“partnerships”?
Introduction
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In this illustration, the outer ellipse represents all the health research problems to be solved in order to attain perfect health for all in the world. The institutions responsible for undertaking this research are the national governments, health research institutes and universities, multilateral and bilateral development agencies financing re s e a rc h , national and international civil society organizations, foundations and private-sector companies. But, as indicated by the 10/90 gap, research presently undertaken by the above-mentioned institutions represents only about 10% of the outer ellipse.
The objective therefore is to gradually fill the outer ellipse or, to put it another way, to gradually reduce the space between the research actors, as they integrate more and more of the world’s health research needs.
There are two ways to do this:
• each research institution can take actions to i n t e rnalize some of the “extern a l i t i e s ” within its immediate sphere of influence (corresponding to an enlargement of the small blue-shaded capsules re p re s e n t i n g the activities of each institution);
• an expansion of the collaborative a rrangements and partnerships linking the d i ff e rent actors, thereby responding to re s e a rch needs which have so far been c o n s i d e red as “externalities” from the point of view of the individual actors but which a re high priority re s e a rch areas from a world public health point of view (re p resented by the grey-shaded ellipses in Insert 3.1).
Both approaches are in fact needed to solve the important health research challenges in the years to come.
The first approach, i.e. the decision by each institution to internalize some of the
“ e x t e rnalities” in health re s e a rch, is the responsibility of the governing body in each institution. As the evidence of
interdependence grows in the world, there has been a gradual movement within institutions towards “more global thinking”
(i.e. internalization of some extern a l i t i e s ) . Although progress coming from this direction is difficult to predict, it is very important to help correct the 10/90 gap.
The second approach, i.e. the development of health partnerships linking the efforts of several (or many) actors around priority areas of health research (thus gradually reinforcing the global “health research governance”) is, in the view of the Global Forum, equally indispensable for the following re a s o n s : 1. The magnitude of the problems to be
solved
The magnitude of the problems is such that they are beyond the capacity of any single institution to resolve and re q u i re the concerted efforts of a coalition of partners.
The magnitude of the global problems can be described in terms of the number of cases (reaching into the hundreds of millions), the number of countries (often more than half the countries in the world are affected), the complexity of the diseases, the development of antimicrobial resistance and the complexity of the interventions, which very often go beyond the capacity of the primary or secondary care unit, and so on.
These characteristics indicate that solutions can only be found by the joining of forces of hundreds or even thousands of institutions (i.e. partnerships), at the global, regional, national and local levels. By acting together, the probability of finding solutions increases m a r k e d l y. But bringing together so many
what extent) than to act individually, i.e.
whether the results of acting together would be greater than the sum of the individual actions, for the same amount of time and re s o u rces invested. It is basically a question of benefit-cost analysis, based on the following:
On the benefit side of the equation, discussions among the partners may permit:
• better definition and understanding of the problem
• better identification of the priority research areas
• better identification of more eff e c t i v e strategies for reaching solutions
• better focus of research efforts on the most promising areas
• decrease in the duplication of efforts
• more effective solutions.
On the cost side of the equation:
• a substantial amount of time invested, on the part of each partner, for each of the elements mentioned above.
In the view of the Global Forum, with good management of the partnership, the benefit-cost ratio of the joint undertaking may be very high and the effectiveness of the partnership a multiple of the sum of each institution's efforts. However, with poor management, the estimated benefit-cost ratio may fall below
“one” (in which case the costs tend to become bigger than the benefits) and even approach
“zero” (in which case the benefits are very limited and may approach zero, while the costs of collaboration remain high).
