Report of World Tour

Report of World Tour
Report of World Tour

Chris Silagy Chair, Cochrane Collaboration Steering Group

1. BACKGROUND TO THE VISIT

During the 1996 strategic planning meeting of the Cochrane Collaboration Steering Group in Oslo it became clear that there was a need for someone within the Collaboration to invest a substantial amount of time in exploring opportunities at an international level for obtaining funding and support for the activities for the Cochrane Collaboration as an international endeavour. I offered to make myself available for this purpose for a total of one month during 1997. The principal objectives of the trip were as follows:

* To explore opportunities for securing funding and support for the international activities of the Cochrane Collaboration. * To establish strategic links between the Cochrane Collaboration and other organisations internationally, that may assist the Collaboration in fulfilling its mission statement. * To support efforts of local Cochrane Centres in securing funding from national organisations (particularly in the United States). * To increase my personal familiarity with the different healthcare systems and environments in which the Cochrane Collaboration needs to respond internationally.

The trip was undertaken during March 1997, to coincide with the Steering Group and Cochrane Centre Director meetings, both of which were held in San Francisco. I also organised to conduct a one day support workshop for Cochrane Reviewers in Auckland, New Zealand (on my way to the United States) and a one day workshop for potential Cochrane Reviewers in Bangkok, Thailand (on the way home from the trip). Part funding was provided by the Australasian Cochrane Centre. The remainder of funds were from my personal consulting funds.

Mrs Kelly Binelli assisted me with the administrative arrangements throughout the tour. Dr Iain Chalmers was responsible for organising the UK portion of the tour. Drs Jos Kleijnen and Peter Gotzsche organised the Amsterdam and Copenhagen components respectively. Dr Cindy Mulrow facilitated the visit to the American College of Physicians. Staff from the Australasian Cochrane Centre assisted in preparing written materials for use during the tour. Mrs Anne Lewis and Ms Vanessa Jones typed the final report. To all of these people who have assisted the organisation of the trip and / or provided generous hospitality to me in their homes, I am extremely grateful.

2. ORGANISATIONS VISITED

2.1 UNITED STATES

2.1.1 Zynx Health Inc., Los Angeles

This organisation is a small for-profit company which was established out of the Health Services Research Unit from Cedars Sinai Hospital. It has four MDs and a small team of support staff (including a librarian, two research assistants, and administrative support) who are involved in providing a range of consultancy work supporting evidence-based practice (including guideline development and implementation) in teaching hospitals throughout the country. Their major product has been the Physicians Desk Reference, which consists of the top 20 ticket items in acute care, for which the company produces a series of reviews of the literature in a semi-systematic way. Compared with the Cochrane Collaboration, the reviews are far less structured and do not attempt to use any quantitative synthesis techniques, even where these may be appropriate. Instead, where there are multiple primary articles identified on a subject, one of the MD reviewers simply writes a narrative synthesis. The most impressive aspect of the Physicians Desk Reference is its "explosion" of a clinical problem into its component parts, in order that evidence-based summaries can be provided for each element of a clinical problem. In this way the product is extremely useful to clinicians with a specific problem. The senior staff at Zynx were keen to look at ways in which links could be formed with the Cochrane Collaboration. They certainly would plan to incorporate Cochrane Reviews into their Physicians Desk Reference if we had covered an element of a specific topic that they were interested in. They seemed less interested in participating in preparing Cochrane Reviews because of the time involved in preparing a systematic review.

The major lessons I learnt from this visit were that as soon as there is a good idea within an academic environment, there is a tendency to commercially exploit it (as in the case of the health services research unit becoming an incorporated entity). I also learnt that because of the corporate orientation of such organisations, there was little likelihood of them collaborating with the Cochrane Collaboration in a truly two way partnership. Their principal customers were acute care hospitals in the United States.

