1. Copyright: Knowledge Utilization Research Center1 Chapter 2 Building and Sustaining Strong National Health Research Systems World health report 2012

2. Copyright: Knowledge Utilization Research Center2 Kazem Heidari PhD student of epidemiology Knowledge Utilization Research Center; Tehran University of Medical Sciences

3. Copyright: Knowledge Utilization Research Center3 Introduction-An Overall Framework  Research improves health through three primary paths Better products and services Evidence-informed policies and practice Empowering people towards healthy behaviors  The mechanisms through which these goals are achieved are a set of activities which occurs within an entity called a national health research system (NHRS)

4. Introduction-An Overall Framework  NHRS requirements to achieve the desired goals A sound conceptual framework and a pragmatic strategy An ability to monitor and evaluate its own progress An appreciation of the forces beyond research which needs to be in place for success. Copyright: Knowledge Utilization Research Center4

5. Introduction-An Overall Framework Copyright: Knowledge Utilization Research Center5

6. Introduction-An Overall Framework  The movement towards a stronger NHRS is driven by its three primary constituencies(and beneficiaries) or stakeholders: 1. Researchers (in the public and private sectors); health professionals; 2. People: patients and the general public; 3. Decision- and policymakers(including health system managers). Copyright: Knowledge Utilization Research Center6

7. The movement towards a stronger NHRS 1. The NHRS needs to be more inclusive of research activities which promote innovation, as well as giving more emphasis to implementation research. 2. The NHRS needs to play a role in finding innovative ways of communicating and disseminating health knowledge derived from research to the public in a manner which is accessible and understandable 3. The goal is to promote evidence-informed decision- and policy- making by inculcating an evidence informed 'culture' among decision makers within the NHRS, as well as establishing effective mechanisms and processes to strengthen the evidence to policy linkages to make this happen. Copyright: Knowledge Utilization Research Center7

8. What is a National Health Research System? Who Are Its Key Stakeholders?  Responsibility of countries to promote activities to strengthen NHRS Improvement of the knowledge base for making decisions Setting priorities Managing research Monitoring performance Adopting standards and regulations for high quality research and its ethical oversight Ensure participation in such activities of the community, nongovernmental organizations and patients.  The research system should be seen as the 'brains' of the health system - a means to analyze, understand and improve the health system. Copyright: Knowledge Utilization Research Center8

9.  An integrated and holistic 'systems' approach to health research is arguably a rational approach to maximize its value and impact.  The health system, in turn, must also inform the health research system. For example, reliable, accurate and accessible health information, is critical for informing priority research agendas and as a means of tracking the impact of research. Copyright: Knowledge Utilization Research Center9 What is a National Health Research System? Who Are Its Key Stakeholders?

10.  How the three stakeholder groups can effectively contribute to the overall system (UK experience) The diverse needs of the various groups must be addressed A facilitating mechanism at the interface between the health research system and its various stakeholders should be developed Additional resources should be allocated to expand the scope of the health research system while maintaining support for basic science Copyright: Knowledge Utilization Research Center10 What is a National Health Research System? Who Are Its Key Stakeholders?

11.  Key activities Generate knowledge Synthesize and utilize it to improve health outcomes. Use knowledge to effectively coordinate and manage the system itself and monitor and evaluate its performance  The intrinsic goals of the NHRS system are the advancement of scientific knowledge and the utilization of knowledge to improve health and health equity. Copyright: Knowledge Utilization Research Center11 What is a National Health Research System? Who Are Its Key Stakeholders?

12. Copyright: Knowledge Utilization Research Center12 Four principal functions of NHRS

13.  Stewardship can be seen as the 'umbrella' function of a NHRS The overall organization and governance of a NHRS needs to be established in order to deliver to coordinate and monitor the system so that it delivers the expected results and benefits.  The effective implementation of the functions of the NHRS can, in turn, be considered in by identifying the building blocks or key capacities for such a system. Copyright: Knowledge Utilization Research Center13 What is a National Health Research System? Who Are Its Key Stakeholders?

