Document(s) 3 of 21

Research uses the scientific method to discover facts and their interrelationships and then to apply this new knowledge in practical settings. This process was the means by which the jet engine was invented, the atom split, and the green revolution of the past 25 years generated. Research holds the same promise for health, a promise that we have seen fulfilled with the development of new tools such as antibiotics for the treatment of disease, vaccines for its prevention, and insecticides for controlling the vectors that transmit it. Yet for the world’s most vulnerable people, the benefits of research offer a potential for change that has gone largely untapped.

— CHRD (1990, p. vii)

This was the challenge, just more than 12 years ago. It led to a major review by an independent international initiative, the Commission on Health Research for Development, to determine why this was the case and what could be done. After 2 years of intensive consultation and debate, the Commission presented its findings and recommendations to an international conference at the Karolinska Institute in Stockholm, Sweden, in February 1990. Its principal finding was that only 5% of the global health-research investment is directed to conditions accounting for 95% of global disease. It recommended four actions:

• Encourage all countries to undertake Essential National Health Research (ENHR);
• Address common health problems through international partnerships linking the efforts of developing and industrialized countries;
• Mobilize larger and more sustained financial support from international sources to supplement developing-country investments; and
• Establish an international mechanism to monitor progress and promote financial and technical support for research on health problems in developing countries.

A direct follow-up from the Stockholm conference was the interim Task Force on Health Research for Development. It began working with developing countries implementing the ENHR strategy and set the stage for a more permanent mechanism to support their efforts. This was the Council on Health Research for Development (COHRED), a Geneva-based nongovernmental organization (NGO), established in March 1993.

During the 1990s, the World Health Organization (WHO) was also active in strengthening the role of research to address the health problems of the world’s needy peoples. An important example was a collaborative analysis of global health-research priorities, resulting in the 1996 report, Investing in Health Research and Development (Ad Hoc Committee 1996). In 1993, for the first time, the World Bank’s annual world development report focused on health (World Bank 1993). Since then the World Bank has become an increasingly important investor in health development, including health research. Another new institution, the Global Forum for Health Research (GFHR), was created in 1996 to provide a forum for stakeholders to review global health-research priorities, promote ongoing analysis of the international health-research situation, and facilitate coalition-building. The central objective of GFHR is “to help correct the 10/90 gap” (GFHR 1999, p. 8).

This chapter summarizes other examples of efforts to strengthen health research and its application to important national and global health problems, including several international programs: International Clinical Epidemiology Network (INCLEN), International Health Policy Program (IHPP), Applied Research on Child Health (ARCH) project, and the Multilateral Initiative on Malaria (MIM). It also discusses examples of special initiatives in some industrialized countries: the Swedish Agency for Research Cooperation with Developing Countries (SAREC), Canada’s International Development Research Centre (IDRC), and the Swiss Commission for Research Partnerships with Developing Countries (SCRPDC).

The chapter concludes with the view that although one finds more awareness of the 10/90 disequilibrium over the past decade and intensified action at national, regional, and global levels, the “system” is still too fragmented and uncoordinated. This raises questions about how effectively global health research has benefited the world’s most vulnerable people during this time, which in turn sets the stage for the chapters that follow.

In the last 10–15 years of the 20th century, the international development community made an effort to examine the role of health research as an important contributor to sustainable human development. Leading this endeavour was the work of the independent international Commission on Health Research for Development, which presented its landmark report to the Nobel Conference in Stockholm in February 1990. Several other organizations and agencies have shared its concerns and initiated special programs, including United Nations agencies, principally WHO and the World Bank. These actors have reached considerable agreement about the challenges and possible strategies to address them.

Now, as a new century begins, it is appropriate that the global health research-and-development (R&D) community will be meeting in Bangkok, Thailand, in October 2000. It will review progress on actions recommended a decade ago and renew a vision and an action agenda for the coming years.

Within this context, a group of colleagues concerned about the role of health research as an “essential link” to equity in development produced this document. This book is one among a number of contributions to the global review of health research for development. It attempts primarily to present a national perspective, with a special emphasis on the experiences and views of developing countries. It complements other documents prepared for the international conference, which focus more on global issues, such as the future “architecture” for health-research cooperation or the current status and future prospects for global financial flows.

This background introductory chapter will

• Restate the problems — or challenges — as described 10 years ago;
• Summarize the findings and recommendations of the Commission and trace follow-up actions, with special attention to what has been done to facilitate ENHR in developing countries;
• Highlight the roles and activities of other key players in health R&D over the past decade or so, including WHO, the World Bank, GFHR, some international programs, and some donor countries; and
• Comment on the status of the international health-research system at the beginning of this century, as it addresses the globally dominant health problems of our time.

