Designing research funding schemes to promote global health equity: An exploration of current practice in health systems research

International research is an essential means of reducing health disparities between and within countries and should do so as a matter of global justice. Research funders from high‐income countries have an obligation of justice to support health research in low and middle‐income countries (LMICs) that furthers such objectives. This paper investigates how their current funding schemes are designed to incentivise health systems research in LMICs that promotes health equity. Semi‐structured in‐depth interviews were performed with 16 grants officers working for 11 funders and organisations that support health systems research: the Alliance for Health Policy and Systems Research, Comic Relief, Doris Duke Foundation, European Commission, International Development Research Centre, Norwegian Agency for Development Cooperation, Research Council of Norway, Rockefeller Foundation, UK Department of International Development, UK Medical Research Council, and Wellcome Trust. Thematic analysis of the data demonstrates their funding schemes promote health systems research with (up to) five key features that advance health equity: being conducted with worst‐off populations, focusing on research topics that advance equitable health systems, having LMIC ownership of the research agenda, strengthening LMIC research capacity, and having an impact on health disparities. The different types of incentives that encouraged proposed projects to have these features are identified and classified by their strength (strong, moderate, weak). It is suggested that research funders ought to create and maintain funding schemes with strong incentives for the features identified above in order to more effectively help reduce global health disparities.     

Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries.

Summary points

• The Coronavirus Disease 2019 (COVID-19) pandemic threatens progress toward a “grand convergence” in global health—universal reduction in deaths from infections and maternal and child health conditions to low levels—and toward achieving universal health coverage (UHC).
• Our analysis suggests that COVID-19 will exacerbate the difficulty of achieving grand convergence targets for tuberculosis (TB), maternal mortality, and, probably, for under-5 mortality. HIV targets are likely to be met.
• By 2035, our analysis suggests that the public sectors of low-income countries (LICs) would only be able to finance about a third of the costs of a package of 120 essential non-COVID-19 health interventions through domestic sources, unless the country increases significantly the priority assigned to the health sector; lower middle-income countries (LMICs) would likewise only be able to finance a little less than half.
• The likelihood of getting back on track for reaching grand convergence and UHC will depend on (i) how quickly COVID-19 vaccines can be deployed in LICs and LMICs; (ii) how much additional public sector health financing can be mobilized from external and domestic sources; and (iii) whether countries can rapidly strengthen and focus their health delivery systems.

     

A research agenda for helminth diseases of humans: health research and capacity building in disease-endemic countries for helminthiases control

Capacity building in health research generally, and helminthiasis research particularly, is pivotal to the implementation of the research and development agenda for the control and elimination of human helminthiases that has been proposed thematically in the preceding reviews of this collection. Since helminth infections affect human populations particularly in marginalised and low-income regions of the world, they belong to the group of poverty-related infectious diseases, and their alleviation through research, policy, and practice is a sine qua non condition for the achievement of the United Nations Millennium Development Goals. Current efforts supporting research capacity building specifically for the control of helminthiases have been devised and funded, almost in their entirety, by international donor agencies, major funding bodies, and academic institutions from the developed world, contributing to the creation of (not always equitable) North-South "partnerships". There is an urgent need to shift this paradigm in disease-endemic countries (DECs) by refocusing political will, and harnessing unshakeable commitment by the countries' governments, towards health research and capacity building policies to ensure long-term investment in combating and sustaining the control and eventual elimination of infectious diseases of poverty. The Disease Reference Group on Helminth Infections (DRG4), established in 2009 by the Special Programme for Research and Training in Tropical Diseases (TDR), was given the mandate to review helminthiases research and identify research priorities and gaps. This paper discusses the challenges confronting capacity building for parasitic disease research in DECs, describes current capacity building strategies with particular reference to neglected tropical diseases and human helminthiases, and outlines recommendations to redress the balance of alliances and partnerships for health research between the developed countries of the "North" and the developing countries of the "South". We argue that investing in South-South collaborative research policies and capacity is as important as their North-South counterparts and is essential for scaled-up and improved control of helminthic diseases and ultimately for regional elimination.     

