of services? Given current burden of disease estimates, what is the likely need for emergency care services (age/sex) at the national (and where available) subnational level? Aside from burden of disease, what additional metrics (e.g., access to care) are important to include in analyses demonstrating the need to expand emergency care?
SUMMARY In recent decades, there has been significant interest and financial investments made toward global health programming and research. Funding focused on global emergency care research, however, is quantitatively unknown and qualitatively limited in both amount and scope. This consensus conference has identified the current challenges and raised important research questions that will need to be addressed to improve funding opportunities for global emergency care research. In particular, invested stakeholders in emergency care research will need to quantify funding for global health and emergency care research, better understand existing research funding priorities and the barriers to funding directed at emergency care research, and use existing data and collect new data to identify priority areas of emergency care research relative to the national needs. References 1. Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet. 2009; 373:2113–24. 2. Hsia R, Razzak J, Tsai AC, Hirshon JM. Placing emergency care on the global agenda. Ann Emerg Med. 2011; 56:142–9. 3. Institute of Medicine. Hospital-based Emergency Care: At The Breaking Point. Washington DC: National Academies Press, 2007. 4. Kaji AH, Lewis RJ, Beavers-May T, et al. Summary of NIH medical-surgical emergency research roundtable held on April 30 to May 1, 2009. Ann Emerg Med. 2010; 56:522–37. 5. Neumar RM. The Zerhouni challenge: defining the fundamental hypothesis of emergency care research. Acad Emerg Med. 2007; 14(Suppl 1):s4–5. 6. Glickman SW, Kit Delgado M, Hirshon JM, et al. Defining and measuring successful emergency care networks: a research agenda. Acad Emerg Med. 2010;17:1297–305. 7. Lurie N, Manolio T, Patterson AP, Collins F, Frieden T. Research as a part of public health emergency response. N Engl J Med. 2013; 368:1251–5.
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8. Schneider H, Blaauw D, Gilson L, Chabikuli N, Goudge J. Health Systems Strengthening and ART Scaling Up: Challenges and Opportunities. Available at: http://www.auachsr.com/aspher/workshop/docs/ new/B62%20Health%20systems%20and%20ART.pdf. Accessed Oct 3, 2013. 9. Mock C, Lormand JD, Joshpiura M, Peden M. Guidelines for Essential Trauma Care. Geneva, Switzerland: World Health Organization, 2004. 10. Leach-Kemon K, Chou DP, Schneider MT, et al. The global financial crisis has led to a slowdown in growth of funding to improve health in many developing countries. Health Aff (Millwood). 2012; 31:228– 35. 11. Terry RF, Allen L, Gardner CA, Guzman J, Moran M, Viergever RF. Mapping global health research investments, time for new thinking–a Babel Fish for research data. Health Res Policy Syst. 2012; 10:28. 12. Sridhar D, Batniji R. Misfinancing global health: a case for transparency in disbursements and decision making. Lancet. 2008; 372:1185–91. 13. Kobusingye OC, Hyder AA, Bishai D, Hicks ER, Mock C, Joshipura M. Emergency medical systems in low- and middle-income countries: recommendations for action. Bull World Health Organ. 2005; 83:626–31. 14. Institutes of Medicine. Emergency Medical Services: At the Crossroads. Washington, DC: National Academies Press, 2006. 15. Institutes of Medicine. Emergency Care for Children: Growing Pains. Washington, DC: National Academies Press, 2006. 16. Cairns CB, Maier RV, Adeoye O, et al. NIH roundtable on emergency trauma research. Ann Emerg Med. 2010; 56:538–550. 17. National Institute of Health. Office of Emergency Care Research. Available at: http://www.nigms.nih. gov/About/Overview/OECR/. Accessed Oct 3, 2013. 18. Mitka M. NIH signals intent to boost funding of emergency care research and training. JAMA. 2012; 308:1193–4. 19. Kilama WL. The 10/90 gap in sub-Saharan Africa: resolving inequities in health research. Acta Trop. 2009; 112(Suppl 1):S8–15. 20. Stevens P. Diseases of Poverty and the 10/90 Gap. International Policy Network. Available at: http:// www.who.int/intellectualproperty/submissions/InternationalPolicyNetwork.pdf. Accessed Oct 3, 2013.
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21. Leroy JL, Habicht JP, Pelto G, Bertozzi SM. Current priorities in health research funding and lack of impact on the number of child deaths per year. Am J Public Health. 2007; 97:219–23. 22. Gillum LA, Gouveia C, Dorsey ER, et al. NIH disease funding levels and burden of disease. PLoS ONE. 2011; 6:e16837. pin KA, Leach-Kemon K, Schneider M, Sridhar 23. Gre D. How to do (or not to do) … Tracking data on development assistance for health. Health Policy Plan. 2012; 27:527–34. 24. Koram KA, Molyneux ME. When is “malaria” malaria? The different burdens of malaria infection, malaria disease, and malaria-like illnesses. Am J Trop Med Hyg. 2007; 77:1–5. 25. Basnet S, Adhikari N, Koirala J. Challenges in setting up pediatric and neonatal intensive care units in a resource-limited country. Pediatrics. 2011; 128: e986–92. 26. AbouZahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ. 2005; 83:578–83. 27. Oxman AD, Fretheim A. An overview of research on the effects of results-based financing. Report from Norwegian Knowledge Centre for the Health Services Nr 16-2008 3-page executive summary. Available at: http://www.kunnskapssenteret.no/publikasjoner/3219.cms?threepage=1. Accessed Oct 2, 2013. 28. Ireland M, Paul E, Dujardin B. Can performancebased financing be used to reform health systems in developing countries? Bull World Health Organ. 2011; 89:695–8. 29. Sridhar D. Who sets the global health research agenda? The challenge of multi-bi financing. PLoS Med. 2012; 9:e1001312. 30. Rifkin S, Walt G. Strategies for child survival: program vs. process. World Educ Rep. 1986; 25:8–11. 31. Cruz VO, Kurowski C, Mills A. Delivery of priority health services: searching for synergies within the vertical versus horizontal debate. J Int Dev. 2003; 15:67–86. 32. Wachira BW, Wallis LA, Geduld H. An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya. Emerg Med J. 2012; 29:473–6.
