The findings are based on the document review and analysis of the 33 key informant interviews including: four respondents from development assistance partners (DAPs), five from health-related ministries, seven from academic institutions, five from private research organizations, four from regulatory institutions, and eight district health officers.
The results section is organized according to the five domains of the framework: (1) contextual factors, (2) prerequisites, (3) processes, (4) implementation of priorities, and (5) outcomes and impacts.
Contextual factors for HRPS
This domain reflects on the degree to which the political, social, and cultural contexts are conducive for HRPS. Politically, the reviewed documents and the interviews alluded to the idea that the Ugandan government recognizes the importance of health research for evidence-based policy and decision-making. For example, the 1997 Local Government Act stipulated that while the DHOs set and implement priorities which should be aligned with national priorities; at the national level, health-related ministries manage and implement research. Furthermore, the health policies also mandate the establishment of a national health research organization with specified roles and responsibilities. The other contextual factors were discussed in terms of barriers to HRPS and implementation whereby lack of funding and negative cultural beliefs are believed to hamper HRPS and health research.
“it has set up bodies like NDAs, like UNHRO, like us UNCST then there is political will otherwise they would have just shut us down.” However, ‘Political will is constrained by limited resources.” #18.
“Then cultural issues play a role but at a very micro level. They get pieces of research showing that may be there is resistance to immunization because of certain cultural issues and practices or beliefs.” #30.
Prerequisites for HRPS
The evaluation framework identifies three prerequisites for successful HRPS: (1) political will, (2) availability of human and financial resources, and (3) a HRPS institution with the capacity to set priorities.
Political will for HRPS
As discussed above, there is political will is demonstrated by the establishment of the different health research management structures and the mandates of various political offices. The Ministry of Science, Technology, and Innovation (MoSTI), Ministry of Education and Sports (MoES), and the MoH are the key ministries involved in providing oversight for health research in Uganda. The MoH’s affiliate organization, the Uganda National Health Research Organization (UNHRO) is the umbrella organization for health research coordination. Established in 2009, UNHRO undertakes, coordinates, promotes, and provides guidance for health research and development in Uganda. Respondents thought there was political will.
“…Currently the political will in the Ministry of Health, like the Permanent Secretary, is very committed to research. Being scientists, so many people are committed to research verbally, but I don’t think they have appreciated the nighty gritty of what it takes to do research. There is importantly, the institutional commitment like politically, institutions have been set up” #16.
“UNHRO was instituted by parliament. The law is in place for UNHRO, and it clearly stipulates UNHRO as the key organization to coordinate health research actors in the country – both public and private.” #10.
Furthermore, there are several government policies that explicitly support HRPS such as: the UNCST policy (2009), the MoH health research policy (2012–2020), the Health Research Strategic Plan (2010/11–2014/15) based on the UNHRO Act (2011), and the One Health Strategic Plan (2018–2022).
However, some respondents expressed doubt, referring to the lack of funding. These respondents believed that relative to other political priorities, health research did not enjoy as much political support.
“I don’t think even political will which is there. It’s not as much as a high agenda as security, it’s not as a high agenda as infrastructure, it’s not a high agenda as probably looking for markets, tourism. I don’t think it’s that level.” #28.
Availability of financial and human resources
Several respondents reported that there were limited financial and human resources to support HRPS. Health research priority setting receives funding from the GOU or from donor agencies, but this funding is often meagre. For example, the governmental allocation for health research for 2017–2018 was only 0.17% of the health sector allocation and 0.01% of the overall budget allocation (16).