Profiles,motivations and expectations of participants to EC funded research in Health (2002–2010): A statistical analysis

The Health Directorate of the European Commission's Directorate General for Research and Innovation launched a consultation through a questionnaire of all participants involved in health research projects from 2002 to 2010. The EU funding over this period, for projects involving collaboration between research teams, reached around €4.9 billion and involved 12,460 teams in 114 different countries. This survey was performed to contribute to the preparation the next Framework Programme for research and innovation called “Horizon 2020” (2014–2020). A statistical analysis of the questionnaire replies has been carried out. This paper provides a short summary of the most salient features and results of this survey. The survey reveals a significant scientific and socio-economic impact of EU funding in the area of health research and a positive long-term impact of this funding on health research capacities in Europe.     

Reflections on the development of health economics in low- and middle-income countries

Health economics is a relatively new discipline, though its antecedents can be traced back to William Petty FRS (1623–1687). In high-income countries, the academic discipline and scientific literature have grown rapidly since the 1960s. In low- and middle-income countries, the growth of health economics has been strongly influenced by trends in health policy, especially among the international and bilateral agencies involved in supporting health sector development. Valuable and influential research has been done in areas such as cost–benefit and cost-effectiveness analysis, financing of healthcare, healthcare provision, and health systems analysis, but there has been insufficient questioning of the relevance of theories and policy recommendations in the rich world literature to the circumstances of poorer countries. Characteristics such as a country''s economic structure, strength of political and social institutions, management capacity, and dependence on external agencies, mean that theories and models cannot necessarily be transferred between settings. Recent innovations in the health economics literature on low- and middle-income countries indicate how health economics can be shaped to provide more relevant advice for policy. For this to be taken further, it is critical that such countries develop stronger capacity for health economics within their universities and research institutes, with greater local commitment of funding.     

Informed Consent in Health Research: Challenges and Barriers in Low‐and Middle‐Income Countries with Specific Reference to Nepal

Obtaining ‘informed consent’ from every individual participant involved in health research is a mandatory ethical practice. Informed consent is a process whereby potential participants are genuinely informed about their role, risk and rights before they are enrolled in the study. Thus, ethics committees in most countries require ‘informed consent form’ as part of an ethics application which is reviewed before granting research ethics approval. Despite a significant increase in health research activity in low‐and middle‐income countries (LMICs) in recent years, only limited work has been done to address ethical concerns. Most ethics committees in LMICs lack the authority and/or the capacity to monitor research in the field. This is important since not all research, particularly in LMICs region, complies with ethical principles, sometimes this is inadvertently or due to a lack of awareness of their importance in assuring proper research governance. With several examples from Nepal, this paper reflects on the steps required to obtain informed consents and highlights some of the major challenges and barriers to seeking informed consent from research participants. At the end of this paper, we also offer some recommendations around how can we can promote and implement optimal informed consent taking process. We believe that paper is useful for researchers and members of ethical review boards in highlighting key issues around informed consent.     

Impact of health research capacity strengthening in low- and middle-income countries: the case of WHO/TDR programmes

Background

Measuring the impact of capacity strengthening support is a priority for the international development community. Several frameworks exist for monitoring and evaluating funding results and modalities. Based on its long history of support, we report on the impact of individual and institutional capacity strengthening programmes conducted by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and on the factors that influenced the outcome of its Research Capacity Strengthening (RCS) activities.

Methodology and Principal Findings

A mix of qualitative and quantitative methods (questionnaires and in-depth interviews) was applied to a selected group of 128 individual and 20 institutional capacity development grant recipients that completed their training/projects between 2000 and 2008. A semi-structured interview was also conducted on site with scientists from four institutions. Most of the grantees, both individual and institutional, reported beneficial results from the grant. However, glaring inequities stemming from gender imbalances and a language bias towards English were identified. The study showed that skills improvement through training contributed to better formulation of research proposals, but not necessarily to improved project implementation or communication of results. Appreciation of the institutional grants'' impact varied among recipient countries. The least developed countries saw the programmes as essential for supporting basic infrastructure and activities. Advanced developing countries perceived the research grants as complementary to available resources, and particularly suitable for junior researchers who were not yet able to compete for major international grants.

