Report to the Regional Director on its nineteenth session: WHO South-East Asia Advisory Committee of Health Research, New Delhi, 10-15 April 1993

WORLD HEALTH ORGANISATION MONDIALE ORGANIZATION DE LA SANTE SOUTH-EAST ASIA REGION SEA/ACHR/19 15 July 1993 RESTIUCTED SOUTH-EAST ASIA ADVISORY COMMITTEE ON HEALTH RESEARCH Report to the Regional Director on its Nineteenth Session New Delhi, lo-15 April 1993 WHO Project: ICP RPD 001 ’ I I The issue of this document does not constitute formal publication. It should not be reviewed, abstracted or quot $ without the agreement of the World Health Organization. Authors alone are responsible for views appe ring under their names. P SEA/ACHR/19 CONTENTS Page 1. INTRODUCTION 2. INAUGURAL SESSION 1 2.1 Welcome Address by the Director-General, ICMR 1 2.2 Address by the Regional Director 1 2.3 Address by the Chairperson, SEA/ACHR 2 2.4 Address by the Secretary (Health), Ministry of Health and Family Welfare 2 2.5 Address by the Minister of Health and Family Welfare 3 3. BUSINESS SESSION 3.1 Introductory Statement by the Chairperson, SEA/ACHR 3.2 Opening Remarks by the Regional Director 3.3 Nomination of Vice-Chairman and Rapportem 3.4 Introduction of Documents 3.5 Adoption of Agenda 3.6 Progress Report on the Regional Research Promotion and Development Programme 3.7 Review of RPD Activities in Relation to Past SEA/ACHR Recommendations in Specific Areas 3.8 Matters Arising out of Meetings of Global ACHR and ACHRs of Other Regions 3.9 Progress Reports on Special and Global Programmes 3.10 Strategy for Health Research in SEAR 3.11 Research for Improvement in Health Care Delivery Systems - Regional Perspective 3.12 Strategic Plan for Promoting and Strengthening Health Economic Research: Regional Approach 3.13 Suggestions for Agenda of the Twentieth Session of EA/ACHR 3.14 Time and Place of the Twentieth Session of SEA/AC 3.15 Adoption of the Report 9, ( ~ 4 5 9 15 17 23 28 29 33 35 35 4. CLOSING SESSION 35 4.1 Remarks by Members 35 4.2 Address by the Regional Director 35 4.3 Address by the Chairperson 36 5. RECAPITULATION OF RECOMMENDATIONS 1 36 SEAiACHRl19 Page ii Annexes 1. Agenda 2. List of Participants 3. List of Working and Information Documents 4. Text of Address by the Regional Director 5. Text of Inaugural Address by the Minister for Health and Family Welfare, Government of India 40 42 44 47 50 SEA/ACHR/l9 1. INTRODUCTION The nineteenth session of the South-East Asia Advisory Committee on Health Research (SEA/ACHR) was held at the Indian Council of Medical Research (ICMR), New Delhi, from 10 to 15 April 1993. For agenda, list of participants, list of working and information documents, text of address by the Regional Director, and text of inaugural address b# the Minister of Health and Family Welfare, see Annexes 1, 2, 3, 4 and 5 respectively. I 2. INAUGURAL SESSION 2.1 Welcome Address by the Director-General, ICMFf i Dr S.P. Tripathy, Director-General, ICMR, in his welcome address, said that he deemed, it, a privilege and honour to extend a warm welcome to all those resent, particularly to the Hon’ble Union Minister of Health and Family Welfare, Government of Ind,a, Mr B. Shankaranand, who had headedP the organization when he steered the Ministry of Health and F well. During this period, ICMR had received considerable suppo ily Welfare in the early 1980s as for its activities from the Ministry of Health and Family Welfare. The emphasis at that Stage 1 had been on research capability strengthening. The Council now had 26 permanent institutions spread evenly throu$hout the country. These regional medical research centres were particularly equipped to research on specific diseases of major public health importance such as leprosy, tuberculosis, diseases, AIDS and malaria as well as on locally endemic diseases that required special ICMR had had a close association with the World Health Organization which had provided appropriate support to ICMR as well as to Indian scientists was an& when necessary. 2.2 Address by the Regional Director Dr U Ko Ko, Regional Director, thanked the Government of India for hosting the nineteenth session of the WHO South-East Asia Advisory Committe ’ on Health Research. He expressed his“i gratitude to His Excellency Mr B. Shankaranand, Minister of IHealth and Family Welfare, Government of India, for his presence and for kindly agreeing to deliver the inaugural address. Dr U Ko Ko extended a warm welcome to the distinguished members of SEA/ACHR, the special invitees, the distinguished scientists and research workers of India, the senior officials from the Ministry of Health and Family Welfare and other honoured guests present on the occasion. Dr U Ko Ko stated that the WHO South-East Asia Advisory Committee on Health Research served as the main advisory body to the Regional Director on matters of research policy. The Region could look back with justifiable satisfaction at the achievements made in the field of health research since 1976 when the Regional Advisory Committee on Medical Research was first established. The initiatives taken by the WHO Regional Office had had a profound effect on fostering health research, especially in those countries that lacked a long tradition of medical research. He then dwelt on some of the future perspectives pertainingi to health and health research. He referred to the major changes that had taken place in the political, !economic and social structures in SEA/ACHR/19 Page 2 several countries of the world, including those in the South+East Asia Region. Further, whilst the prevalence of many communicable diseases remained high in the countries of the Region, additional health problems had been created by the increase in the population aged over 60 years as welI as by rapid urbanization, industrialization and environmental degradation. Therefore, the subject, “Strategy for Health Research in the South-East Asia Region” was an important Agenda item for this meeting of the South-East ‘Asia Advisory Committee on Health Research. He was confident that, based on the report of the ‘Consultative Meeting which had been convened earlier, and additional suggestions made by SEA/ACHR, it would be possible to evolve a revitalized strategy based on a realistic vision of the future to serve as a powerful influence that would guide health research in the Region. He said that a constitutional function of WHO was to :‘promote and conduct research in the field of health”. WHO could fulfil this role only with the active~ cooperation and participation of policy makers, administrators and research workers of a country. i In this respect, it is fitting that this nineteenth meeting of SEA/ACHR was being convened at 4 Indian Council of Medical Research, which was the apex body for the formulation, coordination and promotion of health research in India. The Ministry of Health and Family Welfare and the Indian Council of Medical Research had actively collaborated with WHO in several research programmes and he looked forward to continued collaboration in the future as well. Dr U Ko Ko concluded by thanking the Government of India once again for hosting the nineteenth session of SEA/ACHR. He stated that his thanks w re also specially due to His Excellency aleMr B. Shankaranand, Minister of Health and Family Welf , Dr S.P. Tripathy, Director-General, ICMR, and to the members of the Organizing Committee for the excellent arrangements made for the meeting. 2.3 Address by the Chairperson, SEA/ACHR Dr Sneh Bhargava, Chairperson, SEA/ACHR, thanked His Excellency Mr B. Shankaranand, and, through him, the Government of India, for so graciously agreeing to host the nineteenth session of SEA/ACHR. She said that it was during his tenure as Minister that the National Health Policy of India was developed and approved by Parliament in 1983. She also expressed her thanks to Mr R.L. Misra, Secretary (Health), Ministry of Health and Family Welfare, ~Govemment of India, and to Dr S.P. Tripathy, Director-General, ICMR, for making available lthe facilities of a national research organization for the meeting. She pointed out that ICMR had a ~history of 82 years and was established even before WHO. The purpose of convening the session of SEA/ACHR i a Member Country rather than in the WHO Regional Office was a recognition of the fact that the tember Countries played a major role in health research activities while WHO and its constituent bodies served as a major catalyst to these activities. 2.4 Address by the Secretary (Health), Ministry of Hea$h and Family Welfare Mr R.L. Misra, Secretary (Health), Ministry of Health and Family Welfare, Government of India, in his address, stated that the countries in the Region were faced with compelling challenges due to the double burden of disease and the advent of the AIDS pandemic. This was further compounded SEA/ACHR/19 Page 3 by the limited resources available both for the provision of health scare and for health research in those countries. The deliberations of SEA/ACHR at the current session would serve as a means of developing a policy framework for a regional research programme under the aegis of WHO. Research could be highly individualistic, being motivated by a researcher’s own personal interests. Whilst this type of research should not be discouraged, the larger part of the resources available should be utilized for research on priority areas which kho,uld be clearly defined by policy makers and health managers. WHO and SEA/ACHR were in a position to optimize the utilization of the limited resources by providing close coordination to ensure that there was no overlappi)ng of research activities. This could be done by maximizing regional cooperation and sharing of information. An important area for research was on resource allocation in order to improve cost-effectiveness and operational efficiency. 2.5 Address by the Minister of Health and Family Wklfarel Mr B. Shankaranand, Minister of Health and Family Welfare, Government of India, delivering the inaugural address, warmly welcomed the distinguishedmembqks of SEA/ACHR to India. He was glad that SEA/ACHR was able to accept the invitation of the Government of India to convene the nineteenth session of the WHO Regional Advisory Committee on Heal& Research at ICMR, New Delhi. He said that India had a rich tradition in biomedical research and It& played a leading role in conducting basic as well as clinical research in critical are* sue as tuberculosis,. Ieprosy, hepatitis, viral diseases, reproductive biology, cancer and cardiovascular amongst others. A substantial proportion of the allocation of the Ministry of Health research since it was the fulcrum on which the formulation of disease control One of the biggest challenges faced by India as weB as other countries in the Region was population growth He was glad to learn that research on human reproduction was one of the Agenda items. Also, research on tropical diseases would help to mitigate the problems created by these diseases. The Hon’ble Minister placed on record his deep appreciation for the achievement of national targets in biomedical research. 4 f the assistance provided by WHO 0 assistance had been substantial and had resulted in institutional strengthening for undertaking research as well as in the formulation of national control programmes. He was aware that WHO/SEAR0 was currently reviewing its health research strategies and that SEA/ACHR would critically examine this matter and make recoirnnendations for a revised health research strategy for the Region. He assured that his Government would give due consideration to the recommendations made and adopt the new strategies to the extentithat they were relevant to India. The success of research was not determined by wh t occnrred within the four walls of a4 laboratory but by the extent to which the results of research met1 the needs of the largest possible section of the population. In conclusion, he made a plea for a more dynamic interaction between SEA/ACHR/19 Page 4 research and the needs of the people to ensure that the outcomes of research would be more focused and relevant. He wished all success to the deliberations of & Committee. Dr D.S. Agarwal, Chief, Division of Epidemiology, and Communicable Diseases, ICMR, proposed a Vote of Thanks. 3. BUSINESS SESSION 3.1 Introductory Statement by the Chairperson, SEAIACHR (Agenda item 1) Dr Sneh Bhargava, Chairperson, welcomed the members of SEA/ACHR, the special invitees and the Secretariat. Drawing an analogy with the weather in New Delhi, where a changing weather pattern was the norm and the people had to adapt themselves to the summer: heat that was soon due, she stated that in health research too, the challenge was to find solutions to the problems created by the various changes that were taking place, particularly demographic, epidemiological and environmental. The members of SEA/ACHR could be regarded as the agents of change in that they would have to develop a health research strategy with a flexibility that would permit it to face not only the changes that were currently taking place in the health scenario, but also the changes likely to occur in the next decade or two. 3.2 Opening Remarks by the Regional Director (Agenda item 2) Dr U Ko Ko, Regional Director, once again welcomed the participants and the special invitees. He thanked the Government of India, both on his behalf and1 on behalf of WHO and the South-East Asia Advisory Committee on Health Research, for hosting and for the excellent arrangements made for conducting the meeting. He then introduced the new member of SEA/ACHR, Dr U Myint Lwin, and also expressed his appreciation of the services rendered by those members whose terms concluded last year: Dr Gopal Prasad Acharya, Dr Usha K. Luthra, and Dr Daw May May Yi. The report of the Consultative Meeting on Health Research Strategies for the South-East Asia Region, convened in February 1993, had been distributed as a~ working document together with a draft document prepared on the basis of the outcome of this meeting. Agenda item 9 of this meeting was “Strategy for Health Research”, and the valuable comments of SEA/ACHR would enable the Regional Office to finalize the document prepared after the consultative meeting and to issue it as a technical publication of WHO/SEARO. This new publication would serve as a valuable adjunct to the famous “Green Book’ on “Research Needs for Health for All by the Year 2000”. Further, the views of SEA/ACHR would serve as the regional input to the “Research Strategy Update”, now being prepared by the Global ACHR. The two subjects for technical discussions this year, viz., “Research for the Improvement of Health Care Delivery System” and “Strategic Plan for Promo&g and Strengthening Health Economics Research” were not only of particular relevance today but were inter-related: on the one hand, there were problems related to the improvement of health care delilvery and, on the other, problems related to resource allocation for health care services. SEA/ACHR/19 Page 5 I Dr U Ko Ko referred to the Eighth Meeting of Diqctors of Medical Research Councils or Analogous Bodies (MRCs), held in November 1992. The tieetings of SEA/ACHR and MRCs were amplementary to each other since MRCs were instrume@l in translating SEA/ACHR and other WHO recommendations on research into action at the nati& level. He expressed the hope that the discussions would be conducted in the usual earnest but friendly manner and assured that the Regional Office would pay serious attention to the views and recommendations of SEA/ACHR. The Regional Director nominated Dr S.P. Tripathy (I Lwin (Myanmar) as Rapporteur. 3.4 Introduction of Documents (Agenda item 4) Dr K. Jayasena, Regional Adviser in Medical Researcl documents that had been circulated. 3.3 Nomination of Vice-Chairman and Rapporteur enda item 3) iia) as Vice-Cl@irman and Dr U Myint introduced the working and information 3.5 Adoption of Agenda (Agenda item 5) The Provisional Agenda and the suggested working s@edule were adopted. 