Document(s) 4 of 21

As the principal NGO for health, WHO has traditionally seen its role as one of having a “wider vision and larger responsibility” than other institutions and organizations engaged in health research. As articulated in the 1986 report of the WHO Advisory Committee on Health Research, WHO is able to view health problems from a historical and global perspective and, as a result, “assess the determinants of health, and arrive at a just balance between preventive and therapeutic measures, between basic and applied research and between the needs of developed and developing countries” (ACHR 1986, p. 43). Although WHO itself is not primarily a research organization, it facilitates and supports research in collaboration with other agencies, through programs such as the long-running Special Programme of Research, Development and Research Training in Human Reproduction and the Special Programme for Research and Training in Tropical Diseases (TDR). WHO also incorporates its research into its regular programs, such as those on diarrheal diseases and essential drugs. Its various technical programs and their expert committees have responsibility for developing and monitoring its research strategy. Global and regional Advisory Committees on Health Research (ACHRs) provide broad guidelines.

Throughout the latter part of the 1980s and into the 1990s, WHO’s goal of achieving HFA/2000 has shaped its research strategy. In 1984, WHO’s director general requested its ACHR (then titled the Advisory Committee on Medical Research [ACMR]) to outline a fresh health-research strategy in light of HFA/2000. Chaired by Professor T. McKeown, a specially appointed subcommittee of ACMR recommended that WHO promote research in five priority areas to “raise the health of all people to an acceptable level as rapidly as possible” (ACHR 1986, p. 22). ACMR recommended that WHO’s first priority should be to encourage research on diseases of poverty and the tropics. Other recommended priorities included diseases of affluence (that is, noncommunicable illnesses predominant in developed countries and threatening to advance into developing countries), treatment and care of the sick, and delivery of health services. ACMR also resolved that WHO should strive to improve the quality of research so that certain minimum standards would be maintained throughout the world and should continue to support research trainees from developing countries.

WHO revisited its role in health research 6 years later, in May 1990, during the Technical Discussions of the 43rd World Health Assembly (where the Commission first distributed its report). These technical discussions focused on health-systems research, research capacity-strengthening, nutrition, and advances in science and technology (S&T). The Assembly called on WHO to take on a more active leadership role in monitoring disease patterns, advances in research, and resource flows; informing a global research agenda; coordinating the health-research policies of various international players; and promoting selected directions in health research, particularly national health-systems research (HSR) and nutrition. It requested the director general to work in collaboration with the global and regional ACHRs and “use appropriate mechanisms to assess new and emerging areas of science and technology, investigate evolving problems of critical significance to health and identify appropriate methodologies for trend assessment and forecasting, including epidemiology” (Davies and Mansourian 1992, p. 209). Such monitoring would position WHO “to promote the harmonization of science and research policies in health between the WHO, the UN system and other international agencies and organizations” (Davies and Mansourian 1992, p. 209). In addition, it encouraged WHO to strengthen its capacity to support countries developing HSR and set an example by incorporating it into its own action programs. Similarly, it urged WHO to give nutrition a higher research profile so that member states would follow suit.

WHO was a full partner with the World Bank in preparing the World Development Report 1993: Investing in Health (World Bank 1993) (see below). In particular, WHO contributed to a jointly sponsored assessment of the global burden of disease, a major feature of the report. Shortly after its release, IDRC hosted a “next-steps” international conference in Ottawa (IDRC 1993). IDRC, WHO, and the World Bank cosponsored the conference, which had three major outcomes:

• WHO would serve as the secretariat for an ad hoc review of health-research priorities (see below);
• With support from the Canadian government, IDRC would initiate a research project to test the development of nationally defined health-intervention packages, health-policy reform, and improved donor coordination (as recommended in the World Development Report 1993) (this became the Tanzania Essential Health Intervention Project); and
• The World Bank would lead an initiative to examine issues in increasing and redirecting investment into equity-oriented health development.