2.1.2 Value Health Services and Pfizer Health Solutions, Los Angeles

This organisation is an offshoot of the Rand Corporation which focuses on developing clinical guidelines and information systems that it sells to the major health insurance companies in the US. The approach adopted is based on the Rand philosophy and involves developing consensus based guidelines, with some input of scientific evidence. The organisation sees the Cochrane Library as a useful resource to the guideline development panels that it sponsors, and may be interested in commissioning systematic reviews of specific topics if they can be completed within a relatively short time frame (e.g. within three months).

2.1.3 Kaiser Permanente, San Francisco

I spent a full day meeting with a broad cross section of people from Kaiser International, Kaiser Health Plan Inc, and Kaiser Medical Inc. Kaiser is one of the large US managed health care organisations, with most of its operation on the West Coast of the USA, Hawaii, and some parts of the Mid-West. Although it is a non-profit organisation, it does seem to generate profits which are then returned to the company for further investment. I met with a total of nine people during the day and learnt a considerable amount about the way in which this organisation operates. There was considerable interest in the work of the Cochrane Collaboration, and how this could link with their own initiatives. The organisation is involved in providing health care to a population of approximately 6 million. It is divided into three geographical regions, which have been largely autonomous until recently, when there have been moves to restructure the organisation into a more streamlined outfit.

Each of the Kaiser regions develops their own clinical guidelines, which they try to base on evidence. Those involved in this process welcome the idea of using the Cochrane Library as a potential resource, and were keen to explore this possibility further.

The only part of the organisation which had previously heard about the Cochrane Collaboration was its research arm, which is headed by Dr Joe Selby. I found this somewhat surprising, given the close proximity of the San Francisco Cochrane Center to this organisation.

One part of the organisation which was particularly interested in exploring the development of links with the Cochrane Collaboration was its funding agency, the Garfield Foundation. Dr Ed Thomas (who is the head of this foundation) could see the advantages of using the Cochrane Collaboration approach to pin-point gaps in existing knowledge and highlight areas requiring further research. He was particularly interested in the prospect of commissioning systematic reviews prior to funding new projects and was keen to follow-up this possibility with the San Francisco Cochrane Center.

Overall, I was impressed with my visit to this organisation. It was my first insight into a large managed care organisation in the United States and gave me a good perspective of the approach used, and the underlying philosophies. I was somewhat surprised, and disappointed, to learn how little awareness existed about the Cochrane Collaboration. No-one I spoke to was fundamentally opposed to the aims or methods of the Cochrane Collaboration, although some people expressed concern at the amount of effort that had to be invested to produce a systematic review, and questioned whether their somewhat less structured approach would produce results with substantially different clinical implications.

2.1.4 Healthwise, San Francisco

I met with the Vice President of this consumer based organisation, which seeks to develop knowledge databases that provide health care information to consumers. The organisation has entered into partnership with Kaiser Permanente to produce a consumer health book that is made freely available to all Kaiser members. They have also developed an internet based version of this product. They were excited about the possibility of collaborating with the Cochrane Collaboration and could see a number of ways in which this could occur. For example, they were keen to explore the possibility of expanding their advisory board to include people from the Cochrane Collaboration. In addition, they were interested in making the Cochrane Library accessible as part of the Healthwise database. In the longer term, they wanted to see whether it would be possible to integrate the two databases more closely, and provide consumer information based on the Cochrane material. Currently, most of their information focuses on self management in the home setting, rather than health care information about acute care and chronic disease management.

I spent the next four days attending meetings of the: * Cochrane Collaboration Publishing Policy Group * Cochrane Collaboration Steering Group * Cochrane Collaboration Centre Directors * Pre-exploratory meeting to establish a Cochrane HIV/AIDS Collaborative Review group

2.1.5 World Bank, Washington

Jimmy Volmink accompanied me on the visit to the World Bank and Agency for Health Care Policy and Research. At the World Bank we met with Dr Peter James who is one of their pubic health specialists focusing on southern Africa. He explained the current structure and function of the World Bank, and emphasised that it was currently undergoing a period of strategic realignment and review. It was becoming increasingly concerned in using evidence-based information to inform its advice about health care financing and health care sector reform, although he stressed its growing emphasis was on a need for evidence-based health care policy rather than specific clinical interventions. He highlighted that the major areas of interest lay in these macro and organisational issues, although at a clinical level the key areas that the World Bank has previously focused on include reproductive health, TB, injuries, tobacco, nutrition, mental health and malaria.

