Globally, the total amount of money, public and private invested in health research and development is estimated to be 73 billion US dollars a year. Although the poor represent 25% of world population, they carry a disproportionate burden of disease and ill health. Currently, however, less than 10% of global funding for research is spent on diseases that afflict more than 90% of the world's population. This disparity in spending the health research dollars on diseases that affect the rich rather than the poor countries is known as ‘The 10/90 gap’.
In 1990, the Commission on Health Research and Development1 recognized the seriousness of the matter. This led to the formation of the Health Forum under the auspices of WHO. The Health Forum is an international organization managed by a 20-member council, the members of which are drawn from a wide variety of partners: government policy-makers, donors, women's organizations, and international NGOs. The Health Forum's report, ‘Health Research: Essential Link to Equity in Development,’ made several observations and recommendations. It identified four major challenges the world will face in the coming decades: (1) high burden of infectious diseases among the poor that can be addressed using the existing cost-effective drugs; (2) continually increasing threat of HIV/AIDS, Tuberculosis, and Malaria; (3) the increasing epidemics of noncommunicable diseases, such as heart disease, diabetes, and injuries, in the low- and middle-income countries; and (4) disparities in efficiency and equitable health services in different populations.
The Health Forum developed strategies and short- and long-term agendas to help decrease the 10/90 gap through many programs. It recommended that there is a need to develop national research agendas, develop new collaborations between private and public sectors, and increase funding for health research and development. The committee also recommended the creation of a Global Forum for Health Research as an independent committee to address these issues. Since the first Health Forum report, scientists and international organizations have been actively engaged in reversing the disequilibrium. So far the Global Forum has held nine annual meetings, each dealing with a specific topic of global importance; the last was held in October 2005 in India.
A crucial factor that sets up the vicious cycle of the 10/90 gap is the paucity of research in the developing countries. Investigators are attempting to quantify this gap. For example, Mendis et al.2 found that although 75% of the global cardiovascular disease burden is borne by developing countries, research emanating from these countries is minimal. They found that of the randomly selected 3000 citations on the subject, 78% were from developed countries and only 6–8% were from developing countries. Further, there were no publications from 42 of the 192 WHO member states. These issues are being addressed through establishment of research units in developing countries.3
For conducting research, in addition to adequate funding, there is a need for capacity building and free access to most current information. Most countries cannot afford to subscribe to scientific journals. Individuals aspiring to be clinical or basic scientists cannot afford to maintain personal subscriptions to professional journals. Recognizing these deficiencies and the importance of rapid and steady flow of information, WHO took an initiative to provide electronic access to biomedical journals for qualifying countries.4 The poor countries can easily establish electronic access to libraries at no cost. Similarly, other notable journals, such as Lancet and BMJ,5 have enabled developing countries to access their journals electronically at no cost. Still, these well thought projects are severely curtailed because of inherent local issues of lack of affordability of a computer and/or continuous availability of electric power.
In spite of the above-mentioned concerns and activities of the Forum to reverse the 10/90 gap, some believe that the 10/90 gap is a myth.6 They argue that drugs to treat the majority of the diseases suffered by the poor are already available in developing countries. It is estimated that 88% of child diarrheas (which account for 2 million deaths of children every year), 50% of malaria (1 million deaths/year), and other childhood diseases can be prevented using existing medicines. The issue, however, is not the unavailability of medicines in the world market. The problem in their view is that the poor are unable to access these medicines largely because of poverty, inadequate health infrastructure, and overbearing governments. These barriers need to be removed to make the drugs available to poor people. Some nongovernmental agencies in developing countries also view this as intrusion and oppose the involvement of rich countries in the matters of poor countries for fear of economic and political dominance by the rich.
