Dr Thomas Nchinda is a Cameroonian medical doctor; he was a University Professor before working at the World Health Organisation in Switzerland for the Special Programme for Research and Training in Tropical Disease (TDR). He also worked as a Public Health Specialist for the Global Forum for Health Research.
The 12 wise men and women’s report
In 1990, the famous report by the “12 wise men and women” i.e. the “Commission on Health Research for Development” was published. The “12 wise men and women” studied health research carefully especially as it relates to development issues and concluded that something had to be done. They came up with their visionary report, “Health Research for Development” in the hope to move the health research agenda from fighting tropical disease to actually improving health of people and getting the full political and financial involvement of Ministries of Health in this effort.
One of the outstanding recommendations of the report was asking the Ministries of Health to allocate at least 2 % of their national budget to health research. This influential report generated a lot of interest around the health community. In the meantime, primary healthcare had become a priority since the Alma Ata conference of 1978 meaning that health research needed to be taken down to grassroots level, and Ministries needed to get involved in this.
Coincidentally, at the World Health Assembly that same year, the subject of the usual Technical Discussions was on Health Research.
The World Scientific and Health Research Community decided to convene an International Conference at which that Report Research would be discussed. The discussions at the meeting were lively and interesting and the far reaching recommendations that emerged were voted and adopted almost unanimously. A decision was taken that these recommendations needed to be implemented. The recommendations were, broadly speaking, concerned mainly with putting research into the agenda of Ministries of Health emphasizing more specifically primary health care type research that would enable decision makers to take informed decision, based on health research findings.
From the Commission to the Council
A Task Force on Health Research for Development was created to carry out this task. The Task Force decided to use Essential National Health Research as its main thrust this being the essential type of research that countries need for their national development. The task force took on that work for two years and I collaborated with it throughout the 2 years. A second meeting was then held to review and discuss the outcomes of the Task Force. It was decided at that meeting that, based on the positive outcomes, a Council on Health Research for Development (COHRED) needed to be created to carry on the work.
When the task force started, some countries, especially some French speaking African countries, were not familiar with research and research methodology. Thanks to the work of the Task Force and its collaboration with WHO, when COHRED was created, many of these countries had moved forward and some had already developed national health research plans as part of their ministries of health. In this way COHRED could easily fit into that set up, as most of the countries had already fertile atmospheres for it. So, COHRED started by continuing and expanding on what the Task Force has started, and took care of a whole area of research on the Health Systems which nobody was doing effectively, not even the WHO. I worked closely with both bodies in training and developing research expertise in the countries and strengthening their research institutions.
Health services were, hitherto, inadequately planned by Developing Countries, they used scanty or no evidence, coverage was often dubious and monitoring was hardly carried out and outcomes were inappropriately indicated. It has been one of the areas where COHRED has tried to push very hard, i.e. not only looking at diseases, but at organizational capacities of Ministries of Health to deliver good health services. When I worked for TDR, my work was focused on the research capability strengthening and training young nationals for the research, especially in Africa. As already described, I was familiar with the Task Force and with COHRED from its inception (I suppose I can dare to consider myself one of the “founding fathers” of both bodies) and collaborated closely with their activities especially as we all worked at the grass-roots level of the developing countries promoting research and training and building national capabilities.
There was a close overlap of our activities at that level especially when I had to focus on research training for implementation of outcomes and tools of TDR and, by extension, of health care delivery and disease control. We frequently carried out joint research training activities especially in the African countries. Benin, Guinea and Mali, for example, are some of the classical countries where TDR programme and COHRED (particularly its precursor, the Task Force) worked together, especially for research training and integrating research into action at the level of the Ministry of health.
One of the outcomes of ENHR is that the Ministry of Health became primed to now understand the part Research could play in furthering both control of disease and improve health care management and delivery. Primary Health Care grew in tandem with disease control and it all crystallized and culminated in the development of a good Public Health spirit. This must have been a contributory factor in Benin for building in that country, with assistance from the WHO Regional Office, what has become a very good Public Health School that trains its own Public Health Workers. That School has taken on a Regional character in West Africa particularly among the French Speaking Countries. I ran many of the workshops on research methodology and protocol development and taught many young scientists in Benin, Guinea and Mali how to conduct research and write their own research protocols. Participants were not only from the Universities and Research Institutions but from the Ministry of Health. It is interesting to note that one of my more resourceful workshop trainees undertook further post-graduate training afterwards and developed into a good researcher. She is now the current Minister of Health for Benin!
