Document(s) 18 of 21

Summarizing the earlier chapters of this book, this concluding chapter reviews the new and not so new realities confronting the global health-research community at the beginning of the 21st century:

• Widening disparities — Despite some indications of progress in human development over the 1990s, health and socioeconomic disparities have widened for many countries and populations. More than 80 countries have lower per capita incomes than a decade ago, and the income gap between the richest and poorest quintiles of the world's people continues to widen, from 30 to 1 in 1960, to 60 to 1 in 1990, to 74 to 1 in 1997. With some exceptions, the health gap between countries is widening as well, particularly for three country groups: African countries suffering most severely from the AIDS epidemic, countries in Eastern and Central Europe where infrastructures have collapsed and sociobehavioural illnesses are escalating, and countries ravaged by prolonged and devastating internal conflicts. Again with some exceptions, within-country disparities in health have also widened — a phenomenon not limited to developing countries.

• Globalization — Even though some aspects of globalization have a long history, the past decade saw an accelerated growth in this phenomenon. Examples include new markets, new organizations (for example, the World Trade Organization [WTO]), new rules, and faster communication tools. Some aspects of globalization do improve the conditions of the poor (“globalization with a human face”), but for the most part it has increased poverty, inequality, and insecurity. Globalization has had impacts on health, for example, through the actions of transnational corporations in the sale and control of pharmaceuticals and the marketing of tobacco in low-income countries.

• Continuing pandemics — Several major health conditions affecting millions of people around the world loom larger than they did a decade ago, such as the epidemic of tobacco-related diseases, accounting for perhaps 4 million deaths in 2000. Another is the AIDS epidemic — HIV-1 is now the single largest cause of death from infectious disease, expected to account for 2.5 million deaths in 2000. When measured by disability-adjusted life years (DALY), injuries (both intentional and unintentional) account for 16% of all DALY and more than 6 million deaths annually. Malaria continues to worsen, particularly in Africa.

• Knowledge and new information and communication technologies — Over the past decade, knowledge has become a central element in human development. Many high-income countries now call themselves “knowledge societies,” reflecting the impact of the knowledge explosion on economic and social development. The new information and communication technologies (ICTs) are a major feature of this remarkable trend. Yet, the world's poorest people, 2 billion or more, are missing out on the potential benefits. Despite some promising innovations, such as the use of community-based telecentres, large investments of money, persistence, and creativity are still needed to ensure that health knowledge improves the lives of the poor.

• New understandings of health and development — The development community increasingly sees health as an integral part of human development. The 1990s brought us three important insights:

  • Investing in health is critical to economic productivity and human development,

  • Greater equity promotes economic growth and development, and

  • The application of knowledge is central to global development.

Despite the growing recognition that knowledge production and use are critical to health in development, most of the world's poor have yet to benefit from the fruits of health research. Some key challenges for the new decade are presented in this chapter, which gives special attention to the following strategic implications for the leadership of health research in low-income countries:

• Persisting with the equity goal — Although large and growing inequities remain, something can be done, and persisting with the equity goal is therefore critical. Strategically targeted health research can accelerate progress toward the equity goal. These strategies include focused epidemiological studies, analytic studies to explain the causes of health inequities, cost-effectiveness studies for interventions that produce the best outcomes for poor and marginalized peoples, and practical operational research to improve the use of available health interventions.

• Strengthening national health-research systems — The reasons for placing a major emphasis on strengthening country-specific health-research mechanisms are as valid today as they were 10 years ago, when the Commission on Health Research for Development made its strong and clear recommendations. Although many countries have made substantial progress and more tools and strategies are now available, much remains to be done, including establishing regional and global support mechanisms with a focus on the needs and realities of low-income countries.

• Focusing on capacity development for national health-research managers — Complex leadership competencies are needed for equity-oriented, priority-driven health research. National health-research managers may benefit from more systematic and comprehensive capacity-development programs. This chapter suggests some specific strategies to develop competencies, such as those needed to manage knowledge, create demand for research, build coalitions, and foster leadership skills among junior colleagues. These strategies include the dissemination of appropriate materials (increasingly through electronic channels) and the use of these materials in “learning-while-doing” situations, supplemented by skilled mentoring and purpose-specific events.

• Going local — To create a concurrent but countervailing trend to globalization, national health-research leaders must concentrate increasingly on local systems. The strategy of decentralization in health-sector reform illustrates this phenomenon. This chapter offers several suggestions for strengthening the role of research in local health development, including an emphasis on local capacity development and on equity-oriented research-to-action projects.

• Building coalitions — Activities in health research for development over the past decade have too often been fragmented, uncoordinated, uneven, and unsustained. The reasons are more human than technical or conceptual. Using the benefit of some promising experience, backed by scholarly studies of the coalition-building process, this chapter makes several suggestions, including the proposal that the new critical mass should be national and subnational research and learning networks that are focused on specific health problems and firmly linked to other relevant regional and global research efforts.

