Improving Health in Developing Countries

International initiatives to combat diseases have proliferated, in some cases dramatically, during the past decade. For example, world spending on HIV/AIDS has increased from $300 million in 1996 to about $5 billion in 2003. President Bush’s Emergency Plan for AIDS Relief alone has promised to deliver $15 billion during the next five years to combat the epidemic.

Initiatives such as the president’s plan are valuable in the fight against HIV/AIDS in that they support and build in-country health infrastructures for prevention, care, and treatment. However, there is an additional and equally important piece of the puzzle that is largely missing: a scientific infrastructure in emerging and developing countries that provides in-country capabilities to respond to health crises.

In many global programs, it is generally assumed that the efforts of donor countries to improve health outcomes in emerging and developing countries will rely heavily, if not exclusively, on the ability of researchers in the industrialized world to identify local, regional, and national needs and to devise strategic plans for implementation. Jeffrey Sachs, director of Columbia University’s Earth Institute, has proposed a global health research facility, akin to a global National Institutes of Health (NIH), to conduct research on high-burden diseases such as HIV/AIDS, malaria, and tuberculosis. However, as with President Bush’s plan, there has been little discussion of the specific need to build in-house research capacity in the emerging and developing countries themselves. It is implied that outside sources would supply the researchers, be able to understand indigenous conditions, and enact appropriate steps to achieve goals.

Supporting emerging and developing country health challenges through science is important. Just as important, though, is to support indigenous empowerment through science. Based on our evaluation experience, we believe that it is primarily through in-country research capacity development that emerging and developing countries can attain long-term solutions to critical health needs. There are several advantages to this strategy.

First, with appropriate inhouse capacity, emerging and developing country researchers, especially when they have effective partnerships with user communities in clinics, government, or elsewhere, can eventually address many of their public health challenges faster, better, and more cost effectively than if they were addressed from the outside. This is because diseases manifest themselves differently in different countries, and their cultural contexts are best understood in the countries themselves. For example, in Thailand, it makes sense to focus research on the sex trade, which is a significant cause of the spread of HIV/AIDS. In Russia, on the other hand, research needs to be focused on issues relating to intravenous drug use, which is the single most important factor in the spread of the disease. Additionally, researchers in the industrialized world cannot understand the sociopolitical conditions as clearly as do researchers in the developing world. Social stigmas, discrimination, and government policies alter the best practices for combating these diseases in different countries. Therefore, having research led by in-country scientists makes it possible to incorporate local, regional, state, and national factors in how resources are best spent.

A second reason for supporting indigenous research capacity is that having such capacity enables researchers to better interact with their counterparts in the industrialized world. This is not a particularly new idea. Experts have recommended systems in which recipient countries submit proposals for actions to combat diseases of interest, rather than having outside entities set priorities and actions. The rationale behind this system is that it would help overcome social and political variability and ensure that actions are most relevant to local conditions and needs. Donor countries could be organized under an international umbrella organization such as UNAIDS, and proposals would be panel-reviewed by independent experts. The panel could recommend projects to donors, establish communications with applicants, and suggest modifications to ideas.

We believe this is a good start. However, if the idea of indigenous researchers applying for aid is meant to overcome local variables that outsiders cannot understand, then could a peer review panel of outside experts overcome this barrier? Facilitating dialogues between the countries and the panels on how to amend proposals may help formulate effective plans, but there is no guarantee. This shows that it is critical to develop local capacity so that researchers have the tools to effectively participate in the dialogue.

Ground-level research capacity is also an important asset when aid is delivered. Reasonably developed research infrastructures can help absorb the aid by applying knowledge of where and how the resources are best utilized. A lack of such a capacity is evident in the struggles of Botswana’s anti-AIDS program, which during the past four years has received $50 million from the Bill and Melinda Gates Foundation and the Merck Foundation. Yet the program has been able to spend only 70 percent of that money, largely because of a shortage of healthcare workers who are culturally and technically competent, as well a lack of clinics, laboratories, and warehouses. In such a case, building a scientific infrastructure could also be a valuable use of funding to help develop prevention programs and the capabilities such as systems for monitoring treatments that are necessary to compliment the health-care infrastructure,.

A third reason for developing research capacity is to help emerging and developing countries to prepare for and respond to future scourges. The example of SARS in 2003 is a case in point. A reasonably well-developed scientific infrastructure in Hong Kong and China helped Chinese researchers work better with the international community as well as conduct research closer to the crisis. China’s SARS Epidemiology Consortium continues to research the disease and has made important discoveries, including tracing the genetic modification of SARS during the outbreak.

It is worth emphasizing that in emerging and developing countries, HIV/AIDS, tuberculosis, and malaria elicit far more financial support than do diseases such as cardiovascular disease, cancer, and respiratory disease. Indeed, according to the Global Forum for Health Research, only 10 percent of the world’s health R&D expenditures are devoted to illnesses that account for 90 percent of the world’s disease burden (known as the 10/90 gap). When heads of state at the G8 Summit in 2000 recognized health as a global challenge, they mostly pledged to help fight HIV/AIDS, tuberculosis, and malaria. No money has been allocated for research on chronic diseases in emerging and developing countries, despite the fact that cardiovascular disease kills more people each year than do HIV/AIDS, tuberculosis, and malaria combined. Empowering emerging and developing countries with indigenous research capacity would help address this inequity as well.

