Document(s) 14 of 21

This chapter explores the link between national health-research activities and regional organizations. The analysis covers six regions where most countries are in the low- to middle-income range. Research leaders from these regions provide profiles (“snapshots”) of the regions — past, present, and future — and describe existing organizations, in particular those that influence health research at the national level. This chapter also discusses lessons learned and future possibilities.

Historical records show that centuries ago, Africa was a strong contributor to science in such areas as advanced mathematics, astronomy, agriculture, medicine, and other fields. During the colonial period, health research focused largely on conditions affecting expatriates and was based in topic-specific research centres. With independence, countries took over these existing research structures and, together with universities, tried to revise health-research systems to meet the countries’ needs.

Over the past 10 years, 24 African countries have adopted the Essential National Health Research (ENHR) strategy, identifying national health-research priorities, strengthening coordination mechanisms, and promoting networking. Regional structures include the African ENHR network, the World Health Organization (WHO) regional system, and a number of other health and health-research networks. Overall, there is a sense that, collectively, the networks have not significantly strengthened national health-research systems. Out of the lessons and experiences of the past, African countries have developed a vision and agenda for health research for the future: health research must be country-driven, with a particular emphasis on research that places equity at the forefront of health development.

More than half of the world’s people live in Asia, a region of remarkable diversity of every kind — economic, cultural, social, and political. WHO allocates the countries of Asia to three regional offices. Several networks and organizations are concerned with health research, both within countries and in the region as a whole. Organizations, such as the Tropical Medicine and Public Health Center of the Southeast Asian Ministers of Education Organization (SEAMEO–TROPMED), have made important contributions to health research, including research capacity-strengthening. However, with some exceptions, regional organizations have been slow to foster research cooperation on new and emerging health issues. More can be done to create and facilitate intercountry research coalitions to address problems such as the impact of trade liberalization on health services and the effects of human migration on the transfer of health risks. The section on Asia describes a recent experience involving the creation of the Asian Forum for Health Research. It has focused on the specific issue of preparing an “Asian voice” for the October 2000 conference on health research and has innovatively and effectively engaged the energy and contributions of many national and regional health-research groups.

The section on the Caribbean presents the experience of this region’s English- and Dutch-speaking islands. Relevant regional structures are the Conference of Ministers Responsible for Health (CMRH), the Pan American Health Organization (PAHO), and the Caribbean Health Research Council (CHRC). Analyses of papers submitted and presented to the annual scientific meetings of the CHRC indicate a gradual shift in the content of research toward health problems that health ministers have designated the highest priorities for the region. Overall, however, a “research culture” is lacking in the region, which has low levels of government support for health research and a fairly weak capacity in terms of infrastructure, management, and links to health policy. Countries perceive CHRC as making some strong contributions, such as a forum (the annual scientific meeting) and training workshops, administration of research grants, and advocacy of the ENHR strategy. Four countries in this group now have ENHR committees, and a recent initiative is under way to identify regional health-research priorities.

There is a strong tradition of health-related research in the Central and Eastern European countries and newly independent states (former Soviet Union) (CEEC–NIS), which has world-renowned scientists and research institutions. With the dramatic socioeconomic transitions of the late 1980s and early 1990s, the region suffered a concurrent drop in research funding and a decline in research capacity in many countries. Rapid social change created new challenges for health researchers, particularly in behavioural research (research on social inequalities) and health-systems research. During this period, many of the previous regional structures disintegrated, but new relationships were created, particularly with counterparts in the industrialized countries of Western Europe. New regional networks have been appearing, such as the Central Asian Research Information Network (CARIN), initiated by the WHO’s Regional Office for Europe. Despite these major system changes of the past decade, many health-research institutions have survived — a tribute to the strong legacy of human resources and research traditions. Now the challenge is to build on this base and strengthen capacities in such areas as priority-setting, research management, community participation, and mutually beneficial coalition-building.

The 23 countries under the purview of WHO’s Regional Office for the Eastern Mediterranean show a remarkable diversity. Old civilizations and entrenched cultural traditions are characteristic of this region. Although its diversity is reflected in the status of health research across countries, some general features pertain to most countries: the planners’ demand for research is minimal; for the most part, only the researchers establish research priorities; few countries have national health-research networks; and research capacities are weak, particularly in the broader aspects of the research process. The only regional health-research structures are those facilitated by WHO’s regional office. A regional task force on health research, established in 1986, has assisted a number of countries in developing national health-research policies and strategies. Few countries in the region have adopted the ENHR strategy. A recent regional consultation emphasized the importance of multistakeholder national health-research organizations and the need for a regional health-research forum.

