Document(s) 12 of 21

In its report, the Commission on Health Research for Development emphasized the importance of capacity-building for country-specific health research. What have been the achievements over the past 10 years in building national capacity to both produce and use equity-oriented health research, particularly in low-income countries? This is the central question addressed in this chapter. Following an analysis of this question, it goes on to present some lessons from the initiatives of the past decade and to propose strategies to guide future action.

To indicate trends and draw conclusions from a range of diverse efforts, several case studies are presented in this chapter. At the global level, it examines the capacity-strengthening activities of two programs: the Special Programme for Research and Training in Tropical Diseases (TDR) and the International Clinical Epidemiology Network (INCLEN). It examines regional initiatives, including the training activities of the Tropical Medicine and Public Health Center network of the Southeast Asian Ministers of Education Organization (SEAMEO–TROPMED) and an initiative to analyze malaria-research capacity in Africa, conducted as a contribution to the Multilateral Initiative on Malaria (MIM). At the national level, it describes a 1998 study of capacity development for health research in Uganda and complements this with six brief country profiles of health-research capacity-strengthening activities.

Several types of evidence are considered to determine whether efforts over the past decade have indeed strengthened national health-research systems. Although it is difficult to make a direct causal link, it would appear that the global burden of illness borne by the poor has not decreased substantially in the past decade and that the global investment in health research (including capacity-strengthening) directed to the problems of the poor and disadvantaged has not increased substantially over the same 10 years. The available data suggest a mixed picture of research-related human-resource development and its deployment to meet the needs of low-income countries. Although the return rate of scientists to their own countries from the major training programs looks encouraging, the brain drain continues (both to developed countries and to transnational corporations within developing countries). Furthermore, the quality of the research environment is still a major impediment to enhancing and sustaining efforts in most low-income countries.

This chapter also briefly examines several output indicators. Although the percentage of scientific contributions from low-income countries to the global health knowledge base has increased slightly, the predominant pattern of the past 10 years continues to be one of imbalance. An overwhelming proportion of global scientific output is contributed by scientists in industrialized countries and focuses on the health problems of the North.

Wide disparities remain, therefore, between the research capacity of low-income countries and that of middle- to high-income ones. Also apparent is the need for more relevant and comprehensive information to evaluate activities in research capacity-strengthening. One encouraging sign is a renewed interest in the issue of health inequity and the need to accelerate research, and its application, on this fundamental issue. Also, awareness is growing among international agencies of the need to strengthen research capacities at the national level.

Five lessons can be learned from the capacity-strengthening experience of the past 10 years:

• Capacity-development activities should be more country driven;

• The focus has been too narrow, restricted mostly to individuals and institutions (the need is for a broader national-systems approach);

• The predominant emphasis has been on a supply-side approach, with relatively little attention to demand-driven capacity development;

• Capacity-strengthening programs and policies should pay more attention to the goal of equity in health; and

• Capacity-strengthening initiatives should put more emphasis on fostering broad problem-solving competencies across the whole spectrum of the research process.

The goal for the next decade remains unchanged: it is to ensure that all societies, particularly those in low-income countries, have the capacity to apply both local and global knowledge to their own health and development problems, particularly those of poor and disadvantaged people. As a corollary, it follows that these same countries, given the opportunity, would have much to contribute to the global understanding of health and development. The following are four elements of a more efficient framework for achieving this goal:

• New research and learning coalitions at both national and subnational levels to address high-priority health and development problems;

• New tools to set health-research priorities, assess health equity, monitor resource flows, and evaluate efforts to develop capacity;

• New leadership, both individual and collective, with a focus on special competencies such as creating demand, building coalitions, developing leadership per se, and managing knowledge, with the latter including the ability to harness the potential benefits of the new information and communication technologies (ICTs); and

• New forms of partnership, which are sorely needed, particularly between countries and institutions of the North and South (these must be truly collaborative relationships, based on mutual respect and shared goals).

“Strengthening research capacity in developing countries is one of the most powerful, cost effective and sustainable means of advancing health and development” (CHRD 1990, p. 71). This is the bold and sweeping first sentence of the chapter “Building and Sustaining Research Capacity” in the Commission’s 1990 report. It reflects the optimistic premise that has characterized health-research capacity-building efforts since the 1970s. At that time, encouraged by the gains made through research against smallpox, polio, and other diseases, the global scientific community confidently believed that more research would soon lead us to understand and eradicate other microbial diseases — perhaps most of them. Poor countries, situated for the most part in tropical climates, would be the most important beneficiaries. And so thousands of scientists from low-income countries received specialized training to do research on the “major killers,” such as malaria and other endemic infectious diseases.

