Strategies for health research development in WHO South-East Asia Region (Draft)

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 26 th Session of WHO South-East Asia Advisory Committee on Health Research 17-20 April 2001, Thimphu, Bhutan SEA/ACHR/26/6 Agenda Item 3.2 9 April 2001 STRATEGIES FOR HEALTH RESEARCH DEVELOPMENT IN WHO SOUTH-EAST ASIA REGION (DRAFT) Health Research Strategies of the South-East Asia Region were drawn up in 1993, as per guidance from SEA-ACHR. Due to new opportunities and challenges that are emerging in the 21st century, it is crucial that regional health research strategies are to be reviewed, and revisions to be made to support the concerted efforts for reforms in health sector. Keeping in view developments in international and national health research systems, Regional Director constituted an expert group, which met in WHO-SEARO from 29-31 March 2001, to review and update the regional health research strategies. The expert group made this draft paper - “Strategic Framework for Health Research Development in WHO South-East Asia Region”, which is now placed for consideration by 26 th session of SEA- ACHR, in April 2001. Taking into accounts of the observations, comments, guidance and recommendations made by 26ACHR, the expert group will review and revise the draft, into a final strategy document, by July 2001. The final “Regional Health Research Strategy” paper will be submitted to the 54 th session of WHO Regional Committee for South-East Asia to be held at Yangon in September 2001, for its review and endorsement. WHO Regional Office, in collaboration with ACHR, national health research councils and institutions will implement activities within this strategic framework, and an evaluation will be done after two years, in 2004. Contents Page 1. Introduction .................................................................................................... 1 2. Objective ........................................................................................................ 2 3. National health research system ....................................................................... 2 3.1 Role and function of health research system............................................... 2 3.2 National health research system architecture .............................................. 4 3.3 Some characteristics of health research systems ......................................... 6 3.4 The functions of the health research system............................................... 8 4. Key challenges in health research development ................................................. 9 4.1 The health research value.......................................................................... 9 4.2 Research environment............................................................................. 10 4.3 Sustainable Health Research System ........................................................ 12 4.4 Knowledge production and application...................................................... 14 5. Strategies for health research development..................................................... 14 5.1 Knowledge.............................................................................................. 14 5.2 National health research system............................................................... 16 5.3 Research capacity ................................................................................... 17 5.4 Support to health research systems.......................................................... 21 5.5 Governance ............................................................................................ 24 6. From strategies to actions.............................................................................. 25 6.1 Situation analysis .................................................................................... 25 6.2 The framework and tools......................................................................... 26 6.3 Regional partnership and the WHO roles .................................................. 26 Bibliography......................................................................................................... 29 1. Introduction The World Health Organization (WHO) from its inception has recognized the vital role played by health research in health development. The Constitution of WHO includes, as one of its functions, the promotion and conduct of research in the field of health. At various Governing Bodies’ meetings and other forums, WHO has repeatedly stated that all national and international health policies should be based on valid scientific evidence, that such evidence requires health research, and that research has significant potential in promoting health and a vital role in improving health through applications or solutions that are already available and through generation of knowledge for the development of new solutions. WHO promotes health research through developing its own health research strategies, that influence, and are in turn influenced, in an interactive manner by national health research strategies in support of specific country needs. Since the development of the "Health Research Strategies of the South- East Asia Region" in 1993, there have been a number of unprecedented changes in health and health research development. These are exemplified by the socioeconomic and political changes around the world, including the rapid economic growth followed by crisis in Asia, massive population movement within and between countries, natural disasters and other human-made calamities, globalization and trade liberalization, rapid advancement of information technology and biotechnology, etc. Unprecedented changes also occur in health development area. Most notably have been the rapid spreads of health problems across national boundaries such as HIV/AIDS, drug- resistant malaria and tuberculosis, highlighting the vulnerability of nations. Development and use of new drugs and vaccines and the scientific breakthrough of the genomes sequencing, introduction of new health system performance indicators and variety of health care reforms have occurred at a rapid pace and are beyond expectations. WHO nowadays becomes one of the many actors in international health, especially in relation to development of health research. In addition to WHO, other UN Agencies and numerous bilateral, multilateral and international agencies, foundations and financial institutions including the World Bank, the international NGOs and alliances such as the Council for Health Research and Development (COHRED), the Global Forum for Health Research, the Rockefeller Foundations and the Alliances for Policies and Systems Research, are becoming major players in health and health research field. This multitude of active players is possibly causing confusions, fragmentation, redundancy and gaps of efforts to improve health of the countries. New global public and private partnerships such as the Bill and Melinda Gates Foundation and the stronger involvement of multinational pharmaceutical industries in the neglected areas of health research have offered new opportunities for international cooperation to promote health through health research. These changes coupled with the continuing health disparities in a globalized world and the continuing deaths and avoidable burden of diseases from preventable health conditions among the countries, especially the developing world, prompted many agencies to review and revise their strategic plans. WHO has endorsed new Corporate Strategies in 1999 in order to address such 1 profound rapid global changes. WHO are also working with its Members to review and update their national health development strategies in order to guide their own reform processes. In the light of these developments, it is appropriate to review and revise the strategies for health research development in the South-East Asia Region, in order to optimally support the countries to cope with their health problems through research. 2. Objective The present document aimed to provide a “Strategic Framework for Health Research Development in WHO South-East Asia Region”, over a medium term period. It is mainly intended for countries of the Region and WHO-SEARO, in order to review and plan their health research development efforts. Such review and planning on health research development will allow the countries and SEARO to jointly develop mechanisms for partnerships between WHO and countries, and thus strengthening the responsiveness of health research in solving health problems in the light of rapid changes affecting health. It is aimed that the document will serve as a generic framework to generate understanding and to encourage a broader debate leading towards an effective health research support for improving health system performance. It might also help countries beyond the Region to use this document as the guidelines for improving their health research systems. The document describes the role, functions and architecture of health research systems, as they now exist in countries or as they should be in ideal situation and also suggests ways and means of improvement. It highlights the development and strengthening of national health research systems, as key strategy to health research development in the South-East Asia Region. 3. National health research system 3.1 Role and function of health research system 3.1.1 General role: It is in general assumed that the purpose of a health system is to improve equity, quality and efficiency of health. Health-for-all (HFA) movement is to support the principle of health quality, equity and social justice. Other purposes include fairness (e.g. fairness in financing and responsiveness as parts of health system performance) (WHR2000), investment for development (World Bank 1993), and health services as commercial products (e.g. private sector care and technology as a product). 2 There is still continuingly debating on the meaning and clarity of these words. The understanding of the word “equity” might differ depending on the ideology that lies behind. Whatever it may, equity is a desirable value regardless of how it is defined. Equity in health may not directly be achieved by health research alone. Promoting equity is more of a function of health systems and its interaction with national development. The overall socioeconomic development systems, health systems, sciences and technology systems, all operate at the national and international levels in more cohesive and interactive way. Health policy, planning and service delivery are the management instruments to operationalize the values and principles of health and other systems. Health research can affect equity by producing and applying knowledge that support the health policy, planning, service delivery, and policy instruments related to equity. 3.1.2 Values and principles: Health research systems therefore operate within the context of the national health system as well as within those of the sciences and technology and development systems. Health research has its own values and principles, namely: (a) Generate and validate knowledge and information, (b) Monitor and evaluate policy and ensure that policy gets into practice that are relevant to improve health; (c) Develop new and appropriate technology, and (d) Contribute to development, using sound scientific principles. Due to the multiple players dealing with health research systems, there is a tendency of knowledge, being generated through health research, to be fragmented, redundant. There are gaps in health research, which do not received adequate attention from researchers. There is a strong suggestion that the focus should be made on research generation and management at the country level. This gives rise to the notion of supporting and improving the functioning of national health research system (NIHRS). 3.1.3 Key functions: of a national health research system are to: (a) Coordinate health research; (b) Align health research to national health priorities and needs; (c) Conduct health research to meet the ultimate goals of equity and development according to the values and principles; (d) Ensure that appropriate knowledge produced is efficiently used and linked to policy, planning, service delivery and policy instruments; (e) Create synergy and promote a collaboration and multi-disciplinary linkages; (f) Develop capacity to do and manage health research and related sciences; (g) Develop rules, procedures and standards (ethics, fair partnership, quality around methodology, accountability and transparency); 3 (h) Advocate and be vocal when the broader systems are not reflecting goals, values, and principles originally set up for health system; and, (i) Mobilize resources for research and development. The functions of a health research system at national level as mentioned above apply as much as to those health research systems at the international level. In addition, certain issues pertaining to the international health research systems include the notion of correcting north-south imbalance; country focus (focus of developing countries determining their own research agenda); decentralized decision making; transparency; not self-serving. In other words, research should not be carried out for the sake of research but must be channeled for the sake of improving health and promoting equity and development. 3.2 National health research system architecture 3.2.1 Health research system architecture: refers to the relationship and governance between functional components of agencies and bodies related to health research, within a structure or network of structures to carry out the essential core functions. Countries in the Region are with different stages of development. They also have varying sizes of population as well as different political imperatives. They will need different architecture for their own national health research systems. Occasionally, the architecture or structure exists not by choice. To map whether core functions of a health research system are carried out, one needs to design an ideal group of functions and then map the structures in relation to those ideal functions. It is suggested that the operating principles of Asian Voices 1 agreed by the Asian Forum of Health Research organized in early 2000, could be adapted to guide the development of health research system’s architecture at national, regional and global levels. The principles included: a) political commitment to support equity, b) capacity to set research priority and direct research policy, c) regional agenda setting, and d) regional clearing house and strategies to empower national research communities. Countries having different architectures that operate within different contexts will need to make their own arrangement of the structures to perform the particular functions. While some may be able perform all the functions of the research system through one structure (or even one person), some would have a whole range of structures. There are a few sketchy descriptions of national health research system of countries in the Region . 2 1 A progress report of Regional Consultative Process, Asia, submitted to the International Conference on Health Research for Development, Bangkok, 10-13 October 2000 2 WHO-SEARO, National Mechanisms for Health research Coordination and Management in the countries of South- East Asia Region, 1989; Report of SWG on Formulation of National Health Research Strategies, Jakarta, 1999 and Report of SWG on Management and Coordination of Health Research Activities, Bangkok, 1999 4 WHO may need to update such information on health research system for each country, especially on how national mechanism and linkages for health research work and see whether all the functions are covered. If not, modification of the architecture or structure may be warranted to make improvement of national health research systems. Examples of architecture and mechanism of national and regional health research systems could also be given to demonstrate to other countries, how arrangements of the structure can be carried out to perform the functions. Such analytical documentation on national health research system and their development evolution would be used as reference documents for strengthening health research system. One process at the national level involves the formation of “National Health Research Forum”, which allows a much wider participation and brings people together to discuss issues towards for a unified concept at the national and sub-national levels. 3.2.2 Research networks: Strengthening the linkages and functioning of research networks of institutions and expertise in specific technical areas within a country and across the countries have been the recurring themes in the discussions of ACHR and other WHO Governing Bodies. The experience showed that many networks have not been created and functional at the national or regional levels or even at international level. There may be some important factors missing in linkages for effective and efficient functioning. A few of these factors are (a) lack of sharing information, (b) lack of monitoring and (c) lack of sharing resources. Currently, several networks of intercountry technical collaboration are initiated in variety of technical areas such as essential drugs and vaccines, disease surveillance, nutrition, health policy and health systems research, national health accounts. There is a need to define and summarize the organizations, technical bodies, health research councils, and medical associations, the ASEAN, SAARC, and other intergovernmental bodies and try to identify the collaboration at national, regional and international levels. Such technical cooperation among developing countries can enhance the capacity building. There are many training programmes on health research in the Region that are regional in scope of reasonable quality. These programmes, which can improve through an enhancement of south-to-south collaboration, could easily be documented. WHO needs to establish or strengthen existing regional health research networks. Regional ACHR in addition to its advisory role, played as the coordination mechanism at the regional level, particularly coordination between the development agencies. The Asian Health Research Forum or similar coordination forum at the regional level might be considered. The groundwork for such forum at regional level has already been laid out to use strategies effectively. One possible way for effective networking is to assign these networks with appropriate health research programmes of regional priority and shared the research results at ACHR or regional health research forum platforms. WHO-SEARO could facilitate such processes in collaboration with other development partners. WHO has a vast network of WHO Collaborating Centres and other networks of national centres of 5 expertise, which could be used as part of the regional architecture and research network. The increasing role of WHOCC needs to be defined in this new architecture. Many existing health research networks such as the Action-cum-research Network for Nutrition, Asia Pacific National Health Account Network, Asia Pacific Network of Health Systems and Health Policy Research, ACT-Malaria, Mekong-basin Disease Surveillance, and INCLEN are quite successful. These networks consist of national apex institutions linking each other and they are carrying out the health research on specific subjects of interest such as nutrition, malaria, disease surveillance, national health accounts, clinical epidemiology, representing national and regional priorities. They involved the institutions in the network to set the research priorities, to make joint research protocol and to share the lead role in the conduct and coordination of research. Every two years, they usually have a journal article. WHO continues to facilitate the functioning of such networks in close collaboration with development partners. The importance of existing networks of health research must be recognized and fully supported, as they are valuable for promotion of research at the national and regional levels. 