Report of the Advisory Committee on Health Research1

The PAHO/WHO Advisory Committee on Health Research (ACHR) held its 32nd meeting from 16 to 18 July 1997 at PAHO Headquarters in Washington, D.C. The ACHR consists of top-level health researchers from throughout the Americas who meet yearly with staff of the PAHO Secretariat to evaluate the Organizations technical cooperation in the area of research, discuss various research issues, make recommendation on ongoing activities, and propose new initiatives. Each of the six WHO regions have regional ACHRs, which mirror the work of the Global ACHR.

The issues discussed at the latest meeting and the Committees recommendations are summarized below.

INSTITUTIONAL POLICIES ON HEALTH RESEARCH

Dr. Alberto Pellegrini Filho, chief of PAHOs Research Coordination Program, explained that the Organizations technical cooperation in the area of health science and technology policies at the institutional level is geared toward helping institutions to enhance their capacity for setting their own policies and priorities and to assume a leadership role in guiding the development of health science and technology. It also originated as a response to the difficulties that these institutions are experiencing in adapting to the rapid changes in their environment, especially changes in the role of the State.

The target institutions, known as health science and technology organizations (HSTOs), are public-sector entities that have relatively broad administrative autonomy. Although there is great diversity among them, HSTOs also have some common characteristics; for example, they bring together a sizable number of semiautonomous units involved in research, training, epidemiologic surveillance, drug quality control, vaccine production, and other activities.

HSTO directors from seven countries met with invited experts and PAHO/WHO staff in April 1997 in Rio de Janeiro, Brazil. The basic document for this meeting, entitled Policies and Management of HSTOs, looked at the new role of these institutions in the context of changes in science and technology, government, and society. While the meeting was not expected to produce specific responses to the problems and questions raised by the transformation of HSTOs, it did create an opportunity to systematize the inquiries and to share experiences. With regard to future technical cooperation, the participants recommended that this learn ing process be given continuity through mechanisms such as the following:

  exchanges via electronic media, incorporating other HSTOs and universities;

  technical advisory services of specialists in response to specific problems and promotion of horizontal technical cooperation among the HSTOs;

  leadership training courses and intermediate-level courses in selected subject areas;

  literature reviews and studies on specific aspects of strategic administration;

  development of indicators for monitoring and evaluating changes in HSTOs; and

  broad dissemination of materials and reports stemming from PAHO cooperation.

Comments and recommendations of the ACHR

The Committee, stressing the importance of this area of technical cooperation, agreed that the recommendations made at the April 1997 meeting were pertinent and should be implemented as resources permit. Noting an imbalance between the in-depth situation diagnosis and the relatively weak responses to the problems identified, it under scored the need to continue this line of work and to support initiatives for implementing the recommendations.

In addition to the external challenges facing HSTOs, attention was called to difficulties arising from within the scientific community, which had shown some resistance in adapting to the transition from a world of research and education to a world of science and technology. Failure to recognize the importance of science administration or technology management was an example of that resistance.

The Committee recommended that the HSTOs should make the results of their work more visible, so that their potential would be more widely recognized by the State, by politicians, and by other social actors; that a more systematic body of knowledge about the problems facing HSTOs should be developed through specific studies; that this area of cooperation should be expanded beyond the HSTOs to include institutions not tied to the State and that, in so doing, attention should be given to the problems seen in smaller countries; and that more North-South exchanges should be promoted, since many of the same problems are found in developed countries.

TRENDS AND CHALLENGES FOR HEALTH RESEARCH IN LATIN AMERICA: A PERSPECTIVE

This topic was presented by Dr. Roberto Belmar, Professor of Epidemiology and Social Medicine at the Albert Einstein School of Medicine (New York, U.S.A.). He explained the work being done by a group of Latin American researchers, convened by Canadas International Development Research Center (IDRC), to identify gaps in knowledge resulting from recent trends in the Regions health situation. This working group, of which Dr. Belmar is a member, is preparing a research agenda for governments and the academic world that will be disseminated in book form and in other types of publications and communications media.

