Anda di halaman 1dari 23

10/90 Gap: What is the Solution?

D R M A S O O M S H A H , M S c . H e a l t h P o l i c y
M a n a g e m e n t

A g a K h a n Un i v e r si t y , K ar a c h i

E m a i l : s a y e d . m a s o o m @ y ah o o . c o m

1
Research is a central and
indispensable component
of improving health

Helping to get the


right research for
health done

2
Contents
Defining the Terms........................................................................................................................................ 4
HSR ............................................................................................................................................................ 4
10/90 Gap ................................................................................................................................................. 4
The Issue: 10/90 Gap .................................................................................................................................... 4
Figure 1 ................................................................................................................................................. 5
Figure 2 ................................................................................................................................................. 6
Figure 2 ................................................................................................................................................. 6
Figure 3 ................................................................................................................................................. 7
10/90 Gap-Progress or Deterioration: An Inquiry ........................................................................................ 9
Figure 4 ................................................................................................................................................. 9
Critique on Theory ...................................................................................................................................... 11
10/90 Gap and Equity Lens: An Alternate Dimension ................................................................................ 12
Figure 5 ............................................................................................................................................... 14
Situation in Pakistan.................................................................................................................................... 15
Figure 6 ............................................................................................................................................... 16
What is needed? ......................................................................................................................................... 16
Figure 7 ............................................................................................................................................... 16
Figure 8: .............................................................................................................................................. 17
A Way Forward............................................................................................................................................ 19
Figure 9: .............................................................................................................................................. 19
References: ................................................................................................................................................. 21

3
Defining the Terms

HSR
Health systems research (HSR) or health policy and systems research (HSPR) has been
defined as “the production and application of knowledge to improve how societies organize
themselves in order to achieve health goals. It encompasses how societies plan, manage and
finance health services as well as investigation of the role and interests of different actors in the
health system.”1. HSR focuses on enhancing efficiency and effectiveness of health system as an
important part of the overall socio-economic development through participation of all
stakeholders in order to improve the health of people and communities2.

A good HSR must be based on priority problems; must be action oriented; multi-
disciplinary; participatory; timely; emphasize of simple and short-term designs; cost-effective
and present results in formats most useful for administrators, decision-makers and the
community. Lastly and more importantly, the evaluation of HSR must not be done on the
number of papers published out of it but its ability to influence policy, improve services and
ultimately lead to better health2.

10/90 Gap
The notion of 10/90 gap pertains to the research in health around the world and the
accompanied funding issues with it. It states that 90% of the money spent on research is
targeted towards curing diseases that affect 10% of the world’s population3. This means that
only 10% of the health research dollars are spent to improve the health of 90% of the world’s
population.

The Issue: 10/90 Gap


In a world where disparities exist in every field of life, health and health research is not
exclusion nonetheless. There is a gap between rich and poor, intra-countries and inter-
countries. Similarly the gap exists in knowledge i.e. what we know and what we need to know,
and research gap that signifies gap between the health problems and solutions and the know-
do gap which represents what we actually do as health workers and what evidence based
solutions suggest4. The movement started following a report commissioned by World Health

4
Organization (WHO) in 1990 Commission on
Health Research for Development (hereafter CHR-
D) that estimated that 1986, less than 10% of all Figure 1
the research resources (30 billion USD) were
focused on the health problems and needs of
developing world that constitutes around 90% of
population around the globe5. As most of the
world’s disease burden was found to be in
developing world, the fact eventually led to the
use of phrase “10/90 gap” to denote the
imbalance between needs and resources5. Later in
1996, WHO Committee of Health Research in its
report, Investing in Health Research and
Development, once again highlighted insufficient
research attention towards the health problems of
developing world and health issues that were long
been neglected. This led towards formation of Source: 10/90 Gap of Health Research 2003-04
“the Alliance for Health Policy and Systems
Research”1. According to Gwatkin and Gulliot’s re-examination of 1990’s Global burden of
disease data and disability causes, poorest 20% of the world suffered from 47.3% of total
deaths and 49.8% of total DALY loss due to communicable diseases where as the 20% rich
segment account for only 4.2% of all the deaths and 2.6% of DALY loss due to the same6.Global
health spending on health research steadily increased but the spending on health research kept
on decreasing and especially on issues of concern for developing world which led to further
disparities in health research spending. This fact is evident from the review conducted by
WHO’s Ad Hoc Committee on Health Research Relating to Future Options, five years after CHR-
D report in 1990, which found that the situation had further deteriorated and only 4.4% (5%
public funds in 1990) of all public sector funds for health research and development were
directed towards the health problems faced by low to middle-income countries6. Investment in

