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‘The Virtuous Cycle’: Implications of the Health and Medical Research Strategic Review

‘The Virtuous Cycle’: Implications of the Health and Medical Research Strategic Review Editor-in-Chief, Australian and New Zealand Journal of Public Health This year there will be a number of changes to the format and structure of the Journal to assist it in its role as the forum for the best research in public health in Australia and New Zealand. Content and access Journal articles will be accompanied by structured Abstracts. This will allow people to “scan” the Journal for articles of pertinence to their work and interests. In addition to the objective, method, results and conclusions, the Abstracts will require the authors to state, under a separate heading, the research’s ‘Implications’. This format will encourage all authors to draw a link between the research and practice. Beginning in April, every article will be accompanied by the dates when it was submitted, revised and accepted. This will provide you, the reader, with useful information about the article’s content. Furthermore, we will be adding a new section called Public Health Practice Notes. With the ever-changing public health practice, the Journal will invite experts in theory, methodology and policy development to write ‘state of the art’ papers on issues relevant to public health practitioners and researchers. The old clichC, ‘time is of the essence’, has never been more true in public health than it is today. Information that is current and accessible is required. To increase the usability of the material and make it available as quickly as possible, Abstracts of articles accepted for publication are available, prior to printing, on the PHA website. Starting with the February 1999 issue, the full Journal will also be available on the new PHA website. This is our first step towards moving more into electronic publishing of the Journal. Printed copies of the Journal will continue to be posted out. To remind everyone, the Journal is indexed by Australian Public Affairs Information Service, Current Contents, Excerpla Medica, Index Medicus, the Cumulative Index to Nursing I% Allied Health Literature and Social Sciences Citation Index and is available on microfiche from University Microfilms International. then be used throughout the evaluation and review process. Reviewers will receive the document and evaluation form via e-mail wherever possible. The detailed review and evaluation can be returned to the Journal electronically as well. Of course, where an author or reviewer does not have access to e-mail, the Journal will continue to post printouts of the manuscripts. We hope that encouraging authors and reviewers to use electronic formats will help with the smooth and efficient flow of manuscripts and enable us to minimise the time between submission of manuscripts and publishing accepted papers. Before submitting manuscripts, we suggest that authors read the updated ‘Guide to Contributors’ now available at the PHA website or contact the Journal’s Editorial Office for a copy. The Journal also now has a dedicated e-mail address for administrative correspondence and queries: anzjph@ozemail.com.au Feedback This is your Journal, what you want from this Journal and the way that it is presented is important. I look forward to hearing from you and feel free to e-mail me atj.lowe@mailbox.uq.edu.au ‘The Virtuous Cycle’: Implications of the Health and Medical Research Strategic Review Peter Sainsbury Division of Population Health, Central Sydney Area Health Service, and Department of Public Health and Community Medicine, University of SydneK New South Wales Jeanette Ward Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, New South Wales Manuscript submission and evaluation The new year has brought a number of changes to the procedures involved in the administration and evaluation of manuscripts submitted to the Journal. The Journal is moving to take advantage of advances in the efficiency of electronic data transfer and the increasingly widespread access to e-mail facilities. Authors are asked to submit the original manuscript on disk, in a Word for Windows compatible format, accompanied by one printout. Initial manuscripts will not be accepted via e-mail; they must be sent on disk with a printout. This electronic copy will In December 1998, a discussion document arising from the Strategic Review of Australia’s health and medical research sector chaired by Mr Peter Wills, Chairman of the Garvan Institute of Medical Research, was released, entitled The Virtuous Cycle Working together for health and medical research.’ The Federal Minister for Health and Aged Care, Dr Michael Wooldridge, has invited submissions by 19 March to feed into a final publication*. Among its terms of reference, the Strategic Review was required to consider how Australia’s health and medical research capacity might most usefully contribute to improving the health of the population and, further, in which broad discipline areas Australian health and medical research capability would be required. In his Foreward (sic), the Chairman identifies four structural issues placing the current approaches to health and medical research ‘at risk’, including “a greater need for research that 1999 VOL. 23 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Editorials contributes directly to the health of the population and a wellfunctioning, evidence-based health system”. The discussion document is ambitious in scope. Many of its recommendations are laudable and inspired, including increased funding for both investigator-driven and priority-driven research (the latter described as Strategic Research and Development and Evaluation Research); workforce development; re-organisation of the