Document(s) 15 of 21

For the purposes of this section, the Caribbean means the English-speaking Caribbean, made up of 18 countries and territories where English is the first language,[2] and the 5 Dutch-speaking islands of the Netherlands Antilles.[3] They are set in a sea of islands spanning about 3 500 km between Belize and Guyana. These countries show wide variations in size and population, resources and capabilities, religions and cultures, and ethnic groups. The English-speaking Caribbean has a combined population of about 6 million, and the Netherlands Antilles has a population of 200 000.

By the mid-1970s, the global economic crisis threatened to erode gains made in health conditions in the region. Infrastructure was deteriorating, supplies were dwindling, and many health personnel were migrating to high-income countries. It was unlikely that the strategy of national self-reliance would, by itself, correct the decline and restore the previous rate of improvement in health conditions.

Health services

In 1986, CMRH adopted six priority health areas, under the Caribbean Cooperation in Health (CCH) initiative: environmental protection (including vector control), human-resource development, chronic noncommunicable illnesses and accidents, strengthening health systems, food and nutrition, and maternal and child health and population activities. In 1988, CMRH added AIDS to the list. An assessment of this initiative in 1992–94 found it was beneficial to the Caribbean countries.

In 1996, CMRH mandated a redefinition of the CCH initiative for 1997–2001. It held a regional consultation in 1997 with people from a wide range of disciplines, and it then selected eight priority health areas, recommended strategies for implementation, and identified areas for joint action. The new priorities were health-systems development, human-resource development, family health, food and nutrition, chronic noncommunicable illnesses, communicable diseases, mental health, and environmental health.

Caribbean Health Research Council

The English-speaking governments of the region have supported CHRC as a regional organization, which until 1997 was known as the Commonwealth Caribbean Medical Research Council. Over the past 45 years, it has had major responsibility for promoting health research. Its activities have included

• Promoting and supporting the establishment of ENHR by helping countries define national health-research priorities and create national ENHR committees (to date, four countries have these committees: Barbados, Curaçao, Jamaica, and Trinidad and Tobago);

• Organizing annual scientific meetings, including an annual symposium;

• Administering a block-grant scheme; and

• Strengthening research capacity through a program of research-skills workshops.

Pan American Health Organization

PAHO has a representative in most Caribbean countries and also has an office in Barbados for the Caribbean program coordinator; the office houses PAHO staff specifically assigned to areas such as chronic noncommunicable illnesses and maternal and child health. It is one of the most important regional organizations in health and health research in the Caribbean and has taken the lead role in producing CCH I and CCH II, the publication Health Status of the Caribbean, and several other documents. PAHO facilitates health research by mobilizing resources, convening meetings and workshops, and arranging technical-cooperation activities. PAHO works for and through national governments and collaborates with other regional organizations to improve health.

The Caribbean has six medical schools, including three affiliated with the University of the West Indies, and these schools conduct research to varying degrees. The region has nine health-research institutions, which focus on subjects ranging from human nutrition, to chronic noncommunicable illnesses, to environmental health. CHRC and PAHO also support, facilitate, and coordinate research across the region.

The topics of the papers at the annual scientific meetings reflect the content of health research in the region. Content analyses of these papers were conducted in 1995 and 2000. The 1995 survey showed a gradual increase in health-service research to 40% of all papers by 1994 (over more than two decades) and a decrease in laboratory studies to about 20% (Walrond 1995). Clinical studies remained about the same (25%), as did those in epidemiology and public health (10–15%). The survey conducted in 2000 was done to determine the degree to which research activities matched the eight regional health priorities (Picou 2000). About half of the papers presented before 1984 related to health-service priorities; since then the proportion has increased to 60%.

One can infer some indication of the status of the health-research system itself from recent surveys in Jamaica and Trinidad. These surveys indicate that the main features of the health-research system in the Caribbean are as follows:

• Individual researchers drive and finance a significant proportion of research;

• Universities and health-research institutions do the majority of research;

• Less than half of completed research appears in peer-reviewed journals;

• Governments commission or conduct only a small proportion of research;

• Researchers perceive constraints such as

  • Inadequate funding, time, equipment, and facilities,

  • Problems with data collection and analysis, and

  • Lack of support staff; and

• Research funding comes from a variety of sources: the researcher’s own resources, grants from universities, CHRC, pharmaceutical companies, the regional private and public sectors, and international agencies (less than 10% comes from governments).

