Reducing the Tension between True Ownership and Empowerment versus Continued Top-down Colonial Models of Development: Development Aid for Health Research to Developing Countries

Beyene Petros Chair, Ethiopian Bioethics Initiative (ETBIN) Professor, Biomedical Sciences Faculty of Life Sciences Addis Ababa University

Presentation Outline

1. General observations 2. Research collaboration/partnership models - Old/Colonial models - ‘New’ models 3. Global policy frameworks 4. Donor priorities for developing world health 5. A cross-national diffusion of ideas and Preferences 6. The new communicable diseases Control/Research Initiatives & Alliances 7. Conclusion

1. General Observations

• • • •

In low-income/poor countries, most (health) research conducted is donor-driven: No/insignificant local budget recommendation for Africa.

Vs 2% Annual budget –WHO/AFRO ACHRD Research outputs in health sciences have revolutionized the prevention and treatment of developed-world diseases Inadequate research on diseases prevalent in low-income countries:

•

Neglected Tropical Diseases (NTD) with billions at risk and over billions infected; E.g. Out of about 1,400 new drugs approved in the USA between 1975-1999, only 15 targeted NTDs* Effective implementation of medicines for NTDs, when available, has one of the highest benefit-to-cost ratios for any medical intervention * E.g. Merck’s donation of Ivermectin for Onchocerciasis benefitted over 700 million people ; eliminated the disease in several African and Latin American countries.

*Conteh, et al. 2010

2. Research collaboration/partnership models

Research collaborations that existed between individuals and institutions in the North and South ‘ is/was ’ referred to as “scientific colonialism” by many; - funding comes mainly from Northern institutions, - Northern “collaborators” dictate the scientific agenda and its execution. Commission on Health Research for Development estimated in 1990: - about 93% of the world’s preventable deaths occurred in low and middle-income countries, - only about 5% of the world’s resources for health research were being applied to these health problems.

The Global Forum for Health Research coined the designation the manner resources are devoted to addressing it.

“10/90 gap” to capture the major imbalance between the magnitude of the problem and

Models of partnerships in health research between the North and South have been evolving*

2.1. The Old (colonial) Models of Research Partnerships **

• “Postal research” – Donor country scientists collecting and shipping samples for analysis by their Northern “collaborators”.

• “Parachute research”- Northern scientists come to a developing country, take biological samples, assisted by local “collaborators”=> fly them out for analysis and publication with no/minimal further input from their Southern counterparts.

=> Use a considerable part of the research budget in a short period of time.

• “Annexed sites” – Field research sites led and managed by Northern Scientists , involving/employing local and neighboring country expertise with better remunerative incentives, to the detriment of developing country manpower needs. • Binka, 2005; Ofori-Adjei & Gypong – http://www.nuffic.nl

: (Accessed on 22 Nov, 2011).

• **Castello & Zumla, 2000)

2.2. Changing landscape of health research collaborations

• • Northern partners accepting the need for transforming North-South ‘collaborations’ into true partnerships. E.g. The 11 Swiss principles: “Guidelines for Research in Partnership with Developing Countries” (often quoted among many as the “ charter” of North-South partnership ) Although most collaborative projects are initiated from the North, joint planning followed by joint analysis and publication.

2.3. The “New” models of health research partnerships

• The “ changing game in funding ” – Non-state actors in addition to Governments engaged in funding health research in low and middle income countries: “Grants and call for proposals” model Partnerships - donor initiation & pre-defined conditions; - require participation of Northern partners; - Conditions on who should lead and determine the use of resources; - Poor exit strategy & sustainability. E.g. HIV research in Ethiopia • • “Hubs and Spokes” model (EDCTP, etc) - A South-South collaboration; - Nodes & networks of excellence; - Research agenda of Southern scientists

“Southern-led and northern-funded” model

- Concepts of ownership and partnership combined - Southern partners’ control of fund management

“Ethiopia loses HIV research centre”- E.g. Of a Grant

• • • (Khabir Ahmad – Newsdesk) A Dutch grant of approximately $13 million U.S. for an eight year period (1994–2002). Capacity development in HIV/AIDS research Research identified HIV-1 genetic subtypes unique to Ethiopian => the country in a leading position to launch vaccine research and development initiatives.

- ”… lack of support for the project in future .. a blow to vaccine research in Ethiopia” - José Esparza of the WHO UNAIDS HIV Vaccine Initiative.

- ENARP’s Ethiopian project manageress, Dr Tsehaynesh Messele, “…a devastating loss and very discouraging….If ENARP is closed, then it is going to have enormous negative effects on AIDS research in Ethiopia”.

