PERSPECTIVES

Setting priorities for health research: lessons from low- and middle-income countries

Yvo Nuyens¹

University of Leuven, Leuven, Belgium

During the past two decades, researchers and policy-makers have become interested in priority setting for health research both at the country and international levels, and this has increased its visibility. The 1990 report by the Commission on Health Research for Development¹ clearly acted as a catalyst in creating this momentum. It recommended that each country should develop a strong national plan to conduct research on both country-specific and global health problems, and that each country should set its own national priorities for research. As a result, a number of low- and middle-income countries started to experiment with comprehensive and problem-focused approaches to setting priorities for health research involving various stakeholders from health and non-health sectors in a consensus-building process. The Council on Health Research for Development, which was established as a direct result of the commission’s report, facilitated, reviewed and documented many of these developments.²

In parallel, the WHO Ad Hoc Committee on Health Research Relating to Future Intervention Options published its report in 1996.³ This report was intended to complement the commission’s work which emphasized national-level research. This committee’s report focused on setting priorities for global health research, and recommended a five-step approach that could be used to inform decision-making about the priority allocation of research and development resources.

As a direct result of this report, the Global Forum for Health Research was established in 1998 to help correct the "10/90 gap" in health research – the fact that less than 10% of the funds spent on health research target the health problems of the developing world, which account for 90% of the global disease burden. One of the main strategies adopted by the Global Forum for Health Research was to promote more evidence-based priority setting; it developed the Combined Approach Matrix as a tool that can be used for this purpose. The matrix has been applied by the Global Forum for Health Research "to a range of settings, including global programmes and national plans, communicable and non-communicable diseases, risk factors and vulnerable groups".⁴

In January 2006, resolution EB117.R13 of WHO’s Executive Board highlighted the importance and relevance of priority setting, reflecting the growing consensus that setting priorities for health research is as critical as conducting the research itself.

This paper looks at major issues emerging from countries’ experiences in setting priorities during the past 15 years, and at the challenges still to be addressed.

A country-driven activity

The promotion and advocacy work of a number of international, regional and national organizations, as well as programmes and institutions, in support of national priority setting clearly has had an impact. During the past decade, an increasing number of developing countries have embarked on priority-setting initiatives to identify the most important problems in health, health systems and health policy for which research might provide solutions. This has provided national decision-makers with a solid foundation for negotiating with donor agencies to support national research. It also has created a wealth of information about and experiences with the methods, tools and processes through which countries can learn from one another.

Challenge: although the commission recommended that national priorities should determine global priorities for health research, the movement of national priorities to regional and global levels remains unfinished. Past efforts to identify global priorities for health research, for instance by the Ad Hoc Committee on Health Research Relating to Future Intervention Options,³ the Global Forum on Health Research and the WHO Task Force on Health Systems Research, have not taken full advantage of various national research agendas and priorities, thus reconfirming and extending the one-sidedness of global agenda setting. Therefore, an effort to change this national–global schism to a national–global interface is the first challenge facing the health research community.

Both a process and a tool

Activities by countries and activities at country level, as well as methodological and conceptual efforts, have shown that it is important to differentiate between the process of selecting priorities and the tools used in that process. The process is the mechanism by which constituencies are involved in and decide on research priorities, while the tools are the instruments that allow the information needed to set priorities to be collected, organized and analysed. There is now general agreement that both are necessary for effective priority setting: the process cannot function without proper tools, and the tools require a well-defined process.

Challenge: efforts to develop improved methods and conceptual frameworks for compiling information and presenting data must take into account the processes and mechanisms required to apply these tools in specific sociopolitical contexts. Likewise, countries’ efforts to plan and organize a priority-setting process should involve the development and/or adaptation of methods and tools for collecting, analysing and presenting information. More convergence and synergy are needed between the planning and organization of priority setting as a process and the development and implementation of supporting methods.

An evidence-based activity

Countries’ experiences in priority setting have gradually shifted away from an incremental approach, in which existing priorities and practices are extrapolated to the future without an explicit evidence base. The trend is towards a more rational approach in which the collection and use of information (on what is needed and what is possible through research) has become crucial. International organizations have made significant contributions to developing and refining methods for collecting and analysing information and thus facilitating the development of priority setting as an evidence-based activity.

Challenge: serious obstacles to evidence-based priority setting include a lack of quality data, particularly about health systems and health research systems, and weak national (and subnational) capacity to collect and analyse relevant information. These obstacles have raised questions about the reliability and credibility of outcomes. The development of the Health Metrics Network, which brings together the producers and users of health information, represents a promising effort to strengthen national health information systems. It has the potential to make a significant contribution to the use of evidence in priority setting.

A participatory and transparent process

The recognition that the mix of stakeholders participating in priority setting is a key determinant of the selection of research and development priorities has significantly influenced practices.⁵ Priority setting is no longer the exclusive domain of civil servants, corporations, bureaucrats or experts. Most countries now make conscientious efforts to involve all constituencies or stakeholders – researchers, decision-makers, health workers and community members – in some or all phases of the process.