By 1990, the Commission concluded that despite two decades of effort,

far too little attention is being given to the critical importance of building and sustaining individuals and institutional health research capacity within developing countries. To remedy this problem, leadership and commitment by national governments as well as longer-term support by international agencies will be necessary.

CHRD (1990, p. 85)

The specific conclusions on capacity-building from chapter 8 of the Commission’s report are presented in Box 6.1. In the final chapter of the Commission’s report it urged, as part of the recommendations on Essential National Health Research (ENHR), that every country develop a national health-research plan. The recommendation included the following statement:

Implementing such a plan will require building and maintaining research capacity within developing countries and sustained reinforcement from the international community. A critical mass of health researchers is needed in every country, nurtured by improved career paths, including incentives and rewards. The research capacity should be closely linked to the policymakers, managers and other users of the results of research. Government support is essential.

CHRD (1990, pp. 85–86)

In the same year, the theme of the World Health Assembly (WHA) was the role of health research in the strategy to promote Health for All by the Year 2000. The resolutions of this 43rd WHA (Davies and Mansourian 1992) included several specific recommendations about research capacity-strengthening:

• URGES member states, particularly developing countries: … to build and strengthen national research capabilities by investing resources in national institutions, by providing appropriate career opportunities to attract and retain the involvement of their own scientists, and by creating environments that will foster scholarship and creativity;

• URGES bilateral and multilateral development agencies, non-governmental organizations, foundations and appropriate regional organizations: … to increase their support for essential health research, and research capability building.

Now, 10 years later, what can the global health-research community say about another decade of activity? More specifically, what have been the achievements in building national capacity to produce and use equity-oriented health research, particularly in low-income countries?

Paying special attention to these features, this chapter devotes a section to each of the following questions:

• What has been achieved in the past 10 years?

• What are the key lessons from the initiatives of the past decade?

• What strategies can be considered to guide future efforts?

To begin the exploration of this question, it may be useful to look at examples (case studies) of efforts to develop health-research capacity over the past decade. It is not the intention here to present a comprehensive in-depth analysis. Rather, by examining several diverse efforts, we can observe trends and draw some conclusions. Also, the reality is that efforts to develop health-research capacity in the past decade have been diverse. Although diversity has its benefits, the aggregate global capacity-development effort is still fragmented. This can be seen in the sources of any given initiative (for example, country or external agency), the lack of coordination among external agencies and networks, and the variable focus (for example, institution, discipline, disease). The examples selected for this chapter include two global programs — one supported by multilateral agencies — and one supported by a foundation; two regional initiatives; and a national study and some country “snapshots” of research capacity-strengthening.

Cosponsored by the United Nations Development Programme (UNDP), the World Bank, and the World Health Organization (WHO) and supported by other agencies, TDR began operations in 1976. In most of these operations, it has addressed eight tropical diseases through research and development (R&D) directly and through capacity-strengthening (it should be noted that it recently added tuberculosis and dengue to its list). In the Commission’s 1990 report, it recommended “continuing and expanded support” (CHRD 1990, p. 88) for the TDR program, along with another WHO-associated initiative, the Special Programme of Research, Development and Research Training in Human Reproduction (HRP). The main elements of TDR’s research capacity-strengthening component include grants for research training (more than 1 300 since 1976), for reentry (about 300 during this same period), and for institution-strengthening (266 during this time). The total financial investment has been more than 100 million USD.

Major reviews of research capacity-strengthening activities were conducted in 1990 (WHO 1991) and again in 1998 (as part of an external review of TDR) (TDR 1998). The 1992 review, done in collaboration with HRP and the Global Programme on AIDS, paid special attention to least-developed countries (LDCs) — the 42 countries where the per capita gross national product is less than 300 USD/year. Although TDR had supported research capacity-strengthening activities in nine of these countries, the general consensus was that the overall contribution of the three participating WHO programs to the research capacity of LDCs left much to be desired. This report recommended a 12-month initial action plan, in which three to six countries would have special attention, with the stated expectation that the three WHO-associated programs and the interim Task Force on Health Research for Development (charged with facilitating ENHR) would collaborate actively.

