Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative

Prioritization of research options in health is essential to plan for achieving efficient and impactful investment of limited resources against a large number of competing research options1. There is an increasing need and effort to set research priorities in health in a systematic way using a sound and transparent methodology and through engagement of the various key stakeholder constituencies23. Research priority setting (RPS) in India has traditionally been guided by a small group of experts, mostly identified from major metropolitan areas of the country. Subsequent to India's impressive yet inadequate improvement towards achieving Millennium Development Goals (MDGs) 1, 4 and 5, an expert group had convened on May 23, 2011 at the Indian Council of Medical Research (ICMR) Headquarters in New Delhi to discuss RPS. The participants observed that evidentiary gaps in the country impeded informed action in Maternal, Newborn, and Child Health and Nutrition (MNCHN) themes, and that an inclusive and transparent method should be adopted to decide the national research agenda. The agenda so developed should also identify areas for innovation and strategies to improve deliverability, efficiency, scalability and sustainability of existing interventions, avoid common blind spots in MNCHN research (e.g., still birth & neonatal health) and engage the multiple stakeholder constituencies including end users of any funded health research activity. This led to the formalization of the ICMR-INCLEN collaboration for undertaking the national RPS exercise for MNCHN using the Child Health and Nutrition Research Initiative (CHNRI) methodology. Since 2006-2007, the CHNRI priority setting methodology has been increasingly acknowledged as a flexible yet systematic priority-setting method for ranking competing research options using an objective, quantified and inclusive approach234567. The method is opined to be effective at the national level where the results derived from inputs from national stakeholders can have a direct and prominent impact on the research investment policy8. As a major conceptual advancement, this method ranks the broadly defined competing research options that not only generate new knowledge but also synthesize evidence for efficient implementation of what is already known9. The ranking of these research options employs ‘crowdsourcing’ through the engagement of a wide range of stakeholder constituencies with due cognizance of their core expertise. The various dimensions of the research priorities are carefully examined by the experts using a predefined context and set of strictly defined scoring criteria. The collective optimism of the stakeholders, which can be considered as the ‘wisdom of the crowd’, helps in identifying research priorities through a democratic method of scoring, weighting and ranking of competing research options15.

National Research Priority Setting (Rps) Exercise for Maternal, Newborn, and Child Health and Nutrition (Mnchn)

The protocol was reviewed and approved by the Independent Institutional Ethics Committee of INCLEN, and the exercise was undertaken between 2012 and 2016. The context, in which the research priorities were identified in this exercise, are provided in Box 1.

Box 1 Context of the Indian Council of Medical Research-International Clinical Epidemiology Network (ICMR-INCLEN) National Research Priority Setting Exercise for maternal, newborn, child health and nutrition

The exercise was woven around four key structures, namely, the National Steering Group (NSG), the Thematic Research Subcommittees (RSCs) constituted for each of the four MNCHN themes (112 experts in India were identified based on active contribution to contemporary research), the Nation-wide Network for Crowdsourcing (experts of various disciplines related to MNCHN with due attention to regional representation from 256 institutions) and the Larger Reference Group (LRG) (84 members group) constituted with Central and State policy decision makers, politicians and bureaucrats from key ministries, MNCHN programme managers, eminent researchers and representatives from research funding organizations. The list of participants in the Nationwide Network is provided in

The NSG for the exercise, co-chaired by the Secretary, Department of Health Research (DHR) and Director General (DG)-ICMR and the Executive Director of The INCLEN Trust International, was formed with key officials from concerned Ministries, namely, Ministry of Health & Family Welfare (MoHFW) (National Health Mission, Child Health, Maternal Health and Nutrition Divisions, Directorate General of Health Services and DHR-ICMR), Ministry of Women and Child Development [Integrated Child Development Services (ICDS), Food and Nutrition Board] and Ministry of Science and Technology (Department of Biotechnology, Department of Science & Technology). There was a wide range of invited subject experts, Central and State programme managers, national and international donors and multilateral agencies, who were members. Two NSG meetings were organized, one at the initiation of the exercise to ratify the context and protocol (April 18, 2013) and second, at the conclusion for reviewing and endorsing the findings (February 4, 2016).

The Thematic RSCs contributed to research ideas in the first round of crowdsourcing, helped in refining and consolidating the ideas into research options, finalizing the scoring criteria, participated in second round of crowdsourcing for scoring the research options and presented the results to the NSG for ratification.

The Nationwide Network of experts participated in the first and second round of crowdsourcing for pooling of research ideas and scoring the research options, respectively.

The LRG assigned relative weights to the five scoring criteria, namely answerability, relevance, equity, innovation and out-of-the-box thinking and investment on research.

The exercise was centrally coordinated by the RPS Management Team at the Executive Office of The INCLEN Trust International, New Delhi.

