esearch into Action - COHRED

RESEARCH INTO ACTION 1

esearch into Action

COHREDNEWSLETTER

In this issue of In this issue of In this issue of In this issue of In this issue of Research Into ActionResearch Into ActionResearch Into ActionResearch Into ActionResearch Into ActionExploring Inequity in Health in Southern Africa 2Health Research for Development:

Promoting an African Perspective for the New Millenium 5Making ENHR Happen:

the IndiaCLEN/COHRED partnership 7The Pakistan Public Health Network:

A New Commitment to Health and Development 8One Decade of ENHR 9International Conference on Health Researchfor Development 2000 13New Faces of the COHRED Board 14Publications 15Conference Announcements 15

The Newsletter of the Council on Health Research for Development / Issue 18 / October - December 1999

COHRED, theCouncil on Health

Research for Development, is anongovernmental organisation.

It was established in March1993, and is located in the

European Office of the UnitedNations Development

Programme in Geneva,Switzerland.

While everybody is no doubt preparing for theirChristmas celebrations, the preparations for theInternational Conference on Health Research for Developmentare continuing, and COHRED’s contribution isbecoming even further defined. In this issue, wefeature the special projects that COHRED isundertaking for the October 2000 meeting. As aspecial lead-up to the International Conference, weintroduce the first in a series of ‘opinion pieces’. Thisissue highlights the successes and the future challengesthat COHRED faces in two interviews with successivegenerations of COHRED actors. Dr John Evans,Chair of the Commission on Health Research forDevelopment talks with Nancy Johnson about hishopes for the future, based on the Commission’s goals,and Dr David Okello speaks candidly with LucindaFranklin about the challenges facing COHRED andENHR in the new millennium.

‘ENHR in Action’ is highlighted with snapshots onThe African Conference on Health Research forDevelopment, and some innovative developments inIndia and Pakistan. And we introduce COHRED’snewest Board Members to the fold.

Our feature article this quarter looks at HealthEquity in Southern Africa, and how EQUINET andENHR are helping to fill the knowledge gap.

Finally, it’s been five years since the first issue ofResearch Into Action went to press, and since then we’venever really taken stock of our approach, or surveyedour readership about their needs. So, it’s that time ofthe year, where we hope you’ll put pen to paper, and

complete our short survey which looks at everythingfrom the format of the newsletter, to your currentaddress details, so that you will continue to receivethis exciting read in 2000!

Once again, we would like you to know that if youhave an article or story which you think would makeinteresting reading for other Research Into Actionreaders, we’d love to hear from you! We’re alwaysglad to hear from our readers, so if you’d like to seeyour organisation’s name in lights in the following issueof Research Into Action, please post, fax, or email yourstory to the Secretariat (details on the back page ofthis issue), for the attention of The Editor, ResearchInto Action.

COHRED wishes all Research Into Action readers aMerry Christmas and a Happy New Year. See you in2000!

2 RESEARCH INTO ACTION

Recognition of the importance of equity in national,regional and global agendas was the driving force behindthe formation of the Southern African network of researchinstitutions on equity in health, otherwise known asEQUINET. A network of institutions and individualsworking on equity in health in Southern Africa,EQUINET is guided by a steering committee consistingof representatives from Zimbabwe, Botswana, Tanzania,South Africa and Zambia, and involves collaboration withcolleagues from Sweden and the UK. This network ofequity actors in the Southern African region is coordinatedby Dr Rene Loewenson, Director of the Training andResearch Support Centre (TARSC), based in Zimbabwe.Dr Loewenson provided the keynote address to the plenaryof The African Conference on Health Research forDevelopment, incorporating the 6th African ENHRNetworking Meeting, which was held in Harare, inSeptember 1999.

Exploring Inequity in Health inExploring Inequity in Health inExploring Inequity in Health inExploring Inequity in Health inExploring Inequity in Health inSouthern AfricaSouthern AfricaSouthern AfricaSouthern AfricaSouthern Africa

“Issues of social allocation of economic resources cannot be separated from the role of participatorypolitics and the reach of informed public discussion” (Sen, WHO 1999)

Quoting Sen, Dr Loewenson began byhighlighting the relationship between socialforces and their ability to drive policy choicesabout how resources are allocated. Sheemphasised the importance of these social forces,indicating that where resources end up and howthey are used depends on the degree to whichpeople are able to participate in directingresources towards their needs. Citing the recentUNDP report, Dr Loewenson went on toindicate concern over increasing globalinequities.

“The assets of the top three billionaires inthe world are more than the combined GNPof all least developed countries and their 600million people (UNDP 1999).”

She went on to quote further statistics from theUNDP 1999 Human Development Report,further emphasising the growing global inequity:

By the late 1990s the fifth of the world’s peopleliving in the highest-income countries had:

◆ 86% of world GDP, while the bottom fifth had1%

◆ 82% of world export markets, while thebottom fifth had 1%

◆ 68% of foreign direct investment, while thebottom fifth had 1%

◆ 74% of world telephone lines, while thebottom fifth had 1.5%

Community involvement is theCommunity involvement is theCommunity involvement is theCommunity involvement is theCommunity involvement is thekey to effective resourcekey to effective resourcekey to effective resourcekey to effective resourcekey to effective resourceallocation allocation allocation allocation allocation and greater equityand greater equityand greater equityand greater equityand greater equity

The importance of integrating communities intothe resource allocation process was a key pointin Dr Loewenson’s paper. Communities should

SummarySummarySummarySummarySummary1 Recent research about equity in Southern

Africa has shown that inequities exist inrelation to:

◆ Health inputs (literacy, educationetc)

◆ Public health services

◆ HIV (Rich - Poor differences; genderdifferences)

2 There is good evidence from SouthernAfrica that when resources for publichealth services are carefully deployed(“vertical equity”) that health gains can beequitably achieved

3 Integration of communities into resourceallocation processes is important tomotivate vertical equity

Feature Article


not be merely affected by inputs andsubsequently reflect the outcomes of the process.Community involvement, she suggested, is thekey to effective resource allocation and greaterequity, as further evidence shows that the burdenof HIV/AIDS impact is relatively greater athousehold than at sectoral or national level.