NHMRC to include appointment of a full-time Chief Executive Officer respected by the wide range of research stakeholders; greater co-ordination of the national research effort and community engagement. Echoing previous sentiment^,^ it recommends the creation of large, multidisciplinary centres of excellence with Strategic Research and Development and Evaluation Research capacity. Yet the groundrules for research envisaged by the Strategic Review still could fail the public’s health. document than desired. Perhaps it is ominous that the creation of “an effective health and medical research sector built on high impact Fundamental Research, world-class workforce and infrastructure” (Chapter 2) precedes consideration of “population-health and evidence-based health care” (Chapter 3). Research classifications are distinguished on the basis of their relevance to contemporary health care issues. ‘Fundamental Research’ represents world class research conducted for its own sake as evaluated by an international scientific peerage. ‘Strategic Research’ generates knowledge about specific health issues. ‘Development and Evaluation Research’ is the most applied of the three (see Figure I). Having uncoupled Fundamental Research from accountability to the health sector, the Strategic Review concludes, in a potentially circular argument, that Strategic Research, and Development and Evaluation Research alone offer “great potential for Australia to improve population health and the efficiency, effectiveness and equity of its health care system”. Fundamental Research is seen as largely beyond the need to be relevant and applicable. Long-term targets specified for contestable NHMRC funding encompass scientific output (e.g. relating to citations and patents); industry formation (e.g. relating to new enterprise formation and establishment of regional headquarters); and economic benefits (e.g. reduced international pharmaceutical trade deficit and new jobs in the life sciences). Improved health, improved health care and increased efficiency of health services do not feature as targets for this type of research. By contrast, priority-driven Figure 1: Research definitions proposed by the Strategic Review Fundamental Research generates knowledge about problems o scientific significance. A broad coverage of areas i f s encouraged, focussing on areas where Australia can lead the world due to particular competence, history o excellence, f access to unique populations or unique circumstances. Peer review o its international standing i advocated. Fundamental f s Research is typically investigator-initiated,such that 84% i to s advance knowledge while 16% is to change practice. Strategic Research generates knowledge about specific health needs and problems.These may be conditions, risk factors or sources of inefficiency or inequity in health systems (50%to advance knowledge; 50%to change practice). It should focus on important issues that require special attention from Australian researchers, beyond what would be expected from fundamental investigator-initiatedresearch in Australia or around the world. Development and Evaluation Research creates and assesses products (vaccines, drugs, diagnostics, prostheses or equipment), interventions (public or personal health services) and instruments o policy that improve on existing options (21% f to advance knowledge and 79% to improve practice), endorsing that Australia should have the capacity to integrate the broad spectrum of health and medical and other relevant knowledge, wherever generated, into policy and practice targeted at the short to medium term needs o the health o the population and f f the health care system. Further, this type o research calls for a f process that prioritkes the areas where Australia would benefit most from additional research. 1999 VOL. 23 NO. 1 What is the primary goal of health and medical research? For public servants seeking to improve population health, the need for applicable evidence generated through health and medical research never has been greater. The evidence-based health system we espouse embodies the right of every Australian citizen to organised health care which promotes and protects their health, minimises the effects of illness and rehabilitates the chronically ill, irrespective of race, wealth, education, geography or social power by systematically applying interventions known to work. Researchers and their collective research effort are the means to generate the evidence the system requires. Evidence from health and medical research represents the fuel essential to make informed decisions about what and how to provide effective health care to individuals and populations. Health and medical research enjoys unparalleled access to quarantined monies such as the NHMRC endowment because it has successfully asserted its unique focus on issues pertinent to health, well-being, disease and dysfunction. Its primary purpose is not to generate knowledge in and of itselfbut to generate knowledge pertinent to health and medical care in Australia. Thus, the output of health and medical research must be judged against its utility in improving health and well-being. Its output is not the patent, drug, diagnostic tests, screening tool, surgical procedure or commercially attractive commodities per se but rather the improvements in health which accrue from each o f these on the basis of their efficacy. Health and medical research should illuminate the science of health care delivery itself, producing nuggets of timely, valid and reliable knowledge with which to understand health and inform decisions about how to improve service configuration and performance. Research will assure effective governance of health services. Elected representatives in government also require health-related intelligence to