Task Force for Health Services Research, Manila, Philippines, 9-10 July 1979 : report of the fourth session

ICP/HSD/017

25 September 1979

LIMITED DISTRIBUTION ENGLISH ONLY

TASK FORCE FOR HEALTH SERVICES RESEARCH Report of the Fourth Session Manila. Philippines 9-10 July 1979

Printed and «istributed by the Regional Office for the western Pacific of the World Health Organization Manila. Philippines Septelliber 1979

CONTENTS

1.

OPENING

••.••.•••••••.••••••.••.•..•.•.•••••••.••••.•.•.•.. •••.•.••••••••••.•••.••••.••.•••••....•.•.•.•• .............. "".............. <II ........ " ...... " .................... " " .......... " .... " ..

1

2.

ORGANIZATION Ol3J'ECTIVES

1 1 1

4.

PRESENTATION OF THE REPORT PART A: BACKGROUND

••••••••••••.•••••••••••••••••••

• ••. ••• ••. •••••• ••. ••••••• ••••. •• •• . . . •

2 2

(1) (2)

Review of the regional programme on HSR ••••.••.••••• Report on the Second Meeting of the ACMR Sub-committee on HSR .............. " .................. " " .............. " .. " .......................... " .... ..

3

PART B:

THE REGIONAL HSR PROGRAMME

5 S 6 '{

(1) ( 2) (3)

(4) (5 ) (6 )

(7) ( 8)

(9) (10) (11 ) (12) (1:3)

General considerations •.•.•.•••••••••••.•.•......•... Strategyt.o develop nat.ional HSR capability •••••..••• Manpower deve 1 opme nt ••...•....•.•..•................• Project assessment and support ••••••...•..•••.••••••• Coordinating networks •.••••.••••••••••••••••••••..••• WHO collaborating centres for HSR •••••••••.•.•••••••• Information requirements ••••••••.••••••.••.••••.••.•• Programme budget •••••••••••••••••••••••...••••••••••. Programme management •••.•••..........•..............• Involvement of China ••••••••.•••••••••.••••.••••••.•• Future of the Task Force " .................. " " .... " " .................. " .. Closure "........ ".... "........................................................................ .. .................................................... ..

H

'J ':I 10 11 12

...

12 12 12

SUl'I'UIlary of recoDlDendations

13

ANNEXES 1 - List of Participants . • • • • • • • • • • • • • • • • • • • • • • . • • • . • • . • . • 2 - Provisional Agenda .••••••••••••••••••••••••••••••••••• 3 - Report of Secretary of Task Force on Health Services 1') 17

Research ............ ,. . .. . . . .. .. .. . . . .. . .. .. .. .. .. . .. .. . .. .. .. . . . .. .. . . . . . .. . .. .. 19 4 - The Korean Health Development Institute (KHDI) and researcr. activities (Statement by Professor E. Hyock Kwon) 49 5 - Draft report of ACMR Sub-committee on HSR meeting in Alexandria, 26-29 June 1979 •..•••....•.....••..•...... ,~

I'

1.

OPENING

The Regional Director, Dr H. Nakajima, in his opening remarks said that health services research (HSR) was an important element in the strategy to provide an acceptable level of health for all by the year 2000. WHO was anxious to accelerate and expand its HSR programme, and Dr Nakajima hoped that the Task Force would be able to assist in planning such a programme and identifying the resources that would be needed in the future.

2.

ORGANIZATION

Professor E. Hyock Kwon chaired the meeting. The other officers were: Vice-Chairman: Rapporteur: Mr Peter Pflaum Dr George Salmond

The list of participants is attached as Annex 1. After discussion, the preliminary agenda (Annex 2) was adopted without alteration.

3.

OBJECTIVES

The primary objectives of the task force were: (1) to discuss the draft regional programme on HSR; and (2) to develop programme activities, especially in the areas of training, HSR projects and collaborating centre network. Its subsidiary objective was to review ongoing projects supported by WHO.

4.

PRESENTATION OF THE REPORT

The report is presented in two parts. Part A is concerned with the background to the draft regional programme for HSR presented for consideration at the meeting. Also included is a summary of the main points arising out of the second meeting of the Global ACMR Subcommittee on HSR, held from 26 to 29 June 1979 in Alexandria.

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Part B contains the findings and recommendations of the Task Force on the Region's HSR programme. The Task Force did not review ongoing projects supported by WHO but rather considered the mechanisms for supporting research projects (Section 4). PART A BACKGROUND 1.

Review of the regional programme on HSR

The Chairman introduced the discussion by referring to the report of the Secretary of the Task Force on Health Services Research prepared for the meeting lJ(Annex 3) and briefly summarized the achievements to date. Dr Herniman introduced for general discussion a draft HSR programme for the Region, included as an annex to the Secretary's report. The general objective of the programme was to assist member countries in making more effective progress towards the goal of health for all by the year 2000. To this end, the WHO effort in HSR was to concentrate on elements of primary health care. The long-term objective was to enable member countries in the Region to develop and implement national health service research programmes that were part of the health services development process, the results of which would be used to provide more efficient, effective and equitable health services. In the medium term (1978-1983), the objectives were: (a) the development of national HSR programmes within the framework of government health development activities, including identification of priorities for research through the planning process; (b) the development of national capability to conduct activities identified in the programme; (c) the development of a regional HSR structure to support and enhance national efforts. The draft programme was not considered in detail at this stage of the meeting. The document would be revised by the Secretariat in the light of the report of the Task Force and presented first to the Regional Director and then to the WPACMR for appropriate action. Since the report had been prepared, it was noted that the Korea Health Development Institute (KHDI) had been designated as a WHO Collaborating Centre for HSR. The Chairman gave a full account of the activities of KHDI. This is included as Annex 4.

1/ Document WPR/HSR 4/79.2

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2.

Report on the Second Heeting of the ACMR Sub-Committee on HSR

The meeting was held in Alexandria from 26 to 29 June 1979. About 30 people attended including country representatives as well as regional office and head office staff. Dr Herniman and Dr Salmond represented the Western Pacific Region. Dr Salmond introduced the discussion on the draft report of the meeting (Annex 5) and summarized the main points and achievements of the meeting. The main aim was to review regional and headquarters submissions on existing or proposed HSR activities and to prepare and cost a consolidated global programmes for HSR. The present report was very much a draft and would be revised in Geneva before being sent to regions for comment in August. The draft together with the comments would be reconsidered by the subcommittee at a meeting in Washington in November 1979 and a final report with a firm budget would be prepared for transmission to the Director-General. The views and recommendations in the report were very much in line with the proposed HSR programme developments in WPR. The ACHR report would provide strong support, and it was hoped, resources for the implementation of the Region's HSR programme. On the matter of research priorities, it was agreed that this matter was best left to countries, and it was also agreed that the WHO effort in health services research should concentrate on elements of primary health care. It was agreed that the development of a strong national capability for HSR was ·important in all countries. Some developed countries already had a considerable capability for research, but the topics selected for study were often unrelated to priority health problems, and the strategies adapted failed to ensure that the results were used to improve the delivery of care. In such countries, refocussing of the research effort was needed. In developing countries, the problems were different. Many had little or no capacity for studying their health problems. They lacked people with the technical, managerial and leadership skills required to plan, manage and carry out research, and to ensure that the results were used. More people with these skills were needed, as well as the means to multiply their number. The Sub-Committee agreed that all countries should devote a greater proportion of new national health expenditure to HSR. The Alexandria meeting was of the opinion that HSR, like country health programming and primary health ca~e, should be looked upon as one of the strategies which might be used to advance the cause of world health generally. A separate division of HSR within WHO was not considered desirable but rather the HSR component of existing vertical programmes should be strengthened and coordinated by suitable representative ad hoc groups at the Headquarters and regional levels. These groups should ~ adequately serviced by support staff.

- 4 -

Funds to support HSR projects should be available within the regular budget of WHO, and also from extrabudgetary sources. However, as far as possible, projects should be supported by country funds or funds from appropriate vertical programmes within WHO. Before research was funded from WHO's HSR budget, there should be full consultation between all interested parties both within and outside the Organization. At the Alexandria meeting, the Sub-Committee agreed that main emphasis of the WHO HSR programme should cover all aspects of strengthening national HSR capability. Ways and means were suggested in the report as to how this might be done. Information flow was an essential element in the development of the HSR programme at all levels. HSR project inventories shuuld be kept in some form at country, regional and global levels. Within regions and 1n larger countries, news letters or an HSR journal might be helpful. Within each country, there should be a focal point for coordinating the national HSR effort and for communicating with WHO and other outside agencies interested in research. Such a focus should establish close working links with the Health Ministry, the research community, research funding agencies, national socioeconomic and health planning groups and other sectors involved in health related activity. To promote HSR in the regions, the Alexandria meeting suggested that the strategy of regional and national HSR workshops developed in SEARO might be a useful model to follow. WHO had a key role to play at both the headquarters and regional levels in helping countries to strengthen their HSR capability and develop their HSR programmes. Lists of the activities required at both levels are given in the report. If these requirements were to be met, there would have to be significant strengthening of WHO staff at both levels available to support the programme. Budget provision would be needed for this.

On the matter of funding, it was agreed that large sums of money were not needed immediately and could be an embarrassment. What was required was a dependable flow of funds with the potential for growth as HSR capability increased. Initially the biggest investment should be in all aspects of manpower development for HSR. It was confidently expected that, as a result of the ACMR subcommittee's submissions, further funds would be available for the HSR programme. Dr Salmond went on to indicate that plans were being developed at Headquarters to hold a one week working group involving technical experts to develop guidelines for training programmes in HSR at all levels. This was expected to take place early next year and would be of considerable interest and use to the Region.

- 5 -

PART B THE REGIONAL HSR PROGRAMME 1. General considerations

In response to the report of the Alexandria meeting, the following general points were made about the HSR programme: Research activity in health services must take aC'count of the wider aspects of socioeconomic development. Activities in other sectors of the economy which have a bearing on health must be considered. Environmental health and occupational health are important areas for HSR which tend to be neglected. HSR, which involves active community participation in the research process, is a very new type of research of which few people have experience. In such research it is often necessary to devise new research methods or to sacrifice elements of the research design in order to sustain community participation. It is important that those responsible for assessing research proposals for funding take due account of the special requirements and difficulties of this type of research and try to obtain first hand experience of the work being done. Those who have undertaken HSR with rather than on communities should be encouraged to write up their experience so others can benefit and learn from it. Case studies would be useful. In the early stages of programme development it may be necessary to support research which methodologically is high risk. Whenever possible efforts should be made to find help for workers involved in such projects. Such research should usually be small scale and short term. HSR is an integral part of health services planning and development at all levels. Close working relationships should therefore be developed between HSR interests and national socioeconomic and health planning groups in countries and the country health programming activities supported by WHO. The development of an HSR programme in WPR is complicated by the cultural diversity of countries in the Region and the wide range in terms of both ideological orientation and socioeconomic development. In developing the programme, a very flexible apprOach must be adopted to take account of these important differences.

- 6 -

2.

Strategy to develop national HSR capability

Now that the Region's Working Croup on HSR has met and reported, the next stage in the development of the Region's RSR programme is the holding in countries of national HSR workshops. The Task Force agreed that the running of these workshops should jointlY involve the country and WHO. Each workshop should be specifically designed to meet the national need. Such workshops could include the following: The services of a consultant to help to plan the workshop. Such a consultant should spend time in the country before the workshop so that he was well acquainted with the local scene ~nd should participate in the workshop activities and the followup. Seminar for policy makers, senior health administrators and national, socioeconomic and health planners. Seminars specifically aimed at the needs of those who must organize, manage and report research and see that the results are used. Sessions for persons involved in the technical aspects of HSR. Training programmes for health workers involved in HSR projects. Adaptability to local conditions and requirements must be the key factor in running such workshops. One of the reasons for sponsoring country workshops is to identify and support the national focal point for collabprating HSR networks. This should be kept in mind from the outset. Some countries in the Region may be too small to run their own workshops but all should be able to identify a focal point, an institution or a person, for RSR activities. For instance, in the South Pacific, it may be desirable for Fiji to be the centre for RSR activities. In terms of a timetable it is recommended that the first country workshop should be held in the Republic of Korea. based on KHDI, and if possible should be arranged for early 1980. Discussions should begin immediately with a view to holding workshops in Malaysia, the Philippines and in Fiji. Once resources are available from the global RSR programme, there will be good and tangible reasons for countries to be interested in participating in the Region's programme.