Dr Loewenson went on to present the varioustypes of equity-based research that has been, andis currently, occurring in the Southern Africanregion.

Research which highlights inequityResearch which highlights inequityResearch which highlights inequityResearch which highlights inequityResearch which highlights inequityRecent research about equity in Southern

Africa has shown that inequities exist in relationto health inputs (literacy, education etc), publichealth services, and HIV (Rich - Poordifferences; gender differences).

Health InputsHealth InputsHealth InputsHealth InputsHealth Inputs

Disparities in access to health inputs and healthcare have persisted, and in some cases widenedin some southern African countries over the past10 years. In low income, black and ruralcommunities, TB, malnutrition and water-relateddisease rates have been consistently higher.

Public Health ServicesPublic Health ServicesPublic Health ServicesPublic Health ServicesPublic Health Services

Inequalities have been noted between differentpopulation groups, with regards to access to TBcontrol, antenatal care coverage, public healthmeasures, access to quality care facilities. Thesedifferences are distributed across a number ofparameters, including race, rural, urban, andperi-urban status, socio-economic status, agegender, geographical region, and insurancestatus.

HIV/AIDSHIV/AIDSHIV/AIDSHIV/AIDSHIV/AIDS

Much of the ill health and mortality in theregion is now attributable to AIDS, the spreadof the HIV/AIDS epidemic in southern Africaitself exemplifies how inequalities in health andhealth care emerge. Research also showspatterns of transmission, which indicate that thecommon spread of HIV occurs from more

socially and economically powerful adult malesto poor and economically insecure females,particularly adolescent females.

Research which works for equityResearch which works for equityResearch which works for equityResearch which works for equityResearch which works for equityResearch in southern Africa has also shown

that there is good evidence from Southern Africathat when resources for public health servicesare carefully deployed (“vertical equity”) healthgains can be equitably achieved. There have beenmany examples of research showing thatredistribution of investments towards accessibleprimary health services have been highlysuccessful. Dr Loewenson cited further evidencefrom a number of countries, that investments ineducation, and particularly in female education,are a consistent and important determinant ofimproved health in the poorest groups. A reviewof periods of high health gains in Southern Africaindicate that health systems can reduce healthinequalities by redistributing budgets towardsprevention, and by improving rural and primarycare infrastructure and services.

Despite this evidence, “efficiency drivenperspectives have dominated international healthpolicy debates, and focused attention away fromissues of relevance, of services as they interfacewith communities, or of how resources areallocated to these levels”.

The recent push for moreThe recent push for moreThe recent push for moreThe recent push for moreThe recent push for moreefficient management in healthefficient management in healthefficient management in healthefficient management in healthefficient management in healthservices services services services services has done more harmhas done more harmhas done more harmhas done more harmhas done more harmthan goodthan goodthan goodthan goodthan good

Dr Loewenson expressed concern that thedomination of the “efficiency driven perspective”has had a negative impact on the equity agenda.The recent push for more efficient managementin health services has done more harm than good,and has in fact, exacerbated inequity.

She attributed the poor attention “to thepositive experiences in the region that haveemerged from pursuing equity policies” as beingthe enabling environment for “developments inhealth systems in Southern Africa that have

Feature Article


About EquinetAbout EquinetAbout EquinetAbout EquinetAbout EquinetThe Southern African Regional Network on Equityin Health is a network of institutions and individualsworking on equity in health in Southern Africa. Thisnetwork is also known as EQUINET. The aim ofEQUINET is to:

◆ Further the conceptual framework and policyissues in relation to equity in health in SouthernAfrica

◆ Gather and analyse information to supportscientific debates and decisions on equity inhealth in Southern Africa

◆ Engage stakeholders, and in particular thosesocial groups whose interests would be betterserved by more effective pursuit of equitymeasures in health

◆ Use all of the above to provide input intopolicies affecting health at the National andSouthern African Development Community(SADC) regional level

Defining priorities of the EQUINET network includethe exploration of:

◆ The extent to which different groups of peoplein the region are able to make choices overhealth inputs, have the capacity to use thesechoices towards health and the manner in whichpolicies and measures affect such capacities

◆ The extent to which different groups of peoplehave the opportunity for participation, and thepower to direct resources towards their healthneeds, and the policies that influence this.

Financial support for the EQUINET project isprovided by IDRC (Canada).

The EQUINET Network secretariat is based at theTraining and Research Support Centre (TARSC) in

Zimbabwe. Contact Dr Rene Loewensonfor further information on the Network, or visit the

EQUINET website athttp://www.equinet.org.zw

TARSC 47 Van Praagh Avenue, Milton Park,Harare, Zimbabwe

Phone: 263 4 705 108 / 708 835, Fax: 263 4 737 220Email: [email protected]

exacerbated inequity”. Dr Loewenson presentedevidence of this in the absolute reductions in bothreal health budgets, and relative allocations toprimary care, resulting in loss of coverage andpoorer quality of care. She concluded that “manyof these changes reflect the fact that macro-economic and health sector reforms have enabledmore powerful medical and middle-class interestgroups to exact concessions at the cost of thepoorer, less organised rural health workers, orthe urban and rural poor”.

The Challenge for ENHR…The Challenge for ENHR…The Challenge for ENHR…The Challenge for ENHR…The Challenge for ENHR…Dr Loewenson highlighted the challenge for

ENHR as being to lead to “new knowledge” thatfirstly integrates - rather than marginalises -communities into social and economic processesand secondly, enhances informed andparticipatory decision making. The “newknowledge” that allows this to happen is:

◆ That which reveals health costs ofmarginalisation, insecurity and unsustainabledevelopment paths as a sign of a need forchange

◆ That which identifies alternative ways oforganising health systems that direct thatchange

◆ That which builds empowerment and effectiveparticipation in economic and social processes,yielding a greater likelihood of that changebeing effected.

