Research and Development
Why has health improved so dramatically after controlling for income and, hence, the availability of commodities that, like food, are essential for health? Although no unambiguous answer to this question exists, an important factor has been advance in scientific knowledge and its application both in creating powerful interventions and in guiding behavior. Acquisition and use of health research and development or its products becomes, then, an essential function of a country's health system. Moreover, it is important that research extend beyond development of new products to encompass knowledge generation on health system financing and performance.
Much knowledge is embodied in global public goods: once a vaccine against hepatits B has been developed anywhere, it becomes, in some sense, available everywhere. Although monopoly pricing made possible by patents may slow the diffusion of some innovations, the temporary nature of patent-induced monopoly pricing limits that effect. However, an innovation's being cheap, powerful, and globally available in no way assures its global use. The implication is clear: globally available knowledge and products offer enormous opportunities to countries, but national policies and national health systems determine whether that knowledge is put to local use. Additionally, although some information for improving outcomes is principally local and must be locally produced, making the results available contributes to a growing evidence base. Chapter 4 on health research stresses the value of contributing to a global evidence base and summarizes with the observation that "all health care is national" and "all health research is global."
What are the implications for policy? One is that if knowledge gains prove even partially as important for future health improvements as they have in the past century—and chapters in this volume point to a number of reasons for expecting this to be so—then investments in health research and development will continue to have high payoffs in health status and economic productivity. Chapter 7 points to the potential for enormous economic returns. Ensuring an adequate level of research and development investment, therefore, holds strong claim on health budgets—a claim for more than the approximately 3 percent now committed. Equally important—or more important—is that the investments be efficient in generating useful new knowledge and products. Fauci (2005) discusses the need for greater efficiency in conducting research and development in an environment of tightening budgets in U.S. agencies, and he points to a number of specific directions for doing so.
In some cases, additional resources (probably from growth within national health budgets or health aid budgets) will be required to meet these research and development needs adequately. In many cases, institutional change will be necessary to create the information and incentives required for efficient resource allocation. At the international level, resource allocation has often lacked focus, failing to bring results to the point of application, and has neglected important conditions and issues while providing, often generously, for less important ones. Reform is needed. Successful models of competitively driven international funding and experience-sharing networks should be applied to currently neglected clusters of conditions.
Just as the quality and productivity of research efforts vary dramatically from one institution to another within the high-income countries, they vary in the low- and middle-income countries. Exemplary work is done in a number of institutions and countries; but in general, the obstacles to high quality are greater when countries' incomes are lower. Inadequate training, insufficient staff motivation, and lack of competition prevent many institutions from attaining their potential. The instability of short-term funding, isolation from peers, and poor access to the research literature all compound the problem and prevent researchers from responding rapidly to ever-changing demands. Given the shortage of good researchers, an argument exists for the talent to move to countries (including low- and middle-income countries) whose policies are likely to facilitate productive research (WHO 1996). Donor funding should reflect this possibility.
Institutions are more likely to succeed not only if they receive stable core funding but also if a proportion of their work is funded competitively. Some institutions, such as the Oswaldo Cruz Foundation in Brazil, have already moved in these directions with great success—for example, by freeing up intramural resources for competitive allocation between groups and within the institution, with assessments being made by an external review group. Notable successes have occurred in assisting with capacity strengthening, such as the Special Programme for Research and Training in Tropical Diseases collaboratively supported by WHO, the World Bank, and the United Nations Development Programme.
The failure of current incentive structures, essentially the patent system, to produce health products for the lowest income groups demands remedial action (chapter 5). In essence, either the public sector must harness the skills, energy, and capacity of the private sector to develop and bring promptly to market products for the lowest income groups, or it must take responsibility for doing so itself. In reality, a combination of the two is likely, as is exemplified in successful public-private partnerships such as the Medicines for Malaria Venture or the International AIDS Vaccine Initiative. Recently proposed pre-commitments by the public sector to purchase specific new products are an additional potential instrument to generate incentives for private sector investment (Kremer and Glennerster 2004). Developing countries that participate in private sector innovation will be positioned to more quickly learn of and have access to the technical progress that is critical in driving health improvements.
Global challenges demand, in some sense, a global response. All nations share the fruits of research and development. Even though each country may invest a relatively modest sum toward collective goals, the aggregate effort potentially benefits all substantially. Collective action is the economically rational approach to public goods such as research and development; here, responsibility for catalyzing collective action lies principally in the hands of the global community. Far from overshadowing action at the national level, global efforts help both to make national research and development efforts more productive and to lead to a global result that exceeds the sum of national ones. Thus, among the many competing demands on the funds allocated to international assistance for health, those contributing to generation of new knowledge, products, and interventions that can be shared by all have special merit.
