Beyond Forum 2012: some final reflections

David Dickson

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There’s been much talk in Cape Town at Forum 2012 over the past week of the need for a paradigm change in thinking about health research for development.

Certainly the concept is a useful one to describe the switch from an approach focussed primarily on the allocation of research resources, to one that addresses the need to build systems of innovation in the health field (as elsewhere).

It helps us move beyond a fixation with the famous 90/10 imbalance between research expenditure on developed and developing world health priorities, to embrace a wider perspective.

But at the end of three days of lively discussions, I remained unclear whether talking about “Beyond aid” – the theme of the meeting – represented a radical idea, or a useful way of labelling a set of trends that have been in motion for some time, and identifying the general direction in which they point.

Either way, however, such a discussion is timely.

First, as Carl Ijsselmuiden, executive director of the Council on Health Research for Development (COHRED), the main organiser of the conference, pointed out in his opening remarks, it captures the growing feeling that “foreign aid as hand-outs to the poor” is no longer workable.

The approach may not be one that wins many votes for aid-providing governments. But in the long-term, these realise that “foreign aid as capacity building” is much more likely to produce lasting results.

 Second, talking about what happens next – particularly in an area such as health research and innovation, and at a time when external sources of funding are drying up – provides a spur to developing country governments to address their own responsibilities.

Ending on an up-note: the singer Princess Chaka Chaka, UN Goodwill Ambassador and a champion of Africa's fight against malaria, leads participants of Forum 2012 in a farewell chorus (Gabi Falanga)

This has both funding and policy implications. Health research spending needs to become a higher priority for these governments. And they need to create the incentives that will allow the result of this research to be translated into medical products – such as drugs – and services.

Finally, there is the pragmatic issue that, as aid budgets start falling in many developed countries as a result of their financial difficulties, anything that promises to “do more with less” with what funding remains available becomes increasingly attractive.

Moving from “aid as hand-out” to “aid as capacity building” does just that.

So, three good reasons for embracing the concept of a paradigm change. But it also became clear in the Forum 2012 discussions that there are reasons for not expecting too much, too soon.

There may be consensus on what needs to change. But this consensus does not necessarily extend to agreement on what this change should be.

For example, those seeking a new international convention on health research and development argue that it is needed to make up for the failure of the market system to provide developing countries with access to medicines at affordable prices.

Pharmaceutical companies may agree that this is a challenge. And that they need to work with governments – and aid agencies – to tackle it. But their interests ultimately lie in benefitting from the market, not in seeing alternatives put in place.

Similarly health ministers may be persuaded of the arguments for developing home-grown health industries, better equipped to meet local health needs.

But the people who really need convincing work in finance ministries. And the financial case for operating in a new way, rather than, for example, just importing technologies from abroad, is not always self-evident.

Paradigms get embedded in social – and political – systems. Changing them is not just a question of rational debate (even in science). It also requires challenging the interests that the old paradigm served.  And it can have costs attached.

So, big challenges ahead. The major contribution of Forum 2012 was to help cement the idea that “aid for capacity building” is the new mantra that needs to frame aid and government policies, in developed and developing countries alike.

Also that, as in fields such as agriculture and energy, health needs to move away from the idea that developments are research-driven, to recognising that research is one component of a holistic system of innovation – each part of which needs to be addressed.

The immediate task, as always, is to work out what all this means in practice, identifying needs and opportunities, and assessing the potential contributions of all interested parties (including the media).

Not quite the “Beyond aid” vision that the organisers are aiming for. But a step in that direction.

David Dickson is editor of SciDev.Net

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012.

Journals play a key role in bridging knowledge gaps

Lia Labuschagne

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What role can scientific journals play in bringing the knowledge divide, not only between North and South, but also between researchers and policymakers?

A lively general discussion at Forum 2012 focussed on the role of journals in knowledge transfer in the field of sexual and reproductive health and rights. But the same issues relating to disseminating scientific information also apply to other disciplines.

Some current topics relating to the international output of scientific journals were introduced by Marge Berer, editor of Reproductive Health Matters, and Ann Strode, senior lecturer at the School of Law, University of KwaZulu Natal, and editorial advisory board member of AIDS Care.

