Course 1: The Importance of Global Health Research

Closing the 10/90 Gap

“Pneumonia, diarrheal diseases, tuberculosis and malaria, when combined, have been estimated to account for more than 20% of the disease burden in the world (mostly in developing countries), yet they receive less than 1% of the total public and private funds which are devoted to health research.”(1)

Only 10% of the world expenditure on health research and development is spent on health conditions that represent 90% of the global disease burden.(2)  This vast inequity between drug research and development and neglected diseases reveals a need to bolster the research capacity in developing countries through international and national collaboration.  Today, various governmental bodies, in partnership with organizations like the World Health Organization, Canadian Coalition for Global Health and Commission on Health Research for Development, are working to address this global health research inequity, commonly known as the 10/90 gap.  These institutions develop solutions to overcome various difficulties, such as lack of financial and intellectual resources, which hamper efforts to build a solid research community.(3) Already there is evidence of success; new drugs and vaccines are increasingly being developed to treat neglected tropical diseases.(4)   

Global Health Research: Creating Knowledge, Expanding Access

Global health research should not only generate knowledge. More importantly, it should lead to action. In particular, research outcomes must guide policy and program development as well as the delivery of health services. Healthcare interventions should be evidence-based and grounded in solid research.

Consider the case study of antiretroviral therapy (ART), which is widely used to treat HIV-positive patients in developed countries. While ART is in high demand in the developing world, transferring this first world technology to a developing country is not easy.  For example, due to lack of health infrastructure, the widespread use of ART may introduce new risks such as viral resistance.  Thus, research must first be conducted to create structured ART programs that can avoid these unintended consequences.(5)

Moreover, scaling up ART in developing countries is a tremendous project in which success is ultimately dependent on sound research.  For instance, the availability of ART may encourage unsafe sexual practices in a particular community.  To address this concern, researchers must first try to anticipate the potential social impact of ART.  Furthermore, unanticipated logistical issues may arise, as it may prove difficult to keep track of a large number of patients and ensure that they make their follow-up visits. “One study of patients lost to follow-up in Malawi demonstrated that half the patients who had been lost had died, and of those, 58% had died in the 3 months following their last clinic visit.”(6)  Another unforeseen problem could occur while expanding ART treatment to children—because children’s immune systems are still developing, they may respond differently to ART.(7) In such instances, research is essential in order to foresee negative outcomes and ensure the successful implementation of health programs.

Understanding the Cultural Perceptions of Disease & Healthcare Through Research

Research is also needed in order to take an interdisciplinary approach to global health problems, which are multi-faceted in nature. Health is a broad concept that is influenced by various social, economic and political determinants.  While disease is caused by microorganisms, disease is also linked to certain “inherently global health issues,”(8) such as water shortages, deforestation, greenhouse gas emissions, increasing poverty, financial instability, trade, war and conflict etc. For instance, a singular focus on HIV/AIDS ignores the many other dimensions of the disease:

“The HIV/AIDS pandemic, particularly in Africa, affects several vulnerable groups, particularly women. Poverty, war and conflict, and ecological degradation are all important co-factors. Liberalization, structural adjustment programs, and the aid policies of wealthy nations, which constrain taxation revenue and equitable access to health services, are also determinants. Trade agreements underpinning the HIV/AIDS pandemic relate to intellectual property rights (patents) and accessibility of drugs, as well as the decline in “special and differential” exemptions that poorer countries can invoke to protect their still developing domestic economies to ensure greater growth and fairer distribution of its benefits. No single research project on HIV/AIDS should be expected to incorporate all of these elements. A singular focus on HIV/AIDS, however, obscures the important role of these and other co-factors of inherently global health issues.”(9)

Furthermore, perceptions of disease and healthcare vary with culture. In the developing world, different stigmas may be attached to disease, which in turn may be attributed to a variety of beliefs not commonly held by those in the Western world. Oftentimes, the stigma that accompanies disease is so great that people are unwilling to seek treatment. Therefore, stigma is a barrier to effective healthcare delivery which research seeks to eliminate.

“Although the particular negative attributes a society ascribes to a [medical] condition may vary widely with the culture, there is a common thread of implied moral wrong. The stigmatized individual is seen as an affront to the moral order, one who violates the norm, becoming a public enemy who evokes fear, even fear for one’s life, and hence someone who must be put down – or put out – literally isolated.”(10)

When a cross-cultural medical or public health intervention is to be implemented, research should be conducted to examine the social factors that may impede the delivery of care.(11) Without a sound understanding of a community’s cultural psyche, many health workers find that programs fail despite their best efforts and advanced technologies. To avoid such pitfalls, health workers must conduct research to understand the cultural perceptions of disease in the communities where they serve, and develop culturally-sound approaches to healthcare delivery.