The more recent review recognized that the available evidence concerned process and outcome indicators, which led to the following conclusion: “One could observe that the RCS [research capacity-strengthening] programme operates well, that its trainees graduate, that investigators publish, and that technology is transferred. The question of impact requires further thought” (Wayling 1999, p. 6). The 1998 report of the External Review Committee made no reference to the 1992 expectations of collaborative focus on three to six LDCs but made the following statement: “The Committee felt that there was now an increasing urgency to develop more effective strategies to meet the capacity development needs of the least developed countries and to focus on developing countries bearing the largest burden of disease” (TDR 1998, p. 45).

TDR is a good example of sustained collaborative support from three agencies focused on specific disease conditions. The capacity-building strategy has concentrated primarily on individuals and institutions in disease-specific research. Until the 1992 review, strengthening national health-research systems enjoyed little emphasis, particularly in low-income countries. The 1998 third external review included the following as one of two “mandatory” recommendations: “more focused strategies are needed to strengthen the research capacity of countries and regions bearing the heaviest burden of endemic tropical diseases, with an increasing focus on least developed countries” (TDR 1998, p. 6). By 2000, overall funding for research capacity-strengthening in LDCs was 33%. Evaluative efforts to date have featured process and outcome indicators. The available reports have not included evidence on whether the global burden of disease for the conditions in the TDR portfolio has diminished incrementally since the program began 25 years ago.

In the late 1970s, Kerr White, an outspoken supporter of clinical epidemiology, became increasingly concerned about the continuing schism between clinical medicine and public health (White 1991). At the same time, the Rockefeller Foundation was reviewing its investment in health-science institutions, and its report concluded that “the most pressing problem in the broader field of health … is more effective management of health services at all levels” (Evans 1981, p. 11). In addition, this report concluded that “those who might provide leadership and management lack the inclination, breadth of perspective, and analytic skills to respond to this challenge” (Evans 1981, p. 11). In 1982, these concerns led to the creation of INCLEN, which the Rockefeller Foundation initiated and supports. A progress report for INCLEN appeared in 1991 (Halstead et al. 1991).

The key strategy of INCLEN has been to carefully select young professionals from designated academic institutions in developing countries, provide them with training in clinical-epidemiological research, and support the creation of clinical-epidemiological units (CEUs) within universities. A critical mass of INCLEN trainees (usually about 6–10) staff the CEUs. Most of the trainees are clinicians, and the hope is that these young medical practitioners will contribute to solving health-care problems in their respective countries. Over time, INCLEN added special training elements in health economics and health social sciences (Higginbotham 1992). Recognizing that the Rockefeller Foundation would eventually withdraw its financial support, INCLEN began to operate as an independent nonprofit organization in 1991.

Over the almost two decades since INCLEN began, it has given training in research methods in clinical epidemiology and related fields to about 500 professionals. Fifty-four institutions from 28 countries have been involved. INCLEN has received more than 75 million USD from the Rockefeller Foundation and some additional funds from other sources (about 10 million USD).

A 1999 external-review team recognized INCLEN’s strong contributions to education and research in clinical epidemiology. In addition to making several strategic recommendations regarding INCLEN’s future, the review recommended a stronger engagement in the broader field of public health and urged the organization to consider Africa a planning-priority region. INCLEN is currently undergoing a major transition, strengthening regional networks and shifting its leadership to health professionals “living in countries with the greatest burden of disease” (Macfarlane et al. 2000, p. 503).

INCLEN has provided strong technical training in health-research methods. A number of former INCLEN faculty now hold senior positions in universities, ministries of health, and international organizations. Several INCLEN faculty have contributed strongly to the promotion, advocacy, and implementation of ENHR. Like TDR, INCLEN has a strategic focus on training individuals and creating and supporting institutional units (the CEUs). It has produced a cadre of indigenous researchers capable of carrying out their own research, and in this way it has strengthened the national human-resource base for health research. It has also developed strong regional networks (in clinical epidemiology). However, the issue of national health-research capacity-strengthening has not been an explicit priority in INCLEN’s training and research activities. One might also note that it has invested in only 2 of the 42 WHO-designated LDCs — Ethiopia and Uganda.

