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Complementary strategies for efficient use of knowledge for better health
COMMENTARY
Complementary strategies for efficient use of knowledge for better health Knowledge produced by health research is crucial to achieving four of the eight UN Millennium Development Goals—ie, to reduce child mortality, to improve maternal health, to eradicate extreme poverty and hunger, and to reverse the spread of HIV/AIDS, tuberculosis, malaria, and other diseases. The recently concluded Global Forum for Health Research meeting in Arusha, Tanzania,1 was the first to be held in Africa and provided an excellent opportunity to review progress in global health research since the International Conference on Health Research for Development in Bangkok in October, 2000. Despite the view that progress since Bangkok has been slow,2 some advances have been made. The formation of regional health-research forums in Asia-Pacific and Africa (the African one officially launched during the Arusha meeting), with similar plans in Latin America and Central Asia, is particularly significant. Taking a direct cue from the Bangkok conference, the Eastern Mediterranean region of WHO (EMRO) passed a resolution in October, 2001, requiring its member states to allocate 2% of WHO countrybudgets to health-research activities. Information on resource flows in health research has been updated3,4 and an initiative called HINARI (Health Internetwork Access to Research Initiative), first mooted at the time of the Bangkok conference,5 has enabled free full-text access to more than 1500 scientific journals in many developing countries.6 Progress has also been made in defining the concept of a health-research system7 and how the research-to-policy link can be enhanced and, importantly, assessed.8 However, there are still substantial challenges ahead. What of future directions and initiatives? In 2001, the report of the Commission on Macroeconomics and Health9 recommended the formation of a Global Health Research Fund. At Arusha, the US National Institutes of Health (NIH) unveiled a plan for how such a fund may operate through a newly created virtual international NIH, which would support peer-reviewed scientific research through linking institutions in the developed world to leading research institutions in developing countries. What are the implications for this model? It is likely that this approach will focus on the biomedical sciences and may pay less attention to health-systems and social-policy research, for example, which were identified as neglected areas in the same Arusha session. By focusing on leading institutions in the developing world, it may “strengthen the already strong”, risk creating an elite group of researchers within a country, and may even exacerbate the brain-drain problem.1,10 It is also unclear how much influence countries themselves will have on the research agenda, and whether priorities will be set according to the most urgent health problems a country faces. The benefits to the least developed countries, who possess only minimal research infrastructure and weak institutions, are also uncertain. Are there complementary models that can be considered? How can developing countries best use development funds from international sources to promote health research? Foreign aid works best when beneficiaries have a stake in the venture, when it is adapted to local needs, when it generates enthusiasm and cooperation among the participants, and when donor coordination responds to the demands of recipient institutions, not the other way around.11 Experience with various models for use of funds in the field of social and economic development may be instructive, in particular the model of autonomous development funds.11,12 The main aim of such funds is to mobilise external support for development by acting as intermediaries between donor 716
agencies and recipient institutions. The salient features of these funds11 are the national scope of operation, a public but politically independent institution catering for both public and civil society, and a funding, not an operational entity, which aggregates financing from many sources and brings donors and recipients together in new ways. Could the model be adapted to aid for health research in the form of public-health research trusts, as proposed by some health researchers, which will serve to complement the virtual international NIH model? Such trusts, to be managed by forums or entities representing all key stakeholders (eg, national health-research councils), and to be funded by both national and external sources, would have control over setting the research agenda and priorities. An important prerequisite for such an approach is that countries themselves must first demonstrate a capacity for efficient and transparent management, and monitoring, of their own health-research systems. WHO is strongly committed to strengthening national health-research systems in accordance with the view that “the success of WHO will be judged not on the communiqués from lavish governmental conferences, but rather on the work of the organisation at country level”.13 In support of the international NIH model, such trusts could also support relevant biomedical research but would focus primarily on research on health systems and health services, social policy research, operational research, and research into the research process itself. In this way, it would serve to strengthen the health-research foundation and environment within a country and enhance the efficiency of translating research and the overall impact of science-driven initiatives. Linking global science and research is highly desirable, but equity and participation are equally important. Whatever scheme is developed should combine promoting scientific excellence with the goals of promoting selfdetermination, autonomy, ownership, and equity. Tikki Pang Research Policy and Cooperation, WHO, Geneva 1211, Switzerland (e-mail: [email protected]) 1 2 3
