Priority Setting for Health Research

The Essential National Health Research principle of involving the community, scientists and policy makers/administrators in the process of priority setting has been tried in both developing and industrialised countries, to broaden ownership. Bringing together these disparate groups has several challenges. These include: how to involve members of the community – who may not have the ‘right’ expertise in the eyes of the health research and policy community - in a way that creates a meaningful exchange with research and political players; how to best involve the private sector or donors – and ensure a contribution or realignment of their agendas to national priorities; how to best link the technical and political sides of the debate; how to bring together multiple sectors, such as health, science and technology, agriculture and ensure a holistic approach to health and health research. Common features of most of tools and methods to measure magnitude of health issues are estimations of health problems, identification of gaps in the knowledge about ways to eliminate them and of research needed to control them. The focus is on past and current health problems. Common criteria for the choice of priorities include the possibility to address the problem through research, the feasibility and cost of the research and the potential outcome, impact and cost effectiveness of interventions resulting from the research. Criteria for priority setting should respond to the different challenges involved in the process. They should help balance competing pressures faced by a national health research system, such as: basic vs. applied research; public vs. private research; health needs vs. political interests; national vs. international funding; public vs. private funding. These criteria should also respond to health needs reflected at different levels in the country. The application of Foresight methodologies looking at future problems for which research is needed will bring a useful new perspective to the more traditional priority setting methods. An information and feedback strategy should be an integral part of any priority setting process and national research agenda. Continuous dissemination of research results and feedback to key players and beneficiaries of the process is crucial to get and retain the support from partners.

In communicating the research agenda to community members, special care should be taken to explain how their concerns have been addressed in the national research agenda. In some situations, community priorities only have local relevance and may not appear in a national research agenda. In this case, a specific recommendation can be made to address these priorities at the local level, through local institutions. Documenting these decisions and reporting them back to the community members are key actions to retain their interest and commitment during revisions of the agenda. A practical approach to progress is to build on comprehensive nationwide data and analysis, although gathering this depth of information may not be possible in the initial stages - start small and build from there – is a good option in many cases. Initial priority setting could focus on a region or a community, or on specific diseases or institutions. A ‘multiple entry point’ approach should also be considered – that looks at priority setting at the disease and institutional levels. A higher level of coordination is needed when several institutions are involved, or when these institutions are of different types – such as public sector, councils, NGO or private sector.

Priority setting should be seen as an ongoing, iterative process in which the quality of data that is used to set priorities improves over time, and in which an increasing number of institutions and partners are involved. Furthermore, national priority setting must build on inputs and outputs at several levels (district, national and regional levels, institutional levels, etc). allowing more space for curiosity and investigation facilitates the involvement of the research community in the research agenda setting process. It ensures links between the science and technology (aimed at promoting innovation and discovery) and health sectors (aimed at implementing more cost-effective interventions). It allows the development of research, within the national health researchsystem, in areas that may not be seen as a priority at the moment of priority setting. And it gives access to international scientific developments.

A country’s initial environmental scan should include an assessment of existing human resources. The priority setting process needs to assess whether the organisations’ and partners’ current skills are adequate to address the issues defined. Gaps in skills and expertise identified by the scan, then, become a priority area to address. The Foresight methodology further supports this by building the assessment of future skills into the national plan, and by specifying a training plan.

Implementation, monitoring and evaluation

Monitoring and evaluation are vital elements in priority setting, and should become standard practice, just as it is standard practice in health programs. This implies that budget allocation is needed to ensure monitoring, evaluation and follow-up of the research agenda. This is the basis for building a continuous and iterative research priority setting process. It should actively engage an increasing number of players to help improve management of the process over time.
Addressing crises and political imperatives will require specific short-term objectives. Medium and longer term goals and useful milestones should also be defined as part of the plan.