- 7 -

It is recommended that country workshops be held as part of a roll ing programme. At each workshop, there should be 'representatives from the country which has just held a workshop and from the country in which the next workshop will be held. In this way it should be possible for countries to benefit from each others experience and for the workshop format to be improved as the whole programme evolves.

Once the workshop programme is under way, thought should be given to holding intercity, intercountry, regional or interregional conRuitations and meetings on aspects of HSR experience and practice. 3. Manpower development

The Task Fo,ce supports the view of the Alexandria'meeting that manpower development is the single most important element of the HSR programme. In discussion, the following points were made: Training opportunities must be available at a number of levels within the Region. However, it is particularly important at this stage to train people capable of organizing, managing and carrying out HSR. The multidisciplinary aspects of training should be emphasized and the required provisions made. Efforts should be made to involve people from other disciplines than that of medicine in projects and in the WHO programme at all levels. Efforts must be made to find and develop suitable training opportunities within the Region. Training should involve real life situations and learning-by-doing. A variety of training techniques might be used, including attachment to teaching units, case study consultations, short courses on technical and other aspects of HSR, simulation, programme learning and computer-assisted instruction. These need development. Training should be specifically tailored to the needs of individuals. Great care should be taken to ensure that the required training is provided. Preoccupation with academic qualifications of questionable relevance should be discouraged. Within WHO, the fellowship programme provides a mechanism for organizing the training of leaders: those who will plan, organize, manage and report HSR projects. The tra1n1ng of such people is particularly important and should be organized with flexibility and care. Once a worker is adequately trained and has returned home, efforts should be made to ensure that he has the opportunity to use his newly acquired skills.

- 8 -

Where appropriate, tpachi.ng in;1 multidisciplinary .'nvironmf'nt should be encouraged, i.p. persons from different disciplines training together. The proposed working group to develop guidelines for training for HSR will be of considerable interest and use to programme development in the manpower area. It is recommended that those responsible for administering the Region's HSR programme should give special attention to and should actively promote the development of HSR manpower as outlined. 4. Project ass~~sment and support

The Task Force agreed that the WHO programme must continue to make funds available for project support, especially in developing countries. In developed countries, funds can usually be obtained by claiming that investment in HSR will result in more effective and efficient health services. In developing countries, such claims have less appeal, especially if funding research means that certain basic health care needs cannot be met. Outside funds will be probably always be needed to support HSR in the developing world. The Task Force agreed that the present mechanism for assessing HSR project proposals for funding by WHO is not satisfactory. After an internal assessment by interested officers in the Regional Office, proposals are sent to selected members of ACMR for review and report. After these reports have been received, the proposal is again reviewed by the internal assessors and then submitted with a recommendation to a group of senior officers for decision. Projects are dealt with on a first-come first-served basis. This system is not satisfactory for a variety of reasons. First, the process is very slow, projects taking six months or more to be processed. Second, the members of ACMR asked to make assessments often have no first-hand experience of research of the type proposed. This is particularly so in the field of HSR. Third, by funding projects on a first-come first-served basis funds are exhausted eqrly in the year and therefore some good projects cannot receive immediate support. Again from an HSR point of view, this is unfortunate because timely funding to take advantage of a research opportunity is often important. The Task Force recommends that: 1. 2. A sum be identified in the HSR programme budget for the support of projects; The sum provided be split into two parts: a sum for "seed money" and for proposals costing not more than $10 000, and a sum for the support of larger projects; Appl ications involving "seed money" or sum 0 f less than $10 000 should be assessed by the internal assessing group and on their recommendation an immediate decision should be made;

3.

- 9 -

4.

Applications involving $10 000 or more should be reviewed by one or more outside referees with, if possible, first hand experience of the research proposed; The funds available for supporting major projects should be divided into quarters; and Projects should be aggregated each quarter and funding determined on a priority basis.

5. 6.

The Task Force agreed that, once coordinating foci for HSR are established in countries, all research proposals should either come through or be referred to such foci. The Task Force recommended that a list of experts on HSR be developed for the Region who could be called upon for advise and whose help could be sought in assessing project proposals. On the matter of priorities for project support, the Task Force recommended that primary health care projects be given high priority. However, the Task Force recognizes that research into the financing of health services, into the use of appropriate technology and into hospital-based health care is also important and should be considered for funding. 5. Coordinating networks

The Task Force supported the idea of a coordinating network for HSR. Within each country there should be a focal point for coordinating the national HSR effort and for communicating with WHO and other agencies interested in research. Such a focus should establish close working links with the Health Ministry, with research funding agencies, with national socioeconomic and health planning groups and with the research and teaching community in universities and other institutions. While in some countries it may be appropriate for the national focal point to be within the ministry of health, this may not always be so. Wherever it is located, it must fulfil its function as a nodal point for communications on all matters pertaining to HSR. In countries which have national health development centres, as is currently recommended by WHO, the national HSR focus may be conveniently located within such centres. It is recommended that the necessary steps be taken to open discussions with the countries in the Region on the establishment of focal points and coordinating networks for HSR. 6. WHO collaborating centres for HSR

The Task Force supports the concept of WHO collaborating centres for HSR, but sees these as being quite distinct from the coordinating network concept. Coordinating networks are mainly for the purposes of communication and administration of HSR programmes. WHO collaborating centres for HSR should be recognized centres of excellence, which are actively involved with WHO in some aspect of the Organization's programme of work.

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The Task Force agreed that as soon as possible, it would be to have at least three or four WHO collaborating centres for HSR Region. However, it is probably better that these come to light course of events as the programme develops rather than that they actively sought out and pressed into collaboration. 7. Information requirements

desirable in the in the be

The establishment of information flows will be an essential element in the development of the Region's HSR programme. The Task Force recommends that Headquarters and the Regional Office should combine resources to produce general guidelines which countries can use to develop and maintain an inventory or register of HSR projects. The inventories produced by each country should be in keeping with the local needs. It is expected that the keeping of some form of inventory will be an essential part of each country's HSR programme. All countries should send copies of their HSR inventories or project registers to the secretariat of the regional HSR programme. All up-dates should also be sent. The secretariat should then notify through coordinating networks what registers it holds and from whom copies can be made available. The Task Force recommends that, at this stage, no steps should be taken to update the regional register of HSR projects prepared by the Task Force in 1977. The Task Force recognizes that there is a need for some regular communication between HSR interests in the Region. It therefore recommends that consideration be given to establishing a quarterly "HSR Newsletter", to be developed by the secretariat and sent to members of the coordinating networks in the Region. Such a. newsletter might contain details about the development of the WHO HSR programme, about interesting projects in the Region, about training opportunities and about interesting HSR developments in countries. It could also be used as a vehicle for researchers in different parts of the Region to exchange experiences and useful information. The regular production of a newsletter would require considerable time and effort on behalf of the programme staff but the Task Force believes that the results wi.l be worth the effort. Finally, the Task Force recommends that some programme funds should be available to provide books and journals on HSR for research groups who would otherwise have difficulty in obtaining access to such information.

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8.

Programme budget

The Task Force had some difficulty in deriving a budget for the Region's HSR programmes. However, after careful consideration of the various items the following budget was agreed for the next four year period 1980-1983. US$ constant 1980 1.

1981 200 000

1982 300 000

1983 350 000

Support for research projects Strengthening national HSR capability - manpower development - institutional strengthening

100 000

2.

100 000 50 000

125 000 75 000

150 000 100 000

150 000 100 000

3.

Programme development and management meetings of the Task Force country workshops information support professional and administrative support 20 000 25 000 10 000 55 000 360 000 20 000 25 000 15 000 55 000 515 000 20 000 25 000 15 000 55 000 665 000 20 000 25 000 15 000 55 000 715 000

Total budget notes: 1.

Support for research projects is expected to increase rapidly as a result of country workshop activity. It is accepted that a number of countries in the Region will require continuing project support by WHO if HSR activities are to be sustained. ~Anpower

2.

development includes the cost of fellowships 1n HSR (50-60 man months each year) and the cost of running one major 2-3 week training course for 20 people each year.

3.

Institutional strengthening includes funds for building and supporting the collaborating networks and for supporting WHO Collaborating Centres for HSR. It is anticipated that the Task Force (or some other group) should meet at least once a year to assist the secretariat to guide the HSR programme. Country workshops are budgeted for at the rate of two per year. Information support includes support for HSR inventories and funds to develop the Region's "HSR Newsletter".

4.

5. 6.

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7.

Professional and administrative support includes the cost of a programme manager, together with clerical support.

The Task Force recommends that WHO seek to obtain, from extrabudgetary sources, the funds required for the Region's HSR programme budget as outlined. 9. Programme management

The Task Force wishes to recommend that appropriate management support be given to develop and run the Region's HSR programme. Consideration should be given to the provision of a full-time manager together with clerical support. A great deal of work is required on the part of the secretariat if the HSR programme is to develop in keeping with the objectives set and the time-table of work agreed. Initially the load on the secretariat will be very heavy: project proposals must be assessed; coordinating networks organized; WHO Collaborating Centres in HSR approved; country workshops arranged; manpower development promoted in a variety of ways; HSR inventories organized, gathered and extracted; a newsletter developed together with the general organization and development of the programme within WHO. Without the additional staff recommended, the Task Force believes the work required cannot be done. 10. Involvement of China

There are many reasons to believe that the added representation of China to the HSR Task Force would bring a new dimension to our discussions which could greatly enhance the Region's HSR programme. The Task Force noted the intention of the WPACMR to seek a management scientist from China to join the Committee and also to serve as vice-chairman of the proposed subcommittee on HSR and occupational health. The Task Force strongly supports this suggestion. 11. Future of the Task Force

It was noted that the WPACMR had at its last meeting recommended that the Task Force on HSR be disbanded and that a combined subcommittee on HSR and occupational health be created. The Task Force agreed that such an arrangement would be unsatisfactory and not workable because of lack of common interests between the two groups of people who would be involved. It was agreed that research in occupational health is of considerable importance but it is only one area in which HSR is required. Similarly there are important areas for research in occupational health which are outside the realms of HSR. The Task Force therefore recommends that the WPACMR reconsider its decision and if necessary establish two subcommittees, one for HSR the other for occupational health. 12. Closure

In his closing remarks, the Director of Programme Management. Dr S.T. Han thanked the officers and members of the Task Force for their help in developing and costing the Region's HSR programme. Dr Han said that the work of the Task Force would greatly assist WHO in its search for extrabudgetary funds to support the programme.

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13. 1. 2.

Summary of recommendations The Task Force agreed that the running of country HSR workshops should jointly involve the country and WHO. It is recommended that the first country workshop be held in the Republic of Korea, based on KHDI, and if possible be arranged for early 1980. Discussions should begin immediately with a view to holding workshops in Malaysia, the Philippines and Fiji. It is recommended that country workshops be held as part of a rolling programme. It is recommended that those responsible for the Region's HSR programme should give special attention to and should actively promote the development of HSR manpower as outlined. The Task Force agreed that the WHO programme must continue to make funds available for project support, especially in developing countries. The Task Force agreed that the present mechanism for assessing HSR project proposals for funding is not satisfactory. The Task Force recommends that the mechanism be revised along the lines suggested in the body of the report. The Task Force agreed that, once coordinating foci for HSR are established in countries, all research proposals should either come through or be referred to such foci. The Task Force recommends that a list of experts on HSR be developed for the Region who could be called upon for advice and whose help could be sought in assessing project proposals. On the matter of priorities, the Task Force recommended that primary health care projects be given high priority.

3. 4.

5.

6. 7. 8.

9.

10. 11.

It is recommended that the necessary steps be taken to open discussions t,ith the countries in the Region on the establishment of focal points and coordinating networks for HSR. The Task Force agreed that as soon as possible it would be desirable to have at least three or four WHO collaborating centres for HSR in the Region. The Task Force agreed that Headquarters and the Regional Office should combine resqurces to produce general guidelines which countries can use to develop and maintain an inventory or register of HSR projects. All countries should send copies of their HSR inventories or project registers to the secretariat of the regional HSR programme. The Task Force recommends that, at this stage, no steps should be taken to update the regional register of HSR projects prepared by the Task Force in 1977.

12.

13.

14.

- 14 -

15.