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Ferriman A. Where there is despair, there is hope. BMJ 2002; 325: 1194. Abbasi K. Progress is slow in narrowing the health research divide. BMJ 2001; 323: 886. Monitoring financial flows for health research. Geneva: Global Forum for Health Research, 2001. http://www.globalforumhealth.org/FilesUpld/ 20.pdf (accessed Dec 17, 2002). Measuring expenditure on health-related R&D. Paris: Organization for Economic Co-operation and Development, 2001. http://www1.oecd.org /publications/e-book/9201061E.PDF (accessed Dec 17, 2002). Godlee F, Horton R, Smith R. Global information flow-publishers should provide information free to resource poor countries. BMJ 2000; 321: 776–77. Malakoff D. Journals offered free to poorest nations. Science 2001; 293: 189–90. National health research systems: report of an international workshop. Geneva:,World Health Organization, 2001. http://www.who.int/rpc/pdf/ChaamDoc.pdf (accessed Dec 17, 2002). The utilisation of health research in policy-making; concepts, examples and methods of assessment. HERG research report no 28. Uxbridge, UK: Health Economics Research Group, 2002. Macroeconomics and health: investing in health for economic development: report of the Commission on Macroeconomics and Health. Geneva. World Health Organization, 2001: http://www3.who.int/whosis/cmh/cmh_report/report.cfm?path=cmh,cmh _report&language=english (accessed Dec 17, 2002). Pang T, Lansang MA, Haines A. Brain drain and health professionals. BMJ 2002; 324: 499–500. Hyden G. Reforming foreign aid to African development—a proposal to set up politically autonomous development funds. Dev Dialogue 1995; 2: 34–52. Musuveni Y. The role of independent funds for social and economic development in Africa—an opening address. Dev Dialogue 1995; 2: 7–10. Horton R. WHO: the casualties and compromises of renewal. Lancet 2002; 359: 1605–11.
THE LANCET • Vol 361 • March 1, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Complementary strategies for efficient use of knowledge for better health Knowledge produced by health research is crucial to achieving four of the eight UN Millennium Development Goals—ie, to reduce child mortality, to improve maternal health, to eradicate extreme poverty and hunger, and to reverse the spread of HIV/AIDS, tuberculosis, malaria, and other diseases. The recently concluded Global Forum for Health Research meeting in Arusha, Tanzania,1 was the first to be held in Africa and provided an excellent opportunity to review progress in global health research since the International Conference on Health Research for Development in Bangkok in October, 2000. Despite the view that progress since Bangkok has been slow,2 some advances have been made. The formation of regional health-research forums in Asia-Pacific and Africa (the African one officially launched during the Arusha meeting), with similar plans in Latin America and Central Asia, is particularly significant. Taking a direct cue from the Bangkok conference, the Eastern Mediterranean region of WHO (EMRO) passed a resolution in October, 2001, requiring its member states to allocate 2% of WHO countrybudgets to health-research activities. Information on resource flows in health research has been updated3,4 and an initiative called HINARI (Health Internetwork Access to Research Initiative), first mooted at the time of the Bangkok conference,5 has enabled free full-text access to more than 1500 scientific journals in many developing countries.6 Progress has also been made in defining the concept of a health-research system7 and how the research-to-policy link can be enhanced and, importantly, assessed.8 However, there are still substantial challenges ahead. What of future directions and initiatives? In 2001, the report of the Commission on Macroeconomics and Health9 recommended the formation of a Global Health Research Fund. At Arusha, the US National Institutes of Health (NIH) unveiled a plan for how such a fund may operate through a newly created virtual international NIH, which would support peer-reviewed scientific research through linking institutions in the developed world to leading research institutions in developing countries. What are the implications for this model? It is likely that this approach will focus on the biomedical sciences and may pay less attention to health-systems and social-policy research, for example, which were identified as neglected areas in the same Arusha session. By focusing on leading institutions in the developing world, it may “strengthen