5
health research increased by more than 60% from
1990 to 2003 however the inequalities persisted in
Figure 2
prioritizing the research agenda for instance around
102USD per DALY was spent on diabetes type 2 in
2003 while in same era research on diarrhea
Figure 2
received only 10USD per DALY7.

Gap in research spending existed even before


they were realized by the CHR-D report in 1990, for
example between 1975 and 1997, only 13 out of
1233 drugs (only 1%) reaching global market were Source: WHO 1993. Investing in Health Research & Development

for the tropical infectious diseases that primarily


YET ANOTHER
affects the 80 to 85% of poor in low and middle
income countries8. If we look at the figures in later
CHALLENGE OF LOW
years, things had not changed much as in year 2000, SPENDING ON
Pneumonia and diarrheal diseases represented RESEARCH AND
about 11% of the total global burden of disease but DEVELOPMENT:
only 5th portion of the 1% for health research
funding was spent on these major killers9. Due to A 10/90 GAP WITHIN
such a low spending the major killers flourished and 10/90 GAP .
only in the course of three years, the Child Health
Epidemiology Reference Group (CHERG) of WHO,
reported pneumonia contributing 19% and diarrhea 18% of the deaths to children under 5
years of age over the period 2000-200310. CHERG estimated that six causes accounted for 73%
of the deaths of children under-5 years, of which diarrhea and pneumonia topped the list and
apart from these two killers, malaria (8%), neonatal sepsis (10%), preterm delivery (10%), and
asphyxia at birth (8%) distressed the situation10. An important issue was brought forward by
CHERG’s report that under nutrition was the underlying cause of 53% of all child deaths
globally10. This is an indication of the paucity of health research on issues of concern for
developing nations as the under nutrition is widely prevalent in developing world only.

6
Figure 3 Other dimension of 10/90 gap in
health research is the under-
representation of developing countries in
research and publication which not only
triggers disinterest in researchers from
developing world but also results in
further widening of the 10/90 gap.
Analyses of five high impact journals in
year 2000 revealed that authorship from
UK, US and OECD dominated all the
journals while publications of authors
from rest of the world had 6.5%
representation11. The analyses also
revealed that even out of that 6.5%
representation, around 68.9% involved
authorship from Europe or North
America11. This depicts the “parachute
scientist” phenomenon12, where
Source: 10/90 Report of Health Research 2003-04 researchers from developed world
collected samples from developing nations, return back to home country and publish papers,
which is against the participatory, action oriented and policy shaping philosophy of health
systems research described earlier2.

Developing countries spend very little on health research (figure 3). Health systems
research agenda in developing countries is more than often driven by donors13 that happen to
be the developing world and the 10/90 gap is less likely to fill. Developing countries are
vulnerable to such a phenomenon and under representation in health research and for these
reasons the 1990 CHR-D report recommended the governments in low and middle income
countries to allocate at least 2% of national expenditure and 5% of foreign aid budget in health
research and research capacity building5. In addition a term Essential National Health Research

7
(ENHR) was coined in order to enhance health research on context specific, timely, participative
and above all priority health concerns5. The ENHR stated, “

“The core of an essential national health research (ENHR) strategy is to promote


research on country-specific problems that could underpin national and community decisions on
health policy and management. It involves researchers, decision-makers and community
representatives, who jointly choose the priorities to be addressed.”5

