Can academic health science centres drive translational research to meet health needs in low-income countries?

By Alexandra Edelman

Alexandra attended the 2015 World Bank and International Monetary Fund (IMF) Annual Meetings in Peru. 

Abstract

Public investment in health and medical research is dominated by high-income countries and their health needs. Academic health science centres (AHSCs) are structured to bridge research translation gaps to improve health for their patient populations, and many are developing internal structures to drive and enable research targeted to improving health for populations further afield. An exploratory analysis of three case studies of globally-focussed AHSCs and related structures reveals shared objectives in: developing collaborative institutional linkages and networks targeted to underserved populations globally; influencing policy development for global health; and building a globally-accessible knowledge base. Crucially, all three case studies recognise that AHSCs offer a uniquely valuable institutional framework to enable innovation and research translation for global health with a focus on low-resource settings. The findings of this exploratory analysis offer models and lessons for Australia’s role in the Asia Pacific region, World Bank initiatives and the global Tropics.

Recommendations

a) The developing Australian AHSCs should work towards establishing global health units such as the Office for Global Health at Manchester Academic Health Science Centre to coordinate, incentivise and enable translational research targeted to neighbouring countries, via strategic partnerships to ensure that scientific priorities are selected according to social and economic priorities of the target populations.

b) The Australian Government should consider resourcing AHSCs in Australia to develop and deliver translational research and related projects targeted to improving health in neighbouring countries.

c) In working with the World Health Organisation to implement the findings of the Report of the Consultative Expert Working Group on Research and Development, the World Bank should consider resourcing AHSCs within global health partnerships to incubate research targeted to the health needs of developing countries.

d) The developing AHSC in northern Queensland could consider establishing an Alliance of key AHSCs and other key stakeholders across the global tropics to promote research agenda setting, research translation and adaptation of health care best practice to meet health care challenges and opportunities across the region, modelled off the M8 Alliance.

Introduction

Health is a significant and growing cost to national budgets worldwide, as well as a critical investment: a healthy population is necessary for a productive workforce, and the health care and life sciences industries are important engines of economic growth. The provision of effective, efficient, and equitable health care underpins all development activities, particularly for developing countries as they strive to sustain economic growth and development initiatives.[1]

There are profound challenges to improving health in developing countries.[2] Alongside other development initiatives targeted at improving the social determinants of health, such as poverty alleviation and infrastructure development, health and medical research is a critical element of the development toolkit. Research improves health by providing new therapeutic discoveries as well as information to inform policy, such as on disease trends and risk factors, outcomes of treatment or public health interventions, patterns of care, and health care costs and use.[3]

Public investment in health and medical research, however, is dominated by high income nations and their health needs, and market mechanisms have been unable to provide sufficient incentive for research into effective health technologies, medicines, vaccines and diagnostics for low income populations.[4] Effecting this ‘translation’ of health and medical research to tangible products and other deliverables is also becoming more challenging as a variety of actors are now involved at different stages, and there is greater pressure for scientific, social and economic priorities to align.[5] Accordingly, the ‘linear model’ of translational research, whereby universities or research institutes develop basic or fundamental research and commercialisable elements are picked up by the private sector, is less applicable today.[6]

Movements towards implementing ‘Universal Health Coverage’[7] attest to a global recognition that it is unacceptable for lifesaving medicines, vaccines or other interventions to be widely available in the developed world while millions continue to suffer and die in developing countries due to lack of access and availability.[8] To address health and medical research inequities, the World Health Assembly emphasises the need for a range of incentives to facilitate better targeting of research and development to diseases that disproportionately affect developing countries.[9] A range of policy options for strengthening global financing and coordination for research of this focus is currently being considered by the global development community.[10]

The 2015 World Bank/International Monetary Fund Annual Meetings, with their focus areas on shaping the future, promoting sustainable economic growth through effective policy, poverty alleviation and international development, present an opportunity for the World Bank in particular to consider its role in financing research and development to meet health needs and Universal Health Coverage goals in developing countries. The tropical location of the event, Peru, supports a focus of these considerations on the tropics.

