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Introduction required, the levels of funding may well soon exceed the capacities of the philanthropic sector and it will be vital to attract larger investments from the public sector if this “push” mechanism is going to fulfil its promise 13 . It will also be vital to ensure that the efforts of the different philanthropic and public sector donors become better aligned, avoiding duplication or competition to back early “winners” and ensuring that the complete spectrum of “neglected diseases” receives adequate support. The Organisation for Economic Co-operation and Development's (OECD) initiative with the Dutch Government in the “Noordwijk Medicines Agenda” represents one important strand in the current efforts to develop a more coherent and collaborative approach to meeting this challenge 14 . ✜ At the same time, “pull” mechanisms are being developed that are intended to provide incentives for investment, especially by the private sector, to create new products where there has been a market failure. One approach now being implemented is the “advance purchase commitment” (AMC) through which governments guarantee a viable market by means of a binding contract to purchase a newly developed pharmaceutical product if it meets pre-determined criteria. Several countries have recently announced support 15,16 for this approach and, in a pilot case announced in February 2007, an AMC is being applied to a new pneumococcal vaccine 17 . ✜ It has been argued in some quarters that part of the cause of market failure in the creation of drugs for neglected diseases is the patent system which has evolved over the last two centuries. The large investments needed to create high-technology products such as pharmaceuticals are rewarded by the granting of exclusive intellectual property rights for a period of time, during which the inventor can charge high prices in order to recover the initial investment and potentially earn large profits before the patent life expires and generic copies drive prices down. This matter has been extensively debated during the work of the Commission on Intellectual Property Rights, Innovation and Public Health 18 and its successor, the Inter-Governmental Working Group on Public Health, Innovation and Intellectual Property 19 . A number of proposals have been advanced for alternative systems to stimulate and reward innovation and to lower barriers to more collaborative and less competitive efforts. These include creating open access drug companies and patent pools and de-coupling the rewards for invention from the subsequent pricing of the products, rewarding innovation by offering prizes or compensation based on the amount of disease averted in developing countries 20,21 . These variants on the wellestablished patent system provide a “twist” to supplement the “push” and “pull” mechanisms outlined earlier, which work within the existing regime of intellectual property protection. ✜ In the last few years, a number of new initiatives have been developed for the purchase of available medicines for neglected diseases. These include new bodies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance, and fund-creating mechanisms like UNITAID and the International Financing Facility for Immunization 12 . Although they do not themselves fund drug research, the existence of these funds, which assure large-scale finances for the purchase of needed products for a number of years to come, may also stimulate greater investment in R&D to create new products. Equity in research The domain of research itself exhibits a range of inequities: imbalances in the allocation of resources to different types of research and to the health problems of people in different situations; limitations of access to decision-making and priority-setting about the use of resources, to participation in research and to the interpretation and use of its results. Thus, while research may be aimed at tackling problems associated with inequities in access to health, the research itself must be rigorously inspected to remove biases that may contribute to the perpetuation of inequities. The BIAS FREE Framework is an analytical tool published by the Global Forum 22 . It has rapidly gained popularity in a number of settings in both developed and developing countries as a powerful methodology for uncovering biases in research due to a wide range of discriminatory factors deriving from social hierarchies. Across the world, there is broadly a consistent relationship between health status and the availability of skilled health workers, with those countries having the highest levels of burden of disease also being the ones with the fewest trained health-care providers 23 . Increased attention is now being directed towards the crisis in human resources for health, including through the establishment of the Global Health Workforce Alliance 24 , with efforts focusing on critical elements of the recruitment, training and retention of health workers in poorer countries. However, an equally stark lack of skilled health researchers – especially in Africa – has received much less attention, as highlighted in an expert consultation on human resources for health research held in 2006 in Nairobi 25 . Enabling research to make a full contribution to addressing health and health equity issues