14. 1. Setting relevant research priorities -allocation of resources 2. Building and strengthening research capacity - people and institutions 3. Defining norms and standards - rules of the game 4. Translating knowledge into actions which can improve health outcomes. Copyright: Knowledge Utilization Research Center14 Key capacities needed for NHRS

15.  In performing this analysis, we draw on three sources of inputs: (1) the existing body of knowledge and experience on national health research systems - with an emphasis on more recent additions to this body of knowledge; (2) novel ideas and approaches, and recently developed tools and methodologies - many of which are relatively untested; (3) where available, country- and evidence-based experiences of applying and evaluating the impact of specific strategies to strengthen various aspects and functions of health research systems.  It should be mentioned, however, and despite increasing interest in the importance of NHRS, that there is currently only a limited pool of primary research, as opposed to opinion, on how health research systems can best be organized at an overall level. Also, whatever primary research exists tends to be from developed countries.  This highlights both an opportunity and a key knowledge gap - it is hoped that the Report will stimulate and catalyse more quality research in the future to address this important issue. Copyright: Knowledge Utilization Research Center15 What is a National Health Research System? Who Are Its Key Stakeholders?

16. Setting National Health Research Priorities  Some middle-income countries in the developing world have been increasing their investments in R&D (e.g. India, China, Brazil, S. Africa).  There needs to be a strategy for prioritizing health research.  Various methodologies have been developed and applied in different settings. Copyright: Knowledge Utilization Research Center16

17.  Combined Approach Matrix (CAM): by Global Forum for Health Research, public health and institutional dimension  COHRED: by using ENHR (Essential National Health Research) strategy which takes into account four criteria: appropriateness, relevance, chance of success and impact of the research outcome.  CHNRI group (Child Health and Nutrition Research Initiative): Applied successfully in developing country settings and with different childhood diseases. Focuses on the principles of legitimacy, fairness and inclusiveness Provide scores to individual questions against pre-defined criteria with technical experts independently scoring each research option. The process identified twenty 'universal challenges' in setting priorities in health research Copyright: Knowledge Utilization Research Center17 Tools for priority setting

18. Copyright: Knowledge Utilization Research Center18 Setting National Health Research Priorities

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21. How a methodology for setting priorities in health research investments was used in South Africa and globally for defining research priorities in child health and nutrition.  The CHNRI methodology was developed between 2005 and 2007 through 12 meetings of a trans-disciplinary panel of experts from the fields of international health, health research policy, pediatrics and child health, economics and management science, political science, law and ethics, along with programme leaders from low and middle- income countries and members of international organizations.  They addressed a number of key challenges related to multi-dimensional problem of setting priorities in health research investments. After available in a form of an algorithm that could enable systematic, transparent, legitimate and fair, scientifically rigorous and replicable process of priority setting. Copyright: Knowledge Utilization Research Center21

22.  Key stakeholders : investors in health research, community of health researchers and members of general public  The context : expectations on returns from investments in health research, the style of investment, population of interest that would benefit from the investments, the focus of investments in health research, and time frame within which the “returns” are expected.  The investors were also expected to agree transparently on the set of five criteria that would discriminate between many competing research options  Likelihood that the proposed health research would be answerable  Likelihood that it would result in an effective health intervention  Likelihood that this intervention would be deliverable, affordable and sustainable  The maximum potential of intervention to reduce disease burden  Likelihood that the research would reduce inequity. Copyright: Knowledge Utilization Research Center22 How a methodology for setting priorities in health research investments was used in South Africa and globally for defining research priorities in child health and nutrition.

23. A large number of researchers were invited to contribute hundreds of their ideas towards a systematic conceptual framework, so that all dimensions of health research (descriptive, fundamental, translational and implementation research) are represented and that all the questions have a similar level of “depth” (e.g., a 3-year research project). Once a list of a manageable number of ideas – “research investment options” - is consolidated, dozens of researchers are invited to submit through the internet their scores for each research option In the final step, a large number of members of general public set different thresholds and weights for each of the five criteria, so that the overall score also includes the value system of a wider community – which may give more weight to e.g. likelihood of effectiveness, or the impact on equity. Copyright: Knowledge Utilization Research Center23 How a methodology for setting priorities in health research investments was used in South Africa and globally for defining research priorities in child health and nutrition.