Journal articles can help bridge the gap between research and policymakers (Credit: Reproductive Health Matters)

Berer commented that “there has never been so much information before, nor so many means of disseminating and using it”.

Participants in the general discussion nevertheless pointed out that, especially in developing countries, there is often a big time lag between research being completed and finding its way into text books.

Factually outdated information is often still being taught. And although new health and other policies may be adopted, there may be no change in teaching material.

Scientific journals provide a useful link across this divide, partly because their up-to-date research findings and information is increasingly becoming available in accessible, electronic format to a global readership of academics and practitioners within various disciplines.

Advocates and lobbyists also use the information in journals as the basis of advancing well-founded arguments for change of policies and practices.

Strode said journals such as AIDS Care are therefore used by both researchers and policymakers as a high-quality source of knowledge that they can provide from a multi-disciplinary perspective.

Some additional ideas to emerge from the discussion of ways to use the contents of scientific journals to aid development included translations of articles into local languages, and selecting key pieces of writing on specific topics to be made them available as thematic packages.

In terms of the North/South divide, Berer pointed out that “more authors from developed countries than from developing countries have access to the resources to publish in international journals”.

To help to redress this imbalance, she said that RHM gives preference to papers about developing countries by authors from those countries, or written with authors from those countries.

Broader issues discussed at the session included the continued debates around open and closed peer review processes, formal recognition for reviewers, and questions of ownership and funding.

Lia Labuschagne is a freelance journalist based in Cape Town

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012. 

Mapping an inclusive road ahead for health research

David Dickson

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It’s not often that a department of transport gets applauded for solving a major health problem. But this happened in Uganda, where health officials had been struggling to reduce infant mortality rates in an area outside the capital Kampala.

Success came not with a new medical strategy, but with the opening of a road built to speed bananas to Kampala’s markets. An unplanned consequence was that the road gave mothers quicker access to better medical facilities – and mortality rates dropped sharply.

Banana transport in Uganda: an unlikely aid to reducing infant mortality (Credit: IITA)

The story was picked up at the closing session of Forum 2012 by the chair of the meeting’s steering committee, Francisco Sogane, former minister of health in Mozambique, as epitomising one of its main conclusions.

“We need to cut across sectors in addressing the multiple challenges still faced by billions of people across the world,” Sogane said.

“We in the health sector need to open the doors of our community and work with other sectors in meeting our common challenges. The way forward is to bring together expertise from different sectors, and develop novel and sustainable solutions to the problems that we face”.

The same theme was echoed by Gwen Malegwale Ramokgopa, South Africa’s deputy minister of health, who urged that “we must make health research everyone’s business”.

Ramokgopa stressed that governments in developing countries needed to invest more in health research, particularly at a time when funding from donor agencies in the developed world – the traditional source – was falling due to the financial difficulties of their governments.

“We can see this situation as a threat, or we can see it as an opportunity to look at better and more sustainable ways of dealing with research and innovation in our countries and regions,” she said.

Indeed, there’s been a general feeling at the three-day meeting that the idea of moving “beyond aid” – the title under which it is being held – is a robust one whose time has come, and that the challenge is now to move from talk to action.

Sogane: "We need to open the doors of our community" (Gabi Falanga)

Sogane pointed out that developing country governments needed to address three tasks: setting their own priorities for health research (rather than letting these be determine by donors); training more people to carry out the necessary research; and providing incentives for turning research results into pharmaceutical products and medical treatments.

Ramokgopa picked up the same theme, pointing out that South Africa had already held its own national research summit of stakeholders to agree on joint objectives – and ensure that the country’s research goals are aligned with its health priorities.

“Those in the knowledge-based sector have been focussed on their own priorities, those in government on theirs, and civil society organisations on theirs,” she said. “Our summit helped us to develop a common research agenda for improving the health of our people.”

There was also a general feeling that, despite the lack of any major new developments, Forum 2012 has strengthened the case for focussing on the links between health research and health innovation, and broadening the debate to include new actors, including the private sector – and even the media.

The next forum is provisionally planned to take place in two years’ time. Before then, discussions are taking place about holding regional fora on the same theme, perhaps in Africa and Asia.

