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Biomedical and Health Services Research in Canada: A Review
FalUAutomne 1992
Volume 5, No. 3
Biomedical and Health Services Research in Canada: A Review by Godwin 0.Eni
"If we agree that the relevance to human welfare and the value of man has a high priority, then we must recognize that medical research together with its related scientific and technological fields belong on the top of the list of our scientific choices because numerous surveys show that people attach great importance to health problems and want, within certain limits, the best possible health care system. In our democratic regime, we must accept the public preference as our goal."' (p. 234) This statement by Senator Lamontagne, made in 1971 during his address to Medical Research Council (MRC) scholars, raises numerous questions about the role of biomedical and related health care research in Canada today. Given the wisdom that is implied in the senatox's statement one may ask, 20 years later, whether research activity in these areas is a major goal and, more importantly, whether such an activity is contributing to creating the "best possible health care system"? If biomedical and health care research activity is achieving this important goal, then what are the challenges for the future and, if not, what are the issues that confront medical and health services research in Canada today? Gestion des soins de sant6
Evidence seems to indicate that Canada is a long way from achieving Senator Lamontagne's dream. A somewhat critical examination of the system by Rachlis and Kurshne? has provided numerous examples of failure to meet stated goals. Although it has been argued that, on balance, the system is one of the best in the world? the authors' compelling evidence and recent findings and recommendations of several provincial royal commissions point to important deficiencies. For example, Rachlis and Kurshne? noted the existence of "massive misallocation of resources", the continuing "high status of curative medicine", the expenditure of "billions in the wrong place", outrageous inefficiencyresulting from "mismanagement and a basic neglect of science". (p. 3) A Royal Commission on Health Care and Costs4was sufficiently concerned with the performance of a provincial health care system that some of the recommendations included "a commitment to develop alternative health service delivery organizations" which will lead to the shift of resources to new alternative systems as well as "the development, coordination 21
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and integration of policies, procedures and possibly legislation” required ”to support alternative health service organization”. (p. B.55) The challenges of today’s health care system seem to have changed from issues associated with infectious diseases (except for modem day epidemics such as acquired immunodeficiency syndrome [AIDS])and curative medicine, to organizational, management and socio-psychologicalissues. How, therefore, have biomedical and health services research efforts assisted in addressing the recent challenges to the system? Where, in the last 20 years, have policy makers and research interests focused their directional and investigative energies? Who should control the direction of health care and related research in Canada? More importantly, what degree of social relevance and on-thefield investigative activities should be expected of health care research? How should research results be transferred to the field for immediate application? These questions, separately and collectively, do not lend themselves to simplistic responses; they are sufficiently complex that more comprehensive discussion will be required. However, this paper does not deal with these questions, but it calls attention to the need for new approaches to present challenges using the historical development of research funding in Canada to assist in explaining why things are the way they are. The current status of federal research funding is discussed as well as issues facing biomedical and health services research. In addition, it will be argued that although a need for re-direction from ”sickness care” to ”health care” has been indicated, this has yet to be realized in terms of funding support, personnel needs and the level of research activities available in Canada today. In addressing the issues, some separation has been made between biomedical research, strictly defined as research into areas pertaining to biological organs, organ systems and organisms as opposed to health care research which embraces health care delivery, health services administration, and socio-psychological influences on health and health care.
Histo y and context of biomedical and health services research in Canada Canadian medical research was forced into the limelight in 1921with the discovery of insulin by Sir F. Banting in Toronto. Since then, Canadian medical researchers have led the way in numerous areas covering both basic and clinical research in addition to some research in health care delivery. Over the past 25 years, the infrastructure and support systems for funding medical research activities in Canada have grown and evolved considerably. In the early 1930s,the National Research Council (NRC)and the Department of Agriculture provided ~~
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some support for research into special fields related to human illness. In 1938, the NRC established an associate committee on medical research that provided grants-in-aid with a budget of $53,000 for research. However, with the advent of the World War I1 this committee embarked on a program of support to areas of investigation affiliated with the armed services. The committee worked with the universities, each section of the armed forces and the Commonwealth to provide resources and facilities to conduct research. The associate committee was replaced in 1946with the Division of Medical Research. One of the division’s terms of reference was to “initiate, stimulate and co-ordinate medical research in Canada’’ with a $200,000 budget. Funds were made available to the universities for continuing research in medical sciences. Other federal agencies involved with providing research support were the Defence Research Board (grants-in-aid and an intramural program) and the Department of Veteran Affairs (research within its own hospitals). In 1948, the Department of National Health and Welfare established a public health research fund that provided research funds to the provinces. By the mid-l950s, medical research in Canada was done primarily in medical schools and associated hospitals and in several university departments. Other laboratories supported by the government included the Health and Welfare division of the Bureau of Statistics. This laboratory probably represented the beginnings of an agency concerned solely with research into health care delivery. The universities meanwhile focused on basic, biologically oriented research activities in which investigations concentrated in the areas of disease prevention, diagnosis and treatment. The emphasis on biologically oriented research in university and hospital environments probably set the precedent that was to guide further research efforts in . Canada. Since infectious diseases were prevalent at the time, it was only appropriate that the universities engaged in basic research into diseases in collaboration with government agencies such as the Department of National Health and Welfare. Whatever emphasis there was on ”applied research” was found in the clinical services of university teaching hospitals. An overview of research funding in 1958 and 1959 is presented in Table 1to indicate the pattern of resource allocation. Government spending for medical and health services research in 1958-59represented 0.01% of the gross national product (GNP), of which the largest allocation, 37%,went to Health and Welfare. This was, however, perceived as acute shortage of funding for biomedical and related research, especially in view of the rising number of medical schools. However, the sudden expansion of university-based scientific
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programs, the arrival of complex and expensive medical technology and the overwhelming expansion of medical sciences in the late 1950s and the early 1960s contributed to a marked increase in need for research funding within the biomedical arena. After all, biomedical research offered important, dramatic results that addressed the significant health conditions of the time (e.g., advances in antibiotic research in the wake of the discovery of insulin for the treatment of diabetes). In spite of some marked increase in the needs of biomedical investigations, the Department of National Health and Welfare continued to fund research activities into preventive medicine, epidemiology, public health and health care delivery -areas previously supported by the public health research fund established in 1948. With the burgeoning amount of research in progress at the time and the dramatic increase in the need for funding by 1958, a need was felt for an independent body to advise the government on policy and matters relating to medical research and its administration. This new body, the Medical Research Council (MRC) would be directed by a council of eminent medical scientists and would have the Same independence and flexibility that the NRC had. Health and Welfare would continue to co-ordinate research activities within the areas of public health and what we have come to know today as health care delivery. By 1965, the MRC had become the largest single source of funds for medical research, a responsibility that it still holds today. Of the $14.9 million spent on medical and health care research in 1965, $9.3 million or 62%originated from the MRC with the Department of National Health and Welfare providing a third of the total -$4.8 million or 32%.Of Health and Welfare's portion, $4OO,OOO was devoted to physical fitness and smoking research with the remainder going toward public health research. Despite the marked rise in research funding through the early 1960s, it was still felt that a crisis in research funding existed. This notion was supported by the Royal Commission on Health Services which observed: "There is a general agreement that health research in Canada has developed remarkably within the last generation; that the conduct of health research has broad implication for the well being of mankind, but that health research in Canada is failing to keep pace with the opportunities now available in the medical and health related sciences; and that money available for health research both from government granting bodies and from voluntary organizations, lay behind the amounts needed for the support of resear12h.I'~(p. 107) In a report to the government on medical research in Canada endorsed by the deans of medical schools, Gestion des soins de sant6
FalUAutomne 1992
Table 1: Extra-Mural Medical Research Support, 1958-59 (Thousands of dollars) Source
Amount
National Research Council Dept. of National Health and Welfare Defence Research Board Dept. of Veteran Affairs Private Organizations
$1,970 2,570 412 9 2,000
Total
$6,961
medical scientists and voluntary agencies, the deficit in medical research funding was estimated to be $7.2 million in 1966, a marked increase from $2.1 million in 1962.6!7Another major drawback of medical research in Canada identified by the royal commission was that there were no formal programs of research into such areas as quality of health care and the effectiveness of health services programs in relation to the health needs of the community. The commission noted that one of the goals of a university health sciences centre should be: "To conduct research of appropriate substance and diversity, not only to advance knowledge in the fields of science essential to medicine but also to evaluate: (a) its own education operation, (b) the health needs of the community, and (c) the quality of care being rendered."' (p. 80) It also recommended that a Health Sciences Research Council be created from a broadened MRC that would incorporate the provision of public health research grants. The council would conduct research intc the broader areas of health care. This recommendation however, was opposed by the medical and scientific community on the grounds that it would dilute the funding and quality of medical research and that it would violate a basic premise of scientific investigation (i.e., investigator-initiatedresearch). In a report to the government from the scientific community, it was noted that: "The opinion of scientists in general is that it is not possible to direct the course medical research should take if the desire is to maximize the opportunity to expand knowledge? (p. 32) The implication of this statement is very important given that the opposition to a change in policy direction from investigator-initiated research to include policy-directed enquiry in areas other than biomedical was driven by biomedical research scientists themselves. How could they be expected to conduct research in other areas of health care when it was being argued that more funds were required for biomedical research? More importantly, a change in paradigm was required for investigations in "other areas of health care". Whatever funds were available for medical research were expected to remain for biomedical studies. 23
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.