The Task Force recommends that a quarterly "HSR Newsletter" be developed by the secretariat and sent to members of the coordinating networks in the Region. The Task Force recommends that some programme funds should be available to provide books and journals on HSR for research groups who would otherwise have difficulty in obtaining access to such information. The Task Force recommends that WHO seek to obtain, from extrabudgetary sources, the funds required for the Region's HSR programme budget as out lined. The Task Force recommends that appropriate managerial and clerical support be provided to develop and run the Region's HSR programme, if possible, in the form of a full-time programme manager. The Task Force recommends that a management scientist from China be invited to join the Task Force and to serve as vice-chairman of the proposed subcommittee on HSR and occupational health. The Task Force recommends that the WPACMR reconsider its decision to disband the Task Force and replace it with a subcommittee combining HSR and occupational health interests and suggests that if necessary, two subcommittees be created, one for HSR, the other for occupational health.

16.

17.

18.

19.

20.

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ANNEX I

LIST OF PARTICIPANTS

Professor E. Hyock Kwon (Chairman) Professor Department of Preventive Medicine College of Medicine Seoul National University Seoul Republic of Korea *Vr N.I. Chandra-sekharan Associate Professor Clinical Diagnostic Laboratory Medical Center University of Malaya Kuala Lumpur Malaysia Dr George C. Salmond Director Management Services and Research Unit Department of Health P.O. Box 5013 Wellington New Zealand Dr Antonio de Jesus Project Director, Health Division International Institute of Rural Reconstruction Ermita Manila Philippines *Professor S.S. Ratnam Head. Department of Obstetrics and Gynaecology University of Singapore Singapore 8 Republic of Singapore

*Unable to

atte~d.

- 16 -

Annex 2 Mr Peter Pflaum Policy and Planning Division Department of Health Canberra, A.C.T. P.O. Box 100 Woden, A.C.T. 2606 Australia WHO STAFF Dr R.D. Mercado Director Health Services Development and Planning WHO Western Pacific Regional Office Manila Philippines Dr R.H. Hernima~ Regional Adviser on Health Services Development WHO Western Pacific Regional Office Manila Philippines Dr Wan Fook Kee Regional Adviser on Health Services Development WHO Western Pacific Regional Office Manila Philippines Dr E.H. T. Goon Regional Adviser in Health Manpower Development WHO Western Pacific Regional Office Manila Philippines Dr G.A. Farid Medical Officer, Intercountry project on Tropical Diseases Research WHO Western Pacific Regional Office Manila Philippines Dr G. Nugroho Medical Officer, Intercountry project on Primary Health Care WHO Western Pacific Regional Office Manila Philippines Dr J. Dewdney Medical Officer, Strengthening of Health and Medical Care Delivery project Seoul Republic of Korea

- 17/18 -

ANNEX 2 PROVISIONAL AGENDA Item 1.

Introductory Speaker Regional Director Chairman Chairman Chairman Secretary

Opening of the meeting Election of Vice-Chairman and Rapporteur Adoption of Agenda Introductory statement by Chairman and report of Secretary Second meeting of Global ACMR subcommittee on HSR, Alexandria, June 1979 Regional HSR programme Development of national HSR programmes Collaborating network for HSR Regional information system for HSR programme Support to research activities Role of WPACMR subcommittee on health services and occupational health Programme budget R~view

2. 3.

4.

s.

Dr G. Salmond

6. 6.1 6.2 6.3 6.4 7. 8. 9. 10.

Chairman Secretary Chairman Secretary Chairman Chairman Rapporteur Director, Programme Management

of draft report and recommendations

Closure of meeting

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REPORT OF SECRETARY OF TASK FORCE ON HEALTH SERVICES RESEARCH 1

Iprepared by Dr R. Herniman, Regional Adviser in Health Services Devl' lopment, WHO Regional Office for the Western Pac i fic, Manila

- 20 -

Annex 3 1. 1.1 TASK FORCE ACTIVITIES UP TO THE PRESENT

Meetings of the Task Force

The Task Force for health services research (HSR) was formed by the WHO Advisory Committee on Medical Research for the Western Pacific (WPACHR) in July 1976. The in it ia 1 "task" was to prepare comprehens ive proposals on aspects of (HSR) including budgeting .... and to present them at the next RACMR (WPACMR) meeting" (WPR/ACMR/76.13 report to the first meeting of the WPACMR, 1976). Since the Task Force was established there have been three meetings: in 1976, 1977, and 1978. The results of these meetings have'been to define and clarify policies, approaches, and strategies in developing a regional HSR programme. These are reflected in the reports of the Task Force meetings, and in recommendation made by the Task Force to the WPACMR. 1.1.1 The first ,meeting of the Task Force, Manila, 1976

The first meeting took several important steps. Firstly, the Task Force formulated a definition of HSR that has been adopted in developing the HSR programme. The Task Force defined HSR as: an integral development and as any group of activities which information or the application of knowledge on a view to providing more effective, efficient, and defined popUlations. part of health service involve the generation of scientific basis with a equitable health care for

By using this definition, the Task Force stressed that it regarded HSR as not only a means of improving efficiency and effectiveness of existing health service systems, but as an approach to studying a much broader health system, and to introducing change in any part of this broader system. Having defined HSR, the Task Force then reviewed the scope, areas and priorities for HSR. The scope for HSR was classified under the fOllowing headings: operation technology manpower management cost and financing policy development methods In reviewing areas for HSR, the Task Force points: emphasi~ed

the following

(a) C -"Jntries should develop national programme. for HSR with a central coordinating body for HSR thet was linked to both the planning and operation of health services.

- 21 Annex 3 (b) HSR proposals and studies should be funded largely at country level through the national HSR programme. (c) The role of WHO should be to promote the development of national capability for HSR. The recommendations made by the Task Force at the end of the first meeting were: - to develop a directory of HSR projects in the Region; - to promote the formation of national advisory councils; - to promote all aspects of HSR through workshop held at country level; - to support HSR in the Region through various WHO mechanisms, namely, fellowships, development of educational packages, encouragement of communication, using regional office staff to collaborate in HSR at country level, and funding some HSR proposals. 1.1.2 The second meeting of the Task Force, Manila, April 1977

At this meeting the Task Force addressed itself to several specific objectives; analysis of the results of a questionnaire sent to countries for the HSR directory; consideration of a number of specific research proposals; consideration of a proposal for a regional workshop on HSR; consideration of establishing WHO collaborating centres for HSR in the Region; and review of the continuing role of the Task Force. HSR directory. With regard to the HSR directory, it was agreed that the questionnaire had provided the basis for the directory, but that further information was needed to revise it. It was suggested that the directory be updated with fresh information in 18 months to two years' time. (b) Research proposals. In considering specific research proposals, the Task Force agreed that they should play a role in assessment of proposals submitted for WHO funding. (c) Regional workshop. The proposal for a regional workshop was strongly supported by the Task Force. The objectives and content of such a workshop were considered and the Task Force accepted responsibility for steering the project. (d) Collaborating centres. The Task Force agreed that such collaborating centres for HSK would be desirable, and considered the Korea Health Development Institute as a possible centre. It was agreed that this matter should be considered at the regional workshop. (e) Continuing role of the Task Force. The Task Force felt that in the short term, it should Play 'a role in the following activities: HSR directory assessment of HSR proposals designation of collaborating centres as the steering committee for the regional workshop on HSR (a)

- 22 Annex 3 For the long term, the Task Force, or any group evolving from the Task Force, would be responsible for the development and servicing of an ongoing programme for HSR development in the Region.

1.1.3

The third meeting of the Task Force, Kuala Lumpur, in April 1978

The Task Force was mainly occupied in planning the regional workshop on HSR for August 1978 {discussed in the next paragraph}. lIowever, the meeting also considered other points of importance. The lack of HSR proposals was a concern. The Task Force felt there was a need to prepare guidelines for proposal formulation and that the WHO secretariat should develop and distribute this. The Task Force then made further strategy recommendations following those made at the first meeting: - It was emphasized again that national HSR groups should be formed. These groups should be able to coordinate research, work with government and generate funds. - HSR should be conducted in the framework of health services development and planning, and should follow the primary health care concept. Projects that are isolated from or irrelevant to the national development process should not be supported. - Where possible, maximum use should be made of existing information, and studies using this approach could be impressive and useful. - The lack of trained HSR workers was identified as a major constraint to HSR in the Region, and attention should be given to this area. - Also important was the dissemination of HSR information. Methods for informing HSR information transfer needed to be developed. 1.2 Regional Working Group on HSR

Originally cc'nceived as a regional workshop, this was held in Manila 1n August 1978 as a regional working group. The meeting marked an important step in the efforts of the Task Force to develop a regional HSR programme. The regional working group meeting was a critical point in programme development for the following reasons: (a) the working group reviewed the work of the Task Force,

(b) priorities were identified, and the organization, strategies and methods for the HSR programme were outlined.

- 23 Annex 3 1.2.1 To be more specific, the working group considered the following topics: - review of HSR in the Region organizational straregies and tactics - priorities for HSR - the HSR register - research promotion - education and training - research methods - research planning - the WHO programme 1.2.2 The results of the working group meeting were brought together 1n a comprehensive report that provides a convenient basis for preparing a regional HSR programme, and is thus a key document. The report consists of the following points: - description of the working group meet·ing and recommendations for action; - background documents including: reports of Task Force meetings, country synopses on HSR, papers on research methods and planning; research proposals submitted from countries participating. 1.2.3 The recommendations for future action made by the working group can be summarized as follows: - countries should create a national focal group; - priorities for WHO in developing a programme for HSR should be the fields of p-:imary heal.th care, economic basis of health services, and technology assessment; - country HSR registers should be prepared; - the development of national HSR programmes should be promoted, and these programmes should include training of HSR workers; - the use of simple HSR methods involving where possible the use of existing information should be encouraged; - WHO should establish a programme for HSR within the Western Pacific Region.

- 24 -

Annex 3 Each of these main recommendations were broken down to subsidiary recommendations that will not be listed here. 1.3 Results of HSR activities up to the present

In order to assess the results to date, we can refer to the recommendations of the working group listed under 1.2.3. 1.3.1 National focal groups The following countries have activities in this direction: New Zealand: an institutionalized national focal group for HSR is the joint MaC-Department of Health HSR Committee. Korea: The Korea Health Development Institute has recently been estabiTSfied (1976) by the Government to "conduct systematic empirical research on problems related to public health in order to facilitate the formulation of national policies and programmes in developing an effective system of national health care". Japan: The Ministry of Health supports HSR activities by different agencies under the heading of "research subsidy for health and welfare administration". Australia: The national focal group in the Department of Heal th, although state administrations also are involved. Malaysia: There are various divisions within the Ministry of Health with HSR capability as well as the Institute for Medical Research. The coordinating body is the National Council for Scientific Research and Development. The Ministry of Health has its own Health Research Committee and a representative of this will sit on the National Council. Papua New Guinea: It has been suggested that the Medical Research Advisory Committee could act as the national focal group of HSR. Phili~pines: At present capability for HSR exists within the Ministry of Health Planning Division and Project Management Staff Office), and in certain scientific institutions. Although not yet officially designated, the Ministry of Health Planning Division could act as a national focal group of HSR.

1.3.2

Priorities for HSR

These were identified by the working group as primary health care, financ ing of heal th services, and technology assessment. For primary health care, the Task Force had already indicated earlier that research was necessary to identify mechanisms for the implementation of the concept. Since the Alma Ata Conference, WHO has also turned its attention to this aspect. In the Western Pacific Region, the programme is

- 25 Annex J already working, therefore, HSR must study how to make the PHC concept operational in health services development; and one of the major components of the HSR programme will be in this area. There are important implications in the adoption of this priority in terms of research methodology and strategies for organization and implementation of HSR. As implied in the definition of HSR, the scope of HSR becomes much broader, and includes research into the whole health system, rather than the health services subsystem. If this priority is adopted in national programmes, these implications will have to be taken into consideration. Several rese.Jrch proposals in this area will be mentioned later in this report. For financing of health services. This is of great importance to all countries in the Region and this interest has been clearly expressed to the Task Force. Several studies are proposed, and following a recommendation of the working group, a WHO adviser from HQ will visit several countries in the Region to promote activities further in this field (Dr E.P. Mach). With WHO collaboration, studies on costing of various health programme components have already been carried out (Papua New Guinea and the Philippines). These are mentioned later (Annex 2). As a result of the WHO/HQ study group meeting on financial aspects of health services in November 1978, a technical report was issued (TRS 625). A follow-up meeting, held immediately after with Regional Office Staff attending, identified three WHO programmes that should be involved in financial studies. These were HSR, country health programming (CHP) and primary health care (PRC). For the Western Pacific Region, the proposals presented to the working group in Manila would be followed up. Costing exercises would be expanded in the context of CHP and PHC. Additional WHO programmes where costing studies would be of interest are the expanded programme on immunization, and the programme for diarrhoeal disease control. For technology assessment, there is little to"report. Priority refers to studies concerning the use of high cost technology in health services a matter of major concern to governments with limited resources for health. This aspect could also include the whole field of appropriate technology for health at all levels. 1.3.3 Health service research registers

The regional HSR register or directory was produced after analysis.of completed questionnaires received from Member States. 1.3.4 Development of national HSR programmes

As a result of the activities of the Task Force and the working group meeting, four countries are taking positive action on development of an HSR programme (Malaysia, Papua New Guinea, Philippines and Republic of Korea). Three countries already have an existing programme structure (Australia, Japan and New Zealand).