As for the content of such discussions, the road ahead already seems well mapped out. And this time, meeting health needs – not those of Ugandan bananas – will be the top priority.

David Dickson is editor of SciDev.Net

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012.

New opportunities in a changing landscape

Kathryn Strachan

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African countries are at a turning point, where they have an opportunity to invest in research capacity and ‘leapfrog’ over research institutions in other parts of the world.

This was the optimistic message from Val Snewin, international activities manager for Britain’s Wellcome Trust, who was addressing a session of Forum 2012 on the topic of developing research capacity.

Snewin said that, in light of the recession in Europe and the United States, and set against positive economic growth in Africa, a new opportunity presented itself for African research capability.

Getting fitter: new opportunities are opening up for health research in Africa (Credit: Flickr/Oxfam)

“The world is shifting on its axis here,” she said. “But very few national governments are stepping up and engaging with it. We need political will, and for governments to invest in research capacity, where they can afford it.”

Two examples were Ghana and Tanzania, both of which were showing commitment to creating research and innovation.

Rene Loewensen, of EQUINET in Zimbabwe, said that a changing landscape, in which countries were being encouraged to take charge of their own health research agendas, also brought an opportunity to shift the paradigm of how research is carried out.

Previously the focus had been on building capacity in research institutions in universities, she said. Now there was a need to extend this research to a broader context.

Placing research capacity in the community and in health services would enable it to be more responsive to the needs of both the community and the country.

“It allows us to look at the real world, rather than at theoretical issues,” said Loewensen.

But this new focus on community and multidisciplinary research had also brought new challenges, such as how to keep track of quality in a rapidly changing field.

Yogan Pillay, deputy director general of the South African health department, said that policymakers were increasingly recognising the importance of research, but were now seeking an answer to “how to make it happen”.

The questions they faced were around the implementation of research results, and scaling them up to make a wide impact.

Kathryn Strachan is a freelance health and development journalist working in Johannesburg.

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012. 

Social media rises to the challenge of health communication

Lia Labuschagne

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Health researchers should consider the creative use of social media – and in particular of new communication tools such as “edutainment” – as part of a comprehensive communication strategy because, like anything else, research findings need to be effectively marketed.

In the words of Kirsten Patrick, clinical reviews editor of the British Medical Journal, addressing a session of Forum 2012 devoted to the topic of science and social media, “it is our job not only to do the research, but to get it out there.”

Soul City: Showing how "edutainment" can communicate health messages (Credit: Soul City)

One example of how edutainment can be done successfully is demonstrated by Soul City in South Africa – or to give it its full title, the Soul City Institute for Health and Development Communication.

This uses an entertaining storyline in television drama to influence behaviour and practices relating to health, nutrition and sexuality.  Recent themes have included medical male circumcision and the prevention of mother-to-child transmission of HIV.

Bongiwe Ndondo, monitoring and evaluation manager of Soul City, told the session that edutainment as a technique for transmitting social messages through entertainment had been practiced in traditional societies for centuries.

Soul City has brought the idea up-to-date by translating this concept into national television series, supported by 23 radio talk shows on seven community radio stations, printed material, internet-based social media such as Twitter, Facebook and YouTube, and mobile applications, in particular Young Africa Live.

She explained that research is the cornerstone of the roadmap leading to the production of a new television series, which is always “based on an extensive and rigorous research process that ensures quality, relevance and effectiveness.”

Denis Jjuuko, a media and communication consultant from Uganda, argued that social media could stimulate discussions and fill gaps left by reports in traditional, mainstream media. This was especially important in countries with limited press freedom, or where mainstream media shy away from sensitive topics.

Jjuuko said that the rapid growth of mobile technology in Africa provided an important new distribution medium. “Social media has become mainstream, and can sometimes do what other media cannot do, especially in some parts of Africa, where mainstream media may, for example, be virtually closed when you deal with certain issues of sexuality.

“In such cases you can use mobile technology and social media such as blogs and video on YouTube to get your message across.”

ResearchAfrica managing editor Linda Nordling argued that social media “give you quite a lot of control, because you can respond and you do not rely on an intermediary such as a journalist as in the traditional media.”

