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Global Forum Update on Research for Health Volume 5 � 023

Innovating for healthand development

024 Research and innovation in Brazil: the institutional role of the Ministry of Health Suzanne Jacob Serruya with Reinaldo Guimarães, Itajai Oliveira de Albuquerque and Carlos Medicis Morel

030 Health markets and future health systems: innovation for equity Gerald Bloom with Claire Champion, Henry Lucas, M Hafizur Rahman, Abbas Bhuiya, Oladimeji Oladepo and David Peters

036 Strengthening the base: innovation and convergence in climate change and public healthSaqib Shahab with Abdul Ghaffar

041 Global health diplomacy – a bridge to innovative collaborative action Thomas E Novotny and Ilona Kickbusch with Hannah Leslie and Vincanne Adams

048 Hideyo Noguchi Africa Prize Kiyoshi Kurokawa with Tamaki Tsukada and Eri Maeda

054 Health research and innovation: recent Spanish policies Flora de Pablo with Isabel Noguer

059 The changing landscape of research for health Kirsten Havemann with introduction by Ulla Tørnæs

066 Global health and the foreign policy agenda Jonas Gahr Støre

072 “Policies for innovation”: evidence-based policy innovation – transforming constraints into opportunities Miguel Angel González Block

23 Title page:GF5 22/10/08 14:04 Page 23

During the course of the last century, public policieswith a focus on technological innovation have shownthe importance of this issue for the governmental

agenda of several countries. Technological innovationacquires more importance to the extent that the countries’markets are strengthened, and reach, in the last two decadesof the 20th century, an increasing strategic weight inproportion that the international inequality scenario ofeconomic globalization is characterized by the interplay of thefollowing actors: (i) economically wealthy and innovativecountries; (ii) poor countries situated on the boundaries ofworld consumption of goods and services; (iii) countries at anintermediate development stage, such as the “BRICs” (Brazil,Russia, India, China) or, as they are also denominated, theInnovative Developing Countries (IDCs)1.

According to the World Health Organization’s records, in itsWorld Health Report 1998, at the beginning of this newmillennium we live a unique moment of acceleratedtechnological evolution that has never been seen in thehistory of health care. To that effect, the Swedish Council onTechnology Assessment in Health Care (SBU) emphasizesthat at least 50% of all therapeutic methods in use, were notavailable ten years ago.

Regarding biomedical sciences, it has been observed, atrend by the knowledge production international centres ofignoring the diseases of major prevalence in humanity,providing substantial funds for research and development ofproducts that generate greater economic earnings, clearlydescribed by the so called 10/90 Gap and its effects on thefinancing of researches related to neglected diseases and, asa consequence, on national health care of the poor anddeveloping countries, where such diseases constitute a factorwhich defines the epidemic challenges to be faced.

Although the Brazilian C&T system is the most solid inLatin America, the Ministry of Health, since its foundation inthe 1950s, was of less importance in the development oftechnological research and innovation of interest to publichealth issues. Traditionally, science and technology policyand management have been conducted by the Ministers ofScience & Technology and Education, responsible for thehorizontal promotion of research and personnel trainingthrough their agencies, namely: the National Council of

24 � Global Forum Update on Research for Health Volume 5

Innovating for health and development

Article by Suzanne Jacob Serruya1 (pictured), Director, Department of Science andTechnology, Ministry of Health, Brazilwith Reinaldo Guimarães1, Itajai Oliveira de Albuquerque1 and Carlos Medicis Morel2

Research and innovation inBrazil: the institutional roleof the Ministry of Health

Scientific and Technological Development (CNPq), theStudies and Projects Funding Body (FINEP) and theCoordination for the Improvement of Higher EducationPersonnel (CAPES).

As a consequence of the constitutional acknowledgementthat health is a citizen’s right and the State’s obligation(1988) and, particularly, after publication in 1990 of Law8080, which regulates the Brazilian Unified Health System(SUS; 1990), it established the legal landmarks whichallowed the Ministry of Health to incorporate the mission todevelop a vertical fomat to technological research,development and innovation, in compliance with theprerequisites of Brazilian sanitary reform and the politicalatmosphere resulting from, at that time, recentredemocratization of the political institutions.

Therefore, it was in the light of the principles of universality,equity, integrality and decentralization related to the attentiongiven to health, which guided the SUS management, that the1st National Conference of Science and Technology in Health(1st CNCTS; 1994) established that the National Policy ofScience and Technology in Health (PNCTS) cannot beseparated from a National Health Policy, having as a goal thegeneration of knowledge and material goods to strengthenBrazilian social policies. It must be pointed out that PNCTS,due to the nature of its constitutional object, is a sectorialcomponent of the National Innovation System, since “itsearches for a complementarity between agents and systemsin a new and more strategic context and contemplates allrelevant processes: basic research, strategic research,directed research, applied research, operational research,disclosure of results, technological development andmanagement, pilot and industrial scale production, qualityguarantee, marketing, technological regulation and evaluationand patent protection. It shall further contemplate a widerange of development of human resources. The parametersshall be applied to health technologies, such as: healthprocesses and products, health organization, control andmanagement, environment and health information”.

The recommendations of the 1st CNCTS however, were notvery effective, due to the prevailing influence, at that time, ofneoliberal ideas in the economy of the peripheric countries,based on the forecasts of the so-called Washington

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Consensus (1989). Concerning sector C, T, & I policies,according to Guimarães2, the 1980s in Brazil:

“did not represent a radical breaking up, in relation tomodels, political proposals or system development. Itbegan in a period of economic recession, and, due toone of these dramatic ironies, it was also the time of thecountry’s redemocratization associated with a reboundof the neoliberals against the developing model anddestruction of the public sector. To the C & T system, thisrepresented a continuous limitation of the previousdecade’s achievements, that was only discontinued from1985 through 1988, when it pursued a return to thesituation existing in the 1970s, a vain attempt due to thetax crisis and the impasse with foreign creditors whichrespectively, hindered the increase of National Treasuryfunds and raised difficulties to the negotiation of newagreements with multilateral organizations”.

A revisiting of the project has occurred during the twogovernments of President Luiz Inácio Lula da Silva. As from2003, the Ministry of Health redefined its structure and anew strategy was set forth for the purpose of strengtheningthe managing role of the institution concerning thedevelopment of scientific knowledge and technologicalinnovation significant for the Brazilian health system3. Themost important institutional event of this period was thesecond National Conference of Science, Technology andInnovation in Health (2nd CNTIS), based on 300 municipalconferences and 24 state conferences, therefore further,extending the debate on science and technology to theinterests of the academic community.

Within a macro-organizational structure, over the last fiveyears, the following may be pointed out: the establishment ofthe Secretary of Science, Technology and Innovation inHealth (SCTIE), encompassing the following departments:Pharmaceutical Assistance, Science and Technology and theIndustrial Complex and Innovation in Health; signature of aTechnical Cooperation Agreement between the Ministries ofHealth and Science and Technology (MCT); establishment ofthe Science, Technology and Innovation Council of theMinistry of Health; representation of the Ministry of Health inthe Forum of Competitiveness in a Pharmaceutical andBiotechnological Productive Chain organized by the Ministryof Development, Industry and Foreign Trade and, chiefly, the“More Health” Programme (Programa Mais Saúde).

The health production chain, marked by a strong relianceon imports and a high trade deficit (US$ 5.5 billion in 2007)accounts for 7–8% of the GDP, using funds of approximately

R$ 160 million (US$ 102 million). As per 2007, for thepurpose of promoting economic growth, the Braziliangovernment launched the Growth Acceleration Programme(PAC) – 2007–2010. PAC gathers a set of institutionalactions representing a larger public investment ininfrastructure, credit and financing incentives, improvementof investments and tax system in the medium and long term.It is expected the application of funds amounting toapproximately R$ 503.9 billion (US$ 320.5 billion), forinvestments in social and urban infrastructure, transportlogistics and energy.

The “More Health” Programme (Mais Saúde), an integralpart of PAC, is a mobilizing programme, under thesupervision of the Ministry of Health, which has thechallenge of reducing the vulnerability of the National HealthPolicy, from a strategic point of view, including the nationalproduction chain into the health industrial complex, bymeans of major investments in innovation, modernizationand development of a public laboratory network, exportexpansion and diversification and by attracting moretechnologically advanced foreign companies to produce inthe Brazilian market.

As a productive system structuring programme, the “MoreHealth” Programme (Mais Saúde), will invest R$ 5.1 billion(US$ 3.3 billion) in (i) the consolidation of a morecompetitive Brazilian industry in the production of medicalequipment, materials, reagents and diagnosis devices, bloodby-products, immunobiologics, chemical intermediates andvegetable extracts for therapeutic purposes, active principlesand drugs for human use and (ii) in strategic areas of thefield of scientific-technologic knowledge for the purpose ofreducing the vulnerability of the National Health System. It isexpected that 80% of the needs of the NationalImmunization Programme (PNI) will come from localproduction, including the incorporation of new vaccines:pneumococcus, meningococcus AC, double viral andquinquivalent (DPT & HiB & Hepatitis B virus). The purposeof Mais Saúde is to replace the import of 20% of the demandfor pacemakers, ultrasonography and mammographyequipment for the Brazilian National Health System (SUS).

The other action of great impact on the National InnovationSystem is the conclusion of Hemobrás, a state-ownedcompany that will allow Brazil’s self-sufficiency in blood by-products, complying with 100% of SUS demand for FactorIX, immunoglobulin and human albumin and 30% of thedemand for Factor VIII. The funds necessary for expansion ofthe production capacity will be provided by the BrazilianDevelopment Bank (BNDES), by means of the Novo



Health production chain, marked by a strong relianceon imports and a high trade deficit (US$ 5.5 billion in2007) accounts for 7–8% of the GDP, using funds ofapproximately R$ 160 million (US$ 102 million)

The other action of great impact on the NationalInnovation System is the conclusion of Hemobrás, a

state-owned company that will allow Brazil’s self-sufficiency in blood by-products, complying with 100%

of SUS demand for Factor IX, immunoglobulin andhuman albumin and 30% of the demand for Factor VIII

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Profarma (Programme to Support the Development of theHealth Industrial Complex). Development of Mais Saúde ispointed out as a fundamental factor to reach the proposedobjectives, Brazilian integration with Latin American,Caribbean and African markets, as a strategic space toexpand the local industry scale and productivity, integratelocal and regional production chains and establish technicalcooperation for technical and scientific abilities4.

In addition to provisions for Mais Saúde, considering the2002–2007 period, the Secretary of Science, Technology andStrategic Supplies (SCTIE) has been guaranteeing increasingfunds to comply with the guidelines provided by the HealthResearch Priority National Agenda Funds for the selectedprojects have been guaranteed through resources from SCTIE,MCT and state governments. The total investment applied toinnovation projects (see Table 1), during the 2002–2007period, was approximately R$ 109 251 729 (US$ 70 033160), or up to 40% of all funds intended for the 25 sub-agendas of ANPPS (see Figure 1).

Research and development on neglected diseases is anexample of a key strategic area that only now is receiving thehigh priority it deserves. Through open competition and peer-review processes the Ministry of Health and the Ministry ofScience and Technology, through their funding agenciesDECIT and CNPq, invested in 2006–2007 R$ 20 million(US$ 12 million) in six diseases that disproportionately hitpoor and marginalized populations in Brazil: Dengue, Chagasdisease, leishmaniases, leprosy, malaria and tuberculosis. Ina radical departure from traditional national or internationalinitiatives in this area that are usually academic and justcuriosity-driven, the DECIT/CNPq Neglected Diseases R&DProgramme is based on a Call for Applications thatsimultaneously require the proposals to have high scientificmerit and to address critical health priorities. In addition,efforts are made to invest at least 30% of the R&D funds ingroups located in the three Brazilian geographic regionswhere these diseases are highly prevalent – the Centre West,the North East and the North, particularly the Amazon (see Table 2).

This example should not be perceived as an isolated case,but as representing the paradigmatic shift occurring in Brazil’sscience, technology and innovation policies in health,traditionally limited to “Mode I” and now also addressing



“Mode II” of knowledge production5.Upon evaluating the present stage of the Science,

Technology and Innovation Policies in Health, we observethat there has been progress concerning a definition of thepriorities of research topics and corresponding funding, bymeans of public calls. The Mais Saúde Programmeconstitutes a powerful strategy to implement and strengthenthe National Innovation System, through investments ininfrastructure which will enable Brazilian public and privatecompanies to incorporate adequate programmes to introducenew health technologies into the local and foreign markets.However, since it is a medium- and long-term structuringproject, it is necessary to take into consideration scenarioswhich may, if existing, jeopardize, the success of thesepublic policies.

At first, among a possible combination of events, we mayconsider non-accomplishment of funding within thedeadlines and amounts necessary to implement the policy,due to a need to increase the primary surplus, which meansthe economy of budget resources intended for payment ofgovernment debt charges. Although Brazil is now enjoying abetter situation regarding economic turbulence in theinternational market, Brazilian interests have recentlyreturned to an increasing trend and additional resources fromthe federal budget may be requested to pay the governmentdebt, therefore jeopardizing the funds intended for the MaisSaúde Programme. The increase of interest and shortage ofoffers from other funding sources may also be reflected on theaccess to credit lines offered by the BNDES, leading to aredefinition of priorities. On the other hand, Mais Saúde,pointed out as a structuring programme for developing theHealth Industrial Complex, requires a commitment forcontinuation beyond the government of President Lula, a

Table 1: Total investments applied to innovation projects by theNational Agenda of Priorities Sub-agendas

Sub-area Number of Total of projects resources (US$)*

Pharmaceutical care 19 18 432 362Nontransmissible diseases 8 7 579 845Transmissible diseases 19 6 085 187Clinical research 1 27 128Elderly health 1 447 572Health of individuals with special needs 1 254 492Oral health 1 8 281Violence, accidents and trauma 13 699 962Others areas 44 36 498 330Total: 4 Sub-agenda(s) 107 70 033 160

Source: Source: Brazil, Ministry of Health, Department of Science and Technology –Decit. Managerial Database. Captured on 7 May 2008*US$ conversion rate August 2008: US$ 1 = R$ 1.56Search criteria: sub-agenda and transversality Health Productive Complex in Health

Table 2: Numbers of projects and resources by neglecteddiseases

Sub-area Number of Total of projects resources (US$)*

Malaria 2 367 821Leishmaniasis 5 1 076 487Leptospirose 1 25 189Dengue 3 123 769Tuberculosis 1 30 628Total 12 1 623 894

Source: Brazil, Ministry of Health, Department of Science and Technology – Decit.Managerial Database. Captured on 7 May 2008*US$ conversion rate August 2008: US$ 1 = R$ 1.56

0

500

1000

1500

2002/2003 2004/2005 2006/20070,00

20,00

40,00

60,00

80,00

100,00

Number of projects US $ (million)

Figure 1: Evolution of the department of science and technology’ssupport the health research

Source: Brazil, Ministry of Health, Department of Science and Technology – Decit.Managerial Database. Captured on 7 May 2008

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practice that is not usual in terms of the political culture inBrazil, particularly if, the Programme deadlines do notinclude strict regulatory limits to account for the currentsectorial needs. Finally, reliance on foreign resources andtechnologies may constitute another difficulty, intensified bythe current international financial crisis. Foreign companieshave been cautious concerning new investments indeveloping countries and they have shown a trend, as a

result of this adversity, to sell their assets in these countries.Innovation policies are important instruments to foster

national economies. When well executed they shouldoriginate a favourable socioeconomic ambience thatpositively influences the internal economic market and thenational balance of trade. Besides, the scientific developmentcan potentially promote social inclusion. �

Suzanne Jacob Serruya MD, PhD is director of the Departmentof Science and Technology, Secretariat of Science, Technology andStrategic Inputs of the Brazilian Ministry of Health.

Reinaldo Guimarães MD, MSc is chairman of the Secretariat ofScience, Technology and Strategic Inputs of the Brazilian Ministryof Health.

Itajai Oliveira de Albuquerque MD, MSc is assessor for HealthTechnology Assessment in the Department of Science andTechnology, Secretariat of Science, Technology and StrategicInputs of the Brazilian Ministry of Health.

Carlos Medicis Morel MD, PhD is director of the Centre forTechnological Development in Health, Oswaldo Cruz Foundation.



Key messages

� Innovation policies are important instruments tofoster national economies and they should originatea favourable socioeconomic ambience thatpositively influences the internal market and thenational balance of trade.

� In Brazil, the “More Health” Programme (MaisSaúde) constitutes a powerful strategy to strengthenthe National Innovation System by means of majorinvestments in innovation, modernization anddevelopment of public laboratory work, exportexpansion and by attracting more technologicallyadvanced foreign companies in Brazilian Market.

1. Morel CM, Acharya T, Broun D, Dang AJ, Elias C, Ganguly NK, GardnerCA, Gupta RK, Haycock J, Heher AD, Hotez PJ, Kettler HE, Keusch GT,Krattiger AF, Kreutz FT, Lall S, Lee K, Mahoney R, Martinez-Palomo A,Mashelkar RA, Matlin SA, Mzimba M, Oehler J, Ridley RG, Pramilla S,Singer P, Yun MY: Health innovation networks to help developing countriesaddress neglected diseases. Science 2005, 309:401-404.

2. Guimarães R. FNDCT: Uma nova missão."http://www.schwartzman.org.br/simon/scipol/pdf/fndct.pdf"http://www.schwartzman.org.br/simon/scipol/pdf/fndct.pdf , 1-35. 2008.

3. Morel CM, Carvalheiro JR, Romero CNP, Costa EA, Buss PM: The road torecovery. Nature 2007, 449:180-182.

4. Ministério da Saúde: Mais saúde: direito de todos: 2008-2011. Brasília:Editora do Ministério da Saúde; 2008.

5. Gibbons M, Limoges C, Nowotny H, Schwartzman S, Scott P, Trow M: Thenew production of knowledge: the dynamics of science and research incontemporary societies. London; Thousand Oaks; New Delhi: SAGEPublications; 1994.

References

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Many low- and low-middle income countries havepluralistic health systems, characterized bywidespread and often highly segmented markets

offering a diverse range of health-related goods andservices1,2,3. Out-of-pocket payment for health care averagesmore than 50% of all health spending in these countries4,with non-state providers, both private and not-for-profit,typically providing the majority of outpatient curative care5,6.If health services are to benefit the poor, it is essential to gaina detailed understanding of such markets that can bothinform attitudes towards them and guide innovations thatattempt to engage with them to improve health outcomes.

The spread of market relationships in the provision ofhealth services has coincided with the growth of markets inother sectors. In some countries this has been associated witheconomic liberalization and economic growth. In others, itsemergence is linked to economic decline and the failure ofstate-provided services to meet popular expectations. In manycircumstances the spread of markets has been much fasterthan the capacity of the state and other key actors to establishregulatory arrangements to influence their performance. Alarge proportion of market transactions now take placeoutside a legal regulatory framework or in settings whereregulatory regimes are poorly implemented, particularly forthe poor. In addition, the boundaries between public andprivate sectors have become blurred. In many countries usersroutinely make informal payments for services or drugs atpublic facilities, or consult government health workersprivately7. In others, public providers are officially encouragedto generate income in order to supplement often very limitedgovernment subsidies8.