- 26 -

Annex 3 1.3.5 Use of existing information in HSR No activities have yet been developed. 1.3.6 Establishment of a WHO programme This will be discussed in the following section. 2. 2.1 ACTIVITIES OF WHO SECRETARIAT

Development of WHO WPR HSR programme

Following the meetings of the Task Force and the WHO working group, the Western Pacific Region programme has been drafted (Annex 1). The programme appears in the WHO format of a programme profile to conform with the WHO information system. It has been prepared using the following materials as a guide: - the reports of the Task Force meetings; - the report of the working group in HSR; - the report of the WHO global ACMR subcommittee on HSR; - the report of the study group on financing of health services. It is hoped that the draft reflects a programme that will respond to the regional requirements, and harmonize with the policies and strategies of individual countries. Although the draft is attached to this report it retains the status of draft until formally approved by the Task Force on HSR. This will be considered at the proposed meeting of the Task Force in July 1979. 2.2 WHO's global HSR programme

The activities on the WHO global level are relevant to the development of the regional programme. The global ACMR, at its 20th session, established the ACMR subcommittee on HSR. This subcommittee comprises the chairman and five members of the glogal ACMR. The subcommittee met for its first session in November 1978 and a report was subsequently issued (ACMR/HSR.1/78.l).

- 27 -

Annex 3 The subcommittee made certain proposals. "Proposals for action" Recognizing the immense variation between nations and regions it seems desirable to establish the primary level of coordination, cooperation and facilitation of health services development at the regional level close to the countries served. In this respect, the following action is recommended. 1. Urgent action should be taken to establish Regional ACMR Subcommittees on Health Services Research supplemented, where desirable, by additional expertise - in some regions already existing as study groups or task forces. 2. Regional ACMRs should be active in seeking out suitable individuals and in advising the Regional Directors on the composition of the membership of the Regional Subcommittees on Health Services Research. It is suggested that these Regional Subcommittees on Health Services Research include in their composition members interested or experienced in health services research, supplemented, if considered desirable, by experts from other sectors and from outside the Region. It would also be useful to establish procedures which assure that Subcommittees on Health Services Research can evolve to meet the changing needs of the Region. This can be done by regular review of the terms of reference and the expertise of the membership. 3. The Regional Subcommittees on Health Services Research should inter alia participate in the definition of action items with regard to inventories of planned or ongoing health services research, strengthening of institutions, orientation and training of researchers, sensitization of managers and politicians, manpower development, collaboration between and among countries, relevant information and the formation of advisory working groups for the planning, monitoring and evaluation of the regional programmes. Information about worthwhile investigation should be made widely available. 4. The Regional Subcommittees on Health Services Research, in cooperation with WHO staff, should urgently identify and cost definite health services research projects in relation to priority problems in fields such as nutrition, maternal and child health (including human reproduction), expanded immunization programmes and infectious diseases (including diarrhoeal diseases), and the formulation and evaluation of comprehensive health delivery schemes, taking into account national priorities and programmes in related sectors. Such proposals and information on any other related action should be made available, to the extent possible, in the form of a regional programme to WHO/HQ by the end of March 1979 for synthesis and consideration by the Subcommittee on Health Services Research of the global ACMR at its meeting in June 1979, to which meeting the Chairman of each regional ACMR Subcommittee on Health Services Research will be invited. At the global level, it 1S recommended that the following support be offered to reinforce efforts at the national and regional levels. These are quoted below:

- 28 -

Annex 3 5. HQ staff be requested to document both the health services research component of existing technical and special WHO programmes and the experience in institution strengthening for circulation to the regions and for use in the preparation of the programme plan and the proposal for funding. 6. HQ staff be requested to review reports and literature relating to health services research so as to identify projects and procedures which may be useful to the Regional ACMR Subcommittees on Health Services Research and to all other interested groups. 7. HQ staff and members of the Subcommittee on Health Services Research of the ACMR be asked to suggest names for a pool of suitable consultants, and participate in their briefing and debriefing. 8. Regular communication between national, regional and global levels be maintained through visits of staff, consultants and subcommittee members to their counterparts at regional level. 9. Efforts be made to stimulate and facilitate interregional communication and collaboration. To provide the necessary financial support for the launching of the health services research programme, the following is recommended. 10. The combined cos ted programmes from the regions together with the recommendations from the June 1979 meeting of the Subcommittee on Health Services Research form the basis of a proposal for extrabudgetary funding to be completed for submission not later than September 1979. To provide the complete picture the health services research component of existing technical and special programmes should also be documented in the submission. 11. WHO be urged to seek extrabudgetary assistance for the health services res each programme to commence in 1980 based on the consolidated submission. 12. Financial support necessary to continue the planning and coordination activities and subcommittee meetings be made available during the development stage of the health services research programme. If adequate funds are not available from the regular budget, the Subcommittee on Health Services Research of the ACMR is prepared to cooperate in seeking extrabudgetary assistance. It can be seen that the Task Force on HSR has already initiated many of these recommendations. The proposals 5 to 12 are of interest as they are aimed to support regional programmes particularly in regard to funding, and it is noted that regional programmes will be proposed for extrabudgetary funding.

- 29 Annex 3 The subcODDllitte.e's report also gave a programme of future activities and this programme is as follows: Programme of future activities of the ACMR Subcommittee on Health Services Research A. Scheduled meetings First meeting of the ACMR Subcommittee on Health Services Research Report of the ACMR Subcommittee on Health Services Research to Regional ACMRs. Regions should submit plans and recommendations for health services research to HQ. Contributions should also be submitted from HQ divisions and programmes. Meeting of ACMR Subcommittee on Health Services Research with country representatives and RO/HQ staff to review regional and global submissions and prepare a consolidated programme. Preparation in HQ of proposal for funding. Meeting of ACMR Subcommittee on Health Services Research to review proposal for funding. Send health service research proposal for funding to DirectorGeneral for submission to donors. Prepare report of ACMR Subcommittee on HSR and circulate to ACMRs and regions. Report to glob41 ACMR on progress in health services research development for submission to the Executive Board and World Health Assembly in 1980.

29 November to 1 December 1978, Geneva January 1979

March 1979

25-29 June 1979, EMRO/Alexandria

July-September 1979 13-14 September 1979, PAHO/AMRO, Washington Late September 1979

12-23 November 1979

B.

Unscheduled visits

Members of the ACMR Subcommittee on HSR or outside consultants will attend regional ACMR meetings or visit Regional Offices to facilitate communications in the accelerated schedule of programme development.

- 30 -

Annex 3 2.3 Collaborating centre As a further step in following up the recommendations of the Task Force and working group, a visit was made to the Repuhlic of Korea by

Dr Herniman and Dr Rossi Espagnet. The purpose of the visit was to discuss with the Korean UI'alth Development Institute (KHDI) and the government authorities, the designation of the KHDI as a collaborating centre for research on heal th development. During the visit, a proposal for collaboration together with a plan of work was prepareo. It is hoped that the official designation will take place before the WPACMR meets in April 1979. 3. MATTERS FOR CONSIDERATION BY THE WPACMR

The following matters are submitted to the ACMR for their consideration. 3.1 Future activities of the Task Force T.~sk

The immediate priority is the designation of a chairman of th .. Force to replace Dr H.J. Park.

It is also necessry to fill the vacancy on the Task Force created by the expLry of Dr Park's term. It is proposed that the next meeting of the Task Force be held on 9-10 July 1979 in Manila. The objectives of this meeting are: - to discuss the draft regional HSR programme: - to develop programme activities especially in the area of training, HSR projects and the collaborating centres' network; - to review RSR projects supported by the Western Pacific Regional Office. 3.2 Advisory panel on HSR R

The WPACMR at its third session in Kuala Lumpur in 1978 agreed that panel of experts in HSR should be established to support research in the Region. The Regional Committee subsequently at its 29th meeting in its resolution WPR/RC29:RIO endorsed the recommendation of the WPACMR to "establish a panel of experts 1n health services research to support researches in the Region".

The terms of reference, rules of procedure, and composLt10n of this regional advisory panel could be considered by the ACMR. The procedural requirements of WHO for the establishment of advisory panels are currently undergoing review and will be reported at the time of the WPACMR meeting.

- 31 -

Annex 3 DRAFT HEALTH SERVICES RESEARCH PROGRAMME Prepared by WPRO Secretariat

Contents 1. 2. 3. 4. 5. 6. 7. Objectives and targets Description of programme Approaches Milestones/checkpoints for 1979-1980 Major achievements Difficulties encountered Rrcommendations

- 32 -

Annex 3 Health Services Research 1. 1.1 Objectives and targets Long-term objectives

To enable member countries in the Region to develop and implement national health service research programmes that will be part of the health service development process, and the results of which will be used to provide more efficient, effective, and equitable health services. 1.2 Medium-term (1978-1983) objectives

(a) The development of national HSR programmes within the framework of government health development activities including identification of priorities for research through the planning process. (b) The development of national capability to conduct the research activities identified in the programme. (c) The development of a regional HSR structure to support and enhance national efforts. 1.3 1.3.1 Targets (by 1983 unless otherwise stated) In relation to objective 1.2(a)

1.3.1.1 Organizational framework to advise, guide, and support HSR programmes developed in six countries. 1.3.1.2 Mechanism to identify priority areas for HSR established In six countries. 1.3.2 In relation to objective 1.2(b)

1.3.2.1 Netional capability for the formulation, implementation and evaluation of HSR programmes developed in four countries. 1.3.2.2 Training of national staff in HSR methods from six countries.

1.3.2.3 Support of individual HSR study proposals from countries in the Region; at least four studies every year. 1.3.3 In relation to objective 1.2(c)

1.3.3.1 At least two regional collaborating centres for training and dissemination of information on HSR studies in the Region established. 1.3.3.2 A register of HSR activities established and procedures developed for maintenance of the register.

- 33 Annex 3 Health Services Research 1.3.3.3 An advisory panel on HSR that will be representative of the countries of the Region to guide further development of HSR in the Region established. 1.3.3.4 To have developed guidelines for the formulation of HSR studies in the areas of health services financing, primary health care implementation and the application of appropriate technology. 1.3.3.5 2. To prepare medium-term programme for HSR 1n the Region.

Description of programme

The scientific study of health systems and the components of these systems is a relatively new field in the Western Pacific Region. The translation of the results of such studies into operational terms within the health services is also new. In this Region, the government/WHO general health services development projects have pioneered in this field (as they were designed to do). A project systems analysis of the health services in a province in the Philippines was followed by operations research studies on general health services in three countries: Malaysia, the Philippines, and the Republic of Korea. Tn these studies, the results have led to changes in the general health services delivery system of the countries concerned. Thus, in the Western Pacific Region it has been ~hown that through systematic health services research it is possible to provide valid and feasible modifications to health services to improve their efficiency and effectiveness. The above studies, and others, have facilitated the formulation of an integrated HSR programme structure with the objectives specified in 1.2. 3. Approaches In relation to objective 1.2 3.1 Development of national HSR programmes This will be promoted by: the establishment of national advisory committees the development of guidelines to permit HSR programme planners to identify priorities for research, develop protocols for study, carry out studies and implement findings promotion of collaboration between national health plannprs and HSR national advisory council, to ensure proper identification of research priorities.

- 34 Annex 3 Health Services Research 3.2 Development of national capability In relation to objective 1.2 The WHO HSR programme will identify individuals and institutions carrying out HSR (HSR inventory). In cooperation with the national advisory committees, WHO can offer fellowships for training research workers, either in other countries in the Region, or outside the Region. WHO will provide the framework for the exchange of information and experiences by means of study units, group meetings and short training courses given by suitable institutions. The development of collaborating centres will also be an approach to assisting countries to develop their HSR capability. At a national level, the collaborating centres can act as national coordinating centres for HSR, and provide the linkage between health planning, research, and implementation of research findings. At the international level, collaborating centres can form most of WHO's regional and global programmes in the following ways: dissemination of information training of HSR workers multinational collaborative studies. In the long-term, health manpower development 1n the field of HSR will have to be considered and the various institutions identified for HSR will collaborate in the development of HSR educational packages for postgraduate students. 3.3 Regional HSR structure In relation to objective 1.2 During the period of the programme the following WHO/WPR HSR structure will be developed. In accordance with the wishes of the WPACMR, the Task Force on HSR has met annually since 1976 and has advised the WPACMR on the development of the HSR programme for the Region. Once the programme has been accepted by the WPACMR, it is envisaged that the Task Force will still meet on an ad hoc basis at the request of the WPACMR. An additional regional body will be formed according to RCM resolution WPR/RC29RlO which calls for an advisory panel of experts in health services research.