make sound decisions about government policy and resource allocation. An imbalanced portfolio Recognition of the primary purpose of health and medical research to improve health is less explicit in the discussion AUSTRALIAN AND NEW ZEALAND JOURNAL O F PUBLIC HEALTH Editorials research (encompassing Strategic Research and Development and Evaluation Research) will reflect informed priority-setting; embrace investigator-initiated research within its priorities and will be commissioned to assure timeliness, ‘relevanceand application. The discussion document states, with supporting conjecture but not evidence, that “managing priorities in Fundamental Research (e.g. to reflect the burden of disease) makes little sense” since, among other factors, “serendipity is important in achieving outcomes from Fundamental Research”. Further, “Fundamental Research should be primarily investigator-initiated and the key criteria for allocating funds should be whether the research is potentially of high impact [in terms of publication and citation not health improvement] and innovative in world terms” yet ... “Strategic, Development and Evaluation Research should follow an effective priority-setting process so that scarce resources are applied where they can have the greatest impact on health and health care”. While the discussion document takes pains “not to imply anything about relative importance or funding” between research classifications, it does ask rhetorically, “how should a relatively small country like Australia allocate its resources for maximal effect?”Yet, if resources are so scarce that Australia cannot fully fund health and medical research which addresses specific health needs and problems or creates and assesses products, interventions and instruments of policy, can we afford to fund research which doesn’t? sector should not be achieved at the expense of increased socioeconomic inequality in Australia. Many of the envious comparisons made in Chapter 4 of the discussion document are with the US, a country which may well have an admirable research investment record but which also has one of the most unequal societies and certainly one of the most inequitable health care systems of the developed world. These facts are not entirely unrelated, both being in part reflections of the underlying culture in the US of individuality and personal success rather than collective responsibility for each other’s and society’s welfare. Despite its impressive size, the American investment in research has not assured health for all. Similarly, our response to the statement that “any taxation revenue foregone by changing the existing system would be insignificant compared with the economic boost to the nation from the industry created” is initially cautious. How exactly will the industry contribute to greater health? Who will reap the economic benefits? Will they’be reaped by the poor [unlikely]? Will they be shared equally through society [unlikely]? Will they favour the already affluent [highly likely]? Australia could have unprecedented levels of research activity, attracting more global investment dollars but inadvertently create more socioeconomic inequity and, in turn, more ill health which, in itself, will increase health care costs. Furthermore, commercial interests will likely shape funding opportunities for their own purposes. It has been documented that tobacco companies have funded research to maintain an artificial controversy about the health effects of passive smoking in order to undermine the public health consensus prompted by compelling evidence of significant harmss It also is inevitable that commercial interests will pursue only profitable avenues. Which commercial interest will fund, design and evaluate health promotion programs when a patentable drug, screening test or surgical procedure appears more ‘profitable’? Growth of the biotechnology and pharmaceutical industries is not an end in itself for health and medical research. As health practitioners, we can have little interest in products which do not bring about net health benefit beyond current practice. Funding levels Through international benchmarking, the Strategic Review confirms the need for an absolute increase for both investigatorinitiated and priority-driven research funding and a need for greater transparency and innovation in its allocation. We agree. Competitive systems as currently structured in the National Institutes of Health bias against outcomes-oriented r e ~ e a r c hThe Strategic .~ Review proposes “funding for a national program of prioritydriven health and medical research, building to 1% of government health expenditure over five to ten years based on demonstrated financial benefits and improved health outcomes”. Upon closer examination however, the plans for strengthening the funding base for Fundamental Research are presented with considerably more definition and detail than the plans for those for priority-driven research. While approximately $300 million per year will be allocated to each of Fundamental Research and prioritydriven research, the discussion document lacks a clear picture of the size, sources and disbursements of the overall health and medical research budget in 2005. Research literacy and reverence for evidence The discussion document recognises the need for researchliterate decision-makers in health bureaucracies, clinical services and public heaPh. It suggests that decision-makers are “not very likely to read p er-reviewed scientific journals”. Regrettably, this insight is not n w. We envisage a third millenium in which there is a seamless tr .nsition from evidence acquired through research to its broader i: iplementation in practice. While one study rarefy behoves immet iate change in practice, accumulated evidence as synthesised in vidence-based