The marketization of health services has created bothopportunities and challenges for poor people. They may havegreater choice about where to seek drugs and medical advice,but cost is often a barrier to access. There are examples ofexcellent services but, as Das et al9 document, the quality ofservices that both public and private health workers provideis often flawed, partly in response to perverse incentives.Such incentives also result in an emphasis on medical care atthe expense of prevention and health promotion. It is widelyrecognized that both government and other intermediaryorganizations can play important roles in altering these

incentives and improving the performance of these markets.There is less agreement on what those roles should be indifferent development contexts and how health systems canconstruct the institutional arrangements for them to playthese roles effectively.

The spread of market relationships has advanced so far inmany countries that official policies often have limitedrelevance to the realities that poor people face when copingwith health problems. We propose an approach whichexplores the operation of health markets in order to helpexplain how health systems are changing, identify potentialopportunities for intervention and innovation, and guide thedesign of monitoring systems that can track and learn fromboth the intended and unintended consequences of suchinnovations. We then examine different types of emerginginnovations, and focus on two in Nigeria and Bangladesh.

Conceptual frameworkThis section describes an approach for analysing andunderstanding health markets in low- and middle-incomecountries. It draws on the framework for understandingmarkets that poor people use presented in a recent paper byElliot et al10 and summarized in Figure 1. The authors of thatpaper place at the centre the relationship between providersand consumers, that is in our case, the relationship betweenhealth service providers and patients. Those relationships aregreatly influenced by a multi-dimensional and complexenvironment made of formal and informal rules and ofagencies that undertake a number of supporting functions.Strategies for change need to take into account the diversecomponents of this context as well as ways to improve themanagement of a single organization or intervention. Theyalso need to acknowledge the importance of conflicts ofinterest and the degree to which power relationshipsinfluence the organization and functioning of relevantmarkets. For example, many health-related markets aresegmented, with well-regulated components used mostly bythe better off and unregulated ones used by the poor2.

An important aspect of the relationship between providersand patients concerns the transfer of the benefits of medicalexpert knowledge to the latter. This transaction ischaracterized by varying degrees of asymmetry of information



Article by Gerald Bloom (pictured), Heath policy analyst, Institute ofDevelopment Studies, UKwith Claire Champion, Henry Lucas, M Hafizur Rahman, Abbas Bhuiya,Oladimeji Oladepo and David Peters

Health markets and futurehealth systems: innovationfor equity

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and a consequent imbalance in power, which possessors ofexpertise can use to their advantage. Societies have evolvedmechanisms to address this problem through a combinationof regulation by the state, different forms of self-regulationand organizations that build and maintain a reputation forcompetent and ethical behaviour. The relevant actors includethe regulatory arms of central and local government,professional and trade associations, large service provisionorganizations, and a variety of civil society organizations andconsumer associations.

Current rules and regulations often do not take intoaccount the importance and diversity of health markets indeveloping countries, and thus many actors operate outsidea legal framework. Barriers to appropriate regulations areoften linked to a lack of government capacity to enforce themor incentives to do so11. Many government regulatoryagencies focus on the services used by the better off and shyaway from attempts to regulate the informal sector which isof paramount importance for the poor. This has led to theemergence of a variety of partnerships between governmentsand other actors to co-produce rules and improve marketperformance12, 13.

Where regulation is limited and information asymmetriesare large, trust is a key dimension in the relationshipsbetween providers and consumers. Patients in low- and

middle-income countries have shown a willingness to paymore for the services of providers whose competence theytrust and many providers have adopted strategies to buildand maintain a reputation for high expertise and ethics 14, 15,

16, 17. Trust and reputation may be based on a variety of factorsincluding directly experienced quality of services (e.g.,availability of drugs, cleanliness, courteous staff), perceivedstatus of providers (e.g., professional title, advertisedqualifications and experience) and brand recognition (e.g.,widely known franchise, accreditation or licensing authority).Less formal arrangements are often important at thecommunity level, where providers operate within local trustnetworks. Word of mouth is an important medium for theestablishment and maintenance of a facility’s reputation18.

Another important aspect of the performance of health-related markets relates to information flows. Providers andusers of health services get information from many sources.In Bangladesh, for example, the primary source ofinformation for informal providers is from salesrepresentatives or wholesalers who are associated withgeneric manufacturers. Other sources include the diversecommunications media that national and internationaladvocacy groups, government agencies and commercialadvertising agencies increasingly use to deliver messages toboth providers and the general population. New



Market players

Rules

LawsInformalrules andnorms

Sector -specific regulations and standards

Non-statutoryregulations

Not-for-profitsector

Membershiporganisations

Representive bodies

Informal networks

Government Private sector

Infrastructure Related services

SUPPORTINGFUNCTIONS

Setting and enforcing rules

Informing and communicating

Supply Demand

Figure 1: Conceptualizing market systems

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communication tools, such as mobile telephones and theInternet, are significantly increasing the options and capacityfor information dissemination, even in some of the poorestcountries. This increasing volume of circulating informationcreates an urgent need for trusted knowledge brokers.

Health market innovations in developingcountriesInnovations aimed at improving health services have takenplace in both informal and formal sectors. Those happeningin organized markets have taken various forms, ranging fromcommercial models (mostly found in Asia and Latin America)to highly subsidized but market-oriented interventions such as the establishment of provider networks, socialfranchises or accreditation schemes (mainly run bynongovernmental organizations or faith-based organizations).

Notwithstanding the innovations described above, manyhealth transactions involving poor people still take place inthe informal sector, where there are minimal qualitystandards and no reporting requirements. To examine ways ofaddressing these constraints, two initiatives that involvepartnerships between informal providers, policy-makers andthe public to shape better health markets for the poor arediscussed below.

In Bangladesh, informal providers (village doctors,medicine vendors) are the major source of health care forrural people. A recent formative study conducted in onesoutheastern sub-district (560 000 people) of Bangladesh byICDDR,B found that 96% of health-care providers wereinformal including village doctors, traditional healers(Kabiraj), traditional birth attendants and spiritual healers.The study found many instances of inappropriate and evendangerous prescribing. The consortium has launched a three-pronged intervention of training informal providers,establishing an association of these providers to implement adegree of quality control and the involvement of theBangladesh Health Watch in monitoring the performance ofinformal providers.

In Nigeria where malaria is a major cause of illness anddeath, most people depend on patent medicine vendors(PMVs) as a source of anti-malarial medication. PMVsoperate in poorly markets. A scoping study by the School ofPublic Health at Ibadan University found that PMVs were themajor source of malaria treatment (39%) followed by self-treatment (26%)19. It also indicated that PMVs oftenrecommend inappropriate products that are inexpensive butalso ineffective. In this complex and unregulated marketenvironment, local PMV associations were identified asinstitutions with the potential to play an important role inproviding information, influencing PMV behaviour, andprocuring drugs. Also, a large proportion of PMVs (92%) saidthat community involvement in drug regulation would behighly desirable to complement the relatively weakgovernment system. For example, they could use relativelyinexpensive equipment to test the efficacy of anti-malarialdrugs. Recent consultations with stakeholders foundoverwhelming support for an intervention that would involvea partnership between public and private sectors. �

AcknowledgementThis paper is an output of the DFID-funded Future HealthSystems Consortium (http://www.futurehealthsystems.org/).The opinions expressed do not necessarily reflect the viewsof DFID. It also draws on a soon-to-be publishedbackground paper for an initiative of the RockefellerFoundation on the role of the private sector in healthsystems. This initiative applies a broad health systems lensand is undertaking exploratory work in three broad areas:attitudes of key stakeholders, analysis of five functionalareas (risk-sharing, regulation, logistics, contracting andprovider performance) and identification of country levelprogrammes and organizations that show a strong potentialfor replication and/or scaling up. It is expected that theRockefeller Foundation and additional partners will launcha programme in the near future.

Gerald Bloom is a health policy analyst at the Institute ofDevelopment Studies (IDS) in the UK, whose work has focused onthe management of health system change in societies undergoingrapid transition. He has worked in a number of African countriesand in China. He is presently the coordinator of a multi-institutestudy of poverty and illness in China, Cambodia and Laos, asenior researcher in the Future Health Systems researchprogramme consortium and health domain convener of the STEPS



Key messages

Given the pervasiveness of markets for health-relatedgoods and services and the great degree to which thepoor obtain medical care in these markets, it is time forhealth policy-makers to take action to improve theirperformance, based on a systematic understanding ofhow these markets operate. In doing so, they need totake account of the following:� Attempts to achieve long-lasting change through the

efforts of a single organization or a particularlyinnovative individual tend to be unsuccessful; it isimportant to understand and address marketsystems as a whole in order to achieve sustainablechange.

� Reforms should begin with markets in which poorpeople are already engaged and will often involveinformal providers, who operate outside formal legaland regulatory frameworks, and local agencies suchas provider associations, citizen groups and localaccountability structures.

� Interventions intended to benefit the poor need toacknowledge and take into account the influence ofpower and conflicts of interest on their outcome andthis should be anticipated in a detailed stakeholderanalysis.

� Interventions that focus solely on providers of healthservices are unlikely to have a great impact on thepoor unless they are linked to measures that provide more equitable access to government funding anddonor financial flows

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Centre. He is co-Chair of the China Health Development Forum.

Claire Champion is a doctoral student at Johns Hopkins Schoolof Public Health (International Health). Prior to her doctorateprogramme, Ms Champion managed various health private sectorstrengthening programmes in Africa and Asia. She has an MBAfrom Harvard Business School and an MPH from Johns HopkinsUniversity.

Henry Lucas is an expert in management information systemsand on methodologies for monitoring and evaluation at theInstitute of Development Studies (IDS). He has long experienceof work in many countries in Africa, Asia and the Pacific in avariety of studies focusing on different aspects of povertyreduction and on health systems.

M Hafizur Rahman is a public health physician with years ofexperience in directing health research programmes in severalcountries in South Asia, Africa and the United States. He hasparticular interests in reproductive health, equity of healthservices and research methodologies. He is the manager for theFuture Health Systems research consortium, and a facultymember at the Johns Hopkins University Bloomberg School ofPublic Health.

Abbas Bhuiya is the head of the Social and BehaviouralScience Unit and Poverty and Health Programme of the Centerfor Health and Population Research (ICDDR,B). For the last 25years, Dr Bhuiya has been engaged in community health

research with special focus on equity issues, behaviour change,and community development-oriented action research for theimprovement of health of the poor and reduction of socialdisparity in health. He is the country coordinator of the FutureHealth Systems: Innovations for Equity research programmeconsortium in Bangladesh.

Oladimeji Oladepo is a health promotion specialist withextensive experience in evaluating public health interventions inNigeria. He has a special interest in social, behavioural andeducational research in the control of tropical diseases,reproductive health, planning and evaluation of primary health-care services, and policy development. He is head of theDepartment of Health Promotion and Education at the Universityof Ibadan, and the country coordinator of the Future HealthSystems: Innovations for Equity research programme consortiumin Nigeria.

David Peters is a public health physician and associateprofessor in the Health Systems Program in the Department ofInternational Health at Johns Hopkins Bloomberg School ofPublic Health, and is a senior public health specialist at theWorld Bank. He has an interest in the performance of healthsystems in developing countries, and has worked as a researcher,policy advisor, bureaucrat and manager of health systems inCanada, Africa and South Asia. He is director of Future HealthSystems: Innovations for Equity, a consortium of researchersfrom Uganda, Nigeria, India, China, Bangladesh, Afghanistanand the United Kingdom and United States.



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3. Berman P, Rose L. The role of private providers in maternal and childhealth and family planning services in developing countries. Health PolicyPlan, 1996, 11:142-155.

4. World Health Organization. Data on national health accounts, 2008.http://www.who.int/nha/country/Regional_Averages_by_WB_Income_group-En.xls

5. Hanson K, Berman P. Private health care provision in developingcountries: a preliminary analysis of levels and composition. Health PolicyPlan, 1998, 13:195-211.

6. Peters DH, Marchandani G, Hansen PM. Strategies for engaging theprivate sector in sexual and reproductive health: how effective are they?Health Policy and Planning, 2004, 19(Suppl.1):5-20.

7. Das Gupta M, Gauri V and Khemani S. Decentralized delivery of primaryhealth services in Nigeria: survey evidence from the states of Lagos andKogi. Development Research Group, Human Development Sector, AfricaRegion, World Bank, 2004.

8. Bloom G, Kanjilal B and Peters D. Regulating health care markets inChina and India. Health Affairs, 2008, 27.4:952-63.

9. Das J, Hammer J and Leonard K. The quality of medical advice in low-income countries. Journal of Economic Perspectives, 2008, 22(2):93-114.

10. Elliot D, Gibson A and Hitchins R. Making markets work for the poor:

rationale and practice. Enterprise Development and Microfinance, 2008,19(2):101-119.

11. Ensor T and Weinzierl S. A review of regulation in the health sector inlow and middle income countries. Signposts to more effective states,2006, Brighton: Institute of Development Studies.

12. Joshi A and Moore M. Institutionalized co-production: unorthodox publicservice delivery in challenging environments. Journal of DevelopmentStudies, 2004, 40(4):31-49.

13. Peters DH and Muraleedharan V. Regulating India’s health services: towhat end? What future? Social Science & Medicine, 2008, 66:2133-2144.

14. Montagu D. Franchising of health services in low-income countries.Health Policy and Planning, 2002, 17(2), 121-130.

15. Montagu D. Accreditation and other external quality assessment systemsfor health care, DFID Health Systems Resource Centre Working Paper,2003.

16. Mills A, Brugha R, Hanson K and McPake B. What can be done aboutthe private health sector in low-income countries? Bulletin of the WorldHealth Organization, 2002, 80(4):325-330.

17. Prata N, Montagu D and Jeffeys. Private sector, human resources andhealth franchising in Africa. Bulletin of the World Health Organization,2005, 83:274-279.

18. Leonard K. Learning in health care: evidence of learning about clinicianquality in Tanzania. Economic Development and Cultural Change, 2007,55(3):533-555.

19. Oladepo O et al. Malaria treatment and policy in three regions in Nigeria:the role of patent medicine vendors. Future Health Systems WorkingPaper No. 1, 2008.

References

30-33 Bloom:GF5 22/10/08 14:04 Page 33

This short paper briefly highlights the “10/90 gap”between high-income and low-income countries forboth climate change as well as public health research.

The term “10/90 gap” as used here is broadly reflective of thedisequilibrium between high- and low-income countries inresearch and other investments in health interventions. Thepaper then goes on to discuss the significant overlaps andcommonalities in terms of climate change impacts as well assolutions when considered against the broad unfinishedpublic health agenda. Through the use of a few selectedexamples, readers are encouraged to think about how theycan foster a holistic, comprehensive approach to address both climate change as well as public health within their jurisdictions.

The 10/90 gap in research and interventionin climate changeThere is now irrefutable proof that climate change due tohuman activity is occurring, and will accelerate in the comingdecades unless significant mitigation to reduce greenhousegas emissions occurs1. Empirical data from meteorology,agriculture, hydrology, ecology and other natural sciences is demonstrating the ecological impact of anthropogenicclimate change.

Direct and indirect, short- and long-term effects of climatechange on human health are being recognized. Data at theglobal and high-income country level is good. Data from low-income countries is improving. Researchers, policy-makersand civil society now need to use established knowledgetranslation tools and approaches to ensure that researchinforms practice and vise versa. Expanding empirical researchonly from high-income to low-income regions in itself will notbe sufficient or timely to bring about change. This isespecially true because some of the modelling exercises are complex and the impacts not easily generalizable to thelocal context.

Health, environmental, ecological and social sciencesresearchers have learnt a great deal about the value of linkingresearchers with civil society and policy-makers. Theselessons learnt need to be applied broadly to the climatechange and health agenda.

The 10/90 gap in research and interventionin public healthMany of the successes of public health that are now taken forgranted in high-income countries remain unattainable for themajority of the population in low-income countries.

There have been notable successes in public healthachievements in low-income countries, such as childhoodimmunization programmes, resulting in reduction ofchildhood deaths from vaccine-preventable infectiousdiseases. However preventable illnesses due to issues suchas unsafe water, malnutrition and vector-borne diseases suchas malaria remain unacceptably high. It is pertinent to notethat many of the existing gaps in public health in low-incomeregions continue to have a major environmental, nutritional orinfectious disease component. These are the very issues thatwill be further negatively impacted by global climate change.

Research gaps are not limited to technical issues. They arealso in governance, funding and operationalization. Thereforeresearch should not only be on causes of morbidity andmortality due to climate change and surveillance of healtheffects, but also on feasibility of applying cost-effectiveinterventions and evaluating their impact.

Opportunities for convergence in climatechange and public health research and actionThere is considerable overlap between research needs forpublic health and climate change when one considersprotecting human populations form the adverse effects ofclimate change, especially for the worlds’ most vulnerablepopulations. For these populations, the greatest impact ofclimate change will not be some novel disease or otherenvironmental stress; it will be an accentuation of existingchallenges including vector-borne diseases such as malaria



Article by Saqib Shahab (pictured), University of Alberta with Abdul Ghaffar

Strengthening the base:innovation and convergence inclimate change and public health

Table 1: Key tools for application of climate change research andinterventions by level of implementation

Level of implementation Key toolsIndividual EducationHousehold EmpowermentCommunity Information, resilience, facilitationRegion/country Policy, regulation, financing, equityGlobal Collaboration, equity, financing



Investments made in research in public healthprogrammes and interventions that are impacted by

climate change now and into the future are also, inmany instances, issues that are or should also

currently be high priority in terms of preventablepublic health disease burden

Table 2: Approach to application of technical knowledge in low-income settings

Issue

Vector-borne diseases

Disasters: hurricanes,cyclones

Water stress

Safe water supply

Changing agriculturalyield

Poverty and inequity

Conflict

Do technicalsolutions exist?

Yes

Limited

Limited

Yes

Historically strongcapacity toincreaseagricultural yields

Limited

Limited

Are technical solutionssuccessfully implemented inlow-income countries?

Somewhat

Limited

Limited

Not uniformly

Significant experience intranslating research intoimproved agricultural yields

Significant successes relatedto micro credit, literacy andempowerment

Non conflict based disputeresolution as advocated byintergovernmentalorganizations and local andglobal civil societies

Barriers to implementation

Climate, geography, economy,governance

Populations already vulnerable

Loss of local control over waterresources. Powerful competinginterests on decreasing freshwater supplies

Macroeconomic limitations; lackof local training and infrastructure

Some areas may have peaked intheir capacity to sustainincreasing yields

Continuing unmet needs infemale literacy and gender equity

Perceived national self interest.Historical rivalries

Opportunities for research, knowledgetranslation, implementation and evaluation

Solutions need to be appropriate, acceptableand sustainable

Increase state and community capacity andresiliency to predict and respond to naturaldisasters

Resource poor communities have alwaystraditionally conserved water; localknowledge and empowerment has to belinked to new technologies for waterconservation

National fiscal transfers to public health;investment in infrastructure and point of usecapacity

Understanding fundamental changes thatmay be required in crop types

Demonstrating how addressing poverty andinequity can increase community capacityand social capital

Demonstration of non conflict basedsolutions as ultimately more sustainable

and dengue; poor water quality and quantity; hunger andmalnutrition; hot and unpredictable weather patterns; andmore frequent storms and natural disasters2.