This article features excerpts from the paper by Dr Rene Loewenson titled“Equity in Health in Southern Africa: Can research fill thegap?” and is based on her keynote address to The African Conference on Health Research for Development, incorporating the 6th AfricanENHR Networking Meeting, held in Harare, Zimbabwe, September 19 - 23, 1999.

Note: A review of inequity was recentlypublished in The Lancet (Gwatkin DR, GuillotM, Heuveline P (1999) The burden of diseaseamong the global poor, The Lancet, 354 (August14), 1999), illustrating the attention that equityis currently attracting in both academic journals,and the popular media. In support of this trend,Research Into Action plans to feature an article onthis paper in a forthcoming issue.

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Feature Article


Health Research for Development:Health Research for Development:Health Research for Development:Health Research for Development:Health Research for Development:Promoting an African Perspective for the New MillenniumPromoting an African Perspective for the New MillenniumPromoting an African Perspective for the New MillenniumPromoting an African Perspective for the New MillenniumPromoting an African Perspective for the New Millennium

In the past year, the African ENHR Networkextended its open door policy to Africannetworks at large, not just its inter-countrynetworks. This was plainly illustrated at TheAfrican Conference on Health Research for Developmentwhich took place in Harare, September 19-23,incorporating the 6th African ENHR NetworkingMeeting. Participants from all sectors,representing more than 25 African countries, metfor three consecutive days and discussed manymajor health research issues, such as how Africancountries can ‘work for equity in health’ through‘collaborative partnerships’ in order to worktowards African solutions for African problems.

A full day of the conference programme wasspent discussing ENHR competencies (eg.priority setting for health research, linkingresearch to policy and action, involving thecommunity in research, and capacitystrengthening). Following the keynotepresentations, breakaway sessions offered theopportunity for representatives to exchangeexperiences, highlight lessons learned andidentify future challenges. Feedback from thesediscussions has been provided to COHRED’sTask Force on ENHR Competencies, so that itmay incorporate these in the further developmentof learning materials.

Joint initiatives between COHRED andWHO were highlighted in the address by Dr ESamba, regional Director of WHO/AFRO. DrSamba emphasised the new partnership andencouraged the ENHR focal points to get intouch with national WHO representatives andministries to address problems together. Heindicated that in the last few years, WHO/AFROhas given a high priority to health research ingeneral, and to Health Systems Research (HSR)in particular. From his perspective the HSRprojects at country level could be a strong partnerin the implementation of ENHR

In his opening address to the plenary, theMinister for Health and Child Welfare, Dr TStamps, stressed that in this time of majorreforms in Zimbabwe’s Ministry of Health, policymaking needs to be driven by evidence-basedresearch to ensure that limited resources areinvested in areas with the highest social returns.Therefore, he pledged his assurance that adedicated budget line item for health researchwould be created in the Ministry of Health.

Dr Stamps challenged participants to identifymechanisms for demystifying research and torecognise the importance of including policymakers and communities into the research fold.He suggested that one way of achieving thiswould be to provide opportunities to discussresearch questions and define priorities forresearch collaboratively.

“This conference comes at an opportune timefor the African region as we look forward to theyear 2000 International Conference on HealthResearch for Development, in Bangkok,Thailand” said Dr Stamps, indicating that the“African meeting should be used to prepare forgood African representation at the conference inBangkok”.

Dr T Stamps, Minister for Health and Child Welfare,Zimbabwe

ENHR in Action - Africa


Dr Stamps not only provided the openingaddress to the conference but also attendedsessions throughout the conference, showing hisinterest in issues such as the value of researchfor policy decisions, and in ENHR in general.

The meeting closed with the adoption byunanimous acclamation of the ‘African resolutionon ENHR’.

Renewed Collaboration betweenRenewed Collaboration betweenRenewed Collaboration betweenRenewed Collaboration betweenRenewed Collaboration betweenWHO/AFRO and COHREDWHO/AFRO and COHREDWHO/AFRO and COHREDWHO/AFRO and COHREDWHO/AFRO and COHRED

In June this year, the African ENHR MentoringTeam met with Dr E. Samba, regional Directorof WHO/AFRO, and representatives from theHSR project. It was agreed that the AfricanENHR Network and WHO/AFRO would workcollaboratively in order to:

◆ Compile an inventory of experts andresearch institutions in the African Region(This project is currently underway)

◆ Undertake a project on leadershipdevelopment

◆ Promote coordination of health researchat the country level

◆ Promote better communication andinformation sharing at the country level

The African Resolution on ENHRThe African Resolution on ENHRThe African Resolution on ENHRThe African Resolution on ENHRThe African Resolution on ENHR

We the participants attending the EssentialNational Health Research (ENHR) AnnualNetworking Meeting in Harare in September1999,

Recognising....

the deteriorating health and developmentconditions in Africa due to:

◆ the changing global social, politicaland economic scenario

◆ the diminishing global resources base, andthe diminishing social returns for theinvestments

◆ the increasing competitive demands fromother emerging regional/zones

◆ the large human resource drain ordisplacement to other more lucrativeregions

Realising...

◆ the need for essential health research forhealth development

◆ the need for Africa to address its healthproblems and offer its own possiblesolutions

◆ the need to address the imbalance inresources for health research

◆ the need to influence policy throughevidence based decision making

Reaffirming...

◆ the commitment to essential national healthresearch as an essential tool to addressequity in health and for health development

‘Uplifting’ entertainment was enjoyed by all at theconference dinner

(continued on pg. 7)

ENHR in Action - Africa


Hereby resolve...

