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Model rural health research units in India: A research priority setting exercise
For correspondence: Dr Sanghamitra Pati, Director, ICMR-Regional Medical Research Centre, Bhubaneswar 751 023, Odisha, and Additional Director General, Indian Council of Medical Research (ICMR), New Delhi 110 029, India e-mail: drsanghamitra12@gmail.com
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Received: ,
Accepted: ,
Abstract
Background & Objectives
Research in rural health has historically been opportunistic, lacking alignment with strategic goals or community needs. The Government of India established Model Rural Health Research Units (MRHRUs) to address these disparities through targeted research. However, inconsistent outputs highlight the need for a strategic research agenda. Identifying research priorities is critical to inform policy and funding strategies of MRHRUs.
Methods
A nationwide Research Priority Setting (RPS) exercise was conducted, involving 120 respondents for free listing of questions, and 250 for ranking. Respondents from various stakeholder groups, including policymakers, researchers, and community representatives, participated. Research priorities were categorised into three domains – Description, Development, and Delivery. An iterative process was employed to refine and consolidate the 122 research questions into 36, which were subsequently ranked using a scoring system that assessed their importance, feasibility, and impact. The list of priorities was finalised through stakeholder deliberation.
Results
The top five research priorities across the three domains addressing key rural health challenges as identified in this study are presented. ‘Descriptive’ priorities included investigating social determinants of hypertension, medicine supply chain bottlenecks, and mental health in the elderly. ‘Development’ priorities focused on interventions using electronic health records in hospitals, tuberculosis control, and menstrual hygiene education. ‘Delivery’ priorities emphasised improving healthcare resilience, emergency care, and technology-driven diabetes management. These priorities were disseminated to MRHRU managers and policymakers to guide decisions with regard to perceived priorities for research in rural health.
Interpretation & conclusions
This first-of-its-kind RPS exercise provides inputs towards a strategic roadmap for rural health research, ensuring that future studies align with the needs of rural populations, leading to improved health outcomes. These findings illustrate perceptions and priorities of a selection of respondents from different stakeholder groups and need to be taken into consideration by the Department of Health Research and at the local level by each of the MRHRUs.
Keywords
Health policy
implementation research
India
model rural health research unit (MRHRU)
research priority setting
rural health research
stakeholder engagement
India has a population of over 1.4 billion people, with around 65 per cent residing in rural areas1. Despite significant improvements in health indicators over recent years, rural populations in India continue to be at a relative disadvantage, particularly regarding healthcare infrastructure and access2,3. Public health and clinical research are critical in addressing these challenges. However, research in rural health in India has historically been driven by investigator interests and available resources rather than strategic imperatives4. This has created a gap between the healthcare needs of rural communities and the research aimed at addressing these issues.
Recognising this, in 2013, the Ministry of Health and Family Welfare, Government of India, launched the initiative to establish Model Rural Health Research Units (MRHRUs)5. These units aim to develop research infrastructure that improves health outcomes in rural areas. To date, 34 MRHRUs have been established across 22 States in India. Each such unit is supported by a one-time fund of over ₹30 million (∼US$ 360,000) for infrastructure construction and equipment, followed by an annual recurring grant of over ₹9 million (∼US$ 108,000) for manpower and research activities6. In addition to this, the units are expected to generate external funding in addition to the core funds, from research grants. These MRHRUs managed by institutes linked to the Indian Council of Medical Research (ICMR), are intended to carry out research relevant to improving the healthcare of citizens from rural areas of India. Despite this investment, the research output has been inconsistent across units, with no clear alignment to the specific needs of rural populations.
To bridge this gap, there is a need for a structured and strategic approach to prioritising research in MRHRUs, ensuring it is aligned with the needs of rural communities and policymakers. This shift from opportunistic to strategic research planning is crucial for making meaningful contributions to public health, ensuring that research outputs are aligned with policy priorities and have a tangible impact on health outcomes. Research priority setting (RPS) exercises are recognised as practical tools for identifying key areas for research funding and improving the relevance and impact of research7-9. Additionally, RPS exercises can help ensure that research is conducted in a coordinated and collaborative manner, involving stakeholders from various sectors and disciplines. This can facilitate the development of partnerships between researchers, policymakers, and practitioners, and can help ensure that research findings are effectively translated into policy and practice10-12. In this study, we conducted an RPS exercise to identify key public health and clinical research questions that are pertinent to rural populations in India, which could be addressed within a 5-yr timeframe.