We then met with Dr Eugene Boostrom who heads the Global Health Network initiative, which is a somewhat ambitious undertaking on an international scale to try to ensure that people in developing countries have access to up-to-date information about health care that can be used to under-pin and inform their local reform initiatives. We discussed the possibility of the Cochrane Collaboration participating at a forthcoming Global Health Care Network planning workshop where we would have an opportunity to profile the work of the Cochrane Collaboration, and discuss how this could be incorporated as part of this initiative. Unfortunately, at the time of writing, despite several letters from me I have not heard anything further about this initiative.

The final meeting at the World Bank was with Dr Richard Feachem who heads their health care activities. He re-emphasised many of the points raised during the earlier meetings, but provided extremely useful advice on how the Cochrane Collaboration could interact with this organisation. He suggested three major strategies: 1. Local field work: Here the emphasis was on how to get the right research done and in the right way. He felt the Cochrane Collaboration had an important role to provide input into this process. He suggested that Prahbat Jah should act as the focal point for the Collaboration. He felt that we should provide regular information to members of the World Bank involved in field work about the Cochrane Collaboration, and should consider organising a seminar in the Autumn of 1997 to present further details of the work and activities of the Collaboration. Although this has been done previously he felt that there was value in repeating this. He stressed some possibility of providing contributory support to enable such a workshop to occur.

2. Special Grant program: The World Bank has run for several years, a special granting program, which is currently in its last financial year. This will be replaced by a new grant program that will begin towards the end of 1998. At this stage they are unsure as to how competitive it will be or what its orientation will be. However, Richard Feachem agreed to provide information to the Collaboration as this becomes available.

3. Other international activities: Specific mention was made of a recent report relating to future international options for investing in health research and development, that was sponsored by WHO, and produced by an international ad hoc committee. As a result of this report an international forum in health research and development has been established. There are plans for this forum to meet in Geneva on the last weekend in June. Richard Feachem felt it would be appropriate for the Cochrane Collaboration to seek the opportunity to be a participant at this meeting and provided the name of an appropriate contact (Dr Louis Curratz, Swiss Development Corporation). Since returning to Australia I have written a letter to Dr Curratz requesting an opportunity for the Collaboration to nominate a representative to participate in this meeting. He has agreed to this, and Iain Chalmers has kindly agreed to represent the Collaboration.

2.1.6 Agency for Health Care, Policy and Research, Rockville (Maryland)

This visit was organised as a series of short meetings with senior staff (including Lisa Simpson, Acting Administrator, Douglas Kamerow, Carolyn Clancy, and Terry Shannon). The initial discussion focussed on exchanging general remarks about the progress of the two organisations, and the approach that had been adopted in various countries around the world towards developing links between national funding agencies, health technology assessment agencies, and the Cochrane Collaboration. We had an opportunity to discuss the proposed centres for evidence-based practice, which have largely been designed in a way that duplicates the work of the Cochrane Collaboration. These centres will have a responsibility to produce commissioned systematic summaries of the best available literature. These evidence-based reports will then be made available freely over the internet. There was an open recognition that this potentially duplicated what the Cochrane Collaboration was trying to achieve, and at one level there seemed to be little interest in trying to minimise this. However, I suggested that we explore the possibility of comparing our respective systematic reviews to see whether there were differences in the methodology underpinning the way which these had been produced and their results. In addition, the possibility of hot-linking our internet-based reviews in areas where only one of the two organisations covered the topic was also worthy of further exploration. There was general support for this idea. The AHCPR expressed the view that whilst it broadly supported the concept of the Cochrane Collaboration, it had some difficulty knowing how best to relate to the four existing US Centers, given that these had not been established according to an open competitive process. The AHCPR recognised that several of the individual Cochrane Centers would be participants within consortia bidding for the evidence-based centres, however, it felt that this funding would be unavailable to support infrastructure needs of the Cochrane Collaboration at the present time. My clear sense from the meeting was that the agency has its own agenda, which it is reluctant to consider modifying in any way to incorporate or seriously work with the Cochrane Collaboration, given our present structure and the processes. There also seemed a reluctance to accept the notion that if reviews were produced using public funding from the US that it would be possible for these to be included in a database like ours, which was available commercially (even though it has a low price).