The specific research proposals being prepared by the working group pertain to three dimensions: the complex determinants of the health situation in Latin America, deficiencies in the health systems response to these challenges, and the deleterious effects of environmental changes. Dr. Belmars presentation included a review of the problems in each of these three areas and a summary of priority lines of research to address them.

Comments and recommendations of the ACHR

The Committee pointed out that the research agenda presented utilizes some categories of analysis that are controversial and have been subjected to numerous challenges. For example, such terms as marginality, lifestyle, and demographic transition are open to different interpretations. Nevertheless, the Committee also recognized some innovative aspects of the proposed approach, noting such nontraditional subjects as consumerism and loneliness in the elderly. It was important that the research agenda take into account not only the challenges and weaknesses of the Regions scientific community but also its strengths. In addition, strategies should be spelled out for implementing the agenda and applying research findings.

RESEARCH AGENDA TO IMPLEMENT NEW HEALTH-FOR-ALL STRATEGIES

Dr. B. Mansourian (Director, Research Policy Strategy Coordination, WHO) presented the Agenda for Research prepared by the ACHR system to support the implementation of new WHO health- for-all strategies. To give context to the discussion of health research and development (R&D), he presented data on the global situation. Worldwide, 90% of the expenditure on health R&D was used to benefit only about 20% of the worlds population. For example, the countries of North America spend 100 times more than those of South America on R&D. The Global ACHR argued that, while it was desirable and necessary to increase research capacity in the Southern Hemisphere, it was also imperative to improve cooperation and mobilize part of the resources allocated for research in the Northern Hemisphere to address the problems of the South.

The Agenda for Research emphasizes the following:

  the evolution of problems of critical importance for global healthfor example, those associated with population growth, migration, urbanization, environmental degradation, industrialization, infrastructure, education, unemployment, value systems, and social phenomena;

  the recent and anticipated contributions of science, technology, and medicine to public health;

  the imperatives and opportunities for research in various substantive areas;

  methodological research and development; and

  topics related to the research process itself.

Implementation of the Agenda would involve strengthening the methodological capability for research planning; promoting the establishment of intelligent research networks for the exchange of information, services, and contacts; and developing and improving visual representations of the status of health and health care. Responsibility for implementing the Agenda would be shared by WHO and its cooperating institutions; governmental authorities; multilateral, bilateral, and private funding agencies; the scientific community; and industries in the public and private sector with an interest in health research.

Comments and recommendations of the ACHR

The Committee reiterated its belief in the im portance of bolstering both the scientific ability to define a list of research topics and the capacity to identify strategies for implementing the Agenda, which would require the involvement of various actors. The role of PAHO and WHO in this process needed to be more clearly delineated.

The Committee believed that it would be difficult to persuade scientific institutions in the North to allocate resources for investigate problems afflicting their neighbors to the South, as proposed by the Global ACHR. A more effective strategy would be to establish links between institutions in developed and developing countries that are focused on problems of mutual interest. That strategy also had the advantage of strengthening the research infrastructure in developing countries.

More involvement of private nonprofit institutions, such as foundations, in supporting health research was needed, along with better criteria by which to select projects for funding. PAHO should study these problems and assume an advisory or advocacy role so that these institutions will adopt funding criteria that take into account the needs of countries in the Region.

REPORT OF THE SUBCOMMITTEE ON HEALTH SYSTEMS AND SERVICES RESEARCH (HSSR)

