Debate on the paper by Guimarães et al.
Debate sobre o artigo de Guimarães et al.
Naftale Katz; Vânia Maria Corrêa de Campos
We wish to discuss two points raised in the author's paper: (a) Brazilian scientists have extensive experience, expertise in medical and biomedical research, and certainly research results that may be applicable to the Unified National Health System (Sistema Único de Saúde SUS). Is the Ministry of Health using this academic knowledge, developed by scientists in public universities and institutes and sponsored by the Brazilian National Research Council (Conselho Nacional de Desenvolvimento Científico e Tecnológico CNPq) and other research support agencies to improve SUS medical care? (b) Since 2003 the Ministry of Health has been playing a central role in structuring national efforts in health research, and is it possible to evaluate the impact of its efforts only two years later? What has changed since then?
Traditionally, Brazilian academic research results have not been used in national government policies. To illustrate this point, it is worthwhile to remember the case of the Integrated Program for Endemic Diseases (Programa Integrado de Doenças Endêmicas PIDE) created and supported by the CNPq and linked to the Ministry of Science and Technology in the 1970s. Most of the research reports submitted by scientists to National Research Council failed to reach or were not analyzed and discussed by the Ministry of Health. Nevertheless, PIDE must be considered a successful program, by significantly increasing the number of scientists and research projects in endemic parasitic diseases such as Chagas disease, leishmaniasis, schistosomiasis, and malaria.
Another historical example can be cited: in 1949 José Pellegrino and Emmanuel Dias sent a telegram to the Minister of Health, Mário Pinotti, stating very effusively that it was possible to control Chagas disease by spraying houses with pesticide. No sooner than 30 years later, the Ministry of Health launched a national Chagas disease control program, which proved to be a complete success after 10 years of continuous work.
When the National Program for Schistosomiasis Control (Programa Especial de Controle da Esquistossomose PECE) of the Ministry of Health began in 1975, most of the scientists working in the field, even though recognized nationally and internationally as experts, were not called on for advice, and when these scientists made suggestions and recommendations, they were not taken into consideration.
Nevertheless, the experience acquired by Brazil in the last three decades shows that the diagnosis and treatment of schistosomiasis can and must be incorporated into the National Health System.
The tools are simple, cheap, and were developed by Brazilian scientists. Results of field studies made in different States have clearly shown that disease control is possible through repeated clinical treatment. This incorporation transforms the vertical centralized Ministry of Health control campaign into horizontal and decentralized action to be conducted by the Municipalities and States. However, for transmission control, sanitation and health education must be incorporated into the action, and unfortunately the Federal Government is repeatedly neglecting such matters. It must be pointed out that an entire century has passed since Schistosoma mansoni was first described and identified in Brazil by Pirajá da Silva.
In the late 1980s, the political behavior of the Ministry of Health changed, and fortunately in recent years the relationship between scientists and sanitarians is quite good, with a highly productive exchange of opinions and knowledge. Fortunately the antagonism in Brazil between these two groups of professionals is now over, after decades of misunderstanding.
For three years now, the Brazilian Ministry of Health has been playing a role in structuring national health research efforts. What has changed since then? First, it is worth mentioning the success of the 2nd National Conference on Science, Technology, and Innovation in Health, in both its preparatory phase and results. Broad participation at various levels was a challenge (as the authors pointed out) for scientists and community leaders to interact like they never had before. It was difficult to find a common language in order to discuss, in depth and openly, their frequently conflicting points of view. As in the national phase, the most controversial point in Minas Gerais was the Ministry of Health proposal to create a health research support agency. Several arguments were applied to convince community leaders that the resources to support research projects would not be withdrawn from public basic health care. The Brazilian State Company for Agricultural Research (Empresa Brasileira de Pesquisa Agropecuária EMBRAPA), transferring research results from the laboratories straight into the field and bringing widespread benefits, provided a positive example, as did models from other countries that have successfully centralized resources for health research, as in the United States, Canada, and France.
The impact of the Ministry of Health Project "Research for the National Health System" in the State of Minas Gerais can be measured primarily through changes in relations and attitudes: (a) the improvement of the relationship between scientists and health care policymakers regarding the possible use of patient data; (b) the interaction between the Minas Gerais State Secretariat of Health and Minas Gerais State Research Foundation (Fundação de Amparo à Pesquisa do Estado de Minas Gerais FAPEMIG) and the subsequent relationship that was established; (c) the knowledge and acceptance, by health care policymakers, of the scientific community's values and practices like peer review and independent approval of research projects; and (d) more commitment by academic scientists to public health policy. This fact is evidenced by the number of proposals researchers succeeded in getting approved in the second call launched jointly by the Ministry of Health and FAPEMIG in 2004, as compared to the previous call in 2003. In response to the first call, scientists had 24% of their proposals approved. Some of the projects were refused, although presenting scientific merit evaluated by peer review, because they were not relevant to the SUS. During the second call, in 2004, 42.2% of the proposals were approved.
The monthly meetings of the Nucleus of Science and Technology in Health, implemented within the scope of the Ministry of Health project with the initial aim of discussing research topics for the calls for proposals, became an excellent opportunity for interaction between professionals from the State health system, health managers, and scientists. Discussions on such topics as bioethics and transgenics, intellectual property, information, and data dissemination enriched the participants' universe.
By working together with the various State Research Foundations in Brazil, the Ministry of Health has helped strengthen them in various ways. Besides the fact that State governments are required to match the funds provided by the Ministry of Health, some FAPs with previous experience in calls for research projects learned how to conduct them with the assistance and active participation of Ministry of Health staff. For these agencies, it was an important experience with an objective system for selecting research proposals. FAPEMIG was created in 1986 and had selection and evaluation processes already consolidated, according to the scientific community's values and practices, but it has been fighting for resources since the very beginning. By launching joint calls for research projects with the Ministry of Health, it not only guaranteed Federal resources, but also State government funds for health research. The result was double the amount of funding in the second call for projects as compared to the first.
The efforts by Guimarães et al. started a large process in order to involve the Ministry of Health as the principal health research player in Brazil. We congratulate them for the success and also thank them for the opportunity to share in the project's implementation in Minas Gerais. It has been a very enriching experience for everybody involved in the project. We hope that the Ministry of Health will accept the remaining challenge, making this initiative permanent and sustainable.