the already strong”, risk creating an elite group of researchers within a country, and may even exacerbate the brain-drain problem.1,10 It is also unclear how much influence countries themselves will have on the research agenda, and whether priorities will be set according to the most urgent health problems a country faces. The benefits to the least developed countries, who possess only minimal research infrastructure and weak institutions, are also uncertain. Are there complementary models that can be considered? How can developing countries best use development funds from international sources to promote health research? Foreign aid works best when beneficiaries have a stake in the venture, when it is adapted to local needs, when it generates enthusiasm and cooperation among the participants, and when donor coordination responds to the demands of recipient institutions, not the other way around.11 Experience with various models for use of funds in the field of social and economic development may be instructive, in particular the model of autonomous development funds.11,12 The main aim of such funds is to mobilise external support for development by acting as intermediaries between donor 716
agencies and recipient institutions. The salient features of these funds11 are the national scope of operation, a public but politically independent institution catering for both public and civil society, and a funding, not an operational entity, which aggregates financing from many sources and brings donors and recipients together in new ways. Could the model be adapted to aid for health research in the form of public-health research trusts, as proposed by some health researchers, which will serve to complement the virtual international NIH model? Such trusts, to be managed by forums or entities representing all key stakeholders (eg, national health-research councils), and to be funded by both national and external sources, would have control over setting the research agenda and priorities. An important prerequisite for such an approach is that countries themselves must first demonstrate a capacity for efficient and transparent management, and monitoring, of their own health-research systems. WHO is strongly committed to strengthening national health-research systems in accordance with the view that “the success of WHO will be judged not on the communiqués from lavish governmental conferences, but rather on the work of the organisation at country level”.13 In support of the international NIH model, such trusts could also support relevant biomedical research but would focus primarily on research on health systems and health services, social policy research, operational research, and research into the research process itself. In this way, it would serve to strengthen the health-research foundation and environment within a country and enhance the efficiency of translating research and the overall impact of science-driven initiatives. Linking global science and research is highly desirable, but equity and participation are equally important. Whatever scheme is developed should combine promoting scientific excellence with the goals of promoting selfdetermination, autonomy, ownership, and equity. Tikki Pang Research Policy and Cooperation, WHO, Geneva 1211, Switzerland (e-mail: [email protected]) 1 2 3
4
5
6 7
8
9
10 11
12 13
Ferriman A. Where there is despair, there is hope. BMJ 2002; 325: 1194. Abbasi K. Progress is slow in narrowing the health research divide. BMJ 2001; 323: 886. Monitoring financial flows for health research. Geneva: Global Forum for Health Research, 2001. http://www.globalforumhealth.org/FilesUpld/ 20.pdf (accessed Dec 17, 2002). Measuring expenditure on health-related R&D. Paris: Organization for Economic Co-operation and Development, 2001. http://www1.oecd.org /publications/e-book/9201061E.PDF (accessed Dec 17, 2002). Godlee F, Horton R, Smith R. Global information flow-publishers should provide information free to resource poor countries. BMJ 2000; 321: 776–77. Malakoff D. Journals offered free to poorest nations. Science 2001; 293: 189–90. National health research systems: report of an international workshop. Geneva:,World Health Organization, 2001. http://www.who.int/rpc/pdf/ChaamDoc.pdf (accessed Dec 17, 2002). The utilisation of health research in policy-making; concepts, examples and methods of assessment. HERG research report no 28. Uxbridge, UK: Health Economics Research Group, 2002. Macroeconomics and health: investing in health for economic development: report of the Commission on Macroeconomics and Health. Geneva. World Health Organization, 2001: http://www3.who.int/whosis/cmh/cmh_report/report.cfm?path=cmh,cmh _report&language=english (accessed Dec 17, 2002). Pang T, Lansang MA, Haines A. Brain drain and health professionals. BMJ 2002; 324: 499–500. Hyden G. Reforming foreign aid to African development—a proposal to set up politically autonomous development funds. Dev Dialogue 1995; 2: 34–52. Musuveni Y. The role of independent funds for social and economic development in Africa—an opening address. Dev Dialogue 1995; 2: 7–10. Horton R. WHO: the casualties and compromises of renewal. Lancet 2002; 359: 1605–11.
THE LANCET • Vol 361 • March 1, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.