An overview on health research in the Eastern Mediterranean Region

An overview on health research in the Eastern Mediterranean Region

June 10th, 2014

34 slides

The status of health research in the key priority areas across the region is not satisfactory.

There are critical deficits in: stewardship; translation of research into policy and practice; and often research agenda.

These problems are mainly attributable to the weak political and subsequently financial support available to health research systems.

Main message

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Publication in selected key priority areas from 2007-2012

  Equity in access

Maternal health

Child health Tobacco  Obesity Diabetes Breast 

cancer HIV/AIDS Malaria Polio Influenza ARI

Afghanistan 20 26 231 11 3 4 3 43 53 58 10 3Bahrain 1 7 92 6 27 39 6 3 8 0 2 0Djibouti 0 0 21 4 1 2 0 5 7 0 2 0Egypt 11 200 2096 54 170 448 226 78 41 10 132 1Iran 18 409 4288 131 499 1337 490 365 161 17 116 271Iraq 11 34 323 13 20 55 20 18 10 0 8 1Jordan 7 57 576 33 60 132 62 29 2 1 17 2Kuwait 1 31 336 9 79 163 62 15 6 2 11 0Lebanon 9 76 788 47 107 140 110 84 9 2 23 1Libya 0 4 83 0 6 24 12 18 2 0 1 0Morocco 3 32 415 15 33 73 43 39 19 0 13 2Oman 1 30 271 10 39 99 18 16 7 1 12 0Pakistan 26 284 1551 113 99 351 118 173 115 84 32 2Palestine 0 12 90 4 12 29 1 3 1 1 1 0Qatar 1 19 168 10 36 92 12 10 5 1 4 1Saudi Arabia 6 140 1834 46 219 490 153 66 32 8 80 3

Somalia 2 9 53 1 1 6 0 10 15 4 1 0

Sudan 7 52 339 22 19 32 19 44 161 9 6 0

Syrian Arab Republic 1 9 52 15 10 10 6 0 0 0 0 0

Tunisia 0 56 912 51 95 230 117 39 6 5 12 0

United Arab Emirates 1 32 248 22 63 138 29 24 10 2 9 0

Yemen 1 16 121 11 5 14 17 10 23 3 4 1

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Quantity of research, by means of number of publications, in each priority area is not satisfactory to fill the knowledge gap.

Composition of Systematic Review, Health Service Research and Clinical Trials in the region, 2007-2012.

92.6%

5.1%

1.2%

1.1%Other

Clinical trial

Systematic review

Health Service Research

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H-index of publications (1996 -2012) by countries group

Brazil

Turkey

Saudi Arabia

United Arab Em

irates 

Qatar 

Iran (Islamic Republic of)

Tunisia

Morocco Ira

qLibya

PakistanYemen

Djibouti

South Sudan

0

25

50

75

100

125

150

175

200

Source: The SCImago Journal & Country Rank, the Scopus® database (Elsevier B.V.), (http://www.scimagojr.com/index.php), Nov, 2013.5/23

AmericaEuropeWestern Pacific South-East AsiaEastern MediterraneanAfrica

Source: Røttingen JA, et al. Lancet. 2013 Oct 12;382(9900):1286-307.

Share of the region in the on-going clinical trials

20500; 24.9%

43880; 53.4%

13280; 16.1%

2080; 2.5%

1100; 1.3%

1400; 1.7%

Clinical Trials

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EMRO is even lagging behind AFRO in number of registered clinical trials.

 Number of patent applications registered in medical technology, biotechnology and

pharmaceuticals, 1997 - 2011Saudi Arabia

Kuwait 

Qatar 

Egypt

Tunisia

Morocco

Libya

Pakistan

Sudan

Djibouti

South Sudan0

5001000150020002500300035004000

Total of 5753 for15 years

383.5 per year

Source: The World Intellectual Property Organization (WIPO) (http://www.wipo.int/about-wipo/en/), Nov, 2013.7/23

The published papers seem to lack the answers to the very needs of the health priority areas by means of:

Quantity; Relevance; and Type.

A large proportion of the region’s research do not result in tangible outputs (product manufacture and/or decision-making).But contradictory to this discouraging state of affairs, there are some opportunities still remain.