i
Table 2: Comparison of Major Federal Government Research Funding In Health for Fiscal Years
(Thousands of dollars)
I
MRC Dept. of Natl. Health & Welfare [Health Services Research]
I
$4,083
$35,642
773
$5,129
$14,551
184
orientation sought to achieve a close matching of resources to present needs but at the same time was believed to diminish the role and importance of biomedical research. Coincident with the New Perspective, two other symposia on health care research also called for changes in the funding and research priorities in Canada. In an opening address at a symposium on health care research commemorating the opening of the University of Calgary Health Sciences Centre in May 1973, Dr. Leclair noted that: 'We have valued and emphasized fundamental or curiosity inspired research almost to the point of depreciating the work of applied research. Some fields of applied research escaped this downgrading. Medical care research was one of them but health care delivery research was not."" (p. 2) In the same symposium, a report was presented to the Science Council of Canada in which Dr. R. Robertson, a former vice-chancellor of McGill University, called for the establishment of a Health Care Research Council that would have a similar function that the MRC had within biomedical research. This new council would concentrate on the social rather than physical needs of medicine and health care delivery." Similarly, in a symposium celebrating the 25th anniversary of the Faculty of Medicine of the University of British Columbia in 1974, Dr. R. Gaudry, the Chairman of the Science Council of Canada, called for a larger effort to be placed on health care delivery and a re-orientation from sickness research to health research. In the same address, he also noted the lack of co-ordination among private and public organization in the entire health care delivery system.'* These efforts, since the 1960s, of trying to redirect research from purely biomedical to health care delivery, culminated in the establishment in 1975 of the National Health Research and Development Program (NHRDP).The basic mandate of the NHRDP was to support research related to national health objectives, and to support public health and health services research. How, therefore, have the structure, operations and funding arrangements changed within the MRC and NHRDP since 1975?
Current status of federal funding agencies Administrative structure of the MRC The MRC is a departmental corporation established by parliament to promote, assist and undertake basic, applied and clinical research into the health sciences and to advise the minister of Health and Welfare about health research. The council has the task of deciding what research is most urgent and requires financial support. It aims "to improve the health of Canadians through the promotion and support of excellent basic,
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Table 4: MRC Grants by Research Area, 1987-88
Table 3: Expenditures MRC, 1987-88
(Thousands of dollars) Grant programs University-Industryprograms Personnel support programs Other activities
141,197 653 27,883 732.6
Total
170,465
clinical and applied research in the health sciences”.13 (p. 9) The council has a full-time president and 21 other members representing the scientific and lay community who serve without remuneration. The council includes three associate members representing the Department of National Health and Welfare and the other federal granting agencies. The MRC also has 34 committees that review applications for research projects and awards. Input into these committees is provided on a parttime unpaid basis by some 350 researchers. Although the council has no laboratories of its own, it supports research and training in universities, affiliated hospitals and institutes. The council has also recently initiated a university-industry collaborationprogram. General services to the council and committees are provided by about a 52-member secretariat of full-time employees located in Ottawa. MRC programs The MRC has several avenues for research funding. MRC groups: Multi-year research projects involve groups of scientists from different areas of expertise working on specific projects. Group programs: Grants for group programs provide support for projects proposed and carried out by investigators in Canadian universities, institutions and other health science schools and departments. Support is provided through the following grants: operating, equipment, development, biotechnology development and general research grant to deans. Personnel support programs: These programs provide support for research personnel under three categories: salary support programs (e.g., research associate, career investigator and MRC scientist);research training programs (e.g., fellowships);and travel and exchange programs. University-industry programs: These programs create collaborationbetween Canadian companies and researchers conducting research in Canadian universities. Costs are shared with the private sector in a symbiotic arrangement.
Gestion des soins de santd
Classification Bacteriology Biochemistry Blood Cancer Cardiovascular Cell Biology Dental Science Drug Research Endocrinology G.I. & Liver Genetics Hearing Imaging Transplantation Metabolism Musculo-skeletal Nephrology Neurosciences Nutrition Reproductive Respiration Virology Vision Total
Funding ($000)
Percentage of total
3,767 16,228 4,547 5,083 10,498 4,418 3,435 3,372 7,846 6,070 4,576 432 722 7,851 6,166 3,566 2,971 20,308 1,186 4,788 5,713 3,398 2,378
2.9 12.5 3.5 3.9 8.1 3.4 2.7 2.6 6.1 4.8 3.5 0.3 0.6 6.1 4.8 2.8 2.3 15.7 0.9 3.7 4.4 2.6 1.8
129,317
100%
Funding For the 1987-88 fiscal year, the MRC provided a total of $170 million for biomedical and health care research; $141 million was through the grants program and $27 million was provided via the personnel support programs (Table 3). Since the MRC classifies research on the basis of organ system, it was not possible to determine how much of its funding goes toward research in the delivery of health services. Nevertheless, Table 4 shows a breakdown of the MRC funding by areas of research. The largkt funding support, of about $115 million for research (excludingindustry programs and fellowships),was allocated to neurosciences, cardiovascular investigations and biochemistry, in that order. One of the least funded is research into nutrition (a public health and community health problem). The main direction of MRC research funding has been for the laboratories or universitybased institutions such as teaching hospitals. At the same time, medical specialtieswith communityoriented research activities (e.g., occupational health and epidemiology),have been of very little interest to the MRC. Therefore, these specialtieshave been forced to seek support outside of the MRC and apply to the NHRDP, thereby reducing the amount of money available from that organization for non-medical research into the delivery and management of health services. 25
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NHRDP programs
Table 5: Total Health Expenditures in Canada by Category, 1985 Category
Absolute (Millions $)
34,980.6 21,096.8 8,953.6 4,930.1 530.2 1,674.0 1,757.6 356.5 494.4 74,773.8 Source: Department o f t Ath and W Expenditures in Canada: 1975-1985. Personal health care Institutional Professionalservices Drugs 8 appliances Administration Public health Capital exp. Heaith research Misc. Total
$ Per person
%
Yo
listributio
of GNP
4.00 1,378.27 47.0 2.40 831.24 28.0 12.0 1 .oo 352.78 7.0 0.70 194.25 0.06 0.7 20.89 0.10 2.0 65.96 2.3 0.20 69.25 0.4 0.03 14.05 0.05 0.6 19.48 8.61 1,567.90 100.0 ‘ae, 19& Jational t ilth
The NHRDP has the following programs through which funding may be obtained: (a) research projects and study awards, (b) demonstration projects, (c) formulation and grants, and (d) conferences and workshops. In addition to the project-oriented sponsorships, the NHRDP also has an active personnel support program that seeks to motivate, maintain and train researchers in health care services. The various personnel support programs include research training, career and career development, and student fellowships. A selection committee structure, made up of primarily university-based academicians, is used to evaluate and recommend funding support. The relevance of a particular study to national priority is assumed to be determined by NHRDP.
Canadian research jknding overview NHRDP The NHRDP operates under authority from the Department of National Health and Welfare and incorporates the provisions of the former national health and public health research grants. Its purpose as outlined by Health and Welfare is: ”The NHRDP exists to enable the Department of National Health and Welfare to obtain information and to evaluate and develop innovative options pertinent to the achievement of broad departmental objectives which embrace promotion, protection, maintenance and restoration of the health of the residents of Canada.”’4 (p. 1)The NHRDP basic mandate has been the support of research related to national health objectives. It is the only federal program that supports public health and health services research. The NHRDP manual further claims that the ”Program encourages and supports ideas and proposals generated spontaneously or in response to departmental statements of problem priority areas.”14 (p. 1)Current priorities of the NHRDP therefore have included the following areas: (a) organization and delivery of health care, (b) risk assessment, (c) health promotion, (d) habilitation and rehabilitation, (e) immune status and communicable disease control and (0native health and AIDS. Via special competitions NHRDP periodically attempts to focus limited grant sums to an area, often for a very short period. Only once in the last six years has health administration been targeted as a special competition not exceeding $20,000 per study. Instead, the NHRDP appears to focus on disciplinary grants related primarily to the fields of economics, psychology and epidemiology. These disciplines lend themselves to more precise measurements, finite analytic approaches and focused findings which often do not consider variables that are imprecise, such as those found within the socio-administrative environment of health care or which are more reflective of reality.