She also said that social media were also “important in terms of ‘narrow casting’:  talking not only to many people, but the right people”.

In the discussion that followed the presentations, participants pointed to some of the difficulties that researchers have encountered with social media, and indeed with attempting to engage in the public communication of their research results.

These includes the dangers of being misquoted, ethics issues – particularly when sensitive clinical trials were involved –  fears around the improper use and interpretation of data, and the adverse effects of an indiscriminate dissemination process, especially when researchers were working on sensitive topics.

Speakers on the panel also included contributions by SciDev.Net editor David Dickson and Brenda Zulu, founder of Africa Interactive Media in Zambia.

Lia Labuschagne is a freelance journalist based in Cape Town

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012. 

Enterprise comes to the aid of health

Kathryn Strachan

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Forum 2012 has heard several examples of ways in which entrepreneurs in developing countries are beating a new path for bringing health innovation to poor communities.

In Bangladesh, where there are not enough doctors and nurses to provide care for a population of 160 million, almost 70 per cent of care comes from the ‘barefoot doctors’ – 400,000 informal healthcare providers.

An enterprise based on providing these informal health workers with medical information –  particularly in prescribing medicine to diabetic and chronic patients – through mobile and smart phones has gone a long way to providing better care for these patients.

Sikder Zakir, managing director of the Telemedicine Reference Centre, said the enterprise had so far reached 1.5 million people with diabetes. But with a total of seven million people with diabetes in Bangladesh, they still had a long way to go.

Another of its projects was aimed at the 11 million Bangladeshi migrants who are working in eight countries in the region. The scheme provides a hotline number for them – and their family members back home – which refers them to the local health services.

The enterprise has been operating for seven years, and in the past two years it had extended to India and Pakistan.

The advantage of the service has been that it could be provided at a far lower cost than by government – and it made business sense too.

The element that worked in favour of his enterprise was that the technology had become significantly cheaper over time. And the potential market of 160 million people made it a powerful platform for attracting investors.

Another example came from South Africa, where the enterprise Care Cross is offering high quality medical care for half the cost of a normal doctors’ visit to members under its medical scheme.

And in Rwanda, a public-private partnership One Family Health was setting up primary healthcare clinics on a franchise system, a business-model which was bringing health care to the village level.

An issue discussed over several of the forum’s sessions was how to stimulate private sector interest in African countries. In India part of the success was the support from its government in attracting private investment, and this government-level support needed to be encouraged on the African continent.

Ralph Schneideman of PATH, the non-profit organisation based in Seattle which aims to transform global health through innovation, said companies in the United States and Europe had lost out on the opportunity to form public-private partnerships with India in the 1990s.

However they now had a window of opportunity in Sub-Saharan Africa. Similar initiatives were starting up in Africa, and these companies did not want to lose out again, he said.

Kathryn Strachan is a freelance health and development journalist working in Johannesburg.

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012. 

Cometh the hour, cometh the solutions…

Lia Labuschagne
Freelance journalist working in Cape Town

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Research on humanitarian responses to emergencies faces practical challenges relating to data collection and feasibility. In addition, there are often sensitive ethical implications relating to carrying out research in such conditions.

A case study presented at Forum 2012 by Jun Yan, director of the mental health division of China’s Ministry of Health, and Sun Xueli  of Sichuan University, looked at some of the experiences relating to mental health services after the deadly 7.9 magnitude earthquake near Wenchuan, in the Sichuan province, in May 2008.

The Wenchuan earthquake in May 2008 caused 69,000 deaths (Flickr/Wen Chuan)

More than 69,000 people had died, a further 370,000 were injured, with about 4.8 million people left homeless: in total 40 million people were affected by the disaster.

A guideline for psychological crisis intervention in emergency situations was published by the Chinese ministry of health, five days after the disaster.

Among the responses was a post-disaster mental health aid project aimed at adolescents and children. This was prompted by the fact that many thousands of school children had died, and at least 7,000 school buildings in the province had collapsed.

There were very few counsellors to provide mental health support services to children, said Jun, and teachers were ill-prepared to take on the task.

The challenge was to find quick, effective ways to treat mental problems among the affected children, and to help them get through the traumatic period following the disaster.