- 35/36 Annex 3 Health Services Research This advisory panel would have the role of technical resource for HSR programmes.. The role and functions of the advisory panel are yet to be defined. The advisory panel would work with the Western Pacific Regional Office and report to the Regional Director. Thus, there will be three regional groups closely interlinked to form the central structure for the HSR programme: the Western Pacific Regional Office, the Task Force on HSR, and the advisory panel. Between this central grouping there will be the collahorating centres. two of which are envisaged, whose functions and activities wi 11 he in the areas of actual research studies, information dissemination and training of research workers. The organizational structure for the regional programme can be illustrated as in Figure 1: WPR/HSR PROGRAMME ORGANIZATIONAL STRUCTURE

WHO/HQ ( ACMR

Subcommitt. " on HSR)

Tnk !Advisory

,, "" ""

National ..,...,.., Programma

\

National Advisory

Council·

dept. 0 Health

Ministrr

o o

established agency or inslitu lion functional working group

..

...

- 37 -

Annex 3 Health Services Research

4.

Milestones/checkpoints for 1979-1980 Milestones Activity Date of completion

In relation to targets 3.3.1.1 and 3.3.1.2 1.

National focal groups for HSR formed

A. B.

Prepare plan for development of national focal groups Obtain designation of responsible national officers/agencies for HSR as contact points for WHO Hold national workshops for HSR Republic of Korea Malaysia Philippines Institutionalize national" focal groups 1979 1980 1980

c.

D.

In relation to target 3.3.2.1 '1 •

National HSR programmes prepared

E.

National focal groups prepare national HSR programmes Republic of Korea

Mid 1980

In relation to objective 3.3.2.2 3. National staff F. trained in HSR methods Provide fellowships for national research workers

In relation to objective 3.3.2.3 4. Individual HSR study proposals provided G. Fund individual HSR proposals after reviewing procedures satisfied: at least four studies per year Continuous

- 38 -

Annex 3 Health Services Research In relation to objective 3.3.3.1 5.

Korean Health H. Development Institute designated as collaborating centre

Obtain agreement of KHDI and government

March 1979

T. J. K.

Designate KHDI as collaborating centre Finalize plan of work for KHDI collaborative activities Explore feasibility of designating another collahorating centre Obtain agreement of institution and government Designate centre Finalize plan of work for collaborative activities

March 1979 June 1979 June )Q7<l

L. M.

Sept 1979 Dec ) 979 Dec 1979

N.

In relation to target 3.3.3.2 6.

HSR register revised

o. P.

Ask national contact points to submit revisions Prepare format for annual revision of register

Oct 1979 June 1979

In relation to target 3.3.3.3

7.

Annual meeting of Task Force on HSR held Advisory panel on HSR formed

Q.

Hold Task Force meeting

July 1979

8.

R. S. T.

Obtain agreement of WPACMR concerning role of advisory panel Task Force plans first meeting of advisory panel Hold first meeting of advisory panel

April 1979 July 1979 Jan 1980

- 39 -

Annex 3 Health Services Research In relation to target 3.3.3.4

Y.

Guidelines for the formulation of HSR studies prepared

U.

Prepare guidelines for study formulation for primary health care financing of health services application of technology Submit to national focal groups on HSR

Dec 197CJ March 1980 March 1980 Apri I 1980

V.

In relation to target 3.3.3.5 10. Medium-term W. Programme drafted programme for HSR prepared X. Programme consoL.jated at meeting of global ACMR subcommittee in Alexandria Programme finalized by Task Force on HSR March 1979 June 1979

Y.

July 1979

Evaluation findings (for period July 1977 to June 1979) 9.2.1 Major achievements

The health services research programme has only recently been established 1n the Region, and follows the creation, by the WPACMR, of the Task Force on health services research in 1976. For the period under review, the Task Force has met annually. A landmark in the health services research programme for the Region was the meeting of the working group on health services research in Manila in August 1978. This meeting was the foundation stone for the programme. Priorities for research were identified, and the organization, strategips and methods for the development of the programme were formulated. The report of this meeting is thus a key document when reviewing health services research in the Region. However, before the programme development activities initiated by the Task Force in health services research began, there were several important operational studies that may be said to have been the forerunners of the programme now being developed. In the Republic of Korea, an operations research study was undertaken by the Ministry of Health and Social Affairs in collaboration with WHO and UNICEF to further improve the effectiveness and efficiency of health services design developed by the Health Services Development project. The results have been accepted by the Ministry of Health Rnd Social Affairs as a significant improvement to the existing system. Accordingly, as a first step in nationwide implements.tion, the Government has emharked on an ambitiouFl retraining programme. In thC' process, " national operational research tellm wss formed which could become a nucleus of national expertise for further studies in this area.

- 40 -

Annex 3 Health Services Research Cooperation with the Research Institute of Tuberculosis, Tokyo, Japan continued in the conduct of operational studies to further improve and develop an efficient tuberculosis control strategy. In the Western Pacific Region, operational research studies have demonstrated their tactical effectiveness with strategic long-term beneficial effects, and studies undertaken in Malaysia, Philippines and the Republic of Korea as a component of general health services development projects have all yielded a basis for orientation to further development of health services in these countrips. The multidisciplinary operational research team members involved in the studies in these countries are forming the nucleus for collaborative research within, between and among the countries in the Region. Initial efforts to establish the regional framework have resulted in the designation of one collaborating centre for research in health development. This is the Korea Health Development Association situated in Seoul. This centre will act as a national coordinating agency for health services research and a plan for health services research and a plan for collaborative activities have been prepared. As a result of the increasing interest of countries in this programme a number of studies have been submitted for review and financial support. Although one of the main objectives of the programme is to develop a national programme for health services research, it is important to support individual studies, especially at the beginning of the programme. In this way, a pool of research akills can be built up. The stress of the programme is that if health services research is to be useful it has to be done in the countries and settings that will benefit from the results. Hence the emphasis on developing national programmes. 6. Difficulties encountered

There has been a very favourable reaction by countries in the Region to the programme. There is already an awareness of the importance of health services research to apply existing knowledge in the best way possible to the betterment of health. The problems are essentially those of harnessing the skills and resources available to produce acceptable and applicable results. There is a need to develop a framework: both on a regional basis and in individual countries. In some countries, the difficulty is to provide health service research workers with the appropriate support so that studies can he carried out that are relevant to health programmes. This essentially means bringing heal th services research into a close working relationship with government health authorities. There is mlch excellent work being carried out in institutions the results of which are used for teaching and development of health programmes, but the practical application of which are not used.

- 39 -

Annex 3 Health Services Research In relation to target 3.3.3.4 ':I •

Guidelines for the formulation of HSR studies prepared

U.

Prepare guidelines for study formulation for primary health care financing of health services application of technology Submit to national focal groups on HSR

Dec 1971} March 1980 March 1980 April 11}SO

v.

In relation to target 3.3.3.5 10.

Medium-term W. Programme drafted programme for HSR prepared

March 1979 June 1979

x.

Programme consoL.jated at meeting of global ACMR subcommittee in Alexandria Programme finalized by Task Force on HSR

Y.

July 1979

Evaluation findings (for period July 1977 to June 1979)

Y.2.1 1n

Major achievements

The health services research programme has only recently been established the Region, and follows the creation, by the WPACMR, of the Task Force on health services research in 1976. For the period under review, the Task Force has met annually. A landmark in the health services research programme for the Region was the meeting of the working group on health services research 1n Manila in August 1978. This meeting was the foundation stone for the programme. Priorities for research were identified, and the organization, strategies and methods for the development of the programme were formulated. The report of this meeting is thus a key document when reviewing health services research in the Region. However, before the programme development activities initiated by the Task Force in health services research began, there were several important operational studies that may be said to have been the forerunners of the programme now being developed. In the Republic of Korea, an operations research study was undertaken by the Ministry of Health and Social Affairs in collaboration with WHO and UNICEF to further improve the effectiveness and efficiency of health services design developed by the Health Services Development project. The results have been accepted by the Ministry of Health and Social Affairs as a significant improvement to the existing system. Accordingly, as a first step in nationwide implementation, the Government has embllrked on an ambitiouR retraining programme. In the process, a national operational research tf'anl was formed which could become a nucleus of national expertise for further studies in this area.

- 40 -

Annex 3 Health Services Research Cooperation with the Research Institute of Tuberculosis, Tokyo, Japan continued in the conduct of operational studies to further improve and develop an efficient tuberculosis control strategy. In the Western Pacific Region, operational research studies have demonstrated their tactical effectiveness with strategic long-term beneficial effects, and studies undertaken in Malaysia, Philippines and the Republic of Korea as a component of general health services development projects have all yielded a basis for orientation to further development of health services in these countriE's. The multidisciplinary operational research team members involved in the studies in these countries are forming the nucleus for collaborative research within, betwE'en and among the countries in the Region. Initial efforts to establish the regional framework have resulted in the designation of one collaborating centre for research in health development. This is the Korea Health Development Association situated in Seoul. This centre will act as a national coordinating agency for health services research and a plan for health services research and a plan for collaborative activities have been prepared. As a result of the increasing interest of countries in this programme a number of studies have been submitted for review and financial support. Although one of the main objectives of the programme is to develop a national programme for health services research, it is important to support individual studies, especially at the beginning of the programme. In this way, a pool of research skills can be built up. The stress of the programme is that if health services research is to be useful it has to be done in the countries and settings that will benefit from the results. Hence the emphasis on developing national programmes. 6. Difficulties encountered

There has been a very favourable reaction by countries in the Region to the programme. There is already an awareness of the importance of health services research to apply existing knowledge in the best way possible to the betterment of health. The problems are essentially those of harnessing the skills and resources available to produce acceptable and applicable results. There is a need to develop a framework: both on a regional basis and in individual countries. In some countries, the difficulty is to provide health serVice research workers with the appropriate support so that studies can he carried out that are relevant to health programmes. This essentially means bringing heal th services research into a close wor~ing relationship with government health authorities. There is mlch E'xcellent work being carried out in institutions the results of which are used for teaching and development of health programmes, but the practical application of which are not used.

- 41/42 -

Annex 3 Health Services Research Many health administrators are unaware of the value of health services research in the development of health programmes. The problem is not with policy makers who are usually very susceptible to scientific evidence on health services observation particularly in relation to efficiency and effectiveness. At the regional level the main problem the interest shown by countries. ~s

one of being able to support

There are, at present, inadequate manpower resources to meet the ever increasing requests for co11aboraton. Steps are being taken to remedy this as the programme develops. 7. Recommendations

(a) National focal groups for HSR should be formed. As a strategy for promoting this, i.t is recommended that national workshops on HSR be held. (b) Research workers should be trained as a part of the regional HSR programme - by awarding fellowships and by supporting research institutions as well as individual study proposals. (c) A regional information system should be established and particular efforts should be exerted to make the HSR register a basis for this. (d) Collaborating centres for research on health development should be established in the Region to strengthen the recommendations above, and also to provide a linkage with health planners and programme managers (and with the CHP process). (e) Specific plans for action should be made for the programme priority areas of: primary health care, financing of health service, and assessment of technology.

- 43 -

Annex 3

SUMMARY OF HSR RESEARCH PROPOSALS IN HSR PROGRAMME SINCE 1978 MEETING OF WPACMR A. Studies completed or ongoing since last meeting of WPACMR Proposal 1.

Present status report available from WPRO

Country Agency Title Summary

Papua New Guinea Department of Health, WHO In-depth study on hospital expenditure (Phase II) The study involved four hospitals and examined total expenditure, capital expenditure, recurrent expenditure and unit costs. Recommendations for further study on unit cos ts were made. The study was for one month.

1.

Cost 2.

Country Agency Title Summary

Ph il i pp ines Ministry of Health, WHO Cost analysis of immunization rural and urban areas ~n

report available from WPRO

The study analysed the unit cost of immunization for DPT and BCG in the expanded programme of immunization in the Philippines. The information gained is intended to help guide in the planning of the expansion of the programme. Duration was four months.