Three years later, WHO published the 1996 report of its Ad Hoc Committee on Health Research Relating to Future Intervention Options, entitled Investing in Health Research and Development (Ad Hoc Committee 1996). The Ad Hoc Committee convened under the auspices of WHO at the request of a number of health-research investors, including governments, bilateral and multilateral development-assistance agencies, and private foundations present at the 1993 Ottawa conference. It reviewed the health needs and related priorities for R&D in low- to middle-income countries. The intention of its report was “to contribute to an agenda for international action in which individual nations’ agendas inform global priorities and global needs and experience influence national agendas” (Ad Hoc Committee 1996, p. xxi). The issues of resource allocation and efficiency, which crept into the 1990 Technical Discussions in terms of “doing the most with less,” were the focus of the 1996 Ad Hoc Committee report. It argued for the need to make “hard choices” to direct limited resources to areas of greatest need and promise.

The Ad Hoc Committee outlined a systematic approach to allocating health-research funds. Its five-step strategy included calculating the burden of disease, identifying reasons for the persistence of the burden, judging the adequacy of the current knowledge base, assessing the promise of the R&D effort (with special attention to cost-effectiveness), and determining how much is already being done about the problem. The result was a list of “best buys,” or key investments, along with some other initiatives applied to four “unfinished agenda” health challenges: maternal and child health, continually changing microbial threats, noncommunicable illnesses and injuries, and health policy and systems.

Among these best buys were three new proposed initiatives: Research and Training on Non-communicable Diseases and Healthy Aging; Research, Training and Capacity-Building on Injuries; and Research and Training on Health Systems and Policy — along with a mechanism to review global health needs, assess R&D opportunities, and monitor resource flows. The proposed mechanism would take advice from scientific advisory groups already involved in enabling health research at national and international levels, such as the WHO global and regional ACHRs, scientific and advisory groups of existing international research programs, and organizations such as COHRED, INCLEN, and IHPP. The mechanism (which would become known as GFHR) would then present its recommendations and conclusions to existing programs for implementation.

The tenor of the Ad Hoc Committee’s report demonstrates that by the mid-1990s the problem confronting the international health R&D community had been reframed to include not just the gross imbalances in burden of illness, investment in health research, and research capacity within and between countries, but the fragmented nature of the community itself and the resulting inefficiencies and lack of coordination of effort and resources. In short,

the distribution of resources and effort across the spectrum of health problems [is seen] to reflect uneven advocacy and special pleading rather than rational and coordinated responses to need. Some work is duplicated, significant gaps remain, and the dispersion of resources constrains capacity to focus resources on high-priority problems.

— Ad Hoc Committee (1996, p. xxxiv)

The challenge of creating a pluralistic, worldwide health-research system as envisioned by the Commission (in which the various partners exchange information, link their efforts, and base resource-allocation decisions on explicit analysis of priorities) was taken up on two fronts: by WHO’s ACHR and by the newly initiated GFHR. In 1997, ACHR published A Research Policy Agenda for Science and Technology to Support Global Health Development (ACHR 1997). The research-policy agenda highlighted a number “domain-based” global “research imperatives and opportunities,” indicating the scope and variety of needed research, as opposed to a ranked list of disease-based global research priorities.[2] The research agenda outlined a strategy to “initiate and sustain a systematic, dynamic process of dialogue, joint planning and multidisciplinary participation in research” (ACHR 1997, p. 36). WHO would exploit modern information and communication technologies to create a global planning network for health research, comprising “intelligent” research networks built on common themes and critical issues.[3] To initiate the development work for such a global planning network, ACHR has, on behalf of WHO, sponsored the Planet HERES (Planning Network for Health Research) project.

In 1998, WHO appointed Dr Gro Brundtland its new director general. Within a few months, WHO undertook a major restructuring at its Geneva-based headquarters, including a reconsideration of internal mechanisms to support WHO’s R&D. WHO commissioned an internal working group in late 1998, along with an external Board of Advisors. The working group recommended that WHO create a Department of Research Policy and Cooperation within the cluster of Evidence and Information for Policy, and this new department started operations in August 1999. It has the following objective (WHO 2000[4]):

to stimulate research for, with and by developing countries through:

• The ability to identify emerging trends in scientific knowledge with the potential to improve health;
• The mobilization of the world research community toward tackling priority health problems;
• The development of initiatives aimed at strengthening research capacity in the developing world with the ultimate aim of enshrining research as a foundation for policy.