SEAMEO–TROPMED network

More than 30 years ago, the governments of Southeast Asia established SEAMEO–TROPMED and aimed it at reducing the burden of illness in the subregion (more information is available from http://www.tm.mahidol.ac.th/en/index.htm). One of the network’s objectives is “to support research on endemic and newly emerging diseases that are associated with changing environment and lifestyle” (CHRD 1990, p. 78). It has designated four institutions as TROPMED Regional Centres; they are located in host institutions in Jakarta, Kuala Lumpur, Manila, and Bangkok. Over these 30 years, more than 3 500 medical and allied health professionals have received training in various subspecialties of tropical medicine and public health. Cooperation arrangements with institutions in industrialized countries have provided supplementary expertise, as needed. The network serves as a link to bilateral and multilateral assistance programs under WHO and other United Nations agencies.

TROPMED’s research-capacity program has had no formal assessment. However, information is available about the number of proposals funded and completed, publication patterns, and research-funding trends. The report of WHO’s April 2000 meeting on research capacity-strengthening, held in Annecy, France, stated that “TROPMED alumni have distinguished themselves in both the public and private service sectors — as administrators, outstanding scientists, academicians, health practitioners, technocrats, and national leaders” (WHO 2000c, p. 5). Since 1990 most of TROPMED’s training efforts have focused on the basic knowledge and skills for research design and methodology to support the specific national health programs of SEAMEO member countries; exceptions are Indonesia, Malaysia, Philippines, and Thailand, which are already quite advanced in this regard. This network is a good example of the value of cooperation among countries in the same region. In fact, the eight ministers of education who originally founded the network believed that cooperation among Asian countries (in this case, focused on tropical medicine and public health) is vital to the region’s prosperity and stability.

Malaria research in Africa

MIM is a global initiative concerned particularly with building malaria-research capacity in Africa to address the increasing threat of this disease. As part of the initiative, Wellcome Trust recently published a study to assess Africa’s capacity for malaria research (Beattie et al. 1999). The study surveyed training opportunities and provided an assessment of capacity and training. Some of the key findings were as follows:

• Using the Science Citation Index (SCI) database, an analysis of malaria publications for the period of 1995–97 revealed that 17.2% of the articles had an African address. The United States contributed 30% of all malaria publications globally; the United Kingdom, 17.8%; and France, 9.6%. During this same period, the contribution of Africa to overall research in health and biomedicine was only 1.2% of the world’s output. Of additional interest is that the 1 000 articles on malaria published in 1995 represented only 0.3% of all articles in the SCI, compared with 10.2% for cardiology and 2.4% for arthritis and rheumatism.

• Of the 752 malaria researchers working in 52 centres in Africa at the time of the study, 192 (26%) were postdoctoral scientists, and 168 (22%) were clinicians. They were dispersed across 22 countries. About one-third of Africa’s malaria research groups were led by nonnational scientists.

• The study attempted to measure the impact of research through an analysis of the malaria management guidelines and policies of 11 African countries. This proved difficult because much of the evidence used for policy was in “grey literature.” Also, many of the bibliographies in policy documents were incomplete.

• For the 5-year period of 1993–98, the study found that 88% of malaria-research grants awarded to Africa researchers came from organizations outside the continent. For PhD training, 65% of acknowledgments were to industrialized-country agencies, and 17% were to African governments or local sources.

The report gave several recommendations of particular relevance to the issue of fostering national capacity; it made a strong plea for “overarching mechanisms” to match capacity development to national research priorities and recommended that initiatives continue to prepare African scientific leaders to hold major roles in the future.

A country case study: capacity development for health research in Uganda

In 1998, the Board of the Council on Health Research for Development (COHRED) decided to review its strategy for ENHR capacity development. Part of this review involved country consultations and studies; Uganda did one of these studies (UCD 1998). This was a timely initiative for Uganda, as the country had considerable experience with implementing the ENHR approach, including applying this approach at the district level. In addition, it had recently developed a new ENHR plan (with a revision of health-research priorities); however, the capacity-development component of the plan was weak and required strengthening and specification.

The study had three objectives:

• To review Uganda’s current capacity to conduct, use, and manage priority-driven health research;

• To use the results of this review to develop a capacity-development plan as an integral component of Uganda’s new ENHR plan; and

• To contribute to an international exploration of capacity development for ENHR.

