The Research and Development Agenda
The research and development priorities for emergency care are challenging to define because emergency care is a neglected area of research in low-income countries and the needs are great. As a neglected topic, emergency care is part of the "10-90" gap of health research: less than 10 percent of global research investments are for problems affecting 90 percent of the world's population (Global Forum 2000).
Approach to Research and Development for EMS
The spectrum of research required is diverse and may be easily understood with the help of the schematic shown in figure 68.2. The rectangle is a schematic representation of the totality of the global burden of disease that can be potentially addressed by EMS (see "Burden of Disease"). A portion of this potential burden is being addressed (or reduced) by those existing interventions that have been implemented, defined by box A. If the efficiency of current interventions were to be enhanced and their coverage increased, then another portion of the burden defined by box B could be addressed; this increase in efficiency will require operations research, policy research, and social science research. If existing interventions, which have not been implemented because of their high costs, were made more cost-effective, then another portion of the burden defined by box C could be reduced. This process of making interventions more cost-effective will require economic analysis and clinical research in many instances. Finally, a portion of the burden exists for which we do not have existing interventions, defined by box D; it requires basic and clinical research to develop and pilot interventions that can address other determinants of the emergency care-related burden in the future.
[Figure
68.2]
This schematic representation is thus useful to demonstrate two critical needs:
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essential research on emergency care in low-income countries
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a diverse set of research studies and approaches to reduce the burden that can be addressed by EMS.
Priority Setting for Research and Development of Emergency Care
Setting priorities for research and development on EMS needs to be a region-specific, if not country-specific, process. No current list exists of global research and development priorities for EMS, again reflecting the need for more attention and investments in this area. This chapter does not intend to prescribe a list of issues or topics for global research and development efforts, but rather to highlight the gap in global research and development and to suggest possible issues and topics that may be broadly relevant to low-income countries for these efforts in the short to middle term.
A number of methods exist for setting research priorities in the health sector, such as the Combined Approach Matrix promoted by the Global Forum for Health Research (Global Forum 2002) and the Essential National Health Research process promoted by the Council for Health Research for Development. Countries and regions can use these approaches to help develop their research agenda for EMS.
The review of evidence available in the field of emergency care as applicable to low-income countries reveals many gaps in global knowledge. Following on the illustration of figure 68.2, there is a need to better understand the epidemiology of those conditions that can be addressed by an EMS in a low-income country and which interventions currently in place are addressing them. We have little knowledge of how to enhance the efficiency of these existing interventions and reduce their costs. Most important, the lack of intervention trials done in low-income countries creates a major research priority for the field of EMS. Well-designed, locally appropriate interventions that establish their effectiveness are urgently needed and should include both interventions that may be available in high-income countries and new ones. Economic analysis is another area for major research input in the field of EMS, where cost and cost-effectiveness information from low-income countries is scant. These gaps only reflect the need for a more systematic analysis of where research investments should be directed in the next five years for EMS.
