Global Health in Transition: A Synthesis: Perspectives from International Organizations (1996)

Commission on Health Research for Development. 1990. Health Research: Essential Link to Equity in Development. New York: Oxford University Press. The Commission on Health Research for Development, an independent international initiative, was formed in 1987 with the aim of improving the health of people in developing countries through a focus on research, in a belief in its enormousand, in great part, neglectedpower to accomplish that goal. Over 24 months, the Commission reviewed information, implemented a survey, commissioned papers and case studies, and convened regional workshops. The Commission had a multinational, multidisciplinary membership, and its work was supported by a diverse group of 16 donors from Europe, North America, Asia, and Latin America. The report has three sections. The first reviews inequities in health and argues for health as both a beneficiary of and a spur to development. The second presents survey and country study findings related to the financing, focus, location, and promotion of health research. The third presents conclusions and recommendations for action.

• To analyze health research as a tool for health and development, both for applying solutions already available and for generating new knowledge to tackle problems for which solutions are not yet known.

• There is a gross mismatch between the burden of disease, whose occurrence is overwhelmingly greater in the developing world, and investment in health research, which is overwhelmingly focused on

the health problems of people in developed countries. Of the estimated $30 billion world expenditure on health research, only 5 percent ($1.6 billion) is devoted to the health problems of people in developing countries, which account for 93 percent of the years of potential life lost in the world.

• Of that $1.6 billion, 42 percent ($685 million) originated in the developing countries themselves; 58 percent ($950 million) originated in the developed countries. However, of the $950 million devoted to research on health problems in developing countries, only $150 million was actually transferred to those countries. Almost half of the research funding on the health problems of people in the developing countries goes to support researchers in developed countries working in their own countries.

• Overseas development assistance (ODA) varies greatly among developed countries, from 0.2 percent of gross national product in the United States and 0.3 percent in Japan, to about 1 percent in Scandinavia. The percentage of ODA invested in health research also varies widely, but overall, it seems to have been static or declining over the past decade, because of economic recession and a decline in ODA in real terms.

• Though some major health problems are receiving attention, others notably, the policy and social sciences, epidemiology, and management researchare relatively neglected. Biomedical and clinical research initiatives are somewhat stronger, but capacity-strengthening efforts in these fields are modest in scale and are narrowly targeted. Major gaps exist in information, monitoring, and assessment of the evolving health picture.

• Still, the number of international research promotion programs is growing and could form the core of a worldwide health research system. Joint efforts by United Nations agencies are noteworthy, and privately sponsored efforts have been productive, though these are characterized by fragmentation and multiple, narrowly focused research initiatives.

• Although investment in health research in developing countries is impressive, 75 percent of this investment comes from eight large or rapidly developing countries; most developing countries invest little in health research. In those countries that invest little, scientists and institutions are pursuing a range of research activities, but they face serious professional, institutional, and environmental constraints. Coherent research responses to high-priority problems at the national level are limited, and national commitment and international reinforcement for health research, specific actions to tackle constraints, and capacity building and maintenance are, at best, uneven.

1. The most urgent need is the rapid expansion of country-specific health research through the development of institutional and individual capacities, especially in the neglected fields of policy and the social sciences, epidemiology, and management research. Each country, taking account of its own circumstances, should carefully plan and carry out sustained, long-term programs for essential national health research. The four major components of such a process would be

   • research priority setting;

   • professional recognition and construction of career paths;

   • development of reliable and continuing links between researchers and research users; and

   • investment of at least 2 percent of national health expenditures in essential national health research.

2. Recommended priorities for internationally organized research programs are

   • expanded support for the World Health Organization's tropical disease, human reproduction, and diarrheal disease control programs;

   • rapidly expanded research on acute respiratory infections, emphasizing simple, effective treatment;

   • improved methods for case detection, ambulatory treatment, and prevention of tuberculosis;

   • national programs to eradicate micronutrient deficiencies, especially deficiencies of vitamin A, iron, and iodine;

   • modifiable factors associated with a high risk of diabetes, coronary heart disease, and hypertension;

   • behavioral interventions to reduce injuries, sexually transmitted diseases, and substance abuse;

   • international collaborative research on mental health problems, emphasizing methods of diagnosing and dealing with the most prevalent and treatable conditions; and

   • establishment of sustained international research networks in the most important areas of environmental and occupational health.

3. Humanity's greatest health problems can be addressed most effectively through cooperative efforts by scientists

around the world. Developing and developed countries and international agencies should promote and support establishment of international partnerships and steady growth in collaborative research networks as the main means for mobilizing scientific talent to attack common problems and share research strategies and results.

4. Investment in health research and strengthening the capacities of tropical disease institutes, medical and public health schools, and development studies groups should be elevated to at least 2 percent of national health expenditures in developing countries and at least 5 percent of the health portfolios of development agencies, with greater investments as well by developed country research agencies, foundations, non-governmental organizations, and the pharmaceutical industry to support research focused on the health problems of people in developing countries, with longer time horizons than is typical for most development assistance projects.

5. Establishment of an independent, objective international mechanism for monitoring progress in health research and, when needed, promoting financial and technical support for research on health problems of the developing world, would provide sustained impetus to the global research enterprise.

The analysis of the Commission on Health Research for Development is focused and insistent. There is no doubting the importance of health-related research centered on the problems of developing countries. Far from being a luxury, such research is a particular necessity in those countries, where better health status for more people must be achieved with sometimes painfully limited resources. The Commission identifies equity of opportunity as an overriding, if elusive, goal of development, for which research is imperative.

A large part of the necessary health research will have to be done in the developing countries themselvesto delineate the problems specific to each country and to serve as a basis for policy making and strategy development. Nonetheless, research capacities in those countries are generally quite limited, as are the capabilities for absorbing research findings from elsewhere.

Attention to building such capacities in developing countries has been weak to nonexistent. Neither training nor support for health

research has had the coherence and continuity required and both have tended to be fragmented, short term, and focused on the interests of individual organizations. Moreover, while research on some health problems is well supported, research on other problems of importance remains largely unattended.

The Commission recommends the establishment of an international mechanism to monitor the progress of research on developing country problems and to identify unmet needs. The mechanism would be responsible for monitoring, assessment, convening, and advocacy, but it should not itself be an executing agency. In a way, the Commission has served this function in its own workan analysis of the situation with respect to research in developing countries and recommendations for strengthening the areas of research to which it would give priority. This recommendation of the Commission to establish an independent mechanism for monitoring and research exemplifies the ways in which the independent sector can ensure progress in other areas of development as an essential component of global governance.

In fact, the Commission envisages something morea pluralistic, worldwide health research system that will nurture productive scientific groups linked in diverse national and transnational networks to address both national and global health problems.

This interest of the Commission parallels the call in other documents reviewed in this Synthesis for international mechanisms to bring greater coherence to the functions of donors and supporters of development-related activities. This raises the following question: How susceptible to international coordination and control are global strategies and programs for supporting health system development, including research?