Health research for development conference, Bangkok, 8-13 October 2000.

INTRODUCTION

This conference, attended by more than 700 delegates from more than 100 countries, proved to stimulate thoughts about enhanced collaboration in the health research fields, among numerous stakeholders and among many countries with similar health care problems.

This conference was organised by the Council on Health Research for Development (COHRED), which is an international non-governmental organisation, operating within the United Nations Development Programme (UNDP). COHRED supports countries implementing the Essential National Health Research (ENHR) strategy and publishes countries' experiences with this programme (Webpage: www.cohred.ch). COHRED was established in 1993 and hosted this international conference mainly to evaluate the health research done by different stakeholders in different parts of the world since 1990, and to set research priorities for the next decade. Another purpose of the conference was to bring together different stakeholders concerned with health research, including the World Health Organisation (WHO), UNAIDS, the World Bank, private sponsors, ministries of health, academic researchers and non-government organisations (NGOs). Judged by the hundreds of posters and presentations exhibited in the Market Place of the Shangri-La Hotel, this aspect of the conference was indeed most successful.

Due to the vast amount of knowledge acquired during this week, this report is divided into subsections focussing on the

* posters and exhibitions displayed with contact details, which might prove to be useful in obtaining further information or in establishing specific communication contacts

* conference delegates' suggestions for identifying and meeting the challenges inherent in health research, produced by the different work groups.

POSTER DISPLAYS AND EXHIBITIONS: MARKETPLACE: SHANGRI-LA HOTEL, BANGKOK: 8-13 OCTOBER 2000

These poster sessions and exhibitions provided unique opportunities to talk to many health care researchers from many parts of the world within one large venue. Lively debates carried on in this venue throughout the entire conference, which proved to be a melting pot for divergent ideas about health care and the ethics thereof.

Some of the exhibitions with particular reference to health care research, included the:

* Electronic Publishing Development Program Open Society Institute, Budapest: providing electronic access to quality controlled and evidence based research from all parts of the globe, which can be accessed at http://search.global.epret.com

* Global Forum for Health Research: promoting research to improve the health of the poor as an independent international foundation, which promotes public-private partnerships for health and can be accessed at www.ippph.org or at www.globalforumhealth.org.

* Soma-Net, which is a regional health research network, promoting and advocating for the application of social sciences in improving human health and development, including establishing long-term holistic and sustainable solutions to health in Africa. Their mission, primary goals, challenges and strategies as well as contact persons and numbers can be obtained at http://www.somanet.org or by sending an e-mail to [e-mail].

* Centre for Health Economics, Faculty of Economics, Chulalongkorn University, Thailand (A World Bank Institute) offering courses in and research about health sector reform and sustainable financing (e-mail: [e-mail]).

* Alliance for Health Policy and Systems Research, established during 2000, as an initiative of the Global Forum for Health Research, is a global network striving to make a difference in the research-to-policy cycle, enhancing the implementation of research findings in the formulation of health related policies (Website: http://www.alliance-hpsr.org).

* International Clinical Epidemiology Network (INCLEN), proclaiming its mission as: "We are dedicated to improving the health of the people by promoting clinical practice based on the best evidence of effectiveness and the efficient use of resources. We achieve this through a network of physicians, statisticians and social scientists throughout the world who work together to build and sustain institutional capacity for excellence and relevance in research and medial education." More information can be obtained at http://www.inclen.org globally or from the African office's e-mail address: [e-mail]

* Liverpool School of Tropical Medicine exhibited copies of their latest publications, including The Annals of Tropical Medicine and Parasitology and The Annals of Tropical Paediatrics; more information can be obtained at www.tandf.co.uk/journals.

* International Center for Diarrhoeal Disease Research, Bangladesh dealing with health and population issues popularly associated with developing countries by providing simple and cost effective solutions to complex health and population problems (Website: www.icddrb.org).

* UNAIDS exhibited the research results of global research projects (Website: http://unaids.org).