The logic is straight forward; to


build internal capacity and to flourish in Research Capacity in Developing World
health system research and reduce the
 1909, Carlos Chagas discovered American
existing 10/90 gap in health research. tryponosomiasis- County of origin: Brazil
World Banks report of 1999, “Investing in  India developed oral rehydration therapy: H N
Chatterjee published first human study of ORS
Health”, also suggested similar in 1953
recommendations for developing  1969, Jaime Zipper Abragan & Howard tatum
developed 1st copper IUD- Country of origin:
nations14. The report states that if the
Chile
mortality rates in developing world are  1972, Atemisinin developed by China
brought down to the level of developed  Malaria treatment protocol on resistance to
chloroquine- Sudan
nations, 11 million fewer children would  1991- Cuba developed 1st meningitis B vaccine-
die for which the developing world must Gustavo Sierra & Concepcion Campa published
1st RCT on meningitis.
shift their focus from specialized care to
 Thailand built up evidence for health system
more cost-effective public health development.
programs14. World Bank estimated that
Source: Essential Health Research: Holding to
around 25% burden of disease can be Account, Global Health Watch 2005 Report E|7
reduced by adopting this strategy which
is equivalent to averting more than 9 million infant deaths14. To attain this goal the increased
external funding for health research in developing countries must be ensured and priority
health problems must be focused including diarrhea and respiratory diseases on the top of the
list14.

8
10/90 Gap-Progress or Deterioration: An Inquiry

Due to strong advocacy role by


the Global Health Forum and the Figure 4

recommendation of CHR-D 1990 and


later report by WHO Ad Hoc committee
in 1996, the global investment in health
research increased from 55 billion USD
to 125.8 billion USD during 1993-
200315. Estimates for year 1998
suggests that out of 21 developing
Source: Global Health Forum Review 2006
countries (15 from Latin America, four
from South East Asia, plus Turkey and
India) Brazil and Cuba had complied
with recommendation of 1990 CHR-D report and raised the public investment in health
research up to 2% (Figure 3)8.
During 1990s, formation of the Council on Health Research and Development
(COHRED)16, International Development Research Center (IDRC)17, an exemplary report by
World Bank in 199314, WHO Alliance for Health Policy and System Research1 and several civil
society groups strengthen the advocacy role for reducing the 10/90 gap. In accordance to
recommendation of 1990 CHR-D report, several North-South alliances for global research
formed like Multilateral Initiative against Malaria, the European and Developing Country Clinical
Trials Partnership, the Global Alliance for Vaccines and Immunization, and the International
AIDS Vaccine Initiative etc18. Efforts to compile the complex data sets for expenditure on health
research had been challenging but OECD book Measuring Expenditure on Health-Related R&D
has been formed in 1999 and in 2000 OECD published A System of Health Accounts followed by
the Guide to Producing National Health Accounts with special applications for low and middle-
income countries promoted by the World Bank, WHO and USAID8. United States National

9
Institute of Health (NIH) has doubled its funding for health research since 1998 and in five years
the figure reached to US$ 27.3 billion8.
While the above facts and figures are overwhelmingly optimistic, an observation by the
Commission on Microeconomics and Health is worth mentioning that states that the actual gap
is probably greater than the notion of 10/90 gap itself19. African economic growth is still facing
challenges from Malaria which is slowing the economy by 1.3% per year and HIV accounting for
annual loss of 2.6% of many Sub-Saharan African counries19. Despite the fact that the global
funding for health research tripled since 1999, most of it is still spent by high-income countries
in high-income countries to generate technology for their hi-tech health care markets8. A
survey initiated by European Medical Research Council after its Plenary Meeting in April 2002
suggested that research combined budget allocation to global health issues by Denmark,
Sweden, France, Norway, Netherlands and Portugal is even less than 6% of their entire health
research spending8. Some developing countries are already investing considerably in health
research but substantial portion of research money is spent on researchers’ salaries and
maintaining the inadequate research infrastructure8. The formation of different alliances for
research have been achieved but the so called “Northern” “magic bullet” agenda has
overstrained certain developing countries which are hardly able to integrate even a single
vertical program in to their national health research systems8. This could result in further
widening the 10/90 gap and further fragmentation of the Southern research system as the
research carried out is not conforming to the national needs but to global funding availability
only8. The 2% formula of public allocation to national health research is still a dream in
majority of developing countries and at the same time development assistance allocations by
may rich countries still fall short of the United National’s 0.7% GDP target8. A study conducted
in 2000 suggests that selected tropical diseases like leishmaniasis, malaria, trypanosomiasis and
TB that together accounts for 5% of total global disease burden (75 million DALYs) received only
0.11% of the total global investment on health research8.
A review conducted in 2002 of over 1.6 million papers published between 1996 and
2001 suggest a wider gap in published research8. Pneumonia, malaria, diarrheal diseases and
dengue that accounted for 13% of the global disease burden in 2002, had representation in less