The direct effects of climate change such as thermal stresshave been well quantified for high-income countries and arebeginning to be modelled for low-income countries. Similarly,the indirect but early effects of climate change such asincrease in water- and vector-borne diseases are also nowbeginning to be estimated. Long-term effects however, suchas impact of ecological changes on food security, wateraccessibility and extreme weather events such as hurricanesand storms is harder to estimate globally3.

There is some debate about what the microclimatic impactsof climate change at the local level will be. It is a fairassumption that they will be predominantly negative for themajority of people living in low-income countries. They maybe initially climate neutral or positive for a few people livingin low-income countries and some in high-income countries.However, over time, the global impacts on health, economy,and ecology are now considered to be profoundly negative4.

Investments made in research in public health programmesand interventions that are impacted by climate change nowand into the future are also, in many instances, issues thatare or should also currently be a high priority in terms ofpreventable public health disease burden. This convergenceensures that limited resources are used ethically, equitablyand efficiently. So, for example, comprehensive steps towards

achieving the Millennium Development Goals (especially asthey relate to hunger, universal primary education, genderequality, child mortality, malaria, environmental sustainabilityand a global partnership for development) will increase theresilience and adaptive capacity of the most vulnerablepopulations to the known and potential negative consequencesof climate change, in addition to being a demonstrated publichealth goal in their own right5.

The “new public health” stresses not just the direct,proximate causes of ill-health, but also the more distal,broadly defined “determinants of health”. Application of thesepublic health principles would foster a more holisticunderstanding of the approach to health protection andhealth promotion in the face of climate change6,7. Healthshould, after all, be “a state of complete physical, mental and social well-being and not merely the absence of diseaseor infirmity”8.

Source: Shahab S, Ghaffar A, Stearns BP, Woodward A: Strengthening the base: preparing health research for climate change. Global Forum for Health Research, April 2008

The synergistic, catalytic power of this convergence hasgreat potential. It can protect vulnerable populations fromcurrent known public health threats that are also beingpotentiated by climate change; and also make vulnerablepopulations more resilient to cope with future potentiallyunknown threats. Not seeking convergence of the climatechange and public health research and intervention agenda,however, runs the risk of potentially undoing many of thepublic health gains of the recent past.

Innovative strategies for research in climatechange and public healthMitigation is preventing climate change in the first place,primarily by reducing greenhouse gas emissions and other



anthropogenic activity contributing to climate change.Adaptation is adjusting to current and future impacts ofclimate change. The health sector needs to engage with andsupport research in both the mitigation as well as theadaptation sector.

While research in mitigation is primarily seen as aresponsibility of the energy sector. There are substantialpotential co-benefits to health beyond reversal of climatechange if health-centric approaches to mitigation areadopted. These include:� Improved air quality with reduction of fossil fuel use and

greater use of cleaner alternative energy sources.� Reduction in injuries due to road traffic accidents with

increased reliance on public transport and better urban,

Health impacts ofclimate change

Adaptation toclimate change

Impact ofmitigation onhealth

x Research x Evidence x Policy x Action

Whatworks

Can it be applied toother settings:- Translation- Generalization- Cost

Whatincentivesexist forreducingthe impacton health

Who will putin place thesemeasures?May notalways be thehealth orpublic sector

Figure 1: Framework for conceptual map of research areas and domains

Effective coverage in population

Com

bine

d ef

fica

cy o

f int

erve

ntio

n m

ix

0% x y 100%

100%

z

Unavertable with existing interventions

Averted withcurrent mix ofinterventions andpopulationcoverage

Avertable withimprovedefficiency

Avertable withexisting but non-cost-effectiveinterventions

Research anddevelopment toidentify newinterventions

Research anddevelopment to reduce the costof existinginterventions

Research on healthsystems and policies

Figure 2: An approach to analysing the burden of a health problem to identify research needs. Relative shares of the burden that can andcannot be averted with existing needs

x – population coverage withcurrent mix of interventions

y – maximum achievable coveragewith a mix of available cost-effectiveinterventions

z – combined efficacy of a mix of allavailable interventions

Source: Ghaffar A, de Francisco A,Matlin S. The Combined ApproachMatrix: a priority-setting tool forhealth research. Global Forum forHealth Research, 2004. Adaptedfrom Ad Hoc Committee on HealthResearch, Investing in HealthResearch and Development. WHO,1996.



community and work life planning.� Prevention of chronic diseases such as diabetes, stroke

and heart disease by promoting active transport such aswalking and cycling and healthier diets.

As the benefits for mitigation are global, for both high-income as well as low-income countries, momentum isbuilding globally for a concerted effort to mitigate the healthimpacts of climate change. It is important to continue todocument the health impacts of climate change as well asmitigation by enhanced surveillance systems to continue toprovide evidence and impetus for climate change mitigation.

Meanwhile, it is essential that populations globally prepareto adapt to some of the inevitable adverse consequences ofclimate change until such time that mitigation efforts start tohave a stabilizing effect9.

The application of research for adaptation, while of globalsignificance and import, has to be rooted in local contexts ofgeography, economics and culture.

It is important to have a conceptual map of what researchis required (see Figure 1)10. It is also important to ensure thatresources for research are used most efficiently to maximizethe public good. Many of the most urgent impacts of climatecan be countered with existing knowledge and a more cost-effective way of leveraging proven public healthinterventions for vulnerable populations in sustainable ways(see Figure 2)11.

Research approaches need to be empirical but alsoecological. The translation and application of existing andnew research findings needs to act both at the communitylevel in terms of empowerment as well as at a global/regionallevel in terms of policy and funding. Many public healthinterventions that will also protect vulnerable populationsagainst progressive climate change act at a variety of levelsincluding individual, household, community, national andregional (see Table 1)12.

Examples of successful interventions include:� Household uptake of long-lasting insecticide-treated bed

nets when combined with other more standard vectorcontrol programmes.

� Provision of effective, affordable, locally manufacturedpoint-of-use water filters.

For each example of a successful or promising intervention,it is not sufficient just to know whether a technical solutionexists. Research on cost-effective and sustainableimplementation also needs to occur (see Table 2)10.

ConclusionsWhile the challenges are significant, so are the opportunities.Climate change seems to have acted as a catalyst promotingtrans-disciplinary, holistic, global partnerships in research,knowledge generation, translation and action.

Many initiatives are currently underway especially in theenvironmental, agricultural and water resources sectors toassess impacts to and adaptation from a developing countryperspective. The issue of health should be one of the explicitfoci of these initiatives.

Key messages

� Incorporation of climate change health impacts intopublic health planning:a) Estimate current and future impacts of climatechange when planning public health interventions.b) For each public health intervention assess if there will be an impact of climate change, and adjustfor that.c) Climate change should be one of the variableswhen estimating the impact and outcomes of publichealth interventions.

� Partnering with all stakeholders:a) Partner with other stakeholders outside thehealth sector for climate change adaptationstrategies.b) Continue to advocate for mitigation as theultimate goal to address climate change.c) Maximize the diffusion of innovations throughcivil society and the Internet.d) Incorporate climate change mitigation andadaptation impacts in intra- and intersectoralplanning. Should include all possible sectors suchas transportation, housing, energy policy,education, health, agriculture, land use,environment, industries, trade etc.

� Supporting innovation, collaboration andknowledge translation in research:a) Include climate change as an element to considerfor trans-disciplinary research funding.b) Make knowledge translation and collaborationwith low-income countries a prerequisite forresearch funding approval in high-income countries. c) Support the establishment of public healthsurveillance systems that monitor the impact ofclimate change as an integral part of health statusand assessment measures. d) Ensure research is translated into locally relevant,cost-effective and sustainable interventions.

Innovative approaches from regional “second generation”assessments of the impacts of and adaptation to climatechange done primarily in agriculture and water resourcesneed to be replicated and expanded to include direct andindirect health impact and adaptation assessments13.

Civil society is well prepared to engage with governmentsand researchers to advocate for and adopt contextuallyappropriate local interventions to mitigate and adapt toclimate change. There is unprecedented open access formost if not all stakeholders to information thorough the WorldWide Web.

Along with the expected increase in funding for climatechange research and interventions, it is vital that this spirit ofopenness and collaboration is maintained. Innovation inclimate change research and interventions potentially has thepromise to address many existing and long-standing publichealth issues as well as prepare for future risks. �

Saqib Shahab is a physician specializing in public health andpreventive medicine. He has trained and worked internationally,including in Pakistan, the UK, US and Canada. Within publichealth, Saqib has a special interest in environmental andoccupational health, communicable and noncommunicabledisease control, and surveillance systems. His current interestsinclude incorporating climate change research and interventions asan integral part of public health practice.

Abdul Ghaffar is a physician and public health specialist who iscurrently the Regional Adviser for Research Policy and Cooperation,

at the Regional Office for the Eastern Mediterranean Region, WorldHealth Organization.

He has a long history of working internationally in global publichealth, including with the Global Forum for Health Research, witha special interest and expertise in enhancing health systemscapacity to participate in and apply research, especially indeveloping country and resource poor settings. His recent focushas been emphasizing research not just on technical andbiomedical issues, but also health system organization, policy,capacity and cost effectiveness.



1. Confalonieri U et al. Human health. Climate change 2007: impacts,adaptation and vulnerability. Contribution of Working Group II to theFourth Assessment Report of the Intergovernmental Panel on ClimateChange. Parry ML et al, eds. Cambridge University Press, Cambridge, UK,2007, 391-431.

2. Cambell-Lendrum D, Corvalan C, Neira M. Global climate change:implications for international public health policy. Bulletin of the WorldHealth Organization, March 2007, vol.85, no.3, p.235-237.

3. McMichael AJ et al, eds. Climate change and human health: risks andresponses. WHO 2003.

4. Stern Review on the Economics of Climate Change. HM Treasury, UK,2006.

5. McMichael AJ, Butler CD. Emerging health issues: the widening challengefor population health promotion. Health Promotion International,December 2006, 21 Suppl 1:15-24.

6. Few R. Health and climatic hazards: framing social research onvulnerability, response and adaptation. Global Environmental Change,2007, 17 (2), pp.281-295.

7. Hanlon P, Carlisle S. Do we face a third revolution in human history? If so, how will public health respond? Journal of Public Health, 21 July2008, Oxford.

8. Preamble to the Constitution of the World Health Organization as adoptedby the International Health Conference, New York, 19–22 June 1946;signed on 22 July 1946 by the representatives of 61 States (OfficialRecords of the World Health Organization, no. 2, p.100) and entered intoforce on 7 April 1948.PK:64167702~piPK:64167676~theSitePK:4503324,00.html

9. MEbi KL, Kovats RS, Menne B. An approach for assessing human healthvulnerability and public health interventions to adapt to climate change.Environmental Health Perspectives, December 2006, 114(12):1930-4.

10. Shahab S, Ghaffar A, Stearns BP, Woodward A. Strengthening the base:preparing health research for climate change. Global Forum for HealthResearch, April 2008.

11. Ghaffar A, de Francisco A, Matlin S. The Combined Approach Matrix: Apriority-setting tool for health research. Global Forum for HealthResearch, 2004.

12. McMichael AJ, Kjellstrom T, Smith KR. Environmental health. In: MersonMH, Black RE, Mills AJ, eds. International public health: diseases,programs, systems and policies, 2nd Ed. Jones and Bartlett, 2006.

13. Leary N, Kulkarni J. Climate Change Vulnerability and Adaptation inDeveloping Country Regions. Draft Final Report of the AIACC Project,April 2007. GEF/START/ UNEP.

References



Global health diplomacy may be thought of as apolitical activity that meets the dual goals of improvinghealth while maintaining and strengthening

international relations. As diplomacy is frequently referred toas the art and practice of conducting negotiations, the term“global health diplomacy” aims to capture the multi-level andmulti-actor negotiation processes that shape the global policyenvironment for health. It bridges the commitment todevelopment and the need to define collective action in aninterdependent world. This emerging field draws on a broadrange of disciplines including international relations, medicalanthropology, political science, history and public health.Therefore it is important to understand some of the historicaland conceptual underpinnings of this emerging field.Academic rigour applied to global health diplomacy is acritical leaven in a chaotic global health environment. Thispaper presents a brief review of the issues that provide apossible focus for future training, research and service inglobal health diplomacy.

Historical rootsA historical perspective may help illustrate an emergingtension surrounding health cooperation and diplomacy. Infact, international public health agreements were originallycreated to protect against the importation of foreign-borndiseases and as a defence for national commercial andtrading interests, going as far back as the Middle Ages in Europe.

We may also find some roots of health diplomacy in earlymissionary work, which adopted medical treatment as part ofevangelical activities. For example in India, Fitzgeralddescribed the emergence of medical assistance as a tool forreligious conversion among British colonial subjects1. There isthus a need to consider the normative foundations of globalhealth diplomacy, such as in the humanitarian activities ofthe Red Cross Movement, with equity and social justice beingkey components2. The current structures of global public

Article by Thomas E Novotny (pictured left), Director, International Programs,UCSF School of Medicine and Ilona Kickbusch (pictured right), Director, GlobalHealth Program, Graduate Institute of International and Development Studies,Geneva with Hannah Leslie, Vincanne Adams

Global health diplomacy– a bridge to innovativecollaborative action

health may perpetuate the imbalance of power between thedeveloped and the developing world. However, we now see apower shift in the role of the emerging economies, as in therecent Doha rounds of World Trade Organization negotiations.

From the mid 1850s, countries have dealt with theincreasing risk of disease from beyond their borders as anational and economic security issue3. These nationalinterests now mandate that countries engage internationallyas a responsibility to protect against imported health threatsor to help stabilize conflicts abroad so that they do not disruptglobal security or commerce. Concerns for health securityinclude the threat of bioweapons (accidental or purposeful) aswell as both infectious diseases and noncommunicablediseases that can wreak havoc on global economies. It is thecareful balancing of sometimes competing global healthpriorities, playing out both nationally and globally, that makepartnership across disciplines essential in raising the profileof health as a foreign policy concern. Global health efforts willfounder unless and until nation states cooperate in combiningtheir national interests with the global public good.

Contributing concepts Humanitarian assistanceThe notion of humanitarian assistance as part of foreignpolicy was described in a 1974 editorial in PreventiveMedicine, wherein Cahill advocated using medicine as a toolof modern diplomacy4. His more recent work suggests thathealth is a common ground for understanding andcooperation among peoples and nations with differingtraditions and values5. This is especially true in nations thatare shattered by war, civil conflicts and ethnic violence. Overthe next 25 years, humanitarianism rather than foreign policyper se was the focus for health diplomacy. However,humanitarian assistance provided by the United States andothers to disaster areas such as Sudan fulfilled broaderpolitical and economic objectives rather than justbeneficence6. Aligning aid organizations with dysfunctionalgovernments may enable these governments to beunresponsive to their own national crises7. These examplessuggest that aid organizations must be politically and ethicallymore savvy in order to assure justice-based approaches tointernational health assistance8. Health diplomacy attempts

“Medicine is a social science, and politicsnothing but medicine on a grand scale.”RUDOLF VIRCHOW, 1858

41-45 kichbusch:GF5 23/10/08 09:17 Page 41



to prioritize the health outcomes of humanitarian aid as aroute to negotiations in the political sphere.

A critical new development in global health is theproliferation of private sector and government donations ininternational aid; these have been largely disease-specificenterprises (such as the Global Fund for AIDS, TB andMalaria). A 2004 estimate suggested that internationalfunding for global health reached US$ 14 billion in that year,due largely to contributions from the Bill & Melinda GatesFoundation and the US government’s Presidential EmergencyPlan for AIDS Relief (PEPFAR)9. The proliferation of smallernongovernmental organizations (NGOs), privately fundedand focused on single communities, specific healthoutcomes or specific medical interventions is alsounprecedented in history. Along with this bonanza, there isincreasing convergence of thought on the evidence ofeffectiveness for global health interventions10. This evidencehas been thoroughly reported in the hallmark publication,Disease control priorities in developing countries11. Whatmay be missing from these discussions, however, is a senseof the absorptive capacities and global governance needs that are necessary for both recipients and donors to managethese resources12.

Human rightsThe emergence of human rights as a global movementclearly sparked challenges and debates within the field ofhumanitarian assistance that have yet to be resolved. Thenotion of human rights and health assistance has emergedas a basis for cooperative action across nations, the privatesector and NGOs. The right to health became a key elementof this discourse, but its importance remained largelyunderstated until the world acknowledged the enormousimpact of HIV/AIDS. Health and human rights emerged as adistinct movement and was made concrete with the 1994founding of the Journal of health and human rights byJonathan Mann, head of the WHO HIV/AIDS programme atthe time. He clarified this union of human rights and health,stating “that the human rights framework provides a moreuseful approach for analyzing and responding to modernpublic health challenges than any framework thus faravailable within the biomedical tradition”13. Building on thisfoundation, Paul Farmer’s written works and leadership havedramatically advanced the human rights agenda in healthdiplomacy, arguing that the international public health andforeign policy communities both fail to recognize the needs ofthe world’s poor and neglect to address the structuralinequalities that lead to illness among them14. Given adecade since health and human rights emerged as amovement, health diplomacy must now incorporate both aconcern for resource equity and a concern for social justicein health assistance. It must also consider the political andeconomic landscape in which these standards must be defended.

GlobalizationDuring the 20th century, researchers have recognized thespread of both communicable and noncommunicablediseases as a consequence of globalization. Global changes

in trade, transport, medicine and society have created idealconditions for emerging infections with potentiallydevastating impacts15. However, deficiencies in public healthinfrastructure argue for greater public health preparedness toprevent global pandemics16.

Globalization has also expanded the threat ofnoncommunicable disease to populations and economiesworldwide17. This latter set of threats (tobacco-relateddiseases, obesity, injuries, mental health problems, cancers,stroke and cardiovascular disease) are much less attention-grabbing as global health problems compared with the high-profile infectious diseases that are now so well funded;nevertheless, they are the largest contributors to the globalburden of disease11. Noncommunicable diseases have emergedas global threats, no longer considered a condition of onlyaffluent populations18. These conditions may contribute todevelopmental stagnation in emerging economies, and theymay lead to inordinate demands on health systems thatdisrupt production and trade capacities of these economies.

Enlightened self-interestImprovements in health status globally – especially indeveloping countries – promote economic and securityinterests for both donor countries and the larger globalcommunity19. In 1997, the Institute of Medicine (IOM)published a volume of evidence supporting the United States’critical need to address global health as a vital nationalpriority20; following this, infectious diseases were recognizedin the National Intelligence Estimate as a significant threat tonational security, with an emphasis placed on theimportance of HIV/AIDS21. Recently, some have evensuggested that the avian influenza threat presents potentialfor cooperation between the militaries of, for example, theUnited States and China. They may be encouraged to pool theirresources in order to address a common threat such as this22.