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How much therefore does Canada spend on research; how are the resources distributed; and from where do they originate? A review of national health expenditures in Canada (Table 5) reveals that about $350 million or $17 per person per year was spent on health services and biomedical research in 1985.15This represents 9.9%of total health expenditures and .08% of the GNP, a proportion that has remained remarkably constant over the past 10 years (.06%in 1975).In contrast, the United States spent $7.4billion in biomedical and health services research in 1985.This represents $30 per person per year, or 1.7%of total health expenditures or 0.19% of GNP.Research spending in Canada therefore seems to equate to about half that of the United States on a per capita basis. The key question, therefore, is whether Canada is underspending or whether the United States is overspending on health care research. A report of the Ontario Council of Health observed in 1973 that based on research and development expenditures in industry, health research was grossly underfunded and should make up 4.5% of all health expenqitures. The health care system appears to be placing inadequate resources into research in Canada compared to the United States.I6Thus, the so-called ”centralized funding arrangements” for delivering health services in Canada appears not to have kept pace with the so-called “free market” arrangements in the United States in the level of support for health care research. The lower level of research funding in Canada has led to further funding difficultiesfor non-biomedical research activity. Although, over the years, continuing recommendations have been made for change in policy, the limited available funding continues to be directed to biomedical investigator-initiatedresearch. This trend has continued despite publically articulated policy goals aimed at improvement in quality of care, effective delivery of health services and management efficiency. From Table 5, it is evident that funding for Healthcare Management FORUM
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Table 6: Expenditures for Biomedical Research of Canadian Facultiesof Medicine, 1986-1987 Sources MRC Health & Welfare NRC Natural Science Council Other agencies Sub-total Provincial govt. Nationalnon-profit foundations Provincialnon-profit foundations Private industry Local sources Internaluniversitysources Hospitals & universities Foreign sources Miscellaneous Total
Thousands Percentage of Distribution dollars % 137,809 35.2 9,749 2.3 240 0.1 5,491 1.4 4,527 1.2
Table 7: Research Expenditures by Canadian Facultiesof Medicine by Field of Research, 1986-87
Indexed 1981-100 $ 165.9 140.7 28.7 353.6 264.1
(157,816)
(40.2)
(167.7)
87,047 64,152
22.2 16.4
203.0 167.2
Basic sciences Clinical fields Biomedical engineering Community health & related Continuing education History of medicine Nursing Nutrition & Dietetics Miscellaneous
7,980
2.0
138.3
Total
15,794 12,667 20,913 644 20,784 4,552
4.0 3.2 5.3 0.2 5.3 1.2
333.7 343.0 203.2 128.0 193.2 261.3
392,349
100.0
184.3
Source: Canadian Medical Education Statistics, 1988, Association of Canadian Medical Colleges.
administration and health care research in 1985 constituted less than 1%of total health care expenditure. Data from the Association of Canadian Medical Colleges provide more detailed analysis of the sources of expenditure for biomedical and health care research (Table 6). Federal agencies provided about 40% of the funds with 22% coming from provincial governments. Non-profit national and provincial foundations provide a considerable proportion (18%)of the expenditures. The contribution by private industry is 4%. If these figures are indexed to 1981 dollars, it becomes apparent that the federal contribution has remained relatively stable, whereas non-profit foundations and various internal university sources have had the most proportional increases between 1981and 1986. However, what is unclear is the effect this trend will have on the control and direction of research in the future. Approximately 40% of the total research funds available to faculties of medicine was spent on basic sciences, 52% on clinical fields and only 5% “in other fields” (Table 7). On closer examination, only about 4% or $15 million was s ent on community health and related programs.J’me ”relatec programs refer to activities in disciplinary areas that influence health rather than sickness (i.e., behavioural sciences, environmental health, epidemiology, health administration, medical humanities, occupational health, public health, and social and preventive medicine). Unfortunately, no data are available on disbursements within each of these sub-areas. This clearly reflects an Gestion des soins de sant6
Total
Field of research
158,672 206,031 2,508 15,114 770 244 386 2,181 6,441
40.4 52.3 0.6 4.1 0.2 0.1 0.1 0.6 1.6
392,347
100.0
unfortunate state of affairs 14 years after Lalonde called for “a new perspective on the health of Canadians”. Clearly, a performance gap exists between stated objectives and the means for achieving those objectives which have been the focus of policy statements since the 1970s.On the one hand, public policy continues to push for a return to self-care and responsibility for individual health habits. On the other, many of the resources are directed toward sustaining the status quo (i.e., emphasis in funding support for biomedical research rather than improvements in delivery systems and efficiency in management). To reduce work environment hazards, occupational health specialists need to know about new dangers to the health of workers. More importantly, the coping ability of individuals via interactive relationships in an increasingly multicultural society merits attention. It would appear that funding for research into these areas has remained stagnant. A quick review of NHRDP inventory for the years 1986 to 1988 yields some interesting observation^:'^ During the three-year period, 543 research grants were awarded. Without thk benefit of study abstracts and judging from research topics, only 127 studies or 27% appear to relate to health administration, occupational health, health services delivery, medical humanities, social and preventive care, and health promotion. A crude but very generous categorization of the study topics reveals that less than 2% pertain to health administration or alternative delivery systems. About 13%may be seen as relating to medical humanities in which psycho-social studies are predominant. About 12% seem to focus on retrospective economic analyses. A total of nine formulation proposals were funded during the same period, out of which four, or less than 50%, sought to investigate service needs and service delivery to communities. 27
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In all, 116 conferences, symposia and workshops were funded by NHRDP from 1986 to 1988. Judging from the topics, about half, or 53%,focused on community health needs; 47%of this was used to s u p port professional or international meetings mostly related to interest groups. About one third (33%)of postdoctoral fellowships were awarded for behavioural sciences. However, 66%of the awards were directed to applicants with biomedical interests. Similarly, 28%of the 47 national health research scholar awards seem to have supported interests in social and preventive medicine, health economics, sociology and health administration, excluding psychology. Only two scholars were listed as having a health administration base. About two thirds (66%)of the total number of awards for the period were given to researchers with biomedical interest. It seems therefore that a funding agency established to fill the gap created by MRC‘s emphasis on biomedical research has, over time, come to mirror the funding pattern of MRC. It has not only focused most grants to the furtherance of biomedical research, but it has also gone into the business of providing funding support for the continuing generation of biomedical researchers via its post-doctoral fellowship, scholar and workshop programs. Given that the mandate of NHRDP includes the ”evaluation and development of innovative options” that would embrace health promotion, and that present challenges in the health care system relate to self-care, de-institutionalization, efficiency of resource management, and innovative planning of delivery systems, a change in research funding structure and support seems to be indicated. Health services administrators are bewildered by competing and often contradictory expectations. They must respond to the realities of institutionalization in which biomedical pressures and interests dominate; thus, they must cater to these interests by seeking to maintain and even increase the role of institutionalization in health care resource allocation arrangements. Yet, they are criticized for not championing the movement toward community-based delivery of health services. Health service administrators read about inefficiency problems and the lack of rational planning in the administration of health care, yet there is insufficient research activity and supportive findings from which innovative management approaches can be transferred to practitioners for meaningful field application.