3.6 Progress Report on the Regional Research Promotibn and Development Programme (Agenda item 6.1) , 3.6.1 Introduction Introducing the progress report, Dr N.K. Shah, Acting, D@ector,. Program*me Management, stated that health research was a constitutional function of the WorldjHeakh Organization. Since 1976, when research activities were decentralized by WHO headquarters and the South-East Asia Advisory Committee on Medical Research was constituted, there had been rapid development of research activities in the Region, especially in the coUfltfies which did not previously have an established tradition of medical research. SEA/ACHR had, among the Regional Advisory Com@tees on Health Research, taken the leadenhip in many fields of activity. The Global Advisory C<ljmmittee on Health Research, at its last meeting, for example, had referred to WHO/SEAR0 as a leader in the development of health systems research. Although the achievements in the field of research in th$ Region were not all due to the efforts of WHO, and though in financial terms its contributions might! not be very large, WHO had provided significant and continuous catalytic technical assistance. Dr Shah stressed that WHO did not impose its though@ and could not decide what research activities should be undertaken by each country. WHO provided guidance, but it was the national SEAlACHR/19 Page 6 authorities who had to make the final decision, In providing this guidance to the countries, SEA/ACXIR played a major role as it constituted the main advisory body to the Regional Director on matters pertaining to research. I 3.6.2 Summary of RPD Activities During the Preceding year (Agenda item 6.1) I Dr K. Jayasena presented a report of the Research Promotion and Development activities undertaken during the preceding year. In accordance with the recommendation made by SEIA/ACHR at its eighteenth session, the Regional Director convened a Consultative Meeting on Health Research Strategies for South-East Asia with appropriate terms of reference. The Meeting concluded that the overall objectives and strategies for the development of health research, as stated in 1982, were still valid today; however, certain modifications were suggested. Details were provided in the documents relating to Agenda item 9 on “Strategy for Health Research”. In the field of health systems research, the activities undertaken by the Regional Office were the provision of: - a separate budgetary allocation for strengthening the research capability of selected institutions to undertake HSR. This scheme had met with mixed success as some countries have not made lull use of the potential available under the scheme. - technical support by a staff member through a site visit to the Health Services and Research Development Centre in Surabaya; and consultant support to Nepal and DPR Korea. Such support was directed towards sensitizing decision-makers and health managers to utilize the results of HSR for decision-making; “training of trainers” who would constitute a nucleus that could undertake training activities thereafter; to assist in developing research project proposals through on-the-job training of selected research workers. - support to undertake health behaviour research. SoLe examples that were provided were studies on the use of personal protective measures for the prevention of malaria; the use of impregnated bed nets; and community p cipation for the control of vectors in dengue fever. In clinical research, the Regional Office recruited a ultant to provide extensive training on controlled clinical trial methodology in DPR Korea. He al vided assistance in the preparation of research project proposals for assessing the efficacy of Korean traditional medicines scientifically. To date, WHO/SEAR0 had supported eight proposals to test the efficacy of these remedies through controlled clinical trials in a wide variety of conditions. Dr Jayasena reported that the project for the developmelnt of a vaccine for dengue haemorrhagic fever (DHP), initiated over a decade ago with support fror.1 the WHO Regional Office and other sources, had been brought to a successful conclusion. The objective of this study was to develop a safe and immunogenic vaccine against the four types of dengu: virus. The live, attenuated tetravalent vaccine, developed by Mahidol University, had proved to be both safe and immunogenic in Phase 1 and Phase 2 clinical trials. A new study would be undertaker. to test the efficacy of the vaccine under SEA/ACHR/19 Page 7 actual field conditions, i.e., to prove that the vaccine was in preventing dengue and DHF among children of the target age-group in communities where ese diseases were endemic. Among the scientific meetings supported during the period der review was the Eighth Meeting of Directors of Medical Research Councils or Analogous ~Bodi s (MRCs) at which the subjects for technical discussions were: I” - Research on Human Resources for Health; li - Research on Human Genetics - Needs and Perspectives for the Future; and - Research on Health and Environment. Another meeting that was supported was a Resources for Health. SEA/ACHR was informed for Health for HFAL2000” was the subject for technical Regional Committee, held in Kathmandu, Nepal, in Septem from the countries and several areas where sufficient info Research in Utilization of Human Relevance in Human Resources at the forty43t.h session of the 2. The subject evoked much interest was not available were identified. Continuing further, Dr Jayasena said that one of programme was to strengthen the capability of Member being achieved through a variety of means, which include Visiting Scientists Grants, Fellowships and Research Research Councils. Financial and technical assistance WHO/SEAR0 for the establishment and/or development and coordination of health research. In this co ward of Research Training Grants, Strengthening of Medical for the appraisal of research project proposals developed by 1 and Development (NIHRD), Indonesia, in consultation witl There were 75 WHO collaborating centres at present centres were recommended for designation in the ‘fields of ( for health, viral hepatitis and genetics. Active measures were units in the Regional Office to promote the establishmen centres, national centres and other research establishments 1 In a review of the research activities undertaken wii Research Promotion and Development, Dr Jayasena informe others: - the recruitment of short-term consultants in fields molecular biology, biotechnology, demography am rapid assessment procedures (RAP) in nutrition surv sociology, health behaviour, health economics etc.; - improvement of institutional facilities by the acquit - publication of research bibliographies and abstracts - conducting workshops to impart training in researc of research project proposals; : National Institute for Health Research ?HO. hiring the lasd year, new collaborating aster preparedness intersectoral action )w being take4 by the various technical If linkages between the collaborating h common areas of interest. the WHO country budget support for SEA/ACHR twat these included among lch as health systems research, ~calth statistics1 nutrition, use of s, pathogenesis of DHF, medical on of supplies and equipment; j periodicals related to research; nethodologies and development SEA/ACHR/19 Page 8 - provision of research grants; - award of fellowships in diverse fields related to re arch. Reference was then made to the regional inputs into : pecial Programme activities and it was stated that details regarding these would be provided under genda item 8. In conclusion, Dr Jayasena referred to the v ‘ous annexes in the Working Paper (SEA/ACHR/19/5), which provided details pertaining to on oing research projects supported by ICP RPD funds; WHO Visiting Scientists Grants/Research Tr ‘ning Grants; Scientific Working Group meetings/meetings supported with research funds; WHO 1 c llaborating centres and WHO national centres in the countries of the South-East Asia Region and c nsultants recruited with ICP RPD funds. Discussion SEA/ACHR expressed its appreciation of the lu progress report on the Research Promotion and Development (RPD) activities undertaken ring the period April 1992-March 1993. The Secretariat provided additional informatio system for the appraisal of research projects supported utilization of research results; and the system ado collaborating centres. by the Members on the two-tier country RPD budget in Indonesia; ation and termination of WHO The need to establish a mechanism for the incorpor delivery programmes was reiterated by SEA/A liaison between researchers and programme managers. of research findings into health care d, among other things, a close SEA/ACHR took note of the scope and quantum of ivity being supported and carried out in countries as a component of the country RPD pmj by WHO. It expressed the view that WHO/SEAR0 should encourage and ensure that ad e mechanisms exist in countries to manage such research activities. This means that there d be some uniform procedures for prioritization of research areas, evaluation of the results (and s of the project, when completed) and for the utilization of research results. It was suggested that SEAR0 should provide a set o idelines to the countries for screening, monitoring and evaluating research activities and utilization results. The system should be developed in such a manner that potential users at the manageme consumer levels participate in the identification of research questions and conducting of re Universities and research institutes should be encouraged to participate in health would ensure that the research undertaken was relevant to the needs of the country, an sults were used. SEA/ACHR recognized the fact that WHO may not able to support all research activities identified as priority areas by a country. Hence, prior&i ton should be done within the national perspective as some of the identified projects may be sup ed by other agencies. In the same context, the use of informat lsewhere in the Region and the use of networking need to be maximized. SEA/ACHR/19 Page 9 kFrom the point of view of research capability strength ning, the coun 5 ‘es may wish to exercise a certain amount of flexibility - i.e some ‘open ended’ res arch, the objecti ii e of which was training of young research workers rather than the utilization of suits should alsb be provided for. With respect to research capability strengthening, it was recount that when SE&ACHR was established in 1976, the research projects that were supported were m nly disease-orie@.ed. When the question of research capability strengthening was considered by SE ACHR in the 1(98Os, it was agreed that in view of the limited financial resources available, the Reg’ nal Office shotid concentrate on health systems research, especially since funding for other types bf research was also available from the Special Programmes. SEA/ACHR agreed that in framing guidelines for the countries, a very rigid approach should be avoided. Certain types of research may be undertaken by countries for the development of expertise in a certain field; also, some studies may be undertaken by researchers, even in non-priority areas, if funds were available for such research. However, WHO funds should be provided only for research in priority areas. Recommendiations SEA/ACHR recommends that WHO/SEARO: (1) assist countries to prepare guidelines for the prioritization of research areas and topics; appraisal of research project proposals; monitoring and evaluation of research projects; and for the utilization of research results. (2) promote: (a) the dissemination of information on resear& tine in cow&s; and (b) networking of research institutions in the Region. 3.7 Review of RPD Activities in Relation to past SEA/ACHR Recommemtations in Specific Areas 3.7.1 Research Capability Strengthening in SEAR (Agenda item 6.2(a)) Dr Lim Teong Wah, Medical Research Offker (Special Programmes) in his presentation, stated that research capability strengthening (RCS) was identified as one of the main objectives of WHO/SEARO’s activities at the commencement of the RPD programme in 1976. Subsequently, SEA/ACHR made a number of recommendations and comments with respect to RCS. These included among others, that: - a significant proportion of tk RPD budget be utilized for institutional strengthening; - in RCS, there should be a judicious balance between strengthening’ of human and material resources. WHO/SEAR0 recognized that the capability to conduct research depends on several factors. These included the availability of well-trained motivated scientists; infrastructure support such as SEA/ACHR/19 Page 10 equipment, technical assistance, library facilities, transport etc.; and managerial and administrative support. WHO/SEAR0 had supported countries with respect to ‘the development and attainment of the above factors through a wide variety of mechanisms which Iincluded the provision of institutional strengthening grants for HSR; the award of Visiting Scientist$ Grants, Research Training Grants anc! Fellowships; providing financial and technical support @r workshops and training courses; strengthening of Medical Research Councils and Analogous Rodies; provision of consultant support; designation of WHO collaborating centres; provision of tiainin’ % materials; etc. WHO/SEAR0 had also distributed copies of the Training Manuals on HSR, prepared ~y WHO/HQ, to concerned institutions and departments. A WHO/SEAR0 technical publication on “The Appraisal of Health Systems Research”, would be released shortly. Research capability strengthening was a slow, gradual I d cumulative process, and the efforts of WHO/SEAR0 in this activity were complemented by additional inputs from the national governments, the Special Programmes and other donor agencbes. Discussion I ACHR expressed appreciation of the follow-up actions ~&en by WHO/SEAR0 with regard to providing support for research capability strengthening in the c untries. Y ACHR was informed that since 1988 a concerted effort had been made towards providing spec fit institutional strengthening for HSR. Such support to HSR has been provided in the form of a package to include consultant support, supplies and equipment and research grants. It was recognized that the effectiveness and the impact of such support with respect to the development of capabilities to carry out HSR would need to be evaluated. I ACHR was informed that research training comprised only a small portion of the Fellowships programme and that the Fellowships programme of WHO had frequently been evaluated at global, regional and country levels within the Human Resources for Health Development programme, full details of which were available. The network of WHO collaborating centres worldwid’ and in the Region was an important mechanism for research capability strengthening the potenti fof which had not been fully utilized. Many WHO collaborating centres, according to their terms of reference, provide consultancies, research training and reference material to researchers. It was realized that access to reference material and research reagents, some of which were not commercially available, could promote research activities. Research scientists and institutions in the Region should be made more aware of such facilities being provided by WHO collaborating centres. The provision of such services by WHO collaborating centres should be increased. The Directory of WHO Collaborating Centres in the Region, published by WHO/SEARO, will give some indication of the type of services offered by them. It was pointed out that research capability strengthening was being done by many technical units within WHO; by the Special Progmmmes; by other UN agenci s; by bilateral and international bodies; and by national institutes. LThere should be some means of ensuring that such effo were not duplicated. At the regional level, there was a certain amount of coordination to prevent duplication in such efforts within WHO SEA/ACHR/19 Page 11 and between UN agencies. However, WHO was strengthening activities undertaken by bilateral and and it was possible that such efforts may be duplicated. Mechanis have to be explored. aware of research capability and NGOs within countries such duplication would Emphasis should be gradually shifted to the trans-disease ‘sciplines such as health economics, epidemiology and behavioural science, so as to enhance thu cap f bility of the scientists to carry out research, especially in areas where they relate to the non-health ector. Recommendations SEA/ACHR recommends that: (1) the network of WHO collaborating capabilities in countries; in particular, they should be able reagents not commercially available to researchers in made better aware of such facilities. tter utilized to strengthen research reference material and research and institutions should be (2) WHO should endeavour to improve coordination( and h onization of research capability strengthening within WHO and with the Special Programmes, and, if possible, with other agencies and organizations, particularly at the country level. ” 3.7.2 Research Related to Nutrition (Agenda item 6.2(b$ ; which provided a review of the developments and proposals for Regional Nutrition Research Programme, submitted to SEA/A recommendations thereon. In reviewing SEAR0 activities in relation to past ACHR ) reco Dr Aung Than Batu, Director, Research and Human Resources, he future development of WHO HR in 1988, and SEA/ACHR mendations on nutrition research, to the background paper During the four years since 1988, WHO/SEAR0 had been im Programme endorsed by SEA/ACHR, and promoting and supporting in accordance with SEA/ACHR recommendations. (1) South-East Asia Nutrition Research-cum-Action Nqtworl IWHO/SEAR0 promoted and partly supported the for/natio and functioning of the nutrition research-cum-action network in the South-East Asia Region. The first consultative meeting of the Network took place in Thailand in August 1990 with SEARG sup wt. A mechanism for the Network with focal points in each Mc centres in nutrition and WHO/SEAR0 acting as a clearing (housc centres are: Nutrition Research Development Centre, Bogor, Indone Hyderabad, India; Institute of Nutrition of Mahidol University, Br of Food and Nutrition, M.S. University, Baroda, India. Jementing the Nutrition Research a number of activities which were &er Country, four collaborating was devised. The collaborating ia; National Institute of Nutrition, lgkok, Thailand; and Department SEA/ACHR/19 Page 12 Research-cum-action projects have been designed to deal with priority operational issues in nutrition in primary health care decided on jointly by the Member Countries and collaborating centtes. Three research protocols were finalized and funded by SEARO: - Vitamin A Deficiency: