Western Pacific Advisory Committee on Medical Research Sub-committee on Health Services Research, Manila, Philippines, 27 - 28 April 1981 : report of the first meeting

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ICP/HSR/OOI

25 August 1981 ENGLISH OMLY

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WESTERN PACIFIC ADVISORY COMMITTEE ON MEDICAL RESEARCH SUB-COMMITTEE ON HEALTH SERVICES RESEARCH

Report of the First Meeting 27-28 April 1981

Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines August 1981

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CONTENTS t

Page 1.

INTRODUCTION

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1

2.

OBJECTIVES OF THE MEETING REPORT OF THE MEETING 3.1 3.2

1 2 2 2

3.

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Report of the Secretary .••••..............•....•...•• Terms of reference of the Sub-Committee ..••.•••••••••

3.3 3.4 4.

The WHO HSR programme 1981-1983 •••••••••••••••••••••• Report of the Sub-Committee on Health Services Research to the sixth session of WPACMR •••••••••••••••

5

RECOMMENDATIONS OF THE WPACMR SUB-COMMITTEE ON HEALTH SERVICES RESEARCH ••••••••••••••••••••••••••••••••.•• 4.1 General recommendations .•..•••.....••..••••.•.•......

5 5 7 8

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4.2 4.3

WHO/WPR HSR programme in 1981-1983

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Terms of referenc@ for the Sub-Committee

ANNEX 1 - HEALTH SERVICES RESEARCH PROGRAMME: WESTERN PACIFIC REGION, 1981-1983 ............................ ANNEX 2 - REPORT OF DR GEORGE SALMOND ••••••••••••••••••••••••••• ANNEX 3 - WELCOME ADDRESS BY THE REGIONAL DIRECTOR AT THE OPENING CEREMONY OF THE MEETING •••••••••••••••••••••• ANNEX 4 - REPORT OF THE SECRETARY

9 31 37 39

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ANNEX 5 - LIST OF SUB-COMMITTEE MEMBERS AND OTHER PARTICIPANTS ........................................ '" .. ,. '" ................ .

61

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1.

INTRODUCTION

The WPACKR Sub-Committee on Health Services Research (HSR) was established during the fifth session of the WPACMR in April 1980. Previously there had been a Task Force on Health Services Research, which reported to the WPACMR. This Task Force met four times, its final meeting being in July 1979. The first meeting of the new Sub-Committee was held in the WHO Regional Office of the Western Pacific in Manila on 27-28 April 1981, immediately before the sixth session of WPACKR held on 28-30 April 1981. The Chairman of the Sub-Committee was thus able to report the result of the SUb-Committee's meeting to WPACMR. WPACMR also considered the recommendations made by the SubCommittee and endorsed these recommendationa. The latter will now be submitted to the Regional Director, Dr Hiroshi Nakajima, for his consideration.

The Sub-Committee's meeting was opened by the Regional Director, referred to the activities of the earlier Task Force on Health Services Research. Dr Nakajima noted that the HSR programme now had a clear role in supporting the regional strategy for health for all by· the year 2000 and that the re.ponse by Member States in the Region was encouraging. However, he felt progress was still slow, and he asked the Sub-Committee to review the HSR programme and make recommendations on activities for the future, in particular to review the draft plan for 1981-1983 prepared by the secretariat. (The full text of Dr Nakajima's speech is attached as Annex 3.) In opening the meeting, Dr Nakajima pointed out that the SubCommittee's Chairman had left WPACMR and that the office was at present vacant. Professor Gu Shin-Yuan as Vice-Chairman would normally take the chair but had asked that the Sub-Committee elect its own chairman for the meeting. Accordingly, the meeting elected Dr George Sslmond (New Zealand) to chair the meeting. Dr Datu Khalid Bin Sahan (Malaysia) was elected Rapporteur.

2.

OBJECTIVES OF THE MEETING

The objectives of the meeting were as follows: \a) to review the HSR programme in the Region and the action taken, and the relevance of previous recommendations of the task force, particularly in the light of the regional health for all strategy;

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(b) to define the terms of reference of the Sub-Committee for submission to WPACMR at its sixth session; (c) to outline a plan of work for the promotion and development of health services reaearch at regional and country level.

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3.

REPORT OF THE MEETING

3.1

Report of the Secretary

The Secretary of the Sub-Committee, in presenting his report, said that, as the first meeting of the Sub-Committee was only now taking place, the report would limit itself to describing the activities of the WHO programme over the previous year. (The full report is attached as Annex 4.) During the previous year, there had been one major development that would have an important effect on the HSR programme. This was the completion by WHO of its regional strategy for health for all by the year 2000. This would imply a reorientation of the HSR programme in the following sense: the concept of national health development networks which would coordinate at national level the areas of planning, manpower development, information system and HSR. the modification of existing systems to support primary health care would be a major priority for research. With regard to HSR activities carried out with WHO support, these had continued in the priority areas already identified, namely, primary health care, financing of primary health care, and use of technology. There had been a modest increase in the amount of this support. As had already been noted, the global WPACMR Sub-Committee on HSR had now been changed into a WHO Scientific Steering Committee. 3.2 Terms of reference of the Sub-Committee

The Sub-Committee prepared its terms of reference to be recommended for adoption by WPACHR. They appear in the recommendations under paragraph section 4.3 below. Inasmuch as the recommendations were endorsed by WPACHR, these terms of reference may be considered as accepted a8 the basis for the operation of the Sub-Committee. 3.3 WHO HSR programme 1981-1983 The Sub-Committee studied in detail the draft programme prepared by the secretariat.

A considerable number of changes and modifications were suggeated, and these have been included in the revised programme, attached as Annex 1.

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The main cOllllllents made by the Sub-Comm; t tee were as follows: (a) Health for all by the year 200U. The Sub-Committee agreed that the programme's emphasis on primary health care was important, but suggested that a balanced and broad view should be taken. The Sub-Committee emphasi$ed that the HSR programme should address itself to health systems support for primary health care. Redirection of the health system towards primary health care would be a major area for research in the near future. (b) Country profiles. The Sub-Committee suggested that the country information presented in the situational analysis of the document was inadequate. It recommended the compiling of country profiles on HSR and said that members of the Sub-Committee could assist the secretariat in this. (c) Objectives of the programme. The Sub-Committee suggested that the objectives be revised to emphasise the need to support HSR strategies and in addition to make specific mention of the need for manpower development in HSR. (d) Programme development. The Sub-Committee made the following suggestions:

The proposed regional workshop on manpower for HSR should be held in 1982 rather than 1983. Consideration should be given to holding a national workshop Or workshops in China. With regard to collaborating centres, the Sub-Committee accepted that there might be certain difficulties in designating such centres in view of the lack of suitable institutions in the Region. However, it still felt that this was an important mechanism for institution strengthening and hoped that there would be more centres designated. The role of the country-based WHO services planning and management projects was of great interest to the HSR programme. The Sub-Committee felt that these projects were a very important way of developing national HSR programmes. It suggested that a regional or subregional meeting of the WHO project staff together with their counterparts to discuss national HSR progran~e development would be most useful. This could be held in conjunction with the usual WPCs' meeting or with a meeting of the Su b-Commi t tee. (e) HSR information system. In its discussion of the regional HSR inventory some different views were expressed_

It was stated that the investment in such an inventory would be wasted lin 1". s the in format ion was used. NevertheJes s, such an inventory could be u • .,1ul if the matPrial included in it was limited and selective, and if research activities were included that could stimulate activities in the rr0~ramme.

.anc' fl'rtr. part of

Also such 8 selective inventory could be summarized by country 8 national inventory.

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Thp nped for WHO to have country profiles on HSR activities had alrPBoy hf'pn raised hy the Sub-Committpe.

The sub-Committee examined with interest the New Zealand project to establish its own national guide to HSR. The format of this was considered suitable as a basis for both country profiles and national inventories. Thp same tvpe of format could be used to prepare a regional guide to HSR. At the regional level, in addition to the proposed inventory and guide, the need for an information sheet or booklet to be distributed by the secretariat on a regular basis was identified by the Sub-Committee as an economical way of disseminating information. (f) Manpower development. The Sub-Committee identified this component as the most important and yet the most deficient in the programme. It felt that the proposals in the draft were not adequate and should be extended. However, the Sub-Committee regretted that it was not able to give specific guidance to the secretariat on this. There was agreement that existing training and manpower development resources available in the Region should be identified. Individuals and institutions that could collaborate with WHO should be contacted. WHO Headquarters could be asked to provide information from outside the Region. (g) HSR methodology. The Sub-Committee agreed with the proposal in the draft plan that a short manual or booklet should be prepared for distribution within the Region. This manual should explain by means of short case studies the methods used in HSR and their application. (h) Support for research studies. The Sub-Committee noted that funds were likely to be limited but stre.aed the fact that for good study proposals funding could usually be found. WHO should harbour its resources by, as far as possible, providing "seed" money for small-scale research. LarRe-scale or expensive studies could be funded from other sources. (i) Coordination with other programmes. The Sub-Committee noted that the need for coordination between programmes was important in that the HSR programme could support other programmes engaged in HSR in the areas of training, use of methodology, and information on research. The Sub-Committee pointed out that there was also s need to coordinate at different levels in WHO particularly between global and regional programmes. The relationship of WPACMR, the Sub-Committee and the new Scipntific Steering Committee on HSR, for example, was not at all clear.