Cost

- 44 -

Annex 3

Proposal 3. Country Agency Philippines University of the Philippines Institute of Social Work and Community Development Rural-urban doctors in some Southern Tagalog (Philippine) areas: A social psychological comparison The study in surveying physicians in rural and urban areas with regard to their attitudes to medical training. Malays ia Ministry of Health, University of Malaysia, IPA, University of Social Sciences, Pennng Department of Statistics of Government of Malaysia High risk approach in MCH/FP case The study aims at developing procedures for identifying and utilizing high risk factors for better allocation of health resources, by providing an acceptable level of care for all but special care for those at risk Duration two years

Present status report will be available early in 1979

Tit le

Summary

4.

Country Agency

Title Summary

- 45 -

Annex 3

B.

Already submitted for review

Proposal 5.

Present status WHO/WPRO has agreed to support his study with funds from JSIF to the amount of $20 800. Professor Ilinohara has been asked to submit protocol for review.

Country Agency Tit Ie

Japan Life Planning Centre Research on the effect on health of the inhabitants of a rural community expected to be brought by the transformation of their living habits. The study aims to clarify risk factors in chronic disease and methods of avoiding these factors by a change in living habits. A rural village conununity will be studied. $25 000 for first year

SUJllllla ry

Cost 6. Country Agency Title

Korea, Republic of Korea Health Development In~titute An experimental study for village health services through village heal th workers The project is to provide hea I th services through using village health workers at the most peripheral level in an attempt to provide improved services as part of a low cost delivery system. The study will be conducted over 3 years in a Gun (country) in a rural area. Total $94 880; $47 660 1n first year

In process of being reviewed. clarification being obtained on whether study is part of an ongoing progranune or a new proposal.

SUJlllllary

Cost

- 46 -

Annex 3

Proposal 7.

Present status

Country Agency Ti t Ie

Reviewed by WHO/WPR procedure. Decision to support International Institute of phase one of study, and Rural Reconstruction agency invited to submit revised protocol for phase Evaluation on the use of traditional one: design of information healers as primary suppliers of requirements. oral rehydration mixtureR Traditional healers in a rural community area already being trained as village health workerR. The study will attempt to show over a two-year period the feasibility of these workers distributing oral rehydration mixtures and the impact of this on diarrhoeal disease. $50 000; $23 500 for first year

Philippines

Summary

Cost

8.

Country Agency

Papua New Guinea University of Papua New Guinea Faculty of Medicine, Department of Community Medicine Demographic denominations and epidemiology in Rigo District, PNG The study aims to develop a data base of census and demographic information, so that by 1980 reliable information would be available on the country in question. Kina 18 647; Kina 11 512 Philippines University of the Philippines, Department of Sociology Annotated bibliography/resource book on folk medicine in the Philippines

Study being reviewed by WPR procedure

Title Summary

Cost

9.

Country Agency Title

Under reVlew hy WHO/WPR

Summary

A grant is requested to complete an annotated bibliography on folk medicine in the Philippines. It would involve surveys of libraries in Metro Manila, Luzon, Visayas and Mindanao. $8 603

Cost

- 47 -

Annex]

Proposal 10.

Presen t Sta tus Presented at Working Group on HSR, August 1978

Country Agency Title SUDDnary

Australia/New Zealand

Cost containment in primary health care prescribing The proposal will study costs of prescribing of pharmaceuticals ~n primary health care services. It is hoped to develop a programme of studies 1n this area. The first study would be to examine the effectiveness of review in a medical centre as a means of controls. One year duration

Cost II

$16 000

Country Agency Tit Ie Summary

Japan Ministry of Health Utilization of health resources for the forthcoming aged society The study will estimate future medical care needs of the aged, and the feasibility of developing a separate social welfare programme for the aged. not stated Korea, Republic of Korean Health Development Institute The study proposes to implement a system of health care in a rural area using a primary health care approach provided by a health insurance scheme. Duration not known.

Presented at Working Group on HSR, August 1978

Cost

12.

Country Agency Summa ry

Presented at Working Group on HSR, August 1978

Cost

Not stated

- 48 -

Annex 3

Proposal 13.

Present Status Presented at Working Group on HSR, August 1978

Country Agency Title

Papua New Guinea

Analysis of expenditure patterns for provincial health services 1n four selected provinces The study seeks to establish a financial information base for planning and evaluating provincial health services and to establish a system for the financial analysis for provincial health services. Duration 10-12 man months

Summary

Cost 14.

not stated Phili ppines Ministry of Health, University of the Philippines Patterns of financing of health services at the local levels in the Philippines rural setting The study proposes to review the patterns of financing health services in three study areas. The objective is to provide a research mechanism at regional level that will provide information to planners. The proposed duration i~ three years. External support is sought for consultant services and funding at the initial stages. $92 500

COImtry Agency Title

Presented at Working Group on HSR, August 1978

Sunnnary

Cost

- 49 -

ANNEX 4 KOREA HEALTH DEVELOPMENT INSTITUTE (KHDI) AND RESEARCH ACTIVITIES (Statement by Professor E. Hyock Kwon) Since 1960, Korea has attained a remarkable improvement in its livinf!, standards, in conjunction rapid economic development and the growth of th(' Saemaul (New Community) Movement. Korea is thus taking a promisi.ng strid,' the road to a "Welfare State".

.~lonl'

National policy has been consequently focused on measures to assure national welfare and the equitable delivery of health services for people 1n Korea as is done el.3ewhere in the developed world. However, in spite of vigorous government efforts to raise the living standards of the people, and current advancements in the medicare service field, the scope and availability of outreaching services and actual benefits have been so far relatively meager. This can be attributed mainly to commodity price hikes, expensive treatment costs, maldistribution of health personnel, overspecialization in the medical sciences and the operational ramifications of health service technology. Thus, the health problems for the low-income groups 1n both urban and rural sectors remain serious and unsolved. The Government has emphasized the importance of the social development sectors, including health, which are closely related to the people's standard of living as well as with the rapid growth of income sources. The Government has further stressed the critical need to establish a national health system by which low-cost medical services and insurance benefits can be made easily available to people; thus in its Fourth Five-Year Economic Development Plan (1977-1981), social development sectoral investment for expanding the health system is clearly earmarked. Under these circumstances, the Korea Health Development Institute (KHDI) has been established to study various aspects of a low-cost health delivery system through the implementation of experimental primary health care programmes and relevant research projects. The Law concerning the Korea Health Development Institute (KHDI) was promulgated in December 1975 and a Presidential Decree for its enactment was approved and promulgated in April 1976. In the development process, it is known that improvements in the rural health field are the consequence of developments in many different national sectors, i.e. economic development, community participation, education, and political representation which influences the health serV1ces. The role of KHDI has thus become significant in the sphere of primary health care research and developments; it is of particular relevance to economic and social analysis, as a support for the programming and planning process, and the assessment and evaluation of various aspects of the country's health services.

- 50 -

Annex 4 As the Social Development sector of the Fourth National Development Plan attaches importance to health, the feed-back and appropriate supply of research study materials in the service of the national health programme are of crucial importance to the policy-makers and top level administrators. In the course of the Health and Social Affairs think-tank for supporting function of the Ministry. 1979 designated KHDI as a Development. four years of operation of KHDI, the Ministry of made on epoch-making decision to develop KHDI as the and providing feedback for the policy planning WHO Western Pacific Regional Office has, since March WHO Collaborating Centre for Research on Health

With these multiple responsibilities and functions added to KHDI's original role, its policy-oriented research and developmental. activities, and its programme and situational analysis for the government's policy formulation and planning are considered to be of the utmost importance in providing cooperation in the area of ministerial planning for a comprehensive health care service and primary health care. Once the functions assigned to this Institute, are being appropriately discharged, it will undoubtedly stand as an exemplary model of a significant research and development institution with the multifaceted and innovative mission of planning technology designs, inquirer-evaluator, priority setter, architect of the future, operational-system facilitator, health advocator, and activator for national and local health services implementation. Certain key research studies have already been conducted by KHDI and these include the following: 1. Study on curriculum development for the supplementary (in-service) education of nurses, and nurse-aides 1n primary health care and other related activities in the community. Selection of control areas for the evaluation of demonstration programme effects of primary health care service. Comparative studies on health insurance systems - with special reference to medical remuneration methods. A review on feasibility of the HMO in the Korean health care delivery settings. Functions of the middle-level health workers and their supply In rural areas. A study on demand of physical facilities, medical supplies and (drugs) health care systems in Korean rural areas. Evaluation of the medical aid programme - a quick survey for immediate feedback to the policy-making process.

2. 3. 4. 5. 6. 7.

- 51 -

Annex 4 8. 9. 10. 11. 12. Study on the acceptability of the farmers with regard to the medical insurance programme. Survey on the status of local practitioners and other types of medical doctors in the rural areas. Research on the sources of information media in rural areas for health and sanitation aspects. Study on the operational status of hospitals and clinics in rural areas. Analytical study on major complaints and disease prevalence among rural residents.

However, these are not quite enough to provide sound support for research activities, and some further research and study activities which would take the following aspects into account are of the utmost importance: A. Organizational aspects Administration, delivery services Coverage Planning, policy set up Quality Efficiency Utilization Public administration system B. Technological aspects Skills and professional level Training facilities Logistics and facilities Delivery skills and systems Service qualities Transport and communication, MIS C. Financing aspects Budgetary provision Insurance Medical aid and care Subsidies Private investment Cost-benefit output Public resource allocation Local service Community share

- 52 -

Annex 4 D. Surveillance control and evaluation on health care standards Monitoring and reporting prevalence Environmental control Registration, licenses, Data collection and processing Compilation and dissemination E. Manpower aspects Available resources Turnover Forecasting needs and supply Geographical distribution Qual ity control Mechanism for optimum supply Optimum investment for production of skilled manpower and semi-skilled personnel

- 53 -

ANNEX 5

Covering note The drafting group regrets that time constraints in preparation of this draft have been such that it has neither been possible to eliminate all repetition nor to establish a really satisfactory order for presenting some of the material.

- 54 -

Annex 5 Table of contents I.

Format of the Meeting Health for all by the year 2000 Health Services Research Objectives of the programme for IISR 1n WHO Priorities - a definition Stimulation of countries to engage in IISR 4.1

2. 1 " 2 • .L

2.3 3. 4.

4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 5,

Current lack of interest A sequence of action Improvement of research proposals Entry points Inter-country collaboration External assistance Criteria and review mechanisms Use of case studies Assessment of the "state-of-art"

Strengthening national capabilities 5.1 5.2 5.3 5.4 5.5

National capability for HSR Organization Manpower Information Collaboration

6.

Development and management of HSR programme in WHO 6.1 A regional item for research orientation and development 6.2 Ongoing support of HSR activities 6.2.1 Coun try level 6.2.2 Regional level 6.2.3 Global level

7.

Funding and accountability

7.1 7.2 7.3 7.4

The need for careful planning of a budget Budget projections Review and accountability Manpower benefits of "seed money"

- 55 -

Annex 5 ACMR Sub-committee on Health Services Research Second Session Alexandria, 26-29 June 1979 DRAFT OF PROVISIONAL REPORT 1. Format of the Meeting 29 June 1979

Dr Shoib opened the Meeting on Dr Taba's behalf by welcoming participants and reading Dr Taba's message. The authors of five papers on HSR and representatives from 5 of the Ii Regions presented summaries of material which had been circulated hefore the Meeting and this was discussed. Then there was a discussion of the HSR component of the FHE and HRP programmes which was led by the HQ' staff representatives of those programmes. 2.1 Health for all by the year 2000

Accepting health for all by the year 2000 as a feasible target which WHO encourages countries to achieve, with primary care as the crucial element in WHO strategy, HSR is fundamental for the success of this strategy. But only 20 years remain, so the need for action is urgent. PHC is an innovation accepted by all Member countries in spite of the .vagueness of its various operational aspects as reflected in the questions and statements of the Member countries who attended the Alma Ata Conference on PHC. 2,2 Health Services Research

HSR should concentrate on increasing efficiency and effectiveness of the health delivery system of a given country. The definition proposed by the Sub-committee of the ACHR at its previous meeting had the merits of brevity and of placing emphasis on health rather than health services, that is to say outcome rather than process. Most HSR is culture bound and hence it has low transferability. This also requires that problem formalization and conceptualization should emerge from within the Health Services system itself and not imposed from outside the country. The time element in HSR is very crucial for utilization of its results by decision makers and hence scientific short cuts are of great importance in this matter. Decision makers need very fast answers on their questions and they will in many cases use available crude answers rather than wait for highly refined answers. In developing countries we started by symptomatic administration, moved to symptomatic planning and at last we are moving into HSR in order to develop more relevant policies, strategies, plans and management practices to our Health Services.