◆ to be united in healthdevelopment using awell coordinated ENHRstrategy of health for allin Africa

◆ to offer African solutionsto the African healthproblems using Africaninstitutions

◆ to work with ourgovernments and allother partners in healthdevelopment in Africa

◆ to develop thenecessary criticalcapacity for healthresearch development

◆ to develop anappropriate structureand mechanism tofacilitate increasedresource flows of globalfunds to the AfricanRegion

◆ to contribute actively, asan African community,to the global body ofknowledge andexperience baseconcerning healthresearch fordevelopment

◆ to participate fully withother currently activehealth networks inAfrica

The African Resolution on ENHR(continued)

ENHR in Action - India

Making ENHR Happen: theMaking ENHR Happen: theMaking ENHR Happen: theMaking ENHR Happen: theMaking ENHR Happen: theIndiaCLEN / COHREDIndiaCLEN / COHREDIndiaCLEN / COHREDIndiaCLEN / COHREDIndiaCLEN / COHRED

partnershippartnershippartnershippartnershippartnership

ENHR by serendipity?ENHR by serendipity?ENHR by serendipity?ENHR by serendipity?ENHR by serendipity?An Annual Meeting of IndiaCLEN (the India chapter of the

International Clinical Epidemiology Network, INCLEN) becamea vehicle for renewed interest in the ENHR strategy in India, asreported by Dr Manjula Datta of IndiaCLEN recently.

ENHR in India was first implemented in 1992 through twoNGOs, with the support of the Indian Medical Research Council(IMRC). Since then, ENHR has been less visibly active in thecountry. However, earlier this year discussions between INCLENand COHRED took place that began to concretise collaborationbetween the two initiatives in the Asian Region. This led to ENHRfamiliarisation workshops for INCLEN’s country-based initiativesbeing encouraged.

IndiaCLEN recently held their Annual Meeting, which includedscientific sessions on AIDS research in India, IndiaCLEN’sInfectious Diseases Initiative (IIDI), various epidemiologicalstudies taking place throughout the country, policy research andhealth management issues, the Institutional Review Board, andIndiaCLEN’s Public Health Program Evaluations. Day three ofIndiaCLEN’s Annual Meeting, was intended to be a familiarisationworkshop for members of IndiaCLEN to promote collaborationbetween the country network and COHRED, but instead, becamea workshop for ENHR constituents in India, effectively generatingrenewed vigour and interest in the ENHR strategy.

As a result of this, IndiaCLEN announced that it would activelypursue a program of promoting ENHR within its activities.Initiatives are on their way to construct a platform, in whichIndiaCLEN, the BAIF Development Research Foundation (anactive NGO in the country) and the Indian Council on MedicalResearch, and possibly other actors, could work out a joint strategyfor the promotion of ENHR in India.

Is this luck, or ENHR occurring by serendipity? It just goes toshow that ENHR can’t be forced to operate. If the environmentis right, it will happen naturally.For further information on the ENHR partnership in India, please contact DrManjula Datta of IndiaCLEN. Email: [email protected]


September 18, 1999 was aspecial day in the unfolding ofpublic health and developmentin Pakistan. It saw the birth ofa formal network of institutionsinvolved in health research anddevelopment in the country -the “Pakistan Public HealthNetwork”. More than a dozenkey institutions in the countrywere present at a meetingsponsored by COHRED whichwas held at the Department ofCommunity Health Sciences,Aga Khan University inKarachi, Pakistan. The meetingwitnessed an inter-institutionalcommitment to share scarceresources, learn from organi-zational experiences andexplore the development of anEssential National HealthResearch (ENHR) agenda forPakistan. The meeting was afollow-up from two workshopsthat were held in the previousyear to promote and discuss theorganization of such a network.

The Karachi meeting involveda core group of researchinstitutions. Participantsidentified key focus areas for thecountry, such as the role andneed for capacity developmentin Pakistan; the evaluation andmonitoring of capacity develop-ment efforts; and the healthsystems and academic environ-ment within which capacitydevelopment efforts need tooccur.

The Pakistan Public Health Network:The Pakistan Public Health Network:The Pakistan Public Health Network:The Pakistan Public Health Network:The Pakistan Public Health Network:A New Commitment to Health and DevelopmentA New Commitment to Health and DevelopmentA New Commitment to Health and DevelopmentA New Commitment to Health and DevelopmentA New Commitment to Health and Development

The meeting also formalisedthe role of the network ofinstitutions involved in publichealth research and develop-ment in the country, and helpedto define a strategy for movingahead with the implementationof ENHR in the country.

The outcome was theformation of two special TaskForces. The first is to be chairedby the Pakistan MedicalResearch Council, and willundertake further explorationof the Essential National HealthResearch strategy. The secondgroup will work on the financialand legal formalities of thenetwork.

The day closed with a feelingthat something important hadhappened - key stakeholders inthe country had agreed to worktogether for Essential NationalHealth Research. The spirit ofmutual understanding,commonality of need and unityof purpose was tangible, andeach representative headed fordifferent parts of the countryresolving to make a difference.For countries that are inadvanced stages of implement-ing an Essential NationalHealth Research agenda, thismay seem to be a small step. Fora country that has seen majorpolitical and economic shiftswithin the past 10 years, thiswas a real step forward. Withthis first step, Pakistan joins

other ENHR players - a game(to use the analogy of golf),where we are all playing by thesame rules, but with individualhandicaps. The globalcommunity welcomes the newplayer!COHRED wishes to thank Dr AdnanA. Hyder, for contributing this article.For further information on thePakistan Public Health Networkplease contact Dr Hyder at the Schoolof Public Health, Johns HopkinsUniversity, USA

Tel: +1 410 955 3928

Fax. +1 410 614 1419

Email: [email protected]

Pakistan StatisticsPakistan StatisticsPakistan StatisticsPakistan StatisticsPakistan StatisticsPopulation1:144 million

Life Expectancy at Birth1:64.0 years

Adult Literacy Rate1:40.9%

HDI1,4: 0.508

REAL GDP per capita ($):1,560

Public expenditure (as a % ofGNP) on:Education2: 3.0Health3 : 0.8Defence2: 5.6

Notes:1. 1997 statistics2. 1996 statistics3. as a % of the Gross Domestic

Product (GDP) (1995)4. The Human Development Index (HDI)

is a composite measure of life expectancy,educational attainment and income. TheHDI value ranges from 0 to 1, where tomaximum possible value is 1.

