Report to the Regional Director on its eighteenth Session: WHO South-East Asia Advisory Committee of Health Research , SEARO, New Delhi, 20-24 April 1992

SEA/ACHR/lLI 1. IRTRODUCTIObJ The eighteenth session of the South-East Asia AdvisoryCommittee on Health Research (SEA/ACHR) was held at the Regional Office, New Delhi, from 20 to 24 April 1992. For agenda, list of participants, list of working and information documents, text ofinaugural speech by the Regional Director, see annexes 1, 2, 3, and 4 respectively. 2. INAUGURAL SBSSIO# 2.1 Address by the Regional Dire&or Dr U Ko Ko, Regional Director, extended a warm welcome to the participants of the eighteenth session of the NH0 South-EastAsia Advisory Committee on Health Research (SEA/ACHR). He stated that it was pertinent to reiterate the objectives of the regional research programme which are to strengthen thenational research capabilities and to promote and coordinate research activities related to the regional priority healthproblems including those on socio-behavioural and economic aspects of health. In this effort, the NH0 SKA/ACHR serves as themain advisory body to the Regional Director on matters of policy. Dr U Ko Ko said that the achievements made in the field of research since 1976, when the W-IO South-East Asia AdvisoryCommittee on Medical Research (SEA/ACMR) was established, could be looked at with some justifiable pride. The initiatives taken by the Regional Office together with the support received fromWHO Headquarters have had a major impact on fostering health research, especially in those countries that backed a longtradition of medical research. The need to undertake health research in order to support national health programmes has been fully recognized by the Member Countries in the Region. Therealignment of the regional research programme from a disease- oriented approach to that of an effort directed towards theattainment of the goal of Health for All by the Year 2000 has resulted in health systems research receiving greater emphasisand priority in the countries. The other areas of research which had been focused upon were communicable diseases, including thosedealt with by the Special Programme on Tropical Diseases and the Global Programmes on Diarrhoeal Diseases and Acute RespiratoryInfections. The Regional Office has also been closely associated with efforts to develop a safe, live attenuated virus vaccineagainst dengue haemorrhagic fever, an attempt now close to fruition. He referred to the call for a new paradigm for health bythe WHO Director-General, Dr Hiroshi Nakajima following the SEA/ACHR/18Page 2 profound changes that have taken place in the political, economicand social structures in the world, which changes have had implications on the WHO strategy of achieving health for all. Hementioned some examples of the issues raised by the Director- General which could be addressed through research, especiallyhealth systems research. Further, the developing countries arebeginning to face the serious situation of a double burden of communicable diseases and 'diseases of affluence'. This is being aggravated by the spread of the AIDS pandemic and the resurgence of old problems such as malaria, tuberculosis and cholera. In view of this complex picture pertaining to the healthsituation in the Member Countries, the Regional Director statedthat the members of the SEA/ACHR would need to consider how the research strategy that was developed in the 1980s to meet the challenges of achieving the goal of Health for All should bemodified and adjusted so that it could meet the challenges now existing in the health sector as well the new problems that could emerge in the future. Further, health systems research alonecould not solve some of the emerging problems, and it was for theSEA/ACHR to consider how the regional research strategy should provide for a judicious mixture of health systems research, biomedical research and clinical research. He concluded by quoting Dr Nakajima, the WHO Director-General: IlIt is clearly no longer possible for us to continue doing what we have always done. Tomorrow cannot be just more of yesterday. We need flexibility and pragmatism as much asinnovation, and the stress must be on action. To this end a framework for new public health action must be defined that is adapted to current and changing realities (economic, social and political) at the global, regional and country levels andreflects demographic and epidemiological profiles - in other words a new paradigm for health. I) The Regional Director thoughtthat it was permissible to add 'research' after the word 'health' in this passage because the ideas expressed for health actioncould be expeditiously realised by health research (for full text of the address, see annex 4). 2.2 Address by the Chairperson, SBA/ACHR Dr Sneh Bhargava, Chairperson, SEA/ACHRwarmlywelcomedthe members of the Committee, the special invitees and thesecretariat to the meeting. She said that the selection of the Regional Office as the venue of the 18th session of the SFA/ACHRwas logical for several reasons: this meeting constitutes one of the first steps in the regional research programme, thedevelopment and implementation of which is dependent on the Regional Office; further it offered an opportunity for the sevennew members to become familiar with the organizational set up of the Regional Office; and lastly it offered an opportunity to theRegional Office to host the meeting after an interval of several years. She expressed appreciation of the fact that the Regional SEA/ACHR/lSPage 3 Director had been intimately connected with all seventeensessions of SEA/ACHR held earlier and said that his presence provides continuity to the activities of the Committee and provided a sense of confidence as well to the members. Dr Bhargava observed that in the seven new members therewas a wealth of experience gained from their roles as eminent scientists and research managers in their own countries, and theywould be able to infuse new ideas to the Committee. Together with the older members, who have laid the foundation on which we must build, the new members would provide an opportunity for theSEA/ACHR to have continuity with change. In the fast changing world of today, the SF,A/ACHR has toface great challenges and it was their responsibility to ensure that they provide advice in the manner in which health relatedproblems of the Region could be solved through a judicious mixture of mission-oriented biomedical research, clinicalresearch and even more importantly, social and epidemiologicalresearch. In conclusion, she said that she was confident that withthe cooperation of the members as well as the special invitees from the global and regional research scene, it would be possiblefor their deliberations to make a significant contribution to research promotion and development in the Region. 2.3 Address by the Chairman, Global SEA/ACHR Professor M. Gabr, Chairman, Global Advisory Committee onHealth Research in his address stated that SEA/ACHR occupied a premier position among the WHO Regional Advisory Committees. Itwas the only Regional Advisory Committee to continue with annual sessions in contrast to the others which now met only once in twoyears. The SEA/ACHR had several accomplishments to its credit, including the support provided for development of the dengue vaccine. Professor Gabr stated that since he took over the chairmanship of the Global ACHR, there had been sweeping changesin the world. The Global ACHR now had not only the task of serving as the body for laying down policy for research but alsothe responsibility for harmonizing and coordinating the research activities undertaken by the Special Programmes and for promotingHealth Development Research. SEA/ACHR had been successful inincorporating the activities of the Special Programmes into the Regional Programmes. Funds for research were getting meagre and it was importantto ensure that sufficient funds are made. available to the developing countries for health research. Such research shouldalso include behavioural and economic research as well as SEA/ACHR/18 Page 4 research on subjects such as nutrition and maternal and child health which were of prime importance to developing countries. Professor Gabr said the Global ACHR had responded to the Technical Discussions on Health Research at the Forty-third session of the World Health Assembly. He stressed the need for the WHO research programme to respond to the evolving health problems as a result of socio- political and demographic changes and the AIDS pandemic. In the field of technology, it was necessary to ascertain how some of the health problems could be solved utilizing existing technology as well as to assess new and emerging technologies and to disseminate scientific information on new technologies. In conclusion, he stated that the methodologies for trend assessment and indicators for health development need improvement - they should be able to monitor both qualitative and quantitative changes in health parameters. 3. BUSINESS SESSION 3.1 Introductory Btatement by the Chairperson, BEA/ACIiR (Agenda item 1) Dr Sneh Bhargava, Chairperson, in her introductory statement once again welcomed the participants and the secretariat and expressed her appreciation for being appointed Chairperson of the Advisory Committee. Dr Bhargava stated that the Regional Advisory Committees on Health Research were established to promote regional research programmes in a decentralized manner in partnership with the Global ACHR and WHO Headquarters. She stressed that the ACHR played an advisory role to the Regional Director on matters pertaining to health research; it had no managerial or executive role. She recalled that the Committee which reviewed the role, functions and working of the SEA/ACHR had also reiterated its advisory role and the need for the ACHR to be forward-looking to enable it to respond effectively to the health conditions prevailing today. Dr Bhargava stated that this year's agenda addressed several important issues, including emerging problems affecting the South-East Asia Region. She hoped that with the cooperation of the members it would be possible for the SEA/ACHR to respond in a pro-active manner. 3.2 Address by the Regional Director (Agenda item 2) Dr U Ko Ko, Regional Director, once again welcomed the participants and special invitees and introduced the seven new SRA/ACHR/lSPage 5 members of the SEA/ACHR. He also expressed his appreciation ofthe services rendered by the members whose terms had concluded the previous year. He referred to Resolution WHA43.19 on The Roleof Health Research adopted by the forty-third World Health Assembly in 1990. He hoped that the SRA/ACHR would take up the challengeposed by WHA43.19 which called upon Member States to undertake essential health research appropriate to national needs (a) tofoster innovation and experimentation; and (b) to contribute to new knowledge, and especially its call to the research communityto increase its commitment to the development of essential health research appropriate to national needs. He hoped it would propose ways and means of helping the Member States and the researchcommunity to adequately respond to this call. He highlighted the main agenda items and mentioned that theChildrens' Vaccine Initiative Programme was included as one of the items to bring it to the notice of the SEA/ACHR whichhitherto had not been involved. He expressed the hope that the deliberations of theSEA/ACHR would be carried out in the usual earnest but friendly and informal manner. He nominated Dr Sumarmo P. Soedarmo as Vice-Chairman and Dr U.T. Vitarana as Rapporteur. 3.3 Introduction of Documents(Agenda item 3) Dr K. Jayasena, Regional Adviser in Medical Research,introduced the working and information documents that had been circulated. 3.4 Adoption of Agenda (Agenda item 4) The agenda was adopted with the proviso that members wouldalso discuss the health research strategy and priorities. 3.5 Progress Report on the Regional Research Promotion andDevelopment (RPD) Programme (Agenda item 5.1) 3.5.1 Introduction Introducing the progress report, Dr D.B. Bisht, Director,Programme Management stated that the Regional Research and Development (RPD) programme concentrated on priority healthproblems in the countries of the Region. The programme was SEA/ACHR/18 Page 6 developed by the Research Development Committee of the RegionalOffice, taking into consideration the recommendations of theSEA/ACHR. The report concentrated on the activities initiated by the Regional Office; however many additional research activitieswere being undertaken by the countries utilizing resources of the WHO country budget as well as of other funding agencies. Heoutlined the philosophy underlying the regional researchprogramme which was directed towards achieving health for all through the primary health care approach. 