Capacity-Building for Health Research in Developing Countries: a Manager’S Approach

Special report

Capacity-building for health research in developing countries: a manager’s approach

Franklin White1

ABSTRACT Research may be viewed as rigorous inquiry to advance knowledge and improve practices. An international commission has argued that strengthening research capacity is one of the most powerful, cost-effective, and sustainable means of advancing health and development. How- ever, the global effort to promote research in developing countries has been mostly policy driven, and largely at the initiative of donor agencies based in developed countries. This policy approach, although essential, both contrasts with and is complementary to that of research managers, who must build capacity “from the ground up” in a variety of health service settings within countries and with differing mandates, resources, and constraints. In health organizations the concept of research is broad, and practices vary widely. However, building research capacity is not altogether different from building other kinds of organizational capacity, and it involves two major dimensions: strategic and operational. In organizations in the health field, if reference to research is not in the mission statement, then developing a relevant research capacity is made vastly more difficult. Research capacities that take years to develop can be easily damaged through inadequate support, poor management, or other negative influences associated with both internal and external environments. This paper draws from key international research policy documents and observations on the behavior of research and donor agencies in relation to developing countries. It examines capacity-building primarily as a challenge for research managers, realities underlying operational effectiveness and efficiency, approaches to resource mobilization, and the need for marketing the research enterprise. Selected examples from South Asia and Latin America and the Caribbean are presented.

Key words Research, developing countries, health resources, health manpower, staff development.

Building research capacity is similar practices.” In management terms, gation, problem analysis, and external to building other kinds of organiza- building such a capacity reflects a com- audit. In this holistic sense, research is tional capacity. A utilitarian definition mitment to “quality improvement” as basic to effective and efficient health of research is simply “rigorous inquiry and characterizes a “learning organi- care as financing. to increase knowledge and improve zation” (1). Health research is therefore Effectiveness and efficiency in health best viewed as a broad and robust con- services were highlighted in the 1970s cept that includes not only biomedical by Archie Cochrane in his analysis of and clinical research but also epidemi- the British National Health Service (2). 1 The Aga Khan University, Department of Com- munity Health Sciences, Karachi, Pakistan, and ological and related community health In the 1980s “health as a resource” was also Dalhousie University, Department of Com- research, health systems research, recognized in the health promotion munity Health & Epidemiology, Halifax, Nova Scotia, Canada. Send correspondence to: Franklin health services research, operational movement (3), and “investing” in this White, Department of Community Health Sci- research, and so on. Research is also resource by the World Bank in 1993 (4). ences, The Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan; e-mail: implicit within other functions: plan- This evolution reflected the growing [email protected] ning, evaluation, surveillance, investi- recognition of an “evidence-based” ap-