Three general conclusions can be drawn from the regional analysis:

• Regional health-research structures should primarily respond to country needs;

• Regional organizations are most effective if they provide distinctive added value, over and above what countries can and should do for themselves; and

• Several regions see the need to create and strengthen regional health-research forums to fulfill special functions, such as advocacy of the perspectives and needs of countries in global discussions.

The profile of science and technology (S&T) in Latin America during the 1990s reflects its general recovery from the financial crisis of the previous decade. As a result, the region has seen increases in health research and development (R&D) investment, the number of researchers, and the volume of scientific publications. Most of these increases occurred in a small number of countries — principally Argentina, Brazil, Chile, and Mexico. Regional health trends feature decreasing mortality rates and increased life expectancy, on one hand, but widening health inequities, on the other. The Latin American health-research community is trying to respond to this changing situation by increasing the emphasis on health-research priority-setting and paying more attention to the dissemination and use of research results. PAHO has concentrated particularly on the health-research needs of low-income countries in the region, promoting institutional networks to conduct research on high-priority problems. Several of these coalitions focus on health inequities. Among the lessons learned is the realization that the change process is difficult and slow — for example, the use by scientific councils of a broader set of criteria in the peer-review process, including policy relevance. The coalitions are using the new information and communication technologies (ICTs) to support more decentralized, participatory, and problem-oriented research policies and practices.

For many countries, health-research activities are substantially influenced by interactions with other countries, facilitated by regional structures and arrangements. These arrangements range in nature from informal networks to formal organizations. Sometimes they are geographic subdivisions of global organizations, such as the WHO regional offices. Potentially, countries benefit from these regional affiliations through information exchange, funding, technical support, and participation in a range of collaborative intercountry projects and activities.

This chapter explores the relationship between regional structures and national health-research activities, including analyses of six regions: Africa, Asia, the Caribbean, Central and Eastern Europe, Eastern Mediterranean, and Latin America. Mostly low- to middle-income countries are found in these regions.

Research leaders from these six regions provide profiles (snapshots) of their regions, outlining the main developments over the past 10 years or more, the current situation, and future trends. They describe regional organizations that influence national health-research activities and comment on how regional arrangements have helped (or possibly hindered) national efforts to conduct equity-oriented, priority-driven health research. In some cases, they discuss lessons learned and make suggestions for the future. A summary of some crosscutting issues and observations concludes the chapter.

People often have the false impression that Africa has lacked a tradition of S&T. Yet, history tells that people in various parts of the continent made studies and practical use of advanced mathematics, astronomy, steel-engineering, architecture, agriculture, and medicine. European explorers and colonizers divided the continent into spheres of political and economic influence, and this has had a profound impact on the direction of general development. It also appears to have erased past scientific achievements and blocked further progress.

During occupation, the interests of colonial governments largely determined investments in science. They gave priority in research to areas of direct commercial value, such as agriculture and livestock development. Health research was a low priority, except in the case of diseases posing a threat to empire-building. With this end, the earliest of the research institutes were contracted to expatriate scientists from colonizing-country medical-research councils, institutes, and universities. The original research laboratories were therefore led by such bodies as the British Medical Research Council, the Institute Pasteur, and schools of tropical medicine in London, Liverpool, and Antwerp.

Colonial governments invested in health research to varying extents, from minimal inputs to extensive regional networks of laboratories. In the early stages, research and control programs targeted such health issues as malaria and other tropical diseases, hemorrhagic fevers, and a few uncommon conditions. The African-based laboratories, in collaboration with parent institutions, made significant scientific contributions in the epidemiology, etiology, transmission, and management of tropical parasitic diseases. Many young visiting research scientists made their careers in these laboratories; some became world authorities in tropical health.

Before independence, the region developed a few strong health-research networks. The East African Medical Research Council, in the former British Empire, ran a chain of laboratories in Kenya, Uganda, and Tanzania, each with specialized functions. In French West Africa, research was undertaken in networks supervised by the Scientific Research Institute for Development, the French Institute for Black Africa, and the Institute Pasteur. These networks were well established in many countries, including Benin, Burkina Faso, Cameroon, and Guinea–Conakry. South Africa, as an isolated country, set up its own South African Institute for Medical Research, although for the most part the growing mining industry determined its initial interests. Even though these institutions conducted high-quality research, they gave little priority to developing indigenous research capacities.

