Frenk power ideas

WWHAT SHAPES THE IDEAS OF POWER, THAT IS TOsay, the assumptions, concepts and val-ues of those with the power to makedecisions? It would be naive to assumethat decision-makers are always rational,

in the sense of basing their conclusions strictly onobjective evidence about the best means to achieve thedesired ends. Often, such evidence is not available.Even when it is, the decision-maker — particularly inthe public sector — must balance the weight of evi-dence against the economic and political feasibility offollowing the desired course of action.

While it is clear that decisions are made on the basis ofmany other forces apart from scientific information, it isalso true that good evidence can steer those who havethe power to decide towards a better course of action.In other words, the power of ideas can help to shapethe ideas of power. At the very least, sound researchplaces limits on the discretion granted to decision-makers, who have to consider the costs of ignoringthe available data.1 In the absence of such data, thedecision-maker may not even be aware of the short-comings of his or her policies. But good evidenceshould not be seen mainly as imposing limits on thedecision-maker. It can also be an empowering tool.Armed with the results of research, the decision-maker can better counter the vested interests thatoppose an enlightened decision, and may then bemore willing to assume the risks of being innovative.The value of sound research to enlightened decision-making is underscored by the wave of health reformsthat is currently sweeping the world. Countries at alllevels of economic development and with all types ofpolitical structures are planning, implementing or eval-uating reforms in the health arena. A worldwide search

Issue 2 n July — September 1995

IN THIS ISSUE OF RESEARCH INTO ACTION

COHRED in ActionCountry Updates

LaosSouth Africa

News from ENHR PartnersRegional Developments

Upcoming EventsPublications

3556781112

C O H R E DC O H R E D

The Newsletter of the Council on Health Research for Development ( COHRED )

TTHEHE PPOWEROWER OFOF IIDEASDEAS ANDAND THETHE IIDEASDEAS OFOF PPOWEROWER::CCHALLENGESHALLENGES TOTO ENHR ENHR FROMFROM HHEALTHEALTH SSYSTEMYSTEM

RREFORMEFORM

by Julio Frenk

... Continued on page 2

for better ways of financing and delivering health careis under way. In addition to economic, political andideological considerations, health system reform hasbeen fueled by the need to find answers to the com-plexities posed by epidemiological changes, wherebymany nations are facing the simultaneous burdens ofold, unresolved problems and new, emerging chal-lenges. In a context marked by transition and complexity,

societies are discovering thatthe existing formulas mayno longer provide therequired responses. All overthe world there is a sharedsense of impending inno-vation, as we witness whatcould prove to be the birth ofa new paradigm for health systems.

The process of rethinking and renewinghealth systems needs to be illuminatedby research. There are still so manyunknowns about the determinants ofhealth system performance that a re-search agenda must be an integral partof every reform initiative. Essential

National Health Research has a crucial role to playhere. ENHR is not a type of research but a strategy toensure that priorities are defined in a participatorymanner, that projects respond to the most pressingnational problems, and that explicit bridges are builtbetween researchers and decision-makers for the opti-mal use of results. Few topics like health system reformdemand this sort of participatory, problem-oriented anduser-centred approach to research. What is essentialabout ENHR is its commitment to goals like equity,quality and efficiency, which are precisely the sameones that the reform movement promotes.In order to achieve these goals, a comprehensivereform must encompass four policy levels: systemic,which deals with the institutional arrangements for reg-ulation, financing and delivery of services; program-matic, which specifies the substantive priorities of thesystem by defining benefit packages of health careinterventions; organisational, which is concerned withthe actual production of services by focusing on issuesof quality assurance and technical efficiency; andinstrumental, which generates the institutional intelli-gence for improving system performance through infor-mation, research, technological innovation and human

resource development.2

At each of the four policy levels there are fundamentalquestions that need to be answered. Because of thegaps in our current knowledge, every reform initiativeshould be seen as an experiment, the effects of whichmust be documented for the benefit of every other ini-tiative, both present and future.The opportunities for reform are so few that failing to

learn from them condemnsus to rediscover at greatcost what is already knownor to repeat past mistakes. Toreform it is necessary toinform, or else one is likely

to deform.1

The only way to make learning systematic and cumula-tive is to build ENHR into every phase of the reformprocess. The first product from this research is a precisediagnosis that may justify the reform effort. A secondproduct is the development of the tools to be used forimplementing the proposed changes. Finally, ENHR iscrucial to monitor unforeseen obstacles and to evaluatethe effects of reform, thus opening up a new cycle ofimprovement.The opportunities for ENHR to play a constructive rolein health system reform have been greatly enhanced bythe development of new tools to gather and analyseinformation. Indeed, our analytical armamentarium hasbeen enriched by innovative approaches, such as themeasurement of the burden of disease through Disab-ility-Adjusted Life Years, the use of cost-effectivenessanalysis to devise packages of essential health interven-tions, national health accounts, performance analysis ofhealth care institutions, and political mapping, amongothers. These tools give firmer quantitative and qualita-tive bases for the formulation and comparison ofreform options. While much progress has been made,there is still a long way to go in order to standardiseand refine the new analytical approaches. Hence,methodological development should be grantedincreasing attention now and in the years to come.

By its very nature, thistype of effort requires aglobal scope.