Ten years ago, the Commission described the problems and challenges confronting the international health-research community. At the development level, it felt that people failed to adequately understand or appropriately value the role of health as a key component of sustainable human development. It also realized that phenomena such as continued population increase, insecurity, civil strife, and the demographic shift toward higher numbers of elderly people all have major implications for our understanding of the determinants of health and the ways these factors contribute to health gains.

At the health level, the Commission recognized that disparities in health persist and grow across and within countries, an observation that pertains to both industrialized and developing countries. It also described the rapidly changing health context, including the health-transition phenomenon, with its “double burden of disease”; impacts of the economic crisis of the 1980s on the health status of populations; the increasing demand for curative services; the rising cost of care, reflecting the introduction of new technologies; and the range of new and different health actions.

At the health-research level, it felt that decision-makers and communities alike failed to assign an appropriate value to research, seeing it as peripheral to their interests and livelihoods. Particularly in developing countries (and also to some extent in industrialized countries), health research was largely unrelated to local concerns and realities; and the results of the research were frequently unavailable, or if they were available no one used them for policy or action. Box 1.1 reproduces the major findings of the Commission’s report. Together they capture most of the concerns and descriptions of the problem found in other documents published at that time. However, the core finding of the Commission was that the international health-research system demonstrated “a gross mismatch between the burden of illness, which is overwhelmingly in the Third World, and investment in health research, which is overwhelmingly focused on the health problems of the industrialized countries” (CHRD 1990, p. xvii).

The idea of an independent commission on health research was a topic of discussion as early as 1985.[1] The justification for establishing a commission stemmed from three commonly held beliefs: developing countries had important unmet health needs; international health R&D activities could be more effective in meeting these needs; and donors were often unaware of promising opportunities to do so. Forty-seven individuals from around the world attended a planning meeting in Celigny, Switzerland, in July 1987, to clarify the problems and make recommendations on the desirability and nature of an independent international commission (Commission Secretariat 1987). The 16 sponsoring agencies selected a 12-person panel of three women and nine men (a remarkable range of eminent individuals, only four of whom were from industrialized countries). The work of the Commission was supported by a secretariat at Harvard University, with branches in London and Tokyo.

Why was this an “independent” Commission? The notes from the Celigny meeting describe a vigorous debate on whether the United Nations agencies should be sponsors. The United Nations Development Programme (UNDP) was already directly involved both in the discussion and eventually in the financial support of the Commission. But the attitude of many participants toward WHO was described as “ambiguous.” Some believed that WHO would not welcome recommendations about health research from an “outside group.” In fact, some commissioners described an ongoing tension between the Commission and WHO during the Commission’s entire 2-year study. For example, WHO resisted the idea of distributing the Commission’s report at the 1990 World Health Assembly. As well, the United Nations Children’s Fund clearly advocated equity-oriented initiatives but was reluctant to invest directly in research. As it turned out, UNDP was the only United Nations agency listed as a Commission sponsor, although the World Bank provided some funds as well.

The Commission began its task in late 1987, using several strategies, such as full-Commission meetings (eight of these meetings over a period of 27 months, held in various parts of the world), collaborative workshops, secretariat workshops, and a range of consultative activities. In particular, developing-country leaders strongly participated through in-country collaborative workshops. Many working papers were submitted in the form of both country reports and contributed papers. More than 600 individuals helped to the formulate the Commission’s vision of “a pluralistic worldwide health research system that will nurture productive national scientific groups linked together in transnational networks to address both national and global health problems” (CHRD 1990, p. xviii). The acknowledgments section of the report lists these individuals.

The Commission presented its report, Health Research: Essential Link to Equity in Development (CHRD 1990), at an international conference sponsored by the Nobel Assembly and supported by SAREC. The conference took place at the Karolinska Institute in Stockholm on 21–23 February 1990. Its objectives were threefold: to obtain an independent view of the Commission’s work (about four-fifths of the 83 participants had not previously worked directly with the Commission), to define some next steps, and to identify issues for further elaboration. David Bradley, the conference rapporteur, stated in his report that the conference participants gave “extremely strong endorsement” to the four main recommendations of the Commission, as listed in the “Summary,” above. A detailed presentation of the specific recommendations of the Commission’s report is found in Box 1.2. These recommendations reflect the key messages of the Commission: that research can, in fact, contribute to the enhanced health and well-being of people in developing countries, that a major focus must be on building sustainable capacity at the country level, and that coalitions of research producers and users should address priority research problems.