Issues facing biomedical and health services research Integration The information reviewed so far indicates that Canada is spending more resources on biomedical 28
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research (both basic and clinical), whereas health care delivery and management-focused research appear to have taken a back seat. This has occurred despite a call in the early 1970s for a reorientation of the entire health care system. As stated by Dr. Gaudry: ”the study of how biomedical research can best be integrated within the whole health care delivery system is extremely underdeveloped.”’2 (p. 202) Our system appears to be lacking not in knowledge, but in the distribution of resources. It seems that many actors are pursuing different interests with no central co-ordination or planning. How to integrate the country’s research efforts to create the best possible health care for an advancing society is a major challenge that has not been overcome. To meet this challenge, a few key questions regarding Canada’s health care research efforts may be asked. (1) Who should control health care research activity in Canada and should it have social relevance? (2) Is there adequate training and funding for the right kind of researchers? (3) Should more research activity be field-based? (4) How should research results be transferred to the field for application? Control and social relevance Most of biomedical and health care research done in Canada is investigator-initiated.The investigators are supported either by private or government agencies that usually have little control over the identification of research interest beyond some general guideline. From the beginning it was felt necessary to nurture scientific creativity rather then stifle it with bureaucratic controls and directions. However, will it be possible for Canada to find a mix of approaches to enable some areas of research to be undertaken for immediate applicability to areas of national health priorities? Dr. Gaudry put it in perspective when he stated: ”Predictably the capacities of biomedical research will be sorely stretched by public consumer demand at a time when governments are taking an increasingly jaundiced view towards costs. Have the biomedical researchers made any concerted effort to aid governments in coping with the pertinent levels of complexity involved in devising a rational health care system? My layman’s answer would have to be no.”’* (p. 209) Biomedical researchers are often accused of conducting esoteric research with no interest in the application of the results. The literature is full of examples of new therapeutic and diagnostic techniques that appear efficacious but have not been evaluated for cost-effectiveness to society. In discussing medical research and public interest, Sir R. Doll noted that “it is not enough for research to show that a certain procedure can relieve disability or diminish the risk of death, it must also take account of the total effect of the intervention which may have social side-effects that are as counterproductive as the Healthcare Management FORUM
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medical side-effects"." (p. 179) Sir Doll further noted that an important objective is "the provision of medical care in a way that is available to all who need it, economic in delivery and acceptable to the public". (p. 179) Therefore, any serious attempt to define the best means of organizing and supporting research would require "a detailed examination of the successes and failures of the system that we have had in the past". (p. 179) Biomedical research has served the system well and will continue to do so. Early in the 20th century, Canadian society, like many industrialized societies, was concerned with infectious diseases and survival of the individual during epidemics. The discovery of antibiotics, immunization and advances in medical treatment technology have resulted in Canada possessing one of the highest life expectancy years for its citizens. During the early years it was necessary to isolate and sequester the sick and the infectious in institutions. Now, society is more concerned with the quality of life, the de-institutionalization of care and a return to community-focused care. In addition, society seems to be more concerned with what may be regarded as "diseases of industrial societies", namely stress, alienation and diminishing coping abilities. Illness, defined as the experience of disease, has been shown to differ among cultural groups. The personal and social interpretations of what constitutes good health differ among individuals and societies, although some will have us believe that only biomedical interpretations are valid. Although we know little about the implications of community-based health services and other proposed reforms, little funding support has been provided to social science researchers with interest in health care and its management. It may therefore be suggested that any reorganization of the health care research funding mechanism, such as the one presently being contemplated by the MRC, should consider integration of cross-disciplinary approaches that would include nonbiomedical scientists in funding arrangements as well as the social and medical relevance of the study. More importantly, will the results be useful to the field in the solution of problems or will the findings simply add to existing knowledge? The argument is that greater emphasis in research funding priority should be placed in the support of crossdisciplinary studies of social relevance and application.
Research training, funding and application The general viewpoint is that the MRC has occasionally considered expanding its role to include funding support for some of the marginal medical specialtiessuch as epidemiology and health services research, presently a domain of NHRDP. Given prevailing biomedical interests and clinically oriented influences within it, it is unlikely that the MRC will Gestion des soins de santt!
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accommodate non-biomedical research adequately. However, the NHRDP seems to have difficulty in counteracting biomedical influences within it, primarily because of investigator-initiated research and biomedical peer-review interests, as well as uncertainty in policy direction. Logically, a new and different research funding arrangement is required, given the present emphasis on biomedical training and research by the MRC and the NHRDP, and the widening disparity between public research interest and social relevance of current research activities. The new research funding arrangement needs to: (a) be relatively independent of investigator-initiated interests but driven by the changing realities of health and health services, (b) operate under policies that will enable the identification of present health and societal needs, and (c) actively support social and community-based research into health services, in particular, improvements in management. The long-term goal should be to encourage collaborative field-based research activities among biomedical and social science researchers. One proposal that merits consideration is the formation of a Health Services Research Council to support research into areas most pertinent to application research, including health administration, health services planning, policy planning program evaluation, delivery of health services, and the sociology of health and health care, among others. Although some of the research initiatives of such a council may be investigator initiated, most research activities should be identified, initiated and conducted in a manner that focuses on prevailing immediate system needs. In other words, the council needs to determine, from the bank of existing knowledge in the literature, what limitations exist in meeting a particular need and request specific investigations on how to overcome or minimize the effects of such limitations in the provision of health services. For example, concern for efficiency in resource management will attract substantial research funding for theoretical, field-based and application research activities in this area until satisfactory answers are found. By specifymg collaboration with practitioners, technological transfer for practical application will be immediate and occur with minimum delay. Many provincial governments are beginning to explore this direction based on local needs and emergencies. The community health organization experiments in British Columbia are one example. Also, the British Columbia Health Care Research Foundation (BCHCRF)has begun to support field-based research into health services. The Ministry of Health has gone further, to support collaboration between hospitals and communities in the delivery of services by withholding one half of one percent of a hospital's budget for that purpose. This approach appears to overcome 29
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one limitation of the MRC (i.e., little concern whether or not funded research results are ever applied or of greater or lesser benefit to clients of the health care system).
Conclusions It is apparent that precedents were established during the formation of research funding agencies. The division between ”biomedical” and ”health services” research has existed for decades. Biomedical research has tended to lie in the domain of the universities and funding has always been allocated primarily on the basis of investigator-initiated priorities. Therefore, planned change to meet current needs has become problematic. Increased funding support for health care research in Canada is needed if this country is to follow the example of the United States. The increased involvement of industries and private concerns in health care research support may be needed to relieve some funding pressure on governments and to increase the proportion of funds available for research in general. An integrated approach to research activity is suggested, even at the current funding level. However, it is hoped that a little injection of funding for health services research will go a long way to balance present funding inequities. First, policy makers should re-examine existing arrangements and determine if funding patterns are in step with ”performance gaps”. Second, a response to inconsistencies in research support and gaps in performance should lead to restructuring. A restructuring that simply integrates one agency with another or the incorporation of some of another agency’s functions will not address the key issues raised in this discussion. Third, consideration should be given to the establishment of a Health Services Research Council with a mandate to promote collaborative, field-based, policy-relevant and community-focused research that will be consistent with changing health service needs and societal expectations.
References and notes 1. Lamontagne, M. 1971. Address to the Medical Council. In Gibson, W. (ed.),Health Cure Teaching and Research. Vancouver: University of British Columbia Alumni Association and Faculty of Medicine. 2. Rachlis, M. and Kurshner, C. 1989. Second Opinion:
What’s Wrong with Canada’s Health Care System and How to Fix It, Toronto: Collins.
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3. Eni, G. 1989. Should we do things differently? Health Care 31(8):12-14. 4. Report of the Royal Commission on Health Care and Costs, 1991. Province of British Columbia. 5. Report of the Royal Commission on Health Services, 1964, vol. 2, Ottawa: Ontario Government Printer. 6. The Canadian Society of Clinical Investigation. 1966. Medical Research in Canada, Ottawa. 7. Medical Research Council of Canada. 1965. An Analysis of Zmrnediate and Future Needs, The Canadian Society of Clinical Investigation, Ottawa. 8. Report of the Royal Commission on Health Services, 1964, vol. 1, Ottawa: Government Printer. 9. Lalonde, M. 1974. A N m Perspective on the Health of Canadians, Ottawa: Department of National Health and Welfare. 10. LeClair, M. 1974. In Larsen, D and Love, E. (eds.), Health Care Research: A Symposium (opening address), Calgary: University of Calgary. 11. Robertson, R. 1974. Health care research in Canada: report to the Science Council of Canada. In Larsen, D. and Love, E. (eds.), Health Care Research in Canada: A Symposium, Calgary: University of Calgary. 12. Gaudry, R. 1974. Biomedical Research and Science Policy. Address to the 25th Anniversary of the Faculty of Medicine, Vancouver: University of British Columbia, June 15. 13. Medical Research Council of Canada. July 1988. Report of the President, 1987-88,Ottawa: Government Printer. 14. Health and Welfare Canada. 1988. National Health Research and Development Program Inventoy (198687), Ottawa. 15. Department of Health and Welfare. 1985. National Health Expenditure in Canada: 1975-1985, Ottawa. 16. Ontario Council of Health. 1973. Report of Committee on Health Research, Toronto. 17. Doll, R. 1974. Medical research in the public interest. In Health Care Teaching and Research: Prospect and Retrospect, University of British Columbia Alumni Association and the Faculty of Medicine, Vancouver.
Godwin 0 .Eni, PhD, is Director, Graduate Program in Health Administration, Department of Health Care and Epidemiology, University of British Columbia, Vancouver.