Furthermore, the development of better analytical toolsis only one of the items in the agenda for a globalresearch effort linked to health system reform. While

HEALTH

SYSTEM

REFORM

SHARING EXPERIENCES

Council on Health Research for Development2

SYSTEMICIssues:

Basis for population eligibilityInstitutional arrangements

Objectives:Equity, quality, efficiency

PROGRAMMATICIssues:

Priority settingCost-effectiveness ofinterventions

Objectives:Allocational efficiency

ORGANISATIONALIssues:

ProductivityQuality of care

Objectives:Technical efficiency

INSTRUMENTALIssues:

Information systemsScientific researchTechnological innovation

Objectives:Institutional intelligencefor performance enhancement

A Comprehensive HealthSystem Must Encompass

Four Policy Levels :

The Power of Ideas ...Continued from page 1


HELD IN NEW YORK IN FEBRUARY 1995, THE PURPOSEof the meeting was a dual one: to provide thedonor community with feedback from

COHRED and to obtain feedback from the attendingdonor agencies on COHRED’s activities since its incep-tion. Participants in the meeting included representa-tives of the following—potential andactual—donor agencies: The AmericanAssociation for the Advancement ofScience, U.S.A., The CarnegieCorporation of New York, U.S.A., TheChina Medical Board of New York,Inc., U.S.A, The Edna McConnellClark Foundation, U.S.A., The FordFoundation, U.S.A., The InternationalHealth Policy Program/WB, U.S.A.,The Ministry of Foreign Affairs, TheNetherlands, The RockefellerFoundation, U.S.A. and UNICEF.The major points emerging from thediscussions were: wFunding ENHR country activitiesremains a problem. However, givenproper exploration, funding couldcome from multiple sources. Someorganisations can fund operationalresearch (e.g. UNICEF) where commonthemes can be determined such asimmunisation, social security, etc.Other donors are willing to supportresearch projects within national pro-grammes with bilateral collaboration,provided coordination at the countrylevel can be improved.wCOHRED’s budgets should becomemore transparent and comprehensive, indi-cating not only the financial support fromCOHRED to countries but also contribu-tions for ENHR activities made by the countries themselves,as well as additional external resources that are mobilised bythe countries and/or COHRED.

Concerning the strategy of Essential National HealthResearch itself, it was noted that:

wResearch on health reform is a growing priority;wResearch must go beyond researchers, i.e. the differ-ent stakeholders of ENHR (policy-makers, academia,

the public, the media, etc.) shouldhave an appropriate involvement inthe consecutive stages of the researchprocess;wCommunity involvement is vital ifdistortion of the ENHR strategy is tobe avoided, and the principle ofinclusiveness needs to be practised;wEssential National Health Researchis a growing but “slow process” dueto its complexity;wNational priority setting for healthresearch is an essential preconditionfor any process of regional and/orglobal health research priority setting;wTo make ENHR an attractiveapproach for more and more coun-tries, it is necessary to present clearlywhat it can do and how this willimpact on the health status of a coun-try’s population;wConcomitantly, COHRED activitiesand ENHR work have to be givengreater visibility;wUnder its mandate as a coordi-nating body, COHRED needs toform appropriate alliances, par-ticularly since such alliances areactively being sought!The meeting welcomed this“open house” session and recom-mended that COHRED organise

similar sessions at regular intervals, for instance,in combination with its Board Sessions. q

RESEARCH INTO ACTION Issue 2 July — September 1995 3

COHRED IN ACTION

COHRED / DONORS FORUM ADVOCATES EQUAL PARTNERSHIPS AND

OPEN HOUSE WITH DONOR COMMUNITY

COHRED, the Council on HealthResearch for Development, is anon-governmental organisation.

It was established in March1993, and is located in the

European Office of the UnitedNations Development

Programme in Geneva,Switzerland.

The Council consists of membercountries, agencies, organisa-

tions and an 18-member board,the majority of whom are from

developing countries.Its objectives are to promote the

concept of Essential NationalHealth Research, which aims to

assist countries in identifyingtheir health and research priori-ties as well as strengthening their

research capacities, andencourages multi-disciplinary

and multi-sectoral collaborationto ensure that health policiesand decisions on importanthealth issues respond to the

actual needs of the public andwill translate into health gains for

the population at large.In addition, COHRED brokers

national financial and other sup-port for countries if requested to

do so.

v v v v v vBringing together delegations from its 190 Member States, the 48th World Health Assembly of the World Health

Organization, which convened from May 1–12, 1995, in Geneva,Switzerland, proved an ideal occasion for COHRED to hold informal dis-

cussions on the progress made so far in implementing Essential NationalHealth Research, as well as on future directions. COHRED was able to talk to delegates from the following countriesor groups of countries: Barbados, Botswana, Cuba, Indonesia, Kenya, Malawi, Mauritius, Namibia, Nepal, Niger,South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, the Commonwealth Health Secretariat and the JointHSR Project for the Southern African Region. q

every reform experience will have fea-tures that are specific to its national cir-

cumstance, there are always importantlessons for other countries to learn.

Hence, there is need for concerted actionsamong countries in order to compare options

and evaluate experiences.National initiatives will have a higher likelihood

of success if they can all benefit from a globalmechanism for shared learning. Such a mechanism

should foster sound cross-national comparative analy-ses of health systems. It should also coordinate multi-

centric studies where specific organisational and financinginnovations can be tested in different contexts. In addition,

it should establish a repository of documentation on healthreform experiences that would be accessible to every country

that is considering a change in its health system. Alongside themethodological development mentioned above, the mechanism

should integrate and update a data base with comparative data onkey variables. What is crucial is that experiences and data must be

aggregated so that they can be made comparable.

The proposed mechanism might adopt several forms, but what is important isthat it should have a guiding mission as a resource for all countries in the world. This would help to supersede the false dilemmabetween national and global research. Defining a shared agenda, developing a set of agreed-upon tools for analysis, feeding intoa common set of measurements, contributing to a repository of documentation accessible to everyone and comparing experi-ences — all these are essential to both the national and the global research efforts.

At every step these efforts should be guided by the humble realisation of how much we still need to learn and of how much thislearning could improve the quality of decisions. President Václav Havel of the Czech Republic has written: “Improvements andchanges must be made according to whatever has proved to be good, practical, desirable and meaningful, without the arrogantpresumption that we have understood everything about this world, and thus know everything there is to know about how tochange it for the better.”3

Reform and research should walk together in the quest for better health. When we can achieve convergence, we will have at lastintegrated ideas and power. q

Julio Frenk, M.D., Ph.D. is Executive Vice-President of the Mexican Health Foundation and Director of the Centre for HeaIth andthe Economy in Mexico City; he also teaches at the National Institute of Public Health and at the Faculty of Medicine of theNational University of Mexico.