The response programme included setting up an education-healthcare mental health platform, based on local educational administrative departments.

A major resource was the West China Hospital of the Sichuan University, which has one of the best mental health centres in China and which formed the core of an expert group providing professional guidance. Support also came from the numerous motivated volunteers.

A pilot study was aimed at collecting evidence through a baseline survey, creating service teams, developing training material and guidelines, equipping facilities, training the trainers, and organising working teams.

The subsequent programme actions included, among others, group therapy for high-risk students, family support and therapy, prevention interventions focusing on single-parent and divorced, training teaching staff to integrate mental health issues into regular teaching, and building school counselling centres.

As an extension of the programme, a mental health outpatient service was set up in villages and towns by training part-time and full-time primary mental health staff.

Lessons learnt included the importance of multi-sector coordination and participation with government leading; the need for a provincial level expert group (consisting of psychiatrists, as well as educational and public health experts) to provide professional guidance; and support from private bodies, both locally and internationally.

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012. 

Making the most of the Arab Spring

Kathryn Strachan

Freelance health and development journalist working in Johannesburg

 Research for health has traditionally received little attention in the Arab world. And the extent to which the situation that has followed last year’s ‘Arab spring’ is influencing the region’s agenda for health research was discussed in a session at the Forum 2012 meeting.

In particular, several speakers pointed out that people in the Arab world now have a voice – and that this presents an opportunity to change the way decisions about both health research and development are made.

According to Hassen Ghannem, professor of medicine at the university hospital Farhat Hached in Sousse, Tunisia, people in his country were now asking about issues that had been accepted without questions in the past.

“The main message from Tunisia is to listen to the population,” he said. People were now demanding answers from policymakers. This created an opportunity to change that way decisions were made, and to place research at the centre of those decisions.

Fouad M Fouad, co-ordinator of the Syrian Centre for Tobacco Studies, said that in an emergency situation, where there was no food or proper sanitation, the place of research was not always clear.

Virtually no research had been carried out in Syria in peaceful times, he said. But the current conflict in the country had brought a renewed need for research on questions such as why vaccination rates had fallen over the past year.

“This should keep us motivated to work harder for research. We should keep going, even when we are in such a shaky position, and work together for change,” he said.

Francisco Becerra, the head of projects at the Council on Health Research for Development (COHRED), said change in Egypt had to be about more than replacing one group of leaders with another.

Political leaders had to listen to the voice of the people. Otherwise the previous neglect of the needs of the population would be repeated, and the opportunity for changing society would be lost.

Other speakers pointed out that the changes sweeping across the Arab world had brought opportunities at every level. But there was a danger that previous hard-won gains – such as progress in women‘s rights – could be lost if they were not adequately protected.

“We have achieved a lot in the past in the areas such as reproductive health, informed choice, and family law, but now the old language is reappearing again,” Hoda Rashad, director of the Social Research Centre at the American University of Cairo, Egypt told the meeting.

“In people’s excitement with the new revolution, they want to cut all ties to the past, and this includes throwing out all the achievements that have been made over the past few years.”

It was essential for researchers to remain aware of the complexities of the issues that they faced, and to have informed debates about them. Otherwise there was a risk that progress made in women’s rights and in health equity would be lost.

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012. 

A paradigm shift that promises a better future

David Dickson
Editor, SciDev.Net

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Can the governments of both developed and developing countries be persuaded to back a paradigm shift in the way that research into novel treatments for the diseases of the developing world is funded?

Eye on the future: keeping vaccines affordable is the challenge ahead (Credit: Gates Foundation)

This is the challenge being thrown down by supporters of a proposed international convention on the funding and co-ordination of health research that is being proposed to the World Health Assembly next month (see my recent editorial).

As described to a session of Forum 2012 devoted to the proposal, the case for change is clear. Carlos Corea, a member of the WHO’s Consultative Expert Working Group on Research and Development (CEWG) which draw up the proposal, outlined three reasons that change was needed.

Firstly, he said, although investment by pharmaceutical companies has increased significantly in recent years, product innovation – measured by the number of new drugs emerging – has gone down.

Secondly, despite increased investment in research and development for diseases in developing countries, a lack of incentives means that this remains insufficient. And thirdly, “there is little co-ordination [in drug research]. Global efficiency is not very high.”