* Human Development Report (1999)United Nations DevelopmentProgramme (UNDP) Geneva

ENHR in Action - Pakistan


The Commission on Health Research forDevelopment (CHRD), a twelve-memberindependent group was established in 1987 torecommend ways in which research can improvethe health and well-being of people in thedeveloping world. The commission operatedfrom the central premise that research is anessential, but often neglected link between humanaspiration and action, and that there are manyways in which research could be applied toimproving health. It placed highest priority onthe generation of relevant and timely research tosupport informed and intelligent decision-makingfor health policy. The commission called for anaction agenda for undertaking research that wasessential and of national importance. In this waythe Essential National Health Research (ENHR)agenda was born.

Talking with John Evans…Talking with John Evans…Talking with John Evans…Talking with John Evans…Talking with John Evans…Dr John Evans served as Chairman for the

Independent Commission on Health Researchfor Development in 1990. Since the Commissionreleased its report entitled, “Health Research:Essential Link to Equity in Development” in1990, Dr Evans has continued to be involved ininternational and domestic research fordevelopment endeavours, serving as the Chairof the International Health Policy Program andmore recently as the Chair of the CanadianNetworks of Excellence Initiative. Dr Evans iscurrently Chairman of the Torstar Corporation,a large Canadian telecommunications company.Nancy Johnson spoke to Dr Evans about hislandmark Commission’s work, and how he feelsabout the direction that has been taken since1990.

One Decade of ENHROne Decade of ENHROne Decade of ENHROne Decade of ENHROne Decade of ENHR

Research Into Action’s editorial team is planning to feature a number of ‘opinion pieces’ in theissues leading-up to the International Conference on Health Research for Development (October2000). This is the first of those opinion pieces, and looks at two views of COHRED and ENHR- one from COHRED’s past, and one from the future.

What have been the most important impacts ofthe Independent Commission on HealthResearch for Development and its 1990 Report?

The central conclusion of the Commission wasthat every country needed an analytic capabilityrooted in measurement and social sciences, aswell as biomedical science, to inform its decisionson the use of limited resources to meet the healthneeds of its population. The Commission focusedattention on the need, or demand side of healthpolicy and programs and the importance of localcircumstances in the successful implementationof health programs. The enormous investmentin health research in the industrialized world hadachieved an avalanche of biomedical andtechnological advances, but little served thepredominant health needs of three-quarters ofthe world’s population living in developingcountries.

The Commission made the case not only forstrengthening local health research capability inthird world countries but also for broadening therelevant sciences, particularly the measurementand social sciences, as important components ofinstitutional strengthening. As well, it drewattention to the fact that translation of evidenceinto policy was an active, skill-demanding processand not something that flowed spontaneouslyfrom the power of the evidence. More broadly,the Commission stressed that research was notmerely an academic exercise outside themainstream objectives of health organizations butan essential and integral component of theirstrategy to meet health needs and to managehealth programs.

International Conference - Opinion Piece


How have the challenges facing the internationalhealth research community changed over thepast ten years?

Market economics, which have dominated overthe last decade, have exaggerated differences inhealth status in populations. The playing field hasbecome much more tilted against equity by forcesoutside the health sector. The reasons fordisparity are doubly important now as they wereten years ago. More important than ever isresearch that looks at the needs of people andaccepts a political philosophy that those needsdeserve to be among the highest priorities.

Learning more about the socio-behaviouraldeterminants of health has also becomeincreasingly important. The socio-behaviouralaspects of health – for example, the availabilityof support systems, nutritional practices early inlife, the nature of one’s occupation and degree ofself-determination – have been shown to have aprofound effect on health status. Social contextis as important as the technological sophisticationof health services in determining health outcome.It is possible to have good technology andrelatively poor health outcomes. Alternatively,significant improvements in health outcomes arepossible despite limited technology. This may beachieved by socio-behavioural change, withoutnew technologies and financial investment. Thespectrum of Essential National Health Research– research that relates to local health needs –provides the evidence for new insights andstrengthens the capacity for leadership in policy,and management of programs and the mosteffective use of scarce resources.

The Commission Report highlighted the role ofresearch in achieving health equity. Much of thepresent dialogue seems to focus on healthresearch as a means of improving decision-making or achieving efficiency in healthsystems. In other words, equity seems to havefallen off the agenda. Would you agree? Whatis needed to put equity back on the agenda?

In my opinion, yes, equity is getting lost. Asfor putting it back on the agenda, you need toask yourself, should equity come back byrevolution or by evolution? Gross inequitiescannot be tolerated forever. If disparities becometoo extreme then concepts of law and order,property, and justice are overruled. Countriesthat wish to maintain political stability have torecognize the obligation to prevent enormousinequities in their populations. The currentanalysis of how equity is reached recognizes thatthe supply side – for example, access to services– is important, but one has to look also at howpeople view their own lives and how they can bemobilized to pursue equity rather than think ofit as a passive concept. The type of research thatis embodied in the concept of Essential NationalHealth Research will help to show whichmechanisms can be successful in trying toimprove equity.

What are the future directions for healthresearch and development?

Being in a position to monitor, evaluate, andunderstand what is happening to populations isincreasingly important. No matter how manynew technological innovations we have, we stillmust try to assess what their impact is going tobe. This is part of Essential National HealthResearch – understanding the demand side andlooking at how the needs of people can mosteffectively be met with obvious limits on theresources that can be devoted to them,particularly in the developing world. I must saythat I am pretty optimistic about the future. Theconcept of Essential National Health Researchis now being adopted by a number of countries,including jurisdictions in Canada. If movementhas occurred in the decade since the CommissionReport, that is a big step forward.


“The Commission Report, published in 1990”


…and David Okello…and David Okello…and David Okello…and David Okello…and David Okello

Lucinda Franklin spoketo Dr David Okelloabout his role in the newCOHRED, and histhoughts on whereCOHRED is headingin the next 10 years. DrOkello, a Ugandanmedical doctor, iscurrently based inZimbabwe, working asa research consultantfor the African regionaloffice of WHO. In

Uganda, he holds the position of lecturer atMakerere University’s School of Medicine, andwas head of the International Health PolicyProgram (IHPP) group. He has a special interestin the ENHR element of priority setting, whichhe has championed both in his own, and in manyother countries over the years. Dr Okello is as amember of several of COHRED’s WorkingGroups for the Task Force on ENHRCompetencies.