1 Frenk J. Comprehensive policy analysis for health system reform. Health Policy 32: 257–277, 1995.

2 Frenk J. Dimensions of health system reform. Health Policy 27: 19–34, 1994.

3 Havel. V. The responsibility of intellectuals. The New York Review of Books, June 22, 1995: 36–37.


RESEARCH INTO ACTIONThis newsletter of the Council on Health Research for Development is publishedfour times a year.

RESEARCH INTO ACTION is issued complimentary upon request.Editor in Chief COHRED: Yvo Nuyens, Ph.D.Editor, layout and desk-top composition COHRED: Hannelore Polanka, M. A.

The Power of Ideas ...Continued from page 2

LAOSMANY COUNTRIES IN THE SOUTH-EAST ASIAPeninsula have begun to play more activeroles in the international arena. Many areseen as new markets for economic activi-ties but, more importantly, they pose bigchallenges to the world community, aswell as offering rich lessons in socialdevelopment. The Lao People’s Demo-cratic Republic is a small country with

only four million population and an area of 236,800sq. km., landlocked by the neighbouring countries ofCambodia, Vietnam, Thailand and China.The Republic was established following liberation in1975, and has since then drawn up a national socio-economic development plan. The policies and plan-ning include health as an important component that iscrucial for long-term development of the country. Atthe fifth Congress of the Lao People’s RevolutionaryParty it was also made clear that research is essentialfor future success. The country is now in its third five-year plan, which spans the period 1992-1996.The health sector has adopted a global health strategywhich was systematised into nine work plans in 1993;one of the nine is devoted to health research. Afteralmost three years, the Ministry of Health reviewed thenine work plans at a national workshop on planningand budgeting in February 1995, and they were subse-quently reduced from nine to six well-defined workplans, one of which still relates to health research. Thisshows once again the importance and value that theMinistry of Health accords to health research for healthsector development and for the health benefits it con-fers on the Lao people.Although a country with relatively low economicdevelopment (GNP per capita of about US$335 in1993/1994), it has had its own Council of MedicalSciences since 1990. The Council has served as a coor-dinating mechanism for the country’s efforts in healthresearch through a joint committee, whose memberscome from different institutes and departments in theMinistry of Health. Indeed, the Chairman of the Coun-cil was appointed by the Minister. One of the mainworking partners of the Council is the Ministry ofScience and Technology, which will work closely toensure the appropriate transfer and use of health tech-nology to improve the health of the Lao people.

The first five-year master plan forhealth research was developed bythe Council, with support from

the International Development Research Centre (IDRC),Canada. The plan aims to achieve five main objectives:•To identify priority health problems and developstrategies to solve those problems.

•To develop policies and strategies in health researchthat will contribute to solving the priority problemsidentified.•To act as counsellor to the Ministry of Health in thedevelopment, allocation and utilisation of healthresources, especially technology that will best meet thehealth needs of the country.•To prepare a long-term infrastructure for healthresearch with a view to the future, starting from theestablishment of the Council of Medical Sciences.•To effectively mobilise government as well as inter-national support for the health research that is crucialfor the country’s health development.Since good infrastructure and human resources forhealth research are lacking, one of the main strategiesof the five-year plan is to increase the awareness andorientation of people working in the health sector andother related sectors about the importance of healthresearch, and to build up capacity for such researchactivities. Effectively, there has been no existingresearch capacity in the country prior to this. Therewere some research activities in health but they weremostly limited to matters of clinical or biomedical con-cern. Now that attempts are being made to develop areliable health service system for the majority of theLao population, there is a great need for differentgroups of people to be familiar with or able to carryout research aimed at directly improving the heaIth ser-vices delivery system, or at finding appropriate ways ofensuring that available health technology will benefitthe populace as a whole and not just a limited few.The Council itself has been instrumental in bringingmore awareness along these lines to various institutesand departments in the Ministry of Health. At the sametime, in many institutes and departments researchefforts are directed towards better solutions to priorityhealth problems. Examples may be seen in the Instituteof Malaria Control, which has launched studies into theeffectiveness of using bed-nets impregnated withPermetrine to protect the rural population from mos-quitoes in endemic areas. Studies are also being madeon drug-resistant malaria parasites and the effectivenessof available new drugs. The Institute of Maternal andChild Health has also carried out research to assessmaternal and infant mortality; this has helped us to abetter understanding of the situation, since the existinginformation system is still under development. TheFood and Drug Department has developed nationaldrug policies and will be closely monitoring their effec-tiveness; there will therefore be need for studies in thefuture. The Council of Health Sciences is also trying tourge provinces to develop their research capability sothat their many health problems will be betteraddressed through the results of research studies,especially where existing routine information is still in


COUNTRY UPDATES

BetterHealthfor the

LaoPeople

Fivemain objectives


HEALTH RESEARCH IN SOUTH AFRICA IS fund-ed through a diverse range of sources, bothpublic and private. Public funds are chan-

nelled through at least three central departments, namelyHealth, Education and Arts, Culture, Science andTechnology.The private sector is a significant funder of health research. Areview of articles published in the South African MedicalJournal in 1994 identified a wide variety of private sources offunding, both through private foundations and directly fromthe corporate sector, particularly from multinational and localpharmaceutical companies, which spend a considerableamount on drugs trials in South Africa.Failure to institute adequate systems of feedback andaccountability by tertiary institutions, reticence by the phar-maceutical sector to disclose allocations for health research,and undetermined funding of health-related researchby statutory councils other than the Medical ResearchCouncil(MRC), haveobscured thetrue pictureof fundingfor healthresearch inSouth Africa.Both themagnitude offunding andthe nature ofits expendi-ture areuncertain.Despite this uncertainty, it is clear that there are considerabledisparities in the distribution of funds to tertiary institutions,which together consume the lion’s share of health researchfunding in South Africa.First, only 1.1% of funding for health research in the tertiaryeducation sector is spent in technikons, as opposed to univer-sities.

