PHA-Exchange> 26 In preparation of PHA 2

[Claudio]

Pushing the international health research agenda towards equity and effectiveness'The Lancet' piece by PHM:

 

Pushing the international health research agenda towards equity and effectiveness

David McCoy, David Sanders, Fran Baum, Thelma Narayan, David Legge

 

Despite substantial sums of money being devoted to health research, most of it does not benefit the health of poor people living in developing countries-a matter of concern to civil society networks, such as the People's Health Movement. Health research 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 increased global wealth, enhanced knowledge, and more effective technologies.

 

Previous Editorials in this journal, and other reports, have already highlighted three important issues. First, that the 10:90 gap-whereby only 10% of worldwide health research funds are allocated to the problems responsible for 90% of the world's burden 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 commercial 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 addressing the health needs of poor people. Part of the solution to addressing this overall deficit in funding includes continuing 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 international authority that is able to effectively tax global corporate profits, or applying levies against global financial transactions (eg, 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 globalisation on poor health and growing health inequities, and on the development of proposals to reform the current global, political, 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 research 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 0·7% 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 (eg, water and adequate nutrition). As health systems become increasingly inequitable 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 technology and

knowledge are not used, for example, to prevent millions 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 existing 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 obstruct access to effective health care. Such research would bring together political and social scientists, health economists, public health professionals, ethicists, and civil society organisations. To promote the transfer of knowledge from research into policy and practice, several issues should be examined. Presently, there is a research culture and incentive system that encourages researchers to be more

concerned with publishing their results in academic journals than with ensuring that their research leads to improved policy and practice. Furthermore, 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 aggravated by the steady brain drain of capable health professionals to richer countries or from the public sector to the domestic private or non government sectors (including the health research 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 research 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 controlled 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 organisations 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 disproportionately 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 inequities within the health research community might include mapping out the distribution of research funds for health problems between research institutions in rich and poor countries, documenting 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 research 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 security. Lancet 2003; 362: 2033].

 

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