The study team used several methods to conduct this review, including a standardized interview-based survey of health organizations and institutions, with both producers and users of research; a Medline search of Ugandan health-research publications; and an analysis of health-research projects registered in the database of the Uganda National Council for Science and Technology.

A striking observation was that virtually all of the funding for research (more than 99%) came from external sources. Although much of the research in Uganda was on the recently revised health-research priority themes, many researchers were unaware of these priorities; it also appeared that donors were equally unaware of them. Most health-research organizations in Uganda shared the goal of conducting and using research to improve the health of Uganda’s citizens. Although the actual number of researchers was considerable, a number of major barriers stood in the way of Uganda’s effective deployment of this “pool” of competent individuals, such as competing demands, weak infrastructure, limited and irregular funding, and low professional recognition. Although many research projects were at the district level, the study team felt that COHRED could do much more to involve district-level groups and organizations at all stages of the research. The team fully recognized the need to create a national health-research network (or organization) to facilitate interactions among stakeholders and provide overall coordination.

The study team presented these findings at a national workshop, which put forward several specific recommendations. In particular, it strongly supported the creation of the Uganda National Health Research Organization (UNHRO). Some personnel shifts at the Ministry of Health, made shortly after the workshop, delayed action on most of the recommendations. Although the UNHRO initiative is now back on track, the government has still not ratified the organization as an official parastatal body. In part, this is because the Government of Uganda is busy with the next phase of its evolving political system. UNHRO is nevertheless functioning on an interim basis, with some support from the Ugandan government, and has responsibility for several specific tasks, such as strengthening a national health-research database, organizing an annual health-research forum, facilitating district-level research (beginning with several “demonstration districts”), and refining a health-research plan within the current national health plan.

The Ugandan story illustrates the vulnerability of good plans (prepared by good people) to local political shifts. However, it is also a tribute to a small cadre of individuals who, despite considerable odds, have persisted in nurturing the vision of a national health-research system responsive to the needs of the Ugandan people.

“Snapshots” from other countries

Several other low- to middle-income countries have conducted reviews of their national health-research capacities. Some of these reviews were presented and discussed at the Annecy meeting. Others were national initiatives of other kinds. Summarized below are some of the highlights of these reviews.

• Pakistan — Created in 1962, the Pakistan Medical Research Council has been more active in the last several years on national health research: it has conducted workshops on research methodology, organized a biennial research congress, and sponsored several national conferences on specific issues. An example of these efforts is a conference to discuss the findings and policy implications of a national health-research survey. The report (presented at the Annecy meeting) stated that Pakistan had made “no discernible progress with the development of health research capacity” (Akhtar 2000, p. 1). It also described the “health bureaucracy” as lacking interest in health research and as being sceptical of its importance. This reflects an overall lack of “research culture” in the country, and the report recognized the need for long-term planning, including an overhaul of the educational system itself, to bring about a change in thinking and behaviour.

• Kenya — In 1998, Kenya conducted a major review of its national health-research activities of the previous 5 years, including an analysis of activities in research capacity-strengthening. The review recognized that Kenya had many highly qualified researchers, working in several research institutions and organizations, but concluded that capacity-development activities needed to include a broader range of stakeholders. It made specific recommendations for developing community leaders and strengthening links with the private sector. In addition, it noted that Kenya had recently put more emphasis on helping researchers develop competencies and skills in all aspects of the research process, with a view to complementing “core” expertise in particular disciplines.

• Indonesia — An analysis of health-research capacity-strengthening was a component of Indonesia’s recently revised National Policy on Health Research and Development. Led by its National Institute of Health Research and Development, Indonesia has prepared a national health-research agenda, strengthened its health-research network, and provided opportunities for guided research training at various levels. It has recognized that decision-makers and health-research managers should make a more explicit commitment to capacity-strengthening and that donor agencies need a forum to create specific collaborative arrangements for realistically responding to the capacity-development needs of the national health-research system.