With independence and the departure of expatriate scientists, some laboratories, especially in the former French countries, were abandoned. Often these laboratories were left in the hands of technicians who lacked research-leadership abilities. Thus, each country, as it gained statehood, inherited whatever research structures were in existence. Lacking a research culture, most countries paid little attention to locally directed S&T development. In the early stages, they emphasized the adoption of technologies available on the market. Development and direction of health research were largely left in the hands of emerging local universities, which, in collaboration with their external partners, set the priority agenda. Not surprisingly, individuals, institutions, and funding agencies drove the priorities.

With increasing recognition of the value of research in development, countries in the region began to place science and research on a higher platform, and they established research councils and ministries of S&T. Unfortunately, policy decisions did not always translate into effective implementation. Often, they failed to provide commensurate funding for research to councils, institutes, and universities, and this stifled outputs. Within the total scientific scenario, health research has traditionally received low priority. Typically, government leaders have regarded funding for the social sector, including health, as a financial burden, rather than as an investment.

At the start of the new millennium, Africa’s contribution to the global S&T portfolio is marginal, with the continent’s share of the world’s scientific output having fallen to 0.3%. Furthermore, sub-Sahara Africa hardly benefits from 1% of the global health-research expenditure. Such low investments in health research and the prevalence of demotivating environments have resulted in a low capacity for research and the flight of human capital. In the mean time, many countries have been spending large sums on external consultants and technical assistance, expenditures that currently consume nearly 40% of overseas development assistance.

Despite the prevailing challenges of new and reemerging diseases, increasing health inequalities, and the impacts of globalization, hope is mounting. The past few years have shown signs of better governance and improving economies, both of which may direct more resources to health and health research.

Since the 1990 report of the Commission on Health Research for Development 24 African countries, with the assistance of the Council on Health Research for Development (COHRED), have adopted the ENHR strategy. Although not all of these countries have successfully implemented their plans, nearly half have made major strides in revisiting their national health-research systems. Priority-setting has been at the forefront in determining a new approach to research development. In an inclusive way, countries have analyzed health situations and the status of health research, organized district and regional consultations, and held national workshops for multiple stakeholders to determine a priority agenda to drive future research. Another major outcome of these consultations has been discussions on national research mechanisms to advocate research and promote networking. A few countries have evolved fairly sophisticated mechanisms. On the downside, as a result of shortages of local and external funding, countries have faced difficulties in translating priorities into research projects.

At the regional level, the African ENHR network started in 1994 and has identified a “focal point” (coordinator). In 1996, the network hosted 11 other regional health-research networks in an attempt to forge closer collaboration between them. As a result of one of the recommendations, African Research Organizations and Networks started operations to enhance electronic dialogue between health researchers in the region. Since then network meetings have taken place annually. These meetings have provided a useful forum for sharing country experiences and developing work plans. Promotion efforts have enlarged the network, and a number of countries have now produced detailed monographs. Country studies on, for example, capacity development, community participation, and priority-setting have been commissioned, and findings have been used to guide country research processes. Stronger countries have continued to support the weaker ones. A major achievement of the African ENHR network has been its facilitation of the African consultation to prepare for the conference in Bangkok in October 2000.

Forty-six African countries are members of the WHO regional system, and each has a WHO representative. Health Ministers meet regularly as a regional committee and focus deliberations on health strategies for the region. Although the WHO regional office has a research agenda, it has so far not been particularly proactive in health-research development. The Organization of African Unity, which also has an S&T desk, has not been a significant player in health research. (These two regional bodies nevertheless have the potential for leadership in health research.) Apart from the African ENHR network, other major research networks with some history in the region include the following:

• Commonwealth Regional Health Community;

• Joint Project on Health Systems Research (now under the WHO regional office);

• International Clinical Epidemiology Network;

• International Health Policy Programme;

• Network of Public Health Institutions;

• Social Science and Medicine Africa Network;

• University Partnerships Project; and

• African Network on Malaria and Vaccine Trials.

The African region has many other recently formed networks.

Many respondents in the African consultation believed that regional networks can serve a useful role as catalysts for research development in the region. However, the widespread opinion was that the existing networks have not collaborated well and that this is why they have not made the expected impacts, particularly in capacity-building, collaborative research, and information exchange. In the opinion of many, the majority of these networks lack a broader vision of Africa’s health-research needs and consequently have tended to operate in pursuit of narrow interests. The last 10 years have witnessed the formation of a number of international initiatives, all aimed at supporting health research in developing countries. Some of these are COHRED, the Global Forum for Health Research, the Alliance for Policy and Health Systems Research, and Scientists for Health and Research for Development.

