www.jogh.org [email protected] Scotland, UK Teviot Place,EdinburghEH89AG University ofEdinburgh Population HealthSciencesand Informatics Director ofResearch,TheUsher Institutefor Population HealthResearchand Training Research andWHOCollaboratingCentrefor Joint Director,CentreforGlobalHealth Medicine Chair inInternationalHealthandMolecular HonMFPH Professor IgorRudan,MD,DSc,PhD,MPH, Correspondence to: University of Edinburgh, Scotland, UK Population Health Sciences and Informatics, Research and Training, The Usher Institute for Collaborating Centre for Population Health Centre for Global Health Research and WHO Igor Rudan,DeviSridhar of theglobalhealthresearchsystem Structure, functionandfivebasicneeds • doi:10.7189/jogh.06.010505 was established in Geneva in 1998 to support WHO’s focus on health re ly discontinued. The first is the Global Forum for Health Research, which to support and co–ordinate global health research efforts have been large In the past four years, two major initiatives that were set up with the aim value for money invested in health research. the evaluate to andprovided support,the in areasbetween equity tools that could assist donors to co–ordinate funding and (eg, ensure more andrapid and broadly accessible publication of the new knowledge portant research (eg, systems used by editors of the leading journals) searchquestions (eg, the CHNRI method), quick recognition of im prioritizationreeffectiveof needexamplesofof responsesthe for sible to identify solutions that could improve this. There are already andspontaneously. Ithas not been optimally efficient, but it is pos Conclusion investments in health research. ination of results and their accessibility; and (v) to evaluate return on results of successful research; (iv) to ensure broad and rapid dissem (ii) to prioritize among many research ideas; (iii) to quickly recognize emerged: (i) to co–ordinateneeds fundingbasic among donorsfive more effectively;system, the within stakeholders many for roles function of the global health research system and exposed places and Results effectively support the system to increase its efficiency. core structure, functions its and dynamic nature, mind we in proposed a framework Bearing on how decade. to past the of butions search system, as it has evolved under the increased funding contri search. This allowed us to map the structure of the global health re re health global to attributed flows funding in shifts and changes the studied we Moreover, health. global in research co–ordinate Methods port and co–ordinate global health research in the 21st century. factorsthethatcontribute sustainability theto initiativesof sup to operation. These developments provide an interesting case study into World Health Organization's Department for Research PolicyandResearch Health for Forumand Global the years:Co recent in tinued co–ordinateglobalhealth research efforts havebeenlargely discon Background PLoS One Based on our framework,ourBasedon whichchartedstructure the and 1 We reviewed the history of attempts to govern, support or The globalhealthTheresearch evolvedsystemhasrapidly Two supportmajorinitiativesandto up were set that journal as an example). It is still necessary to develop June 2016 •Vol. 6No. 1•010505 global journal of health ------

VIEWPOINTSPAPERS PVIEWPOINTSapers FO funding invested in high–income countries the whether to on study consensus health of lack also is There health. research funding from broader development assistance for difficulty distinguishingthe in largelytocrepancy dueis demics,providedrather different figures dis [5–9]. This aca other and Evaluation and Metrics Health for stitute Health Research in its annual reports, G–FINDER, the In tried tracking this funding – such as the Global Forum for not happen in any planned or coordinated way. Those who lion1993US$240billioninto 2009 in[5],butthis did research has increased rather dramatically from US$ 50 bil Over the past two decades, the funding available for health GLOBAL HEALTH RESEARCH SYSTEM THE EVOLVING STRUCTURE OF THE effectively support the system to increase its efficiency. dynamicnature, willwepropose frameworka howonto decade.Bearingstructure,minditsin corefunctions and past fundingtheincreases theevolvedofunder has it as will map the structure of the global health research system currentcontextshown is the set thatcentury.events 21st key the oftimeline in A to govern, support and co–ordinate global health research the factors that contribute to the sustainability of initiatives These developments provide an interesting case study into Health Coverage Eventually,retitled“ wasreport the “ entitled: series, the to editorial journal's the in discussed as port, researchinparallel tothe release ofthe World Health Re PLoSMedicine wasto be coordinated by the WHO RPC [2]. The journal “ as: theme itsannounced ironically, the annual WHO World Health Report for 2012 erations in 2012 during the WHO's internal reform. Almost Policy and Cooperation (WHO RPC), which ceased its op search [1]. The second is WHO's Department for Research Rudan andSridhar determined the current context. Figure 1. CO June 2016 •Vol. 6No. 1•010505 " ON RE "E ME RE NA 10/90 R DE R HE MMI SSE SE 1990 SE