3.3 Some characteristics of health research systems 3.3.1 Different system contexts: Varieties of forms of health research systems already exist in countries of the Region within a certain socioeconomic and political context. Efforts must be directed at strengthening existing systems rather than establishing new systems. It requires an emphasis and importance of these environmental contexts, within which health research system is operating (historical, political, ideological, socioeconomic, cultural, demographic and environmental conditions). An overview of above environmental influences is important to design a “Strategy for health research development” of a particular country. It may be desirable to collate the characteristics and responsibilities of national health research systems of the countries in the Region, and the common issues and challenges could be derived based on the general overview of the individual countries’ contexts. Due to the different contexts within which the countries operate, each would have variable aims and objectives for health research development that will then be translated into appropriate operational strategy and organizational or institutional framework. The purpose of the health research strategy would be to combine different actors into a more cohesive whole. A few questions that would summarize the characteristics of national health research systems are: Who are the players for health research system development? What are the criteria to define the stakeholders, primary or secondary role players? What are their constituents, roles and responsibilities (leadership, referee, a separation of funding from prioritization)? How to deal with people who join the systems with different agenda? How will coordination and intelligent solidarity be 6 established? How will the rules, procedures and governance be established? How will system be evaluated in achieving the aims and goals? 3.3.2 Changing role of health research system: The national and sub- national health research institutions are forming health research networks within a national health research system. Their roles are changing over a period based on different development stages, from those of executing and conducting health research themselves, to the managing and disseminating research and empowering the public with knowledge and also to foster some check and balance mechanism for government policy. For example, the Thailand’s National Health System Research Institute (NHSRI), which is executing research projects in its earlier existence, assumed at later stage the role of research coordination, resource mobilization, results dissemination and facilitator for networking to promote health research based on a long-term policy perspective. Thailand’s NHSRI efforts to empower the public and to engage them in using knowledge in order to influence policy process are under way, e.g. participation of the public in the governance of autonomous hospitals and empowering the policy makers in the health reform initiatives. Knowledge management also entails efforts to create a common understanding between the policy makers and the public about specific issues. The role also depends on the capacity evolved within and around the institutions over the years. 3.3.3 Away from political interference: Independence of interference from the higher administrative level and maintenance of scientific rigor and objectivity are the essential requirements of the national health research system. This will make the research not being used by politicians to advance their political objectives. Research results in some cases might be in agreement or disagreement with the principles, purposes and expected results of the national health development. Too much attachment to the policy makers can be harmful if the research questions are changing along with frequent changes of policy makers, which is common in most developing countries. 3.3.4 Setting priority and long-term strategic plan: National health research system should have its own strategic development plans for health research promotion and development, which are debated and agreed by all stakeholders, including the government. When research results are available by implementing those development plans, they can be shared back with the stakeholders. The process of sharing is a process of empowerment of the stakeholders. Sharing also provides the formative evaluation of the researchers, so that they understand the research questions and implications better. 7 3.3.5 Ways to communicate research results: All researchers have to learn how to communicate research results with the policy makers. For example, research about the feasibility of establishing autonomous hospitals owned by the public was not acceptable to one government, while the next government wanted to support this policy. The research had been carried out despite the disagreement of the government and this really paid off when the results came out and accepted by new government. In some cases, the new government did not accept at all of the research results that they had not a chance to involve with. 3.4 The functions of the health research system In general, the following five core functions could be identified as the essential functions of an ideal health research system. The brief interpretations of these primary functions are highlighted below. 3.4.1 Stewardship: It is the quality leadership in promotion of health research, whose task is to develop strategic vision for health research development, and steer the whole research community in coherent manner, including the oversight function. 3.4.2 Financing: Research funding covers more than supply of money. Appropriate human and financial and other material resources are required to support the long-term health research strategies, including capacity strengthening, which will eventually be cost effective. Long-term investment of national health research system aims at future savings. 3.4.3 Knowledge generation: It has to reflect the health agenda required to improve health and to reduce inequity. There are two kinds of knowledge generation, i.e., (a) knowledge for the purpose of improving health (identification of knowledge gaps relevant to improve health) and (b) knowledge for improving the management of health system (application of knowledge to determine health issues and appraise appropriate interventions that would lead to the greatest improvement in health). Health research should not be too perfect beyond its needs. In the past, research aimed at generation of knowledge to improve health, such as discoveries of vaccines against smallpox or malaria were important. Later, there has been increasing needs for knowledge to manage health care system more effectively. Smallpox vaccine was resulted from biotechnology research. How to bring the vaccine to the people who need them reflects more of the management aspect of research. 8 3.4.4 Utilization and management of knowledge: Health research is not just to generate knowledge, but also to make the knowledge to be useful for health improvement. The results of health research need to be presented in suitable format and translated into policy or action or absorbed into existing knowledge and technology. There is a need to promote an “information culture” that would recognize the importance of producing, sharing and using knowledge. It is also to ensure that health research brings tangible benefits to health status improvement. This implies that the links among health researchers, health care workers, health planners, policy makers and communities. 3.4.5 Capacity development: One key function within health research system is to strengthen its own capacity and capability in health research. Both the demand and supply sides of capacity need to be strengthened. 4. Key challenges in health research development A group of four key challenges for health research development could be identified as follows. The first three challenges, i.e., health research values, research environment and sustainable health research systems are important for the vitality of health research system. The last fourth challenge, knowledge production and its application, is also important, because it deals with the relationship between the health research system, health systems and broader development systems. Specific issues related to each of the challenges are highlighted below. 4.1 The health research value Sustaining the equity and ethics are the main social value for health research. 4.1.1 Equity: in health is the basic value for the health system development and might not be the direct result of a health research system. Equity in health research could be measured by the degree to which funding is allocated to health research on priority health issues and the needs of countries. By that it means how strong national health research system could influence and negotiate for resource funding based upon their own research agenda in a systematic way. The role of health research is not just to support for improvement of equity in health, but also to aim at improvement of health. HIV/AIDS and malaria vaccines are developed to reduce the disease burden as these diseases affect many people of the world. Research and development of HIV/AIDS or Malaria Vaccine is a valid investment. Inequity in health occurs when the vaccines against HIV/AIDS or Malaria are only available for the rich who can afford to use them. It may be noted that the investment in vaccine research is not the issue, but investment in managing the use of the vaccine might have given the problem. Inequity in health research can happen 9 when development agencies put funds in the wrong areas, and thus, miss the opportunity of improving health of the diseases affecting the poor. Some clinical drug trials, including development and testing of new drugs had been carried out in the developing countries, were not related to the priority health issues of those countries. The SEA Region has major proportion of global burden of Tuberculosis. The drugs available for DOTS programme for TB control are off patent, but still expensive to be used on national scale. Even then, if the countries want to produce these drugs, they have to import raw materials from developed countries, and these raw materials are still very expensive. Imbalance of TB drug production is an example of the condition not conducive for equity in health for development. Several efforts are underway to cope with this situation. For example, the Global WHO/TDR programme has a policy to have special grants for scientists or institutions only from least developed countries. Bill & Melinda Gates Foundation has put in USD 60 million for research for TB drugs and vaccines, where institutions in developing countries will be involved. On top of health research contribution to equity in health, there are some others, more difficult aspects of inequity in health research. 4.1.2 Ethics: One challenge in health research is parachuting health research from outside agencies (both from public and private domains with financial and other incentives attached). After the collaborative research was carried out, the capacity of institutions involved has to be fully strengthened. However, in many instances, especially those related to research and development of vaccines and vaccine production, the capacity was not sufficiently strengthened. Therefore, before the start of any collaboration, appropriate agreements on the transfer of technology and strengthening of human resources or other institutional capacity should be in place. The country should then be able to procure the vaccines or produce the vaccines itself at an affordable price, since the country provided field research for test of such vaccine. People who participated in research should be considered an investment. 4.2 Research environment 4.2.1 Inadequate resource: of health research usually in least-developed countries creates a dependency of foreign assistance. These external development agencies usually tend to set their own research agenda and to insist in most cases that the country should participate in donors' driven agenda. Countries should make it a policy not to receive funds with conditionality from the development agencies if the areas of funding do not coincide with the national priorities. At this moment, tuberculosis, HIV/AIDS and malaria receive high priority for global health research. Similar high priority health problems of the Region that required a lot of support by conducting health research, like dengue/dengue fever, kala-azar or snakebites, are not receiving adequate attention for putting more 10 resources. Therefore, a system that allows generation of more resources for health research is desirable. One possible way is to request all countries, which have to agree to take certain percentages on sale of some drugs and vaccines or sale of some harmful items like tobacco or alcohol, and invest the funds accumulated for research. In addition, the operation agencies can put a certain percentage of operation funds for research that could be utilized for the actual research needs of the country. Secondly, countries should have a national priority for research linked to the health systems development investment. Thirdly, a national research capacity strengthening plan should be set up to ensure that adequate human resources is available to carry out different national research priorities set up. In addition, WHO should take the lead in allocation a certain portion of its operational funds for research. 4.2.2 Globalization: entails multiple actors at the country level. One key challenge is to have effective national mechanisms for coordinating external development partners. This can also include coordination to tackle cross-country issues. Recent rapid advances in science and technology, trade liberalization, communication and transport, fluid cross-border movement of population and rapid urbanization, etc., really make the biggest challenges on health research. The challenge is how to anticipate the consequences of new discoveries rather than reacting to the effects, how to assess the ethical, social, cultural and other impacts of new knowledge, and how to ensure widest possible access of such knowledge. Health research system could able to provide answers to determine which of downstream products of the new discoveries are public goods. 4.2.3 Research culture: is lacking especially in the decision-making process for development of the health system and non-health systems related to health. How do we create and improve the research culture? The term "Research Culture" usually makes people frightened and threatened if not expressed well. Rather than talking about research culture in general, research stakeholders should be stimulated to make science and knowledge based decision- making at all levels. Science-based decision-makings have been deficient in many countries, challenging the development of an environment conducive for research. Research environment and research culture are related. Even though the research culture is broader than research environment, research culture can be an outcome of the research environment. Good research environment makes it possible for the actors in the health system to adopt the research culture by demanding evidence in policy processes. The research culture also extends beyond the environment of health research to that of health systems and non-health systems. It includes not only the producers but also the consumers of research such as the health care providers. Research environment focus on institutional environment and the researchers themselves including their career structures. Focusing on research environment is a good entry point to establish a research culture. 11 4.3 Sustainable Health Research System 4.3.1 The relationship between stakeholders (governance): A health research system includes many actors like the government health and health related agencies, the private providers, the industries and the international development agencies. There needs to be some detailed descriptions about the roles and functions of such stakeholders. The description should include issues around who has the authority over what. Who in particular has a control over of financing? Where are the powers located? Some institutions or stakeholders might have formal authorities, but the real powers lie elsewhere (power versus authority). {E.g., the differences of National Research Council and Thai Research Funds in Thailand.} Mapping of the spread and location of function, authority, power and financial control would be one way of mapping the health research system. The idea of using legislative and statutory environment might be explored, if it suits the environment of each country. In some countries, the medical research council was effective partly because of the legislative support. The degree and level of coordination, collaboration and partnerships in health research actually existed, and the environment of trust and solidarity is another issue in addition to the requirement by the law. What level of coordination exists? To what extent there is consensus and element of trust? To what extent there is solidarity? For example, the development of Dengue Vaccine in Thailand requires sustained collaboration between development agencies (WHO at all levels and WHO/TDR), the academic institution (Mahidol University), the Ministry of Public Health, the City Health Authorities, the Commerce and the Pharmaceutical Industries. The academic and research institution develop the research products (prototype vaccines), while the industries transform the prototype vaccine into commercial products. The Joint Initiative of USAID and Indian Medical Research Council in supporting joint research collaboration between private and public institutions for HIV/AIDS vaccine production for India may be another example. The USA and India jointly planned to produce research products and the Indian industries will have to transform these products into mass production through some joint ventures. The sad story of the Rotavirus Vaccines production could be avoided. The vaccine was developed in the US, tested in developing countries of Asia and elsewhere, and the production stopped due to some complications even though there is some potential usefulness for developing countries where the disease is much more prevalent. Partnerships must be promoted to handle other development areas that can affect health such as Genetically Modified Foods, both in agricultural and animal products. Also, the ethics of international collaboration as described in Washington Post and the Lancet needs special consideration (guinea pig and negotiation with weak countries). An important issue involves the level and quality of communication and dialogues that exist among the different constituents within the health research system. 12 4.3.2 Capacity development: It is well known that the lack of research capacity is a major problem of many developing countries. The real challenge is the differential emphasis according to the stages of development of the countries. Therefore, efforts to strengthen capacity should be in line with the differential needs for capacity development. In addition, capacity building for research that helps generate knowledge should be differentiated from the capacities to adapt and apply the existing knowledge. Some countries might need strengthening health research of the former category and others the latter. Therefore, the research capacity must be strengthened according to certain identified areas and priorities. 4.3.3 Financing: of health research is the biggest challenge. Economic crisis in Asia has shown that the amount of government investment in research has reduced. Due to inadequate resource, research has no career structure in most developing countries. In most cases, the decision-makers tend not to use evidence as the basis of decision-making, and also they do not value much on the need to support research. Good governance in health research system can produce a better research environment, such as transparency of priority setting and the allocation of enough funds through competitive processes. 4.3.4 Knowledge management: One key challenge on knowledge management is to encourage health knowledge as a public domain. Oral rehydration treatment including use of scientific formulae for Oral Rehydration Salt (ORS) was developed at the SEATO laboratory in Bangladesh (later known as International Center for Diarrhoeal Diseases Research, Bangladesh) in mid- 1960s. Only 10-15 years later, this technology was widely available to the world for saving millions of lives of people. Another example of delay in making knowledge available to public for some decades was related to ‘Why BCG is not effective for protection to adult tuberculosis?”. Efforts made to classify health knowledge as public domain, would prevent such avoidable large gaps of information made available to public. Innovative methods to digest the materials from research findings of health, biomedical and other sciences for the public and potential users are needed. One approach that has been tried with some successes is to translate the analysis of complicated scientific materials in a “medium” that may be acceptable to users. E.g., in Thailand, the findings of a series of complicated anthropological studies have been translated in the form of short video-plays and storybooks that are easily acceptable for the lay community. The successes prompted medical and nursing schools to use the materials to teach research and ethics. In the knowledge management, advocacy for evidence-based policy has potentially negative political connotation and must be handled with care to build up 13 the research systems towards evidence-based health actions. Some researchers stay away from it. 4.4 Knowledge production and application Some forum or mechanisms or platforms at national or institutional levels should be created to promote and clarify the ideas of health research inputs to the functions of health systems and policies. Also, there are challenges concerning the relationship between research and industries and commerce, including intellectual property right. 