3.5.2 Summary of RPD Activities During the Preceding Year (Agenda item 5.1) Dr K. Jayasena, Regional Adviser in Medical Research, presented a report of the Research Promotion and Developmentactivities undertaken during the preceding year. He stated that in accordance with the recommendations made by various WHO bodies concerned with research policy, includingthe SEA/AHCR, even greater emphasis was now being laid on thepromotion and development of Health Systems Research, through a series of inter-related strategies: the InstitutionalStrengthening Scheme; provision of technical and consultant support; support for training and direct support for research. The scheme of providing Institutional Strengthening Grants whichwas implemented in Bangladesh, DPR Korea, Myanmar and Thailand earlier was extended to Nepal in 1991. The grant is beingutilized to establish a Health Systems Research Unit under the aegis of the Nepal Health Research Council. Technical support wasprovided by the RPD unit, WHO/SEAR0 through a site visit to the WHO Collaborating Centre for Primary Health Care at the District Level (at the Institute of Public Health Administration) inPyongyang, DPR Korea, when research project proposals were developed and training imparted on HSR methodologies. Assistancewas also provided to Sri Lanka at a National Consultative Meeting for the Assessment of Needs in Health Systems Research and to prepare the draft proposal for phase II of the HSR Programmefunded by the International Development Research Centre (IDRC), Canada. He also gave an example of collaboration between the RPDUnit and a technical unit at the regional level as well as between the Regional Office and Headquarters when a staff member of the RPD Unit together with the Medical Officer (Leprosy)participated in the WHO Interregional Workshop on Health Systems Research in Leprosy. Dr Jayasena also described a strategy of utilizing the services of a consultant for periods of 8 to 10 weeks in each ofthree countries in the Region - Bangladesh, Myanmar and Nepal in the first instance. The consultant had already completed thefirst assignment in Myanmar and the activities undertaken have resulted in the formation of a small but critical mass ofresearch workers and trainers, with a supportive administration, which is expected to result in a sustainable HSR programme in thecountry. He also reported that three countries in the Region - SEA/ACHR/18Page 7 India, Indonesia and Myanmar - have made specific provision forHealth Systems Research amounting to US$456 700 for the 1990-91 biennium in their WHO country budgets. He reported that as afollow-up to the Consultative Meeting to Develop Criteria for the Appraisal of HSR Project Proposals, a document entitled "The Appraisal of Health Systems Research" will be published as aWHO/SEAR0 Technical Report. WHO/SEAR0 has provided technical and financial support to the Dengue Vaccine Development project since its inception in1980. The Ninth Peer Review meeting on the Development of Dengue Vaccine Virus was held in August 1991 and the second meeting, on the Long Range Perspectives of Dengue Vaccine DevelopmentProgramme, was held in February 1992. The project, which was advocated and supported by SEA/ACHR, has made good progress. Ithas been estimated that the objective of the project which is to develop an immunogenic, safe, live, attenuated tetravalentvaccine against the four types of dengue viruses - Dengue 1, 2, 3 and 4 - will be achieved in about 18 months. It is envisagedthat thereafter, a new project entitled "Phase III field trials to test the efficacy of the live, attenuated, tetravalentvaccine" will be launched with funding by WHO and other donor agencies. A multicentre collaborative epidemiological study on HCV in five countries of the region to reveal the relationshipbetween HCV and HEV in chronic liver diseases has been commissioned. In the field of research on Human Resources for Health,activities pertaining to research in nursing and on research in medical education had been promoted and supported. As a follow-up to the recommendations made by the SEA/ACHRon the subject of research in nursing in 1989, national study groups have been set up initially in India, Indonesia andThailand. An Intercountry Consultation on Research on Nursing highlighted the need for more research in nursing practice. AnInterregional Workshop on Nursing Research in Primary Health Care was also conducted, the overall objective of which was toidentify and develop research questions related to the delivery of nursing and midwifery services and the most efficient andeffective use of nursing/midwifery resources towards theattainment of better health. With the objective of introducing problem-based learninginto the medical curriculum through a research-based approach, a WHO/SEAR0 Intercountry Workshop on Research in Problem-based Learning in Medical Schools was held in 1991. The rationale isthat this academic approach would appeal to medical educators and also help innovators to convince decision-makers and win peersupport to introduce and maintain problem-based learning in traditional medical schools. Inquiry Driven Strategies forCurriculum Innovation in Medical Schools have been used by a SEA/ACHR/18 Page 8 consortium of medical schools in India for the purpose ofReorientation of Medical Education (ROME) and to demonstrate the need for innovation and for initiating, facilitating andmonitoring implementation of innovation. These efforts have been actively supported by WHO/SEAR0 through financial and technicalassistance. The WHO/SEAR0 Library has prepared and circulated anInformation Document (SEA/ACHR/18/Inf.l1) entitled "Information Support through HELLIS and other Sources", describing the facilities available at different levels - national, regional andglobal - for information support for research. As of March 1992, there were 89 Collaborating Centres inthe region and a further five institutions that have beenrecommended for designation. There were 54 National Centres in nine of the member countries of the Region. It was proposed to use more stringent criteria for the designation of newCollaborating Centres and for the re-designation of existing Centres to ensure that Collaborating Centres will fulfil the roles expected of them as centres of excellence recognized andutilized by WHO. More use will be made of the existing Centres especially in commissioned research and training. The developmentof functional networks between Collaborating Centres with closely related areas of research will be promoted. The regional inputs into the Special Programme Activities -the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and the Special Programme for Research, Development and Research Training in Human Reproduction W-1 - were reported upon. A Small Grants Scheme for the SEARegion, particularly in the socioeconomic research component of the TDR target diseases is proposed to be set up. In the field of human reproduction, the volume of research activity has showna noticeable increase in the recent past. During the period under review, a Long Term Institutional Development (LID) Grant wasawarded to Sri Lanka; and Myanmar and Nepal were provided withfinancial and technical assistance to conduct Research Needs Assessment Workshops (in the field of reproductive health) andto prepare LID Grant applications. Reference was made to'the several annexes in the working paper (SEA/ACHR/18/5) for details of ongoing research projectssupported by ICP RPD funds, WHO Visiting Scientist Grants/Research Training Grants, Scientific Working Groupmeetings/meetings supported with research funds, WHO Collaborating Centres and National Centres in the countries ofthe South-East Asia Region and Consultants utilized with ICP RPD funds. Discussion Members of the SEA/ACHR appreciated the clear presentation of the activities undertaken during the period April 1991 - March SEA/ACHR/18 Page 9 1992. The report indicated the wide spectrum of activities promoted by WHO/SEARO. Other areas for inclusion need to beconsidered such as development of diagnostic tools and laboratory animals for research. The general question of how these and otherrecommendations of ACHR were taken up by WHO was explained. Several factors were involved, chief among which were theavailability of resources and the response by Member States. ACHR suggested that the presentation of RPD activities during the previous year could be more informative. More completeinformation should be provided on the number of research projects initiated and completed during the period under review, theextent to which research results were utilized, constraints and successes, and the sustainability of research projects supportedby WHO/SEARO. An indication of the linkages between research supported from the WHO country budget and the ICP budget would be desirable. The emphasis on the promotion and development of HealthSystems Research in the Region was commended. Special mention was made of the usefulness of assigning. Consultants for periods ofat least 6-8 weeks to countries so that a beneficial residual effect was left behind to ensure the sustainability of HSR in thecountry. The long-term commitment of one or two Consultants tothe institutions in a country was considered to be a very important mechanism for promoting HSR. The multi-disciplinary nature of most HSR necessitates the deploymentofmulti-disciplinary teams including, as appropriate,economists and para-medical health professionals. The Institutional Strengthening Grant scheme was apotentially effective mechanism for the promotion and development of HSR in the Region. "However, it is a two-way interactive systemand a positive response from the recipient institution was equally or even more important for its success than the effortsof WHO; continuity of effort and commitment is required on both sides. The development of a framework or paradigm for HSR and criteria for its appraisal and the publication of a WHO/SEAR0Technical Report on the subject would be useful to research workers and funding agencies; it should also be utilized as atool for publicising and evaluating HSR in the Region. The role of the WHO Collaborating Centres in researchactivities was considered at length. There was agreement that the Collaborating Centres should be more utilized in researchactivities in the Region. Usually, institutions designated as WHO CollaboratingCentres already perform important roles in their national programmes and the designation of these institutions as WHOCollaborating Centres is a recognition of their expertise. Such SEA/ACHR/18Page 10 institutions may be called upon to participate in additionalactivities to support WHO collaborative programmes at the national, regional or global level in the areas of their competence. The utilization of a Collaborating Centre at thecountry level depends largely on the national authorities. Under- utilization of a Centre at the regional or global level could be due to various reasons - WHO's lack of financial resources toundertake the activities in which the Centre can participate, because the technical programme is already saturated, or becausethe Centre's activities are no longer relevant to WHO. Formal functional linkages have been organized to promotea common programme with well defined objectives and a plan of action. Informal linkages and contacts between Collaborating Centres with similar interests and expertise should also beestablished and expanded. The Directory of WHO Collaborating Centres, as well as other sources of information such as thosemaintained by the WHO Special Programmes, can be used by any scientist or institution to identify other centres of interest and to establish contact without WHO intervention. Networkingbetween Collaborating Centres engaged in related activities is an important means of strengthening their capabilities andincreasing their usefulness to WHO and should be done in a planned manner. It was pointed out that there were significant gaps in therange of subjects covered by the existing WHO Collaborating Centres and there were some fields of research which had only a few or no Collaborating Centres. The question of financial support by WHO to theCollaborating Centres was raised. It was explained that an institution was designated as a Collaborating Centre only when it had reached a certain stature and relevance to WHO throughnational support and financial support by WHO is not implied. However, expenses incurred in providing technical services to WHOcould be reimbursed and Collaborative research activities would be provided with research grants. The Chairman of Global ACHR informed the meeting that the Global ACHR is reviewing certain issues related to theCollaborating Centres, including the steep upward trend in their numbers. In view of the report that commercial production of theDengue Vaccine which WHO helped to develop is being explored, SEA/ACHR evinced interest in the target population and thepotential market in Asia, as well as the fair pricing system. These were explained by Professor Natth Bhamarapravati, thePrincipal Investigator and Special Invitee. In connection with the planned phase III field trials of the dengue vaccine, it was pointed out that research directedtowards the development of models on the delivery of dengue SEA/ACHR/18 Page 11 vaccine would be useful for determining the optimum cost- effective delivery system. Recommendations (1) The SEA/ACHR recommends that WHO/SEAR0 should continue topromote Health Systems Research in the countries of the Region with emphasis on institutional strengthening and on the utilization of research results by policy makers and healthmanagers at the various levels of the health care delivery system. (2) The SEA/ACHR recommends that WHO/SEAR0 fosters linkagesbetween Collaborating Centres with similar interests and expertise. (3) The SEA/ACHR recommends that WHO/SEAR0 should promote thedesignation of Collaborating Centres in important subject areas where such Centres are lacking, care being taken, however, that stringent criteria are used to ensure that these CollaboratingCentres fulfil the roles expected of them as centres of excellence. (4) The SBA/ACHR recommended that the regional researchprogramme should aim at a well balanced mixture of Health Systems Research, biomedical research and clinical research relevant tothe needs of the Region. (5) The SEA/ACHR recommends that the Regional Office shouldpromote and support more commissioned Health Systems Research projects focused on socio-behavioural and socioeconomic themes.These projects should be implemented with a very close liaison between the Regional Office, the national health authorities and research workers. (6) The SEA/ACHR recommends that the report on the summary ofRPD activities during the preceding year should include information on research projects completed during the period. 