Document(s) 16 of 21

It is now 10 years after the Commission on Health Research for Development released its 1990 report. Essential National Health Research (ENHR) remains a vibrant strategy for achieving greater equity in health and a more integral role for research in development. Taken up in only a few countries in 1993, it has spread around the globe to nearly 60 countries.

In mid-1996, the Board of the Council on Health Research for Development (COHRED) commissioned an interim assessment of the ENHR strategy and of COHRED’s performance in facilitating ENHR (COHRED 1996). The report of the external evaluation team drew attention to the need to capture and share country experiences on a set of “ENHR competencies” or “ENHR technology.” The team also recommended more work on identifying indicators of ENHR success and a more comprehensive approach to capacity development that would include all stakeholders in the process. The COHRED Board responded by creating several task forces and working groups, involving members of the COHRED Board, national and regional research leaders, and other colleagues. Their tasks were to identify the requisite knowledge and skills for each competency, develop tool kits to assist ENHR planners in various countries, and address the capacity-development needs of national ENHR groups.

A 1999 internal review led to a sharpened sense of COHRED’s institutional identity. COHRED stated its aims in three key messages: put countries first; work for equity in health; and link research to policy and action. One of COHRED’s primary functions now is taking these messages to the countries and the international health research and development (R&D) community.

COHRED continues to provide technical support to countries engaged in ENHR, working with national research leaders to promote development-oriented health research, to set research priorities, to strengthen research mechanisms, and to build the capacities to do research and to use its results. It facilitates the interaction of leaders in health research, within and between countries. Countries share their experiences of creating a research environment to improve health and increase equity. Through printed and electronic publications, forums for discussion, and joint initiatives, COHRED facilitates experience-sharing among researchers, health workers, ministries of health, community organizations, and others. COHRED’s regional- and country-level initiatives thus aim for the widest possible sharing of ideas and information.

Alongside preparations for the October 2000 international conference, past and present Board members reviewed COHRED’s activities and possible future contribution. COHRED has an expanded role in supporting ENHR. It has a new set of messages and a stronger communication strategy.

To help countries improve their ENHR competencies, COHRED has provided tool kits, forums, and leadership training and has thereby established itself as a learning community, offering mutual encouragement and support among colleagues. It has developed partnerships with other health-research organizations, such as the World Health Organization (WHO) (headquarters and regional offices), the International Clinical Epidemiology Network (INCLEN), the Global Forum for Health Research (GFHR), and the Alliance for Health Policy and Systems Research, and it has helped to create networks and link countries with donors. COHRED now wants to strengthen these efforts and fashion coalitions with the widest range of stakeholders.

COHRED recently interviewed national research leaders and found that, in their view, ENHR should make simultaneous changes at all levels but keep its country focus. These national leaders gave four general recommendations, each discussed in detail in this chapter: local solutions for local problems, strengthened national leadership, greater regional cooperation, and a new deal with donors.

ENHR has caught on in Africa like wildfire because it’s the kind of song we’ve been waiting for, for a long time. We want equity, we want consensus, we want to prioritize so that the little resources we have can be shared, and we want to work together and network together. ENHR is the kind of philosophy we’ve been waiting for.

— Dr Mohamed Said Abdullah, National Health Research and Development Centre, Kenya

Ten years after the Commission’s 1990 report, ENHR remains a relevant and vibrant strategy for ensuring that countries derive real benefit from investments in health research. It works to acheive greater equity in health and to make research an active and integral part of development. From just a handful of countries in 1993, ENHR has spread around the globe. With COHRED acting as a facilitating mechanism, nearly 60 countries are currently implementing the ENHR strategy (see Box 8.1). Some of these countries are still in the exploratory start-up stage, whereas many others are well on the way to putting ENHR into practice. What is more, a number of other countries, programs, and networks have applied some of the underlying principles of ENHR without identifying themselves explicitly with the strategy (for example, the International Health Policy Program [IHPP], the Social Science and Medicine Africa Network, and Health Systems Research). Countries in five regions — Africa, Asia, the Caribbean, Eastern Europe–Central Asia, and Latin America — have pooled available technical and human resources to create a networking process for ENHR at the regional and, in some cases, at the subregional level (for example, the subregional ENHR network of French-speaking African countries).

Still, ENHR and COHRED have experienced inevitable growing pains. There are tales of success, as well as of failure, along the way. The preceding chapters have recounted many of the lessons learned. This chapter picks up the story of COHRED from where it left off in Chapter 1. It looks back at the role COHRED has played in support of ENHR, and it gives the views of COHRED’s colleagues — national research leaders, in particular — on current challenges and the way ahead for COHRED and ENHR.