24.  The final output: a list which ranks up to 200 research investment options by the 5 transparent criteria and the overall score – from the most to the least attractive for investment support  The applications of CHNRI methodology proved helpful to systematically list and transparently score a very large number of research options in very diverse areas of health research.  It has been used to define national-level priorities for child health research in South Africa Copyright: Knowledge Utilization Research Center24 How a methodology for setting priorities in health research investments was used in South Africa and globally for defining research priorities in child health and nutrition.

25.  Drivers: Systematic nature Transparency Well defined (a priori) context and criteria chosen for discriminating between research investment options A highly structured way in which relevant information is obtained from the scorers Independent scoring that limits influence of strong-minded individuals on the rest of the scorers Informative and intuitive quantitative output, Ability to expose points of greatest agreement and controversy Low implementation cost and replicability  Barriers Perception that the tool is complex and difficult to apply Possible biases, e.g. some good ideas and investment options may not get included in the initial list of research options scored by experts because the CHNRI process only aims to achieve a manageable coverage of the spectrum of all possible research options Copyright: Knowledge Utilization Research Center25 Box 2.1. How a methodology for setting priorities in health research investments was used in South Africa and globally for defining research priorities in child health and nutrition.

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27.  The COHRED approach to research priority setting seems to be the most appropriate for health systems and policy issues for which it is important to consult policymakers, managers and other stakeholders Copyright: Knowledge Utilization Research Center27 Setting National Health Research Priorities

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29.  Another approach uses a cost-effectiveness analyses of medical research as a means to set research priorities, using a 'value of information' perspective. These kinds of objective approach to priority setting are not desirable, but could be improved by including a subjective component (e.g. stakeholder consultation).  Priority setting in health research is a dynamic process and strongly influenced by local context and capacities. Copyright: Knowledge Utilization Research Center29 Setting National Health Research Priorities

30.  It is unrealistic to try and decide which of the various methods developed is 'the best' one, and it is most likely that no one size fits all  Instead, it is suggested that a checklist approach be considered where the use of a particular priority setting tool is only part of the armamentarium. Copyright: Knowledge Utilization Research Center30 Setting National Health Research Priorities

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32.  Commonly, criteria can be categorized into one of three dimensions: Public health benefit (should we do it?) feasibility (can we do it?) Cost  Participants in the priority setting exercise should decide by consensus on appropriate criteria at the beginning of the exercise Copyright: Knowledge Utilization Research Center32 Setting National Health Research Priorities

33.  Who should be involved in priority setting exercises? Patients, health practitioners and the general public are key stakeholders within a NHRS  Regardless of which tool or methodology is used in setting health research priorities, the process by which these are ultimately arrived at is also very important. Copyright: Knowledge Utilization Research Center33 Setting National Health Research Priorities

34. How Brazil set their priorities for health research  Objectives are to meet the targets of the United Nations MDGs on child mortality reduction, combating HIV/AIDS, TB and malaria, and poverty eradication.  The construction of the National Agenda of Priorities in Health Research in Brazil followed a democratic model, based on the epidemiologic and demographic profiles, regional inequality, institutional and intellectual resources Copyright: Knowledge Utilization Research Center34

35.  The key steps : 2003: a Technical Advisory Committee of 20 distinguished scientists and policymakers was appointed to oversee the process; they classified the health research field in several sub-agendas; A National Seminar with 400 scientists and health policy makers to propose research topics in each sub-agenda and to elaborate the first document; The draft of the Agenda was presented to a public consultation on the website for 45 days having registered 1,900 individuals consulting online and 360 comments and contributions received; 2004: the Agenda was approved during the 2nd National Conference on Science, Technology and Innovation in Health, which involved 15,000 participants in 24 states (out of 29). The Agenda was legitimized by scientists, health providers and community leaders. Copyright: Knowledge Utilization Research Center35 How Brazil set their priorities for health research

36.  Evaluation/impact following implementation? Sustainability? The fulfillment of the National Agenda of Priorities in Health Research is being tracked since its implementation, taking into account the life cycle, race, disease, industrial complex, health impact, health system characteristics and technological development, among other criteria The conclusion is that all sub-agendas were reviewed through Calls for Proposals and almost 4,000 research grants were awarded. So far the budget allocated has met the demands. The new federal budget for the quadrennial 2012-2015 will be voted later in 2011 Copyright: Knowledge Utilization Research Center36 How Brazil set their priorities for health research

