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supplement presents seven case stu-dies of successful health biotechnologysectors in developing countries, each at

a different stage of economic developmentwhen compared with industrially advancednations. Each case study is structured to detaila country’s health biotechnology sector’sstrengths, defining characteristics (govern-ment, research institutes and universities,industry, public perception), challenges todevelopment and conclusions concerning thefactors important for success. As far as we areaware, this is the first time such a side-by-sidecomparison has been made on healthbiotechnology innovation in developingcountries. By analyzing each country’s bio-technology sector in this manner, we haveidentified several factors that appear toencourage successful development and sev-eral common challenges that countries sharein continuing and sustaining development ofhealthcare biotechnology.

Characteristics that define a successfulbiotech sectorAlthough the seven countries studied were atdifferent stages of economic development andhad companies of varying degrees of matu-rity, several factors emerged from our analysisthat appear key to the establishment of a suc-cessful health biotechnology sector.

Focus on local health needs. Despite lim-ited resources the countries studied havefound ways to use biotechnology to meetlocal health needs, even for the poor. Forexample, South Africa is responding to the

HIV/AIDS pandemic by prioritizing researchon the disease; it is promoting the develop-ment of a vaccine against HIV sub-type C, the strain mostprevalent in that country(as well as in the restof Africa and Asia).Egypt, in the face of an acuteinsulin shortage,has emphasizedthe developmentof affordablerecombinant insulinto reduce its depend-ence on expensive imports.It now has a 2-year supply ofinsulin in storage. Cuba responded to an meningitis outbreak caused by meningococciserotype B by successfully developing theworld’s first and only meningitis B vaccine.Indian biotechnology companies now pro-duce hepatitis B vaccine at a much lower costthan developed countries. They sell the vac-cine within India and to the United NationsChildren Foundation (New York).

Furthermore, preliminary analysis of scien-tometric data1 suggests that some of the sevencase study countries publish predominantlyin scientific fields relevant to the health prob-lems within their own countries. Brazil, forexample, publishes heavily on tropical medi-cine, based on research on tropical diseases,such as Chagas disease, that affect many of itscitizens. South Africa publishes extensively onvirology, including HIV/AIDS1.

This focus on local health needs countersthe commonly held belief2,3 that health

research in developing countries isoriented toward the prob-

lems of developed coun-tries that have richer

markets rather thantoward indigenoushealth problems.Supporting localhealth biotech-nology endeavors

is a promising wayto encourage the

development of healthproducts for developing

countries.Success is expressed in many ways. There

is no one-size-fits-all solution. In fact thereare many different ways of succeeding inhealth biotechnology. We see success in thedevelopment of leading-edge innovations,such as the case of the meningitis B vaccinein Cuba, but most countries have found suc-cess in licensing preexisting technology, aswas the case for recombinant insulin devel-opment in Egypt. The Cuban vaccine projectwas so effective that the rate of meningitisinfection in the country is much lower thanit was before the outbreak of the disease inthe late 1970s. In Egypt, a capacity to locallyproduce recombinant insulin allows thecountry to address diabetes locally and meethealth needs of their population. Withincreasing geopolitical uncertainties in someregions of the world, self-sufficiency in

Conclusions: promoting biotechnologyinnovation in developing countriesHalla Thorsteinsdóttir, Uyen Quach, Abdallah S Daar & Peter A Singer

Halla Thorsteinsdóttir is Assistant Professor, Canadian Program on Genomics and Global Health, University of Toronto Joint Centre for Bioethics and Dept. of PublicHealth Sciences, 88 College Street, Toronto, Ontario M5G 1L4 Canada; Uyen Quach is Research Assistant, Canadian Program on Genomics and Global Health,University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, Ontario M5G 1L4 Canada; Abdallah S. Daar is Director of Ethics and Policy, McLaughlinCentre for Molecular Medicine; Professor of Public Health Sciences and of Surgery, University of Toronto; and Co-director Canadian Program on Genomics and GlobalHealth, University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, Ontario M5G 1L4, Canada; and Peter A. Singer is Sun Life Financial Chair andDirector, University of Toronto Joint Centre for Bioethics; Professor of Medicine, University of Toronto; and Co-director Canadian Program on Genomics and GlobalHealth, 88 College Street, Toronto, Ontario M5G 1L4 Canada. e-mail: halla.thorsteinsdottir@utoronto.ca

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providing health products has becomeimportant to many countries.