3.6 Review of RPD activities in relation to past SEA/ACER recommendations in specific areas: (a) Follow-up Action On ReSOlUtiOll WWM3.19(Agenda Item 5.2(a)) Dr Jayasena made a brief presentation on this subject. Manyof the follow-up actions on Resolution WHA43.19 were described in the report of the research promotion and developmentactivities undertaken during the preceding year. The subject of the Role of Health Research (resolutionWHA43.19) was discussed at length at the Seventh meeting of the Directors of Medical Research Councils or Analogous Bodies (MRCs)in Kathmandu, Nepal in November 1990. The meeting had endorsed T SEA/ACHR/18Page 12 . the call for action embodied in resolution WHA43.19 and the viewpoints expressed in the preamble. The meeting recommendedthat Health Systems Research is the type of research that is essential for every country and that provision should be made for small grants for HSR of short duration. As follow-up action, the Regional Office extended theInstitutional Strengthening Grant Scheme to Thailand. WHO/SEARO, jointly with other agencies, strengthened the ASEAN Institute ofHealth Development, Mahidol University, to enable it to provide technical back-up and small grants directly to district health managers to undertake HSR. This Institute will be used as a modelfor replication elsewhere. An institutional strengthening grant was also provided toNepal to establish an HSR unit. In order to establish HSR within a more institutionalized framework, WHO/SEAR0 promoted consultative meetings attended bysenior administrators and scientists to make assessments of the priority HSR needs in some Member Countries. Reference was alsomade to the Consultative Meeting to Develop Criteria for the Appraisal of HSR Project Proposals and the follow-up activity ofpublishing a WHO/SEAR0 technical report on "The Appraisal of Health Systems Research". Other follow-up activities pertaining to resolutionWHA43.19 included a national meeting in Indonesia where consensus was reached that HSR should be the main focus of researchactivities. Technical/consultant support was provided to DPRKorea, Myanmar and Sri Lanka to further promote and strengthen HSR activities. The SEA/ACHR at its seventeenth session suggested that theRegional Office should collaborate closely with RPD/HQto provide inputs into the work of the task forces and committees involvedin the implementation of the resolution. Discussion There had been far reaching changes in the socio-politico-economic structure in the world in the recent past, and iwo- facto there was a need for a reassessment of the context in which matters pertaining to health as well as health research wasconsidered. Further, another important development was theenunciation of the new paradigm for health by the Director- General of WHO. As evidence of the new situation that has arisen, were cited changes in the expectations of the community vis-a-vis thetype and availability of health care; the increasing cost of health care with a decreasing outlay of the gross domestic product on the health sector by the state and hence the need forthe community to pay at least a part of the costs of health care SEA/ACHR/lBPage 13 services; and the need to determine the appropriate mix of healthrelated activities in the health and non-health sectors provided by the private and public sector, which applies to education inhealth as well. The strategy for health research should be consideredwithin the context of this new socioeconomic milieu that wasdeveloping. Research was urgently needed to determine how bestto improve the cost-benefits and cost-effectiveness of the health services, how existing traditional and modern health personnelof all categories could be utilized in the health-care delivery system, and to develop more appropriate methods of training forhealth personnel. It was also felt that in the present context of escalatingcosts of health care, research should be directed at ascertaining how good health could be promoted and maintained rather than atcoping with ill-health. This necessitates research on healthbehaviour as well as the development of more effective information, education and communication (IEC) systems for thepromotion of good health. In view of the socioeconomic changes, there was an urgentneed to examine national research capability, especially from the point of view of the availability of research manpower, bothmedical and non-medical. Further, students as well as health workers should be sensitized towards the need to undertake health research. Health systems research should be conducted at theprovincial level if local problems were to be solved. This needs better communication between the central and the provincial health authorities. Some of the emerging health problems would need the back-upof clinical research as well as biomedical research. It was important, therefore, to improve both clinical and laboratoryfacilities. The development of social marketing techniques would also be important in the present context. The SEA/ACHR was informed of the genesis of the World Health Assembly Resolution WHA43.19 and how the concept ofessential health research, essential national health research,and health systems research had been understood, interpreted and accommodated in the text of WHA43.19. WHO had been involved inpromoting health systems research in the countries for several decades. New terms such as essential health research, essentialnational health research and health development research had been introduced and irrespective of the term, what the least developedcountries in particular and the developing countries in general required was problem solving research related to health in orderto obtain the best possible health care services within the limited resources available to them. SEA/ACHR/18Page 14 WHO/SEAR0 has brought the resolution to the notice of theMember Countries and the research community of the Region who would be involved in its implementation at the country level. The"New Paradigm I1 would be further discussed at the World HealthAssembly together with the Ninth General Programme of Work and would be further elaborated by the Programme Committee of theExecutive Board in August 1992. The New Paradigm and the development of future strategy for the promotion and developmentof health systems research were inter-linked. In order for ACHR to consider these far-reaching issues it was suggested that a Consultative Meeting be convened by the Regional Director toexamine them in depth and report to the SEA/ACHR. Recommendation In order to meet the challenges of the emerging'and futurehealth scenario in developing countries and in the South-East Asia Region, and the role that health research will need to playin helping to meet these challenges, and in order that SEA/ACHRmay play its part in responding to the request addressed to the research community and WHO in WHA43.19, including the updating of the WHO health research strategy, and in order also toparticipate in the further development/refinement of the New Health Paradigm with respect to its health research aspects - it is recommended that the Regional Director convenes, inconsultation with the Chairperson of the SEA/ACHR, a consultative group or a study group or a sub-committee of the SEA/ACHR with appropriate terms of reference. 3.7. Review of RPD activities in relation to past SEA/AC!HRrecommendations in specific areas: (b) Technology Development, Assessment and Transfer (Agenda item 5.2(b)) Dr Aung Than Batu, Director, Research and Human Resources(RHR), prefaced his presentation by stating that the activities undertaken were a follow-up to the recommendations made at theeleventh and twelfth sessions of SEA/ACHR. RHR recapitulated the issues considered at the 11th and12th SEA/ACHR on Technology,Development, Assessment and Transfer (TEC). SEA/ACHR had considered that useful technologies werethose with the greatest potential for impact on health at present and in the foreseeable future, with the greatest likelihood ofsuccessful adaptation or adoption leading to the development of national capability and self-reliance, and which assistdeveloping countries to 'leap-frog' and catch up with moderndevelopments in the shortest possible time. SEA/ACHR recognized that transfer of health technologycould be considered only in relation to national health policy and emphasized the need to clearly define national healthpolicies as an essentialpre-requisite. Strategies for technology SEA/ACHR/18 Page 15 transfer would depend basically on the predominant health problems of individual countries, their social and economic set- up and their existing health and technology base. The recommendations that emerged from the 11th and 12th ACHR were in essence to promote the development of national health technology policies and the establishment of appropriate national mechanisms; to facilitate the process of health technology transfer by providing appropriate information to countries; to to promote the development of the infrastructure; and identify common areas of interest and priority region-wise, which should include technology related to Immuno-diagnosis, Immuno-prophylaxis and MCH. RHR then gave an account of the activities that have been undertaken by WHO at Global and Regional levels, most of which were in consonance with SEA/ACHR recommendations. 1989, RHR informed SEA/ACHR of two meetings on TEC, in 1987 and in which key scientists and administrators from the SEA region participated, which helped to sensitize participants to TEC issues and advocate rational approaches. In 1989 SEAR0 also organized a meeting of the "Heads of Collaborating Centres in SEA Region", in which their role in TEC was discussed. In 1990 the second evaluation of the strategy of HFA 2000 was carried out using the Common Framework of Evaluation (CFE/2) and this presented an opportunity for ascertaining the stage ofdevelopment of policies and plans on health technology in the countries of the Region. Based on the responses from countries an assessment was made that most countries are aware of the crucial role that technology plays in health care systems and are trying to acquire technology which is appropriate and affordable. Policy statements on the need to select and use technology appropriate to and consistent with national health development strategies and aims have been explicitly pronounced in only a few instances but are implied generally in the health policies of most countries. The transition of policy statements into mechanisms and practice is seldom clearly discernible. Such mechanisms for theassessment of health technology to be acquired are largely ad hoc, and organized on a disciplinary basis in most instancesrather than being broad-based and inter-disciplinary. The degree of influence exerted by general policy statements, where they exist, cannot be ascertained but it is probable that the cost factor may be the major consideration. specific New mechanisms related to areas of technology have been described in some countries. More recently in 1991, Technology Assessment, a meeting of Regional Advisers onDevelopment and Transfer, which reviewed the nature and extent of the'organization's activities in the area of TEC and delineated the priorities for action by WHO over - SEA/ACHR/18Page 16 the next few years, was held at WHO/HQ. The meeting recommendedthat the principal focus of the health technology (TEC) programme over the next few years should be at country and regional levels,with the object of establishing effective mechanisms forformulation and implementation of national policies in this area. actionThe priority areas of action included drawing up a plan offor interregional collaboration in selected areas ofhealth technology and establishing a global forum to exchange national and regional experiences and policy options; conductinga study on the feasibility of developing and operating a system to provide countries and other interested parties with access tothe information on health technology they require in a form appropriate to their needs; and initiating a continuing dialoguewith donor agencies and other international organizations on priorities and the most effective use of resources. SEARO's priorities with regard to TEC are: (1) (2) (3) (4) (5) to promote and help development of nationalpolicies and mechanisms which would enablecountries to make rational decisions onavailable and emerging technologies; to harmonize WHO efforts in TEC; to help countries in acquiring new and emergingtechnologies and discarding obsolete andwasteful, inappropriate technologies; to give equal attention to technologies fordisease prevention, health promotion andrehabilitation as well as on curativetechnologies; and to give priority to technologies applicable at Primary Health Care level and the immediatesupportive level of the health systems, where the possible approach would be to take accountof technologies for each of the essential elements of Primary Health Care. Recognizing that "information" is the essential pre-requisite to all rational decisions concerning TEC, WHO is examining the possibility of developing and operating a systemto provide countries and other interested parties with access to the information on health technology they require and in a form appropriate to their needs. RHR then gave an account of the sources of information atvarious levels (national and international), the content of such information and the recipients of the information. He then gavea brief description of the likely information needs of national professional leaders at central and national level and of SEA/ACHR/18Page 17 operators, scientists and technicians, and gave a shortdescription of the type of information system that WHO is planning to build up and make available to countries. WHO/SEAROs activities with regard to follow-up of SEA/ACHRrecommendations have been largely confined to promoting and advocating the formulation of nationalhealthtechnology policiesin the countries. WHO SEAR0 will continue its activities on three actionpoints: (a) formulation of national health technology policies, (b) setting up and strengthening of national mechanisms forhealth technology assessment and transfer, and (c) access by countries to available information required for rational decisionmaking in health technology acquisition, development andtransfer. In the next few years SEARO, depending upon the resources available, will endeavour to initiate more activities at country level and will need active collaboration andconcurrence by countries. As mentioned above WHO's role in technology assessment andtransfer is implicit in its mandate as the lead agency in the field of health and in the technical nature of its functions. WHO's activities in health technology, assessment, developmentand transfer will therefore be continuous and will permeate all its technical and special programmes. SEA/ACHR recommendations have been broad as well as farreaching, and notwithstanding what has been accomplished so far much remains to be done. It will be a continuous process. Discussion SEA/ACHR expressed appreciation of the follow-up actions taken by WHO/SEARO. ACHR was informed that during the last six years, with UNDPassistance, WHO has supported the production of immunodiagnostic reagents in Bangladesh, India, Myanmar and Sri Lanka. In India,the National Institute of Immunology has developed several immunodiagnostic reagents. The technology for some of these hasbeen transferred to commercial manufacturers and these kits are now available on the market. Several other kits are under development.for producingMyanmar is now ready for the transfer of technologyHBsAg detection kits, while other countries are in various stages of development. There was a need for a suitable inter-phase mechanismbetween the laboratory, which develops a new technology, andindustry, which would use the technology for commercial purposes. The National Research Development Corporation of India was citedas an example. SEA/ACHR/18 Page 18 Many appropriate technologies, especially in the fields ofdrugs including essential drugs, immunodiagnostics, biomedical reagents and equipment were already available in developingcountries. The transfer and assimilation of such technologies toother countries would be relatively easy. Intellectual property rights and royalties with respect totechnologies developed in academic institutions and transferred to industry were matters which would be of increasing concern indeveloping countries of the Region. It was pointed out that technology transfer is not apassive process. The receiving country should be prepared for theabsorption and utilization of the technology. The possibility of utilizing appropriate academic institutions for the evaluationand assimilation of transferred technology should be explored. Recommendations (1) The recommendations of the 11th and 12th sessions of ACHRshould continue to be intensively followed up, especially those pertaining to the establishment of national focal points and mechanisms. (2) WHO should actively pursueselective its efforts to develop asystem of information which provides access to information required by countries in order to make informeddecisions regarding the acquisition, development and transfer ofhealth technology. In this context, the system may also aim atfacilitating exchange of information between the providers and users of health technology. (3) In the context of recommendation No.1, WHO should also aimat helping countries to develop mechanisms and linkages which will make smooth the different stages of technology development and technology transfer. Development of mechanisms and linkageswhich would facilitate technology transfer between countries of the Region should be an area of particular interest andattention. 