Both regional and international networks have, without doubt, made contributions within their specific mandates; in particular, most have provided training, organized meetings and conferences for research dissemination, brought policymakers and researchers closer together, and enhanced collaboration. However, there is a widespread feeling that they have made, collectively, no significant impact. They have not given priority to issues profoundly affecting the development of health research, such as policy, operational mechanisms, funding, networking, information technology, ethics, and partnership arrangements. The narrow territorial interests of some of the networks may even have contributed to further fragmentation of research.

Out of the past lessons and experiences, African countries have developed a vision and agenda for health research in the coming decades. Particular emphasis will be on research that places equity at the forefront of health development. The way ahead for health research at the national level is very country specific. However, in all cases, health research must be country driven. Other efforts, whether regional or global, must support that principle. Greatest attention must be directed to capacity development, coordination, and the enabling environment. Capacity-building will be broad and will relate to quantity and quality, multidisciplinary research, demand for and use of research, health leadership and management for research, policy analysis, publication and dissemination, partnership development, communication technology, and institutional facilities. All countries see an important need for an efficient national coordination mechanism. Whatever the mechanism, it should be widely accepted and have political and financial support from government and other national partners. It should be appropriate to the country, co-owned, transparent, and bottom up, with a clear orientation toward national and district problems. A national forum is worth considering, as already exemplified in a few countries. Among its functions should be advocacy, coordination, networking, and knowledge use.

At the regional level, it is strongly believed that Africa should have an effective, autonomous health-research forum, with a secretariat. The forum should be located in Africa, have a board of directors, and work in close association with the WHO regional office and other major partners in health-research development. The main functions of this mechanism would be to define general policy and work plans for the region, serve as an “African voice” to speak for Africa in its dealings with international initiatives and development partners, provide active networking, act as a support mechanism for country activities, perform analytical functions, and provide oversight on generic concerns of ethics, good practices in North–South collaboration, and mobilization of funds.

At the global level, there is concern that most of the international initiatives do not seriously represent the interests of Africans. The fragmentation at the international level leads to confusion in national research systems: arbitrary choices concerning what to do, who to collaborate with, and who to bring in as experts. People in most countries resent this mode of operation. Their wish is to see a more united donor community that respects national priorities and mechanisms and works in partnership to promote better management, greater effectiveness, and more sustainable research. They want to see a further strengthening of the model that COHRED sets, with its focus on national research mechanisms.

It is virtually impossible, in a few paragraphs, to present an accurate picture of this vast part of the world. More than 50% of the world’s people live in Asia, and the region shows large variations of every kind (economic, cultural, social, and political) between and within countries. India alone is said to have 40 distinct language groups; some Indian states have populations approaching 100 million people. Within the continent of Asia are subregions that differ markedly from each other.

Added to this remarkable diversity is the effect of globalization. A striking instance is the recent economic crisis, with its unexpected and serious impacts, not only on those Southeast Asian countries directly affected, but also on economies around the world. With the loosening of trade restrictions, the health sector has seen a rapid growth in private medical services, medical technology, and uncontrolled health-insurance markets, which, in some instances, have led to wider health disparities (COHRED 2000a).

Several distinct trade and economic organizations operate within Asia, such as the Association of Southeast Asian Nations (ASEAN) and the South Asian Association for Regional Cooperation. The WHO system allocates Asian countries to three regions. Countries such as Afghanistan and Pakistan come under the purview of the WHO Regional Office for the Eastern Mediterranean. The rest of Asia is divided between the regional offices for Southeast Asia and for the Western Pacific. Other global agencies divide Asia into various constellations.

Many health-research structures and organizations work within the larger Asian region. Vast countries, such as China and India, have their own large health-research organizations and networks. For example, the Indian Council for Medical Research comprises a network of problem-specific research centres scattered throughout the country; it serves as a strong coordinating mechanism for health research in this country of now 1 billion people. A Chinese example is the China Network for Training and Research in Health Economics and Financing. Created under the auspices of the Ministry of Health, this network comprises the China National Health Economics Institute and 10 other institutions located in medical universities throughout the country.

Some regional health-research organizations have been in existence for many years; an example is SEAMEO–TROPMED — an organization devoted to the support of health development, including health research, in Southeast Asia. (See Chapter 6 for a more detailed description of SEAMEO–TROPMED activities.) Other groups are more recent — an example is the Southeast Asia Clinical Epidemiology Network (SEACLEN). Led by training centres in Indonesia, the Philippines, and Thailand, SEACLEN is an active network of academic professionals with expertise in clinical epidemiology and public-health research. Other examples are the recently created Asia–Pacific Health Economics Network and the Asia–Pacific Network of the International Forum for Social Sciences and Health.