5. Strategies for health research development The following strategies are suggested to deal with the challenges. 5.1 Knowledge Knowledge as the output of the national health research system should also include new research findings, information, education, and solutions that knowledge might lend itself to the relevance of problem solving. All these have to impact on desirable outcomes of the health system. Finally, there is a need to align knowledge output of the research system and the values and principles of the broader system and the society. 5.1.2 Management of knowledge as a public good: Generation, validation and use of knowledge as well as the services resulting from the knowledge ought to be in the public domain. Measures must be taken to make the knowledge accessible and appropriately link to permit its effective use. Public and private partnerships have to be enhanced to tackle the problems associated with patent and, as much as possible, to make knowledge as a public good. Finally, some investment is warranted to reduce the digital and other divides which hinders effective accessibility to knowledge as a public domain. 5.1.2 Expanding creativity in research: Promotion of research culture among the producers and users of research should be explored as strategies to increase creativity in knowledge generation and knowledge management and improve research ideas and products. 5.1.3 Databases on health research systems: Efforts should be put into compiling knowledge about health research system and its interaction with the health system. This includes the components of the health research systems, the relationships between the various components, and the effective management of knowledge and its interaction with the health systems. 14 5.1.4 Effective information network and website linkages: Creating an effective information network could enhance effective management and use of knowledge. Effective linkages will permit the use of knowledge. A compendium of various reports related to the national health research system can be made available, including information on country portal or websites for each country. WHO-SEARO can work closely with the country portals. Country portals might be designed to include the government and non-government agencies. The portals can be strengthened to assume more of the knowledge management role. Some mechanism could be established for ensuring the validation of all the documents, which are put in the websites. Existing linkages and network of the Health Literature and Library Information Services (HELLIS) could be expanded. Countries should make the library network of the UN System accessible, not only in abstract forms but also in full documents. The information to be put in the websites can be case studies of successes and failures with linkages to validated pieces of knowledge from the professional sector, folk sectors and popular sector. Some training on information technology management to support knowledge management is warranted. 5.1.5 Exploring the frontiers: An involvement of emerging developments both in scientific and social arena will require efforts to explore new frontiers. Exploration of these frontiers will need new capacity currently lacking in the Region such as research and development in human genetics, including genomes sequencing, the role of law and social empowerment in enhancing health, and reducing disparities among social groups and nations. Despite the needs to explore new frontiers of sciences and social movement, the primary responsibility of research agenda setting belongs to the countries. Some thorny questions about knowledge generation must be addressed. � Does knowledge produced attempt to promote equity? � What kind of research or portfolio of research within the health research system to achieve the values of priority driven, need-based and equity? � To what extent a balance is needed: � between the different potential types of research, � between the biomedical clinical and public health spectrum, � between the investigator driven and systems driven (problems related to policy, planning and delivery of services designed to improve health and equity), � between goal oriented and non goal oriented, � between operational designed to improve operational activities versus research designed to generate knowledge, � between research to answer the 'what' question versus "why and how" questions, and 15 � between disease based research activities versus policy and system orientated research? � Is there a way to map out ratio, to monitor research and relate it to the portfolio of research in the country and relate that to the context? � Is there a way that countries begin to map out for themselves the appropriate ratio between different types of research so that they can approximately begin to identify whether or not the direction of research fit the country strategically? � Is there a way of relating the research to country context? � If the country is undergoing health care reform in transition, can it be said that within the given context, what would be the appropriate ratio between the policy and system research and investigator driven research as opposed to countries with more stable environment? 5.1.5 Types and areas of health research: Very little have been said about what types and areas of health research to be undertaken by countries in the Region in five to ten year’s time. The prioritization of the research areas for the Region and development of detailed strategies for health research to address each and every other priority health problems could be addressed at many technical forums. SEA Region has organized such forums like taskforce on development of health systems research on making pregnancy safer, development of regional vaccine policy and vaccine research policy, development of health research in HIV/AIDS, etc., during last few years. A strike of balance is needed in the Region between the research to generate new knowledge and research to apply existing knowledge to local situation. The current document at this moment would only focus the attention on the strengthening of national health research systems. The Regional ACHR and the countries could identify and make appropriate recommendations on the exact areas of health research at various policy forums. No doubt, the countries in the Region can be involved in the global health research that embraces new development of science. 5.2 National health research system 5.2.1 Situation analysis: Countries have to include the statement of health research policy as part of the national health policy. There could also be specific statement of national health research policy and national health research system (NHRS) policy within the framework of national health policy. Countries need to analyze the situation of their health system and the role of health research system within the overall national health system, identify their strengths and weaknesses, and develop case studies indicating successes and failures. These will then allow countries to look at possible options to improve their own health research systems and can then choose a strategy, which will move their health research systems forward. 16 WHO-SEARO could provide technical support to the member countries to carry out the situation analysis, and provide a forum for countries to share their experiences in understanding and improvement of the contribution of health research system to enhance the performance of health system. Coordination done by WHO-SEARO will have an added comparative advantage, having a common framework already developed to collect and analyze information. In the situation analysis, there might be some problems due to deficient information, e.g., lack of information on resource flows and lack of a comprehensive health research-financing scheme. Strategies can be formulated to tackle those components, which could be coordinated to identify knowledge gaps, fragmentation, and redundancy. 5.2.2 Research and training: One possible strategy is to conduct health research, while education programme is initiated in parallel, for the interaction with the public. This community education, in parallel with health research, will enhance the understanding of stakeholders about the role of research in addressing the pressing health issues and thus develop some strategic alliance between stakeholders. Similarly, the regular forum for stakeholders’ interaction and the empowerment of people by effective use of media are some important strategies. WHO has generated a platform and opportunity for national health/ medical research councils and analogous bodies, within the framework of regional ACHR to work together to find the partnership and interaction among themselves to create their own agenda. Regional health research forum with new managerial approaches might also allow partnership and enhance collaborative works. 5.3 Research capacity Considering the requirements of the national health research systems as well as capacities needed for its good performance, different ways and means for strengthening capacity for health research have to be identified. 5.3.1 Technical capacity: First, technical training on ethics in health research is needed both for managerial and technical people who are responsible for health research, especially those members of ethical review committees at institutional or national levels. This need has been expressed in many circles including ACHRs, both at regional and global levels. The second area is strengthening the capacity of health research associated with new science and biotechnology, such as human genetics, research informatics. For example, there will be a scientific debate on human genetics at the 26 th session of SEA-ACHR and also a consultative meeting jointly organized by SEARO and WPRO at Bangkok in 4-6 June, 2001, where discussion will be concentrated on what the Region will go forward for strengthening the capacity in the area of human genetics. It could be strongly arguable that a different kind of technical capacity strengthening is needed and competition for financial support might be intensive. 17 The third area is on strengthening capability and capacity on health research laboratory management and health-research-related legislation, including those applicable to experimental animals. The fourth area relates to revitalizing the training courses on research methodologies, in order to push them up in such a way that would improve the country technical research skills, management and use of research, especially research on traditional medicine. 5.3.2 Management: capacity or capability are needed both on the supply and demand side of health research. Demand side issues usually relate to the absorptive capacity for research among the users, such as senior executives, the funders, the community and the media. Even before the design of the research, researchers might have to calculate the investment and the expected benefit (e.g. investment in research can produce a return of 20 dollars from 1 dollar investment). The demand side, usually, the funders and policy makers would like to see these estimates before they agree to support the research. These might involve some clarification of the assumptions. The supply side includes the management capacity of researchers and the managers. They all need improved skills in research management, leadership, negotiation, team building, and capacity to work in a multi-disciplinary environment, involving medical, social and political sciences. One important aspect of research management is the publication of research findings and the preparation of the research results into acceptable packages, relevant to specific policy issues of the countries. Such a capacity for research management should be enhanced. Some users of research results may be the researchers themselves, who want to use research results to improve health systems issues and therefore not published. However, there is a strong view that publication and utilization should be separated. Publications normally amongst others aim at the peer review of scientific validity. Many publications are not scientifically scrutinized these days and the editorial boards of scientific journals need appropriate training for peer review. Documents to encourage utilization have to be synthesized from scientifically valid work into packages for different target users. For example, the packages for the policy makers on the “Reforms for Civil Servant Benefits Schemes in Thailand” were developed from the analysis and synthesis of more than ten scientific publications, into a form that users (decision-makers) could understand. The packages have included the recommendations of actual actions to be taken or avoided as well as the consequences of those actions. Therefore, a series of research questions must be packaged to answer some policy questions at the outset. Uses of research are not usually in the hand of the researchers alone. Users normally decide themselves whether they should use research results or not. What is in the hands of the researchers is the dissemination of research results in understandable form. There could be two possible forms of dissemination. One is to 18 disseminate in scientific journals for consumption by the scientific communities. Another form is the dissemination to users outside the scientific community, such as policy makers and the general public, in an attractive form. A challenge is transform such knowledge conveyed in the scientific journals into relevant forms or messages understandable by the users. Academics or research scientists often do not have such skills. Thus, the capacity of the supplier of research to package the research results to various user targets needs to be strengthened. 5.3.3 Resource mobilization: There are two key strategic areas for resource mobilization, (a) coordination at the country level and (b) impact assessment, i.e., the cost effectiveness of investment. Some issues, as stated below, about what capacities on research resource mobilization to be developed still remain and need to be clarified and evolved. � How does a country measure its capacity (institutional and human resources) in a given context to identify the gaps and imbalances of research resources to deal with priority agenda? � How a country can avoid that the research agenda may be driven by the capacity already existing in the country? � If a country has clinicians or public health specialists or epidemiologists and no biomedical researchers, the persons and capacity available might influence the priority research agenda. In other words, how does a country identify the extent to which the existing research capacity determines the research agenda? � What can be done to correct the imbalances and the gap? Other important questions include: � Is there a 'critical mass' required to sustain a meaningful health research system? � What is the approach to a balance effort for capacity development of individuals, institutions and the systems itself? � How can countries tackle the problems of internal and external "brain drain"? � How do countries build capacity of the research system or retain them? � How, who and when to address these issues? It is essential that the development of National Health Research System has put emphasis on the utilization and impact of research. Only when research producers can show the impact of research through publications and utilization, it would be difficult to argue for more funds especially in the time of economic crisis. 5.3.4 How to build the needed capacity? The following strategies might be adopted to strengthen the needed capacity. Mobilization: Can the countries mobilize existing resources within countries? 19 Networking: A single country does not have enough capacity. It could be strengthened through arrangement of networking. The establishment of the HELLIS network is one example to increase access to health literature and library information materials to countries. Networking among institutions and individuals within a country or across the countries in specific research agenda is also another example. Networking and partnerships with mobilization of potential resources can assist countries in capacity strengthening. Country-focused capacity strengthening plan: Development of capacity in technical skill and competence for research development and management, negotiation skill, leadership skill and networking are major areas for strengthening. Catalytic role of WHO: WHO-SEARO could act as a catalyst or facilitator, but countries should have to work closely with WHO in their capacity development meaningful. For example, a significant cadre of experts from both inter- country and national training workshops on ethics has been established with the support and facilitation by WHO-SEARO. How the countries would use these experts to cope with the ethical issues of health research in their own countries? Clearinghouse of experts: There should definitely have the listings of regional experts and participants who have gone through such specific trainings. Countries can share their cost and host trainings to help others. Countries can take turn to carry out workshops through cost sharing mechanisms. Clearinghouse of modules: WHO can also act as or make a few national institutions or WHOCC to function as clearinghouses for the health research training materials, including educational modules for countries. Refinement of tools and methods: A compilation of health research tolls and methodologies and guidelines should be encouraged and SEARO can coordinate the use and refinement of these tools for use in the region. Use of information technology: It has to be emphasized that in response to rapid changes, countries will need capacity strengthening about how to use of information technology for research system development including the capacity to screen important emerging knowledge and technology. Capacity strengthening is more than training. It involves the creation of an environment of learning organization, through partnerships among producers and users of health research. Such a partnership will empower both the producers and the users. In a learning organization, mechanisms have to be set up to monitor, evaluate, summarize lessons learnt and give feed back to the players in the learning organization. 20 Regional research programmes: could be used as the mechanisms to foster capacity strengthening through such learning organizations. Involvement in inter-country research programmes to tackle regional health problems such as thalassemia, drug-resistant malaria, management of kala- azar or arsenic poisoning, snakebites, etc., helped the researchers to strengthen the capacity. Also, inter-regional partnerships can be explored to create many learning organizations relevant to global problems such as multi- drug-resistant tuberculosis, or genetic diseases. Information technology can be capitalized to strengthen the "learning organizations" around national, regional and global priority areas addressing not only the resurgence of infections and diseases associated with poverty but also problems where advances in sciences such as genomes technology can help to tackle. The capacity developed through the learning organizations around a specific topic can be applied to other areas when existing problems are adequately addressed. 5.4 Support to health research systems Strategies have to be practical and meaningful to support the notion of enhancing country focus in the use of health research to support health systems. This will entail increasing support for health research from the government. A compendium of examples on how countries get their resources for research could be developed. At the country level, the possible steps to increase support for research are: (1) The analysis of resources and resource flows for health research: Optimization of resources from several funding agencies is necessary to pool the resources and optimize its use in research in similar areas. In genomic projects, at least six donors are giving support to India without much coordination between them. (2) The encouragement of the countries to organize donors’ meetings and getting consensus with them about health research needs with clear- cut documents. (3) The development of training courses in several countries where health/medical research councils and appropriate agencies can share common burden. (4) The information sharing on health research development 5.4.1 Capture any opportunity: Research institutions could capture any opportunity from the country political environment and argue for support for evidence-based policy. There are some advocates for a smaller health ministry and efforts to further accelerate public health sector reforms. These could be the challenges to the health research systems as how they would bring more support to the health system. Improved communication with the stakeholders to create appropriate understandings of the people about the need to 21 support health research system, in response to the changing political environment can help create a healthy atmosphere for good research environment. 