Executive Summary

reviews the efforts undertaken over the past

Background few years in this field, particularly since the
2000 Bangkok Conference on Health
Research and Development.
The Global Forum for Health Research was
established in 1998 to help correct the 10/90
Chapter 4 reviews the progress made in the
gap in health research, the fact that only about
field of priority-setting methodologies,
10% of funding is targeted to the diseases
including the recent applications of the
which account for 90% of the global disease
"Combined Approach Matrix".
burden. The human and economic costs of
such misallocation of resources are enormous,
Chapter 5 gives an overview of research
particularly for the poor. In pursuit of this
priority areas.
central objective, the Global Forum has
adopted the following strategies:
Chapter 6 summarizes the most recent
information on the public and private
• support to public and private sector
resources invested in health research
networks/partnerships focusing research
worldwide and recommends activities to be
efforts on diseases representing the heaviest
undertaken under a second phase.
burden on the world's health;
• support to better priority-setting
Chapter 7 draws attention to the urgent need
methodologies;
for making further progress in the crucial field
• the organization of an Annual Forum
of research capacity strengthening in low-and
meeting;
middle-income countries.
• dissemination of findings; and
• measurement of results.
Finally, Chapter 8 reviews the results of the
efforts to build networks and partnerships in
The 10/90 Report on Health Research 2001-
some of the priority areas recommended in
2002 is the third report of the Global Forum
Chapter 5.
for Health Research summarizing the efforts
undertaken by a wide variety of actors in
helping to correct the 10/90 gap. Some of
these efforts were supported by the Global
Forum for Health Research, others were not.

Chapter 1 draws attention to the central role

of health and health research for
development, the fight against poverty and
global security.

Chapter 2 gives an overview of the objective,

strategies and activities of the Global Forum
for Health Research since its inception in
1998.

Chapter 3 explores the rationale for the

so-called "health research governance" and

Executive Summary xiii

 • build social safety nets;
Chapter 1: Health research, • increase the effectiveness of foreign aid;
health, development, poverty • focus on country-level efforts and capacity
and global security strengthening, particularly in the sector of
health and health research;
• develop partnerships in the promotion of
Chapter 1 draws attention to: global public goods, particularly in the
• the central importance of health for field of health;
development • revisit the global, national and local budget
• the central importance of health for the allocations;
fight against poverty • develop the political will and the
• the central importance of development and empowerment of the people.
a reduction in poverty for global security,
and The role of research is to ensure that the
• the central importance of health research measures proposed above are based as far as
for health. possible on evidence, so that the resources
available to finance these measures are used in
At the country level, poor health tends to the most effective way in the fight against ill
increase poverty in two ways: (a) indirectly, health and poverty. Health research can be
through its negative impact on growth and made more effective by taking the following
development; (b) directly, through the vicious measures:
circle of poverty, i.e. malnutrition, disease,
unemployment or underemployment, low • help correct the 10/90 gap in health
income, poor housing, low level of education, research, by reallocating some health
low productivity, no access to clean drinking research funds from lower- to higher-
water, no access to health care services, larger priority projects, from projects benefiting
number of children, unwanted pregnancies, the few to those benefiting a large
substance abuse. In addition, the poor are proportion of the world's population;
more likely to suffer as a result of degradation • increase overall funding for health research;
of the environment and discrimination. • improve the efficiency of health research
funding;
Once trapped in the vicious circle of poverty, • improve collaboration between the various
the chain of causality is very difficult to break. actors by developing partnerships;
In order to do so, the following measures have • decrease the isolation of research and
been recommended: increase its impact on people's health.
• revisit the functioning of the public and In conclusion, good health is central for (a) the
private components of the primary health promotion of development; (b) the fight
care system; against poverty; and (c) global security. This is
• create employment at low cost per job; not surprising, as good health (and education)
• look at poverty and poor health from a are key to building up the human capital which
gender perspective; is necessary for the efficient creation and use of
• support and ally with the civil society the physical capital of a nation. In turn, health
organizations (CSOs); research is central for the efficient and effective
• undertake multidisciplinary actions promotion of health. But it must be made more
(environment, education, water supply, effective and brought out of its ivory tower.
etc.);

xiv
 • the organization of an Annual Forum
Chapter 2: An overview of the meeting;
Global Forum for Health • dissemination of findings; and
Research • measurement of results.