requires ensuring equitable access to a range of resources, including: capacity development and human resources; tools to measure equity; and funding for health research in all its dimensions, including those relating to creating conditions for health, for health promotion, prevention, treatment and care. Access to the process of priority setting is also vital and this needs to involve the application of equity principles and criteria to setting the priorities for use of limited research resources to address health needs, especially of the poor and vulnerable 26 . Decision-making and governance The research agenda relating to equitable access to decisionmaking and governance includes examining how: ✜ policy-making involves all stakeholders (in particular those who historically have been excluded from decision- Global Forum Update on Research for Health Volume 4 ✜ 015
Introduction making), takes account of all bodies of evidence and is accessible to producers and users of research; ✜ health research systems can be built on principles of equitable access and can contribute to its achievement; ✜ greater coherence and coordination among the funders and directors of research at global and national levels can increase equitable access to sustainable basic preconditions for health, health services and products. ❏ References 1. Anand S, Peter F, Sen A. Public Health, Ethics, And Equity. Oxford University Press, 2005. 2. United Nations. UN Millennium Declaration. New York: UN, 2000. www.developmentgoals.org 3. World Health Organization. Revised Global Burden of Disease (GBD) 2002 estimates: Mortality estimates by WHO region. Geneva: WHO, 2004. www.who.int/healthinfo/statistics/bodgbddeathdalyestimates.xls 4. G. Dahlgren and M. Whitehead. Policies and strategies to promote social equity in health, 1991. Stockholm: Institute for Futures Studies. 5. WHO Commission on the Social Determinants of Health. www.who.int/social_determinants 6. Whitehead M. A typology of actions to tackle social inequalities in health. Journal of Epidemiology and Community Health, 2007, 61, 473-8. http://jech.bmj.com/cgi/content/extract/61/6/473 7. WHO defines a health system to include all the activities whose primary purpose is to promote, restore or maintain health. See: World Health Organization. World Health Report 2000 – Health systems: Improving performance. World Health Organization, Geneva, 2000, p5. 8. Gilson L et al. Challenging inequity through health systems. WHO Commission on the Social Determinants of Health, Knowledge Network on Health Systems. Final Report. Geneva: WHO, June 2007. www.wits.ac.za/chp/kn/HSKN%20final%20combined%2020%20July.pdf 9. Gardner CA, Acharya T, Yach D. Technological And Social Innovation: A Unifying New Paradigm For Global Health. Health Affairs, 2007, 26:4, 1052-61. 10. Report of the Commission on Intellectual Property Rights, Innovation and Public Health. Public health, Innovation and Intellectual Property Rights. Geneva: World Health Organization, 2006. www.who.int/intellectualproperty/documents/thereport/en/index.html 11. Pecoul B et al. Access to essential drugs in poor countries: a lost battle? Journal of the American Medical Association, 1999, 281, 361-7. 12. Matlin SA. ‘The changing scene’, in: de Francisco A, Matlin SA (eds), Monitoring Financial Flows for Health Research 2006: The changing landscape of health research for development, Geneva: Global Forum for Health Research, 2006. 13. Moran M et al. The New Landscape of Neglected Disease Drug Development. London: The Wellcome Trust, 2005. www.wellcome.ac.uk/assets/wtx026592.pdf 14. OECD. Noordwijk Medicines Agenda. High Level Forum on Medicines for Stephen A Matlin has been Executive Director of the Global Forum for Health Research since January 2004. Educated as an organic chemist, he worked in academia for over 20 years, with research, teaching and consultancy interests in medicinal, biological and analytical chemistry. This was followed by periods as Director of the Health and Education Division in the Commonwealth Secretariat, Chief Education Advisor at the UK Department for International Development and as a freelance consultant in health, education and development. Neglected and Emerging Infectious Diseases: Policy Coherence to Enhance their Availability, 20–21 June 2007, Noordwijk-Aan-Zee, the Netherlands. www.oecd.org/dataoecd/62/11/38845838.pdf 15. Center for Global Development. G7 To Pilot Advance Market Commitments. Washington DC: CGD, 2005. www.cgdev.org/content/article/detail/5253. 16. Wikipedia, Advance market commitments (Wikipedia, 2007). http://en.wikipedia.org/wiki/Advance_market_commitments. 