Siriwan Pitayarangsarit; Viroj Tangcharoensathien*
International Health Policy Program, Ministry of Public Health, Tivanond Road, Nonthaburi 11000, Thailand
Strengthening research capacity in developing countries is aimed at generating and translating knowledge into policy decisions to improve health systems and increase equitable access to health services in the population.1
The International Health Policy Program (IHPP) in Thailand has strengthened health policy and systems research capacity in the Ministry of Public Health since 1998 and has sustained its capacity for a decade. This paper analyses and illustrates the experience of building and sustaining capacity in health policy and systems research in Thailand to provide lessons for developing countries.
We found that international and national collaboration were important in strengthening research capacity but that migration of well-trained health professionals impeded sustainable capacity development.2 While individual training was an entry point in capacity building, challenges remain on how to enhance the research environment to sustain the individual's capacity and interest so as to maximize their contribution.3
IHPP was established in 2001 through a memorandum of understanding between the Health Systems Research Institute and the Ministry of Public Health. It emerged from the Thailand Research Fund's Senior Researcher Scholar (SRS) programme in health economics and financing. Two rounds of 3-year institutional grants to SRS and other funding sources have been meaningful in building capacity in health policy and systems research. Since 1998, SRS has recruited young professionals with a strong public health background for research apprenticeships to conduct policy-relevant research under the mentorship of senior researchers before their placement for doctoral training. Long-term fellowships have been sought from WHO and other competitive sources. The WHO Country Office and IHPP have jointly managed the fellowship programme since 2000.
International collaboration with the Health Economics and Financing Programme at the London School of Hygiene and Tropical Medicine since 1993 and other networks in Europe and North America has been an important platform for long-term capacity building, especially in granting Doctors of Philosophy (PhDs).
Of the 36 WHO long-term fellowship grants approved in the 10-year period since 1998, 17 were masters degrees, 5 certificates and 14 doctoral degrees. There was a zero attrition rate and no international loss. All fellows returned upon graduation to serve mostly in the Ministry of Public Health and a few universities. This successful return rate was an asset for sustaining capacity development. IHPP researchers and post-doctoral contributions have been significant. Publication performance has increased especially in international journals, from two papers in 2001 to 13 papers in 2006.
Policy impact was just as important as publication rates. Recent major reforms for universal coverage relied on strong human capacity in health policy and systems research as well as synergistic political and civic society movements.4,5 The main contributions of IHPP were cost studies, the estimation of budget requirements for the universal coverage scheme in its implementation phase and a manual for analysis of hospital financial status and performance. In addition, several IHPP partners, such as the European Union-supported Health Care Reform Office, the Center for Health Equity Monitoring, Naresuan University and the Health Systems Research Institute, contributed to the policy decisions. Based on parameters applied by Gonzalez Block,6Table 1 summarizes the evolution of Thailand's health policy and systems research capacity and its outcome.
The critical factor in sustaining research capacity was the selection of young professionals for research apprenticeships and long-term fellowship placements. It was vital that they had a good track record of commitment, especially towards rural health services. Honest and sincere referees and recommendations from supervisors and peers were important criteria for their selection, rather than brief interviews and impressions by members of selection committees. Research skills and competencies were easily trainable. The following three experiences were found to be useful in sustaining capacity in the health policy and systems research field.
Critical mass and collegial environment
All IHPP fellows came back to Thailand and were mostly posted in IHPP where they provided mentoring to junior researchers. In 2007, 10 PhDs in IHPP extended the capacity to supervise and conduct more diversified health policy and systems research agendas. This larger capacity to deliver attracted greater funding and provided increased supervision capacity which attracted an increasing number of post-doctoral fellows from universities to work either on part-time contracts or full-time secondment. In addition, the larger capacity fostered international collaboration and the provision of technical support to countries in the region.
Critical mass in the institution created an enabling environment for academic activities, allowing researchers to keep abreast of scientific advancements and current debates. Critical mass and a collegial environment prevented "work in isolation" and helped maintain regular activities such as a journal club, discussions on proposal development and mutual support for submission to journals. Health policy and systems research is complex and requires interdisciplinary teams. The post-doctoral phase requires 3 to 5 years to develop a strong, independent researcher with ample publication records.
Relevance, impartiality and accountability
IHPP had a comparative advantage. As a quasi-public institution within the Ministry of Public Health, it was exposed directly to relevant policy questions, concerns and demands. It had a physical proximity to policy circles yet an "arms-length" relationship with the ministry, i.e. it managed to maintain scientific integrity and independence from political influences. Delivery of comprehensive and relevant answers through policy-relevant research to support decision-making was more convincing than theoretical recommendations.
Political neutrality was important in maintaining continuity of research contributions, as the ministers of public health came from different political parties at different times. Programmatic and financial accountability to funding agencies and the ministry were important in providing immunity for IHPP and were ensured through annual external financial audits and annual reports to all partners.
Financial incentives were important to keep and sustain commitments and to maximize contributions by researchers. Most IHPP staff were seconded by the Ministry of Public Health and universities, on full salaries. Additional payments from research projects were adjusted to better reflect the competitive market rate. Non-seconded staff were fully paid on a competitive rate. In 2005, IHPP registered the non-profit Foundation of the International Health Policy Programme which provided a legal status for financial management.
Non-financial incentives included opportunities to attend scientific conferences for presentation of papers and networking with international peers. Publication records were considered as important as financial incentives, as they boosted an individual's track record. Social recognition was important when their work had significant policy impacts. Mutual sharing of benefits and credibility were the most vital elements in the building of incentives and motivation. A shared responsibility in the governance of IHPP was important to ensure participation and ownership by researchers.
Issues and lessons on building and sustaining capacity were consistent with a checklist proposed by Nchinda7 and the enabling environment discussed by Lansang et al.,3 e.g. leadership, career structure, critical mass, infrastructure, information access and interface between research producers and users. One weakness identified was that IHPP still had to catch up to acceptable levels of publication in international peer reviewed journals.
Key success factors were "self-initiation" and "local ownership", external support from international partners, notably the WHO fellowship programme, as well as research networking in the phase of capacity development. In the phase of sustaining capacity, it was the responsibility of the organization to ensure equitable sharing of benefits, both financial and non-financial, critical mass, policy-relevant research, political impartiality, programmatic and financial accountability and a collegial environment. Scientific links with stronger partner institutes played a crucial role in sustaining capacity. Although these lessons are context specific, the principles are applicable to other developing countries.
Funding: The Thailand Research Fund and Health Systems Research Institute provided institutional grants.
Competing interests: None declared.
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(Submitted: 1 June 2007 - Revised version received: 13 September 2007 - Accepted: 13 February 2008 - Published online: 4 November 2008)