The chapter concludes with a call for renewed collaboration, driven by values of fairness and solidarity, and for intensified, purposeful action to ensure that health research becomes a stronger tool to improve the health of all people.

Much of the world, perhaps 2 billion people or more, will fail to share in the benefits of global growth without a complete change in international strategy. … A better balance needs to be struck between incentives for innovation on one hand, and the interests of the poorest on the other. … the world's leaders have a chance to will both the ends and the means for the kind of globalisation that can serve all the world. They must seize this chance.

— Sachs (2000, p. 81)

This challenge was put to the world's leaders who met at the United Nations Millennium Assembly in September 2000. A similar challenge confronts the global health research and development community, which is now taking stock of its collective achievements of the past decade and charting a course for the future.

This final chapter begins with an overview of important new realities (some of them not so new) impacting on the global health-research community at the beginning of the 21st century, as described in previous chapters. This is followed by a summary of the major challenges these features of the global situation present to those committed to strengthening the contribution of health research to the well-being of the world's people.

The dawning of a new millennium has stimulated much analysis and reflection on the human condition and the challenges ahead. These contributions can be found in the annual reports of global agencies, special editions of professional journals, and many other sources. It is a somewhat daunting task to extract the facts and insights most relevant to the aims of this book. The following list is necessarily selective, an attempt to present those aspects of the global situation that relate most directly to the goal of health research for equity in development. These new and not so new realities are

• Widening disparities;

• Globalization;

• Continuing pandemics;

• Knowledge and the new ICTs; and

• New understandings of health and development.

In the Human Development Report 1999, the United Nations Development Programme (UNDP) included a balance sheet of human development, presenting some facts about human development from 1990 to 1997 (UNDP 1999). This information pertained to health, education, and other sectors and fell under two headings: global progress and global deprivation. The table in the report is a reminder that both advances and regressions occurred in the 1990s.

On the progress side of the ledger, for example, a life expectancy at birth of more than 70 years was found in 84 countries in 1997, which was up from 55 countries in 1990. Within this group of countries, the number of developing countries rose from 22 to 49. Between 1990 and 1997, the share of the population with access to safe water nearly doubled, from 40% to 72%. During the same period, adult literacy rose from 64% to 76%. Food production per capita increased by nearly 25%. The ratio of girls to boys enrolled in secondary schools increased from 36% to 61%. The decade saw these and other significant achievements.

However, from several recent sources the sobering observation is that for most developing countries and many population groups disparities widened during the past decade. Economic disparities are particularly well documented, but disparities across gender, race, and geography also widened. In the World Development Report 1999/2000: Entering the 21st Century, the World Bank put the following question: What has been the record to date of development? (World Bank 2000). It went on to note that some parts of the world have made gains. For example, in South Asia as a region, the proportion of the population living on less than 1 USD/day declined. But it has increased in other regions, such as Africa and Latin America. Using the commonly accepted benchmark of 3% or more as the rate of per capita growth needed to reduce poverty significantly, one finds that between 1995 and 1997 only 21 developing countries met this rate — 12 of them in Asia. Of the 48 countries designated least developed, only 6 met this benchmark. Overall, more than 80 countries now have per capita incomes lower than a decade ago. The worldwide total of those living on 1 USD/day or less continues to rise, in part because of an increase in overall population levels. From 1.2 billion in 1987, the total number of people living on this amount today is 1.5 billion. With current trends, this figure will be 1.9 billion in 2015. Another 2 billion people or more survive on 2 USD/day. The World Bank added this sobering note: “Current trends suggest that even the gains achieved could prove short-lived in the absence of new policies and institutions” (World Bank 2000, p. 24). The income gap between the fifth of the world's people living in the richest countries and the fifth living in the poorest countries continued to rise in the 1990s, from 30 to 1 in 1960, to 60 to 1 in 1990, to 74 to 1 in 1997. A startling statement from the 1999 UNDP report highlights the enormity of this income gap: “The assets of the 200 richest people are more than the combined income of 41% of the world's people. And the assets of the top three billionaires are more than the combined GNP [gross national product] of all least developed countries and their 600 million people” (UNDP 1999, p. 3).

Although health status has improved in most countries in the past decade, it appears to be worsening in some developing countries. For instance, in Kenya the infant mortality rate increased from 62 per 1 000 live births in 1993 to 74 per 1 000 live births in 1998. The mortality rate for children under 5 years old increased from 96 per 1 000 live births to 112 per 1 000 live births during the same period. The prevalence of chronic undernutrition increased from 32.1% in 1987 to 34% in 1998. The economic crisis in Indonesia also saw an increase in the rate of children with malnutrition.