17. GAVI Alliance. Advance market commitments for vaccines. Geneva: GAVI Alliance, 2007. www.vaccineamc.org. 18. Report of the Commission on Intellectual Property Rights, Innovation and Public Health. Public Health, Innovation and Intellectual Property Rights. Geneva: World Health Organization, 2006. www.who.int/intellectualproperty/documents/thereport/en/index.html 19. Intergovernmental Working Group on Public Health, Innovation and Intellectual Property, Report of the first session: Geneva, 4–8 December 2006. Geneva: WHO, 2006. www.who.int/gb/phi/PDF/A_PHI_IGWG1_6- en.pdf. 20. Nathan C. Aligning pharmaceutical innovation with medical need. Nature Medicine, 2007, 13, 304-8. www.nature.com/nm/journal/v13/n3/full/nm0307-304.html 21. Love J. Submission of CPTech to IGWG, 15 November 2006. www.who.int/phi/public_hearings/first/15Nov06JamesLoveCPTech.pdf 22. Burke MA, Eichler M. The BIAS FREE Framework: A practical tool for identifying and eliminating social biases in health research. Geneva: Global Forum for Health Research, 2006. www.globalforumhealth.org/Site/002__What%20we%20do/005__Publicat ions/010__BIAS%20FREE.php 23. World Health Organization. World Health Report 2006 – Working together for better health. Geneva: World Health Organization, 2006. www.who.int/whr/2006/en/index.html 24. Global Health Workforce Alliance. www.globalhealthtrust.org/ 25. COHRED, Human Resources for Health Research, An Africa Perspective. Final report of expert consultation, Nairobi July 2006. Geneva: Council on Health Research for Development, 2006. www.cohred.org/publications/informal_reports.html 26. Ghaffar A, de Francisco A, Matlin SA. The Combined Approach Matrix: A priority-setting tool for health research. Geneva: Global Forum for Health Research, 2006. Global Forum Update on Research for Health Volume 4 ✜ 017
Page 1 and 2: Global Forum Update on Research for
Page 3 and 4: Editorial Advisory Board: Luis Gabr
Page 5 and 6: Contents 096 Child immunization: ac
Page 7 and 8: Introduction Research contributions
Page 9: Introduction Type I Type II Type II
Page 13 and 14: Access to health Strengthening heal
Page 15 and 16: Access to health raising public awa
Page 17 and 18: Access to health Recent trends in r
Page 19 and 20: Access to health districts with a p
Page 21 and 22: Access to health Understanding heal
Page 23 and 24: Access to health This study investi
Page 25 and 26: Access to health References continu
Page 27 and 28: Access to health combining particip
Page 29 and 30: Access to health 2002 2005 Diff. SU
Page 31 and 32: Access to health References continu
Page 33 and 34: Access to health Americans think th
Page 35 and 36: Access to health threatening and se
Page 37 and 38: Access to health References 1. Worl
Page 39 and 40: Access to health Open access to res
Page 41 and 42: Access to health References 1. Rose
Page 43 and 44: Access to health national and globa
Page 45 and 46: Access to health Senior Research Fe
Page 47 and 48: Access to health ✜ Rights alone a
Page 49 and 50: Access to health meaningful communi
Page 51 and 52: Access to health Inequality, margin
Page 53 and 54: Access to health questions, develop
Page 55 and 56: Access to health reasonable in abou
Page 57 and 58: Access to health References 1. Kohn
Page 59 and 60: Access to health The diverse pathwa
Page 61 and 62:
Access to health 2001, WTO ruled th
Page 63 and 64:
Access to health knowledge and educ
Page 65 and 66:
Access to health References 1. Lee
Page 67 and 68:
Innovation 076 Towards the developm
Page 69 and 70:
Innovation ✜ Creating a viable va
Page 71 and 72:
Innovation Natural sciences and env
Page 73 and 74:
Innovation References 1. Morel C et
Page 75 and 76:
Innovation The changes in internati
Page 77 and 78:
Innovation promoting health in deve
Page 79 and 80:
Innovation efficiently converted in
Page 81 and 82:
Innovation future global health fin
Page 83 and 84:
Innovation References 1. See http:/
Page 85 and 86:
Innovation Health system strengthen
Page 87 and 88:
Innovation Being healthy: the role
Page 89 and 90:
Innovation when much progress and a
Page 91 and 92:
Innovation The role of Knowledge Tr
Page 93 and 94:
Innovation knowledge - the “know
Page 95 and 96:
Research resources 110 Research imp
Page 97 and 98:
Decision-making implemented on a sm
Page 99 and 100:
Research resources 30 27.5 25 20 19
Page 101 and 102:
Research resources poliomyelitis an
Page 103 and 104:
Research resources Nursing research
Page 105 and 106:
Research resources utilization are
Page 107 and 108:
Research resources The need to deve
Page 109 and 110:
Research resources ✜ Health resea
Page 111 and 112:
Research resources References 1. Co
Page 113 and 114:
Research resources investigated the
Page 115 and 116:
Research resources A new landscape
Page 117 and 118:
Research resources 13 + 1*- HIV/AID
Page 119 and 120:
Research resources References 1. Da
Page 121 and 122:
Research resources international le
Page 123 and 124:
Research resources Partnership dyna
Page 125 and 126:
Research resources that many public
Page 127 and 128:
Research resources compounds from m
Page 129 and 130:
Research resources References 1. So
Page 131 and 132:
Decision-making Delivering evidence
Page 133 and 134:
Decision-making Equitable access: g
Page 135 and 136:
Decision-making years’ experience
Page 137 and 138:
Decision-making Policy-makers Compl
Page 139 and 140:
Decision-making interview studies),
Page 141 and 142:
Decision-making References 1. Haine
Page 143 and 144:
Decision-making reviews in this fie
Page 145 and 146:
Decision-making Inequities in healt
Page 147 and 148:
Decision-making Deaths Crude death
Page 149 and 150:
Decision-making Group I Group II Gr
Page 151 and 152:
Decision-making Low- and middle-inc
Page 153 and 154:
Decision-making Europe and Central
Page 155 and 156:
Decision-making Europe and Central
Page 157 and 158:
Decision-making References 1. Banni
Page 159 and 160:
Decision-making irresponsible-to be
Page 161 and 162:
Decision-making Several strategies
Page 163:
To achieve better health, particula
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