The Sub-Committee also felt that the HSR programme would find WPCs an important link in cross programme coordination at country level.

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3.4

Report of the Sub-Committee on Health Services Research to the sixth session of WPACMR

Dr George Salmond, who acted as Chairman of the Sub-Committee meeting presented the report to WPACMR on Thurlday, 28 April. Dr Salmond explained that at pre.ent the poat of Chairman of the Sub-Committee was vacant and that normally the Vice-Chairman, Professor Gu Shin-Yuan, would have been Chairman tor the meeti~. Howeve~, this was Professor Gu's first meeting and he hArl :~ggested that ~the Sub-Committee nominate an Acting Chairman of ~he meeting. The group had therefore elected Dr Salmond to act. The report of Dr Salmond is attached aa Annex 2. ---.~-

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4.

RECOMMENDATIONS OF THE WPACMR SUB-COMMITTEE ON HEALTH SERVICES RESEARCH HADE AT ITS FIRST MEETIRG ON 27 - 28 APRIL 1981

4.1 4.1.1

General reCQPBendationa Progress in health services research

Although there has been much discu •• ion about health services research in the Region, progress haa been .low. HSR methodologies and knowledge of how to make use of existing methodologies are lacking. In view of the global strategy of health for all by the year 2000, the need to develop HSR programme to aupport this strategy becomes urgent. Recommendation Interest in HSR programmes should be sustained and further nourished at regional and national level. by giving greater effects to the recommendations made so far, identifying and following up specific activity targets, and developing and setting aside appropriate resources for them. This should be done by implementing the plan for 1981-1983 as modified by this Sub-Committee (see subsequent recommendation). 1••

1.2

Regional Strategy for HFA/2000 and HSR programme

The HSR programme will support development and strengthening of health systems based on primary health care. Among the issues that health services research can address itself to are: community involvement

traditional medicine tinancing type of community workers

approaches for special programmes

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• communication technology evaluation types of infrastructures managerial/organizational changes referral system -

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health/professional education. -

The shortage of HSR resources, and the numerous issues that have to be dealt with are noted. Recommendation All available resources should be utilized maximally. At country levels, HSR expertise may be available within ministries of health, academic institutions and other related establishments. Co-operation among them should be encouraged and additional collaborating centres designated. There is a need to develop and carry out HSR activities in different settings with the necessary and appropriate involvement of grassroot workers. There is a need to develop the health services research programme as part of an integrated R&D effort. 4.1.3 HSR programme management

The HSR Sub-Committee at global and regional levels has not been entirely effective. It is noted that the global ACHR at its session in lQ80 recommended that its HSR Sub-Committee should be developed into a Scientific Steering Committee reporting direct to the Director-General of WHO. Development and coordination of HSR activities will be the main function of this Committee, although it can deal with specific areas which have been neglected or not taken up. It will deal with issues which cut across programmes, manpower, institution strengthening, substantive funding for specific projects, and information dissemination. At the regional level, HSR issues are handled by the HSR Sub-Committee of the ACHR, which was formed in 1976, and HSR activities are coordinated by regional advisers of programmes. Funding bases have been defined, and the mechanics of research proposals' clearance have been worked on. At the national level, Member countries have been urged to establish appropriate research management machinery in countries where no such machinery exists.

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Recommendation In order to encourage HSR actlvltlCS and develop HSR expertise in Member countries, the criteria for approving and WHO funding of research proposals should be reviewed, so that the conduct of modest but methodologically sound studies can be facilitated. The use of WHO funds as 'seed' mainly to attract outside funding for major projects is recommended. Other points to be recommended are: (a) To compile information on regional/national HSR manpower needs snd availability. (b) To request WHO Headquarters, Geneva, to compile materials/experience in HSR training developed/gained in regions for the purpose of formulating training schemes in HSR. (c) To prepare with the assistance of Sub-Committee members country profiles on health service research. (d) To ensure that the HSR programme provides a balanced support for systems development based on primary health care, and that the programme covers all components of such systems. Also to ensure that WHO staff members are aware of the importance of health services research in this approach to development. 4.2 WHO/wPR HSR programme in 1981-1983

The meeting considered the draft HSR programme 1981-1983 prepared by the Secretariat. There was general agreement on prioritie., objectives, approaches, programme activities, and activity targets. Recommendation 4.2.1 General

(a) The proposed regional HSR programme 1981-1983 and funding rroposals should be transmitted to the Regional Director for consideration. (b) In view of the lack of expertise in health services research, priority should be given to activities relating to manpower development for health services research. 4.2.2 Specific (a) Information booklet should be prepared and distributed on: the HSR programme and activities in WPR in form of booklet; the HSR studies ongoing, planned or completed during a given period;

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the HSR findings and methodology as

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become available.

Procedures and mechanisms should be drvp10ped at regional and copntry Ipvels to facilitate the above. I

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(b) ~llcourag"d

The estsblishment of nation81 HSR inventories should be and facilitated.

(c) HSR activities should be disseminated to focal points through the regular publication of HSR information in simple readable form, with emphasis on methodology. 4.3 Terms of reference for the Sub-Committee The following terms of reference are recommended: (a) The Sub-Committee comprises two members designated by WPACMR who shall be Chairman and Vice-Chairman and additional members a8 may be coopted in accordance with procedures laid down in the Regional WHO Handbook.

(b) The Sub-Committee will meet as often as may be required and meetings shall be called by the Chairman with the agreement of the WHO Secretariat. (c) The Sub-Committee will report to WPACMR on the development, implementation and evaluation of the WHO regional HSR programme. (d) The Sub-Committee or members may collectively or individually col18borate with the WHO Secretariat in specific activities of the HSR programme. In particular: collaborate with WHO/WPRO in the development and application of HSR methods; review research proposals submitted tor WHO funding; promote HSR activities in their own countries;

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provide information to WHO on health services research in their own countries,

strengthen manpower development; promote the mobilization of extra-budgetary resources for the WHO regional HSR programme.

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ANNEX 1

HEALTH SERVICES RESEARCH PROGRAMME: WESTERN PACIFIC REGION 1981-l9fl]

1. Progr~e

INTRODUCTION

The WHO programme classification places the Health Services Research in the major programme: Health Services Planning and Management.

Because health services research is a relatively new programme and, for many, a new idea, the boundaries defining the programme have to be rather arbitrary. A new expression: health systems research is being increasingly used and appears to be more appropriate for the present time than limiting the title to health services research only. However; for simplicity, the term health aervices research (HSR), will continue to be used. There are two definitions as to whst is health services research. HSR in 1976: "Any group of activities that involve the generation of information or the application of knowledge on a scientific bssia with a rise to providing more effective, efficient, and equitable health care for defined populations". The second definition formulated by the Global ACHR sub-committee on HSR is equally applicable. "Health services research is the systematic study of the means by which biomedical and other relevant knowledge is brought to bear on the health of individuals and countries under a given spt of conditions". These definitions are broad, and it is accepted that all WHO programmes involved in the delivery of health care services should have their own HSR components, so as to solve specific operational or developmental problems. What is less genprally accepted, especially by Member States, is that HSR is R useful tool for application in health services development, wi thout which it would be difficul t to plan for health care delivery pfficiently and ~ffpctively. The WHO programme in the Western Pacific Region may be said to have started in 1976 with the creation by the WPACHR of a Task Force on HSR (now the Sub-Committee on HSa). The

WPR definition formulated by the first meeting of the WPACMR Task Force on

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Annex 1

The programme has addressed itselt to two main issues: (1) (2) to develop national awareness of HSR and to promote national programmes; and to promote and support RSR studies in countries in the Region.

At the beginning of 1981, a reassessment is needed, hence the retormulation of this programme for the remaining three years of WHO's 6th General Programme of Work, 1981 to 1983. The need for this reassessment follows the major policy changes in national health services development activities in the region that have resulted in the adoption of the goal of HFA/2000, with primary health care as the main strategy for reaching this goal. For WHO, clearly, this will lIIean considerable pro·gramme reorientation, and the HSR programme will also need to be reoriented to support the development of health systems based on PRC. With this present policy, Member States and WHO have to ask themselves: how is PHC implemented? what changes are required in the health services to implement PHC? what are the resource and financing implication of implementing PHe? what are the implications of HSR on PHC implementation? The HSR programme must be able to provide the snswers to these questions. This document was just prepared as a draft and this was reviewed by the WPACMR Sub-Committee on HSR at its first meeting in April 1981. The draft was then revised in the light of the Sub-Committee's comments and the present document is the result. 2. 2.1 Policy basis BACKGROUND AND ANALYSIS

lhe direction of WHO's present policies for HFA/2000 is therefore to ensure that PRC forms the basis for national health development. 111" previous activities of the been in conflict with this. It may the Task Force on 115R, and also the in Manila in 1978, foreshadowed the main focns for health development.