The Ad Hoc Committee presented its findings in Geneva in June 1996, at a meeting of researchers, government officials, and representatives of NGOs and donor agencies. The participants endorsed the Ad Hoc Committee’s findings, particularly the creation of a mechanism to review global health needs, assess R&D opportunities, and monitor resource flows. One year later, in June 1997, GFHR began its work. Its functions have included providing a forum for stakeholders to review global health-research priorities, promoting ongoing analysis of the global health-research situation (including resource flows), and facilitating coalition-building for research on important global problems. GFHR has thus become part of the Commission’s recommended international mechanism to monitor and convene discussion on global themes, allowing COHRED to work directly with countries to facilitate the ENHR strategy (see Box 1.2).

GFHR is an independent entity and is registered as a Swiss foundation. It is managed by a council of 20 members representing government policymakers, multilateral and bilateral development agencies, foundations, international NGOs, women’s associations, research institutions, and the private sector. The GFHR Secretariat, located at the WHO headquarters in Geneva, started its operations in January 1998.

GFHR’s mandate is to work to correct the alarming disparity in worldwide health-research expenditures (widely referred to as the “10/90 disequilibrium”). This disparity concerns an estimated 56 billion United States dollars (USD) a year, of which 90% is spent on research on health problems that concern only 10% of the world’s population. GFHR selected five strategies to achieve its goal: organize an annual forum, undertake analytical work in priority-setting, promote partnership initiatives in priority health-research areas, disseminate information about the 10/90 disequilibrium, and evaluate and monitor progress in correcting this gap.

Among the outputs of GFHR is “a practical framework for setting priorities in health research,” published in The 10/90 Report on Health Research 1999 (GFHR 1999). This framework relies on the five-step process outlined by the Ad Hoc Committee in 1996. It uses the Visual Health Information Profile, advanced in the research-policy agenda of WHO’s ACHR, to assess priority research areas at the local, national, regional, or global level. It has also been a supporting partner in a series of concerted initiatives to address key health problems. These initiatives include the WHO-led Global Tuberculosis Research Initiative, Initiative on Control of Cardiovascular Diseases in Developing Countries, MIM, International AIDS Vaccine Initiative (IAVI), and the Alliance for Health Services and Health Systems Research. A special program called the Public/Private Partnerships Initiative addresses the inaccessibility of drugs and vaccines for the poor. GFHR has created a secretariat to assess these partnerships and facilitate new ones, such as the recent Medicines for Malaria Venture (GFHR 2000).

As a primarily financial institution, the World Bank jointly supports or finances health-research programs or initiatives, such as TDR, MIM, and IAVI. Its internal research activities focus on economic policy as applied to the health, nutrition, and population (HNP) sector. Although focused on health systems rather than health research, the World Development Report 1993 (World Bank 1993) had a significant impact on discussions in this sector. It reiterated the Commission’s recommendation to establish a global mechanism for better coordination of international health research. It also made a case for allocating resources for epidemiological and health-policy research to increase evidence-based decision-making, as well as research on national research priorities. Of equal importance was its emphasis on misallocation and waste (in addition to inequities) in world health spending. One of its key messages concerned the need to reduce inefficiencies and improve cost-effectiveness, a message that has broadened the formulation of problems confronting the international health R&D community.

Since the publication of this significant report the World Bank has steadily increased its investment in health-sector reform. Representatives of the World Bank’s health group have been actively involved in many of the discussions and initiatives in health research for development. The Bank has also become a significant source of health-research funding. For example, the 1997 Sector Strategy: Health, Nutrition and Population stated that

country-specific research and analysis of HNP (Health, Nutrition and Population) issues supported through Bank loans and credits has [sic] recently ranged between approximately US$50 and US$75 million per year. This is 5 to 6 percent of total lending and by far the largest source of external research funding for HNP in client countries.

— World Bank Group (1997, p. 11)

In addition, the World Bank’s Policy Research Department has spent more than 1 million USD annually on HNP issues.

Over the past 10–15 years, a number of international programs (in addition to those linked to WHO) were created to build health-research capacity in developing countries. They have been important contributors to all aspects of health research for development over this period. For example, in early 1990, when the Commission was about to release its report, a group of nine international programs issued a joint statement, the Puebla Declaration. It supported the main thrust of the Commission’s recommendations, particularly on capacity development (see TFHRD 1991). Each of these programs has undergone its own distinctive evolution during this period. Brief summaries of some of these programs appear below.