“There is political will, but the ability to support I know is limited through allocation of resources.” #27
External funds often support actual research. However, it is difficult to quantify, as these contributions do not come via GOU budget support and the Ugandan annual national health accounts do not itemize health research as a study category (17):
“There’s a lot of research work going on, but is funded through project support not budget support, and it is not captured in the government reporting framework—even if they are consistent with national research priorities.” #18
Arguably, the limited resources also impact the number and quality of human resources that are available to provide health research oversight:
“But you look at the entire ministry, we had challenges with human resource capacity in every aspect—inadequate numbers and inadequate capacity. UNHRO has no representation at sub-national level (e.g., regional, district); they should be represented in all centers where power belongs.” #16
“I don’t think they [UNHRO] have a budget, and if they do it must be very minimal. And they do not have real mechanisms to implement their mandate.” #19
Institutional capacity
The most commonly mentioned entities responsible for HRPS were the MoH, UNHRO, UNCST, and MoSTI. However, UNHRO is the institute that is mandated to lead and coordinate health research in the country. Some respondents felt that the MoH and UNHRO had the capacity to achieve HRPS, while others felt there was need to strengthen the other institutions’ capacities:
“…Institute of Public Health, Uganda National Research Organization … the Ministry of Health: their capacity is, I would say, over 80%. But the others, maybe just give some cheques, so you can maybe rate them at around 60 to 70%...” #24
Furthermore, respondents also reported that the very busy landscape of actors in health research undermines UNHRO’s capacity to manage and coordinate research activities.
“…There are multiple layers, a busy landscape—NGOs, donors, development partners—so coordination becomes difficult. Determining priorities becomes difficult…” #18
“…There are so many research institutions that do not talk to each other..”. #8
“…I think there is no proper coordination of … either the research institutions or those who generate the research questions. There is no repository for research either—evidence or even research questions. There is no … research hub or a unit … such that these things can be taken up, can be prioritized, can be discussed and funded…” #11
Although the districts are also mandated to identify their own research priorities, their capacity to do so was doubted:
“For local governments, some don’t have capacities to identify priorities, they are not able to observe and articulate a priority because they are too engrossed in being part of the community and are not exposed to other contexts.” #18
Priority Setting Processes: A Historical Perspective
Although Uganda has one main designated institution, UNHRO, for health research priority setting, since Uganda adopted the ENHR strategy, different research institutions have conducted HRPS. These include; (i) the Ad hoc Committee on ENHR (1997), (ii) College of Health Sciences, Makerere University (2011), (iii) the Medical Research Council—UVRI Unit (2014), the School of Public Health, (iv) Makerere University (SPEED Project) (2015), and (v) UHNRO-Busitema University-MoH (2018). We describe these processes in detail, where information was available. These processes have been conducted independently although they should, ideally, support the ENHR strategy. For each initiative, we identify the critical parameters relevant to the evaluation framework for a standardized evaluation.
Table 2 summarizes the previous HRPS in Uganda, identifying the leaders of the initiative, the stakeholders who were involved, the criteria used to rank the priorities, outputs and dissemination and implementation. Below we organize the descriptions under the parameters according to the evaluation framework.
Table 2
Summary of the five previous HRPS initiatives
Initiative
|
Year
|
Facilitator
|
Criteria
|
Outputs
|
Dissemination and impact
|
Ad hoc committee
|
1997
|
UNCST
|
-Avoidance of duplication, Feasibility
-Political acceptability, -Capability
-Urgency, -Ethical acceptability
|
A list of both disease and health system health research priorities.
|
Shared with stakeholders and each research institution was encouraged to set its own research priorities
|
College of Health Sciences (CHS) Makerere University
|
2011
|
CHS
|
-Public health benefit, Research Capacity and Relative cost
|
-A list of health research priorities.
-An end-of-workshop evaluation showed 80% participant satisfaction.
|
Disseminated to the college constituents and Periodic evaluations were suggested.
|
Medical Research Council (MRC) -
|
2014
|
UVRI Unit
|
- Disease burden in Uganda; CHS research priorities; future 10–20 years’ health priorities
|
A list of future health research priorities for UCRI/MRC,
|
A summary of these future research priorities is available on the MRC Uganda website.
|
School of Public Health, Makerere University
|
2015
|
SPEED Project.
|
What 2–3 solutions need to be prioritized for scaling up of the UHC vision? What 2–3 problems need solving to accelerate the attainment of UHC vision?
|
A list of health research priorities to address UHC
|
Disseminated to all stakeholders who attended the workshops via email. Some organizations have aligned their research to these priorities
|
School of Public Health (MakSPH),
|
2015
|
MakSPH & PEPFAR
|
|
A list of HIV/AIDS research priorities
|
The list was used in the PEPFAR-Uganda Country Operational Plan 2016.
