Readers will know that I often play with ideas in my posts. Views expressed here are not necessarily my final and resolute viewpoint and I value further dialogue. My idea this week, is that, increasingly, health services research in resource poor and economically developed countries should be more closely aligned.
On the most superficial level, the stark difference in diseases is no longer as evident as it was when I set out in my professional career, some three decades ago (OK then, four decades ago). In those days, heart attacks, high blood pressure and depression predominated in rich countries, while malaria, diarrhoea and tuberculosis were most important in poor countries. This has changed quite radically. For example, infant deaths have dropped around the world (exceeding the millennium goal in many countries)1, while resource poor populations are ravaged by diabetes, obesity, heart attacks and stroke. In the end, it was even easier to get on top of the HIV epidemic, than to halt the rising incidence of the chronic ‘degenerative’ diseases of middle and old age.
However, I think the differences go deeper than just a change in disease patterns. Thirty years ago, Stockholm would have been effectively all middle class, while Addis Ababa or Mumbai would be constituted of a minute elite astride a vast deprived population. Visits to these cities now show a rapidly changing kaleidoscope with pockets of deprivation in Stockholm and a burgeoning middle class over most of the poor countries of the world. Looking ahead, I discern that we are moving towards a new kind of stratification; one which is increasingly within, rather than between, countries. Dani Rodrik is fond of pointing out that a person is better off (materially at least) if they are a random member of the lowest 10 per cent by income of a typical rich country than the highest 10 per cent in a typical low income country. However, projections based on current economic growth rates will likely change this.
Perhaps there are even deeper changes going on than those concerning just wealth and disease, but affecting also educational attainment. Only in extremely poor countries (Afghanistan) or those where the sources are hopelessly inadequately divided (Equatorial Guinea), are the majority of people neither numerate or literate. Children in Nairobi’s Kabela slum can go to school. The exceptions are mostly countries that have suffered prolonged war, such as Democratic Republic of Congo or South Sudan. About five years ago I visited Gonda in northern Ethiopia to work for a week in the maternity department. I found I really had very little to teach the local doctors. With few exceptions, where they deviated from evidence-based guidelines, it was because they did not have the necessary drugs or equipment, not because they were ignorant of modern standards2. Collaborations across countries involve networks of intellectual equals.
Moreover, the research methodologies that one would want to use across different settings are not dependent to any significant degree from those that one would use in the West. In fact, the flow of knowledge is not necessarily one way. For example, most practical applications of the step wedge design of clinical study were carried out in Africa, but the method is now being increasingly used in rich country settings (including the National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country I direct here in the West Midlands of England). Of course, the topics studied might differ in the particular. In a resource-poor setting, one might study the use of cheap and widely available materials for hernia repair,3 or a birthing mat for use in childbirth,4 but the fundamental tools of evaluation would remain unchanged. In health economic analysis, one might wish to discount costs (or even benefits) at a higher rate to take account of rapid economic growth rates, but this is a detail, rather than a fundamental change in method. Moreover, many of the problems of health services research are the same. Thus, integration of care, and delivering care holistically (rather than in silos) is a pressing issue in both rich and poor countries,5 while ‘lean’ methods to streamline surgery developed in India could improve productivity in Birmingham, Alabama.
It seems to me that, far from it being desirable to partition health-related research between the developed and resource poor countries of the world, there is a great deal to be learned from studies which cross national borders. The obvious reason for this is that it allows the effect of context on interventions to be studied, and this in turn can help generate theory and hence new hypotheses to test.6 A corollary of this thinking is that funding mechanisms should be merged – I contend that there would be profit in merging funds across funding agencies, and incentivising international studies; Qatari National Foundation Grants make provision for 30 per cent of funds to be spent abroad. I hypothesise that this would have not only normative scientific value, but it would also be symbolically important, representing a more egalitarian collaboration across countries and would make reliance on formal codes of conduct, such as the Arusha Accord7, less relevant, since the provisions of the code would be inherent in the structure of the research.
1. Countdown to 2015. Maternal, Newborn & Child Survival. Accountability for Maternal, Newborn & Child Survival. The 2013 Update. World Health Organization: Geneva. 2013. Available at: http://www.countdown2015mnch.org/documents/2013Report/Countdown_2013-Update_noprofiles.pdf [Accessed 2013 May 31].
2. Pitchforth E, Lilford RJ, Kebede Y, Asres G, Stanford C, Frost J. Assessing and understanding quality of care in a labour ward: a pilot study combining clinical and social science perspectives in Gondar, Ethiopia. Soc Sci Med. 2010;71(10):1739-1748.
3. Stephenson BM, Kingsnorth AN. Inguinal hernioplasty using mosquito net mesh in low income countries: an alternative and cost effective prosthesis. BMJ. 2011; 343: d7448.
4. Dhaka. Mat red. Medical technology need not be sophisticated to be effective. The Economist. 18 May 2013. Available at: http://www.economist.com/news/science-and-technology/21578025-medical-technology-need-not-be-sophisticated-be-effective-mat-red [Accessed 2013 May 31].
5. Marquez PV et al. No more disease silos for sub-Saharan Africa. BMJ. 2012; 345: e5812.
6. Banerjee A, Duflo E. Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty. PublicAffairs: New York, NY. 2011.
7. Horton R. Offline: 107 602 707 791. Lancet. 2013; 381:278.