Reduction in its prevalence by the promotion of increased consumption of vitamin A rich foods that can be grown in the home garden or were locally available. - Anaemia in Pregnant Women: Strategies to improve compliance with iron supplementation. - Weaning Foods - to overcome protein-energy malnutrition in young children. These projects all involve community/social/behavioural research methods that were not in the usual armamentarium of medical managers or researchers. As a first phase, the three projects were undertaken in the four centres of excellence which were, in the meantime established as WHO collaborating centres. WHO/SEAR0 was now awaiting the results of ‘s phase of the research agenda to see whether the methods developed at these lead institutions wo 3 be technically feasible and appropriate for transfer to the nutrition service departments of the coun ‘es, which would subsequently be undertaking the next phase of the studies. I More recently, projects have been started using rotocols modified for country situations - in Bangladesh, Myanmar, Nepal and Sri Lanka - using extrrbudgetary funds. Collaborating centres would (if funds become available) support these country studi s.Efforts have been made to mobilize further support. e In summary, the South East Asia Nutrition Research-cum-Action Network and its associated research serves to strengthen regional and national nutritional research capabilities, and to support research in important areas recommended by ACHR. , (2) Large-scale multidisciplinary studies in other programme areas with a strong nutritional research component1 ’ WHO/SEAR0 had been promoting and supporting a number of large-scale studies where nutrition research was a strong component. They strengthen the links between nutritional research and other programme areas and help to promote the comprehensive health care approach. These are: (a) Health and health-related aspects of the P verty Alleviation (Janasaviya) Programme, Sri Lanka P (b) The low birth weight studies I (c) The Joint Nutrition Support Programme in My ar and Nepal (funded by the Italian Government) (d) Epidemiological studies on the health of the elderly. SEA/ACHR/19 Page 13 (3) Specific nutritional control programmes with r WHO’s specific nutritional control programmes, vitamin A deficiency etc. have a research component, espe research type. deficiency disorders, f the health systems and operational (4) Nutritional component of other WHO programmi Ies Other WHO programmes, especially Control of Dia and Maternal and Child Health, promote and support nutritional component. Diseases, Intestinal Hehninthiasis, some of which have a strong (5) Small grants related to nutrition supported by Wb ’0 country bqlgets WHO’s RPD/I-ISR budget in countries such as Indonesia, Bangladesh, Nepal and sometimes in.~ India, was being used to promote and support small short-term research projects on various topics, including nutrition. As can be seen from the activities described above, most of the nutrition research promoted and supported by WHO/SEAR0 was of the operational and HSR types, including community, social, and behavioural aspects of nutrition. Technology-oriented nutrition research was not emphasized except where there was a possibility of a breakthrough with respect to improving: nutrition,, as in the case of amylase rice flour, to lessen the viscosity and bulk of Uant food. WHO/SEAR0 had not been able to support basic biomedi6ai. research reIating to mrtrition requirements, nutrition standards and indicators. The nutrition research component of many studies was sometimes not visible, such as in the case of studies of diarrhoea and intestinal helminthiasis. Strengthening of national capability for nutrition research was done mainly by support of research projects. Many HSR training activities in the countries, although not specifically aimed at nutrition research, do increase the capability of countries to undertake nutrition research of the HSR type. Linkage between research institutions and nutrition services was fostered by supporting collaborative arrangements in nutrition research. As shown, the Regional Nutrition Research Programme, as endorsed by the fourteenth session of SEA/ACHR, was being implemented gradually and incrementally depending upon the availability of resources. Nutrition, as one of the key elements in primary health care (PHC), was a major determinant of health, growth and well-being of children. Without good nutrition, physical growth, mental development and health cannot be optimum. SEA/ACHR/19 Page 14 Biomedical research in nutrition had succeeded in identifying the immediate causes of malnutrition, explain the clinical manifestations of nutritional disorders and develop biomedical methods for correcting nutritional deficiencies and imbalances. Although biomedical research may still need to look into some remaining areas such as the effbct of malnutrition on mental development - the main emphasis of research should now be shifted to uddressing deeper underlying basic causes so that preventive measures could be developed and good nutrition may be promoted. Several causative factors, such as inadequate fobd supply, food taboos, early weaning and improper weaning practices as well as improper child r ’ *g practices, all lead to a vicious cycle of malnutrition and infection. Therefore, a holistic appro h involving agriculture and food sciences, education, health and community development would”required to tackle this problem. A comprehensive programme of nutritional improvement should aim at correcting malnutrition, preventing malnutrition and nutritional disorders and1 promoting good nutrition. This may be progressively achieved by addressing immediate causes Isuch as inadequate or inappropriate dietary intake; underlying causes such as insufficient household f t d security, inadequate caring capacity, and an unhealthy environment; and basic causes such as low f, od productivity, improper food and feeding habits, and poor environmental sanitation - which thems$lves were rooted in low education, poverty and lack of political will. The South-East Asian countries face four major ubitional problems which include protein- energy malnutrition in young children, iron deficiency1anaemia), iodine-deficiency disorders and vitamin A deficiency. With changing lifestyles and urbanization, obesity in children was emerging as a nutritional problem. In the past, much attention was giv n to the curative aspects after malnutrition had occurred. For control of these nutrition deficiency idisorders, the focus should be shifted to preventive measures by addressing the underlying causes s ch as inadequate child care-giving (breast- feeding, appropriate supplementary food, immunization, etc.) insufficient household food security,r insufficient health services and unhealthy environment. In the management of nutritional disorders, an attempt should first be made to determine the underlying ause; if this was established, the next step should be to determine the reason for the existence of the t nderlying cause. Ultimately, to completely eradicate these nutritional problems, emphasis must be pla ed on the basic causes which include food habits and feeding behaviour, low agricultural pmduction leading to inadequate food supply, improper education and poor environmental sanitation. Nutrition research should be promoted and undertaken in the context of the above chain of causation and factors underlying malnutrition and good nukrition.I It was realized that the more research probes into underlying basic causes and factors, the more does such research move away from the domain of the health sector into other domains such as social science, economics, agriculture, and politics. General issues then emerge concerning intersectoral boundaries, competency of the health and traditional allied professions, efficient organization and mobilization of scientific manpower to deal with nutritional problems and the underlying social and economic problems. The question then arises as to how far the health sector or the health profession and the health policy makers should reach out to address, influence and take on tasks and responsibilities which gradually recede beyond their competence and experience or influence and address issues that other domains and sectors were better equipped to influence, such as, in tackling social and economic problems. A decision had then to be made in respect of those aspects of nutritional problems thatlcan be dealt with by health professionals SEA/ACHR/19 Page 15 and those which should be left to be solved by non-health personnel with expertise in social and economic factors. Experience in Thailand had shown that the mobilization of other sectors to improve the nutritional status of the population can be better achieved if nutrition was portrayed not only as a factor in health but as an essential component of human development. Research related to nutrition then should include policy research and1 policy analysis leading to advocacy for policies which would protect and improve nutrition. Studies to examine the implications for nutrition of health, agriculture, trade and other policies should be encouraged and these may be equally as important as biomedical research and HSR related to nutrition. Also, qualitative research methods, such as participatory research and research on behavioural modification, may need to be emphasized. Recommendations The Committee took note of WHO/SEARO’s wide-ranging act@ities in promoting and supporting nutrition research within the framework of the Regional Nutrition Research Development Programme and the resources available. It recommends that: - increasing attention be given to research into the socioeconom@ and bebavicmral determinants of nutrition practices and to develop means of changing these to improve nutrition. This includes research on the nutritional tmplications of changing lifestyles, urbanization, changes in age pattern and societal vques (both under+nutrition and over- nutrition) which may lead to chronic, degenerative and other diseases. - strengthening of intersectoral collaboration in nutrition research and encouragement of research by other sectors which may be more relev t for the improvement of nutrition than those undertaken in the health domain. c - increasing attention be given to policy research influencing activities of other sectors which may 3.8 Matters Arising out of Meetings of Global of Other Regions (Agenda item 7) Professor M. Gabr, Chairman, Global ACHR, co Office for developing a Health Research Strategy for promotion and development, the South-East Asia Region an active ACHR. East Asia Regional the field of research ve features including At the global level, there was a need to articulate emanate as a policy statement from the World Health As on Health Research Strategy, issued in 1986, was bei that health research did not receive the attention it de her;llth research strategy which should , the WHO publication was of the view governments or from WHO. SEA/ACHR/19 Page 16 Health research was most needed by the least developed co tries in order to determine the most cost- effective way to utilize the limited resources available Harmonization of research activities was very impo WHO and other UN, bilateral and nongovernmental better utilization of funds. For example, activities, such socio-behavioural research and research capability st effectively if the Special Programmes linked up with nly within WHO but also between Harmonization was required for raining, HSR, epidemiological and , could be undertaken more cost- ts, bilaterals and NGOs. Professor Gabr stated that apart from the Spec mes, WHO provided very limited funding for research, and referred to several options considered to increase funding. WHO would need to act as a broker to motivate other ch as UNICEF and UNDP, the World Bank and NGOs to support research; to seek su rt from industry for research, ensuring, however, that there would be no conflict of interests. With respect to ethics and health research, the glo ACHR had requested that WHO endorse the CIOMS guidelines for epidemiological research and re h involving human subjects. Adherence to ethical guidelines was especially important in rese supported with extrabudgetary funds in developing countries. Referring to future ACHR activities, the Global give priority to research that would help developing multisectoral research; give priority to HSR; and that evolving problems or future scientific advances. had recommended that WHO should s which were in greater need; support should have a futuristic orientation on Professor Gabr then briefly outlined the activities the ‘Task Force on evolving problems of critical significance; the Task Force on impact of scien and technological advances on health; the Task Force on Health Development Research and SubCcommittee on Research Capability Strengthening. The Sub-committee on Research Capability WHO regions and also supported a few prototype Offices. He then referred to the essential features identi research capability in developing countries. had carried out several surveys in ts in cooperation with the Regional by ‘the Sub-committee for strengthening Professor Gabr stressed the need for international d bilateral cooperation - North and South cooperation through a twinning mechanism especially for research and for certain areas of training. South to South cooperation should be one method of avoiding a brain drain from South to North. The Global ACHR had also discussed the role of to strengthen the review mechanism to a need to reduce the number of collaborating centres. 0 collaborating centres. There was a need centres. There was also perhaps Discussion ) SEA/ACHR noted that many issues regarding he ACHR, had also been addressed by the Consultative th research strategy, raised by the Global on Health Research Strategy held in February 1993 and at the current meeting of SEA/AC SEA/ACHR/19 Page 17 The ACHR mechanism had played a major role in prom ting research in the countries and was instrumental in emphasizing fields and issues such as women’s alth, equity, harmonization of health research, research capability strengthening and HSR. The Chairman, Global ACHR, noted that the SEA egion not only had a very active SEA/ACHR which met annually but had also decided to ea ” ark approximately 5 per cent of its intercountry funds and 5 per cent of its country budget for RP activities. 3.9 Progress Reports on Special and Global Programmesl 3.9.1 UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (Agenda item 8.1) Dr Lim Teong Wah presented the progress report on behalf of the Special Programme. The Special Programme had identified four thrust areas for the 199Os, namely, Field Research; Product Development including Rational Drug Development; Socioeconomic Research, and Research Capability Strengthening. Further, a prospective thematic review (PTR) on scientific directions of TDR had been carried out. The report of this review, “TDR towards the Year 2000: Strategic considerations in R and D”, would be submitted for endorsement by the’sixteenth session of the Joint Coordinating Board in June 1993. The PTR reviewed the directions and organizations of RCS of TDR. The RCS activity had been evolving, since its inception, and moving towards increasingly flexible policy choices. Initially, RCS was focused on institutional strengthening. Then, as research capacity and capability grew, these RCS activities began to be located within the framework of R&D projects. With this flexible approach, the Programme’s policy was now to follow the research and the researcher. In order to strengthen such linkages between RCS and R&D, a differentiated approach had emerged to fit individual and country-specific needs through a variety of igrant systems that allows continued support to research groups at increasingly competitive levels using time-limited support mechanisms appropriate for each level. This differentiated approach identifies three levels of support, i.e., Least Developed Countries (LDC), Advanced Developing Countries and those in between. Various types of grants were devised in order to support these various needs It was anticipated that this form of support would increase scientific productivity, solidify networks and emphasize on human resources development. As a result of this policy shift, institutional strengthening and research training grants had also undergone modifications. There were now three types of institutional strengthening grants and five research training grants plus two other arrangements for training of clinical monitors and training within national organizations through mutual agreements, and these have been adequately described in recent TDR publications and newsletters. Specific support for RCS during the last two years had been provided to institutions in the SEA Region. Training activity had been substantial at the end of 1992. During the period, 29 training grants were supported by TDR in the SEA Region, making a cumulative total of 201. Similarly, 42 research projects were supported and funded, out of 283 research projects funded so far by the TDR. As for Research and Development activities, TDR had sponsored research in malaria, filariasis, leprosy and leishrnaniasis in the Region. In malaria, such studies included the use of impregnated bed- SEA/ACHR./19 Page 18 nets, drug resistance and utilization, experimental chemotherapy, pharmacokinetics, molecular entomology, vector control, vaccines, pathology, epidemiology and socioeconomic aspects of the disease. In leprosy, multicentric studies in India and Myanmar on field trials of ofloxacin - containing drug regimens had been initiated. In addition, other studies on immunology, pathology, combined chemotherapy, diagnosis and socioeconomic aspects were also supported. In fdariasis, comparative studies between ivermectin and diethylcarbamazine (DEC) were being pursued with the development of five new study designs. These studies were designed and initiated by Indian and Sri Lankan scientists. Workshops were held in India to formulate research proposals for studies to assess the social and economic impact of lymphatic filariasis in South-East Asia, Western Pacific and African regions. In leishmaniasis, several projects have been funded for diagnosis, epidemiology, vectors and drugs. For the future, increased emphasis would be placed for support for human resources development, particularly in applied field and social and economic research, adoption of a differentiated country approach to capacity building (RCS) and development of research and training networks using advanced communication technology. Discussion Information concerning new initiatives of partnership and linkage grants was further elaborated. Such information was usually provided through announcements made by TDR. Individual members expressed interest in receiving information more expeditiously on any new initiatives of the Programme, including TDR news. They observed that the dissemination of such information to the Member Countries should be more specifically directed to potential users. There was interest regarding the status of malaria vaccines. Only one synthetic peptide vaccine had undergone large-scale field trials. The initial results have shown about 40 per cent protection. Questions were raised on drug-resistant malaria. SEA/ACI-IR was informed that clinical trials with artemisinin derivatives per se as well as controlled clinical trials to compare the efficacy of these derivatives with quinine were under way in Myanmar and Thailand. Opinions were expressed concerning possible problems of schistosomiasis in relation to construction of dams. This was especially mentioned in relation to the Mekong dam bordering Thailand and Indochina. More research should be carried out on its epidemiology following such dam constructions. 