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AmericaEuropeWestern Pacific South-East AsiaEastern MediterraneanAfrica

Publication in Medicine by WHO regions

212,898

241,546

56,75711,734

6,1114,123

2002

Source: The SCImago Journal & Country Rank, the Scopus® database (Elsevier B.V.), (http://www.scimagojr.com/index.php), Nov, 2013.9/23

In 2002, the region’s share was 6111 articles.

AmericaEuropeWestern Pacific South-East AsiaEastern MediterraneanAfrica

Publication in Medicine by WHO regions

300,220

329,019

148,90724,430

12,4219,195

2007

212,898

241,546

56,75711,734

6,1114,123

2002

Source: The SCImago Journal & Country Rank, the Scopus® database (Elsevier B.V.), (http://www.scimagojr.com/index.php), Nov, 2013.

More than 2 times

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This was doubled and reached 12421 after 5 years in 2007

AmericaEuropeWestern Pacific South-East AsiaEastern MediterraneanAfrica

Publication in Medicine by WHO regions

212,898

241,546

56,75711,734

6,111

4,123

2002

357,821

367,895

173,946

37,532

35,940

13,537

2012

Source: The SCImago Journal & Country Rank, the Scopus® database (Elsevier B.V.), (http://www.scimagojr.com/index.php), Nov, 2013.

Almost 6 times

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In 2012 the number of articles has grown by almost 6 times compared to 2002.

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

0

100

200

300

400

500

600

700

800

900

1000

LebanonJordanUnited Arab Emirates Kuwait Qatar IraqOmanSudanSyrian Arab Republic

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Iran (Islamic Republic of)EgyptSaudi ArabiaPakistanTunisiaMorocco

Trend of publication in medicine by the EMR countries

All the countries have had considerable Rises in their publications.

More than 1000 publications/year

200 -1000 publications/year

To support health care programs through sustainable health research systems and develop necessary capacities for generation of appropriate knowledge and its utilization towards improved health.

Mission statement

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To support health care programs through sustainable health research systems and developing necessary capacities for generation of appropriate knowledge and its utilization towards improved health.

Stewardship

Production and utilization of

research

Resources

Financing

Source: Pang T, Sadana R, Hanney S, Bhutta ZA, Hyder AA, Simon J. Knowledge for better health: a conceptual frame- work and foundation for health research systems. Bulletin of the World Health Organization, 2003, 81(11):815–820.

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•through sustainable and transparent processes for mobilizing and allocating funds for research

Financing

•generation of scientifically valid research findings that respond to health challenges, and allow for translation into new tools (e.g. drugs, vaccines) and policies.Production and

utilization of research

•human and institutional capacity to support research work

Resources

Stewardship • provision of leadership to direct, coordinate, manage and review research

Source: Pang T, Sadana R, Hanney S, Bhutta ZA, Hyder AA, Simon J. Knowledge for better health: a conceptual frame- work and foundation for health research systems. Bulletin of the World Health Organization, 2003, 81(11):815–820.

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Financing

Production and

utilization of research

Resources

Stewardship

AmericaEuropeWestern Pacific South-East AsiaEastern MediterraneanAfrica

Financial investment in R&D and health research

30.2%

28.7%

25.0%

8.7%

4.6%2.7%

Gross Income

Source: World Health Organization, Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.GNI2020?lang=en (Nov 24, 2013).

Financing

Production and

utilization of research

Resources

Stewardship

4.6% of the world’s financial resources are produced in this region.

AmericaEuropeWestern Pacific South-East AsiaEastern MediterraneanAfrica

Financial investment in R&D and health research

35.8%

28.9%

30.6%

2.9%

1.1%

0.8%

Gross domestic expend on R&D (GERD)

30.2%

28.7%

25.0%

8.7%

4.6%2.7%

Gross Income

25%of the proportional

ity

Source: World Health Organization, Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.GNI2020?lang=en (Nov 24, 2013).Røttingen JA, et al. Lancet. 2013 Oct 12;382(9900):1286-307.

Data for 15 countries are based

on modeling

Source: World Health Organization, Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.GNI2020?lang=en (Nov 24, 2013).Røttingen JA, et al. Lancet. 2013 Oct 12;382(9900):1286-307.

Financing

Production and

utilization of research

Resources

Stewardship

The share of research resources in the region is 1.1%.