guidelines, for example, ought to trigger purpost hl efforts to modify health care. Australia’s 1 .:alth system has no reliable capacity to generate The double-edged sword of diversification The desire to promote research by diversifying sources of funding, particularly the enhancement of private sector research funding, is understandable. However, organisations other than government which fund health and medical research have goals other than health improvement. It is the relative influence of these potentially conflicting goals which needs further consideration. Private support of health and medical research in the public Continued on page 79 1999 VOL. 23 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH The Incidence module of the Cardiovascular Disease Policy Model 10. Elandt-Johnson RC, Johnson NL. Survival models and data analysis. New York Wiley, 1980. 1 1. Australian Bureau of Statistics. Estimated resident population by sex and age, States and Territories ofAustralia. Canberra: ABS; 1997.Catalogue No. 3201 .O. 12. WHO MONICA Project Principal Investigators. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascu1ardisease):Amajor international collaboration.JClin EpidemiolI988; 41(2): 105-14. 13. Clinical Epidemiology and Biostatistics. Newcastle MONICA data book: Coronary events JY84-IYY4. Newcastle (Australia): The University of Newcastle, 1995. 14. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: A 26-year follow-up of the Framingham population. Am Heart J 1986; 1 1 l 2 : 383-90. () 15. Kame1 WB, Vokonas PS. Demographics of the prevalence, incidence, and management of coronary heart disease in the elderly and in women, Ann Epidemiol 1992;2(1/2):5-14. 16. Kannel WB, Wolf PA, Garrison RJ. The Fmmingham Study: An epidemiological investigation oj’cardiovascular disease: Some risk factors related to the annual incidence ofcardiovascular disease and death using pooled repeated biennial measurements: Framingham Heart Studys 30-year follow-up. Bethesda (MD): National Heart, Lung, and Blood Institute; 1987 February. NIH Publication No. 87-2703. 17. WHO MONICA Project. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project: Registration procedures, event 1 rates, and case-fatality rates in 38 populations from 2 countries in four continents. Circulation 1994;90(1): 583-612. 18. Citro CF, Hanushek EA. The uses of micmsimulation modeling, Volume I: Review and recommendations. Washington: National Academy Press, 1991. 19. Australian Bureau of Statistics. Projections of the populations of Austmlia. States and Territories. 1995-2051. Canberra: ABS; 1997.Catalogue No. 3222.0. 20. Landt I, Harding A, Percival R, Sadkowsky K. Reweighting a base population jor a microsimulation model. Canberra: National Centre for Social and Economic Modelling, Faculty of Management, University of Canberra; 1994. Discussion Paper, No.3. 21. Harding A. New estimates of poverty and income distribution in 1990:The effects of reweighting the 1990 Income Distribution Survey. In: Saunders P, Shaver S , editors. Theory and pmctice in Australian social policy: Rethinking the.fundamentals. Proceedings ofthe National Social Policy Conference; 1993 July 14-16. Sydney: University ofNSW, December 1993;(2):203-24. 22. Weinstein MC, Coxson PG, Williams LW, et al. Forecasting coronary heart disease incidence, mortality, and cost:The coronary heart disease policy model. Am J Public Health 1987;77( 1 I): 1417-26. 23. Jamrozik K, Hockey R. Trends in risk factors for vascular disease in Australia. MedJAust 1989; 150: 14-18. 24. Bennett SA, Magnus P Trends in cardiovascular risk factors in Australia: Results from the National Heart Foundation’s Risk Factor Prevalence Study, 1980-1989. Med JAust 1994; 161:519-27. 25. Dobson AJ, Gibberd RW, Leeder SR, et al. lschaemic heart disease in the Hunter region of New South Wales, Australia, 1979-1885.Am J Epidemiol 1988; 128(1): 106-15. 26. Dobson AJ, Alexander HM, Al-Roomi K, et al. Coronary events in the Hunter Region of New South Wales, Australia: 1984.1986. Acta Med Scand Suppl 1988;728: 84-9. 27. Hobbs MST,Jarnrozik KD, Alexander HM, et al. Mortality from coronary heart disease and incidence of acute myocardial infarction in Auckland, Newcastle and Perth. Med JAust 1991; 155: 436-42. ‘The Virtuous Cycle’: Implications o the Health and f Medical Research Strategic Review Continued from page 5 and summarise evidence in a systematic manner and then disseminate it purposefully to practitioners for incorporation in routine practice.The need to develop and test systems with which to disseminate research findings is underplayed and confined to Strategic Research and Development and Evaluation Research. The discussion document gives cursory acknowledgment to the complexities of an evidence-based health system, it advocates expertise in mass media, web sites and public relations rather than health services research, organisational change, critical appraisal and other techniques to enhance research transfer. future for Strategic Research and Development and Evaluation Research is conditional and painted with a much broader brush. The underpinning values, reforms and performance indicators advocated by the Strategic Review potentially misconstrue health and medical research as a commercial activity rather than as a means to the end of improved health. Dr Wooldridge anticipates “that the 2 1st century will be known as the century of healing”.2 In its final document, the Strategic Review will need to reconcile its vision with the social purpose of health and medical research. Comments about The Virtuous Cycle should be addressed to Ms Margaret Norington, ONHMRC, phone (02) 6289 5466, by 19 March 1999. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

‘The Virtuous Cycle’: Implications of the Health and Medical Research Strategic Review