3.0 Matters Arising out of' Meetings of the Global ACER and ACHRs of other Regions(Agenda item 6) Prof. Gabr, Chairman, Global ACHR, in his presentation referred to Resolution WHA43.19 and the Progress Report by theDirector-General to the Eighty-ninth Session of the Executive Board on "The Role of Health Research" (Information DocumentSEA/ACHR/18/Inf.2). Following the technical discussions at the World Health Assembly in May 1990, Resolution WHA43.19 was the firstresolution that dealt with health research. SEA/ACHR/18Page 19 The resolution revolves around the importance of essentialhealth research; however, this does not mean that biomedicalresearch and clinical research are precluded. The resolution stressed the vital rolethathealth researchcould play in improving health and, therefore, the importance of promoting research which would be of use inparticular problems in developing countries. solving the It had to be realized that, though the WHA Resolutioncalled upon Member States to define national health research policies, many of the least developed countries had not evenidentified an appropriate health policy. The Resolution made a number of requests to the Director-General including the request to: - use appropriate mechanisms, in close collaboration with the global and regional Advisory Committeeson Health Research, to: (a) assess new andemerging areas of science .and technology; investigate Wevolving problems of criticalsignificance to health; and (c) identifyappropriate methodologies for trend assessment and forecasting, including epidemiology to improvehealth; - develop further a clearly enunciated healthresearch strategy for WHO in order to translate the research goals, priorities and programmes intocoherent and coordinated action in support of health for all. The Global ACHR supports Resolution WHA43.19 completely.It recognizes that for health problems to improve there has to be concomitant improvement in the social, behavioural andenvironmental sectors. The basic tenets of the report "HealthResearch Strategy for HFA/2000V@ (popularly referred to as McKewen's Report or Blue Book) submitted to the Seventy-seventh session of the Executive Board in January 1986 are still valid;however, it needs updating in the light of new information and experiences and a group of persons is now engaged in this task. The Global ACHR meets only once every two years andappointed a Standing Committee to better maintain continuity of its functions ad interim. Taking into consideration the importance of the subject,the Global ACHR set up: (a) A Task Force to assess new and emerging areasof science and technology. The brief of this Task Force was to identify existing technologythat could be used or adapted to solve problems SEA/ACHR/18Page 20 in health care; assess new and emerging science and technology with potential for future use;catalyze research that would meet identified technological needs; and disseminate information. (b) A Task Force to investigate evolving problemsof critical significance to health such as demographic transitions and their consequences,migration, urbanization, employment, nutrition, new and emerging diseases such as AIDS and moregenerally the interaction between development and health. (c) A Task Force on health development research,which suggested opening research avenues into such subjects as access to health services(through health services research, health manpower research, health economics research, behavioural research, etc.); and ethics andequity in health, including cost sharing. It was recognized that WHO had a major role to play in theadvocacy of research in the countries. WHO should support workshops, seminars, conferences, etc. which bring the academic community, personnel from the Ministry of Health and evenconcerned members of the community together to promote research. It was important to ensure that the quality of research was maintained at all levels of research activity; peer review shouldbe utilized to ensure quality. It was also very important to ensure that there wascompliance with strict ethical standards; there have been instances where, eventhoughthe countries concerned had acceptedcertain projects, research activities had been unethical. The Global ACHR had also established a Sub-committee on research capability strengthening. In the past, much money hadbeen spent by WHO on research capability strengthening. However, this was in the field of research and development for projectssupported by the Special 'Programmes. The Sub-committee on Research Capability Strengthening had decided to study a fewselected research institutes with a good track record to determine the critical determinants of success. Among theinstitutions studied were the University of Ibadan and the ASEAN Centre at Mahidol University. The amount of financial resources available for research was very limited in developing countries. Dr Gabr complimentedthe national authorities of the South-East Asia Region for making a statutory allocation for research from the WHO budget. He saidthat no other region had a separate budget identified exclusively for research. SRA/ACHR/18Page 21 Discussion SEA/ACHR expressed concern about the brain-drain from thecountries of the Region. This was observed especially in thefield of research in that there were fewer young graduates interested in a career of research. Generating resources for research was proving to be moreand more difficult. ACHR felt that it was important to face the challenge of diminishing resources for research. It was necessary to identify the areas in which WHO research activities should befocused; it would be a futile exercise if attempts were made to solve isolated problems by research. It was felt that one reasonfor the lack of resources for research was the weak linkages between academia and Ministries of Health. The question was posedas to how policy makers and administrators could be persuaded to implement the recommendations of the SEA/ACHR. Research onsubjects such as expenditure on health to maximize cost-effectiveness and on the methods by which equity could be ensured in spite of the socioeconomic changes occurring in the countrieswould help to convince policy makers of the value of research. On the question of ensuring the quality of research work,it was reiterated that quality had no relationship to the depth of research. Whether the research project was simple and carriedout locally or whether it was a big national project, ensuring the quality of the research was equally important. 3.9 Strengthening the Capability for EpidemiologicalResearch - A Regional Approach(Agenda item 7) This item was presented by Dr Jacob John who referred tothe two working papers prepared on the subject (SEA/ACHR/18/6). Within the scope of epidemiological research, two facetsof epidemiology need consideration: the first is the application of epidemiologic principles to define problems, designinterventions and assess outcomes; and the second is thedevelopment, refinement and study of epidemiological techniques. Epidemiology is the tool to identify and quantifydeficiencies, to design and test interventions, and to measure the efficiency of efforts, the effectiveness of endeavours andthe equity of the sharing of resources. Epidemiologicalresearch may be regarded as the applicationof epidemiological methods to define health problems, to prioritize them, to design, fieldtest and upscale interventions,and to evaluate outcomes, while simultaneously examining, modifying or innovating epidemiological methods themselves, inorder to fit them for the task under the given conditions of the South-East Asia region. SEA/ACHR/18Page 22 In order for epidemiological research to have regionalrelevance it should focus on the health policies and programmes which would narrow the widening gap in equity in health. Thedevelopment of effective interventions will depend upon the proper understanding of causal pathways peculiar to a country or region and, yet therefore, need-based research is essential and mayinclude aetiological identification. The paucity ofepidemiological data in many developing countries has to be remedied by improving skills in the use of epidemiological techniques for health management. For effective planning and implementation of public healthmeasures and delivering primary health care, reasonably reliable denominator data are essential. The crucial question for each country is to define the optimum unit for denominator data. Also,studies are essential to make predictions and to quantify changes and necessary inputs for preventing, controlling or treatingdisease burdens. Some of the existing models of epidemiological programmesin countries which are described in detail are: (a) National Epidemiology Board (Thailand) (b) International Clinical Epidemiology Network(c) Field Epidemiology Training Programme (d) Epidemiology and Health Management Network(India) (e) North Arcot and Tiruvannamalai Districts HealthInformation (India) Epidemiological methods applicable in developed countriesmay not always be suitable in developing countries and thus research into epidemiological techniques themselves is of critical importance. There is ample scope for research into theepidemiological methods themselves in order to make epidemiology relevant and applicable in SEAR countries. Innovative and newlyemerging epidemiological methods such as rapid epidemiological assessment and cluster sampling are described. A review of the epidemiological research projects funded by WHO/SEAR0 revealed some common methodological and statisticaldeficiencies, and approaches,that could be made to remedy these deficiencies were suggested. The term research is often associated with individual-initiated, curosity-drivenEssential national and a highly selective process.epidemiological research in developing countries must be health systems initiated, responsibility driven and comprehensive and also has to be service oriented andcomprehensive. WHO should simultaneously strengthen the service, trainingand research components of epidemiology in the SFAR countries. i I SEA/ACHR/ iaPage 23 As a first step, tools must be developed for assessment ofthe current status of each of these components in every country. The framework should be designed in order for every country todevelop a blueprint for the establishment of these threecomponents of epidemiology. Research should be encouraged within the framework of service and training so that it serves the current needs of the countries. WHO may design a plan for epidemiology manpower developmentand for utilization of epidemiology from policy to PHC levels in SEAR countries. WHO should draw up a list of epidemiologic items with whicheach country may address itself in the context of health care delivery and public health. The shape of the population pyramid which is now broad-based is bound to change. Discussion ACHR commended the authors for the preparation of theworking, document on llEpidemiological Research - RegionalApproachI'. The working papers had touched upon two aspects of epidemiological research - (i) the methods used in epidemiologicalresearch; and (ii) the content of epidemiologicalresearch. Regarding the methods used for epidemiological research inthe Region, it was noted that the review in the working paper was based only an thoseRegional Office submitted to and supported by the WHOand does not necessarily reflect allepidemiological research undertaken in the Region. Thedeficiencies detected could be due to the level of expertise and training of investigators submitting proposals to WHO, thestringencies or otherwise of the screening system in WHO, or the intent and purpose of supporting the projects (for training orfor outcome), and whether there was a deliberate conscious acceptance of the prevailing standard in order not to inhibitdeveloping researchers, or it may be due to the framework andcriteria used in evaluating the papers. One important consideration in evaluation of the qualityof the methods is the scientific rigour necessary to arrive at conclusions to help informed decision making in health management- for which some of the research projects may have been undertaken. The scientific rigour of the methods used should becommensurate with the purpose for which research findings are to be utilized. However, it should be noted that even in publications inwell established journals only about 20% of them are without some methodological/statistical flaws. SBA/ACHR/18Page 24 Some of the studies may have involved the use ofbehavioural science and social science methods which are more flexible. These findings and considerations, as well as the pointsmade in the working paper regarding the usefulness of new and simplified epidemiological methods developed elsewhere outsidethe Region, in the study of health problems in developing countries and the SEA Region (such as cluster sampling, lot quality assurance sampling