* University of Melbourne, Faculty of Medicine, Dentistry & Allied Health Sciences (a WHO Collaborating Centre for Women's Health) exhibited information about the short courses offered in Women's Health (it can be accessed at http://www.kcwh.unimelb.edu.au).

* Wellcome Trust exhibited the results of their global malaria surveys and treatment regimes (www.wellcome.ac.uk/publications).

* Collaborative research project under the Ministry of Public Health, Thailand and the Research Institute of Tuberculosis, Japan exhibited research results about the increasing incidence of TB, especially in the Chiang Rai Province of Thailand, concomitant with the incidence of HIV/ AIDS in this area (http://www.jata.or.jp/ EINDEXHTM or e-mail: [e-mail] or [e-mail])

The exhibitions and posters provided a wealth of information and proved the necessity for better collaboration among health care researchers worldwide to the ultimate benefit of the world's people.

THE COUNCIL ON HEALTH RESEARCH FOR DEVELOPMENT (COHRED): CONFERENCE: 10-13 OCTOBER 2000

COHRED is an international non-government organisation, based in Geneva, Switzerland, and affiliated to the United Nations (UN). It works closely with a large number of developing countries, international research programmes, UN agencies and other organisations to promote and advocate for effective health research systems based on the strategy of essential national health research (ENHR). COHRED identified eight key challenges, or priority focus points, for this international conference on health care for development. Each delegate was assigned to a specific working group concentrating on a specific issue at local, regional and global levels. Each working group had a specific chairperson and a rapporteur who had to distil their group's decisions for each day to be presented at early morning plenary sessions, followed by concurrent workshops every morning on these eight issues, with optional alternative workshops during the afternoons and evenings.

This part of the report presents a summary of the keynote address delivered by Dr Gro Harlem Brundtland, director-General, WHO, followed by COHRED's standpoints about each of the eight issues, distributed to the delegates prior to the conference, followed by the major proposals of each working group, and some proposals from a selected number of optional (additional) workshops as well.

Keynote address: Dr Gro Harlem Brundtland, Director-general, WHO

Dr Brundtland, specified that the WHO will strive to support research and development for international health by:

* Continuing to monitor emerging trends in knowledge generation and tracking resource flows for research.

* Helping to promote and advocate for resources to support relevant high quality research.

* Offering norms and standards for the conduct of research, including ethical frameworks.

* Supporting better dissemination of knowledge within all its programmes.

* Strengthening research capacity in developing countries.

* Supporting key research in key areas where gaps continue to exist.

Dr Brundtland also emphasised that good health is the key to development and to human well-being. Technology as well as lifestyle changes could help to reduce global morbidities and mortalities, especially those concerning AIDS, malaria and reproductive ill health. Knowledge and understanding can only be enhanced through universal access to and application of research results. The World Health Organisation's websites are among the most often visited websites in the whole world. Thus the WHO is willing and able to continue to support the collaboration of global health research efforts and to optimise the dissemination of relevant, evidence based research results, including basic and applied, as well as biomedical and social research.

WORK GROUPS' PROPOSALS ABOUT COHRED'S EIGHT PRIORITY AREAS

Equity

The benefits of health knowledge must be made available to the poor and marginalized people of the world, who continue to bear a disproportionately large--and in many cases increasing share of the global burden of disease. They must have choices and hope for the future. This is the fundamental challenge of all health research for development.

Regarding the health research system itself, there are continuing inequities between developed and developing countries. The challenge here is to ensure that research systems in low-income countries have access to the resources they need to address their priority problems and contribute to the global agenda.

The working group on equity concluded that inequities continue to exist among academic and non-academic, male and female, central and peripheral researchers and research projects. Communities should not only be the recipients of research findings but should be partners in the research process. Research funding should be redirected to traditionally neglected researchers to ensure that research efforts embrace the health care needs of the world's marginalized peoples, including the Pacific Region, and indigenous peoples. Funding of research projects should not be determined solely by the scientific quality of submitted research proposals, but should move toward greater inclusiveness and empowerment of the researched, especially of disadvantaged groups.

