Strategic Directions Outlook, June 2001, Institute of Health Services and Policy Research, Canadian Institutes of Health ResearchObjectives
The overarching objective of the Institute of Health Services and Policy Research is to identify and overcome key deficits in our understanding of the ways in which health care services can better contribute to human health and/or be more effectively or efficiently organized. The main vehicles for achieving this objective are the development of superb researchers and innovative programs of research likely to address those gaps. The Institute will thus support strategic initiatives designed to improve the manner in which health care services are organized, regulated, managed, financed, paid for, and delivered, in the pursuit of preventing illness and improving health and quality of life for Canadians.
The Institute recognizes the current unmet needs for health services and policy research. The supply of Canadian researchers with the requisite skills and experience falls well short of the rapidly growing calls on their time, and opportunities. This capacity deficit has been made even more acute by the identification of "health systems and services" as one of four key connected components of CIHR's architecture. Building on the already considerable CIHR commitment to addressing this problem, through its CADRE partnership with the Canadian Health Services Research Foundation (CHSRF), the Institute will emphasize training and other forms of capacity-building among its early strategic priorities, and will seek to develop other partnerships that might expedite the development of additional expertise.
The Institute also believes that providing researchers with the necessary tools to conduct research is crucial. To that end, the Institute will seek to identify opportunities to support the development of innovative new methods and approaches to analysis and measurement. It will also work diligently to facilitate the development of information systems, population and other databases, and linkage capabilities, and access to those data resources where such is currently restricted or unnecessarily difficult. It will work closely with other partners, in- and outside CIHR to promote the development of data privacy/access protocols that ensure that important research of potential benefit to the health of Canadians is not hindered by unduly restrictive data access policies.
These two 'infrastructure' priorities are, of course, not ends in themselves. They are intended to enable the timely completion of more and more informative, high quality, health services and policy research of relevance to Canadians. The Institute has already completed a comprehensive process of identifying key research gaps, and has begun designing strategies to meet the information needs of policy-makers and managers in those areas (see below). These priority research areas will guide the funding of strategic research through the Institute over the next three-five years. However, work is underway to develop mechanisms for 'refreshing' these priorities over time as the health care landscape, and what is possible, are constantly changing. The Institute's objective is to stay 'ahead of the curve', to be flexible, anticipatory, and responsive to changing needs for research evidence, while at the same time providing sufficient thematic and funding stability to permit the research community to develop comprehensive, first-rate programs of research that can provide that evidence.
Knowledge Transfer and Uptake
None of this activity is worthwhile if the outcomes of the strategic research supported by the Institute do not reach those who can use the information to guide decisions, whether they be policy adjustments, changes in management protocols, or changes in accepted clinical practices. Accordingly, the Institute has established knowledge transfer (K.T.) as its fourth envelope of strategic activity. Working closely with CIHR-central, and drawing on the extensive expertise in this area that resides within the current members of the Institute's Advisory Board (IAB), the Institute has already begun to develop a number of activities intended to improve the uptake and translation of key research evidence into decisions in the policy, management and clinical spheres. It is anticipated that the range of activities within this 'envelope' will include funding strategic research on effective K.T. approaches within each of these spheres, developing new communications tools, and canvassing the Institute's research community to identify work of potential interest to the public and decision-making audiences.
Finally, the Institute takes seriously the special challenge of nurturing "health systems and services" research, one of the four cross-cutting themes, across the entire realm of CIHR-supported strategic priorities, through the development of innovative partnerships with other Institutes and non-CIHR partners.
The health care policy and management landscape in Canada is perhaps best characterized as being composed of areas in desperate need of additional research, and areas where we already have a good understanding but where the key challenge is one of effective knowledge transfer and uptake. Examples of the former include questions relating to the effectiveness, efficiency, organization and financing of mental health services, or questions bearing on the determinants of public understandings and expectations of health care services and how those influence the health care financing agenda, or the architecture and dynamics of wait lists in Canada and how those influence health care financing decisions as well as patients' health and quality of life, or questions addressing the key determinants of uptake of research evidence by policy-makers. Examples of the latter include the impact of demographic changes on Canadians' use of health care services into the future, or the impact of user charges on health care service utilization, or the impact of increasing private sector financing on public sector wait lists. And even here there are research challenges, albeit of a different nature, with questions focusing on the keys to effective knowledge transfer and uptake.