- 56 -

Annex 5 Most of HSR is evaluative in nature and hence it is usually met with tremendous resistance of the bureaucracy. Unless it influences policy it is worthless. Therefore all efforts should be made to coopt, sensitize or educate bureaucrates and decision makers in all stages of HSR. It should consider the consumers interest and consumer participation could be beneficial. 2.3 Objectives of the programme for HSR in WHO

The aim of the programme for HSR in WHO is to assist Member countries to make more effective progress towards the goal of HFA/2000. From the broad range of possibilities for HSR, the first objective is to foster HSR on elements of primary health care. The second objective is to develop the capability to carry out HSR within each country. Heal th polic ies and prac t ices in genera I and primary care in particular, have a high degree of cultural specificity. The third objective is to concentrate the attention on the needs of the less developed countries since these countries have very limited resources, the largest proportion of population has no access to primary health care and they suffer the gravest health problems. The overriding consideration in undertaking HSR is to produce reliable information on pertinent problems which will influence the political and managerial decisions and thereby improve the coverage and quality of health care. 3. Priorities - a definition

Although the term priority means first things first it is ambiguous. In its economic sense it is used to denote establishing an order for those things upon which limited resources are to be spent, when other things must be foregone. But it also has the sense of inexorable sequence; for instance, if a house is to be built, bricks must be made but first men must be found to make the bricks. In this document the word will be used in the first sense only. It is nevertheless the responsibility of WHO to decide the sequence in which the programme in HSR should develop; however, it should be left for countries to establish priorities for subjecting their own health problems to HSR, taking into account the resources available to them. 4. Stimulating of Countries to engage in Health Services Research

As regards the formulation of realistic and potentially useful study proposals in counties, the group emphasized that HSR have been a neglected area and most of its concepts are new to its potential consumers as well as the research community.

- 57 -

Annex 5 4.1

Current lack of interest

Many countries now spend over 7 percent of GDP on their health services. Despite this increasing expenditures health status is in some instances declining. Few countries are aware of the potential of HSR and fewer still spend more than a token sum on health services research and development activities. It has been suggested that of the order of 3-5 percent of health funds should be used for this purpose. In'speaking with politicians and planners parallels may be drawn between the health sector and other parts of the economy. 4.2 A sequence of action

The time has come for WHO to emphasize the development of events that will ultimately lead to the institutionalization of Health Services Research in countries. Health Services Research component of various WHO programmes should be integrated within the context of PHC. A sequence for activlt1es which could stimulllt., interest in II country and through action lead to the institutionalization of HSR is as follows: 1.

Sensitization of health decision makers in various countries. Assistance to countries in the development of research policies and priorities and access their resources in HSR. Support the development of national institutional framework. c~pabilities

2. 3. 4. 5.

in HSR within an

Assist countries to develop feasible and realistic proposals for country HSR studies. Make funds available to assist health services research studies 1n various countries with special attention to the least developed countries and taking in consideration the cost-effectiveness of utilization o.f resources. Exchange information in the area of HSR. Improvement of research proposals

6. 4.3

Development of study proposals should be seen within the context of HSR priorities which emerges from the stimulation of HSR in the countries. Assistance in the area of proposal development using examples from WHO Health Services Research projects and other projects could be very useful. Successful HSR projects could be written up as case studies in collaboration with competent organizations.

- 58 -

Annex 5 The need for interdisciplinary approach requires us to find suitable mechanisms to involve social and behavioural scientists in a more effective way than they are being involved now. The issue of cancer prospectives should be given ample attention. The contribution of researchers should be distinguished from that of scientists. The input of scientists is mostly in the design and evaluation stage (pre or post implementation), while other stages are handled by researchers. Health workers of all categories should be viewed af potential researchers in HSR and should receive reasonable inservice training. Special training in research methodology and development of research proposals is also important. 4.4 Entry points

HSR is action oriented it should be evaluated by the change it can produce in the health delivery system and ultimately in the health status of the people. Therefore the logical entry point is through the providers of health care in the community Ministry of Health or other agencies. Simultaneous entry points could be the scientific community and other influential agencies in health decision making, e.g. planning, finance, education, labour, social welfare, science and technology ministries, etc. Different methods could be used to sensitize the entry point such as e.g. information materials, newletters, drawing on successful studies from countries similar in culture, consultations, seminars, or even implementation of a micro-case study within the same culture etc. In this concern translation of cases written in local languages should be provided. Methods used depend on the prevailing attitude of decision makers, the stage of development of HSR in the country. 4.5 Inter-country collaboration

Inter-country training activities are a promising entry point for research activities. Such collaboration could also be achieved through collaborative centres which can serve a group of countries. inter-cou~try

Also differenciation between inter-country and multi-countries studies was raised in the sense that the first may involve exchange of researchers between countries to participate in similar studies while the latter excludes such notion. HSR in primary health care in general was reviewed as a feasible area for such collaborative work. The role of the Regional Office in such collaborative efforts was emphasized and innovative mechanisms in this area should be encouraged. The areas of coverage and health statistics were suggested as feasible areas for inter-country studies. Communication between countries in the areas of theoretical and methodological aspects of HSR should be enhanced by all possible means.

-

';/)

Ann(~x

':.>

4.6

External assistance

The provision of external assistance to HSR activities should be an integral part of the mechanism of stimulating the interest of a country In HSR. Research proposals could be more realistically developed if the applicant knows in advance the size and nature of external assistance.

WHO should be prepared to develop with each country a flexible general framework for collaboration which could include discussion of country priorities rather than developing rigid guidelines for assistance. The grouping of countries with common interest may come as a following step based on common needs in HSR and/or complementary of their HSR resources, etc. The difficulty of costing HSR may require special attention.

4.7

Criteria and review mechanisms

The development of criteria and review mechanisms should aIm at improving the quality of HSR in various countries. Review procedures should be developed at the country level with WHO assistance provided on request. Review criteria and review mechanisms should emerge as an integral part, the process which starts with Stimulation and leads to Action at the country level. Carefully developed criteria for WHO assistance of country HSR activities could be helpful. 4.8

Use of case studies

Concrete examples of HSR study results. that led to policy changes or services improvement should be obtained and systematic search at the country level should be organized. It was suggested that few examples of HSR which utilized relatively large amounts of resources with no or very little impact should be analyzed and distributed to demonstrate the factors which led to their failure.

4.9

Assessment of the "state-of-the-art"

An assessment of the state-of-the-art should be undertaken and directed to evaluate the impact of WHO HSR programme and activities within various countries in each Region. HSR in PHC was felt to be the main area around which such activity should be concentrated. 5.

Strengthening national capabilities National capability for HSR

5.1

Capability in HSR at country level may be defined as the ability to plan and conduct systematic, multidisciplinary research into the structure and functioning of health services, concentrating on the primary health needs of the population and on questions to which answers are likely to be found. A general prescription to improve national health capabilities is

not possible because of cultural difference and differences in the resources available to individual countries. Each country must develop its own strategies for the promotion and support of HSR. There are however some general principles which may have applications. Some countries already have major capabilities for carrying out HSR although sometimes the

- t)O -

Annex 5 results of research are not used to good effect in the rlevelopment of health services or the research topics and approaches are unrelated to the priority health problems and to the social and cultural aspects of the decision making processes. Such countries require encouragement to use their investment wisely bllt are otherwise self sufficient. Other countries have little or no existing capacity for HSR. These countries require active outside: help to improve their HSR capability. The ultimatE' aim is t(l attain national self reliance in HSR. The development of nationnl capability for HSR is as important in the developed as in the rleveloping world. Countries must set their own priorities and establish their own strategies and programmes for the promotion of HSR. Country programmes 5hould focus down on the 8 elements of primary health care set out in the report of the Alma Ata meeting. Once research priorities are estahlished, coun tr ies should act i vely seek to promote research in priori ty areas. Research activities should involve and commit people at all levels in the health system from the politicians and bureaucrates to community leaders and the people themselves. An appropriate balance should be sought hetween simple descriptive research and more complex research designs while there is a place for long term and expensive studies. The most useful results will be obtained from well planned, executed and rE'ported short term studies. A building block approach using small hlock may he necessary to get national HSR activities off the ground. Efforts should hE' madE' to ensure that only methodologically sound projects are att(>mpted. Bad research resulting in misinformation can seriously undermine national research effort.

5.2

Organization

Each country must develop an appropriate mechanism to support its HSR programme. A national HSR council (or equivalent body) should ensure that research priorities are established actively to pursue these priorities, seed research in priority areas, arrange for project and programme grants, promote individual and institutional strengthening, encourage the wide dissemination of research results and should endeavour to see that the results of research are used appropriately for health services development. Through their respective governments this group should develop and maintain links with WHO and other national and international organizations and agencies interested in supporting research or using research results. The following diagram indicates the relationships between key groups ln

.....--

-

.....--

-- --t 1nlts wtu('h may be ~iSllng

(or weak)

__ F."aollohed Ilnll.

- 61 -

Annex 5 Potentially the most important influences lie with the researchers and the sources of funding. Therefore the links between these and the Ministry of Health where policy is formulated should be as strong as possible. One way of doing this is to earmark funds in the Ministry of Health for research, but this is only likely to be helpful if personnel are available in the Ministry to administer the funds properly, and researchers are available. Fear, jealousy and suspicion among civil servants and professional groups may have to be overcome before policy to promote change is implemented. Unless the interest of bureaucrates is aroused and they are stimulated to ask questions it will be difficult to initiate HSR. A common problem in many countries is the poor standard of proposals. As well as developing appropriate mechanisms for assessing research suitable ways and means must be found to assist those making inadequate proposals in priority areas to obtain the help they require. 5.3 Manpower

It is generally accepted that the most important single factor limiting HSR development is the inadequate quality and quantity of the available manpower. Deficiencies exist at all levels. At the level of Policy makers, administrators and community leaders. There are too few people who appreciate and can use the contribution of HSR. Also there ~s a serious lack of research leaders - people able to mobilize the resources needed to organize, manage and carry out research. At the technical level of research design data collection and data processing there are serious deficiencies and at the lowest level, field staff and community workers are inadequately prepared for roles in HSR. What is required are strategies at all levels to develop the manpower required for HSR. Also needed is an increasing awareness on the part of all health workers of the potential contribution of HSR to health and social development. A variety of strategies may be used to develop the manpower needed to promote HSR. At the basic training level all health workers should be exposed to some teaching on the principles and practices of HSR. Seminars, workshops, short courses, carefully planned and structured training-over a period of years - all have their place. Generally speaking there should be little formal or didactic teaching and where possible the emphasis should be on case studies a'ld learning by doing. If national capabilities for Health Services are to be expanded and otherwise developed it is important to recognize the need for an appropriate career structure for those working in the field. Although this may not be a problem in the early phases of programme development it ultimately must be faced and dealt with. At the local level there is need to promote training and support for health workers and other people who as part of their work may be required to take part in HSR. The content of training programmes should be oriented and be carefully tailored and flexible to individuals. In general emphasis should be placed carry out systematic inquiry. However, it is also task based and problem the needs of groups and on the skills required to important that researchers

- 6Z -

Annex 5 understand the social and cultural environment in which they must work. In health services research to be technically skillful is rarely enough to succeed. Final justification for HSR is the actual use of the funding in changing the health care system. There is a global shortage of people and institutions willing and able to provide sound instructions in health services research. An urgent need exists to increase this capability. Potential teachers with proven skills in HSR should be identified and encouraged to develop the required training programmes. Better cooperation and coordination is required between universities and other training agencies in developing the manpower needed to promote HSR. WHO might help by: (a) collecting and distributing information on training activities; (b) organizing teacher training programmes at the inter-country level; (c) support technically and financially national training activities on request; (d) provide opportunities to those concerned to exchange experience and educational material. When planning the training and career development of recruits to the core group of HSR activities a flexible approach should be adopted. Great care should be taken to ensure that the training provided is in keeping with the precisely specified requirements for each trainee at senior level. In general training should be arranged locally under which closely approximate the environment in which the trainee will ultimately work. Training should involve a considerable amount of practical work in the field. 5.4 Information strengthening

A variety of information is required to support HSR. This includes basic census and other demographic data, research inventories, information about training opportunities, research funding and the like. country inventories of HSR may be of use for a variety of purposes. In New Zealand a national health service research register is being developed in three parts. Part I is a description of the organization and workings of the concerned Department of Health - Medical Research Council HSR Committee. Included here are the committee's priorities for HSR and descriptions of the mechanisms for seeding research in priority areas and for funding definitive proposals. Part two is carefully cross-indexed national inventory of HSR. Part three is a listing of the principal individuals and institutions involved in HSR and their activities and interests. This register is designed to meet the needs of planners, decision makers and interested health workers as well as those principally involved in HSR. It is suggested that such a register could include information about training opportunities.