10
than 2% of publication over a period of 6 years8. While the 20% rich countries experienced a
rise in their per capita income, economy in African least developed countries (LDCs) further
depreciated as their per capital expenditure on health dropped from 11% in 1990 to 8% in
199819. This resulted in failure to provide vaccination against measles, tetanus and pertusis that
went on killing 1.6 million children in poor countries19. While 80% population in half of the
global developing economies has access to essential medicine, the drug shelves of 41 out of 47
LDCs are still empty19. While the poorest 20% around the globe face the agony of 63.6% of
DALYs due to communicable, maternal, perinatal and nutrition related diseases, only 10.9%
DALYs are attributable to the same in richest 20% of the globe19. The question is still
unanswered, have we progressed in reducing the 10/90 gap or in fact we have made it even
wider?

Critique on Theory

Valid, as it sounds, it may be but the 10/90 gap had received criticism by many and
considered a flawed and unsound notion. One of the major criticisms of 10/90 gap came from
the director of Health Projects, International Policy Network UK Philip Stevens in 2004 in form
of a report called “Diseases of poverty and the 10/90 Gap”20. Under this heading some key
points from the report are shared as follows;

 A large proportion of illnesses in low-income countries are entirely avoidable or


treatable with existing medicines or interventions
 It is estimated that 88% of childhood diarrheas killing 2 million annually, 91% of malaria
killing over 1 million annually and close to 100% of childhood illnesses such as measles
and tetanus can be prevented using existing treatments.
 Vaccines for polio, measles and pertussis have existed for at least 50 years, yet only
53% of children in sub-Saharan Africa were immunized with the DTP in 2000.
 Exposure to biomass smoke in poorly ventilated houses increases the risk of Acute
Lower Respiratory Infections (ALRI) in childhood, above all pneumonia. Globally ALRI is

11
the single most important cause of death in children under 5 years and accounts for at
least 2 million deaths per year.
 Malnutrition mainly affects people in poor countries. For instance as a result of vitamin
A deficiency, 500,000 children go blind each year despite availability of cheap, easy to
administer food supplements.
 Sadly, governments around the world and especially in poor countries are simply failing
their people by imposing taxes on medicines, and by prioritizing military spending over
health.

10/90 Gap and Equity Lens: An Alternate Dimension

When we define health system, we usually forget the difference between health care
and health system. Health system extends beyond health care and encompasses formal,
informal sector, societal norms, cultural beliefs, economic, social and political structure of a
country as well as other sectors including housing, education, water and sanitation, transport
and communication, broader environmental conditions and last but not the least status of
women. Thus the paradigm of health research broadens with broadening of the health system
definition. OECD and UNESCO defined health research as, “Research and experimental
development comprises creative work undertaken on a systematic basis in order to increase the
stock of knowledge, including knowledge of man, culture and society, and the use of this
knowledge to devise new applications” 8. With inclusion of culture, society and economics the
poverty status also becomes a concern for overall health and any disparities in these
determinants will lead to disparities in health much wider than 10/90 notion. To address such
disparities, 106 world leaders pledged at the Millennium Assembly to have the number of
people living in poverty by 201521 and earlier in this course WHO raised the slogan of “Health
for All” in its Alma Ata Declaration22, where all the signatory members gave their solemn
declaration to the slogan. Health for All not just advocates alleviating ill-health, but positively
promoting health, preventing diseases and helping people make healthy choices22. This was the
era which could be rightly called as an era of focus on equity which preceded the later paradigm
shift from equity to efficiency in severe economic downfall and influx of free market concept in