Conclusion

The study highlights the need for a more equitable process to improve the effectiveness of health research capacity strengthening activities. Support should be tailored to the existing research capacity in disease endemic countries and should focus on strengthening national health research systems, particularly in the least developing countries. The engagement of stakeholders at country level would facilitate the design of more specific and comprehensive strategies based on local needs.     

Community engagement in global health research that advances health equity

Community engagement is gaining prominence in global health research. So far, a philosophical rationale for why researchers should perform community engagement during such research has not been provided by ethics scholars. Its absence means that conducting community engagement is still often viewed as no more than a ‘good idea’ or ‘good practice’ rather than ethically required. In this article, we argue that shared health governance can establish grounds for requiring the engagement of low‐ and middle‐income country (LMIC) community members in global health research, where such research aims to help reduce health disparities. This philosophical basis has important implications for the ethical goals ascribed to engagement and the approach adopted to undertake it. We suggest the ethical goals of engagement in equity‐oriented global health research should include: (a) generating research topics and questions that reflect the key problems disadvantaged groups face in accessing healthcare, services and broader social determinants of health and (b) promoting the translation of research findings into policy and practice in ways that benefit the health of disadvantaged groups. We propose engagement practice should have the following features: deliberation with LMIC community members to make a range of project decisions, beginning with setting research topics and questions; inclusion of members of disadvantaged groups and those with the power to change policy and practice to benefit them; and purposeful structuring of deliberations to minimize the impact of power disparities between LMIC community members. Finally, we reflect on how these features differ from those typical of much current community engagement practice in LMICs.     

2011-2015年度国家自然科学基金微生物学学科项目申请与资助情况分析

本文总结了国家自然科学基金委员会生命科学部微生物学学科2011-2015年度各类项目的申请和资助概况,统计分析了五年来项目依托单位和主要研究方向的变化情况,并从鼓励学科交叉、优化资助格局和加强人才培养的角度对微生物学科资助方向进行展望,以期为微生物学领域的科研工作者提供参考。     

Programs for invasive research in North American zoos and aquariums

Zoo-based research in North America is an emerging field, which has progressed from an ad hoc approach in a small number of zoos to a coordinated, integrated network of scientists with recognized research programs in approximately one half of the accredited institutions in North America. The disciplines most active in these programs--veterinary medicine and pathology, nutrition, reproductive biology, contraception, and behavior--are now becoming coordinated in zoos through Scientific Advisory Groups. Zoos with research programs generally establish either an institutional animal care and use committee or another committee to evaluate research proposals. In addition to scientific merit and experimental design, zoos evaluate proposals based on factors such as priority by conservation program/identified need; direct effect on species conservation, species type, and appropriateness; availability and location of animals; operational requirements/logistics; communication between institutions; and available funding. Euthanasia is considered only in rare circumstances. Zoo-based research has evolved into an integral component in animal management and conservation programs by providing practical information that is used to improve animal care, well-being, health, and reproduction. However, the degree to which zoos participate in invasive research varies considerably among institutions, due not only to resource limitations but also to how the term "invasive" is defined and accepted at each institution. A more standardized approach among zoological institutions for examining and approving research projects that are supported by zoo-based conservation programs would greatly facilitate the wildlife research efforts of North American zoos.     

Reinterpreting Responsiveness for Health Systems Research in Low and Middle‐Income Countries

The ethical concept of responsiveness has largely been interpreted in the context of international clinical research. In light of the increasing conduct of externally funded health systems research (HSR) in low‐ and middle‐income countries (LMICs), this article examines how responsiveness might be understood for such research and how it can be applied. It contends that four features (amongst others) set HSR in LMICs apart from international clinical research: a focus on systems; being context‐driven; being policy‐driven; and being closely linked to development objectives. These features support reinterpreting responsiveness for HSR in LMICs as responsiveness to systems needs, where health system performance assessments can be relied upon to identify systems needs, and/or responsiveness to systems priorities, which entails aligning research with HSR priorities set through country‐owned processes involving national and sub‐national policymakers from host countries. Both concepts may be difficult to achieve in practice. Country ownership is not an established fact for many countries and alignment to their priorities may be meaningless without it. It is argued that more work is, therefore, needed to identify strategies for how the responsiveness requirement can be ethically fulfilled for HSR in LMICs under non‐ideal conditions such as where host countries have not set HSR priorities via country‐owned processes. Embeddedness is proposed as one approach that could be the focus of further development.     