Regarding within-country health disparities, it is important to strive for a balanced assessment. In some countries, the health gap narrowed during this past decade. In a helpful annex on assessing progress, the most recent human development report illustrates the virtue of using diverse measurement perspectives (UNDP 2000). Taking immunization of infants in Egypt as an example and using an “average perspective,” one sees only 67% of infants immunized in 1992, compared with 93% in 1998. Using distributional data (the “inequality perspective”), one finds that the gap in immunization rates between the best- and worst-off regions narrowed dramatically over this same 6-year period, from 31% to 7% (UNDP 2000). UNDP presented similar findings from Guatemala, comparing mortality rates between 1995 and 1998-99 for children under 5 years old. Gaps narrowed between various social groups: geographic (regional), urban-rural, and ethnic groups (UNDP 2000). But for many countries, including some high-income countries, the health gap between various population groups has widened. In the World Health Report 1999, the World Health Organization (WHO) gave data from around 1990 on the health status of the poor versus the nonpoor (WHO 1999). WHO's intention was to provide updated information on health inequalities on a regular basis so that comparisons over time can be made. Another sign of the importance of this topic is that the first 2000 issue of the Bulletin of the World Health Organization featured the theme of inequalities in health (Feachem 2000), including several national, regional, and global analyses of health disparities.

The health gap is also widening between countries. In the last several years, it has become apparent that in many countries, the health situation is in fact deteriorating. These countries fall into three groups:

• In several countries of sub-Saharan Africa, indicators show reversals in previous health gains, primarily as a result of the AIDS epidemic. For nine countries in Africa, studies project a loss of 17 years of life expectancy by 2010 — back to the levels of the 1960s. Ten years from now, in Botswana, where 36% of the adult population now has the HIV infection, the life expectancy from birth will be 29 years. In Namibia and Zimbabwe, it will be 33 years; and in South Africa, 35 (WHO 1999).

• Researchers attribute health setbacks in some of the former socialist republics of Eastern and Central Europe to a disintegrating health and social infrastructure, along with a complex set of sociobehavioural factors.

• A third group comprises countries where the health of the population has deteriorated because of war. In Iraq, the health status, particularly of children, continues to decline, partly as a result of United Nations sanctions. Protracted within-country conflicts in places such as Afghanistan, Angola, Sierra Leone, and Sudan have had devastating consequences for the health and well-being of their citizens.

Much has been written about the globalization phenomenon, particularly in the last few years. Although aspects of globalization have been evident for decades — even centuries — some people nevertheless argue that certain features of it are new. In a box entitled “Globalization — What's Really New?,” the Human Development Report 1999 displayed a list of “what's new this time” (UNDP 1999, p. 30). The list included new markets, new actors (WTO, for example), new rules and norms, and faster and cheaper communication tools. Overall, the report tried to present a balanced assessment of this phenomenon (“globalization with a human face”), suggesting that societies benefit both from the free flow of money and trade and from the free flow of ideas and information (driven by new technologies). But it also recognized that globalization negatively affects marginalized groups and that it is creating new threats to several kinds of human security: financial, occupational, personal, cultural, and environmental. Global competition is putting pressure on the time, resources, and incentives for the “caring” aspect of human development, an essential element for social cohesion and strong communities. What is more, global competition is placing developing countries, which have less ability to cope and compete, in a disadvantaged position. This results in further deterioration of social and economic conditions. ICTs are creating polarization — a point that Sachs emphasized in his recent essay, “A New Map of the World” (Sachs 2000). Free flow of information also creates demands beyond the economic affordability of individuals or countries. The United Nations General Assembly vigorously debated the entire issue of globalization at its special session in Geneva in June 2000. One writer reporting on this session said that

The … session concluded that poverty, inequality and insecurity have increased since globalism was launched. The time has come to write the obituary of globalism as an economic doctrine that purports to bring progress and development to international society. It has failed.

(Pfaff 2000, p. 6)

What are the impacts of globalization on health and health policy? This question raises important issues (Lee 1998; Bettcher et al. 2000). Some people express concerns about the role of transnational corporations in the control and sale of pharmaceuticals and the marketing of tobacco in developing countries. A particularly contentious issue concerns the Trade-Related Aspects of Intellectual Property Rights (TRIPs) agreement. This introduces an international standard (enforceable through WTO) to protect the intellectual property rights of the inventors and link these rights to trade. But are society's rights adequately protected? For example, many developing countries have laws to intentionally exclude pharmaceuticals from product-patent protection (allowing only process patents). The move to protect patents introduced under the TRIPs agreement limits opportunities for companies in low-income countries to produce less expensive versions of important drugs (UNDP 2000, p. 84). The General Agreement on Tariffs and Trade also exposes developing-country institutions to a more hostile world in which they cannot compete.

A pandemic is any health condition that causes more than 1 million deaths a year. The intention of this section is not to describe current pandemics in any detail. Many useful reports have already done so (WHO 1999). Rather, it is to use a few examples to remind the reader that pandemics are continuing; in some instances, they are much larger than they were 10 years ago. Importantly, most of these conditions disproportionately affect the poor. From this perspective, the 10-year report card of the global health community's performance (including the health-research sector) is not encouraging:

• Tobacco-related illnesses — Mortality and morbidity rates of illnesses caused by tobacco have continued to rise, from less than 3 million deaths annually 10 years ago to a current rate of 4 million deaths a year. Tobacco-related deaths will increase to 10 million a year by the late 2020s, and 70% of these deaths will be in developing countries (WHO 1999). We urgently need locally relevant research in support of tobacco control to convince governments, health professionals, and consumers of the risks of smoking.

