Combining health and social protection measures to reach the ultra ...

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IntroductionLiving and workingconditionsGeneral socioeconomic, cultural and environmental conditionsWorkenvironmentUnemploymentSocial and community networksWater andsanitationEducationIndividual lifestyle factorsAgricultureand foodproductionAge, sex andconstitutionalfactorsHealthcareservicesHousingFigure 1: Factors affecting health 4global movement for action on social inequities, humanrights, and the other broad social determinants necessary toachieve health equity. The Knowledge Networks are buildinga detailed picture of the linkages between health and thesocial determinants, and their work should uncover anextensive research agenda that will need to be addressed toaccomplish the Commission’s overall goals.Margaret Whitehead 6 has set out a typology of actions totackle social inequalities in health, which helps to generate auseful framework for a research agenda to support practicaland effective policies and programmes. Whitehead’sapproach begins with identifying the theory underlyinginterventions: recognizing the logical reasoning that connectsintervention programme inputs to intended outcomes (Figure1) provides a basis for assessing whether there is anyreasonable likelihood that programme goals could beachieved and enables the development of appropriate criteriafor evaluating success.Whitehead’s typology of actions to reduce healthinequalities includes four categories:✜ strengthening individuals;✜ strengthening communities;✜ improving living and working conditions;✜ promoting healthy macro-policies.This framework may also be useful for analyzing andplanning research in the field of health inequalities andequitable access.ProblemofhealthinequalityPerceivedcausesofproblemPolicy goalsto addresscausesTheoriesabout howand whyinterventionsmight work tobringabout changeDesign ofinterventionprogrammeOutcome ofprogrammeFigure 2: The logic of health inequalities interventions 8Global Forum Update on Research for Health Volume 4 ✜ 013
IntroductionType IType IIType IIIPrevalent in both rich and poor countries, with largenumbers of vulnerable population in each.Prevalent in both rich and poor countries, but with asubstantial proportion of the cases in poor countries.Overwhelmingly or exclusively prevalent indeveloping countries.Box 1: Categories of diseases according to their relativeprevalence in higher- and lower-income countriesThe role of health systems 7 in challenging inequity hasbeen the subject of study by the CSDH Knowledge Networkon Health Systems. The report of this Knowledge Network 8synthesises a large amount of available evidence on howhealth systems can contribute to reducing health inequitiesand provides a policy guide on actions that can be taken toaddress these inequities, including mobilizing intersectoralrelationships, facilitating social empowerment, building upuniversal coverage, revitalizing primary health care,strengthening the process of developing and implementingpolicies, and securing international support for nationally-ledhealth system transformation and action. While the focus ofthe report is on the use of existing knowledge, it identifiesmany gaps and also serves as a stepping off point for anextensive agenda of new research. This is especiallyimportant in the light of the fact that, as the report itself notes,the experience of health systems is always context-specific.InnovationResearch to improve health is best understood as a processwithin a chain of health innovation that begins with aconcept, question or observation and proceeds throughexperimental investigation towards the eventual application ofthe results to the use of a new process or product in the field.Innovation for health equity should not be regarded as beingrestricted to the creation of affordable and appropriatemedical products and technologies 9 . It also includesdeveloping and applying understanding of how to improveequitable access through novel health policies, services andsystems, interventions and support mechanisms; andencompasses the application of health technologyassessment to assist in selecting the most appropriated andcost-effective technologies to meet health needs, especially ofthe poor and vulnerable. And it includes innovations inunderstandings and measurements of health and healthequity.Pharmaceutical products for diseasesendemic in developing countriesDiseases have been categorized into Types I to III accordingto their relative prevalence in higher- and lower-incomecountries 10 (Box 1).For a range of diseases that substantially or predominantlyoccur in poorer countries (Types II and III), access topharmaceutical products for prevention, diagnosis andtreatment has often been very poor. Two major elements ofthis limited access can be identified:1.For many of the diseases which have little or no prevalencein high-income countries, there has been a dearth ofresearch and development (R&D) resulting in theregistration of new products. Thus, of the newpharmaceutical products registered for human use in theperiod 1975–1997, only 13 (around 1%) were for tropicalparasitic infections 11 . As a result, treatments are either notavailable or depend on very old generic drugs that mayhave significant side effects and efficacies that are limitedand declining due to emerging resistance. Wherediagnostic tools for these diseases exist, they may be slow,insensitive or unsuited to field conditions prevailing in thedisease-endemic countries, requiring highly skilledpersonnel or sophisticated laboratory settings.2.In cases where newer and more effective drugs, vaccinesand diagnostics are available, these have sometimes foundrelatively low levels of uptake and use in developingcountries, due to factors including affordability and theavailability of health systems for their delivery.It is clear that, to a large extent, these two elements arerelated to a common problem – that of market failure.Substantial R&D investments are needed to create newpharmaceutical products and these are unlikely to be madeby the private sector where there is not seen to be a goodmarket for recouping the investments. Drugs created for amarket in high-income countries, where per capitaexpenditures on health run into thousands of dollars per year,may prove too expensive for use in low-income countrieswhose health expenditures are far less than 100 dollars percapita per year.Several different approaches have been explored orproposed to solve the problem, varying according to the stagein the chain of innovation and product delivery/uptake atwhich the market failure is perceived to be occurring:✜ For a range of “neglected diseases” – especially tropicalparasitic infections, but also HIV/AIDS and TB –investments in R&D for drugs, vaccines and diagnosticshas come from the philanthropic sector, with theRockefeller Foundation taking a lead in the mid 1990s inthe creation of product development public-privatepartnerships (PDPs) beginning with the InternationalAIDS Vaccine Initiative. The Bill & Melinda GatesFoundation has made substantial contributions since2000. More recently, a number of bilateral donors (e.g.Ireland, Netherlands, Norway, UK) have started tobecome increasingly significant supporters of thisapproach 12 . PDPs have generally taken a portfolioapproach, creating a pipeline of candidate products indevelopment, some of which are now in or about to enterclinical trials. Since the latter – especially Phase III trialsto prove efficacy and involving large numbers of patientsin the field – are very expensive, a major challenge nowfacing the world is how to provide adequate funding toensure that effective new products reach registration andenter clinical use in disease-endemic countries. Acrossthe range of diseases and products for which support is014 ✜ Global Forum Update on Research for Health Volume 4