The Stockholm conference (later referred to as the First International Conference on Health Research for Development) included presentations from five countries already engaged in ENHR activities: Indonesia, Mexico, Philippines, Thailand, and Zimbabwe. Concerning the way ahead, the conference participants agreed unanimously on two parallel activities: to immediately “assist committed countries to maintain the momentum of ENHR and to build research capacity, and encourage others to join in” (SAREC 1990, p. 31); and to make an ongoing international effort “to advocate and sustain ENHR, to mobilize resources and to facilitate networks of support, interaction and collaboration in research” (SAREC 1990, p. 31). Specifically, the conference recommended the creation of an interim task force to function for 2 years to allow time to establish longer term mechanisms (a secretariat and a council). The final sentence in the conference report urged leaders from developing countries “to take the key role in moving ahead the recommendations of the Report” (SAREC 1990, p. 36). (In Box 1.3, two former Commission members reflect on the major impacts of the Commission and its 1990 report.)

In May 1990, shortly after the Stockholm conference, the Technical Discussions of the 43rd World Health Assembly in Geneva focused on the role of health research in the strategy for Health for All by the Year 2000 (HFA/2000). At this meeting, the Commission first distributed its report, despite initial WHO resistance. Participants at this meeting agreed that health research should become an integral component of national strategies for achieving HFA/2000. The Assembly’s resolution (43.19) on the Role of Health Research included a call to all member states to undertake essential health research appropriate to their national needs (Davies and Mansourian 1992). Much of the wording in the resolution reinforced the recommendations of the Commission.

Before the end of the year (November 1990), an international conference on ENHR took place in Pattaya, Thailand. At this conference, participants from developing countries identified seven elements in the implementation of ENHR: promotion and advocacy, ENHR mechanism, priority-setting, capacity-building and capacity-strengthening, networking, financing, and evaluation. The Task Force later disseminated these in a 1991 publication, Essential National Health Research: A Strategy for Action in Health and Human Development (TFHRD 1991), which included descriptions of the ENHR process in Mexico, Mozambique, Philippines, and Thailand.

As mandated by the Stockholm conference, IDRC and SAREC collaborated to establish the Task Force. Its several members had also been members of the Commission, including Professor V. Ramalingaswami of India, who served as Task Force chair. A secretariat based in the UNDP offices in Geneva supported the Task Force. Its original plan was to work in depth with a small number of countries. But interest in the ENHR process was intense, and over a 2-year period the Task Force was working with more than 20 countries. These countries saw ENHR as a powerful and innovative strategy to plan, prioritize, and manage national health research and mobilize its three main constituencies: researchers, policymakers, and the community.

Following a pattern begun by the Commission, the IDRC office in New Delhi published and distributed a monthly newsletter (enhr Forum). Working groups were formed, including one with the task of recommending longer term mechanisms to support ENHR. Another working group focused on monitoring progress.

These working groups consulted widely with many stakeholders, including WHO. The work of the Task Force culminated in the Second International Conference on Health Research for Development, held in Geneva in March 1993 (COHRED 1993). (Box 1.4 gives a list of key events in health R&D over the past 15 years.)

At this conference, representatives from 18 countries (as well as Commonwealth Caribbean countries as a group) presented their experiences with ENHR. The proceedings of this conference describe an extensive debate on an ongoing mechanism to facilitate and coordinate ENHR. Eventually, conference participants adopted a Declaration of Health Research for Development, supporting a mechanism called the Council on Health Research for Development (or COHRED). This was a direct response to one of the recommendations of the Commission on supporting country initiatives. Immediately after the conference, on 10 March 1993, the Constituting Assembly formally adopted statutes and implementing regulations, and COHRED was born. By the end of June, it had a 17-member Board and was registered as an NGO in Switzerland (although COHRED retained its formal links with UNDP). Meanwhile, five countries had completed their ENHR plans and were ready to present them to prospective partners.

Over the years, COHRED has continued to assist a steadily increasing number of countries in exploring and implementing ENHR. In Africa, Asia, and the Commonwealth Caribbean, it has created regional ENHR networks to facilitate work at the national level. In addition, a variety of both regional and global working groups and projects have captured the experience of the ENHR strategy and built further capacities for it. Using several communication strategies (such as a quarterly newsletter, a website, and a range of publications), COHRED has attempted to capture the experiences of ENHR and thus contribute to a growing knowledge base on this approach. It has also made efforts in capacity development for ENHR, often through partnerships with other like-minded networks and organizations. (Chapter 8 gives a description of COHRED activities.)

On the eve of the next international conference on health research for development, COHRED is also playing an important role as one of several partner organizations reviewing the experience of health research for development over the past 10 years and devising a global strategy for the first years of the new millennium.

[1] An account of these discussions, written by Joseph Cook of the Edna McConnell Clark Foundation, can be found as an annex of the report of the planning meeting, held in Celigny, Switzerland, 15–17 July 1987.

Document(s) 3 of 21