To summarize, the Caribbean region lacks a research culture, as reflected in the low level of government support and funding. Researchers feel that they have inadequate time, facilities, and infrastructure support. The number of full-time posts for researchers in universities, institutions, and government is thought to be much too small. Research administration and management are ineffective. Only just more than half of the current research relates to the regional health priorities. With some notable exceptions, the research to date has been primarily descriptive, epidemiological, and clinical. The research community communicates inadequately with the users of research (planners, policymakers, and the public in general). A wider range of stakeholders should be included in the research process; it should include, for example, the private sector, NGOs, trade and credit unions, religious groups, and the media. Including these groups as partners would facilitate the use of research.

The following are some of the positive and negative impacts of regional organizations on health research in the region:

Positive impacts

• Researchers have a forum (annual scientific meeting) in which to present their work and get feedback from their peers and the network;

• A research-grant scheme assists young researchers beginning their careers;

• Training workshops in research skills and technology are available at both basic and advanced levels;

• Organizations convene workshops on common health problems, and this has resulted in the publication of clinical guidelines to manage conditions such as asthma, diabetes mellitus, and hypertension;

• Linkages and partnerships with researchers in other countries and donors are facilitated;

• Advocacy for health research occurs at the national level; and

• Advice is available on all aspects of research.

Negative aspects

• Some people have perceived CHRC as promoting esoteric research;

• Some have felt that CHRC competes with national groups for research funds;

• A number of researchers have become antagonistic because their papers were not accepted for the annual scientific meeting; and

• Some Health Ministry officials feel that they are too overburdened to help develop regional health-research initiatives.

Much attention has rightly gone to defining priority health areas. Yet, few Caribbean countries have defined national health-research priorities or a national health-research agenda. Although CCH II did not include a regional health-research agenda to match the eight health priorities, chief medical officers in the Caribbean have considered the creation of such an agenda a top priority for the region. In fact, the Caribbean has embarked on a process to identify its health-research agenda for the next decade, based on the eight health priorities. A Caribbean consultative process is under way.

There is a growing trend in the Caribbean to develop partnerships within and outside the region, and these partnerships are expected be one of the mechanisms to tackle these major health-research priorities.

More countries in the Caribbean region need to establish ENHR and use this mechanism to define national priorities for health research. CHRC should strengthen its capability to promote and support ENHR in more countries and continue its program of training in research skills and methodology. The region should mobilize more resources to plan and implement priority health-research projects and programs. With the definition of regional health-research priorities currently under way, the Caribbean will have the opportunity to renew efforts to ensure that health research contributes strongly to the health of the people in the region.

Health-related research has a strong tradition in CEEC–NIS. Almost all the countries in the region once had or still have prominent scientific institutions and world-renowned scientists contributing to developments in their fields. From World War II until the end of the one-party regimes and planned economic systems, health research in Eastern European countries and the Soviet Union kept pace with global scientific progress, particularly in some areas of biomedicine and clinical research.

The health-related social sciences were in a considerably different position. For a long period, the behavioural sciences were a marginalized branch of health research. Furthermore, as a result of the political-economic system and its consequences for health care, some areas of research on health systems and health economics were either underdeveloped or missing entirely.

The socioeconomic changes at the end of the 1980s and the beginning of 1990s brought new challenges to health research. Most of the region’s countries voted for a pluralistic, multiparty political system, and they all started to build the conditions for a market economy. This transition took place over a remarkably short period in the last decade. At the beginning of this transition, a deep economic crisis led to a considerable drop in the gross domestic products of these countries, and their financial capacities decreased. This led countries throughout the region to impose large-scale restrictive monetary measures, which obviously affected research financing as well. It became impossible to maintain the previous research capacities.