Second, the total expenditureon health research in the ninehistorically black universities(HBUs) is considerably less

than that spent in any one of the Universities of Cape Town,Pretoria, Witwatersrand, Stellenbosch, Natal or Orange FreeState. This is reflected in the publications output, with HBUsaccounting for only 5% of papers published in peer reviewedjournals in 1994.Third, not only is the total expenditure in HBUs considerablyless than in established white universities, but allocationsfrom public sector sources (through statutory councils andthe Department of Education) to HBUs are significantly lessthan per capita allocations to established white institutionsand universities.Major gaps in existing information pertain to spending bystatutory councils, the corporate sector, and universities andtechnikons.A review of health research finance and expenditure pre-pared for the South African Health Expenditure Review, esti-mated that South Africa spent R2.8 billion on research in1991/2, representing 1.04% of the Gross Domestic Product.Of this, roughly R200 million (6.9%) was spent on healthresearch, considerably less than research expenditure in thefields of engineering (33.7%) or agriculture, biology and

forestry (14.1%). However, this percentage probably reflectsa significant underestimation of the private sector’s contribu-tion. The amount spent by multinationals in South Africa ondrug trials alone is estimated to be in the order of R100 mil-lion. In addition, some of the research conducted by statutorycouncils other than the MRC may be classified as “healthresearch.”Taking these factors into account, it is estimated that 310 mil-lion rand was spent on health research in the 1992/3 finan-cial year, equivalent to 1.03% of the total expenditure onhealth care in South Africa. This percentage is considerablybelow the ballpark figure of 2% recommended by theCommission of Health Research for Development.But just as cogent as the levels of expenditure on healthresearch, is the nature of research undertaken. The biennialsurvey of the Department of Education and Training (NATEDSurvey) categorised research into “basic research, applied

research and experimentaldevelopment.” In 1991/2,

29% ofhealthresearch wasclassified as“basicresearch,”59% wasregarded as“appliedresearch”,while 12%was viewedas “technolo-gy develop-ment.” Of all

health research conducted in 1991/2, only one-fifth (23%)was categorised as comprehensive medicine and oncotherapy(incl. community health, epidemiology, geriatrics, nutritionand radiotherapy). While this categorisation permits someunderstanding of the predominant methodologies employedby health researchers, it provides little guidance as towhether this research addresses, in the main, problems thatare of priority to health in South Africa. Although a country’shealth priorities cannot be equated with its health researchpriorities, the two are intimately linked, and investments inhealth research should be directed toward areas in which theprobable impact on health is greatest.An indicator of the tenuous relationship between health plan-ners and researchers is the predominance of clinical andbasic disciplines in research, which together comprised overfour-fifths of the 720 publications by South African authorslisted in MedLine in 1994. This disproportion does not neces-sarily imply that existing capacity in clinical and basic disci-plines be down-scaled, but points to a pressing need todevelop research capacity in health systems research, tech-nology development, community-based epidemiology andcross-sectoral studies.

A number of recent activities representsuccessful models for the development ofrelatively neglected research disciplines.The Centre for Epidemiological Research

of Southern Africa (CERSA), which forms part of the MRC,has been instrumental in developing the country’s capacity toconduct relevant epidemiological studies.In recognition of weaknesses in data pertaining to healthfinancing and expenditure, and in health economics in gener-al, the Health Systems Trust (HST) has invested significantly

SOUTH AFRICA

Sources offinance


Expenditureon health research

Progress todate

in 1991/2 south africa spentr2.8 billion, or 1.04% of its gdp,

on research, of which on


THE

WHO/WORLD BANK/UNDP

NETWORK ON HEALTH REFORM

As part of its global support to countries, the World Health Organization’s ICO (Division of IntensifiedCooperation with Countries) embarked in 1994 on a joint venture with two other major agencies of the UnitedNations system to set up a Network on Health Reform to channel technical cooperation to developing coun-tries. The Network, known as the PARTNERS FOR HEALTH NETWORK FOR HEALTH REFORM, was launched in col-laboration with the United Nations Development Programme (UNDP) and the World Bank to assist developingcountries to implement health reforms.The Network is intended to promote, in both developed and developing countries, a wider exchange of informa-tion and experience of health reform, so that lessons learned can be made widely available, and adapted for usein other countries, where appropriate. The Network will also be useful to development agencies which, them-selves, need to learn about the complex process of health reform in order to provide better guidance and sup-port to developing countries.Through Network contacts, non-governmental organisations (NGOs), major development agencies and agenciesof the United Nations system will be brought together to identify country priorities and needs, as well as assist-ing country staff to analyse and identify appropriate policies and plans.An important feature of the PARTNERS FOR HEALTH NETWORK will be the database on health reform whichWHO intends to set up at its headquarters in Geneva. This computer-based information bank on health reformwill make use of advanced informatics technology to collect, organise and make accessible the most up-to-dateinformation available on the health reform process. Network members with access to the lnternet electroniccommunications system will be able to gain access automatically to this database and to benefit directly fromthe expertise and experiences of other Network members. The aim is to make this information and expertisewidely available to as many individuals and institutions as possible, in both developed and developing countries.The PARTNERS FOR HEALTH NETWORK is broadly supported by a range of WHO technical programmes whichcontribute their specialist expertise and experience to health reform processes. Further technical input to theNetwork is provided by selected focal points in each of WHO’s Regional Offices, reflecting the Organization’swide experience of working with developing countries.Membership of the Network — which includes the Country Focal Points and Board Members of COHRED — isalready widely representative of the interest in this field expressed by United Nations and development agen-cies, non-governmental organisations and institutions in developing countries.