• • The Government of Ethiopia requested the Netherlands government to extend its support for a new phase (2003–2006) Dutch government: “…the research done under ENARP is too expensive and is not in line with the current needs of Ethiopia.

” => decided to fund family planning and HIV prevention projects.

3. Global policy frameworks vs donor behavior in health research funding

3.1. A provider/donor interest framework – Allocation of DAH by donors driven by considerations other than the burden of disease: a) A disease prioritized because the donor political elite perceives it a national threat. E.g.

- The 2000 President Clinton administration’s labeling HIV/AIDS “a national security threat” => PEPFAR - US Army researchers developing vaccine for Japanese encephalitis* b) The interests of constituencies in the donor countries - Profit potentials for pharmaceutical companies in drug and vaccine sales - Interest-group mobilization in rich countries.

3.2. A recipient need framework – donors’ response to the seriousness of the problem in developing nations. E.g., Trachoma, leprosy, polio, Onchocerciasis, Dracunculiasis and Chagas’ disease.

*Halstead and Thomas, 2010

Donor priorities for developing world health Moved in waves*:

• Vertical disease control in the 1950s and 1960s, • Primary health care in the 1970s and • Health sector reform and sector-wide approaches in the 1980s and 1990s.

 Tension exists in funding allocations between the two approaches: - Concentrated campaigns to effectively address one disease**, to the neglect of others, - Horizontal approach lacking capacity to address multiple diseases effectively *** *Perin and Attaran, 2003; **MacFarlane et. al. 2000; Waitzkin, 2003; ***Task Force on Health Systems Research, 2004

5. A cross-national diffusion of ideas and Preferences towards disease control/research funding

• Donor states and non-state actors influence one another in setting priority research agendas. E.g. Gates Foundation or WHO agrees that a particular disease be targeted => many others following the decision => Simultaneous global shift in priorities.

• Direct aid for research & control of communicable diseases as a percentage of total funding for health rose markedly.

• Overall, donor support for communicable diseases control/research in developing/poor countries has been increasing over time since 1996*. • On the whole, a strong correspondence exists between burden of diseases that co-occur in industrialized world and developing countries and donor funding for their control.

• Need for balanced allocation of funds.

* Shiffman, 2006

DAH by health focus area, 1990-2008*

Increase in global financing to control and eliminate NTDs needed

• • $2 to $3 billion was estimated to be needed for a five year period (from 2008 to 2012) to control and eliminate NTDs. The funding gap for drugs alone was an estimated $222 million* The funds committed represent only a fraction of what is needed for global control of the seven major diseases.

* Hotez, et al., 2009

6. The new communicable diseases Control/Research Initiatives & Alliances

• • • • • WHO Strategic and Technical Advisory Group for Neglected Tropical Diseases (STAG-NTD) The 2008 US government Incentives for drugs and vaccines for NTDs.

Alliances brought together donors in public-private partnerships - Gates Foundation - The international AIDS Vaccine Initiative (IAVI), - The Global Alliance to Eliminate Lymphatic Filariasis* => Elimination by 2017.

Global Fund, PEPFAR, PATH, etc Use of a venture capital approach through product development partnerships (PDPs) – vaccines, drugs and other tools. E.g: a) The Medicines for Malaria Venture (MMV) - Novartis and MMV =>identified a new class of compounds that targets both the blood- and liver-stage of malaria (17 November 2011).

b) New malaria medicine developed in partnership by sigma-tau and MMV (10 November 2011) c) Dundee and MMV make rapid progress towards a potential new treatment for malaria (14 November 2011) d) The Human Hookworm Vaccine Initiative e) Institute for One World Health developed intramuscular injection drug for visceral leishmaniasis Injectable Paromomycin for Visceral Leishmaniasis in India * GlaxcoSmithKline, Merck, WHO, Gates Foundation, ministries of Health and many other organizations

7. Conclusion

• A combination of effects: donor interest, recipient need and interest group mobilization in the North appear to interact to shape health research funding priorities.

• The relative share of DAH for sub-Saharan Africa has grown, reflected by the continued rise in funding for HIV/AIDS,TB & Malaria.

• Global policy diffusion driven by interactions among donors led to the high burden communicable diseases receiving significant increases in funding. • Although the tension between true ownership/empowerment VS top-down colonial model in health research development is softening with the changing landscape of health research funding, research applied to the needs of low-and middle-income countries remains grossly under-resourced in the areas of NTDs.

• The designation “10/90 gap”, while not representing the current quantitative measure, remains to be a symbol of the continuing mismatch between research needs of poor countries and investments.