Frenk and Chen Health Research Policy and Systems 2011, 9:11

http://www.health-policy-systems.com/content/9/1/11

COMMENTARY Open Access

Overcoming gaps to advance global health equity:

a symposium on new directions for research
Julio Frenk1, Lincoln Chen2*

Abstract
The 20th anniversary of the groundbreaking 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, and knowledge continues to
occupy center stage amidst growing complexity that characterizes the global health field. The way forward will
entail a reinvigoration of research-generated knowledge as a crucial ingredient for global cooperation and global
health advances. To do this we will need to overcome daunting gaps, including the divides between domestic
and global health, among the disciplines of research (biomedical, clinical, epidemiological, health systems),
between clinical and public health approaches, public and private investments, and between knowledge gained
and action implemented. Overcoming systematically these obstacles can accelerate progress towards research for
equity in health and development.

Introduction new avenues in global health research have opened; and

Twenty years ago, an independent international initia- research capacity in developing countries has been
tive, the Commission on Health Research for Develop- enhanced. In just the past decade, development assis-
ment, issued its landmark report, Health Research: tance in health increased from US$10.7 billion in 2000
Essential Link to Equity in Development [1], on how to to US$21.8 billion in 2007 [2], although the fiscal impact
“accelerate health improvements and overcome health of the recent financial crisis has yet to be registered.
disparities worldwide.” At that time, the landscape of There are now more than 100 multilateral partnerships,
global health was strikingly different. There were fewer agencies and initiatives in global health.
actors and severely-limited resources. The reigning para- The 20th anniversary of the report provided an occa-
digm was paternalistic and unidirectional: solutions were sion to review progress and re-launch a movement
exported from the north to the south, while problems around research as a crucial ingredient for the renewal
flowed from the south to be solved by the north. This of global health cooperation. More than 200 panelists
seminal Report broke boldly through the crippling and and participants from around the world convened in
rigid mindset by recommending that every country, no Boston at a Symposium hosted by the Harvard School
matter how rich or poor, should acquire key core of Public Health on May 13, 2010, to grapple with “New
research capability–"essential national health research” - Directions for Global Health Research.” The discussion
to tackle priority national problems. Recognizing the focused on the Commission’s major recommendations,
interdependence of nations and of knowledge, the which remain as valid today as 20 years ago:
Report also underscored the value of global partnerships
for health research to address commonly shared 1. strengthening “essential national health research”
challenges. so every country can pursue research to advance
The past 20 years have witnessed remarkable growth national health goals;
in the realization of the importance of global health; 2. mobilizing global health research partnerships so
that scientists in all countries can join together in
* Correspondence: [email protected] advancing knowledge as an international public
2
China Medical Board, 2 Arrow Street, Cambridge, MA 02138, USA
Full list of author information is available at the end of the article good.