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References (21)

Publisher
Wiley
Copyright
Copyright © 1999 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1999.tb01197.x
Publisher site
See Article on Publisher Site

Abstract

Editor-in-Chief, Australian and New Zealand Journal of Public Health This year there will be a number of changes to the format and structure of the Journal to assist it in its role as the forum for the best research in public health in Australia and New Zealand. Content and access Journal articles will be accompanied by structured Abstracts. This will allow people to “scan” the Journal for articles of pertinence to their work and interests. In addition to the objective, method, results and conclusions, the Abstracts will require the authors to state, under a separate heading, the research’s ‘Implications’. This format will encourage all authors to draw a link between the research and practice. Beginning in April, every article will be accompanied by the dates when it was submitted, revised and accepted. This will provide you, the reader, with useful information about the article’s content. Furthermore, we will be adding a new section called Public Health Practice Notes. With the ever-changing public health practice, the Journal will invite experts in theory, methodology and policy development to write ‘state of the art’ papers on issues relevant to public health practitioners and researchers. The old clichC, ‘time is of the essence’, has never been more true in public health than it is today. Information that is current and accessible is required. To increase the usability of the material and make it available as quickly as possible, Abstracts of articles accepted for publication are available, prior to printing, on the PHA website. Starting with the February 1999 issue, the full Journal will also be available on the new PHA website. This is our first step towards moving more into electronic publishing of the Journal. Printed copies of the Journal will continue to be posted out. To remind everyone, the Journal is indexed by Australian Public Affairs Information Service, Current Contents, Excerpla Medica, Index Medicus, the Cumulative Index to Nursing I% Allied Health Literature and Social Sciences Citation Index and is available on microfiche from University Microfilms International. then be used throughout the evaluation and review process. Reviewers will receive the document and evaluation form via e-mail wherever possible. The detailed review and evaluation can be returned to the Journal electronically as well. Of course, where an author or reviewer does not have access to e-mail, the Journal will continue to post printouts of the manuscripts. We hope that encouraging authors and reviewers to use electronic formats will help with the smooth and efficient flow of manuscripts and enable us to minimise the time between submission of manuscripts and publishing accepted papers. Before submitting manuscripts, we suggest that authors read the updated ‘Guide to Contributors’ now available at the PHA website or contact the Journal’s Editorial Office for a copy. The Journal also now has a dedicated e-mail address for administrative correspondence and queries: anzjph@ozemail.com.au Feedback This is your Journal, what you want from this Journal and the way that it is presented is important. I look forward to hearing from you and feel free to e-mail me atj.lowe@mailbox.uq.edu.au ‘The Virtuous Cycle’: Implications of the Health and Medical Research Strategic Review Peter Sainsbury Division of Population Health, Central Sydney Area Health Service, and Department of Public Health and Community Medicine, University of SydneK New South Wales Jeanette Ward Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, New South Wales Manuscript submission and evaluation The new year has brought a number of changes to the procedures involved in the administration and evaluation of manuscripts submitted to the Journal. The Journal is moving to take advantage of advances in the efficiency of electronic data transfer and the increasingly widespread access to e-mail facilities. Authors are asked to submit the original manuscript on disk, in a Word for Windows compatible format, accompanied by one printout. Initial manuscripts will not be accepted via e-mail; they must be sent on disk with a printout. This electronic copy will In December 1998, a discussion document arising from the Strategic Review of Australia’s health and medical research sector chaired by Mr Peter Wills, Chairman of the Garvan Institute of Medical Research, was released, entitled The Virtuous Cycle Working together for health and medical research.’ The Federal Minister for Health and Aged Care, Dr Michael Wooldridge, has invited submissions by 19 March to feed into a final publication*. Among its terms of reference, the Strategic Review was required to consider how Australia’s health and medical research capacity might most usefully contribute to improving the health of the population and, further, in which broad discipline areas Australian health and medical research capability would be required. In his Foreward (sic), the Chairman identifies four structural issues placing the current approaches to health and medical research ‘at risk’, including “a greater need for research that 1999 VOL. 23 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Editorials contributes directly to the health of the population and a wellfunctioning, evidence-based health system”. The discussion document is ambitious in scope. Many of its recommendations are laudable and inspired, including increased funding for both investigator-driven and priority-driven research (the latter described as Strategic Research and Development and Evaluation Research); workforce development; re-organisation