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Cad. Saúde Pública vol.22 n.9 Rio de Janeiro Sep. 2006
Debate on the paper by Guimarães et al.
Debate sobre o artigo de Guimarães et al.
Sylvia de Haan
Head Projects and Programmes, Council on Health Research for Development, Geneva, Switzerland. email@example.com
The authors must be commended for their article. As rightly pointed out in the text, there is very little published literature on the questions of how to set and implement priorities. The authors provide a good description of the process followed in setting priorities, emphasizing both the participatory approach (which also involves the public) and the need to document and make public the process, related decisions, and the research agenda itself. They illustrate how equity and ethical considerations have been secured as key principles in health and health research system development in Brazil. The article is a highly useful contribution to the global debate on how to ensure that health research priority setting works for everyone 1.
Two issues could be addressed in more detail by the authors. The first concerns the link between priority setting and the overall strengthening of the health research system. The second issue concerns implementing the agenda.
In their conclusion, the authors refer to the four main functions of a health research system (stewardship, financing, creating and sustaining resources, and producing and using research) and how the Brazilian priority setting process contributed to strengthening these four functions. The article addresses in detail how priority setting (as part of the stewardship function) can support the Ministry of Health in strengthening its position within Brazilian efforts on research for health. It also highlights how existing resources (especially within the Ministry of Health) can be used to address priority research areas. However, it does not address how priority setting can be used to identify priorities for strengthening the health research system. Relevant questions that could have been raised include: are new skills needed to conduct the prioritized research areas? Does the system have sufficient capacity to ensure the utilization and communication of research results thus generated? How will the community remain engaged in the research process, and what skills are needed to empower the communities to use such results?
The priority agenda presented has become a general listing of diseases, disciplines, and vulnerable population groups: this perspective provides little guidance for development and strengthening of all four functions of the health research system.
My second comment concerns the ability to put the agenda of priorities into action. The article describes in detail how the agenda led to calls for proposals by the Ministry of Health to develop specific sub-agendas. In some occasions these calls for proposals were done jointly with the Ministry of Science and Technology or the various State health departments. The authors also provide an overview of the expenditures in health research in Brazil. Interestingly, this illustrates that the Ministry of Health is only a relatively small contributor to total health research funding available in Brazil. The call for proposals initiated by the Ministry of Health can thus only redirect a small proportion of total health research expenditure available in the country. The authors' ideas and strategies for how to influence these other sources of funding would make a welcome addition to the article.
Brazil has met some key conditions for a successful priority setting process, especially in its inclusive approach and by public communication of its decision making processes and key reports. The issue of coordination between the various sectors is less explicitly addressed. This includes the link with the private sector, which is likely to become the next big challenge in making priority setting sustainable and for increasingly reallocating funding (from all funders) to focus on health research priority areas.
1. Council on Health Research for Development. Health research: getting the priorities right. Geneva: Council on Health Research for Development; 2004. (Policy Brief Series Making Health Research Work for everyone, n. 2004.1).