Development of capacity for research ethics review in low- and middle-income countries: need for a systems approach

In their paper in this issue of Public Health Action, Denholm et al. describe the developments in the area of public health research in the Pacific Islands but decry the lack of adequate capacity for ethical review of research. They point out that a better capacity to reflect local health priorities and values, overall research capacity building and strengthening of systems beyond research ethics are the advantages of establishing local ethics committees in this region.¹

Research ethics committees were established worldwide in the early 1980s, initially as committees to formally endorse research for scientific journal publications. Although their role has gradually strengthened in high-income countries,² the development of local capacity for research ethics review lags behind in many low- and middle-income countries. Reasons for such ill-developed ethical review capacity includes lack of resources, limited legislative framework for ethical oversight, lack of expertise in bioethics, confusion over which ethical guidance to follow among the litany of recommendations and the over-burdening of limited existing research ethics committees.^3–5 Even those research ethics committees that are well established in these areas are fraught with problems of excessive focus on the scientific and technical basis of research rather than participant protection, inconsistent funding to conduct the meetings and poor attendance of members in the committee meetings. There is a distinct advantage in following a systems approach to strengthening research capacity and ethical review capacity in these regions.

In their project report on a systems approach to the protection of research participants, the Institute of Medicine of the United States recommend that, ‘… all research involving humans takes place in settings or through organizational affiliations where the culture, announced and exemplified by the leadership, emphasizes the highest ethical standards and dedication to the welfare of every study participant.’⁶ This emphasis on a systems approach has distinct advantages.

Conduct of ethical research is largely dependent on the overall research culture and ethos of the country. Political commitment of the country to encourage ethical conduct of research is essential to create such a research environment. Political commitment should encourage the establishment of health research systems, as proposed by the World Health Organization.⁷ Such a health research system has four components: stewardship, financing, resource generation and knowledge production. The component of stewardship within this health research system comprises ethical review and an oversight mechanism in addition to good governance mechanisms. It is important that ethical oversight is integrated into this health research system and that it does not stand alone as a vertical component. As this health research system will be complex-adaptive, strengthening of the ethical review and oversight mechanism will lead to the overall strengthening of all the components.⁸

In addition, building up the ethical review capacity in these countries would reflect a political environment of freedom, social protection, transparency and general accountability, all of which can foster public trust in the health research system. It can also empower people and the civil society.⁷ Development of such enabling environments to conduct ethical research will attract international collaborative research, further strengthening the health research system.

The world is faced by an ever widening inequity in health in different regions. Strengthening of local health research systems is therefore an ethical imperative to achieve global health equity. Unless good quality, locally relevant ethical research comes from low- and middle-income countries, the target of global health equity cannot be achieved. Strengthening local ethical review capacity in low- and middle-income countries is therefore an ethical obligation.⁹ Furthermore, in addition to strengthening the research outputs from these countries, such an ethical review capacity may also lead to a complex adaptive response of overall health systems strengthening.