2.1.7 John Eisenberg, Administrator-Elect, Agency for Health Care Policy and Research.

We had an opportunity to meet with John Eisenberg who is in the final stages of Congress approval for his appointment to the position of Administrator of the Agency for Health Care Policy and Research. He is an experienced health services researcher, who understood broadly about the Cochrane Collaboration and was keen to explore ways in which collaboration between the two organisations could be established. This was a positive development, particularly given the views expressed by the existing agency staff. However, he also reiterated the concern that several research groups in the US feel about the selection process for the existing Cochrane centers. We agreed to maintain an active dialogue during the coming months and maintain regular exchange of information such as newsletters etc.

2.1.8 American College of Physicians, Philadelphia

I met with Dr Frank Davidoff and other senior staff of this organisation. They have had a formal Cochrane Task Force, appointed by their Board, which has been working for the last nine months to prepare a report on how they could more closely collaborate with the Cochrane Collaboration. The draft of this report contained a number of useful suggestions, which we discussed, and the final report will be presented to the Board of Regents later this month. The College is extremely supportive of the Cochrane Collaboration, and keen to continue to promote the Cochrane Library. They also express some difficulty in knowing how best to relate to the Cochrane Centers in the US given their dispersed nature, and lack of a clear joint structure. The College was keen to explore how it could utilise information from the Cochrane Collaboration as part of its new peer education program, which appears to be a collection of knowledge based resources that they intend making available for purposes of continuing medical education in various electronic formats. The College agreed to try to assist in increasing the academic recognition and credibility for the work of producing systematic reviews. Practical suggestions, such as including systematic reviews within their own journal under the heading of the "original research" were also agreed to. It was felt that there were a number of key opinion leaders, particularly in the leading US medical schools, who need to have greater awareness of the Collaboration if it is to really "take off". In addition, there was a feeling that the current coverage of topics by the CDSR was relatively limited, and not structured in a way which made retrieving information user friendly from the perspective of the clinician. There was interest in exploring the use of new knowledge retrieval systems, such as "Aries Knowledge Finder", which may help partly overcome this problem. Ovid was suggested as another alternative with exploring.

2.2 UNITED KINGDOM

2.2.1 Current Science, London

I visited this publishing organisation together with Mark Starr and Iain Chalmers. Its managing director, Mr Vitek Tracz, has been interested and enthusiastic about becoming involved in publishing the Cochrane Library on the internet. His publishing company is moving into internet and electronic-based publishing in a big way, and offered us the option of a number of additional electronic services (such as electronic discussion groups and conferencing). We explained that at this stage the Collaboration was not interested in pursuing these options, because it was managing with its current electronic communications approach. However, we were keen to keep the door open for further discussions in the future. An interesting idea raised by Mr Tracz, concerned the possibility of establishing a paper based publication focusing on methodological issues in relation to systematic reviews. He felt that there was no such journal available, and was keen to see one created using the Cochrane Collaboration as its primary source of scientific information, as well as one of its principle target audiences. We agreed to discuss this idea further with Andy Oxman, in his capacity as coordinator of Methods Groups within the Collaboration. Mr Tracz also expressed interest in publishing aspects of Cochrane reviews (e.g. summaries and/or abstracts) in his various specialist update journals, which are focused on specific clinical topics.