But we lack a comprehensive map of HSPR in Canada, and a mapping between the research community and areas of inquiry. Indeed, a critical early challenge and priority for the Institute is the development of a comprehensive database of researchers with skills and interests in HSPR. Though there are pieces of such a database residing in a variety of places, including CIHR itself, none is sufficiently comprehensive to serve the multiple needs of the Institute. The breadth of research (e.g. disability research, integrated and complementary health, mental health services, primary care, trauma/injury research, health technology assessment, health care policy, drug policy, access to care for disadvantaged populations, knowledge transfer, and so on) and methods on which HSPR can draw (including, without pretending to be exhaustive, epidemiology, public health, sociology, economics, anthropology, mathematics, statistics, law, political science, business, health care professions, and geography) creates a multiplicity of mini-research communities, but no integrated comprehensive source of information that would permit the identification of new potential teams and networks. A key near-term challenge for the Institute will be the mapping of the HSPR landscape in the country, the identification and support of areas of expertise in need of a 'capacity boost', and the development of strategies for identifying and attracting researchers (particularly from the social sciences and humanities, law, ethics, etc.) with important methodological skills who have not worked previously in health services or policy research. The recently established CHSRF-CIHR CADRE "Reorientation" awards (see below) may provide a useful model on which to build.
While creating a short-term mapping problem, this diversity of skills and interests is, however, a key strength of this research community. The challenge for the IHSPR will be to harness some of that capacity in the service of new cross-disciplinary and cross-Institute strategic priorities at a time when the demands on the community, and the multiplicity of research opportunities, has created a (hopefully short-term) 'expertise gap'. These multiple communities also lack any common 'meeting ground', spread as they are across a variety of more-or-less natural, but largely narrow, affiliations based either on training (e.g. the health economists) or areas of research interest (e.g. complementary and alternative health care, or technology assessment). In collaboration with key partners such as CHSRF, CIHI, Health Canada, a number of the FPT Advisory Committees, and some of the voluntary organizations with interests in health services and policy research, the IHSPR can play a key role in creating a sense of 'common mission and connection', a home, for those communities of researchers.
As noted in the Objectives section above, the Institute has identified four strategic envelopes of activity: people, data infrastructure, research, and knowledge transfer. We have been working in all four arenas, but insufficient developmental progress has been made to support allocating strategic funds in the current fiscal year to data infrastructure or knowledge transfer initiatives. Institute support grant resources, amounting to about $400,000 annually, will continue to support activities within those envelopes(1). In the short-term the strategic focus will be on people and targeted research.
Recognizing the gap between demand for health services and policy research and supply of researchers able to respond, the Institute intends to build on earlier CIHR commitments to training and other forms of capacity building. The CIHR has already signaled its recognition of this important need through its partnership with the CHSRF on the "Capacity for Applied and Developmental Research and Evaluation" (CADRE) program in health services and nursing research. Through this program, CIHR provides support for mid-career chairs in health services and nursing research, Regional Training Centres, career renewal awards for non-health researchers interested in applied health services or nursing research, post-doctoral awards, and regional partnerships for developing additional capacity in these areas.
To this end, an IAB Training Working Group has been formed to provide advice to the IAB on strategic directions in this area. In order to send a strong signal to the health services and policy research community regarding the Institute's commitment to capacity-building, and to prime this key strategic area, in excess of 40% of strategic funds will be invested in this fiscal year, in the following areas:
Graduate students (3 yrs.) and post-docs (2yrs) $ 150,000 (2)
Top-up funds for CIHR training program grants (6 yrs) $ 250,000 (3)
Training programs (6 yrs) $ 600,000 (4)
The amount available for these capacity-building activities may be increased through the development of partnerships.
Through a complex process of consultation in collaboration with a number of key national partners, the Institute has identified several priority themes that will guide the development of many of the strategic RFAs over the next 3-5 years. Most of the other priority themes that emerged from that partnered consultation will be incorporated within the priorities of the partners and, in addition, a number of partnerships on IHSPR priority themes are currently under discussion. An IAB Strategic Research Working Group has been formed to provide advice to the IAB on strategic research themes (short and long term), continuous canvassing of the research, policy and management communities on priorities, and articulating RFA content.
An IAB priority process resulted in a decision to feature 2 themes for immediate (current fiscal year) RFA attention. The Institute will commit $1.2 M in strategic funding to the following two themes (with examples of research questions for each theme):
role of public values and expectations in determining what is publicly funded;
influences on public values, attitudes and expectations; relative roles of media, professional groups, government, culture, expert commentary and research evidence;
approaches to combining public values and technical information, particularly in the areas of new technology assessment and defining the overall basket of publicly funded health care services;
implications for overall costs, access, quality and patient outcomes of different mixes of public and private financing, particularly for rapidly expanding services such as drugs and long-term care;
measuring the changing burden of care on the informal and voluntary sectors, and funding & organizational mechanisms to better coordinate and integrate informal and voluntary care with the formal care system;
Improved Access for Marginalized Groups (minor commitment, approx. $300,000 per annum plus $400,000 from the Institute of Gender and Health and the Institute of Aboriginal Peoples' Health, plus potential funding from other partners)
implications of different models of primary care on needs of and access to services for those living in small, rural, remote and isolated communities;
innovative approaches to deployment of human resource, technology and transportation in addressing access to specialty services for small, rural and remote communities;
identification of barriers (and innovative approaches to addressing them), to access for groups such as those with mental health problems or addictions, aboriginal peoples, particular ethnic minorities or socioeconomic strata.
