In preparation of People's Health Assembly II - part 26
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'The Lancet' piece by PHM:
Pushing the international health research agenda towards equity
and effectiveness
By David McCoy, David Sanders, Fran Baum, Thelma Narayan, David
Legge
Despite substantial sums of money being devoted to health re-
search, most of it does not benefit the health of poor people
living in developing countries-a matter of concern to civil so-
ciety networks, such as the People's Health Movement. Health re-
search should play a more influential part in improving the
health of poor people, not only through the distribution of
knowledge, but also by answering questions, such as why health
and healthcare inequities continue to grow despite greatly in-
creased global wealth, enhanced knowledge, and more effective
technologies.
Previous Editorials in this journal, and other reports, have al-
ready highlighted three important issues. First, that the 10:90
gap-whereby only 10% of worldwide health research funds are al-
located to the problems responsible for 90% of the world's bur-
den of disease, mainly in poor countries-needs to be reversed.
Second, that greater emphasis should be placed on research in
the social, economic, and political determinants of ill health,
relative to clinical and biological research. Third, that the
barriers to the transfer of knowledge from research into policy
and practice need to be overcome.
The 10:90 gap largely represents a funding gap shaped by commer-
cial interests, and inadequate funds being provided through the
public budgets of poor countries, development assistance grants,
charitable foundations, and non-government organisations who
have an interest and a mandate to invest in public or non-
commercial research activities that are orientated towards ad-
dressing the health needs of poor people. Part of the solution
to addressing this overall deficit in funding includes continu-
ing with current efforts to increase development assistance,
hasten the cancellation of unfair debt and reform unjust trade
structures. But we also need creative thinking and bold action
around new proposals, such as raising funds through an interna-
tional authority that is able to effectively tax global corpo-
rate profits, or applying levies against global financial trans-
actions (e.g., the Tobin tax).
With respect to research on the social, political, and economic
determinants of health, we draw attention to three points. The
first is the need for more research into the effects of global-
isation on poor health and growing health inequities, and on the
development of proposals to reform the current global, politi-
cal, and economic institutional order. In addition to research
on more effective mechanisms for global resource redistribution,
research should focus on how health equity can be protected from
the market failures of economic globalisation and the operation
of transnational commercial interests. Second, we want more re-
search applied to the question of why the cancellation of the
odious debt of many poor countries has not been forthcoming, why
many rich countries' development assistance still falls short of
the UN's 0ยท7% gross domestic product target, and why bilateral
and multilateral trade agreements continue to be unfavourable
and even punitive towards the poorest and sickest people. Third,
more research is needed into the design and financing of systems
and basic services and into how these factors determine access
to good quality care and other health inputs (e.g., water and
adequate nutrition). As health systems become increasingly ineq-
uitable and fragmented, research on the drivers and effects of
the liberalisation, segmentation, and commercialisation of
health-care systems is essential. These three points complement
the call for more research on why available and affordable tech-
nology and knowledge are not used, for example, to prevent mil-
lions of children from dying of diarrhoeal disease and acute
respiratory infections. Appropriate research would indicate how
the mainly social and political barriers to application of ex-
isting technologies might be overcome.
This achievement could be aided by country case studies that
combine an analysis of the political economy of poverty and ill
health together with the health systems factors that help or ob-
struct access to effective health care. Such research would
bring together political and social scientists, health econo-
mists, public health professionals, ethicists, and civil society
organisations. To promote the transfer of knowledge from re-
search into policy and practice, several issues should be exam-
ined. Presently, there is a research culture and incentive sys-
tem that encourages researchers to be more concerned with pub-
lishing their results in academic journals than with ensuring
that their research leads to improved policy and practice. Fur-
thermore, policy makers and programme implementers in developing
countries are either sceptical about the value of research, or
do not have the skills to appraise and use new information. The
scarcity of capacity in the public sector has been further ag-
gravated by the steady brain drain of capable health profession-
als to richer countries or from the public sector to the domes-
tic private or non government sectors (including the health re-
search sector).
These difficulties could be overcome by changing the incentive
system and allocating a greater share of health research funding
to academic and non-government research institutions in poor
countries that work closely with policy makers, health managers,
service providers, and communities. This allocation of funding
needs to be complemented with more investment in developing re-
search capacity within the health systems of poor countries.
Research geared towards practical health systems development is
also often qualitatively different from research that is geared
towards the imperatives of academia and the medical industry.
For example, research on the efficacy of interventions in a con-
trolled environment is different from that on the practicability
of applying effective interventions in the real world.
More action research that involves service providers can help to
bridge the gap between research and implementation, and ensure
that research is embedded within the day-to-day realities and
constraints of under resourced health-care systems. The use of
participatory research methods can also help poor communities
shape health systems to meet their needs.
Research findings are also more successfully implemented when
researchers include mobilized citizen constituencies.
Successful implementation is aided first by ensuring a vigorous
community of civil society organisations with a mandate to keep
a watch on health policy development and implementation; second,
by use of research funds to actively foster the capacity of
these organisations to change the commissioning and priority
setting for research; and third, by including civil society or-
ganisations in research production and encouraging partnerships
that link them with academic researchers.
Finally, the imbalance in power between researchers in rich and
poor countries must be bridged. Many academic and non-government
institutions in more developed countries benefit disproportion-
ately from the meagre research funds that are focused on poor
health in developing countries. This imbalance is in a context
where academic and research institutions in developing countries
are struggling to gain their own funding and find it difficult
to retain good staff. Practical ways of addressing the inequi-
ties within the health research community might include mapping
out the distribution of research funds for health problems be-
tween research institutions in rich and poor countries, docu-
menting the obstacles to the development of research capacity in
developing countries and conducting in-depth case studies of the
health-research funding policies and patterns of selected donor
and international agencies.
Global conferences and summits on health research, such as the
two that are due in Mexico this November, by themselves are
unlikely to substantially affect the challenges we present. The
current pattern and use of health research shows the balance of
prevailing global power, perspectives, and interests. Redressing
the imbalance will require consciousness raising, mobilisation,
and pressure at many different points in the global health re-
search system and in health-care systems more broadly. Pressure
for change will need to be exerted at all levels and by many
different actors. The Peoples Health Movement is committed to
being increasingly influential.
[The Lancet: Mexico, 2004: research for global health and secu-
rity. Lancet 2003; 362: 2033].