Rev Panam Salud Publica/Pan Am J Public Health 12(3), 2002 165 proach to health issues, especially as knowledge and improve practices” of goals and objectives. This “manage- applied to policy, programmatic, and must come from the top. The quality of ment cycle” applies to organizations, clinical decision-making. management can make or break re- systems within organizations, and par- According to a 1990 report of the in- search capacity. This starts with a vision ticular functions within those systems. ternational Commission on Health Re- and/or mission statement. For exam- If reference to research is not in the search for Development (5), “strength- ple, during the early 1990s, the Carib- mission statement (at least implicitly), ening research capacity in developing bean Epidemiology Center (CAREC) developing a relevant research capac- countries is one of the most powerful, developed the following mission state- ity is made vastly more difficult. cost-effective, and sustainable means ment, which explicitly includes a com- In developing countries one often of advancing health and develop- mitment to research (8): hears that the health sector cannot de- ment.” That this applies to countries at velop research due to a lack of man- all stages of development is illustrated To advance the health status of agerial support, time, and funding. If by the World Health Organization Eu- Caribbean people by advancing the we look carefully, we may also find lit- ropean Regional Office statement in capabilities of member countries in tle or no reference to research in mis- 1997 that “there is little research-based epidemiology, laboratory technology sion statements. Some organizations and related public health disciplines evidence about the components of ef- may not even have a statement. Devel- through technical cooperation, service, fective hospital management” (6). training, research and a well–trained oping or revising a mission statement The challenge of promoting health motivated staff. enables the role of research to be ad- research in developing countries was dressed or updated and will help to recently addressed by the Global Illustrating a similar commitment develop a learning organization. Forum on Health Research (7), with from South Asia, the Aga Khan Uni- particular origins in the international versity (AKU) President’s Order num- perspective of the United Nations and ber 3 states (9): Prioritizing research other development agencies. How- ever, this approach is mostly policy– Whereas His Highness Prince Karim Responsibility for developing a re- driven and contrasts with (although Aga Khan and the Aga Khan Founda- search-friendly environment applies it’s complementary to) that of the re- tion have established in Pakistan a beyond health issues to public policy search manager, who must build ca- Health Sciences Complex whose pro- as a whole, and it brings us to the issue pacity “from the ground up” within a grams will promote human welfare of priorities, which is also relevant to given context. Furthermore, like all in general and the welfare of the peo- capacity-building. National priorities ple of Pakistan in particular and have managers, the research manager must for education and for health services— expressed the desire to establish an manage change, for example, adjust- autonomous University . . . for the including related research—are re- ing the capacity of a research organi- promotion and dissemination of flected in the level of public sector in- zation to the rapidly evolving patterns knowledge and technology and for vestment, especially when compared of health and disease, such as the providing instruction, training, re- with other expenditures or with coun- emergence of the AIDS pandemic and search, demonstration and service in tries experiencing similar resource con- the now-burgeoning impact of non- the health sciences . . . straints. All of the countries of South communicable diseases in virtually all Asia spend far more on their military developing countries. Departments may also have mission establishments than on health, while statements, and in Community Health the converse holds for Latin America Sciences at Aga Khan University this is: (10). For example, in India and Pak- CAPACITY-BUILDING istan during the period of 1996–1998, To train young people for leadership public expenditures on health were, re- In addressing research capacity- in addressing health problems of the spectively, only 0.6% and 0.8% of gross building, there are two main levels: people of Pakistan, particularly those domestic product (GDP) while military of the more deprived populations, strategic and operational. The strategic spending amounts were, respectively, through the primary care approach, level is more fundamental because, in and to contribute to improvements 2.1% and 4.2% of GDP. This was in order to be effective operationally, one in the health services of Pakistan, par- sharp contrast to the nations of Latin must first be sure of the philosophical ticularly through the development America, where the median expendi- basis and must operate within a strate- of prototypes that are effective and ture on health was 2.5% of GDP and gic framework. affordable. on the military was 1.25% of GDP. The only exception in Latin America is Planning cycles flow from mission Colombia, with military spending The strategic management context statements, and the cycles incorporate being 2.6% of GDP in this period and goals, objectives, strategies, action health outlays being 1.5% of GDP. Like other good management prac- plans, monitoring, and evaluation. In While Colombia’s share for health is tices, “rigorous inquiry to increase turn, they lead to the periodic revision below the median for Latin America, it