In India, the patenting laws haveencouraged the country’s biotechnolo-gists to invent around existing patentsand to come up with processes thatreduce production costs. Lower pricesfor biotechnology health products is a measure of Indian success, for its population cannot afford the cost ofimported products from the developedworld.

Another measure of success is alsothe expansion of knowledge creation inbasic scientific research, which plays alarge role in health biotechnology andfrom which many applied research dis-coveries arise serendipitously. BothSouth Korea and China have increasedtheir level of publishing in healthbiotechnology remarkably during thepast decade. From 1991 to 1993, SouthKorea was in 25th position in the world interms of the number of papers published onhealth biotechnology in international peer-reviewed journals. By 2000–2002, it hadreached 12th position, moving ahead of coun-tries like Switzerland. China started in 22nd

place in the 1991–1993 period, but reached14th position by 2000–2002. Significantly,South Africa and Brazil published the resultsof their research in journals with relativelyhigh impact factors, compared with othercountries in our study.

Because success is demonstrated in suchdiverse ways, rank ordering the countries interms of their success is not feasible. Fur-thermore, because health biotechnology isrelatively risky, there is no guarantee thatthese countries will be able to sustain theirsuccesses and get both health and economicbenefits in the long run. Continued successwill depend on many factors, including howwell the innovation systems develop andfunction. What is clear is that countries withstrong scientific foundations are well placedto succeed, but economic benefits will likelybe linked to how well they can engage andsustain private sector growth and commer-cialize scientific discoveries as products.

Build on educational and health systems.This study points to the importance of goodbasic education and health systems as build-ing blocks for health biotechnology develop-ment. All the countries in this study haverelatively good schools, at least for a subset oftheir citizens. Good education has enabledtheir experts to understand the potential ofbiotechnology and seize new opportunitiesoffered by the technology at the same timethat their policy makers, business people and

the general public have recognized the impor-tance of biotechnology and have supportedits development.

In Figure 1, the education enrollment ra-tios and education indices are presented forall the countries in this study. The enrollmentratios for all the countries, except for India,are higher than the 60% that is the average fordeveloping countries. Furthermore, the en-rollment ratio of all countries in this study,except for India and China, is higher than the70% average for middle-income countries.India and China have a large number of verywell educated people, but because of the sheersize of their populations, they have not beenable to reach the education averages of mid-dle-income countries. The education indicesof the countries under study are also veryhigh; only Egypt and India lag somewhatbehind the other countries. The fact that thefemale literacy rate in both countries has notreached 50% reduces their education indices.

A well-functioning health system is also

important for health biotechnologydevelopment. Through their linkageswith the health system, researchersdevelop innovative ideas for solutionsto problems and use the health systemsfor testing, clinical trials and the com-mercialization of the end products.This is illustrated well in the case ofCuba, where the health system is notjust a beneficiary of innovation in thisfield but also a great contributor toinnovation.

Table 1 shows the proportion of thepopulation with access to affordableessential drugs. South Korea and Cubahave access to drugs comparable tothat in the developed world. In all ofthe other countries, except for Braziland India, access to medication is reasonable, indicating that health biotechnology development is notnecessarily stifled by the poor access

of a country’s population to medicine. Thecontributing impact of the health systems onhealth biotechnology innovation fits wellwith the innovation systems framework,where information flow between users andproducers of new technology is importantfor innovation.

How to promote health biotechnology indeveloping countries?In Table 2 we list the main lessons from eachcountry’s case study. In this section, we sum-marize the six core lessons that emerged fromour case studies and discuss their applicabilityto other developing countries.