12
European socialist countries by mid 1980s23. Later in mid to late 1990s in conformance with the
same direction Poverty Reduction Strategy Papers (PRSP) were submitted by forty-one nations
to International Monetary Fund (IMF) and World Bank23.Different international agencies at the
same time came up with their initiatives in the same area like Department for International
Development’s (DFID) white paper focusing on international development of countries below
poverty line and Rockefeller Foundation’s Global Health Equity Initiative along with organized
efforts by Nordic countries and Netherlands23. Following the Alma Ata Declaration, several
reports like reports issued by United Kingdom (UK) focusing on inequalities in health in UK,
including Black Report in 198024, Whitehall study25 and Acheson Report26 followed. Similarly
depicting the 1984 targets of World Health Organization (WHO) reducing poor–rich disparities
“By the year 2000,” reported were generated by WHO like World health report of 1995 focusing
on health of the poor and Bridging the gap27 between rich and poor23, World health report
(Fighting disease, fostering development)7 of 1996 focusing on inequalities between rich and
poor23. These were substantial efforts to bridge the 10/90 gap not only in health research but in
every field of economic and social development. However, the question of how far did we
reach the success is still unanswered.

Today when world population has grown to 6.7 Billion28, approximately 1.4 billion in the
developing world are living below the poverty line (below 1.25$ a day)29. This figure is not
evenly distributed; if we look at inter country comparison and a gap wider than 10/90 exists.
According to World Development Report (WDR) 2009, an average person living in New York
enjoys a lifetime income of 4.5 million USD while that of rural Zambia will have a lifetime
income less than 10,000 USD in her/his lifetime30. Statistics show that per capita income ranges
from lower bound of $600 (Ghana) to an upper bound of $27,000 (New Zealand) and Shanghai
(China), today, has reached a per capital GDP level which Britain had in 198830. Apart from
inter-country disparities, example of which preceded, immense intra-country inequalities can
be seen as WDR 2009 points out that, in developing countries like Indonesia, Brazil, Sri Lanka
and Ghana, households in well-off areas have 75% higher consumption than their counterparts
in less successful areas of respective countries30. Around 1 billion people in developing world
today live in rural villages and slums30 which signifies large urban and rural disparities around

13
the globe and such rural-urban Figure 5
gaps in developing nation
results in disproportionate
access to basic education,
health, drinking water and
sanitation30. Consequently
people migrate in order to look
for better living opportunities
both within the country and
outside. According to WDR
2009 estimates around 200
million of world’s population is
living in region other than their Source: http://www.globalissues.org/article/26/poverty
http://www.globalissues.org/article/26/poverty-facts-and-stats
birth place and annually 2
million migrate from
underprivileged nations to developed world30.

Competent and effective workforce migrates because they lack an enabling


environment to flourish in their own country and thus contribute to the development of
nations which are already
lready developed. This again leads to disparities in technical workforce
distribution for example in United States for every 10,000 people there are 26 doctors
rendering a physician to population ratio of 1:385 while if we look at Sub-Saharan
Sub Saharan African the
octor to population ratio is 1:10,00031. In Pakistan same picture prevails but relatively far
doctor
better than Sub-Saharan
Saharan Africa as doctor to population ratio is 1: 1,436 and specialist to
population ratio is 1:12,80032. This is a result of vast disparities in social and cultural
determinants and health research focus should broaden to reduce this gap. Michael Mormot,
chairman of the WHO’s Commission on Social Determinants of Health, said that “if the major
determinants of health are social, so must be the remedies”33.