2.2.2 British Medical Journal, London

Iain Chalmers and I met with Richard Smith, primarily to establish contact and to provide an opportunity for me to thank Richard for the support that the BMJ has given to the Cochrane Collaboration during its formative stages. Richard expressed a keen interest in continuing to support the Collaboration in its endeavours. We discussed a number of specific items in relation to copyright, duplicate publishing policy, and citation of Cochrane reviews. Iain Chalmers presented a seminar to senior staff at BMJ about the Cochrane Collaboration which I attended and contributed to. This was well received and there was considerable discussion about the role of the Cochrane Collaboration in stimulating debate about new and innovative methods of publishing research information in a synthesised manner.

2.2.3 Lancet, London

Iain Chalmers and I met with Richard Horton and senior editorial staff. A number of similar issues were raised as during the BMJ visit. However, most of the discussion focused on the Collaboration's strategic plan. Richard Horton voiced the opinion very strongly that one of the major attractive features about the Cochrane Collaboration was its non commercially driven idealism, and there was a danger that this may be compromised as the Collaboration develops and endeavours to become more organised and sustainable as an international effort. He cautioned against modelling our organisation on commercial enterprises, and was critical of much of the language in our strategic plan, which he felt reflected business orientated ideology. Despite these comments, the Lancet was extremely supportive of the Collaboration's work and was committed to supporting us in a variety of ways. For example, The Lancet has pioneered the duplicate publication of Cochrane Reviews in electronic and paper based formats. In addition, they have been active (together with BMJ) in promoting the moratorium on unpublished trials.

2.2.4 Professor Sir Michael Peckham, London

Iain and I paid a courtesy visit to Sir Michael Peckham, principally to thank him for his strong support of the Collaboration during the time he was Director of the NHS Research and Development initiative. We also had an opportunity to discuss some of the strategic directions the Collaboration was taking, and to seek his input and views. He expressed the view that we needed to strengthen our strategic links at a senior level with the European Commission if we wanted to attract significant funds from that source. A number of practical suggestions were made, which Iain agreed to follow up. Overall, he was extremely positive about the direction that the Collaboration had taken, and was willing to support us in whatever way he could.

2.2.5 Pharmaceutical Partners for Better Health, London

I met with Nancy Mattison, who was visiting London from Sweden (the head office for this organisation). The meeting was held at the British Pharmaceutical Industry headquarters, and Dr Richard Tiner, one of their senior medical advisers, was also present, as were Iain Chalmers and Christina Funnell (an active member of the Cochrane Consumer Network who had been instrumental in arranging the meeting). I had an opportunity to thank the British Pharmaceutical Industry for their support and willingness to explore ways in which the industry could work with the Collaboration in the UK and the UK Cochrane Centre in particular. I also mentioned how we viewed their efforts in this regard as providing a leadership role for their counterpart organisations in other parts of the world to follow.

Pharmaceutical Partners for Better Health is an organisation that is funded by the major pharmaceutical companies in the world (on an agreed basis in relation to their profits). Its function is to promote and establish partnerships between the pharmaceutical industry and the wider health care industry that are designed to facilitate discussion and debate about improving health care generally. They have funded specific initiatives in Europe and the US, focused on workshops to promote consumer involvement in health care, explore managed care, and different models of care coordination etc. They viewed the work of the Cochrane Collaboration with great interest, and could see its obvious potential links to the work of the pharmaceutical industry. We agreed that it would be beneficial if a small group from the Cochrane Collaboration could meet with senior board members from the organisations (who are generally medical directors or their nominees from the major pharmaceutical firms). Such a meeting would provide an opportunity to discuss how a partnership may be developed between the Collaboration and the industry, and could form the basis for undertaking a number of activities in the future, such as promoting and supporting consumer involvement, as well as encouraging the industry to explore developing policies and/or agreements with the Collaboration about providing unpublished data and supporting the compilation of specialised registers of trials in CRGs. As a first step to setting up such a meeting, it was agreed that the Collaboration would nominate one or two individuals to speak at the next board meeting of the organisation to explain the role of the Cochrane Collaboration and to seek their interest in having a more formalised meeting/workshop in 1998. Because of my inability to return to the UK within the next few months, it was agreed that Iain Chalmers and Jos Kleijnen would be asked to represent the Collaboration at such a meeting. I felt this meeting was one of the most productive meetings that I held during my trip, and had provided a real opportunity for exploring collaboration with the pharmaceutical industry.