What, in your opinion, has been the mostimportant impact of the work of theCommission on Health Research forDevelopment, and that of COHRED?

The Commission acted as the catalyst, andenabled that essential first step towards gettingpeople to start asking the right questions aboutwhat research is for. Following that, the mainimpact of ENHR for me, was that the strategystimulated people to think rationally about whatis important for health research. COHRED’srole in that has been to keep that thoughtforemost in people’s minds, which they havedone, and are still doing . Translating the “rightquestions” into a tangible change though, issomething that we have yet to document.

The Commission’s concept as such, of linkingdevelopment to evidence is still right. I doubthowever, whether we have achieved that yet. Wehave made a diagnosis. We have seen a linkbetween development and how to get there, that

we need evidence, but there’s still no adequateanswer as to how we can do this. Getting theresearch going is what we have beenemphasising, and doing research in the correctareas, but we have to work on creating the rightenvironment for translating research results intocorrect actions and a correct chain of practicebefore we can notice a change in health problems.

I am not sure how long the Commissionexpected this process would take, but at least inthe developing countries, it is definitely a longerprocess than what was originally expected. Andof course this period will vary from country tocountry.

What impact have you noticed in relation to theCOHRED message “Put countries first”?

It is a very important message to me, and as faras I can see the impact we have had so far, hasnot been enough. I am concerned that althoughENHR has been around for 10 years, many ofthe countries have not had the opportunity to givethe strategy a chance. For the strategy to work,a supportive government - an organised systemof civil society - is very important in terms ofachieving development.

The first entry point of ENHR into a countryis another crucial issue which impacts on itssuccess, or otherwise. Ensuring that thestructures already in place - the structures setup by the nation - are made to feel part of theday to day operationalisation of ENHR is veryimportant. Ignoring structures already in placeand setting-up our own, expecting them to beblindly integrated into the national structures isunrealistic.

If you say you want to put countries first, youhave to strengthen country mechanisms ratherthan talk about regional programmes.Otherwise, “put countries first” becomes astatement we cannot support. In short, at leastin terms of budgetary investment, we shouldmove away from the idea of regional focal pointsand concentrate on country support. This doesnot exclude of course, effective regionalnetworking, which facilitates exchange ofexperience between countries and helps tomaintain a learning environment.

Dr David Okello



What kind of impact do you think COHRED’semphasis on equity has had?

At the global level, COHRED has created ademand for equity. At the country level, we arejust starting to address the inequities that exist.Now that the environment has been created inwhich equity demands consideration, we shouldstart to define what we really want to do in moreconcrete terms. The main task as I see it, is forthe people who claim to be the ones who aregenerating the information, to try and get themessage across to the right audiences. I doubt ifmany of our governments know that inequity isa big problem in their countries.

COHRED’s message about doing research thatleads to action has been around for some timenow. Do you believe that this message haschanged anything?

I think COHRED’s new focus oncommunication strategies for countries is goingto make a major impact. Up to this point, wehadn’t quite found the solution for really makinga difference in the countries themselves. Thecommunications strategy is a practical way to dothis, to help people see how they can translate aresearch paper into action, into a tangible policythat positively affects equity in the country. Ifwe can help guide the research process fromresults to translating this into a language that willinfluence parliamentary decisions, and intoMOH plans, to demystify research, and helpcommunities see how they can use research tomake a change for themselves, that can only be apositive impact.

We need to be clearer about the kind ofresearch that needs to be done, so that whateverefforts the countries are making with researchgets translated into real development changes.We need to work on creating the rightenvironment for translating research results intocorrect actions and the correct chain of practicebefore we can notice a change in health problems.

What do you see as being the way forward forCOHRED?

In relation to the International Conference onHealth Research for Development in October2000, I would say that we need to look at whysome countries have advanced with ENHR and

others are now back at square one. We need tolook at the reasons why our activities for the past10 years have not been properly translated intohelping countries. I’d like to see people at thisconference talk about how they can translatethese global tools and concepts that have beendeveloped, into useful ones for answeringquestions in the countries.

As for COHRED’s role in the future, challengenumber one is to strengthen countries. Not onlytheir capacity for research, but also the wayresearch is used and distributed, and enablinggovernments to see the added value that researchlends to the development of a country.

I would like to see research institutions anduniversities become an integral part of the workof the Government Ministries in a country. In-country ENHR mechanisms need to bestrengthened, so that governments sit up and takemore notice. At present, it is rare for the ENHRmechanism to be overtly supported by thegovernment, and the national planning processin the countries is completely divorced from in-country ENHR activities. Parliament must bemade aware of ENHR so that the strategiesbecome an integral part of the five-year plans.Doing this will create an essential bridge betweengovernment and research institutions.

Dissemination of research findings in thecountries needs to be pushed, along with thequestion of coordination as an entity. Often wewill find that there is a lot of research going onin the countries, but it is not well coordinated.These two things form an integral part of thecountries own communication strategies.

In short, I would like to see COHRED staywith its’ current approach rather than set up allsorts of structures, rules and standards. Thisapplies to both the organisation’soperationalisation and to the ENHR strategyitself. Just as priority setting is a fluid processthat cannot be approached in a textbook manner,so too COHRED’s way of working. Constantrehashing of the priorities and expectations is agood thing, and we need to embrace that.Nothing is set in concrete. We all continue tolearn about the right and wrong way to do things,answering to the needs of the day. That’ssomething to strive for. It’s really just thebeginning for COHRED and ENHR in manyof our countries.