WHO HSR programme have not in any way be noted that the various meeting. of report of the working group on HSR held current preoccupation with PHC as the

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• Annex 1

In 1980, a much more positive initiative was taken by WHO in WPR together with the Regional Committee. At its 31st session in Manila in 1980, the Regional Committee endorsed a document entitled "Regional Policies and Strategies for Health for All by the Year 2000" by an appropriate resolution (WPR/RC31.R12). Research was noted in the Regional Committee report (WPR/RC31/15 Part II) as oriented towards the solution of problems related to HFA/2000. As such, HSR would be promoted as an integral function of strategies in primary health care. The major implication for the HSR programme that is emphasized in the re~ional strategy document is at the national level, HSR should be part of a framework or network for national health development. These national health development networks should be the managerial support for implementing national strategies. The direction of this programme is to focus on areas where the application for HSR is for development. As such, research studies can and should supplement programme areas of MCH, CVD, PHC, EHE, CDS, EPI, etc. The HSR programme will thus have to be integrated with WHO Programmes related to planning and management of health development (country health programming, general programme development, health information and managerial processes).

As conceived by WHO, the regional strategy will include the establishment of and support for national health development networks which includes: strengthening of the planning and management, and promotion of decentralization;

training in planning and management;

research and development (including HSR); and development of a national health information systems. Up to the present five countries/areas have indicated interest in such networks: the Republic of Korea, Malaysia, the Fhilippines, Papua New Guinpa, and countries/areas in the South Pacific. A similar activity may be developed in China.

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2.2 2.2.1

Situation analysis RSR and health development in the region

It will be assumed for the purposes of this document, that all countries in the region have problems in providing health care services and delivery for their people. It will also be assumed that implementation of PRC strategies would substantially alleviate these problems. In considering the present situation in the region, various countries will be cited. For those countries not mentioned, it should be assumed that, either WHO does not have relevant information to make a report or that HSR implementation of activities or capability has not yet been reported. From the point of view of the region as a whole, it can be said that since the beginning of the HSR programme 5 years ago, there has been considerable progress. The WHO progrsmme has generated awareness of HSR in the region and has promoted and stimulsted national efforts with in some cases quite dramatic results. However, there is no room for complacency as the section on problem identification will indicate. (a) Australia

At the federal level, and at the state level, HSR capability is well developed and useful. That is to say HSR is us'ed in planning and management of health care. HSR capability in terms of manpower development and use of methodology is also advanced. However the health system in Australia ia pluralistic with state autonomy, health insurance, and a vigorous private sector as important factors. There is increaaing awareness of cost problems with the present system and some HSR is being carried out on alternatives through PHC. (b) People's Republic of China

Since liberation, a new and different health care system has evolved that has given many of the ideas now currently incorporated into the primary health care approach. China has always strongly endorsed the value of national HSR programmes, and has stated that HSR methods have been used in the evolution of the Chinese health care system. It is hoped that the future WHO HSR programme will have much more information exchange with China. As one of the countries in the region that has successfully implemented PHC, there would seem to be much valuable information to be obtained.

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A further consideration that would justify closer collaboration with Ch ina would he the fact that health is included as one of the four modernizations. The mana.erial, resource allocation, and manpower dpv~lopment implication of this would be obvious areas of HSR activity. (c) Lao People's Democratic Republic

The Government has already defined the health care system baspd on the primary health care approach. This system, if it is to be implemented thr~ughout the country will need to be carefully managed. A government/WHO health services development project is studying the operational and managerial requirements of. the health care system in one demonstration area. It is planned to expand the number of demonstration areas, that will be used at the same time as training areas. This will have a multiplier effect and lead ultimately to national implementation. This is a good example where simple HSR Methods sre used in health services dpvelopment and become part of the operational system. (d) Malaysia

The government has a declared policy of developing HSR as a component of health care planning and in health care management. This is stated in the 4th Malaysia Plan. The Public Health Institute in Kuala Lumpur has been designated as the head agency for coordination and trainina in HSR. WHO is hoping to develop a collaborative project with the PHI. Thus, the mechanism and structure for a national HSR programme are being established. (e) New Zealand

This country has a well established structure for using HSR in planning and management of health care. HSR capability is strong and training facilities are available. (f) Papua New Guinea

The n,Hional development plannin~ procpss is wpll dpvelopen. The health sector contribute. to be national rolling plan (National Public Expenditure Plan). Within the Health Department, there is a Planning and Research Division. This division is active in HSR and collaboration with WHO ~'i 11 be continued •

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Annpx I

(g)

Philippines

There is no organized HSR programme, although the Division of Health Planning in the Ministry of Health has considerable expertise and experience. The restructuring of the health care delivery system carried out from 1976 to 1979 by means of a World Bank loan was based on an operations research study of the health services. Potentislly, there are good possibilities for an effective HSR programme. (h) Republic of Korea

Here there is a national focal agency for HSR: the Korea Health Development Institute. This Institute sponsors and carried out HSR for the Ministry of Health and Social Affairs. Training activities are also undertaken. The Korea Development Institute slso carried out a certain amount of HSR for the Economic Planning Board. This research is mainly 1n health services financing and information system. (i) Solomon Islands

The Ministry of Health and Medical Services is in the process of implementing a primary health csre project. This involves the training of village health workers (village health aides), village leaders, and traditionsl healers. Using simple methodology, this project will be evaluated and the results used to determine the future implementation of the project. Conclusions It is accepted that at present the informat; on available to WHO is not adequate for anything other than broad generalization. More detailed country profiles will be prepared for the region.

As far as the region is concerned, the nine countries listed above may be said to be actively involved in HSR or likely to be involved. This is approximately one third of the region. Project activities are continuing rind most importantly will increase

during 1981-1983. Through the efforts of this programme it is hoped that the rise of projects show an increasing interest by countries in applying the HSR approach to national problems in health. There are of course certain countries/areas in the region where a

distinct HSR programme would seem unnecessary either because of size or dependent status. There remllins a group of countries where thf' status oi" HSR is not

known, but where it would seem that HSR activities to support health servicps development would seem desirable.

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These countries/areas are: Fiji, Hong Kong, Japan, Samoa, Singapore, Tonga, the Trust Territory of the Pacific Islands, Vanuatu and Socialist Republic of Viet Nam. Of these countries/areas, Hong Kong, Japan and Singapore are grouped together as being a priority for information gathering. Plainly the WHO HSR programme should have more contact with HSR related agencies and activities in these countries. The Socialist Republic of Viet Nam with its comprehensive health care system may wish to consider the use of HSR in management and evaluation of this system. Fiji may also be in a similar position where USR could support a programme for management and evaluation. Samoa, Tonga, TTP!, and Vanuatu, are all island countries and here, HSR could have a role albeit a less sophisticated one in health services development. 2.2.2 Problem identification

The problems identified by the programme may be divided into regional and national. It is convenient to list with the problems, factors that influence these problems. Problem Regional level: 1. Policy on HSR not clear Role of HSR in PHC implementation is not understood. HSR programme not integrated into other technical programmes. Information on application of research not

Contributing factors

distributed to policy-rnaking groups. 2. Lack of information No information exchange because of a lack of a mechanism or focal points for HSR in some countries. No national information system on HSk.

• 3. Lack of expertise

Lack of promotional bodies for HSR thereby absence of formalized project activities for priorities. Lack of knowledge of existing methodology and research in developing new methodologies. Inappropriate programme structure and organizBtion

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Lack of coordination

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Annex 1

National level: 1. Lack of awareness of HSR: 2. 3. 4. need for HSR use of HSR what HSR can accomplish how HSR is conducted - lack of staff exposed to or trained in HSR - lack of information base on HSR especially methodology - lack of health development agency, group or network - lack of priority setting for HSR in allocation of resources

Lack of focal point for HSR Lack of resources for HSR Lack of manpower and training development

HSR not recognized as a priority research area.

- No mechanism for manpower and training development 5. Lack of research studies Priorities - all problems listed above

2.2.3

For the WHO regional programme in HSR, certain priorities emerge clearly. The programme should promote health services research capabilities at national level into development of health systems based on primary health care. This may be divided into several areas: (a) (b) (c) (d) (e) (f) the dynamics and structuring of community participation; the technology required for PHC; the modifications needed for existing health care systems to support PHC; the mechanism for intersectoral collaboration at all levels. the financing mechanisms required for the extension of health care through PHC; and the efficiency and effectiveness of PHC delivery to the community.