5.4.2 Conducive to a good research environment: The creation of a good health research system is conducive to a good research environment. Isolated programmes to create researchers without research system development can be undesirable, since the researchers produced will have no stable career and job opportunities. Career development of researcher, research managers and research coordinators can be considered as a part of the research system development. The system and the environment should be a part and parcel of the same development, which would take care of both innovations and agenda based research. It is difficult to have a good career without a good research system. E.g., the Thailand’s NHSRI has facilitated some big-scale long-term research projects such as those dealing with empowerment (decentralization) or issues related to reduction of imports and improvement of self sufficiency in health technology. These projects would entail involvement of several disciplines of scientists, such as genetics and biological scientists, clinicians and social scientists. Also, the NHSRI have supported many multi- disciplinary research programmes, in which PhD students work as apprentices on research questions which can contribute to long term national and health development, and supported area-based research programmes to strengthen the capacity of local researchers. At the community levels, researchers in specific catchments areas have been gloomed in problem-and need-driven research relevant to local problems for eventual decentralization and sustainability of health care system. 5.4.3 Specific programmes targeted: In addition to the contribution by the research system to good health research environment, there can be specific programmes targeted at improvement of the research environment per se. An example is the pairing of health care providers, practitioners with academic institutions in research to tackle local problems. This has helped build research capacities among the providers and help orient academics in formulating appropriate questions. Another example is the effort of Thailand Research Fund (TRF) that has supported inter-disciplinary and basic research in all branches of science. Recently, the TRF has received approval from the Thai Cabinet to launch the Royal Golden Jubilee Project commemorating the 50th anniversary of the ascension to the throne of His Majesty the King. The Funds give sufficient no-bonded research grants to each student for Ph.D. studies in Thai Universities. Each grant covers not only the student’s stipend, tuition and research allowance, but also a budget to pursue elective studies, research and data analysis in any collaborating universities abroad. The efforts will enable Thailand to improve its research capacity and the University infrastructure in addition to production of researchers. Focusing on research culture and the career structure of the researchers can improve research environment. 5.4.4 Measure against brain drain: By creating a good research system, research institutions will be strengthened, which can be an important measure against brain drain. Institutions should also be strengthened with respect to 22 the capacity to link the researchers and users both at the level of providers as well as linking directly with the consumers and civil society levels. Users will then be more appreciative of research and therefore the strategy can be conducive to good environment. Strengthening multi-disciplinary research within and between institutions can make research more effective and therefore produce better argument in support for research. For example, linking basic research and operation research, hand in hand, can be encouraged. Research on vaccine development could be linked to research on good methods of vaccine delivery. This can make research more effective and therefore become conducive to creating good environment. 5.4.5 Consortium approach: At the international level, the consortium approach at the regional level, with WHO as the focal point for coordinating development partners in health research, could be encouraged. Intrinsic funding of WHO for research has been diminishing. The extra- budgetary funds also are diminishing in the past decades. There are some good prospects of bringing in funds. WHO has to expand partnerships with a wider range of development partners by outsourcing the international support for research and development, e.g. Leprosy and Polio eradication programmes, HIV/AIDS, TB control. In all these programmes, WHO has to use its technical leadership strengths to draw in development partners to help improve health development in the Region. The role of WHO-SEARO and WHO Representatives should be strongly identified within the framework of the strengths and limitations of WHO. One critical role is that of an honest broker who helps channel resources for research. In doing so, the countries should have some research agenda, to be ready to enable WHO advocate on their behalf. Regardless of WHO acting as a convener of development partners to support health research efforts, the principle of country-focus must be maintained. International collaboration in research should tackle common problems that expand beyond international boundaries. Countries should coordinate donors at country level; conduct resource flows analysis to understand the situation; and cooperate in international efforts for research on international issues. 5.4.6 Partnerships: One key objective of regional partnerships is to mobilize support to countries with different stage and rate of development. Research capacity development should respond to different and distinctive needs. As changes are rapid and unpredictable, countries should have the capacity to respond rapidly to changing research needs. The first step to develop a partnership is to identify cross cutting needs of development partners and set priorities for research issues related to the concerns by development partners. At the later stage, partnerships might be formed to address the special needs of some partners. Finally, countries with poor resources and infrastructure need more attention in capacity strengthening. WHO can use some of its country and intercountry budget to facilitate the formation of partnerships in the 23 Region to promote the development of the national health research systems rather than supporting the inter-country research projects alone. Partnerships and twinning countries or institutions must be based on equal partnerships to address special complementary needs and mutual benefits. In designing a partnership package, it is important to guard against enthusiastic promotion of specific interventions perceived by one partner as useful. Rather, an equal partnership should be based on a good design of a two-way dialogue, which could avoid dominance of one partner. Some guides for good partnerships might be needed. A good partnership must respond to the legitimate needs of the partners in terms of knowledge generation, transfer of technology and capacity strengthening. Partnership efforts should also be monitored. The use existing infrastructure like network of WHOCC and national centres of expertise for fostering good partnerships could be explored. At the moment, some WHOCCs are not utilized to their full potentials. SEARO can facilitate inter-country cooperation in strengthening the health research system to tackle health issues of the countries by encouraging inter-countries collaboration using inter-country budget. The experiences gained can be documented and compared based on the concepts of equal partnership and learning organization. 5.5 Governance 5.5.1 The country level: Mechanisms must be established to empower the people and the society to demand good governance and engage them in the policy process. The central importance of ownership and involvement of the community and the public in general is to be emphasized. How this will happen is a big challenge. How it will happen in an equitable way is going to be a bigger challenge. Another challenge is how the community and the public will be more involved in the determination of the broader systems and health research priorities? In order to allow productive and meaningful involvement of the community and the public, there must be some mechanisms to develop their capacity to understand usefulness of health research. If we involve the community only as a token, it can be more harmful than good. Documenting various systems of governance for health research in countries must be encouraged. In India, the Division of Planning convenes experts for advices to set resource allocation goals. Many ministries do not talk to one another and independently draw their own plan of action. The Indian Medical Research Council, through its own governing body has its own objectives and plans. Many academic and research institutions do the same. Many of them link directly to international donors and carry out programmes agreed upon by the agencies and donors. The research studies on the effectiveness of DOTS for TB control and national immunization days for polio eradication (pulse-polio) were carried out in India, but the importance of such research results had not been conveyed properly to the decision-makers. It came back to India via a roundabout route through WHO advocacy. It is, therefore, necessary to do the analysis of the existing systems and suggest appropriate national architecture, which will make help effective coordination and promotion of close 24 interaction. In Indonesia, the Ministry of Social Welfare, Education and Health, has been creating a platform of working together. This allows some form of interaction and good governance. The decentralization in Indonesia is another example that takes the issues of good governance to the grass root levels. These are a few examples that countries are encouraged to share. WHO together with countries must establish and enforce the codes of conduct for international cooperation in health research, to dampen the criticisms by some, that the international political economy for health research has been unfair, inequitable, and exploitative. There has been some work already done on it. Further discussions are needed to design actions to address the recurring issues related to intellectual property rights, especially health research related to traditional medicine, drugs and vaccines, since there have already been a lot of discussions in various forums. 5.5.2 International levels: The issues described above apply to the institutions at the international level. However, many complaints of unfair cooperation are based on non-systematic experiences. To what extent is there a problem of un-coordination between international agencies that are harmful to countries? Is this affecting research agenda of the countries? If so, by how much and is this a problem? To what extent is the continuity of knowledge generation in countries affected by donor driven agenda? Is increasing inequity and impoverishment be adequately helped by more coordination? 6. From strategies to actions There is an agreement about the values, the principles, the focus of health research, and health research system. It is assumed that health research system might be useful and have added advantage if efficient. There are also some agreements about the components of health research systems and what they are supposed to do. The question is what next? What can countries do to move this forward and be useful as expected? 6.1 Situation analysis In order to understand what is happening within a complex health research system development, there is a need for a thorough situation analysis. Such situation analysis goes beyond the description of the systems. The analysis should be part of national process and also include generation of information for better understanding of the strength and weaknesses of the health research system, which would then help strengthen the effectiveness of the system. 25 A situation analysis can be shared with stakeholders to start discussions about how to move things forward. Situation analysis starts with what exists, is non- threatening and neutral and links to the notion of planning forward. It should be context based and emphasizing the notion of country-base approaches. The activity in itself can lead to capacity development. Some external involvement is desirable because it can lend additional objectivity to the process. It may allow situation to represent multiple perspectives and it can facilitate consensus and acting as an 'honest broker' in a situation when the solidarity within countries can be improved. Situation analysis will lend itself to an easier 'knock-on' effect for other countries. It may lend itself to facilitate some appropriate cross country comparisons, but not ranking. It may promote linkages between countries and enhance regional cooperation. 6.2 The framework and tools Some framework and lay-out and tools can allow some commonality between countries. The common framework consists of country contexts; use of policy analysis to understand the supply side; understanding of the stakeholders, their roles and functions, structures or some coordinating networks; and understanding about the whole issues of financing (source, growth, allocation). Countries can cooperate to define and refine tools to conduct a situation analysis. There are tools already available such as priority setting and resource flows analysis. Countries can adopt different methodologies keeping the basic principles of analysis on specific areas. Once the tools are being used, they can be further refined and eventually perfected to address the effective performance of the health research system within the context of the health system and the broader development system. How is this going to happen will require some strategic thinking. Who will coordinate and initiate the process from within the country? Should it be decided through national consensus? Is there an obvious 'focal point' and commitment, time, resources? What is degree of solidarity and capacity to move the situation analysis forward? 6.3 Regional partnership and the WHO roles Regional partnership must be strengthened to support countries in their effort to build the national health research system. The Annecy Document reported about operational roles of WHO in supporting regional partnership. Many of these recommendations are valid for today. WHO through consensus with the regional partners can play a pivotal role in the strengthening of partnership for health research. The regional partners include not only the UN Agencies, but also the Asian Development Bank, the bi-lateral and multi-lateral organizations, the NGOs and the development agencies. The partnership covers the financial assistance, as well as other resources such as exchanges of 26 publications, secondment of personnel and sharing existing programmes and activities supported by these agencies. The operating principles for WHO to support research capacity strengthening efforts should be operationalized, i.e.: � WHO should contribute to the national efforts for promotion and development of health research that should be tailored to the distinctive needs and priorities of the countries. Different strategies would be needed to support the country’s needs. � WHO should act as proactive partnerships in health research development, seeking the opportunities to complement and strengthen what other development partners are already doing. WHO and the countries may need to explore possible mechanisms to strengthen regional and national partnerships to avoid fragmentation and redundancy of efforts and provide an efficient approach to identify problem gaps in the region, which can be answered by research. Proactive partnerships could be expressed in several forms such as provision of meeting points and platforms for discussions; support training, sharing lessons leant from the “learning organization”, exchanges of software; and targeting consultancy roles. This would avoid unnecessary and unhelpful duplication and maximize synergy among various players. WHO should also keep away from generating more ill conceived “initiatives” in research capability strengthening, which might complicate existing complex situation. � The key role of WHO is to develop a global leadership, advocacy and promotion of health research. The emphasis should be placed on the exploration of WHO stewardship role in making advocacy for increased investment (both political and financial) in science and technology generally, and equity-oriented health research in particular, and enhancing its coordination of all development partners at the country level. This implies that the first next step for WHO is to implement a situation analysis of all actors in the regions (UN and non-UN system) and sharing plan of works and results. WHO may also need to develop mechanism to coordinate potential actors. � WHO should maximize the utility of its current functions, structures and mechanisms to support capacity strengthening needs of countries such as fellowship awards, support of WHOCCs, selection and placements of short term consultants, and exchange of research scientists and expertise. WHO should improve its own coordination of health research within WHO at all levels. � WHO should be a role model of health research especially on evidence based planning, learning and innovation within the organization. 27 Finally, some mechanisms must be designed in advance to monitor the progress and to evaluate the strategies for health research development. A time line and responsible groups must be defined at an early stage. This strategy document should not only be served as a guideline, but also be translated into action plans with appropriate incentives, resources required and monitoring mechanisms in place, in order to advance health research system development forward. The present draft is prepared by the expert group consisted of: (a) the ACHR members - Professor N.K. Ganguly (India), Professor Chitr Sitthi-Amorn (Thailand) and Professor Dulitha N. Fernando (Sri Lanka); (b) the senior health research scientists - Professor Aung Than Batu (Myanmar), Professor V. Ramalingaswami (India), Professor C.A.K. Yesudian (India), Dr Wiput Phoolcharoen (Thailand) and Professor Amal C. Syaaf (Indonesia). WHO Staff (Dr Than Sein, Dr Adik Wibowo, Mr. A Meliala and Dr Stephen Jost) provided the secretariat support. 28 Bibliography World Health Organization (1989); National Mechanisms for Health Research Coordination and Management in the countries of South-East Asia Region (unpublished document), WHO SEARO, New Delhi World Health Organization (1993); Health Research Strategies of the South-East Asia Region, WHO SEARO, New Delhi World Health Organization (1997); Declaration on Health Development in the South- East Asia Region in the 21 st century; WHO SEARO, New Delhi World Health Organization (1999); Research strategy and mechanisms for cooperation, report of the Secretariat to the 104 th Session of WHO Executive Board, EB104/2, WHO, Geneva World Health Organization (2000); Management and Coordination of Health Research Activities in the Countries; Report on the Meeting of Scientific Working Group, Bangkok, Thailand, 6-8 October 1999, (SEA-RES-111), WHO SEARO, New Delhi World Health Organization (2000); Formulation of National Health Research Policies and Strategies; Report on the Meeting of Scientific Working Group, Jakarta, Indonesia, 6-8 December 1999, (SEA-RES-112), WHO SEARO, New Delhi World Health Organization (2000); Criteria for setting health research priorities, Report on Meeting of Scientific Working Group, New Delhi, India, 1-3 November 1999, (SEA- RES-113), WHO SEARO, New Delhi World Health Organization (2000); Management of Health Research Information, Report on Meeting of Scientific Working Group, New Delhi, India, 15-17 December 1999, (SEA-RES-114), WHO SEARO, New Delhi World Health Organization (2000); Report of WHO Meeting on Research Capacity Strengthening in Developing Countries; Annecy, France, 26-28 April 2000, WHO, Geneva World Health Organization (2000); Report to the Director-General on the 38 th session of Global Advisory Committee on Health Research (ACHR) held at Bangkok, October 2000 World Health Organization (2001); Proposed Programme Budget for 2002-2003, Document PPB/2002-2003, WHO, Geneva COHERD, Regional Consultative Process-Asia {The Asian Voice}, International Conference on Health Research for Development, Bangkok, Thailand, 10-13 October 2000 COHRED, Health research for development: the continuing challenge, A discussion paper prepared for the International Conference on Health Research for Development, Bangkok, Thailand, 10-13 October 2000 29