Given the potential for new commitments to global healthdiplomacy in a changing global political environment, theIOM’s Board on Global Health is now organizing a 14-monthconsensus study to examine and articulate the case for whymultiple agencies from government and the private sector inthe United States should make a deeper commitment toglobal health. This study will greatly expand on the 1997IOM report to consider the diplomatic agenda, expandedglobal research cooperation and perhaps new ways ofaddressing the global health workforce crisis (seewww.iom.edu/CMS/3783/51303.aspx).

Multinational cooperationIn December 2004, the United Nations issued an importantreport, A more secure world: our shared responsibility: reportof the high-level panel on threats, challenges and change23,a follow-up to the 2000 UN Millennium Summit, wherecommitments to global cooperation were made in responseto several major health and development challenges. The2004 report emphasized the need to achieve the MillenniumDevelopment Goals (MDGs; see Table 1), with a focus onhealth and biological security.

The focus of the UN report also extends to the socialdeterminants of health (especially poverty and economic




inequities), infectious diseases and environmentaldegradation. Although sovereign states are the front line indealing with health threats, the report emphasized that nostate can stand wholly alone and that collective strategies,collective institutions and a sense of collective responsibilityare indispensable in addressing the global health challengesof the 21st century. The WHO has flexed its muscle in thisarena with new instruments, such as the FrameworkConvention on Tobacco Control (see below). Additionally,governments have begun to align themselves in newarrangements, such as in the 2007 Oslo Declaration,wherein the Ministers of Foreign Affairs (not of Health) ofBrazil, France, Indonesia, Norway, Senegal, South Africa andThailand recognized the need for new forms of cooperationto support development, equity, peace and security24. TheUN MDGs are a framework for multinational healthdiplomacy, monitored and promoted by the member states ofthe United Nations, and some have called for codifying themin a Framework Convention on Global Health25. Today’shealth diplomats must understand how global healthgovernance has and must change.

Global health governanceThe shifting role of nation states and the growing insecurityin global public health has generated tremendous discussionconcerning global health governance, particularly given therise of new actors within the field. Cohen drew attention tothe increasing role of private philanthropy, illustrating thenearly unfettered influence and unintended consequences ofefforts by wealthy individuals and organizations now activein the field26.

Further, sovereign nations may lose their power to setother priorities if they must adhere to donor priorities fordisease-specific activities (such as in the first version ofPEPFAR). In fact, the World Bank has suggested a moralhazard argument regarding external funding such as thatwhich is now proliferating: if upwards of 50% of governmentspending comes from external sources, a country may losecontrol of its priorities, programmes and strategies, yieldingall control to the donors27. In this context, what should be theglobal health governance structure and what should be therole of multinational membership organizations in governingglobal health? Without systematic attention to thegovernance needs and social justice issues of healthassistance, global health financiers will fall short of theirintended humanitarian goals.

The role of nonstate actors, including privatephilanthropies, private individuals and private industry, hasemerged as a concern from both political28 and social scienceperspectives29. These new global networks are clearly a 21st century humanitarian assistance phenomenon. The

disparate, uncoordinated efforts within global health call fora more systematic global cooperative effort30,31. However,neither the traditional state actors nor the modern nonstateactors are likely32 to accept either centralization under aruling global authority or harmonization of goals, practicesand procedures across organizations. Nonetheless, theacceptance and integration of health as a global public goodhas crossed a variety of thresholds, including trade, security,bioethics, international relations and economics. Thissuggests that the principles and policies of global healthgovernance, what Fidler terms the “source code”, havefunctioned independently of centralized efforts. Instead ofdeveloping a new governance structure, global health actorsshould consider how successful applications of this sourcecode will look in the 21st century. A range of proposals thatbuild on network governance and aim to bring together themany actors in this new political space have since been putforward33. A growing international consensus on what worksand what does not work in global health, and the growth ofthe new academic global health programmes andphilanthropic structures will redefine global healthgovernance in the years to come.

What should also be evident is the need for new publichealth instruments to support collective health efforts. Fidlercalls for further examination of new efforts in global healthgovernance such as the Framework Convention on TobaccoControl (FCTC) and the revised International HealthRegulations (IHR). The FCTC was the first treatyimplemented under the WHO’s constitutions, Article 19. Ithas now been ratified by 155 countries and will call fornational policies to assure full participation in the Conferenceof the Parties, the supervising entity for the treaty34. Inaddition, there are challenges posed by the new IHR as aconsensus agreement within the WHO for countries tosupport global responses to critical public health problemsand to share information and responses to these problems35.

Emergence of health diplomacy in theUnited StatesIn 2001, the Council on Foreign Relations36 made a strongcase that the US government had a critical responsibility tomake health a priority in foreign policy. US global healthpolicy today is rooted in both national security concerns anda worldwide desire for social justice and equity37. Healthdiplomacy offers the potential for breaking free of thegovernance dilemma by bringing together health and foreignpolicy based on a concept of human security that embracesrights and well-being rather than only enlightened nationalself-interest.

Recently several US government officials have discussedmedical diplomacy as an element of foreign policy, oftenfocusing on the delivery of health care within low-resourcesettings and the distribution of medical technology38,39. In2005, the IOM reviewed a number of international modelsfor increasing humanitarian assistance within the HIV/AIDSepidemic with the suggestion for development of a GlobalHealth Corps that would provide for improved global healthcapacity through elective service by US healthprofessionals40. This programme would actually emulate

Table 1: The United Nations Millennium Development Goals for 2015

1. Eradicate extreme poverty and hunger;2. Achieve universal primary education;3. Promote gender equality and empower women;4. Reduce child mortality;5. Improve maternal health;6. Combat HIV/AIDS, malaria and other diseases;7. Ensure environmental sustainability; and8. Develop a global partnership for development.




efforts such as those provided by Cuba over recent decades41

and that China has recently adopted42.

ConclusionsThis brief review provides an overview of the history,conceptual basis and new inputs into the growing field ofhealth diplomacy, and it provides some perspectives thatwe may include as elements of professional education andresearch in the coming years. Health diplomacy is a field inthe making43, and there is ample material in the history ofinternational relations, humanitarian aid and medicalassistance with which to begin serious analytic work aswell as to develop pedagogy within the academicenvironment. Today, there are literally dozens of globalhealth educational programmes in the United States andEurope, and many of these were described in a recent(January 2008) special issue of Academic medicine. Yetthere are few educational initiatives that focus specificallyon the interface between international relations, diplomacyand public health (Personal Communication, I Kickbuschand C Erk, A survey of training programmes and courses,11 August 2008). With so many new educationalprogrammes involving multiple disciplinary approaches toglobal health education, it is clear that health diplomacy willbe an exciting new academic pursuit within theseprogrammes in the coming decades. �

Thomas E Novotny is a Professor of Epidemiology andBiostatistics at the University of California, San Francisco, and co-director with Professor Kickbusch of an executive training courseon global health diplomacy conducted with support from theCenters for Disease Control and Prevention and the FulbrightSenior Specialists Program. He is director-designate of the JointDegree Program in Global Health at San Diego State Universityand the University of California San Diego.

Ilona Kickbusch is the Director of the Global Health Programmeat the Graduate Institute of International and DevelopmentStudies, Geneva Switzerland with a focus on global healthgovernance and global health diplomacy. She is a politicalscientist with a PhD from the University of Konstanz, Germany,and she is recognized for her contributions to innovation in publichealth, health promotion and global health.

Hannah Leslie is a Program Analyst with the University ofCalifornia, San Francisco Global Health Sciences Program and anMPH candidate at the University of California, Berkeley, School ofPublic Health.

Vincanne Adams is Professor of Anthropology, History andSocial Medicine at the University of California, San Francisco. Shedirects the joint (with UC Berkeley) medical anthropology programin the San Francisco Bay Area.

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19.Fox DM, Kassalow JS. Making health a priority of US foreign policy.American Journal of Public Health, 2001, Oct;91(10):1554-6.

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23. Report of the Secretary-General’s high-level panel on threats, challengesand change, UN. A more secure world: our shared responsibility. Doc.A/59/565 (2 December 2004) http:// HYPERLINK“http://www.un.org/secureworld” www.un.org/secureworld/report.pdf.

24.Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal,South Africa and Thailand. Oslo Ministerial Declaration – global health: apressing foreign policy issue of our time. Lancet, 2007, 369:1373-78.

25.Gostin LO. A proposal for a Framework Convention on Global Health.Journal of International Economic Law, 2007, 10(4), 989–1008.

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29.Wehrenfennig D. Beyond diplomacy: conflict management in a diverseworld. Paper presented at the annual meeting of the Western PoliticalScience Association, Hyatt Regency Albuquerque, Albuquerque, NewMexico, 17 March 2006. Online <PDF>. 2008-06-27, accessed 11August 2008 at http://www.allacademic.com/meta/p97357_index.html.

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References continued


On 28 May 2008 Brian Greenwood, of London Schoolof Hygiene and Tropical Medicine, and Miriam Wereof National AIDS Control Council of Kenya, were

awarded the First Hideyo Noguchi Africa Prize.The presentation ceremony hosted by Prime Minister Yasuo

Fukuda was attended by their Majesties the Emperor andEmpress of Japan and hundreds of international dignitaries,including more than 40 heads of state and government of theAfrican countries participating in the Fourth TokyoInternational Conference on African Development (TICAD IV).The presentation ceremony marked the first day of the TICADIV held in Yokohama. The day happened to coincide with the“80th anniversary plus one week” of Noguchi’s death inGhana, 21 May 1928.

The best description of the ideals of the Hideyo NoguchiAfrica Prize is perhaps the acceptance speeches of the twolaureates (excerpts as follows):

“Forty-three years ago, as a young man, I set off on my firstvisit to Africa to take up an appointment at University CollegeHospital, Ibadan in Western Nigeria. At that time, this wasconsidered rather a strange thing to do. I had up to that pointdone well in my medical career in England and some of myseniors in the UK considered that going to work in Africa wasbizarre, almost a form of professional suicide for a youngphysician. This evening is the occasion on which I havefinally proved them wrong. The concept underlying theNoguchi Prize is an extremely important one as it establishesthe point that what is sometimes considered as rather soft,that is applied or field, research, is as intellectually rigorousand demanding as the high technology laboratory researchthat, in the past, has usually attracted the international prizes.The establishment of the Noguchi Prize will help to redressthis balance and the Japanese Government is to becommended on taking this initiative”, (Brian Greenwood)1.

“Reduction of the disease burden on the people of Africaand improvement of health is crucial for the creation of wealthand improvement of the overall socioeconomic situation inAfrica. People who live in poverty and who are frequently sickcannot be productive enough to improve the situation. Africa’shistory that includes the massive transatlantic slave trade thatdisorganized the continent for nearly 500 years followed bycolonialism and apartheid for a further 100 years laid theroots of poverty and disempowerment in Africa that casts along shadow into the present and future. Healthy people,



Article by Kiyoshi Kurokawa (pictured), Chair, Hideyo Noguchi African Prize andSpecial Advisor to the Cabinet of the Japanese Governmentwith Tamaki Tsukada and Eri Maeda

Hideyo Noguchi Africa Prize

creation of wealth and social stability are some of therequirements for us, the people of Africa, to get out of theindignity in which most of us live. We, the people of Africa, believe that through this forum (TICAD) and the prize outcomes will be positive for Africa”, (Miriam Were)2.

The creation of the prize came out as a typical Koizumi-style coup de main during his visit to Africa in May 20063. Itwas literally a top-down initiative. Nobody at the time actuallythought about the meaning, let alone the consequence, ofcreating yet another prize in the already over-crowdedinternational prize market. However, it turned out that thisparticular field of science – tropical medicine, public health,or so-called translational research – lacked a proper system ofreward which commanded substantial international outreachand legitimacy. It was precisely this area of science andresearch which warranted particular attention of theinternational science community if we were to defeat theglobal health challenges.

Why do we have to constrain ourselves on a specificcontinent when a global issue like health and medicine is atissue? Because Africa is the continent most in need ofresources, financial or otherwise, in order to achieve theUnited Nation’s Millennium Development Goals (MDGs).

These were the founding principles and parameters whichdetermined the framework of the new prize. The prize has setitself a totally different and radical approach on how torecognize, inspire and shape research in a globalizing world.

Before going into the prize further, let us briefly reviewHideyo Noguchi, a figure who captivated Koizumi’simagination to conceive this prize.

Who is Noguchi?Hideyo Noguchi (1876–1928) was a prominent Japanesebacteriologist in the early 20th century, internationallyacclaimed for his contribution to the understanding ofinfectious diseases4. Noguchi eventually died in Accra, GoldCoast (now Ghana) of yellow fever while working in search ofits pathogen5. It is said that the death of his close Rockefellercolleague Dr Adrian Stokes of yellow fever made Noguchidecide to travel to Africa. It was still a decade before the viruswas discovered by mankind and ascertained as the pathogen.

Noguchi was born in a very poor family in theimpoverished rural village of Fukushima. He had a physical

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handicap, a deformity on his left hand due to a burn that hesuffered during his early childhood. Nothwithstanding thesehandicaps, he managed to obtain, through extraordinaryhard work, a licence to practise medicine in Japan. He didexceptionally well in school but in those days, obtaininghigher education, especially in medicine, was expensive andexclusive. The professional horizon of a medical student froma lowly family background without a degree from the ImperialUniversity, could not extend much further than a provincialpractitioner. Noguchi was not content to remain in obscurity.

In 1901, at the age of 23, Noguchi moved to the UnitedStates and made his way to the laboratory of Simon Flexnerat the University of Pennsylvania. In 1904, Flexner wasinvited to head the newly founded Rockefeller Institute forMedical Research (now Rockefeller University), and broughtNoguchi, his most trusted protégé, with him. In the earlyyears in the institute, Noguchi earned the epithet “humandynamo”, not without a racist hue. But by the 1910s he wasone of the top researchers leading the institute to world famecomparable to its European counterparts. In those days inthe field of medicine (and to a large extent science ingeneral), the United States had been playing the secondfiddle to Europe.

His extraordinary appetite for research and zeal to conquerthe cause of diseases, brought him to various places in thewestern hemisphere in Central and South America where therate of death from yellow fever was particularly high. TheRockefeller Institute for Medical Research had formed aspecial task force for South America and appointed Noguchias one of its leaders. In 1918, Noguchi landed on Guayaquil,Ecuador, the epicentre of this disease; his battle againstyellow fever thus began. In just nine days, he isolated thepathogen (Leptospira icteroides) and produced a vaccine andantiserum, successfully lowering the death rate. Noguchiwas worshipped as a crusader against yellow fever in placeswhere he visited: Mexico, Brazil and Peru. However, it wasnot possible at that time to identify a virus; it did not existeven in people’s imagination. However, Noguchi harbouredsome doubts about the veracity of his findings and he didrecord certain observations to this effect true to his academicconscience. That was what motivated Noguchi to set sail for Africa.

A prominent Rockefeller scientist travelling all the way toAfrica, notwithstanding various prejudices against a non-white, physically handicapped upstart had a tremendousimpact worldwide. It is this courage and passion combinedwith his belief in field-based research that makes Noguchiand his contribution remarkable. And this is the nexusbetween Noguchi and the newly created prize.

Business model or process of the prizeIt is not possible to make a simple comparison between thestyle of research in the days of Noguchi, when researcherswere honoured simply by discovering or isolating agents frompatients, and that of the contemporary scene whereconditions and requirements have become much morecomplex. However, the field-based research style of Noguchiis increasing in its value in combating diseases in Africa.There is an atavistic call for simple but high quality researchbased on practical needs on the ground combined with adeep understanding of the ecological and human factorsindigenous to Africa.

In May 2006, Prime Minister Koizumi announced theestablishment of the prize in the joint press conference withPresident Kufuor of Ghana. After returning to Japan, Koizumiinstructed the ministries of foreign affairs, health and welfare,and science and education to elaborate on the concept. TheCabinet Office was designated as the coordinating agencyand in July 2006, in the Japan-African Union (AU) summit,the prize became the main agenda. In the joint pressconference by Prime Minister Koizumi and AU ChairpersonKonare it was announced that the prize will be awardedevery five years and that the first will be awarded in 2008within TICAD IV. A cabinet decision was made to that effect.

The latter part of 2006 was consecrated to establishing atruly effective business model or process in order for thisprize to be competitive and attractive in the sciencecommunity as well as pertinent to the global (i.e. African)health needs.

The first demand was to ensure diversity andinclusiveness. Nominations will be sought from around theglobe including all the 53 countries in Africa. Africa has oftenbeen a non-entity in the science community. Byinclusiveness, we do not mean affirmative action. What isneeded is a truly fair and equitable playing ground toencourage research of Africa, for Africa, by Africa. Thecomposition of the three selection committees will be international with a balanced representation from various continents6.

The second demand was to ensure fairness and academicrigour of the selection process. Not only the outcome but alsothe process through which the laureate is elected should besuperlative, that is worthy of the substantial amount ofhonorarium attached to the prize. Prestige and appeal of aprize is not something which could be bought but onlyearned by example. For this purpose, two sub-committeeswere set up to conduct the expert level screening in respect



Hideyo Noguchi (1876–1928) was a prominentJapanese bacteriologist in the early 20th century,internationally acclaimed for his contribution to theunderstanding of infectious diseases. Noguchieventually died in Accra, Gold Coast (now Ghana) ofyellow fever while working in search of its pathogen

The latter part of 2006 was consecrated toestablishing a truly effective business model or

process in order for this prize to be competitive andattractive in the science community as well as

pertinent to the global (i.e. African) health needs

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of medical research and medical services. The HideyoNoguchi Africa Prize Committee, the parent body presidingover the two sub-committees, will finalize the candidates to be recommended to the Prime Minister of Japan for final decision.

The third demand was to ensure relevance of the prize tothe health/medical reality on the ground. The “connectivity” ofthe prize with the people and society of Africa is the corevalue of the prize. The connectivity is embodied in thefinancial mechanism too. One half of the honorarium will befinanced by the Government of Japan and the other half bydonations from the public which will be administered by theJapan International Cooperation Agency (JICA).

What are the main target areas of the prize? The prize willfirst and foremost vigorously encourage research on the majorand most relevant medical and heath issues in Africa.Although dramatic achievements have been made in recentdecades in this area, there is still an absolute shortage ofawareness beyond the expert community. The prize, by itsinstitutional linkage to the TICAD process and its strongresonance with global health policy, aspires to be a keyinstrument in addressing the medical as well as public healthchallenges in this area.

The prize values not only the advancement of ourunderstanding of African diseases in terms of biomedicalresearch in its conventional sense, but also our understandingof the bigger picture in terms of human and environmentalecology surrounding these diseases.