Another report, organization and perspective
As COHRED was being created there were many other interests and developments in the World on Global Health and its inequalities. The World Bank Health Development Report (WDR) of 1993 was entirely focused on Health globally. One of the most important facts that stood out in that report was the measurement of the burden of disease in all the countries of the World. Rather than using the conventional mortality as had been traditionally done, new measure was used, the Disability Adjusted Life Years (DALY). This had proven itself to be much more accurate and has become the absolute indicator for measuring the Burden of Disease in all countries of the world.
This Report was considered very interesting but incomplete by leading Health Foundations and Health researchers and scientists, and they decided to take up the work started in WDR 93 and move it further pledged funds for this. A well-attended Scientific Conference was convened in WHO in which the unfinished agenda of WDR 93 was discussed. An independent Ad Hoc Committee of 32 top health research researchers and scientists was set up to work with 13 chosen heads of WHO technical units to take this work forward by doing further analytical work. Funds for this work was provided by many major Foundations, research groups and the World Bank. The core review work was done by 3 Working Groups meeting in Geneva and elsewhere with clear briefs and timelines. These discussions and their deliberations led to the creation of the Global Forum for Health Research (GFHR). A big difference between GFHR and COHRED, besides its history, was that the GFHR was looking at health globally across all the countries of the world with, of course quite a lot of emphasis on emerging democracies, while COHRED’s approach was from a country perspective especially developing countries. This is where my involvement with GFHR became rather pertinent.
At the time an Ad Hoc committee was created at WHO to advance the work started in WDR 93, and I was named by the Director of TDR as Secretary of that commission. I had to do the work alongside my normal TDR/RSG responsibilities. A decision was taken to create GFHR (in a similar manner as the earlier Conference had done to create COHRED) and, once more, I was present at this meeting. What similarities in action and what a coincidence! That conference named Mr Louis Currat as the Director of the GFHR to take the Recommendation forward. I retired from WHO in 1996 soon after GFHR was created and I found myself as one of the first persons recruited by GFHR, as I had been involved in organising all the work that went into its creation.
The modus operandi of GFHR was summarized in its adopted slogan “Correcting the 10/90 Gap”. Operationally the idea was to create self-supporting Initiatives corresponding to disease problem areas for which further R&D was needed to develop mechanisms useable products that would benefit third world countries. Thus, for example there were initiatives dealing with malaria, the focus being the development of tools to combat the disease. Other Initiative looked at Road Traffic Accidents, Violence Against Women, Tuberculosis especially in the light of the growing problem of drug-resistant TB, Women’s Health, Cardiovascular Disease that had become a growing world health problem, Tobacco Control, an important Alliance on Health Policies and Systems Research and of course Research Capacity Development in developing countries that would continue to present challenges as their scientists need support to join the global research community. Each of these Initiatives had its own advocates and partners and developed using its own funds to the point of becoming completely independent from GFHR.
A complementary merger
When the merger of GFHR with COHRED took place, I considered it a good move as the two bodies could, in a world of shrinking finances, then focus on the remaining activities for which they had a common comparative advantage. The one key GFHR activity, in which COHRED was participating a lot, was its organizing and convening role of the Annual Forums in which all stakeholders, world governments, private sectors and the civil communities participated as equal partners.
This was an important activity that created excellent opportunities, because I know the situation of many scientists from developing countries who, no matter how much research they do, only consider themselves productive if they can discuss results of their research with their peers and get critics from other colleagues, in a scientific setting. These are young researchers who lack the competence to publish in good peer–reviewed journals or money to do research and to attend scientific meetings.
During the forum, emphasise was put on young scientists who were funded by the programmes presenting. I remember the first forums, and these young scientists being so happy to have the opportunity of having their worked presented and criticised by others, which was very helpful and satisfying to them. They knew that what they have done was seen by others. Plus they could discover other areas of interests for making useful research in their countries. Two things were happening at the same time: south scientists were getting more experience and TDR had been pushing them to do research relevant for their own countries/settings. So the annual Forum organized by GFHR became a very important meeting place for these exchanges.
COHRED has now determined clear areas they want to focus on. One of these remain health services research that is going to inform policy makers and national health administrators on better mechanisms for improving their health services delivery and disease control. This is what made COHRED relevant and popular in the first instance, this is where action needs greater emphasis and this is where the focus must be. It is important that COHRED does not cut itself from the WHO that represents the mouth-piece of the World on Health matters. However, the current move where COHRED is being decentralized, with an office in Botswana, among others, appears good moves as its activities are being brought even more closely to countries and their Ministries of Health, their supporting Universities and Medical research institutions and Councils. Indeed research capacity strengthening is being greatly enhanced – as is sub-regional collaboration – with this current process of de-centralization taking place.