3.9.2 Special Programme of Research Development and Research Training in Human Reproduction (Agenda item 8.2) Dr Egon Diczfalusy, Senior Consultant, presented the progress report on behalf of the Director of the Programme. He first provided some background information on the Programme. The Programme was the main instrument within the UN system for research on human reproduction. It was a global Programme of technical cooperation designed to promote, coordinate, support, conduct and evaluate research on human reproduction, with particular reference to the needs of the developing countries. He described the structure and organization of the Programme. A unique feature of the Programme was that it was conceived, directed and executed by the scientific community. By the end SEA/ACHR/19 Page 19 of 1991,343 scientists from 26 developed countries and 3 18 scientists from 43 developing countries had participated in the scientific direction of the Programme. Dr Diczfalusy said that the basic philosophy of the Programme was simple and straightforward. It recognized the fact that human reproduction had a wide-ranging impact on the health of women and children, status of women, population, socioeconomic development and global environment. Family planning, together with maternal care, infant and child care, and prevention of sexually transmitted diseases constituted the four fundamental pillars of any reproductive health policy. He then described the Programme’s main activities, which were in the areas of Research and Development, Strengthening Resources for Research, and the provision of statistics and data processing assistance as a “back-up” to the above two activities. In the field of Research and Development, the activities were organized along five major lines: Technology Development and Assessment; Technology Introduction and Transfer, Epidemiological Research on Reproductive Health, Social Science Research on Reproductive Health and Essential National Research. Technology Development and Assessment activities were conducted by a series of Task Forces. He said that the major achievements in this area were the development of a variety of new and improved technologies such as once-a-month injectables; two-to-three monthly injectables; hormone releasing vaginal rings; implantable contraceptives; post-ovulatory methods; new and improved intrauterine devices (IUDs); birth control vaccines; the development of “male” methods; natural methods of fertility regulation and developments in the prevention and treatment of infertility. Dr Diczfalusy provided brief descriptions of each of these areas. Referring to Strengthening of Resources for Research, Dr Diczfalusy said that this was an area of paramount importance to the Programme, which spent approximately one-third of its budget for research capability strengthening activities in developing countries. Three regional committees of scientists - for Africa, Asia and the Americas - were responsible for the activities of this division of the Programme. The aim was to achieve national self-reliance in the assessment of research needs, formulation of research objectives and conducting of research on reproductive health problems in as many developing countries as possible. Dr Diczfalusy then gave additional information on research activities promoted by the Programme in the South-East Asia Region. I-IRP activities in the South-East Asia Region have been accelerated with the award of five new LID grants. Discussion ACI-IR expressed interest in the studies on copper IUDs and “Norplant”. Studies carried out so far indicate that copper IUDs have been very effective. China has decided to replace the use of stainless steel devices with copper IUDs in view of its higher efficacy (and lower failure rate). With respect to Norplant, one system has been approved for use in some countries and the Programme is collaborating in conducting post-marketing surveillance. Some other versions of Norplant are currently undergoing Phase II trials. However, Norplant is still very expensive. SEA/ACHR/19 Page 20 Regarding the safety of oral contraceptives, especially its association with cardiovascular diseases, several multicentric studies would soon be completed and the results made available. The HRP birth control vaccine is about to enter Phase II trials. However, this apprqach has not been well received by women’s organizations in general; they are generally mote supportive of barrier methods, especially those that afford protection against sexually transmitted diseases (STD) as well. Female condoms have been developed and a second trial has been conducted among sex workers in Bangkok; however, the acceptance of these condoms is generally not encouraging. 3.9.3 Acquired Immunodeficiency Syndrome (AIDS) (Agenda item 8.3) Dr N.K. Shah, in his presentation, stated that the Global Programme on AIDS (GPA) was responsible for coordinating world-wide research related to HIV and related infections,, identifying global research priorities, supporting institutional research primarily in developing countries, and for disseminating the results of research on HIV/AIDS. The Programme supported intervention development research, social and behavioural research, and biomedical and epidemiological research. Research on intervention development was, focused on effective approaches and guidelines for youth and the general population. This included information, education and communication (IEC), sex work-related interventions, STD management, condoms promotion and drug use prevention. A study in Thailand had shown that increased use of condoms amongst sex workers led to a remarkable reduction in STD, which was an indirect indicator of possible reduction in the risk of AIDS. Studies had shown increased risk of HIV in people with STD. This was maximal with chancroid and syphilis. Social and behavioural research in six countries had shown that while information on AIDS reached the people, misconceptions about HIV persisted and the desired change in sex behaviour or pattern of sexual activity had not resulted. The Programme was emphasizing culture and area-specific research and social marketing research for altering the behaviour of the people. In 1991, the Programme reviewed the findings of 83 intervention projects in 38 developing countries. These studies were directed more to female sex workers and not so much to the clients. Peer education might prove to be a powerful intervention in the Programme. Studies of sexual negotiation were of fundamental importance and, in this context, it was important to empower women in their negotiation for safer sex. Support was provided for epidemiological research, surveillance and forecasting to promote descriptive epidemiological research. Research on drugs was on evaluation of anti-retroviral therapy. The drugs were at present expensive and could cause adverse effects, which was likely to prevent their widespread use. Vaccines were being developed to prevent HIV-negative persons from getting infected; to vaccinate HIV- infected pregnant women to protect the foetus/newborn from being infected and to delay the progression to AIDS in HIV-infected persons. The genetic variability of the virus and the difficulties in HIV isolation had retarded the efforts directed towards vaccine development. Vaccine field trials were now planned. Thailand was a site and India might also participate in Phase II trials. The Programme was supporting evaluation of diagnostic assays, evaluation of alternative strategies for confirmation and field evaluation of cost-effective strategies. SEA/ACHR/19 Page 21 Discussion SEA/ACHR observed that research was required to develop a better understanding of the mode of transmission of AIDS and the best methods of preventing the disease. Why the disease continues to have a low prevalence in certain countries needs to be determined. This information may prove very useful in arresting the spread of the disease. The IEC efforts using mass media have no doubt brought about increased awareness about HIV. However, a change in practices had not yet taken place. This would require consideration of social, ethnic and religious aspects as a part of behavioural studies. This research must be area-specific and culture specific to be useful. There was a need to identify the best methods and convincing approaches required for modifying behaviour. Success stories in Australia, Indonesia and Thailand have related to involvement of peer groups or religious leaders. More information was required to explore effective ways of bringing about a change in attitudes and behaviour. The lessons learnt from the experience in AIDS might be applied to control of other problems of public health importance. People continue to have a fatalistic attitude to AIDS. Effective ways to bring about a change in this attitude need to be determined. While the stress on clinical management of the disease and on prevention through vaccines must continue, it was necessary to realize that preventive behaviour by the community, especially by high- risk groups, would be useful in controlling the epidemic. Research must be promoted to focus on effective methods of changing the behaviour of the people. 3.9.4 Control of Diarrhoeal Diseases (Agenda item 8.4(a)) Dr R.L. De Sylva, Short-Term Professional, Diarrhoeal Diseases, WHO/SEARO, made a presentation on research activities in diarrhoeal diseases, undertaken in 1992. Research activities in diarrhoeal diseases were funded, monitored and evaluated by the Control of Diarrhoeal Division (CDD) in WHO headquarters. In 1992, the Programme continued to support research aimed at the development and evaluation of new improved approaches for the prevention and treatment of diarrhoeal diseases. Increased emphasis was placed on developing research activities related to programme implementation: assessment of the effectiveness of selected interventions for diarrhoeal disease control and the identification of key factors that determine their success. Nineteen new research projects were supported in 1992. The main areas of research were: - Case management research, which includes the use of improved ORS formulations; feeding during and after persistent diarrhoea and the rational use of drugs; - Nutrition research: research pertaining to feeding, weaning, vitamin A and micronutrient supplementation; - Hygiene research, which encompasses hand washing, sanitary disposal of faeces, etc.; - Vaccine evaluation research, i.e., evaluation of ‘promising candidate vaccines for the most important causes of acute diarrhoea - rota virus diarrhoea, cholera, shigellosis and diarrhoea due to enterotoxigenic E.coli; and - Descriptive studies on severe diarrhoea: includes risk and prognostic factors for dehydration and risk factors for shigellosis. Discussion Noting the important connection between breast-feeding and nutrition of the infant, diarrhoeal diseases and acute respiratory infections, the members felt that~this should be brought to the notice of the governments in order to consider appropriate measures sue h as extending the duration of maternity leave, establishment of creches close to the mother’s working place, etc. Clarification was provided to the members regarding th duration of immunity and IgA levels following immunization with live oral cholera vaccine. t With respect to the immunization of children having were informed that the current practice was for a dose of if the child was having diarrhoea because there was a this was not counted as a dose and the child was given anoth clinic. with polio vaccine, members (OPV) to be given even of the vaccine “taking”. However, on the next visit to the The management of watery diarrhoea by physicians d nurses leaves much to be desired because of their tendency to use drugs inappropriately in th management of patients with watery diarrhoea. The CDD Programme, therefore, accords the highe t priority to training of physicians and establishment of diarrhoea training units in hospitals. i other health care providers by enabling them to receive “han s on” training in the management of watery diarrhoea with oral rehydration therapy alone. The CDD Programme also promotes the 3.9.5 Acute Respiratory Infections (Agenda item 8.4(b)) ~ Dr Vijay Kumar, Medical Officer, Acute Respirato Infections, WHO/SEARO, in his presentation, stated that standard case management of AR1 by WHO to reduce mortality in young children. The Programme otion of available vaccines, including measles, for the prevention of pneumonia. Research and was coordinated by the WHO- CDR Unit in WHO/I-IQ. The Programme emphasized and behavioural, health systems and disease prevention research. A 1988 and 1992. Of these, 18 were sanctioned during 1992. There was between services and research activities with stress on development of Case management research included multicentre pneumonia, sepsis and meningitis in young infants; evaluation of clinical significance of laborato evidence of drug resistance; research on simplified or cheaper antibiotic treatment regimens d on improved methods of oxygen administration. In behavioural research, focused ethnographic studies were completed in several countries. Standard research protocols were available for this purpose Behavioural research would include evaluation of maternal understanding of home care messages d the mother’s ability to recall them. SEA/ACHR/19 Page 22 SEA/ACHR/19 Page 23 Health systems research comprised surveillance of antibiotic resistance, intervention studies to evaluate standard case management and assessment of drug use in the treatment of pneumonia. In disease prevention research, the Programme identified 23 risk factors for extensive review for the development of potential interventions. Research on interventions to reduce indoor air pollution, the use of Huemophilu.s influenzue type B vaccine and of conjugated pneumococcal vaccine was proposed. Protocols for health facility surveys, and combined CDD-AR1 and mortality surveys were field-tested and finalized. I Discussion Observations were made regarding cotrimoxazole taken orally by mothers and its secretion in breast milk. Social and behavioural research should aim at improving maternal understanding of the safety of the drug when given orally in the treatment of pneumonia. Exclusive breast-feeding promotion for prevention of AR1 and diarrhoea in children should be studied for cost-effectiveness. If proven, a strong case be made for longer maternity leave and other measures for the promotion of exclusive for the first 4-6 months of life. Results of research on clinical signs for diagnosis of pneumonia, such as respiratory rate and crepitations, were discussed. While the respiratory rate count was useful for management decisions, search for precise indicators that can be used as the gold standard should be continued. In the busy out-patient clinics, the time allocated for each case was short. Signs which can be quickly evaluated should be investigated. 