This was also a time of rapid social change and restructuring of societies, with mass unemployment, rising poverty, and changing societal norms and patterns. These trends resulted in new health risks. Life expectancy decreased in many countries — in some countries, such as the Russian Federation, the decrease in life expectancy was dramatic. The reform of health systems, including new methods of health-care financing, raised new questions for health-systems researchers.

To summarize, the socioeconomic transition of the past decade dramatically reduced funds for health research and posed new challenges for researchers in the fields of health-related behavioural sciences and health-systems research.

Over the past 10 years, the state of health research in CEEC–NIS has reflected the overall socioeconomic crisis in the region. Countries attempted to maintain their research capacities under conditions of economic crisis and unbalanced state budgets. Nevertheless, most of the existing national health-research structures remained intact, together with financing mechanisms and career systems. The price of chronic underfunding, however, was a weakened research infrastructure and underpaid research staff. The consequence was a brain drain to the West and loss of a younger generation of researchers.

Globalization, increased involvement and research leadership of other countries, and rapid technical developments all helped to even further marginalize many of the region’s research institutions or teams at a time when health-research systems were wrestling with financial difficulties. Some institutions managed to cope with these challenges, but in general the region’s research centres lost their importance in terms of their contribution to global research.

Previous regional structures disintegrated; for example, cooperation dissolved between institutes within the framework of the Council of Mutual Economical Assistance and related bilateral and multilateral agreements. This happened in parallel with weakened or discontinued relationships in commerce, industry, and culture. The collapse of the Soviet Union and the rise of the independent republics have led to the disintegration of academic networks in the former Soviet republics as well.

Concurrently, researchers concentrated on establishing relationships with their counterparts in industrialized countries. This trend varied from country to country. It was most evident in the countries aiming to join the European Union (Central European, Baltic, and some Eastern European states). This reorientation of health research to new collaborative links and the simultaneous disintegration of regional structures led to a decline in the intensity of regional health-research cooperation.

Most health-research institutions successfully survived the first and probably the most difficult decade of the socioeconomic transition. The key to this was the strong and competitive pool of human resources and other nonmaterial resources: research traditions, scientific institutions, and the academic-scientific career system.

Health research is concentrated at state-run universities and academic institutions. The role of private-sector and nonprofit organizations is negligible except in countries that privatized their pharmaceutical industry, a move that resulted in some pharmaceutical research.

A competitive, merit-based resource-allocation system is in place in most countries, regardless of the subregion. Although most have set health-research priorities, funding does not always follow declared priorities; sometimes these priorities capture only a small portion of the available funds. Furthermore, the relevance of declared priorities to the actual health problems of the population is questionable, along with the quality of the priority-setting process. Weaknesses in the priority-setting process are partly attributable to the previous, antidemocratic regimes (including the communist and the preceding autocratic, antidemocratic regimes in most of CEEC–NIS). These traditions explain the lack of broad stakeholder and community involvement in priority-setting and the low emphasis on research concerning the sociocultural determinants of health (for example, inequality, ethnic minorities).

Another weak area is the poor research management found throughout the region — that is, the ineffectiveness of resource allocation and the inability to use available resources efficiently. The previous planned economies had no tradition of research management; they gave complete control of resource flows to their bureaucratic administrations. Thus, weak national and local research management accompanied the sharp decline in available funding, and this situation has persisted throughout the past 10 years.

International partnerships within CEEC–NIS mostly take the form of bilateral cooperation involving individual researchers and institutions. These are thematic partnerships that focus on narrow fields of health research and use the structure of professional organizations. Although universities and academic institutions enter into some partnerships, most are personally initiated, involving joint projects and workshops.

One sees some good examples of subregional cooperation. These are often initiated by international organizations. In other cases, the scope of collaboration goes beyond the boundaries of the region. An excellent example is the Finland Baltic Health Monitoring of Adults program, which reflects cooperation between the Scandinavian and Baltic countries (Estonia, Latvia, and Lithuania). Initially, this was a collaboration of Finnish and Lithuanian partners; later, the other two Baltic republics joined. In addition, all of the Baltic states have good relations with the scientific organizations of the Scandinavian states, involving regular contacts between universities and research teams, mainly in the field of public health. WHO’s Regional Office for Europe initiated CARIN. This network exchanges information on research subjects, projects, and results between the five former Soviet republics of Central Asia.