Political will. All the case studies stress theimportance of political will for promotinghealth biotechnology innovation in develop-ing countries. The governments of most ofthe seven countries started to pay attention tobiotechnology in the 1980s (that is, quite earlyin the development of the field) and havecontinued to support its development. India,for example, emphasized health biotechnol-ogy in its sixth five year plan, 1980–1987, as atool to tackle India’s underdevelopment andto improve the health of its population.Health biotechnology is a science-intensivefield requiring considerable investments oftime and money before it is likely to generatebenefits. Long-term support and policycoherence is therefore essential for promotingthe field. In the cases we examined, a strongpolitical agenda for health biotechnology wasmanifest in several ways.

Governments have developed specific policies for the development of the field,and these were generally well articulated,publicized and executed. An example includes

Education indexEnrollment ratio

0.0

0.2

0.4

0.6

0.8

1.0

SouthKorea

SouthAfrica

IndiaEgyptCubaChinaBrazil

Figure 1 Education enrollment ratios and education indices for countries in this study. The Enrollment Ratio refers to thecombined primary, secondary and tertiary enrollment ratio; 1 refers to 100 per cent enrollment. Data is for the 2001–2002school year. Source ref. 10.

Table 1 Access to essential drugs ofpopulations in seven countries in thisstudy

Country Percentage of populationwith access

Brazil 0–49

India 0–49

China 80–94

Egypt 80–94

South Africa 80–94

Cuba 95–100

South Korea 95–100

Source: Ref. 10

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Egypt’s National Strategy for GeneticEngineering and Biotechnology, which out-lined short and long-term goals with specificdisease targets and technologies to improvethe health of its citizens.

Far-sighted politicians have also providedfunding and recognized the importance ofresearch. A good example is the establishmentof the South African AIDS Vaccine Initiativeby the South African Medical ResearchCouncil (Tygerberg, South Africa), supportedwith funding from several ministries.

Governments in this study have also foundways of responding to the ongoing challengeof brain drain. In China, for example, sincethe late 1990s the authorities have made con-certed efforts to encourage expatriate profes-sionals to return. Incentives include theprovision of funding for the establishment oflaboratories in China and schemes to enablereturning scientists to establish firms.

Politicians have also encouraged the dev-elopment of healthcare biotechnology by providing biotechnology enterprises withincentives to overcome problematic economicconditions. For example, Brazilian authoritiesdealt with high inflation rates and Cubanauthorities revised foreign investment laws. Infact, political will and a strong governmentrole have been essential for all countries withstrengths in biotechnology. For example, theUS government has played an important rolein almost every stage of its biotechnologyindustry’s development and federal supportfor biomedical research continues to increase4.

The political will to promote healthbiotechnology emerged for different reasons,depending on the country. In South Africaand Cuba, geopolitical conditions played animportant role. In South Africa, the healthbiotechnology sector owes some of its successto decisions made during the apartheid years. The isolation of the country over a longperiod provided impetus for self-sufficiencyand the development of its own researchcapacity to address its needs. The sameapplies to Cuba. The long-standing US tradeembargo has pushed the small country todevelop its health solutions locally.

Individual leadership. A common theme in the case studies on health biotechnologydevelopment is that a few individuals haveplayed important leadership roles and havebeen instrumental in setting health biotech-nology development in motion for theircountries. These individuals have not beenconfined to government positions; they havecome from the universities, public researchsystem or the business sector.

These individuals are people with visionwho understand the potential of the technol-ogy early on in its development. They showingenuity and determination to overcome thechallenges that inevitably arise in promoting anew technology development of this sort.They work tirelessly and relentlessly to set upconditions and align the necessary factors topromote health biotechnology innovation.

Define niche areas. Several of the countriesin this study have focused their efforts on

particular niche areas in health biotechnol-ogy. Preventive vaccines have been one ofthose niche areas. These are particularlyattractive because in several cases recombi-nant vaccines are available where the technol-ogy for producing them is relatively simpleand can easily be reproduced (see Box 1). Ingeneral, they are a much more efficient andcost-effective way of dealing with infectiousdiseases than drugs, and they can providelong-term immunity. They are very relevantto the health agenda of most developingcountries with large, poor populations. SouthAfrica, for example, is focusing on vaccinedevelopment for diseases such as hepatitis Band C and HIV/AIDS.