and rapid epidemiological assessment)indicate the need for efforts to develop the capability to devise innovative and appropriate epidemiologicalmethods in our Region. Epidemiological research should not merely study thedistribution of health problems, but should move to thedeterminants of health problems. Epidemiological research will also be needed to analyse trends and predict the changes andnecessary interventions and inputs for preventing, controlling or treating disease burdens. Research should be encouraged within the framework of service and training. Epidemiological researchhas to be service-oriented and comprehensive. It is obvious that improvement in epidemiology training isa key requisite for improvement in the quality of research in the Region. Training, both in conventional epidemiology as well asin epidemiological research methods, should be undertaken. The type of training, place of training, and the people who are tobe trained, should be systematically reviewed in order to improve epidemiological research. It may not be sufficient merely toimprove the quality of epidemiologists but the training and quality of different types of health workers who participate inthe collection of primary data should be improved. SEA/ACHR took note of the different models of epidemiologytraining and epidemiology service existing in the Region. It was suggested that the establishment of an epidemiology research unitin the Ministry of Health or in the service departments close to the Ministry of Health would be one more way of developingexpertise in epidemiology and improving its usefulness in e countries. Recommendations (1) Recognizing that for improvement in the quality ofepidemiological research, training in epidemiology needs to be further improved, it is recommended that: (a) Basic epidemiological principles be inculcatedinto all categories of health workers, and that they be given the opportunity to receivetraining in simple epidemiological methods at appropriate stages of pre-service or continuingeducation. SRA/ACHR/18 Page 25 (b) The quality and level of training in epidemiology for public health specialists and epidemiologists should be of a higher standard commensurate with the increased need for epidemiological analysis at central and peripheral levels of health care - and that this calls for review of the selection of trainees, curriculum content and strengthening of the infrastructure of training institutions and facilities. (c) One or several of the national institutes of public health or national centres for training in epidemiology which exist in countries of the Region be developed into regional centres of excellence - to impart epidemiological training of the highest standard, and to generate innovative ideas and methods in epidemiology applicable to current and emerging health problems of the developing world and the South- East Asia Region. (2) It is recommended that epidemiological services in generalbe strengthened at all levels in the countries of the Region; that such strengthening should include the capability for epidemiological analysis and research at central level - one important way of achieving which would be to establish a national level epidemiological research unit. (3) It is recommended that the epidemiological methods used inresearch supported by WHO/SEAR0 should be scientifically rigorous and commensurate with the objectives of the research projects. (4) Recognizing that social science, and economic andbehavioural science methods are increasingly necessary and being utilized in health related studies and research, including Health Systems Research, conducted in countries of the Region - it is recommended that WHO should further promote and supportappropriate training of health workers in the above methods, as well as development of training materials and training methods. (5) Epidemiological research should be service-orientated andproblem-solving and should not be confined to problem-finding; it should be directed towards research which would facilitate application of existing knowledge and implementation of findings. 3.10 Research on Prevention of Cardiovascular Diseases (Agenda item 8) Dr K. Jayasena, Regional Adviser in Medical Research, madea presentation based on the contents of a working paper prepared by the Regional Office (SEA/ACHR/18/7) entitled "Research on Prevention of Cardiovascular Diseases". He stated that when life SEA/ACHR/18Page 26 expectancy exceeds 65 years cardiovascular disease constitutesan important cause of death. The countries of the South-East Asia Region have reached or are approaching this level of longevity. In South-East Asia, the two major cardiovascular diseasesare rheumatic fever, which is a disease of poverty, and coronary heart disease, which is a disease of affluence. Rheumatic heart disease constitutes a severe burden in manycountries of the South-East Asia region. Rheumatic heart diseases (RHD) are due to an immunological reaction to streptococcalinfections which are prevalent under low socioeconomicconditions. The two obvious approaches are primary prevention, through control of streptococcal infections, and secondary prevention, through improved methods of detection/diagnosis ofrheumatic fever and RHD and prevention of streptococcal infection in these patients. The prevalence of coronary heart disease (CHD; ischaemicheart disease) and hypertension in the Region is significant and rising. This is due to changing demographic patterns, and environmental and socioeconomic conditions. The type of extensiveresearch conducted on these cardiovascular diseases in developed countries is not considered feasible in the South-East AsiaRegion. A more relevant approach would be studies directed towards the identification of advantageous life-styles and foodhabits as well as of groups vulnerable to heart disease due to genetic causes or particular life-styles. A case could also be made for research studies which focuson cardiovascular diseases specific to the SEA region such as nutritional cardiomyophathies, effects of exposure to toxins (e.g. snake venoms) and the cardiovascular effects ofdegeneration. Research on the use of traditional medicine for the prevention and treatment of cardiovascular diseases is another area to be considered. Dr Jayasena then referred to research issues identified inthe working paper and also to the report of the International Symposium on Preventive Cardiology and Cardiovascular* Epidemiology held in New Delhi, where research priorities had been identified. Dr S. Padmavati, Special Invitee, made a .presentation onthe prevention of heart disease in the developing countries of SEA region with emphasis on the Indian experience. She statedthat data on prevalence are very difficult to accept. The usual sources available in developed countries are not readilyavailable or are unreliable. The available data are from population surveys in the case of adults and from school surveys in the case of children. The latter are the more reliable. Thegeneral impression in India is that the problem of RHD remains as before whilst there is an increase in deaths due to coronaryarterial disease and hypertension. SEA/ACHR/18Page 27 In India, many research programmes have addressed thequestions of prevalence, epidemiological features, naturalhistory and the control of RHD. The prevalence among school children in the 5-15 years age-group is between 6-ll/lOOO and there has been no significant decline between 1972 and 1990. The ~OdUS OPerandi for integration of the secondary prophylaxisprogramme through the school health services and integration into the normal health care system through the primary health careservices has been worked out. This model could be adapted byother countries in the Region. A research need in the field of RHD is the development ofan effective vaccine against streptococcal infection. With respect to ischaemic heart disease, smoking,hypertension and diabetes are important risk factors in India whereas serum cholesterol is not as important as in western countries. Research should be directed towards eliminating riskfactors through effective health education measures. The prevalence of hypertension has been estimated to bebetween 5 and 10 per cent in a recent study conducted by the Indian Council of Medical Research. Prevention at the presenttime is confined to high-risk groups. The use of non-pharmacological methods such as low salt and vegetarian diets, Yoga I meditation and exercise needs further study. The cardiomyopathies are an important group of diseases inmany parts of India and ongoing research studies are directed towards determining the aetiology. Dr H.S. Wasir, Professor and Head of Cardiology, All IndiaInstitute of Medical Sciences, Special Invitee, next made his presentation on the prevention of cardiovascular disease. Hefirst dealt with the aetiological factors associated with congenital heart disease: pharmacological agents, maternalinfections such as rubella and other maternal illnesses such as diabetes mellitus. He said that, contrary to common belief, someof the congenital heart diseases are preventable by, forinstance, immunization of young women against rubella, andgenetic counselling and health education regarding exposure to teratogens. With respect to RHD, Dr Wasir took the position that thehallmark of prevention of this disease should be primary prevention of acute rheumatic fever. Secondary prevention hasbeen evaluated on a large scale world-wide, but its limitations were well recognized. Future research should therefore be moreon primary prophylaxis against streptococcal sore throats, withthe ultimate aim being the development of a vaccine against streptococcal infection. Guidelines have been provided by WHO for the primaryprevention of essential hypertension. Future research for the SEA/ACHR/18Page 28 prevention of systemic hypertension should concentrate on the role of trace elements, the role of the mind, and hopefully onexperimental work on immunological aspects aimed at developing a vaccine against hypertension which is thecardiovascular disorder of modern society. commonest Dr Wasir said that the risk factors associated with CHDhave been extensively covered in the medical and even lay literature.factors Research should be focused on various protectivesuch as the role of physical exercise and behavioural factors including the role of the mind. He also referred to aortoarteritis, endomyocardial fibrosis and the cardiomyopathies- the aetiological factors involved in the pathogenesis of these disorders constituted another area for research. Discussion There was considerable and extended discussion on thescope, content and emphasis to be given in the recommendations that ensued. Some of the scientific questions that were discussedincluded: the consumption of coconut oil in relation to blood cholesterol levels and incidence,of ischaemic heart disease. The evaluation of interventions on health behaviour, life-styles and food habits was considered to be an important area for research. There may be regional differences in the influence ofvarious risk factors. There was a need therefore for HealthBehaviour Research on life-styles in different countries of the region. The same applied to dietary practices and there may besome foods that are thrombolytic while others may predispose to thromboembolic phenomena. There was a need for more research onthe efficacy of traditional medicines in cardiovascular disease and there was a distinct possibility of obtaining drugs fromnatural products. With respect to the role of streptococcal infections in thecausation of rheumatic fever which led to RHD, more research was j needed on the various types of streptococci - i.e., therheumatogenic type, the nephrogenic type, etc. Recommendations Realizing .the burden of cardiovascular diseases in the Region, SEA/ACHR recommended that priority should be given topromote research in the following important areas: - Rheumatic Fever/ Rheumatic Heart Disease (RF/RHD);- Hypertension; and - Coronary Heart Diseases (CHD) SHA/ACHR/lSPage 29 It is recommended that research with respect to the above cardiovascular diseases should cover the following topics: (1) (2) (a) (b) (3) (a) (b) (cl (d) (4) Socio-behavioural research to develop more effective methods promoting healthy life-styles and behaviours which are conducive to the prevention and control of CVDs, especially in high risk groups and youth. In RF/RHD Behavioural, economic and socio-behaviouralresearch for control through secondary and possibly primary prophylaxis using the existinghealth care infrastructure (like the school health services, primary health care and other health care infrastructure). Further research for the development of rapid methods of streptococcal identification for useat field level. In Hypertension/Coronary Artery Diseases (CAD) Population based studies to measure more precisely the prevalence of hypertension and coronary artery diseases and risk factors/protective factors in selected populations. Pilot studies to assess the effectiveness of behavioural modifications and of yoga in the prevention of coronary artery diseases, especially in high risk groups. Controlled clinical studies on: - use of non-pharmacological methods; and - traditional drugs for the prevention and treatment of hypertension and CAD. More Centres of MONICA studies should be established in the SPAR countries. It is recommended that a scientific working group be convened to identify and prioritize regional research areas in CVD with 'the possibility of initiating a commissioned programme. SEA/ACHR/18Page 30 3.11 Research on Maternal Mortality (Agenda item 9) Dr (Mrs) Raj Karim, Director-General, National Populationand Family Development Board, Kuala Lumpur, Malaysia, Special Invitee, presented her paper on Research on Maternal Mortality. She stated that it has been estimated by WHO that more than500 000 women die every year from causes related to pregnancy and childbirth and that 97 per cent of these deaths take place in the developing world. Worldwide attention on the causes, magnitudeand implications of maternal mortality was highlighted at the International Safe Motherhood Conference in Nairobi in 1987. This resulted in the Safe Motherhood Initiative Programme and the goalto reduce maternal mortality by 50 per cent by the year 2000. About half of maternal deaths occur in Asia with highdisparity between countries. Three countries - India, Pakistan and Bangladesh, account for 46 per cent of the world's maternaldeaths and 28 per cent of its births. Maternal mortality prevails at high rates in many countries of South-East