AmericaEuropeWestern Pacific South-East AsiaEastern MediterraneanAfrica

53.7%

27.0%

15.8%2.3%

0.6%

0.5%

Health Research budget

Financial investment in R&D and health research

30.2%

28.7%

25.0%

8.7%

4.6%2.7%

Gross Income

14% of the proportional

ity

Source: World Health Organization, Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.GNI2020?lang=en (Nov 24, 2013).Røttingen JA, et al. Lancet. 2013 Oct 12;382(9900):1286-307.

Data for all countries are based

on modeling

Source: World Health Organization, Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.GNI2020?lang=en (Nov 24, 2013).Røttingen JA, et al. Lancet. 2013 Oct 12;382(9900):1286-307.

Financing

Production and

utilization of research

Resources

Stewardship

The budget share of health research is 0.6% .

Trend of investment on GERD/GDP

Expenditure on research does not exceed 0.3% of GDP, 97% of which comes from government sources.

Source: UNESCO Science Report, 2010. http://unesdoc.unesco.org/images/0018/001898/189883E.pdf.

1.25

2009

1996

0.03

Financing

Production and

utilization of research

Resources

Stewardship

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R&D investment was 0.03% in Tunisia in 1996, but had crossed 1% in 2000.

The countries’ plan in R&D investmentin all areas –not specific to health

Expenditure on research does not exceed 0.3% of GDP, 97% of which comes from government sources.

Source: UNESCO Science Report, 2010. http://unesdoc.unesco.org/images/0018/001898/189883E.pdf.

3.0

2016

Financing

Production and

utilization of research

Resources

Stewardship

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Iran has a Five-Year Plan to reach 3%

The countries’ plan in R&D investmentin all areas –not specific to health

Trend of investment on GERD/GDP

Expenditure on research does not exceed 0.3% of GDP, 97% of which comes from government sources.

Source: UNESCO Science Report, 2010. http://unesdoc.unesco.org/images/0018/001898/189883E.pdf.

2.8

2011

Financing

Production and

utilization of research

Resources

Stewardship

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The countries’ plan in R&D investmentin all areas –not specific to health

Qatar had a plan in which this figure was to reach 2.8% in 2011

Expenditure on research does not exceed 0.3% of GDP, 97% of which comes from government sources.

Source: UNESCO Science Report, 2010. http://unesdoc.unesco.org/images/0018/001898/189883E.pdf.

1.0

2012

Financing

Production and

utilization of research

Resources

Stewardship

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The countries’ plan in R&D investmentin all areas –not specific to health

Egypt had targeted 1% by 2012

Expenditure on research does not exceed 0.3% of GDP, 97% of which comes from government sources.

Source: UNESCO Science Report, 2010. http://unesdoc.unesco.org/images/0018/001898/189883E.pdf.

Financing

Production and

utilization of research

Resources

Stewardship

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The countries’ plan in R&D investmentin all areas –not specific to health

Many countries have shown their interest in greater investments in R&D.

Number of academic institutions in health by countries group

Saudi Arabia

Bahrain 

Kuwait 

Egypt

Libya

Lebanon

Jordan

Palestine

Pakistan

Afghanestan

Somalia

05101520253035404550

Source: University of Copenhagen. The Avicenna Directory for medicine. http://avicenna.ku.dk/database/medicine/(Nov, 2013).

Financing

Production and

utilization of research

Resources

Stewardship

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Pakistan, Iran, Sudan, Egypt and Saudi Arabia have the highest numbers of institutes.

0 10 20 30 40 50 60 700

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Chart Title

Number of academic institutions in health vs publication in 2012

Pakistan

Sudan

Pub

licat

ion

in 2

012

Number of academic institutions

Financing

Production and

utilization of research

Resources

Stewardship

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Pakistan and Sudan academic institutions haven’t had as many publications as expected.

Human capital: skilled migration among countries of the region(2006 estimate by World Bank)

Turkey

Brazil

Kuwait

Qatar

Saudi Arabia

Morocco Ira

q

Palestine

Egypt

Afghanistan

Djibouti

Yemen

0%

5%

10%

15%

20%

25%

30%

Source: Measuring international skilled migration. Michel Beine, Frédéric Docquier and Hillel Rapoport, July 2006. (World Bank contract PO. 7641476)

Financing

Production and

utilization of research

Resources

Stewardship

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The emigration rate is high in group 2 and 3 countries.