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Biomedical and Health Services Research in Canada: A Review by Godwin 0.Eni
"If we agree that the relevance to human welfare and the value of man has a high priority, then we must recognize that medical research together with its related scientific and technological fields belong on the top of the list of our scientific choices because numerous surveys show that people attach great importance to health problems and want, within certain limits, the best possible health care system. In our democratic regime, we must accept the public preference as our goal."' (p. 234) This statement by Senator Lamontagne, made in 1971 during his address to Medical Research Council (MRC) scholars, raises numerous questions about the role of biomedical and related health care research in Canada today. Given the wisdom that is implied in the senatox's statement one may ask, 20 years later, whether research activity in these areas is a major goal and, more importantly, whether such an activity is contributing to creating the "best possible health care system"? If biomedical and health care research activity is achieving this important goal, then what are the challenges for the future and, if not, what are the issues that confront medical and health services research in Canada today? Gestion des soins de sant6
Evidence seems to indicate that Canada is a long way from achieving Senator Lamontagne's dream. A somewhat critical examination of the system by Rachlis and Kurshne? has provided numerous examples of failure to meet stated goals. Although it has been argued that, on balance, the system is one of the best in the world? the authors' compelling evidence and recent findings and recommendations of several provincial royal commissions point to important deficiencies. For example, Rachlis and Kurshne? noted the existence of "massive misallocation of resources", the continuing "high status of curative medicine", the expenditure of "billions in the wrong place", outrageous inefficiencyresulting from "mismanagement and a basic neglect of science". (p. 3) A Royal Commission on Health Care and Costs4was sufficiently concerned with the performance of a provincial health care system that some of the recommendations included "a commitment to develop alternative health service delivery organizations" which will lead to the shift of resources to new alternative systems as well as "the development, coordination 21
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and integration of policies, procedures and possibly legislation” required ”to support alternative health service organization”. (p. B.55) The challenges of today’s health care system seem to have changed from issues associated with infectious diseases (except for modem day epidemics such as acquired immunodeficiency syndrome [AIDS])and curative medicine, to organizational, management and socio-psychologicalissues. How, therefore, have biomedical and health services research efforts assisted in addressing the recent challenges to the system? Where, in the last 20 years, have policy makers and research interests focused their directional and investigative energies? Who should control the direction of health care and related research in Canada? More importantly, what degree of social relevance and on-thefield investigative activities should be expected of health care research? How should research results be transferred to the field for immediate application? These questions, separately and collectively, do not lend themselves to simplistic responses; they are sufficiently complex that more comprehensive discussion will be required. However, this paper does not deal with these questions, but it calls attention to the need for new approaches to present challenges using the historical development of research funding in Canada to assist in explaining why things are the way they are. The current status of federal research funding is discussed as well as issues facing biomedical and health services research. In addition, it will be argued that although a need for re-direction from ”sickness care” to ”health care” has been indicated, this has yet to be realized in terms of funding support, personnel needs and the level of research activities available in Canada today. In addressing the issues, some separation has been made between biomedical research, strictly defined as research into areas pertaining to biological organs, organ systems and organisms as opposed to health care research which embraces health care delivery, health services administration, and socio-psychological influences on health and health care.
Histo y and context of biomedical and health services research in Canada Canadian medical research was forced into the limelight in 1921with the discovery of insulin by Sir F. Banting in Toronto. Since then, Canadian medical researchers have led the way in numerous areas covering both basic and clinical research in addition to some research in health care delivery. Over the past 25 years, the infrastructure and support systems for funding medical research activities in Canada have grown and evolved considerably. In the early 1930s,the National Research Council (NRC)and the Department of Agriculture provided ~~
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some support for research into special fields related to human illness. In 1938, the NRC established an associate committee on medical research that provided grants-in-aid with a budget of $53,000 for research. However, with the advent of the World War I1 this committee embarked on a program of support to areas of investigation affiliated with the armed services. The committee worked with the universities, each section of the armed forces and the Commonwealth to provide resources and facilities to conduct research. The associate committee was replaced in 1946with the Division of Medical Research. One of the division’s terms of reference was to “initiate, stimulate and co-ordinate medical research in Canada’’ with a $200,000 budget. Funds were made available to the universities for continuing research in medical sciences. Other federal agencies involved with providing research support were the Defence Research Board (grants-in-aid and an intramural program) and the Department of Veteran Affairs (research within its own hospitals). In 1948, the Department of National Health and Welfare established a public health research fund that provided research funds to the provinces. By the mid-l950s, medical research in Canada was done primarily in medical schools and associated hospitals and in several university departments. Other laboratories supported by the government included the Health and Welfare division of the Bureau of Statistics. This laboratory probably represented the beginnings of an agency concerned solely with research into health care delivery. The universities meanwhile focused on basic, biologically oriented research activities in which investigations concentrated in the areas of disease prevention, diagnosis and treatment. The emphasis on biologically oriented research in university and hospital environments probably set the precedent that was to guide further research efforts in . Canada. Since infectious diseases were prevalent at the time, it was only appropriate that the universities engaged in basic research into diseases in collaboration with government agencies such as the Department of National Health and Welfare. Whatever emphasis there was on ”applied research” was found in the clinical services of university teaching hospitals. An overview of research funding in 1958 and 1959 is presented in Table 1to indicate the pattern of resource allocation. Government spending for medical and health services research in 1958-59represented 0.01% of the gross national product (GNP), of which the largest allocation, 37%,went to Health and Welfare. This was, however, perceived as acute shortage of funding for biomedical and related research, especially in view of the rising number of medical schools. However, the sudden expansion of university-based scientific
~~~
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programs, the arrival of complex and expensive medical technology and the overwhelming expansion of medical sciences in the late 1950s and the early 1960s contributed to a marked increase in need for research funding within the biomedical arena. After all, biomedical research offered important, dramatic results that addressed the significant health conditions of the time (e.g., advances in antibiotic research in the wake of the discovery of insulin for the treatment of diabetes). In spite of some marked increase in the needs of biomedical investigations, the Department of National Health and Welfare continued to fund research activities into preventive medicine, epidemiology, public health and health care delivery -areas previously supported by the public health research fund established in 1948. With the burgeoning amount of research in progress at the time and the dramatic increase in the need for funding by 1958, a need was felt for an independent body to advise the government on policy and matters relating to medical research and its administration. This new body, the Medical Research Council (MRC) would be directed by a council of eminent medical scientists and would have the Same independence and flexibility that the NRC had. Health and Welfare would continue to co-ordinate research activities within the areas of public health and what we have come to know today as health care delivery. By 1965, the MRC had become the largest single source of funds for medical research, a responsibility that it still holds today. Of the $14.9 million spent on medical and health care research in 1965, $9.3 million or 62%originated from the MRC with the Department of National Health and Welfare providing a third of the total -$4.8 million or 32%.Of Health and Welfare's portion, $4OO,OOO was devoted to physical fitness and smoking research with the remainder going toward public health research. Despite the marked rise in research funding through the early 1960s, it was still felt that a crisis in research funding existed. This notion was supported by the Royal Commission on Health Services which observed: "There is a general agreement that health research in Canada has developed remarkably within the last generation; that the conduct of health research has broad implication for the well being of mankind, but that health research in Canada is failing to keep pace with the opportunities now available in the medical and health related sciences; and that money available for health research both from government granting bodies and from voluntary organizations, lay behind the amounts needed for the support of resear12h.I'~(p. 107) In a report to the government on medical research in Canada endorsed by the deans of medical schools, Gestion des soins de sant6
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Table 1: Extra-Mural Medical Research Support, 1958-59 (Thousands of dollars) Source
Amount
National Research Council Dept. of National Health and Welfare Defence Research Board Dept. of Veteran Affairs Private Organizations
$1,970 2,570 412 9 2,000
Total
$6,961
medical scientists and voluntary agencies, the deficit in medical research funding was estimated to be $7.2 million in 1966, a marked increase from $2.1 million in 1962.6!7Another major drawback of medical research in Canada identified by the royal commission was that there were no formal programs of research into such areas as quality of health care and the effectiveness of health services programs in relation to the health needs of the community. The commission noted that one of the goals of a university health sciences centre should be: "To conduct research of appropriate substance and diversity, not only to advance knowledge in the fields of science essential to medicine but also to evaluate: (a) its own education operation, (b) the health needs of the community, and (c) the quality of care being rendered."' (p. 80) It also recommended that a Health Sciences Research Council be created from a broadened MRC that would incorporate the provision of public health research grants. The council would conduct research intc the broader areas of health care. This recommendation however, was opposed by the medical and scientific community on the grounds that it would dilute the funding and quality of medical research and that it would violate a basic premise of scientific investigation (i.e., investigator-initiatedresearch). In a report to the government from the scientific community, it was noted that: "The opinion of scientists in general is that it is not possible to direct the course medical research should take if the desire is to maximize the opportunity to expand knowledge? (p. 32) The implication of this statement is very important given that the opposition to a change in policy direction from investigator-initiated research to include policy-directed enquiry in areas other than biomedical was driven by biomedical research scientists themselves. How could they be expected to conduct research in other areas of health care when it was being argued that more funds were required for biomedical research? More importantly, a change in paradigm was required for investigations in "other areas of health care". Whatever funds were available for medical research were expected to remain for biomedical studies. 23
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.