The prize will also give more emphasis on the human andsocietal aspect of the research or health activities in concern.We do not believe that such an approach will compromise thedisciplinary rigour of research or health activities. If anything,this kind of emphasis will lead to a bigger impact in terms ofachieving the MDGs more effectively.

Achievements of the two laureatesNomination requests together with the nomination guidelineswere sent out to more than 2000 individuals and institutions,and slightly more than 100 nominations were received.

From February to December 2007, the Medical ResearchSub-Committee selected three among 57 candidates.Meanwhile, from June to December 2007, the MedicalServices Sub-Committee selected three among 23candidates. These six candidates were referred to the HideyoNoguchi Africa Prize Committee for final consideration. InFebruary 2008, the Hideyo Noguchi Africa Prize Committeeunanimously recommended Brian Greenwood and MiriamWere as the candidates for the first prize. This was dulyapproved and announced on 26 March 2008 by the Prime Minister.

Reactions from the international health and researchcommunity were cordial and encouraging. The WHO, the World Bank, the Gates Foundation, the RockefellerFoundation and the Rockefeller University were among those who issued genial statements congratulating the laureates7.

Brian Greenwood was honoured for his bold and innovativework on malaria. At a time when malaria was spreading



uncontrollably across the African continent claiming morethan 1 million lives a year, Greenwood contributed to thecreation and designing of effective strategies to controlmalaria. His crucial contributions in malaria research greatlyhelped developing the tools and knowledge that are essentialin turning the tide on this devastating disease. His workbrings hope where very recently only despair existed.

Greenwood has spent more than 30 years on site in Africaincluding 15 years as Director of the MRC Laboratories in TheGambia where he pioneered landmark research contributingto the understanding of the immunology, pathogenesis andepidemiology of malaria, a major killer in Africa, and otherinfectious diseases such as meningitis and pneumonia, allmajor contributors to mortality among children in Africa. Hisresearch and translational clinical studies, involving simplebut high quality methods as well as field trials of drugs andvaccines, have provided the scientific underpinning to a widerange of influential public health policies at national andinternational levels. His important contributions include:� Demonstration of the effectiveness of insecticide-treated

bed-nets for control of malaria, which is now thecornerstone of malaria interventions throughout thecontinent, supported and financed by many donoragencies;

� Primary studies on artemisinin-based combinationtherapies (ACTs), now widely adapted as first-linetreatment for malaria;

� Demonstration that malaria chemoprevention reduceschild mortality. This is now being applied for intermittentpreventive treatment in infants, children and in pregnancy;

� Substantial contributions to trials of malaria vaccines,including the efficacious RTS,S vaccine.

Another important aspect of Greenwood’s achievements ishis reinvention of field research in tropical medicine –changing it from an ancillary colonial or military activityfocusing on hygiene to a multi-partite, multi-disciplinaryendeavour, wherein holistic solutions are required – based oncutting-edge science and a genuine understanding of thecomplex eco-system as well as real-life challenges unique toAfrica. Thus laboratory and clinical research, preventive andcurative medicine, epidemiology, anthropology, andbehavioural research were all brought together. These modernapproaches which we now take for granted came fromGreenwood’s prescience and leadership.

Over the years, Greenwood has made capacity building –another lasting legacy of his research based on African soil –a central objective including the training and support of youngAfrican scientists. A cohort of students, doctors and clinicianswho developed their careers under Greenwood’s inspirationalmentorship has immensely contributed to the increase in

The prize will first and foremost vigorously encourageresearch on the major and most relevant medical and

health issues in Africa

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stature of medical research in Africa amongst the scientificcommunity in general.

Under the medical services category, the inaugural awardwent to Miriam K Were, whose efforts to bring basic medicalservices and health rights to women and children in thevillages of East Africa has been a beacon of hope for millionsof people in Africa and the world. Through her work withAfrican Medical and Research Foundation (AMREF)8 andUZIMA Foundation9, Were has been a source of inspirationfor all people on the African continent.

For the past 40 years, Were has dedicated her life toadvancing the health and welfare of the people of Africathrough a focus on the practicalities of delivering service at alocal level. She has united communities to develop andimplement innovative solutions to quotidian health problems.The most illustrious example of her community-basedapproach is her ongoing work to build public toilet facilitiesin local communities, improving hygiene and overcominglongstanding taboos. She also drastically raised the infantvaccination rate by organizing children into small groups tovisit local clinics. Her innovation and systemic precedentshave had enduring impacts not only in Kenya but throughoutthe East African region and across the entire continent,through her engagement with the African Union and as a keyhealth adviser to the African Heads of State on AIDS,tuberculosis and malaria.

Her style of work through the direct engagement of theyouth, sex workers, intravenous drug users, homosexualsand others to encourage openness and frank discussion onsexuality and HIV/AIDS has galvanized communities inKenya and contributed to the reduction of stigma anddiscrimination against people living with HIV/AIDS. She is adedicated advocate for vulnerable populations, especially thepoor and the marginalized. She is also committed to theempowerment and development of all voices across lines ofsex, tribe, and age and class background. Widows andorphans severely affected by HIV/AIDS are amongst thosemost positively touched by her contribution to expandingaccess to medical services.

We would also like to pay tribute to the families,particularly the spouses, of the two laureates whosecontinuing support and understanding for the harsh workingenvironment of medical profession/career in Africa has beeninstrumental to realise these achievements. The importanceof these familial ties came home to all of us during the flowerpresentation ceremony by the children of the alma mater ofHideyo Noguchi in Fukushima when Alice Greenwood (wifeof Brian Greenwood) and Humphreys Were (husband ofMiriam Were) hugged each other in tears congratulating eachother’s enduring assistance over the years.

ConclusionThe prize is a unique call to marshal the multitude ofactivities on research and service delivery in the field ofhealth transpiring on the African continent – a continent mostin need of resources and care but often marginalized andneglected – and eventually to transform the way in which theinternational community addresses medical and health

issues on Africa.Japan as Chair of G8 this year, which is incidentally the

year of TICAD, is leading the efforts to harness the surgingenthusiasm of the international community on the healthagenda10. The Japanese government considers the HideyoNoguchi Africa Prize mechanism to be an integral part of thispolicy context.

Health and medical interventions tend to be subject to thewhim of pity. Of course, health matters are by naturehumanitarian. However, we need to conscientize the publicthat charity is not sufficient to roll back the overwhelminghealth challenge in Africa. We need to encourage robustscience and research in Africa. Science should not be amonopoly of the developed world. Research on Africanhealth cannot be truly meaningful or sustainable unless it isowned by Africans.

The following excerpt from an article by ProfessorMakgoba, Vice-Chancellor of KwaZulu Natal University,perhaps best captures the African hope and expectations.

“Major international prizes that have shaped modernmedical scientific advancements such as the Nobel Prize,have the thrust on individualistic scientific achievementswithout a direct link to society or a focus on global healthburden. For these reasons they have advanced science andhealth research in a particular, esoteric way; have becomeprizes of the elite and advantaged science and scientists ofthe developed world; and have been detached from realglobal health problems. As a result, while prestigious, inreality they have been exclusive and insensitive to thehealth realities of the developing world. Often the processesand structures of their decision-making have beenshrouded in secrecy and have lacked diversity andinternationalism. It will be interesting to see how theseestablished awards rise to the challenges of the modernworld and in particular to the impact of this newly launchedHideyo Noguchi Africa Prize.”

We wish to acknowledge our indebtedness to each and allof the three selection committees in particular the threechairpersons for their intellectual and moral supportthroughout the process. We must also record our deepgratitude and almost thunderstruck admiration for JunichiroKoizumi for his sense of mission which constantly motivatedand inspired us to make this concept a reality*. �

*The opinions contained herein do not necessarilyrepresent the views or policies of the Government of Japan.

Kiyoshi Kurokawa MD is Chair of the Hideyo Noguchi AfricaPrize Committee and Special Advisor to the Cabinet of theJapanese Government. See www.kiyoshikurokawa.com11

Tamaki Tsukada is Director of the Hideyo Noguchi Africa PrizeUnit, Cabinet Office (currently Director of Economic SecurityDivision, Ministry of Foreign Affairs).

Eri Maeda is Officer of the Hideyo Noguchi Africa Prize Unit,Cabinet Office (currently South-East Asia Division, Ministry ofForeign Affairs).



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1. See acceptance speech by Brian Greenwood at the Presentation Ceremony,28 May 2008 (http://www.cao.go.jp/noguchisho/jyusyousiki-sikisidai-e/greenwood-e.pdf).

2. See acceptance speech by Miriam Were at the Presentation Ceremony, 28 May 2008 (http://www.cao.go.jp/noguchisho/jyusyousiki-sikisidai-e/were-e.pdf).

3. See address by Junichiro Koizumi to the Nippon Keidanren (Confederationof Japanese Business), 4 July 2007(http://www.cao.go.jp/noguchisho/bokin/aisatsu-e.pdf).

4. Noguchi’s major research achievements could be summarized as follows:1. Discovery of Treponema pallidum, the causative agent of syphilis, inthe brains of progressive paralysis patients (1913). 2. Success in growing pure culture of Syphilis spirochete (1911),however, no one has succeeded ever since in the replication of pureculture of Syphilis spirochete.3. Proves that both Oroya fever and Verruga peruana are caused by asingle pathogen Bartonella bacilliformis by verifying that Bartonellabacilliformis invades red blood cells in both cases (1926).4. Observation of Leptospira icteroides from patients of yellow fever(1919). (Leptospira, which was then identified as the cause of yellowfever by Noguchi, was later disproved and proved to be in fact thespirochete of Weil’s disease. His name is remembered in the binomialleptospira noguchi in the classification of spirochetes.)The number of research papers written by him reached almost 200 andvarious kinds of infectious diseases came under the scope of his interest,varying from study of pathogens and immunology to development ofvaccine and experimental technique. Noguchi was three times nominatedas a Nobel-Prize candidate in the period 1914–1920.

5. The Noguchi Memorial Institute for Medical Research was established in1979 and named after Hideyo Noguchi who died from yellow fever in1928, the very same disease he was researching into(http://www.noguchimedres.org/).

6. The nationality of the members of the Hideyo Noguchi Africa PrizeCommittee is as follows: 8 Japan, 1 UK, 1 USA and 1 Senegal. See the

following for details: http://www.cao.go.jp/noguchisho/iinkai/iinmember-e.htmlThe nationality of the members of the Sub-Committee for MedicalResearch is as follows: 19 Japan, 1 France, 1 Mexico, 1 USA, 1 Ghanaand 1 Australia. See the following for details:http://www.cao.go.jp/noguchisho/iinkai/medicalresearch-e.htmlThe nationality of the members of the Sub-Committee for Medical Servicesis as follows: 3 Japan, 7 African (Mali, Nigeria, Gambia, South Africa,Côte d’Ivoire, Zambia and Mozambique), 1 Mexico and 1 USA. See thefollowing for details:http://www.cao.go.jp/noguchisho/iinkai/medicalservice-e.html

7. See for example the following statements and press releases: WHO: http://www.who.int/mediacentre/news/releases/2008/pr10/en/World Bank: http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,contentMDK:21701357~pagePK:34370~piPK:34424~theSitePK:4607,00.htmlRockefeller University: http://newswire.rockefeller.edu/?page=engine&id=736Gates Foundation:http://65.117.201.112/GlobalHealth/Announcements/Announce-080326.htm

8. Professor Were serves as a Chairman, International Board of Directors ofthe African Medical and Research, Foundation, AMREF from February2003 to date (www.amref.org).

9. Professor Were was Founding Chairperson up to 2001 and is a Member ofthe Board of Trustees of the UZIMA Foundation to date. The Foundation isa charitable trust registered in Kenya (http://uzimafoundation.org/main/).

10.See for example the following report by the G8 health experts group:http://www.g8summit.go.jp/doc/pdf/0708_09_en.pdf

11.See following commentaries and reports by the author Kiyoshi Kurokawa:http://www.bdafrica.com/index.php?option=com_content&task=view&id=1726&Itemid=5821http://www.kiyoshikurokawa.com/en/2008/04/announcement-of.htmlhttp://www.kiyoshikurokawa.com/en/2008/05/hideyo-noguchi.html

References

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Innovation is a complex concept referring to the creation ofsomething new, normally through study andexperimentation. In the context of public health,

innovation usually results from research and may includenew medicines, medical devices, diagnostic methods, clinicalpractices or means of health care delivery1.

Economic development is associated with a progressiveincrease and improvement in the production of goods andservices, however, social development is associated with thelevel of cohesion and distribution of wealth2. The Index ofHuman Development is an approximation to the degree ofsocial development, and is a weighted measure of the GDPper capita, life expectancy and literacy level3. In this context,the Millennium Development Goals have galvanizedunprecedented efforts to meet the needs of the world’spoorest and range from halving extreme poverty to halting thespread of HIV/AIDS and providing universal primaryeducation, all by the target date of 2015. These estimatesmake evident a tendency towards the globalization of healthproblems4, sharing risks, disability and moral consequences,all of which require uniting efforts to combat these threats.

Within the broad context of health and innovation and itsoutlook in the context of world health we will briefly commenton the recent advances in defining objectives and policyinstruments in research and development in health-relatedareas in Spain, and some of the challenges still facing us.

The Spanish framework of research,development and innovationThe general aim of biomedical research is still the prevention,improvement or cure of human diseases. Spain has one ofthe best national health systems in the world; it providesessentially free medical and hospital health care coverage toall residents of Spain, including immigrants, as well as highstandards of diagnosis and treatment. Although biomedicalresearch has increased significantly in Spain in the lastdecade, it is still not among the ten most productive countriesin the EU, keeping in mind a number of indicators andcorrected for population. We have, therefore, developed anew framework to try to close this gap, based on: � The Biomedical Research Act (of July 2007), which

provides modern regulation for the most advanced toolsin biomedicine, i.e. human stem cell and embryonictissue use, genetic analysis, biobanks, etc. The Act alsoaddresses the recognition of health research as a careerfor health professionals and provides incentives forpursuing it. This new law was fostered by the Ministry ofHealth and Consumer Affairs and many of its aspects willbe implemented by the Instituto de Salud Carlos III(ISCIII).

� The Research and Development and Innovation (R&D&I)2008–11 National Plan, including all areas of publiccentral government funded research, came into effect inSeptember 2007. The three guiding principles of thisplan for scientific and technological policy in Spain are: i)to serve the citizens, increasing social well-being andsustainable development with complete and equalincorporation of women; ii) to contribute to improvingcompetitiveness in the private business sector; iii) torecognize and promote R&D as an essential element forthe generation of new knowledge. The health componentpursues the following goals: 1) to generate knowledge inorder to improve health; 2) to foster innovation; and 3)technology transfer and translational research “from thebench to the bed side”. The budget allocated to thisinitiative has greatly increased and new initiatives havebeen set up such as research networks, training andtechnology transfer. Main lines of research include: 1)cellular and molecular technologies; 2) translationalresearch; 3) public health, environment and occupationalhealth; 4) pharmaceutical research; and 5) scientific and technical research.

� The recently created Ministry of Science and Innovation(April 2008) will manage the majority of centralgovernment funds earmarked for R&D&I and willcooperate with the 17 autonomous regions, each ofwhich have independent budgets for health and R&D&I.

According to the 2008 edition of Science, Technology andInnovation in Europe published by EUROSTAT, analysing thedata of 2006, Spain spent 1.16% (6546 million euros) of itsGDP in R&D, whereas the EU27 devoted 1.84% of their GDP



Article by Flora de Pablo (pictured), Director-General, Instituto de Salud Carlos III,University of Salamanca, Spainwith Isabel Noguer

Health research andinnovation: recentSpanish policies

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(210 000 million euros). The range is broad among differentcountries, with Sweden and Finland reaching 3.82% and3.45% respectively, whereas Romania, Bulgaria andSlovenia do not reach 0.5%. With a rather limitedinvestment, however, Spanish scientists have markedlyincreased the number of publications included ininternational databases (Web of Science): they represented1.9% of the world’s total in 1999, and 3.1% in 2006. Thisplaces Spain in tenth position in the world based on numberof articles, but in position 36 based on citations perdocument. More than 50% of these publications in the lastdecade correspond to biomedical disciplines and healthsciences.

Science moves fast in a global world context andcontinuous support is required to obtain valuable results. Westill face many challenges and pending tasks in biomedicalresearch that need to be tackled:� The modern hospital where clinical care, research and

teaching are intrinsic synergistic daily activities is notwidespread in the country, although a group of excellentcentres have, or soon will have, achieved accreditationas “Institutes of Health Research”, recognizing theirqualification at the highest standards level.

� The transfer of knowledge to the productive system isvery slow. We have to promote and facilitate theregistration of patents and the creation of “spin off”technologically based companies to levels comparable tothose of countries in our economic sphere. For that tohappen, the main task is to build trust among publicand private partners for fruitful collaborations.

� Participation in the most innovative EU programmes, aswell as in the Seventh European Framework Programme(7FP) has to increase. In this context the Spanishgovernment has launched EUROINGENIO 2010 in orderto increase Spanish participation and funding from thewhole of health related programmes and tools offered bythe 7FP. Spain is one of the most important contributorsto European Development Clinical Trials Partnerships(EDCTP) or Ambient Assisted Living (AAL), both ruled byarticle 169 of the European Union Treaty.

In summary, we are beginning a most exciting time forbiomedical research growth in quality and impact ininnovation in Spain. The target of the new Ministry ofScience and Innovation is to make Spain one of the world’sten most productive countries in the field of science,technology and innovation by 2015. We already have thehuman potential, we just need to be successful in themanagement of economical resources, and to keepincreasing these resources with public and, in higherproportion than now, private participation.

The Spanish contribution to some worldhealth challengesA recent study on Global Burden of Disease (GBD)projections from 2002 to 20305 predicts significant changeswith regard to mortality and disabilty in the world. Lifeexpectancy in all continents will increase, mortality due to

infectious diseases will decrease while that caused bynoncommunicable diseases will rise. Ischaemic heartdisease and cerebrovascular disease will be the two leadingcauses of mortality in the world (see Table 1).

Although deaths due to HIV/AIDS are still on the rise , theywill be overtaken by deaths due to the consumption oftobacco. Vascular diseases are the first cause of mortality inall regions, with major differences based on the classificationof countries according to their income. In general, theseforecasts place the world on an equal footing with regard tothe definition of research priorities and the benefits ofpossible results.

The three leading causes of Disability Adjusted Life Years(DALYs) are projected to be HIV/AIDS, unipolar depressivedisorders and ischaemic heart disease. In this case, there arealso significant differences based on the level of income ofcountries (see Table 2).

Infectious diseases have not yet been overcome. In thiscontext, aside from the potential benefits of a global strategyfor more efficient development cooperation, synergy andwealth generation, greater investment in health is needed6.On the other hand, forecasts for HIV/AIDS growth create newchallenges for cooperation and R&D&I policies. Thisepidemic, as well as other infectious diseases, on account oftheir relationships with the adoption of behaviour patterns,offers areas for cross research with chronic diseases, so verywidespread in developed countries. Strategies like “MultipleHealth Behaviour”7 could benefit developing countries intheir fight against HIV. Evidence-based medicine and rationaluse of antibiotics still suffer from large gaps in theirapplication, extension and potential benefits both indeveloping and developed countries8, 9, 10.