Ethics

Health research at both national and international levels should be guided by clear ethical principles, based on respect for the dignity of the individual and for sociocultural norms, and recognition of the importance of the engagement of the communities involved and the right of everyone to enjoy the benefits of research. Sound ethical principles should also form the basis for partnerships in health research.

The working group on ethics suggested that specific training should be available on research ethics; monitoring of ongoing research projects should be maintained; and the existing international guidelines on research ethics should be coordinated. The setting up and maintaining of ethics review committees face numerous challenges, especially in developing countries where capacity in this field needs to be further developed. Regional linkages need to be established, and possibly even a global alliance.

Governance

Governance is the process through which those responsible for organisations involved in health research exercise the function of stewardship. The challenge is to create an arrangement that facilitates effective co-ordination among all organisations, institutions and groups involved at various levels in national, regional as well as international health research systems.

The working group on governance identified the underutilisation of research results as a key challenge in the field of governance of health research. A national research coordinating mechanism should coordinate the setting of health research priorities and the dissemination of health research findings. The role of each country's Minister of Health should be specified in governing health research.

Thematic networks might provide effective ways of regional governance. It is essential to conduct research within existing structures, but these regional structures' functions and interactions need to be specified, possibly by COHRED. Regional mechanisms should facilitate and monitor the mobilisation and allocation of resource flows, but need to remain responsive, flexible and proactive.

Financing

The disequilibrium in allocation of health research funds identified ten years ago by the Commission on Health Research for Development, remains a key challenge for the coming years. Despite the recent injection of funds from philanthropic foundations and public-private partnerships, both the absolute amounts available for research and alleviation to that of wealth creation. This focus should assist in formulating priorities for capacity development and action plans to develop a stable number of health researchers in each country.

Regional capacity development for health research should focus on inter-activities guided by common problems. International organisations should coordinate such efforts, and should advocate the importance of health research internationally. Research capacity development should incorporate marginalized communities, and should strive to prevent and/or contain the south-north brain drain of researchers.

A critical mass of researchers should be established and maintained by developing:

* research skills and expertise of individuals and institutions at national and international levels

* skills in writing proposals and managing funds for specific research projects

* decentralised research activities whilst maintaining networking amongst institutions, with communities and with journalists, multinational sponsors and policy makers

* short and medium and long term national health care priority settings.

The major recommendations which emanated from the Research Capacity Development sessions addressed the 10%-90% gap in research funding with the North getting 90% of the funds and the South 10%; the perceived health researchers' brain drain to the North; and the need that Principal Investigators of research projects sponsored by the WHO, should be renumerated. Effective research can accelerate the provision of effective health care services and can help to overcome health inequities. However global health care researchers would need to address the challenge of spending 15% of the health research budget in the South where 77% of the people live. Community members should be co-producers of health care services, not merely passive receivers of such care. Communities, including Primary Health Care (PHC) workers, should identify, initiate and maintain meaningful and relevant research projects, ensuring meaningful evidence based health research results enhancing the quality of life and the quality of health of specific communities and persons. Postgraduate students could be a useful source for making contributions to the health of communities, countries and regions. Comparative research between various countries could be conducted by postgraduate students. Meaningful and relevant research agendas should focus on:

* safe motherhood

* enhanced family planning services

* evidence based practice, including nursing and midwifery services

* HIV/AIDS 

* malaria

* TB.

Research environment

Three elements of this challenge are presented:

* Intersectorality: the health research community needs to be more closely linked to the development community. The challenge is to create purpose-specific, equity-oriented research and action coalitions, and to manage them in an effective way.

* Globalisation: the challenge is to find ways of enabling all countries to identify and use the opportunities offered by globalisation, and at the same time limit the harmful effects.

* Research culture: the challenge is for each country to develop a culture that recognises the value of research and of researchers, creates a sense of "ownership" of research by the community, and facilitates the emergence of a supportive research environment.