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www.jogh.org sweringthosequestions, knowledgenewcontinuously is tinenthealthresearch questions. thisway,In through an donors’funding tosupport experiments that address per tionof the global health research system: it is there to use There should not be much controversy over the main func HEALTH RESEARCH SYSTEM THE CORE FUNCTIONS OF THE GLOBAL mercialize their work and set up spin–out companies. versitieshave set upstructures tohelp researchers tocom dustryof companies offering those services. Moreover, uni professionallyevaluated and replicated, with growinga in a positive result. In the end, the published knowledgevance orcan novelty,be concerns over its quality,get published or in anysimply way – perhaps a lack due to insufficientof rele the internet. Finally, in many cases, newport toknowledgethe funder, asdoes“grey not • doi:10.7189/jogh.06.010505 performance. Figure 2. The structure of the global health research system and the five basic needs to ensure its efficient

literature”,orsimply posted on ------3 accurately to ensure efficiency in selection of work that re progressimportantrecognize to need media and editors even when the result is negative. Third, managers, journal experiments carefully to ensure that their efforts are useful theconduct anddesign to needdownstreamThey ones. benefit the public relatively soon with more speculative and prioritizeresearch balanceideaswell,tothosecouldthat to researchersneed Second,investments. their of ciency effi ensures turn, in This, areas. certain under–funding and targets; the derstand need to be several of its sub–components ( sub–components its of several perform its main function will depend on the efficiency of to researchsystem health global the effectivenessof The health–related improve outcomes. and population the in disease of burden the both clinical and public health practice in order to reduce into translated then is knowledge This generated. being Structure, functionandneedsoftheglobalhealthresearchsystem motivated to continue investing; June 2016 •Vol. 6No. 1•010505 coordinated Figure 2 Figure to avoid over– and over– avoid to ). First, donors First, ). informed to un - - -

VIEWPOINTSPAPERS PVIEWPOINTSapers unbalanced, with high preferencetopicstowardshighcertain unbalanced, with becominglargecarriesofun–coordinatedalsorisk a and development, but it requires their sustained motivationpositive a certainly isand donors new ofemergence the that stakeholders in the system. At the top of marily needs–based, and therefore likely welcomed by the cyof the global health research system that would be pri We now propose an alternative route to improved efficien ITS EFFICIENCY PROPOSED SOLUTIONS TO IMPROVE HEALTH RESEARCH SYSTEM AND FIVE isBASIC largely NEEDS unrealistic OF THE GLOBALand outdated. fromfacta that they are employees oraffiliates of the UN exclusively legitimacy their drive who experts of group a by “outside” the fromprocesses and stakeholders vant such a dynamic system, any attempt to influence the rele mercializationimplementationand researchof results. In com translation,rapid for mechanismssupport creased Scholar, Scopus, Research Gate (like output research of assessment of measures now many web–based routes to publication, new tools and teamsand their collaborations on “big science”. There are research of consortia international large of organization creativemechanisms, finance innovative donors, big ing vious decades. This is happening at all levels – with emerg introducing changes in the models that worked well in pre selvesare continuously inventing improved practices and them stakeholders the which manner,in “laissez–faire” “bottom–up”,a in developedhas research systemhealth the UN was established. However, the 21st century global from the perspective of the post–World War II world, when proach may have seemedap a ‘top–down’ feasible a and using sustainable system missionevolving unpredictably and dynamic a such co–ordinate and support to tempts segments.At its of all in own its of life a took and cade 20th century, the system evolved rapidly over the past de the of halfsecondsearchthe throughoutsystem of most After the relatively stagnant nature of the global health re coverage of existing interventions. infrastructureprojects, simplyincreasedor purchase and could also improve health, such as development assistance, healthin research withother competing investments that investmentscomparisonsallowalsoreturnswouldon of researchisingprocess. projectstheearlierideasIt in and portant because it could help recognizing the most prom knowledge into practice needs to be evaluated. This is im new the effectivenesstranslationof theof Fifth, ception. research and rapid accessibility of information without ex open access to all new knowledge that results from health ceivesattention. Fourth, publishers needensureto broad Rudan andSridhar June 2016 •Vol. 6No. 1•010505 and