3.10 Strategy for Health Research in SEAR (Agenda item 9) Dr Aung Than Batu, in presenting the working paper on Health Research Strategies of the South-East Asia Region, recounted the steps taken by SEAR0 in producing the working paper. In response to SEA/ACHR recommendation at its eighteenth session, calling for a review of the current research strategy, formulated in 1982, SEAR0 had convened a consultative meeting in February 1993, the report of which formed the main basis of the working paper prepared by SEARO. After receiving comments and suggestions from SEA/ACM, the working paper would be reviewed to incorporate pertinent inputs and to produce the finalized accepted version of the “Health Research Strategy of SEAR.” This would be published for wide distribution in due course. The need for a review had arisen because of changes in three main areas. First, there were political, economic and social changes linked to changes that were occurring in the proximate determinants of health, such as population structure, urbanization, lifestyles, industrialization and the environment. Second, changes were occurring in the epidemiological pattern of diseases. While there had been gains in the control of some of the communicable diseases, such as childhood immunizable diseases and leprosy, many of them remained significant health problems. Some countries and sections of population were beginning to experience the double burden of noncommunicable diseases in addition to the existing burden of communicable diseases. Thirdly, there had been remarkably rapid advances in science and technology as related to health with potential for new and improved tools for better prevention and treatment of disease and implications for assessment, adaptation and transfer of appropriate health technology into countries. At the same time, the health research capacity of SEA/ACHR/19 Page 24 countries had increased, although unevenly. All these changes ylould influence the way health care was sought and provided and the type and scope of health research needed. A brief description of the emerging health scenario in the South-East Asia Region was given in terms of: (1) demographic transition: population growth ageing population; (2) urbanization; (3) socioeconomic changes; (4) food and nutrition; (5) lit racy; (6) women’s health and their development; (7) changes in the health environment, such as water supply and sanitation, industrial and occupational hazards; (8) changes in health, such as heal of vulnerable groups, communicable diseases, noncommunicable diseases; (9) progress towards : A/2000 and PHC, (10) advances in science and technology; and (11) changes in resources for he th research. The Health Research Strategy for the SEA Region, which had been developed on the basis of the recommendations of the Consultative Meeting, was then described, as given below. The Research Strategy, formulated in 1982, had been u&en as a starting point and revised in the light of the aforementioned changing situation.. II (1) The research objectives and strategies, started in 19 ’ 2, were still generally valid today. That is, the research objectives and strategies should be related o the attainment of the goal of HFA through primary health care and the eight essential elements of HC should be the framework in which researchable areas were identified and research priorities dete ined.1 (2) In response to the emerging challenges of the changing health scenario, there was a shift in emphasis with respect to the researchable areas. Research relating to the eight essential elements of PHC continue to be important. t Research on major infectious diseases would continue to be of prime concern. Research to improve the delivery system and use of existing and new too for the control of infectious diseases would be emphasized. Research related to vaccines would ecus on the improvement of existing: vaccines and the testing of newly-developed vaccines, such as kor malaria, AIDS, cancers and chronic diseases, caused by viral agents. I There would be a relative shift in emphasis towards r search on noncommunicable diseases, including cardiovascular diseases, degenerative diseases, cant rs, mental illnesses, injuries, chemical poisoning, genetic disorders and “socially induced illnesse “. Nutrition research would shift its emphasis towards anticipating, preventing and controlling nutri ‘anal problems arising out of the social1 and demographic changes. Research in relation to appropriate treatment of common diseases and injuries would respond to the changing pattern of diseases and the double burden of illnesses. Research to adapt and assess the newly developed health care technologies for application at all levels of health care in proper balance would also receive increased attention. Research related to child care would change in relative emphasis between infections and health problems arising out of social changes in family life. Rese ah related to maternal health would concentrate on the optimization of delivery systems for matem care and on social factors underlyingB; maternal mortality and morbidity. I SEA/ACHR/19 Page 25 Research related to education would take advantage of rapid advances in information technology and communication systems. Research related to the provision of adequate supply of safe water and basic sanitation would continue to emphasize health, especially the behavioural aspects. (3) Regarding types of research to be emphasized, research related to promotion and preventive aspects of health and health systems research would continue to be the main thrust. Within HSR, health policy research and research concerning economic aspects of health and human resources development would receive greater attention. Relevant aspects of the methods used in social sciences, behavioural sciences and health economics would be incorporated or internalized into health research. There would be increased attention to clinical research relevant to primary, secondary and tertiary levels of care in the descending order of priority. Basic research, which was an integral part of research programmes related to PHC, would not be excluded. (4) A systems approach would be used to develop health research and the input-process-output model would provide the context. Measures to optimize inputs to the research system, especially human resources, would be of prime importance and mechanisms and measures to disseminate and utilize research findings would be developed. (5) WHO/SEARO’s role would be promotive, facilitative and coordinating. Its operational approach would be selective, catalytic and forward-looking. Medical research councils and analogous bodies would continue to be strengthened. The major effort would be on research capability strengthening. It would concentrate on helping countries to develop the health research system as a whole, and to adopt measures that would optimize the resource inputs and better utilization of research results. Direct support to investigator originated research would be curtailed, with some exceptions, and the principal mode of supporting research would be through commissioned research to institutions for the purpose of promoting research in critical areas of existing or emerging priority health importance. (6) WHO/SEAR0 was an integral member of the Organization’s global team carrying out its global research activities, including those of the Special Programmes, and was specially responsible for research activities within the Region. It would continue to collaborate with ministries of health, universities and research institutions and would expand collaboration with potential partners elsewhere. It would also work more closely with WHO collaborating centres, professional societies and nongovernmental organizations. (7) Within the framework of the research strategy and with the advice of SEA/ACHR, several broad researchable areas would be targeted for concentrated efforts lasting at least several biennial budget cycles. Discussion It was recognized that the roots of many health problems extend beyond the health sector, and that the factors beyond the domain of health, such as food production, trade, urban development, SEA/ACHR/19 Page 26 poverty alleviation, control of population growth, economy, etc., were basic to the attainment of a healthy life. It was realized, therefore, that while research by scientists and institutions in the health sector or domain was necessary, it was not sufficient by itself ‘to produce the knowledge and technology necessary to contribute effectively to the development and implementation of intersectoral programmes and measures which would accelerate progress towards the achievement of the goal of Health for All in the countries of the Region. The incorporation and internalization of the relevant basic methods used in socio-behavioural and economic sciences into health research, especially into health systems research, would be important and necessary for studying both the determinants of health and of ill-health and changing the underlying causes in the desired direction. SEA/ACI-IR, therefore, agreed that an additional strategic approach to health research development should be: - to promote and intensify intersectoral collaboration in research that had potential for affecting health development. - to promote and accelerate the incorporation and’ internalization of the relevant basic methods used in the social, psychological, behavioural and economic sciences into health research. - to identify, promote and advocate research in areas of’relevance to health (within the context of eight elements of primary health care) in non-health sectors and domains, and by scientists and institutions in scientific disciplines other than the health sciences. Health was defined as not merely the absence of disease but as a state of complete physical, mental and social well-being that enables people to lead socially and economically productive lives. Therefore, in describing the revised health research strategies, it should be stated more explicitly that the strategies aim at treating and controlling diseases and ill-health as well as promoting positive health. When considering the health of the community, women’s1 health was an essential, important and significant element of health development. Hence, in promoting health research aimed at improving the health of the community and the people, the health of women would be implicitly included. However, it was pointed out that women, because of biological, social and other determinants, were specially vulnerable to certain types of ill-health and diseases and elim’ination and amelioration of the proximate causes may need different approaches and methods to which sufficient attention may not have been given in the past. Research into the determinants of women’s health and the development of measures to change them in the desired direction as part o a holistic approach, may differ from those that were applicable to the health of the population in g neral and, therefore, should be giveni more emphasis when identifying priority areas for research. In addition, research would be needed on how women can promote family health and health in general and how such potential may be enhanced. It was realized that the child health problems directly related to urbanization, industrialization and changes in family life would increase. Also, health proble s of the underprivileged, under,erved and vulnerable groups would need a new approach. The classi al type of health research may not be applicable and a social science approach (or critical interventio research for the underprivileged) may” SEA/ACHR/19 Page 27 be required. These considerations should be the basis for a shift in emphasis with respect to researchable areas, type of research and target groups. It was suggested that in describing the projected changes in the health scenario leading up to and beyond 2000 that would influence health research, events and factors such as disasters, violence, etc. should be mentioned, if not already done. It was pointed out that the socioeconomic status projected for the countries of the Region may be overly optimistic and that this should be revised more realistically in accordance with the information available in published documents. It was also suggested that, as mentioned in WHO operational approach to implement the strategies, when considering areas for concentrated efforts, WHO should refer to previous recommendations by SEA/ACHR regarding researchable areas such as development of immuno- diagnostics, etc. Recommendations SEA/ACHR recommends that: (1) The health research strategies of the South-East Asia Region as contained in the “Research Needs for Health for All by the Year 2000” (SEAR0 Publication No.2) and revised as “Health Research Strategies of the South-East Asia Region”, contained in the Working Paper SEA/ACHR/19/9, be accepted and adopted with further modifications as hereunder: (a) to add as an additional strategic approach: - to promote and intensify intersectoral collaboration in research that had potential for affecting health development. - to promote and accelerate the incorporation and internalization of the relevant basic methods used in the social, psychological, behavioural and economic sciences into health research. - to identify, promote and advocate research in areas of relevance to health (within the context of the eight elements of PHC) in non-health sectors and domains, and by scientists and institutions in scientific disciplines other than the health sciences. (b) to include in addition to disease control, the attainment of positive health as a goal to which health development would aspire and to which research efforts should contribute. (c) to emphasize research into women’s health in priority researchable areas and research on how to enhance the role of women in promoting health. (d) to emphasize critical intervention research for the under-privileged, and for vulnerable groups, including children. SEA/ACHR/19 Page 28 (2) WHO transmit the health research strategies 0f the South-East Asia Region, as agreed and adopted, to the Global SEA/ACHR for incorporation, as desirable, in revising the global health research strategy. 3.11 Research for Improvement of Health Care D livery Systems - Regional Perspective (Agenda item 10) Dr El-Naggar, Regional Adviser, Primary Heal : Care, introduced the topic, referring to the global strategy of HFA and the importance of reshaping and strengthening the health care system in conformity with the principles of health care system based on PHC. Using the “three dimensional cube” of comprehensive health systems based on PHC, reflecting the basic principles, the elements of PHC and levels of PHC were explained. The importance of the district health system as the local operational framework for service delivery of PHC was emphasized. Problems and issues in the development of health care delivery systems in SEAR countries, mainly persistence of inequity, narrow scope of health care, slow progress of community participation and intersectoral action, the changing sociopolitical and epidemiological patterns, the rising cost of medical care, the concern for quality of health care, and the ongoing restructuring of health care delivery systems with its possible implications on the provision of primary health care were mentioned. The role of research in improving health care delivery and the essential preconditions for research to contribute to improving health care delivery were presented. Priority areas for research in the improvement of health care delivery system that were identified included: - research on policy formulation and decision making process at the national level: - research on health care delivery: day-to-day aperational issues; - research to address inequity; - research for improving quality; and - research for improving effectiveness and efficiency of health care delivery. Discussion The importance of health system research at the district level in the context of the goal of HPA was supported. It was agreed that the type of research for: improving health care delivery at the district level needs to be of the operational, problem-solving type, with the involvement of health care delivery personnel from the beginning. Problem-solving research needs to he applied to address the day-to-day operational issues and for improving the quality of health care delivery. Research was needed to develop and test criteria, operational procedures, and feedback mechanisms for referral between different levels, transport of patients, and to develop innovative financing schemes appropriate to each country situation. Research was required on quality assurance, to develop standards for assessment of the quality of care at different levels of the district health system, to find the most appropriate methods for SEA/ACHR/19 Page 29 effective utilization and application of the standards for improving health care, to monitor the effects of application and utilization of the standards and to develop and test the replicability of developed methodology and adopt it for wider application. Quality assurance in health care delivery was of interest to all the countries of the Region. The document prepared by the International Consultation on Assurance of Quality in Health Care in Pyongyang, Democratic People’s Republic of Korea, in October 1992 may be used by the countries of the Region. In order to mobilize intersectoral action at the district level, it was required to develop tools for district personnel to conduct situation analyses, in relation to critical social indicators which affect health. These tools can be used to stimulate action from social development sectors. ACHR was informed that in Indonesia, decision makers, health care managers and research workers were invited to make presentations on national health programmes, and problems were discussed with researchers at the Clinical Epidemiology and Biostatistics Unit, Medical Faculty, Gadjah Mada University. Countries of the Region need to develop their own mechanisms for ensuring the involvement of decision makers and health care managers from the beginning. Recommendations SEA/ACHR recommends that: (1) Health systems research continue to be given priority. with the emphasis on research development programmes of the country, by WHO. (2) In particular, research into ways and means of improving the referral systems, especially at the district level, be emphasized, including the development and testing of criteria, operational procedures, and feedback mechanisms and financial support appropriate to local situations in each country. (3) Research into quality assurance of health care at primary health care and district levels be further promoted. (4) Research on the role of community volunteers, their training, supervision, sustainability and their linkage with health care delivery systems need to be taken as a priority. 