|
UHNRO-Busitema University-MoH
|
2018
|
UNRHO
|
-Importance of the problem, availability of viable interventions, opportunity for change, uncertainty about the issue, availability of relevant research
|
None reported
|
A nine-member committee was set up for the follow up on activities. These activities are yet to be implemented.
|
Stakeholder involvement
As discussed above, several institutions are involved in HRPS in Uganda. These have implemented HRPS processes over the years, as demonstrated in Table 3. To date, there have been five national HRPS initiatives in Uganda. These have invariably involved a wide range of stakeholders including: UNCST, UNHRO, MoH, Development Partners, Academia, Research Institutes, other Ministries, Departments and Agencies (MDA), the District Leadership, the community (direct), and community (indirect: CSOs, NGOs, etc.)(Fig. 1).
All initiatives involved representatives from academia. However, among all initiatives, the Ad Hoc committee, which was the first HRPS initiative in Uganda, was the most participatory; involving focus group discussions with the community representatives and districts - a stakeholder group that is consistently missing from most of the subsequent initiatives.
One DHO recalled attending an HRPS event organized by the Ad Hoc Committee on ENHR at regional level 10 + years earlier. At this meeting, several districts were represented by the political and technical leaders, including DHOs, to seek their perspectives on research priorities.
“Every district would present a list, then we would say among these (which are the priorities)? There would be a scale… some kind of ranking. The forum was interactive, guided by some lectures, experience from some countries…” #29.
Other than that initiative, however, most of the district respondents reported participating at dissemination meetings as opposed to the meetings where priorities are determined.
“So you are called at the end (at national dissemination meetings); basically that you’re given the research priorities but have not contributed to determining them.” #24.
Table 3
Stakeholder involvement for HRPS events, 1997–2018
|
Ad hoc Committee
on ENHR
1997
|
CHS 2011
|
MRC-UVRI 2014
|
MakSPH
(SPEED) 2015
|
MakSPH
(PEPFAR) 2015
|
Busitema University-UNHRO
2018
|
Separate Stakeholder Meetings
|
✓
|
|
✓
|
|
✓
|
|
Stakeholders
|
|
|
|
|
|
|
UNCST
|
✓
|
✓
|
|
|
|
✓
|
UNHRO
|
|
✓
|
|
|
|
✓
|
MoH
|
✓
|
|
✓
|
✓
|
|
✓
|
Development Partners
|
|
✓
|
|
✓
|
✓
|
|
Academia
|
✓
|
✓
|
✓
|
✓
|
✓
|
✓
|
Research Institutes
|
✓
|
✓
|
✓
|
✓
|
|
✓
|
Other Ministries, Departments and Agencies (MDA)
|
✓
|
✓
|
|
|
✓
|
✓
|
Community (direct)
|
✓
|
|
|
|
|
|
Community (indirect: CSOs, NGOs, etc.)
|
|
|
|
✓
|
|
|
District Leadership
|
✓
|
|
|
|
|
|
Others
|
|
|
|
|
|
✓
|
Some key informants noted the limited stakeholder involvement, although they recognized the relevance of including a broad range of participants in the PS process in improving the process’s success and the subsequent uptake of the priorities:
“…The problem I’m seeing is the way they organize the process of setting the priorities, because it’s like they went and sat in [region]. How many were there? How many people come? Instead they should have broken it into regions … they can go to some sub-counties and invite sub-county chiefs, CDOs…” #6
Use of an explicit approach/ method, evidence, and criteria
All five initiatives reported a systematic approach however, these varied from using a specific approach e.g. the ENHR approach with the Ad hoc committee, to explicit steps in which options are identified and ranked based on specific considerations or criteria, or “consultations” with experts about what they perceived the priorities to be, as exemplified by a respondent who stated, “…It was more of a consultative process to start research priority setting...” #10
The prioritization processes were all achieved in face-to-face workshops. All the approaches considered research evidence, evidence on the disease burden, and gaps in the literature. However, notably, only the UVRI process, considered the previously identified research priorities.