Regional organizations such as SEAMEO–TROPMED have spearheaded investments in health research. In some areas, regional and global investments have been complementary. For example, both SEAMEO–TROPMED and the global Special Programme for Research and Training in Tropical Diseases (TDR) have contributed to direct research and capacity-strengthening; this has been instrumental in improving health and decreasing the incidence of infectious disease.

The WHO regional offices have made useful contributions to national efforts by fostering exchanges between countries and, in some instances, stimulating intercountry research collaboration. Collaboration between WHO regions is increasing but needs further development. Collaborative activities sponsored by regional trade and economic organizations (such as ASEAN) have contributed some benefits in the health sector and, indirectly, in the health research of participating countries.

Regional organizations, however, have been slow to use their strengths in fostering research cooperation on new and emerging health and development problems. A recent encouraging example is the network for Surveillance of Infectious Diseases operating among countries in the Mekong Basin; partial assistance from the Rockefeller Foundation is helping to establish this network. Regional research cooperation would be helpful in resolving such problems as the following:

• Health disparities resulting from privatization of health insurance and health services, as a consequence of trade liberalization;

• Impact of human migration on the transfer of health risks, such as epidemics of infectious diseases like AIDS and zoonoses (for example, the spread of chicken and Nippah viruses);

• Rising cost of health care, as a result of chronic and social diseases, such as drug dependence, sexually transmitted diseases, injuries, and mental illness; and

• Global environmental impacts on human health in the region, such as land degradation, persistent use of organic pollutants, and increasing traffic congestion.

Regional health-research networks and organizations can also assist countries with some of the more difficult aspects of strengthening national health-research systems. Some possible forms of assistance would be the following:

• Convincing decision-makers (in government and in the private sector) that funding for health research can be a sound economic and social investment, not just a marginal budget item (countries in the region need stronger strategies to link national health services, including health policy, and national health-research systems); and

• Broadening the base of stakeholders in the health-research process to include citizens and nongovernmental organizations (NGOs). Health research can empower citizens to make good choices and thus participate in policy processes. Health research can also make NGOs more effective. Citizens and NGOs can in turn demand accountability from governments and health-research organizations and serve as a check and balance on governance, encouraging international donors to focus on country priorities.

Some useful and important lessons can be learned from recent experience with a health-research network in Asia — a mechanism that became known as the Asian Forum for Health Research. A number of regional health-research leaders saw the need for health-research groups in Asia to prepare for the October 2000 conference. An ad hoc planning group convened in September 1999. It comprised representatives from several health-research networks and organizations, the WHO regional offices, and various countries. The group decided to use a three-stage, innovative participatory strategy to engage a wide range of stakeholders: a preforum dialogue, 3-day forum, and postforum follow-up arrangements leading to the October 2000 conference. A 5-month preconference electronic dialogue involved 300 individuals across Asia. Among its aims were sharing information and determining key research issues of relevance to the Asian region, for further discussion at the forum.

About 100 people met for the 3-day forum in Manila in February 2000. The format of this meeting included some innovations, such as plenary roundtable discussions, collaborative team discussion of regional research priorities, a marketplace (including a “speaker’s corner”), and a technology-support centre. An outcome of the forum was a draft of an Asian-voice statement. This synthesis document captured the key ideas and recommendations from the working teams, with a view to taking them forward to the international meeting in Bangkok (Sitthi-amorn 2000[1]). Following the meeting in Manila, the participants used a website to continue their exchange of information and dialogue. Organizers agreed to expand the network by encouraging each of the original 300 dialogue participants to invite others from their own institutions and countries.

The Asian-forum participants and planners have reflected on the lessons learned through this process, including the following:

• By focusing on a specific issue (in this case, the need to prepare an Asian voice for the upcoming conference), it was possible to engage the interest, energy, and commitment of many national and regional health-research groups;

• Electronic communication proved to be a satisfactory and efficient method of facilitating the participation of 300 individuals across Asia; and

• A small coordinating team (supported by some technical expertise) required considerable effort to facilitate the electronic dialogue, plan and manage the actual forum activities, and sustain the follow-up planning.

[1] Sitthi-amorn, C. 2000. Report of the Asian Forum for Health Research. Manila, the Philippines, 17–19 Feb 2000. Internet: http://heapol.oxfordjournals.org/cgi/content/abstract/17/2/213. (In draft.)

Document(s) 14 of 21