• hiv-aids — Whereas HIV-1 was responsible for some 300 000 deaths in 1990, it is now the single largest cause of death from infectious disease and is expected to cause about 2.5 million deaths in 2000. This pandemic illustrates the global equity gap: 95% of the world's 34 million HIV-infected people live in developing countries, but these countries receive only 12% of the money spent on AIDS worldwide. Recently suggested research priorities for developing countries include randomized trials of behavioural interventions to prevent HIV and assessments of the cost-effectiveness of making drugs more widely available to treat opportunistic infections (Ainsworth and Waranya 2000).

• Injuries — Injuries account for 16% of all DALY (compared with 7% for the combination of HIV-AIDS, tuberculosis, and maternal conditions). Almost 6 million people died of injuries in 1998, more than a million from road traffic accidents. More than 2 million died from intentional injuries; almost half of these were self-inflicted. Homicide, violence, and war account for the rest. Recent research is beginning to reveal the enormity of the global burden of illness suffered by women as a result of violence (Yusuf et al. 2000). Almost twice as many war-related deaths occurred in 1998 as in 1990. All of these situations add costs in addition to human lives. The Carnegie Commission on Preventing Deadly Conflicts estimated that the cost of the seven major wars in the 1990s (not including Kosovo) to the international community was 200 billion USD — during the same period in which the flow of development aid steadily declined (UNDP 2000). Although researchers have also studied the health effects of war (Bush 2000; Spiegel and Salama 2000), we need to do much more on this topic.

• Malaria — Another example of a condition making the global burden of illness worse today than 10 years ago is malaria — more than 1.1 million deaths in 1998, compared with less than a million in 1990. Again, this is a condition that affects the vulnerable — particularly children and the poor, who constitute 90% of cases in sub-Saharan Africa. The economic impact of malaria in Africa is substantial: estimated productivity losses through premature death and illness may be greater than 1% of gross national product. The challenges to the health-research community are enormous; nevertheless, it is encouraging to note evidence of increased collaboration and funding to “roll back” this disease through research and action.

The list could go on to include other major conditions. For some conditions, the global burden of illness is larger than it was 10 years ago; tuberculosis and maternal mortality are examples. For other conditions, trends in death and disability demonstrate modest progress over the 1990s; examples are the water-borne and respiratory diseases. Mental-health disorders, as a category of illness, constitute an increasingly large proportion of the illness burden, causing an estimated 10% of all DALY in low- to middle-income countries in 1998 (Ustun 2000).

… economies are built not merely through the accumulation of physical capital and human skill, but on a foundation of information, learning and adaptation. Because knowledge matters, understanding how people and societies acquire and use knowledge — and why they sometimes fail to do so — is essential to improving people's lives, especially the lives of the poorest.

— World Bank (1999, p. iii)

This is the introductory paragraph from the World Development Report 1998/99: Knowledge for Development (World Bank 1999). It illustrates the increasing attention paid to knowledge as a central element of human development. In fact, some propose that knowledge is development. The World Bank report focused on two kinds of knowledge, each with its own distinctive set of challenges. The challenge concerning “knowledge of technology” (for example, in the health or agricultural sector) is to narrow the wide gaps in social development by acquiring, absorbing, and communicating all forms of knowledge. Another kind of knowledge, that of “attributes,” concerns the quality of a product or work done by an individual or institution. Knowledge of this kind can relate to problems that hurt the poor, such as when institutions fail to understand the issues confronting the poor. Solving these problems involves taking the time to learn about these people's particular needs and concerns so that they are less isolated and can improve their access to certain institutions and resources.

The debate about the evolution of the “knowledge economy” has its counterpart in the health sector. One formulation (Suwanwela 2000) suggests that the generation of knowledge (that is, research) is a product of three elements:

• Health-research planning, policy development, and management;

• Capacity development for health research; and

• Collaborative health-research programs (including the public and private sectors).

• The resulting body of knowledge must then go through further processes, including

  • “Optimization” (validation and meta-analysis);

  • Dissemination; and

  • Use (to develop policy, sustain evidence-based practices, empower people, and educate health workers).

Part of the discussion of the optimal use of available knowledge is linked to the idea of empowerment through knowledge and involves a debate about how to integrate both “scientific” knowledge and the indigenous wisdom of various societies. One approach to the bridging of the knowledge-to-action gap in the health field is “translational research” (see Box 9.1).