Taking a process perspective puts the emphasis on delivering a plan for implementation, with financial and human resources mapped out (or gaps identified) and including components for performance evaluation, capacity building and quality improvement. Special attention should be given to changes in government and administration to ensure that the set priorities are respected. Other elements on the time axis such as monitoring and evaluation and dissemination of information to key stakeholders, are activities that will keep the priority setting process alive.
Experience shows that if the priority-setting process has a space for negotiation and ‘appeal’, it is much more likely to become a truly national agenda, one in which a much larger proportion of stakeholders can find themselves.

Advocacy is important at national and international level and should be extended beyond the health sector and also be directed to proponents of other sectors, which harbour important health determinants particularly water, sanitation, agriculture.

Decentralised structure of the health system. The Philippines has a decentralised health and health care system, where local governments take budgetary decisions. This bottom-up experience made people feel empowered and involved in the decision making process. Some argued that the bottom-up approach could be best complemented with top down initiatives so that both approaches would capture what the top wants and what the bottom needs (Note:
70% of funding for health research comes from central government). Research agenda setting is best done after the administration has set its plans and programmes and new initiatives have been identified. Reviews conducted to date have allowed the integration of new priorities (such as disaster management in response to natural disasters taking place), and the consideration of global developments and their relevance to the national health research situation. However, in general, the reviews do not show major changes in the priority issues on the agenda.

The quality of participation of stakeholders, expertise and commitment of stakeholder were also an issue, as not all participants considered the process relevant. In addition, the private sector was not represented in the process and there is no mechanism in place to facilitate links between the public and private sectors.

This consultation is a first step in a continuous learning process around priority setting for national health research. Stakeholders and partners can use web-based interactions and face-to-face meetings to engage many more research managers and development partners to build on new experiences and recommendations from countries to improve priority setting. People and organizations interested in priority setting for research will be encouraged to contribute to this ‘learning spiral’ and to share their expertise.

•Basic Principles in priority setting:
- Legitimacy and fairness
- Trans-disciplinary approach
- Involving the stakeholders in the process
- Promoting health and development on the basis of equity and health maximisation for the greatest number of people with fixed level of investment
- Realistic assessment of affordability, deliverability and sustainability of the proposed research
- Realistic assessment of likelihood of research success in terms of both reaching the end point, and the endpoint being effective in reducing disease burden
- Respecting the principles of economy in terms of research and cost effectiveness of intervention delivery.

The competing research options by the type of disease burden have impact to inform the priority issues ranking process. The approach is based on a 3 steps process: 1) review of literature and subsequent brainstorming sessions with the reference group; 2) categorisation of competing options according to the type of disease burden that they affect; 3) assessment of prevalence of risk exposure in a population of interest.

Risk assessment takes into consideration the estimation of relative risks, the burden of disease of interest, the cost of research and delivery per unit of population and the level of existing funding that is already invested in each research avenue.

Priority ranking is affected by stakeholders’ view of the world. Managers consider priorities in terms of issues, policy-makers in term of interest groups, public in terms of problems, researchers in terms of disciplines or methodologies and clinicians in terms of diseases. Two approaches are suggested forranking priority issues. 1) The “technical assessment approach” allows ranking of priority issues across potential clinical trial investments. This approach tends to hide under a series of assumptions many value judgments that may reflect those of the broader population of users and payers. On the other hand it requires the adoption of single clear objective to guide the exercise. 2) The “interpretive assessment approach” is best applied in agency wide assessments. It relies on the subjective judgments of participants expressed through structured exercises. This approach offers the possibility of dealing with multiple assumptions and objectives at the same time. Involving diverse stakeholders should contribute to increase transparency and accountability and allow to better respond to societal needs. Target stakeholders could be: business and civil society involved in the central advisory council on science andtechnology, mutli-stakeholders involved in bodies that coordinate or fund research, scientific experts, policy, business and community representatives.

Criteria for priority setting should respond to the different challenges involved in the process: balancing competing pressures (basic versus oriented research, core funding versus project funding, competition from increasing industry funding), institutional funding (rigidity of the research system, autonomy of research institutions, financing of high risk pre-competitive research),responding to emerging technologies and societal needs, promoting multidisciplinary research. The following criteria should be considered when setting priorities in health care organisations: strategic fit, alignment with external directives, academic commitments, clinical impact, community need, partnerships, interdependency, and resource implications. Fairness is a key ethical goal of priority setting when health care resources are scarce.

