General medicine/concept
Placing Emergency Care on the Global Agenda

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Emergency care serves a key function within health care systems by providing an entry point to health care and by decreasing morbidity and mortality. Although primarily focused on evaluation and treatment for acute conditions, emergency care also serves as an important locus of provision for preventive care with regard to injuries and disease progression. Despite its important and increasing role, however, emergency care has been frequently overlooked in the discussion of health systems and delivery platforms, particularly in developing countries. Little research has been done in lower- and middle-income countries on the burden of disease reduction attributable to emergency care, whether through injury treatment and prevention, urgent and emergency treatment of acute conditions, or emergency treatment of complications from chronic conditions. There is a critical need for research documenting the role of emergency care services in reducing the global burden of disease. In addition to applying existing methodologies toward this aim, new methodologies should be developed to determine the cost-effectiveness of these interventions and how to effectively cover the costs of and demands for emergency care needs. These analyses could be used to emphasize the public health and clinical importance of emergency care within health systems as policymakers determine health and budgeting priorities in resource-limited settings.

Introduction

Establishing a health research agenda in developing countries has increasingly been recognized as crucial in determining health and budgeting priorities in resource-limited settings. Yet the concept of emergency care has largely been overlooked or, at times, disregarded as beyond the reach of health systems in resource-limited settings. Traditionally, research in these settings has generally existed within, as stated by the Commission on Health Research for Development, “vertical programs which are not fully integrated in the national health research picture and therefore do not contribute optimally to the development of a strong and self-reliant national health research system.”1 Certain devastating diseases, such as HIV,2, 3 malaria,4, 5 and tuberculosis,6, 7 have received widespread funding attention, leading to important basic science research, clinical trials, cost-effectiveness analyses, and implementation strategies. However, although these vertical programs help to broaden the frontiers of knowledge concerning specific diseases, there is a paucity of information about how to best deliver care in resource-limited settings.

One area of investigation that has been long neglected on the global health research agenda is that of emergency care in lower- and middle-income countries.8, 9 Significant efforts have been made by those within the emergency medicine community to highlight the need for emergency care research, but outside of this field emergency care has attracted little attention. Acute medical and surgical needs grow increasingly important as populations undergo the epidemiologic transition from communicable diseases to noncommunicable diseases.10 Thus, policymakers should be increasingly aware of the abilities or inabilities of their health systems to respond to these needs.

Emergency care encompasses more than emergency medicine as practiced in developed countries. It can be conceptualized as the ability of a health system to provide access to acute health care, such as injury stabilization and initial treatment of acute illnesses, many of which are not preventable. However, emergency care can also serve as an access point for other health care services, such as preventive care and more definitive medical care. There is a critical need for documenting the role of emergency care within specific health systems and its effects on overall morbidity and mortality. Emergency care should be thought of more broadly as a means of meeting important health care needs for a population, rather than as just a location of care delivery. We argue that emergency care should be on the list of essential priorities to be studied in lower- and middle-income countries. Research on the importance of emergency care and its cost-effectiveness can enhance a meaningful appreciation of the need for and role of emergency care services in resource-limited settings. Emergency physicians interested in global health should understand these issues to initiate discussions with those outside of the specialty concerning the importance of emergency care in lower- and middle-income countries.

Section snippets

Paucity of Data on Emergency Care in Health Systems

Traditionally, emergency care has often been conceptualized as peripheral and costly health care services that only well-developed and well-funded health systems are able to offer, in comparison to primary care services, which are frequently touted as low cost.11, 12 This emphasis on primary care resulted from the International Conference on Primary Health Care, held in Alma-Ata in 1978. The 1978 Declaration of Alma-Ata emphasized primary health care as a method of achieving “health for all.”

Measuring the Importance of Emergency Care

WHO has suggested a systematic approach to resource allocation for strategic health research that includes calculating the burden of disease, judging the adequacy of the current knowledge base, and assessing the current level of effort.8 More recently, the Child Health and Nutrition Research Initiative has proposed a systematic methodology for setting health research investment priorities that has been used successfully in a variety of contexts.30, 31, 32, 33, 34, 35, 36 However, this

Developing a Research Agenda for Emergency Care in Global Health

Research in emergency care falls within, as Jamison et al64 point out, “core functions” of international health organizations because they can be viewed as public goods. There has been significant effort by some to place the broad concept of emergency care on the global health agenda through such venues as the WHO Guidelines for Essential Trauma Care,65, 66 the Pre-hospital Trauma Care Guidelines,67 and the essential obstetric care guidelines.68 Similarly, the WHO Office of Essential Health

Conclusion

This article delineates the need for increased research activities and better measurement of the role of emergency care in developing countries. A critical component of this need is for health practitioners, researchers, and policymakers globally to be aware of the large and growing societal demand for emergency care. Many communities often judge the success or failure of their government by the government's ability to provide critical infrastructure, such as security and access to critical

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      Despite this, little is known about the burden of emergency conditions and the frequency at which patients seek medical care in these countries [2,4,5]. The paucity of information regarding the burden of emergency conditions hinders attempts to develop appropriate systems and to improve the effectiveness of existing emergency care in sub-Saharan Africa [3,6,7]. Furthermore, in sub-Saharan Africa, data on the local burden of emergency disease, particularly at a local level, are scarce due to a lack of standardized reporting methods [4,5,8].

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    Supervising editor: William R. Mower, MD, PhD

    Dr. Callaham recused himself from the decisionmaking about this article.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

    Publication date: Available online February 6, 2010.

    Reprints not available from the authors.

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