Setting Priorities

The contribution of health research to early detection, treatment and prevention of disease has been remarkable. Today's health research is tomorrow's health service. The importance of research is often underestimated, because the results cannot be implemented immediately. However, without research we would not achieve eradication of smallpox, elimination of poliomyelitis, control of measles, rubella, tetanus, diphtheria or haemophilus influenza. Even when highly effective interventions exist, research is still needed to identify effective and efficient delivery mechanisms. Today, millions of children are dying from diseases like diarrhea and pneumonia, although highly cost effective interventions exist to prevent most of these deaths. Clearly, available interventions are not reaching the children who need them most. One of the main reasons for this failure is lack of knowledge about effective and efficient context-specific delivery mechanisms for available interventions.

Currently, there is a large discrepancy between resource flows for health research and the diseases and conditions that account for the greatest share of disease burden in children. The 1990 Commission on Health Research for Development showed that less than 10% of global health research funding was spent on diseases and conditions accounting for 90% of the world's disease burden. Moreover, most major funding agencies favor basic research. Implementation research is still not on their priority list. This is why CHNRI believes that it is very important to develop a framework that could evaluate not only proposed research to generate new knowledge, but also delivery research hat should result in better use of the existing knowledge and thus influence the priorities for health research funding.

Until now, no systematic methodology was available to identify priorities in health research. Several attempts have been made towards a more systematic approach to priority setting, but none of them could successfully compare long-term strategic research with the other areas of health research, including delivery research or equity in resource allocation or prioritizing the needs of the largest population groups. Furthermore, research questions were never compiled in a truly systematic way, using scientifically convincing conceptual framework and objectives. In most cases, the priorities were set through consensus reached by different panels of experts.

With limited funding resources for health research, which is especially the case in low and middle income countries, and with many diseases and factors contributing to mortality and morbidity in children under five years of age, it is important to develop a systematic methodology that could prioritize the investments into health research to achieve equitable reduction of the global disease burden.

A NEW MODEL OF PRIORITY SETTING FOR GLOBAL HEALTH RESEARCH INVESTMENTS
In 2001, CHNRI initiated its own priority-setting initiative by requesting proposals on the Regional Assessment of Research Priorities and Research Institutions and in 2002 contracted with three institutions in Latin America, Asia, and Africa to conduct the assessments in their respective regions. These initiatives have made recognized contributions to promoting priority setting in child health and nutrition research.

In 2004 the CHNRI Board approved a proposal to further expand priority setting to focus on key conditions affecting childhood morbidity and mortality. Adopting the strengths of the previous approaches to priority setting in health research, CHNRI has developed a new model for priority setting.

The advantage of the new methodology is that it doesn't consider generating new knowledge as the sole endpoint of research, but it rather addresses several components of a research option, such as likelihood that the results of research would lead to effective and deliverable intervention. It also incorporates the views of both technical experts and stakeholders (donors and recipients in health research). Involving the stakeholders in priority setting process is very important, as research priorities defined by the scientists are often different from those defined by the donors or the recipients of the conducted health research.

This new methodology has been devised with the assistance of substantial number of experts in theory of priority setting, as well as technical experts who worked on the problems of priority setting in health research.

The proposed methodology involves the following key steps:
  • Technical experts are first invited to make a systematic list of research questions within their area of expertise. The experts are then expected to systematically score listed options independently of each other for each of the following criteria-
    • Likelihood that research option would be answerable and generate new knowledge in an ethical way
    • Likelihood that resulting new or improved intervention would be effective in reducing disease burden
    • Deliverability, affordability and sustainability of resulting intervention
    • Maximum potential of intervention to reduce disease burden
    • Impact on equity in a population
  • This combined value according to the criteria above is then considered together with the estimated cost of the research to derive an optimal mix within a given budget in terms of projected maximum disease burden reduction for a given research investment
  • A larger reference group, consisting of a spectrum of representatives of the stakeholders, is expected to place weights and thresholds on each of the five criteria to incorporate an element reflecting public opinion and demand and to allow stakeholders to also influence the outcome
  • Finally, a weighted mean score for each research option, a "research priority score," is derived to indicate where the major priorities lie in health research
This methodology thus acknowledges different categories of health research and assesses their potential to reduce disease burden in an equitable way, while limiting research interest bias of the individuals involved in the process.

TESTING OF THE METHODOLOGY
The development of the methodology is now in a testing phase. In this phase, seven child health and nutrition conditions and risks have been selected for implementation (pneumonia, diarrhea, malaria, birth asphyxia, child development, zinc and falls injuries), and a country-level application has also been undertaken in South Africa. The first results will be presented at Global Forum 10 in Cairo, Egypt in October 2006. The Child and Adolescent Health Department of the World Health Organization has also adopted the methodology to address 10 main causes of child deaths globally and set research priorities to address UN's Millennium Development Goal 4, which is to reduce child mortality by two thirds by the year 2015. The preliminary results of this work are expected to be available by December 2006.

FUTURE DIRECTION
The product of this initiative will be a methodology that enables systematic, fair and transparent listing and scoring of competing research options. With the use of this methodology, researchers, donors and others will be able to make informed decisions about investments into child health and nutrition research. Although this new methodology is being developed and tested in the context of child health and nutrition research, it is anticipated that the methodology will be able to be applied to other areas of research. CHNRI hopes the application of this new methodology will make a major contribution to evidence-based priority setting, ensuring that more health research is conducted on the most important and often neglected areas of diseases globally.