In the preaccession phase of the European Union, research institutes of Central European countries are eligible to participate in its research-project financing schemes. Depending on their country’s agreement with the European Union, they can compete for research funds in cooperation with European partner institutes. Favouring this type of cooperation indicates the intention of the research communities of these countries to reorient their international partnerships, even if the socioeconomic conditions in Central European states differ remarkably from those of the European Union.

Overall, however, the region is far from fully exploiting its opportunities for partnerships in science and research, and the current relationships are only a fraction of those that were in place a decade ago.

Regional cooperation would add great value to health research in CEEC–NIS. The basis of regional partnership might be a network of professional societies from various disciplines. The most appropriate approach to regional cooperation would be to follow the structure of subregions (for example, Central Europe, Eastern Europe and Russia, Central Asia). An important first step would be to establish a regional clearinghouse for research projects and results.

Furthermore, in the opinion of several health-research experts, CEEC–NIS definitely needs region-wide health-research training in local centres of excellence — this can serve as the basis for new institutions. A crucial issue with respect to regional cooperation would be the sustainability of these institutions, as the most common reason for terminating collaborative initiatives is lack of appropriate funding.

International organizations, such as WHO and COHRED, can contribute to building these structures by providing the basic expertise and methodology for effective networking, partnership development, and other aspects of strengthening national and regional health-research systems.

WHO’s Regional Office for the Eastern Mediterranean has 23 countries under its purview, and they display a remarkable cultural, political, and socioeconomic diversity. Old civilizations with strongly entrenched cultural patterns are characteristic of the region, making systemic social change difficult and slow. Several countries have also suffered prolonged internal conflict. National populations range from just more than 600 000 in Bahrain to 139 million in Pakistan. More than 90% of the region’s people live in low- to middle-income countries.

Despite the underfunding of health systems in many countries of the region, access to local health services and immunization coverage have improved. The profile of health conditions reflects the economic situation, with a high prevalence of vaccine-preventable and other communicable diseases in the poorest countries. Most new cases of tuberculosis have appeared in nine countries. Six countries have a severe malaria problem. The AIDS epidemic is spreading, although slowly, and the incidence of noncommunicable illnesses (including intentional and unintentional injuries) is rapidly increasing.

The wide diversity of the region’s countries also appears in its profile of health research. Most countries now consider research an essential function of the health system, but they seldom apply research in formulating or revising health policies and programs. Demand for research from health planners and managers is minimal. Researchers and academicians are the ones who set research priorities, usually through consultations and workshops; in a few instances, they have used the results of health surveys. Countries in the region have made no attempt to broaden the base of stakeholders or establish some sort of national forum to discuss health-research issues. Coordination of health research within countries is weak and inefficient, having neither appropriate systems for research management nor transparent mechanisms to review and follow up on research proposals.

Few countries in the region have well-established research cultures to integrate research training into university education. Weaknesses appear at all stages of the research process: defining problems, data collection and analysis, and dissemination of results, including writing reports. With the exception of some short-term training courses and workshops, countries in the region have made no systematic or sustained efforts to strengthen the research capacities of their various stakeholders. This weak base also shows in the inability of researchers to tap external sources of funding and participate vigorously in regional and global debates on the future of health research.

The countries of this region are members of various political and economic forums, such as the Gulf Cooperation Council, the League of Arab States, Arab Ministers of Health, the Organization of Islamic States, and the Economic Cooperation Organization. However, they have no forum or regional structure for health research, other than those activities that the WHO regional office established and funds. The region has few functional health-research networks and, as a result, little intercountry collaborative research.

In 1976, WHO’s regional office established its Advisory Committee on Health Research (ACHR), along with a system to award grants for research and research training. Since the early 1980s the directors of medical-research organizations or similar groups have met occasionally to exchange information and promote research on priority issues. WHO’s regional office has supported, through its intercountry and national budgets, various national training activities in research methodology, management, and writing.