Some of the countries in this study havealso identified areas that leverage some spe-cific technological strength or other resourcesthey possess. South Korea has stressedmicroarrays/biochips and bioinformatics toexploit its competitive advantage and localknow-how in information and communica-tion technologies. India also has been able to capitalize on its large pool of well-trainedEnglish-speaking science and technicalexperts, as well as its relatively cheaper costsin R&D. The Egyptian Agricultural GeneticEngineering Research Institute’s previoussuccesses in agricultural biotechnology areproviding the country with a platform forpossibly developing a plant-made hepatitis Bvaccine. Some of the other countries, such asSouth Africa and Brazil, are using theirindigenous knowledge and biodiversity todevelop innovative products.

Defining niche areas and relying on somesort of competitive advantage in these areasare lessons that are generally applicable to all developing countries. Because of theirlimited resources for technological develop-ment, it is important that developing nationsprioritize specific areas and rely on theirexisting strengths for health biotechnologydevelopment.

Close linkages. The case studies have con-firmed what the innovation system literatureemphasizes5–7, namely that close linkages andactive knowledge flows are essential for inno-vation to take place. By encouraging collabo-rations and resource sharing among differentinstitutions in its innovation system, Cuba hasbeen able to succeed in health biotechnology,despite its very limited financial resources.Some of the case studies noted that lack ofcollaboration and linkages among healthbiotechnology institutions restrained innova-tion efforts. In China, lack of collaborationprevented its scientists from being the first inthe world to sequence the severe acquired respiratory syndrome (SARS) virus. Lack of

Table 2 Lessons learned from case studies in this supplement

Brazil

• Focus on developing a strong science capacity

• Promote linkages and exploit existing strengths in disparate fields

• Exploit local biodiversity for health

• Gain access to key actors

China

• Provide long-term government support

• Attract expatriate professionals

• Ensure that biotechnology development goes hand-in-hand with regulation

• Leverage large population base

Cuba

• Ensure long-term governmental vision and policy coherence

• Promote domestic integration to spur innovation

• Capitalize on international linkages

• Tap into national pride

Egypt

• Focus on health needs

• Gain access to key actors

• Take advantage of international linkages

India

• Leverage strengths when cultivating linkages

• Meet international standards

• Use competitive advantage

• Pay attention to the regulatory environment

South Africa

• Focus government policy on public health needs

• Exploit both indigenous knowledge and science-based innovations

• Develop local R&D infrastructure for self-reliance

South Korea

• Create a mix of small and large firms

• Exploit existing competitive advantages

• Go global

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linkages, especially between universities andindustry, has also slowed innovation efforts inBrazil and Egypt. Those countries have suc-ceeded more because of strong individualswho played pioneering roles in their healthbiotechnology development. Although contri-butions of ‘champion’ individuals can neverbe downplayed, in the long run a systemicapproach is likely to be more sustainable.

Several of the countries here have em-barked on an active policy of encouragingcloser collaborations. Promoting clusters inhealth biotechnology has become a standardpolicy, and most of the countries in this studyhave initiated cluster development of somesort. Examples include South Korea’s DaedukScience Town, India’s Genome Valley, Cuba’sWest Havana Scientific Pole and Egypt’sMubarak City for Scientific Research andTechnology Applications. A general lesson fordeveloping countries to draw from this workis to encourage close linkages of research,business, policy, health institutions and otheractors in the field and to ensure an activeknowledge flow among them.

Enterprise creation. We found that privatefirms were essential for integrating varioussources of knowledge in health biotechnologyand turning them into products and services.However, the countries differed in terms ofhow far they were able to build up private sec-tor involvement. A shortage of financingmechanisms and resources for fosteringstartup creation and sustainability is a com-mon problem.