As for future threats to health, Spain is contributing in avariety of ways. The National Plan for R&D&I 2008–2011,



Table 1: Ten leading causes of death, 2030

Rank Disease or injury % of total deaths

1 Ischaemic heart disease 13.42 Cerebrovascular disease 10.63 HIV/AIDS 8.94 Chronic obstructive pulmonary disease 7.85 Lower respiratory infections 3.56 Trachea, bronchus, lung cancers 3.17 Diabetes mellitus 3.08 Road traffic accidents 2.99 Perinatal condition 2.210 Stomach cancer 1.9

Table 2: Estimated leading causes of DALYs in 2030

Rank Diseases

1 HIV/AIDS 2 Unipolar depressive disorders3 Ischaemic heart disease 4 Road traffic accidents 5 Perinatal conditions 6 Cerebrovascular disease 7 Chronic obstructive pulmonary disease8 Lower respiratory infections 9 Hearing loss, adult onset 10 Cataracts

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prioritizes translational research in those diseases that createthe highest mortality and burden of disease in the world.Public health, environmental health and occupational healthare common to the entire set of prioritized diseases.

International cooperation is present in the National Planand other solidarity-based government initiatives. TheIberoamerican Program for Science and Technology (CYTEC)endowed with US$ 6 million (70% donated by Spain)strengthens all areas of knowledge and technology, financingprojects, research networks or technological innovationconsortia. The Interuniversity Cooperation Program withIberoamerican and Mediterranean countries was endowedwith 21.5 million euros in 2008.

Within the framework of the World AIDS Conference for2008, the Spanish government has just announced acontribution of 10.2 million euros to the UNAIDS Programmegiving priority to research on vaccines and microbiocides. Asfar as other infectious diseases are concerned, in 2008,Spain contributed 16.3 million euros to the InternationalUnion against Tuberculosis and 12.9 million euros to the fightagainst zoonosis in the Mediterranean.

In the Iberoamerican context, the Spanish governmentsupports the Pan American Health Organization’sprogrammes with a total of 14 million euros to fight the mainhealth problems in Iberoamerica especially communicablediseases. Lastly, the ISCIII contributes to the Tropical DiseasesResearch Programme of the WHO and other multilateralpartners, focused on research and development ofprogrammes to fight neglected diseases, as well as others led by the WHO within the field of infectious and chronic diseases.

The most important benefit of progress in understandingthe human genome may be for common chronic diseasessuch as cardiovascular disease, diabetes mellitus and cancer.However the integration of such knowledge into clinicalpractice is still in its early stages. Therefore many questionssurround the current state of this translation. Someresearchers have found gaps in knowledge about medicalorganization, clinical behaviour and practice, and patientneeds that should be addressed to translate scientificadvances of chronic diseases into practice11. It is estimatedthat it takes on average 17 years for proven medical advancesto be incorporated into common practice, with the exceptionof new technologies and pharmaceuticals12.

We have not found estimates applicable to developingcountries, including technologies that are already widespreadin the developed world. However, new and innovativeinitiatives of public private partnership are underway13, 14, 15, 16,



17 and the results of such programmes will create a precedentfor R&D&I at the service of the neediest populations. �

Flora de Pablo is Director-General of the Instituto de SaludCarlos III (National Health Institute Carlos III). An MD and PhDfrom the University of Salamanca, she worked at the NationalInstitutes of Health in Bethesda (USA) for nine years until 1991,and in the California Institute of Technology in Pasadena (USA) in1996. Until 2007 she was Professor at the Center for BiologicalInvestigation (CSIC) in Madrid, where her group studied growthfactors in embryonic development.

Isabel Noguer MD, MPH, PhD Isabel Noguer is currently workingfor the Instituto de Salud Carlos III, as a Deputy Director-Generalof International Research Programmes, and mainly devoted topromoting the participation of the ISCIII and National HealthSystem centres in international research programmes, especially7FP of the EU.

She is an epidemiologist and public health expert. She workedfor the Spanish Ministry of Health for 15 years in different fields,particularly HIV/AIDS. She conducted a wide range of technicaland operational studies for international and multilateral agencies(World Bank, PAHO, UNAIDS, WHO), has several internationalpublications and led different European and international projects.

Key messages

� Global burden of disease makes evident a tendencytowards the globalization of health problems,sharing risks, disability and moral consequences, all of which require uniting efforts to combat these threats.

� Spain is beginning a most exciting time forbiomedical research growth in quality and impact ininnovation. The target of the new Ministry of Scienceand Innovation is to make Spain one of the world’sten most productive countries in the field of science,technology and innovation by 2015. We already havethe human potential; we just need to be successfulin the management of economical resources, and tokeep increasing these resources with public and, inhigher proportion than now, private participation.

� New and innovative initiatives of public-privatepartnership are underway, especially in vaccines.The results of such programmes may create aprecedent for R&D&I at the service of the neediest populations.

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1. Report of the intergovernmental working group on public health,innovation and intellectual property. 61st World Health Assembly actions.www.who.int/mediacentre/events/2008/wha61. Consulted on 30 July2008.

2. Accountability in poverty reduction strategies: the role of empowermentand participation. Social development papers. Participation and civilengagement. Paper 104, May 2007.

3. United Nations Development Programme (UNDP). Human DevelopmentReport 2006, UNDP 2007. http://www.undp.org.cn. Consulted on 1August 2008

4. Murray CJL, Lopez AD. Alternative projections of mortality and disabilityby cause 1990–2020: global burden of disease study. Lancet, 1997349:1498–1504.

5. Mathers CD, Loncar D. Projections of global mortality and burden ofdisease from 2002 to 2030. PLoS Medicine, 2006, 3(11):e442. doi:10.1371/journal.pmed.0030442.

6. Macroeconomics and health: investing in health for economicdevelopment. Report of the Commission on Macroeconomics and Health.World Health Organization, 20 December 2001.

7. Prochaska JO. Multiple health behavior research represents the future ofpreventive medicine. Preventative Medicine, 2008, 46:281-5.

8. Howland RH. Limitations of evidence in the practice of evidence-basedmedicine. Journal of Psychosocical Nursing and Mental Health Services,2007, 45:13-6.

9. Finch R. Innovation – drugs and diagnostics. Journal of AntimicrobialChemotherapy, 2007, 60 Suppl 1:i79-82.

10.Owen N, Glanz K, Sallis JF, Kelder SH. Evidence-based approaches todissemination and diffusion of physical activity interventions. AmericanJournal of Preventative Medicine, 2006, 31(4 Suppl):S35-44.

11.Scheuner MT, Sieverding P, Shekelle PG. Delivery of genomic medicine forcommon chronic adult diseases: a systematic review. Journal of theAmerican Medical Association, 2008, 19;299:1320-34.

12.Liang L. The gap between evidence and practice. Health Affairs(Millwood), 2007, 26:w119-21.

13.Mahoney RT, Krattiger A, Clemens JD, Curtiss R 3rd. The introduction ofnew vaccines into developing countries. IV: Global Access Strategies.Vaccine 2007, 16;25:4003-11.

14.Graham WJ et al. Measuring maternal mortality: an overview ofopportunities and options for developing countries. BMC Medicine, 2008,26;6:12.

15.Ryman TK, Dietz V, Cairns KL. Too little but not too late: results of aliterature review to improve routine immunization programs in developingcountries. BMC Health Services Research, 2008, Jun 21;8:134.

16.Lawes CM, Vander Hoorn S, Rodgers A. Global burden of blood-pressure-related disease, 2001. Lancet, 2008, 3;371:1513-8.

17.Manzi F et al. From strategy development to routine implementation: thecost of Intermittent Preventive Treatment in Infants for malaria control.BMC Health Services Research, 2008;31;8(1):165.

References

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There is a need to rethink the role of research indevelopment assistance and move beyond healthresearch to a new paradigm, called “research for

health”. The Danish Government considers research forhealth the tipping point in building good governance anddemocratic processes that are important for health. It isthrough such progress that long-term change on indicators ofhealth and overall well-being can be accomplished. Healthindicators, in particular, have come increasingly into focus asthe world aims to achieve the Millennium Development Goals(MDGs) by 2015. However, it is also becoming evident thatcapacity to undertake research is as important as theresearch itself. Without a mass of qualified personnel able tothink and act critically at all levels of the health system, coreindicators of maternal and infant mortality, nutrition, malariaand tuberculosis will not reach the targets set by theinternational community, especially in Africa1.

The Council on Research for Development (COHRED) hasdefined this new paradigm, research for health, as “the widerrange of activities and strategies that take health research onestep further, and make it an essential input into both humanand economic development”2. Research for health demandsmultidimensional knowledge which takes into account social,political, economic, ecological and environmentaldeterminants of health, while simultaneously redefining“who” has the power to lead, fund, implement and use

Article by Kirsten Havemann, Senior Technical Adviser, Ministry ofForeign Affairs, Denmark

The changing landscape ofresearch for health

Introduction: policies for innovation – the Danish perspective and experiences

It is my pleasure to present the article, “The changing landscape of research for health” below, whichdescribes more than 30 years of Danish experiences in funding research as part of developmentcooperation. The article demonstrates a deep commitment to the ultimate goal of equal partnershipbased on a new paradigm, through the process of research for health.

The Danish Government is committed to ensuring that the support to research is demand driven andadheres to the Paris Declaration. It is also important to emphasize that the research results are an

essential element of poverty reduction efforts. I find it important to stress that the developing countries together with their development partners will need to work

together and broaden the scope of research to extend beyond academic institutions. In an environment of globalization,urbanization and rapid technological innovation there is an urgent need for innovation and rethinking of the role ofresearch and the knowledge that it generates. In particular, it needs to become integrated as part of development co-operation.

It is my hope that the article on the Danish perspectives and experiences can contribute to the rethinking and innovationneeded in the area of research and health.

Ulla Tørnæs, Minister for Development, Ministry of Foreign Affairs, Denmark

research. Thus, traditional biomedical models and systems ofhealth research are giving way to a more holistic paradigm3

based on equity and inclusion in order to impact and improve global health. This new emphasis, along with greaterfocus on quality of the research processes, will require major attention to capacity development, most notably for governments and civil society organizations in developing countries.

Through case studies emerging from Denmark’s support ofresearch cooperation, and from global experience, this articlewill demonstrate how traditional research can bestrengthened and complemented through the emergingparadigm and utilized in an effort to positively impact globalhealth and well-being. More specifically, the articleprogresses as follows: it details the requirements of the newparadigm, and subsequently touches upon the road towardsnew standards, attitudes and behaviours as well as tools andmethods within the framework of research for health. It endswith key challenges and recommendations based on theDanish experience.

Shifting paradigm The World Health Organization states that three out of eightMDGs, eight of the 16 targets to achieve the MDGs and 18of the 48 indicators for success of the MDGs relate directly tohealth4. Health is an important contributor not only to the

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MDGs, but is also the basis for effective social and economicprogress. In order to achieve the MDGs, a focus on betterhealth for all – regardless of status – is very much needed.In addition, research and the knowledge it generates is indemand. The emerging research paradigm requires buildinga broad based public health and research system5. Thisrequirement demands a shift in the culture and practice ofhealth research to “reach beyond academic institutions andlaboratories”6 for providing a comprehensive evidence basefor rights-based approaches to health policy7 that will includepolitical and socioeconomic determinants that influencehealth and well-being8. Policy-makers, implementers of healthsector reforms, health promoters and researchers need toexpand their understanding of what constitutes “legitimate”evidence in this new paradigm, research for health, with theaim of more positively impacting inequities, and for thecreation of conditions that create better research environments.

Take for example the Danish funded ENRECA(Enhancement of Research Capacity in DevelopingCountries) which had the goals of enhancing local researchcapacity and partnership through cooperation on equal termsbetween Southern and Northern partners. ENRECA began15 years ago and spearheaded an increased focus oncapacity building as a more integrated part of researchprojects. The researchers from the South who haveparticipated in the ENRECA programme have been able toshare their knowledge with other local co-researchers, andthey have often been called upon as advisers by localauthorities and by donor countries, such as Denmark. WithinDenmark, ENRECA has been supportive in building anetwork of researchers for health. These programmes werethe basis for what is now the Danish Research Network forInternational Health (DRNIH) (see Table 1).

What are the standards in the new researchfor health paradigm?Central to the notion of Essential National Health ResearchSystems (ENRH) is the reference to “creating the conditionsfor health”9 and therefore the conditions for research forhealth. This not only implies that local communities,sociologists, development practitioners, economists, urbanplanners and public health specialists may inform the healthagenda at the national level. It also increases theresponsibility of the policy-makers in ensuring that they havethe evidence needed to make appropriate policyrecommendations for the health of their populations. Thisresponsibility is amplified when considering civil society’sincreasing role in research and “evidence-based advocacy,”and the trends towards a rights-based perspective in health internationally.

In the sphere of health and development, the gap betweenthose who “know” (research community), those who “rule”(policy-makers) and those who “implement” (healthtechnicians) has often been cited as a reason for politicalfailure and the rise of the global burden of disease. A growingbody of literature refers to this as the “know-do” gap10. Thetrend towards research for health introduces more domainsof knowledge into the landscape aiming to ensure that all

relevant fields (for example: social, environmental, political,economic) and levels (for example: individuals, civil society,local communities, academia at national level) of society areconsidered in health research policies and practices. This isfurther complicated by the changing burden of disease wherenoncommunicable diseases now have overtakencommunicable diseases worldwide. These diseases are theprimary cause of death in the 21st century – and willdemand a very different approach to knowledge. In addition,other key challenges in bridging the know-do gap include thediversity of communication styles between the various actors,the tendency to develop research in isolation, competingagendas, time conflicts, and a difference in theunderstanding of “new” and “relevant” knowledge andresearch methods11. Approaching these challenges andcreating appropriate research conditions will require theestablishment of new standards with a stronger focus on capacity strengthening, collaboration, and the creation/management of knowledge through networks and partnerships.

Effective application of research implies that Denmark andour partner countries have the capacity to integrate newknowledge for policy-making and sustainable development.Thus, capacity building (or strengthening) must be anintegral part of research programmes in the Danishdevelopment co-operation.

Capacity strengthening is not only intended to providetechnical skills to our partner countries in the South. Itprovides a learning environment where multiple actors andstakeholders can engage in a process of producing andsharing knowledge from research which promotes socialmobilization for accountability, inclusion, cohesion andparticipation. In doing so, it strengthens the demand side ofgovernance, giving an impetus to local knowledgeproduction, management, and partnership as well asnarrowing the know-do gap. It is important here todifferentiate between networks and partnership. Networksexist as a “loose form of cooperation”, whereas partnershipsare “highly structured forms of cooperation”12. Partnershipsdemand multisectoral actions and the setting of newstandards on research for health which was stressed by thePearson Commission on International Development.

North-South and South-South research networks andpartnerships can serve mutual benefits when they promoteand support equal participation of Southern partners. Thisapproach has been promoted through support to the DanishResearch Network for International Health (DRNIH) with aview to create synergy between research and policy13. Inaddition, they contribute to the evidence base on whichinformed action can be taken. While these types of networksand partnerships are not new in the research/policyparadigm, Denmark has observed that the emergingparadigm is shifting away from the traditional definitions of a“researcher” to include actors ranging from nationalgovernments and the private sector to institutions of highereducation and civil society organizations. These actors are nowtaking an active part in networking or partnerships aroundresearch for health14.

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Global Forum for Health Research (1998-present)18

History Mission and objectives Activities

• Established as anindependent internationalfoundation

• Reduce inequities in health research and in thedistribution of health research expenditures foraddressing health problems of the poor

• Correct the 10/90 gap through health research in: • Biomedical and behavioural sciences• Health systems and health policy• Socioeconomic, sociopolitical and culturaldimensions of health

• Bring together influential stakeholders in health research fordevelopment to:

• Initiate research• Build networks• Stimulate use of research findings

• The above is accomplished through:• An annual conference• Other related forums• Disseminating up-to-date information about global research initiatives

on the web



Table 1: Networking towards partnerships

African Health Research Forum (AfHRF) (2002-present)19


• Emerged fromconsultation process withinAfrica on health research,concluding limited researchinput from countries inAfrica due to lack ofconducive researchenvironments andleadership to build strongerhealth research systems(CCGHR 2006)

• Ensure that Africa’s voice on health research isrecognized.

• Emphasizes the importance of ethical analysis inresearch

• Organizes regional health research forums to enhance communicationand collaborative efforts, and training for both researchers and communitymembers

• Publishes Africa Health Research Review and sponsors the Africa HealthResearch Fellowship to train research leaders and managers

• Considers itself a “network of networks” (COHRED 2004)

• In conjunction with WHO Regional Office for Africa and African AdvisoryCommittee for Health Research and Development (AACHRD), providestechnical support to African nations on developing their respective healthresearch systems to meet local priorities (CCGHR 2006)

Danish Research Network for International Health (DRNIH) (1996-present)History Mission and objectives Activities

• An amalgamation ofENRECA programmes withemphasis on capacity-building in the South andthe North

• An informal networkfunded by Danida untilNovember 2004. Thereaftera general assembly washeld which changed thecourse of the network,making it a formalizedentity

• Members include: Danishresearch institutions,consultancy firms, NGOs,advisers and researchpartner-institutions in low-income countries

• Strengthen dialogue and interaction betweenresearch and development assistance ininternational health as a means of improving healthin low-income societies, in line with the principles ofDanish Development Assistance (DRNIH, 2007)

• Encourage collaborative approaches to research ininterdisciplinary settings

• Generate new knowledge in areas that spantraditional disciplinary boundaries

• Provides unique set-up for different actors to work hand-in-hand indefining needs for further research in the area of international health aswell as consolidating new knowledge

• Funds projects in thematic areas such as vaccine development, nutrition,neglected tropical diseases, noncommunicable diseases, environmentalhealth, sociocultural aspects of illness and medicine, the use ofpharmaceuticals and drug resistance, capacity development for researchand research networks

Project examples:• Bandim Health Project in Guinea Bissau assessing the effect of vaccination• University of Copenhagen to work on skills development of AfricaUniversities• Tororo Community Health project in Uganda to focus on capacityenhancement. Together with district health teams are researching changeprocesses in health systems to improve intersectoral collaboration• Jointly with Danish Water Forum, supported Ghanaian partners inconducting workshop on water, health and sanitation. Forum advocated fornew knowledge, exchange of international experiences, identifyingeffective methods to improve conditions, and gathering financial supportfor relevant research. The forum used to identify specific research projectsand proposals that could be undertaken through a consultative processwith all stakeholders involved

The South Africa-Netherlands Research Program on Alternatives in Development (SANPAD) (1997-present)20


• A collaborative researchprogramme between South African and theNetherlands

• Promote dialogue between Dutch and SouthAfrican researchers

• Advance more conducive research environment,particularly in historically disadvantagedcommunities, for quality research

• Adheres to joint committee governance structurewith North and South representation aiming tohighlight policy relevance of research (Baud, 2002)

• Subsidize and foster research projects that are social development orpolicy oriented through annual call for proposals

• Organize Research Capacity Initiative (RCI), an intensive researchmethodology course intended to enhance research capacity ofdisadvantaged/inexperienced researchers

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In considering the conditional and contractual aspects ofpartnerships, Maxwell and Riddell argue that actors in thecurrent development environment have yet to reach truepartnerships, which requires more than information sharingand policy dialogue15. Characteristics of a true partnershipinclude jointly agreed country programmes and multi-annualfinancial agreements. Using these guidelines, a recentcollaboration between the Danish Water Forum and theDRNIH to support practitioners in Ghana around issues ofwater, health and sanitation demonstrates an early stage ofsuch partnership (see Table 1).