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 26 th Session of WHO South-East Asia Advisory Committee on Health Research 17-20 April 2001, Thimphu, Bhutan SEA/ACHR/26/6 Agenda Item 3.2 9 April 2001 STRATEGIES FOR HEALTH RESEARCH DEVELOPMENT IN WHO SOUTH-EAST ASIA REGION (DRAFT) Health Research Strategies of the South-East Asia Region were drawn up in 1993, as per guidance from SEA-ACHR. Due to new opportunities and challenges that are emerging in the 21st century, it is crucial that regional health research strategies are to be reviewed, and revisions to be made to support the concerted efforts for reforms in health sector. Keeping in view developments in international and national health research systems, Regional Director constituted an expert group, which met in WHO-SEARO from 29-31 March 2001, to review and update the regional health research strategies. The expert group made this draft paper - “Strategic Framework for Health Research Development in WHO South-East Asia Region”, which is now placed for consideration by 26 th session of SEA- ACHR, in April 2001. Taking into accounts of the observations, comments, guidance and recommendations made by 26ACHR, the expert group will review and revise the draft, into a final strategy document, by July 2001. The final “Regional Health Research Strategy” paper will be submitted to the 54 th session of WHO Regional Committee for South-East Asia to be held at Yangon in September 2001, for its review and endorsement. WHO Regional Office, in collaboration with ACHR, national health research councils and institutions will implement activities within this strategic framework, and an evaluation will be done after two years, in 2004. Contents Page 1. Introduction .................................................................................................... 1 2. Objective ........................................................................................................ 2 3. National health research system ....................................................................... 2 3.1 Role and function of health research system............................................... 2 3.2 National health research system architecture .............................................. 4 3.3 Some characteristics of health research systems ......................................... 6 3.4 The functions of the health research system............................................... 8 4. Key challenges in health research development ................................................. 9 4.1 The health research value.......................................................................... 9 4.2 Research environment............................................................................. 10 4.3 Sustainable Health Research System ........................................................ 12 4.4 Knowledge production and application...................................................... 14 5. Strategies for health research development..................................................... 14 5.1 Knowledge.............................................................................................. 14 5.2 National health research system............................................................... 16 5.3 Research capacity ................................................................................... 17 5.4 Support to health research systems.......................................................... 21 5.5 Governance ............................................................................................ 24 6. From strategies to actions.............................................................................. 25 6.1 Situation analysis .................................................................................... 25 6.2 The framework and tools......................................................................... 26 6.3 Regional partnership and the WHO roles .................................................. 26 Bibliography......................................................................................................... 29 1. Introduction The World Health Organization (WHO) from its inception has recognized the vital role played by health research in health development. The Constitution of WHO includes, as one of its functions, the promotion and conduct of research in the field of health. At various Governing Bodies’ meetings and other forums, WHO has repeatedly stated that all national and international health policies should be based on valid scientific evidence, that such evidence requires health research, and that research has significant potential in promoting health and a vital role in improving health through applications or solutions that are already available and through generation of knowledge for the development of new solutions. WHO promotes health research through developing its own health research strategies, that influence, and are in turn influenced, in an interactive manner by national health research strategies in support of specific country needs. Since the development of the "Health Research Strategies of the South- East Asia Region" in 1993, there have been a number of unprecedented changes in health and health research development. These are exemplified by the socioeconomic and political changes around the world, including the rapid economic growth followed by crisis in Asia, massive population movement within and between countries, natural disasters and other human-made calamities, globalization and trade liberalization, rapid advancement of information technology and biotechnology, etc. Unprecedented changes also occur in health development area. Most notably have been the rapid spreads of health problems across national boundaries such as HIV/AIDS, drug- resistant malaria and tuberculosis, highlighting the vulnerability of nations. Development and use of new drugs and vaccines and the scientific breakthrough of the genomes sequencing, introduction of new health system performance indicators and variety of health care reforms have occurred at a rapid pace and are beyond expectations. WHO nowadays becomes one of the many actors in international health, especially in relation to development of health research. In addition to WHO, other UN Agencies and numerous bilateral, multilateral and international agencies, foundations and financial institutions including the World Bank, the international NGOs and alliances such as the Council for Health Research and Development (COHRED), the Global Forum for Health Research, the Rockefeller Foundations and the Alliances for Policies and Systems Research, are becoming major players in health and health research field. This multitude of active players is possibly causing confusions, fragmentation, redundancy and gaps of efforts to improve health of the countries. New global public and private partnerships such as the Bill and Melinda Gates Foundation and the stronger involvement of multinational pharmaceutical industries in the neglected areas of health research have offered new opportunities for international cooperation to promote health through health research. These changes coupled with the continuing health disparities in a globalized world and the continuing deaths and avoidable burden of diseases from preventable health conditions among the countries, especially the developing world, prompted many agencies to review and revise their strategic plans. WHO has endorsed new Corporate Strategies in 1999 in order to address such 1 profound rapid global changes. WHO are also working with its Members to review and update their national health development strategies in order to guide their own reform processes. In the light of these developments, it is appropriate to review and revise the strategies for health research development in the South-East Asia Region, in order to optimally support the countries to cope with their health problems through research. 2. Objective The present document aimed to provide a “Strategic Framework for Health Research Development in WHO South-East Asia Region”, over a medium term period. It is mainly intended for countries of the Region and WHO-SEARO, in order to review and plan their health research development efforts. Such review and planning on health research development will allow the countries and SEARO to jointly develop mechanisms for partnerships between WHO and countries, and thus strengthening the responsiveness of health research in solving health problems in the light of rapid changes affecting health. It is aimed that the document will serve as a generic framework to generate understanding and to encourage a broader debate leading towards an effective health research support for improving health system performance. It might also help countries beyond the Region to use this document as the guidelines for improving their health research systems. The document describes the role, functions and architecture of health research systems, as they now exist in countries or as they should be in ideal situation and also suggests ways and means of improvement. It highlights the development and strengthening of national health research systems, as key strategy to health research development in the South-East Asia Region. 3. National health research system 3.1 Role and function of health research system 3.1.1 General role: It is in general assumed that the purpose of a health system is to improve equity, quality and efficiency of health. Health-for-all (HFA) movement is to support the principle of health quality, equity and social justice. Other purposes include fairness (e.g. fairness in financing and responsiveness as parts of health system performance) (WHR2000), investment for development (World Bank 1993), and health services as commercial products (e.g. private sector care and technology as a product). 2 There is still continuingly debating on the meaning and clarity of these words. The understanding of the word “equity” might differ depending on the ideology that lies behind. Whatever it may, equity is a desirable value regardless of how it is defined. Equity in health may not directly be achieved by health research alone. Promoting equity is more of a function of health systems and its interaction with national development. The overall socioeconomic development systems, health systems, sciences and technology systems, all operate at the national and international levels in more cohesive and interactive way. Health policy, planning and service delivery are the management instruments to operationalize the values and principles of health and other systems. Health research can affect equity by producing and applying knowledge that support the health policy, planning, service delivery, and policy instruments related to equity. 3.1.2 Values and principles: Health research systems therefore operate within the context of the national health system as well as within those of the sciences and technology and development systems. Health research has its own values and principles, namely: (a) Generate and validate knowledge and information, (b) Monitor and evaluate policy and ensure that policy gets into practice that are relevant to improve health; (c) Develop new and appropriate technology, and (d) Contribute to development, using sound scientific principles. Due to the multiple players dealing with health research systems, there is a tendency of knowledge, being generated through health research, to be fragmented, redundant. There are gaps in health research, which do not received adequate attention from researchers. There is a strong suggestion that the focus should be made on research generation and management at the country level. This gives rise to the notion of supporting and improving the functioning of national health research system (NIHRS). 3.1.3 Key functions: of a national health research system are to: (a) Coordinate health research; (b) Align health research to national health priorities and needs; (c) Conduct health research to meet the ultimate goals of equity and development according to the values and principles; (d) Ensure that appropriate knowledge produced is efficiently used and linked to policy, planning, service delivery and policy instruments; (e) Create synergy and promote a collaboration and multi-disciplinary linkages; (f) Develop capacity to do and manage health research and related sciences; (g) Develop rules, procedures and standards (ethics, fair partnership, quality around methodology, accountability and transparency); 3 (h) Advocate and be vocal when the broader systems are not reflecting goals, values, and principles originally set up for health system; and, (i) Mobilize resources for research and development. The functions of a health research system at national level as mentioned above apply as much as to those health research systems at the international level. In addition, certain issues pertaining to the international health research systems include the notion of correcting north-south imbalance; country focus (focus of developing countries determining their own research agenda); decentralized decision making; transparency; not self-serving. In other words, research should not be carried out for the sake of research but must be channeled for the sake of improving health and promoting equity and development. 3.2 National health research system architecture 3.2.1 Health research system architecture: refers to the relationship and governance between functional components of agencies and bodies related to health research, within a structure or network of structures to carry out the essential core functions. Countries in the Region are with different stages of development. They also have varying sizes of population as well as different political imperatives. They will need different architecture for their own national health research systems. Occasionally, the architecture or structure exists not by choice. To map whether core functions of a health research system are carried out, one needs to design an ideal group of functions and then map the structures in relation to those ideal functions. It is suggested that the operating principles of Asian Voices 1 agreed by the Asian Forum of Health Research organized in early 2000, could be adapted to guide the development of health research system’s architecture at national, regional and global levels. The principles included: a) political commitment to support equity, b) capacity to set research priority and direct research policy, c) regional agenda setting, and d) regional clearing house and strategies to empower national research communities. Countries having different architectures that operate within different contexts will need to make their own arrangement of the structures to perform the particular functions. While some may be able perform all the functions of the research system through one structure (or even one person), some would have a whole range of structures. There are a few sketchy descriptions of national health research system of countries in the Region . 2 1 A progress report of Regional Consultative Process, Asia, submitted to the International Conference on Health Research for Development, Bangkok, 10-13 October 2000 2 WHO-SEARO, National Mechanisms for Health research Coordination and Management in the countries of South- East Asia Region, 1989; Report of SWG on Formulation of National Health Research Strategies, Jakarta, 1999 and Report of SWG on Management and Coordination of Health Research Activities, Bangkok, 1999 4 WHO may need to update such information on health research system for each country, especially on how national mechanism and linkages for health research work and see whether all the functions are covered. If not, modification of the architecture or structure may be warranted to make improvement of national health research systems. Examples of architecture and mechanism of national and regional health research systems could also be given to demonstrate to other countries, how arrangements of the structure can be carried out to perform the functions. Such analytical documentation on national health research system and their development evolution would be used as reference documents for strengthening health research system. One process at the national level involves the formation of “National Health Research Forum”, which allows a much wider participation and brings people together to discuss issues towards for a unified concept at the national and sub-national levels. 3.2.2 Research networks: Strengthening the linkages and functioning of research networks of institutions and expertise in specific technical areas within a country and across the countries have been the recurring themes in the discussions of ACHR and other WHO Governing Bodies. The experience showed that many networks have not been created and functional at the national or regional levels or even at international level. There may be some important factors missing in linkages for effective and efficient functioning. A few of these factors are (a) lack of sharing information, (b) lack of monitoring and (c) lack of sharing resources. Currently, several networks of intercountry technical collaboration are initiated in variety of technical areas such as essential drugs and vaccines, disease surveillance, nutrition, health policy and health systems research, national health accounts. There is a need to define and summarize the organizations, technical bodies, health research councils, and medical associations, the ASEAN, SAARC, and other intergovernmental bodies and try to identify the collaboration at national, regional and international levels. Such technical cooperation among developing countries can enhance the capacity building. There are many training programmes on health research in the Region that are regional in scope of reasonable quality. These programmes, which can improve through an enhancement of south-to-south collaboration, could easily be documented. WHO needs to establish or strengthen existing regional health research networks. Regional ACHR in addition to its advisory role, played as the coordination mechanism at the regional level, particularly coordination between the development agencies. The Asian Health Research Forum or similar coordination forum at the regional level might be considered. The groundwork for such forum at regional level has already been laid out to use strategies effectively. One possible way for effective networking is to assign these networks with appropriate health research programmes of regional priority and shared the research results at ACHR or regional health research forum platforms. WHO-SEARO could facilitate such processes in collaboration with other development partners. WHO has a vast network of WHO Collaborating Centres and other networks of national centres of 5 expertise, which could be used as part of the regional architecture and research network. The increasing role of WHOCC needs to be defined in this new architecture. Many existing health research networks such as the Action-cum-research Network for Nutrition, Asia Pacific National Health Account Network, Asia Pacific Network of Health Systems and Health Policy Research, ACT-Malaria, Mekong-basin Disease Surveillance, and INCLEN are quite successful. These networks consist of national apex institutions linking each other and they are carrying out the health research on specific subjects of interest such as nutrition, malaria, disease surveillance, national health accounts, clinical epidemiology, representing national and regional priorities. They involved the institutions in the network to set the research priorities, to make joint research protocol and to share the lead role in the conduct and coordination of research. Every two years, they usually have a journal article. WHO continues to facilitate the functioning of such networks in close collaboration with development partners. The importance of existing networks of health research must be recognized and fully supported, as they are valuable for promotion of research at the national and regional levels. 