of the NHMRC to include appointment of a full-time Chief Executive Officer respected by the wide range of research stakeholders; greater co-ordination of the national research effort and community engagement. Echoing previous sentiment^,^ it recommends the creation of large, multidisciplinary centres of excellence with Strategic Research and Development and Evaluation Research capacity. Yet the groundrules for research envisaged by the Strategic Review still could fail the public’s health. document than desired. Perhaps it is ominous that the creation of “an effective health and medical research sector built on high impact Fundamental Research, world-class workforce and infrastructure” (Chapter 2) precedes consideration of “population-health and evidence-based health care” (Chapter 3). Research classifications are distinguished on the basis of their relevance to contemporary health care issues. ‘Fundamental Research’ represents world class research conducted for its own sake as evaluated by an international scientific peerage. ‘Strategic Research’ generates knowledge about specific health issues. ‘Development and Evaluation Research’ is the most applied of the three (see Figure I). Having uncoupled Fundamental Research from accountability to the health sector, the Strategic Review concludes, in a potentially circular argument, that Strategic Research, and Development and Evaluation Research alone offer “great potential for Australia to improve population health and the efficiency, effectiveness and equity of its health care system”. Fundamental Research is seen as largely beyond the need to be relevant and applicable. Long-term targets specified for contestable NHMRC funding encompass scientific output (e.g. relating to citations and patents); industry formation (e.g. relating to new enterprise formation and establishment of regional headquarters); and economic benefits (e.g. reduced international pharmaceutical trade deficit and new jobs in the life sciences). Improved health, improved health care and increased efficiency of health services do not feature as targets for this type of research. By contrast, priority-driven Figure 1: Research definitions proposed by the Strategic Review Fundamental Research generates knowledge about problems o scientific significance. A broad coverage of areas i f s encouraged, focussing on areas where Australia can lead the world due to particular competence, history o excellence, f access to unique populations or unique circumstances. Peer review o its international standing i advocated. Fundamental f s Research is typically investigator-initiated,such that 84% i to s advance knowledge while 16% is to change practice. Strategic Research generates knowledge about specific health needs and problems.These may be conditions, risk factors or sources of inefficiency or inequity in health systems (50%to advance knowledge; 50%to change practice). It should focus on important issues that require special attention from Australian researchers, beyond what would be expected from fundamental investigator-initiatedresearch in Australia or around the world. Development and Evaluation Research creates and assesses products (vaccines, drugs, diagnostics, prostheses or equipment), interventions (public or personal health services) and instruments o policy that improve on existing options (21% f to advance knowledge and 79% to improve practice), endorsing that Australia should have the capacity to integrate the broad spectrum of health and medical and other relevant knowledge, wherever generated, into policy and practice targeted at the short to medium term needs o the health o the population and f f the health care system. Further, this type o research calls for a f process that prioritkes the areas where Australia would benefit most from additional research. 1999 VOL. 23 NO. 1 What is the primary goal of health and medical research? For public servants seeking to improve population health, the need for applicable evidence generated through health and medical research never has been greater. The evidence-based health system we espouse embodies the right of every Australian citizen to organised health care which promotes and protects their health, minimises the effects of illness and rehabilitates the chronically ill, irrespective of race, wealth, education, geography or social power by systematically applying interventions known to work. Researchers and their collective research effort are the means to generate the evidence the system requires. Evidence from health and medical research represents the fuel essential to make informed decisions about what and how to provide effective health care to individuals and populations. Health and medical research enjoys unparalleled access to quarantined monies such as the NHMRC endowment because it has successfully asserted its unique focus on issues pertinent to health, well-being, disease and dysfunction. Its primary purpose is not to generate knowledge in and of itselfbut to generate knowledge pertinent to health and medical care in Australia. Thus, the output of health and medical research must be judged against its utility in improving health and well-being. Its output is not the patent, drug, diagnostic tests, screening tool, surgical procedure or commercially attractive commodities per se but rather the improvements in health which accrue from each o f these on the basis of their efficacy. Health and medical research should illuminate the science of health care delivery itself, producing nuggets of timely, valid and reliable knowledge with which to understand health and inform decisions about how to improve service configuration and performance. Research will assure effective governance of health services. Elected representatives in government also require health-related