Correcting the 10/90 gap constitutes a major

Health research is essential to improve the contribution to growth, development and the
design of health interventions, policies and fight against poverty. Correcting the 10/90
service delivery. Every year more than US$70 gap is possible, but requires the individual
billion is spent worldwide on health research and concerted efforts of thousands of
and development by the public and private institutions. The Global Forum works as a
sectors. An estimated 10% of this is used for catalyst to spur such efforts.
research into 90% of the world's health
problems. This is what is called 'the 10/90 gap'.

The Global Forum's central objective is to

help correct the 10/90 gap by focusing
research efforts on diseases representing the Chapter 3: Governance of health
heaviest burden on the world's health and research
facilitating collaboration between partners in
both the public and private sectors. A
reallocation of one per cent of research Much has been said and written in recent
spending would provide US$700 million for years about “health research governance”.
priority research. This term may cover different concepts for
different persons or institutions, ranging
The Global Forum believes that solutions to broadly from formal coordination agreements
current health challenges will depend on the between a limited number of institutions to
strength of the partnerships created between informal collaborative principles discussed and
governments (policy-makers), multilateral gradually agreed upon by a widening circle of
and bilateral development agencies, institutions at the global, regional and
international foundations, civil society national levels. These arrangements of very
organizations (CSOs), women's organizations, different nature are often referred to as
research institutions, private sector partnerships. The sum of these partnerships at
companies and the media, which are all the global, regional and national levels can be
partners in the Global Forum. referred to as the system of health research
governance.
The strategies of the Global Forum include
the following: The objective of this chapter is to:
• support to public and private sector • explore the rationale for the so-called
networks/partnerships focusing research “health research governance”;
efforts on neglected diseases; • review the main recommendations made
• support to better priority-setting over the past ten years in this field (by the
methodologies (including a “combined 1990 Report of the Commission on Health
approach matrix”, measurement of Research for Development, the 1996
resource flows into health research, cost- Report of the Ad Hoc Committee on Health
effectiveness analysis and burden of disease Research, the 1997 Advisory Committee on
measurement); Health Research, and, in particular, the

Executive Summary xv
 2000 International Conference on Health governance. The overall health research
Research for Development in Bangkok); governance should ideally be the result of a
• review the efforts since the Bangkok bottom-up approach starting at the national
Conference. level and relayed by the regional efforts. With
the thousands of sovereign and autonomous
Section 1 concludes that the need for health institutions involved, the efforts could focus
research partnerships and governance is real on a set of collaborative principles which
for a number of reasons: first, the magnitude could contribute much to the allocation of
of the problems to be solved is such that they health research funds to the priority public
are beyond the capacity of any single health needs.
institution to resolve and require the
concerted efforts of a coalition of partners;
second, provided they are well managed, the
benefit-cost ratio of joint undertakings may be Chapter 4: Progress in priority-
very high; third, partnerships can help ensure setting methodologies
an interdisciplinary approach to a problem;
finally, partnerships can play a significant role
in helping to correct the general under- Priority setting is as critical as conducting the
investment in global public goods, as partners research itself. Yet there is no simple way to
identify the benefits accruing to them as a set priorities. Failure to establish a process for
group. this has contributed much to a situation in
which only about 10% of health research
Sections 2 and 3 review the recommendations funds from public and private sources are
made since 1990 in the field of “health devoted to 90% of the world’s health
research governance”. problems.

Section 4 reviews the efforts undertaken since This chapter reviews progress in the
the 2000 Bangkok Conference in this sector, development and implementation of priority-
in particular at the country level (for example setting methodologies developed since the
with the creation of the Tanzania National 1990 Commission on Health Research for
Health Research Forum or the ENHR efforts Development. Three important changes have
undertaken by COHRED), at the regional been observed in health research management
level (with the planned African Health since the work of the Commission: (i) there is
Research Forum, the planned Asian and a better understanding that health research
Pacific Health Research Forum and the can play a crucial role in policy decisions;
preparatory meetings held in Latin America (ii) there is a better recognition of the need for
and the Caribbean), and at the global level a sound scientific basis for selecting the topics
(preparation of the planned 2004 World to be researched; and (iii) the lack of
Health Research Summit). These partnerships methodologies to select and recommend
and forums can be considered as the building research priorities have stimulated the pace of
blocks of the overall health research development of these tools and processes in
governance system, as each partnership can recent years.
make a contribution to the better allocation
of the resources invested in health research. In an attempt to differentiate between the
process of priority selection and the tools
Finally, Section 5 draws some preliminary used for that purpose, the chapter reviews
conclusions on the future of health research progress in both approaches.

