In 1990, the independent Commission on Health Research for Development drew attention to the disparate burden of disease in developing countries (93%) with global health research investment to address these limited to only five percent [1]. This set in motion a range of global commitments with the establishment of the Council on Health Research for Development (COHRED), tasked to support the development of health research systems capacity with a focus on lowand middle-income countries (LMIC) [2]. In 2005, the World Health Assembly adopted resolution WHA58.34, which acknowledged the critical role of research in realising global development goals and equitable health, urging member states and the global scientific community and relevant stakeholders to work towards strengthening national and global health research systems.

The Pacific region discussion on health research systems in Pacific Island countries and territories in 2007 began with a presentation on the status of health research in the Pacific based on the use of a mapping tool devised by COHRED [3]. This tool comprised 18 questions modified for the Pacific context seeking health research information through structured interviews with key informants from 15 Pacific Island countries and territories. The mapping tool investigated four key health research areas; governance, policies and priorities, communication dissemination and utilization, and routine health information systems, as well as health research stakeholders. Results suggested that health research systems in the Pacific were poorly resourced and structured. A set of 19 recommendations from the meeting proposed a range of strategies to bridge the health research systems gap including the ring-fencing of research funds by member countries (2% health budget) and international partners (5% health development aid) [4].

It was estimated that up to 85% of maternal and neonatal deaths in LMIC could have been prevented if only current research evidence was implemented [5]. The lack of utilization of research evidence, let alone the lack of evidence generation, is a result of a limited or nonfunctioning health research system, where research producers, consumers and other stakeholder partners in utilizing research to achieve national development and health equity [6-8]. Whereas there has been an increase in research capacity building (RCB) in LMIC over the last three decades, the World Health Organization (WHO) since 2005 preferred strengthening national health research system (NHRS) as a way of developing capacity from top down [9]. The concept was formed on the basis that health research could only be performed where there was a living health system. The top down approach includes amongst other values, building governance and management skills, research policy development, legislation and ethics processes and research utilization procedures [2].

The aim of this study was to map and compare the NHRS of six Pacific countries to determine whether there had been any changes in the NHRS of six of the 15 Pacific countries since the WHO mapping in 2007. Countries selected as part of the building reproductive health research and audit capacity and activity in the Pacific Islands (BRRACAP) study [10], were included (Cook Islands, Fiji, Solomon Islands, Samoa, Tonga and Vanuatu). The secondary aim of the study was to determine if there was any correlation to selected economic indicators. The study should inform whether the six countries had a NHRS that would be supportive of researchers and research.

Quantitative data was collected and analyzed utilizing similar research methodologies used to investigate the status of Pacific health research systems in 2007, based on the COHRED structured questionnaire [4]. The COHRED questionnaire was sent by email to senior representatives of the Ministries of Health and/or senior researchers of the six countries in 2012, inviting them to participate in the study. An updated version was completed in 2015 to verify health research system status.

No attempt was made to verify the accuracy of the data given so the information, as with that of the 2007 mapping, should be considered indicative. One of the authors (AE) provided additional information with a subjective score for each of the 18 questions in the governance and management section based on the scoring scheme as outlined in the 2007 mapping study [4]. The scoring scheme assigned zero (0) if the response was no or none, one (1) if there was some development, and two (2) if the area was well developed. As with the previous study, each question carried equal value and they were not ranked for importance.

Two informants who were senior or appointed representatives/ senior researchers from Samoa, Fiji and the Cook Islands completed the questionnaire. Only one informant from the Ethics Committees and Ministry of Health completed the questionnaires for Vanuatu and the Solomon Islands respectively. In the case of Tonga, the questionnaire was completed by one of the authors (AE) during an interview with five members of Tonga’s Ethics Committee.

To determine if there was a correlation between a country’s NHRS score and selected demographic measures in population size, gross national product (GDP) per capita, government expenditure on health per capita in international dollars, number of physicians per 1,000 population and a SCImago country ranking [11] for research output were used. A Pearson chi square test was used to test for association (IBM SPSS Version 23). Ethics approval was obtained from the University of Auckland Human Participants Ethics Committee.

Study results suggest that Fiji has the most developed NHRS among the Pacific Island countries assessed followed by the Cook Islands, Solomon Islands and Samoa (Table 1). All countries were more developed in the areas of research structures, health priorities, a responsible party for Monitoring and Evaluation of policy/ intervention, systems to collect/analyse/report routine health information, health care institutions, international research partners, and engaging key stakeholders. Less developed areas were those relating to research plans and policies, formulating research priorities, research legislation, stated values and aims, actual monitoring and evaluation, engagement of other ministries, other research organisations and media active in dissemination of research evidence.

The scoring of the various responses are presented in Table 2 and are ranked by highest total score (Fiji) to the lowest (Vanuatu). All the countries had a reasonably well-developed research structure except Tonga and Vanuatu. No country had published research policy or plans. However, while all countries had systems to collect and analyse data, we were unable to ascertain the integrity and usefulness for clinical practice. There was no statistically significant association between the NHRS scores and any of the demographic and economic variables listed in Table 3.

Table 2: Scores for components of NHRS governance and management.

Table 3: Countries with their demographic/economic variables.

Table 4: Scores for all components of the NHRS (using COHRED components and tool) and comparisons between the WHO Study and this study for six countries. (calculation using a paired sample test, SPSS 23).