Asia Region - over500 per 100 000 live births in India and Bangladesh; 700 in Bali, Indonesia and 1 600 in Bhutan. Sri Lanka has an exceptionally low rate of 80 (1987). The high mortality in the Region reflectsdemographic and socioeconomic factors as well as inadequacies in the health care system. Generally, these women begin childbearing young I continue until an advanced age, have many pregnanciespoorly spaced, have little access to health services, are malnourished due to poverty and socio-cultural traditions, andare uneducated. Direct medical causes are responsible for more than 80 percent of the deaths in most countries of South-East Asia where mortality is high. Obstetric haemorrhage is the leading cause; others include puerpual sepsis (infection) due to uncleandeliveries or septic abortions, hypertensive disorders ofpregnancy and abortion. Non-availability of basic maternity services and under utilization of the available services are major contributing factors to the nonmedical causes. Antenatalcare coverage varies from 8-98 per cent in Asia, with an average G of 45 per cent for SEA. A review of maternal mortality research studies of theRegion shows that in the 70's and 80's the major thrust of research was on purely epidemiological studies to obtain ameasure of maternal mortality, identify causes and circumstancesand to determine its correlates. hospital based, These studies were mainlystudies. and were followed later by community basedIt is interesting to note that the findings in relation to causes, contributory factors and correlates have many commonfeatures among countries in the Region. Among the major findings which have implications for future research and strategydevelopment are the fact that two-thirds of deaths are due to direct causes and one-third are from indirect causes; and that SEA/ACHR/18Page 31 66-70 per cent of deaths appear to be preventable. While the studies have been epidemiological, study designs have notincluded an intervention component and this has been identified by several studies themselves as an aspect which needs to bedeveloped in future studies on mortality. Studies on maternal mortality would be best developed along the lines of healthsystems research studies, with a research and developmentcomponent, and this has recently been encouragedthroughthe Safe Motherhood Initiative Operational Research Programme. A review of the types of research that has been conductedhas revealed some issues on which future research needs to be directed. These include: - the application of researchepidemiological findings of studies - study of how thisknowledge can be applied and translated into action by health care workers, families and womenthemselves; - the need for intervention studies especially on the reduction of direct causes of obstetricdeaths: to include studies on reduction of postpartum haemorrhage; on prevention of deaths from sepsis and infection; on appropriatemanagement of hypertensive disorders of pregnancy; on management of anaemia in pregnancy; and ondeaths from unsafe abortions; - the need for studies on the heaith services asmore than two-thirds of deaths investigated revealed the involvement of health service factors by which deaths could have been avoided; further studies to devise a system for producing improved maternity care and making it availableand accessible to all pregnant women. Within the ambit of this are included the issues of devisinga system for screening and management of pregnant women; application of the risk approach inmaternal health care; improvement of'transport and communication system, etc.; - a review of research that has been conducted onTraditional Birth Attendants (TBAs) to determine how best they can be utilized and theirtraditional roles adapted or changed in line with the development of health services and communityneeds with a view to reducing maternal deaths and maternal morbidity; - social and behavioural research on a woman's own perception and beliefs of her pregnancy and health SEA/ACHR/lZ) Page 32 status in order to facilitate the development ofcommunity education and innovation strategies. Discussion SEA/ACHR complimented Dr Karim for her excellentpresentation which covered the current status of maternal mortality, a review of the research already done and identification of issues for further research. The group agreed that in view of the fact that maternalmortality is a serious problem in the Region, research to reduce maternal mortality should be given its due priority. The issue of maternal mortality should be regarded as aneffort to save the lives of women who are in their prime years of reproductive life and are an important asset for ensuring the health and well-being of their families and children. The meeting suggested that a plan of action should bedeveloped to formulate research strategies and priorities for the Region and for their implementation and monitoring. The need for operational research in maternal mortality studies washighlighted so that interventions could be developed as part of the research strategies. Taking into consideration the fact that high maternalmortality rates prevail in many countries of the Region, and that there exists basic epidemiological information from variousstudies and that the immediate concern is to translate this knowledge into problem-solving, action-oriented and operationalresearch for the application of this information, the SKA/ACHR made the following recommendations. Recommendations SEA/ACHR recommended that: (1) WHO/SEAR0 undertake, as a matter of priority, thedevelopment of a plan of action for undertaking operational research on safe motherhood and maternal mortality and shouldassist countries in the 'development of national research programmes; (2) studies to fieldtest, monitor and evaluate the feasibilityand effectiveness of interventions which cover the major causes of maternal mortality, i.e. haemorrhage, sepsis, hypertensive diseases of pregnancy and severe anaemia in pregnancy, beundertaken. The approach for this purpose should preferably be the district team problem solving methodology using commonprotocols developed- for the Region and providers and the community; and involving service SEA/ACHR/18Page 33 (3) besides clinical research, socio-cultural, behavioural andhealth economic research related to maternal mortality should be undertaken as a package. 3.12 Children's Vaccine Initiative Programme(Agenda item 10) Dr S. Ramachandran, Secretary, Department of Biotechnology, Ministry of Science 61 Technology, New Delhi, Special Invitee,presented an account of the current status of the Children's Vaccine Initiative Programme. He said that the Children's Summit in New York in September1990 exhorted the establishment of a children's vaccine initiative (CVI) with the aim of producing and delivering idealchildren's vaccines which would provide lasting protection against a wide range of diseases of childhood, need fewer contacts, have more heat stability, are simple to administer andare affordable. The CVI was set up by WHO, UNICEF, UNDP, the World Bank and the Rockefeller Foundation. While the achievement of all the original aims wouldrequire a long period, the following five short-term specific goals have been set: (a) (b) (cl (d) (e) to monitor, assess and stimulate developmentswhich permit delivery of multiple heat-stable antigens in single or few dose formulations foruse soon after birth and, if possible, by the oral route. to apply all appropriate existing and newtechnologies to improve vaccines currently used by EPI. to evaluate existing non-EPI vaccines for theirsuitability for incorporation into EPI, e.g. Hepatitis B. to stimulate research on and initiate thedevelopment of new vaccines which will protect children against diseases which cause highlevels of morbidity and mortality. to promote mechanisms to introduce new and improved vaccines into routine immunizationprogrammes. To implement these objectives, product development groupsand task forces have been organized to tackle priority areas. Three product development groups have been set up to explore theissue of developing a single dose tetanus toxoid vaccine, thermostable OPV and improved measles vaccine for newborns. SBA/ACHR/18 Page 34 Advances in vaccinology and the technical presentations made at the first Consultative Group of CVI meeting in Geneva on 16-17 December 1991 were described. Regarding the possibility of oral immunization replacing parenteral immunization, the gastrointestinal tract has an immense mucosal surface available (more than 400 sq.m) in which lymphoid tissues can phagocytose micro-encapsulated antigens, killed or living, which could home in to target organs. Micro-encapsulation of antigens with microspheres of various sizes would ensure bio-degradation at timed intervals and pulsed release, administration to a thus reducing the vaccinesingle dose, replacing multiple administration. Vectored genetically recombinant vaccines may be another method of reducing the vaccination delivery contacts. With reference to the issue of global equity o-f access to vaccines, it was pointed out that the developing countries use 80 per cent of total vaccines, while vaccine production is less than 30 per cent of the global production. It is hoped that as the new improved vaccines become available, the licensing procedures in developing countries will become simpler so that the new vaccines should become available to the community very rapidly. Dr Natth Bhamarapravati, Special Invitee, focused his presentation on self-reliance in vaccine production in the developing countries. This can make vaccine development less expensive and reduce the period required for taking the vaccine from the laboratory to the field. It was hoped that technology transfer in vaccine production to developing countries would be carried out to achieve the objectives of self-reliance, which would have the salutary effects of development of expert scientist cadres and streamlining vaccine manufacturing facilities. It should also address itself to efficient quality control facilities and simpler regulatory controls. The question of patents, intellectual property rights, royalties and front-end technology transfer fees also needs to be settled. It was hoped that the SEA region may think of developing a Regional Vaccine Scientific Advisory Group on the lines of the one established in PAHO, to oversee the streamlining of vaccine development programmes in the region. Discussion SEA/ACHR expressed their appreciation to Dr S. Ramachandran and Dr Natth Bhamarapravati for their presentations. ACHR pointed out the desirability for vaccine development that would specifically meet the needs of the region - the examples cited were the development of a live attenuated Dengue vaccine, a controlled-release Japanese Encephalitis vaccine andan Epstein-Barr virus vaccine. The situation posed by a reduction in the number of commercial vaccine manufacturers was discussed. It was pointed SEA/ACHR/18Page 35 out that this was due to the high costs of research anddevelopment, the tight regulatory procedures, the low profit margin and the possibility of legal suits for liability. The need to develop regional licensing procedures that areacceptable to several countries and would obviate the need for a repetition of licensing procedures in each country wasstressed. ACHR expressed concern over the cost-escalation in thefield of immunization. It was pointed out that the cost of a vaccine was only 10 per cent and that the rest of the expenditureconcerned the delivery of the vaccine. There was an urgent needfor research aimed at improving the cost effectiveness of vaccine delivery systems. Recommendations SEA/ACHR recommended that: (1) research should be undertaken.to identify and improve thecost-effectiveness of vaccine delivery systems in countries, including the development of predictive economic models; (2) self-reliance in vaccine production should be a general aimfor countries of the Region and research towards the realization of the goal should be promoted; and (3) Member Countries should be encouraged by WHO/SEAR0 toundertake studies to determine the feasibility of incorporating non-EPI vaccines with the EPI Programme. 3.13 Guggestions for the Agenda of theNineteenth Session of SEA/ACHR (Agenda item 11) The secretariat pointed outthatthe criteria for selectionof priority areas for research in the Region were identified at the First Session of the SEA/ACHR in 1976. Though usually onlyspecific research topics were selected for technical discussion, the SEA/ACHR was also concerned with the broader issues of research promotion and development such as research capabilitystrengthening. The criteria as set out in the first session have to be modified in the light of the revision of research strategyfor HFA 2000 as described in the "SEAR0 Technical Publication(2) - Research Needs for Health for All by the Year 2000VV. In the selection of topics, in order to have a good llmixll,it was desirable to select areas where SEAR0 was already active. Further, regional needs rather than national needs should betaken into consideration in the selection of subjects for discussion by SEA/ACHR. The potential for implementation shouldbe an important criterion in the selection of topics. Another SEA/ACHR/18Page 36 factor which should receive attention was the training component- i.e., opportunities or suggestions scientists for training of youngthat would arise as a consequence of therecommendations following the discussion of a particular topic. Based on suggestions given by SEA/ACHR members to theSouth-East Asia Regional Office before as well as during the meeting, the following short list of topics to be discussed at the Nineteenth session of SEA/ACHR was drawn up: - Research into the improvement in health caredelivery systems - Regional Perspective - Development and application of Immuno-diagnosticmethods in the South-East Asia Region - Strengthening the capacity for multi-disciplinary operational research - Strategic plan for promoting and strengtheningHealth Economic Research: Regional approach - Socio-cultural/behavioural research on HIVinfections - Research and development of Drugs: RegionalPerspective - Research on the impact of industrialization andurbanization on health - Research on Hypertension - Research on post-disaster health care - Information Technology in support of researchmethods - Research into forest related malaria With respect to AIDS it was pointed out that it was emerging as a major health,problem in the SEA Region. The successachieved in disseminating information regarding the avoidance of high