In addition, the Institute has taken the lead, with the Institute of Population and Public Health, in the development of a partnered (with the Canadian Institute of Health Information) initiative within another of the IHSPR's priority themes, Improving Quality.
This cross-Institute initiative resulted in the issuance of the first of the CIHR's RFAs, on Improving the Quality of Health Care in Canadian Hospitals.
This leaves approximately $200,000 in annual commitments available after the current fiscal year.(5) This strategic funding has been set aside to support health services and policy-related priorities of the other Institutes once they are further along in their development of strategic research priorities, and will be committed in consultation with the Scientific Directors and the Institute's Advisory Board.
To address the issues related to database development and access, an IAB Data Infrastructure Working Group has been formed to guide the development of strategic activities in this area. The Institute is working closely with the Institute of Population and Public Health, and with the CIHR-central Office of Ethics on key issues in this area. A planning meeting in June 2001 will develop an agenda for a multi-partnered strategic priorities workshop in the fall 2001. The Institute may partner with the IPPH to commission some background work in preparation for that workshop.
An IAB Knowledge Transfer Working Group has been formed, and has set an ambitious agenda, including the development of a knowledge transfer strategy, for the early fall meeting of the Advisory Board.
Longer Term Outlook
Some planning for the longer term has taken place within all four of the strategic envelopes, though progress to date is most advanced in setting research priorities.
Over the longer term, strategic investment will focus on some or all of the 10 strategic research themes(6), including those to which current year funds are being committed, which will be prioritized in the fall 2001 RFA development process:
Financing and Public Expectations
Improved Access for Marginalized Groups
Evolving Role of Informal and Voluntary Care
Health Human Resources
Governance and Accountability
Health Care Evaluation and Technology Assessment
Public Advice-Seeking in the Era of 'e-Health'
Continuum of Care & Delivery Models
Performance Indicators, Benchmarks and Outcomes
In addition, a number of inter-Institute strategic initiatives for future years are currently under discussion. The following are examples of some of those early discussions:
With the Institute of Genetics: Health services and genetics
With the Institute of Population and Public Health and CIHR-central: Research priorities
bearing on rural & remote health
With the Institute of Gender and Health and the Institute of Aboriginal Peoples' Health:
Access to care for marginalized populations
With the Institute of Infection and Immunity, and other Institutes: Models of care for
With the Institute of Human Development, Child and Youth Health: Off-label use of
prescription pharmaceuticals by children and adolescents
With the Institute of Healthy Aging: Health care system implications of cognitive
With the Institute of Healthy Aging and other Institutes: Development of a healthy aging
Future commitments will depend, in part, on the outcomes of the current round of initiatives. The expectation, however, is that the Institute will continue to support additional trainees and post-doctoral fellows who are highly rated but not funded through "programs". The training working group will also be exploring a variety of "career reorientation" initiatives that would complement the support already provided through the CADRE program in partnership with the CHSRF.
A data infrastructure working group of the Advisory Board will be developing a longer-term strategy in this area. Possible initiatives could include supporting the development of new databases including patient registries (in partnership with other Institutes), the linkage of heretofore unlinked databases, the facilitation of access to data for the research community through assistance with the development of access guidelines, and other initiatives whose objectives are to improve the quality and availability of health services and outcomes information resources for researchers across the entire CIHR spectrum.
It is anticipated that some knowledge transfer strategic initiatives will be supported for fiscal 2002-03 and beyond, in partnership with CIHR-central and possibly other Institutes and partners.
In addition, the Advisory Board has formed a working group on Partnerships that will have, as early tasks, the identification of potential partners for the initiatives of the Institute, and the development of a partnerships-building strategy.
(1) Support grant funding has already been committed to a variety of workshops, including one on population-based health databases (partnered with IPPH), one on health services research training initiatives (with INMHA), and one on developing a research agenda on home care (partnered with IPPH, IGH, IHA). The Institute has also commissioned work on the feasibility of developing a new knowledge translation vehicle (a journal) for health services and policy research of particular relevance to a Canadian policy and management audience. A standing review committee of the IAB has been struck to review future workshop or other developmental requests for support.
(2) These funds will be used to support Ph.D. trainees who were highly ranked but not funded out of the fall 2000 trainee competition, and the spring 2001 post-doctoral fellow competition. They represent a commitment of approximately $115,000 in fiscal 2001-2002 assuming awards commence July 1, 2001.
(3) These funds would be used to expand the capacity of one or more training programs funded through the current CIHR-central-led training program grants competition.
(4) These funds would be used to support up to two additional training programs with significant health services/policy components, that are highly ranked but not funded through the current all-Institute training program grants competition
(5) These funds would not be available in the current fiscal year because of the timing of the student and post-doctoral fellowships which would draw for ¾ year, not 1/3 year.
(6) Descriptions of each of these themes, including examples of research questions within each, can be found in the document Listening for Direction: A National Consultation on Health Services and Policy Issues. This document can be downloaded from the IHSPR website.