The COHRED Task ForceThe COHRED Task ForceThe COHRED Task ForceThe COHRED Task ForceThe COHRED Task Forceon ENHR Competencieson ENHR Competencieson ENHR Competencieson ENHR Competencieson ENHR Competencies

Established in 1997, the Task Force on ENHRCompetencies is operating through variousWorking Groups which are addressing criticalcompetencies in the practice of ENHR. TheTask Force is chaired by Mary-Ann Lansang.Learning materials are being developed toenhance the capacity of various target groupsincluding decision-makers, researchers andcommunities.

At present these competencies include:

◆ Priority setting for health research

◆ Promotion and advocacy forENHR

◆ Setting up and maintaining anENHR mechanism

◆ Linking research to action andpolicy; and

◆ Community participation inhealth research

These materials are being made available tocountries in order to test their relevance andfeasibility with a view to refining them torespond better to user needs. Theinternational conference will create anopportunity to present these products to a

wider audience and to organizeworkshops on the use of the materials. Itwill also provide an arena whereadditional experiences and inputs fromothers can be acknowledged anddiscussed.

Email Mary Ann Lansang forfurther information:

[email protected]

The COHRED Book ProjectThe COHRED Book ProjectThe COHRED Book ProjectThe COHRED Book ProjectThe COHRED Book ProjectCOHRED is currently preparing a pre-conference publication broadly reviewinghealth research for development over thepast 10 years and, more particularly, the roleEssential National Health Research has playedin this development. The document will lookahead to the next decade and suggestmilestones for equity-oriented health researchdevelopment.

The publication will provide the reader withan introduction and background to the healthresearch and development context, past andpresent followed by an examination of 3 keythemes based on the ENHR perspective of“putting countries first”. These themes are:community participation, linking research toaction and fostering a national climate forequity -oriented health research. Thegeographical principle for organizing researchcollaboration will also be discussed. Theexperiences of stakeholders will beinterspersed throughout the text.

A further aim of this publication is to examinethe way forward for ENHR including its rolein the architecture for internationalcooperation in health research.

It is less than 12 months now untilthe October 2000 Conference, anda mere 3 issues of Research Into Actionto go before this event takes place.In the months leading up to theConference, we are planning topublish a series of articles that willgive our readers a taste ofCOHRED’s contribution to thismeeting. These contributions are, ofcourse, open to debate, and yourcomments would be welcome, someof which may be published inforthcoming issues.

In this article, we feature three ofthe COHRED projects that arehelping to form COHRED’s inputto this important event.

ConferencePartners

GlobalForum for

HealthResearch

WorldHealth

Organization

TheWorldBank

Otherpartners/

conferencecommittee

COHRED

International Conference

For further informationcontact:David [email protected] Peter [email protected]

Email Vic [email protected] orNancy [email protected] further information

U P D A T E

Examples ofCOHRED’s

contribution

Enclosed with this newletter, pleasesee brochure which further describesthis conference.

International Conference

Initiated to try and compensate for theperceived lack of information on countries’health research status, this project’s ultimategoal is to provide a tool for countries whichwill allow the continual assessment of nationalresearch activities.

The project will also allow a comparativeanalysis between countries and regionalgroupings of countries. The testing of thisinstrument will take place in 15 countries,chosen for their cultural diversity, economicand social development and epidemiologicalsituation.

A health research profile is being constructedusing the following indicators: financialresources, research capacity, equity, researchto policy, and quality.

The International Conference on HealthResearch for Development will be the platformfor discussion with users of the profile,

including countries, research networks,UN agencies and donor organisations.

The Health ResearchThe Health ResearchThe Health ResearchThe Health ResearchThe Health ResearchProfile (HRP) Project:Profile (HRP) Project:Profile (HRP) Project:Profile (HRP) Project:Profile (HRP) Project:

How does healthHow does healthHow does healthHow does healthHow does healthresearch lead toresearch lead toresearch lead toresearch lead toresearch lead to

equitable development?equitable development?equitable development?equitable development?equitable development?


Dr Izzy GERSTENBLUTHDr Izzy GERSTENBLUTHDr Izzy GERSTENBLUTHDr Izzy GERSTENBLUTHDr Izzy GERSTENBLUTHDr Gerstenbluth holds the position of Head of

the Epidemiology and Research Unit, and Headof Communicable Diseases in the Medical andPublic Health Service in CURACAO. DrGerstenbluth, 42, has held the position of nationalepidemiologist for the Netherlands Antilles forthe past 2 years.

Dr Samia HABBANIDr Samia HABBANIDr Samia HABBANIDr Samia HABBANIDr Samia HABBANIDr Habbani is the Director of the Research

Directorate of the Federal Ministry of Health inSUDAN. She is 42 years of age. Dr Habbani iscurrently the ENHR focal point for Sudan.

Professor Marian JACOBSProfessor Marian JACOBSProfessor Marian JACOBSProfessor Marian JACOBSProfessor Marian JACOBSHead of the Child Health Unit at the

Department of Paediatrics & Child Health,University of Cape Town in SOUTH AFRICA,Dr Marian Jacobs is 52 years of age. She holdspositions on the Boards of both a prominenthealth NGO, and with the Medical ResearchCouncil (MRC) in South Africa.

Dr Peter MAKARADr Peter MAKARADr Peter MAKARADr Peter MAKARADr Peter MAKARADr Makara, 53, from Hungary, recently joined

the WHO European Centre for Health Policyin DENMARK. Dr Makara has been active inpromoting ENHR in Hungary and EasternEurope. He is also active both nationally (inHungary) and internationally in the field ofhealth promotion and health education.

Dr Susan Pineda MERCADODr Susan Pineda MERCADODr Susan Pineda MERCADODr Susan Pineda MERCADODr Susan Pineda MERCADODr Mercado holds the position of

Undersecretary & Chief of Staff in theDepartment of Health, in the PHILIPPINES.She has extensive experience working inacademia and in NGOs. Dr Mercado, 40, hasalso been actively involved in various mediaproductions.

Dr Absatou Soumaré N’DIAYEDr Absatou Soumaré N’DIAYEDr Absatou Soumaré N’DIAYEDr Absatou Soumaré N’DIAYEDr Absatou Soumaré N’DIAYEDr N’Diaye is 43 years of age. She holds the

position of Head of the Department ofCommunity Health in the National Institute ofPublic Health Research in MALI. She has beenactive in a variety of research projects in Mali.