3.12 Strategic Plan for Promoting and Strengthening Heal& Economic Research: Regional Approach (Agenda item 11) Dr M.Z. Husain, Director, Planning, Coordination and Information, presented the subject essentially on the basis of the working paper prepared by Professor Somkid Kaewsonthi, member, SEA/ACHR, who was unable to attend. Health economics research (HER) was now presented as a sub-set of health systems research (HSR) but whether HER was viewed as a sub-set of HSR or as a separate ‘discipline’ (is .of no great significance) as the substance of HER was the same. It provides information which can be used to SEA/ACHR/19 Page 30 support decisions at all levels, on how limited resources should be best utilized to improve the health of the COmmunitieS. It was necessary to recognize that the conceptual framework used by health economists could bc used both within and without the health care system, to make fundamental value judgements more transparent and to try to make the best use of the resources available. A framework for HER should take into consideration several interdependent issues such as: - the determinants of the state of health. These include environmental, behavioural, social, economic, demographic and genetic factors. - the needs and demands of the community for health care. In this context, the nature of health care; the quantity and quality of health care; the income and wealth of the community and the ‘price’ of health care; access to health care and the perceptions and knowledge of the community on matters pertaining to health were important factors. - the role played by the government and the contribution of the public and the private health sectors. The government had to consider the welfare and political issues in developing its policies, especially with regard to supply of health care and financing of health care. Both the public and the private sectors have to make decisions on how and what to produce (and supply) and in what quantity; to whom to distribute and at what price to provide the services. There was very little hard evidence on the effectiveness and impact of HER in the Region. Information on the nature, extent and impact of expenditure on health and the quality, effectiveness and equity of health care was only just beginning to emerge as health economists analyse the outcomes from the past two to three decades. However, these were studies based on retrospective data. Based on a personal assessment, the author had observed deficiencies with respect to both the relevance and the quality of HER undertaken in the Region With respect to quantity in general, the more HER studies were undertaken, the greater the chance that there would be an impact on planning decisions and operational efficiency. However, training in economics per se does not necessarily produce an increase in the quantity of HER. The quantity of HER depends upon a demand for research as well as the availability of trained personnel. Clear and timely identification of health economics problems by planners and operational managers was essential if health economics researchers were to direct their efforts to the right problems at the right time. Even when the research was relevant and of high quality, there would be little impact without operational competence. Weaknesses were apparent in the ability of health economists to work with potential funders, with planners and managers in the health sector and to communicate the research results in a language non-specialists can understand. Some positive factors include the growing realization among health planners, especially due to the current resource constraints on the need for HER to improve operational and planning efficiency. International authorities, such as WHO and the World Bank and other funding agencies, were also fully supportive of HER. The author had identified several trends, such as demographic changes, social and economic conditions, health conditions, developments in health care systems,’ performance of the health care SEA/ACHR/19 Page 31 system vis-a-vis obtaining ‘value for money’ that would create a tremendous need and demand for HER at all levels of the health systems. With the experience gained mainly from Thailand, the author had recommended strategies to promote HER in the Region. The objectives of the H$R Promotion Programme should be to institutionalize HER in planning and operational activities and establish a self-renewing critical mass of HE trainers, researchers and support staff in each country. Among the actions required for this purpose are: - raising awareness about the nature and value of HER; - identification and provision of support to a leader to initiate action for the promotion and development of HER; - establishment of national training capacity for the production of professional health economics researchers; and - institutionalization of HER to ensure that it was a component of national health development planning and evaluation. Discussion SEA/ACHR agreed that health economics research was essential for the development of health programmes in view of financial and other resource constraints and the need to secure adequate resource inputs for the development of health care systems. SEA/ACHR discussed the place of HER in the context of HSR. Whereas the working paper presented HER as a sub-set of HSR, two different conceptual approaches were possible - HER as a sub-set of HSR or HER as a sub-set of economics research. The placement of HER in the different contexts had implications in promoting and supporting the development of HER. The need, effectiveness and impact of HER given in the working paper was further elaborated and supplemented by the meeting. At the national (macro) level, HER deals with prioritization of resources to and within the health and other sectors that affect health in a cost-effective manner within the total GNP available. At the intermediate and local or operational (micro) level, distribution of resources within the health sector should take into consideration not only the cost-effectiveness but also the quality of life of individuals and communities. As a framework for HER factors to be reckoned with are: on the supply side - health care provided by both the public and the private sectors and on the demand side - consumer needs, including intermediate variables such as choice, awareness, resources and technology. The assessment of the cost-effectiveness of providing health care (both curative and preventive) can be undertaken by decision based HER. There may also be a need at the national (macro) and local (micro) levels to determine the cost-effectiveness of inputs from other non-health sectors, such as education, housing, agriculture, that would cause an improvement in the health status of the community. Some of the operational or micro-level research needs to be done at the local level: no one local area was necessarily the same as another. SEA/ACHR/19 Page 32 For prioritization of allocation of resources at the national level, HER was essential to determine the most cost-effective means of improving the quality of health and the quality of life through the PHC approach. It should be remembered that health was the focus of economic development and is, therefore, a prerequisite for improvement of the quality of life. HER may also be useful, for example, to determine whether the prevention of urbanization was more cost-effective than tackling the problems created by urbanization. In relation to the strategies to promote HER, ACHR took up the issue of establishing national training capacity and producing professionals competent to do health economics research. SEA/ACHR agreed that training of personnel to undertake HER should be considered at two levels: - at the national (macro) level, where the results of HER would have an impact for making policy decisions. The question was whether to make economists out of health workers or health workers out of economists. For this type of HER, what was required were either economists who have had an in-depth exposure’ to health aspects or health professionals who were provided with training in economics. It was felt that the training of a large number of ‘pure’ health economists, i.e. economists trained in some aspects of health, was probably not necessary. There was no doubt that there were experts in economics, but if they do not have adequate knowledge and involvement in health matters, they would not be able to contribute effectively to HER. - at the micro level, i.e., conducting HER at the operational level, was best done by health professionals who were provided with training in the relevant aspects of economics. In this respect, an analogy was drawn with the disciplines of nursing, biostatistics and biochemistry. Whilst specialization was needed in these fields at the academic level, when it came to health care delivery and health research, only some components of these disciplines were necessary. Similarly, when health workers realize the need for health economics, they would acquire that degree of knowledge of economics that was needed for their research or operational work. There was a general consensus that training in basic economics should be given to health personnel. Since the countries of the Region were at various stages of economic and health systems development, each country should draw up its own country-specific medium-term action plans to strengthen health economics training and its applications in the health sector. In doing so, the needs of the private sector as much as of the public sector should be catered to. WHO should promote awareness of the need and development of the necessary country capability according to particular needs, as identified by the countries. WHO should also support intercountry cooperation with a view to developing regional self-reliance in health economics in training. SEA/ACHR/19 Page 33 Recommendations ! Taking note of the working paper on “Strategic Plan for Promoting and Strengthening Health Economics Research: Regional Approach” and the discussions thereon, and the need for prioritizing expenditure between sectors in the economy at national, regional and district levels with the aim of achieving HPA/2000 through primary health care, SEA/ACHR recommends that: (1) Health economics research receive emphasis in the revised health research strategy of the SEA Region. (2) With respect to action required in each country to promote and support health economics research: (a) Training in health economics research was of importance and be undertaken at two levels: - for national policy (macro)-level health economics research, professional economists should be exposed in-depth to health issues; and - for district or operational (micro)-level health economics research, health professionals be trained in relevant, basic aspects of economics. (b) Health economics research be institutionalized as a component of HSR in organizations/departments responsible for the planning and delivery of health Ci-iR. 3.13 Suggestions for Agenda of the Twentieth Session of SEA/ACHR (Agenda item 12) The Regional Director stated that it was best to avoid too technical a subject for discussion by SEA/ACHR - the role of SEA/ACHR was to serve as an advisory body to the Regional Director, especially on matters of health research policy. The subjects chosen should be on problems that would be likely to be of critical significance in the future. It may be worthwhile, for example, to have a working paper on research issues that were likely to emerge in the year 2005. SEA/ACHR considered the following subjects which had been suggested by members earlier, as well as certain additional topics mentioned during the discussion: (I) Health Systems Research (a) Health policy research (b) Research on impact of economic development and policies on health (c) Health systems research on policy development and health planning (d) Strategic plan for research on health behaviour for health promotion (e) Research on community actions for health (f) Research on the changing role of the private non-health sector in the maintenance of nutrition and other matters which affect health indices (g) Research on changing requirements for dental practitioners (h) Role of medical education in 1.6 and 1.7 above SEA/ACHR/19 Page 34 (2) Environmental Health (a) Occupational and environmental health - Strategic plan for research and action (b) Research on health problems arising out of urbanization (c) Research on pesticide poisoning (3) Health Technology Research on immunodiagnostics (4) Traditional Medicine Research on traditional medicine: Utilization in health care programmes. Clinical and laboratory evaluation. (5‘) Nutrition Research on the benefits of high dose vitamin A administration in relation to other aspects of the health status of under-five children. (6) Communicable Diseases Research on encephalitis (7) Miscellaneous (a) Critical evaluation of the effects of the discussions of past SEA/ACHR sessions (b) Strengthening cooperation among researchers in the region. Recommendations SEA/ACI-IR recommended that the Regional Director, in consultation with the Chairperson (SEA/ACHR) choose three or four subjects from among the following topics: (a) Health policy research (b) Strategies for the development of behavioural research related to health. (c) Strategies for the development of research on environmental and occupational health. (d) Guidelines for the assessment, development and transfer of appropriate diagnostic technology. I (e) Research on contraceptive practices and HIV transmission. SEA/ACHR suggested that suitable guidelines be provided for the preparation of working papers on the subjects selected for technical discussions. For ekample, on the subject of health policy research, it was pointed out that this should include research for policy analysis, policy development SEA/ACHR/19 Page 35 and health planning, with particular attention to the impact of economic development and government policy trends on health. I 3.14 Time and Place of the Twentieth Session of SEAJACHR (Agenda item 13) Dr Tonny Sadjimin, said that with the concurrence lof Dr Hidayat Hardjoprawiro, Secretary- General, Ministry of Health, Jakarta, who was a special invited for the present session, he was pleased to extend an invitation to SEA/ACHR to convene the twentieth session of SEA/ACHR in 1994 in Indonesia. The venue would be either Bali or Yogyakarta. Members accepted this invitation and decided that the next session be held from 11 to 15 April 1994. Recommedation SEA/ACHR recommended that subject to the agreement of the Government of Indonesia, the twentieth session of SEA/ACHR be held from 11 to 15 April 1994 either in Bali or Yogyakarta, Indonesia. The exact location and the dates will be decided in consultation with the national authorities. 3.15 Adoption of the Report (Agenda item 15) SEA/ACHR unanimously adopted the report as presented to them, with the proviso that minor modifications suggested by them would be incorporated in the final report by the Secretariat, in consultation with the Chairperson. 