The rich–poor gap in global health research: challenges for Canada

It is now 10 years since the Commission on Health Research for Development released its landmark report.¹ It found that spending on health research, when viewed from a global perspective, was grossly skewed. Only 5% of the total funds (US$30 billion in 1986) were spent on research addressing the problems of developing countries whose citizens bore 93% of the global burden of preventable conditions affecting health. The international research effort was found to be poorly coordinated and fragmented. The Commission recommended that all countries, no matter how poor, should undertake “essential national health research” (ENHR).² It also recommended substantial increases in funding: that developing countries should strive to allocate at least 2% of public health expenditures to health research, and that at least 5% of international aid for the health sector should be earmarked for research and strengthening of research capacity. Furthermore, the Commission made recommendations about improving international research partnerships and monitoring progress.

What has been achieved over the past decade, and what is the vision for global health research for the first years of the new century? These questions were vigorously debated by 800 participants (including the authors of this commentary) from 100 countries at the International Conference on Health Research for Development that was held last year in Bangkok, Thailand.³

Since 1990, there has been some progress but much remains to be done. More than 50 developing countries are using the ENHR strategy in some form and, by 1998, global health research and development expenditures had risen to US$70.5 billion.⁴ The established market economies spent US$350 million on health research within their overseas development budgets. This is about 6% of international aid for the health sector (estimated to be US$5.4 billion in 1998) and thus reaches the target (5%) recommended in 1990. Although this increased proportion is to be applauded, it must be viewed in the context of a steady decline in overseas development assistance during the 1990s. In 1970 the United Nations recommended that donor countries spend 0.7% of their gross domestic product in foreign aid; only 4 countries (The Netherlands, Sweden, Denmark and Norway) are presently meeting this target.⁵ The decline is slightly offset by private sector investment in particular in private–public partnerships to develop new drugs, vaccines and diagnostic tests for 3 conditions: HIV/AIDS, malaria and tuberculosis. In addition, some philanthropic organizations have increased their support for research into the health problems of developing countries.

Several developing countries (such as Argentina, Brazil, Mexico, Thailand, the Philippines, Malaysia and India) have increased their investment in health research. Some of them approach the recommended 2% of public health expenditures to be allocated for health research. The aggregate amount from these countries is estimated to be US$2.2 billion.

Overall, however, the “disequilibrium” described in 1990 remains, namely, the amount currently spent globally on research relevant to the health status of 90% of the world's people is approximately US$3 billion, which is still less than 5% of the global aggregate of US$70.5 billion. Thus, the rich–poor gap in health research investment persists and, for many parts of the world, health disparities between and within countries are widening.⁶ For example, for 9 countries in Africa, previous health gains are being reversed primarily because of the AIDS epidemic; studies project a loss of 17 years of life expectancy by 2010 — back to the levels of the 1960s.7

What opportunities are there for Canada to promote equitable development in this new era of health research?

1. Increase awareness: As an influential group in a country that for several years has been rated “number 1” on the United Nations Human Development Index, health professionals in Canada must become more knowledgeable about global health problems and how these can be solved by conducting, managing and carefully applying relevant health research. We recommend a concerted effort to include education about global health issues (including health research) in Canada's education programs for health professionals. It is also imperative that national Canadian organizations such as the Canadian Medical Association include global health in their advocacy agendas. It is no longer adequate for such organizations to focus solely on a Canadian agenda.

2. Increase involvement: With the remarkable recent increase in Canadian investment in science (including health research),⁸ it is time to re-examine the relevant recommendations from the 1990 report of the Commission on Health Research for Development.¹ Specifically, the Canadian Institutes for Health Research must consider the following recommendations for industrialized countries and adapt these decade-old suggestions for the 21st century:

· “provide career opportunities for young [Canadian] scientists to become engaged in research on health problems of developing countries;

· promote the strengthening of … medical schools [and other health-related institutions] and development studies groups … to pursue advanced research, conduct training of industrialized-country and developing-country scientists, and participate in international networks;

· commit a larger share of the budgets of [Canadian] health research funding agencies to support research focused on health problems of developing countries.”

3. Increase funding: Over the past 10 years, the core health research budget of the International Development Research Centre (IDRC), through which the Canadian government supports health research in developing countries, has decreased from about Can$15 million to less than Can$4 million. However, the IDRC recently earmarked increased funding for health-related programs in sub- Saharan Africa. In 2000/01 the Canadian International Development Agency is investing approximately Can$6 million in research on priority health problems of the poor (Dr. Yves Bergevin, Canadian International Development Agency, Hull, Que.: personal communication, 2000). This combined amount of Can$10 million is approximately 5% of Canada's international aid to the health sector and thus reaches the target recommended in the 1990 Commission report. However, as is the case for many other industrialized countries, Canada's overseas development assistance budget has declined steadily over the last decade to less than 0.29% of the gross national product (GNP) — well short of the internationally accepted standard of 0.7% of GNP suggested by Lester Pearson more than 20 years ago.

Following the invigorating exchange of ideas at the Bangkok conference, it is time for all those in Canada concerned with equitable health care and health development — our governments, the health care professions, academic and research institutions, and individuals — to renew our commitment to investing resources in equity-oriented health research. These resources include not only finance, but also, perhaps more importantly, our collective energy and talent.