166 White • Capacity-building for health research in developing countries is still double the health investment is strongly advocated by organizations complex challenges built upon initial level of India and Pakistan. It is there- that seek greater financial allocations, successes. fore little wonder that the health situa- especially for global programs ori- tion in the countries of Latin America ented towards “priority diseases.” The and the Caribbean compares favor- alternative model, of “poverty to dis- The operational context ably, reflecting to a large extent the ease,” requires at least equal emphasis higher priority given to investment in on local actions, and it is more firmly The most critical element in any en- health over the decades. established in the scientific literature. It terprise is usually the human resource. In health policy forums a shift to- is clear therefore that the public health Building an effective team requires wards a greater use of evidence from research agenda in developing coun- good operational management, in research is being urged, with an em- tries must not be left up to the interna- which members share the mission and phasis on optimizing health benefits tional community to prescribe, and the commitment to a self-correcting and promoting equity (11). There is that it is the responsibility of the coun- cycle, and have the right mix of skills also a critical need for more broadly tries themselves to define their priori- to ensure success. This requires well- based participation in this process as ties. In this sense the global agenda thought-out post descriptions, attrac- an increasingly important political and is complementary at best. Developing tive recruiting strategies, and criteria managerial dimension (12). However, countries themselves must build their for appointment and promotion, thus just as global priorities are not synony- systems more assertively in accor- ensuring that appropriate people are mous with national priorities, neither dance with self-determined needs and hired and promoted. Performance ap- are national priorities synonymous with their own resources. praisal systems must be keyed to real- with local or institutional ones. Each To foster research at national and istic and evolving expectations, mutu- level requires its own process and is subnational levels, appropriate struc- ally negotiated between each team subject to a differing set of realities. tures are required. For example, at the member and the team leader. This principle can be illustrated national level, many countries have a Having just outlined an ideal ap- with two examples, one from the medical research council. In large proach, let us note some common real- Global Fund to Fight AIDS, Tubercu- countries such as Brazil, Canada, and ities: the promotion of people to jobs losis and Malaria and the other from India there may also be a need to de- for which they are inadequately quali- the Commission on Macroeconomics velop similar structures at the provin- fied, and the assignment of people to and Health. The Global Fund reflects a cial or state level. At the other extreme posts for which their training is under- continuing emphasis on programming there is a need to consolidate this kind utilized or is not recognized. There is a for a few diseases deemed to be glo- of guidance capacity, such as with the better way. bal priorities (13). However, in many countries of the West Indies, which The paradigm of good practices is countries of Latin America and the have pooled their capabilities and cre- shifting from a synthesis of pathophys- Caribbean (LAC), and even of South ated the Caribbean Health Research iological concepts, experience, and Asia, these conditions are not of equiv- Council (formerly the Commonwealth common sense to one that increasingly alent public health concern. For exam- Caribbean Medical Research Council). recognizes scientific evidence as its ple, malaria is of little consequence in Universities that aspire to research foundation. The education of health many LAC countries, while the impact within their mission, in turn, must professionals now requires the disci- of AIDS in Pakistan is so far very have a research office to facilitate skills pline of “keep on asking, keep on small. In both Asian and LAC coun- development, grant opportunities, peer searching, keep on learning” (15). Un- tries diarrheal disease is still widely review, and linkages. fortunately, however, many physicians endemic. In all those nations, attention However, research capacities that still practice the medicine of their year must be given to more than just two or take years to develop can easily be of graduation rather than moving with three diseases. destroyed through inadequate sup- the times (16). How then can one pro- The Commission on Macroeconom- port or poor management. Capacities mote the discipline of lifetime learn- ics and Health advocates “essential can also be damaged by shifting pol- ing? This major aim of professional interventions,” an approach that im- icies of international granting agen- education requires the capacity to criti- plicitly requires mostly top-down deci- cies (especially when projected as in- cally read and understand scientific lit- sions, with little reference to building struments of foreign policy), by the erature, to incorporate what is relevant local capacity (14). Both the Global political directions of countries, and by into practice, and to discard outmoded Fund and the Commission cases em- unresponsive bureaucracies at any approaches. For example, an undue phasize the “disease to poverty” path- level. Examples of this can be found dependence on textbooks must be re- way, which holds that people who be- in the histories of both Asian and LAC placed by a greater reliance on journals, come ill are downwardly mobile countries. To build effective structures MEDLINE searches, and the intelligent economically, so that investing in dis- and functions requires investment use of the Internet. Future health pro- ease prevention is a form of poverty al- of vision, time, and energy, steadily fessionals must exercise independent leviation. This view, understandably, working towards progressively more judgment and must have the capacity