4. CLOSING SESSION 4.1 Remarks by Members Dr U.T. Vitarana, retiring member, whilst thanking the Regional Director and the RPD Unit, wished to place on record the distinctive role played by Dr U Ko Ko, Regional Director, in promoting research activities in the Region. Dr Vitarana’s remarks were supplemented by the Chairperson, Dr Sneh Bhargava, the Vice Chairman, Dr S.P. Tripathy, and several other members of SEA/ACHR. It was noted that Dr U Ko Ko had been associated with every session of SEA/ACHR since its inception. Today SEA/ACHR occupies a leading position amongst all ACHRs because of the continuing and unstinted support extended to it by him. 4.2 Address by the Regional Director The Regional Director, in his concluding address, stated that he was grateful for the kind words and sentiments expressed by the members about his contribution to research activities in the Region. SEA/ACHR/19 Page 36 He was pleased at the outcome of the present meeting, which was able to finalize the research strategies for the Region. The new strategies, together with the earlier SEAR0 publication on “Research Needs for Health for All by the Year 2000”, would be the basis for the regional research programme. However, it was important to ensure that these strategies permeate to the country level. The strategies developed by SEA/ACHR should serve as a guide to the countries and not be looked upon as an effort to limit the research activities of Member States to the priority areas identified by WHO. He expressed a word of caution about donor-driven research activities - countries can be safeguarded from such attempts only by strengthening the national coordinating mechanisms for research such as medical research councils. In this respect, SEA/ACHR members should help their countries to strengthen the national mechanisms. The Regional Director thanked Dr Vitarana and Dr Sumarmo P. Sudarmo, who would be completing their terms of office this year, for their valuable contribution and hoped that they would continue to interact with WHO. The Regional Director concluded by stating that this was the last session of SEA/ACHR that he and Dr Atmg Than Batu were attending as Regional Director and Programme Director for Research and Human Resources respectively, and whilst extending his best wishes to the members, expressed the hope that SEA/ACHR would continue to function in the same active manner as before. 4.3 Address by Chairperson Dr Sneh Bhargava thanked the Regional Director for the leadership he provided to the Region in promoting research activities. The active participation of the members contributed to the success of this meeting; she was particularly glad that the Committee was able to arrive at a consensus on the research strategies for the Region. She thanked Dr Aung Than Batu for his role in providing the foundation for the discussion on health research strategies. She thanked the staff of the RPD Unit, who worked very hard, both directly and behind the scenes, to provide technical and logistic support to the meeting. She concluded by thanking Dr Tripathy for placing the facilities of ICMR at the disposal of SEA/ACH.R. 5. RECAPITULATION OF RECOMMENDA’lIONS Agenda item 6.1: Summary of RPD activities during the preceding year SEA/ACHR recommends that WHO/SEARO: (1) assist countries in preparing guidelines for the prioritization of research areas and topics; appraisal of research project proposals; monitoring and evaluation of research projects; and for the utilization of research results. (2) promote: (a) the dissemination of information on research done in countries; and (b) networking of research institutions in the Region. SEA/ACHR/19 Page 37 Agenda item 6.2(a): Research Capability Strengthening in SEAR SEA/ACHR recommends that: (1) the network of WHO collaborating centres should be better utilized to strengthen research capabilities in countries; in particular, they should be able to provide reference material and research reagents not commercially available to researchers in countries; researchers and institutions should be made better aware of such facilities. (2) WHO should endeavour to improve coordination and harmonization of research capability strengthening within WHO and with the Special Programmes, and, if possible, with other agencies and organizations, particularly at the country level. Agenda ifem 6.2 (b): Research Related to Nutrition in SEAR The Committee took note of WHO/SEARO’s wide-ranging activities in promoting and supporting nutrition research within the framework of the Regional Nutrition Research Development programme and the resources available. It recommends that: - increasing attention be given to research into the socio-economic and behavioural determinants of nutrition practices and to develop means of changing these to improve nutrition. This includes research on the nutritional implications of changing lifestyles, urbanization, changes in age pattern and societal values (both under-nutrition and over-nutrition), which may lead to chronic, degenerative and other diseases. - intersectoral collaboration in nutrition research and encouragement of research by other sectors which may be more relevant for improvement of nutrition than those undertaken in the health domain. I - policy research and policy analysis as a me aI4 s of influencing activities of other sectors which may affect nutrition I Agenda item 9: Strategy for Health Research in sEAR SEA/ACHR recommends that: (1) the health research strategies of the South-Ebst Asia Region, as contained in “Research Needs for Health for All by the Year 2000” (SEAR0 Technical Publication No.2) and revised as “Health Research Strategies of the South-East Asia Region” contained in the Working Paper SEA/ACHR/19/9, be accepted and adopted with further modifications as hereunder: (a) to add as an additional strategic approach: - to promote and intensify intersectoral collaboration in research that had potential for affecting health development. SEA/ACHR/19 Page 38 - to promote and accelerate the incorporation and internalization of the relevant basic methods used in the social, psychological, behavioural and economic sciences into health research. - to identify, promote and advocate research in areas of relevance to health (within the context of the eight elements of PHC) in non-health sectors and domains, and by scientists and institutions in Scientific disciplines other than the health sciences. (b) to include, in addition to disease control, the att&nment of positive health as a goal to which health development would aspire and to which research efforts should contribute. (c) to emphasize research into women’s health in priority researchable areas and research on how to enhance the role of women in promoting health. (d) to emphasize critical intervention research for ~ the under-privileged, and for vulnerable groups including children. /I (2) WHO transmit the health research strategies of the South-East Asia Region, as agreed and adopted, to the Global SEA/ACHR for incorporation, as desirable, in revising the global health research strategy. Agenda item 10: Research for Improvement in Health Care Delivery Systems - Regional Perspective SEA/ACHR recommends that: (1) health systems research continue to be give priority with emphasis on research development programmes of the country by WHO. ? (2) in particular, research into ways and means of i proving the referral systems, especially at the district level, be emphasized - including the develop “, ent and testing of criteria, operational procedures, and feedback mechanisms and financial support appropriate to local situations in each country. (3) research into quality assurance of health care at rimary health cam and district levels be further promoted. P (4) research on the role of community volunteers, their training, supervision, sustainability and their linkage with health care delivery systems need to + taken as a priority. Agenda item 11: Strategic Plan for Promoting and Strengthening Health Economics Research: Regional Approach Taking note of the working paper on “Strategic Plan Promoting and Strengthening Health Economics Research: Regional Approach” and the discussio s thereon, and the need for prioritizing SEA/ACHR/19 Page 39 expenditure between sectors in the economy at national, regional and district levels with the aim of achieving HPA/2000 through primary health care, SEA/ACHR recommends that: (1) health economics research receive emphasis in the revised Health Research Strategy of the SEA Region. (2) research: G-4 @> With respect to action required in each country to promote and support health economics Training in health economics research was of importance and be undertaken at two levels: - for national policy (macro) level health economics research, professional economists should be exposed in-depth to health issues; and - for district or operational (micro) level health economics research, health professionals be trained in relevant, basic aspects of economics. health economics research be institutionalized as a component of HSR in organizations/departments responsible for the planning and delivery of health Care. Agenda item 12: Suggestions for Agenda of the Twentieth Session of SEA/ACHR SEA/ACHR recommended that the Regional Director, in consultation with the Chairperson (SEA/ACHR) choose three or four subjects from among the following topics: (a) Health policy research (b) Strategies for the development of behavioural research related to health. (c) Strategies for the development of research on environmental and occupational health. (d) Guidelines for the assessment, development and transfer of appropriate diagnostic technology. (e) Research on contraceptive practices and HIV transmission. Agenda item 13: Time and Place of the Twentieth Session of SEA/ACHR SEA/ACHR recommended that subject to the agreement of the Government of Indonesia, the twentieth session of SEA/ACHR be held from 11 to 15 April 1994 either in Bali or Yogyakarta, Indonesia. The exact location and the dates will be decided in consultation with the national authorities. SEA/ACHR/19 Page 40 Annex 1 AGENDA B. 1. 2. 3. 4. 5. 6. 6.1 6.2. 7. 8. 8.1 8.2 8.3 8.4 9. 10. 11. INAUGURAL SESSION Agenda for the InauguraI Session was issued separately. BUSINESS SESSION Introductory statement by the Chairman, SEA/ACHR Opening remarks by Dr U Ko Ko, Regional Director Nomination of Vice-Chairman and Rapporteur Introduction of documents Adoption of Agenda Progress report on the Regional Research Promotion and Development (RPD) Programme Summary of RPD activities during the preceding year Review of RPD activities in relation to past SEWACHR recommendations in specific areas: (a) Research capability strengthening in SEAR; and (b) Research related to nutrition in SEAR Matters arising out of meetings of Global ACHR and ACHRs of other regions Progress reports on special and global programmes: ~ I I UNDP/World Bank/WHO Special Programme r Research and Training in Tropical Diseases Special Programme of Research, Development d Research Training in Human Reproduction u-v Acquired immunodeficiency syndrome (AIDS) 1 (a) Control of diarrhoeal diseases (b) Acute respiratory infections Strategy for health research in SEAR Research for improvement of health care delive ry systems - regional perspective Strategic Plan for Promoting and Strengthening Health Economic Research: Regional Approach SEA/ACHR/19 Page 41 12. 13. 14. 15. Suggestions for Agenda of the twentieth session of SEA/ACHR Time and place of the twentieth session of SEA/ACI-R Any other business Adoption of report C. CLOSING SESSION SEA/ACHR/19 Page 42 Annex 2 LIST OF PARTICIPANTS A. 1. 2. 3. 4. 5. 6. 7. “8. “9. 10. 11. B. 1. SEA/ACHR MEMBERS Professor A.P.R. Aluwihare, Chairman, University Grants Commission, 20, Ward Place, Colombo 7, Sri Lanka Professor Aree Valyasevi, Dean, Faculty of Medidine, Thammasaat University, Rangsit, Nondabur, Thailand Dr (Mrs) Sneh Bhargava, A-103, New Friends ~Colony, New Delhi-l 10065 , Dr S.G.M. Chowdhury, President, Bangladesh fociety of Hypertension, 369, Elephant Road, Dhaka-1205, Bangladesh Professor B.N. Dhawan, CSIR Emeritus Scie tist and Head, 1 CMR Centre for Advanced Research in Traditional Remedies, Central D g Research In titute, Chattar Manzil, P.B. No. 173, Lucknow, India 1 Professor U Myint Lwin, Director-General, partment of Mkdical Research, Ministry of Health, No. 5 Ziwaka Road, Yangon, Myanm Dr Tonny Sadjimin, Director, Clinical and Biostatistics Unit, Medical Faculty, Gadjah Mada University, Dr Sardjito General ospital, Yogyakarta, Jndonesia 55281 Dr Sumarmo P. Soedarmo, Head, National of Health Research and Development, Ministry of Health, Jalan Percetakan Negara 2 , Jakarta, Indonesia, and Professor Somkid Kaewsonthi, Centre for Chulalongkom University, Bangkok 10330, Dr S.P. Tripathy, Director-General, Indian Cou cil of Medical Research, Ansari Nagar, New Delhi 110 029 n Dr U.T. Vitarana, Deputy Director, Medical Vi logy, Fairfield Hospital, P.O. Box 65, Yarra Bend Road, Fairfield 3078, Victoria, Australiat SPECIAL INVITEES I Professor M. Gabr (Chairman, Global ACHR~, Head, Paediatric Department, Faculty of Medicine, Cairo, Egypt * Unable to attend SEA/ACHR/19 Page 43 2. 3. Dr Hidayat Hardjoprawiro, Secretary-General, Ministry of Health, Jakarta C. 1. 2. 3. 4. 5. D. WHO/HQ AND OTHER REGIONS E. 1. 2. 3. 4. 5. 6. 7. Dr Pradit Charoenthaitawee, President, Mahidol University, Rama VI Road, Bangkok 10400, Thailand WHO SECRETARIAT - (South-East Asia Regional Office) Dr U Ko Ko, Regional Director Dr D.B. Bisht, Director, Programme Management Dr Aung Than Batu, Director, Research and Human Resources Dr K. Jayasena, Regional Adviser in Medical ResearchI Dr Lim Teong Wah, Medical Research Officer (Special Programmes) Dr E. Diczfalusy, Senior Consultant, HRp/HQ RESOURCE PERSONS Dr N.K. Shah, Director, Prevention and Control of Diseases Dr M.Z. Husain, Director, Planning, Coordination and Information Mr M.L. Gupta, Chief, Promotion of Environmental Health Dr M.N El-Naggar, Regional Adviser in Primary ~ Health Care Dr Vijay Kumar, Medical Officer, Acute Respiratory Infections Dr R.L. De Sylva Short-Term Professional, Diardtoeal Diseases Mr R. Srinivasan, Short-Term Consultant, WHO/SEAR0 SEA/ACHR/l9 Page 44 Annex 3 ~ LIST OF WORKING AND INFOd MATION DOOUMENTS Working Documents 1. Provisional Agenda 2. List of participants 3. Suggested working schedule 4. List of working and information documents 5. Summary of RPD activities during the preceding year 6. Review of RPD activities in relation to past ACHR recommendations in specific areas - Research capability strengthening in SEAR 7. Review of RPD Activities in relation to past ACHR recommendations in specific areas - Research related to nutrition in SEAR 8. Research activities in the Control of Diarrhoeal Disease Programme 9. Health research strategies of the South-East SEA/ACHR/19B (Relating to Asia Region Agenda item 9) 10. Research into the improvement in health care delivery systems - Regional Perspective 11. Strategic Plan for Promoting and Strengthening Health Economic Research: Regional Approach 12. Topics suggested for technical discussions at the twentieth session of SEA/ACHR 13. Programme for the Control of Acute Respiratory Infections (ARI) in Children 14. AIDS - A Summary of GPA research initiatives and priorities SEA/ACHR/19/1 SEA/ACHR/19/2 SEA/ACHR/19/3 SEA/ACHR/19/4 SEA/ACHR/19/5 (Relating to Agenda item 6.1) SEA/ACHR/19/6 (Relating to Agenda item 6.2(a)) SEA/ACI-IR/19/‘7 (Relating to Agenda item 6.2(b)) SEA/ACHR/19/8 (Relating to Agenda item 8.4(a)) SEA/ACHR/19/10 (Relating to Agenda item 10) SEA/ACHR/19/11 (Relating to Agenda item 11) SEA/ACHR/19/12 (Relating to Agenda item 12) SEA/ACHR/19/13 (Relating to Agenda item 8.4(b)) SEA/ACHR/19/14 (Relating to Agenda item 8.3) SEA/ACHR/19 Page 45 Information Documents 1. 2. Information Bulletin SEA/ACHR/l9/Inf.Bull. Report of Eighteenth Session of SEA/ACHR, SEARO, SEA/ACHFV19/Inf. 1 New Delhi, 20-24 April 1992 (Relating to Agenda item 6.1) 3. Report of the Eighth Meeting of Directors of Medical Research Councils or Analogous Bodies Concerned Research Foci in the Relevant Ministries, 3-6 November, Bangkok, Thailand 4. Report of the 3 1st Global ACHR, WHO/I-IQ, Geneva, SEA/ACHRf19/Inf.3 28 September to 2 October, 1992 (EB9l/InfDoc/3) (Relating to Agenda item 7) 5. Food Policies, Nutrition and Health: Some SEA/ACI-IR/19/Inf.4 (Relating Reflections on Related Research Priorities to Agenda item 6.2(b)) 6. Research Needs for Health for All by the Year 2000 7. 8. Role of Health Research, WI-IA Resolution 43.19, Geneva, 17 May 1990 I Extracts from Health Research Strategy - WHO/RPD/ACHR(HRS)/86 9. 10. 11. 12. 13. 