2.2.6 Medical Research Council, London

I met with Dr Peter Dukes at the Medical Research Council headquarters. Professor Martin Bobrow (who is Chair of the UK Cochrane Centre Steering Committee and a former member of the MRC) accompanied me during the visit. This was extremely valuable given his knowledge and experience in dealing with the organisation. Our discussions were broad ranging, and included thanking the MRC for their current support of the Cochrane Collaboration and exploring ways in which it could be strengthened further in the future. The MRC already provides funds to a number of people who are active within the Cochrane Collaboration through their regular grant schemes. For example, there are several people in receipt of training fellowships, project grants, and longer term program grants. The MRC does not see its role in providing infrastructure funds for the Collaboration, or for funding specific review groups. However, they see their major role as providing support for reviews on specific topics (particularly those which are necessary in order to inform the need for future research). In addition, they are keen to support methodological research (particularly in relation to the science of systematic reviews and their application). Finally , they see a smaller, but important contribution in acting as a "role model", to influence similar funding agencies in Europe to consider providing funds to support the Cochrane Collaboration in other countries.

2.2.7 The Wellcome Trust, London

I met with Dr David Gordon, who is the program director of the Trust, again in the presence of Martin Bobrow (who is a member of the Board of Trustees). The Wellcome Trust was also keen to support the work of the Cochrane Collaboration, but explained that the type of work undertaken within the Collaboration is somewhat different to their major biomedical focus, and occasionally meets opposition amongst some of the trustees. Despite this, the Wellcome Trust is providing support to several individuals within the Cochrane Collaboration, particularly through training fellowships (where the systematic reviews are made part of the trainee's program of work). One area where David Gordon felt there was considerable scope to support the Collaboration's work was in developing countries, where the numbers of applications for funding were less than what the trust was able to fund. He specifically suggested that we prepare an outline of several potential projects which could be submitted to the Board of Trustees for consideration. He suggested that these be focussed on developing countries, and incorporate systematic reviews as part of broader research projects. He felt that it may be possible to include some limited infrastructure support funds within the developing countries. He also encouraged the applications to have a strong training component, ideally through linkage with experienced groups in more developed countries. I agreed to coordinate this process, and to come back to him within the next couple of months with an outline of several possible proposals.

2.2.8 House of Lords

Iain Chalmers and I paid courtesy visits to Baroness Julia Cumberledge (the then Minister of State for Health) and Baroness Margaret Jay (the then Shadow Minister of State for Health) in the House of Lords. Both of these women were strong supporters of the Cochrane Collaboration, and recognised its potential importance to improving health care decision making. Irrespective of the outcome of the next British election, I felt it was likely that the Collaboration would continue to receive strong support in the UK. Baroness Cumberledge agreed to make contact with her European counterparts, particularly Mrs Els Borst-Eilers in the Netherlands, to see if it would be possible to encourage Ministers in other countries in Europe to provide full support to Cochrane initiatives in their countries. Baroness Jay, on the other hand, had particular interest in supporting consumer involvement within the Collaboration and was interested to learn of the progress that has been made in that area.

2.3 NETHERLANDS

Jos Kleijnen and I met with Mrs Els Borst-Eilers, who is the current Minister for Health in the Netherlands, and chair of the European Council of Health Ministers. She is an extremely strong supporter of the Cochrane Collaboration, having come from a strong academic public health background. I had an opportunity to thank her for the support she is currently giving to the Dutch Cochrane Centre. She generously agreed to secure that Centre's funding for the long term, and explore how it may be possible to increase this to a level that matched the relative investment being made in other countries (such as Asia and the UK). She was also supportive of our desire to see other European governments increase their support for the Collaboration, and undertook to raise this issue in writing with her counterparts in the European community. I felt this was also one of the most highly productive meetings of the trip, and reassured me about the long term security of tenure for the Dutch Cochrane Centre. I feel it will be important to make public recognition of this support during the 1997 Colloquium in Amsterdam.