When COHRED was established in 1993, its primary role was to advocate ENHR and provide technical assistance on the seven strategic elements of ENHR (TFHRD 1991): promotion and advocacy, the ENHR mechanism, priority-setting, capacity-building and capacity-strengthening, networking, financing, and evaluation. Over the next several years, with technical and, in some cases, financial assistance from COHRED, a number of countries initiated or extended their activities related to one or more of these elements. By mid-1996, the COHRED Board decided it was important to review the ENHR experience, so it commissioned an interim assessment of the strategy and of the council’s performance. A four-person external evaluation team reviewed many relevant documents and interviewed key informants, donors, organizations, and leaders of research networks. The team also conducted site visits in seven countries, and one member of the team attended regional ENHR networking meetings in Africa and Asia.

The assessment team’s report, The Next Step: An Interim Assessment of ENHR and COHRED (COHRED 1996), was tabled at a COHRED Board meeting in October 1996. Among the major observations was a statement of the need for a tool kit, or set of methods, to promote and implement ENHR. When ENHR was first launched and the Task Force on Health Research for Development identified the strategy’s seven key elements, the Task Force assumed that people would see the need for these elements and implement them on their own. Indeed, that is what happened, and country ENHR groups implemented the seven strategic elements with various degrees of success. The interim-assessment team, however, drew attention to the need to capture and share country experiences of ENHR competencies, and it recommended meeting this need “through the systematic application of a knowledge and skills base” (COHRED 1996, p. 29). These competencies (also referred to as “ENHR technology”) included the original seven strategic elements, plus two new ones: community participation and the translation of research into policy and action (see Figure 8.1). The team went on to suggest that “the definition, elaboration and use of this technology represents COHRED’s niche, its value added contribution to the global health and development endeavour” (COHRED 1996, p. 29).

Although COHRED had made some progress in defining indicators of ENHR success, it needed to do more work to move beyond process description to analysis of impacts and outputs. As well, the team noted that in many instances capacity-building focused primarily on researchers. It recommended a more comprehensive approach to capacity development for ENHR, to include all stakeholders: policymakers, communities, their NGO representatives, donors, the media, health professionals, and the private sector. (A summary of the recommendations made in the interim assessment report appears in Box 8.2.)

The COHRED Board vigorously debated these observations and suggestions and then quickly moved to implement their spirit and substance, creating several task forces and working groups. COHRED’s Task Force on ENHR Competencies (comprising four working groups) was created to look at priority-setting; research to policy and action; promotion, advocacy, and the ENHR mechanism; and community participation. COHRED established two other task forces, one on resource flows and the other on evaluation and critical indicators of success. A year later, at its 1997 annual meeting, the Board created the Advisory Committee on Health Research Capacity Strengthening, thus recognizing that this issue pervades many aspects of the ENHR process.

The various groups — involving members of the COHRED Board, national and regional research leaders, and other colleagues — took responsibility for identifying the requisite knowledge and skills for each competency, developing tool kits to assist ENHR planners in various countries, and providing training for national ENHR groups. (Specific objectives of a number of COHRED working groups and task forces are listed in Box 8.3.) Although these groups are currently at diverse stages in their work, several have begun to produce a variety of materials, including manuals, evaluation tools, issues papers, pamphlets, and learning briefs (see Box 8.4) (available through the COHRED Secretariat). Others have been less successful. The Resource Flows Task Force failed to get off the ground; instead, COHRED undertook several intercountry studies, which it used to provide input into GFHR’s Core Group on Resource Flows. COHRED’s Critical Indicators Task Force developed a survey instrument to enable countries to assess their progress in ENHR. However, the evaluation tool proved too cumbersome, and the work of this task force has stalled.

In February 1999, an ad hoc group of COHRED associates joined the COHRED Coordinator and the Board Chair in Geneva to conduct an informal, internal review of COHRED’s role and performance. They reflected on the “new realities” in the global community and the international health-research sector (see Chapter 9), as well as on the challenges these present for COHRED. Among these new realities are the growing importance of knowledge management and innovative use of communication technologies, the emergence of several new international health-research organizations, and the concern, of late, that equity has fallen off global and national health-research agendas in favour of efficiency-based health reforms.

An analysis of strengths, weakness, opportunities, and threats resulted in a sharpened sense of COHRED’s institutional identity and how it complements the goals of the many other international health-research organizations and initiatives, such as WHO, GFHR, and the Scientists for Health Research and Development. COHRED captured its niche in three key messages:

• Put countries first;

• Work for equity in health; and

• Link research to policy and action.

These messages have become the core of the newly energized COHRED communication strategy, which harnesses the latest communication technologies. COHRED has subsequently devised an electronic library and a number of paper and electronic promotional materials, such as The ENHR Handbook (COHRED 2000c). The electronic library now enables the COHRED Secretariat to respond faster and more effectively to requests for specific or customized information. In the future, it will provide direct access to these materials through the COHRED website (http://www.cohred.ch) or a CD-ROM database.

Document(s) 16 of 21