This paper explores the role that academic health science centres (AHSCs) can play in facilitating and incentivising health and medical research targeted to the health needs of developing countries. The paper considers approaches adopted in three globally-focussed AHSCs and related structures towards designing and translating research to benefit underserved populations beyond their own patient population boundaries. The paper concludes by considering policy application of the findings to Australia’s role in the Asia-Pacific region, World Bank activity, and the tropics worldwide.

Academic health science centres

Academic Health Science Centres (AHSCs) are complex organisations that are largely defined by their tripartite mission: to achieve high standards of clinical care, undertake clinical and laboratory research, and educate health professionals.[11] Although governance and operational models vary considerably, AHSCs are typically a partnership between a leading university, medical research institute and one or more health system partners.[12]

Newly-developing constructs in Australia, AHSCs are well-established in the United States, and are either established or newly developing in all leading healthcare jurisdictions worldwide.[13] With a key focus on research translation, key deliverables of AHSCs include new treatments, diagnostic tools and guidelines, new health care delivery models and new approaches to health professional education and training.[14] AHSCs are designed to cut across the silos between universities, health systems and research institutes to improve health service delivery to their target populations.

The gap between the volume of research discoveries and their uptake in health care settings remains a longstanding and widely recognised global phenomenon – persisting despite advances in evidence-based medicine.[15] Reflecting the challenges of bridging this gap, the translation of basic science breakthroughs into clinical applications is sometimes referred to as ‘bridging the valley of death’ between researchers and clinicians.[16] Reducing the 17-year lag between research discoveries and their integration onto physician practice[17] is cited as a key driving factor for the establishment of AHSCs in the United Kingdom.[18]

Where they are well developed, AHSCs are recognised as leaders in developing innovative approaches to delivering high-quality and highly reliable care.[19] For over 50 years, AHSCs have acted as ‘ideas factories’ for new discoveries in biomedicine and technological innovation – transforming our understanding and approaches to human biology and the pathophysiology of disease.[20]

Public investment in AHSCs is justified on both social and economic grounds. Health organisations that undertake research produce better health outcomes.[21] Good health and effective health systems are also widely recognised as critical contributors to economic growth.[22] In addition, investing in health innovation delivers economic returns.[23] Reflecting the economic returns of investment in innovation, AHSCs in the US had a combined positive economic impact of $512 billion on the national economy in 2008.[24]

Academic health science centres and global health

Contributing to international health care is recognised as a particular benefit of ‘academic medicine’ – a foundational concept of AHSCs, defined broadly as work undertaken by clinicians that combines service delivery, research, teaching and/or administration.[25] Beyond improving health and service delivery for local populations, AHSCs are increasingly building the ‘final essential component of the discovery-care continuum’[26] by adding global health to their research translation pipeline.

As AHSCs have the capability to transform medicine, improve health, and reduce health-care disparities both locally and globally, they are also seen as having a ‘collective responsibility’ to do so.[27] Barriers to delivering these benefits in under-resourced settings, however, stem from the geographic location of most teaching and research-intensive hospitals (as core partners of AHSCs) within high income countries. Although AHSCs are known for creating novel drugs, devices and other medical technologies, their capacity to contribute ‘broad, inexpensive preventive and treatment strategies’ among populations – the sorts of products desperately needed in low income countries – is less developed.[28] To overcome the barriers, AHSCs need to develop deliberate structures and incentives to deliver value in under-resourced settings outside of their patient population boundaries.

AHSCs already face a number of barriers contribute to achieving their mission to translate research into health care products and benefits. These include tensions that exist between the various internal and external requirements of the partner organisations, such as KPIs and service missions.[29]  Finding a space for ‘broad, inexpensive preventive and treatment strategies’ targeted to the needs of populations outside of AHSC patient boundaries presents a significant additional challenge.