• Lao pdr — In 1992, after recovering from a costly and devastating war, the Government of Lao PDR turned its attention to creating a master health plan. Health research was one of nine components of this 5-year plan. To develop human resources for research was a major goal during this period. The activities for this purpose included holding various training workshops, creating collaborative research arrangements with other countries in the region, encouraging publication of reports and articles, and introducing research training into the university curriculum. Health research again features prominently in the current health plan, which includes responses to lessons learned from the previous 5 years, such as the importance of integrating health research into health-system management at all levels, strengthening the incentive system for researchers, and involving policy- and decision-makers in research activities. The report (presented at the Annecy meeting) also included a list of further challenges. It recognized that research is vital to realizing expected health gains and, in particular, vital to assuring “equity in health and quality of life of Lao people, including all ethnic minority groups as well” (Boupha 2000, p. 5).

• Tanzania — Over the past 2 years, Tanzania has taken some important steps to strengthen its national health-research system. It created a multistakeholder National Health Research Forum in 1998. In 1999, it undertook a major effort to revise national health-research priorities. These developments took place in the context of a comprehensive program of national health-sector reform. Tanzania has recognized it has a capacity gap in health-research management and leadership. A national workshop in January 2000 gave a venue for discussion of this gap, which led Tanzania to initiate a planning process for capacity development in health research. The country is conducting capacity inventories at various levels and has a major initiative under way to establish a research-support system for district-based health and development.

• Myanmar — Through the Department of Medical Research in the Ministry of Health, Myanmar has made considerable progress over the past 10 years in strengthening its health-research capacity. Official policy statements have recognized the importance of research. A variety of training opportunities are available to individuals. The country has conducted various institutional-development activities, such as national seminars on research management and the enhancement of the use of research findings. It has identified several needs. For example, the report (also presented at the Annecy meeting) stated that “the most serious factor hindering research in Myanmar is the need to further enhance a research culture, … [including] an abiding belief in research as a necessary tool for development” (Pang Soe and Than Tuu 2000, p. 11).

These case studies and country stories are illustrative of various aspects of health-research capacity-strengthening over the past 10 years, including a long-standing program sponsored by multilateral agencies, a global network funded largely by a single foundation, two regional initiatives, a national initiative in Uganda, and the national initiatives of several other countries.

What is the evidence that the efforts of the past decade have actually strengthened national health-research systems in low-income countries for the purpose of benefiting poor and disadvantaged people? The remainder of this section considers four types of evidence (among various possible data sources) on this question.

Burden of disease

Have investments in health in the past 10 years lessened the burden of disease among the poor in low-income countries? Obviously, given the growing realization that many factors, in addition to the interventions of the health system itself, determine ill-health, it is impossible or inappropriate to directly link changes in the burden of disease with levels of investment in health research. However, it is possible to put two general statements side by side and consider some implications:

• The global burden of disease borne by the poor has not decreased substantially during the decade of the 1990s; and

• The global investment in health research directed to the problems of the poor and disadvantaged has not increased substantially over the same decade.

It should be emphasized that these statements are very preliminary and intentionally provocative. One can expect the participants at the October 2000 conference to debate more detailed information on each of these statements.

In recent work on the global burden of disease among the poor, Gwatkin and others (Gwatkin et al. 1999; Gwatkin and Guillot 2000) reanalyzed the Murray-Lopez reports on the global disease burden. Using various types of distributional analyses (that is, comparing the richest and poorest groups), they found that the poor are still burdened mostly with communicable diseases. They extrapolated that a faster decline in communicable diseases would decrease the poor–rich gap, whereas a faster decline in noncommunicable illnesses would increase this gap. If health inequity is the pervading concern, investments in health research (including capacity-strengthening) and action should, for the foreseeable future, remain priorities on the “unfinished agenda” on communicable diseases.

Recently, WHO prepared a brief entitled “Health: a Precious Asset” (WHO 2000a), as a contribution to the June 2000 special session of the United Nations General Assembly (called Copenhagen Plus Five). At this meeting, the United Nations reviewed progress on commitments made at the 1995 World Summit for Social Development. The report of this meeting included the following sobering admission: “we must frankly acknowledge that the poor quality or, in some instances the absence, of data is a significant obstacle to tracking the health status of the poor (WHO 2000a, p. 9). It went on to present some of the available evidence concerning “the health revolution that left out a billion people” (WHO 2000a, p. 9) and summarized some tables from The World Health Report 1999 (WHO 1999) concerning the health status of the poor versus that of the nonpoor, using 1990 data. It then described how certain major health conditions (HIV–AIDS, malaria, tuberculosis, malnutrition, maternal mortality, and others) all hit hardest on the poor and vulnerable. In a section entitled “Health Services in Decline,” it described inequities between and within countries. One section of the report began with the assertion that “the delivery of health care itself is often profoundly anti-poor” (WHO 1999, p. 13). Within WHO’s proposals for action, two of WHO’s own contributions would be to