H–index Figure 2 metric), and in , it is clear Google Google ------4 tion of research results ( Then,theatlevel stakeholders of whogovern dissemina used specific priority–setting method [16]. CHNRImethodology, frequentlymostthewhichitmade exercisesin global health research in recent years used the cent independent review showed that 18% of prioritization further exercises are being conducted presently [15]. A re tion exercises have been published by mid–2015, and[12–15]. many The results from 50 conducted research applicationsprioritiza many through validated been has research, long–termand visiondifferentand instruments healthof andmanaging research ideas, whilebalancing short–term tively[11]. This “crowd–sourcing” approach to generating seems to be an example of this need being met rather effec Initiative (CHNRI) of the Global Forum for Health Researchod” edge” of research. As a possible solution, “ prioritiespresentedcouldbedonors fromto “cuttingthe orities, so that a more balanced and unified case on fundingto communicate and agree on their own field's research pri of published work that is not relevant. its publication, but also quite specific, reducing the amount would be highly sensitive to important research and ensure thatsystem developmenta allowshouldThisoftime. of nal's impact, and of individual papers – over long periods review the results of their work – both at the level of jour more of their decision–making systems and processes and learn to Wepropose systems. well–performing veloped qualitysubstantialand clearlyhaveimpact timedeover high maintain to manage that journals the publication, that many of them select less than 10% of submissions for reaching their decisions on which papers to publish. Given ingly,alreadysystemswhilesuchoperate editors journal search, promote and reward it appropriately [17]. Interest re - important recognize would that system a or process the communities of researchers ( The main need at the level of the recipients in the system – problems, using the most recent available information. problemswiththe investments being committed thoseto differenthealthburdenof thecompare to marketsstock ment Options” – a tool that would use analogy to real–time ResearchHealthGlobalInvest for Market “Stock a pose sentatives.possibleaAs solution, areweworking proto preference, thus assisting policy–makers and donor repre strongneglectedcomparisonareareasdonorofineas to ply tracking funding, a tool is needed to ensure that no ar preferably by more than one agency/institute. Beyond sim track funding using an internationally agreed methodology,continuously to need a is there level, this at way uitable flows [7]. To help the system develop and grow in an eq fundinganalysisof basic most the even inexposed been already has that risk real a is This others. of neglect and developed by the Child Health and Nutrition Research Figure 2 www.jogh.org Figure 2 ), there is a need for a tool, • doi:10.7189/jogh.06.010505 ) – is to find ways the CHNRI meth ------www.jogh.org year still growing strongly. At the same time, given an un in2013 staggeringa 31 137 papers; in 2007 it already published 1230 papers, and state that in the year of its inception, in 2006, it published needtheofglobal health research system. enoughisIt to particular this to solution effective an provided it cause be- precisely expectations, beyond well and time, short very a in succeeded journal the that We believe ample. success of gines, social networks and internet–based media [20]. The en search and dissemination publication, for solutions cess” movement, world wide web development, IT–based ac “openaddressedthrough presentlythebeing is edge ure 2 Atthe next level –dissemination of new knowledge ( generated and citations they received [19]. yearsdetermineto theirimportance through impactthey many for wait to having than rather evaluated, are they ceptional nature of biomedical research articles at the time transparentframework that could allow capturing the ex made some of the first steps towards a more systematic and exercise Their [19]. Difficulty” Publication and Surprise Interest,GreatererSynthesis, Disruptive Innovativeness, They termed these six criteria work. “Continuous exceptional truly Progress, to inherent be Broad may pothesized criteriasixthefromhyperstheythat ofeach0–100 for (123 of whom responded) to score their 10 most cited pa world the in scientists biomedical cited most 400 about biomedicalanymakeresearch “exceptional”. askedThey addresseddimensionscapturebekey tothetoneed that yourmost cited work your best?”, Ioannidis et al. tried to citedpapers of all time [18]. In a related feature, titled “Is devoted a special news feature to analysis of the 100 most papers that have most impact. Recently, the journal searchforcommon patterns thatareshared amongthose receivedcitationstheirtoresearch and papersof tabases itis possible to conduct massive exercises in available da being evaluated. However, in the new world of “big data”, ticles may have in the future at the point at which they are Clearly, it is difficult to predict the impact that research ar ) – the need for broad and rapid access to new knowl • doi:10.7189/jogh.06.010505 PLoS One journal can be used as an excellent ex