Case studies

Many universities have interdisciplinary centres focussing on global health – including over 40 in North America. [30] However, not all of these centres utilise the AHSC structure to translate discoveries into deliverables quickly and efficiently. Some notable AHSCs and related structures in the United States and the United Kingdom have developed programs aimed at improving health in low-resource settings, and their activities are briefly explored below.

Duke Medicine

Duke Medicine is an AHSC that includes the Duke University Schools of Medicine and Nursing, the Duke University Health System and related organisations. Duke University established the Duke Global Health Institute (DGHI) i   n 2006 with a vision of ‘academic excellence to meet the global health challenges of today and tomorrow and to achieve health equity worldwide’.[31] 

One of the key goals of DGHI is to ‘catalyse and conduct innovative research that responds to the changing global burden of disease and influences policy.’[32] DGHI delivers this via a series of university-led projects involving globally-focussed research collaborations and the establishment of an Evidence Lab to evaluate promising technologies and programs.[33]

DGHI is intended to fulfil the final stage of Duke Medicine’s ‘discovery-care continuum’, which includes a focus on ‘bi directional service learning’ via a series of projects designed to link investigators in global strategic partnerships to refine discoveries and disseminate findings.[34]

Manchester Academic Health Science Centre

The Manchester Academic Health Science Centre (MASHC) was established in 2006 as a partnership between the University of Manchester and six National Institute of Health organisations in the United Kingdom. MAHSC established an Office for Global Health (OGH) in 2014, which is led by an Executive Director and informed by an Advisory Board of ‘renowned global health practitioners from around the world’.[35]  

Reflecting an interpretation of global health as ‘policies and practices that address the transnational health concerns flowing from globalisation’, MAHSC stresses the importance of global health cooperation to improving the health security of local populations in an interconnected world.[36] The OGH has a particular focus on improving health in low and middle income countries, and has developed research programs focussed on the development of low cost interventions to address non-communicable diseases to improve women’s health. OGH was recently commissioned by the World Health Organisation (WHO) to deliver a systematic review of postnatal interventions to prevent morbidity and mortality in the postnatal period, which subsequently informed the WHO postnatal guidelines.[37]

M8 Alliance

The M8 Alliance of AHSCs, universities and national academies was formed in 2009, with the primary goal of ‘developing science-based solutions to health challenges all over the world’.[38] The Alliance incudes partners from the UK, Australia, US, Germany, France, Japan and Russia, and is recognised as a permanent platform for considering and responding to global health care challenges.[39]

To promote research translation and adaptation of health care practice to meet new challenges in the global environment, the M8 Alliance pursues five strategic goals, which centre on developing a global network of AHSCs to facilitate dialogue between the stakeholders, set the global health agenda and create a global knowledge base.[40]

Case study analysis

Key shared objectives of the case studies above include developing collaborative institutional linkages and networks targeted to underserved populations globally, influencing policy development for global health and building a globally-accessible knowledge base. Crucially, all three approaches recognise that AHSCs offer a uniquely valuable institutional framework to enable innovation and research translation for global health with a focus on low-resource settings.

DGHI offers a capacity for policy-focussed research and is recognised as the final stage of Duke Medicine’s research ‘discovery-care continuum’. The operational linkages between DGHI and Duke Medicine, however, are unclear and as such DGHI may represent a more traditional university-based global health research institute model.

The MAHSC OGH, by comparison, is situated within the AHSC and includes a strong focus on improving service delivery through collaboration between academics and health practitioners in both established high-income centres and less developed centres in low-income settings. The projects delivered within the OGH are strongly linked to the achievement of practical health and service delivery outcomes and explicitly align with existing international global health initiatives.

The M8 Alliance, as a global partnership model, is structured as a forum for agenda setting and sharing best practice for global health rather than as a delivery vehicle for projects to improve health in low resource settings.

