Key Recommendations
The priority-setting process should focus initially on defining a small number of key priorities that have a reasonable chance of succeeding and yielding cost-effective outcomes in resource-constrained environments and that are, thus, least likely to divert limited resources from being more effectively directed elsewhere. Five broad recommendations emerge from this chapter.
Invest More Wisely in Health R&D
The focus should be on how best to invest limited resources for health R&D. This approach raises hard questions about selecting priorities and the extent to which the burden of disease and scientific opportunity to play a role. A telling example of the dilemma may be a vaccine against bird flu. Because bird flu, A (H5N1) or other strains, is not yet a major human disease, the setting of priorities by the disease burden criterion would not accord a bird flu vaccine high priority. But knowing that between 20 to 40 million people died in the 1918 influenza epidemic, and that with a transmission time of 1.5 days, there would be few public health measures other than a vaccine that would make a difference in preventing a pandemic, developing and testing multiple candidate vaccines should be an urgent research priority.
Despite the paucity of past analysis of the relationship between the cost of research in an area and its success in improving the level of health, the amount invested is unlikely to have been the most important determinant of success. The What Works Working Group has developed 17 case studies of success stories, all of which were supported by public finance mostly in resource-constrained settings (Levine and What Works Working Group 2004). A review of lessons learned from the 20 biggest research successes in improving health in low- and middle-income countries would be a worthwhile undertaking.
Shift the Paradigm for Priority Setting
The paradigm shift from dividing the world's health problems into those of the industrial countries and those of the developing countries toward creating a better understanding of the commonality of health problems between the industrial and most developing countries lies at the core of priority setting for global health research. Implicit in this shift is the recognition that the health problems of Sub-Saharan Africa are urgent and require special emphasis on the devastating burden of infectious diseases, particularly HIV/AIDS, and on the need to develop effective infrastructure for health. In time, the expectation is that the health needs of most Sub-Saharan African countries will similarly converge with those of other regions of the world and that knowledge developed in these regions will be transferable and helpful to accelerating development there.
As sociologists have long recognized, scientific and medical technology diffuses from the industrial to the developing countries, and it will, in the short term at least, increase the disparities between rich and poor countries—and perhaps to a comparable extent between the rich and the poor within countries—because more affluent and better-educated populations tend to have greater access to new technologies. However, even though disparities in health between affluent urban dwellers and poor rural populations in China and India have increased over the past decade, the overall quality of health of the entire population has increased during the same period. The hope is that information derived from research will be a great leveler over time and will contribute to reducing global inequities.
The shift in thinking in relation to the convergence of health burdens and research opportunities in both industrial and developing countries has far-reaching implications for the formulation of research priorities. In addition to emphasizing the commonality of health problems, it also emphasizes the importance of stronger global research collaboration in tackling major health problems and underscores the need for much stronger public-private partnerships to ensure that affordable drugs and vaccines will be developed and made available in resource-constrained environments.
Maximize the Potential of Information Technology
No advances in science have more potential for improving health globally than the information and communication sciences. At the scientific level, the ability to handle increasingly massive amounts of data, whether from genetics, epidemiology, or clinical trials, offers the opportunity to mine the world of knowledge in ways that could not be contemplated a decade ago. Knowledge can be transferred instantaneously through the Internet; through access to open databases; and through the new public libraries of science and medicine, such as the U.S. National Library of Medicine PubMed Central. With information technology, procedures can be put in place to minimize medical and pharmaceutical errors and to provide greater accounting for medical costs and outcomes. Finally, research with partners in many parts of the world can now be carried out in real or in lag time, as in the case of clinical research on malaria (Royall and others 2004). The tools, hardware, and software for this informatics revolution must be made available as widely as possible to universities and health systems in developing countries.
Increase Global Research Capacity
Research capacity continues to limit the successful implementation of those interventions most needed to improve health in resource-constrained environments. The number of people trained to carry out the surveillance and the laboratory and operational research that are so essential to the successful implementation of cost-effective interventions remains woefully inadequate. Redressing this limitation is a daunting task that will require substantial financial investment and creative approaches to create conditions that will reverse the brain drain and strengthen academic and research institutions in developing countries.
Create a Global Health Architecture
Health is not the sole provenance of the health sector, and yet there is no forum or architecture for coordinating the increasingly important multisectoral interactions to improve health.
Cardiovascular and pulmonary disease in Europe and the United States are increasingly determined by China's energy sector, and global warming is impacted by the policy of the U.S. President. Health is critically affected by education, energy, transport, finance, trade, immigration, communication, and the environment. Major health problems will be most successfully addressed if partnerships can be developed between sectors, governments, NGOs, business and industry, and academe.
Support Freedom of Scientific Inquiry
No country has a monopoly on ideas, and every country has something important to contribute to knowledge about health. The universality of science requires that scientists everywhere strive for the highest level of rigor and quality and that every country have some sustainable level of scientific research and problem-solving capacity. Encouraging and supporting scientists with the ability and passion to contribute to knowledge about health, globally or locally, must become one of the key aims of the global health and development agendas.
Notes
1. Obviously, nonrivalry does not pertain to knowledge that is proprietary, as in the pharmaceutical industry, although the system of patents was created to make such enabling knowledge available to all by providing a limited monopoly for its exploitation by discoverers or inventors.
2. For this formulation, we are indebted to Suwit Wibulpolprasert, deputy permanent secretary of the Ministry of Health, Thailand.
