Strengthening governance for global health researchBMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7264.775 (Published 30 September 2000) Cite this as: BMJ 2000;321:775
The countries that most need health research should decide what should be funded
- Kelley Lee, senior lecturer in global health policy,
- Anne Mills, professor of health economics and policy
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT
Education and debate p 813
As experts from around the world gather in Bangkok to attend the international conference for health research for development and to ponder the challenge of strengthening this research, they face a monumental task. About $56bn (£37.3bn) per year is spent worldwide on health research by both the public and private sectors; this is more money than ever before.1 Yet far more could be done both to increase the amount spent and to improve how funds are used. The Global Forum for Health Research, one of the sponsors of the Bangkok conference, estimates that less than 10% of research funds are spent on the diseases that account for 90% of the global burden of disease. This gap is now widely quoted as epitomising the inequitable nature of health research. The consequences of this gap are profound: diseases affecting large proportions of humanity are given comparatively little attention. Similarly, simple and low cost technologies, appropriate for use in settings with few resources, are undervalued and hence inadequately researched.1
Much of the problem lies in how health research is governed. Governance of health research concerns the means and rules by which relevant stakeholders set and achieve their agreed research goals. This includes decisions about what kind of research should be supported, by whom, and for what ends. How good the governance of health research is can be assessed by criteria such as representativeness, transparency, and accountability.2 Achieving good governance of health research is essential for ensuring research is ethically conducted, relevant to the people who it is targeted for, and of recognised scientific quality.
The state of global health research suggests that too often governance is not good. Imbalances in financial and intellectual resources between the wealthy and poor have contributed to the latter being the subject of health research that primarily benefits the former. How ethical is it to test drugs for AIDS in countries that cannot afford these treatments?3 Another challenge is that the competitiveness of medical research can hamper collaborative research.4 Money for research into tropical medicine usually comes from funding bodies such as North American and European governments, foundations such as the Wellcome Trust and the Bill and Melinda Gates Foundation, and international agencies such as the World Health Organization's tropical diseases research programme. Each funding body tends to favour commissioning research themselves, rather than supporting research initiated by investigators; this makes it hard for some countries to set their own research priorities. Although there have been some efforts to improve coordination, for example through the multilateral initiative on malaria that tries to promote collaboration in the research community, most research relations are vertical—that is, they exist between research groups in a particular country and research groups or funders in the developed world. There is little horizontal interaction between research groups within countries.5 It is difficult to scrutinise the quality of funding decisions because of poor data on how much money is spent worldwide, by whom, and for what purposes.
A second area of concern is the role of research in health policy making as a whole. Research should have an important role in the policy process, providing the evidence for identifying issues and prioritising them, laying out the options for addressing policy problems, and feeding back the appropriateness of those decisions. Health research is thus a central component of effective health governance.
In developing countries the ability of national institutions to produce and use high-quality health research that is appropriate to their own needs can be weak at every stage of the policy process as described by Sitthi-Amorn and Somrongthong in this issue (p 813).6
Financial and technical support from donors to train and retain national researchers in these countries, and to build up research institutions where researchers can ply their trade, remains woefully inadequate. Without such support, developing countries will continue to struggle to define their own needs and to contribute meaningfully to research that meets those needs. This matters for global health because understanding the health needs of poorer communities is critical to the collective good of health worldwide. Health research is the starting point for achieving such an understanding.
It is on this basis that a new approach to global health research could be initiated in Bangkok. Developing countries should not be seen as recipients of charitable handouts but as partners in producing health research that is of a high quality and tackles major problems such as health inequalities, infectious diseases, and changes in the environment.7 Such an approach should begin with larger scale commitments by funding bodies to train researchers in developing countries in areas ranging from basic to applied research. Investment in research capacity would need to be made for the middle to long term, and it should be better coordinated and strategically deployed, should be programme based rather than project based, and should make a more serious commitment to building local, national, and regional institutions. What must be different, above all, and no doubt will be most difficult for funding bodies to accept, is the need to at least share the driver's seat when it comes to making decisions. From this starting point, the governance of health research would need to be very different.