South Korea is undoubtedly furthestadvanced. A policy encouraging technologytransfer and a change in policy that alloweduniversity professors to set up private firms or spin-off companies have contributed to promoting private sector involvement. Smalland medium-sized companies dominate the

industrial scene in health biotechnology, butare complemented by large conglomerates,the so-called chaebol firms, which are impor-tant providers of marketing networks and re-sources for the smaller companies.

A central aspect of China’s new innovationsystem policy has been to promote the forma-tion of enterprises. In health biotechnology,the Chinese have converted some existingresearch institutions into companies thatmanufacture medicine. Also former employ-

ees of public research institutes and Chineseprofessionals who have returned from abroadhave set up small firms that are becoming anew force in the health biotechnology sector.Even in socialist Cuba, commercial entities,although not in private ownership, are sellingCuban health products to numerous coun-tries and making agreements with foreignfirms to develop and market Cuban vaccines.

Government policies have therefore playeddiverse roles in encouraging private sectordevelopment in this field. The venture capitalsectors in the countries we have studied has sofar made limited investments in healthbiotechnology development. In most cases,the venture capital sectors are almost nonex-istent or immature. South Korea has the mostadvanced venture capital sector of all thecountries we examined and it has become one of the main sources of biotechnology

financing in the country. It started with theliberalization of South Korea’s financial markets from the mid 1990s and strength-ened extensively after the 1997 financial crisis.Some governments have placed an emphasison encouraging venture capital development.This is the case both in China and in India. InIndia, venture capital for biotechnology isemerging from various sources, includingstate governments, insurance companies andbanking institutions. This, in turn, is helpingto encourage foreign investors.

Developing countries that have not yetembarked on health biotechnology shouldconsider the role of the private sector andidentify promising ways to encourage itsdevelopment. This fits well with currentefforts highlighting the role of the private sec-tor in promoting sustainable developmentand given prominence in a recent report bythe UN Commission on the Private Sectorand Development8.

Intellectual property. Patent legislation hasplayed an influential role for private sectordevelopment in health biotechnology. All ofthe countries in this study started their healthbiotechnology development under lenientpatenting environments, which offered themopportunities for reverse engineering ofpreexisting technologies and brand productsand the creation of low-cost generic products.Indian patent laws in the past only allowedprocess patenting for pharmaceutical prod-ucts. This nurtured a strong pharmaceuticalindustry with strong capacities in bulk andgeneric manufacturing and cost-effectiveprocess innovations.

With increased maturity, however, Indiaand other countries must now be ready toventure into more research-intensive andcostly innovative product development intandem with the adoption of more stringentpatenting systems. With accession to theWorld Trade Organisation’s (Geneva) Agree-ment on Trade-Related Aspects of IntellectualProperty Rights (TRIPS), countries that havenot built innovative capacity in the healthbiotechnology field may find it harder toachieve success. They will, for example, find it difficult to export reverse-engineered healthbiotechnology products to countries thathave patents protecting these products.Encouraging commercialization and a well-developed private sector is an important wayto address this challenge.

The bottom line: seize the opportunityThe lessons described above are critical forfostering the development of a successfulhealth biotechnology sector in the sevencountries studied. They provide a strong

Box 1 Hepatitis B vaccine. A promising start?

Effective and safe recombinant hepatitis B vaccines have been available since 1982.However, despite efforts to incorporate them into national immunization programs around the world, cost has been a significant problem for many of the lower incomecountries. This situation is rapidly changing today with numerous countries, including ones considered middle-to-low income, locally developing and producing the vaccine andeffectively reducing the price for the treatment. However, by targeting this technology,there have been more benefits beyond simply achieving affordability.

The recombinant hepatitis-B surface-antigen vaccine was one of the first biotechnologyproducts generated by the majority of the countries in our study. The benefits for targetingthe development of a hepatitis B vaccine include the relative ease in mastering thetechnology, the relevance to local health problems, and as several of these countries havealready demonstrated, the large domestic and international market potential. Moreover,efforts in developing a hepatitis B vaccine have provided technological knowledge thatthese countries can use for various innovations.