Materials & Methods
This study was undertaken by the Model Rural Health Research Unit, Sheragada, under the ICMR-Regional Medical Research Centre (ICMR-RMRC), Bhubaneswar, Odisha, India. The study was approved by the Institutional Human Ethics Committee of ICMR- RMRC, Bhubaneswar. The research was carried out following ICMR’s National Ethical Guidelines for Health Research in India13.
This study follows the REPRISE reporting guidelines, and a compliance checklist has been included as a supplementary file14.
Context and scope of Research Priority Setting (RPS)
The RPS exercise was conducted specifically for rural regions of India. While the RPS had no defined health area or disease as its focus, broad research questions were elicited, considering the rural populations of India as intended beneficiaries. The target audience for the RPS is researchers, policymakers, and funders, particularly the managers of the MRHRUs and programme officers from the Department of Health Research, Ministry of Health, Government of India. The timeframe for the exercise was aligned with the 5-yr funding cycle of the MRHRUs. The scope of the exercise focused on ‘Descriptive,’ ‘Development,’ and ‘Delivery’ types of research, while excluding ‘Discovery’ or basic science research, as this was outside the mandate of the MRHRU scheme6. Box 1 shows the categories recommended by the steering group into which the responses were grouped.
Governance and team
A steering group was set up comprising experienced members from policymakers, funders, rural health researchers, methods experts, clinicians, and community representatives. The group provided overall technical guidance, defined the scope of the research priorities, and supported dissemination for participation in the RPS exercise among key stakeholders. The group had experts who had conducted national priority settings for other conditions as well as method experts on RPS. The members were selected carefully by the study team in consultation with some key experienced independent methodologists. The nodal officer of the lead MRHRU played the role of the convenor and performed other secretarial duties for the committee. The governance leadership in the steering group was provided by the Additional Director General of ICMR. A smaller working group consisting of methods experts and MRHRU nodal officers was responsible for executing the study steps.
Framework for priority settings
We used the principles for priority setting provided by World Health Organization (WHO) in the 3-D framework that uses some form of data, dialogue and decisions to guide the RPS exercise15. This aimed to ensure inclusiveness and adaptability, considering the availability of resources. The process was iterative, with no pre-defined research types, allowing flexibility in identifying and categorising research priorities. The systematic steps followed in this RPS process have been outlined in figure 1.
- Study design for research priority setting for rural health in India.
Participants
To ensure a comprehensive and representative RPS exercise, we included a diverse group of participants. They were identified through professional bodies, institutional mailing lists, social media, and community groups. Snowball sampling was employed to expand the participant pool, and all participants were required to meet specific inclusion criteria, provide informed consent, and confirm their identity. Participation was voluntary, with no financial incentives provided. The inclusion criteria for respondents were as follows: (a) clinicians and healthcare providers, (b) community representatives, (c) researchers and academicians, (d) non-governmental organizations, and (e) funders and policymakers.
Identification and collection of research priorities
Two tools were developed for this study. The first was an open-ended tool, uniform across all respondent categories, allowing free listing of research priorities. The second was a structured ranking tool used in the subsequent phase to prioritise identified research questions based on importance, feasibility, and potential impact. The tool used for elicitation has been attached as a supplementary file.
A nationwide survey was conducted using the open-ended tool. Respondents were invited to list research priorities freely, and the responses were systematically analysed for feasibility, scope, clarity, and duplication. The research priorities were grouped under three main domains: ‘Descriptive’ research, ‘Development’ of interventions, and ‘Delivery’ of healthcare systems, as guided by a pre-determined framework by the steering group16.