The growing international research for health landscape alsoboasts a range of networks that progressively show theemergence of true partnerships. Table 1 lists case examples,starting from the more global network, the Global Forum forHealth Research, the regional African Health Research Forum(AfHRF), the national DRNIH and lastly to an institutionalizedNorth and South linkage, the South Africa-NetherlandsResearch Program on Alternatives in Development (SANPAD).In its trajectory to partnership, Denmark has been an activeparticipant in the international dialogue for developing globalresearch norms and has provided funding for specific researchprogrammes. Furthermore, numerous thematic areas havebeen addressed with Danish research funding (see Table 1). Aconscious choice is thus made to ensure that the researchbecomes demand driven, adheres to the Paris Declaration16,and focuses on the research results to be used andimplemented as a contribution to poverty reduction. In thisway the know-do gap that currently exists can be bridged.

What are the attitudes and behavioursneeded in the research for health paradigm?There is growing recognition globally that simply channellingadditional funds into traditional health-care services (such asclinical medicine) and health research cannot be equated with“good health” and “good research” particularly whenconsidering the rise of noncommunicable diseases. In order totruly impact the global burden of disease and reach the MDGs,the vision for research for health must not be limited to thenational research/policy regime. It needs to be expandedlocally and globally in order to ensure that knowledge is sharedequally and capacity is enhanced in the research and policyregimes of countries which have limited resources to build upand sustain their research communities. This does not implythat the “North” defines its technical assistance in this regardto funding a handful of doctoral candidates from the “South”.Rather, research for health should be considered a learningprocess for all partners involved, and this requires collaborativenetworking (horizontal South-South, vertical North-South andSouth-North, as well as diagonal across sectors and levels)between partners, and a balancing of health care betweenmicro (immediate) and macro (long-term) needs. It should bebased on the principles of the Ottawa Charter17 and includeconsiderations beyond funding/financing. Understanding thediversity of the landscape and considering issues related tosustainability, relevancy and power relationships are a few ofthe requirements of this attitude shift. One important lessonlearnt for Denmark has been that the shift in attitude had to

start “at home” with recognition of the need to adapt to thenew environment, as well as to develop our institutionalcapacity. This was the first step in ensuring equity and equalityin the health sector.

Which tools and methods are used forresearch for health?Crucial to the process of innovation in research for health arethe different types, methods and tools of research. Types ofresearch are for example biomedical research, health policyand systems research, social science and behaviouralresearch, operational research and participatory actionresearch. While the spectrum of the research landscape variesfrom the controlled clinical trials in the biomedical sphere tothe analysis of power in the participatory action researchsphere, each of the two spectra has their own strengths andweaknesses. While quantitative research often contributes tothe understanding of the biological nature of diseases andassists in developing the products for treating ill health,qualitative research adds to the understanding of the “how,who, why, what when and where” of health. Qualitativeresearch also informs the products and interventions of healthsystems and planning and provides the relevant knowledge ofscaling up efforts that have the greatest potential of benefitingcommunities. How different methods and tools are selectedand merged will depend on the researchers and the relevantstakeholders involved, as well as the context in which researchis being implemented. It is important to remember that whilemethods and tools are scientifically developed, the choice ofwhich is needed must remain context-specific.

Key challenges in research for healthThe key challenges ahead for development research include thegrowing impact of globalization, technological innovations andurbanization, which will make it increasingly difficult to separateresearch relevant for poverty reduction and research relevant fortechnological advances. Furthermore, 42% of global spendingon health research and development is made by thepharmaceutical sector. Adjusting research funding to thechanging aid modalities means that networking andpartnerships in the future will be increasingly important. Havingeffective and efficient research structures and systems built intothe local level planning systems, and having sufficient andqualified human resources to undertake research, add to thechallenges emerging in the research for health paradigm. Thisfact will not only impact the funding and financing of researchbut will also impact the priorities of research as adjustments aremade to the contingencies of this new reality. While this processneeds to be addressed in donor countries such as Denmark,the importance of system strengthening and capacity buildingof our partner countries and us cannot be overlooked. The long-term aim is to ensure that qualified researchers willcontribute to the global knowledge base as well as be able todevelop their own countries.

ConclusionDenmark’s lessons learnt from funding, implementing andsupporting research, have been two-fold. First of all, capacity

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building must be an inherent part of the development andresearch process. This does not simply mean funding PhDresearch students from the South to study in the Northerncountries. Capacity building implies that both the South andthe North are engaged in a “learning process.” This meansrecognizing that the Northern countries have just as much tolearn as their Southern partners about process andcollaboration. Investing more into higher educationcollaboration, which is fundamental for having qualifiedresearchers in the first place, could be one option to beconsidered. Secondly, that establishing networks is only thebeginning and not an end goal. The ultimate goal in the processof research for health is equal partnership. This process is ever-advancing and “mistakes” become stepping stones andopportunities for consultation and reflection in order to changestandards, behaviours and/or tools necessary for good research.

Drawing from these points on the Danish experiences andthe core messages of the new paradigm, three important futuresteps include:� Consensus on redefinitions and rearrangements of who is

involved in research, how it is conducted and a commonunderstanding of what principles laid the foundation of theresearch within each local and national setting for theevolution of a new landscape of research for health.

� Risk taking and synergy building between developmentpartners such as funders, researchers and implementers ofhealth leading to good governance and based on ideals ofpartnership.

� Global health research priority setting to support thestrengthening of essential national health research systems

and the creation of effective research environments.

The Global Ministerial Forum for Research for Health inBamako, November 2008 will be an opportunity to discusscommon challenges and to develop genuine partnerships onresearch for better health. �

Kirsten Havemann is a social and public health specialist withinterest and expertise in health and social sector analysis, design andsystems development. She has extensive knowledge and skills inparticipatory and action-oriented research and operations. After hermore than 20 years of field experience in Africa and Asia where sheheld substantive posts, such as Senior Adviser for the DanishGovernment, she moved to the World Bank’s Social DevelopmentDepartment working on social accountability, the WHO asgovernance research officer and now for the Danish Government asSenior Adviser for Health.

Ulla Tørnæs has been Minister for Development Cooperation inDenmark’s Ministry of Foreign Affairs since February 2005.Following studies at the University of Chambéry, France (1984–85),Copenhagen Business School (1985–88) and CopenhagenUniversity (from 1991), she worked in the Secretariat of the LiberalParliamentary Party from 1986 to 1994. She sat on the PartyCommittee and the Executive Body of the Liberal Party in ØstreStorkreds (a Copenhagen constituency) from 1988 to 1991.

Following several roles within the Liberal Party, Ulla Tørnæsbecame its Political Spokesman in the Folketing (Danish Parliament)in 1998. She was Minister of Education from November 2001 toFebruary 2005.

1. United Nations Development Program. Millennium Development GoalsReport. New York, UNDP, 2006.

2. Council on Health Research for Development (COHRED). Supporting HealthResearch Systems Development in Latin America, Results of Latin AmericaRegional Think Tank. Presented at Latin America Regional Think Tank,Antigua, August 2006, Record Paper 6. (Quoting p. 4.)

3. A paradigm is what members of a scientific community, and they alone,share. See Kuhn, T.S. The Essential Tension. Chicago, University of ChicagoPress, 1977. A paradigm shift is therefore a major change in thinkingtowards a new set of standards and behaviors for which practioners may beaccountable. The degree of success can be measured by the ability of theseparadigms to solve increasingly difficult questions. See Barker, J.A.Paradigms: The Business of Discovering the Future. In: Pierce, J.L. &Newstrom, J.W., eds. The Manager’s Bookshelf. A Mosaic of ContemporaryViews. New York, HarperCollins College, 1996.

4. World Health Organization. Health in the Millennium Development Goals.Online: http://www.who.int/mdg/goals/en/ (date accessed 31 July 2008).

5. Hunter, D.J. Health Needs More Than Health Care: The Need for a NewParadigm. The European Journal of Public Health, 2008, 18 (3): 217-219.

6. World Health Organization. World Report on Knowledge for Better Health:Strengthening Health Systems. Geneva, WHO, 2004. pp. XVI.

7. Johnstone, P. Evidence for Evidence-Based Policy. Presented at 6thInternational Cochrane Colloquium, Baltimore, Maryland., 1998.

8. Bryant, T. Role of Knowledge in Public Health and Health Promotion PolicyChange. International Health Promotion, 2002, 17 (1): 89-98. Citing:Tesh, S. Hidden Arguments: Political Ideology and Disease Prevention Policy.New Brunswick, NJ, Rutgers University Press, 1990Raphael, D. TheQuestion of Evidence in Health Promotion. Health Promotion International,2000, 15 (4): 355-367.

9. Hunter, D.J. Health Needs More Than Health Care: The Need for a New

Paradigm. The European Journal of Public Health, 2008, 18 (3): 217-219.10. World Health Organization. “Bridging the Know-Do Gap”. Meeting on

Knowledge Translation in Global Health. Geneva, WHO, 2006.11. Academy for Educational Development (AED) Center for Health

Communication. Bridging the Gap between Public Health Research andPractice: Lessons from the Field. Washington, D.C., AED, 2005.

12. Baud, I. North-South Partnerships in Development Research: AnInstitutional Approach. International Journal of Technology Management andSustainable Development, 2002, 1 (3): 153-170. (Quoting pp. 154-155)

13. Tostensen, A. Bridging Research and Development Assistance: A Review ofDanish Research Networks. Bergen, Chr.Michelsen Institute, 2006/7.

14. Baud, I. North-South Partnerships in Development Research: AnInstitutional Approach. International Journal of Technology Managementand Sustainable Development, 2002, 1 (3): 153-170.

15. Maxwell, S. & Riddell, R. Conditionality or Contract: Perspectives onPartnership for Development. Journal of International Development, 1998,10 (2): 257-268.

16. Organization for Economic Co-operation and Development (OECD). TheParis Declaration. Online: http://www.oecd.org/document/18/0,2340,en_2649_3236398_35401554_1_1_1_1,00.html (date accessed 31 July2008).

17. This Charter supports the building of healthy public policies, creatingsupportive environments, strengthening community action, developingpersonal skills and re-orienting health services.

18. Global Forum for Health Research. Online: http://globalforumhealth.org(date accessed 26 July 2008).

19. African Health Research Forum. Online: http://www.afhrf.org (date accessed26 July 2008).

20. South Africa-Netherlands Research Program on Alternatives inDevelopment. Online: www.sanpad.org.za (date accessed 26 July 2008).

References

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This article is based on the transcript of a speech delivered at the State of the Planet Conference on 27 March 2008, held by the Earth Institute at Columbia

University in New York, United States.1

This afternoon I would like to share with you what I wouldcall a personal journey, which has meant a great deal to meand helped to shape some of the key ideas that we areworking on now.

You might ask why a foreign minister has been invited hereto talk about health. Surely we have health ministers for that.I will try to answer this question.

I was brought into the field of global health in 1997, whenDr Brundtland, the outgoing Norwegian Prime Minister,decided to run for Director-General of the World HealthOrganization. And I was invited in on her team.

In the autumn of 1997, we campaigned in Africa. Duringthese travels with Dr Brundtland, I saw things that I hadnever really seen before. I saw that health issues hadimportant implications extending far beyond the health sector.And how incredibly important human health, national healthand global health were to so many of the dimensions of society.

I remember when we arrived in Botswana, a country thatNorway has worked closely with for many years. We had justconcluded our development cooperation with Botswanabecause the country had made so much progress. Lifeexpectancy had risen to 70, which is quite sensational in anAfrican context.

But while we were there, researchers from the University ofHarare published new figures that readjusted average lifeexpectancy in Botswana to 35 years. This was in 1997,when the first AIDS figures really started to make an impact.And we could literally see and feel the consequences for thepopulation, for the integrity of the state. What would happento the teachers, the police, the army, the civil servants, the

mothers and fathers? Then we went on to Angola, which had a seat on the board

of WHO and was going to cast its vote. There we met with the Health Minister, and I discovered that the Ministerwas not in the Angolan cabinet, not in the inner circle of government.

I then developed my own thesis that there is a negativecorrelation between the weight of the health challenge andthe influence of the health minister.

In my country, as in other developed countries with goodhealth status, you win or lose an election because of healthpolicy. Whereas in the poorest countries, health is all toooften simply given low priority.

When Dr Brundtland was elected and took up her post inGeneva, one of the first things she said was that our mainchallenge is not to deal with health ministers – because theyknow the problems. It is to try to get through to presidents,prime ministers and finance ministers, and give them thissimple message: you too are health ministers.

We need to find new ways of portraying healthexpenditures as more than costs, but also as an investment.And we need to develop a new language and a new mindsetthat will enable us to reach and communicate with the realcircles of power. Health professionals are too focused on theirown field and have a limited ability to communicate withpeople in other sectors.

This is really an extension of the conclusion of theBrundtland report, Our Common Future. We need to get tothe core of the economic dimension and speak a languagethat people with power really understand.

We need to establish a link between investing in health andimproving the health status of the population – of theproductive fabric of society. We need to convince politicalleaders that if we do these things, there will be more to share.If they fail they will be wasting their opportunity as political leaders.

This is in fact what brought us to Jeffrey Sachs. We wantedsomeone who could convene some of the world’s leadingeconomists with experience in these areas to work ondocumenting what everybody could see – that if you are poor,you are more likely to have poor health. But it is less welldocumented that poor health in itself breeds poverty, creatinga vicious spiral. So we were convinced that we had to get thisdown on paper and document it and its implications.



Article by Jonas Gahr Støre, Minister of Foreign Affairs, Norway

Global health and theforeign policy agenda

We need to establish a link between investing in healthand improving the health status of the population – of the productive fabric of society. We need to convincepolitical leaders that if we do these things, there will bemore to share

66-69 Norway Minister:GF5 23/10/08 09:22 Page 66

Jeffrey Sachs’ commission presented the report at the endof the year 2000. I am certain that the process we launchedthen contributed to the methodology used in devising theMillennium Development Goals (MDGs). The studydocumented how appropriate, timely action can save 8 to 10million lives a year. That in itself would be a realhumanitarian gain. But such action would also help toincrease life spans, productivity and economic well-being,especially of the poor.

But the study also documented that this will not happenby itself. There has been a prevailing idea that as long ascountries continue to develop, health will simply follow. Thisis not the case.

So there is a need to scale up the spending on health, bythe poor countries themselves, and by better targetingdevelopment assistance for health. The report is particularlyvaluable because it demonstrated how affordable thisoperation could be. It documented the difference it wouldmake if rich countries devoted one tenth or 1% of their grossnational income to health-targeted development assistancefor specific interventions.

That would be an investment that would be repaid manytimes and save millions of lives every year, and it wouldprovide economic development and global security.

There were many who criticized this approach and arguedthat there are too many vertical interventions, such as bednets and vaccines. And that the approach to health careshould be much more horizontal.

But these approaches can be combined. Unless we havea massive focus on what is literally on our own doorstep, wecan forget about the horizontal process, and about makingtangible differences in health.

Another conclusion of the report was the importance ofpartnership – which I believe is really a key lesson.Partnership is a simple word, but a very complex thing topractise. The Sachs Commission concluded that moredevelopment assistance should be targeted towards health,while poor countries should allocate more money for healthover their budgets.

It is only if this works together that it will make adifference. Partnerships between rich and poor, partnershipsbetween the private and the public sectors.

Some said that this was going to be a great challenge forthe UN. Why are we inviting the private sector in? Isn’t it theUN that has the mandate to do these kinds of things?

You have to remember that the idea of public-privatepartnerships still was quite new as it first emerged as an ideain the 1990s. We felt that in the WHO, working with DrBrundtland, the way she reached out to the private sector,was being criticized by those who said “it says in ourmandate that we are the leaders in health”.

But let’s not forget that it was Kofi Annan himself whoinvited other sectors to join the global fund to fight AIDS, TBand malaria. To mobilize US$ 10 billion every year to makea difference. So if the UN had not embarked on that course,I think the idea would have been marginalized.

There were a number of other areas that started to attractattention. Vaccines for example. A major effort by the WHO

and UNICEF in the 1990s had brought coverage up to 80%.A very high level. But since 1990, there has been stagnationand almost status quo. How do we mobilize a new campaignfor vaccines? How do we create new markets for malariamedicine?

When the first Stoltenberg government took office in March2000, the Prime Minister decided that Norway would takeon responsibility for providing vaccines for every child in theworld. So this was a “Norway–Gates coalition” in a way.Gates in the private sector and Norway in the public sector– investing in a specific alliance: GAVI, the Global Alliance forVaccines and Immunization.

I remember discussing this with Prime MinisterStoltenberg, and how easy it was to bring him on board – forthree reasons. First, because he was a father and he had hadhis children vaccinated. It is something you do for free in Norway. You don’t have to think about paying for it, you take it for granted. Because it is part of what the welfarestate offers. Secondly, he is an economist, and he saw thatvaccination is by far the most cost-effective intervention youcan make. You can prevent disease with two shots at a veryearly stage in life. And, finally, he was a politician. So hecould bring this into the realm of political action.

I believe that what happened around 2000, with thelaunching of the MDGs, was a response to the heightenedawareness of all politicians, not just health ministers, of thelink between health and development.

I would like to touch briefly on a few of the changes thathave taken place since then. Ten years ago, worldinvestments in health aid totalled US$ 4 billion a year. Thishas more than tripled to US$ 15 billion today.

Around 2000 AIDS treatment was out of reach, and whendrugs came on the market, it was at a cost of US$ 40–100a day. A cost that neither poor people nor donors could afford. Now it costs 4 cents a day to treat AIDS, andmore than 2 million people are receiving treatment. That isfar too few, but it is a beginning.

Malaria was and is the top priority of every African healthminister. Today, tens of millions of bed nets have beendistributed and new drugs have been made available on abroad scale. Where the majority of children sleep under nets,malaria wards stay empty.

As I said, there was great frustration about vaccination,with coverage stagnating and new vaccines not beingintroduced. This situation has now been turned around, andfor example measles mortality has dropped by 90% in Africa.

Additional hundreds of millions of children are beingvaccinated. The GAVI Alliance has saved between two andthree million children from dying every year since it began its work. Tobacco was another serious world health problem.Around 2000, it was predicted that tobacco would be theleading cause of death by 2020. That might still happen, butit is likely – thanks to the framework convention on tobaccocontrol – that this prediction will not come true.