The Chairman of the Subcommittee, Dr. Gordon DeFriese (Director, Center for Health Services Research, University of North Carolina, U.S.A.), reported that the principal activity of the Subcommittee since the 1996 ACHR meeting had been the creation of a research competition on the organizational and financial aspects of health sector reform. Around 90 proposals had been received, and the five best ones were awarded funding of US$30 000 each. The Subcommittees plan of work for the coming year called for increased use of electronic media for transmitting information and research results, as well as the publication of a journal to disseminate research findings in the area of HSSR. Dr. DeFriese expressed regret that PAHO/ WHO had not called upon the Subcommittee in the past year and reiterated the desire of the members to work more closely with the Organization, especially the Division of Health Systems and Services Development. Comments and recommendations of the ACHR The Committee emphasized the importance of HSSR for closing health gaps between population groups. It also noted that HSSR has great value not only at the national and local levels but also internationally, and said that efforts should be made to strengthen mechanisms for the transfer of knowledge and the promotion of comparative research. The Subcommittee could play an important role in this regard and, to that end, it should establish links with other international agencies active in this field. It was recognized that the Subcommittee could not limit itself to merely reviewing research projects; it needed to take on tasks such as developing the conceptual aspects of HSSR, promoting the broad participation of different actors in this type of research, promoting interventions based on research finding and then evaluating the results, and developing strategies and mechanisms for disseminating research findings. PAHO/WHO COLLABORATING CENTERS Dr. Pellegrini informed the Committee that the topic of PAHO/WHO Collaborating Centers in the Region of the Americas was included on the agenda of the ACHR in order to promote the improved utilization of the Centers as sources of expertise, in compliance with recommendations contained in Resolution WHA50.2 of the World Health Assembly (May 1997). The Region of the Americas has 264 Centers, approximately 20% of the world total. Four countries (Argentina, Brazil, Canada, and the United States of America) account for 86% of the Centers in the Region. The main subject areas on which the Centers concentrate are disease control (41%), health promotion (23%), and organization of systems and services (22%). In 1996 a survey of PAHO managers found that they believed that the designation of Centers was the decision solely of WHO, that the Centers typically had no specific work plan, and that even when they did, it had little to do with PAHO priorities. Nevertheless, the managers recognized the potential of the Centers if these problems could be corrected. Based on the results of this survey, an initiative was begun to identify potential Collaborating Centers in the Americas, and 25 new Centers were designated in 1996. The WHO Collaborating Centers in the Region were renamed PAHO/WHO Collaborating Centers, and the designation/redesignation process was streamlined. Despite these achievements, there was still a need to improve the criteria and mechanisms for designating, monitoring, and evaluating the Centers. The Committee then heard three additional presentations. Dr. Arlene Fonaroff (Program Officer for the Americas, Fogarty International Center for Advanced Study in the Health Sciences, National Institutes of Health, U.S.A.) informed the Committee that the 22 Collaborating Centers associated with NIH were interested in strengthening their ties with PAHO and WHO and improving communication with those agencies and with each other. To these ends, at a meeting of representatives of the Collaborating Centers in the United States, it had been recommended that the Centers form networks in related technical areas, make better use of information provided by WHO, and define their functions and activities to justify the benefits of designation. For their parts, PAHO and WHO had been urged to provide access to databases on the activities of the Centers, use the Internet to facilitate linkages among them, clarify their functions, and identify communication focal points within the organizations. In the other presentations, Ms. Maricel Manfredi of the PAHO Human Resources Development Program and Dr. Primo Arámbulo of the PAHO Veterinary Public Health Program reported on some successful joint work experiences with Collaborating Centers in the areas of nursing development and veterinary public health problems such as rabies, plague, and foodborne diseases. Comments and recommendations of the ACHR While recognizing the great value of the Collaborating Centers in fulfilling certain roles, the Committee insisted that the recent interest in improving utilization of the Centers should not in any way be linked to the idea that their activities can substitute for the work that PAHO and WHO must carry out themselves, thereby justifying budget cuts in these organizations. The process of selecting, monitoring, and evaluating the Centers needed to become more rigorous, perhaps by making the selection competitive and classifying Centers according to their level of performance. Evaluation of the Centers should take into account that some might not be very active at all times but could be held in reserve and mobilized quickly if their high level of expertise were needed. The Committee emphasized the importance of creating networks of Collaborating Centers to facilitate joint work not only between the Centers and PAHO/WHO but also among the Centers themselves. Such networks must have a clearly defined purpose and program of work and a focal point, designated by the members of the network, to promote interactions. STATUS OF MULTICENTER PROJECTS The completed and planned activities related to a project on cultural norms and attitudes toward violence (Project ACTIVA) and another on health and the elderly were reviewed for the Committee by Dr. Rebecca de los Ríos (PAHO Research Coordination Program). For Project ACTIVA, field work had been carried out in 1996 in 12 Latin American cities, some of which would soon be presenting final results from their studies. A workshop for participating investigators had been held in early 1997 to develop a plan for analyzing the results, and a strategy for disseminating the findings had also been launched in the cities themselves. PAHO was facilitating exchanges among the research groups to aid in comparative analyses. Preliminary, descriptive regional results were presented by Dr. Luis Fernando Vélez, an investigator from the Center for Research in Health and Violence, Colombia. He pointed out the diversity of responses among the cities and stressed that the studies would not only generate original knowledge but also would provide the basis for interventions to curb violent behaviors. The project on the health of older adults began in 1997. A definitive protocol and draft questionnaire had been prepared, principal investigators had been selected, and a meeting of investigators had been held to discuss the protocol and questionnaire. Dr. Martha Peláez (PAHO Family Health and Population Program) presented the rationale for the study, pointing out the relative absence of research on the health situation of older adults and the health care they are receiving. The investigation will be conducted in seven Latin American and Caribbean countries. The results will be used to formulate interventions and will serve as a baseline for future evaluations. Comments and recommendations of the ACHR The Committee emphasized the importance of the violence initiative and expressed hope that the project would pave the way for subsequent studies to gain a more in-depth understanding of certain findings. It pointed out that only PAHO could promote the mobilization of resources and create the opportunity for the comparative approaches needed in this type of study, as the required expertise may not be available locally. It recommended that PAHO devote more resources to such projects to permit greater exchange among investigators and to strengthen its own coordination and leadership role. With regard to both multicenter projects, the Committee discussed methodological problems that had been or might be encountered. In the study of the health of older persons, it recommended also investigating the extent of older adults use of health technology and medications and the resultant impact on their income. ACTIVITIES OF THE RESEARCH GRANTS PROGRAM Dr. de los Ríos reported that 1996 had been a year of transition for the Research Grants Program, which still provided support for spontaneous research proposals but was also using new modalities, such as research competitions, to identify worthy proposals; funding training programs for public health researchers; and providing support for multicenter projects. In 1996, the Program had approved and financed 12 spontaneous proposals and nine proposals resulting from special initiatives (five grants stemming from the regional competition on research in health sector reform, and four public health research training grants). Total funding for individual projects plus technical cooperation activities related to Project ACTIVA had amounted to US$ 675000.