The working group, which focussed on the research environment, concluded that the lack of stability and continuity, at national policy making levels as well as within research institutions, hampered the development and/or maintenance of a supportive research environment in any country. Researchers should not operate in vacuums but should establish national forums for exchanging ideas, use existing networks but ensure "inclusiveness" of all groups, publish the research results in journals and on the Internet. Furthermore researchers need to involve all stakeholders in their research projects, including community members. The research environment in the South could be enhanced by:

* Encouraging South-South collaboration, possibly by using centres of excellence.

* Lobbying multinationals to leave a fraction of their profits in the Southern countries for research.

* Specifying that donor support should have a research component.

* Creating a voice for the South by developing negotiation and communication skills.

* Involving researchers and decision-makers from the South in developing policies for research funding for the South.

* Training researchers from the South in the South to reduce the brain drain.

* Establishing a forum of researchers from the South to inform global donors about South specific research priorities.

RECOMMENDATIONS THAT AROSE FROM SELECTED CONCURRENT (OPTIONAL) SESSIONS

Tuberculosis

Public-private partnerships (PPPs) endeavour to combine resources from both public and private sectors to discover new technologies and to address the TB control needs, not addressed by other mechanisms.

Sexual violence against women

This remains a public health problem, warranting research efforts to be better coordinated and to concentrate on sexual abuse and coercion of adult and adolescent women, child sexual abuse, and sexual violence in war situations.

Community involvement in health research

The formal health care system should demonstrate the benefits of research to the communities. Researchers need to be sensitive to the needs of communities and to ethical issues including legitimacy and accountability.

Traditional medicine

The intellectual property rights pertaining to traditional medicine should be established globally. Research into traditional medicine remains underfunded. Therefore a traditional medicine component should be built into all large research projects.

Universities and health research

Universities are in a good position to initiate and maintain research projects, which could improve the performance of health systems. Universities could create coalitions with civil society to improve the health of the disadvantaged. The WHO should find more productive ways of working directly with universities as knowledge producers. The WHO was regarded as a global "clearinghouse" mechanism for knowledge dissemination among members.

HIV/AIDS

Effective HIV/AIDS prevention will require upscaling of available interventions and developing new prevention tools, especially vaccines and new drugs to prevent mother-to-child transmissions. HIV/AIDS related research must meet the highest scientific and ethical standards, especially in developing countries. Research grants should include specific allocations for capacity building of researchers in developing countries.

Poverty and health

Research into these aspects should become more democratic and promote the participation of the poor people. The impact of globalisation on the health of the world's poor people should be recognised.

War and health

Wars impact on health in terms of injuries and diseases, often resulting in more casualties among civilians than among the soldiers. War results in disabilities, emergence of communicable diseases, and psychological trauma to war victims (women, children, soldiers).

Information Technology (IT) and health research

Capacity for health research will only be built if high-quality electronic health information is readily accessible. This requires global coordination, focused advocacy, garnering of resources, attention to inequity of access, sustainable support in obtaining and using information. Capacity building involves raising people's awareness, training local researchers in using search strategies and their critical evaluation abilities. This will only be feasible if stable technical support is maintained.

Safe motherhood

The assessment indicators of antenatal care (ANC) should be expanded beyond mere medical indicators and should include health education outcomes and behavioural changes. ANC should be studied in low-income communities and effective referral systems should be established. Maternal health should be made a health research priority, focussing on appropriate community based interventions, which could improve the quality of maternal care. Human rights approaches should be employed to advance maternal health.

Reproductive health and health sector Reform

Reforms in reproductive health need to be evaluated as they impact on the health of the most vulnerable groups, women and adolescents. The combination of sexually transmitted diseases (STDs) and family planning (FP) services worldwide needs to be assessed prior to accepting that this integration of services promoted measurable positive public health outcomes.

CONCLUSION

The conference ended with the Bangkok Declaration on Health Research for Development, affirming:

* a strong ethical basis for health research

* the inclusion of a gender perspective

* knowledge generated through research should be accessible to all

* research is an investment in human development

* research should be inclusive, involving civil society partnerships at local, national and international levels.

Acknowledgement

I wish to thank UNISA for making this financially possible.

Dr VJ Ehlers

Department of Advanced Nursing Sciences

UNISA