intelligence to make sound decisions about government policy and resource allocation. An imbalanced portfolio Recognition of the primary purpose of health and medical research to improve health is less explicit in the discussion AUSTRALIAN AND NEW ZEALAND JOURNAL O F PUBLIC HEALTH Editorials research (encompassing Strategic Research and Development and Evaluation Research) will reflect informed priority-setting; embrace investigator-initiated research within its priorities and will be commissioned to assure timeliness, ‘relevanceand application. The discussion document states, with supporting conjecture but not evidence, that “managing priorities in Fundamental Research (e.g. to reflect the burden of disease) makes little sense” since, among other factors, “serendipity is important in achieving outcomes from Fundamental Research”. Further, “Fundamental Research should be primarily investigator-initiated and the key criteria for allocating funds should be whether the research is potentially of high impact [in terms of publication and citation not health improvement] and innovative in world terms” yet ... “Strategic, Development and Evaluation Research should follow an effective priority-setting process so that scarce resources are applied where they can have the greatest impact on health and health care”. While the discussion document takes pains “not to imply anything about relative importance or funding” between research classifications, it does ask rhetorically, “how should a relatively small country like Australia allocate its resources for maximal effect?”Yet, if resources are so scarce that Australia cannot fully fund health and medical research which addresses specific health needs and problems or creates and assesses products, interventions and instruments of policy, can we afford to fund research which doesn’t? sector should not be achieved at the expense of increased socioeconomic inequality in Australia. Many of the envious comparisons made in Chapter 4 of the discussion document are with the US, a country which may well have an admirable research investment record but which also has one of the most unequal societies and certainly one of the most inequitable health care systems of the developed world. These facts are not entirely unrelated, both being in part reflections of the underlying culture in the US of individuality and personal success rather than collective responsibility for each other’s and society’s welfare. Despite its impressive size, the American investment in research has not assured health for all. Similarly, our response to the statement that “any taxation revenue foregone by changing the existing system would be insignificant compared with the economic boost to the nation from the industry created” is initially cautious. How exactly will the industry contribute to greater health? Who will reap the economic benefits? Will they’be reaped by the poor [unlikely]? Will they be shared equally through society [unlikely]? Will they favour the already affluent [highly likely]? Australia could have unprecedented levels of research activity, attracting more global investment dollars but inadvertently create more socioeconomic inequity and, in turn, more ill health which, in itself, will increase health care costs. Furthermore, commercial interests will likely shape funding opportunities for their own purposes. It has been documented that tobacco companies have funded research to maintain an artificial controversy about the health effects of passive smoking in order to undermine the public health consensus prompted by compelling evidence of significant harmss It also is inevitable that commercial interests will pursue only profitable avenues. Which commercial interest will fund, design and evaluate health promotion programs when a patentable drug, screening test or surgical procedure appears more ‘profitable’? Growth of the biotechnology and pharmaceutical industries is not an end in itself for health and medical research. As health practitioners, we can have little interest in products which do not bring about net health benefit beyond current practice. Funding levels Through international benchmarking, the Strategic Review confirms the need for an absolute increase for both investigatorinitiated and priority-driven research funding and a need for greater transparency and innovation in its allocation. We agree. Competitive systems as currently structured in the National Institutes of Health bias against outcomes-oriented r e ~ e a r c hThe Strategic .~ Review proposes “funding for a national program of prioritydriven health and medical research, building to 1% of government health expenditure over five to ten years based on demonstrated financial benefits and improved health outcomes”. Upon closer examination however, the plans for strengthening the funding base for Fundamental Research are presented with considerably more definition and detail than the plans for those for priority-driven research. While approximately $300 million per year will be allocated to each of Fundamental Research and prioritydriven research, the discussion document lacks a clear picture of the size, sources and disbursements of the overall health and medical research budget in 2005. Research literacy and reverence for evidence The discussion document recognises the need for researchliterate decision-makers in health bureaucracies, clinical services and public heaPh. It suggests that decision-makers are “not very likely to read p er-reviewed scientific journals”. Regrettably, this insight is not n w. We envisage a third millenium in which there is a seamless tr .nsition from evidence acquired through research to its broader i: iplementation in practice. While one study rarefy behoves immet iate change in practice, accumulated evidence as synthesised