xvi
Process: Priority setting must include a • Communicable diseases not prevalent in
multidisciplinary and participatory process. the high-income countries continue to
Progress in the Essential National Health account for a large share of disease burden
Research (ENHR) process conducted by in lower income countries.
countries supported by COHRED is reviewed, • Vaccines developed for industrialized
at both country and regional levels. At the country markets may not be effective
country level, progress has been achieved in a against the different types of viruses and
number of countries by ensuring broad bacteria prevalent in poorer countries.
participation in the identification of research • Determinants of ill health can vary greatly
priorities. Similarly, regional networks have between regions.
been strengthened to contribute to this process. • Performance of health systems and services
vary greatly between countries.
Tools: Progress has also been made on priority- • Access to treatment and medicines is very
setting methodologies and tools. The strength different between and within countries.
of the five-step approach (which is part of the • Interventions for noncommunicable
Global Forum Combined Approach Matrix for diseases available in more advanced
priority-setting) lies in its ability to relate countries may not be directly adaptable,
research on burden of disease with appropriate or cost-effective in lower
determinants, cost-effectiveness and financial income countries due to costs and
flows. Problems with these methods and infrastructure requirements.
potential ways to solve them are reviewed.
Therefore, the 10/90 gap in health research
The chapter also describes practical remains a reality and prioritization in health
experiences in the use of the Combined research funding at the global and national
Approach Matrix applied in the priority-setting levels an absolute necessity if we want the
exercise conducted by the TDR Programme in limited health research funds to have the
WHO. The tool was used and modified to be greatest impact possible on the level of world
part of an exercise for priority setting in that health.
programme. The chapter provides instructions
on how to make use of the tool. In addition, it Section 2 underlines that priorities in health
describes for the first time the application of research have traditionally been formulated in
the Combined Approach Matrix to identify terms of diseases and conditions. It is now
research priorities for one of the important realized that this is only one dimension of
determinants of disease burden (indoor air health research and that health determinants
pollution). themselves have to be prioritized and are
competing for the same funding as disease-
focused priorities. But, to make things more
difficult, there are at least two more
Chapter 5: Priorities in health dimensions to health research which have
research to be prioritized against the others, i.e.
methodologies for priority-setting and cross-
cutting issues in health research, such as
Section 1 of this chapter revisits the concept policies, poverty and health, gender and
of the 10/90 gap and concludes that the direct health, and research capacity strengthening.
transferability of findings from high- to low-
and middle-income countries is limited due It is therefore proposed that the prioritization
to the following factors: exercise in health research take into account

Executive Summary xvii

 all four dimensions mentioned above, i.e.:
Chapter 6: Monitoring financial
1. Research on diseases and conditions flows
2. Research on proximate determinants and
risk factors
3. Research on priority-setting methodologies Tracking financial flows into health research is
4. Research on policies and cross-cutting key to identifying the degree of funding for
issues affecting health and health research. priority research and for the analysis of the
10/90 gap. Yet, the information on health
Section 3 reviews key recommendations made research financing is very fragmented.
in the past 12 years regarding research
priorities on diseases and conditions and The Commission on Health Research for
concludes that there has been very broad Development drew attention to the importance
consensus in these recommendations around of health research as the “essential link to
the following conditions with the highest equity in development” and recommended that
levels of morbidity and mortality but very low governments in low- and middle-income
levels of investment: acute respiratory countries review their current spending on
infections, diarrhoeal diseases, cardiovascular health research and strive to meet
diseases, mental health, tuberculosis, tropical recommended goals (2% of national health
diseases, perinatal conditions and HIV/AIDS. expenditures and 5% of foreign aid in the
Of the 1233 drugs that reached the global health sector). Since most low- and middle-
market between 1975 and 1997, only 13 were income countries were not actively tracking the
for tropical infectious diseases that primarily pattern of spending on health research, it was
affect the poor in low- and middle-income difficult to know how close they were to the
countries. Given this consensus, the focus target and what trends were occurring over
should now be shifted to the identification of time. One major obstacle was the lack of tested
priorities within each of these diseases. This is methodologies for monitoring spending on
discussed in Chapter 8. health research at the country level.

Section 4 reviews key recommendations made Beginning in 1999, the Global Forum for
in the past 12 years for research priorities on Health Research supported efforts to develop
determinants and risk factors. It concludes and implement a system for tracking and
that broad consensus also exists around reporting investments in health research. This
priorities in determinants. For details on chapter aims to provide a summary of the first
priorities within some of these determinants, see results of this project and the progress with
Chapter 8. the methods developed.