With regards to criteria, while all five initiatives considered several factors when determining their research priorities, these again varied from explicit criteria to questions that the stakeholders were asked to consider. The criteria used by the different initiatives collectively included: feasibility (including costs, capacity), avoiding duplicity, urgency, acceptability, potential benefit, disease burden, link to (institutional, national e.g. UHC, and regional) research priorities, degree of uncertainty, and opportunity for change. While all these criteria could potentially be relevant to any HRPS process, no single initiative considered all these criteria when identifying their research priorities. Another controversial criterion was the funders’ priorities,
“…Donor interests will influence what kind of research you would want to do. Remember we do a lot of collaborative research [with] people from the west…” #4
Overall, there was no clear documentation on the origins of the criteria with the exception of the CHS initiative where they identified Vierger’s framework (7) as the source of the factors/criteria they considered.
Publicity
All initiatives developed a list of health research priorities (Table 4). The lists show a shift from disease-specific priorities to health system issues.
Table 4
Summary of the lists of health research priorities derived by different organizations, 1997–2015
ENHR
Ad Hoc Committee (1997)
|
CHS
(2011)
|
UVRI/MRC (2014)
|
SPH
(2015)
|
UNHRO-Busitema University (2015)
|
1. Water, sanitation, and environment
2. Communicable diseases
3. Non-communicable diseases
4. Health policy and health systems
5. Drug-use studies
|
1. Infectious and communicable diseases (including HIV, TB, and malaria)
2. Maternal, adolescent and child health, sexual and reproductive health (including behavioural research)
3. Health systems research
4. Professionalism, health professional education, ethics and medico-legal
5. Non-communicable diseases (including mental health)
6. Basic sciences
7. Trauma
8. Occupational health
9. Environmental health
10. Neglected tropical diseases
11. Geriatrics
|
1. Infections (especially HIV, malaria, TB, neglected and emerging infections)
2. Non-communicable diseases
3. Maternal neonatal and child health issues
4. Health systems research
5. Urban health, food security
6. Environmental/climate change
|
1. Governance: Finding relevant, effective, and sustainable ways to regulate the private sector
2. Service Delivery: Mechanisms through which different factors influence quality of care and finding solutions to address those problems
3. Health Financing: Effective means for increasing national budget allocation to health programs
4. Community Health: Community empowerment and role clarification, including community production of health and improvement of community health literacy
5. Others: Understanding socio-determinants of health
Streamlining multi-sectoral engagements: tools, methods, and approaches to motivate or enable multi-sectoral collaboration for health
|
1. Motivation of the health workforce
2. Corruption in the health workforce
3. Decentralization versus recentralization of health service management
4. Weak public sector engagement with private sector
5. Inequitable distribution of interventions in the country; poor quality of care in health facilities
6. Poor utilization of evidence to address to inform practice
7. Promotion of indigenous medical products and technology
8. Health insurance models that work in Uganda
Interoperability of health information systems of the public and private sectors
|
The study team found a list of priorities dated 2005–2010 on the UNHRO website, a narrative summary of the MRC-UVRI on the MRC website, and the report of the SPEED project PS events on the SPEED website. The other priorities (usually within HRPS event reports) were sourced from key informants, since they seemed to be available only within institutions. This was supported by the key informants who reported that their priorities are usually disseminated:
“…We disseminated to those who were in the space: the Ministry of Health, those who attended. We had a mail list actually, many of these conferences, these are documents we print and put on the desk for people to pick…” #7
However, one respondent highlighted the need for priorities to be made available to stakeholders who are not usually considered in the dissemination process. Complementing this suggestion, and considering that not everyone may have access to the above mechanisms, were recommendations to pursue more channels for publicizing priorities:
“…A research agenda, I believe it would be important to communicate it to key stakeholders who would at least participate in research especially universities, some health facilities. The big ones like national referral hospitals, regional referral hospitals … But also, it should be available to the public in various fora … and should be freely available online…” #15
Implementation of the health research priorities
This domain includes allocation of resources according to the identified research priorities.
The initiatives did not report clear and explicit implementation plans. For some, the process ended with submitting the list of research priorities to the organizations that contracted the HRPS or the MOH (for example the UVRI and MUSPH initiatives). The latter hoped that their priorities would be used by the MOH, recognizing their limitations to actually ensure resource allocation:
“The goal was actually not necessarily around research funding. It was to give the kind of document which speaks to issues that are necessary to move the agenda with HSDP forward. And some of the research is being guided by that, but also other players have come to do the research. But I can’t tell you how much money has been spent on those topics because we don’t have capacity to tell who is working in this area but at least there was a dissemination of that information for use.” # 7.