Prioritisation of research questions
The responses received from the nationwide survey were cleaned and analysed to identify and categorise the most frequently mentioned priorities. A follow up ranking exercise was conducted among respondents, who were asked to rank research questions based on their importance, feasibility, and potential impact on improving rural health. The respondents were presented with a closed-ended tool with a scale for each question ranging between 1 and 10, with instructions for ranking, where 10 was the highest possible score and 1 the lowest. The top five research questions based on the average scores were identified as key priorities for future research.
Statistical analysis
Study data were collected and managed using the REDCap electronic data capture tool hosted at ICMR17. Descriptive statistical analysis was employed to represent the data, focusing on the highest median scores to identify the top five health research priorities. Respondent profiles for the free-listing and ranking priorities were illustrated using bar plots, organised by gender, age group, and occupation. All descriptive analyses were conducted using Microsoft Excel, while the Sankey diagram illustrating stakeholder group priorities was generated using RStudio (version 2022.12.0)18,19. The statistical significance threshold was not applicable as no inferential analysis was performed. The analysis was conducted under assumptions consistent with descriptive statistics, and all data handling adhered to standard quality control procedures.
Results
Forms with complete responses were included for analysis. The initial phase of free listing for research priorities resulted in 128 detailed and complete responses. For the subsequent ranking exercise, we received complete responses from 250 individuals across 20 States in India. The characteristics and distribution of respondents for both steps have been shown in figure 2.
- Respondent profile for (A) freelisting and (B) ranking of priorities.
From the initial free listing, 122 distinct research questions/topics were identified. These were systematically reviewed, and duplicates or overlapping questions were merged, leading to a refined list of 36 research questions. This condensed list was then used in the ranking exercise, the results of which have been provided in the supplementary file.
The research questions were ordered to develop a final list of the top five research priorities for each of the three key domains: Description, Development, and Delivery. This output was deliberated and agreed upon by the steering group (Box 2).
Priorities among each respondent group
The subgroup analysis identified key research areas shared among different stakeholder groups. Clinicians and researchers emphasised the need for community-based tuberculosis control. While Clinicians, health workers and community members identified addressing bottlenecks in non-communicable disease (NCD) medicine supply chains and understanding the social determinants of hypertension and other NCDs as priorities, researchers and community members found exploring forest foods and their nutritional value in tribal communities as a shared priority. These shared priorities highlight the importance of interdisciplinary collaboration to improve healthcare access and outcomes. The group-specific priorities are illustrated in figure 3.
- Sankey Diagram showing the priorities ranked in each of the groups of respondents.
Implementation
The findings of this RPS exercise were used to build a policy brief (Supplementary File). This was shared with national-level funders and programme managers of the relevant schemes that promote rural health research in India at the Department of Health Research. The results will also be disseminated to the Local Research Advisory Committees responsible for funding decisions at each of the 34 MRHRUs, to help ensure the research aligns with the identified priorities and contributes to evidence-based rural health policy and practice.
Discussion
The RPS exercise successfully identified critical questions across three domains: Description, Development, and Delivery, reflecting the unique challenges and opportunities in rural health in India. While there is an inherent overlap between the Development and Delivery categories within health systems and policy research, they are distinguished by their primary focus. The Development category focuses on evaluating interventions and generating new evidence, whereas the Delivery category emphasises implementation science and scaling of proven interventions.
In the Description domain, respondents prioritised understanding the social determinants of NCDs, particularly hypertension, and addressing barriers in the supply chain of essential medicines for NCDs. Additionally, research on the nutritional value of forest foods used by tribal communities and addressing mental health issues among the geriatric NCD population were also identified as key areas for further investigation. These findings underscore the importance of understanding the complex social, environmental, and economic factors affecting rural health outcomes, especially in underserved and marginalised populations20-24.
In the Development domain, priorities centred on evaluating the effectiveness of key interventions, such as the impact of electronic health records (EHR) on hospital safety and care quality, and the potential for community-based tuberculosis interventions to reduce disease burden. Additionally, research on fall prevention among elderly adults, geriatrics, and gerontology, as well as the application of technology-based interventions in diabetes management, was identified as key areas. While many of these interventions have shown promise in improving healthcare delivery, their effectiveness in rural settings, where resources are limited, warrants further investigation25,26. Furthermore, many of these interventions are crucial to attain the national elimination goals27.