The process of developing the convention is quite anotherstory, and I will not spend time on it here. But work on theconvention started two months after Dr Brundtland tookoffice, and was concluded two months before she left the




WHO. It is modelled on the Kyoto Protocol. So it is anotherexample of lessons learned across sectors.

These approaches gave rise to an ethics of politics. It isabout engagement, it is about the political will to seizeopportunities, it is about partnership, and it is about burden sharing. And I believe that these approaches can beused to combat climate change, to promote health, not onlyin a number of development areas, but also in dealing withinternational conflict. And it coincides closely with what weare trying to achieve in Norwegian foreign policy.

In 2005, Jens Stoltenberg returned as Prime Minister andI became his Foreign Minister. And we scaled up ourapproach to health. Stoltenberg took the vaccine initiative onestep further, and Norway pledged to make a real difference,not only in vaccinating every child, but also in fulfilling MDGs4 and 5 – reducing child and maternal mortality.

And we are now investing 100 million dollars a yearspecifically for interventions in this area, not alone, but inpartnership with the private sector and with specificgovernments. Having worked with and been inspired by mycountryman Jan Egeland and his work in the UN andelsewhere, and with Jeffrey Sachs, I saw that as ForeignMinister, I could deal with health differently than has been thecase in the past.

I realized that health was not just the province of healthministers, finance ministers, presidents, prime ministers, butalso of foreign ministers. Because health disasters are also acause of conflict. They are a cause of environmentaldegradation and of collapsing and failing states.

We all know that threats to health do not respect nationalborders. So this is clearly a challenge for foreign policy. Weknow that developing countries carry the heaviest burden asregards disease, but have the lowest capacity for prevention,treatment and control. So global health security is only asstrong as the weakest link.

Are we prepared, as foreign ministers, to face a globalhealth crisis? Norway closed its border with Sweden for thefirst time in modern history during the outbreak of mouth andfoot disease in 2000. And we were completely puzzled by thequestion “how do we reopen borders? When are you certainthat the epidemic is over and we can do so safely?” This is aforeign policy issue. It is easy to deal with Sweden, ourneighbour, in such cases. But there can be other settingswere this is more complicated. As foreign ministers, we needto review government structures and systems and adapt themto better respond to global interdependence.

When I became Foreign Minister, I called six of mycolleagues in different corners of the world and asked them tojoin me in an informal setting to address this issue. And to tryto highlight what it means to be a foreign minister in an erawhere health problems are global. I approached France,Thailand, Indonesia, South Africa, Senegal and Brazil. Andthey all responded favourably. We met at the UN in 2006 andappointed experts to work out an agenda, identify theproblems and to advise us on a plan of action. We cametogether in Oslo in March last year to adopt the Oslo Agenda,the Oslo Declaration and a plan of action. We singled out tenforeign policy areas where we need to take a look at the



health implications. Are health concerns being given thenecessary priority? Are we applying the foreign policy tools atour disposal to get to grips with them?

Against the backdrop of an evolving health anddevelopment agenda, I believe we have something newemerging here. At the UN General Assembly last September,we were 30 foreign ministers who came together to discussthese fields.

In order for us to make these ideas workable, we need tocontinue take a broader view and work out new perspectives.We still take a very traditional approach in the debate onnational and global health security. We discuss our owncountry’s perspective – with the main focus on protecting ourown population. That is our responsibility as governments.

Even the threats of pandemic flu can be seen in this light.We buy drugs for our populations. But as we all know, virusesand bacteria know no borders. So if we include theperspective of interdependence and shared vulnerabilityacross nations and regions, we need to add a broaderdimension to this debate. More than anything, it calls for solutions in which the benefits of preparedness areequitably distributed.

Because my insecurity does not depend on the Norwegianhealth system, it depends on systems far beyond Norway. Allof this has to influence our development policy, our UN policyand also our Norwegian foreign policy.

As a final observation, one important insight of this groupof experts is that health security cannot be interpretednarrowly. What we need is an understanding of thedeterminants of health. Poverty is of course intuitivelyrecognized as a core determinant even though we have failedto address it fully.

Two more direct determinants of health that are oftenoverlooked are trade and intellectual property rights. In manycountries, HIV and AIDS are overloading already weak healthsystems and having impacts on capacity, preparedness,human rights and movement across borders. This has foreignpolicy implications.

We also have to address how fragile states might collapseunder what we call “the double burden of disease”. Poorcountries struggling with the burden of infectious diseases areincreasingly being burdened with non-infectious diseases –which often cripple a poor health system.

Another dimension is that rich countries are recruitinghealth workers from poor countries to take care of an ageingpopulation. This gives rise to a number of very serious, ethicaland economic issues. These, too, must be brought into theforeign policy agenda.

I would like to conclude by mentioning a concrete examplethat I never thought I would deal with as foreign minister –the issue of virus sharing.

Indonesia has been hard hit by avian influenza. Bird fluis widely considered to be one of the most likely sources ofthe next global pandemic. And global preparedness reliesheavily on monitoring the outbreaks, particularly thosewhich affect humans. A year ago, Indonesia felt that it wasbeing short-changed by the international community andasked bluntly why it should contribute to the production of


a vaccine it will not be able to afford and would be unlikelyto ever have access to by sharing its virus – good question.

I disagree with Indonesia’s decision to stop sharing thevirus from local outbreaks, because I believe that Indonesiaand all other countries should contribute fully to globalpreparedness. But I also understand and agree that we mustmake sure that the benefits of preparedness are sharedequitably and sustainably.

One of the most shocking observations I was met withwhen I got to the WHO was that there is no opportunity toprepare malaria drugs, because where there is no moneythere is no market for these drugs. But for a disease thatstrikes somewhere between a half and one billion peopleeach year, how can we say there is no market?

And if we accept that there is no market for malariamedicine simply because people can’t afford to buy it, that isalso a market failure.

What this all adds up to is that this is a matter of politicalwill, of knowledge and of partnership.

Thank you for accompanying me on this personaljourney. �

Jonas Gahr Støre is Minister for Foreign Affairs of Norway. Hehas a degree in political science from the Institut d’EtudesPolitiques de Paris, and has held a teaching position at HarvardLaw School. His first introduction into public life was as SpecialAdvisor to the Prime Minister, followed by a three-year tenure asDirector-General of the Prime Minister’s International Department.In 1998, Mr. Støre was appointed Ambassador of Norway’sPermanent Mission at the United Nations in Geneva, but servedonly briefly as he was asked by former Prime Minister of Norwayand then Secretary-General of the World Health Organization, GroHarlem Brundtland, to become her Chief of Staff.



1. The sppech has been made public formerly at www.regieringen.no and asan audio file at http://www.earth.columbia.edu/sop2008/index.php?id=agenda

References


Health policy in developing countries is increasinglycommitted to the worlds of science and equity.Evidence-based policy-making can thus be conceived

as an innovation process integrating, within politics, thevalues of healthy life, objective truth and fairness. Innovationbecomes particularly important to support the politicalprocesses of decentralization, poverty reduction and regionalintegration. Health metrics are increasingly focusing oninequities and therefore on the potential as well as on theurgency for improvement. Comparative sociology, economicsand health system sciences are responding throughinnovative social and policy arrangements as well as throughimproved evaluation methods.

This article presents case studies in innovation at the twohealth system poles of decentralization and regionalization.Attention is given to the role of evidence-based financialprotection policy implementation by local health authorities.Two case studies are presented to illuminate evidence-basedpolicy-making at the regional level: Salud Migrante, a pilotproject to develop binational health insurance for Mexicanmigrants in the United States, and the Mesoamerican HealthSystem, a multi-national effort to address disease control andhealth system strengthening. These examples suggest thatresearch can be an invaluable tool to transform what are political constraints for policy-making at local and regional levels into opportunities to move towards neworganizational frontiers.

Health system vulnerabilityMiddle-income countries, particularly in Latin America, arefinding it increasingly difficult to extend health care throughtraditional social security institutions due to increasing costs



Article by Miguel Angel González Block, Executive Director,Centre for Health Systems Research, National Institute ofPublic Health, Mexico

“Policies for innovation”:evidence-based policyinnovation – transformingconstraints into opportunities

Man has created new worlds – of language, of music, ofpoetry, of science; and the most important of these is theworld of the moral demands, for equality, for freedom, andfor helping the weak.

KARL POPPER.1

of medical care, growing competitiveness from internationalmarkets, and the growth of the informal sector. Innovativesocial protection models are thus being designed andimplemented to reduce catastrophic family healthexpenditure, channel national and state subsidies and toencourage family prepaid contributions2.

Mexico’s System of Social Protection in Health was thusestablished in 2003 through a Constitutional amendmentwith the aim of reaching universal coverage of pre-paid healthcare for 20103. Seguro Popular was established to implementthe programme through payments to state health authoritiesbased on strengthening infrastructure, meeting federalstandards and promoting the voluntary and in most casescontributory affiliation by families to the insurance scheme.Yet reaching this goal may not be easy, particularly in poorstates where the proportion of the uninsured is highest andthe health system capacity gap also the greatest.Furthermore, health expenditure is currently being channelledthrough out-of-pocket private health care for about half of thetotal, involving families across the social spectrum.

Adding to this complexity is the fact that 11.8 millionMexicans work as migrant labour in the United States ofAmerica, accounting for 10% of the population. They alsoleave behind close to 4 million relatives, and have 4 millionUS-born children with them, for a total of close to 20 millionof population that rely to different extents on institutions bothsides of the border4. Up to one third of financing for privatecare in Mexico could be resourced from the remittances sentby migrants. These families face a complex scenario for healthinsurance. They express health needs in both countries, theyface highly differentiated service and insurance demand andsupply factors across them, including insurmountable barriersfor comprehensive health insurance in the United States. Thequestion is whether Seguro Popular will be able to insurehealth needs in Mexico and to reduce private expenditure.Another question is whether Seguro Popular can provide abackbone of services to support returning migrants and toprovide health care for needs that cannot be insured abroad.

Looking South, Mexico shares an ecology with its CentralAmerican neighbours and needs to address health issuessuch as malaria, dengue and HIV-AIDS from a regionalstandpoint. Mexico also has an important number of

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Guatemalan migrants and is a pass-through country formigrants to the United States. Mexico and Guatemala havejust established a Binational Health Commission, whileCentral American countries have kept a common healthagenda for decades. Thanks to long-standing research onhealth and migration, Mexico is now leading a Global Fundfinanced project to pilot strategies to promote migrant HIV-AIDS prevention and promotion in border-crossing pointsthroughout Central America and Mexico. More recently,presidents of Central American countries plus Mexico andColombia agreed to develop the Mesoamerican HealthSystem, an evidence-based policy development platform led by the National Institute of Public Health (INSP).

Strengthening local capacities andknowledge brokeringTo address the need to strengthen research capacity at statelevel in Mexico a number of research and policy institutionsjoined forces to establish the consortium Health SystemsResearch for State Sector Development (INDESES). Thiseffort is being supported through national and internationalfunding and collaboration, including Mexico’s Science andTechnology Institute (CONACYT), the Canadian HealthServices Research Foundation (CHSRF), IDRC and theAlliance for Health Policy and Systems Research. INDESESaimed to strengthen specially the demand of health systemsresearch by state policy-makers and managers throughassessing and intervening along the four “A”s of research –acquisition, assessment, adaptation and application.

INDESES developed a curriculum originally structured byCHSRF’s EXTRA training programme, aiming to strengthenevidence-based policy-making through increasing capacity toutilize research5. The focus has been on multi-institutionalmanagerial teams to address their coordination issuesthrough research-based interventions. Specific tools tostrengthen the interface between researchers and users werealso developed. Literature synthesis methods were developedon the basis of international experience focusing oninterventions for vulnerable groups. On this basis a listeningexercise was developed to identify policy-maker andmanagerial concerns. CHSRF’s 1:3:25 executive summaryformat was also implemented to provide an effective meansto divulge research results.

Policy-makers and mangers were provided with a tool alsodeveloped initially by CHSRF’s to assess their capacity toutilize research and to plan strategies to strengthen itaccordingly6,7. Results of a first wave of application werecollated to test the tool and to obtain a diagnosis of utilizationcapacity at the aggregate level. Not surprisingly, resultsdemonstrated widely differing capacities and strengtheningneeds according to level of development. Less evident werefindings suggesting that research acquisition is a higherpriority above analysis, adaptation and application. In richerstates it was recommended to strengthen acquisition mainlythrough increasing the skill levels of mangers. In poorerstates preference was given to strengthening the importanceaccorded to research by top decision-makers. No majordifferences were detected across the various public

institutions or private providers, in spite the fact that theyoperate with very different resource bases. This suggests theimportance that the socioeconomic context plays indetermining research utilization patterns and capacities.

Much is being said about the importance of developingknowledge brokers as a bridge between researchers andusers. To put this idea to the test, the National Institute ofPublic Health (INSP) developed State Centers for HealthSystems Development (CEDESS) as a franchise-likearrangement for operation by interested nongovernmentorganizations working in health systems. Agreements aresigned between INSP and the NGO, enabling them to offer,adapt and execute existing training courses and appliedresearch protocols with state health agencies. CEDESS alsodisseminate research results through executive summariesand liaise INSP researchers with local projects anddevelopment programmes. Importantly, CEDESS do theirwork as far as possible with local academic and consultingagencies, thus strengthening local capacity. Activities haveincluded the evaluation of the state immunizationprogrammes, support for the development of a range ofmodel innovations in selected municipalities, and training inevidence-based health promotion.

South-North collaboration for binationalhealth insurance innovationsINSP established a collaboration between US and Mexicohealth providers, authorities and academics to develop SaludMigrante, an evidence-based binational health insurance formigrants. Innovation design were based on evidence comingfrom a wide range of intersectoral issues: the effects ofremittances on private health spending in Mexico,catastrophic health spending in the US, lack of access tohealth services due to distrust, forced repatriation of migrantsto Mexico due to unmanageable health conditions, thepolitical pressure for regularization of migrants in the US aswell as willingness to pay studies for highlighting thepotential of cross-border health services.

Innovation design focuses on integrating the private not-for-profit health providers and insurance agencies in the USwith the public health system in Mexico, with the aim ofintegrating as far as possible financing and referrals. Acoalition of partners has been established and pilots arebeing prepared across two US and two Mexican states. TheMexican federal government has made critical commitmentsto support binational health insurance. On this basis, apackage of essential primary care services is being designedfor universal access by migrants in the United States, to beprovided mostly by community health centres and insuredthrough non-profit health plans. A key provision is thatfunding for services in the US should come from migrantcontributions and other private or public sources. Migrantswill be supported to access Seguro Popular in their statesparticularly to access secondary care services and to insuretheir dependents’ integral care in Mexico. To this end, SeguroPopular promotion and affiliation will be made available inthe United States through web-based facilities and with thesupport of community agencies.



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The main challenge of Salud Migrante includes organizingthe insurance scheme in such a way that it gains themigrants’ trust to cross the border for secondary care and toreunite with a public service in Mexico that has not alwaysresponded to their needs. A key component to surmount thisbarrier will be the design and implementation of SaludMigrante, an agency in Mexico capable of articulating healthservice providers and insurers within each country and acrossthe border.

Research is being undertaken to develop the operationalplatforms required for the sound operation of Salud Migrante.This involves a coalition of research and service providerpartners and is being led by INSP. This effort represents a historic South-North collaboration in research andinnovation. INSP is well prepared to assume this task givenits full accreditation with the Council on Education for PublicHealth, the US body accrediting most schools of public healthin the US.

South-South collaboration for regionalintegrationINSP is collaborating with efforts to establish theMesoamerican Health System, an initiative recentlyannounced by the presidents of Central America, Colombiaand Mexico as part of their ongoing regional integration. Withthe international funding from partner countries, foundationand bilateral agencies, such a system aims to eradicatemalaria and undernutrition, the control of dengue, loweringthe costs of medicines and strengthening capacity to addressemerging epidemiological risks. CISS is now leading aregional effort to assess research and epidemiologicalsurveillance capacity by public health institutions inparticipating countries, an initiative funded by theInternational Association of National Public Health Institutes.Based on this assessment, a Mesoamerican Public HealthInstitute is being developed as a consortium to provide thesecretariat and technical support coordination functions forthe Mesoamerican Public Health System. This effort will

implement a range of programmes to strengthen healthsystem capacity through applied research and training, thusensuring that the vertical programmes at the core of theMesoamerican system lead to a diagonal effort widelybenefiting national health systems.

LessonsMiddle-income countries in Latin America and other regionshave the capacity and indeed the imperative of promotinginnovations for health systems integration through national-local, South-South and South-North collaboration. Theseefforts should be accompanied by North-South selectivefunding efforts and technology transfer to empower theirSouthern partners with the capacity to develop large-scale,international projects based on their proven technical andpolitical leadership.

Research institutions can play a critical role to bridge acrossbureaucratic and international boundaries through mission-oriented research. Projects of sufficient scale and scope canlead innovation design, enable the incubation of newinstitutional arrangements and undertake piloting andevaluation. Research institutions in middle-income countrieshave in many cases developed sufficient networking, trustand accreditation by partners North and South to support thisimportant role for innovation.

Innovations should also be supported through knowledgebrokering and research capacity building efforts. Researchinstitutions can play a key role to help in the assessment ofthe capacity to utilize research by programme managers andpolicy-makers, to train knowledge brokers based on suchassessments, to facilitate the uptake of research by policy-makers through specific tools and methods, and to developresearch and innovation priorities in critical health systemdevelopment areas. �

Miguel Angel González Block is Executive Director, Center forHealth Systems Research, National Institute of Public Health,Mexico.



1. Popper, Karl. The Open Society and its Enemies. Plato, Volume I: Hegel& Marx, Routledge & Kegan Paul, London, 1945.

2. Tokman V. Inserción laboral, mercado de trabajo y protección social.Documento de proyecto. CEPAL 2006.

3. Frenk J et al. Reforma integral para mejorar el desempeño del sistema desalud en México. Salud Pública Mex 2007, 49 supl I:S23-S36.

4. González Block MA et al. Salud Migrante. Propuesta de un SeguroBinacional de Salud. Perspectivas en Salud Pública, Sistemas de Salud,Instituto Nacional de Salud Pública, 2008. ISBN 978-970-9874-81-5.

5. CHSRF Extra Canadian Health Services Research Foundation CHSRF

Canadian Health Services Research Foundation, Executive Training forResearch Application EXTRA. Ottawa: http://www.chsrf.ca.

6. González Block MA et al. Utilización de Investigación por gestores desalud. Desarrollo y validación de una herramienta de autodiagnóstico parapaíses de habla hispana. Salud Pública de México 2008a. Aceptado parapublicación.

7. González Block MA et al. Utilización de investigación por gestores desalud. Desarrollo y validación de una herramienta de autodiagnóstico.Enviado a Publicación. Salud Pública de México 2008b.

References

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