In order to foster this, the programme should also address itself to the organization of suitable national structures for HSR; ideally 8S part of national health development networks.

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3.

OBJECTIVES

3.1

Long-term objective

To enable Member States to plan, develop and implement national health services research programmes that will be part of the process to develop health systems based on primary health care, and the results of which will be uaed to provide more efficient, effective and equitable health care at thp community level. 3.2 Medium term objectives (1981-1983)

3.2.1 To develop national HSR programmes within the framework of national health development activities especially with respect to the development and implementation of primary health care. 3.2.2 To strengthen and develop national capability to carry out health services research, with particular reference to the development of manpower for such research. 3.2.3 To develop a regional HSR policy and programme structure to support and enhance national efforts.

4.

DESCRIPTION OF THE PROGRAMME

4.1

Approaches

In view of the problems and priorities identified in the foregoing paragraphs the following approaches will be used for the period 1981-1983. As already mentioned, the broad approach will be to promote the development of HSR programmes focussing on the development and management of health systems based on primary health care. This will require activities at all levels in a country: central, intermediate, and the community level. Specific approaches adopted by the programme will be: (a) to support PHC research in the areas mentioned in 2.2.3 namely: - community involvement;

- application of technology; - modification needed to health system; - financing mechanism for PHC;

- 18 Annex 1

- manpower and training;

- resource allocation;

- intersectoral collaboration. (b) to support research that will identify the optimal health services system based on PHC. In effect to develop the support systems for the new type of health services. to develop national HSR capability by developing a national and regional HSR networks and by promoting manpower training. to establish a regional information system that will includ~ collecting and distributing and interchange information on HSR methodologies, reports, etc. to promote the development of HSR methodology. to mobilize resources in the region and outside for the development of the national and regional programme.

(c) (d)

(e) (f)

The programme will therefore have the following six components: 1.

HSR programme development Information system Manpower development Methodology development Support for studies Coordination with other programmes

2.

3. 4. 5. 6.

In the programme approaches, the geographical groupings discussed 1n 2.2.1 should be taken into consideration. Clearly, as the HSR information becomes available and a programme is from certain initiated countries, this grouping will change.

4.2

Targets 1981-1983 In relation to objective 3.2.1: to have national or area HSR programmes in support of PHC implementation in the following countries or areas by 1983 that do not now have: Fiji, Hong Kong, Japan, Malaysia, Vanuatu, Papua New Guinea, Philippines, Samoa, Singapore, Viet Nam, Solomon Islands, Tonga, TTPI.

- 19 Annex 1

In relation to objective 3.2,2: ~untries

to have established collaborative actlvltles with the fOllowing by 1983: Australia, China, Malaysia, New Zealand, Republic of Korea, Papua New Guinea and the Philippines.

to have HSR activities included in project operational plans of all country and intercountry SPH projects by 1983. to have trained researchers in arl group 1 and group 2 countries (see 4.1) by 1983. to have held meetings a.nd workshops on SUbjects of priority for the programme where there will be participants from all group 1 and 2 countries by 1983. In relation to objective 3.2.3: to have developed a regional information system on HSR by 1982. to have by 1982 an intercountry project that is able to provide support to national programmes in training, development of study protocols, implementstion of studies, needs identification, and methodology development. by 1982 to have identified, as part of the information system, HSR expertise in the region that can collaborate with the WHO programme. to have obtained extrabudgetary funding for the programme for 1982/1983 and to ensure adequate allocation of funds in the regular budget for 1984/1985. 4.3 Programme activities These will be considered for each programme component. •

(a)

HSR Programme development

The programme will support regional and national meetings and workshops to generate national awareness and disseminate knOWledge. In coordination with the other related WHO programmes and through WHO programme coordinstors, the programme will establish contacts with national planning agencies.

-

20 -

Annex 20

The development of national health development networks will be of specisl interest and close coordination with other programmes will again be required. At regional level, the WPACMR Sub-Committee on HSR will continue its activities snd its future role in the programme has been defined (see recommendations of first meeting of WPACMR Sub-Committee on HSR, April 1981). (b) HSR information system

The system will have two parts - a research inventory and resources inventory. In addition, there will be a mechanism for activating these inventories. This first priority will be for the research inventory and subsequently the resource inventory (in terms of manpower, institutions, and funds). For distribution of information three booklets will be prepared: a guide to HSR in the region; a guide to the application of HSR methodologies; and an information booklet that will provide regularly updated information on HSR in the region. (c) HSR manpower development

These will be four types of activity: identifying manpower needs; identifying training resources available; strengthening institution: training courses and fellowships; and learning by doing (participating research). (d) Development and application of HSR methodology

The WHO HSR programme will collect information on the use of methodology and its application in the Region. This will imply cataloguing studies, and supporting research into methodology. Dissemination of information and demonstration of such methodology will also be a priority. (e) Support for research studies

The programme will continue to support research by direct funding. However, within the priority areas mentioned, WHO will take active steps to:

•

identify topics for study; identify potential researchers;

- 21 -

Anne" J

, , (f)

collaborate in project Bnd protocol formulation; support with funds; monitor progress. Coordination with other programmes

There is a rapidly increasing amount of HSR activity in other WHO programmes and a suitable coordinating mechanism will be established both within the region, with other regions and with HQ. A table of activities for the years 1981 to 1983 by programme component follows: WESTERN PACIFIC REGION: HEALTH SERVICES RESEARCH PROGRAMME ACTIVITIES

Programme component/activity

1981

1982

1983

· A. Al HSR programme development Regional workshop: - financing of health deve lopmen t Manpower for HSR Methodologies for HSR

A2

Regional meeting: (combine with WPACMR meeting)

Research needs for HFA 2000: (with CRP pro gr al1llle ) April April April

•

,

A3

Meeting of WPACMR SubCommittee on HSR (to be held before WPACMR session)

- 22 -

Annex 1

Wt;STERN PACIFIC REGlON:

H!;ALTH SERVICES RESEARCH PROGRAMME ACTIVlllES (cont'd)

•

•

Programme component/activity

1981

1982

1983

A4

*Develop strategies through contact visits on exchange

- member of secretariat

China: technical visit

of information and identification of collaborative activities. With the information collected, country profiles on HSR will be prepared

visits Australia, Japan, New Zealand - focal point identified for China, visit by secretariat

TTPl: visit by secretariat Vanuatu: visit

- continue (combining with routine duty trave 1)

by secretariat

- exploratory contact with SRVN

- correspondence wi th Hong Kong, Singapore, visit combined with other trave 1 if possible AS National workshops: stimulate awareness,

to

develop studies and train personnel A6 Focal group on HSR in WP Regional Office designatedsuch a group having the functions of inter and in tra-programme coordination and liaison with Regional Health Deve lopmen t Group ( RHDG)

Malaysia South Pacific

i'hilippines, Singapore, Republic of Korea People's Republic of China Continue

Papua New Guinea

- establish group that coordinates

Continue

with RHDG on activities for national strategy development networks .'

*1n collaboration with members of the HSR Sub-Committee

- 23 Annex WESTERN PACIFIC REGION: HEALTH SERVICES RESEARCH PROGRAMME ACTIVITIES (cont'd)

Programme component/activity

1981 Malaysia

1982 Philippines, People's Republic of China

1983 Papua New Guinea

A7

Designation of collaborating centres for HSR to be coordinated with development of national

South Pacific

health development network A8 Develop and implement HSR programmes through or existing WHO SPM projects Malaysia, Republic of Korea, Philippines, Papua New Guinea, Lao People's Democratic Republic South Pacific ICP/SPM/002 Vanuatu Lao People's Democratic Republic, Democratic Kampuchea, Socialist Republic of Viet Nam, People's Republic of China South Pacific

A9 Conduct meetings of SPM (a) project staff including counterparts to develop plans of action for national HSR programme development B. Hl

Region excluding South Pacific

HSR information system r.stablish information hasp - send out ques-

In WPRO on HSR studies: - completed In 1980/81 - ongoing in 1981/82 - being prepared

tionnaire to HSR focal points - develop information storage capacity in WPRO - extract information by country and programme

Continuous updating Distribute annually

continue

continue

~~

Support establishment of HSR bibliography for region by appropriate libraries

- revise existing bibliography prepared by Singapore conduc t search

- extend to other libraries - continue

continue

continue

with Medline and other retrieve systems

publish bibliography annually

continue

- 24 -

Annex I

WESTERN PACIFIC REGION;

HEALTH SERVICES RESEARCH PROGRAMME ACTIVITIES (cont'd)

Programme component/activity

1981

1982

1983

B3

Develop linkages with worldwide HSR related data bases Promote development ot national HSR inventories

deve lop Ii s t of health data bases on basis of existing information prepare country summaries - distribute to focal points for updating annual

