In the April 2010 issue of the Bulletin, Date et al. expressed concern over the slow scale-up in low-income settings of two therapies for the prevention of opportunistic infections in people living with the human immunodeficiency virus: co-trimoxazole prophylaxis and isoniazid preventive therapy. In this short paper, the authors discuss the important ways in which policy analysis can be of use in understanding and explaining how and why certain evidence makes its way into policy and practice and what local factors influence this process. Key lessons about policy development are drawn from the research evidence on co-trimoxazole prophylaxis, as such lessons may prove helpful to those who seek to influence the development of national policy on isoniazid preventive therapy and other treatments. Researchers are encouraged to disseminate their findings in a manner that is clear, but they must also pay attention to how structural, institutional and political factors shape policy development and implementation. Doing so will help them to understand and address the concerns raised by Date et al. and other experts. Mainstreaming policy analysis approaches that explain how local factors shape the uptake of research evidence can provide an additional tool for researchers who feel frustrated because their research findings have not made their way into policy and practice.
Monitoring equity and research policy
The Consultative Expert Working Group on Research and Development (CEWG) met from 5-7 April 2011. It was the first meeting of the group, set up at the last WHA, to succeed to a previous group, the Expert Working Group(EWG), whose work was criticised by member states and stakeholders as lacking transparency and being tainted with conflict of interest. The mandate given by the WHA to the CEWG was to take the work of the EWG forward, according to the CEWG Chairperson. The group decided that its core mandate was to help deliver on two elements of the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property (GSPOA). These are element 2 on “promoting research and development”, and element 7 on “promoting sustainable financing mechanisms.” The EWG’s work was mainly focused on element 7 of the strategy. Beyond those two core elements, the group also sees its work as an integral part of the global strategy and will take into account the interrelation with other elements of the strategy, such as prioritising research and development needs, building and improving innovative capacity, transfer of technology and application and management of intellectual property to contribute to innovation and promote public health.
This paper identifies some of the advantages and disadvantages of a global health research and development (R&D) tax credit and considers whether it would succeed in increasing the overall volume of global health R&D. In his analysis, the author remains uncertain whether the tax could increase pharmaceutical firms’ return on investments for global health products with small commercial markets or if it could bring down the costs of philanthropic research and help maintain private sector participation in global health. Since there are minimal profits to be reaped from charitable research and benefits, a tax credit is unlikely to appeal to many firms who are not already interested in supporting global health, the author argues. His findings suggest that a global health tax credit is unlikely to result in significantly more or better global health R&D, but he emphasises the limitations of his research, calling for more research into existing fiscal incentives for R&D to clarify the decision-making process that drives global health research in pharmaceutical firms.
In this study, the authors outline some of the challenges faced when carrying out a financing incidence analysis (FIA) in Ghana, Tanzania and South Africa and illustrate how innovative techniques were used to overcome data weaknesses in these settings. They conducted a FIA for tax, insurance and out-of-pocket payments, drawing data from the Living Standards Measurement Surveys (LSMSs) and household surveys conducted in each of the countries. They found that LSMSs are likely to underestimate financial contributions to health care by individuals. For tax incidence analysis, reported income tax payments from secondary sources were severely under-reported. Income tax payers and shareholders could not be reliably identified. The use of income or consumption expenditure to estimate income tax contributions was found to be a more reliable method of estimating income tax incidence. Assumptions regarding corporate tax incidence had a huge effect on the progressivity of corporate tax and on overall tax progressivity. In terms of policy development, the authors show how data constraints can be overcome for FIA in lower-income countries and provide recommendations for future studies.
The 20th anniversary of the report of the Commission on Health Research for Development inspired a Symposium to assess progress made in strengthening essential national health research capacity in developing countries and in global research partnerships. Significant aspects of the health gains achieved in the 20th century can be attributed to the advancement and translation of knowledge, the authors of this paper argue, and knowledge continues to occupy center stage amidst growing complexity that characterises the global health field. The authors propose a way forward that will entail the reinvigoration of research-generated knowledge as a crucial ingredient for global co-operation and global health advances. However, a number of divisions are identified that need to be addressed, such as the divide between domestic and global health, and the divide among the disciplines of research (biomedical, clinical, epidemiological, health systems), as well as divisions between clinical and public health approaches, between public and private investments, and between knowledge gained and action implemented. Overcoming these obstacles can accelerate progress towards research for equity in health and development.