3.3 Some characteristics of health research systems 3.3.1 Different system contexts: Varieties of forms of health research systems already exist in countries of the Region within a certain socioeconomic and political context. Efforts must be directed at strengthening existing systems rather than establishing new systems. It requires an emphasis and importance of these environmental contexts, within which health research system is operating (historical, political, ideological, socioeconomic, cultural, demographic and environmental conditions). An overview of above environmental influences is important to design a “Strategy for health research development” of a particular country. It may be desirable to collate the characteristics and responsibilities of national health research systems of the countries in the Region, and the common issues and challenges could be derived based on the general overview of the individual countries’ contexts. Due to the different contexts within which the countries operate, each would have variable aims and objectives for health research development that will then be translated into appropriate operational strategy and organizational or institutional framework. The purpose of the health research strategy would be to combine different actors into a more cohesive whole. A few questions that would summarize the characteristics of national health research systems are: Who are the players for health research system development? What are the criteria to define the stakeholders, primary or secondary role players? What are their constituents, roles and responsibilities (leadership, referee, a separation of funding from prioritization)? How to deal with people who join the systems with different agenda? How will coordination and intelligent solidarity be 6 established? How will the rules, procedures and governance be established? How will system be evaluated in achieving the aims and goals? 3.3.2 Changing role of health research system: The national and sub- national health research institutions are forming health research networks within a national health research system. Their roles are changing over a period based on different development stages, from those of executing and conducting health research themselves, to the managing and disseminating research and empowering the public with knowledge and also to foster some check and balance mechanism for government policy. For example, the Thailand’s National Health System Research Institute (NHSRI), which is executing research projects in its earlier existence, assumed at later stage the role of research coordination, resource mobilization, results dissemination and facilitator for networking to promote health research based on a long-term policy perspective. Thailand’s NHSRI efforts to empower the public and to engage them in using knowledge in order to influence policy process are under way, e.g. participation of the public in the governance of autonomous hospitals and empowering the policy makers in the health reform initiatives. Knowledge management also entails efforts to create a common understanding between the policy makers and the public about specific issues. The role also depends on the capacity evolved within and around the institutions over the years. 3.3.3 Away from political interference: Independence of interference from the higher administrative level and maintenance of scientific rigor and objectivity are the essential requirements of the national health research system. This will make the research not being used by politicians to advance their political objectives. Research results in some cases might be in agreement or disagreement with the principles, purposes and expected results of the national health development. Too much attachment to the policy makers can be harmful if the research questions are changing along with frequent changes of policy makers, which is common in most developing countries. 3.3.4 Setting priority and long-term strategic plan: National health research system should have its own strategic development plans for health research promotion and development, which are debated and agreed by all stakeholders, including the government. When research results are available by implementing those development plans, they can be shared back with the stakeholders. The process of sharing is a process of empowerment of the stakeholders. Sharing also provides the formative evaluation of the researchers, so that they understand the research questions and implications better. 7 3.3.5 Ways to communicate research results: All researchers have to learn how to communicate research results with the policy makers. For example, research about the feasibility of establishing autonomous hospitals owned by the public was not acceptable to one government, while the next government wanted to support this policy. The research had been carried out despite the disagreement of the government and this really paid off when the results came out and accepted by new government. In some cases, the new government did not accept at all of the research results that they had not a chance to involve with. 3.4 The functions of the health research system In general, the following five core functions could be identified as the essential functions of an ideal health research system. The brief interpretations of these primary functions are highlighted below. 3.4.1 Stewardship: It is the quality leadership in promotion of health research, whose task is to develop strategic vision for health research development, and steer the whole research community in coherent manner, including the oversight function. 3.4.2 Financing: Research funding covers more than supply of money. Appropriate human and financial and other material resources are required to support the long-term health research strategies, including capacity strengthening, which will eventually be cost effective. Long-term investment of national health research system aims at future savings. 3.4.3 Knowledge generation: It has to reflect the health agenda required to improve health and to reduce inequity. There are two kinds of knowledge generation, i.e., (a) knowledge for the purpose of improving health (identification of knowledge gaps relevant to improve health) and (b) knowledge for improving the management of health system (application of knowledge to determine health issues and appraise appropriate interventions that would lead to the greatest improvement in health). Health research should not be too perfect beyond its needs. In the past, research aimed at generation of knowledge to improve health, such as discoveries of vaccines against smallpox or malaria were important. Later, there has been increasing needs for knowledge to manage health care system more effectively. Smallpox vaccine was resulted from biotechnology research. How to bring the vaccine to the people who need them reflects more of the management aspect of research. 8 3.4.4 Utilization and management of knowledge: Health research is not just to generate knowledge, but also to make the knowledge to be useful for health improvement. The results of health research need to be presented in suitable format and translated into policy or action or absorbed into existing knowledge and technology. There is a need to promote an “information culture” that would recognize the importance of producing, sharing and using knowledge. It is also to ensure that health research brings tangible benefits to health status improvement. This implies that the links among health researchers, health care workers, health planners, policy makers and communities. 3.4.5 Capacity development: One key function within health research system is to strengthen its own capacity and capability in health research. Both the demand and supply sides of capacity need to be strengthened. 4. Key challenges in health research development A group of four key challenges for health research development could be identified as follows. The first three challenges, i.e., health research values, research environment and sustainable health research systems are important for the vitality of health research system. The last fourth challenge, knowledge production and its application, is also important, because it deals with the relationship between the health research system, health systems and broader development systems. Specific issues related to each of the challenges are highlighted below. 4.1 The health research value Sustaining the equity and ethics are the main social value for health research. 4.1.1 Equity: in health is the basic value for the health system development and might not be the direct result of a health research system. Equity in health research could be measured by the degree to which funding is allocated to health research on priority health issues and the needs of countries. By that it means how strong national health research system could influence and negotiate for resource funding based upon their own research agenda in a systematic way. The role of health research is not just to support for improvement of equity in health, but also to aim at improvement of health. HIV/AIDS and malaria vaccines are developed to reduce the disease burden as these diseases affect many people of the world. Research and development of HIV/AIDS or Malaria Vaccine is a valid investment. Inequity in health occurs when the vaccines against HIV/AIDS or Malaria are only available for the rich who can afford to use them. It may be noted that the investment in vaccine research is not the issue, but investment in managing the use of the vaccine might have given the problem. Inequity in health research can happen 9 when development agencies put funds in the wrong areas, and thus, miss the opportunity of improving health of the diseases affecting the poor. Some clinical drug trials, including development and testing of new drugs had been carried out in the developing countries, were not related to the priority health issues of those countries. The SEA Region has major proportion of global burden of Tuberculosis. The drugs available for DOTS programme for TB control are off patent, but still expensive to be used on national scale. Even then, if the countries want to produce these drugs, they have to import raw materials from developed countries, and these raw materials are still very expensive. Imbalance of TB drug production is an example of the condition not conducive for equity in health for development. Several efforts are underway to cope with this situation. For example, the Global WHO/TDR programme has a policy to have special grants for scientists or institutions only from least developed countries. Bill & Melinda Gates Foundation has put in USD 60 million for research for TB drugs and vaccines, where institutions in developing countries will be involved. On top of health research contribution to equity in health, there are some others, more difficult aspects of inequity in health research. 4.1.2 Ethics: One challenge in health research is parachuting health research from outside agencies (both from public and private domains with financial and other incentives attached). After the collaborative research was carried out, the capacity of institutions involved has to be fully strengthened. However, in many instances, especially those related to research and development of vaccines and vaccine production, the capacity was not sufficiently strengthened. Therefore, before the start of any collaboration, appropriate agreements on the transfer of technology and strengthening of human resources or other institutional capacity should be in place. The country should then be able to procure the vaccines or produce the vaccines itself at an affordable price, since the country provided field research for test of such vaccine. People who participated in research should be considered an investment. 4.2 Research environment 4.2.1 Inadequate resource: of health research usually in least-developed countries creates a dependency of foreign assistance. These external development agencies usually tend to set their own research agenda and to insist in most cases that the country should participate in donors' driven agenda. Countries should make it a policy not to receive funds with conditionality from the development agencies if the areas of funding do not coincide with the national priorities. At this moment, tuberculosis, HIV/AIDS and malaria receive high priority for global health research. Similar high priority health problems of the Region that required a lot of support by conducting health research, like dengue/dengue fever, kala-azar or snakebites, are not receiving adequate attention for putting more 10 resources. Therefore, a system that allows generation of more resources for health research is desirable. One possible way is to request all countries, which have to agree to take certain percentages on sale of some drugs and vaccines or sale of some harmful items like tobacco or alcohol, and invest the funds accumulated for research. In addition, the operation agencies can put a certain percentage of operation funds for research that could be utilized for the actual research needs of the country. Secondly, countries should have a national priority for research linked to the health systems development investment. Thirdly, a national research capacity strengthening plan should be set up to ensure that adequate human resources is available to carry out different national research priorities set up. In addition, WHO should take the lead in allocation a certain portion of its operational funds for research. 4.2.2 Globalization: entails multiple actors at the country level. One key challenge is to have effective national mechanisms for coordinating external development partners. This can also include coordination to tackle cross-country issues. Recent rapid advances in science and technology, trade liberalization, communication and transport, fluid cross-border movement of population and rapid urbanization, etc., really make the biggest challenges on health research. The challenge is how to anticipate the consequences of new discoveries rather than reacting to the effects, how to assess the ethical, social, cultural and other impacts of new knowledge, and how to ensure widest possible access of such knowledge. Health research system could able to provide answers to determine which of downstream products of the new discoveries are public goods. 4.2.3 Research culture: is lacking especially in the decision-making process for development of the health system and non-health systems related to health. How do we create and improve the research culture? The term "Research Culture" usually makes people frightened and threatened if not expressed well. Rather than talking about research culture in general, research stakeholders should be stimulated to make science and knowledge based decision- making at all levels. Science-based decision-makings have been deficient in many countries, challenging the development of an environment conducive for research. Research environment and research culture are related. Even though the research culture is broader than research environment, research culture can be an outcome of the research environment. Good research environment makes it possible for the actors in the health system to adopt the research culture by demanding evidence in policy processes. The research culture also extends beyond the environment of health research to that of health systems and non-health systems. It includes not only the producers but also the consumers of research such as the health care providers. Research environment focus on institutional environment and the researchers themselves including their career structures. Focusing on research environment is a good entry point to establish a research culture. 11 4.3 Sustainable Health Research System 4.3.1 The relationship between stakeholders (governance): A health research system includes many actors like the government health and health related agencies, the private providers, the industries and the international development agencies. There needs to be some detailed descriptions about the roles and functions of such stakeholders. The description should include issues around who has the authority over what. Who in particular has a control over of financing? Where are the powers located? Some institutions or stakeholders might have formal authorities, but the real powers lie elsewhere (power versus authority). {E.g., the differences of National Research Council and Thai Research Funds in Thailand.} Mapping of the spread and location of function, authority, power and financial control would be one way of mapping the health research system. The idea of using legislative and statutory environment might be explored, if it suits the environment of each country. In some countries, the medical research council was effective partly because of the legislative support. The degree and level of coordination, collaboration and partnerships in health research actually existed, and the environment of trust and solidarity is another issue in addition to the requirement by the law. What level of coordination exists? To what extent there is consensus and element of trust? To what extent there is solidarity? For example, the development of Dengue Vaccine in Thailand requires sustained collaboration between development agencies (WHO at all levels and WHO/TDR), the academic institution (Mahidol University), the Ministry of Public Health, the City Health Authorities, the Commerce and the Pharmaceutical Industries. The academic and research institution develop the research products (prototype vaccines), while the industries transform the prototype vaccine into commercial products. The Joint Initiative of USAID and Indian Medical Research Council in supporting joint research collaboration between private and public institutions for HIV/AIDS vaccine production for India may be another example. The USA and India jointly planned to produce research products and the Indian industries will have to transform these products into mass production through some joint ventures. The sad story of the Rotavirus Vaccines production could be avoided. The vaccine was developed in the US, tested in developing countries of Asia and elsewhere, and the production stopped due to some complications even though there is some potential usefulness for developing countries where the disease is much more prevalent. Partnerships must be promoted to handle other development areas that can affect health such as Genetically Modified Foods, both in agricultural and animal products. Also, the ethics of international collaboration as described in Washington Post and the Lancet needs special consideration (guinea pig and negotiation with weak countries). An important issue involves the level and quality of communication and dialogues that exist among the different constituents within the health research system. 12 4.3.2 Capacity development: It is well known that the lack of research capacity is a major problem of many developing countries. The real challenge is the differential emphasis according to the stages of development of the countries. Therefore, efforts to strengthen capacity should be in line with the differential needs for capacity development. In addition, capacity building for research that helps generate knowledge should be differentiated from the capacities to adapt and apply the existing knowledge. Some countries might need strengthening health research of the former category and others the latter. Therefore, the research capacity must be strengthened according to certain identified areas and priorities. 4.3.3 Financing: of health research is the biggest challenge. Economic crisis in Asia has shown that the amount of government investment in research has reduced. Due to inadequate resource, research has no career structure in most developing countries. In most cases, the decision-makers tend not to use evidence as the basis of decision-making, and also they do not value much on the need to support research. Good governance in health research system can produce a better research environment, such as transparency of priority setting and the allocation of enough funds through competitive processes. 4.3.4 Knowledge management: One key challenge on knowledge management is to encourage health knowledge as a public domain. Oral rehydration treatment including use of scientific formulae for Oral Rehydration Salt (ORS) was developed at the SEATO laboratory in Bangladesh (later known as International Center for Diarrhoeal Diseases Research, Bangladesh) in mid- 1960s. Only 10-15 years later, this technology was widely available to the world for saving millions of lives of people. Another example of delay in making knowledge available to public for some decades was related to ‘Why BCG is not effective for protection to adult tuberculosis?”. Efforts made to classify health knowledge as public domain, would prevent such avoidable large gaps of information made available to public. Innovative methods to digest the materials from research findings of health, biomedical and other sciences for the public and potential users are needed. One approach that has been tried with some successes is to translate the analysis of complicated scientific materials in a “medium” that may be acceptable to users. E.g., in Thailand, the findings of a series of complicated anthropological studies have been translated in the form of short video-plays and storybooks that are easily acceptable for the lay community. The successes prompted medical and nursing schools to use the materials to teach research and ethics. In the knowledge management, advocacy for evidence-based policy has potentially negative political connotation and must be handled with care to build up 13 the research systems towards evidence-based health actions. Some researchers stay away from it. 4.4 Knowledge production and application Some forum or mechanisms or platforms at national or institutional levels should be created to promote and clarify the ideas of health research inputs to the functions of health systems and policies. Also, there are challenges concerning the relationship between research and industries and commerce, including intellectual property right. 