In 1986, stimulated by the global ACHR’s proposed health-research strategy, the Eastern Mediterranean’s ACHR created a regional task force to help countries establish national health-research policies and strategies. This task force visited 11 countries over a period of 9 years. As a result of this initiative, senior health managers learned about WHO’s health-research policies and programs. The site visits also brought together researchers and health managers to discuss national health-research needs.

To strengthen national capacities for field-oriented research on prevalent tropical diseases, WHO’s Regional Office for the Eastern Mediterranean and TDR jointly launched a small grants initiative in 1992. To date, it has invited seven rounds of applications; it has funded 78 of the 353 proposals received. Investigators in some countries have also benefited from technical and financial support from WHO special programs for research and training in human reproduction and tropical diseases. COHRED has been involved in the initiatives of only a small number of countries in the region.

In June 2000, the region held a consultation to help prepare for the international conference in Bangkok. Representatives from 10 countries participated in this event, along with officials from the WHO regional office and some external observers. The participants identified strategic directions for health research for the coming decade and put forward specific recommendations, directing some to countries and others to regional and global support organizations.

A strong consensus emerged on several strategic directions. Examples include the importance of multistakeholder health-research forums and research priority-setting at not only national but also subnational and district levels. Participants urged WHO to take a more active and dynamic role in advocating the use of health research in health development and in the reduction of inequities in health. The participants recommended that the regional office serve as a prime mover to establish a regional health-research forum; they also recognized that ongoing leadership for health research in the region may need to come from other partners. The functions of the regional forum would include networking (for example, bridging arrangements between countries in the region and others in the North); identifying common regional problems, together with coordinating a regional research response to these problems; and serving as a platform to convey national concerns in various global research forums.

In the 1990s, Latin America focused its attention on recovering from the financial crisis of the previous decade. This recovery appears in the S&T profiles of many Latin America countries:

• Investments in R&D increased substantially, by 57% between 1990 and 1996. Of this amount, more than 80% was in a small number of countries, notably Argentina, Brazil, Chile, and Mexico. Governments made more than 70% of these investments, and universities were the main recipients. Per capita investments in R&D in Argentina and Chile were 33.6 and 31.4 USD, respectively, compared with 25.0 USD for Brazil and 9.7 USD for Mexico (CONICYT 1998).

• The number of full-time equivalent researchers in Latin America rose to 125 000. Two countries accounted for more than two-thirds of this number: Brazil (50 000) and Argentina (28 500). The region had 0.75 researchers per 1 000 persons (in comparison with 3.25 in Spain, 5.51 in Canada, and 7.37 in the United States).

• In 1996, the publications of Latin American scientists represented 2.09% of all publications registered at the Institute for Scientific Information, compared with 1% in the 1970s and 1.5% in the 1980s. More than 60% of these publications were the work of scientists from Argentina, Brazil, Chile, and Mexico. The number of publications per 100 000 inhabitants for 1997 was 10.5 in Mexico and Chile, 9.5 in Argentina, and 3.5 in Brazil (CONICYT 1998).

The general health situation of Latin America has two prevailing characteristics. First, the region is rapidly going through demographic and epidemiological transitions, with declining fertility rates, decreasing mortality rates, and an aging population. It also shows striking health inequities, as seen in morbidity and mortality profiles and in access to health care. Some of this inequity is a consequence of the fragmentation of health services, which disadvantages the poor. Poor people spend nearly 6% of their household income on health care (compared with an average of 2.4% for all developing countries); in Colombia this figure is 12% and in Ecuador it is 17%.

The Latin American health-research community has in various ways attempted to respond to this situation. For example, recognizing the multiple determinants of health status, it has recently proposed a new paradigm of health research, with the following features:

• Transdisciplinarity — establishing links across disciplines while addressing important research problems;

• Complexity — ensuring that health research embraces broad conceptual models and avoids overly simplistic abstractions;

• Multiplicity — rejecting “monolithic” thought and looking for new and creative ways to address important problems; and

• Praxis — translating research findings into evidence-based clinical and public-health practice and into policies that feature high-impact interventions.