- 63 -

Annex 5 If country registers are developed according to a standard format it would be possible to consolidate these into regional and perhaps even global registers. WHO should take a lead in developing the appropriate format for such registers. The existing WHO health services project register is inadequate and should be revised along the lines suggested. In a developing field such as HSR it is particularly important that there be regular and frequent communication between worker~. Inventories and formal research publications are inadequate for this purpose. Suitable low cost publications should be developed at country and regional levels. To facilitate communications between researchers. The journal "The Learner" published by the HMD group in EMRO could be taken as a suitable model. Also recommended is an annotated bibliography of case studies and other material which may be used in research training. A great deal of information concerning the WHO's involvement in HSR was gathered for this meeting. It is suggested that this information be reviewed by an editorial group with a view to making it available in a variety of forms to special interested groups. 5.5 Collaboration

At country, regional and global levels it is essential that collaborating networks be created, to support health services research and development. The concept of a collaborating network involving national or international groups is favoured in preference specifically labelled and institutionalized "national health development centres". Cultural congruence, common problems and involvement in common research strategies and programmes should identify network members. In some regions networks involving a number of countries may be created to coordinate research on lifestyle and environmental health problems. In each country there should be at least one suitably designated centre to act a& the focal point for coordinating the national HSR effort and for collaborating with other countries, WHO and other international organizations. The development of such a focus in all countries is seen as high pr iori ty. In some countries the creation of a national coordinating mechanism for HSR may present only organizational problems in others it may be necessary to identify an individual or individuals who can provide the nucleus for such a mechanism. To initiate the programme WHO should assist in the running of national HSR workshops which might be used to start a 5-year programme of intensive development and collaboration.

- 64 -

Annex 5 A common approach may be used to identify people, institutions and coordinating network for HSR. 1. 2. 3. 4. 5. 6. 7. Actively search for the people required Register them once they are found Assess their capability Link them with others with common interest Help them to grow Validate them by using them on WHO projects Use them to find and encourage others. IS

WHO recognition, whether as a collaborating network or in other ways, seen as providing the status nee~ed which may assist the national effort. There is an urgent need to publicise at national and international levels the potential contribution of HSR to health and socio~economic developmen ~., . This is needed not on ly to raise funds but also to increase public knowledge and interest. And what is done is often not appropriate or IS

not being used.

Particular efforts should be made to stimulate interest in HSR on the part of multilateral and bilateral agencies with a potential interest in the field. Within most WHO programmes there is thought to be scope for the transfer of emphasis and funds away from technical assistance and other traditional activities and towards HSR and development activities within the scope of the programme concerned. But, from a review of the existing proposals identifying those which are reasonably well developed and have justifiable budgets, it should be possible to come up with a sum required for short-term project support. Additional information may be obtained from coun~ries who publish budgetary information on their HSR programmes. From these sources a sum of $ I-2m. may be identified for the first year of the programme. 6. Development and management of HSR programme In WHO

The overriding objective of the WHO programme in HSR is to develop HSR activity within each country. In view of the low level of HSR activity in many countries, a plan for orientation and development should be prepared at the regional level.

- 65 -

Annex 5 6.1 A regional plan for research orientation and development develop a committed nucleus of representatives from each country; - achieve common understanding of HSR; - improve inter-country communication and with HSR organizations in the Reg ion; - identifY needs for ouside experts. Stage I: Regional orientat ion meeting'( I week) - include several senior representatives from each country concerned with health policy, primary health care and HSR; - invite WPC/NWC's from each country; - technical consultants if required. WHO to provide funding and technical consultants. Stage II: National workshop in each country (2 weeks) - dialogue between representatives of key institutions (government ministries, universities, research institutes, scientific academies, etc.); - define topics for HSR; - identifY people to do HSR; WHO to provide technical consultants and assist with funding of first year cycle: subsequently national responsibility for funding. Stage III: Regional Research design workshop - HSR personnel from each country as identified in stage III; - technical consultants; - initiate design of selected research projects. WHO to provide technical consultants and funding.

Purposes: -

- 66 -

Annex 5 Stage IV: Research implementation - specific research projects implemented by national groups and possibly inter-country collaborative projects; - national funding commitment. WHO: experts some extra-budgetary funds Recycle new topics and people Stage III

Monitor:

Evaluate how results of HSR used

The plan described follows closely the arrangement now underway in SEARO and that proposed for WPRO. In Regions with a larger membership of countries plans would be required for as many as 5 or 6 groups of countries. An important outcome of the Stage II National Workshop would be the emergence of a continuing dialogue at national level linking groups responsible for planning, implementation and research. A functional relationship of existing institutions and groups strengthened by HSR activity is strongly favoured rather than isolating HSR activity in a separate institute. The objective for Stage II relates closely to the process of national health planning (and the concept of Country Health Programming) of which HSR is an important and integral component of health development in the broadest sense.

The development plan will need to be repeated several times in the Region as new individuals assume leadership responsibility and as the countries identify new or more complex problems in the national workshops. 6.2 On-going supfort of HSR activities

The growth in HSR activity in Health Services Development and in other technical programmes of WHO requires strengthening of the support and management functions at country, regional and HQ levels. 6.2.1 Country level

At country level, HSR in relation to HSD and special technical programmes will be an increasingly important component of the role of the WPC/NWC. To fulfil these responsibilities it is recommended that WPC/NWCs

- 67 -

Annex 5 receive orientation to HSR by including them in the ~tage ~ Orientation . Meetings and the Stage II National Workshop~ and by 1nclud1ng ~SR as a t?P1C in the HQ orientation course for newly app01nted WPC/NWCs and 1n any reg10nal training courses for staff development. Among the regular activities of the WPC/NWC's special attention might be given to the following functions: I II - facilitate the formulation of project proposals and the preparation of applications for WHO grants for HSRj - identify national health services research activities worthy of consideration, description and dissemination to other countries: - obtain information of use to nationals; III - provide the Regional Offices with information on national institutions and national expertise in the area of health services research; - be the liaison between WHO and the Government ministries and agencies on all matters relating to health services researchj - evaluate the impact of WHO inputs in the country and collaborative in the assessment of the impact of national health services research on the health services of the country; - assist in coordinating demands on the limited HSR capability of the country by WHO programmes and divisions: - To enable WPCs and NWCs to perform as expected, they must be informed and kept up-to-date with all developments concerning the WHO effort in health services research. Health services research should therefore be put on the agenda of the WPC/NWC meetings held in each Regional Office. 6.2.2 Regional level

IV V

VI

The regional office should establish a focal point for HSR; in four regions this is the Research Promotion and Development Officer. The growth of HSR activity wilL require strengthening of staff and it is hoped that . appropriate priority will be given to budgetary provision for HSR in the recommendations of the Regional Director in his proposals to the Regional Committee. It is important, however, to avoid separating HSR from Health Services Development and the other technical programmes it is designed to serve. It would be counter-productive to develop a new vertical structure for HSR. The regional level taking advice from its ACMR should determine whether new sub-committees, task forces or scientific working groups are needed to deal with HSR activities.

- 68 -

!

Annex 5

Collaborative functions which should be considered at regional level include the following: i. Maintain full information on all HSR activities. 11.

F~cili~ate.exchange of information, sharing of experience, dlsse~lnatlon of research results and application of new research

technIques.

Ill. IdentifY experts to meet needs for specific research projects or instit'ltional strengthening. IV.

Mobilize extra-budgetary funds for research activities and seed money for specialized manpower development.

v. Facilitate joint HSR ventures, involve several countries. vi. Coordinate HSR initiatives from HQ programmes and divisions to avoid inappropriate demands on the HSR capability of countries in the Region and to minimize duplication of projects from different sources. vii. Evaluate the effectiveness of the HSR activity and develop whatever review process is considered necessary in relation to the extra-budgetary research funding. viii. Promote application of HSR concepts in traInIng programmes for health professions and management personnel. These functions should be carried out primarily at the regional level in close cooperation with the WPCs at country level. The Regional ACMR should determine whether new sub-committees or task forces to deal with HSR activities are required. 6.2.3 Headquarters level

HSR is already an important part of many technical programmes. No attempt should be made to establish it as a new division. The current efforts by the ad hoc core group to improve coordination of HSR actitivies of SHS, RPD, TDR, HRP~HHD, EHE and FHE within headquarters and between headquarters and the regions should be strongly encouraged. Execution of HSR, however, should continue to be part of the technical programmes. Indeed, coordination of HSR should be in the context of coordinating of the technical programmes which will make a major construction to the development of primary health care. A coordinating mechanism at headquarters should be considered for this purpose. A modest increase in st~ff for HSR activities will be required and this may be achieved in the course of reorganization of headquarters' functions. '

- 69 Annex 5 Collaborative functions which should be considered at headquarters' level include the following: I II III

IV

exchange information among regions faciliate multilateral and inter-regional HSR projects mobilize extra-budgetary funding identi fication of pool of technical consul tants

7. 7.1

Funding and Accountability Need for careful planning of a budget

It is of greatest importance that the development of monetary support is planned in such a way that very large sums do not become available until countries are ready for them; that is to say when the necessary manpower has been trained and such structure for research administration as is relevant has come into being. Therefore what is needed now is confidence that support which is relatively modest in nature will be forthcoming over several years rather than dramatically large sums over a short time. In this respect health services research differs considerably from other forms of WHO research.

7.2

Budget projections

Additional funds will be required in 1980 for the orientation and development plan, for increasing national HSR capability and for programme development and management. At the outset only a limited amount of financial support in addition to what is currently available from other sources will be required for specific HSR projects. This component may be expected to increase rapidly as HSR capability is developed. Extrabudgetary requirements for the next two biennial periods are projected in the table and chart. During this period the funds should be held in a central pool for distribution to the regions according to their needs and absorbing capacity. 1980 in m. 1. 2. Support to substantive research Strengthening of national capability for health services research: Orientation/training communication material, observation visits and fellowships Institutions strengthening Publication of research and research related activities 1981 1982 1n m. us $ 2.0 1983 3.0

us

$ 1.0

0.5

0.6

1.0

1.2

1.2

0.2 0.1

0.6

1.2 0.3

1.2 0.3

0.3

=~====================================~============================~===========

- 70 -

. • •

• .'

t

t

t

b

1980

1981

1982 , • ' , ,1!1, !1','. US .$.

1983

3.

-'rogramme developti;;;'n-t' 'a~d= management Meetings Information support

to"

"iPb!D' _ US, ,$,

0.2 0.1 1.7

0.3 0.1 3,3 5.0

0.3 0.1 5.1 11. 2 . =rt . .

0.3 0,1 6.1

TOTAL

m:ta.: ' ... ~ .. ' . •

So"

•

,

,

.

.,

. 49%

1980 I. Support to substantive research

1981 30%

1982 39%

1983

29%

3.

Strengthening of national capability

53%

58% 53% 44%

3.

Programme development and management

18% 12% 8%

7%

- 71 -

Annex 5 7.3 Review and Accountability

A prospective peer-review mechanism for grants-in-aid of HSR, as is used for biomedical research projects, is not recommended because of the inappropriateness of "second guessing" national priorities and the tight schedule for completion of the projects. Countries should have access to "seed money" to initiate HSR quickly during the development stage. The country should satisfy the regional review mechanism that it has a suitable mechanism for deciding on support of projects with extrabudgetary funds allocated to it. This might be supplemented by a restrospective review demonstrating that the research had been executed with sound methods and providing an indication of the effectiveness of the research in influencing health policy, ~nagement, services or ~npower training. When larger amounts of research funds are requested, a prospective review process should be established which appraises the adequacy of research design and the relevance of the project to national and WHO priorities in the context of Health for All by the year 2000. 7.4 Manpower Benefits of "Seed Money"

Funds for seeding new research in priority areas should be included in all HSR programmes. These funds may be used not only to get new research started but also to attract researchers from needed disciplines to enter the field. In turn this may result in more health related research in university departments, altered teaching and research programme and ultimately improved recruitment to careers in HSR.