International Clinical Epidemiology Network

INCLEN began work in 1982, as a result of the leadership of Dr Kerr White, who was concerned about the continuing “schism” between public health and clinical medicine. White’s vision was to train established clinicians from developing-country universities in the science of public health and epidemiology. Supported largely by the Rockefeller Foundation, INCLEN has prepared about 300 individuals in 30 countries to conduct priority-driven research and teach health-research methods. Beginning with four training centres in Australia, Canada, and the United States, INCLEN has evolved to the point of having centres in developing countries take over the training function. In the last 2 years, INCLEN’s priorities have shifted from capacity development to multicountry health research on specific issues, and INCLEN has evolved into a more regional structure.

International Health Policy Program

Initiated in 1986, with the support of the Pew Charitable Trusts (and later the Carnegie Corporation and the World Bank), IHPP has been concerned about resource issues in effective, equity-oriented health policies. Its principle activity has been to provide support for groups engaged in health-policy analysis and development in Africa and Asia, and it has also awarded Career Development Fellowships, sponsored participants’ meetings and authors’ workshops, and disseminated policy-related research findings.

Applied Research on Child Health project

The ARCH project succeeds the Applied Diarrheal Disease Research project, which supported 150 research studies in 16 countries. Based in the Harvard Institute for International Development and funded largely through the United States Agency for International Development, the ARCH project focuses on the principal causes of infant and child morbidity and mortality. ARCH supports applied research in developing countries through research grants and technical assistance to groups of social and health scientists.

The Multilateral Initiative on Malaria

The more recent initiative, MIM, grew out of an awareness of fragmentation in malaria research, with various organizations independently supporting separate research projects. A January 1997 meeting in Dakar, Senegal, to focus on the malaria problem in Africa identified broad research priorities and needs. Shortly after this, MIM invited the Wellcome Trust in London to serve as the coordinating secretariat for its activities, which now involve advocacy (including fund-raising), facilitation in the areas of coordination and collaboration, and information exchange. An example of its efforts is the Malaria Research and Reference Reagent Repository in Dakar. It has convened major conferences in Durban (in 1999) and Abuja (in 2000). In collaboration with TDR, MIM has created a special task force on Malaria Research Capability Strengthening in Africa. With a commitment to working closely with WHO’s Roll Back Malaria project, MIM is helping to ensure links between research and control activities. The various organizations involved have appeared to welcome MIM, and it is helping to synergize the efforts of researchers, funders, and others committed to addressing this important regional problem.

Special industrialized-country initiatives

Over the past two decades or more, a number of industrialized countries have undertaken special initiatives to support research in developing countries. A few examples are described below.

Sweden — Stimulated by the inclusion of a global action program for S&T in the United Nations Second Development Decade (the 1970s), the Swedish parliament commissioned an inquiry into the organization of research on problems in developing countries. A report, Research for Development, was published in 1973. This report articulated (among other recommendations) some guiding principles for development research: problem orientation, multi- or interdisciplinarity, value (or development relevance), and focus on the developing countries. With these principles as a foundational framework, Sweden created SAREC in 1975. Its major task is to contribute to building research capacity in some of the world’s poorest countries, through support for universities. In the health sector, this policy has resulted in long-term support for health research at universities in such countries as Ethiopia, Mozambique, and Tanzania. SAREC has also supported direct cooperation between institutions in developing countries and Sweden.

By the mid-1990s, SAREC had 380 joint projects involving more than 100 Swedish university departments. At the time of its incorporation into the larger Swedish International Development Agency, in the mid-1990s, SAREC reevaluated its long-term support for research capacity development. It recognized that it needed to take supportive measures for the university as a whole as a supplement to research cooperation, such as through broad support for higher education, research, and university administration. Overall, this 25-year experience of supporting development research has been worth the investment.

Canada — Canada has stimulated and supported development research through IDRC, an autonomous public corporation established in 1970 through an Act of the Canadian parliament. It was the first development-assistance institution to focus exclusively on research for the development of S&T. During the 1970s and 1980s, it implemented its programs through such sectors as agriculture and health. In 1988, through its Health Sciences Division, IDRC was a major supporter of the Commission. During the late 1980s and early 1990s, it adopted a new strategy — empowerment through knowledge — emphasizing the central importance of research capacity development. In 1992, the United Nations Conference on Environment and Development in Rio de Janeiro gave IDRC an expanded mandate to represent (through a revised program framework) Canada’s major contribution to Agenda 21. In 1995, as a consequence of reductions in the federal budget, IDRC downsized its operations and replaced its four division structures with six program themes.