The capacity of the health-research community in Latin America to respond to these challenges has been analyzed. The numbers and distribution of health scientists correspond to the profile of S&T R&D. Only 2.7% of the publications of Latin American scientists deal with public-health issues. An analysis of all articles published by Latin American epidemiologists (60% of which were Brazilian) revealed that 83% dealt with infectious diseases, 4% with chronic noncommunicable illnesses, and 13% with other topics. This profile reflects a pretransitional pattern, not the pattern of currently prevailing conditions in the region.

Several initiatives are under way to reorganize health research for development. These include health-research priority-setting, financing, and dissemination and use of research results.

The issue of priority-setting was highlighted in an important 1998 publication, Priorities in Collective Health Research in Latin America (GEOPS 1998). A team of experts prepared a series of papers using “prospective analysis.” This effort was promoted by the International Development Research Centre, PAHO, and COHRED. The Uruguay-based Study Group on Economics, Organization and Social Policies coordinated the entire initiative. This effort resulted in an important set of guidelines for determining the current and future agenda for public-health research in Latin America.

A trend in financial support in Latin America is increased funding, particularly from development banks and the private sector. Large international drug companies, for example, have supported clinical trials of new drug interventions. However, people have ethical concerns about using vulnerable groups for experimental populations — these groups are at some risk because they will in the long run be unable to afford the drugs. The World Bank and the Inter-American Development Bank are financing several projects in health-sector reform in many countries of the region, and each loan includes funding for operational studies. An assessment is necessary of the impact of these increased funds, particularly in regard to the use of research results and development of sustainable research capacity, and the system for judging the quality of research proposals should be stronger. Quality should include relevance and importance, along with scientific merit. The broader definition of quality would require both peer review (for scientific merit) and additional reviews involving representatives of stakeholder groups other than the researchers, such as decision-makers and other users of research.

For some time a large gap has existed between the production of knowledge and its dissemination and use. To strengthen the dissemination process, PAHO’s Latin American and Caribbean Centre of Information in Health Sciences created a database of Latin American health-science literature. In addition, several Latin American health journals are now electronically accessible. PAHO has created a Virtual Health Library (VHL) on the Internet. Because a variety of users can access this service, it effectively reduces inequities in access to useful health information. Also under review are ways to provide scientific information to various groups of decision-makers, as each requires a unique type of evidence and poses a unique set of challenges in the dissemination and use of information.

In most Latin American countries, the main national research institution is each country’s Comisión Nacional de Investigación Cientifica y Tecnológica (CONICYT, national council for scientific and technological research). The United Nations Educational, Scientific and Cultural Organization and the Organization of American States helped to create these councils in the 1960s and 1970s. During the 1980s, many countries established research units within their ministries of health, often with PAHO’s support. These units functioned as focal points within the CONICYT system. However, for the most part, they remain quite weak and have little influence on national research policies.

The institutions that actually conduct most health research are the universities and public organizations for S&T in health. In part as a consequence of less centralized planning, these institutions have recently become more visible, appearing as privileged actors with an opportunity to participate in defining S&T policies and plans. They have a dual challenge: to remain up to date on new advances in S&T and to respond effectively and efficiently to the problems of national societies and thereby maintain their social legitimacy.

Through its research-grants program, PAHO has attempted to respond to the health-research needs of low-income countries in the region. Its basic strategy has been to promote networks and partnerships between research institutions on specific themes and projects. Some examples of projects are the following:

• Inequities in health status, access, and expenditure: using secondary data to inform policy-making (participating countries are Bolivia, Brazil, Colombia, Nicaragua, and Peru);

• A research competition on the theme of gender and equity in access to health care in reforms to health and social-security systems (projects were approved in six countries: Barbados, Brazil, Colombia, Chile, Ecuador, and Peru);

• A grant to the CONICYTs of Costa Rica and Guatemala to strengthen their development of public-health research; and

• A grant to the Latin American Biological Network to support research on infectious diseases and promote collaboration between laboratories with lower and higher levels of scientific infrastructure.