The RPS Management Team established a national network of 1066 experts from institutions across India during 2012-2013. During the same period, it completed an extensive review of literature (research, academic and policy documents) on burden of diseases of MNCHN in India and presented the summary to the NSG at its first meeting. The NSG decided that topmost causes collectively accounting for at least 75 per cent of mortality and morbidity burden (Areas of Concern) for each of the RPS themes so identified shall guide pooling of research ideas and subsequent framing of research options for priority setting. Between September and December 2013, 3498 research ideas were pooled from the nationwide network using custom-designed online software (1^st round of crowdsourcing). The participation rate was 42.3 per cent [of the 1178 experts contacted (1066-national members and 112-RSC members), 498 experts contributed research ideas]. Several of these research ideas were narrations comprising more than one research idea spanning across themes, areas of concern and domains. With the help of RSC members (January 2014-February 2015), these were split and refined into 4003 research ideas that were further consolidated into 373 research options (Maternal: 122, Newborn: 56, Child: 101 and Nutrition: 94) (http://inclentrust.org/inclen/?page_id=8666). Five criteria (answerability, relevance, equity, innovation and out-of-the-box thinking and investment on research) were identified and defined for scoring the research options (March-June 2015) (Box 2). This was done through a comprehensive review of criteria that had been used in previous exercises at national and global levels and iterative discussion with RSC members and national and international CHNRI experts (University of Edinburgh, Johns Hopkins Bloomberg School of Public Health and the WHO).

Box 2 Criteria used for scoring the research options

Scoring of the research options was done independently by 893 experts (of the 1536 experts approached; Participation rate: 58.1%) using a customized online (SurveyMonkey.com) platform (July-October, 2015) (2^nd round of crowdsourcing). The scores obtained by the research options were adjusted with criteria weights as assigned by the LRG (November, 2015-January, 2016) as per standard CHNRI data analysis practices10. The Average Expert Agreement (AEA) was also calculated for each research option score. The detailed methodology and process adopted for this priority setting has been published elsewhere11. The research options were categorized into four domains; description, discovery, delivery and development.

In addition to national priorities, the States and Union Territories in the country were grouped into three subnational regions to obtain regional priorities [Empowered Action Group (EAG) and North-Eastern States, States in Western and Southern India and States in Northern India (including West Bengal)] (Fig. 1).

Close

Fig. 1

Geographical context of the ICMR-INCLEN National Research Priority Setting Exercise for Maternal, Newborn, and Child Health and Nutrition (2016-2025) (Map courtesy: www.mapsofindia.com modified with permission).

Export to PPT

The number of scorers ranged between 60 and 96 scorers across each region and theme. Therefore, four priority lists were obtained for each theme: one national and three regional priority lists. The NSG reviewed and discussed the ranked list of priorities and made focused observations on the patterns of research that had evolved as priorities and the possible interlinks between the priorities identified. It also discussed other potential priority research options that might not have made it to the topmost priority list. This helped enrich the structuring of the national research agenda and identify the way forward.

Outcome of the Research Priority Setting (Rps) Exercise in the Four Themes

About 43 per cent of all the research options scored pertained to the delivery domain and required implementation research methodology (Fig. 2). It was observed that in each of the four themes, a large proportion (70%) of the top ten prioritized issues were dealing with delivery domain of research and implementation of programmes. Amongst the top ten priorities identified at national level, delivery domain research options accounted for 80 per cent in maternal health, 70 per cent in newborn health, 60 per cent in child health and 70 per cent in nutrition themes. Significant differences were also observed between national and regional research priorities for all the four themes. The AEA was very high for the top ten priorities of research in the four themes both nationally and regionally. There were research options in the top ten regional priorities under various themes that did not figure in the national priority list. The Table enlists the top ten priorities identified under each theme by the exercise at the national level. Top ten priorities and their scores along with the national and region-specific ranks are provided in

Close

Fig. 2

Distribution of the research options in maternal, newborn, and child health and nutrition themes across the four domains of research.

Export to PPT

Table Top ten priority research options in maternal, newborn, and child health and nutrition themes at national level

Discussion

The NSG strongly endorsed the research priorities identified by the exercise as appropriate for investment by different science and research departments of the Government of India and other national and international donor agencies and academic institutions over the next decade. It felt that the research agenda established with this exercise was in alignment with the national programme for achieving the recently enunciated health-related Sustainable Development Goals (SDGs) and will facilitate in accomplishing the unfinished agenda of the MDGs.

The exercise engaged experts who were well dispersed across the country. Thus, for the first time, regional MNCHN research priorities could be identified. In all the four thematic areas, there were differences between the top ten national and regional priorities. This observation made it imperative to take cognizance of the unique research needs of the regions. Although not part of the current project, the NSG suggested that a systematic effort must be made to determine factors that could explain differences in national and subnational (regional) priorities. The States falling under the three regions vary in terms of their health infrastructure, programme implementation and governance, development indicators and availability of baseline information on various health indicators. This may to some extent, explain the differences in the emerging research priorities. Better understanding of these factors will be important to design need-based research programmes and policies for different parts of the country. There are significant rural and urban differences for the health challenges and these have assumed greater significance in the light of rapid urbanization in certain parts of the country. The rural-urban divide will also have to be kept in mind when decisions on research investments are made.