It revealed a new corporate framework in 1997, reflecting lessons learned in 25 years of “success, failure, and persistence” (IDRC 1997, p. 7). It identified three lessons: societies build their own future; knowledge is the key (and information is no longer a substitute for knowledge); and single approaches do not yield results (complex problems require multidisciplinary approaches). For example, a current IDRC research initiative is Macroeconomic Adjustment Policies, Health Sector Reform, and Health Care in the South. More recently, IDRC has provided leadership to coordinate research on the global health problem caused by tobacco.

Switzerland — In 1994, SCRPDC was established under the auspices of the Conference of the Swiss Academies of Science. SCRPDC’s mandate is to define and promote a “Swiss strategy for the Promotion of Research in Development Countries” (SCRPDC 1998, p. 3) and to encourage Swiss scientists to participate in this endeavour. An example of the work of this commission is its recent Guidelines for Research in Partnership with Developing Countries (SCRPDC 1998), which describes 11 principles of research partnership (see Box 6.3).

Over the past 10–15 years, awareness and analysis of the disequilibrium problem in health research for development have clearly increased, and this has been matched to some extent by increased action. Now there are organizations like COHRED (working directly with developing countries) and GFHR (providing a global venue for monitoring and discussion). These organizations were not in existence 10 years ago. Such organizations have identified health-research priorities at both national and global levels. And major organizations (WHO, for example), international programs, and countries (both developing and industrialized) have intensified their efforts to work in partnership with others to address these national and global health-research priorities.

However, the current “international mechanism” (to use a phrase from the Commission’s recommendation) is still too fragmented, slow-moving, and uncoordinated. Moreover, the system’s performance falls far short of its potential in monitoring progress, promoting financial and technical support for developing countries, and accelerating capacity development.

In contrast, an international institution in the global agricultural sector has been instrumental in “sowing the seeds of the green revolution” during these past 15 years (World Bank 1999, p. 4). This is the Consultative Group on International Agricultural Research (CGIAR). Created in 1971, its membership includes both developing and industrialized countries, as well as private foundations and international organizations such as the Food and Agriculture Organization of the United Nations. The key strategy has been to create and support 16 international research centres and train a great many scientists and technicians. According to the World Bank’s World Development Report 1989/99: Knowledge for Development (World Bank 1999), CGIAR has made a major contribution to the development and use of new agricultural technologies. As a result, through increased yields in crops, the global production of food has kept up with a steadily increasing demand, in a world where “90 million new mouths must be fed every year” (World Bank 1999, p. 131). Over the past decade, CGIAR has expanded its scope to include research on environmental issues, forestry, aquatic resources, and the interrelationships of these factors with agricultural research. As a publicly funded global organization, it has also steadily increased its interaction with research institutions in the private sector. But it has not ensured strong national systems of agricultural research and production. And global food insecurity is still a problem for 790 million people. CGIAR recognizes the need to respond to a changing environment and is moving toward more “virtual” institutions and an increasing emphasis on impact assessment.

Can we truly say that over the past 10 years the global health-research community has contributed directly to a “health revolution,” analogous to the green revolution? Given the realities of achieving change over a 10-year time span, where have we made definite contributions? Where have we fallen short? What have been the facilitating and impeding factors? Have the recommended investments been made and appropriately targeted? Why is cooperation among various organizations and institutions still perceived as inadequate?

Some of these questions are addressed in subsequent chapters of this book, primarily from the perspective of developing countries. Other issues will be addressed at the October 2000 international conference. The debate must lead us to respond boldly and creatively to the question of how to intensify our efforts in the next 10 years to ensure that health research contributes maximally as an essential link to equity in development.

[2] The ACHR Health Profile posits five domains of determinants of global health: environment, food and nutrition, sociocultural factors, health-care systems, and disease conditions and health impairments.

[3] “Intelligent” refers to “the characteristic achieved by linking, through networking and communication technologies and knowledge-based technical know-how of researchers for the purpose of solving specific research problems using the minimal pathway approach” (ACHR 1997, p. 41).

[4] WHO (World Health Organization). 2000. Strategic plan: Department of Research Policy and Cooperation, 20 Mar. Unpublished memo.

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