The Delivery domain-related reflections emphasised the application of technology-based interventions for diabetes care, building resilient health systems in rural areas, and improving the emergency response to snake bites, drowning, and road accidents. Training primary healthcare providers in life-saving skills, such as cardio-pulmonary resuscitation (CPR), and promoting physical activity through community-driven initiatives were also prioritised, reflecting the urgent need for scalable, and sustainable interventions that can be integrated into rural health systems28-33.
To ensure that the identified research priorities were structured as actionable research questions, we followed an iterative process incorporating diverse stakeholder inputs. While the initial phase involved free listing of priority areas by community representatives, health workers, researchers, policymakers, and funders, these responses were subsequently refined by an expert panel. This panel, comprising health systems researchers and policy advisors, ensured that the priorities were framed as research questions addressing existing knowledge gaps, rather than remaining just as problem descriptions. This approach aligns with established frameworks in RPS, such as the James Lind Alliance and Child Health and Nutrition Research Initiative (CHNRI) methodology, which emphasise stakeholder-driven question formulation to enhance policy relevance and implementation feasibility7-12. By integrating multi-stakeholder perspectives with expert validation, the study ensured that the final research priorities translated into structured research questions that could guide future research efforts effectively. The identified research priorities, such as improving medicine supply chains and community-based management of tuberculosis or diabetes, directly inform clinical practice in rural settings by addressing gaps that frontline providers encounter daily. These findings provide a practical roadmap for translating research into real-world improvements in healthcare delivery and patient outcomes.
Way forward
A comprehensive evaluation framework has been developed to track the impact of this RPS exercise. This plan involves phases aimed at assessing the impact of the identified research priorities and refining the process based on stakeholder feedback. Key performance indicators will assess the relevance of the identified research priorities by monitoring the number of research projects initiated in MRHRUs based on these priorities, as well as their influence on policy and health outcomes. A feedback mechanism will be established to gather insights from participants and stakeholders involved in the RPS exercise. To assess the long-term impact of the RPS exercise, a follow up evaluation will be conducted after a predefined period of three years during the annual conclave of MRHRUs. This will focus on the integration of research findings into policy and practice at the local and national levels, and the overall health outcomes in rural populations as a result of the research initiatives supported by the RPS exercise.
The RPS exercise has some limitations that need to be noted. It is difficult to ensure that the participants involved in the priority-setting process represented the diverse rural populations and multidisciplinary stakeholder groups in India, often with competing interests. Significant health system-related, cultural and linguistic differences remained a barrier to the generalisation of the findings. Also snowball sampling technique did not ensure a representative selection of stakeholder groups. As with most such exercises, the prioritisation process itself can be influenced by biases, such as personal preferences, political pressures, or funding constraints. Lastly, the evolving nature of rural health challenges meant that some priorities might shift over time, necessitating ongoing adjustments to the research agenda.
Overall, this research priority-setting exercise provided valuable insights into the perceptions and priorities of key stakeholders, including community representatives, healthcare providers, researchers, and policymakers. By integrating diverse perspectives, the study ensured that identified research questions reflected real-world challenges in rural health. While this exercise served as an important input for guiding future research, it should be considered alongside other evidence and policymaking frameworks. The findings illustrated stakeholder-driven priorities with the potential to help align research efforts with pressing health system needs, ultimately contributing to more effective and contextually relevant rural health interventions.
Acknowledgment
Authors acknowledge the time and effort put in by all the respondents and stakeholders towards providing the information sought. Authors are deeply grateful to the steering group members listed below for their constant support and guidance: Dr(s) Ragini Kulkarni, S. K. Sharma, Yogesh Kalkonde, Sanjay Juvekar, Jaideep C. Menon and Mr. Jagdeep Rath.
Financial support & sponsorship
The study received funding from the DHR-MRHRU Sheragada (Grant no. MRHRU/SH/ LRAC02/05).
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
References
- Profile. Available from: https://www.india.gov.in/india-glance/profile, accessed on July 4, 2024.
