Edward Whiting outlines the changes needed for research and development to realise its potential
Research and development has been a powerfully disruptive force in global health governance. The discovery of a new treatment, product, or insight can shift understanding of what is possible in the eradication or control of a disease and can create a new impetus for collective action, often forcing existing governance mechanisms to work better or reform. Over recent decades, the discovery of treatments (such as antiretroviral drugs for HIV or new vaccine candidates for Ebola) has forced the creation of new organisations and delivery models—such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, UNAIDS, and the Coalition for Epidemic Preparedness Innovations—to ensure their prompt and equitable availability.
The “spark” created by these discoveries has the potential for even greater disruptive power by fuelling the urgency to break political impasses and rebalancing the power dynamic between donor and recipient countries. Here’s what needs to happen to realise this potential.
Firstly, ensuring equitable access to the products of research and development is likely to become more challenging as biomedical innovation becomes more expensive and its products more personalised. A 2017 study by Deloitte estimated that research and development returns to the drug industry have fallen to 3.2% from 10.1% in 2010.  Declining profitability has contributed to an accelerating rate of exit from key areas of late stage drug development, such as new antibiotics. The balance between optimal use of public money, private investment, and affordability of end products is increasingly precarious. This pressure will only be exacerbated as treatments become more personalised. We may need new alliances and partnerships to look at how public and private money can be invested across the development pipeline most sustainably for global benefit.
Secondly, global health governance needs a broader understanding of what constitutes research and development. As well as basic science, innovations in tackling non-communicable disease may come from behavioural, economic, and social science disciplines. Our global health governance will need to find creative ways to advocate for interventions that are often politically challenging. Similarly, the global health community should continue to study the role of underlying social factors in, for example, vaccine hesitancy or epidemic response. Our ability to do this will determine the degree to which disease responses and health systems improve. The global health community will need to support more context specific research, like the new THIS institute in Cambridge, focused on the “unglamorous” work of improving performance quality in the NHS through robust research and analysis.
Thirdly, we need to ensure that global health governance creates the best incentives to support the speedy adoption of affordable new discoveries at scale. The WOMAN trial, for example, recommended the use of tranexamic acid for the treatment of postpartum haemorrhage, at cost of $2 (£1.50; €1.80) a dose.  We need to have the right global health governance systems in place to quickly help bring new discoveries, like promising new TB vaccines, to patients who need them around the world.
Finally, new research and development investment and activity have the potential to increase the power of countries with the greatest disease burdens around the negotiating table at major global health meetings. Over recent years several funders have increased investment into networks and institutes of scientific excellence in low and middle income countries, through initiatives like AESA (https://www.aesa.ac.ke/), H3Africa (https://h3africa.org/), and Grand Challenges Africa. Domestic investment in research and development in African countries, towards the agreed target of 1%, remains sluggish. The World Bank’s recent Money and Microbes report set out a compelling argument, with recommendations, for increasing investment into domestic clinical trial capacity across Africa.  The field is open for countries and new regional funders to take greater charge of how global health research is prioritised. The African Development Bank, the Asian Development Bank, and the Inter-American Development Bank, for example, provided $674.4m for global health in 2017.
How we respond to these challenges will determine the degree to which research and development is an “accelerator” of progress towards the health related sustainable development goals. If we can successfully support new knowledge, products, and centres of power, we will see the governance of global health transformed over the coming years.
Competing interests: The Wellcome Trust provides funding to some of the organisations I mention in the article, including AESA and the Coalition for Epidemic Preparedness Innovations.
1 Deloitte. A new future for R&D? Measuring the return from pharmaceutical innovation. 2017. https://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/measuring-return-from-pharmaceutical-innovation.html
3 World Bank. Money and microbes: strengthening research capacity to prevent epidemics. https://www.worldbank.org/en/topic/pandemics/publication/money-and-microbes-strengthening-research-capacity-to-prevent-epidemics