in vidence-based guidelines, for example, ought to trigger purpost hl efforts to modify health care. Australia’s 1 .:alth system has no reliable capacity to generate The double-edged sword of diversification The desire to promote research by diversifying sources of funding, particularly the enhancement of private sector research funding, is understandable. However, organisations other than government which fund health and medical research have goals other than health improvement. It is the relative influence of these potentially conflicting goals which needs further consideration. Private support of health and medical research in the public Continued on page 79 1999 VOL. 23 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH The Incidence module of the Cardiovascular Disease Policy Model 10. Elandt-Johnson RC, Johnson NL. Survival models and data analysis. New York Wiley, 1980. 1 1. Australian Bureau of Statistics. Estimated resident population by sex and age, States and Territories ofAustralia. Canberra: ABS; 1997.Catalogue No. 3201 .O. 12. WHO MONICA Project Principal Investigators. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascu1ardisease):Amajor international collaboration.JClin EpidemiolI988; 41(2): 105-14. 13. Clinical Epidemiology and Biostatistics. Newcastle MONICA data book: Coronary events JY84-IYY4. Newcastle (Australia): The University of Newcastle, 1995. 14. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: A 26-year follow-up of the Framingham population. Am Heart J 1986; 1 1 l 2 : 383-90. () 15. Kame1 WB, Vokonas PS. Demographics of the prevalence, incidence, and management of coronary heart disease in the elderly and in women, Ann Epidemiol 1992;2(1/2):5-14. 16. Kannel WB, Wolf PA, Garrison RJ. The Fmmingham Study: An epidemiological investigation oj’cardiovascular disease: Some risk factors related to the annual incidence ofcardiovascular disease and death using pooled repeated biennial measurements: Framingham Heart Studys 30-year follow-up. Bethesda (MD): National Heart, Lung, and Blood Institute; 1987 February. NIH Publication No. 87-2703. 17. WHO MONICA Project. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project: Registration procedures, event 1 rates, and case-fatality rates in 38 populations from 2 countries in four continents. Circulation 1994;90(1): 583-612. 18. Citro CF, Hanushek EA. The uses of micmsimulation modeling, Volume I: Review and recommendations. Washington: National Academy Press, 1991. 19. Australian Bureau of Statistics. Projections of the populations of Austmlia. States and Territories. 1995-2051. Canberra: ABS; 1997.Catalogue No. 3222.0. 20. Landt I, Harding A, Percival R, Sadkowsky K. Reweighting a base population jor a microsimulation model. Canberra: National Centre for Social and Economic Modelling, Faculty of Management, University of Canberra; 1994. Discussion Paper, No.3. 21. Harding A. New estimates of poverty and income distribution in 1990:The effects of reweighting the 1990 Income Distribution Survey. In: Saunders P, Shaver S , editors. Theory and pmctice in Australian social policy: Rethinking the.fundamentals. Proceedings ofthe National Social Policy Conference; 1993 July 14-16. Sydney: University ofNSW, December 1993;(2):203-24. 22. Weinstein MC, Coxson PG, Williams LW, et al. Forecasting coronary heart disease incidence, mortality, and cost:The coronary heart disease policy model. Am J Public Health 1987;77( 1 I): 1417-26. 23. Jamrozik K, Hockey R. Trends in risk factors for vascular disease in Australia. MedJAust 1989; 150: 14-18. 24. Bennett SA, Magnus P Trends in cardiovascular risk factors in Australia: Results from the National Heart Foundation’s Risk Factor Prevalence Study, 1980-1989. Med JAust 1994; 161:519-27. 25. Dobson AJ, Gibberd RW, Leeder SR, et al. lschaemic heart disease in the Hunter region of New South Wales, Australia, 1979-1885.Am J Epidemiol 1988; 128(1): 106-15. 26. Dobson AJ, Alexander HM, Al-Roomi K, et al. Coronary events in the Hunter Region of New South Wales, Australia: 1984.1986. Acta Med Scand Suppl 1988;728: 84-9. 27. Hobbs MST,Jarnrozik KD, Alexander HM, et al. Mortality from coronary heart disease and incidence of acute myocardial infarction in Auckland, Newcastle and Perth. Med JAust 1991; 155: 436-42. ‘The Virtuous Cycle’: Implications o the Health and f Medical Research Strategic Review Continued from page 5 and summarise evidence in a systematic manner and then disseminate it purposefully to practitioners for incorporation in routine practice.The need to develop and test systems with which to disseminate research findings is underplayed and confined to Strategic Research and Development and Evaluation Research. The discussion document gives cursory acknowledgment to the complexities of an evidence-based health system, it advocates expertise in mass media, web sites and public relations rather than health services research, organisational change, critical appraisal and other techniques to enhance research transfer. future for Strategic Research and Development and Evaluation Research is conditional and painted with a much broader brush. The underpinning values, reforms and performance indicators advocated by the Strategic Review potentially misconstrue health and medical research as a commercial activity rather than as a means to the end of improved health. Dr Wooldridge anticipates “that the 2 1st century will be known as the century of healing”.2 In its final document, the Strategic Review will need to reconcile its vision with the social purpose of health and medical research. Comments about The Virtuous Cycle should be addressed to Ms Margaret Norington, ONHMRC, phone (02) 6289 5466, by 19 March 1999.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Feb 1, 1999

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