Rev Panam Salud Publica/Pan Am J Public Health 12(3), 2002 167 to assess and apply in their practices FIGURE 1. The health system as a self-correcting cycle relevant evidence derived from research. In other words, commitment to Assess determinants of health: social, cultural, and political research in health care must be not only top-down but also bottom-up. Assess health services Exposure to research oriented to relevance, impact, and quality improvement must be instilled within profes- Monitor and evaluate Identify problems and assess needs sional education systems. For example, Community participation at the Aga Khan University we expose medical students to the self-correcting Implement cycle shown in Figure 1. All students Set priorities are also required to carry out a research Plan interventions project, usually community–based, dur- Integrate solutions Options analysis ing their education. In this way the cul- within primary (seek solutions) ture of research and development as in- health care systems herent qualities of health care systems is inculcated. While this approach is the norm in many developed countries, in many developing country settings the more traditional emphasis on rote source will decline. These are stressful as a research manager an individual learning rather than discovery through issues, for which there is a great need to unwilling to proceed along these lines problem-based learning still predomi- encourage young researchers to grow is to risk acting on the “Peter Princi- nates. That must be changed. professionally, through mentoring and ple,” that is, to promote people to their The development of research skills the recognition of accomplishments. level of incompetence (17). generally requires additional, post- The most important task of the re- graduate education. This is an area in search manager is to create an atmos- which Pakistan offers an interesting The research manager phere of freedom from fear of intelli- model to the world, by requiring a dis- gent failure as well as acceptance of sertation for medical specialty certifi- To develop research managers, re- uncertainty as an inevitable ingredient. cation and thereby exposing young search training alone is not enough. This must be understood elsewhere in physicians to the challenge of research. Equal attention must go to the manage- the organization, including the offices This may be compared with the M.D. rial dimension, including skills in such of the chief executive officer, of per- thesis option in some Commonwealth areas as risk analysis, priority-setting, sonnel, and of finance. Each of these of Nations countries, such as at the planning, budgeting, human relations, offices must be flexible and creative in University of the West Indies, which team-building, and developing incen- order to be supportive. While produc- has campuses located in three coun- tives and rewards. Not all researchers tivity cannot be measured in the same tries: Barbados, Jamaica, and Trinidad are destined to become research man- way as in other kinds of work, re- and Tobago. Other options—not lim- agers, and it may be hazardous to pro- searchers may be assessed for their ited to physicians—are to do a post- mote a brilliant researcher into this role contribution to the advancement of rel- graduate research degree requiring a if he or she is not a competent manager. evant knowledge and improvements thesis at the master’s or doctoral level. Based largely on charisma or some- in practices. Research outputs in them- There is no single ideal model, and times their political connections, a few selves are not necessarily enough to skills may also be developed through may succeed, although not necessarily justify the investment, and efforts are relevant short courses with project with happy teams. needed to disseminate and promote requirements. In the management of research, the applications at relevant levels of policy In the end, candidates learn that re- four classical planning steps apply. and practice. search requires rigorous preparation The first is a situation analysis, the sec- Ensuring that the products of re- and significant time and effort. Even ond is setting goals and objectives, the search are relevant is where the Essen- before a competitive grant is obtained third is an action plan, and the fourth tial National Health Research (ENHR) for research, dozens or even hundreds is monitoring and evaluation. After as- concept serves as a model, by linking of hours might go into formulating a sessing the situation, one can identify research to national priorities, policies, proposal. In spite of that effort, only a needs, recognize the gaps, and de- and programmatic applications (18). minority of submissions succeed. Once velop goals and objectives and an ac- Now advocated in all regions of the the proposal is funded, it must be exe- tion plan to close those gaps. In turn, world, including LAC and South Asia, cuted. If one fails to deliver, the likeli- monitoring and evaluation are re- the principle is to link research with hood of future funding from the same quired for accountability. To appoint development needs, which is equally