14
Situation in Pakistan
Pakistan is a developing economy facing challenges in every field of development.
Disparities exist between rich and poor, urban and rural, and between different geo-political
regions of the country. While the service delivery is a mix of public and private in health sector,
private sector largely dominates resulting in higher share of out of pocket spending in health
expenditure. According to W.H.O, Statistical Information system, private spending is around
83% of total expenditure on health in Pakistan and out of that 98% is out of pocket34.
Government of Pakistan is spending 2.42 of its GDP on education and 0.57% on health35
(declined in newly proposed budget 09) and the debt servicing alone eats up to 43 out of every
100 Pakistan rupees of the annual budget36. Pakistan is having 23% of undernourished
population proportion37. Equity in health is absence of systematic disparities in health which
entails that ideally there should be equal distribution of health related characteristics e.g.
health care utilization38. Thus equity is also an issue Pakistan as there are differences in the
access to health care between the rich and the poor as the presence of a well-developed
private system that serves only the rich39,40. As the total health expenditure of 2.1% of GDP35 is
lower than our needs and widens the pre-existing 20/80 gap in resource allocation between
primary and tertiary care in the country35. This further deteriorates the health indicators in the
country as still we are lagging behind in the race to reduce the infant and maternal mortality.
Presently the infant mortality rate is 78 per 1000 and Maternal Mortality Ratio is 320/100,000
live births41 about 25,000 mothers die each year in our country due to pregnancies and related
causes and more than 37,000 suffer from complications associated with pregnancy42. Around
890,000 induced abortions occur each year in Pakistan rendering induced abortion ratio per
1000 women at 2943.
Lion’s share of the government funding for health research goes towards trainings,
salaries, and infrastructure in Pakistan44. Data on health research expenditure is not a part of
the national health accounts and a complete account of sources of funds and allocation of
research topic is still missing in case of Pakistan44. Medical and health research council lack
expertise in several disciplines thus hindering the process of research not only on health but
other fields of development44. Factors like lack of academic liberty, absence of professional

15
incentives, poor funding and unclear career pathways in the country results in an environment
which does not attract researcher and motivate them to work44. Between 1994-2000, around
1.5 million USD was available for health research but less than half of the total could be
disbursed by Pakistan Medical and Research Council due to lack of good proposal44.

Figure 6

Source: Stevens, P.(2004). Diseases of poverty and the 10/90 Gap. International Policy Network, UK. Hanway Print Center

What is needed?
Health research spending Figure 7

globally is skewed and results in


higher disparities in health. While
health is directly related to
development, such disparities
results in deteriorated growth and
development of deprived nations.
Thus to address such
Source: Delisle et al. Role of NGOs in global health research for development.
disparities in health research and Health Research Policy and Systems 2005, 3:3

strengthen the development

16
process of developing world, a systems perspective is required to understand the production,
synthesis, cultivation of demand and use of research and the reason behind its skewed
distribution in funding44. Health system’s research is not a discipline in itself but it provides an
in-depth understanding of the problem through a participatory and collaborative process from
a system’s perspective2.
Figure 8: Research Process

Source: Delisle et al. Role of NGOs in global health research for development. Health Research Policy and Systems 2005, 3:3

A research that is not merely focused on inventing “magic bullets” and increase the
number of publications rather driven by context specific priority issues that believed in
empowering, capacity building, knowledge generation and producing concrete suggestions to
guide the public policy for health, research and development 2. Time is money in today’s world
and to conform to 2015 targets set by MDGs, we need less time consuming, practical and cost
effective research methods which is the domain in true sense. There is also need for integration
of efforts in order to move forward, reduce duplication of research, and avoid wastage of

17
resources and above all to be heard. The developing world especially that of the African
hemisphere and the Southern Asia must form coalition and umbrella organization like European
Observatory on Health Care System to share the regional experiences, enhance the
effectiveness of the research in health development44, and struggle to reduce 10/90 gap by
directing major share of the global health research funding towards the priorities of developing
nations. Furthermore an observatory for monitoring and evaluation of regional health research
focus and effectiveness, transparency of allocation and alignment of the research funding with
priorities specific to the country’s and region’s context44.

Source: WHO 1993. Investing in Health Research & Development

18
A Way Forward
HSR and advocacy for priority health issues must become a continuous process in the
developing region. Health system research must open yet another window for a successful
health system research in other priority areas and in cyclic fashion, first raise awareness locally
and once the cycle is complete; the HSR must spread the
the word around the developing world in
order to reduce the 10/90 gap in health research. This framework not stresses on raising
demand for health, setting context specific priorities and then building agenda to conduct
research. It also advocates that before
before embarking on research, learn from regional experiences
regarding what worked and what did not.

Figure 9: Framework for HSR and reducing 10/90 gap

19
This framework also suggests that only conducting research is not enough, rather
application of the HSR results in to practice is a must to reduce the 10/90 gap. Only by
implementing the results and setting good examples, the country can advice and influence
others in the region to join the effort to reduce the 10/90 gap.

