Problem, Challenge, or Focus:
Access to Medicines in Developing Countries
Listen to John-Arne Røttingen's Story
Listen to John-Arne Røttingen's Story
I originally trained as a physician in Norway. Currently, I am a visiting professor at the Harvard School of Public Health in the Department of Global Health and Population. Before this, I was the chief executive of the Norwegian Knowledge Center for the Health Services, which is the National Health Services research institute with responsibilities within quality of care and evidence informed policy and practice. Since I finished my first medical training, my work has focused primarily on health research and policy issues, except for rural medical services in northern Norway.
My main interest has been how to make decision-making in health care more evidence-based, more rigorous, and more transparent from the clinical to the policy level. On the clinical side, this is called evidence-informed medicine, but on the policy side the process is more complex because you have to balance different stakeholders’ views in addition to research evidence.
So within global health, I have had two major interests. One is how to improve health systems and policymaking using solid health systems and health services and systems research. The other is how to achieve access to affordable medicines and other health technologies in developing countries and whether we have a global innovation system which secures this.
If I really think back to my days as a medical student, I would suggest the World Development Report in 1993, issued by the World Bank. This was in some ways the first big report on health from the World Bank. Although it is a bit old today, this report more or less set the stage for the global burden of disease studies. I think it is a great starting point to understand what we are talking about when it comes to global challenges.
I would also recommend the early works of Professor John Lavis at McMaster University. I have been interested in how to improve evidence-use in policy making, and some of his papers from 2004 and onwards were very useful from my perspective. In addition, Dean Frenk at HSPH is among our most creative conceptual thinkers within global health. Ideas need to be conceptualized to be understood and acted on, and he has contributed in many different ways to the discourse on global health.
I have a bit of an untraditional history and career path. I decided to study medicine partially because I was interested in combining a solid academic field with the potential for doing research, but also because I wanted to help people and connect with them. I started doing basic science research during my medical studies, and ended up creating an M.D./Ph.D. program for myself (which I later got the opportunity to formalize as a program within the university). I did my residency, my clinical qualifications, and finalized by Ph.D. in Norway. But during my years as a medical student, I became more and more interested in global and societal issues than the kind of the cellular signaling issues that my Ph.D. was on. So I started an interest group among some core faculty members and students that focused on the impact of big global and environmental challenges in health. We called it the Patient Earth.
Then I went to the University of Oxford, where I really formally shifted my career path from becoming a basic science medical researcher to a global health researcher. At Oxford, I received a degree in infectious disease epidemiology, and global health. Afterwards, I returned to Norway and did a post-doc, which combined health services and global health research. I was appointed an associate professor at the University of Oslo, where I set up a formal M.D./Ph.D. program that medical students could choose to enroll in.
I didn’t see myself becoming solely a university professor for thirty more odd years, so I decided to quit and planned to go into clinical work. At that time, however, I received an offer to work on a project to merge three Norwegian health services research institutes into one bigger, national body. I enjoyed the leadership challenges and the process of forming an organization, so I applied for the chief executive position there. I headed that organization, the Norwegian Knowledge Centre for Health Services, for 8 years, where I combined management, leadership, research, and more active policy work both in Norway and globally.
After 8 years I felt like I wanted to move on. We had established a collaboration between the Harvard School of Public Health and the Norwegian Knowledge Centre for Health Services. I discussed with the Dean of HSPH, Julio Frenk, whether there was an opportunity for me to come and be part of the work on policy translation from Harvard, which there was. At this time, I also realized I wanted to have a better background in the social sciences, so I applied for a scholarship to do a mid-career program at the Harvard Kennedy School. I completed this over the last year, focusing on economics, political science, and global issues.
This year, I am a visiting professor in the Department of Global Health and Population at HSPH. I will teach a course with a lawyer, Steve Hoffman, on innovation, access to medicine, and global governance.
I also am involved with the World Health Organization in Geneva. I now chair the board of the Alliance for Health Policy and Systems Research, which focuses on how to support capacity building for and utilize health systems research in developing countries. My other role has been in negotiations surrounding intellectual property and innovations issues related to public health. Recently, I chaired an expert working group for the WHO that develops recommendations regarding financing and coordination for research that is relevant to developing countries.
My days are very different, so it is hard to tell. I guess at this stage, I don’t see myself fully as an academic because I want see research and knowledge applied. But I am not, at least at this point in time, a policymaker. So my main interest is to influence policy processes and discussions on global health issues.
At the WHO, I hope to help improve research capacity building in and for developing countries. I try to bring together different constituencies with this same interest, and we develop academic paper or position papers, and work to improve collaboration and coordination on this topic. But to make things more general, I sit on committees and working groups. So a lot of my time is spent in or preparing for meetings or negotiations between member states of the WHO.
My work in the policy arena includes a mix of people with different backgrounds. I think that is both useful and important. I work with other medical doctors, public health professions, and biostatisticians. But then I work with a lot of economists, political scientists, and people with social science backgrounds. So it really is a multidisciplinary group, which I find very rewarding and useful because everyone brings different perspectives to the table. And I’ve learned a lot from collaborating with lawyers and economists.
I made a career shift when I went to study at Oxford. While I was there, I realized that there was incoherence between Norway’s heavy investment in health, when it comes to development and global health issues, and their lack of investment in academic or knowledge-based institutions that could support policymaking and the bureaucracy’s work on it. I felt that this made some of policies less rooted in solid evidence and instead dependent on academic work or institutions in other countries. The work of other countries is of course useful, but as Norway has played a strong role in global health for the past 15 years, it was important to support our own research.
So the challenge was to convince policymakers that we needed to create this capacity in the long-term. It is not something you can do overnight. It was partly a challenge to work with bureaucrats – to get that message across to politicians because the Norwegian Research Council and the primary funders of research in Norway did not prioritize global health. We succeeded though. Between 2001-2005, we managed to get support to build a larger program on global health research in the Norwegian Research Council and to create a unit to support the Norwegian Directorate for Development in academic and research evidence work.
I really like to be out in nature, sea kayaking, running, cross country skiing or hiking in the mountains. I just came back from an awesome trip to the national parks out west in the US, which was amazing.
There are many ways into global health, so it depends on what interests students have. Do they want to work in developing countries or become involved on the international level? Those are the two main options, but it is useful to have both experiences. If you have the opportunity to work on the ground on projects in countries, I think that is a good starting point. Then for more global policy work, academia is another option as a starting point.
I do think it is important to have a base in a country. You need some sort of footing, a jumping off point for making contributions to international organizations. Here in the U.S., that could be through the Department of Health and Human Services or USAID, or the non-profit sector, which is about advocacy, coalition building, and influencing policy processes.
So my advice is really to follow your interests, and based on your experiences and expertise, to find your way in.
There are many ways to have an impact on global health. My thinking is that I would like to see countries take responsibility for their own challenges and problems. I think the most important thing we can do on an international level is to facilitate that and foster an international system to support it. I am less of a believer in long-term development aid, or western NGOs or non-profits going in to actually deliver health services in developing countries. It is definitely necessary in many settings due to the large gaps in health outcomes, but it is a quick fix that ultimately isn’t sustainable.
So I’ve decided instead of focusing on on-the-ground work, that I am really more interested in long-term policy and systems issues. At the same time, those are harder, of course, and more difficult to see results with. You kind of feel like you go two steps ahead, and then one back, and even sometimes maybe three steps back. It is a different way of working, but I think in global health you need these varied approaches. You need on-the-ground interventions, but these should be aligned and hopefully integrated into national or local health systems for the biggest impact.