In this paper, the authors discuss open source approaches for research and development (R&D) for neglected diseases, and their potential to lower costs and R&D time frames, increase collaboration and build a knowledge commons. They describe existing initiatives and debates, and suggest how readers and the global health community might better make use of open source approaches. While most of the open source initiatives examined in the review appear to demonstrate significant potential, the authors conclude that hard evidence of impact appears to be limited thus far. They make three short-term recommendations. Governments and other stakeholders should first develop detailed profiles of open source initiatives for R&D into neglected diseases, then they should prioritise gaining more substantial and long-term investments into the area. Finally, they should start a demand-driven website incorporating a group weblog, which will act as a focal point for disparate threads of discussion as well as seeding connections and a sense of community.
With growing interest in methods to accelerate the development of drugs, vaccines and diagnostics for neglected diseases, product development partnerships (PDPs), non-profit research institutes and private sector groups have come together to conduct R&D in these areas. However, some argue that their efforts are disjointed and that funding flows inefficiently to individual research projects resulting in insufficient resources, funding volatility, poor resource allocation and duplicated, as well as unnecessary, efforts. In this paper, the authors evaluate several pooled funding mechanisms that have been proposed to address these problems: the Industry R&D Facilitation Fund (IRFF) originally proposed by the George Institute; the Fund for Research in Neglected Diseases (FRIND) proposed by Novartis; and the Product Development Partnership Financing Facility (PDP-FF) proposed by the International AIDS Vaccine Initiative (IAVI). These proposals are measured against two criteria: their capacity to raise additional money for neglected disease R&D and their capacity to improve the efficient allocation of those funds. The authors conclude that all three proposals had potential, but the challenge with deciding which proposal to implement is the lack of clarity and agreement on what exactly the core problems facing R&D funding flows for neglected diseases are.
The Soul City Institute for Health and Development Communication, a non profit organisation, was started in 1992 in a bid to reduce child mortality caused by dehydration. "Children were dying unnecessarily and it was because people did not know what they were supposed to be doing," says Goldstein. Information was widely available on the process of rehydration but it did not seem to be having an impact on the desired audience. After studying the situation, Soul City decided to launch a television soap opera to capture their target audience. A radio show and newspaper series quickly followed. In trying to describe the relationship between research and mass media campaigns, Goldstein uses the phrase "simplification versus complexity." At one end stands the scientist who seeks in-depth knowledge and at the other the ordinary non-scientific individual who prefers a simple explanation. Melissa Meyer, Project Coordinator for the HIV/AIDS and the Media Project, says, "Research and entertainment need not be at odds with each other. With just a slight adjustment in perspective, they can be used very effectively to complement each other."
The authors of this study aimed to illustrate the effects of failing to account for model uncertainty when modelling is used to estimate the global burden of disease, with specific application to childhood deaths from rotavirus infection. To estimate the global burden of rotavirus infection, different random-effects meta-analysis and meta-regression models were constructed by varying the stratification criteria and including different combinations of covariates. The models were then compared. The authors found that, in the models they examined, the estimated number of child deaths from rotavirus infection varied between 492,000 and 664,000. While averaging over the different models’ estimates resulted in a modest increase in the estimated number of deaths (541,000 as compared with the World Health Organization’s estimate of 527,000), the width of the 95% confidence interval increased from 105,000 to 198,000 deaths when model uncertainty was taken into account. The authors conclude that sampling variability explains only a portion of the overall uncertainty in a modelled estimate. The uncertainty owing to both the sampling variability and the choice of model(s) should be given when disease burden results are presented. Failure to properly account for uncertainty in disease burden estimates may lead to inappropriate uses of the estimates and inaccurate prioritisation of global health needs.
The current globally agreed definition of cumulative anti-retroviral therapy (ART) coverage is expressed as the number of individuals receiving ART at a point in time divided by the number of individuals who are eligible to receive treatment at the same point in time (including those who are already receiving ART). The authors of this paper acknowledge that so far it has proved an invaluable tool for promoting the systematic estimation of ART coverage at country level and for holding countries accountable through reporting requirements, such as those requested by the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). But, as programmes mature and funding for ART becomes more uncertain, the increasing number of patients on ART included in the definition render the measure increasingly insensitive to annual changes in ART enrolment, the authors argue. In response to the need to expand reporting of ART access to include measures of recent enrolment, they propose a new definition to complement the existing UNGASS definition of ART coverage. The ratio of ART initiation to HIV progression is not only a better reflection of recent programme performance, the authors argue, but also a more robust measure that is less sensitive to model assumptions and to changes in ART eligibility criteria.