© 2011 Frenk and Chen; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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Strengthening national health research systems All underscored the imperative that knowledge be
There is an urgent need to upgrade research capacities translated into evidence that can guide policy and
in all countries, especially low- and middle-income implementation. The focus should be not only on the
countries. This need is validated by the well documen- supply side, doing more research, but also on the
ted power of knowledge to advance health through demand side. Panelists stressed the need to develop core
strengthening new tools, better diagnosis of health pro- competencies so that policy-makers and practitioners
blems, guidance of health care systems, and understand- can be effective users of research. Leadership demands
ing of the social determinants of health. But how should fundamental skills to be able to interpret and apply
countries of all income levels strengthen their health knowledge. Knowledge and ideas, in the hands of those
research systems? who have the capacity to implement health policies,
Capacity building is obviously crucial in countries have enormous power to advance health.
where research infrastructure may be weak. Even the
poorest nations must be capacitated to generate knowl- Establishing global health research partnerships
edge and be able to uptake knowledge created as a glo- In addition to strengthening national health research
bal public good and adapt it to local circumstances. systems, there is a concurrent need to strengthen global
Capacity building efforts are focused mostly on the coordination and promotion mechanisms. The global
development of scientific human resources in order to health research system, both public and private, has
generate a critical mass of health researchers. It also grown greatly in recent years, generating new knowl-
requires the establishment of institutions capable of nur- edge, developing new technologies, and transforming
turing those researchers and their work. health advances. There has been proliferation of public-
Capacity strengthening support is also critical for the private partnerships, and many have brought focus to
expansion and diversification of existing research infra- challenging problems. But how successful have they
structure. This kind of support is usually provided to been? Can a poorer country be a genuine partner in
scientists and institutions in developing countries that these endeavors given its severe human and financial
are already involved in research activities, and its pur- resource constraints? Perhaps the global architecture in
pose is to enhance the research environment through partnerships can be improved to promote knowledge
construction of appropriate facilities for research, finan- generation, translation and utilization.
cial support to projects, access to scientific literature, Chaired by Professor Harvey Fineberg, President of
partnering arrangements with stronger institutions, and the US Institute of Medicine, four Symposium panelists
creation of stable career paths. assessed the state of global health research partnerships.
In an opening panel chaired by Professor Adetokunbo Dr. Tim Evans, then at the World Health Organization,
Lucas of Nigeria, four Symposium panelists cited many described a new initiative to energize health systems
examples of accelerating capacity development for essen- research as a global public good that would be pro-
tial national health research around the world. Professor moted by a major international conference in November
Jo Ivey Boufford of the New York Academy of Medicine 2010 in Montreux, and Dr. Anthony Mbewu, Executive
described the multi-country support offered by the Director of the Global Health Research Forum, noted
Council on Health Research for Development that positive gains have been fostered through a steady
(COHRED), a Geneva-based initiative, to strengthen series of similar global conferences in collaborative
essential national health research in the world’s poorest research. As research and knowledge are cumulative
countries. Professor Marian Jacobs of the University of processes, such global gatherings have been useful in
Cape Town described the growing capacity for research establishing benchmarks of progress, pointing to future
in South Africa and welcomed the recently-announced priorities, and facilitating cooperation among different
US Government initiative (MEPI: Medical Education actors. Professor Dyann Wirth of the Harvard School of
Partnership Initiative) aimed at capacity building of med- Public Health discussed several major collaborations in
ical schools in Africa. MEPI’s transferring control over global research, citing specifically the Medicine for
the capacity agenda to African institutions was Malaria Venture. Dr. Roger Glass, Director of the US
applauded. Professor Srinath Reddy, President of the National Institute of Health Fogarty Center, reaffirmed
Public Health Foundation of India, elaborated on the the major US Government initiative, MEPI, financed by
unprecedented Indian effort to establish more than half a PEPFAR and partner agencies, to build medical school
dozen public health schools. Dr. Abdul Ghaffar of the capacity in key sub-Saharan African countries.
Alliance for Health Policy and Systems Research
described many collaborations among developing country Overcoming gaps: symposium reflections
scientists that foster mutual learning and expand the Future progress will depend upon overcoming divisive
scope and depth of collective research endeavors. gaps that must be bridged systematically. Integration is
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the way forward. For one, there has been a gap between persist between knowledge and action. This is in fact an
global and local interests, which in reality depend on artificial divide, much like the old traditional divide
each other. Global is no longer the opposite of domestic. between body and mind. All knowledge shapes and
A global outlook means that we recognize that the local inspires action, since “knowing” is also “doing.” Such
and the global are united, increasingly interdependent individual connectivity, however, may not be automati-
and interconnected. We recognize that what happens in cally translated institutionally in the real world.
each country affects every other country. There is a cycle of knowledge: it is produced through
For evidence of this we have only to look at the global research; it is re-produced through education and train-
economic crisis. Our world needs to have healthy chil- ing; it is translated into actions that improve health; and
dren and healthy adults to be able to produce econom- it is evaluated scientifically, which feeds back into the
ically. This benefits all economies. Look too at production of more knowledge. To improve health glob-
pandemics: if there is an outbreak in one part of the ally requires stoking the fires of knowledge production
world, it can paralyze commerce and it can eventually and ensuring that the translation into solutions is accel-
spread to all. We cannot ignore problems related to erated. Knowledge translation occurs in three important
HIV/AIDS, tuberculosis, and malaria in poor countries ways: in developing new technologies, such as vaccines,
without understanding that they can eventually have an drugs and diagnostic methods; in individuals who inter-
impact on well-being in the wealthiest parts of the nalize knowledge in their everyday behaviors; and in
world. We cannot have a secure planet if we do not providing evidence on which to base health policy. To
combat the root causes of insecurity, the most dramatic improve the health of populations will require not only
of which are avoidable illness, suffering, and death. development of specific technologies, but also of policy
There have also been gaps among types of research: innovations based on scientifically-derived evidence.
from biomedicine to clinical to epidemiological to public Our challenge too in building bridges across these
health and to health systems. We need to build bridges gaps is to reconcile two fundamental values: excellence
across disciplines, moving beyond the traditional silos to and relevance [3]. This has been an artificial divide as
interdisciplinary research and education, and perhaps well. While some consider these values conflicting, they
more importantly, across levels of analysis, upward from are actually the same because excellence must be rele-
the gene to the entire species. The most exciting junc- vant and relevance means excellence. We need leaders,
tures in science are concentrated at the interfaces of tra- enlightened practice and policy making to provide a cri-
ditional disciplines, as exemplified by genomics and tical voice that is so central to the progress of societies.
bioinformatics. We are in the midst of a revolution in
systems thinking which can allow us to comprehend Conclusion
and transform complexity. We have seen what knowledge-based public health action
We have also experienced very divisive gaps between has achieved in the 20th century. Life expectancy has
public and private. Towards the end of the 20th century, more than doubled. Smallpox has been wiped out, and
private initiatives accelerated, both non-profit and for- polio is close to eradication. In HIV/AIDS we faced one
profit. The sole domination by government began to of the largest public health challenges in the history of
give way to many new public-private partnerships. humankind, and there was a worldwide response, thanks
These partnerships bring together different expertise to which four million people are on anti-retroviral treat-
and capacity, organizations and institutions, and sources ment today. Nearly everyone thought this was impossible,
of funding to achieve commonly shared goals. While not decades ago, but five years ago.
innovative, many partnerships certainly suffer from Today’s challenges are huge, but we have never before
imbalances, including the disappointing financial partici- had the set of resources–intellectual, technological,
pation of private commercial sector in the co-funding of societal–that we do now. We have never before had the
joint ventures. Vibrant partnerships have been created level of public awareness about the central importance
to accelerate product development of new vaccines, of global public health. Its high visibility has been trans-
drugs, and diagnostics. So too have partnerships brought lated into enormous growth in financial assistance to
together private and public stakeholders in addressing health and international cooperation of an unprece-
priority challenges, best exemplified by the UN Millen- dented scale.
nium Development Goals. At the country level, many There is a genuine sense of excitement about what lies
initiatives entail Government working with and through ahead, yet an understanding that progress hinges in part
private agencies or private initiatives supported by pub- on bridging and integrating these gaps. Knowledge will
lic policies and funding. continue to be the key asset to sharpen our understand-
Knowledge is one of the most potent instruments we ing of problems and to create novel solutions. In our
have for improving health worldwide. Yet, large gaps turbulent world, still scarred all too often by ignorance
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and intolerance, science remains a most powerful force