498papers, with thenumber per to the work detailed in this manuscript. sponding author). Authors declare no conflicting financial or other interestwww.icmje.org/coi_disclosure.pdfat form related correrequest(availablefromtheon Declarationof interest: ture, developed the framework and wrote the paper. Authorshipdeclaration: Ethical approval: Funding: Nature None. Fig ------5 Not required. ate the value for money invested in health research. equity between areas in the provided support, and to evalu could assist donors to co–ordinate funding and ensure morenal as an example). It is still necessary to develop tools that sible publication of the new knowledge (eg, editors of the leading journals) and quick and broadlyrapid accesrecognition of important research (eg, systems usedprioritization by of research questions (eg, the CHNRIarealready examplesmethod), ofeffective responses forthe need of possible to identify solutions that could improve this. There spontaneously.Ithasnot been optimally efficient, but it is Theglobal health research system has evolved rapidly and CONCLUSION lution and keep improving it over time. most difficult to address, but we aim to propose a draft so ments in comparison to alternatives. This need will be the that they are concerned about the feasibility of those invest their R&D departments, which may provide an indication especially in the wake of Big Pharma largely closing down ed in health research have been a reasonable investment – some understanding on whether the many trillions invest social welfare, and transportation. It is perhaps time to get munity infrastructure projects, improved education, safety, forms of investments that can also benefit health – eg, com investinghealthresearch,in comparison inalternative to would allow a proper understanding of the actual value of tool a measurable health. public Such global benefits for to way theprogrammes, productsalland into outcomes itor success rates in translation and implementation of the through those investments [21]. The tool shouldgained money alsofor value mon the as seen is what and search, could evaluate returns on investments in global health re Finally, at the level of research outputs, a tool is needed that that addresses one of the system's major needs. recognized have systemresearch years.eralClearly, participantsmany globalthehealthin verya decent impact factor ofaround 4.0 inthe past sev precedentedlylarge denominator, stillit manages keepto The authors completed the Unified Competing Interest IRand DS conducted thereview ofthe relevant litera Structure, functionandneedsoftheglobalhealthresearchsystem June 2016 •Vol. 6No. 1•010505 PLoS One PLoS PLoS One as a solution a as jour ------

VIEWPOINTSPAPERS PVIEWPOINTSapers Rudan andSridhar June 2016 •Vol. 6No. 1•010505

REFERENCES 12 13 11 10 8 9 14 21 20 15 6 7 16 3 2 1 19 5 4 17 18

Instituteof Health Metrics and Evaluation, InstituteHealthofMetrics Evaluationand journal.pmed.1000030 Lancet Sridhar cations/policy–report/financing–global–health–2012–end–golden–age velopment: How much are we really spending? Fontaine Initiative (CHNRI) of the CHNRI Method. eomn dt: hts hr, hts isn, n wa rl i tee o a lbl observatory? global a for there is role what and missing, what's there, what's data: velopment ue lbl otlt fo cidod irhe b 2015. by diarrhoea childhood from mortality global duce Burke 2013 Rudan Moran pub/assoc/s14888e/s14888e.pdf uity.Global ForumforHealth Research, Geneva, doi:10.1371/journal.pmed.1000041 PLoS Medicine Editors PLoS Med. 2011;8: e1001008. Pang T, Terry RF, PLoS Medicine Editors. WHO/PLoS Collectionlapsed–.html. “No Accessed:health 15 Augustwithout 2015. research”: A call for papers. Available:http://www.scidev.net/global/health/opinion/why–has–the–global–forum–for–health–research–col Peterson–StearnsB. Why has the global forum for health research collapsed? SciDev.Net, 15 November 2010. Rudan 15 August 2015. wpro.who.int/health_research/policy_documents/draft_who_strategy_on_research_for_health.pdf 2012 that wasn't. forhealth. World Health Assembly A63/22. Geneva: World Health Organization, World Health Organization R 2013 World Health Organization doi:10.1126/science.1201865 Tomlinson PLoS Med Pneumonia.hood Settingresearch prioritiesreduce globaltomortality from childhood pneumonia 2015.by Lane 7 Wolpert Nature Rudan 6736(09)61910-3 disabilities: an expert opinion exercise.opinionexpert disabilities: an McGregor Medline:22325672 Ioannidis doi:10.1038/514550a tries? A systematic review of published reports. The maze of impact metrics. journal.pone.0108787 Van Noorden Van . r ˇ Medline:23445088 ttingen

; . J 382

,

.