Publish list of data sources

continue

B4

on basis of HSR Information obtained enter into HSR/IS

continue

B5

Establish information distribution mechanism

continue

continue

dis tribution of information on studies by country and programme annual continue continue

distribution of regional bibliography annual continue

distribution of HSR information booklet informat ion services continue

- snnua1 distribution of HSR methods manual - continue

provided on request

- 25 -

Annex 1

WESTERN PACIFIC REGION:

HEALTH SERVICES RESEARCH PROGRAMME ACTIVITIES (cont'd)

Programme component/activity

1981

1982

1983

..•

B6

Prepare and distribute booklet on HSR programme HSR manpower development

commence twice annually

revise and continue

revise and

continue

C.

to provide material for regional meeting STC carries out survey and prepares report - commence

Cl

Identifying manpower needs and resources

C2

Prepare regional manpower development plan

preparation of regional manpower plan - HSR and HMD Regionsl Advisers

finalize plan and initiate implementation

continue

C2

Strengthen institutions

- identify suitable institutions in People's Republic of China, Japan, Malaysia, Philippine. , Singapore, New Zealand - prepare implement and details of WHO add institutions collaboration in Papua New Guinea and South Pacific

Australia

- 26 Annex 1 I'AClFIC R);(;ION: IIEALTH St:RVICE~

WEsn:RN

RESEARCH PROGRAMME ACTIVITIES (cont'd)

Programme component/activity

1981

1982

1983

C3

Include HSR in fellowship provisions for priority countries

where possible,

implement

implement

include fellowship in country allocation for 1982/83 budget identify present institutions giving courses

C4

Develop training materials for HSR for use in national training courses

implement one COurse on a

introduce training

test basis modify as necessary

develop training course

materials to other selected countries

( STC)

outline D. Dl Development and application of HSR methodology Prepare manual or booklet describing HSR methods and applications using case studies where necessary

identify and prepare case studies

- revise aft-er review and

- prepare draft manual (STC)

regional meet ing (STC) - print and distribute - incorporate

continue

D2

Review existing methOdology for priority areas

- e.g. community

evaluatp

participation - technOlogy for hea lth sys tems based on PHC - health systems support for PHC - financing mechanisms for

in HSR Methods Manual ( STC)

heal th sys tems based on PHC

- 27 -

Annex 1

WESTERN PACIFIC REGION:

HEALTH SERVICES RESEARCH PROGRAMME ACTIVITIES (cont'd)

Programme component/activity

1981

1982

1983

D3

Promote development of new methodology for priority aress

- identify suitable projects developing new methods - develop collabora t i ve programme

document

results

incorporate in HSR Methods Manual

• E. E1

Support for health services research studies Provide funds for study proposals in priority areas - use existing

continue

cont inue

procedure for funding - from HSR information system identify suitable research group - develop outline protocols and approach researchers

F.2

Promote the deve lopment 0 f study proposals in priority areas

continue

to carry out studies with WHO funding E3 Obtain funds for HSR from budgetary and extrabudgetary sources

identify sources and

continue

potential donors in the region

- prepare suitable proposals for submission

continue submit,

and follow up

- 28 Annex 1

WESTERN PACIFIC REGION:

HEALTH SERVICES RESEARCH PROGRAMME ACTIVITIES (cont'd)

Programme component/activity

1981

1982

1983

F. Fl

Coordination with regional and global WHO programmes Review and identify HSR activities for other WHO programmes in HQ and WPR - enter in HSR in forma t ion system continue

add information from other regions continue continue

F2

Develop collaborative - identi fy programme for HSR activities suitable with other programmes projects for collaboration - prepare action plan for collaboration Obtain support from other programmes - identify HSR projects of interest to other programmes - negotiate funding from other programmes - develop separate budget item in programme for projects to be funded by other programme

continue

continue

F3

continue

continue

continue

continue

continue

continue

-

~9/30

-

Annex 1

4.4 4.4.1

Resources needed:

Budget for WPR HSR programme

Resources at present available (February 1981) 1981 Biennium 1982/83

Regular budget: Extrabudgetary sources:

$ 50 000 148 300

Regular budget (proposed intercountry: country

$160 800 118 000

Extrabudgetary sources: Total 4.4.2 $198 300 ======-= Total

nil $278 800

Estimated programme budget (1981-1983) Activity 1981 20 000 12 000 10 000 20 000 1 000 500 1982 22 000

1983 24 200 12 000 30 000 40 000 2 50(1 1 000 2 800 10 000 5 000

Al A2 A3 A4 AS

A8 Bl B2 B5 CI C2 C4 01

Regional workshops Regional meeting WPACMR Sub-Committee on HSR meeting Technical visit to China National workshop Project development Supplies. equipment and secretarial expenses Prepare and distribute bibliography Printing and distribution costs STC for manpower needs assessment Supplies and equipment Training courses in HSR STC STC's for manual STC's for methodology Support to studies with innovative m.. thodology Support [0 HSR studies Deve 1opmen [ of collaborative studies Co Uabora te in studies with other programmes

10 000 12 000 3 000 2~ 000 40 000 2 000 1 000 2 800 5 000 10 000 5 000 5 000 5 000 10 000

5 000 5 000

0:' D3 El

10 000 150 000 100 000 50 000 $437 200

80 000

F2 F2

150 000 50 000 50 000 $407 500

50 000 Total $203 500

==================z====c=======

- 31 -

ANNEX 2

REPORT OF DR GEORGE SAL/fOND

"Mr Chai rman,

Together with the Secretary's report, the Sub-Committee considered a draft HSR Programme for the Western Pat'ific Region, which in detail looked at a programme of activities for the ppriod 1981-83. This programme was organized under a number of headings. headings that I would like to take in my presentation. General remarks

It

1S

these

Before I do that, I would like to make some brief remarks about the HSR programme generally. Health Services Research is a recognized priority area in WHO both for countries, at re~ional level, and for Headquarters and the World Health Assembly. It is widely recognized that Health Services Research could play an important part in the promotion of primary health care and the achievement of health for all by the year 2000. In this region. we have been working for five years services research. Despite the fact that we have talked length, we must be modest in our claim that progress has Global Sub-Committee of ACMR on Health Services Research experience.

to promote health and written at been made. The has had a similar

Achievements

There is better understanding of the nature and role of health services research in the development of the health service and a clearer understanding of the problems, and the possibilities and opportunities for developing health services research. Knowledge is more Disappointments wid~ly

shared.

There have been some disappointments. We have to acknowledge the failure of the programme to obtain funding support from extrabudgetary sources. Also, there has been the failure to get the desired number of research projects under way. There have, we suspect, been considerable gains at country level although we are not yet adequately informed. The biggest disappointment is our failure to make the required progress with the institutional strengthening and manpower development aspects of HSR. We have talked a great deal about this but there is little tangible progress to show for our efforts.

- 32 -

Annex 2 In recognizing these disappointments, the Sub-Committee accepted that the task of promoting HSR is difficult, and will require a sustained effort over many years if gains are to be made. The rapid achievement of goals is simply not possible. Achievement is often difficult to assess, but we refuse to be daunted or discouraged by these prob lerns. Turning now to the priorities for our programme.

(1) First must be primary health care and health services research on the delivery of care. Also there should be research on health systems support for primary health care. A balanced programme must include other elements as well, particularly the support systems required for primary hea lth care. (2) Economics and financing of health care.

(3) Appropriate use of appropriate technology: this means the application of appropriate technology rather than the development of new. HSR programme development Health services research is part of any national health development network. Health services research does not stand alone, and must be linked with activities in planning, information systems, manpower development, management training Bnd inter-sectoral cooperation. Network development At regional level, it is felt important to have a network of national contaots that will permit us to: Draw up country profiles. Organize support for health services research.

Identify key people and institutions. Inform about relevant projects. Inform about needs ff'r resea rch; for manpower development; fOT

training support.

Te~earch

Inform about what may be able to contribute to our health services programme.

- 33 -

Annex 2 The Sub-Committee recommends a joint effort by members and by the Secretariat to build up this profile. Programme workshops at regional level are recommended for the following aspects of health services research: Financing of health development in 19R1 HSR manpower in 1982 HSR methods in 1983 It is also suggested by the Sub-Committee that there should be national workshops to bring people together to get the HSR programme started. The issue of collaborating centres is an important one and the Sub-Committee reiterated earlier recommendations in supporting this concept and suggested more of this form of collaboration. Information systems

TI,e Sub-Committee was encouraged by reports on progress made with information systems for health services research and this will be an agenda item at your WPACMR meeting. Concerning appropriate information required, the Sub-Committee considered that: Information should be selected, extracted, and distributed to people in a form which can be used. A booklet should be prepared on the regional health services research programme. There is a need to share information and weld our network together.

It is proposed that the booklet or information document be sent to focal points. This will allow them to be informed on the details of the programme and identify useful information. The Sub-Committee ~ivps this a high priority.