Fueling the “information explosion” is a remarkable increase in the availability and use of ICTs, an issue not mentioned in the 1990 Commission report. The facts are well known, and they are symbolized on the cover of the Human Development Report 1999: it depicts the geography of the world's Internet users in mid-1998 (UNDP 1999). At that time, 88% of Internet users lived in industrialized countries (constituting 15% of the world's population). In contrast, the 20% of the world's population living in South Asia constituted less than 1% of all Internet users. Another index is teledensity. A teledensity of 1 is one telephone for every 100 people. A quarter of the world's countries do not have even this basic level of access to telecommunications. Sweden's teledensity in 1998 was almost 70 (mainline telephones per 100 persons). Information technology is thus creating another form of global polarization and contributes to widening disparities.

Can ICTs contribute to sustainable human development, rather than detract from it? This question led to a study by the United Nations Commission on Science and Technology for Development. The report of this inquiry is now available as a source book (Mansell and Wehn 1998). Its central conclusion is that “ICTs can make a major contribution to sustainable development but that this opportunity will be accompanied by major risks” (Mansell and Wehn 1998, p. 256). The report went on to say that developing countries would need to invest in two kinds of capabilities — technological and “social” (that is, the ability to use ICTs). We can expect greater returns from investments in enhancing utilization capabilities.

Health-research managers in developing countries are often well aware of the exciting prospects that the advances in ICTs offer in facilitating health-research development. Many have seen the benefits first hand, during their training in industrialized countries or other international exchanges. Some leaders of national health-research institutions envision ICTs serving as a bridge between the global world of knowledge and the specific information needs of research groups, policymakers, and the general public in developing countries. However, a host of constraints prevent their realizing this vision, including inadequate funding, weak infrastructures, an ongoing brain drain, and low levels of research uptake. Creative means must be found through international partnerships to reduce the interaction costs of knowledge management. These strategies would include enhancement of the capacities of support staff, free access to international electronic journals, and direct opportunities for research managers to acquire ICT skills. Horton (2000) recently offered some useful insights into the role of researchers, editors, and publishers. We can add to such practical measures by creating and facilitating local learning and innovative coalitions (as suggested in Chapter 4).

Copenhagen Plus Five, a special session of the United Nations, convened in Geneva in June 2000, five years after the 1995 World Summit for Social Development. WHO's submission to this follow-up meeting makes the case that health is both an input and an outcome of development. The argument is as follows:

If health is an asset and ill-health a liability for poor people, protecting and promoting health are central to the entire process of poverty eradication and human development. As such they should be goals of development policy shared by all sectors — economic, environmental and social.

(WHO 2000a, p. 7)

The WHO document puts forward three action proposals as integral elements of the Copenhagen Plus Five follow-up plan:

• Strengthen global policy for social development;

• Integrate health dimensions into social and economic policy; and

• Develop health systems to meet the needs of poor and vulnerable populations.

These proposals illustrate an increasing confidence among health planners as they and the development community discuss the importance of health in human development. It has led some to put forward the idea of “health-led development,” arguing that health improvements and economic growth are mutually reinforcing, both positively and negatively (Bloom and Canning 2000). The Nobel Laureate economist Amartya Sen provided a more focused analysis (Sen 1999b). Agreeing that “good health is an integral part of good development,” he went on to argue that low-income countries should use “support-led” processes, focused strategically on more health care, education, and other social programs (Sen 1999b, p. 623). WHO's Commission on Macroeconomics and Health, launched in January 2000, is studying the links between health and economic growth in more depth. One of the six issues on this commission's agenda is “the economics of investing in the research and development of drugs and vaccines primarily for poor populations” (WHO 2000b, p. 275).

Investments in research and interventions aimed at the sociobehavioural aspects of health promotion and prevention are also important. Primary and secondary prevention of many more illnesses is now possible, as a result of improved understanding of disease risk factors and their interaction. Curative technologies have advanced, becoming sophisticated, as well as costly. The increased demand for specialized care adds to the challenges confronting health-care systems. The public sector can no longer take sole responsibility for provision of care — promotive, preventive, or curative. Financing schemes and business investments in health-care provision under market conditions need appropriate regulatory and consumer-protection mechanisms. Education and mass media play important roles in the new health system. In many instances, the limited resources available to individuals or countries are drawn to the less productive and less cost-effective part of the health-care system. Health development as a whole is affected. Research on the economic and management aspects of health-care systems is therefore also greatly needed.

The author of Chapter 3, David Harrison, takes the argument a step further by considering health research in the context of three important insights from the 1990s:

• Investing in health is critical to economic productivity and human development;

• Greater equity promotes economic growth and human development; and

• The application of knowledge is central to global development.

Thus, research (knowledge production) is not only a strategic tool for making improvements in health but also a “driving force behind all development” (Harrison, this volume, p. 48). Some preliminary explorations in “mapping” the relationship between health research and development are offered in Figure A3.1. Despite this theoretical underpinning, however, the reality is that, because of the market forces of globalization, coupled with narrow scientific incentives, the world has diverted knowledge-related human and financial resources away from the concerns of the poor in low-income countries.