Page 3 and 4: Editorial Advisory Board:Luis Gabri
Page 5 and 6: Contents096 Child immunization: acc
Page 7: IntroductionResearch contributions
Page 11 and 12: Introductionmaking), takes account
Page 13: Access to healthStrengthening healt
Page 16 and 17: Access to healthTraining more healt
Page 18 and 19: Access to healthimperative for acti
Page 20 and 21: Access to healthReferences1.Further
Page 22 and 23: Access to healthDeterminantsAvailab
Page 24 and 25: Access to healthThe authors are inv
Page 26 and 27: Access to healthCombining health an
Page 28 and 29: Access to health100%Availability of
Page 30 and 31: Access to healthhypothesis that an
Page 32 and 33: Access to healthMandatory clinical
Page 34 and 35: Access to healthWhile there are som
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Page 38 and 39: Access to healthReferences continue
Page 40 and 41: Access to healthintegrating individ
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Page 46 and 47: Access to healthMaking human rights
Page 48 and 49: Access to healthResources outsideth
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Page 52 and 53: Access to healthand financial burde
Page 54 and 55: Access to healthDiscrimination as a
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Access to healthReferences continue
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Access to healthsocio-cultural and
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Access to healthIntergovernmental P
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Access to healthand conference stat
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Access to healthReferences continue
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InnovationTowards the development o
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InnovationMajor classificationMajor
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Innovation60% of enterprises5040302
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InnovationUsing the power ofintelle
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Innovationbe adapted - and harnesse
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InnovationFinancing of vaccine R&D-
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InnovationFinancing Ultimate Interm
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Innovationsome of this risk might b
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InnovationChild immunization:accele
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Innovationare revealing previously
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InnovationDeveloping countries % De
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Innovationcapacities. It is indeed
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InnovationSome plausible causes of
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Innovationwhere he was a programme
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Research resourcesResearch impact o
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Research resourcesBiotechnologists6
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Research resources1,61001,41,219080
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Research resourcesReferences1.The R
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Research resources✜ A group of nu
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Research resourcesReferences1.Inter
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Research resourcesThe threat of pan
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Research resourcesChanging environm
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Research resourcesPartnerships offe
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Research resourcesWe encourage othe
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Research resources181614No. of PPPs
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Research resources12010080604020Pro
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Research resourcesCapacity strength
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Research resourcestreatment is prov
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Research resourcesSmall scale busin
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Research resourcesthis process in a
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Research resourcesways. For instanc
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Decision-making148 Delivering evide
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Decision-makingChallenges in employ
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Decision-makingUsing evidence forpo
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Decision-makingdesire to publish. T
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Decision-makingsystems development.
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Decision-makingTowards evidence-inf
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Decision-making✜ develop a critic
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Decision-makingwas prior to 2001, a
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Decision-makingGlobal and regional
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Decision-makingHigh-incomeChildrenE
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Decision-makingLow- and middle-inco
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Decision-makingLow- and middle-inco
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Decision-makingthan a quarter of th
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Decision-makingThe potentials of in
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Decision-makingGenerally, any resea
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Decision-makingReferences1.Hawes H.
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