- 34 -

Annex 2 Manpower development This is an important and difficult <:ireB .. we are still concerned about this aspect of the programme. We can identify needs at, basically, two levels: (1)

specialists 1n health services research; training of managers at various levels to use health services

(2) resea rch.

One approach is by team buildin~ and another by career development for people involved in health services research. There are a variety of efforts at places round the world to develop the required training programmes, but, we have no guidelines nor clear pattern as yet. Unfortunately, there is little visible activity 1n our Region in these areas. The Sub-Committee recognizes the need to summarize training experiences at global level and we have suggested that WHO Headquarters be approached on this. We also suggest that collaborating centres or people in the networks be identified for training. We should encourage learning by doing and use case studies to demonstrate methods and principles. Education should be built into project work. HSR is craft, and teaching must be learned on the job. Even now we can gather information and organize experience for the workshop in 1982. Development of methods There is a need to develop new research methods or approaches especially in primary health care, and to share information on methods. The programme tnkes this into consideration.

Support for health services research studies (1) 'Seed' funds. This is very important to allow flexibility. We should use our regional funds for this and for major project funding, we should try to use outside funds.

(2)

Bilateral agencies can also fund major studies.

(3) In our programme we should build in financial provision to support the associatf>d training componpnt.

- 35/36 -

Annex 2 Coordination with regional and global programmes (1) As stated earlier we must establish regional networks - all Member countries must identify with the programme. (2) In this way, all countries can participate in the programme.

(3) The Region must be the central coordinating structure through which infor.ation flows. Also, in this way, we could see improved country commitment and improved performance by the Secretariat. Within the Regional Office, the HSR programme must establish close cooperation with other programmes. As we know health services research is an important component of other programmes and strong links must be established between the Regional global health services ruearcb programme. In this regard we look forward to establishing a working link with the proposed Global Scientific Steering Committee on Health Services Research. The sub-Coamittee would welcome this and hopes that appropriate mechanisms will be establisbed. Speaking now of the relationship of our Sub-Committee to ACMR we would like to reco.aend that, when decisions sre made with respect to the membership of this body, consideration be given to appointing someone who has a career interest and is actively involved in health services research. Such a person could be a member of the Sub-Coamittee - possibly the Chairman, and this would greatly facilitate communication between the Sub-Committee and ACMR. Finally, I would like to say that despite the all too obvious problems the Sub-Committee is in good heart and is determined to try to advance the CAuse of health services reseArch in the Region. We recognize that manpower development rather than money is our greAtest deficiency and we will work At that. However, we hope that, when we Are Able to bring forwArd our training proposals, And an increased volume of projects for support, ACHR and WHO will in various ways be able to obtain the required resources. Thank you".

- 37 -

ANNEX 3 WELCOME ADDRESS BY THE REGIONAL DIRECTOR AT THE OPENING CEREMONY OF THE WPACMR SUB-COMMITTEE ON HEALTH SERVICES RESEARCH MEETING

Distinguished Colleagues, Friends Good morning and welcome to Manila! I would like especially to welcome the new member of the Sub-Committee, Dr Gu Shin-Yuan, and also the new temporary advisers, Dr Asoy of the Philippines, Dr Hashimoto of Japan, and Dr Onno of Papua New Guinea. I would also like to welcome our old friend, Dr Rossi-Espagnet from WHO, Geneva.

you know, this is your first meeting as the Sub-Committee on Health Services Research of WPACMR, and it is already more than one year since I spoke to the final meeting of your predecessor body, the Task Force on Health Services Research. That was in 1979. At the time, I spoke of my concern that the WHO HSR programme should expand in the Region, and be used as part of the national health for all strategies. As

In 1980, I had the opportunity to speak to your global counterpart, the Sub-Committee on Health Services Research of the Global ACMR, and I emphasized that Member States would have to modify their health services in the future to implement their health for all strategies and that health services research would be needed for this. I said in particular that we needed a clearly oriented programme and that we had not yet fully harnessed the resources available to the programme in the Region. Now, what has happened S1nce then? I think that our HSR programme has now found its orientation in that it will support the development of health systems based on primary health care. At national level, this implies that health services research will be part of the national health development process. We have increased our support to the priority areas, namely, primary health care, technology and financing of health care. We are increasing collaboration with a larger number of institutions and countries.

But progress is slow, and 1 teel that we have a long way to go before the programme i. as strong as 1 should like. Although there is a much more p0sitive response to the programme by Member States in the Region, there is

still a general lack of information about health services research methodology and how to use it. Indeed, even within WHO, this has not been carefully described. Accordingly. this part of the programme will be strengthened.

- 3B -

Annex 3

As you will hear, we still need extrabudgetary funds to supplement the programme's budget and I think there are many resources in the Region that we have still not tapped. Your help in identifying these resources would therefore be a most important contribution.

Among the objectives of the meeting, you have been asked to review progress and make recommendations for the future. This Office has prepared a draft plan for the programme to 1983 and I hope you will consider this plan seriously and decide whether it is feasible in terms of content and resources. This plan is important in that it brings us to the threshold of a new work period for WHO: The Seventh General Programm~ of Work, which runs from 1984 to 1989. I hope that we can start this period with a strong and viable health services research programme. There is one other matter I would like to raise and that is the question of the terms of reference of your Sub-Committee. 1 know that you will be preparing these for submission to WPACMR. I hope that you will think of the Sub-Committee not only as advisory to WPACMR but also as a group that can support the health services research programme directly. The expertise in your group could be a most valuable asset to the programme. I hope you will assign yourselves an active role in our programme and I would value this. Some ot you have already provided much assistance and support and I thank you for this and hope that you will continue to help us. 1 see that your agenda is long and the time is limited. I will therefore simply wish you a fruitful meeting and an enjoyable stay in Manila. Thank you.

- 39/40 -

ANNEX 4

REPORT OF THE SECRETARY OF THE SUB-COMMITTEE ON HEALTH SERVICES RESEARCH by

. I Dr R. Hern1man

IRegional Adviser in Health Services Development, WHO Regional Office, Western Pacific Region, Manila.

- 41 Annex 4

1.

INTRODUCTION

This is the first report on the activities of the Sub-Committee on Health Services Research, which was created in its present form at the fifth session of the Western Pacific Advisory Committee on Medical Research (WPACKR) in April 1980. Previous to that, a Task Force for Health Services Research had been formed by the WPACMR and had been functioning since 1976. This Task Force met annually and four reports werp produced. In as much as the present Sub-Committee will meet for the first time in April 1981, immediately preceding the sixth session of the WPACMR, this report will describe the activities of the regional health services research (HSR) programme for the previous year (April 1980-April 1981). The results of the first meeting of the Sub-Committee will be reported to WPACMR at the time of its sixth session.

2.

aSR ACTIVITIES IR THE WESTERN PACIFIC REGIOR

During the period under review, progress has been varied. There have been a considerable number of developments at national level in the Region, but one cannot escape the conclusion that the amount of productive and usable research remains very limited. This is clearly seen in the small number of research proposals submitted to WHO despite considerable promotive efforts. 2.1 Regional strategy for health for all by the year 2000

a.

This goal has considerable implications for the aSR prosr..... As far thit lesion it concerned, a docUllent entitled "Regional policies SlId .trate.ies for health for all by the year 2000" was submitted to the Regional Committee at its thirty_first session in Manila in September 1980. This document clearly shows that the aSR programme should be an important part of the strategy. Member States, in their country statements for the strategy, identified the need to develop research on appropriate technology and health care delivery systems.

Among the activities identified under the broad objective to provide access to appropriate health care for all were the following: development of community participation/partnership for health; development of health care delivery systems; development of financing schemes, including efficient use of resources; development of appropriate technology for health; and development of a management and support system. The pertinence of aSI to theae activities needa no emphasis.

