The Importance of Global Health Research

Closing the 10/90 Gap

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

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

Global Health Research: Creating Knowledge, Expanding Access

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

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

Moreover, scaling up ART in developing countries is a tremendous project in which success is

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

Understanding the Cultural Perceptions of Disease & Healthcare Through Research

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

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

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

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

When a cross-cultural medical or public health intervention is to be implemented, research

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

Global Health Metrics

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

“Sound information on financial and human resources invested in health, health interventions
delivered to people in need, and the impact of these efforts on people's health is critical for
planning health systems, implementing programs, epidemic response, allocating budgets for
research and development, monitoring progress, and evaluating what works and what does
not.”(16)
The availability of health information to inform decisions can ensure funding and further the
efficacy of global health interventions. Research that defines indicators and collects health
metrics is an integral part of results-based accountability in global health. For example, output
and outcome indicators enable decision makers and donors to assess progress toward intended
goals and best practices.

Outputs versus Outcomes

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

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

Conclusion

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

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

Footnotes

(1) Delisle, Helene, Janet Hatcher Roberts, Michelle Munro, Lori Jones, and Theresa W
Gyorkos. "Health Research Policy and Systems." 21 Feb 2005 Web.25 Jun 2009.

(2) Ibid

(3) Lee, Kelley and Anne Mills. "Strengthening governance for global health research: The
countries that most need health research should decide what should be funded." British Medical
Journal 30 Sept 2000 775-776. Web.24 July 2009.

(4) Norris, Jeremiah. "Global health research: don't ignore achievements so far ." The Lancet
Vol. 317, Issue 961506 Mar 2008 810-811. Web.24 Jul 2009.
(5) Boulle, A and N Ford. " Scaling up antiretroviral therapy in developing countries: what are
the benefits and challenges?" British Medical Journal 19 Nov 2007 Web.24 Jul 2009.

(6) Ibid

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

(8) Labonte, Ronald and Jerry Spiegel. "Setting global health research priorities Burden of
disease and inherently global health issues should both be considered." British Medical Journal
05 Apr 2003 722-723. Web.24 July 2009.

(9) Ibid

(10) Keusch, Gerald T, Joan Wilentz, and Arthur Kleinman. "Stigma and global health:
developing a research agenda." The Lancet Feb 2006 525-527. Web.24 Jul 2009.

(11) Ibid.

(12) CJL Murray. 2004. AD Lopez and S Wibulpolprasert, Monitoring global health: time for
new solutions, BMJ329pp. 1096–1100.

(13) J Kates, JS Morrison and E Lief. 2006. Global health funding: a glass half full?, Lancet368
pp. 187–188.

(14) Horton R. 2005. The Ellison Institute: Monitoring health, challenging WHO. Lancet 366:
179–181.

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

(16) Esipisu, Isiah. Villagers using bed-nets for wedding gowns. Accessed 23 September 2009.

(17) McAllister, K. 1999. Understanding participation: monitoring and evaluating process,

outputs and outcomes. Ottawa: IDRC.

(18) Ibid.