- The National Rural Health Mission in India: Its impact on maternal, neonatal, and infant mortality. Semin Fetal Neonatal Med. 2015;20:315-20.
- [Google Scholar]
- Health systems challenges and opportunities in tackling non-communicable diseases in rural areas of India. Natl Med J India. 2021;34:29-35.
- [Google Scholar]
- There is an urgent need for a global rural health research agenda. Pan Afr Med J. 2022;43:147.
- [Google Scholar]
- Annual report of Indian Council for Medical Research 2013-14. Available from: https://main.icmr.nic.in/sites/default/files/annual_repoorts/ICMR_AR_2013_14.pdf, accessed on December 15, 2024.
- Guidelines for implementation of model rural health research unit (MRHRU) scheme. Available from: https://schemes.dhr.gov.in/mrhru, accessed on September 24, 2024.
- Priority setting of health interventions: The need for multi-criteria decision analysis. Cost Eff Resour Alloc. 2006;4:14.
- [Google Scholar]
- Criteria used for priority-setting for public health resource allocation in low- and middle-income countries: A systematic review. Int J Technol Assess Health Care. 2019;35:474-83.
- [Google Scholar]
- Research priority setting for health policy and health systems strengthening in Nigeria: The policymakers and stakeholders perspective and involvement. Pan Afr Med J. 2013;16:10.
- [Google Scholar]
- Priority setting in health care: Learning from international experience. Health Policy. 1997;42:49-66.
- [Google Scholar]
- Setting priorities for health research: Lessons from low- and middle-income countries. Bull World Health Organ. 2007;85:319-21.
- [Google Scholar]
- Setting health research priorities using the CHNRI method: III Involving stakeholders. J Glob Health. 2016;6:010303.
- [Google Scholar]
- ICMR National Ethical Guidelines. Available from: https://ethics.ncdirindia.org/ICMR_Ethical_Guidelines.aspx, accessed on May 6, 2024.
- Reporting guideline for priority setting of health research (REPRISE) BMC Med Res Methodol. 2019;19:243.
- [Google Scholar]
- Strategizing national health in the 21st century: a handbook. Available from: https://iris.who.int/handle/10665/250221, accessed on October 26, 2024.
- Setting health research priorities using the CHNRI method: IV Key conceptual advances. J Glob Health. 2016;6:010501.
- [Google Scholar]
- The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208.
- [Google Scholar]
- Redmond, WA: Microsoft corporation; 2018. Available from: https://office.microsoft.com/excel, accessed on December 15, 2024.
- RStudio: Integrated Development for R. RStudio, PBC; Available from: http://www.rstudio.com/, accessed on December 15, 2024.
- Marmot M, Wilkinson R, eds. Social determinants of health. Oxford University Press; 2005.
- Supply chain management and health services research: Aligning strange bedfellows. Health Serv Res. 2022;57:223-6.
- [Google Scholar]
- The roles and values of wild foods in agricultural systems. Philos Trans R Soc Lond B Biol Sci. 2010;365:2913-26.
- [Google Scholar]
- Cardiovascular diseases in India: current epidemiology and future directions. Circulation. 2016;133:1605-20.
- [Google Scholar]
- Electronic Health records: Manual for developing countries. Available from: https://iris.who.int/bitstream/handle/10665/207504/9290612177_eng.pdf, accessed on December 15, 2024.
- Falls and their prevention in elderly people: What does the evidence show? Med Clin North Am. 2006;90:807-24.
- [Google Scholar]
- Implementation research on diabetes in India: A systematic review. Clin Epidemiol Glob Health. 2023;24
- [Google Scholar]
- Public health and natural disasters: Disaster preparedness and response in health systems. J Public Health. 2006;14:317-24.
- [Google Scholar]
- Interventions for the management of snakebite envenoming: An overview of systematic reviews. PLoS Negl Trop Dis. 2020;14:e0008727.
- [Google Scholar]
- Physical activity promotion in rural health care settings: A rapid realist review. Prev Med Rep. 2022;29:101905.
- [Google Scholar]
- Community initiatives to promote basic life support implementation – A scoping review. J Clin Med. 2021;10:5719.
- [Google Scholar]