Some compelling reasons are described above to view health research as, potentially, “an essential link to equity in development,” as envisioned in the title of the 1990 Commission report. People in the development community increasingly regard knowledge production and use as critical elements of health in developing countries. Yet, most of the world's poor have yet to benefit from the fruits of health research. This chapter highlights five challenges for the coming decade. All these challenges derive from earlier chapters, and we restate them here to emphasize their importance:

• Persisting with the equity goal;

• Strengthening national health-research systems;

• Focusing on capacity development of national health-research managers;

• Going local; and

• Building coalitions.

With each challenge, we explore some strategic implications for national health-research systems for the attention of the national leaders and people responsible for regional and global support mechanisms.

As stated in a special issue of the Bulletin of the World Health Organization on inequalities in health, an inequity is an unfair and remediable inequality (Feachem 2000). As described above, large and growing inequities remain. But something can be done about them. Thus, the first and overarching challenge is simply and clearly to persist with the equity goal and make health research contribute more effectively to achieving this goal.

The reasons for persisting with this goal are the following (COHRED 2000e):

• The determinants of health status should not be socioeconomic status or any other social distinction, such as gender, ethnicity, age, or geography;

• Equity-oriented development strategies contribute directly to economic growth and human development;

• Concentrating health investments on those who carry the largest disease burden (usually the poor and marginalized groups) improves efficiency; and

• Relatively small investments in the application of existing knowledge can result in substantial health gains for disadvantaged groups (practical operational [problem-solving] research can improve the efficient application of available and affordable health interventions).

At the country level, strategically targeted health research can accelerate progress toward the equity goal. Epidemiological studies can pinpoint inequities in health status. Analytic studies can provide explanations for existing inequities. Cost-effectiveness research can identify those interventions that produce the greatest desired outcomes for poor and marginalized groups. Carefully selected and applied monitoring tools can determine progress in achieving the health-equity goal. These and other equity-oriented research strategies are most practical at the subnational (community) level.

Health research can no longer be exclusively the domain of researchers. It needs to be demystified and made understandable to other stakeholders. For too long, the demand side of health research has been less emphasized than the supply side. The capacity of research users must be strengthened so they can take a more active part in applying research results to health problems. Policymakers can demonstrate accountability and evidence-based decision-making by participating more fully in the research process. Similarly, research can assist policy implementers with technology assessment, operational choices, and evaluation. Individuals and communities learn to ask the right questions and assess alternative answers when they are involved in research. Indeed, being able to do health research for themselves empowers developing countries in their health planning and provision of care.

Several developing countries have followed the example of high-income countries in deriving economic and social benefits from investing in the generation of new knowledge or from adapting existing knowledge to national purposes (World Bank 1999). The reasons given in the 1990 Commission report for the focus on national health research remain valid to this day. But progress has been slow and fragmented. The message from research leaders in low-income countries is consistent: the overall strategy is correct, but much remains to be done (see Chapter 8). Several chapters in this book provide specific suggestions to strengthen national health-research systems, including

• Investing scarce resources more efficiently (Chapter 3);

• Enhancing community participation (Chapter 4);

• Linking the research and policy processes more effectively (Chapter 5); and

• Broadening capacity-strengthening strategies to include national networks (forums), in addition to focusing on individuals and organizations (Chapter 6).

It is also important to understand the dynamic interconnectivity of levels: global, regional, national, and subnational. For example, regional health-research organizations should, for the most part, align their agendas and activities with national research needs and perspectives, as described in Chapter 7. The same principle applies to global agencies and institutions. We can learn much more about how to develop the most effective and mutually beneficial interactions among the various levels.

Many countries have successfully established a more coordinated, priority-driven system of health research. However, significant barriers remain. One is the challenge of moving from the identification of national health-research priorities to the actual implementation of research programs and investments. Recent work in Tanzania provides some useful ideas, tools, and strategies for deploying limited resources to meet country-specific needs equitably and efficiently (Harrison 2000). Another common barrier is the lack of coordination of the inputs (technical assistance and funding) of several donors within a single country. Here a role may be possible for a more explicit “bridging” and coalition-building of the national health-research leadership with external partners, such as the Council on Health Research for Development (COHRED) or a bilateral agency.

In practical terms, the day-to-day work of innovation and change depends on people being determined to make a difference, individually and in teams. Given the emphasis of this book on the national perspective, we believe that research managers have special roles to play in guiding equity-oriented, priority-driven national health research. These people often find themselves taking on major leadership and management roles, based on seniority or a strong scientific track record, but they may be unprepared for the broader set of tasks before them. Of course, many acquire some of the required competencies informally. Our recommendation in this chapter is to take a more intentional and systematic approach to the capacity development of national health-research managers.