MA . I I M I Bertuzzi

2008 , D

, . 2014 AJ

El Arifeen Gibson , Globalhealth research priorities: mobilizing the developing world.

O

, : JP

JA . , 1286 Guzman .

S Batniji , M 2011 Matlin For the sake of inquiry and knowledge — the inevitability of open access. , , , Kosek Boyack

; Henderson ; , 372 Regmi 514

Swartz R

- S

307 , , ; JL

.

8 : R PLoS Med :

1185 Maher Measuring the results of science investments. . 561 :

SA

,

.

e1001099 M S J Setting priorities in global child health research investments: guidelines for implementation doi:10.1016/j.puhe.2011.12.001 Ameratunga

Misfinancing global health: a case for transparency in disbursements and decision–making. . , , S KW Medline:23697824 , . Monitoring. financial flows for health research 2008: Prioritizing research for health eq

Bhutta Ropars

, L doi:10.1056/NEJMp1211410 - , Bhatnagar

2 Eide - Croat Med J , Barbour

91 , . KJ

Officer Medline:25355346 Small B . . WHO’s role and responsibilities in health research: Draft WHO strategy on research . Research for universal health coverage: World Health Report 2013. Geneva: WHO, , , , Medline:18926279

.

Kaldor M

ZA Nuzzo Nature AL 2012 . Medline:21980266 ,

doi:10.1371/journal.pmed.1001008 ,

Young

H , . Accessed: 15 August 2015.

V

A S Black S McDonald , , , , , ; Clark Sorensen

9 El Arifeen Chan . Boschi–Pinto

JM . : R 2008 e1001317 2013

. .

. AJ RE The top 100 papers. 100 top The How are health research priorities set in low and middle income coun

Lancet J

, doi:10.1016/S0140-6736(13)61046-6 , , KY 6 ; Connell . Financing. globalhealth goldenthe2012: ofendTheage? Seattle: ; Viergever 49 Brooks 502 2012

A , AA

: S doi:10.1038/514561a Rudan 720 ,

, : PLoS Med Jameson . .

PLoS ONE 271 Medline:23049486 doi:10.1016/S0140-6736(08)61485-3 Bhutta , .Available:

2009 Klavans C

2008 -

A doi:10.1371/journal.pmed.1001099 L 33 , .

, , Medline:24137834 Chan

RF Simpson Chan I . Medline:19090596 , ;

374 , . Available:. ZA Saxena

Ardal N .

R , , . 2009 KY

: KY Black . 1857 Omune 2014 http://www.healthmetricsandevaluation.org/publi Bibliometrics:Isyour most cited work your best? ,

,

C Duggan

P

Nature et al

S , Science ; LS Med PLoS . 6 . Winker - ;

Mappingof available health research and de M 9 62 : Researchpriorities healthpeopleforofwith e1000030 : http://announcementsfiles.cohred.org/gfhr_ .

e108787 , B

the WHO/CHNRI Expert Group on Child . et al doi:10.1371/journal.pmed.1001317 Medline:19944866 , . . . Accessed: 15 August 2015.

et al C . 2014

2011 , M ; doi:10.1038/502271a et al Child Health and Nutrition Research . www.jogh.org , . . Neglected disease research and de Veitch .

. 2009 Medline:25275315 PublicHealth Medline:19192946 ; ; 514 . 331 Setting research priorities to re

2010 N Engl J Med : : ;

550 678 E 6 • doi:10.7189/jogh.06.010505 . : e41 The World Health Report - - .Available: 80 3 . .

Medline:19278292 Medline:25355343 doi:10.1016/S0140- . Medline:21310987 . 2012 . 2013

; doi:10.1371/ doi:10.1371/ 126 http://www. . Accessed: . ; 368 :

237 Lancet : 785 - 40 ------. .