for enlightened social transformation.
No individual country–no matter how well endowed
with human and financial resources–can generate on its
own an effective response to the most pressing health
challenges of our times. All nations must participate in
the advancement and sharing of research-generated
knowledge, along with developing the capacity to not
just adopt the evidence, but to adapt it to local
circumstances.
We are now ideally situated to expand global networks
of collaboration and develop consortia of national and
regional centers of excellence. With the legacy of crea-
tivity, inspiration, and vision brought forth by the Com-
mission on Health Research for Development, we can
continue to move forward in the cause of equity in
development through research. Our outlook and our
efforts must be global–we do not look inward, but
rather outward, and to the future.

Author details
1
Harvard School of Public Health, 677 Huntington Avenue, Kresge Building,
10th Floor, Boston, MA 02115-6096, USA. 2China Medical Board, 2 Arrow
Street, Cambridge, MA 02138, USA.

Authors’ contributions
Both authors wrote, revised and approved the manuscript.

Competing interests
The authors declare that they have no competing interests.

Received: 29 July 2010 Accepted: 22 February 2011

Published: 22 February 2011

References
1. Commission on Health Research for Development: Health Research:
Essential Link to Equity in Development. Oxford: Oxford University Press;
1990.
2. Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon K, Michaud CM,
Jamison DT, Murray CJL: Financing of global health: tracking
development assistance for health from 1990 to 2007. Lancet 2009,
373(9681):2113-2124.
3. Frenk J: Balancing relevance and excellence: organizational responses to
link research with decision making. Social Science and Medicine 1992,
35(11):1397-1404.

doi:10.1186/1478-4505-9-11
Cite this article as: Frenk and Chen: Overcoming gaps to advance global
health equity: a symposium on new directions for research. Health
Research Policy and Systems 2011 9:11.
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