The definition of a national health-research manager can be broad enough to include those who lead the institutions that produce research as well as those that use it. In the former group are national health-research organizations, forums, networks, and other research centres. The mission of academic institutions includes both the production and the use of research, in particular the education of health professionals who will do research and use it in the future. Research-user institutions include government agencies (for example, policy and planning units of ministries), major implementation programs, and national nongovernmental organizations (NGOs). NGOs are playing an increasingly important role in the development process, at both national and global levels (Fowler 1997). Some are active in both the generation and the use of health research. Improvement in the management of health research in countries needs certain competencies that have also been identified as Essential National Health Research (ENHR) competencies: advocacy and promotion, establishing a coordinating mechanism, priority-setting, capacity development, resource mobilization, networking, and evaluation.

Chapter 6 makes some suggestions on the special competencies of national health-research managers (in addition to those attributes needed for leadership of any organization). These special competencies are as follows:

• Knowledge management — understanding the nature of the knowledge economy and facilitating access to global knowledge to solve local problems;

• Demand creation — working with user groups to accelerate the use of evidence in policy development, practice, and action;

• Coalition-building — using special skills to foster team-building and network development and management; and

• Leadership development per se — being familiar with the scholarly work on leadership and applying this in practice, such as through systematic succession planning and the mentoring of junior colleagues.

Some agencies and organizations already offer courses and workshops on health management and leadership. The reading materials in those courses focus on the role of health-research management (IDRC and WHO 1992). But more can be done to address the specific needs of national health-research managers, such as the following:

• Assemble available materials and make them accessible through “electronic libraries” (as well as “physical” libraries), perhaps in a series of learning modules — for example, a variety of assessment and conceptual tools, collections of case studies and best practices, book reviews, and annotated bibliographies.

• Combine the use of materials (as above) with systematic learning-while-doing arrangements — a strong case can be made for firmly linking the acquisition of new competencies to actual tasks and real-life problems. Managers can acquire new knowledge and skills on site, provided they have a systematic plan, time to devote, available and relevant materials, and skilled mentoring. It is particularly helpful to integrate this study into performance-assessment and quality-improvement strategies.

• Use specific events (workshops, seminars, courses) to serve as adjuncts — but they should serve as component elements of a learning program rooted in actual practice.

Two other groups, in addition to research managers, should receive special attention. One is the “emerging leaders,” that is, young colleagues who have completed their formal training and have embarked on promising professional careers. They have special needs and struggles, such as balancing professional aspirations with commitments to young families and personal (nonprofessional) interests. They also require guidance and mentoring on career planning and professional development. Students are the second group — the thousands of energetic, motivated, and intelligent future health professionals studying in universities and training colleges and postgraduate programs. They are the next generation of leaders in all aspects of research: production, use, and management. Much more can be done to involve students in various aspects of research, although many training institutions already have arrangements for doing this.

Developing countries should consider the creation of explicit capacity-development programs to meet the needs of various research managers. These programs may include a component focused on emerging leaders. Regional mechanisms and global agencies may consider creating special funds and resources to facilitate this aspect of national capacity development.

The World Development Report 1999/2000 discusses the development landscape of the first years of the 21st century (World Bank 2000). The discussion revolves around two major features of this landscape — globalization and localization. Both have their strengths and drawbacks, but both realities of our changing world have important implications for equity-oriented health research. We discussed the issue of globalization earlier, and the suggestion here is that localization presents some special challenges and opportunities for translating research into action. Strong features of localization include enhanced possibilities for community involvement in planning and local governance; also, local arrangements can be more responsive to needs (those of poor and marginalized groups, for example) and opportunities. This is illustrated in the trend toward increased decentralization as a feature of health-sector reform. However, without local capacity development and resources, decentralization can be frustrating and ineffective.

The health-development field already has a strong tradition of local action, such as the Healthy Cities initiative and Community-Oriented Primary Care. The work of most health NGOs focuses on community-based activities. For many years, WHO has been a champion of district health-system development. So a considerable base of experience is already in place.

How can we strengthen the role of research in local health development? Again, one can draw on some important experience, some of which is described in Chapter 6. The Matlab project in Bangladesh is a long-standing example of this concept (Aziz and Moseley 1997). The Navrongo field site in northern Ghana is another (Binka et al. 1995). Through systematic and sustained demographic and health surveillance, many field-site projects have contributed substantially to health-sector reform (Tollman and Zwi 2000). Several field-site projects in low- to middle-income countries have recently come together to form the International Network for Demographic Evaluation of Populations and Their Health. An Africa-based COHRED initiative is exploring the application of the ENHR strategy in district development (COHRED 1998). The University Partnerships Project (an initiative of the International Development Research Centre) explores the role of academic institutions as partners with communities and local governments in locally relevant health research. It features the active involvement of students (IDRC 1991).

The challenge is to greatly accelerate local partnerships in which all aspects of research become integral components of local health-development activities. A strategic focus can be at the district level because in many countries districts are an increasingly important geopolitical entity. Some specific elements of district-based health research are the following:

• Working within a broad development framework (consistent with the concept of health as an integral part of development) — in many cases, this means working directly and intersectorally with district development teams. National human development reports now regularly appear for many countries and provide helpful analyses and information on district development (UNDP 1999).