Follow-Up Programs for Childhood Cancer Survivors in Europe: A Questionnaire Survey

Background

For many childhood cancer survivors follow-up care is important long after treatment completion. We aimed to describe the availability and characteristics of long-term follow-up programs (LTFU) across Europe, their content and aims, their problems, and to assess opinions on different models of LTFU.

Methodology/Principal Findings

We asked 179 pediatric oncology institutions in 20 European countries to complete an online survey on LTFU available at their institution. Of 110 respondents (62% response), 66% reported having LTFU for pediatric survivors, 38% for adult survivors of childhood cancer. Availability varied widely across European regions, from 9% of institutions in Northern Europe reporting LTFU for adult survivors to 83% of institution on the British Isles reporting LTFU for pediatric survivors. Pediatric and adult LTFU were usually located in pediatric hospitals and run by pediatric oncologists. Content of follow-up included screening for adverse outcomes and health education. Important problems included lack of time, personnel and funding. Most institutions without LTFU reported that they would like to offer a program (86%).

Conclusion/Significance

Despite general agreement on the need of follow-up care, there is still a lack of well-organized LTFU for survivors of childhood cancer across Europe.     

Noncommunicable disease outcomes and the effects of vertical and horizontal health aid

Foreign health aid forms a substantial portion of health spending in many low- and middle-income countries (LMICs). It can be either vertical (funds earmarked for specific diseases) or horizontal (funds used for broad health sector strengthening). Historically, most health aid has been disbursed vertically toward key infectious diseases, with minimal allocations to noncommunicable diseases (NCDs). High NCD burden in LMICs underscores a need for increased assistance toward NCD objectives, but evidence on the outcomes of health aid for NCDs is sparse. We obtained annual data on cause-specific deaths and disability-adjusted life years (DALYs) for four leading NCDs across 116 countries, 2000–2016, and evaluated the relationship between these indicators and vertical and horizontal health aid using country fixed-effects models with 1-to-5-year lagged effects. After adjusting for fixed and time-variant country heterogeneity, vertical assistance for NCDs was significantly associated with subsequent reductions in NCD morbidity and mortality, particularly for persons under age 70 and for cardiovascular and chronic respiratory diseases. An additional dollar in per-capita NCD vertical assistance corresponded to reductions in the average annual NCD burden of 7,459 DALYs/281 deaths after one year, 7,728 DALYs/319 deaths after two years, and 8,957 DALYs/346 deaths after three years. The findings suggest that vertical assistance for NCD programs may be an appropriate mechanism for addressing short-term NCD needs in LMICs, where it may help to fill health sector gaps in NCD care, but longer-term evaluation is needed for assessing the role of horizontal assistance.     

Getting ready for malaria elimination: a check list of critical issues to consider

In recent years, a renewed interest in malaria elimination and eradication has emerged and seems to be rooting in the minds of the scientific community, public health specialists, funding bodies, policy makers and politicians. Malaria eradication will certainly benefit from improved and innovative tools; notwithstanding novel knowledge in fields ranging from basic science to mathematical modelling and health systems research. However, the elimination of malaria also encompasses a broad range of essential aspects that countries and other actors need to consider when thinking of embarking on such an adventure, including the implementation of innovative strategies, the ability to incorporate the most up-to-date evidence into policy, the integration of malaria into the broader health agenda, the strengthening of surveillance and health systems, capacity building, funding, advocacy and, very importantly, research. While in some cases this enthusiasm is clearly justified, some countries are still a long way from realistically advancing towards elimination. This paper attempts to provide guidance on all the necessary issues that should be considered when initiating a malaria elimination program.     

Funding the NHS. Is the NHS sustainable?