5. Strategies for health research development The following strategies are suggested to deal with the challenges. 5.1 Knowledge Knowledge as the output of the national health research system should also include new research findings, information, education, and solutions that knowledge might lend itself to the relevance of problem solving. All these have to impact on desirable outcomes of the health system. Finally, there is a need to align knowledge output of the research system and the values and principles of the broader system and the society. 5.1.2 Management of knowledge as a public good: Generation, validation and use of knowledge as well as the services resulting from the knowledge ought to be in the public domain. Measures must be taken to make the knowledge accessible and appropriately link to permit its effective use. Public and private partnerships have to be enhanced to tackle the problems associated with patent and, as much as possible, to make knowledge as a public good. Finally, some investment is warranted to reduce the digital and other divides which hinders effective accessibility to knowledge as a public domain. 5.1.2 Expanding creativity in research: Promotion of research culture among the producers and users of research should be explored as strategies to increase creativity in knowledge generation and knowledge management and improve research ideas and products. 5.1.3 Databases on health research systems: Efforts should be put into compiling knowledge about health research system and its interaction with the health system. This includes the components of the health research systems, the relationships between the various components, and the effective management of knowledge and its interaction with the health systems. 14 5.1.4 Effective information network and website linkages: Creating an effective information network could enhance effective management and use of knowledge. Effective linkages will permit the use of knowledge. A compendium of various reports related to the national health research system can be made available, including information on country portal or websites for each country. WHO-SEARO can work closely with the country portals. Country portals might be designed to include the government and non-government agencies. The portals can be strengthened to assume more of the knowledge management role. Some mechanism could be established for ensuring the validation of all the documents, which are put in the websites. Existing linkages and network of the Health Literature and Library Information Services (HELLIS) could be expanded. Countries should make the library network of the UN System accessible, not only in abstract forms but also in full documents. The information to be put in the websites can be case studies of successes and failures with linkages to validated pieces of knowledge from the professional sector, folk sectors and popular sector. Some training on information technology management to support knowledge management is warranted. 5.1.5 Exploring the frontiers: An involvement of emerging developments both in scientific and social arena will require efforts to explore new frontiers. Exploration of these frontiers will need new capacity currently lacking in the Region such as research and development in human genetics, including genomes sequencing, the role of law and social empowerment in enhancing health, and reducing disparities among social groups and nations. Despite the needs to explore new frontiers of sciences and social movement, the primary responsibility of research agenda setting belongs to the countries. Some thorny questions about knowledge generation must be addressed. � Does knowledge produced attempt to promote equity? � What kind of research or portfolio of research within the health research system to achieve the values of priority driven, need-based and equity? � To what extent a balance is needed: � between the different potential types of research, � between the biomedical clinical and public health spectrum, � between the investigator driven and systems driven (problems related to policy, planning and delivery of services designed to improve health and equity), � between goal oriented and non goal oriented, � between operational designed to improve operational activities versus research designed to generate knowledge, � between research to answer the 'what' question versus "why and how" questions, and 15 � between disease based research activities versus policy and system orientated research? � Is there a way to map out ratio, to monitor research and relate it to the portfolio of research in the country and relate that to the context? � Is there a way that countries begin to map out for themselves the appropriate ratio between different types of research so that they can approximately begin to identify whether or not the direction of research fit the country strategically? � Is there a way of relating the research to country context? � If the country is undergoing health care reform in transition, can it be said that within the given context, what would be the appropriate ratio between the policy and system research and investigator driven research as opposed to countries with more stable environment? 5.1.5 Types and areas of health research: Very little have been said about what types and areas of health research to be undertaken by countries in the Region in five to ten year’s time. The prioritization of the research areas for the Region and development of detailed strategies for health research to address each and every other priority health problems could be addressed at many technical forums. SEA Region has organized such forums like taskforce on development of health systems research on making pregnancy safer, development of regional vaccine policy and vaccine research policy, development of health research in HIV/AIDS, etc., during last few years. A strike of balance is needed in the Region between the research to generate new knowledge and research to apply existing knowledge to local situation. The current document at this moment would only focus the attention on the strengthening of national health research systems. The Regional ACHR and the countries could identify and make appropriate recommendations on the exact areas of health research at various policy forums. No doubt, the countries in the Region can be involved in the global health research that embraces new development of science. 5.2 National health research system 5.2.1 Situation analysis: Countries have to include the statement of health research policy as part of the national health policy. There could also be specific statement of national health research policy and national health research system (NHRS) policy within the framework of national health policy. Countries need to analyze the situation of their health system and the role of health research system within the overall national health system, identify their strengths and weaknesses, and develop case studies indicating successes and failures. These will then allow countries to look at possible options to improve their own health research systems and can then choose a strategy, which will move their health research systems forward. 16 WHO-SEARO could provide technical support to the member countries to carry out the situation analysis, and provide a forum for countries to share their experiences in understanding and improvement of the contribution of health research system to enhance the performance of health system. Coordination done by WHO-SEARO will have an added comparative advantage, having a common framework already developed to collect and analyze information. In the situation analysis, there might be some problems due to deficient information, e.g., lack of information on resource flows and lack of a comprehensive health research-financing scheme. Strategies can be formulated to tackle those components, which could be coordinated to identify knowledge gaps, fragmentation, and redundancy. 5.2.2 Research and training: One possible strategy is to conduct health research, while education programme is initiated in parallel, for the interaction with the public. This community education, in parallel with health research, will enhance the understanding of stakeholders about the role of research in addressing the pressing health issues and thus develop some strategic alliance between stakeholders. Similarly, the regular forum for stakeholders’ interaction and the empowerment of people by effective use of media are some important strategies. WHO has generated a platform and opportunity for national health/ medical research councils and analogous bodies, within the framework of regional ACHR to work together to find the partnership and interaction among themselves to create their own agenda. Regional health research forum with new managerial approaches might also allow partnership and enhance collaborative works. 5.3 Research capacity Considering the requirements of the national health research systems as well as capacities needed for its good performance, different ways and means for strengthening capacity for health research have to be identified. 5.3.1 Technical capacity: First, technical training on ethics in health research is needed both for managerial and technical people who are responsible for health research, especially those members of ethical review committees at institutional or national levels. This need has been expressed in many circles including ACHRs, both at regional and global levels. The second area is strengthening the capacity of health research associated with new science and biotechnology, such as human genetics, research informatics. For example, there will be a scientific debate on human genetics at the 26 th session of SEA-ACHR and also a consultative meeting jointly organized by SEARO and WPRO at Bangkok in 4-6 June, 2001, where discussion will be concentrated on what the Region will go forward for strengthening the capacity in the area of human genetics. It could be strongly arguable that a different kind of technical capacity strengthening is needed and competition for financial support might be intensive. 17 The third area is on strengthening capability and capacity on health research laboratory management and health-research-related legislation, including those applicable to experimental animals. The fourth area relates to revitalizing the training courses on research methodologies, in order to push them up in such a way that would improve the country technical research skills, management and use of research, especially research on traditional medicine. 5.3.2 Management: capacity or capability are needed both on the supply and demand side of health research. Demand side issues usually relate to the absorptive capacity for research among the users, such as senior executives, the funders, the community and the media. Even before the design of the research, researchers might have to calculate the investment and the expected benefit (e.g. investment in research can produce a return of 20 dollars from 1 dollar investment). The demand side, usually, the funders and policy makers would like to see these estimates before they agree to support the research. These might involve some clarification of the assumptions. The supply side includes the management capacity of researchers and the managers. They all need improved skills in research management, leadership, negotiation, team building, and capacity to work in a multi-disciplinary environment, involving medical, social and political sciences. One important aspect of research management is the publication of research findings and the preparation of the research results into acceptable packages, relevant to specific policy issues of the countries. Such a capacity for research management should be enhanced. Some users of research results may be the researchers themselves, who want to use research results to improve health systems issues and therefore not published. However, there is a strong view that publication and utilization should be separated. Publications normally amongst others aim at the peer review of scientific validity. Many publications are not scientifically scrutinized these days and the editorial boards of scientific journals need appropriate training for peer review. Documents to encourage utilization have to be synthesized from scientifically valid work into packages for different target users. For example, the packages for the policy makers on the “Reforms for Civil Servant Benefits Schemes in Thailand” were developed from the analysis and synthesis of more than ten scientific publications, into a form that users (decision-makers) could understand. The packages have included the recommendations of actual actions to be taken or avoided as well as the consequences of those actions. Therefore, a series of research questions must be packaged to answer some policy questions at the outset. Uses of research are not usually in the hand of the researchers alone. Users normally decide themselves whether they should use research results or not. What is in the hands of the researchers is the dissemination of research results in understandable form. There could be two possible forms of dissemination. One is to 18 disseminate in scientific journals for consumption by the scientific communities. Another form is the dissemination to users outside the scientific community, such as policy makers and the general public, in an attractive form. A challenge is transform such knowledge conveyed in the scientific journals into relevant forms or messages understandable by the users. Academics or research scientists often do not have such skills. Thus, the capacity of the supplier of research to package the research results to various user targets needs to be strengthened. 5.3.3 Resource mobilization: There are two key strategic areas for resource mobilization, (a) coordination at the country level and (b) impact assessment, i.e., the cost effectiveness of investment. Some issues, as stated below, about what capacities on research resource mobilization to be developed still remain and need to be clarified and evolved. � How does a country measure its capacity (institutional and human resources) in a given context to identify the gaps and imbalances of research resources to deal with priority agenda? � How a country can avoid that the research agenda may be driven by the capacity already existing in the country? � If a country has clinicians or public health specialists or epidemiologists and no biomedical researchers, the persons and capacity available might influence the priority research agenda. In other words, how does a country identify the extent to which the existing research capacity determines the research agenda? � What can be done to correct the imbalances and the gap? Other important questions include: � Is there a 'critical mass' required to sustain a meaningful health research system? � What is the approach to a balance effort for capacity development of individuals, institutions and the systems itself? � How can countries tackle the problems of internal and external "brain drain"? � How do countries build capacity of the research system or retain them? � How, who and when to address these issues? It is essential that the development of National Health Research System has put emphasis on the utilization and impact of research. Only when research producers can show the impact of research through publications and utilization, it would be difficult to argue for more funds especially in the time of economic crisis. 5.3.4 How to build the needed capacity? The following strategies might be adopted to strengthen the needed capacity. Mobilization: Can the countries mobilize existing resources within countries? 19 Networking: A single country does not have enough capacity. It could be strengthened through arrangement of networking. The establishment of the HELLIS network is one example to increase access to health literature and library information materials to countries. Networking among institutions and individuals within a country or across the countries in specific research agenda is also another example. Networking and partnerships with mobilization of potential resources can assist countries in capacity strengthening. Country-focused capacity strengthening plan: Development of capacity in technical skill and competence for research development and management, negotiation skill, leadership skill and networking are major areas for strengthening. Catalytic role of WHO: WHO-SEARO could act as a catalyst or facilitator, but countries should have to work closely with WHO in their capacity development meaningful. For example, a significant cadre of experts from both inter- country and national training workshops on ethics has been established with the support and facilitation by WHO-SEARO. How the countries would use these experts to cope with the ethical issues of health research in their own countries? Clearinghouse of experts: There should definitely have the listings of regional experts and participants who have gone through such specific trainings. Countries can share their cost and host trainings to help others. Countries can take turn to carry out workshops through cost sharing mechanisms. Clearinghouse of modules: WHO can also act as or make a few national institutions or WHOCC to function as clearinghouses for the health research training materials, including educational modules for countries. Refinement of tools and methods: A compilation of health research tolls and methodologies and guidelines should be encouraged and SEARO can coordinate the use and refinement of these tools for use in the region. Use of information technology: It has to be emphasized that in response to rapid changes, countries will need capacity strengthening about how to use of information technology for research system development including the capacity to screen important emerging knowledge and technology. Capacity strengthening is more than training. It involves the creation of an environment of learning organization, through partnerships among producers and users of health research. Such a partnership will empower both the producers and the users. In a learning organization, mechanisms have to be set up to monitor, evaluate, summarize lessons learnt and give feed back to the players in the learning organization. 20 Regional research programmes: could be used as the mechanisms to foster capacity strengthening through such learning organizations. Involvement in inter-country research programmes to tackle regional health problems such as thalassemia, drug-resistant malaria, management of kala- azar or arsenic poisoning, snakebites, etc., helped the researchers to strengthen the capacity. Also, inter-regional partnerships can be explored to create many learning organizations relevant to global problems such as multi- drug-resistant tuberculosis, or genetic diseases. Information technology can be capitalized to strengthen the "learning organizations" around national, regional and global priority areas addressing not only the resurgence of infections and diseases associated with poverty but also problems where advances in sciences such as genomes technology can help to tackle. The capacity developed through the learning organizations around a specific topic can be applied to other areas when existing problems are adequately addressed. 5.4 Support to health research systems Strategies have to be practical and meaningful to support the notion of enhancing country focus in the use of health research to support health systems. This will entail increasing support for health research from the government. A compendium of examples on how countries get their resources for research could be developed. At the country level, the possible steps to increase support for research are: (1) The analysis of resources and resource flows for health research: Optimization of resources from several funding agencies is necessary to pool the resources and optimize its use in research in similar areas. In genomic projects, at least six donors are giving support to India without much coordination between them. (2) The encouragement of the countries to organize donors’ meetings and getting consensus with them about health research needs with clear- cut documents. (3) The development of training courses in several countries where health/medical research councils and appropriate agencies can share common burden. (4) The information sharing on health research development 5.4.1 Capture any opportunity: Research institutions could capture any opportunity from the country political environment and argue for support for evidence-based policy. There are some advocates for a smaller health ministry and efforts to further accelerate public health sector reforms. These could be the challenges to the health research systems as how they would bring more support to the health system. Improved communication with the stakeholders to create appropriate understandings of the people about the need to 21 support health research system, in response to the changing political environment can help create a healthy atmosphere for good research environment. 