- 42 -

Annex 4 It is further suggested in the document that 'health services research will be promoted as an integral function of a national health development centre/network'. As conceived by WHO, the functions of such national health development networks will include: strengthening of planning and management and the promotion of decentralization;

training in planning and management; research and development (including HSR)j development of national health information systems. The implication of this for the health services research programme are as follows: national capability for health services research has to be developed, including awareness among planners and senior level staff that health services research is an important tool; and the creation of a framework in countries within which HSR can be used effectively. This will be part of the national health development/centre network mentioned above. 2.2 Regional priorities for health services research

As previously identified by the Task Force on Health Services Research (now the present WPACHR Sub-Committee on Health Services Research) and as indicated in the regional strategy document mentioned above, the priorities for the HSR programme in terms of area for research are:primary health care; health economics and financing of health care; use of technology. A summary of on-going research in these areas supported by the WBO/HSR programme is attached as Annex 4-A. 2.2.1 Primary health care

As it is well known, following the Alma Ata declaration in 1978, countries in this Region have strongly endorsed primary health care (PRe) as a key strategy for, health for all by the year 2000. But, how primary health care is to be implemented is not so clear. If the health services are to move into the community and take the initiative in foatering community involvement in health, then there are operational implications that will need study. WHO i. collaborating in luch reaearch in Lao People'. Democratic Republic, Papua New Guinea, the Philippines, and the Solomon Ialand ••

- 43 -

Annex 4 The type of research needed for primary health care implementation requires a broad range of disciplines, not all of which are available in WHO: the nature of community organization and dynamics in relation to health is more a subject for skills of th,> behavioural scientist than of the health scientist. However, considerable experience and information is being built up in the region by WHO on how to introduce the PRC approach to countries. In the Philippines, the Institute of Health Sciences in Tacloban has been developing primary health care. The results of this study have been most interesting, in that it has been shown that the peripheral health services can move into the community, act as agents of change, and involve the community in health development. From this experiment in the Philippines, it has been pos8ible to develop a model for national implementation of primary health care. By using the Tacloban approach, health workers are trained and supported in such a way thst they csn move into their own community. Primary health care thus becomes a multi-centric activity, each community developing ita own health activities. The implications for this in terms of health services infrastructure are extremely important. More resources have to be allocated to peripheral health services, health manpower has to be reoriented to primary health care and curricula have to be changed also. Thus, the implications of primary health care for the health services are beginning to be understood. 2.2.2 Health economic. and financing of health care

The financing of health services is of psrticular importance at tbi. time, both to developing snd industrialized countries. Member Ststes have expressed on several occasions their interest in collaborsting with WHO in thie area. It is known that Australia and New Zealand have carried out considerable studies in this area, a8 has the Republic of Korea. These countries have expressed interest in collaborative studies with WHO. In addition, Malaysia, Papua New Guinea, the Philippines and Singapore are all intere8ted in financing mechanisms for health care. A topic of particular importance that has yet to receive study ia the economic implications-of implementing primary health care, both for the health services and other sectors, and efforts are continuing to promote studies on this topic. Specific activities in this area during the reporting period which can be mentioned are:<a) A review of the organi.ation and financing of health care in the Republic of Korea conducted by a WHO Con.ultant.

- 44 Annex 4 (b) Further discussions were held by Dr E.P. Mach (SHS/HQ) in Japan and the Philippines on the subject of national health expenditure studies. Commencement of a cost analysis of community health services in Papua New Guinea. This will form the second part of a cost analysis exercise. The first part of the exercise analysed hospital costs and was completed in 1978.

(c)

2.2.3

Use of technology

This area covers both the relevance and appropriateness of high cost technology, as well as the development of appropriate technology for primary health care. The HSR programme is attempting to coordinate information on the research activities of other technical programmes as well as in directly supporting research in these programmes. Other technical programmes most active in this area are maternal and child health, expanded programme on immunization, control of diarrhoeal diseases and environmental health. The HSR programme is supporting studies on hospital management and utilization in the Philippines and the Republic of Korea. 2.3

Manpower development of health services research

The lack of an adequate number of research workers in the Region does not need to be reemphasized. In a paper presented st the Manila meeting of the global ACMR Sub-Committee on Health Services Research in April 1980, it was pointed out that in the Western Pacific Region there was a particular need for more research workers in the management sciences and in those behavioural sciences related to the community and primary health care. The paper also suggested that the regionsl strategy for manpower development in HSR .hould be:to develop a network of collaborating institutions that could support training activities; and to promote learning by doing - i.e. develop manpower by involving HSR workers in carrying out sctual studies. Up to the present time, WHO's role in manpower development has consisted in the granting of fellowships for study abroad, and the development of national capability by participating in collaborative studies. ' One activity worth reporting in some detail was the First National Workshop on Health Service Research held by the Korea Health Development Institute, Seoul, Republic of Korea in October 1980. This work.hop wa. supported technically and financially by WHO, and is' the first to ba held in the Region following the Reaional Working Group on Health Services Meeting in 1978.

- 45 Annex 4 The workshop had the purpose of developing awareness of and capability for health services research among participants who are senior and middle level public health workers. It is hoped that this first experience will result in the participants using health services research in their own activities. The Korea Health Development Institute will act as the technical support for such follow-up activities. It is hoped that a second similar workshop will be held in the future. This first experience of a national workshop was interesting in as much as it showed the usefulness of such a gathering in stimulating research and developing manpower. The important factor here would seem to be the need to have some national institute or group capable of coordinating and supporting subsequent activities. 2.4 Information on health services research

One of the main roles of the regional HSR programme is to disseminate information. A register of HSR research projects was developed in 1977. The 4th meeting of the Task Force on Health Services Research in July 1979 recommended that national HSR registers should be established but it has to be admitted that progress in this haa been slow. In the meantime, the regional HSR register has been reviewed and it is clear that a more active approach is needed if such s register is to be useful. WHO has nOW facilitated the processing of information for the register by improved storage and retrieval. WHO will also accept responsibility for obtaining and distributing information on ongoing research. As a result of this, it is hoped that dissemination of accurate and useful information on research in the Region will be svailable by mid-1981. 2.5 Coordination with other programmes

There are several ways in which some coordination of service research activities between special programmes can be beneficial. The HSR programme can or should provide expertise on research methodology. It is also, as has already been stated, responsible for exchange and dissemination of information. It should thus be possible for the HSR programme to provide information on ongoing research or on any particular aspect of health care delivery. At present, the regionsl HSR programme coordinates most closely with family health (MCH, FP), expanded programme on immunization, control of diarrhoeal diseases, health information ancJ., of course, priaary health care. There is no doubt that other WHO programmes are becoming more and more involved in HSR. In the period under review, two meetings were held in Manila that are of interest. The first was entitled 'Action oriented research development and training programmes on nutrition', held in Manila in November 1980; and the aecond wa. the 'Working Group on Re.earch in Health Education in Fa.ily Health', held in Manila in December 1980.

- 46 -

Annex 4

An important area for cross programme coordination is health services research supported by WHO headquarters programmes. Examples are human reproduction, research into tropical diseases, but there are many other programmes that support HSR studies directly. These are now being included in the WPRO HSR register. An important and as yet untapped source of support for the regional HSR programme is the HQ programmes. Headquarters programmes are perfectly willing to consider for funding and research proposal submitted. The problem is that these proposals are not forthcoming (see paragraph 2.6 below>. 2.6 Support for studies

As indicated previously, the number of proposals reviewed for direct funding by the regional programme has been disappointingly small. It can be seen in Annex 1 that most funding has been for ongoing studies. The number of new proposals directly promoted by the WHO programme has increased slightly, and this is encouraging.

However, despite the programmes, earlier promotional efforts. and the identificstion of HSR 'focal points' in many of the countries in the Region, progress is slow.

3.

FUTURE PLANS

A proposed programme for 1981 to 1983 will be discussed by the Sub-Committee at its meeting in April 1981. This will bring the plan to the end of the sixth General Programme of Work of WHO. The new Progra.ae of Work, covering the period 1984-1989. will thus require a new plan. The proposed programme for HSR (1981-1983) reviews the probl.... • cae of which have been mentioned in this report. An attempt is then . .de to relate the problems, and propose solutions within the framework of the HSR programme components. Finally, a specific programme of activities is proposed for each programme component. It will be noted that, for these activities to be implemented. ths necessary funds will have to be forthcoming. The activitiea 88 far as possible are covered by existing allocations except for direct support for studies where additional sources will be sought.

- 47 Annex 4 The programme components covered in the plan are: 1. 2. 3. 4. 5. 6. HSR programme development at national and regional level HSR information system Manpower development Development and application of methodology Support for research Coordination with other programmes.

It will be noted that there is a new component not included until now: development and application of methodology. After review and revision, if necessary, by the Sub-Committee, the proposed plan will be submitted to the WPRO Programme Committee for review prior to final approval by the Regional Director.

4.

GLOBAL PROGRAMME ACTIVITIES

4.1

Global ACMR Sub-Committee on Health Services Research: Manila, April 1980

Pifth sesaion

The global ACMR Sub-Committee on Health Services Research was formed during the twentieth session of the global ACMR in June 1978. The Sub-Committee is composed of the Chairman on the global ACMR and five members. The main thrust of the activities of the Sub-Committee has been to support WHO regional HSR programmes. The emphasis has been on the need to develop national capability through the creation of appropriate structures and the promotion of training. The Sub-Committee had agreed that the fifth seas ion would COncern itself with strengthening of national capabilities for health services research with special emphasis on orientation and training. In order to familiarize themselves with some activitie. in the Region, the members made a series of country visits before the meeting. The countries visited were the People's Republic of China, the Philippines, and the Republic of Korea. During the meeting of the Sub-Committee, a joint session was held with the WPACMR and an interesting exchange of views resulted. The report of the Bub-COGmittee meeting is available. The following points emerged from the report:Although the original emphasis of the meeting was to have been on orientation and training as a strategy to develop national HBR capability, a number of other topics were considered.