2.4 DENMARK

2.4.1 World Health Organisation (European Office)

Peter G�tzsche and I met with Dr Zsuzsanna Jakab, from the European Office of the World Health Organisation. This was the first formal contact that the Collaboration has had with the World Health Organisation in Europe. We spent considerable time discussing the infrastructure of WHO, and explaining how the Cochrane Collaboration works. It appears that there are a number of mutual areas of interest between our respective organisations, and that we ought to be able to work our way through the bureaucracy to identify how we can work more effectively, and potentially obtain financial support. Dr Jakab felt it was important that senior WHO staff within the office were better informed about the Cochrane Collaboration, and invited Peter G�tzsche to return and present a seminar. Following this it would become clearer as to how our respective organisations could collaborate more effectively. Once again, I felt this was a useful meeting, as it laid the ground work for future discussions, and hopefully, collaborative initiatives.

2.5 THAILAND

The final stop on my trip was Bangkok, where I gave a lecture to senior faculty of Mahidol University, and ran a one day seminar on protocol development for approximately twenty people at the Ministry for Public Health. This was a particularly rewarding experience, since many of the attendees had previously participated in protocol development workshops run by Clive Adams and Lelia Duley about six months previously. Many came prepared with plans to undertake protocols and were keen to join collaborative Cochrane review groups.

3. PERCEPTIONS

The principal reason for undertaking this trip was to explore potential funding opportunities to support the international activities of the Cochrane Collaboration. By half way through the trip it had become obvious to me that there were not any easy answers, or sources of funding which were sitting and waiting to be tapped by us. Rather, the process of attracting funding to support our activities was likely to be a much more lengthy process that needs to build on a solid base of networking combined with creating opportunities than can be readily capitalised upon. It also became clear that none of the national government agencies I spoke to were ever likely to be willing to provide funds towards the international infrastructure required to support the Collaboration. The internationally based organisations (such as the World Bank and WHO), did not have appropriate pots of money from which to provide such funding at the present time. As a result, the only realistic source of funding for the international activities of the Collaboration (at least in the short to medium term) will be the revenue generated by sales of the Cochrane Library.

In contrast, I believe there are plenty of opportunities to obtain funding and support for national efforts of the Cochrane Collaboration and for the activities of specific entities. The challenge is to match the funding need to an appropriate source. For example, it is likely that the MRC in the UK would be able to provide funding support for some of the methodological development that the Collaboration wishes to undertake through its Methods Groups. However, any applications from such groups will need to be non Cochrane in focus, even though the relevance and subsequent applicability to the Collaboration's work may be significant. Organisations such as the Wellcome Trust are likely to be able to provide support towards the activities of review groups and centres, particularly when there is a focus on developing countries.

I also believe that we have not capitalised on the opportunities to secure support from the European Commission. Our challenge here is to weave our way into the highly complex and bureaucratic workings of this organisation in order to be strategic in our methods for seeking funding. For example, if we are able to influence the priority setting process for allocation of funds in the next round of health related grants it will place us in a better position to be successful with any subsequent applications we may wish to make. I was heartened to see the level of support by the Dutch Minister for Health, and her willingness to approach her other colleagues in Europe.

The possibility of attracting industry funding is certainly present, particularly through the pharmaceutical industry. However, we will need to be careful that we approach this particular source with a degree of caution so as not to compromise our underlying ethical principles or values in such a way that may introduce bias to the work we do.