5.4.2 Conducive to a good research environment: The creation of a good health research system is conducive to a good research environment. Isolated programmes to create researchers without research system development can be undesirable, since the researchers produced will have no stable career and job opportunities. Career development of researcher, research managers and research coordinators can be considered as a part of the research system development. The system and the environment should be a part and parcel of the same development, which would take care of both innovations and agenda based research. It is difficult to have a good career without a good research system. E.g., the Thailand’s NHSRI has facilitated some big-scale long-term research projects such as those dealing with empowerment (decentralization) or issues related to reduction of imports and improvement of self sufficiency in health technology. These projects would entail involvement of several disciplines of scientists, such as genetics and biological scientists, clinicians and social scientists. Also, the NHSRI have supported many multi- disciplinary research programmes, in which PhD students work as apprentices on research questions which can contribute to long term national and health development, and supported area-based research programmes to strengthen the capacity of local researchers. At the community levels, researchers in specific catchments areas have been gloomed in problem-and need-driven research relevant to local problems for eventual decentralization and sustainability of health care system. 5.4.3 Specific programmes targeted: In addition to the contribution by the research system to good health research environment, there can be specific programmes targeted at improvement of the research environment per se. An example is the pairing of health care providers, practitioners with academic institutions in research to tackle local problems. This has helped build research capacities among the providers and help orient academics in formulating appropriate questions. Another example is the effort of Thailand Research Fund (TRF) that has supported inter-disciplinary and basic research in all branches of science. Recently, the TRF has received approval from the Thai Cabinet to launch the Royal Golden Jubilee Project commemorating the 50th anniversary of the ascension to the throne of His Majesty the King. The Funds give sufficient no-bonded research grants to each student for Ph.D. studies in Thai Universities. Each grant covers not only the student’s stipend, tuition and research allowance, but also a budget to pursue elective studies, research and data analysis in any collaborating universities abroad. The efforts will enable Thailand to improve its research capacity and the University infrastructure in addition to production of researchers. Focusing on research culture and the career structure of the researchers can improve research environment. 5.4.4 Measure against brain drain: By creating a good research system, research institutions will be strengthened, which can be an important measure against brain drain. Institutions should also be strengthened with respect to 22 the capacity to link the researchers and users both at the level of providers as well as linking directly with the consumers and civil society levels. Users will then be more appreciative of research and therefore the strategy can be conducive to good environment. Strengthening multi-disciplinary research within and between institutions can make research more effective and therefore produce better argument in support for research. For example, linking basic research and operation research, hand in hand, can be encouraged. Research on vaccine development could be linked to research on good methods of vaccine delivery. This can make research more effective and therefore become conducive to creating good environment. 5.4.5 Consortium approach: At the international level, the consortium approach at the regional level, with WHO as the focal point for coordinating development partners in health research, could be encouraged. Intrinsic funding of WHO for research has been diminishing. The extra- budgetary funds also are diminishing in the past decades. There are some good prospects of bringing in funds. WHO has to expand partnerships with a wider range of development partners by outsourcing the international support for research and development, e.g. Leprosy and Polio eradication programmes, HIV/AIDS, TB control. In all these programmes, WHO has to use its technical leadership strengths to draw in development partners to help improve health development in the Region. The role of WHO-SEARO and WHO Representatives should be strongly identified within the framework of the strengths and limitations of WHO. One critical role is that of an honest broker who helps channel resources for research. In doing so, the countries should have some research agenda, to be ready to enable WHO advocate on their behalf. Regardless of WHO acting as a convener of development partners to support health research efforts, the principle of country-focus must be maintained. International collaboration in research should tackle common problems that expand beyond international boundaries. Countries should coordinate donors at country level; conduct resource flows analysis to understand the situation; and cooperate in international efforts for research on international issues. 5.4.6 Partnerships: One key objective of regional partnerships is to mobilize support to countries with different stage and rate of development. Research capacity development should respond to different and distinctive needs. As changes are rapid and unpredictable, countries should have the capacity to respond rapidly to changing research needs. The first step to develop a partnership is to identify cross cutting needs of development partners and set priorities for research issues related to the concerns by development partners. At the later stage, partnerships might be formed to address the special needs of some partners. Finally, countries with poor resources and infrastructure need more attention in capacity strengthening. WHO can use some of its country and intercountry budget to facilitate the formation of partnerships in the 23 Region to promote the development of the national health research systems rather than supporting the inter-country research projects alone. Partnerships and twinning countries or institutions must be based on equal partnerships to address special complementary needs and mutual benefits. In designing a partnership package, it is important to guard against enthusiastic promotion of specific interventions perceived by one partner as useful. Rather, an equal partnership should be based on a good design of a two-way dialogue, which could avoid dominance of one partner. Some guides for good partnerships might be needed. A good partnership must respond to the legitimate needs of the partners in terms of knowledge generation, transfer of technology and capacity strengthening. Partnership efforts should also be monitored. The use existing infrastructure like network of WHOCC and national centres of expertise for fostering good partnerships could be explored. At the moment, some WHOCCs are not utilized to their full potentials. SEARO can facilitate inter-country cooperation in strengthening the health research system to tackle health issues of the countries by encouraging inter-countries collaboration using inter-country budget. The experiences gained can be documented and compared based on the concepts of equal partnership and learning organization. 5.5 Governance 5.5.1 The country level: Mechanisms must be established to empower the people and the society to demand good governance and engage them in the policy process. The central importance of ownership and involvement of the community and the public in general is to be emphasized. How this will happen is a big challenge. How it will happen in an equitable way is going to be a bigger challenge. Another challenge is how the community and the public will be more involved in the determination of the broader systems and health research priorities? In order to allow productive and meaningful involvement of the community and the public, there must be some mechanisms to develop their capacity to understand usefulness of health research. If we involve the community only as a token, it can be more harmful than good. Documenting various systems of governance for health research in countries must be encouraged. In India, the Division of Planning convenes experts for advices to set resource allocation goals. Many ministries do not talk to one another and independently draw their own plan of action. The Indian Medical Research Council, through its own governing body has its own objectives and plans. Many academic and research institutions do the same. Many of them link directly to international donors and carry out programmes agreed upon by the agencies and donors. The research studies on the effectiveness of DOTS for TB control and national immunization days for polio eradication (pulse-polio) were carried out in India, but the importance of such research results had not been conveyed properly to the decision-makers. It came back to India via a roundabout route through WHO advocacy. It is, therefore, necessary to do the analysis of the existing systems and suggest appropriate national architecture, which will make help effective coordination and promotion of close 24 interaction. In Indonesia, the Ministry of Social Welfare, Education and Health, has been creating a platform of working together. This allows some form of interaction and good governance. The decentralization in Indonesia is another example that takes the issues of good governance to the grass root levels. These are a few examples that countries are encouraged to share. WHO together with countries must establish and enforce the codes of conduct for international cooperation in health research, to dampen the criticisms by some, that the international political economy for health research has been unfair, inequitable, and exploitative. There has been some work already done on it. Further discussions are needed to design actions to address the recurring issues related to intellectual property rights, especially health research related to traditional medicine, drugs and vaccines, since there have already been a lot of discussions in various forums. 5.5.2 International levels: The issues described above apply to the institutions at the international level. However, many complaints of unfair cooperation are based on non-systematic experiences. To what extent is there a problem of un-coordination between international agencies that are harmful to countries? Is this affecting research agenda of the countries? If so, by how much and is this a problem? To what extent is the continuity of knowledge generation in countries affected by donor driven agenda? Is increasing inequity and impoverishment be adequately helped by more coordination? 6. From strategies to actions There is an agreement about the values, the principles, the focus of health research, and health research system. It is assumed that health research system might be useful and have added advantage if efficient. There are also some agreements about the components of health research systems and what they are supposed to do. The question is what next? What can countries do to move this forward and be useful as expected? 6.1 Situation analysis In order to understand what is happening within a complex health research system development, there is a need for a thorough situation analysis. Such situation analysis goes beyond the description of the systems. The analysis should be part of national process and also include generation of information for better understanding of the strength and weaknesses of the health research system, which would then help strengthen the effectiveness of the system. 25 A situation analysis can be shared with stakeholders to start discussions about how to move things forward. Situation analysis starts with what exists, is non- threatening and neutral and links to the notion of planning forward. It should be context based and emphasizing the notion of country-base approaches. The activity in itself can lead to capacity development. Some external involvement is desirable because it can lend additional objectivity to the process. It may allow situation to represent multiple perspectives and it can facilitate consensus and acting as an 'honest broker' in a situation when the solidarity within countries can be improved. Situation analysis will lend itself to an easier 'knock-on' effect for other countries. It may lend itself to facilitate some appropriate cross country comparisons, but not ranking. It may promote linkages between countries and enhance regional cooperation. 6.2 The framework and tools Some framework and lay-out and tools can allow some commonality between countries. The common framework consists of country contexts; use of policy analysis to understand the supply side; understanding of the stakeholders, their roles and functions, structures or some coordinating networks; and understanding about the whole issues of financing (source, growth, allocation). Countries can cooperate to define and refine tools to conduct a situation analysis. There are tools already available such as priority setting and resource flows analysis. Countries can adopt different methodologies keeping the basic principles of analysis on specific areas. Once the tools are being used, they can be further refined and eventually perfected to address the effective performance of the health research system within the context of the health system and the broader development system. How is this going to happen will require some strategic thinking. Who will coordinate and initiate the process from within the country? Should it be decided through national consensus? Is there an obvious 'focal point' and commitment, time, resources? What is degree of solidarity and capacity to move the situation analysis forward? 6.3 Regional partnership and the WHO roles Regional partnership must be strengthened to support countries in their effort to build the national health research system. The Annecy Document reported about operational roles of WHO in supporting regional partnership. Many of these recommendations are valid for today. WHO through consensus with the regional partners can play a pivotal role in the strengthening of partnership for health research. The regional partners include not only the UN Agencies, but also the Asian Development Bank, the bi-lateral and multi-lateral organizations, the NGOs and the development agencies. The partnership covers the financial assistance, as well as other resources such as exchanges of 26 publications, secondment of personnel and sharing existing programmes and activities supported by these agencies. The operating principles for WHO to support research capacity strengthening efforts should be operationalized, i.e.: � WHO should contribute to the national efforts for promotion and development of health research that should be tailored to the distinctive needs and priorities of the countries. Different strategies would be needed to support the country’s needs. � WHO should act as proactive partnerships in health research development, seeking the opportunities to complement and strengthen what other development partners are already doing. WHO and the countries may need to explore possible mechanisms to strengthen regional and national partnerships to avoid fragmentation and redundancy of efforts and provide an efficient approach to identify problem gaps in the region, which can be answered by research. Proactive partnerships could be expressed in several forms such as provision of meeting points and platforms for discussions; support training, sharing lessons leant from the “learning organization”, exchanges of software; and targeting consultancy roles. This would avoid unnecessary and unhelpful duplication and maximize synergy among various players. WHO should also keep away from generating more ill conceived “initiatives” in research capability strengthening, which might complicate existing complex situation. � The key role of WHO is to develop a global leadership, advocacy and promotion of health research. The emphasis should be placed on the exploration of WHO stewardship role in making advocacy for increased investment (both political and financial) in science and technology generally, and equity-oriented health research in particular, and enhancing its coordination of all development partners at the country level. This implies that the first next step for WHO is to implement a situation analysis of all actors in the regions (UN and non-UN system) and sharing plan of works and results. WHO may also need to develop mechanism to coordinate potential actors. � WHO should maximize the utility of its current functions, structures and mechanisms to support capacity strengthening needs of countries such as fellowship awards, support of WHOCCs, selection and placements of short term consultants, and exchange of research scientists and expertise. WHO should improve its own coordination of health research within WHO at all levels. � WHO should be a role model of health research especially on evidence based planning, learning and innovation within the organization. 27 Finally, some mechanisms must be designed in advance to monitor the progress and to evaluate the strategies for health research development. A time line and responsible groups must be defined at an early stage. This strategy document should not only be served as a guideline, but also be translated into action plans with appropriate incentives, resources required and monitoring mechanisms in place, in order to advance health research system development forward. The present draft is prepared by the expert group consisted of: (a) the ACHR members - Professor N.K. Ganguly (India), Professor Chitr Sitthi-Amorn (Thailand) and Professor Dulitha N. Fernando (Sri Lanka); (b) the senior health research scientists - Professor Aung Than Batu (Myanmar), Professor V. Ramalingaswami (India), Professor C.A.K. Yesudian (India), Dr Wiput Phoolcharoen (Thailand) and Professor Amal C. Syaaf (Indonesia). WHO Staff (Dr Than Sein, Dr Adik Wibowo, Mr. A Meliala and Dr Stephen Jost) provided the secretariat support. 28 Bibliography World Health Organization (1989); National Mechanisms for Health Research Coordination and Management in the countries of South-East Asia Region (unpublished document), WHO SEARO, New Delhi World Health Organization (1993); Health Research Strategies of the South-East Asia Region, WHO SEARO, New Delhi World Health Organization (1997); Declaration on Health Development in the South- East Asia Region in the 21 st century; WHO SEARO, New Delhi World Health Organization (1999); Research strategy and mechanisms for cooperation, report of the Secretariat to the 104 th Session of WHO Executive Board, EB104/2, WHO, Geneva World Health Organization (2000); Management and Coordination of Health Research Activities in the Countries; Report on the Meeting of Scientific Working Group, Bangkok, Thailand, 6-8 October 1999, (SEA-RES-111), WHO SEARO, New Delhi World Health Organization (2000); Formulation of National Health Research Policies and Strategies; Report on the Meeting of Scientific Working Group, Jakarta, Indonesia, 6-8 December 1999, (SEA-RES-112), WHO SEARO, New Delhi World Health Organization (2000); Criteria for setting health research priorities, Report on Meeting of Scientific Working Group, New Delhi, India, 1-3 November 1999, (SEA- RES-113), WHO SEARO, New Delhi World Health Organization (2000); Management of Health Research Information, Report on Meeting of Scientific Working Group, New Delhi, India, 15-17 December 1999, (SEA-RES-114), WHO SEARO, New Delhi World Health Organization (2000); Report of WHO Meeting on Research Capacity Strengthening in Developing Countries; Annecy, France, 26-28 April 2000, WHO, Geneva World Health Organization (2000); Report to the Director-General on the 38 th session of Global Advisory Committee on Health Research (ACHR) held at Bangkok, October 2000 World Health Organization (2001); Proposed Programme Budget for 2002-2003, Document PPB/2002-2003, WHO, Geneva COHERD, Regional Consultative Process-Asia {The Asian Voice}, International Conference on Health Research for Development, Bangkok, Thailand, 10-13 October 2000 COHRED, Health research for development: the continuing challenge, A discussion paper prepared for the International Conference on Health Research for Development, Bangkok, Thailand, 10-13 October 2000 29