Dimension 3 (research on priority-setting The study did not attempt to do a

methodologies) is reviewed in Chapters 4 comprehensive review of all high-, middle-
and 6. and low-income countries' investments in
health research. The total figure for
Finally, dimension 4 (research on policies and worldwide investments into health research
cross-cutting issues) is discussed in Chapter 1 was estimated to be about US$73.5 billion for
(poverty, gender), Chapter 7 (research capacity 1998 from both the public and the private
strengthening) and Chapter 8 (research sectors combined, as compared to an
on policies and systems, public-private estimated US$56 billion in 1992 (in current
partnerships, genomics and health). terms). Governments in high-income

xviii
countries, countries in transition, and low- health of the majority of the world’s
and middle-income countries invested at population, a global public good, are not clear
least US$37 billion (50%), and the and have yet to be documented.
pharmaceutical industry US$30.5 billion
(42%). Private, non-profit and university
funds provided the remaining US$6 billion
(8%). It is estimated that about one-third of Chapter 7: Progress in research
the increase between 1992 and 1998 is in real capacity strengthening
terms. While none of the low- and middle-
income countries studied matched the 2%
figure recommended by the Commission for Health research is increasingly recognized as
Health Research and Development, Brazil one of the driving forces behind development.
and Cuba were quite close to that level of Over the past two decades, there has been
investment in 1998. considerable investment in research capacity
strengthening (RCS) in lower-income
This study proposes a classification method countries. However, this has not been
based on the Frascati family of manuals which matched by efforts to evaluate the outcome
can be used to incorporate information from and impact of this investment in RCS. This
low- and middle-income countries, countries kind of evaluation is critical for identifying
in transition and high-income countries. The best practices, highlighting constraints,
classification suggested here distinguishes justifying further investment in this area and
between the following five categories: providing guidelines for future development.
This chapter focuses on the need for
(a) non-oriented, fundamental research; evaluation of the outcome and impact of RCS,
(b) research into health conditions, diseases starting with a review of the factors critical to
or injuries (classified by disease); success in RCS and the major challenges
(c) research into exposures, risk factors that identified, and continuing with a review of
impact on health (determinants); work done during 2000-2001. Most
(d) health systems research; evaluations so far have focused on measuring
(e) research capacity building. inputs, process and some outcomes of RCS in
a number of lower-income countries. Critical
The chapter describes obstacles encountered issues which RCS evaluation needs to address
in data collection and gaps identified. It include:
also reviews the usefulness of various data
sources for the measurement of resource flows • the extent to which policy-makers
for future exercises. Activities for a second commission research to provide evidence
phase of resource flows measurement for decision-making
incorporating a large number of institutions • use of national scientists by policy-makers
are recommended. for research to meet national needs
• the extent to which research findings are
During the late 1990s and early 2000s, there used for disease control in the country
has been greater involvement of national • the extent to which research results are
research institutions, foundations, CSOs and translated into policy
the pharmaceutical industry in international • the evolution of the national budget for
health. This translated into an increase in research capacity development
investments in health research globally. The • impact of research capacity strengthening
implications of this transition to improve the on the country’s health situation.

Executive Summary xix

 The chapter ends by calling for more studies in A. Networks focusing on diseases and
these critical areas, particularly of the impact conditions
of RCS on health research and its role in Section 1. Global Alliance for TB Drug
correcting the 10/90 gap. Development
Section 2. HIV/AIDS
Section 3. Initiative for Cardiovascular
Health Research in Developing
Chapter 8: Some networks in the Countries
priority research areas Section 4. Multilateral Initiative on Malaria
Section 5. Medicines for Malaria Venture
Section 6. Mental Health and Neurological
The chapter reviews some of the priority areas Disorders
recommended in Chapter 5, describing the
size of the problem and the results of efforts to B. Networks focusing on determinants
build networks which focus on these priority (risk factors)
areas (including their objectives, partners, Section 7. Reproductive Health
governance, strategies and activities). Section 8. Road Traffic Injuries
Section 9. Child Health and Nutrition
Since it would be impossible to review all Research Initiative
research efforts currently under way, this Section 10. Initiative on Sexual Violence
chapter describes the efforts undertaken by Against Women
international networks in only some of the
priority research areas. Some of these efforts C. Networks focusing on priority-setting
were supported by the Global Forum for methodologies (see Chapters 4 and 6)
Health Research, others were not. They are
categorized into the following four groups: D. Networks focusing on policies and cross-
cutting issues affecting health research
Section 11. Alliance for Health Policy and
Systems Research
Section 12. Genomics and Health Research
Section 13. Initiative on Public-Private
Partnerships for Health.

Louis J. Currat Richard G.A. Feachem

Executive Secretary Chair, Foundation Council
Global Forum for Health Research Global Forum for Health Research

xx