Dr Roberta Ritson is the WHO Focal Point for the Partners for Health Network.She may be contacted by fax: (41 22) 791 07 46 or E-mail: [email protected]


N E W S FR O M ENHR PA R T N E R S

C O H R E D , l i k e E N H R , i s a l l - e m b r a c i n g , i n c l u s i v e , p a r t i c i -p a t o r y . T h e E N H R p r i n c i p l e s i t a d v o c a t e s c a n b e u s e d b ya l l t h e g r o u p s t h a t m a k e u p t h e w o r l d o f h e a l t h r e s e a r c h

a n d a r e a l r e a d y b e i n g u s e d b y m a n y — t o w h a t e v e r e x t e n t ,i n w h a t e v e r f o r m a n d u n d e r w h a t e v e r n a m e .

A c t i n g a s a f o r u m f o r c o m m u n i c a t i o n b e t w e e n t h e v a r i o u sE N H R p a r t n e r s s e e m s t o f o l l o w l o g i c a l l y a s o n e o f

C O H R E D ’ s r o l e s . T h i s n e w c o l u m n i s m e a n t t o c o n t r i b u t et o t h a t r o l e .

THE FIRST AFRICAN ENHR NETWORKING MEETING WASheld in Mombasa (Kenya) in May 1994, in con-junction with the National Convention on ENHR

in Kenya. Its forty-odd participants included ENHRFocal Points from Ghana, Kenya, Nigeria, South Africa,Tanzania, Uganda and Zimbabwe as well as membersof the International Health Policy Program (IHPP) fromGhana, Kenya, Nigeria, Tanzania and Uganda, repre-sentatives from the Joint Health Systems ResearchProject for Southern Africa, the CommonwealthRegional Health Community Secretariat, SOMA-Net,AMREF, WHO, UNFPA and UNICEF. The meetingreviewed the headway the different countries havemade in putting the ENHR strategy into action, as wellas the constraints and challenges they encountered inthe process. It further stressed the need for each coun-try to organise a participatory national consultativeprocess to set its health research priorities. Finally, itunderscored the value that regular networking meet-ings have as a forum for sharing experience and exper-tise.A Second African ENHR Networking Meeting was

organised to coincide with the 14th Conference of theEpidemiological Society of Southern Africa (ESSA),which took place in Harare, Zimbabwe, in August1995. Participants came from Egypt, Ethiopia, Ghana,Kenya, Malawi, Mauritius, Nigeria, South Africa,Tanzania, Uganda and Zimbabwe. The African IHPPteams were also attending, as well as delegates fromseveral ENHR-related health research programmes inthe region.The meeting reviewed critically country developmentsin ENHR, discussed an information and communica-tions strategy for ENHR appropriate for the region, andanalysed various ways and means of monitoring andevaluating the ENHR strategy. In addition, it developeda plan of work for the coming two years and formulat-ed recommendations on these issues to the COHREDBoard. q

For further information about the African ENHRNetworking, contact Prof. Dr. R. Owor, Professor ofPathology, Faculty of Medicine, Makerere University, P.O.Box 7072, Kampala, Uganda; Tel: (+256-41) 531 730, Fax:(+256-41) 234 579 or (+256-41) 530 022.


in individuals and institutions working in this field. The publication of a national Review of Health Expenditure and Financing in April 1995was the culmination of a two-year process coordinated by the HST, but directed by a Reference Group representative of the Department ofHealth, the African National Congress, researchers and funders. The World Bank acted as principal technical advisor. This Review has served asa primary source for the national committee appointed by the Minister of Health to investigate the feasibility of some form of national healthinsurance.Recent legislation regulating tobacco sales and related advertising is the consequence of a concerted programme of action by research, healthservice and advocacy groups, aimed at promoting sustained tobacco control. Research, principally conducted by the MRC, has demonstratedtrends in tobacco smoking and its consequences, and identified legislative options for greater regulation.A project in northern KwaZulu-Natal, funded jointly by the HST and the MRC, has demonstrated the benefit of new technology developmentsfor rural health. Using Global Positioning technology, the spacial distribution of malaria has been plotted, permitting greater targeting ofresources in its control and vector eradication. This technology has also proved its worth in health planning outside of malaria control and insectors outside of health.The Glaxo Action TB project represents a model of public/private sector interaction in which a pharmaceutical company has invested significant-ly in a multi-faceted research strategy aimed at the prevention and control of tuberculosis.The lessons learnt and strategies employed in all of the above projects should help to direct the implementation of a national strategy for healthresearch. q

Contact: Dr Craig Househam, Chairperson, National Technical Committee on ENHR South Africa;Tel (051) 405 44 88, Fax (051) 304 958.

REGIONAL DEVELOPMENTS

AFRICAN ENHRNETWORKING

South AfricaContinued from page 6

IN MAY 1994, A REGIONAL MEETING WAS HELD INOlongapo City, Philippines: the 1st Asian EssentialNational Health Research (ENHR) Network Meeting.

The participants were representatives from nine coun-tries of the Asian Region, from Uganda (for the AfricanRegion), and from three agencies: IDRC (InternationalDevelopment Research Centre), IHPP (InternationalHealth Policy Program), and COHRED (Council onHealth Research for Development). What brought themtogether?The Meeting was intended to prepare the ground for an“enhrNET” that would link country programmes in anet spanning an entire region and—eventually—growinto inter-regional networking. The benefits are obvi-ous: country-specific experience, information, method-ologies would all become ‘shareware.’ No more rein-venting of the wheel for newcomers to the ENHRapproach. The “enhrNET” will enable them to draw onthe available experience at considerable savings interms of time, money and human resources. What ismore, a common agenda for action will appear a natur-al, and desirable, consequence of such linkages.

Like its electronic cousins, the “enhrNET” will need an“administrator” to ensure that it runs smoothly and that

it will deliver what it has been designed to provide:

Frequent, friendly, free and flexible communicationsand information exchange

Regional workshops or research training coursesCollaborative regional research projects

Joint advocacy for ENHR among countriesPeer review of research, using experts from member

countries in the region(s)Regional publications, e.g., newsletters

Annual meetings on a selected priority research area.