Clearly, the benefit-cost ratio of a specific p a rtnership is rarely calculated. It is an estimation made by the partners as to whether the time invested in the partnership yields results beyond what they could have reached
individually with the same time and resources invested. Experience in the past few years has shown that the following ten factors play a key role in determining the success of a partnership6:
( i ) clear definition of the problem to be attacked
(ii) “grey” matter comes before “green” matter:
this means that much thinking and preparation time must be invested by the partners in the development of a partnership b e f o re spending much money on it (as illustrated by the points itemized below) (iii) clear definition of the central objective of the network
(iv) clear definition of the strategies chosen to reach the objective
( v ) identification of the partners in the network and their respective comparative advantages/responsibilities
(vi) preparation of a detailed workplan and budget (including financial and human re s o u rces needed) and its submission for approval by the partners
( v i i ) clear definition of decision-making mechanisms and organization: legal entity, g o v e rnance, organigram, secre t a r i a t , responsibilities
(viii) ensuring financing by all partners if possible (in cash and in kind)
( i x ) clear definition of the indicators of progress/success
(x) adjustment of workplan and budget based on experience and reality check.
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6 Presentation by Louis J. Currat, Global Forum for Health Research, at the WHO Noncommunicable Diseases Research Partners Meeting, Geneva, 10-12 December 2001.
3. The interdisciplinarity argument Most institutions active in the field of health research, whether at the national, regional or global levels, are necessarily specialized and focus on a limited number of interventions.
H o w e v e r, the effectiveness of a given intervention often depends on the presence of other actions or interventions in other disciplines which are necessary or at least mutually supportive. As often underlined in the field, the end result depends on the weakest link in the chain of actions.
In this sense, partnerships can play a key role in ensuring the solidity in the chain of interdependent and interdisciplinary actions by a large number of institutions.
4. The global public goods argument It is increasingly recognized that better health for anyone, anywhere on earth, benefits everybody else.As such, health is part of what is called the global public goods7, i.e. those goods which benefit not only the person or nation where the improvement takes place but the world community at large.
C o n v e r s e l y, poor health anywhere in the world fits the definition of a global public
“bad”. For example, infectious diseases can rapidly affect millions of individuals around the globe and, in some countries, the burden of noncommunicable diseases is passed on
(at least to some extent) to the national community through medical insurance charges. More importantly, poor health leads to lower productivity and production and therefore has a generally negative impact on growth and development worldwide, through lower savings, lower investments, higher social charges, etc., and a very negative impact on poverty (see Chapter 1).
To the extent that health research is a key determinant of health improvements, it is also a global public good. Like other public goods, global health and global health research suffer from insufficient investment – both overall and particularly for those diseases which account for the highest global disease burden (as underlined by the 10/90 gap in health research).
Partnerships have a key role to play in helping to correct this under-investment in global public goods, as partners identify the benefits accruing to them as a group.
In conclusion, the Global Forum believes that there is an urgent need for better health research governance and for health research partnerships. It is likely that future solutions to the public health challenges of today will depend to a large extent on the strength of the partnerships between the actors identified in Insert 3.1.
7 Inge Kaul, Global Public Goods and the Missing Link, Politica Internazionale, January/April 2001; Inge Kaul, Isabelle Grunberg, Marc A. Stern, Global Public Goods, International Cooperation in the 21stCentury, UNDP, Oxford University Press, March 1999. See in particular the article by Lincoln C. Chen, Tim G. Evans and Richard A. Cash, Health as a Global Public Good (pages 284-304).
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8 Commission on Health Research for Development, Health Research, Essential Link to Equity in Development, 1990.
9 Ad Hoc Committee on Health Research, Investing in Health Research and Development, WHO, September 1996.
1. Recommendations of the Commission on Health Research for Development (1990)8
As early as 1990, the Commission displayed a s t rong commitment to “health re s e a rc h g o v e rnance” and envisaged a pluralistic, worldwide health research system that would nurture productive national scientific groups linked together in transnational networks to a d d ress both national and global health problems.
Specific recommendations of the Commission on Health Research for Development in the field of health research governance at the national, regional and global levels are summarized in Insert 3.2.
2. Recommendations of the Ad Hoc Committee on Health Research (1996)9
The Ad Hoc Committee on Health Research made four recommendations in the field of management of health research. A summary is presented in Insert 3.2, which demonstrates close parallels with the recommendations of the 1990 Commission.