Michelle Childs, of Medecins sans Frontieres, put it more pragmatically. “We are interested in the proposed convention because of the frustration of our medical teams that many of the tools that they need are unavailable, un-affordable, or ill-adapted to the situations they face on the ground.”

The reason, she suggested, was that drug industry relies on recouping the costs of research and development through high prices on the resulting products, which it is able to charge through the exercise of patent rights.

At the core of the proposed treaty would lie a fundamental break with this principle. Namely, the costs of R&D on new drugs would be de-linked from the costs of providing the drugs to patients.

James Love of Knowledge Ecology International, one of the original architects of this novel approach, described the challenge. “How do you change the paradigm and come up with something new that reconciles the needs for innovation and access.”

Why was this controversial? “Because it challenges current thinking about how R&D is financed”. Furthermore, the principles on which it is based “are seen as a threat to existing business models”.

But Love argued that the treaty model “should not be considered that controversial, since it focusses on areas where the market is not working, and where the access issues are particularly acute”.

The fate of the proposal at next month’s meeting of the WHA is uncertain. “Some people may try to delay the decision for a year,” says Love.  “But you don’t want this report to sit on the shelf.

“What is needed is for the WHO to create an intergovernmental body to move this thing forward. We need to open the door that allows people to start discussing this proposal.”

Francisco Songane, the chair of the Forum 2012 steering committee, warned that for even this to happen, it was important that delegates to the WHA should be fully informed about the proposals.

Otherwise there might be last-minute attempts to block progress not out of disagreement, but out of a lack of knowledge.

Others added that it was not just health ministries that needed to be involved, but other ministries with a stake in the outcome. In particular this included finance ministries, since the treaty has potentially significant financial implications.

Despite the challenges in generating the necessary paradigm change, there was an air of optimism in the discussion in the Forum 2012 session.

“The world we live in today is different from the world in which we will live in 20 years’ time,” said Love. “You have to find a path to change things. The R&D treaty is an attempt to build a different future.”

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012.

Can poor countries produce their own drugs?

Lia Labuschagne
Freelance journalist working in Cape Town

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Can lower and middle income countries (LMICs) engage in producing the drugs needed to combat neglected tropical diseases? And to what extent do their governments hold the key that will allow them to do so?

Where next? Drug production is the next step after research for low and medium countries (Source: ANDDI)

These questions led to a lively round-table discussion at Forum 2012 chaired by Elizabeth Ponder, associate director for scientific affairs at BVGH in the United States.

Ponder pointed out that neglected diseases affect more than 1 billion people around the world.

Millions of people in resource-poor countries die from these diseases, she said, because life-saving drugs, vaccines, and diagnostics are inaccessible, outdated, unsafe, ineffective – or not yet created.

The challenge was put to a panel representing a wide range of interested government bodies, NGOs, funders, and research laboratories, as well as the private biopharmaceutical sector .

Most panelists agreed that capacity was not the problem; many lower and middle income countries had the scientists and technologies needed to develop the relevant products.

The main problem lay in raising the funding needed to get the drugs into production, and to ensure that they were distributed to where they were required. And this frequently required a political – as well as a financial – commitment.

Jean-Pierre Paccaud, director of business development at Drugs for Neglected Diseases initiative in Switzerland, said that it was important to understand the specific needs of the areas in which diseases occurred, and then to focus on leveraging local capacities.

Konji Sebati, director of the department of traditional knowledge and global challenges at the World Intellectual Property Organization in Switzerland, said that lobbying governments was important since “without political will nothing will change”.

According to David Walwyn, chief commercialisation officer with the company iThemba Pharmaceuticals in South Africa, “it is important to articulate clearly to governments what we want, and to set clear targets.”  Universally-accepted goals were needed so that progress could be monitored.

And Alex Ochem, of the African Network for Drugs and Diagnostics Innovation, agreed that the research capacity exists in Africa. But he stressed the sobering truth that “no matter how much research we carry out and articles we publish, if we do not get the product – the medicines – to the market, then we have failed.”

This blog post is part of our Forum 2012 coverage — which takes place 24–26 April 2012.