Challenge: despite consensus about the need for, and relevance of, a participatory process, and despite countries’ related efforts to involve all stakeholders, the strategies and methods necessary to achieve a participatory process have not been developed or implemented systematically. There is no body of knowledge about how and when various stakeholders should be involved or what their functions and responsibilities should be. Individual countries and the scientific community need to address these issues, and to implement and document innovative practices in making priority setting a participatory and transparent process.

A contribution to the development of health research systems

Priority-setting activities have stimulated countries to critically review their health research to identify systematically its strengths, weaknesses, gaps and opportunities, and to address related issues. These include capacity development (including the capacity to set priorities), overall governance (including the development of a mechanism to steer the process), funding (including collecting information about resource flows), coordination (including the coordination between external donor agencies), and the monitoring and evaluation of research (including its impact). In tackling priority setting for health research, many countries discovered that adopting a systems approach can help structure health research in a more ethical, fair, accountable, transparent and sustainable way. This may pave the way for developing an effective national health research system, as recommended by the International Conference on Health Research for Development in 2000.⁶

Challenge: although priority setting helps to tackle broader issues in developing an effective national health research system, in most cases countries have not taken advantage of it. Priority setting has often been handled as an isolated, one-off event that has little impact on, or relation to, other essential components used to construct a health research system. International organizations and research programmes therefore should explicitly promote and support priority setting in health research as an integral component of developing a national health research system, and encourage countries to organize their priority setting accordingly.⁷

The process

Most countries have defined priority setting as an iterative process, organizing it in phases such as preparing and planning, collecting data, consulting and involving stakeholders, organizing national events, aligning resources, etc. The process has tended to be organized geographically, moving from the district, province and region to the national level. This bottom-up approach increases the chances that a more context-sensitive and culturally sensitive process of priority setting will occur, and also that the resulting priorities will be implemented at subnational levels.

Challenge: while most countries have recognized that priority setting needs to be an iterative process, few have made this process a cyclical, continual one. There are two common discontinuities. First, it is often not clear if or how the outcome of a national priority-setting event will be fed back to the subnational level, nor how this level will adapt national priorities to its specific priority needs. Also, there is scant evidence about the implementation of health research priorities and its impact on producers (do they effectively produce prioritized research?) and users (do they effectively use the prioritized research?). Both discontinuities occur in the implementation phase of the priority-setting process, which is poorly documented and inadequately analysed. The scientific community is therefore challenged to evaluate this process systematically and comprehensively.

A value-driven activity

Most countries – and most methodological approaches – recognize the need to rank health research using specific criteria. Identifying, selecting and ranking specific criteria give the process of priority setting a more objective and transparent character. Such ranking also emphasizes the fact that setting priorities means making choices, and those choices must refer to defined underlying values (for example, equity versus cost-effectiveness). Priority setting is thus a value-driven and political activity, not a neutral and scientific process.

Challenge: the goal of any activity to set priorities for health research is to define an investment portfolio of health research and development that will have the greatest possible impact on the health of the majority of the population, in particular those who are poorer. Although equity is included in most lists of possible criteria for priority setting, only in exceptional cases has this criterion been used effectively. Questions that deserve urgent attention and action include how to operationalize equity as a criterion for priority setting, what information to collect and how, as well as how to establish the political will to actually use the criterion of equity.

Conclusion

As priority setting in health research has received increasing interest from researchers and policy-makers, it is time to measure the past two decades’ progress and look at ways to better integrate various approaches, methods and strategies that have been used in this area. Exchanging experiences among strategic stakeholders at the global level and among low- and middle-income countries should be encouraged; this exchange could take place in the context of an annual meeting. Participants might include the Global Forum for Health Research, the Council on Health Research for Development and WHO’s special research programmes. At the same time, all stakeholders should address the need to develop an integrated method to support a synergetic agenda for action, with countries sitting firmly in the driver’s seat.

Competing interests: None declared.

References

1. Commission on Health Research for Development. Health research: essential link to equity in development. Oxford: Oxford University Press; 1990.

2. Council on Health Research for Development. Priority setting for health research: toward a management process for low- and middle-income countries. Geneva: COHRED; 2006 (Working Paper No. 1).

3. Investing in health research and development: report of the Ad Hoc Committee on Health Research Relating to Future Intervention Options. Geneva: WHO; 1996.

4. Ghaffar A, de Francisco A, Matlin S, eds. The combined approach matrix : a priority setting tool for health research. Geneva: Global Forum for Health Research; 2004.

5. Working Group on Priority Setting. Priority setting for health research: lessons from developing countries. Health Policy and Planning, 2000;15:130-6.

6. Report of the International Conference on Health Research for Development, Bangkok, 10-13 October 2000. Geneva: International Organizing Committee; 2001.

7. World report on knowledge for better health: strengthening health systems. Geneva: WHO; 2004.

(Submitted: 7 April 2006 – Final revised version received: 6 October 2006 – Accepted: 21 November 2006)

1 Correspondence to Yvo Nuyens (e-mail: yvo.nuyens@free.fr).