Fiona Godlee on research in the developing world – for whom and by whom?

Fiona Godlee Most of the delegates have managed to make it to Mali, despite a threatened strike by Air France’s pilots. In the end, by various routes, there are over 1000 of us from 75 countries. Our aim is to focus on efforts to strengthen the ability of developing countries to do research for health, but airlines are on all our minds.

One speaker draws parallels between national airlines and national research strategies. Not all countries need their own airline, says Hannah Akuffo, originally from Ghana and now working for SIDA in Sweden, but every country needs its own research strategy. Later Martin McKee from the London School of Hygiene and Tropical Medicine illustrates his talk with planes from two of the countries he works with that have a national airline but no national research strategy.

It’s 10 years since the Global Forum for Health Research coined the phrase “the 10/90 gap” to describe the fact that only 10% of research funds are applied to the health problems of 90% of the world’s population. Gill Samuels, chair of the forum and, I subsequently discovered, the woman who led the Pfizer drug development team that discovered Viagra, calls us to consider what will be the legacy of this meeting.

Progress since the last WHO ministerial summit in Mexico in 2004 is not striking, say most people I speak to, though there is the clinical trials platform as well as new initiatives for knowledge translation networks like EVIDnet, and other local and regional projects that have achieved fragmented success. The Mexico declaration called for health ministries to dedicate at least 2% of their budgets to research. For most developing countries this remains an aspiration, with most still well below 1%. The Lancet’s call for papers for this meeting garnered only about 50 submissions, of which half were from developed countries.

The problem is that research is a hard thing to sell where resources are tight. Even in America, says Mary Woolley, head of Research America. Convincing the public that research is not a luxury can be difficult. How much harder in Africa! On the walk from the hotel to the conference centre, the great expanse of the River Niger carries fishermen in boats thin as pencil strokes against the morning light. The children running barefoot through their smokey encampments along the river bank are a keen reminder of why we are here. The biblical scene is swathed in traffic fumes, acid at the back of the throat. Motorbikes and buses outnumber bicycles, often carrying incongruous loads – one rider drives with his arms around two full pigs carcasses encased in sacking resting on the scooter platform.

Dodging the traffic on Bamako’s hectic roads is almost as difficult as dodging the health policy jargon in the conference hall, as well as the growing sense of déjà vu from discussions at previous meetings. One delegate from Kenya says he’s heard it all before. The call for action being worked on by ministers from 52 countries alongside the global forum is likely to be a cut and paste job from previous calls, he says. One insider says he expects it to be yet again a call for inaction. But the expense alone of getting so many key people together in one of the world’s poorest countries should surely shame us all into coming up with something concrete.

How then to build research capacity in the developing world? Hannah Akuffo says it needs political commitment, national research strategies, budget lines, skills development, people asking nationally relevant questions, the capacity for countries to generate their own knowledge, the ability to use external knowledge, and a culture of enquiry.

From the presentation by Mark Walport of the Wellcome Trust and from other conversations with funding agencies, it’s clear that funders still prefer giving money to individuals rather than institutions. And others say that it’s only when institutions within countries are given funds that will allow them to build over the long term that young researchers will have the confidence to take up research as a career and to stay rather than emigrate.

And how to get locally generated research into policy and practice. The developed world has surprisingly few lessons to offer here. Data from interviews in the developing world show the same barriers to transfer of knowledge between researchers and policy makers – different languages, cultures, time frames, and incentives, and lack of easy access for policy makers to relevant summaries of research results.

When after three days of deliberation the call to action is finalised and read out to a packed conference hall, with full ministerial protocol in the presence of Mali’s prime minister, it’s better than some had feared. It calls for greater investment in research into the health of the world’s poorest people, reiterating that health ministries should allocate at least 2% of their budgets to research, and that at least 5% of external aid from donors should be earmarked for the health sector. It emphasises the role of research as a stimulus for economic development, especially during an economic downturn, and calls for governments to develop their own research agendas and priorities, rather than relying on agendas set by external agencies.

Responding to the declaration, Carel Ijsselmuiden, director of the Council on Health Research for Development (COHRED), which was one of the partners for the meeting, expresses the hope that by the next ministerial summit in 2012, the discussion will no longer be about research for the world’s poorest nations but research by them for themselves. But sadly among delegates rushing to get catch an Air France flight home, it seems all too possible that four years from now we will be having the same conversations.

Fiona Godlee, Editor, BMJ