It is evident from the facts mentioned above that 10/90 gap was a problem in 1980s and
90s and even today the situation persists rather the gap has further widened. With rapid
economic growth in North the income levels have improved and so did the global spending on
health research yet the disparities exist because the rich grew richer and the poor grew poorer
over the time. If the developed economies keep on ignoring the diseases of poverty,
preventable deaths and the drug shelves of least developed countries if not filled will result in
millions of deaths every year. On the other hand if the South joins hands in order to influence
the North and direct the flow towards top ranking diseases in global burden, the scenario might
change. It is advisable for developing countries to team up in order to be heard, form coalitions
to reduce the cost and wastage of resources, conduct hard core health system research that is
efficient, effective, participatory, need based, less time consuming and result oriented
approach. Together we can stand tall but not without considering the socio-economic, political,
cultural and environmental determinants of health. Focus of health system research is always
broad and all encompassing; therefore by adopting the HSR methods, a country will never
underestimate the social determinants of health. In addition HSR adopts a system’s perspective
and hence give concrete statements on “what work” and “what did not work”.

20
References:
1
WHO. (2009). The Alliance for Health Policy and Systems Research. Retrieved 5 27, 2009, from
http://www.who.int/alliance-hpsr/en/

2
Varkevisser, C. M. (2003). Volume I: Proposal Development and Fieldwork. In Designing and Conducting Health
Systems Research Projects (pp. 367). Amsterdam: KIT Publishers, IDRC, WHO-AFRO. ISBN 90 6832 148 X
3
Vidyassagar, D. (2006). Global noted: the 10/90 gap disparities in global research. Journal of Perinatology (2006)
26, 55–56
4
Vitoria Francis. (2004). Bridging the gaps. Community eye health journal. Vol 15;51. 33-34.
5
GFRH. (2005). Focusing research to improve global health. Global Forum for Health Research, 2005 Review.
Geneva
6
Gwatkin & Gulliot (2000). In. IDRC. (2001). Forging Links for Health Research: Perspectives from the Council on
Health Research for Development. Ottawa. ISBN 0-88936-935-6

7
Fontaine O, Kosek M, Bhatnagar S, Boschi-Pinto C, Chan KY, et al. (2009) Setting research priorities to reduce
global mortality from childhood diarrhoea by 2015. PLoS Med 6(3): e1000041.
doi:10.1371/journal.pmed.1000041

8
GFHR. (2004). 10/90 Report on Health Research 2003-2004. Chapter 5; Section 1, Measuring financial flow: A
review of ongoing efforts. Pp 107-127. Global Forum for Health Research.Geneva.
ISBN 2-940286-16-7
9
Roach J,O. (2000). Research does not reflect global disease burden. News,BMJ Vol 320, 1227-1228, 6 MAY 2000,
10
Rudan, I. et al. (2007). Setting Priorities in Global Child Health Research Investments: Assessment of Principles
and Practice. Croat Med J. 2007;48:595-604
11
Sumathipala, A. Siribaddana, S. Patel, V. (2004).Under-representation of developing countries in the research
literature: ethical issues arising from a survey of five leading medical journals. BMC Medical Ethics 2004, 5:5
doi:10.1186/1472-6939-5-5
12
Eva, H. (2004). Building scientific capacity in developing countries. science and society. European molecular
biology organization reports VOL 5:1, 2004
13
Gonzalez-Block, M,A (2004). Health policy and systems research agendas in developing countries. Health
Research Policy and Systems 2004, 2:6 doi:10.1186/1478-4505-2-6
14
World Bank. (1993). Investing in Health: World Development indicators. World Bank Report 1993. Oxford
University Press, NY. ISSNGIS3-5085.
15
GFRH.(2006). Innovating for better health. Global Forum for Health Research, 2006 Review. Geneva
16
COHERD. (2008). About Us. Retrieved 6, 7 2009, from http://www.cohred.org/main/AboutUs.php?pageid=2
17
IDRC. (2008).International Development Research Council. Retrieved 6, 7 2009, from http://www.idrc.ca/es/ev-
1-201-1-DO_TOPIC.html