Global Health Metrics

Research is not only needed to uncover best practices and eliminate barriers to care, it is also needed to measure impact.  This is important because unprecedented amounts of resources are invested in public health and healthcare worldwide.(12) Data from 2000 to 2004 showed a continuation of this trend, with donor funding for global health approaching $14 billion in 2004.(13)  Because of the vast amounts of resources going into global health, funders are beginning to demand performance data in return for their financial assistance.  “This global commitment is now coming under intense scrutiny”.(14)  Donors want to know results regarding health and health-system performance in the countries in which they are investing and they want to set goals and standards for those countries to meet. Thus, it is in the mutual interest of the developing and industrial worlds to invest in research for the collection of health information.(15)

“Sound information on financial and human resources invested in health, health interventions delivered to people in need, and the impact of these efforts on people's health is critical for planning health systems, implementing programs, epidemic response, allocating budgets for research and development, monitoring progress, and evaluating what works and what does not.”(16)

The availability of health information to inform decisions can ensure funding and further the efficacy of global health interventions. Research that defines indicators and collects health metrics is an integral part of results-based accountability in global health.  For example, output and outcome indicators enable decision makers and donors to assess progress toward intended goals and best practices.

Outputs versus Outcomes

In performance assessment, outputs are defined as the goods or services produced by programs or agencies and outcomes are defined as the impacts on social, economic, or other indicators arising from the delivery of outputs.(17) Typically, outputs are used to document the amount, quality, or volume of use of the project's products or services.

While outputs are important to track, evaluation needs to focus on measuring outcomes that reveal the extent and kinds of impact the project has on its participants. Impact could be reported in the amount of change in behavior, attitude, skills, knowledge or condition of the target population. For example, an output would be the number of microfinance loans distributed or the number of loans repaid, whereas the outcome would be the number of microfinance participants who have significantly increased their income or risen out of poverty due to the loans.  Similarly, job training programs have an output of the number of people enrolled in the program.  The outcome would be the number of people who were able to get a job due to the training program.  Research is needed to identify both outcomes and outputs in order to identify best practices and ensure funding.

Conclusion

As discussed, global health research is necessary to remove the various social, cultural, and logistical barriers that confound the well-intentioned efforts of many global health programs. Research must focus on concerns raised by developing countries, closing not only the gap in health disparities within countries, but also the gap in knowledge between the developed and developing world.(18) 

Furthermore, research is needed to establish and collect health metrics which are essential for public health action and form the foundation for policy making, planning, programming, and accountability.  Unfortunately, high quality health information is not widely available in developing countries, and outcomes are frequently not measured by organizations.   As the field of global health research continues to grow, these gaps make it clear that student researchers have the potential to make important contributions.

Footnotes

(1) Delisle, H., Roberts, J. H., Munro, M., Jones, L., & Gyorkos, T. W. (2005). The role of NGOs in global health research for development. Health research policy and systems, 3(1), 1-21.

(2) Ibid

(3) Lee, K., & Mills, A. (2000). Strengthening governance for global health research: the countries that most need health research should decide what should be funded.

(4) Norris, J. (2008). Global health research: don't ignore achievements so far. The Lancet, 371(9615), 810-811.

(5) Boulle, A., & Ford, N. (2007). Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges?.

(6) Ibid

(7) Trial Summary." Arrow: Anti-retroviral Research for Watoto. UK Department for International Development & Medical Research Council of UK. 24 Jul 2009.

(8) Labonte, R., & Spiegel, J. (2003). Setting global health research priorities: burden of disease and inherently global health issues should both be considered.

(9) Ibid      

(10) Keusch, G. T., Wilentz, J., & Kleinman, A. (2006). Stigma and global health: developing a research agenda. The Lancet, 367(9509), 525-527.

(11) Ibid.

(12) Murray, C. J., Lopez, A. D., & Wibulpolprasert, S. (2004). Monitoring global health: time for new solutions. Bmj, 329(7474), 1096-1100.

(13) Kates, J., Morrison, J. S., & Lief, E. (2006). Global health funding: a glass half full?. The Lancet, 9531(368), 187-188.

(14) Horton, R. (2005). The Ellison Institute: monitoring health, challenging WHO. The Lancet, 366(9481), 179-181.

(15) Stansfield, S. 2005. “Structuring Information Systems to Improve Health.” Bulletin of the World Health Organization 83 (8): 562.

(16) Esipisu, I. Villagers using bed-nets for wedding gowns. (Apr. 22, 2009). Daily Nation. https://www.nation.co.ke/kenya/life-and-style/horizon/villagers-using-bed-nets-for-wedding-gowns--589592.

(17) McAllister, K. (1999). Understanding participation: Monitoring and evaluating process, outputs and outcomes. Rural poverty and environment working paper series; no. 2.

(18) Ibid.