The Meeting in the Philippines offered three models forthis “administrator,” or coordinator, role, with the coor-dinating country being preferably one with severalyears’ experience with the ENHR process:

Model One — Dedicated Focal Point — Coordinationof network activities by one country on a rotating basis.Model Two — Catalytic Focal Point — Activities car-ried out by all countries, but coordination done by onecountry on a rotating basis.


very short supply.

What is noticeable about the health research effort in the Lao PDR is the spirit of the various actors involved, who see the needto make research a crucial component for health development efforts rather than a mere matter of academic interest. Thisrequires a highly collaborative working environment, in which all the different external resources available to help in improv-ing the country’s health status must be coordinated to serve the common goal. There is undoubtedly need for research as ameans to acquire crucial information that will assist in health planning and management. We also have a great opportunity tolearn more about locally endemic health problems and undertake research that will benefit not only our country but also theworld community. Our aim should be to improve the nation’s health and to build up a long-term capacity for addressing priori-ty issues, with close collaboration and support from the international community.COHRED intends to contribute towards carrying out the last two years of the first five-year health research plan, as well asassisting the Council of Medical Sciences in drawing up a strong second five-year health research plan. q

Contact: Dr Boungnong BOUPHA, Chairperson, Council of Medical Sciences, Ministry of Health, 473 Samsenthai Road, Ban Kao Nhot, Vientiane, Lao People’sDemocratic Republic; Tel / Fax (+856-21) 21 40 12.

ASIAN REGIONAL NETWORKING

How it startedand where it is heading

Country Updates — LaosContinued from page 5


Model Three — Distributed Focal Point — Action plandrawn up by all countries, with responsibility for activitiesbeing divided up among member countries.Practical networking started right at the meeting inOlongapo City, with all the countries repre-sented giving updates on theirENHR activities. One monthlater, in June 1994,Bangladesh, thePhilippines andThailand, as the threecountries in the AsianRegion with the longest experi-ence with ENHR, came together tochoose the networking focal point.Bangladesh was selected to act as the regionalfocal point, effective from May 1994 to April 1996.Model Three of the above was chosen as the one appropri-ate for the Asian Regional ENHR Network.In a subsequent meeting held at Delhi in November 1994on the tentative regional work plan, it was decided that thepeople experienced in implementing ENHR from the abovethree Asian countries would be assigned to visit each coun-try. The purpose of the visit would be to identify / acquaintthemselves with the leaders / focal points and familiarisethemselves with the concerns of the various stakeholders, aswell as eliciting support for ENHR. A need to assess thedemand for further training, especially in research manage-ment for ENHR, was expressed. It was agreed that a regionaltraining workshop on this would be organised, but only afterspecific country needs and levels of experiences could beascertained to ensure that the workshop serves as a crucialmainstay to support the ENHR movement.

This meeting recommended that a planning meeting for theRegional Workshop on Health Research Management beorganised in Dhaka.Based on the above premise, a Planning Meeting for theRegional Workshop on Health Research Management wasorganised at Dhaka from June 30 to July 02, 1995, aftercountry visits to Cambodia, Indonesia, Lao PDR and Nepal.

During the meeting, the role of the regional ENHRnetwork was discussed in the light of find-

ings from the recent country visits.The meeting concluded with

the recommendation that the pro-posed Regional Workshop on Health

Research Management should be organised atBangkok before mid-December this year,with the goal of developing a national planfor countries new to these ideas and reaf-firming or revising plans that already exist.It is anticipated that the workshop willproduce draft plans from countriesreflecting the critical issues, strategiesand skills required for implementing

ENHR in the best possible way. Expected to participate inthis workshop are the following countries of the region:Bangladesh, Cambodia, China [?], India [?], Indonesia, LaosPDR, Nepal, Pakistan [?], Philippines, Thailand, Viet Nam. q

Contact: Dr Sadia A. Chowdhury, Coordinator,ENHR,B and Director,Women’s Health and Development Programme, c/o BRAC, 66 MohakhaliC.A., Dhaka 1212, Bangladesh; Tel (+880-2) 884 180-7, Fax (+880-2) 883542 or 883 614.


NETWORKING IN THE CARIBBEAN

THE COMMONWEALTH CARIBBEAN COMPRISES 18 POLITICALLY INDE-pendent states and British-affiliated dependencies. Ethnic

composition, resources, capabilities, as well as religion and cul-ture, vary widely from one state to the next. Geographicallysmall and with their resources limited, these states have amajor interest in joining forces in their health research endeav-our. The region’s central agency for health programmes andhealth research is the Commonwealth Caribbean MedicalResearch Council (CCMRC). With support from the Task Forceon Health Research for Development, the CCMRC organised aseries of meetings, workshops and consultations, the result ofwhich was a proposal to establish and implement a five–yearEssential National Health Research programme for theCaribbean as a region and for the individual countries. Unlikethe national programmes, which will reflect each Caribbeancountry’s own priorities, the regional ENHR programme willprovide an overall framework, with the following seven priorityareas for research : •environmental protection (including vec-tor control), •human resources development, •chronic non-mmunicable diseases, •strengthening health systems, •foodand nutrition, •maternal and child health, and •AIDS.Parallel with the above developments in the CommonwealthCaribbean, something started moving in the Netherlands

Antilles as well: the Foundation for Promotion of Research andInternational Cooperation in Health Care , a non-governmentalorganisation based in Curaçao—in collaboration with the Uni-versity of Groningen, the Netherlands—organised a firstNational Symposium on Health Studies (in March 1994) to dis-cuss the initial outcomes of the so-called Curaçao Health Study.This is “a cross-sectional epidemiological study to elicit infor-mation on respondents’ objective and subjective health status,lifestyles and health-related behaviour, including use of tradi-tional and modern care.“ The Symposium, in which theCCMRC participated, recommended exploring the possibilitiesof expanding the Curaçao Health Study to other islands of theNetherlands Antilles and making studies like the CuraçaoHealth Study a component part of the CCMRC proposal forEssential National Health Research for the Caribbean. In April1995, when the CCMRC came together in Barbados for itsannual meeting, the idea of closer collaboration betweenCCMRC and the Netherlands Antilles was taken up once moreat a joint meeting between CCMRC, Netherlands Antilles andCOHRED. A joint Working Group was set up and was giventhe task of:nWorking out a specific, joint research and development project,