168 White • Capacity-building for health research in developing countries relevant to regional, provincial, local, as with case-control studies based on grant programs can help to promote and institutional levels, although needs questionnaire-derived data (22). Time the necessary skills and resilience. and priorities are not synonymous and money are often interchangeable. The human side of research is key, across these levels. In developing The only caveat is that methodological and it is important to recognize and country contexts, is it useful to use the rigor is required. In other words, with support talent and enthusiasm. This is combined term “research and devel- a supportive mission and trained per- true even if the area of research inter- opment” (R&D), in order to maintain sonnel, even with little or no explicit est is not initially necessarily a system- our emphasis on this relationship. In funding, individuals and institutions determined priority. A recently pub- some organizations the critical linkage can conduct research. To a large extent, lished study on diabetes in Bolivia (23) between these two concepts may be therefore, having at least a basic re- is a case in point. Much of the original explicit even in the name of the orga- search capacity is a matter of choice. “push” for this study came from the nization, as in the case of the Center of Making a start on research capacity- involvement of a young representative Experimental and Applied Endocrin- building with minimal financial in- of the Bolivian Diabetes Society in a re- ology, which is located in La Plata, Ar- vestment is different from building regional training course on diabetes epi- gentina, and focuses on research on di- search at a level that can become a demiology, which itself was a project abetes quality of care (19). national or regional resource, which of a nongovernmental organization There are some excellent guides for may involve a major amount of plan- (NGO), the Latin American Diabetes developing health research, such as a ning and development. Realistically, Epidemiology Group, in cooperation manual for priority-setting using the most developing country health care with external partners. This in turn led ENHR strategy available from the organizations cannot aspire to this, but to considerable networking efforts, in- Council on Health Research and De- all countries must ensure that there are volving the World Health Organiza- velopment (18), and a health systems at least some centers within their envi- tion (WHO), the Pan American Health research (HSR) training series avail- ronment with the mission of making Organization (PAHO), the Govern- able from the International Develop- such a contribution. In building capac- ment of Bolivia, and leading Bolivian ment Research Centre, in Canada. The ity, one examines not only priorities NGOs. The end result of this partner- latter includes content on HSR as a (national, provincial, regional) but also ship was a key diabetes prevalence management tool, strategies for pro- “mandate” and “comparative advan- survey on adults in four major cities of moting HSR among policymakers and tage.” For example, product regulation Bolivia (23). senior managers, and the training of is normally a national matter, and it However, good submissions can managers of research institutes, aca- thus stands to reason that there should sometimes be rejected because they do demic departments, and agencies with exist a national research capacity to not fit the established priorities of the supporting and coordinating roles. support this role. In contrast, one organization or the nation, and in this should not normally expect a univer- lies the potential shortcomings of prior- sity hospital to develop regulatory re- ity-setting, including whose priorities Resource mobilization search, especially as conflict may arise are addressed and how adequate the with the competing need for rapid lab- process is. Some priorities are influ- Research is not necessarily a costly oratory response to support patient enced by the “latest fashion,” and some venture; to the contrary, if the goal is care, which is the primary goal. may be “donor driven,” with the po- quality improvement, it should be tential to distort national or local prior- highly cost-effective. For example, case ities. While sound, some proposals may reports and program reviews mostly Developing viable grant not be funded for reasons such as involve examining and writing up ob- submissions strong competition for limited funds. servations in a critical manner. Pro- Some poorly constructed proposals gram reviews, which are usually con- A key ingredient in building re- will be approved because they fit the ducted without additional funding search capacity is the development of official priorities list. On some occa- and are a function primarily of good grant-writing skills. While formal sions groups will be funded simply be- management practices, can stand up training takes care of the basics, there cause they are well established and not well as contributions to the public is no limit to the amount of practice in necessarily because they put forward health literature (20). Literature re- order to become more effective over the best proposals. Good proposals views also require little funding. time. Grant-writing workshops can ex- from lesser-known institutions and in- Process analyses are now routinely pand research activity in an institution, dividuals may be viewed as risky. In conducted by many institutions, and lift standards of internal peer review, the end, however, unless there is some some have stood up well as examples and stimulate attention to the require- return to the researcher in terms of of quality-of-care research (21). Even ments of granting agencies, thereby in- recognition and funding, there will be a some forms of field research can be rel- creasing the chances of success. Re- brain drain, either out of the geo- atively inexpensive, especially if little search is a demanding process, and the graphic area or out of research itself to laboratory support is required, such development of intramural and small other occupations perceived as more

