A. A. Hyder  ( Global Forum for Health Research , C/o WHO, 20 Avenue Appia, 1121 Geneva 27, Switzerland. )

The Changing Context of Health
The past two decades have resulted in significant changes within the global health sector. Decentralization of health systems has been attempted with differential success in many parts of the world; enhanced local autonomy has resulted in changes to the day to day running of health services; the role and nature of leadership in health has changed; and the nature of health organizations has become more horizontal and less hierarchical¹. These define the new realities within the health sector that have implications for actions in health and health research.
The new realities in the health sector and the need for urgent attention to a wide range of health issues, is faced with the lack of capacity to respond - especially in the developing world². This discrepancy between need and capacity is neither new, nor simple for the health sector and yet the urgency is greater. It is within this context that health research becomes a tool for greater equity in health development³. In turn, the need for health research within the context of meager resources for research becomes a critical issue.
It is this context of a changing health sector that is a challenge for Public Health Associations (PHAs) in each country. This means that there will be some learning to be done in the short term, to enable PHAs to manage change. PHAs will need to further strengthen their problem solving skills and become better at exploring creative solutions.
This commentary proposes that the changing context of health requires the use of ,creative and new ways of managing health issues by PHAs. As a result, in addressing the need for health research in their countries, PHAs must strengthen their own capacities to respond. This capacity strengthening will enhance the ability of PHAs to deal with new and dynamic issues using some of the principles of creative problem solving. The 10/90 disequilibrium in global health research investments is a call for more concerted action by PHAs in their countries⁴. Improving the status and support for health research would be an appropriate “problem” to address in this respect.
Public Health Associations and Health Research
It is important to address the following questions, as PHAs explore health research within a national context.
*  What kinds of health research will be done?
*  Who will do it and on what basis?
*  Who will deliver the products of research?
*  Who will pay for it?
*  Who will control it?
In other words, defining a national health research agenda and plan is critical to a thoughtful analysis of such issues. Such a plan must include consideration of the whole process of research from hypothesis generation and testing, to making sure that the results of research are used and reach people who can benefit from them. A number of countries in the developing world have developed such action plans or are in the process⁵. PHAs can take an important role in this enterprise.
The questions above also frame issues of health research investments, which require information on allocation of funds, such as the:
*  Proportion of total budget allocated to economic and social sectors.
*  Proportion of social sector budget allocated to health.
*  Proportions of health budget allocated to services and research.
*  Proportion of research investments actually used.
This information represents the missing link in most countries, as is true of the global level. Estimates of funds allocated and spent on health research for different topics do not exist. Moreover, estimates that have been developed for countries such as the Philippines and Thailand, reflect the severe under funding of health research⁴. The 10/90 or a similar level of disequilibrium exist within countries in the developing world - correcting this imbalance is the challenge for PHAs.
PHAs can use their influence and analytic capacity to address the challenge of reforming health research investments in their countries. One of the first steps in this process is to defme potential partners. They can be defined by constituency such as geographical location or ability to perform research or deliver services (local representation, NGOs); or by issues related to the progress of science (academia, research institutions); or by issues related to the prospect of science such as those involved in research with a high likelihood of success or those conducting nationally relevant research.
The next step is to use the influence of PHAs and other institutions. There are several forms of influence that PHAs can mobilize such as: authority - the more traditional way of using influence; guilt - playing on what has not been done to stimulate action; reward - or the use of incentives for action; fear - also a more traditional use of disincentives to prevent actions; persuasion - one of the preferred modalities to use evidence - based influence; and trust - the desired umbrella of a positive relationship between partners working towards a common goal. The use of persuasion within an environment, based on trust, is an ideal situation for working on such issues.
Response by the PHAs to promote health research for the country should be based on evidence, making the collection of data an important step. Data on health spending in the country is required, as indicated earlier, to assess the status of investments in health research and development.
Estimates of the use (or lack) of health research and research products within the country are also needed. Comparisons of the nature and type of research conducted with the burden of disease in the country will form a tool for comparing needs with action⁶. All of these will form a priority setting framework for defining research needs.
The steps described above will result in the acquistions of skills, evidence and partners for the next step in responding to challenge - informed advocacy. This is the use of evidence in an effective and goal directed manner to help address the disequilibrium in health research investments in the country. Participation by all stakeholders in the process; use of media and modes of communications; and promotion of relevant intra- and international comparisons will make for a concerted strategy for advocacy. In addition, it would comprise promotion of not only greater awareness of a problem, but of potential solutions and re-allocation of funds.
The combination of all these steps in a systemic plan of action will allow for a strengthened movement for changing investments in health research in the country.

The proposal for action set forth in this paper will lead to a number of intended results - some more proximal and short term, while others a little distant in time. The process of responding to the disequilibrium in research investments will energize PHAs and their membership towards a common purpose. It will also further increase the relevancy of PHAs to their national context, as well as enhance the visibility and effectiveness of PHAs in the national health scene. Most importantly, such action will be in line with objectives of PHAs and so represent a reaffirmation of their goals.
In the longer term, PHAs are working towards better health for their countries. Unobstructed access to a decent minimum of health care; a fair system of health care rationing (in view of limits to resources); and the empowerment of patients and communities are parts of this ultimate goal. The specific call to action proposed in this paper contributes to this longer-term goal by promoting appropriate support for essential and relevant national health research.

1.World Health Organization. World Health Report 2000. Geneva: WHO, 2000.
2.Global Forum for Health Research. The 10/90 Report on Health Research 1999. Geneva: GFHR, 1999.
3.commission on Health Research for Development. Health research: essential link for equity in development. Cambridge, Mass: Oxford University Press, 1990.
4.Global Forum for Health Research. The 10/90 Report on Health Research 2000. GenevaGFHR, 2000.
5.Council on Health Research for Development. Essential National Health Research Handbook. Geneva: COHRED, 2000.
6.Murray CTh, Lopez AD (eds.). The global burden of diseases and injuries. Cambridge, Mass: Harvard University Press, 1996.