Human capital: skilled migration among countries of the region(2006 estimate by World Bank)

Turkey

Brazil

Kuwait

Qatar

Saudi Arabia

Morocco Ira

q

Palestine

Egypt

Afghanistan

Djibouti

Yemen

0%

5%

10%

15%

20%

25%

30%

Source: Measuring international skilled migration. Michel Beine, Frédéric Docquier and Hillel Rapoport, July 2006. (World Bank contract PO. 7641476)

A report by the International Monetary Fund in 2009 indicated that Iran tops the list of countries losing their academic elite, with an annual loss of 150,000 to 180,000 specialists. It's equivalent to a capital loss of $50 billion.

Financing

Production and

utilization of research

Resources

Stewardship

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 2003 2005 2009

Djibouti

Somalia

Egypt Iran Morocco

Sudan

 Bahrain

 Jordan

 Kuwait

 Lebanon

 Oman

 Qatar

 Saudi 

Arabia

 Tunisia

 UAE

Yemen

Afghanistan

Iraq Pakistan

Palestine Syria

Formal NHRS structure

Data is not

available

Health research priorities

   2009

Health research policy/plan

NHRS Monitoring and evaluation

Result of National Health Research Systems (NHRS) assessment in the countries of the region

Sources: A study of national health research systems in selected countries of the WHO EMR. Cairo World Health Organization’s Regional Office for the Eastern Mediterranean, 2004.Kennedy A, et al. East Mediterr Health J. 2008 May-Jun;14(3):502-17.Ghannem H., et al. East Mediterr Health J. 2011 Mar;17(3):260-1.

6 did not have structure

9 were not functional

10 did not have all componentsFinancing

Production and

utilization of research

Resources

Stewardship

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Based on the numbers of registered clinical trials and patents it can be induced that studies that lead to the manufacture of tangible products are not well-grounded in the region.

The few studies that have been conducted across the region indicate that research evidence does not influence decision-makings much.

Absence of data on health-specific research financial investment.

Investment in health research has remained low. However, there is a political will in several countries to increase their GERD.

More effective stewardship is required for the region’s health research systems.

Conclusions

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We need better research and research done for the right

reasons

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Global Monitoring Framework9 global voluntary targets for 2025

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Five areas: Epidemiology and burden Governance for NCD Prevention and reduction of risk factors Health system response

Implementing priority interventions Improving access

Surveillance, monitoring and evaluation

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What are the barriers, and potential solutions of inter-sectoral collaboration on NCD?

What is the situation of political economy of healthy vs.unhealthy nutrition? What measures can be considered for improving situation of access and utilization of healthy foods?

What are the actual impacts of priority interventions on risk factor levels and global risk profile distribution?

What are the impacts of community health workers on NCD prevention and control?

What is the impact of patient education on improving adherence and strengthening the self-care?

NCD research priorities

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Which social groups are most adversely affected by NCD and its risk factors and determinants?(upgrading STEPS with appropriate questions and methods of analysis in this regard)

Are people at high risk of cardiovascular disease receiving recommended drug therapy and counseling?

What are the health system-related barriers to access NCD services in primary health care?

What are the practices of delivery of evidence-based NCD interventions at primary health care level?

Are evidence-based guidelines being applied to guide utilization of high-tech approaches (for example coronary revascularization)?

Country specific

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IRA-28

IRA-23

IRA-25

IRA-26

JOR-11

LEB-4

PAK-13

IARC

EMRAIN

EMPHNET

DCPN

AHPSR

AGKU

1 Inter-sectoral collaboration  √ √     √   √            2 Political economy of healthy nutrition                          3 Impacts of priority interventions  √ √                      4 Impacts of community health workers  √                        5 Impact of patient education √ √ √   √   √            6 Impact of capacity building on improving registration                           7 Projected costs (e.g. MPOWER ) √                        8 Economic costs of NCD and key risk factors                      †    9 Population-attributable fractions of risk factors               †          

10 Social groups affected by NCD                           11 Coverage of interventions for people at risk of CVD   √                   √  12 Health system-related barriers to access NCD    √     √             √ †13 Delivery of evidence-based NCD interventions at PHC   √     √             √ †14 Application of evidence-based guidelines   √                   √  15 Policy brief on adherence of health care professionals to 

guidelines                          

16 Policy brief on impact and cost of implementing a package of essential NCD interventions 

17 Effect of NCD policies on ameliorate or worsen NCD social disparities

18 Cost-effectiveness of priority interventions                           

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