14. Report of the Sub-committee on Health and the Economy - 31st Global ACHR Report, WHO/I-IQ, Geneva, 28 September - 2 October 1992 The Implications of Public Policy on Health Status and Quality of Life - Report of a meeting in Bangalore, India, October 1989 A Paradigm for Health: A Framework for New Public Health Action - Discussion Paper by the Director General, EB89/11,9 December 1991 Research Capability Strengthening: Essential SE,A/ACHR/19/Inf. 11 Features - ACHR3 l/92.12 (Relating to Agenda item 8.1) WHO’s Regional Nutrition Research Programme for the South-East Asia Region - A Review of A Review of its Development and a Proposal for its Future Direction towards the Year 2000 Meeting of the Scientific and Technical Advisory Group (STAG), Geneva, 22-25 February 1993 - HRP Report on Asia and the Pacific SEA/ACHR/19/Inf.2 (Relating to Agenda item 6) SEA/ACHR/19/Inf.S (Relating to Agenda item 9) SEA/ACI-IR/19/Inf.6 (Relating to Agenda item 9) SE+A/ACI-IR/19/Inf.7 (Relating to Agenda item 9) SEA/ACHR/19/Inf.8 (Relating to Agenda item 11) SEAlACHRl19/Inf.9 (Relating to Agenda item 10) SEA/ACHR/19/Inf.l0 (Relating to Agenda item 9) SE+/ACHR/19/Inf.l2 (Relating to Agenda item 6.2(b)) SE&/ACHR/19/Inf.l3 (Relating to Agenda item 8.2) SEA/ACHR/19 Page 46 15. Research Abstracts: South-East SEA/ACHR/19/Inf. 14 Asia Region; Volume 4 (Relating to Agenda item 6) 16. Report of the Consultative Meeting on Health Research SEA/ACHR/19/Inf.lS Strategy for South-East Asia Region, New Delhi, (Relating to Agenda item 9) 22-24 February 1993 17. Prospective Thematic Review: Directions and SEA/ACHR/19/Inf.l6 Organizations of TDR Capability Strengthening Activities (Relating to Agenda item 8.1) SEA/ACHR/19 Page 47 Annex 4 I TEXT OF ADDRESS BY THE REGIONAL DIRECTOR Your Excellency, distinguished participants and honourable guests, First of all, I wish to thank the Government of India for session of WHO South-East Asia Advisory Committee on Health Researc P . the interest and support provided by the Government of India to WHO in its efforts to p mote and develop health research. I am most grateful to His Excellency Mr B. Shankaran d, Minister of Health and Family ‘Welfare, for kindly agreeing to deliver the inaugural address an for having found time to grace this occasion. t I have pleasure in extending a warm welcome to the distinguished members of SEA/ACHR, the special invitees and our colleagues from WHO headquarters. We also cordially welcome the distinguished scientists and research workers of India, the senior officials from the Ministry of Health and Family Welfare and other honoured guests who were present here today. WHO South-East Asia Advisory Committee on Health Research serves as the main advisory body to the Regional Director on matters of research policy. The biennial meetings of the Directors of Medical Research Councils or Analogous Bodies serve as the means of obtaining the views of the Member Countries on the strategies for research promotion and 1 development in general and on the implementation of specific research programmes at the national level in particular. Members of SEA/ACHR were appointed in their personal capacity, whilst participants to the meetings of the Directors of Medical Research Councils attend as the official representatives of the governments. I think we can look back with justifiable satisfaction at the achievements made in the field of health research since 1976, when the Regional Advisory Committee on Medical Research was first established. The initiatives taken by WHO Regional Office have had a profound effect on fostering health research, especially in those countries that lacked a long tradition of medical research. One of the primary objectives of the Regional Research Promotion and Development programme was to strengthen the capability of Member States to undertake health research. The most important of these was that largely through WHO’s efforts and the development of WHO’s Regional Research strategies most countries have now developed national research policies which were realigned towards HFA goals and strategies. The Regional office had also provided financial and tee cal assistance for the establishment and/or strengthening of medical research councils or analogous i dies. At present, there were such national mechanisms for the promotion, development and coordi ation of research in nine out of the eleven countries of the Region. WHO/SEAR0 had promoted research capability strengthemng through a variety of other means as well. This includes the award of Research Training Grants and Visiting Scientists Grants; and research grants; and the establishment of WHO collaborating centres and national centres, etc. Over the years, WHO had awarded over 300 Research G Principal Investigator-initiated research projects as well as for resf ‘ants to selected countries for both :arch projects commissioned by the SEA/ACHR/l9 .Page 48 technical units of the Regional Office; the latter were generally of the collaborative type involving several countries. To-date over 200 research projects supported by the inter-country Research Promotion and Development budget have been completed. WHO/SEAR0 was the pioneer in supporting regional collaborative research on diarrhoea and drug-resistant malaria, the results of which have now been translated by countries into operational control programmes. WHO support for chronic liver diseases in 1976 evolved into multi-centre studies on viral hepatitis and NANB hepatitis which laid the ground work and perspective for subsequent control of hepatitis B, through vaccine and continuation of studies~into hepatitis C. A pioneering and forward looking project to develop a vaccine for dengue haemorrhagic fever had been brought to a successful conclusion after about a decade. The aim of this project was to develop a safe, immunogenic vaccine against the four strains of dengue virus. The live attenuated tetravalent vaccine, developed by Mahidol University, was supported by WHO Regional Office and the Government of Thailand, augmented with funds from the Governments of Australia and Italy and the Rockefeller Foundation. ‘The Regional Office had also published technical bulletins on subjects such as “The Concept of Health Services Research“, ”Research Needs for Health for All by the Year 2000” and “Concepts of Health Behaviour Research”. A new publication, “The Appraisal of Health Systems Research” was now nearing completion and it was proposed to publish “Research Strategies for the South-East Asia Region” during 1993. On this occasion, I also wish to dwell on some of the future perspectives pertaining to health and to health research. I feel that this was especially appropriate in view of the presence of many health officials and research scientists from India on this occasion.’ The health and health-related problems faced by many of the countries in our Region - for example, high rate ofpopulation growth; high maternal and child mortality; severe malnutrition; high incidence of many communicable diseases and limited access to isafe water and sanitation - were causes for serious and urgent concern. During the recent past, major changes have taken pl ical, economic and social structures in several countries of the world, including in the th-East Asia Region. Whilst the prevalence of many communicable diseases remains high the countries of our Region, epidemiological transitions linked to changes in lifestyle and environment and the increase in population aged over 60 years had resulted in an increasin ence of cancer, cadiovascular diseases, diabetes and other chronic conditions. This double of communicable diseases and degenerative diseases, commonly referred to as “diseases of e”, faced by the developing countries, was further aggravated by the AIDS pandemic and th ence of old problems such as malaria, tuberculosis and cholera. There is no need for me to spell out in detail to this audi the additional health problems created by rapid urbanization, industrialization and environmental adation. These health problems often manifest in their most severe forms among certain vulne ups in society who were exposed to health risks due to a variety of socioeconomic, and other factors. These include the absolutely poor, the unemployed youth and slum The Director-General of WHO, Dr Hiroshi Nakajima, had d that these new developments should be taken into consideration in implementing public heal tion directed towards achieving SEA/ACHR/19 Page 49 the goal of Health for AlI through Primary Health Care as enunciated first at Alma Ata and reaffirmed at Riga. Further, following the Technical Discussions on “The Roleiof Health Research in the Strategy for HFA/2000”, the Forty-third World Health Assembly, adopted a resolution (WI-IA 43.19) which raised several issues and posed challenges to Member States, bilateral and multilateral development agencies, nongovernmental organizations, foundations and appropriate regional organizations as well as to WHO. The South-East Asia Advisory Committee on Health Research took note of these developments at its eighteenth session, held in April 1992. It was clear that the countries of the Region should be prepared to face the new challenges that were emerging. In view ~of the important role that research could play in finding solutions to the new problems faced by the; countries, the Committee felt that it was opportune to review the objectives of the Regional Research Programme as defined in 1976; the current research strategies which were formulated in 1982 to realign towards HFA/2000 goal and to determine changes, if any, that were now needed to enable the South-East Asia Region to meet the challenges of the emerging and future health scenario of the Region. In response to a recommendation made by the Committee, the Regional Office convened a Consultative Meeting on Health Research Strategies for the South-East Asia Region in February this year. This subject, “Strategy for Health Research in the South-Easq Asia Region” would feature as one of the important Agenda items for this meeting . The discussion on: this subject would be based on the report of the above meeting. After incorporating any additional suggestions made by RACHR, we intend to publish the contents of the report as a technical publication of WHO/SEARO. I am confident that the revitalized strategy, which was based on a realistic vision of the future, would serve as a powerful influence that would guide health research in the Region. It was justifiable for us to be boldly optimistic about the ability of human ingenuity, science and research to shape our future, to change things for the better and to improve the conditions of life from what it was today. A Constitutional function of WHO was to “promote and conduct research in the field of health”. WHO can fulfil this role only with the active cooperation and participation of policy makers, administrators and research workers of a country. In this respect, it was fitting that this nineteenth meeting ,of the South-East Asia Advisory Committee on Health Research was being convened at the Indian Cbuncil of Medical Research, which was the apex body for the formulation, coordination and promotion of health research in India. Some of the foreign participants may not be aware that the Indian Council of Medical Research was one of the oldest medical research organizations not only in South-East Asia but in the world since its origins date back to 19 11. India had made internationally recognized contributions in various spheres of health research. The Ministry of Health and Family Welfare and the Indian Council of Medical Research have also actively collaborated with WHO - both in the Regional Office and in headquarters - in several research programmes. I look forward to continued collaboration with you in the future as well. In conclusion, on behalf of WHO and the Regional Advisory Committee on Health Research, I wish to thank the Government of India once again for hosting this :nineteenth session of SEA/ACHR. My thanks are also specially due to His Excellency Mr B. Shankaranand, Minister of Health and Family Welfare; Dr S.P. Tripathy, Director-General of ICMR, who also happens to be a current member of SEA/ACHR, and to the members of the Organizing Committee who have contributed to the excellent arrangements for this meeting. SEA/ACHR/19 Page 50 Annex 5 TEXT OF INAUGURAL ADDRESS BY THE MINISTER FOR HEALTH AND FAMILY WELFARE, GOVERNMENT OF INDIA Dr U Ko Ko, Mr Misra, Dr Sneh Bhargava, Dr Bisht and distinguished members of the Advisory Committee on Health Research and representatives of WHO secretariat. It gives me great pleasure to welcome the members of the South-East Asia Advisory Committee on Health Research to India. I am delighted that you were able to accept our Government’s invitation to hold the 19th meeting of WHO Regional Advisory Committee for Health Research, in India. India has had a rich tradition in biomedical research and had played a leading role in conducting basic as well as clinical research in areas of critical concern - tuberculosis, leprosy, hepatitis, viral diseases, reproductive biology, cancer, cardiovascular diseases - to name only a few. A substantial proportion of the allocation of the Ministry of Health was spent on biomedical research, which was the fulcrum on which the formulation of disease control strategies was based. In addition to the Health Ministry’s allocation to the Indian Council of Medical Research other organizations, namely, the Department of Biotechnology, Department of Science and Technology and Council for Scientific and Industrial Research were also supporting biomedical research projects. Our effort had been to focus attention on diseases which have high morbidity and mortality levels and to that extent our priorities have been largely focused with a view to arresting and controlling communicable diseases. We have now to also consider diseases of old age, diabetes, cancer, cardiovascular diseases one of the outcomes, no doubt, of the increase in longevity. The biggest challenge which my country as well as most others in the Region face was population growth. Improvement of child survival rates and an increased life-span had arrested the growth rates of the population but not at the pace we need to see. Our country had accorded very high priority to population control and I am glad to learn that research on fertility control figures prominently in your agenda. Tropical diseases, such as leprosy, malaria, filariasis and kala-azar, affect millions of people in this region, and timely research in these areas can help mitigate problems. The threat of expansion of the AIDS epidemic into larger dimensions looms large in Ithe Member Countries. Naturally, we have accorded high priority to research and control of AIDS in India. I am glad that all other countries in the Region have evinced similar concern and were according priority to control of AIDS. I would like to place on record our deep appreciation of the assistance provided by the World Health Organization in the achievement of our targets in biomedical research. WHO assistance had played a catalytic role in many of our research programtnes through provision of fellowships for training and in meeting our needs of essential supplies and reagents which need to be imported. In addition, in many diseases, such as malaria, leprosy and tuberculosis, the inputs of WHO have been quite substantial and have gone a long way towards building and strengthening the institutions and assisting in the formulation of national control programmes. We have always been supportive of collaborative research, and in these endeavours we have been partners not only with WHO but also with other international agencies such as US Public Health Service, British Overseas Development Agency, Swedish International Development Agency, Canadian IDRC and many others. We have shared our experiences with other countries, including those of the South-East Asian Region, who face a similar disease profile. The collaboration had proved to be mutually beneficial and, over the years, SEA/ACHR/19 Page 51 I hope the interaction would continue to enable more meaningful technical cooperation between the member countries. Globally, there had been concern for improving the health of the people through support to essential Health Systems Research programmes. The Advisory Committees at the regional and global levels have played a key role in the formulation of these programmes. I am told that two of our Indian scientists - Dr C. Gopalan and Dr V. Ramalingaswami have contrib ted significantly to these efforts through their contribution as Chairmen of the Regional and Global Iidvisory Committees for Health Research. International research programmes have been successful and reductive, especially the special programmes on human reproduction, diarrhoeal diseases, immuniza on, tropical diseases and AIDS. Nevertheless, experience with these programmes and their evaluation \ ad pointed towards areas where improvements were possible. Many countries have gained by absorbi g the results of research, others remain wary of new developments. A body like this Advisory Corn ittee would do well to provide a ground for interaction and appraisal of the outcome of such resear h for the benefit of those who were yet new to a particular strategy and its acceptability to the peep e. I The countries in the Region have the potential to plan and execute research programmes and hav competent scientists who can implement biomedical and health research projects innovatively. Equi’ y in development and removal of disparities in health between communities and nations must be Aa ieved through enmeshing the bilateral, multinational or international research inputs with an emphasis on strengthening the institutional capabilities within the member countries. I understand that WHO was currently reviewing the health research strategy, and as a part of this exercise, the South-East Asia Advisory Committee would also be having critical look at health research policy and make recommendations for a revised research strategy for e Region. I can assure you that my Government would give due consideration to the outcome of your deliberations and will adopt the new strategies that you recommend to the extent they are relevant for 1 e common man. The success of research lies not on what happens within the four walls of laboratori s and libraries. There has to be a determined effort to match the subjects of research and their outco e to the needs of the largest section of the population and country-wide differences in eography, fo gb d habits and culture. A much more dynamic interaction with the needs of the people w uld make the, outcome of research much more focused and relevant. That is my plea before you while I wish you success in your deliberations.