Supporting the Development of a New Health R&D Strategy

A Rapid Review of International Theory and Practice for Norway's HelseOmsorg21

by Jonathan Grant, Alexandra Pollitt, Sophie Castle-Clarke, Gavin Cochrane, Susanne Sondergaard, Veronika Horvath

This Article

RAND Health Quarterly, 2014; 4(2):17


The HelseOmsorg21 initiative was set up by the Ministry of Health and Care Services to develop a new research and innovation strategy for health and care services in Norway. The HelseOmsorg21 Strategy Group, through the Research Council of Norway which is providing the secretariat for the strategy development, asked RAND Europe to support the strategic review process. RAND Europe’s role was to conduct a series of rapid evidence reviews around the recommendations arising from the five working groups that comprise the initiative. The reviews were conducted around networks and collaboration, data linkage and exchange, culture, values and leadership, and incentives for innovation, while capacity building was a recurrent theme throughout.

This study presents the rapid evidence reviews, summarising relevant literature and highlighting international examples of particularly relevant or innovative approaches. The issues and ideas identified around each theme are then pulled together in a suggested conceptual representation of the Norwegian health and care research system.

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Full Text

The primary objective of any health research system should be to improve the health of the general public and the health outcomes of patients through research. The HelseOmsorg21 initiative was set up by the Ministry of Health and Care Services to develop a new research and innovation strategy for health and care services in Norway, with the secretariat provided by the Research Council of Norway. RAND Europe was invited to support the strategic review by conducting a series of rapid evidence reviews around recommendations arising from the initiative's five working groups. The working groups focused on industrial development and entrepreneurship, research quality and internationalisation, knowledge systems, municipalities and global health challenges.

Rapid evidence reviews are a resource-efficient way to identify and summarise the general characteristics, issues, data and knowledge gaps surrounding a problem. They aim to be rigorous, transparent and explicit in method, but make concessions for the timeliness and utility of the output, and thus are not full systematic reviews of the literature or wider evidence. The rapid evidence review focused on five common themes that arose from the preliminary reports produced by the working groups. The purpose of the review was to examine, test and validate the underlying evidence—and the strength of that evidence—for each theme. The themes were identified by reviewing (translated) summaries of the working group preliminary reports and discussions with the HelseOmsorg21 secretariat. The final set of agreed themes covered research networks and collaboration; research infrastructure; research culture, values and leadership; and incentives for innovation. A fifth theme, capacity building, cut across all the others and so was incorporated into discussions of each theme as appropriate.

Networks and Collaboration

There is strong evidence to show that networking and collaboration are crucial to any research system, and the increasingly complex and interdisciplinary nature of modern health research has served to encourage researchers and research funders to engage and actively promote collaborative research.

Stakeholder engagement plays a critical role in establishing research networks and collaborations. This requires an understanding of who the key stakeholders are, as well as the barriers and enablers to their engagement. The engagement of GPs in primary care research has been low internationally, and the wider context in which primary care research is being conducted must be considered in implementing an intervention to improve engagement. Given the current skew in Norwegian research funding towards six university hospitals, there is a need to try to bring stakeholders from the municipalities into the wider research ecosystem, and to consider strategies for research collaborations between universities and colleges, research centres, hospitals and the municipalities. Central coordinating bodies and Primary Care Research Networks (PCRNs) may help to facilitate this interaction between the various institutions.

Data Linkage and Exchange

The healthcare sector is becoming saturated with previously unobtainable data, from next-generation DNA sequencing to clinical and health outcomes data contained in electronic health records and national registers. This has considerable implications for the delivery of health services and for health research. Data are becoming increasingly integrated into healthcare and health research in several ways: the use of DNA sequencing to determine optimum treatment regimes; electronic health records that make it possible to track the patient through the treatment process; and comprehensive monitoring and surveillance programmes that can address threats such as infectious diseases and antimicrobial resistance by integrating data from a wide range of both structured and unstructured data sources—these are just some examples.

Coping with this vast array of structured and unstructured data brings a number of challenges apart from the skills in bioinformatics necessary to draw meaningful inferences from the data. Ethical concerns (particularly around patient consent to the use of their data), interoperability (both within Norway and internationally), standardisation of records and incorporating information from the increasing numbers of self-diagnostic devices are just some of the issues that are inherent in the use of data for health research.

Culture, Values, and Leadership

Structural changes do not in themselves deliver enhanced quality and performance. Some argue that the management of organisational culture is a necessity in healthcare reform, and in a complex system that ranges from primary care delivery to research institutions, separate organisational cultures can hinder as well as promote collaborative efforts. It seems unlikely that an entire system could ever share a single culture of similar values and behaviours, but it may be possible to shape and align aspects of the system towards a shared goal.

