To face this challenge, countries will need to invest in four critical areas:

- _i. Development of human resources in planning and manaaement._ The strengthening of planning and management acthities at all levels will require to set new priorities for health personnel training. The relationships between universities, technical schools and the health institutions will need to be reinforced (Sober6n, et al. 1988) in a few key areas where collaboration is critical: evaluation of services, cost-effectiveness analysis of alternative interventions, and updating of the curricula and medical personnel knowledge.

- _if. Better quality of health information svstems._ Large amounts of health information are available in middle-income countries, but unfortunately, only a fraction of it is used in decision making (Cordeiro, et al. 1990). Even i all the available information was processed and presented adequately for decision making, critical pieces of information, such as data on expenditure by program, unit costs and resources and activities carried out by the private sector, would usually be missing. Finally, the information on births and mortality, collected through vital statistics, is essential for health planning, but the coverage and quality of the data, still is deficient In most Latin American countries (Chackiel, 1987).

- _ii. Development and strengthening of Essential National Health Research (ENHR)._ ENHR has been proposed (Commission on Health Research for Development, 1990) as one of the most effective means to overcome the heavy burden of disease in developing countries and to reduce the health status inequalities within and between them. This idea, which emerged from several national and intemational workshops and conferences, refers to the capacity to undertake research on health problems primarily relevant for the developing countries and to contribute to advance knowledge on global health issues. It embodies substantial political commitment, adequate financial support, and demand for research. It is a system where the main actors are both research oriented universities, schools of public health and research centers and providers of health services. Brazil, Colombia and Mexico have made substantial investments In higher education and research in the health field. However, their strength is in biomedical research, and less so in clinical and public health research (Bobadilla, et al. 1989; Cordeiro, et al. 1990). The epidemiological transition and the challenges posed to the health system will require a substantial growth in the qua,tity, relevance and quality of epidemiological and health systems research.

- _iv. Capacity building in health technoloov assessment._ New technologies in clinical medicine are typically additive, Inducing more diagnostic: and therapeutic procedures and not substituting the existing ones (Possas, 1981). As a consequence of this characteristic and the high growth rate of technological Innovation, the incorporation of technologies in the health sector has profound effects on the health care costs, with as much as 50 percent of the marginal increments of health care costs being due to new technologies (Panerai et al., 1989). The introduction of new technologies and drugs should be preceded by a thorough assessment of their likely effect on different parts of the health system (cost and effectiveness among other aspects) and on the health of the population (ethical and cultural issues). The sophistication of many modem technologies and the complex analysis required to anticipate likely effects suggest that a critical mass of professionals is required, with advance skills in epidemiology, engineering, health economics, behavioral sciences and health management. A broad range of modem technologies Is already available in these middle-income countries, but limited Information and research on the consequences of their Incorporation into the health system was used to approve their purchase and diffusion (Marques, 1989).

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