The observations made by the leaders of developing countries, however, make compelling arguments in favor of the role of the Health Forum and its efforts to reverse the 10/90 gap. Some of these are worth noting.7 The Prime Minister of Mozambique, whose country has the highest maternal mortality rate (MMR) of 600–1000/100 000 and infant mortality rate (IMR) of 146/1000, noted that ‘Well designed research–not only biomedical but also socio-economic, behavioral and political–can help us enormously.’ Andrew Kitua, Director General of Tanzania's National Institute of Medical Research, said, ‘Developing countries must be active and equal partners in researching to solve their own problems, for example in tropical diseases, they must have a voice in channeling the funds allocated to them.’ These are some of the basic tenets on which future efforts to revert the gap must be based.
After a decade and half of introspection one might ask: are we there yet? Ramsay7 in her article concludes that in spite of a lack of noticeable progress after 11 years of the commission's report, there is hope. According to her, ‘there is growing acceptance that developing countries must have the capacity to investigate their own health priorities.’ Matlin, the director of the Health Forum, analyzing the current situation in 2004, has offered optimistic and encouraging news.8 He reported that overall global expenditure on health has been steadily increasing ($30 billion in 1987, $73 billion in 1990, $85 billion in 1998, $106 billion in 2001). He also noted that developing countries, such as Brazil, Cuba, India, and Mexico, are reaching the targeted 2% of health care dollars for health research.
Still there is a dire need to fill the 10/90 research gap in maternal–child health issues. It is well recognized that women's health issues contribute to the high proportion of global burden of disease for several reasons: special gender-related illnesses, wide gender-based social inequalities, and lack of economic independence. Yet, research in women's health is lacking. Doyal9 in her editorial observes that ‘if gains are to be made, sex- and gender-related research must be promoted to decrease the 10/90 gap.’ During the last few years, several articles on global health situation in this journal10 and in Lancet11 have highlighted the need for initiating research on perinatal health issues in the developing countries.
Jones et al.11 identified major health issues that affect women and children around the world. They also identify the specific health problems that contribute to high infant mortality. Darmstadt et al.10 emphasize the importance of prioritizing research initiatives to decrease global IMR. These articles underscore the fact that focus on women's and children's, health-related research is essential to narrow the gaps in maternal and infant mortality between the rich and poor countries.
As health professionals, we as individuals and collectively should strive to fill the gaps in information and research in developing countries. Perinatologists and Neonatologists in the developed countries have an obligation to actively participate in the global crusade of bridging the 10/90 gap. The task is enormous and the options are many. The options include capacity building through training of selected personnel, providing access to journals, symposia on research and establishing collaborative research in areas of mutual interest. Only then will we begin to see a perceptible decline in global maternal and infant mortality rates.
Commission on Health Research for Development. Health Research: Essential Link to Equity in Development. Oxford University Press: New York; 1990.
Mendis S, Yach D, Bengoa R, Narvaez D, Zhang X . Research gap in cardiovascular disease in developing countries. Lancet 2003; 361(9376): 2246–2247.
Measuring Success in Research Capacity Building: INCLEN as a Case Study in Progress. www.globalforumhealth.org/Non-Comp/Forum3doc344.ht.
Health Inter Network Access to Research Initiative (HINARI). Scientific Publications. www.healthinternetwork.org (assessed March 18, 2004).
Smith R, Williamson A . BMJ journals free to the developing world. BMJ 2002; 324(7335): 444.
Stevens P . Why the 10/90 Gap is 100% Fiction? http://www.fightingdiseases.org/pdf/Diseases_of_Poverty_FINAL.pdf.
Ramsey S . No closure in sight for the 10/90 health research gap. Lancet 2001; 358: 1348.
Fleck F . Spending on neglected diseases has increased, says report. BMJ 2004; 328: 1220.
Doyal L . Gender and the 10/90 gap in health research. Bull World Health Organ 2004; 82: 3 Genebra March 2004.
Moss W, Darmstadt GL, Marsh DR, Black RE, Santosham M . Research priorities for the reduction of perinatal and neonatal morbidity and mortality in developing country communities. J Perinatol 2002; 22(6): 484–495.
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? The Lancet 2003; 362(9377): 65–71.
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Vidyasagar, D. Global notes: the 10/90 gap disparities in global health research. J Perinatol 26, 55–56 (2006). https://doi.org/10.1038/sj.jp.7211402
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