i
Table 2: Comparison of Major Federal Government Research Funding In Health for Fiscal Years
(Thousands of dollars)
I
MRC Dept. of Natl. Health & Welfare [Health Services Research]
I
$4,083
$35,642
773
$5,129
$14,551
184
orientation sought to achieve a close matching of resources to present needs but at the same time was believed to diminish the role and importance of biomedical research. Coincident with the New Perspective, two other symposia on health care research also called for changes in the funding and research priorities in Canada. In an opening address at a symposium on health care research commemorating the opening of the University of Calgary Health Sciences Centre in May 1973, Dr. Leclair noted that: 'We have valued and emphasized fundamental or curiosity inspired research almost to the point of depreciating the work of applied research. Some fields of applied research escaped this downgrading. Medical care research was one of them but health care delivery research was not."" (p. 2) In the same symposium, a report was presented to the Science Council of Canada in which Dr. R. Robertson, a former vice-chancellor of McGill University, called for the establishment of a Health Care Research Council that would have a similar function that the MRC had within biomedical research. This new council would concentrate on the social rather than physical needs of medicine and health care delivery." Similarly, in a symposium celebrating the 25th anniversary of the Faculty of Medicine of the University of British Columbia in 1974, Dr. R. Gaudry, the Chairman of the Science Council of Canada, called for a larger effort to be placed on health care delivery and a re-orientation from sickness research to health research. In the same address, he also noted the lack of co-ordination among private and public organization in the entire health care delivery system.'* These efforts, since the 1960s, of trying to redirect research from purely biomedical to health care delivery, culminated in the establishment in 1975 of the National Health Research and Development Program (NHRDP).The basic mandate of the NHRDP was to support research related to national health objectives, and to support public health and health services research. How, therefore, have the structure, operations and funding arrangements changed within the MRC and NHRDP since 1975?
Current status of federal funding agencies Administrative structure of the MRC The MRC is a departmental corporation established by parliament to promote, assist and undertake basic, applied and clinical research into the health sciences and to advise the minister of Health and Welfare about health research. The council has the task of deciding what research is most urgent and requires financial support. It aims "to improve the health of Canadians through the promotion and support of excellent basic,
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Table 4: MRC Grants by Research Area, 1987-88
Table 3: Expenditures MRC, 1987-88
(Thousands of dollars) Grant programs University-Industryprograms Personnel support programs Other activities
141,197 653 27,883 732.6
Total
170,465
clinical and applied research in the health sciences”.13 (p. 9) The council has a full-time president and 21 other members representing the scientific and lay community who serve without remuneration. The council includes three associate members representing the Department of National Health and Welfare and the other federal granting agencies. The MRC also has 34 committees that review applications for research projects and awards. Input into these committees is provided on a parttime unpaid basis by some 350 researchers. Although the council has no laboratories of its own, it supports research and training in universities, affiliated hospitals and institutes. The council has also recently initiated a university-industry collaborationprogram. General services to the council and committees are provided by about a 52-member secretariat of full-time employees located in Ottawa. MRC programs The MRC has several avenues for research funding. MRC groups: Multi-year research projects involve groups of scientists from different areas of expertise working on specific projects. Group programs: Grants for group programs provide support for projects proposed and carried out by investigators in Canadian universities, institutions and other health science schools and departments. Support is provided through the following grants: operating, equipment, development, biotechnology development and general research grant to deans. Personnel support programs: These programs provide support for research personnel under three categories: salary support programs (e.g., research associate, career investigator and MRC scientist);research training programs (e.g., fellowships);and travel and exchange programs. University-industry programs: These programs create collaborationbetween Canadian companies and researchers conducting research in Canadian universities. Costs are shared with the private sector in a symbiotic arrangement.
Gestion des soins de santd
Classification Bacteriology Biochemistry Blood Cancer Cardiovascular Cell Biology Dental Science Drug Research Endocrinology G.I. & Liver Genetics Hearing Imaging Transplantation Metabolism Musculo-skeletal Nephrology Neurosciences Nutrition Reproductive Respiration Virology Vision Total
Funding ($000)
Percentage of total
3,767 16,228 4,547 5,083 10,498 4,418 3,435 3,372 7,846 6,070 4,576 432 722 7,851 6,166 3,566 2,971 20,308 1,186 4,788 5,713 3,398 2,378
2.9 12.5 3.5 3.9 8.1 3.4 2.7 2.6 6.1 4.8 3.5 0.3 0.6 6.1 4.8 2.8 2.3 15.7 0.9 3.7 4.4 2.6 1.8
129,317
100%
Funding For the 1987-88 fiscal year, the MRC provided a total of $170 million for biomedical and health care research; $141 million was through the grants program and $27 million was provided via the personnel support programs (Table 3). Since the MRC classifies research on the basis of organ system, it was not possible to determine how much of its funding goes toward research in the delivery of health services. Nevertheless, Table 4 shows a breakdown of the MRC funding by areas of research. The largkt funding support, of about $115 million for research (excludingindustry programs and fellowships),was allocated to neurosciences, cardiovascular investigations and biochemistry, in that order. One of the least funded is research into nutrition (a public health and community health problem). The main direction of MRC research funding has been for the laboratories or universitybased institutions such as teaching hospitals. At the same time, medical specialtieswith communityoriented research activities (e.g., occupational health and epidemiology),have been of very little interest to the MRC. Therefore, these specialtieshave been forced to seek support outside of the MRC and apply to the NHRDP, thereby reducing the amount of money available from that organization for non-medical research into the delivery and management of health services. 25
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NHRDP programs
Table 5: Total Health Expenditures in Canada by Category, 1985 Category
Absolute (Millions $)
34,980.6 21,096.8 8,953.6 4,930.1 530.2 1,674.0 1,757.6 356.5 494.4 74,773.8 Source: Department o f t Ath and W Expenditures in Canada: 1975-1985. Personal health care Institutional Professionalservices Drugs 8 appliances Administration Public health Capital exp. Heaith research Misc. Total
$ Per person
%
Yo
listributio
of GNP
4.00 1,378.27 47.0 2.40 831.24 28.0 12.0 1 .oo 352.78 7.0 0.70 194.25 0.06 0.7 20.89 0.10 2.0 65.96 2.3 0.20 69.25 0.4 0.03 14.05 0.05 0.6 19.48 8.61 1,567.90 100.0 ‘ae, 19& Jational t ilth
The NHRDP has the following programs through which funding may be obtained: (a) research projects and study awards, (b) demonstration projects, (c) formulation and grants, and (d) conferences and workshops. In addition to the project-oriented sponsorships, the NHRDP also has an active personnel support program that seeks to motivate, maintain and train researchers in health care services. The various personnel support programs include research training, career and career development, and student fellowships. A selection committee structure, made up of primarily university-based academicians, is used to evaluate and recommend funding support. The relevance of a particular study to national priority is assumed to be determined by NHRDP.
Canadian research jknding overview NHRDP The NHRDP operates under authority from the Department of National Health and Welfare and incorporates the provisions of the former national health and public health research grants. Its purpose as outlined by Health and Welfare is: ”The NHRDP exists to enable the Department of National Health and Welfare to obtain information and to evaluate and develop innovative options pertinent to the achievement of broad departmental objectives which embrace promotion, protection, maintenance and restoration of the health of the residents of Canada.”’4 (p. 1)The NHRDP basic mandate has been the support of research related to national health objectives. It is the only federal program that supports public health and health services research. The NHRDP manual further claims that the ”Program encourages and supports ideas and proposals generated spontaneously or in response to departmental statements of problem priority areas.”14 (p. 1)Current priorities of the NHRDP therefore have included the following areas: (a) organization and delivery of health care, (b) risk assessment, (c) health promotion, (d) habilitation and rehabilitation, (e) immune status and communicable disease control and (0native health and AIDS. Via special competitions NHRDP periodically attempts to focus limited grant sums to an area, often for a very short period. Only once in the last six years has health administration been targeted as a special competition not exceeding $20,000 per study. Instead, the NHRDP appears to focus on disciplinary grants related primarily to the fields of economics, psychology and epidemiology. These disciplines lend themselves to more precise measurements, finite analytic approaches and focused findings which often do not consider variables that are imprecise, such as those found within the socio-administrative environment of health care or which are more reflective of reality.
