Investments in research and development remain among the most powerful tools of government and the private sector to achieve gains in performance through innovation. Studies suggest that R&D investments are at least as important as investments in human capital, infrastructure, physical equipment and technology in producing long-term growth in economic and organizational performance. As the amount of R&D investment increases within an organization or industry, so too does the level of product and process innovation. However, the importance of R&D appears to vary widely across sectors and professions. Data from the National Science Foundation’s periodic Survey of Industrial Research and Development shows that the percent of revenue devoted to R&D varies more than fivefold across sectors (Table above). Not surprisingly, the sectors that face the greatest external pressures to innovate tend to invest much more in R&D than do steady-state sectors, as the table above shows. Such high-pressure sectors often invest more than 10% of revenue in R&D.
The U.S. public health system now finds itself facing mounting external pressure for innovation. After a remarkable century of progress in improving human health through prevention, the public health enterprise faces many new and escalating health threats – ranging from obesity to emerging infectious diseases. Public health faces fierce competition for public resources from other worthy policy domains, including the ever-growing medical care system, while still weathering the fiscal constraints triggered by the economic recession. And in the midst of health reform implementation spurred by the Affordable Care Act, public health is in the process of renegotiating its roles and responsibilities with many other stakeholders that contribute to population health, including medical providers, insurers, employers, nonprofits, and other government agencies. Public health is expected to help the medical care sector bend its cost curve and produce more health for the dollars it consumes.
These growing imperatives for innovation suggest a need for increased investment in public health R&D. Available data indicate that the federal government’s lead public health agency, CDC, spent about $363 million on public health R&D activities in 2012. However, the 10% rule of thumb for high-innovation sectors indicates that public health probably requires at least $7.5 billion annually in R&D investments. Even if we assume that some small portion of NIH and AHRQ funding supports public health R&D, and that additional public health R&D investments derive from state, local, and philanthropic sources, the total investment certainly falls far short of what is likely to be required for successful public health innovation. For these reasons, a recent IOM report called for an expanded, federally-funded program of research devoted to public health services and systems research.
The constrained budget for public health R&D also indicates a need for more efficient and effective mechanisms for conducting research in public health settings. The fact is that many innovations in public health organization, financing, and delivery are occurring throughout the U.S. in response to policy, economic, and institutional changes. Public health professionals and policy-makers are routinely called to act against health threats for which few if any evidence-based strategies exist, or to act in settings where evidence-based strategies are logistically, politically or economically infeasible. In these situations, innovations in public health practice and policy occur but without the comparative research necessary to determine their impact and value. By building pragmatic research designs around these naturally occurring innovations, new evidence can be generated at relatively low marginal cost.
Last month’s issue of the American Journal of Preventive Medicine features a series of studies conducted through a mechanism that holds considerable promise for improving the quality and efficiency of public health R&D: practice-based research networks (PBRNs). Borrowing the concept from primary care physician-researchers, our research center has been working to develop PBRNs in public health settings for more than five years now with the support of the Robert Wood Johnson Foundation. We now have public health PBRNs up and running in 30 states, engaging more than 1200 state and local public health organizations in the design, implementation, and translation of research studies. Our research suggests that PBRNs can be quite effective in engaging public health professionals in the implementation and translation of valuable research studies. For example, we find that public health agencies affiliated with PBRNs are 2 to 3 times more likely to engage in research activities than a comparable sample of agencies without such affiliations. Given NSF’s research showing a strong connection between R&D involvement and successful innovation, our findings suggest that PBRNs can serve as powerful engines of innovation for the public health enterprise.
The PBRN studies published in the December AJPM issue showcase the wide range of research that can be accomplished through these networks. The issue includes studies test the effectiveness of practice innovations designed to improve the delivery of evidence-based prevention programs, explore the use of evidence-based decision-making strategies among public health administrators, elucidate the roles of fiscal policies and financing mechanisms in shaping public health delivery, evaluate decision-making strategies for public health resource allocation during the economic recession, and test the influence of the PBRN model itself on the scope and intensity of R&D activities undertaken public health practice settings.
To be sure, there is much more to come from the public health PBRNs, including the Public Health Delivery and Cost Studies (DACS) now underway, which should be of special interest to readers of this blog. And there are other powerful engines for public health R&D, including the CDC’s Prevention Research Centers program, the embedded R&D units found within in some particularly progressive state and local health departments, the Academic Health Department model, and the many public health quality improvement initiatives spreading across the U.S. The capacity to accelerate public health innovation through R&D clearly exists. Let’s hope that the Institute of Medicine’s call for expanded investments in public health R&D can gain traction as part of the nation’s push for health system transformation.