In 1997 the Biotechnology Research Training Grants Program, a joint PAHO/NIH initiative, planned to concentrate more on the priorities for new vaccine development, focusing on the promotion of collaborative projects on strategic technologies. Toward the end of the year, the Program would be launching a new plan to finance masters and doctoral theses (10 grants per year).

In the 11 years of the Research Grants Programs existence, there had been some tension be tween its objectives of, on the one hand, generating knowledge and, on the other, strengthening research capacity in the countries. It was hoped that the use of a variety of funding modalities would largely resolve this tension by providing support in both directions.

Comments and recommendations of the ACHR

The Committee expressed concern over the cutback of funding for research in the PAHO regular budget. More than a financier of research, PAHO should be an investor in research, developing and strengthening mechanisms for the mobilization of additional resources. It should promote the allocation of resources by other agencies and support the countries efforts at resource mobilization for research. Such activities would entail the setting of medium- and long-term policies and priorities for health research in the Region, which should be an essential function of the ACHR.

NEW METHODOLOGIES FOR HEALTH SITUATION ANALYSIS

The topic was presented by Professor Bruce Sayers (Imperial College of Science, Technology, and Medicine, United Kingdom), a member of the Global ACHR. He reported on two new approaches to health situation analysis being explored under the auspices of the Global ACHR and its subcommittees. The first, known as the Visual Health Profile, uses computer technology to show health deficits in an easily understandable graphic format, while permitting instantaneous access to data on different elements that contribute to health status, as well as trend analysis and comparisons. The other initiative draws upon the potential of expert insight to fill in the gaps in public health data. A knowledge-based indicator captures and uses verbally transmitted information instead of strictly numerical data for assessing the health situation. The observations and insights provided by experts on a given community are analyzed and tested for consistency by computer. The resulting picture constitutes a knowledge map of some aspect of health in that community.