My main area of disappointment lay in the relative lack of likely support for the Collaboration's activities in the United States. Although I am sure this does not reflect the performance or perceived ability of those who are currently involved with the Collaboration in that country, I believe there is a prevailing ethos about the privatisation of health care that makes it difficult for an organisation like the Cochrane Collaboration (which is primarily focussed on doing something in the public good rather than for profit) to flourish. Furthermore, whether we like it or not, there seem to be a number of initiatives in the US which are going down the same track as us (e.g. the evidence based centers within the AHCPR). I think there is little likelihood in the short term that they will be prepared to collaborate with the Cochrane Collaboration. Having said that, I sensed a real desire in some of the organisations I visited in the US to co-operate actively (e.g. the American College of Physicians). However, they expressed concern about the lack of a national identity for the Cochrane Collaboration and a degree of uncertainty as to which Cochrane Center they ought to relate to. I know the issue of creating a more unified identity for the Cochrane Collaboration within the US has been raised on previous occasions, and I simply want to support the moves towards establishing a single US Cochrane Network (or whatever it is finally called).

Everywhere I visited I was met with open arms. Nowhere did I hear anybody speak negatively about the Cochrane Collaboration, although I noted Richard Horton's timely warning that the Collaboration needs to balance its underlying idealism with the need to become a sustainable international organisation in such a way that the idealism of the initiative is not lost.

I returned to Australia with several overriding feelings:

1. The Cochrane Collaboration has achieved a significant international presence in a relatively short space of time. However, it still has a long way to go in raising awareness of its existence in certain countries to a level that is likely to create significant new opportunities for funding and support.

2. In developing the Collaboration during the next few years it will be important for all of us to walk a fine tight rope between being business like in what we do and yet remaining idealistic about our mission. If we fall too much to one side we run the risk of not being a sustainable organisation in the long term.

3. The process of networking and awareness raising depends heavily on individual contacts, which in turn demands a substantial investment of time and energy. This is currently beyond what could be reasonably expected from any individual within the Cochrane Collaboration. Although I think we need actively to seek people at a national and international level who are willing to be ambassadors for our organisation, I think there is a need for Cochrane Centres to take greater responsibility and role in this networking activity. The only two limitations I can see are (i) in several cases the limited funding available precludes the staff in these Centres spending a significant proportion of their time engaged in such activities, and (ii) the activity of networking needs to be coordinated strategically.

4. For the time being, I feel that the Collaboration's funding for international activities will have to rely on the revenue it raises from sales of the Cochrane Library, and efforts should be made by everyone in the Collaboration (in the short term at least) actively to increase the volume of sales, through targeting libraries and institutions in their country in the first instance. Specific plans need to be developed for this process by each Cochrane Centre in conjunction with Update Software. Unless Centres (and other entities) are willing to support this initiative actively, I am not convinced we will maximise the potential sales. Public funding sources available at government level should be strategically targeted by Cochrane Centres and other entities. We should also actively pursue the development of policies and strategies which enable us to liaise effectively with industry to secure funding from that source. All these activities need to be coordinated in a strategic business plan which we need urgently. The responsibility for taking that initiative forward ought to lie with the Company Secretary in the first instance; however, he will require support and assistance from a dedicated Business Manager (or equivalent) in the very near future.

5. The process of securing funding at both national and international levels is likely to be an ongoing and demanding process for at least the next five to ten years. We need a specific plan which shares the workload for this beyond the Chair and other members of the Steering Group. For example, we still need to target a number of international organisations that were not visited during this trip (eg. INCLEN, Charitable Foundations etc). In simple terms, a greater number of people than at present need to be prepared to invest time and effort in the sort of networking activities that I have undertaken during the trip. What we need to do to support these efforts and maximise the return for the investment of time, is coordinate strategically our networking efforts. This ought to be a priority for all Centre Directors (who are generally better placed than members of the Steering Group) to undertake such a process. I would urge this matter be discussed at the October Meetings of the Steering Group, Centre Directors, and the Annual General Meeting. I would suggest we may need to include a requirement for Cochrane Centres to make a meaningful contribution to the international fundraising effort as part of their shared responsibilities (and therefore, performance criteria). If we can collectively share such tasks, I am confident that the return in the longer term will be worth the investment now.

Prepared 23 June, 1997