The survival of the NHS lies largely in the hands of government, and this article suggests steps that it should take to deal with pressures on the NHS in terms of funding, managing efficiency, and demands. Changes to the system of funding may be unfeasible, but management could be improved by research to allow greater understanding of the local effects of national policies. Alternatively health authorities could be given more freedom to manage funds, although this would have to be accompanied by stiff sanctions for those who failed. Demand could be contained by strengthening policies to ensure that new technologies are cost effective. The government could try to reduce demands arising from increased expectations by encouraging informed public debate about priorities and influencing the availability of private health care. All these efforts should be guided by the values underpinning the NHS, which should be debated and decided collectively and confirmed in a new charter for NHS''s 50th anniversary in 1998.     

Patient-level interventions to reduce alcohol-related harms in low- and middle-income countries: A systematic review and meta-summary

BackgroundDisease and disability from alcohol use disproportionately impact people in low- and middle-income countries (LMICs). While varied interventions have been shown to reduce alcohol use in high-income countries, their efficacy in LMICs has not been assessed. This systematic review describes current published literature on patient-level alcohol interventions in LMICs and specifically describes clinical trials evaluating interventions to reduce alcohol use in LMICs.Methods and findingsIn accordance with PRISMA, we performed a systematic review using an electronic search strategy from January 1, 1995 to December 1, 2020. Title, abstract, as well as full-text screening and extraction were performed in duplicate. A meta-summary was performed on randomized controlled trials (RCTs) that evaluated alcohol-related outcomes. We searched the following electronic databases: PubMed, EMBASE, Scopus, Web of Science, Cochrane, WHO Global Health Library, and PsycINFO. Articles that evaluated patient-level interventions targeting alcohol use and alcohol-related harm in LMICs were eligible for inclusion. No studies were excluded based on language.After screening 5,036 articles, 117 articles fit our inclusion criteria, 75 of which were RCTs. Of these RCTs, 93% were performed in 13 middle-income countries, while 7% were from 2 low-income countries. These RCTs evaluated brief interventions (24, defined as any intervention ranging from advice to counseling, lasting less than 1 hour per session up to 4 sessions), psychotherapy or counseling (15, defined as an interaction with a counselor longer than a brief intervention or that included a psychotherapeutic component), health promotion and education (20, defined as an intervention encouraged individuals’ agency of taking care of their health), or biologic treatments (19, defined as interventions where the biological function of alcohol use disorder (AUD) as the main nexus of intervention) with 3 mixing categories of intervention types. Due to high heterogeneity of intervention types, outcome measures, and follow-up times, we did not conduct meta-analysis to compare and contrast studies, but created a meta-summary of all 75 RCT studies. The most commonly evaluated intervention with the most consistent positive effect was a brief intervention; similarly, motivational interviewing (MI) techniques were most commonly utilized among the diverse array of interventions evaluated.ConclusionsOur review demonstrated numerous patient-level interventions that have the potential to be effective in LMICs, but further research to standardize interventions, populations, and outcome measures is necessary to accurately assess their effectiveness. Brief interventions and MI techniques were the most commonly evaluated and had the most consistent positive effect on alcohol-related outcomes.Trial registrationProtocol Registry: PROSPERO CRD42017055549

Catherine Staton and co-workers report on evidence about interventions against harmful alcohol use in low- and middle-income countries.     

Health research funding: Members' of Parliament knowledge of and attitudes toward health research and funding

Background

Establishment of the Canadian Institutes of Health Research (CIHR) in 2000 resulted in increased funding for health research in Canada. Since 2001, the number of proposals submitted to CIHR that, following peer review, are judged to be of scientific merit to warrant funding, has grown by 77%. But many of these proposals do not receive funding because of budget constraints. Given the role of Members of Parliament in setting government funding priorities, we surveyed Members of Parliament about their knowledge of and attitudes toward health research, health research funding and CIHR.

Methods

All Members of Parliament were invited to participate, or to designate a senior aide to participate, in a 15-minute survey of knowledge of and attitudes toward health research, health research funding and CIHR. Interviews were conducted between July 15, 2006, and Dec. 20, 2006. Responses were analyzed by party affiliation, region and years of service as a Member of Parliament.