risk behaviour was limited. This was partly due to varyingtraditional cultural patterns, multiethnicity, low levels of literacy, poverty, etc. These complexities should be taken intoconsideration in deve.loping health education packages. Eachcountry of the region should be provided with a framework for conducting research that takes into account these socio-culturaland behavioural aspects and be given guidance and support to field-test and evaluate the health education packages that aredeveloped. SEA/ACHR/18Page 37 In the field of immunodiagnostics, the latest advances inmolecular biology and biotechnology are employed to develop simple and reliable tests for diagnosis of communicable and non-communicable diseases which constitute major health problems. It would be useful to review the needs of the countries and theavailability of such tests. Several laboratories in the Regionare developing new immunodiagnostic tools. The status ofdevelopment should be assessed and steps identified that would make them available in the region expeditiously. The reviewshould be able to identify researchable areas and to map out the further courses of action that are needed in this importantfield. Recommendations The SEA/ACHR recommended the following five topics fromamong which the Regional Director would finally choose three or four topics in consultation with the Chairperson of SEA/ACHR(however, topics not selected should be distributed to countries and appropriate agencies for consideration as possible researchtopics): - Research into the improvement of health caredelivery systems - Regional Perspective - Strategic plan for promoting and strengthening Health Economic Research: Regional approach - Socio-cultural/behavioural research on HIVinfections - Immuno-diagnostics with reference to the South-East Asia Region - Strengthening the capacity for multi-disciplinaryoperational research 3.14 Time and Place of the Nineteenth Session of the SEA/ACHR (Agenda item 12) The SEA/ACHR recommended that the Nineteenth Session of theSEA/ACHR be held from 12 to 16 April 1993. The venue of the meeting would be in the South-East Asia Regional Office unlessan invitation is received from one of the Member Countries where upon the venue would be decided by the Regional Director inconsultation with the Chairperson of the SEA/ACHR. 3.15 Any other Business(Agenda item 13) A comment was made that the working papers and theinformation documents provided much information. Whilst some of SEA/ACHR/18Page 38 the documents were very useful, others were not so useful. It wassuggested that the Regional Office should provide guidelines to the persons who prepare the working papers. The papers shouldprovide some background information, the state of the situation and then raise important and relevant issues or unansweredquestions which can be addressed by research. The SBA/ACHR endorsed this suggestion. 3.16 Adoption of Report (Agenda item 14) The minor modifications that were suggested would be done in agreement with the Chairperson. 4. CLOSING SESSION 4.1 Address by the Regional Director The Regional Director, in his concluding remarks expressed his appreciation of the contributions made by both the old andnew members to the deliberations of the ACHR. He observed that this year four technical subjects weretaken up for discussion. He reminded members that the SBA/ACHR was not meant to be a specialist or technical body and thatadvice on strategies and approaches were those most expected. As usual, the Regional Office would take note of therecommendations and observations made by the ACHR and appropriate follow-up action would be taken. With regard to the new paradigm, the Regional Director stated that a clearer picture would emergeafter the Ninth General Programme of work is discussed in relation to the paradigm at the World Health Assembly in May andthereafter by the Programme Committee of the Executive Board. The Ninth General Programme of Work, the New Paradigm and the WorldHealth Assembly Resolution WHA43.19 will influence the regional research strategy. He would convene a Consultative Meeting eithertowards the end of this year or early next year as recommended by SEA/ACHR. A specific agenda item on this subject would alsobe included for the nineteenth session of the SEA/ACHR. The Regional Director reiterated that the SEA/ACHR wouldcontinue to meet every year even though the global and other regional ACHRs meet only once in two years. He thanked the three outgoing members, Dr Gopal Prasad Acharya, Dr Usha Luthra and Dr Daw May May Yi for their valuablecontributions to the work of the Committee. He said that this does not mean a cessation of their links as WHO would seek theirguidance and advice on various matters in the future too. SKA/ACHR/18Page 39 4.2 Remarks by Members Dr G.P. Acharya speaking on behalf of the outgoing members .thanked the Regional Director for the opportunity to serve on the ACHR and assured the Regional Director of the cooperation of theoutgoing members in any future activities of WHO. Dr Somkid Kaewsonthi speaking on behalf of the new membersthanked the Regional Director for appointing them to the ACHR and thanked the secretariat for the very thorough briefing that they received. 4.3 Address by Chairperson The Chairperson, SEA/ACHR, expressed her gratitude to theRegional Director for inviting them to serve in the ACHR, the members for the valuable contributions at the meeting and for thecooperation extended by them to make the meeting a success, and to all those who had both directly as well as behind the scenesworked very hard to ensure the smooth working arrangements. 5. RECAPITULATION OF CONCLUSIONS AND RECOl4MRNDATIONS Summary of RPD activities during the preceding year(Agenda item 5.1) The SEA/ACHR recommended that: (1) WHO/SEAR0 should continue to promote Health Systems Researchin the countries of the Region with emphasis on institutional strengthening and on the utilization of research results bypolicy makers and health managers at the various levels of the health care delivery system. (2) WHO/SEAR0 fosters 1inkagesbetweenCollaboratingCentres with similar interests and expertise. (3) WHO/SEAR0 should promote -the designation of CollaboratingCentres in important subject areas where such Centres arelacking, care being taken, however, that stringent criteria are used to ensure that these Collaborating Centres fulfil the rolesexpected of them as centres of excellence. (4) The regional research programme should aim at a well balancedmixture of Health Systems Research, biomedical research andclinical research relevant to the needs of the Region. (5) The Regional Office should promote and support morecommissioned Health Systems Research projects focused on socio- behavioural and socioeconomic themes. These projects should be SEA/ACHR/18Page 40 implemented with a very close liaison between the Regional Office, the national health authorities and research workers. (6) The report on the summary of RPD activities during the preceding year should include abstracts of research projects completed during the period. Follow-up action on Resolution WRA43.19 (Agenda item 5.2(a)) The SEA/ACHR recommended that: In order to meet the challenges of the emerging and future health scenario in developing countries and in the South-East Asia Region, and the role that health research will need to play in helping to meet these challenges, and in order that SEA/ACHR may play its part in responding to the request addressed to the research community and WHO in WHA43.19, including the updating of the WHO health research strategy, and in order also to participate in the further development/refinement of the New Health Paradigm with respect to its health research aspects - the Regional Director convenes, in consultation with the Chairperson of the SEA/ACHR, a consultative group or a study group or a sub- committee of the SEA/ACHR with appropriate terms of reference. Review of RPD activities i,n relation to past SEA/ACHRrecommendations in specific areas: (b) technology Development,Assessment and Transfer (Agenda item 5.2(b)) The SEA/ACHR recommended that: (1) The recommendations of the 11th and 12th sessions of ACHR should continue to be intensively followed up, especially those pertaining to the establishment of national focal points and mechanisms. (2) WHO should actively pursue its efforts to develop a selective system of information which provides access to information required by countries in order to make informed decisions regarding the acquisition, development and transfer of health technology. In this context, the system may also aim at facilitating exchange of information between the providers and users of health technology. (3) In the context of recommendation No.1, WHO should also aim at helping countries to develop mechanisms and linkages which will make smooth the different stages of technology development and technology transfer. Development of mechanisms and linkages which would facilitate technology transfer between countries of the Region should be an area of particular interest and attention. SEA/ACHR/18,Page 41 Str8ngth8ning th8 Capability of Epidemiological R888arCh Regional Approach (Agenda item 7) The SEA/ACHR recommended that: (1) Recognizing the need for improvement in the quality ofepidemiological research, and training in epidemiology; (a) Basic epidemiological principles be inculcated into all categories of health workers, and that they be given the opportunity to receive training in simpleepidemiological methods at appropriate stages of pre-service or continuing education. (b) The quality and level of training in epidemiology for public health specialists and epidemiologistsshould be of a higher standard commensurate with the increased need for epidemiological analysis atcentral and peripheral levels of health care - and that this calls for review of the selection oftrainees, curriculum content and strengthening of the infrastructure of training institutions andfacilities. (cl One or several of the national institutes of publichealth or national centres for training in epidemiology which exist in countries of the Regionbe developed into regional centres of excellence - to impart epidemiological training of the highest standard, and to generate innovative ideas andmethods in epidemiology applicable to current and emerging health problems of the developing world andthe South-East Asia Region. (2) Epidemiological services in general be strengthened at all levels in the countries of the Region; that such strengtheningshould include the capability for epidemiological analysis and research at central level - one important way of achieving whichwould be to establish a national level epidemiological research unit. (3) The epidemiological methods used in research supported byWHO/SEAR0 should be scientifically rigorous and commensurate with the objectives of the research projects. (4) Epidemiological research should be service-orientatedand problem-solving and should not be confined to problem- finding. It should be directed towards research which wouldfacilitate application of existing knowledge and implementation of findings. (5) Recognizing that social science, and economic and behavioural science methods are increasingly necessary and being utilized in --- SEA/ACHR/18Page 42 health related studies and research, including Health SystemsResearch, conducted in countries of the Region, WHO should further promote and support appropriate trainingof health workers in the above methods as well as development of training materials and training methods. Research on Prevention of Cardiovascular Diseases (Agenda item 8) The SEA/ACHR recommended that: Realizing the burden of cardiovascular diseases in the Region, - priority should be given to promote research in the following important areas: . Rheumatic Fever/ Rheumatic Heart Disease (RF/RHD); . Hypertension; and. Coronary Heart Diseases (CAD) - research with respect to the above cardiovascular diseases should cover the following topics: (1) Socio-behavioural research to develop more effective methods promoting healthy life-styles and behaviourswhich are conducive to the prevention and control of CVDs, especially in high'risk groups and youth. (2) In RF/RHD (a) Behavioural, economic and socio-behaviouralresearch for control through secondary and possibly primaryprophylaxis ' the existing healthinfrastructureus;lnlake the school health servizzie primary health care and other healthinfrastructure). car; (b) Further research for the development of rapidmethods of streptococcal identification for use at field level. (3) In Hypertension/Coronary Artery Diseases (a) Population based studies to measure more preciselythe prevalence of hypertension and coronary artery diseases and risk factors/protective factors inselected populations. (b) Pilot studies to assess the effectiveness ofbehavioural modifications and of yoga on theprevention of coronary artery diseases, especially in high risk groups. SEA/ACHR/18 Page 43 (c) Controlled clinical studies on: - use of non-pharmacological methods; and - traditional drugs for the prevention and treatment of hypertension and CAD. (d) More Centres of MONICA studies should be established in the SEAR countries. (4) It is recommended that a scientific working group be convened to identify and prioritize regional research areas in CVD with the possibility of initiating a commissioned programme. Research on Maternal Mortality (Agenda item 9) SEA/ACHR recommended that: (1) WHO/SEAR0 undertake, as a matter of priority, thedevelopment of a plan of action for undertaking operational research on safe motherhood and maternal mortality and should assist countries in the development of national research programmes; (2) studies to fieldtest, monitor and evaluate the feasibilityand effectiveness of interventions which cover the major causes of maternal mortality, i.e. haemorrhage, sepsis, hypertensive diseases of pregnancy and severe anaemia in pregnancy, be undertaken. The approach for this purpose should preferably be the district team problem solving methodology using common protocols developed for the Region and involving service providers and the community; and (3) besides clinical research, socio-cultural, behavioural andhealth economic research related to maternal mortality should be undertaken as a package. Children's Vaccine Initiative Programme(Agenda Item 10) SEA/ACHR recommended that: (1) research should be undertaken to identify and improve thecost-effectiveness of vaccine delivery systems in countries, including the development of predictive economic models; SEA/ACHR/18 Page 44 (2) self-reliance in vaccine production should be a general aimfor countries of the Region and research towards the realization of the goal should be promoted; and (3) Member Countries should be encouraged by WHO/SEAR0 toundertake studies to determine the feasibility of incorporating non-EPI vaccines with the EPI Programme. Suggestions for the Agenda of the Nineteenth Session of SNA/ACNR(Agenda item 11) The SEA/ACHR recommended the following five topics fromamong which the Regional Director would finally choose three or four topics in consultation with the Chairperson of SEA/ACHR (however, topics not selected should be distributed to countriesand appropriate agencies for consideration as possible research topics). - Research into the improvement of health care delivery systems - Regional Perspective - Strategic plan for promoting and strengtheningHealth Economic Research: Regional approach - Socio-cultural/behavioural research on HIVinfections - Immuno-diagnostics with reference to the South- East Asia Region - Strengthening the capacity for multi-disciplinaryoperational research Time and Place of the Nineteenth bession of the SEA/ACER(Agenda item 12) The SEA/ACHR recommendedthatthe Nineteenth Session of theSEA/ACHR be held from 12 to 16 April 1993. The venue of the meeting would be in the South-East Asia Regional Office unlessan invitation is received from one of the Member Countries, where upon the venue would be decided by the Regional Director inconsultation with the Chairperson of the SEA/ACHR. 6. 