- 48 -

Annex 4 It was agreed that efforts should continue to stimulate national awareness as many countries stilt did not realize how health services research could be used in health development. National networks for health Aervices re8~~rch

would develop as national awareness grew and this network

would be coordinated by the national focal point or coordinating mechanism. With regard to training, it was felt that emphasis should be on training of trainees and learning by doing. Fellowships provided by WHO were an important contribution to long term training. It was recommended that the present Sub-Committee become a global scientific steering committee on health services research. 4.2 Global ACKR meeting: Twenty second session, Geneva October 1980

At this meeting, the Sub-Committee on Health Services Research presented the report of the Manila meeting, and the recommendations of this report were strongly endorsed by the global ACKR. At the same time, the recommendation concerning the future of the Sub-Committee on Health Services Research was further amplified. It was agreed that the Sub-Committee should be transformed into a scientific steering committee on health services research in WHO. This steering committee should, among other functions, serve to:establish a plan for health services research, including an evaluation system to alsess the impact of health services research on policy and services; select priorities for use of available funds; keep contact with regional committees in the promotion of health services research at country level; provide technical advice a. an elsential component of the planning for national health development networks; and assist in fund raising. 4.3 Global ACKR Sub-Committee on Health Services Research: Addis Ababa, November 1980 Sixth se.sion, •

The purpose of this meeting was to review health services research activities in the MCR programme of WHO; to identify ways in which health services research could support the strategy for health for all by the year 2000; and to review the activities of the Sub-Committee. Research requirements in MCH service delivery were explored and it became clear that much more research was needed. on the new approaches for maternal and child health required by primary health care. The risk approach was identified as an important way of focussing on MCR problema.

- 49/50 Annex 4 In considering HSR support for Health for All by the Year 2000 strategy. the meeting identified four major taaks:mobilization of political commitment as shown by the pattern of resource allocation; reorientation of heal th systems through better planning and management;

use of appropriate technology; and building on progress made i.e. learning by doing. Several presentations indicated how health services research could help carry out these tasks. During the meeting. several major points emerged. There was a need to stimulate greater awareness of and demand for health services research in countries and WHO should vigorously pursue this promotional role. WHO should also allocate .ore resources and give a high priority to developing national capability by institution strenthening and direct financial support for studies and coordination of information exchange. The meeting of the ACMR Sub-Committee was its last, snd as stated at the Manila meeting. the Sub-Committee will become the Scientific Steering Committee on Health Services Research (SSC).

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•

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Annex 4-A

WHO SUPPORTED HEALTH SERVICES RESEARCH PROJECTS (APRIL 1980 - APRIL 1981) ~:

HSR activities supported by WHO from other programmes include: (a) Family health: risk approach studies in Malaysia and the Republic of Korea; and cost analysis studies of family planning in the Philippines. Primary health care: research and development studies are going on in Lao People's Democratic Republic, Papua New Guinea, the Philippines, and the Solomon Islands. Health information: development of lay reporting techniques for health information is being conducted in Fiji, Papua New Guinea, Philippines, Solomon Islands and Tonga. Control of diarrhoeal diseases: an action research coaponent of this programme is being developed with particular reference to the use of oral rehydration sslts.

(b)

(c)

(d)

Study 1.

Present status Second year in progr•• s. Report of first yeara activities available.

Country Agency Title

Japan The life planning centre (Prof Hinohara) Research on the effect on health by the change of Ii ving hab its The baseline survey has been completed and various factors in life style related to diseaae patterns. The next phaae of atudy aims to further clarify the factors involved and measure the effects of reducing risk factors tn the study of population Two years US$25 000 (WHO contribution) 1981

Summary

Duration Cost

• - 52 -

Annex 4-A

Study 2. Country Agency Title Summary Republic of Korea Korea Health Development Institute Cost analysis of hospital care in Seoul Several hospitals will be selected and cost analysis carried out. The differences in cost and the reasons for this between insured and non-insured patients will be analysed and an optimum price structure defined not known not known

Present status Protocol being prepared for submission

Duration Cost

•

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Annex 4-A

Study 3. Country Agency Title Republic of Korea Seoul National University Strengthening of primary health care through effective supervision in rural Korea The study will attempt to analyse the relationship between supervision by health personnel and performance in provision of PRC in a rural setting not known not known

Present status Protocol being prepared for submission

S IJIIIIII8 ry

Duration Cost

, - 54 -

Anllex 4-A

Study 4. Country Agency Title Summary Papua New Guinea Department of Health Patient cost analysis at health facilities The study will analyse for patient costs at government health facilities (excluding hospitals) 198]

Present status in preparation

Duration

Cost

Approximately $5000 (WHO contribution)

•

- ss Annex 4-A

Study 5. Papua New Guinea Agency Title Development of Health Operational study on the coverage and utilization of Aid Post Orderly The study will use an operation research approach to study the role and functions of the Aid Post in relation to the community and the health services

Present ststus Draft protocol prepared

Summary

Duration Cost

9 months (1981) US$20 000 (estimated WHO contribution)

•

•

• - 56 -

Annex 4-A

Study 6. Country Agency Title Philippines Ministry of Health Operations research study on the emergency hospitals in the Philippines The study will aim to strengthen the efficiency and effectiveness of the emergency hospital delivery system one year

Present status Protocol being prepared

Summary

•

Duration

Cost

Approximately US$lO 000 (WHO contribution)

,

- 57 •

Annex 4-A

Study 7. Country Agency Title Ph i 1i ppi nes Ministry of Health Evaluation of barangay health worker project in Tanay, Rizal The study assessed the results of a 4 years community heslth worker project using operation research methodology 9 months US$7000

Present status Study completed .id 1980 Report available mid 1981

Suannary

•

Duration Cost

•

• - 58 -

Annex 4-A

Study 8. Country Agency Tit Ie Philippines International Institute of Rural Reconstruction Establishment of a mortality reporting system at the village (Barangay) level A mortality reporting system for use by lay workers has been developed and implemented. A system for verbal autopsies was devised. two years US$8000 (1981 WHO contribution)

Present statuI Several years in progress. Report for first year available

Summary

Duration Cost

•

, - 59 •

Annex 4-A

Study 9. Country Agency Title Philippines Institute of Community and Fami ly Health Mobilizing and restructuring health manpower resources in the Philippines barangays and puroks In its first year, the study established a primary health care system in two barangays using community health workers of three types: mothers, teachers and students. The second year of the study will be mainly to evaluate the system development two years US$3600 (WHO contribution 1981)

Present status Report on first first year available. To be completed in 1981.

Summary

•

Duration Cost

• - 60 -

Annex 4-A

Study 10. Country Agency Tit Ie Phi Jj ppines Department of Surgery Philippine General Hospital Evaluation of referral and follow-up system of a government tertiary medical centre

Present status Protocol being prepared for submission

Summary

The study will analyse and follow-up a series of patients treated by the department of surgery. In doing this, it is hoped to design an effective follow-up system that will provide linkage between various components of the health system particularly the primary health care member.

Duration Cost

not known not known

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- 61 ANNEX 5 LIST OF SUB-COMMITTEE MEMBERS AND OTHER PARTICIPANTS

Mr Peter Pflaum Director, Policy and Planning Division Department of Health Canberra P.O. Box 100 Woden, A.C.T. 2606 Australia Professor Gu Xing-yuan Deputy Chief Health Statistics Department Shanghai First Medical College Shanghai China Dr Masami Hashimoto

•

Director and Professor Department of Public Health Institute of Public Health £I-I, Shirokanedai 4, Minato-ku Tokyo 108 Japan Datuk (Dr) Abdul Khalid bin Sahan Director of Planning and Development Ministry of Health Jalan Duta Kuala Lumpur Malaysia Dr George Salmond Director Management Services and Research Unit Department of Health Bowen House Cnr Lambton Quay & Bowen St. Wellington New 'Zealand Dr J. Onno First Assistant Secretary (Health Care) Department of Health P.O. Box 2084 Konedobu Papua New Guinea

•

,

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,

Annex 5

Dr Wilfredo Asoy Chief, Planning and Programming Division Ministry of Health San Lazaro Compound, Sta. Cruz Manila Philippines Dr Ryu Young Hat President Korea Health Development Institute C.P.O. Box 4576 Seoul Republic of Korea Secretariat

Dr A. Rossi-Espagnet Chief Medical Officer Strengthening of Health Services Division WHO Headquarters Geneva Dr R.D. Mercado Director Health Services Development and Planning Western Pacific Regional Office Manila Dr R.H. Herniman (Operational Officer) Regional Adviser on Health Services Development Western Pacific Regional Office Manila Dr D. Stern Regional Adviser on Health Services Development Western Pacific Regional Office Manila Dr R.A. Noordin Medical Officer, Health for All Western Pacific Regional Office Manila Mr M. Subramanian Regional Adviser in Health Information Western Pacific Regional Office Manila Dr L. Wasserman Technical Officer, Health Services Research Western Pacific Regional Office Manila

• !