Rev Panam Salud Publica/Pan Am J Public Health 12(3), 2002 169 rewarding; rather than “capacity-build- Governance as a critical success development of the Caribbean Epi- ing,” this is “capacity-destroying.” factor demiology Center (CAREC) from its From time to time, grant flows di- origins as a national arbovirus labora- minish due to external factors beyond Even if a given unit secures external tory to a PAHO/WHO center with the control of investigators. In these grant funding, not all organizations multicountry membership is another situations, other strategies can be used will be governed in a manner that will case in point (24). Also illustrating this to maintain capacity. Among the pos- result in the desired overall capacity- principle elsewhere in Latin America sibilities are to revert to activities that building. In fact, there are many orga- and the Caribbean are a number of require little or no funding, solicit nizations throughout the world where other specialized PAHO/WHO cen- smaller grants or contracts, seek a more the acquisition of such funds may re- ters, such as the Institute of Nutrition diverse range of funding sources, pool sult in a reduction of core budget, with of Central America and Panama and resources with partners, and undertake the balance being transferred to other, the Latin American Center for Perina- certain kinds of consulting contracts less-efficient units of the organization. tology and Human Development. that may offer value similar to a small In the case of internationally sup- According to Roussel et al. (25), grant. Some institutions may be able to ported operations, the funding may be there are some important management develop the capacity for bridge financ- shifted to other institutions less well rules related to resource mobilization: ing, with a budget provision to under- managed, an instance of the rule that write, at least for a defined period of “the squeaky wheel gets the grease.” • Research projects are never “sa- time, the continued employment of While justified in some situations, this cred”; projects must sometimes be people supported by extrabudgetary phenomenon may also reflect complex suspended or terminated when con- funds. This can ensure that these per- political motivations to restrict devel- ditions render them unfeasible or sons are not automatically released at opment, and it is ultimately a disin- when better proposals arise. the end of an external grant or contract. centive to the research manager and • Time given to unsuccessful ven- This measure can be key in seeing that the staff of the organization. tures cannot be recovered and can skills that are needed for future oppor- One of the key risks during times of be an opportunity cost, that is, the tunities are not lost and that research grant instability is opportunism, that is, cost to passing up one opportunity capacity painstakingly built up over taking whatever comes along without in favor of another. time is not destroyed overnight due to full consideration of its merits. Equally, • Just as in financial investments, one unanticipated external forces. One can there is a danger of exploitation by should not “throw good money use the time creatively to develop some agencies that might perceive that after bad.” more-ambitious grant submissions that a weakened organization will have lost • Good ideas require attention any- may be viable once the funding freeze negotiating power, and they will set time, not just at budget time. lifts, or submit these to previously un- about to create relationships that are • There should be no projects in the involved agencies. For example, during stacked in favor of the funding agency “nothing better to do” category. the 12–15 months immediately follow- or that may not meet the usual norms. • There should be “overbooking”; ing Pakistan’s change to military gov- For example, perhaps by coincidence, that is, one should make more sub- ernment in October 1999, and the con- an international agency donor recently missions than the capacity to imple- sequent withdrawal of funding by backed out of a potential relationship ment them strictly allows, on the many international agencies, the AKU with AKU after the donor was advised assumption that not all attempts Department of Community Health Sci- that their proposal would have to be to generate funds for research will ences sustained a 30% decline in the submitted to local scientific and ethical succeed. value of research and development review. To avoid these risks, it is criti- • Contracting out and partnerships support, but simultaneously doubled cal to be true to one’s mission. are always an option for enhancing the actual number of grants and con- Once capacity is developed and ma- capacity. tracts (smaller, shorter in duration, and tures, a local resource may become a more often locally acquired), increased national or even an international one. publications output, and maintained At AKU, for example, projects else- The marketing of research research capacity by using all these ap- where in Asia and in Africa are now proaches. New grants acquired during considered. These help to broaden How can we encourage our national the early part of 2001 have subse- experience, maintain capacity, and leaders to recognize the importance of quently restored the previous funding buffer periods when viable opportuni- building research capacity? Unless this level, while the situation post-Septem- ties within Pakistan become restricted, is achieved, there is little likelihood ber 11 confronts us with a new kind of such as recently. The best-known ex- that national priorities for research on challenge: how to absorb the new- ample of this process in South Asia is health-related areas will greatly change. found international interest in funding the International Centre for Diarrhoeal Similarly, at other levels in the health, projects in this now “politically correct” Disease Research, which is in Bangla- social, and educational sectors, a nec- but impoverished part of the world! desh. In the Americas, the historical essary part of the solution are chief ex-