Comments and recommendations of the ACHR

The Committee pointed out the relevance of this line of work, as the decentralization of health systems has created an urgent need for new method ologies that permit rapid assessment of local situations for planning purposes. PAHO had launched important initiatives in this regard, which the Committee believed should be given even greater impetus.

The importance of combining statistical information with expert opinion was stressed. It was necessary to get past the false dichotomy of quantitative versus qualitative, but application of such a methodology posed the challenge of training researchers who could gather and analyze both types of information.

REPORT OF THE SUBCOMMITTEE ON BIOTECHNOLOGY

In accordance with the ACHRs recommendation, endorsed by the Director of PAHO, the activities of the Subcommittee on Biotechnology have been more directly linked to those of PAHOs Special Program on Vaccines and Immunization (SVI), in order to encourage a closer relationship between the strengthening of biotechnology in the Region and the development of new vaccines. Dr. Elsa Segura (Director of the Dr. Carlos G. Malbrán National Administration of Laboratories and Health Institutes, Argentina), who chairs the Subcommittee, reviewed its activities since its creation in 1987 and noted that closer ties with SVI should be of benefit to both partners.

Dr. Akira Homma (SVI) presented the plan for new vaccine development that is being promoted by PAHO. Known as the Regional Vaccine Initiative, it is a regional coordination effort aimed at strengthening scientific and technical cooperation among the countries in order to overcome obstacles to the development and production of vaccines by developing countries. The selection of vaccines for inclusion in the Initiative takes into account epidemiologic priorities, along with scientific and technological viability.

In recent years, biotechnology has made possible rapid progress toward the goal of producing more effective, less reactogenic vaccines in adequate volumes for mass use. However, most of this progress has taken place in developed countries, and patent protection of the improved vaccines may make them too expensive for inclusion in the immunization programs of developing countries. To ensure access by the countries of the Americas to the latest vaccines, the Regional Vaccine Initiative has adopted the following strategic lines of action:

  identifying, jointly with the countries, actual and potential capacity for vaccine development;

  coordinating and integrating basic and applied research and vaccine development by groups both within and outside the Region;

  promoting the establishment of consortia of vaccine research and production laboratories and networks of quality control laboratories; and

  encouraging the transfer of technology between laboratories in the Region that produce biologicals and those in industrialized countries.

The estimated operational cost of the Initiatives four-year work plan is US\$ 15 million, which will come from voluntary contributions by the countries and from bilateral and multilateral sources. PAHO will mobilize institutional, human, and financial resources and support the countries in seeking supplemental funding from the international community.

Comments and recommendations of the ACHR

The Committee applauded the results achieved thus far by the Subcommittee and believed it would have an even greater impact by targeting its activities in support of vaccine development. In its new role, the Subcommittee should continue to strengthen ties with the production sector and the biological sciences community and to provide for interaction between the social and biological spheres. In addition, the countries needed to receive training on technology transfer agreements, which should be included in any negotiations for major purchases of vaccines from abroad.

OTHER TOPICS

During the course of the meeting, groups of two or three ACHR members made three-hour visits to the five divisions of PAHO and to SVI. Using a previously prepared guide, discussions were held with staff members on the research component of the technical cooperation activities being carried out in their respective technical areas. Summaries of those discussions were annexed to the report to the Director of PAHO on the ACHR meeting.

Several suggestions were made with regard to the next meeting of the ACHR: (1) a discussion on the future role of international organizations in research should be included; (2) working groups of Committee members and invited guests should be established to prepare documents for presentation during the meeting; and (3) participation in the ACHR meeting should be expanded to include, for example, chairmen of national science and technology councils in the Americas and representatives from other WHO regions.

SYNOPSIS

Informe del Comité Asesor de Investigaciones en Salud