21
18
Global Health Watch. (2005). Essential Health Research: Holding to Account. GHW 2005 Report E7.
19
Labonte, R. and Spiegel, J. (2001)Setting Global Health Priorities for Funding Canadian Researchers: A Discussion
Paper Prepared for the Institute on Population and Public Health
20
Stevens, P.(2004). Diseases of poverty and the 10/90 Gap. International Policy Network, UK. Hanway Print
Center.
21
Editor’s choice. Engaging with global health. BMJ Vol 321 30 September 2000
22
Declaration of Alma Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September
1978 .Eastern Mediterranean Health Journal, Vol. 14, Special Issue. Available from:
www.who.int/hpr/NPH/docs/declaration_almaata.pdf
23
Gwatkin D R. Reducing Health inequalities in developing countries. Oxford handbook of public health (4rth
Edition).
24
Black Report. Retrieved June 21, 2009, from http://www.sochealth.co.uk/history/black.htm
25
Wikipedia contributors, "Whitehall Study," Wikipedia, The Free Encyclopedia, available from:
http://en.wikipedia.org/w/index.php?title=Whitehall_Study&oldid=271362487 (accessed June 21, 2009).
26
Lowdell C. Bardsley M and Morgan D. Acheson Report. Inquiries into inequalities in health: Implication for
London: A Discussion paper.
27
WHO (1995). Bridging the gap. World Health Report 1995. WHO Publication, Geneva
28
World Population Clock Projection, US census bureau. Retrieved 6, 6, 2009, from
http://www.census.gov/ipc/www/popclockworld.html

29
Chen S, Ravallion M. The Developing World Is Poorer Than We Thought, But No Less Successful in the Fight
against Poverty. Policy Research Working Paper 4703 .The World Bank Development Research Group (August
2008).

30
World Development Report (2009); Reshaping Economic Geography. World Bank publication
31
Global health progress. Strengthening Health Care System to Deliver Care and Treatment. Retrieved 6,6,2009,
from http://globalhealthprogress.org/mediacenter/?p=48
32
Telemedicine in Pakistan (online): Retrieved 6,6,2009, from http://www.telmedpak.com
33
Holtz TH, Holmes S, Stonington S, Eisenberg L (2006) Health is still social: Contemporary examples in the age of
the genome. PLoS Med 3(10): e419. DOI:10.1371/journal.pmed.0030419

34
World Health Organization, WHOSIS. Pakistan, core health indicators. Retrieved 6,6,2009, from
http://www.who.int/whosis/database/core/core_select_process.cfm
35
Pakistan Economic Survey 2006-07-Health and Nutrition, Table 12.3 P178: Retrieved 6,6,2009, from
http://www.finance.gov.pk/admin/images/survey/chapters/12-Health.PDF

22
36
B T Shaikh. F Rabbani (2004) the district health system: a challenge that remains. EMRO. Vol 10: 1/2, P208 –
214
37
Undp-Statistics (2007/8) -Getting and using data-Data by Country-Pakistan, Retrieved 6,6, 2009, from
http://hdrstats.undp.org/countries/data_sheets/cty_ds_PAK.html
38
Alistair M. Henderson J. Mooney G. (1987). The Economics of Health Care: Chapter 4; Taylor & Francis, 1988. P
54-55ISBN 071021300X, 9780710213006.

39
Bhutta, Z.A. (2001). Structural Adjustments and their Impact on Health and Society: a Perspective from
Pakistan.International Journal of Epidemiology. 30:712-716.Available at:

40
Abbasi, K. (1999). The World Bank and World Health: Focus on South Asia I - Bangladesh. British Medical
Journal. 318:1066-1069

41
Pakistan Demographic and Health Survey 2006-07 (2008) National Institute of Population Studies
Islamabad, Pakistan. Macro International Inc. Calverton, Maryland USA: June 2008.

42
Khan A. Qurehi A F (1996). Reducing maternal mortality amongst poor Pakistani women in urban squatter
settlement; an alternate strategy: Hsph:Harvard 1996.

43
Population Council. (2004).Unwanted pregnancy and post abortion complications in Pakistan: findings from a
national study. Population council, 2004. Islamabad
44
Sadana, R. D’Souza, C. Hyder, A,A. Choudhury A, M, R.(2004). Importance of health research in South Asia.BMJ
2004;328:826–30

23