26
How much therefore does Canada spend on research; how are the resources distributed; and from where do they originate? A review of national health expenditures in Canada (Table 5) reveals that about $350 million or $17 per person per year was spent on health services and biomedical research in 1985.15This represents 9.9%of total health expenditures and .08% of the GNP, a proportion that has remained remarkably constant over the past 10 years (.06%in 1975).In contrast, the United States spent $7.4billion in biomedical and health services research in 1985.This represents $30 per person per year, or 1.7%of total health expenditures or 0.19% of GNP.Research spending in Canada therefore seems to equate to about half that of the United States on a per capita basis. The key question, therefore, is whether Canada is underspending or whether the United States is overspending on health care research. A report of the Ontario Council of Health observed in 1973 that based on research and development expenditures in industry, health research was grossly underfunded and should make up 4.5% of all health expenqitures. The health care system appears to be placing inadequate resources into research in Canada compared to the United States.I6Thus, the so-called ”centralized funding arrangements” for delivering health services in Canada appears not to have kept pace with the so-called “free market” arrangements in the United States in the level of support for health care research. The lower level of research funding in Canada has led to further funding difficultiesfor non-biomedical research activity. Although, over the years, continuing recommendations have been made for change in policy, the limited available funding continues to be directed to biomedical investigator-initiatedresearch. This trend has continued despite publically articulated policy goals aimed at improvement in quality of care, effective delivery of health services and management efficiency. From Table 5, it is evident that funding for Healthcare Management FORUM
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Table 6: Expenditures for Biomedical Research of Canadian Facultiesof Medicine, 1986-1987 Sources MRC Health & Welfare NRC Natural Science Council Other agencies Sub-total Provincial govt. Nationalnon-profit foundations Provincialnon-profit foundations Private industry Local sources Internaluniversitysources Hospitals & universities Foreign sources Miscellaneous Total
Thousands Percentage of Distribution dollars % 137,809 35.2 9,749 2.3 240 0.1 5,491 1.4 4,527 1.2
Table 7: Research Expenditures by Canadian Facultiesof Medicine by Field of Research, 1986-87
Indexed 1981-100 $ 165.9 140.7 28.7 353.6 264.1
(157,816)
(40.2)
(167.7)
87,047 64,152
22.2 16.4
203.0 167.2
Basic sciences Clinical fields Biomedical engineering Community health & related Continuing education History of medicine Nursing Nutrition & Dietetics Miscellaneous
7,980
2.0
138.3
Total
15,794 12,667 20,913 644 20,784 4,552
4.0 3.2 5.3 0.2 5.3 1.2
333.7 343.0 203.2 128.0 193.2 261.3
392,349
100.0
184.3
Source: Canadian Medical Education Statistics, 1988, Association of Canadian Medical Colleges.
administration and health care research in 1985 constituted less than 1%of total health care expenditure. Data from the Association of Canadian Medical Colleges provide more detailed analysis of the sources of expenditure for biomedical and health care research (Table 6). Federal agencies provided about 40% of the funds with 22% coming from provincial governments. Non-profit national and provincial foundations provide a considerable proportion (18%)of the expenditures. The contribution by private industry is 4%. If these figures are indexed to 1981 dollars, it becomes apparent that the federal contribution has remained relatively stable, whereas non-profit foundations and various internal university sources have had the most proportional increases between 1981and 1986. However, what is unclear is the effect this trend will have on the control and direction of research in the future. Approximately 40% of the total research funds available to faculties of medicine was spent on basic sciences, 52% on clinical fields and only 5% “in other fields” (Table 7). On closer examination, only about 4% or $15 million was s ent on community health and related programs.J’me ”relatec programs refer to activities in disciplinary areas that influence health rather than sickness (i.e., behavioural sciences, environmental health, epidemiology, health administration, medical humanities, occupational health, public health, and social and preventive medicine). Unfortunately, no data are available on disbursements within each of these sub-areas. This clearly reflects an Gestion des soins de sant6
Total
Field of research
158,672 206,031 2,508 15,114 770 244 386 2,181 6,441
40.4 52.3 0.6 4.1 0.2 0.1 0.1 0.6 1.6
392,347
100.0
unfortunate state of affairs 14 years after Lalonde called for “a new perspective on the health of Canadians”. Clearly, a performance gap exists between stated objectives and the means for achieving those objectives which have been the focus of policy statements since the 1970s.On the one hand, public policy continues to push for a return to self-care and responsibility for individual health habits. On the other, many of the resources are directed toward sustaining the status quo (i.e., emphasis in funding support for biomedical research rather than improvements in delivery systems and efficiency in management). To reduce work environment hazards, occupational health specialists need to know about new dangers to the health of workers. More importantly, the coping ability of individuals via interactive relationships in an increasingly multicultural society merits attention. It would appear that funding for research into these areas has remained stagnant. A quick review of NHRDP inventory for the years 1986 to 1988 yields some interesting observation^:'^ During the three-year period, 543 research grants were awarded. Without thk benefit of study abstracts and judging from research topics, only 127 studies or 27% appear to relate to health administration, occupational health, health services delivery, medical humanities, social and preventive care, and health promotion. A crude but very generous categorization of the study topics reveals that less than 2% pertain to health administration or alternative delivery systems. About 13%may be seen as relating to medical humanities in which psycho-social studies are predominant. About 12% seem to focus on retrospective economic analyses. A total of nine formulation proposals were funded during the same period, out of which four, or less than 50%, sought to investigate service needs and service delivery to communities. 27
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In all, 116 conferences, symposia and workshops were funded by NHRDP from 1986 to 1988. Judging from the topics, about half, or 53%,focused on community health needs; 47%of this was used to s u p port professional or international meetings mostly related to interest groups. About one third (33%)of postdoctoral fellowships were awarded for behavioural sciences. However, 66%of the awards were directed to applicants with biomedical interests. Similarly, 28%of the 47 national health research scholar awards seem to have supported interests in social and preventive medicine, health economics, sociology and health administration, excluding psychology. Only two scholars were listed as having a health administration base. About two thirds (66%)of the total number of awards for the period were given to researchers with biomedical interest. It seems therefore that a funding agency established to fill the gap created by MRC‘s emphasis on biomedical research has, over time, come to mirror the funding pattern of MRC. It has not only focused most grants to the furtherance of biomedical research, but it has also gone into the business of providing funding support for the continuing generation of biomedical researchers via its post-doctoral fellowship, scholar and workshop programs. Given that the mandate of NHRDP includes the ”evaluation and development of innovative options” that would embrace health promotion, and that present challenges in the health care system relate to self-care, de-institutionalization, efficiency of resource management, and innovative planning of delivery systems, a change in research funding structure and support seems to be indicated. Health services administrators are bewildered by competing and often contradictory expectations. They must respond to the realities of institutionalization in which biomedical pressures and interests dominate; thus, they must cater to these interests by seeking to maintain and even increase the role of institutionalization in health care resource allocation arrangements. Yet, they are criticized for not championing the movement toward community-based delivery of health services. Health service administrators read about inefficiency problems and the lack of rational planning in the administration of health care, yet there is insufficient research activity and supportive findings from which innovative management approaches can be transferred to practitioners for meaningful field application.