Application of findings

Australia’s role in the Asia Pacific Region

Australian researchers ‘punch above their weight’ in research output – producing 3% of the world’s research with only 0.3% of the population[41] – but it takes around 15 years for evidence to be implemented into clinical practice, and public investment in translational research is comparatively low.[42] The growing emphasis on translational health research in government policy, national reviews and funding initiatives, most recently exemplified in Australia’s Medical Research Future Fund,[43] is a key driver of movements towards establishing AHSCs in Australia, which are being developed with reference to international models and experience.

Within the nascent partnerships, some members have existing global health outlooks, but the focus is not yet embedded into core business. As Australia faces a significant moral imperative to contribute to the social and economic development of its less developed near neighbours in the Asia Pacific region, there is a strong argument for the explicit development of global health programs within the AHSCs. Given that Australian models are likely to embrace prevention, community care and primary care aligned with its uniquely distributed population and broader shifts away from hospital-based care,[44] Australian AHSCs may be particularly well-placed to develop the sorts of research products that are of most value in low-resource settings.

Recommendations:

a) The developing Australian AHSCs should work towards establishing global health units such as the Office for Global Health at Manchester Academic Health Science Centre to coordinate, incentivise and enable translational research targeted to neighbouring countries, via strategic partnerships to ensure that scientific priorities are selected according to social and economic priorities of the target populations.

b) The Australian Government should consider resourcing AHSCs in Australia to develop and deliver translational research and related projects targeted to improving health in neighbouring countries.

The Role of the World Bank

The World Bank Group has a longstanding interest in improving health, with well-developed global strategies including programs aimed at helping countries expand access to quality, affordable health care and a joint framework on monitoring progress towards Universal Health Coverage.[45] As only global efforts can succeed in tackling global health challenges, global institutions like the World Bank and the World Health Organisation (WHO) offer the reach and underpinning data analytic capacity to oversee and enable regionally-based human development efforts.

The Report of the WHO’s Consultative Expert Working Group on Research and Development stresses the importance of partnerships and collaboration to underpin priority-setting for research targeted to developing country health needs.[46] It advocates for the WHO to play a stronger role in improving coordination of research and development directed at the health needs of developing countries, by seeking a critical mass of people and resources and strengthening research advisory mechanisms. [47]

The World Bank has a role to play in enabling and resourcing research targeted to the health needs of developing countries, via cultivation of strategic partnerships with the WHO and other organisations. AHSCs, which are ideally placed to incubate research targeted to these needs, can add value within these partnerships.

Recommendation:

c) In working with the World Health Organisation to implement the findings of the Report of the Consultative Expert Working Group on Research and Development, the World Bank should consider resourcing AHSCs within global health partnerships to incubate research targeted to the health needs of developing countries.

Tropics worldwide

The State of the Tropics Report revealed in 2014 that health care challenges in the tropics include continuing high levels of poverty and persistence of debilitating infectious diseases like tuberculosis, and the growing impact of non-communicable diseases on disability and early death.[48] Health systems are having to adapt to these challenges by developing new models of care and managing rapidly increasing health care costs.[49]

Following the release of the State of the Tropics Report, and given the limited focus on the Tropics as a distinct geopolitical region, there is a role for tropical partnerships to assess health development objectives and priorities for health and medical research.

Recommendations:

d) The developing AHSC in northern Queensland could consider establishing an Alliance of key AHSCs and other key stakeholders across the global tropics to promote research agenda setting, research translation and adaptation of health care best practice to meet health care challenges and opportunities across the region, modelled off the M8 Alliance.

Conclusion

AHSCs are designed to bridge research translation gaps and to better align scientific and technical capacity with health needs. As such they offer significant promise as incubators for translational research targeted to health needs in developing countries – given the right internal structures and incentives. Exploration and analysis of the approaches taken in three case studies underscore the relevance of AHSCs to global health research and development agendas, and highlights models and approaches for testing and adoption by other AHSCs. Additional research could deliver more detailed analysis of these case studies, including assessment of benefits to health and analysis of incentive systems, to inform national and global financing of research and development targeted to underserved populations.

Full Footnotes and Bibliography can be found here or by copying the following URL into your browser: http://bit.ly/Alex-Edelman-2015