37.  Key lessons learnt and recommendations The need to have broad and inclusive consultation. The National Agenda of Priorities in Health Research needs to be updated periodically to accommodate new technological advances and new scientific knowledge, as well as the changing epidemiologic profile of the Brazilian population, The Ministry of Health played a key role in setting up and implementing the Agenda. Many barriers were encountered and partially overcome. The financing mechanisms available at the MoH aren’t adequate to sponsor research projects and the bureaucracy involved hinders the flow of resources in a timely fashion. Copyright: Knowledge Utilization Research Center37 How Brazil set their priorities for health research

38.  Links to documents and URL of any websites. About the Agenda and the Management System: http://bvsms.saude.gov.br/bvs/publicacoes/agenda_ingles.pdf http://bvsms.saude.gov.br/bvs/publicacoes/CadernoPrioridadePesquisa.pdf http://www.saude.gov.br/pesquisasaude http://www.saude.gov.br/sisct http://www.scielo.br/pdf/csp/v22n9/02a.pdf http://www.scielo.br/scielo.php?pid=S0011-52582002000400006&script=sci_arttext  About some research reports: http://ajph.aphapublications.org/cgi/content/short/99/1/76 http://jama.ama-assn.org/content/301/15/1573.full.pdf+html http://www.cienciasdasaude.famerp.br/racs_ol/vol-16-4/IDK1_out-dez_2010.pdf http://www.futuremedicine.com/doi/pdf/10.2217/rme.10.76 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758595/ http://www.ncbi.nlm.nih.gov/pubmed/21200420 http://www.scielo.br/pdf/csc/v9n2/20389.pdf http://www.springerlink.com/content/9678869p224l0l01/fulltext.pdf http://www.trialsjournal.com/content/8/1/2 Copyright: Knowledge Utilization Research Center38 How Brazil set their priorities for health research

39.  Challenge of finding the appropriate balance between investing in biomedical, clinical, educational, public health and health systems and policy research where resources are limited.  The ratio of biomedical research to the rest Probably 9 to 1 in developed countries Ought to be the converse in low income countries as applied research is more likely to provide a good return on investment where resources are very limited. Copyright: Knowledge Utilization Research Center39 Setting National Health Research Priorities

40.  No unequivocal evidence that one priority setting approach is superior to another.  Different approaches may be appropriate for different questions but that consultation is likely to be a key component of all approaches although the stakeholders may vary according to the topic. The Combined Approach Matrix (CAM), for example, is highly systematic but quite intensive of time and resources and therefore may be difficult to operationalize where resources are limited. Copyright: Knowledge Utilization Research Center40 Setting National Health Research Priorities

41.  Importance of incorporating rigorous evaluation alongside major policy innovations and programmes Such an evaluation needs to be planned in advance not added as an afterthought - which makes adequate evaluation impossible.  At a higher level of governance, the setting of appropriate priorities should be guided by a robust national health research policy.  In many countries, the development and implementation of such a policy is entrusted to a national health research (or medical research) council or other similar body Copyright: Knowledge Utilization Research Center41 Setting National Health Research Priorities

42. 1. Setting relevant research priorities -allocation of resources 2. Building and strengthening research capacity - people and institutions 3. Defining norms and standards - rules of the game; and 4. Translating knowledge into actions which can improve health outcomes. Copyright: Knowledge Utilization Research Center42 Key capacities needed for NHRS

43. Building and Strengthening Research Capacity  Capacity is not solely an individual attribute but it implies effectiveness, ability and, most importantly, sustainability.  Capacity strengthening refers to improvement in individual or institutional capabilities within a broader system - and implies purposeful investments and efforts directed at achieving practical results and outcomes.  Several levels and dimensions. Individual researchers Research organizations/institutions There is also receptor capacity which refers to the ability of policy makers and health professionals to use, and even demand, research findings Copyright: Knowledge Utilization Research Center43

44.  Three additional elements Research networks serve to link organizations and/or researchers within countries for conducting research and relating it to implementation and policy; These inner levels are further embedded within a national institutional framework defined by the intersection of government policies, funding priorities and administrative systems The capacity within NHRS to link national to international research networks are critical, especially in developing countries and in the face of the rapid advances in knowledge. Copyright: Knowledge Utilization Research Center44 Building and Strengthening Research Capacity