Organisational culture can be seen as part of a larger “innovation ecosystem,” a concept that takes account of the different components of an environment, and the way these components impact one another to give shape to that environment. The benefit of taking a systems view is that the system itself can be shaped and characterised by an array of legal, cultural, social, economic, organisational, political, commercial, scientific and technological aspects. One of the unique characteristics of health research systems is that they interface and overlap with other “systems,” such as education systems and healthcare systems. It is necessary to understand that the individual components and collective dynamics within and between these systems should be viewed as part of a dynamic whole.

Although systems thinking is prevalent in the academic literature—particularly within organisational theory, including emerging literature on systems leadership—there is very little on systems culture. In discussion with the HelseOmsorg21 secretariat we focused our review on interventions that could enhance the leadership of a health research system, prompted in part by a number of innovative interventions in this area. The literature suggests that leaders required to operate in complex systems may need various attributes including: the ability to span boundaries effectively, strong stakeholder management skills, a collective impact perspective, and the ability to act as stewards, where they are not motivated by individual goals but by motives aligned with the objectives of the system as a whole. Organisations seeking to adopt a stewardship perspective should “aim to widen employees' views of beneficiaries to include a broader base of stakeholders and longer time frame in which to create and maintain value.” The development of leaders operating in a systems context should take these aspects into account.

Finally, in addition to developing leadership capability, it is important to consider the wider capacity building of the health research system, including its “absorptive capacity”—a term used in the innovation literature to describe a system's ability to value, assimilate and apply information and knowledge external to the system. Increasing absorptive capacity needs actions at both individual and organisational levels, depending on the organisation's wider environment and specific needs.

Incentives for Innovation—Supply- and Demand-Side Policy Instruments

It is widely accepted that there is a role for public policy to support innovation-related activities. This is because there is generally thought to be a link between investments in research and economic growth, which in many cases has led to ambitious R&D targets. This is the case in Norway, where there is a 3 per cent target for public and private spending on R&D as a share of GDP. The reason that public policy is needed, it is argued, is that under ordinary market conditions, there may be a tendency for firms to underinvest in R&D due to a number of market failures.

A wide range of incentives can be employed to stimulate innovation. Supply-side measures include those intended to improve the performance of innovation systems and can be financial- or service-oriented (i.e., focused on information exchange or networks). Demand-side incentives are defined as measures to increase the demand for innovations, improve the conditions for the uptake of innovations and improve the articulation of demand to spur innovation and the diffusion of innovations.

On the supply side, policies around R&D tax credits can address problems of under-investment in research by private companies and issues around the awarding of direct government grants, which have become recognised as inefficient. The establishment of science parks also appears to drive innovation and research in some cases, but importantly not in all, and does present an option for Norway to consider given that it has significantly fewer science parks than its regional counterparts—although the number of science parks alone is not a sufficient comparator measure. Moreover, science parks require a significant amount of thought, investment and planning to be successful.

On the demand side, public sector procurement and prizes are both becoming increasingly significant as drivers of innovation. The US Small Business Innovation Research (SBIR) programme and variations thereof are useful models for developing a public sector procurement programme in Norway. For example, prizes have been incorporated into the EU's Horizon 2020 flagship initiative and have been adopted by many other governments, and are increasingly regarded as an important aspect in driving innovation. Prizes can, under some circumstances, have the added benefit of attracting different, sometimes unexpected, disciplines into solving a particular problem.

Taking the Health Research System in Norway Forward

The Norwegian health and care research system, like many others, is inherently complex and features a range of different missions, multiple objectives and different masters. In Figure 1 we have tried to capture this by illustrating how some of the ideas that were identified in the rapid evidence review contribute to that systems thinking. It should be stressed that this is not a comprehensive attempt at describing the system as there are other ideas and interventions that we have not reviewed.

Norwegian Health Research System

Figure 1. Norwegian Health Research System

Given the multiplicity of actors and institutions, it is important to take a systems approach that considers the interactions involved. There may be value in establishing a role targeted at co-ordinating, integrating and brokering across the health system as a whole. To ensure that such a function is embedded within the system, we have identified three key areas of intervention for consideration based on the rapid evidence review: the first is to establish primary care research networks, linking research activities in hospitals, universities and colleges, and municipalities (Section 2.2.1); the second is to further develop Centres of Excellence around different priority areas with a clear focus on delivering high quality patient-oriented research (Section 2.2.2); the third is to establish data linkage and exchange activities across the health research system, providing a unique research (and care) resource, differentiating Norway in a global health research market (Section 3.3).

In addition, the co-ordinating role would work towards developing a system-wide culture that promotes the position of research as an integral part of patient care. A training programme in research and personal leadership, and stewardship contextualised within the wider system could develop leadership capabilities and encourage boundary spanning.

At the same time, policy instruments to encourage innovation aimed at both the supply and demand sides could help to embed research thinking across the system.

The research described in this article was prepared for the HelseOmsorg21 Strategy Group, Research Council of Norway and conducted by RAND Europe.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.