• Build country capacities to assess the impacts of economic, technological, cultural, and political aspects of globalization on health equity and the health status of poor and vulnerable people and design responses to these impacts; and

• Build a global knowledge base on social development in health and on good practices in the protection and improvement of the health status of poor and vulnerable people.

The current global knowledge base cannot tell us clearly whether our collective efforts of the past decade have actually strengthened the health-research systems of low-income countries enough to lessen the burden of disease on poor and vulnerable people.

Human resources

Have the development and deployment of human resources for health research over the past 10 years responded to the needs of low-income countries? TDR and INCLEN have presented some encouraging findings on the brain-drain concern. TDR reported that only 4.5% (6/131) of those who earned PhDs between 1990 and 1997 failed to return to their home country after completing training. Over 25 years, the return rate of TDR-sponsored trainees was 97% (Wayling 1999). During the first phase of INCLEN in 1992 (when all training occurred in industrialized-country centres), it estimated that 10% of trainees failed to complete their studies or failed to return to their home sponsoring institutions (Lansang, personal communication, 2000[1]).

However, a recent study conducted by the United Nations Educational, Scientific and Cultural Organization found that many African PhD graduates were living outside of Africa (about 30 000) (UNESCO 1999). A 1992 study counted only 20 000 scientists and engineers in Africa — 0.36% of the world total (UNESCO 1999). The Human Development Report 1999 has tables displaying the number of R&D scientists and technicians per 1 000 people for 1990–96 (UNDP 1999). This ratio was 1.3 for the world, 4.1 for industrialized countries, and 0.4 for developing countries — no data were available for the LDCs. The World Development Report 1998/99 gave similar information, showing the number of scientists and engineers in R&D per million people for 1981–95 (World Bank 1999). Again, for many developing countries, the data were unavailable. All the available estimates of this number for some low-income countries set it at less than 100, whereas it is higher than 2 000 for most industrialized countries.

Any discussion in a developing country about human resources for health research touches on the issue of the “internal brain drain.” This is the phenomenon of individuals being “pirated” to work within their own countries by multinational pharmaceutical companies and international health agencies. In many developing countries, this phenomenon has resulted in low national health-research capacity and a small number of well-trained and competent individuals being “stretched thin,” taking on a variety of responsibilities.

Although some general studies of the “external brain drain” are available (Carrington and Detragiache 1999), comprehensive information at the national level regarding human resources for health research is lacking. In-depth national studies would be very helpful. In particular, one needs information not only on the numbers of researchers but also on the quality of their research time and whether they are allocating that time to addressing priority health concerns in their countries. Countries should integrate this kind of information into the capacity-development component of their health-research plans and programs. Numerous recent discussions with national health-research leaders have indicated that major challenges remain in enhancing and sustaining the research environment in low-income countries.

Outputs

In a 1995 article in the popular magazine Scientific American, Gibbs gave an analysis of the contributions of researchers from low-income countries to the world’s scientific literature (Gibbs 1995). The key finding was that low-income countries are “nearly invisible” in the world’s most influential scientific journals. He went on to suggest that this situation reflects “the economics and biases of science publishing as much as the actual quality of Third World research” (Gibbs 1995, p. 93). At the April 2000 Annecy meeting, Gibbs presented an update on this issue. The number of accessible journals in the new

Web of Science/SCI-E is now large — more than 5,500 journals compared to about 3,500 journals in the 1995 Science Citation Index database. This has increased the number of papers authored by scientists from low and middle-income countries — for example, from India, Malaysia and Brazil — identified in such surveys. The number of journals from these countries included in the larger database is also “inching up” slowly. However, access by developing country research institutions to this database is decreasing; several journal donation programs have been discontinued — an example is a long-standing program sponsored by the American Association for the Advancement of Science.