45.  Capacity strengthening should be seen in the context of a system, i.e. capacities are needed across the entire spectrum of the NHRS.  Several key areas for capacity Generation of knowledge - researchers and others who perform primary research in a range of disciplines from biomedical to health systems research; Synthesis of research through systematic reviews- often described as 'secondary' research, and a critical tool for decision making; Knowledge translation-turning knowledge into evidence-informed policy and practice, as well as for effective public communication of research – the need for a cadre of 'knowledge brokers'; Manage and monitor the research system itself Copyright: Knowledge Utilization Research Center45 Building and Strengthening Research Capacity

46. Copyright: Knowledge Utilization Research Center46 The core skills and capacities needed for individual researchers

47.  Areas often neglected in both developed and developing countries.  The skills needed here include Accessing scientific publications (including those in the 'grey' literature) Capabilities to do systematic reviews and meta analysis Development of guidelines, research summaries and policy briefs.  NHRS should address the roles of all actors and participants in the research process, not just the academic researchers in universities or research institutions. The participation of nurses, community health workers, policy makers, NGO's and consumers/patients and communities in both the planning and performance of research. Copyright: Knowledge Utilization Research Center47 Capacity for research synthesis and translation

48.  Many NHRS in developing countries face the problem attracting and retaining staff in the public research sector Brain drain of their best scientific talent, mostly to the developed world or to the private sector. Better incentives (e.g. good career structure, appropriate rewards, respect, grant schemes for young scientists, etc) as well as innovative schemes to attract back the scientific diaspora working outside the country A meritocratic career structure, mentoring and regular appraisal together with transparent promotion criteria is vital to sustain a high quality research workforce. Copyright: Knowledge Utilization Research Center48 Building and Strengthening Research Capacity

49.  At the institutional level, infrastructural capacity is needed to support the individual researchers to pursue their research  Beyond individual institutions, effective networking and a coherent national framework between institutions within countries is important.  Networking also extends to international networks  The all important capacity to monitor and evaluate the performance of the NHRS itself needs to be developed within the NHRS  Another key dimension :the capability to disseminate research findings Copyright: Knowledge Utilization Research Center49 Building and Strengthening Research Capacity

50.  Another key dimension of capacity is the capability to disseminate research findings. Need to improve the academic publishing in developing countries. In 2003: only 10 out of 23 francophone African countries had a locally published journal and that many articles in China's 5,000 plus scientific journals go unread and uncited The country's scientific journals are filled with incremental work, read by virtually no one and riddled with plagiarism. Funding local journals must become part of the portfolio of development agencies. Such funding must, however, be accompanied with ensuring that these journals are of high quality. Quality local journals are important for local health workers to keep them up to date with knowledge advances while international journals may be more relevant for the research community. More journals which focus on summarizing research findings, particularly from systematic reviews, for national and local audiences, particularly health workers, health professionals and policy makers Journals which are directly funded by the pharmaceutical industry, should be discouraged. Making content s freely available through the open access model would promote access and visibility of these journals in developing counties Copyright: Knowledge Utilization Research Center50 Building and Strengthening Research Capacity

51.  In overall terms, the building and retaining of research capacity within a NHRS requires a strategic approach which should try to address several key challenges,  Funding larger, well-established centres of excellence in research should also be pursued in parallel to supporting smaller research groups. Copyright: Knowledge Utilization Research Center51 Building and Strengthening Research Capacity

52. Ten recommendations for building, strengthening and retaining research capacity Copyright: Knowledge Utilization Research Center52

53.  Finally, how can a country assess that its efforts at research capacity building has been successful? Bateson et al (20) have developed an evidence-based tool for evaluating health research capacity building (Fig. 2.4) which has been tested and adapted for use at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Copyright: Knowledge Utilization Research Center53 Building and Strengthening Research Capacity

54. Framework for Designing and Evaluating a Health Research Capacity-Building Programme Copyright: Knowledge Utilization Research Center54

55. Copyright: Knowledge Utilization Research Center55 Thank You!