•Quality improvement and capacity strengthening should be developed for fair priority setting. Process monitoring and formal evaluation strategies should be developed to ensure quality improvement and organisational learning. Process should be supported by leadership development and change management strategies to strengthen institutional capacity for priority decision making.

This toolkit proposes the use of futures approach in the priority setting process. The approach helps building new networks, it creates a shared vision of how to move forward where a number of organisations have a stake in an issue, it highlights challenges and opportunities, tests robustness of policies and allows the optimal use of resources.

•Methods that can be applied for the identification of priority issues: Horizon scanning, Delphi, Trend analysis, Driver analysis, Scenarios, Visioning, Technology roadmaps, System maps, Back-casting, Modeling, Simulation, Gaming, Data review, In-depth interview, Focus-group discussions, Consultative meetings, Round tables, Surveys, Field visits, Workshops, Seven questions, Issues trees, System maps, Reviewof areas of science.

•Criteria for deciding on public spending should be based on economic efficiency, ethical reasons and political considerations.
•The economic efficiency dimension takes into consideration: cost-effectiveness (relation between the cost of an intervention and the resulting health gain), public goods, externalities, and catastrophic cost.
•Ethical reasons concern: poverty, horizontal equity (giving equal treatment to people with equal health problems, implying equal effectiveness), vertical equity (preferential treatment for people with worse problems), and the rule of rescue (grouping patients into: those whose lives can be saved by intervening, those who will die even if given treatment, those in between because their lives are not immediately threatened).
•Political considerations relate to public demand (what the public thinks its money should be used for).

Sources:
•http://www.healthresearchfordevelopment.org
•http://www.zonmw.nl
•http://www. saude.gov.br/sctie/decit
•http://www.dst.gov.za/
•www.nih.gov/about/researchpriorities.htm
•www.foresight.gov.uk/HORIZON_SCANNING_C
ENTRE/Toolkit/Toolkit.html

TO COMMUNICATE RESEARCH FINDINGS

Healthlink Worldwide

Are you struggling with finding the best way to communicate research
findings? Are you wondering what communication materials your institution should be producing? Are you trying to persuade colleagues about the importance of communication? Are you trying to get your research programme better known?

If so, and if you're going to be at the Global Forum for Health Research this year in Cairo, you're in luck. Practical advice on how to better organize your research information and communicate your research more effectively is at hand. A team of skilled research communicators from eight institutions - Council on Health Research for Development (COHRED), CRESAR, Cameroon, Development Bank of Southern Africa, Ghana Ministry Of Health Policy Unit, Healthlink Worldwide, Institute of Development Studies (IDS), Makerere University Institute of Public Health, and Research Matters - have joined together to provide a special advisory service on research communication throughout the Forum.

Look for the Advisory Service stall in the Marketplace throughout the Forum. We are at your service, ready to answer your questions and help solve your problems on any aspect of communicating health research.

The purpose of the service is to share our experience with others. Weencourage developing country partners to bring their problems, questions or even documents to the team for advice and input from the team.

* Bring a research paper (or several) and we can help you look
At how to transform it into information that is useful for policy makers, community members or other users.

* Bring us your ideas and we'll give you an honest answer and advice, and we can help you discuss how to develop a communication
strategy or approach.

* Bring a proposal and we can discuss how to make it more
interesting to the intended audience.

* Ask us why is effective information management a critical
Part of good quality research communication? And how can it improve the
relevance of a research institute?

* Ask us for practical advice on how to manage your research
outputs, including advice on open access journals, online databases and
more...

* Ask us how to design a campaign to make your research
Programme better known.

* Bring us your frustrations of what is not working for your
organisation in research communication; we can explore this together.

* Ask us what research communication and knowledge translation
Is all about and why you should be interested in it.

Healthlink Worldwide
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