8. 9. 10. 11. A. B. 1. 2. 3. 4. 5. 5.1 5.2. SEA/ACHR/18 Page 45 Annex 1 AGENDA INAUGURAL SESSION Agenda for the Inaugural Session issued separately. BUSINESS SESSION Introductory Statement by the Chairman, SEA/ACHR Opening Remarks by Dr U Ko Ko, Regional Director Introduction of Documents Adoption of Agenda Progress Report on the Regional Research Promotion and Development (RPD) Programme Summary of RPD activities during the preceding year Review of RPD activities in relation to past SEA/ACHR recommendations in specific areas (a) Follow-up action on Resolution WHA43.19 (b) Technology Development, Assessment and Transfer Matters Arising out of Meetings of Global ACHR and ACHRs of other Regions Strengthening the Capability for Epidemiological Research - Regional Approach Research on Prevention of Cardiovascular Diseases Research on Maternal Mortality Children's Vaccine Initiative Programme Suggestions for the Agenda of the Nineteenth Session of SEA/ACHR Time and Place of the Nineteenth Session of the SEA/ACHR Any other Business Adoption of Report CLOSING SESSION SEA/ACHR/18Page 46 Annex 2 LIST OF PARTICIPANTS SEA/ACHR MEMBERS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Dr Gopal Prasad Acharya, Head of the Department ofMedicine, Tribhuvan University, Kathmandu, Nepal Post Box No. 1524, Mahara, Professor A.P.R. Aluwihare, Chairman, University Grants Commission, 20, Ward Place, Colombo 7, Sri Lanka Dr (Mrs) Sneh Bhargava, A-103, New Friends Colony, NewDelhi-110065 Dr S.G.M. Chowdhury, Chairman, Bangladesh Medical ResearchCouncil, Dhaka, Bangladesh Professor B.N. Dhawan, Director, Central Drug ResearchInstitute, Chattar Manzil, P.B. No.173, Lucknow Professor Somkid Kaewsonthi, Centre for Health Economics,Faculty of Economics, 10330, Thailand Chulalongkorn University, Bangkok Dr (Mrs) Usha K. Luthra, Additional Director-General,Indian Council of Medical Research, Ansari Nagar, New Delhi 110 029 Dr Tonny Sadjimin, Director,Biostatistics Clinical Epidemiology &Unit, Medical Faculty, Gadjah MadaUniversity, Dr Sardjito General Hospital,, Yogyakarta, Indonesia 55281 Dr Sumarmo P. Soedarmo, Head, National Institute of Health Research and Development, Ministry of Health, JalanPercetakan Negara 29, Jakarta, Indonesia Dr S.P. Tripathy, Director-General, Indian Council ofMedical Research, Ansari Nagar, New Delhi 110 029 Professor Aree Valyasevi, Dean, Faculty of Medicine,Thammasaat University, Rangsit, Nondabur, Thailand Dr U.T. Vitarana, Deputy Director, Medical Virology,Fairfield Hospital, P.O. Box 65, Yarra Bend Road, Fairfield 3078, Victoria, Australia Dr Daw May May Yi, Director-General (Retired), Departmentof Medical Research, Ministry of Health, No.5, Ziwaka Road, Yangon, Myanmar SEA/ACHR/18 Page 47 SPECIAL INVITEES 1. Dr Natth Bhamarapravati, Mahidol University, Professor & President Emeritus,c/o Centre for Vaccine Development,Mahidol University at Salaya, Nakhon PathomThailand 73170, 2. Professor M. Gabr (Chairman, Global ACHR), Head,Paediatric Department, Faculty of Medicine, Cairo, Egypt 3. Dr Jacob John, Professor of Microbiology, ChristianMedical College, Vellore, India 4. Dr (Mrs) Raj Karim, Director, Public Health Institute, Ministry of Health,Malaysia Jalan Bangsar 59200, Kuala Lumpur, 5. Dr S. Padmavati, A1/116, Safdarjung Enclave, New Delhi110029 6. Dr S. Ramachandran, Secretary, Department of Biotechnology, Ministry of Science & Technology, CGOComplex, Block 2, Floor 7, Lodi Road, New Delhi 110 003 7. Dr H.S. Wasir, Professor and Head, Department ofCardiology, All India Institute of Medical Sciences,Ansari Nagar, New Delhi 110029 WHO BECRETARIAT - (South-East Asia Regional Office) 1. Dr U Ko Ko, Regional Director 2. Dr D.B. Bisht, Director, Programme Management 3. Dr Aung Than Batu, Director, Research and Human Resources 4. Dr K. Jayasena, Regional Adviser in Medical Research 5. Dr Lim Teong Wah, Medical Research Officer - SpecialProgrammes RESOURCE PERSONS 1. Dr Uton M. Rafei, Director, Health System Infrastructure 2. Dr N.K. Shah, Director, Prevention and Control of Diseases 3. Dr M.Z. Husain, Director, Planning, Coordination &Information 4. Mr M.L. Gupta, Chief, Promotion of Environmental Health SEA/ACHR/18Page 48 5. Dr N.W. Vidyasagara, Child Health Regional Adviser in Maternal and 6. Dr H.L. Sell, Regional Adviser in Health and Behaviour 7. Dr. I.S. Mochny, Immunization Team Leader, Expanded Programme on 8. Dr K.B. Sharma, Services Ag. Regional Adviser in Health Laboratory 1. 2. 3. 4. Provisional Agenda List of Participants Suggested Working Schedule List of Working and Information Documents 5. Summary of RPD activities during the preceding year 6. Strengthening the Capability SEA/ACHR/18/6 for Epidemiological Research (Relating to - Regional Approach Agenda item 7) 7. Research on Prevention of Cardiovascular Diseases a. Research on Maternal Mortality 9. 10. Suggestions for the Agenda SEA/ACHR/18/9 of the Nineteenth Session (Relating to of SEA/ACHR Agenda item 12) Technology Development, Assessment Transfer Information Documents 1. Information Bulletin 2. Report of Seventeenth Session of SEA/ACHR/lS/Inf.l SEA/ACHR, Yangon, Myanmar, (Relating to Agenda 21-27 April 1991 item 5.1) 3. The Role of Health Research - SBA/ACHR/lS/Inf.2 Progress report by the (Relating to Agenda Director-General to 89th EB item 5.2(a) and 6) SEA/ACHR/lS Page 49 Annex 3 LIBT OF WORKING AND INFORMATION DOCUMENTS Working Documents SEA/ACHR/lS/l SEA/ACHR/18/2/Rev.3 SEA/ACHR/18/3 SEA/ACHR/18/4 SEA/ACHR/18/5 (Relating to Agenda item 5.1) SEA/ACHR/18/7 (Relating to Agenda item 8) SEA/ACHR/18/8 (Relating to Agenda item 9) SEA/ACHR/la/lOand (Relating to Agenda item 5.2(b)) SEA/ACHR/lS/ Inf.Bull. SEA/ACHR/18Page 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 50 . Transfer of Technology - Extractsfrom the Reports of SEA/ACHR on SEA/ACHR/18/Inf.3 its Eleventh and Twelfth sessions (Relating to Agendaitem 5.2(b)) Report of a Meeting of RegionalAdvisers on Technology Development, SEA/ACHR/18/Inf.4 Assessment and Transfer (Relating to Agendaitem 5.2(b)) Children's Vaccine Initiative - - Extracts from the Report of the SEA/ACHR/18/Inf.5 meeting of the Consultative Group, (Relating to AgendaGeneva, 16-17 December 1991 item 10) Epidemiology Today - \A Thought-Tormented World' SEA/ACHR/18/Inf.6 (Relating to Agendaitem 7) Development of Rapid Epidemiologic SEA/ACHR/18/Inf.7 Assessment Methods to Evaluate Health (Relating to AgendaStatus and Delivery of Health Services item 7) Epidemiology and the Future of SEA/ACHR/18/Inf.8World Health - The Robert Cruickshank Lecture (Relating to Agenda item 7) Prevention of Cardiovascular SEA/ACHR/18/Inf.9 Diseases in South-East Asia & (Relating to AgendaThe Role of WHO item 7) Report on the Consultative Meeting SEA/ACHR/18/Inf.l0to Develop Criteria for Appraisal (Relating to Agenda of Health Systems Research Project item 5.1) Proposals, Suraj Kund, 2-6 April 1991 Information Support through HELLIS SEA/ACHR/18/Inf.l1 and Other Sources (Relating to Agendaitem 5.2) Abstracts from the Statement by SEA/ACHR/18/Inf.l2the Director-General to the (Relating to Agenda Executive Board at its 87th Session, item 5.2(a)) Geneva, 14 January 1991 The Role of Health Research, WI-IA SEA/ACHR/18/Inf.l3Resolution 43.19, Geneva, 17 May (Relating to Agenda 1990 item 5.2(a)) SEA/ACHR/lSPage 51 Annex 4 TEXT OF THE INAUGURAL ADDRESS BY DR U KO KO, REGIONAL DIRECTOR I wish to extend a warm welcome to you once again to thisEighteenth Session of the South-East Asia Advisory Committee on Health Research (SEA-ACHR). To begin with, I would like to greet Dr Sneh Bhargava,former Director of the All-India Institute of Medical Sciences, who began her term as Chairperson of the SEA/ACHR in April 1991 and is chairing this eighteenth session. We have seven distinguished new members of the SEA/ACHR andI offer you a warm welcome. We have with us Dr S.G.M. Chowdhury, Chairman, Bangladesh Medical Research Council; Dr S.P. Tripathy,Director-General, Indian Council of Medical Research; Professor B.N. Dhawan, Director, Central Drug Research Institute, Lucknow,India; .Dr Tonny Sadjimin, Director, Clinical Epidemiology and Biostatistics, Medical Faculty, Gadjah Mada University,Yogyakarta, Indonesia; Professor A.P.R. Aluwihare, Chairman of the University Grants Commission in Sri Lanka; Professor AreeValayasevi, Dean of the Faculty of Medicine, Thammasat University, Mondabur, Thailand, and Dr (Mrs) Somkid Kaewonsonthi,Professor of Economics at the Chulalongkorn University, Bangkok. I warmly welcome all of you and I have no doubt that with your long experience and high level of expertise you would make asignificant contribution to the activities of the SEA/ACHR. I am also happy to welcome Prof. M. Gabr, Chairman of theGlobal ACHR and Prof. Natth Bhamarapravati, Professor of Pathology and President Emeritus, Mahidol University, who arehere as special invitees. I am also pleased to report to you that during the courseof the sessions, we will be joined by some other special invitees who, we will introduce as and when the occasion arises. It is also appropriate that I place. on record ourappreciation of the services rendered by the members whose terms concluded last year - they are Dr A.H.M. Towhidul AnowarChowdhury, Dr N.S. Deodhar, Dr Darwin Karyadi, Dr Kosin Amatayakul, Dr Preeya Kashemsant and Dr S./D.M. Fernando; DrFernando was a Member of the SEA/ACHR from 1987 and served as its Chairman from 1988. Many of you are aware that following the technicaldiscussions, the Forty-third World Health Assembly in 1990 adopted Resolution WHA 43.19 on the Role of Health Research. Theresolution noted in particular, the conclusions of the technical SEA/ACHR/18Page 52 discussions on the Role Of Health Research in the Strategy forHealth for All by the Year 2000 andrecommendations dealing with health systems research nutritionespecially the research, research capability strengthening and ;he recentadvances in biological and physical sciencesimplications for health care. and their As you know, this Committee, on which you serve in yourindividual capacity, functions in an advisory capacity to theRegional Director and is one of the sources on which we depend to formulate the Regional research policies and programmes. 1 mention all this, because resolution WHA43.19 invited theresearch Community (of which you are distinguished members in this Region): - to increase its commitment towards the developmentof essential health research appropriate tonational needs and its participation in research on global health problems; - to intensify its efforts in communicating research findings and in technology to support decision-making and resource allocation processes; and - to mobilize its human and material resources with a view to strengthening international scientific networks oriented to health development. The WHA resolution also requested the Director-General (of WHO) I among other things, to: - use appropriate mechanisms, in close collaborationwith the global and regional Advisory Committees on Health Research to: (a) assess new and emergingareas of science and technology, (b) investigate evolving problems of critical significance tohealth, and (c) identify appropriate methodologies for trend assessment and forecasting, includingepidemiology to improve health; and - to develop further 'a clearly enunciated health research strategy for WHO in order to translatethe research goals, priorities and programmes into coherent and coordinated action in suPPort of health for all. At this session, Regional ACHR has a number of importantsubjects for discussion: these include technology development assessment and transfer, strengthening the capability forepidemiology research; research on the prevention of cardiovascular diseases; and research on maternal mortality andthe children vaccine initiative programme. SEA/ACHR/18Page 53 You would have observed that we have included theChildren's Vaccine Initiative Programme as one of the agenda items. We did so deliberately to bring to your notice thisimportant programme which is coordinated by UNICEF, UNDP, the World Bank, the Rockefeller Foundation and WHO without taking thebenefit of the ACHR system - both Global and Regional. I trust you will keep the exhortations of resolutionWHA43.19 that I referred to earlier in mind, when you discuss the important agenda items selected as technical subjects fordiscussion this year. There is a need to look into each of the above subjects with a holistic approach rather than in apiecemeal manner, so that we could jointly develop a well thought out research strategy that is realistic and relevant to our Region. Two of the objectives of WHA 43.19 called upon MemberStates to undertake essential health research appropriate to national needs (a) to foster innovation and experimentation, and (b) to contribute to new knowledge. I firmly believe that theSEA/ACHR should take up the challenge and think of ways and means of helping the Member States achieve these objectives. I hope your deliberations will be carried out in the usualearnest but friendly and informal style. As before, I can assure you that we shall heed your advice seriously, and I look forwardto your recommendations.