170 White • Capacity-building for health research in developing countries ecutive officers (CEOs) (using this fore, a special effort must be made to with the public through press releases term in its most inclusive sense, to de- bring research priorities, activities, and other tools, and directly with the note the most senior person in execu- and outputs to their attention. This is political and decision-making con- tive or decision-making authority in no less true for heads of government stituencies. This requires both devel- any organization, regardless of its and for ministers of health and social oping a dissemination plan and fol- type). However, now consider a quote sectors. Similar actions are needed at lowing through with the plan. from our corporate cousins reported other levels. For example, in most de- Research may be viewed as rigorous by Roussel et al. (25): “CEOs actually veloping countries, district health offi- inquiry to advance knowledge and devote only trivial amounts of their cers are the health “CEOs” for very improve practices. Strengthening re- time and energy to these early stages large populations, entailing major research capacity is a requirement for [of research and development]. In- sponsibility for resource management any organization that aspires to ad- stead, they typically have significant for primary health care, which re- vance the quality, relevance, and im- involvement only during production quires its own R&D effort. pact of its services. Building research and marketing—when it’s too late to The critical role of the CEO notwith- capacity requires paying as much at- do anything that can influence the out- standing, the foregoing comments tention to good management practices come [of the enterprise].” should not be taken as “letting the re- as to the research itself. CEOs have a major influence on the searcher off the hook.” Researchers environment and destiny of the insti- and research managers have an oblig- Acknowledgments. Debra Nanan tutions that they head. R&D should be ation to publish their findings in rele- critically reviewed successive drafts part of their preparation, but many vant journals. To the extent that their of this paper, and Kausar Khan con- current CEOs have risen to their posi- work has more immediate relevance, tributed the utilitarian definition of tions without this advantage. There- researchers must also communicate research.

REFERENCES

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Rev Panam Salud Publica/Pan Am J Public Health 12(3), 2002 171 RESUMEN La investigación se puede considerar como un examen riguroso para profundizar el conocimiento y mejorar las prácticas. Una comisión internacional ha sostenido que el fortalecimiento de la capacidad de investigación es una de las formas más poderosas, Formación de la capacidad eficientes y sostenibles de hacer progresar la salud y el desarrollo. Sin embargo, los es- de investigación sanitaria fuerzos mundiales para promover la investigación en los países en desarrollo han sido en los países en desarrollo: guiados sobre todo por la política y, en gran parte, por iniciativa de organismos donantes de los países desarrollados. Aunque esencial, este enfoque político es comple- el enfoque de un gestor mentario de y al mismo tiempo contrasta con el de los gestores de la investigación, que deben fortalecerla “sobre el terreno”, en servicios de salud que varían mucho según el país, y con mandatos, recursos y limitaciones muy diferentes. El concepto de investigación de las organizaciones sanitarias es amplio y las prácticas son muy vari- ables. Sin embargo, la formación de la capacidad de investigación no es muy diferente de la formación de otros tipos de capacidad organizativa y tiene dos grandes aspectos: el estratégico y el operativo. En las organizaciones del campo de la salud, la creación de una capacidad de investigación importante se hace mucho más difícil cuando no se menciona la investigación en el enunciado de su misión. Capacidades de investigación que tardan años en crearse pueden ser fácilmente dañadas por un apoyo insuficiente, una mala gestión u otras influencias negativas internas o externas. Este artículo se basa en documentos clave sobre la política internacional de investigación y en observa- ciones sobre el comportamiento de los organismos donantes y de los organismos de investigación en relación con los países en desarrollo. Se analizan la formación de la capacidad de investigación, fundamentalmente como un reto para los gestores, los he- chos reales detrás de la eficacia y la eficiencia operativas, los métodos de movilización de recursos y la necesidad de la empresa de investigación de realizar actividades de mercadeo, y se presentan algunos ejemplos del sur de Asia, América Latina y el Caribe.

Health Services Research: An Anthology This publication attempts both to illustrate the development of health services throughout the 20th century, especially in the Americas, and to provide a selection of some of the most representative articles on the various topics covered in the health services research literature. Because health institutions and services need improvements in various respects, many of the articles included in this volume deal with the equity, efficacy, effectiveness, and quality of health services. Others expound quantitatively on the development or application of appropriate research methods. Still others made, at the time they were published, significant contributions to an understanding of the policies, organization, and practice of health services.

The 100 articles in this collection will prove instructive and valuable to scientists, health 1992 • 1108 pp. policy makers, providers and consumers of health services, as well as to students of the ISBN 92 75 11534 6 Code: SP 534 field. Price: US$ 40.00 / También disponible en español: Investigaciones sobre servicios de salud: una antología US$ 30.00 in Latin America ISBN 92 75 31534 5 • Código: PC 534 • Precios: US$ 40.00 / US$ 30.00 en América Latina y el Caribe and the Caribbean

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172 White • Capacity-building for health research in developing countries