From left to right:Dr M.Hossain, Dr S. Chunharas, Dr S. Chowdhury,Dr M. A. Lansang, Dr C. Sitthi-amorn, Dr A.Z. Baig

Asian NetworkingContinued from page 9

...Continued on page 11


using the Curaçao Health Study as an entry point;nIdentifying the human, financial and other resources needed for carrying out such a project;nRecommending other areas in which the Caribbean and the Netherlands Antilles could and should join efforts.It is worthwhile noting that these networking activities have already borne fruit:• a technical group from CCMRC and the Netherlands Antilles met in Curaçao (in May 1995) to develop a joint research pro-

ject;• scientists and health workers of Curaçao have been invited to participate in Research Methodology training workshops

organised by CCMRC;• a joint training workshop for the Commonwealth Caribbean and the Netherlands Antilles on Priority Setting for Health

Research is on the agenda for 1995 (Jamaica, in November). q

For further information, contact: Dr David Picou, Director of Research, Commonwealth Caribbean Medical Research Council, 20 Schneider Gardens, Petit Valley,Trinidad; Dr Izzy Gerstenbluth, Department of Epidemiology & Research, Geneeskundige en Gezondheidsdienst, Piscaderaweg 49, Willemstad – Curaçao,Netherlands Antilles, Tel +599-9-625800; Fax +599-9-628343.

UPCOMING EVENTS

M E E T I N G S & C O N F E R E N C E S

Scientific Basis of Health ServicesAn International ConferenceSponsors: Department of Health, United KingdomLocation: Queen Elizabeth II Conference Centre, London,United KingdomContact: Ms Karen Wingad, Conference Manager, Scientific Basisof Health Services Conference, P.O. Box 4124, Hall Green,Birmingham, United Kingdom, B28 9HE; Tel +44(0) 121 7784070; Fax +44 (0) 121 702 2886.Description: The Conference will examine existing linksbetween research and health services in the UK and elsewhere,and will explore how these can be strengthened to secureimprovements in health and health care. Amongst the subjectsthat will be dealt with in plenary lectures, symposia, panel dis-cussions and parallel workshops, and proffered paper sessionsare: nThe use of research methods to analyse, evaluate andpropose solutions to health and health service problems; nThechallenge of Development as opposed to Research and thepractical application of the results of research; nSetting priori-ties for health research and development; nHealth research andthe relationship between developed and developing countries.This international forum for debate will be of interest to thoseengaged in health services research, academic medicine andclinical practice including primary care, public health and epi-demiology, nursing and the professions allied to medicine, bio-logical and physical sciences, social sciences, health econom-ics, health policy, health services management, research man-agement.

European Conference on Tropical MedicineOrganisers: The European Societies of Tropical MedicineLocation: CCH—Congress Centrum Hamburg, Germany

Contact: Conference Secretariat, TROP ’95, c/o Hamburg Messe& Congress GmbH — Congress Organisation — Jungiusstr. 13,

D–20355 Hamburg, Germany; (General Information) Tel +49 403569–2341, Fax +49 40 3569–2343; (Scientific Programme) Tel+49–(0)40–31182–511, Fax +49–(0)40–31182–512.Description: The Conference’s aim is to strengthen the linkswith colleagues from the tropical countries. Of particularinterest to health researchers will be Sessions I & 2(nResearch Priorities in International Health, nHealth in theCommunity) and the presentations on partnership betweenEurope and developing countries in health research, or onsuccessful examples of health systems research. Surroundingthe main themes of the Conference will be symposia, includ-ing one on the subject of n“Essential National HealthResearch — From Theory to Practice” under the chairman-ship of Yvo Nuyens, COHRED, as well as workshops onbasic and applied research, diagnostics and treatment oftropical disease, and an extensive scientific exhibition. Theofficial languages of the Conference are English and French.

International Conference on Governments and HealthSystems: Implications of Differing InvolvementsOrganisers: The Israel National Institute for Health Policy andHealth Services Research, in co-operation with the RegionalOffice for Europe of the World Health OrganizationLocation: The Holiday Inn Crowne Plaza Hotel, Givat Ram,Jerusalem, IsraelContact: The Secretariat, International Conference onGovernments and Health Systems, P.O. Box 50006, Tel Aviv61500; Tel 972–3–514 00 00; Fax 972–3–517 56 74,972–3–514 00 77; E-mail: [email protected]: The Conference will review research on theimplications of government involvement in a country’s healthsystem. Among the issues to be discussed are: regulation versusfree market forces in governing the number and distribution ofhealth institutions, physicians and other health personnel; theextent to which governments should “interfere” in lifestyles topromote health; who should assure the efficacy and safety ofhealth technology and the quality of health care, including