Government policies have therefore played diverse

roles in encouraging private sector development

in this field.

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message that developing countries can suc-cessfully build capacity in health biotechnol-ogy to both increase the availability of healthproducts for their populations and provideopportunities for their economic develop-ment. The case studies offer a variety ofexamples that other developing countries candraw upon to enter the health biotechnologyfield. The information should be of value togovernments and other actors in developingcountries, policy makers in major interna-tional donor organizations and bilateral aidagencies, the business and scientific commu-nity in developed and developing countries,and the general public around the world.Developing countries can actively harness thepotential of health biotechnology to improvethe health of their peoples and thereby reduceglobal health inequities9. To fully realize thepotential benefits of this new science, how-ever, will require concerted and sustainedeffort and ingenuity over many years.

ACKNOWLEDGMENTSPublication of this supplement was supported by theBill and Melinda Gates Foundation (Seattle, WA),

Genome Canada (Ottawa, Canada), McLaughlinCentre for Molecular Medicine (Toronto, Canada)and the Rockefeller Foundation (New York, NY).Special thanks to Archana Bhatt, Zoe Costa-vonAesch and James Renihan for patent analysis, ÉricArchambault, Frédéric Bertrand and Grégoire Côté at Science-Metrix (Montréal, Canada) for analysis of publication data and to Joanna Chataway of theInternational Development Centre of the OpenUniversity (UK), Paul Dufour of the InternationalDevelopment Research Centre, Meric Gertler of theProgram on Globalization and Regional InnovationSystems, and Victor Konde of the United NationsConference on Trade and Development for theirvaluable contributions. The Canadian Program onGenomics and Global Health is primarily supportedby Genome Canada through the Ontario GenomicsInstitute and by the Ontario Research andDevelopment Challenge Fund. Funding partners are listed at http://www.geneticsethics.net. A.S.D. issupported by the McLaughlin Centre for MolecularMedicine, University of Toronto. P.A.S. is supportedby a Canadian Institutes of Health ResearchDistinguished Investigator award. The authors declare that they have no competing interests.

1. Science-Metrix. Benchmarking of Genomics and HealthBiotechnology in Seven Developing Countries, 1991–2004. Report Prepared for University of Toronto, JointCentre for Bioethics (Science-Metrix, Quebec, 2004).Data derived from information (subset of ScienceCitation Index Expanded Database) Prepared by the

Institute for Scientific Information (ISI, Philadelphia,PA, USA).

2. The Health Commission on Health Research forDevelopment. Health Research: Essential Link toEquity and Development. (Oxford University Press,Oxford, 1990).

3. World Health Organisation. Ad Hoc Committee onHealth Research Relating to Future InterventionOptions. Investing in Health Research and Devel-opment. (Document TDR/Gen/96.1). (World HealthOrganisation, Geneva, 1996).

4. Cortright, J. & Mayer, H. Signs of Life: The Growth ofBiotechnology Centers in the United States (TheBrookings Institution Center on Urban and Metro-politan Policy, Washington, DC, 2002).

5. Lundvall, B. A. (ed.) National Systems of Innovation:Towards a Theory of Innovation and InteractiveLearning. (Pinter, London, 1992).

6. Nelson, R. R. (ed.) National Systems of Innovation: AComparative Study. (Oxford University Press, Oxford,1993)

7. Edquist, C. (ed.) Systems of Innovation: Technologies,Institutions, and Organizations. (Pinter Publishers,London, UK, 1997).

8. Commission on the Private Sector and Development.Unleashing Entrepreneurship: Making Business Workfor the Poor. Report to the Secretary-General of the United Nations (United Nations DevelopmentProgram, New York, 2004). http://www.undp.org/cpsd/fullreport.pdf.

9. Daar, A.S. et al. Nat. Genet. 32, 229–232 (2002).10. United Nations Development Program. Human Dev-

elopment Report 2004: Cultural Liberty in Today’sDiverse World (United Nations Development Program,Geneva, 2004). http://hdr.undp.org/reports/global/2004/

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