Dr Tomas SCHICKDr Tomas SCHICKDr Tomas SCHICKDr Tomas SCHICKDr Tomas SCHICKDr Schick, 41, is a representative of one of

COHRED’s funders, the Swiss Agency forDevelopment and Cooperation (SDC). DrSchick is a specialist in Preventive Medicine andPublic Health, and has worked in many countriesaround the world. He is currently based inSWITZERLAND.

New Faces of the COHRED BoardNew Faces of the COHRED BoardNew Faces of the COHRED BoardNew Faces of the COHRED BoardNew Faces of the COHRED BoardCOHRED’s Board has just met for its annual meeting in Geneva. Part of the deliberations involved theappointment of seven new members, who will replace Board members completing their terms of office. Wewish to thank our outgoing members for their support and commitment over the years, and hope that theywill remain in contact with COHRED’s workings in the future. To welcome the newly appointed members,we have provided a short introduction for your interest.

COHRED


These publications can also be accessed throughCOHRED’s website at:

http://www.cohred.ch/publications/

Evolution of Health Research EssentialEvolution of Health Research EssentialEvolution of Health Research EssentialEvolution of Health Research EssentialEvolution of Health Research Essentialfor Development in Ghanafor Development in Ghanafor Development in Ghanafor Development in Ghanafor Development in Ghana

PublicationsPublicationsPublicationsPublicationsPublications

World Health Forum, Interlaken, Switzerland,May 11-13, 1999

“Public Health today: between solidarity andmarket reality”

For more information, please contact theAdministrative Secretariat:

c/o AKM Congress ServicePO Box

CH - 4005 Basel, Switzerlandphone +41-61-686 77 11

fax +41-61-686 77 [email protected]

http://www.akm.ch/whf2000

International Society for Equity in Health(ISEqH) Conference, La Havana, Cuba, 29-30June 2000.

Call for papers (submission date February 15,1999). For registration and further informationcontact:

Jose Maria PaganiniFacultad de Ciencia Medicas

1er Piso Edificio de la BibliotecaCalle 60 y120

1900 La Plata, ARGENTINAPh/Fax: (54 221) 423 5755

Email: [email protected]

Conference on Poverty and Inequity: TheChallenges for Public Health in Southern Africa,24-25 February, 2000, East London, South Africa

This conference will focus on addressing issuesaround poverty, inequity and health with aparticular focus on Southern Africa. For furtherinformation, contact:

Anle OdendaalABO Facilitator

Tel: +27-43-726-7941Fax: +27-43-721-0607

mailto: [email protected]: http://www.essa.za.orgE-mail: [email protected]

ConferenceConferenceConferenceConferenceConferenceAnnouncementsAnnouncementsAnnouncementsAnnouncementsAnnouncements

Conference Announcements - New Publications

“Evolution of HealthResearch Essential ForDevelopment in Ghana”,Council on Health Researchfor Development(COHRED)

A new addition toCOHRED’s countrymonograph series, thispublication provides acomprehensive look atGhana’s progress withhealth research and ENHR.

Available now, from theCOHRED secretariat.

Comment Relancer l’Impact des Mécanismes de Support de laRNES dans un Pays : coup d’Oeil sur les expériences diverses deplusieurs pays : COHRED, février 1999. Disponible en françaiset anglais. Résultat du travail effectué par le Groupe de Travailsur la Promotion, le Plaidoyer et le Mécanisme de la RNES deCOHRED. Cette publication se tourne vers les quatre objectifsprincipaux d’un mécanisme de la RNES, dont le but est de :

1. Promouvoir l’équité en Santé

2. Agir en tant qu’agent de transformation

3. Fournir encadrement etsoutient des systèmesde recherche, et

4. Se développer etévoluer en fonction deschangements decirconstances.

La publication s’efforced’aider les pays enindiquant les facteurs “deréussite ou d’échec” qui ontune influence sur l’efficacitédu mécanisme de la RNES,donnant en même temps desrécits documentés desexpériences de pays etquelques directives simplessur la mise en place de laRNES.

Pour obtenir des copies de cette publication, veuillez contacter lesecrétariat de COHRED.

Nearing the end of the pipeline...A new guide onpromoting and advocating for ENHR. “HealthResearch: Powerful Advocate for Health and

Development, based on equity”Available in February 2000

Comment Relancer l’Impact desComment Relancer l’Impact desComment Relancer l’Impact desComment Relancer l’Impact desComment Relancer l’Impact desMécanismes de Support de laMécanismes de Support de laMécanismes de Support de laMécanismes de Support de laMécanismes de Support de la

RNES dans un Pays,RNES dans un Pays,RNES dans un Pays,RNES dans un Pays,RNES dans un Pays,COHRED 1999COHRED 1999COHRED 1999COHRED 1999COHRED 1999


COHRED

COHRED Colleagues holding lively discussions duringCOHRED Colleagues holding lively discussions duringCOHRED Colleagues holding lively discussions duringCOHRED Colleagues holding lively discussions duringCOHRED Colleagues holding lively discussions duringOctober meetings at COHREDOctober meetings at COHREDOctober meetings at COHREDOctober meetings at COHREDOctober meetings at COHRED

The newsletter of the Council on Health Research forDevelopment is published four times a year.

RESEARCH INTO ACTION is issuedcomplimentary upon request.

This issue of Research into Action was compiled by: SylviaDehaan, Lucinda Franklin, David Harrison, Nancy Johnson,

Vic Neufeld and Yvo Nuyens.

Designed and Printed by: The Press Gang, Durban, South AfricaPhone +27 31 307 3240

Mailing address: COHRED, c/o UNDP, Palais de Nations,CH-1211 Geneva 10, Switzerland

Phone +41 22 917 8558 • Fax +41 22 917 8015

Email: [email protected] Web site: http://www.cohred.ch

esearch into Action - COHRED

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