Gibbs (1995, p. 93)

Will the ICT revolution enable scientists from low-income countries to more equitably access and contribute to the global knowledge base on health? There are promising signs. For example, the British Medical Journal has broadened its editorial board to include several members from developing countries. This journal (and an increasing number of others) is now accessible electronically and for free. Several journals based in industrialized countries now actively commission news and articles relevant to the health situation of developing countries.

Another measure of progress in national research capacity-strengthening may be the increase in the numbers of actually funded and completed research projects and, perhaps more importantly, a greater focus in research activity on national health-research priorities. In the Uganda study (described above), the annual number of projects did not change during the 5-year study (1993–97). Almost all the projects in the registry related in one way or another to six predetermined priority areas, with about two-thirds focusing on communicable diseases and the largest percentage of these on AIDS. Analyses in other countries have given similar findings — for example, the Philippines (COHRED 1997c).

What can we learn from this brief look at research outputs (specifically projects and publications)? In general, the scientific outputs of the industrialized countries contribute overwhelmingly to the global knowledge base, as measured in numbers of journal articles. Consistent with the “10/90 disequibilibrium,” a phrase usually used to describe financial flows, only a small percentage of the world’s scientific literature on health concerns the health problems of 90% of the world’s people.

Funding

What progress has been made over the past 10 years on the objective of allocating a more equitable proportion of health-research funding (including funding for capacity-strengthening) to low-income countries and to research on the health conditions of the poor? It may be useful to return to the Commission’s report. Using 1986 data, the Commission estimated that only 5% of an estimated 30 billion USD was directed to finding solutions to the main health problems of 95% of the world’s population. This situation led the Commission to make specific recommendations on ways to mobilize research funding:

• Developing countries should invest at least 2% of national health expenditures in research and in research capacity-strengthening, and

• Aid agencies should earmark at least 5% of their project and program aid for the health sector for research and research capacity-strengthening.

In addition to making these quantitative recommendations, the Commission also made suggestions about the quality of research and of research capacity-strengthening efforts, such as longer term funding, innovative financing strategies, and broader support.

A review was conducted 5 years later for WHO’s Ad Hoc Committee on Health Research Relating to Future Intervention Options, using a 1992 estimate of global funding for health R&D (at 55.8 billion USD). The review found that the problem was getting worse, with only 4.4% (2.4 billion USD) directed to addressing the health problems of low- to middle-income countries (Ad Hoc Committee 1996). An update of the global situation will be presented at the October 2000 Bangkok conference.

At a regional level, the Pan American Health Organization has an ongoing project to help countries monitor resource flows and obtain alternative funding. The project, known as Opportunities for Health Research Financing, recently analyzed 26 Inter-American Development Bank (IDB) projects between 1992 and 1998 on their health-research component (Panisset 1999). Of all IDB-sector loans, 6.7% went to research (totaling about 260 000 USD). Subanalysis at a country level revealed wide ranges. For example, in Brazil 23% of loan resources went to research; in Argentina, the proportion was only 5%.

Recently, COHRED’s Task Force on Resource Flows undertook national studies of resource flows for health R&D in Malaysia, the Philippines, and Thailand (COHRED 2000a). In the Philippines in 1996, 19% of the government budget went to health, but the R&D allocation was less than 1%, and the allocation to health research was 17% of the R&D budget, or 1% of the health budget. Private hospitals and government academic institutions used just more than half of this amount (55%).

What can we conclude from the analysis up to this point? What progress has been made in strengthening the capacity of low-income countries to produce and use research to decrease the burden of disease on poor and disadvantaged people? One obvious conclusion is that developing countries need more and better information. Overall, wide disparities remain between the research capacities of low-income countries and those of middle- to high-income countries.

There are some encouraging signs. Clearly renewed interest and concern are appearing at many levels in the issue of health inequities and the need to do something about them. As described in Chapter 2, the health-research community is actively engaged in analyzing this problem and proposing directions for action. In addition, international organizations are increasingly aware of the need to concentrate capacity-strengthening efforts at a national level. This also appears in the mission and activities of the recently created Alliance for Health Policy and Systems Research (for more information visit http://www.who.int/rpc/alliance/en/), the work of COHRED (1994), and the recent INCLEN transition, which features strengthened regional and national activities.

[1] M.A. Lansang, Philippine Society for Microbiology and Infectious Diseases, Quezon City, Philippines, personal communication, 2000.

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