Results

A total of 101 of 308 Members of Parliament or their designated senior aides participated in the survey. Almost one-third of respondents were senior aides. Most of the respondents (84%) were aware of CIHR, but 32% knew nothing about its role. Participants believed that health research is a critical component of a strong health care system and that it is underfunded. Overall, 78% felt that the percentage of total government spending directed to health research funding was too low; 85% felt the same way about the percentage of government health care spending directed to health research. Fifty-four percent believed that the federal government should provide both funding and guidelines for health research, and 66% believed that the business sector should be the primary source of health research funding. Participants (57%) most frequently defined health research as study into cures or treatments of disease, and 22% of participants were aware that CIHR is the main federal government funding organization for health research. Participants perceived health research to be a low priority for Canadian voters (mean ranking 3.8/10, with 1 being unimportant and 10 being extremely important [SD 1.85]).

Interpretation

Our results highlight significant knowledge gaps among Members of Parliament regarding health research. Many of these knowledge gaps will need to be addressed if health research is to become a priority.Over the past 8 years, health research has been an important but declining priority for the federal government. The development of the Canada Foundation for Innovation, the Canada Research Chairs, Genome Canada, the Networks of Centres of Excellence, the Canadian Health Services Foundation and the Canadian Institutes of Health Research (CIHR)¹ reflects this initial interest. Although most of these programs receive multi-year funding, CIHR receives annual funding from the federal government. However, its annual increases have not risen proportionately with the number of requests for funding it receives each year.CIHR is the federal funding body for health research and consists of 13 institutes. It supports 4 pillars of research: biomedical research, clinical research, social and cultural aspects of health and population health research, and health services and systems research. With the formation of CIHR,² federal funding for health research increased from $289 million in 2000 to $553 million in 2002, with subsequent 5%–6% annual increases until 2006. That year, the increase was 2.4%.³ The initial increases in funding stimulated a sharp rise in the number of grants submitted and funded annually. In the 2006 competition, the increase in funding was lower than expected and the success rate in the open competition fell to 16% from the mean rate of 31.7% in previous years. As a result, 60% of peer-reviewed grants rated as very good or excellent were not funded, as compared with 38% in 2001 (CIHR: unpublished data,2007).Because Members of Parliament vote annually to determine CIHR''s budget for funding health research, we surveyed Members of Parliament and their senior aides about their knowledge of and attitudes toward health research, health research funding and CIHR.     

‘Disease,Disaster and Despair’? The Presentation of Health in Low- and Middle-Income Countries on Australian Television

Background

In high-income nations mainstream television news remains an important source of information about both general health issues and low- and middle-income countries (LMICs). However, research on news coverage of health in LMICs is scarce.

Principal Findings

The present paper examines the general features of Australian television coverage of LMIC health issues, testing the hypotheses that this coverage conforms to the general patterns of foreign news reporting in high-income countries and, in particular, that LMIC health coverage will largely reflect Australian interests. We analysed relevant items from May 2005 – December 2009 from the largest health-related television dataset of its kind, classifying each story on the basis of the region(s) it covered, principal content relating to health in LMICs and the presence of an Australian reference point. LMICs that are culturally proximate and politically significant to Australia had higher levels of reportage than more distant and unengaged nations. Items concerning communicable diseases, injury and aspects of child health generally consonant with ‘disease, disaster and despair’ news frames predominated, with relatively little emphasis given to chronic diseases which are increasingly prevalent in many LMICs. Forty-two percent of LMIC stories had explicit Australian content, such as imported medical expertise or health risk to Australians in LMICs.

Significance

Media consumers'' perceptions of disease burdens in LMICs and of these nations'' capacity to identify and manage their own health priorities may be distorted by the major news emphasis on exotic disease, disaster and despair stories. Such perceptions may inhibit the development of appropriate policy emphases in high-income countries. In this context, non-government organisations concerned with international development may find it more difficult to strike a balance between crises and enduring issues in their health programming and fundraising efforts.