In addition to the top priorities identified by the exercise, the NSG highlighted some more areas of research in MNCHN themes that deserve investment. These included role of environmental exposures in the occurrence of neurodevelopmental disorders such as autism; early childhood care and stimulation for improving cognitive outcomes; better description of childhood cancers and their risk factors; unsafe abortions; innovations to solve the ‘nutrition enigma’; factors interfering with iron absorption in both women and children; impact of fluoride on health and nutrition of women and children; micronutrient deficiencies and occurrence of congenital birth defects (e.g., neural tube defects with folic acid deficiency); research into processes and strategies to make multisectoral governance for human nutrition workable and effective and technology innovation for developing better tools of nutrition assessment.

As part of Infant and Young Child Feeding and Complementary Feeding research agenda, NSG has also suggested that it is important to innovate strategies to promote breastfeeding; innovation is also needed in the development of low cost nutritious and healthy processed foods that require minimal cooking, are prepared from indigenous raw material and are appropriately fortified. This is important in the context of giving relief to severely time-constrained mothers who have now entered the workforce in a considerable way. Legislations affecting women and child health and nutrition are an important aspect to consider when research programmes and investment decisions are made. NSG suggested that researchers and funding agencies should work with Food Safety and Standards Authority of India in MoHFW to better understand regulatory issues related to food processing and related nutritional impacts.

Adolescents constitute almost 25 per cent of the Indian population. They suffer from several health problems that have been hitherto neglected. The foundation of several chronic diseases in the form of exposure to risk factors is laid during the adolescent years. NSG advised that adolescent-related research options were culled from the four themes and put forward separately with a caveat that scorers did not have an opportunity to see all the options in this section together. These have been put together in

The NSG acknowledged implementation research as an important area for consideration. This necessitates bridging the ‘disconnect’ between the research community, the policy and programme makers, implementers and the communities to achieve the desirable impact. Implementation research involves behavioural changes of health providers, and this cannot be overlooked. Some of the prioritized implementation research options can also help the national and State administrators to either commission research studies or decide to reset the way, in which the health system is working. This will also provide an opportunity for re-engineering health systems and programmes to improve their efficiencies: by dropping redundant programmes and/or making way for newer, refined and ‘need of the hour’ programmes. As a cross-cutting research priority, the NSG strongly pitched the imperatives of improving the quality of administrative data for better use in decision-making at ground level.

The NSG members observed that several of the priority research issues were cross-cutting and common across the four themes; these should be brought together as common research agenda for MNCHN. This will make the research investment efficient and effective by addressing more than one theme at a time and also align the research projects with the national goal to achieve universal healthcare in India. As a follow up on this suggestion, the investigator team has prepared a separate list of cross-cutting research options [

The NSG strongly advised that the DHR and other science ministries along with MoHFW should make efforts to pool resources for addressing priority research issues and also encourage national and international agencies to come together to invest strategically for greater and faster impact. The NSG has suggested that a number of research issues have the ability to be ‘game changers’ for the health systems, and for the health and nutrition of mothers and children, in general. These can be systematically identified and taken up in a mission mode by science ministries and donor agencies as per their own prioritization and investment policies. Recognizing the challenges of programme delivery in the context of weak infrastructure, national policymakers and programme planners have already identified north-eastern States and EAG States for the focus of several developmental schemes including health and nutrition (http://nhm.gov.in/nhm/nrhm.html). To further accelerate the developmental process, region-specific research agenda should become natural corollary. Health is a State subject in India and implementation of research issues can be integrated with the programme monitoring and evaluation frameworks existing therein. The research agenda could be accomplished in an accelerated manner and effectively with multistakeholder and multi-agency engagement through a broader convergent innovation coalition that will add to existing sectoral and cross-sectoral capacity for science, social sciences, economics, technology, innovation, strategy and policy to achieve better health and nutrition for mothers and their children in India.

Conclusion

It was concluded that the logical way forward for this exercise would be to take up these research priorities with different governmental and non-governmental agencies for investment. Various government and non-governmental funding agencies were requested to now re-align their investment with these priorities to achieve better health and nutrition for women and children of India effectively and efficiently. Further, bridging the gap between researchers and programme implementers at the grass root level would be essential along with decentralization of strategies to have State and possibly, district centric solutions for the betterment of health and nutrition scenario in India. In view of the predominance of delivery and implementation research identified as priority in all thematic areas, it was suggested to explore the possibility of supporting such research projects from the programme funds.