A final reason for supporting indigenous research capacity is the benefit that the donor countries receive: gaining political capital; improving worldwide economic stability; promoting international social and ethical standards for conducting research; obtaining access to unique research cohorts and samples; and last but not least, achieving personal satisfaction. In our work, scientists have often told us that their participation in activities aimed at easing suffering and improving other people’s way of life was one of the most rewarding experiences of their research careers.

A systems approach

As we make the case for nurturing a scientific infrastructure in emerging and developing countries, we are by no means suggesting that parallel academic ivory towers be created. On the contrary, standalone research infrastructures disconnected from societal need might be especially detrimental in resource-poor developing countries. What we propose is a research capacity development model that takes a systems approach and integrates the research and user communities.

Research capacity is traditionally defined as the capacity to identify, plan, and implement research. However, recent literature, as well as our own experience as evaluators of international research programs, shows that it is more helpful to think in terms of interrelated research capacities rather than of capacity as a single overarching characteristic. In other words, it is critical to build not just the capacity for academics to produce scholarly research, but also the capacity for policymakers to use such research for policy formulation and the capacity for physicians and health-care workers to use it to inform their practice. This implies a systems-based approach, where the focus is not just on training or funding researchers in developing countries, but also on providing them with proper equipment and managerial skills and linking them with user communities. We find it helpful to view this system as consisting of four dimensions: human, physical, organizational, and social/governmental, and there are clear examples of programs and initiatives that have been successful in building each of these types of capacity.

Human capacity is the individual skills, creativity, and motivation available for conducting research. There are many ways to build this capacity, such as through partnerships and collaborative research, individual grants to researchers in developing countries, and international training. A major concern, particularly with this last strategy, is the potential for brain drain.

One successful venture in developing human capacity is the AIDS International Training and Research Program (AITRP), run by NIH’s Fogarty International Center (FIC). The program trains individuals via long- and short-term immersion in U.S. universities and in developing and emerging countries themselves. The program makes special efforts to prevent brain drain. In some cases it requires guarantees of post-training employment from trainees’ home institutions, or a written statement from trainees stating their intent to return. Some trainees must return home and complete a certain amount of work before they can obtain a degree. NIH’s recently introduced Global Health Research Initiative Program for New Foreign Investigators is designed to promote reintegration of NIH-trained foreign investigators into their home countries. AITRP also uses in-country collaborators, who are often former trainees, to provide a strong research environment and mentoring for returning trainees. According to published FIC data, the return rate for program participants is 80 percent.

Physical capacity comprises the laboratories, offices, and equipment used in conducting research. Not only is this an obvious prerequisite for much of biomedical research, but it is also an incentive for researchers to return home or to stay in their home country to work. The Wellcome Trust is currently funding a center for population studies and social research at Mahidol University in Thailand. The center will study demographic trends on the border between Thailand and Myanmar, as well as the impact of population migration on public health. Results will be disseminated to policymakers and community leaders.

Organizational capacity includes management, strategies, and decisionmaking that contribute to the research process. These skills are invaluable in helping researchers, clinicians, and program directors in emerging and developing countries use resources effectively, assemble teams, network, and form partnerships. The Danish International Development Agency’s Bilateral Program for Enhancement of Research Capacity in Developing Countries has addressed the issue of organizational capital by helping universities lobby to change the registration process for higher degrees, which can add years to the time to completion.

Social/governmental capacity is the economic, social, and political support that is a prerequisite to research. In order for research infrastructures to be sustainable, the research must be valuable to outsiders. This ensures that the indigenous user communities will consider results and be financially supported by government and nongovernment organizations. Projects sponsored by the UN Development Program/ World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases (TDR) have secured this type of support. For example, in 1978, TDR gave an institutional strengthening grant to researchers at Ibadan University in Nigeria. During the past 25 years, the research group has flourished into a sustainable laboratory with links to local hospitals, the Nigerian Ministry of Health,

U.S. institutions, and other Africaninstitutions. Current work includes research on antimalarial drugs as part of the Multilateral Initiative on Malaria in Africa.

These four capacities traverse an ecosystem that includes research-producing communities such as universities and research-using communities of healthcare workers, policymakers, and government officials. This multidimensional view of research capacity development highlights that there is no single action that can lead to success. Rather, building research capacity is a long-term process that necessitates a collection of action steps at multiple levels.

In our work, we have found that each of these four capacities must be adequately developed in order for the expansion to be sustainable. This does not mean that each donor agency must necessarily develop each of the four capacities independently. It does mean, however, that programs within institutions and across donor organizations must partner to ensure that each of these capacities is sufficiently present to be sustainable. The research capacities that must be built will vary largely by country and region, and new initiatives must capitalize on and build bridges between existing capacities and programs to maximize resources. There is no one size fits all solution. However, the above examples of existing research capacity-building efforts and the emergence of large philanthropic efforts show that the potential exists for tremendous synergies and groundbreaking achievements.