Fiji has the most developed NHRS of the six countries with Vanuatu and Tonga having the least developed systems. All six countries had research governance structures although there was a lack of health research planning, policies, research prioritisation and legislation. It would be difficult to have stated research aims and values without a legal or policy framework underpinning them. Although ethical frameworks could be strengthened in four of the countries, what was clearly lacking was the monitoring and evaluation of research. All the countries have health plans and systems for collecting and collating health data. They also had a structure for health service delivery and they had to strategically engage with stakeholders who were in the main, a funding partner of health services. The Cook Islands is the smallest and yet it had a NHRS second only to Fiji. There was no correlation between how well developed a country’s NHRS was with selected demographic and economic indicators.

Compared to the 2007 mapping by WHO [4], there have been improvements in the research governance and management in Fiji, Samoa, Solomon Islands and the Cook Islands with some of them being significant. In contrast, Tonga and Vanuatu seemed to have had a reversal in earlier gains as shown in the 2007 mapping. Factors favouring improvements in NHRS were political stability, health research leaders and a collaboration with a well-developed NHRS as in the case of the Cook Islands.

The political stability following the coupe detat of 2006 has seen major re-investment across the Fijian economy and health sectors which is the most likely reason for the improvement in the country’s health research infrastructure and systems. In contrast, the political instability in Vanuatu for the past 5 years had seen a change of health management personnel, which led to a reversal of earlier infrastructural stability. There was a period when there was no ethics committee in Vanuatu as they had been dismissed as part of the political instability. Health research structures in small Pacific states are prone to collapse, as systems are dependent on a few health personnel with the expertise, enthusiasm and research leadership skills.

Health researchers and research skills are lacking in most Island states. In the case of Tonga, the departure of a key health researcher and a lack in research leadership led to a stagnation in the monitoring and evaluation of research. The ethics committee had not met for a year and there were research projects that the ethics committee were aware of that had been conducted without ethics approval.

In addition, local research funding is either non-existent or limited [3]. In order to attract international funding to build local capacity, there needs to be a local researcher or a functioning research system [12]. Pacific countries, such as Fiji, with researchers, a tertiary medical institution and a more developed NHRS are better placed to attract these funds than the countries without these. There has been significant investment into research capacity building (RCB) in the Pacific Islands by ways of funding and in international research collaborations [3,13-15]. For example, the WHO programme, STEPwise approach to surveillance of chronic diseases, was designed to assist capacity building, but this aim was not realized in most Pacific Island states [10]. The Solomon Islands have however been successful in utilizing a well-funded malaria research programme to develop a wider research capability [16] and other research capacity initiatives [17].

There are Pacific solutions to some of the challenges. The Cook Islands is reliant on NZ institutions for ethics advice. Collaborations across borders between well developed research systems and the not so well developed may provide the capacity needed. Fiji, although lacking in areas, has shown leadership in sharing research expertise between its medical school/research institutions with other Pacific nations. Not all components of a health system need to be developed where resources are constrained. Countries however need to be aware of where the gaps lie and identify areas where they can share expertise with other Pacific countries and Pacific-rim countries such as Australia and NZ. Since all six countries have health plans, they should be encouraged to add a section entitled “health research plan”. The lack of a health research plan with research priorities jeopardizes a country’s ability to control the direction of research relevant to its priorities and may hinder its ability to attract necessary research funding [18]. The Pacific Health Research Council, which has been inactive since 2007, needs to be revived to coordinate assistance where needed. An alternative to developing a NHRS is to set up research or tertiary institutions, which can be encouraged to lead the development of a “micro-health research system” [12] which could evolve into a NHRS when the country’s research capacity improves.

A limitation of our study is that the informants may not have been aware of research developments that had not been communicated by a few policymakers. There was also the possibility that the informants may have “overplayed” their country’s capability in an area. Some of the questions may not have been well understood e.g. media organizations active in dissemination was recorded as none in the Solomon Islands and Samoa. A weakness is that there was no comparison with all the other Island states of the Pacific, especially Papua New Guinea, which has the largest population and several academic institutions.

A further research systems mapping in the Pacific should be repeated within ten years to monitor progress, considering the fragile nature of research workforce numbers. However, the use of the COHRED tool or other more extensive tools is not necessary. The experience of researchers, the end-users, maybe more relevant, in addition to research systems with components defined by Pacific countries.

The paucity of quality data along with competing social and economic priorities in Pacific Island countries and territories are barriers to prioritizing scarce resources for interventions. The lack of health research in Pacific Island countries and territories reflects a wider systemic failure to develop research capacity in the Pacific region [19,20]. Recent research investment in the Pacific has relied on overseas-based funding from the Health Research Council of New Zealand and the Wellcome Trust (United Kingdom) for the Obesity Prevention in the Community (Fiji, Tonga) and the Traffic Related Injury in the Pacific (Fiji, Republic of Palau, Samoa) research projects. With a range of Pacific-relevant solutions and cadre of Pacific researchers identified, non-sustainable research funds place research initiatives to address the specific needs in the region at risk [21]. Global investment in health research has been significant, for example the Global Fund for AIDS, TB and Malaria. The contribution of health research to the achievement of the Sustainable Development Goals is established.

Better developed NHRS in Pacific Island states are associated with political stability, research leaders and associations with other more developed NHRS. There is no need in developing all the components of a NHRS in a resource-constrained setting as long as the various countries develop a Pacific solution that includes research collaborations and resource sharing with other Pacific and Pacific-rim countries.