• Ensuring a strong capacity-building element, including all the elements of the research process, such as problem identification, priority-setting, and research use. This can be part of an ongoing process of problem-solving and district development (TEHIP News 1999).

• Putting a priority on equity-oriented research-to-action projects, including direct involvement of poor and marginalized groups.

People responsible for the mechanisms that coordinate national health research should give special attention to linking national health-research resources to district development. One way of doing this would be to create an inventory of agencies and organizations (including external agencies) conducting projects in particular districts. Some countries have also established training programs for district health managers in such areas as information management, evidence-based planning, and other relevant topics.

My own view is that we are seeing the emergence of a new, much less formal structure of global governance, where governments and partners in civil society, the private sector and others are forming functional coalitions across geographic borders and traditional political lines to move public policy in ways that meet the aspirations of a global citizenry.

— UNDP (1999, p. v)

This was written by Mark Malloch Brown in the foreword to the Human Development Report 1999, soon after he became the new coordinator of UNDP. Under the last challenge of this chapter, we put forward the proposition that building and maintaining coalitions must be a key strategy.

Why this emphasis on coalitions? On reviewing the track record of the initiatives of the past decade, we discovered the pervading and serious criticism that these efforts have been fragmented, uncoordinated, uneven, and unsustained. This is a problem at all levels. The causes of fragmentation and lack of coordination are complex, although most observers agree that they are not primarily technical or conceptual — they are human. Individuals and organizations find it easier to protect their “turf” than to share resources and find it easier to maintain the status quo than to initiate change. But the world around us is rapidly changing, and now many of the problems of 10 years ago are larger and more pervasive.

To be balanced in our assessment, however, we should note the encouraging examples of coalition-building occurring at various levels:

• Copenhagen Plus Five brought together all the relevant United Nations agencies, the World Bank, and the International Monetary Fund to critically review progress on the global goals of social development.

• The last few years have seen an increasing number of global public-private partnerships in the health sector (Buse and Walt [2000a, 2000b] recently described and analyzed these collaborative initiatives).

• COHRED is a mechanism at the global level that responds to the needs of countries attempting to address inequities through health research. Realization of the need for appropriate tools and methodologies for the management of health research at the national and subnational levels has led to a compilation of experiences and lessons learned in various countries.

• At the regional level as well, there are many networks and collaborative arrangements related to health research, such as the Alliance for Health Policy and Services Research. It recently brought together six networks from Africa and Asia, all of them concerned with health-systems and policy research (WHO 2000c).

• At the national level, several national health-research networks or forums have recently been created (some are described in Chapter 6).

As experience with coalitions begins to build, some scholarly studies are becoming available on the various kinds of collaboration and the determinants of their effectiveness. Based on analyses of costs and benefits for participating entities, some of these studies have distinguished various forms of collaboration, such as networks, alliances, consortiums, coalitions, and coordination arrangements (Fowler 1997). Others have offered typologies of partnerships (Kickbush and Quick 1998). The most recent world development report described purpose-specific institutions (a broader term than organizations), which reflects the importance of policies and processes in the new development paradigm (World Bank 2000).

Cooperation among coalition members is essential to allowing for more effective and efficient partnership at several levels. For example,

• A forum where stakeholders with diverse missions, objectives, and modes of operation can talk to each other would promote better understanding and harmonization of activities, thus benefiting all; and

• Collaborative efforts and select initiatives can be launched by those stakeholders with a common interest.

Cooperation is most likely to occur when all stakeholders perceive each other as equal partners and demonstrate mutual respect. Prescriptive, domineering, and imposing views must be avoided, and differences must be reconciled. Efficiency and a common goal should dictate coordination of efforts, and a code of good practice and ethical standards for international cooperation needs to be developed. Lastly, the equity goal should always be kept in focus.

This is not the place to give a detailed analysis of coalitions and their variants. Rather, our intention is to describe the challenge, squarely before us, of doing much better than in the past in sharing information on common objectives, coordinating our efforts (to avoid wasteful duplication), and creating specific joint initiatives (coalitions, partnerships) that benefit all partners.

The following are some suggestions to be considered by national leadership teams:

• Identify coalition-building as a specific “competence,” which can be described in more detail, learned, and assessed;

• Create local (national and subnational) equity-oriented health and development coalitions (as described above), with research as an integral component; and

• Engage in more systematic research on the determinants of effective coalitions and disseminate the results of such investigations.

In the final analysis, the response to the realities and challenges described in this chapter depends on the actions of individuals, those us of who work in one way or another within the global health-research system. And our actions are driven by our fundamental values. The underlying values of this book are equity and fairness — a belief in the worth of every individual and a belief that every person should have opportunities to realize their worth. This book is also about solidarity and collaboration as key requirements for achieving our goal. The goal is clear — to improve the health of all people, using health research as an essential tool. To all of this, we add a note of urgency — the challenges are immense, and there is much work to do. This is the time for renewing collaborative and purposeful efforts to meet these challenges.

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