OCTOBER 2-4, 1995

OCTOBER 22-26, 1995

DECEMBER 17-22, 1995

Caribbean NetworkingContinued from page 10



Supplement to Health Transition Review Volume 4, 1994edited by John Cleland and Peter Way, published byThe Health Transition Centre, National Centre forEpidemiology and Population Health, The AustralianNational University, Canberra, Australia in conjunc-tion with the International Union for the ScientificStudy of Population (IUSSP), 1994, pp 367. ISSN1036—4005.Based on a selection of papers presented at aseminar held in Annecy, France, fromDecember 5–9, 1993, this Supplement isdevoted entirely to the subject of AIDS, itsimpact and prevention in the developing world, and its demographicand social science perspectives. The social and behavioural compo-nents of HIV transmission were not a priority concern until recently.However, with the disease HIV/AIDS threatening to reverse long-stand-ing mortality declines in an increasing number of countries, rapid dis-semination of scientific findings concerning behaviour that contributesto the spread of infections and of studies on its impact has become par-ticularly important. The main policy lessons drawn from the seminarhave been summarised in an IUSSP policy and research paper entitled‘Towards a more effective policy response to AIDS .‘HEALTH CARE PLANNING UNDER SEVERE RESOURCE CONSTRAINTS — Developmentof methods applicable at district level in sub-Saharan Africaby Erik Nordberg. The Unit of International Health Care Research(IHCAR), Department of International Health and Social Medicine,Karolinska Institutet, S–17177 Stockholm, Sweden, 1955, 136 pp. ISBN91–628–1634–9.A poor and economically stagnating region, sub-Saharan Africa tends toremain behind the relatively rapid and dynamic development processunder way in other parts of the developing world. The author of thisthesis describes ways and means of empowering people and institu-tions involved in local health development and health care planning inEast Africa. In this context, he investigates the East African health devel-opment and health sectors in terms of their current opportunities andproblems, which include: rising levels of education, growing politicalconsciousness and pluralism, public sector decentralisation, rapid butslowing population growth, economic stagnation, poverty and under-nutrition, environmental degradation, human rights violations, civilunrest with displacement and involuntary mass migration, unsatisfacto-ry health care and poor social security.TACKLING INEQUALITIES IN HEALTH. An agenda for action.edited by Michaela Benzeval • Ken Judge • Margaret Whitehead. TheKing’s Fund, London, United Kingdom, 1995, 166 pp. ISBN 1 85717088 1.This book reflects the discussions of a seminar organised by the King’sFund in September 1993, which examined the policy options and iden-tified priorities for action in tackling inequalities in health. The authorsstress that “a worthwhile agenda for tackling inequalities in health must... include a strong focus on reducing poverty and a commitment to thecareful monitoring of the impact of major public policies on health,particularly among the most vulnerable groups.” The book’s focus is onthe relationship between poor health and housing, poverty, smokingand access to health care. It outlines “a number of practical and afford-able ways in which the situation could be substantially improved if thepolitical will existed to recognise that tackling equalities in health is afundamental requirement of social justice for all citizens.” And itreviews the evidence for the effectiveness of the practical suggestionsprovided for interventions involving almost every aspect of society (thephysical environment, such as the adequacy of housing, working condi-tions and pollution; social and economic influences, such as incomeand wealth, levels of unemployment, and the quality of social relation-

ships and social support; barriers to adopting a healthier personallifestyle; access to appropriate and effectivehealth and social services).

HEALTH AND DEVELOPMENT

edited by David R. Phillips, Institute of PopulationStudies, University of Exeter, U.K. and Yola

Verhasselt, The Free University, Brussels, Belgium.Routledge London and New York, 1994, pp 331. ISBN

0–415–08529–2 (pbk.)Including regional and country case studies, this clearly

structured work deals with the multi-faceted aspects ofhealth impacts of development. It focuses on crucial issues

such as the effects of economic adjustment and environmental changeon health, the interaction of poverty and health, socio-cultural factors inHIV/AIDS transmission, the use of traditional and community healthcare resources, and women’s health.Investing in People. The World Bank in ActionThe International Bank for Reconstruction and Development/THEWORLD BANK, 1995. 83 pages. ISBN 0-8213-3207-4This publication is intended to provide an introduction to the Bank’swork in the social sectors and to illustrate recent work. The examplesin the booklet are drawn from every region and represent innovative orexemplary lending, policy analysis, technical assistance or donor coor-dination efforts. The examples highlight three main themes: •newefforts to concentrate resources on services that give the most value formoney; •greater emphasis on listening to, learning from and workingwith communities and households; and •fresh ways of using collabora-tion and partnership among all interested parties.Research for Development. SAREC 20 YEARS

Swedish Agency for Research Cooperation with Developing Countries,SAREC, 1995. 199 pages. ISBN 91 86826 25 5.In this book, eminent researchers illuminate the critical part that knowl-edge and information play in Third World development. Of particularinterest to our readers could be the contribution on capacity building,its “south-based” and its “north-based” barriers. The book ends with aview of what is in store for developing countries in the next fifty years.

NEWSLETTERS

HST UPDATEProject for Health InformationDissemination (PHID)Health Systems TrustSouth AfricaThis monthly publication reportson a wide range of topics relat-ed to health care, health poli-cy, health reform, training,etc. Its December 1994 issueincluded an account of thediscussions and the out-comes of a national meet-ing called by the Ministryof Health in December1994 to discuss theimplementation of aprocess of Essential National Health Research (ENHR). The March 1995issue dealt primarily with the process of developing human resources,with emphasis on health workers operating at the community level ofhealth care. It should therefore be of particular interest to community-health workers. Details: HST UPDATE, Project for Health InformationDissemination (PHID), Health Systems Trust, 504 General Building, CnrSmith & Field Streets, Durban, 4001, South Africa.

PUBLICATIONS

rehabilitative care — governments or the health professions? The four scientific sub-committees will deal with the following five subjects: cost, financing and paymentin health services; health manpower, including research and researchers in health care systems; health promotion and disease prevention; capital formation andhealth technology; and quality management.The official language of the Conference is English.

EDUCATIONAL PROGRAMMESThe Nuffield Institute for Health, Leeds, United Kingdomis organising in 1995/6 a series of international masters and postgraduate diploma courses of relevance to our readers. For further information, please address your-self to Information and Admissions Officer, Nuffield Institute for Health, 71 – 75 Clarendon Road, Leeds LS2 9PL, U.K. Tel +44 113 233 66 33; Fax +44 113 246 08 99.

MEETINGS & CONFERENCESContinued from page 11

Health & Medicine

Frenk power ideas