Our respondents recognized the limitation and futility of priority setting without the accompanying allocation of resources:
“…I think as long as priority setting is not linked to resources then it can’t be a priority…” #28
“…If we do not implement what we have put down, then it is as good as a waste of time. So, the experience in Uganda, you will find a lot of write ups on priority setting efforts in Uganda, but what follows after the priority setting exercise? It’s worrying!” #8
Additional implementation challenges exist at the district level. These issues cut across all components of HRPS—either due to funding constraints or resistance to research efforts:
“…Locally there is political will but the ability to support I know is limited; through allocation of resources…” #27
“…When there is poor communication with the community, that one can also affect the implementation of those priorities of research..”. #21
However, previous surveys of health research in Uganda seem to suggest that some of the work being undertaken aligns with the priorities that have been set. One study of publications from Makerere University between January 2005 and December 2009 showed that out of 837 publications, two-thirds (66%) addressed the country’s priority health areas (18). There are no equivalent studies, however, on alignment of research outside the confines of Makerere University.
Outcome and Impact
Our results did not provide clarity with regards to which priorities were actually implemented and had an impact on policy, with the exception of the PEPFAR initiative of priority setting for HIV/AIDS research. In this case, the list was used to identify the annual research focus for funding by PEPFAR. The other output was the recommendation to institutionalize the UNHRO, which was made by the Ad Hoc priority setting initiative
Beyond these two examples, respondents decried the limited translation of research into policy and programming and the disconnect between the research and policy needs:
“…That connection with the government, constant connection with policy makers and implementers, I feel is lacking. They are not connecting, so that that to me is a big weakness in national development. Instead we have got people who do research from outside and talk better about our systems…” #9
“…We have various government structures here where research questions are generated … unfortunately not many of the research questions generated are taken up for research…” #11
The GOU requires each recipient of a budgetary vote to report on specific development indicators based on their responsibilities. For example, the MoH reports on the indicator of “Proportion of research informed policy and guidelines” for funds received for health research, which in 2017/18 was rated as 30%. The same indicator for the same year is reported by UVRI as 20%. A key informant noted that these numbers do not capture external health research funding:
“…The reporting indicator framework for MoH/NPA is an incentive to comply—i.e., you have to report on priorities. This is an in-built mechanism to ensure ministries use resources for what they were purposed, but most research is donor funded and not reported through the government structures, so does not get reported. ..”#18
Recommendations for improvement
At the member check and dissemination meeting the participants, who are stakeholders in HRPS in Uganda, made some recommendations based on the findings. These were related to: stakeholder involvement, championing HRPS, establishing a HRPS think tank, and including HRPS in annual work plans. These are summarised in Table 5.
Table 5
Recommendations from HRPS stakeholders
Recommendation
|
Explanation
|
Illustrative quote
|
Stakeholder involvement
|
This results in nationwide ownership of the set priorities
|
“…The process needs to be so wide, and so integrated in as many constituencies as possible to be owned nationally by as many people as possible…”. #10
|
Champions for HRPS
|
It is not enough to include stakeholders; there must be people whose responsibility it is to drive HRPS
|
“…It requires a champion. Somebody, a senior researcher to champion this agenda. It needs a lot of lobbying and advocacy for research either at parliamentary level or at ministerial level so that research issues are embraced by all institutions…” #11
|
Establishing a think tank
|
One of the private academic institutions has established a think tank consisting of individuals from different disciplines—including the business and industry communities—to advise on research needs in the country
|
“…We also have a think tank, which is specifically to us but not the country at large. At that think tank we have multiple stakeholders; the think tank is very much research driven and majority of our priority setting comes from those conversations…” #3
|
Capturing research priorities in annual work plans
|
Including research priorities in the work plan as an important step towards implementation
|
“…After agreeing on the (research) priorities, we were able also to capture this, to prioritize this and capture in our annual work plan and budget. Where we have the source of fund identified we also include, where we don't have the source of funding, we keep it as unfunded priority then we start looking for the money… #24
|