Approach and Process
The health research priority setting process took place over a period of two weeks, i.e. 8th to 19th December 2014. It was facilitated by the Research Department of the Ministry of Health and WHO Regional Office for Africa. The first week was spent in priority setting workshops with stakeholders. A total of nine workshops were held with the following groups of research stakeholders:
- a) The Principal Secretary, Ministry of Health;
- b) Scientific and Ethics Committee (SEC);
- c) Research Technical Working Group (HRTWG);
- d) Public Health Programmes, Ministry of Health;
- e) Civil Society Organizations (CANGO, SWABCHA, RED Cross);
- f) UN Agencies: WHO, UNFPA, UNICEF, UNAIDS;
- g) Ministry of Health Implementing Partners, e.g. MSF, NERCHA, ICAP;
- h) Faculty of Health Sciences, University of Swaziland; and
- i) All stakeholders combined.
In each of the workshops, the purpose of the priority setting process was explained; justification for developing a national health research agenda was provided; and the process of setting health research priority agenda was explained to the participants. The process entailed identification of research stakeholders; assessment of the situation (national health research system, analysis of health indicators and national health system); identification of major health themes to facilitate delineation of the scope of research agenda; identification of sub-themes under each major theme; identification of research gaps under each sub-theme (What is known? What research has not been used or applied? What is not known? What research is needed?); identification of main topics or research areas (assessment of burden/situation of sub-themes and determinants, research on health policy and systems, assessment of effectiveness and cost-effectiveness of interventions, improving existing interventions, and development of new capacities); agreement on guiding/underlying principles or values; criteria for ranking research for health gaps; and scoring of research sub-topics (gaps) by research stakeholders.
The identification of major health themes and sub-themes was arrived at through review of relevant health indicators and discussions with stakeholders. The major themes and sub-themes identified were as follows:
- Communicable diseases: HIV/AIDS, TB, NTDs, malaria, diarrhoeal diseases;
- Non-communicable diseases ( NCDs): Cardiovascular diseases, diabetes, cancer, hypertension, stroke, chronic obstructive pulmonary disease (COPD), mental health, and substance abuse.
- Allied Health: oral health, dentistry, eye care, physiotherapy, ENT, and occupational health.
- Injuries: intentional and accidental (road traffic accidents) injuries.
- Health system: leadership and governance, services (including quality of care), health workforce, medical products and technologies (pharmacovigilance, laboratory systems), information, and financing, and community health services.
- Reproductive and child health: Neonatal and child health, adolescent health, maternal health.
- Health determinants: water, sanitation, climate change, alcohol, tobacco, and nutrition.
- Emerging and re-emerging diseases: e.g. Ebola.
The guiding principles/values and criteria to underpin priority setting were also considered during the workshops held in the first week.
Criteria for Setting Priorities
- a) Promotive, preventive, curative or rehabilitative relevance at patient/community level
- b) Public health relevance – impact on population health
- c) MDG related or related to post-2015 goal of universal health coverage
- d) Pro-poor/poverty alleviating
- e) Health security relevance
- f) Intersectoral
- g) Equity (gender equity/social justice), human rights and ethics
- h) Positive benefit-cost ratio
- i) Feasibility
- j) Global public good
- k) Innovation
- a) Affordability: How likely is that the results will improve affordability of existing policies and programmes?
- b) Feasibility: How likely is that the cost of the research will be a feasible investment?
- c) Acceptability: How likely is proposed research to be approved taking in account cultural considerations?
- d) Answerability: How likely will the objective be met?
- e) Applicability: How likely is it that the results will immediately be applicable for guiding policies and programs?
- f) Potential effect on Burden of Disease: How likely is the proposed research to lead to significant reduction in burden of disease?
- g) Usefulness: Given the quality of existing evidence, how likely is it that the proposed research will fill a critical gap in knowledge?
- h) Research capacity: How likely is that the objectives will be met given existing research capacities?
- i) Equity: How likely is that the proposed research will benefit those who are most vulnerable?
- j) Sustainability: How likely is that the results will improve sustainability of existing policies and programmes?
- k) Alignment with other policies: How well are the objectives aligned with other existing policies in society?
- l) Competitiveness and publication impact: How likely that the results of research will be seen as competitive against other ongoing work and be accepted for publication in journals with the highest impact?
- m) Deliverability: How likely is that the results will improve the delivery of existing policies and programmes?
- n) Generation of commercial products: How likely is that the proposed research will lead to patents and generate commercial products?
Following identification of major themes and sub-themes, a questionnaire entitled "Questionnaire on national health research agenda for Swaziland" was developed to facilitate the process (Appendix 1). It was structured to obtain information on:
- a) respondent profile: age, gender, highest level of education, occupation, position occupied in workplace, organization worked for, and whether their work entails priority setting.
- b) rating of each of the principles or values that should underpin setting priorities of health research.
- c) rating each of the criterion in order of importance for setting health research priorities.
- d) ranking of the eight major themes in order of research importance, i.e. from number 1 to 8.
- e) scoring of the main research topics under each sub-theme on scale of 0 (lowest priority) to 100 % (highest priority) to be conducted over the next five years.
The participants were asked to score each sub-topic (gap) on a scale of 0% (lowest priority) to 100% (highest priority) guided by the underlying principles/values and criteria and personal expertise and experience.
The data was entered in Excel Spreadsheet and exported to STATA statistical software for analysis. A total of 66 individuals from relevant stakeholder groups, who had participated in the priority setting stakeholder workshops, completed the questionnaire. The analysis revealed a total of 195 research areas, i.e. 39 sub-themes multiplied by the 5 research areas. At a combined stakeholders workshop held during the second week, the 195 research areas were considered too many given the scarcity of research resources. They decided to select the top four ranking major themes in Table 1 below.
Table 1: Ranking of main themes according to median and mean scores
||Reproductive and child health
||Emerging and re-emerging diseases
The workshop considered that health determinants theme was cross-cutting and should be mainstreamed within the relevant major themes selected. It was also decided that although the emerging and re-emerging diseases and injuries were not among the selected major themes, the important research areas could still be included in the agenda.
Thereafter, the participants at the workshop were divided into four working groups according to the four major themes. Each of the working groups consisted of members of HRTWG who had already done literature review on the major themes identifying research gaps, i.e. addressing the what is known,what research has not been used or applied, what is not known and what research is needed. Therefore, the terms of reference for the group were to:
- a) Write a background to the major theme;
- b) Identify subthemes under each major theme;
- c) Make a statement of what research would be attempting to achieve under each sub-theme;
- d) Identify priority research topics under each subtheme according to the scoring in the five research areas:
- Assessment of burden and its determinants;
- Research on health policy and systems;
- Assessment of effectiveness and cost-effectiveness of interventions;
- Research on improving existing interventions; and
- Development of new capacities (tools, products) to reduce burden of disease.
The groups presented in plenary the research topics/gaps identified in the sub-themes according to the major themes selected. The priorities agreed upon in plenary discussions are presented in section 4.