The following are some observations, based mostly on PAHO’s experience, on the role of regional mechanisms to support and strengthen national systems to do equity-oriented health research for development:

• The creation of networks of research institutions has been an effective strategy for sharing resources and decreasing research-capacity gaps across countries. These networks have developed in the context of specific collaborative research projects and training programs, some of them explicitly focused on health inequities.

• Support to develop criteria, standards, and mechanisms for more cost-effective use of resources has led to the adoption of national systems (both peer and nonpeer review) to assess research proposals, using criteria of scientific merit, pertinence, relevance, and ethical compliance. The pattern of research-council funding is slowly changing, from an emphasis on research projects of interest only to researchers (mainly biomedical and clinical) to one that includes research to meet the needs of policymakers. A remaining practical challenge in most countries is to integrate a broader range of criteria (including policy relevance) into procedures for actually selecting projects.

• By explicitly promoting research policies that take account of the local context and feature problem-solving, countries in the region have been able to bring together both the producers and the users of research at all stages of the research process, from problem identification to the implementation and dissemination of results.

• The new ICTs constitute a good platform to support decentralized, participatory, problem-oriented research policies and programs (PAHO’s VHL is an example of this).

Given the focus of this book, on national health-research systems, what observations can be made on these six regional perspectives? How have regional organizations and networks contributed to national efforts? What opportunities present themselves for future consideration? The following are the three general conclusions of this chapter:

• Responsiveness to country needs — Countries show a striking degree of diversity, even within a single region or subregion. We need to be reminded that Sierra Leone and Mauritius are in the same region — so are Bangladesh and Singapore; and Argentina and Haiti. These very different countries will have vastly different expectations of regional organizations. Thus, the message of country specificity, which pervades this book, applies as well to the role of regional organizations. Put another way, the needs of the member countries must drive the agendas of regional organizations (assuming their purpose is to serve the needs participating countries).

• The added-value role of regional organizations — Given the principle that regional entities should not be doing what countries can do, what then is the distinctive contribution of regional organizations and networks to health research for development? Again, the descriptions of the various regional structures are instructive, as they demonstrate a wide variety of goals. The more successful and sustained regional networks and organizations are those that meet specific needs and adapt to changing circumstances. For example, health researchers in the Caribbean live on islands with small populations; their need is for efficiency — a single agency (in this case, CHRC) provides links and services that it would be unrealistic to expect from individual island-states. Almost all the regional organizations described have mandates to facilitate information exchange among countries, improve efficiency through shared resources and expertise, provide technical and financial support, and advocate the needs of countries in the region at global forums.

• Regional health-research forums — Several regions have called for a regional health-research forum (notably Africa and the Eastern Mediterranean). In fact, the Caribbean has had such an intercountry forum for many years. As described above, regional health-research leaders in Asia recently created the Asian Forum for Health Research to serve as an informal consortium of country teams and regional organizations.

In addition to fulfilling some of the duties described above, a regional health-research forum can serve two other proactive functions. First, it can facilitate the creation of health-research and action coalitions to work on region-specific problems, particularly problems requiring an intersectoral response. Examples of such problems are the health risks of human migration and the impact of the drug and arms trade on human health. Second, a regional health-research forum can serve as an entry point for dialogue on the impacts of global trends on national health and social systems. The concerns of countries regarding globalization might then be more easily heard at a regional level, at least initially. An example of such an issue is the so-called jurisdiction gap, the phenomenon of there being more actors at the global level (notably transnational corporations) now than a decade ago, along with the real or merely perceived erosion of national sovereignty. Another example is the impact of structural-adjustment programs on health and education in the late 1980s and early 1990s, particularly in Africa. Research on this issue has received significant attention, in part because of regional intercountry collaboration.

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[2] Antigua and Barbuda, Anguilla, the Bahamas, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St Kitts-Nevis, St Lucia, St Vincent and the Grenadines, Trinidad and Tobago, and the Turks and Caicos.

[3] Bonaire, Curaçao, Saba, St Eustatius, and St Martin.

[4] This section is adapted from a PAHO technical paper, “Science for Health,” by Alberto Pellegrini Filho, Program Coordinator, Research Coordination Program, Division of Health and Human Development, PAHO, Washington, DC, USA.

Document(s) 15 of 21