Issues facing biomedical and health services research Integration The information reviewed so far indicates that Canada is spending more resources on biomedical 28
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research (both basic and clinical), whereas health care delivery and management-focused research appear to have taken a back seat. This has occurred despite a call in the early 1970s for a reorientation of the entire health care system. As stated by Dr. Gaudry: ”the study of how biomedical research can best be integrated within the whole health care delivery system is extremely underdeveloped.”’2 (p. 202) Our system appears to be lacking not in knowledge, but in the distribution of resources. It seems that many actors are pursuing different interests with no central co-ordination or planning. How to integrate the country’s research efforts to create the best possible health care for an advancing society is a major challenge that has not been overcome. To meet this challenge, a few key questions regarding Canada’s health care research efforts may be asked. (1) Who should control health care research activity in Canada and should it have social relevance? (2) Is there adequate training and funding for the right kind of researchers? (3) Should more research activity be field-based? (4) How should research results be transferred to the field for application? Control and social relevance Most of biomedical and health care research done in Canada is investigator-initiated.The investigators are supported either by private or government agencies that usually have little control over the identification of research interest beyond some general guideline. From the beginning it was felt necessary to nurture scientific creativity rather then stifle it with bureaucratic controls and directions. However, will it be possible for Canada to find a mix of approaches to enable some areas of research to be undertaken for immediate applicability to areas of national health priorities? Dr. Gaudry put it in perspective when he stated: ”Predictably the capacities of biomedical research will be sorely stretched by public consumer demand at a time when governments are taking an increasingly jaundiced view towards costs. Have the biomedical researchers made any concerted effort to aid governments in coping with the pertinent levels of complexity involved in devising a rational health care system? My layman’s answer would have to be no.”’* (p. 209) Biomedical researchers are often accused of conducting esoteric research with no interest in the application of the results. The literature is full of examples of new therapeutic and diagnostic techniques that appear efficacious but have not been evaluated for cost-effectiveness to society. In discussing medical research and public interest, Sir R. Doll noted that “it is not enough for research to show that a certain procedure can relieve disability or diminish the risk of death, it must also take account of the total effect of the intervention which may have social side-effects that are as counterproductive as the Healthcare Management FORUM
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medical side-effects"." (p. 179) Sir Doll further noted that an important objective is "the provision of medical care in a way that is available to all who need it, economic in delivery and acceptable to the public". (p. 179) Therefore, any serious attempt to define the best means of organizing and supporting research would require "a detailed examination of the successes and failures of the system that we have had in the past". (p. 179) Biomedical research has served the system well and will continue to do so. Early in the 20th century, Canadian society, like many industrialized societies, was concerned with infectious diseases and survival of the individual during epidemics. The discovery of antibiotics, immunization and advances in medical treatment technology have resulted in Canada possessing one of the highest life expectancy years for its citizens. During the early years it was necessary to isolate and sequester the sick and the infectious in institutions. Now, society is more concerned with the quality of life, the de-institutionalization of care and a return to community-focused care. In addition, society seems to be more concerned with what may be regarded as "diseases of industrial societies", namely stress, alienation and diminishing coping abilities. Illness, defined as the experience of disease, has been shown to differ among cultural groups. The personal and social interpretations of what constitutes good health differ among individuals and societies, although some will have us believe that only biomedical interpretations are valid. Although we know little about the implications of community-based health services and other proposed reforms, little funding support has been provided to social science researchers with interest in health care and its management. It may therefore be suggested that any reorganization of the health care research funding mechanism, such as the one presently being contemplated by the MRC, should consider integration of cross-disciplinary approaches that would include nonbiomedical scientists in funding arrangements as well as the social and medical relevance of the study. More importantly, will the results be useful to the field in the solution of problems or will the findings simply add to existing knowledge? The argument is that greater emphasis in research funding priority should be placed in the support of crossdisciplinary studies of social relevance and application.
Research training, funding and application The general viewpoint is that the MRC has occasionally considered expanding its role to include funding support for some of the marginal medical specialtiessuch as epidemiology and health services research, presently a domain of NHRDP. Given prevailing biomedical interests and clinically oriented influences within it, it is unlikely that the MRC will Gestion des soins de santt!
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accommodate non-biomedical research adequately. However, the NHRDP seems to have difficulty in counteracting biomedical influences within it, primarily because of investigator-initiated research and biomedical peer-review interests, as well as uncertainty in policy direction. Logically, a new and different research funding arrangement is required, given the present emphasis on biomedical training and research by the MRC and the NHRDP, and the widening disparity between public research interest and social relevance of current research activities. The new research funding arrangement needs to: (a) be relatively independent of investigator-initiated interests but driven by the changing realities of health and health services, (b) operate under policies that will enable the identification of present health and societal needs, and (c) actively support social and community-based research into health services, in particular, improvements in management. The long-term goal should be to encourage collaborative field-based research activities among biomedical and social science researchers. One proposal that merits consideration is the formation of a Health Services Research Council to support research into areas most pertinent to application research, including health administration, health services planning, policy planning program evaluation, delivery of health services, and the sociology of health and health care, among others. Although some of the research initiatives of such a council may be investigator initiated, most research activities should be identified, initiated and conducted in a manner that focuses on prevailing immediate system needs. In other words, the council needs to determine, from the bank of existing knowledge in the literature, what limitations exist in meeting a particular need and request specific investigations on how to overcome or minimize the effects of such limitations in the provision of health services. For example, concern for efficiency in resource management will attract substantial research funding for theoretical, field-based and application research activities in this area until satisfactory answers are found. By specifymg collaboration with practitioners, technological transfer for practical application will be immediate and occur with minimum delay. Many provincial governments are beginning to explore this direction based on local needs and emergencies. The community health organization experiments in British Columbia are one example. Also, the British Columbia Health Care Research Foundation (BCHCRF)has begun to support field-based research into health services. The Ministry of Health has gone further, to support collaboration between hospitals and communities in the delivery of services by withholding one half of one percent of a hospital's budget for that purpose. This approach appears to overcome 29
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one limitation of the MRC (i.e., little concern whether or not funded research results are ever applied or of greater or lesser benefit to clients of the health care system).
Conclusions It is apparent that precedents were established during the formation of research funding agencies. The division between ”biomedical” and ”health services” research has existed for decades. Biomedical research has tended to lie in the domain of the universities and funding has always been allocated primarily on the basis of investigator-initiated priorities. Therefore, planned change to meet current needs has become problematic. Increased funding support for health care research in Canada is needed if this country is to follow the example of the United States. The increased involvement of industries and private concerns in health care research support may be needed to relieve some funding pressure on governments and to increase the proportion of funds available for research in general. An integrated approach to research activity is suggested, even at the current funding level. However, it is hoped that a little injection of funding for health services research will go a long way to balance present funding inequities. First, policy makers should re-examine existing arrangements and determine if funding patterns are in step with ”performance gaps”. Second, a response to inconsistencies in research support and gaps in performance should lead to restructuring. A restructuring that simply integrates one agency with another or the incorporation of some of another agency’s functions will not address the key issues raised in this discussion. Third, consideration should be given to the establishment of a Health Services Research Council with a mandate to promote collaborative, field-based, policy-relevant and community-focused research that will be consistent with changing health service needs and societal expectations.
References and notes 1. Lamontagne, M. 1971. Address to the Medical Council. In Gibson, W. (ed.),Health Cure Teaching and Research. Vancouver: University of British Columbia Alumni Association and Faculty of Medicine. 2. Rachlis, M. and Kurshner, C. 1989. Second Opinion:
What’s Wrong with Canada’s Health Care System and How to Fix It, Toronto: Collins.
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3. Eni, G. 1989. Should we do things differently? Health Care 31(8):12-14. 4. Report of the Royal Commission on Health Care and Costs, 1991. Province of British Columbia. 5. Report of the Royal Commission on Health Services, 1964, vol. 2, Ottawa: Ontario Government Printer. 6. The Canadian Society of Clinical Investigation. 1966. Medical Research in Canada, Ottawa. 7. Medical Research Council of Canada. 1965. An Analysis of Zmrnediate and Future Needs, The Canadian Society of Clinical Investigation, Ottawa. 8. Report of the Royal Commission on Health Services, 1964, vol. 1, Ottawa: Government Printer. 9. Lalonde, M. 1974. A N m Perspective on the Health of Canadians, Ottawa: Department of National Health and Welfare. 10. LeClair, M. 1974. In Larsen, D and Love, E. (eds.), Health Care Research: A Symposium (opening address), Calgary: University of Calgary. 11. Robertson, R. 1974. Health care research in Canada: report to the Science Council of Canada. In Larsen, D. and Love, E. (eds.), Health Care Research in Canada: A Symposium, Calgary: University of Calgary. 12. Gaudry, R. 1974. Biomedical Research and Science Policy. Address to the 25th Anniversary of the Faculty of Medicine, Vancouver: University of British Columbia, June 15. 13. Medical Research Council of Canada. July 1988. Report of the President, 1987-88,Ottawa: Government Printer. 14. Health and Welfare Canada. 1988. National Health Research and Development Program Inventoy (198687), Ottawa. 15. Department of Health and Welfare. 1985. National Health Expenditure in Canada: 1975-1985, Ottawa. 16. Ontario Council of Health. 1973. Report of Committee on Health Research, Toronto. 17. Doll, R. 1974. Medical research in the public interest. In Health Care Teaching and Research: Prospect and Retrospect, University of British Columbia Alumni Association and the Faculty of Medicine, Vancouver.
Godwin 0 .Eni, PhD, is Director, Graduate Program in Health Administration, Department of Health Care and Epidemiology, University of British Columbia, Vancouver.
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