Research prioritization for better health is recognized as the key factor for countries to optimize the decision-making process in order to establish their own research policies and achieve better impacts through financial investments [
1]. Recently, broad concern has been raised about how to set priorities in a transparent, systematic, fair, and legitimate way in low- and middle-income countries [
2‐
4]. The adequate fulfillment and implementation of such priorities may depend on the recognition of the agenda by actor institutions and stakeholders. Despite the fact that a universal method for priority setting for health research does not exist, several strategies and methods have been developed in order to facilitate prioritization and have been applied to promote empowerment for decision making at the national and global level [
5]. A recent analysis of the prioritization experiences and methods employed by a group of 18 Latin American and Caribbean countries showed a wide variety of practices and achievements, indicating the need to use a systematic approach to develop research priorities specific to each country’s context [
6].
Local context
Panama is a Central American country of 3.8 million inhabitants and is considered the most promising economy in the region; it shows high-middle income economic performance with a gross domestic product per capita of 12,000 USD [
8], the highest human development index in Central America (0.780), and the fourth highest index among Latin-American countries [
9]. However, structural poverty and inequity still persist; 27.6% of the population lives below the poverty line, and 14.2% of the population lives in extreme poverty [
10]. Indigenous groups compose 12.3% of the total population and are the most affected by health disparities; this disadvantage translates into high mortality and years of potential life lost due to transmissible diseases [
11]. This pattern is different from that of the non-indigenous population, in which mortality from non-transmissible diseases predominates, reflecting the epidemiologic transition resulting from improved quality of life [
12]. Panama does not have a universal health care system, but its implementation has been under debate for several years without a conclusion. Meanwhile, health services and social security for over 60% of the population is provided by the Caja de Seguro Social (CSS) based on contributions from employee salaries. The rest of the population is covered by a network of MINSA hospitals and health services. Together, the CSS and MINSA constitute the Public Health System of Panama; investment in this system is estimated at 1.3 billion USD, equivalent to 5% of the GDP and 14% of the government’s total expenditures [
13].
As recently discussed in previous research [
14], Panama does not have a structured National Health Research System (NHRS). This is related to historical factors, such as the Panama Canal construction by the US government at the beginning of the 20th century. The vector control for transmissible diseases, such as yellow fever and malaria, by William C. Gorgas in 1904, marked a success for the Panama Canal construction and the establishment of health research in the Panamanian isthmus [
15]. In 1921, the Panamanian government established the Gorgas Memorial Laboratory (GML), which, under US administration, succeeded as an active tropical disease research institute. For over six decades, the GML was the only research institution in the country, and its sustainability depended in large part on the US until the 1990s [
15], when the process of returning the administration and territory of the Panama Canal to Panamanian control began. The incorporation of the GML, now Gorgas Commemorative Institute of Health Studies (ICGES), into the National Health System in 1990 began the structuring of the local NHRS.
In 2003, the ICGES was restructured through Law 78 into a public, social interest entity with legal, financial, and technical autonomy, responsible for conducting and stimulating the development of national health research in coordination with MINSA [
16]. However, neither MINSA nor ICGES has dictated an agenda of national priorities for health. Instead, the Plans of the National Secretariat for Science, Technology and Innovation (SENACYT) prevail. SENACYT, which is the key institution for promoting research activities, innovation, and human resources training for all knowledge areas in the country, was founded in 1992 as a joint organization of the Panamanian Presidency [
17]. The institution had jurisdiction over policies and resources to accomplish its function until 2005 [
17], when the National Strategic Plan for Science, Technology, and Innovation (PENCYT) became the means to execute research priorities, including the health research agenda. However, the implementation of PENCYT agendas has been compromised by the low level of local public investment in research and development activities, including the suspension of research funds during the last two years. According to recent data [
18], Panama invested 0.19% of its GDP in research and development in 2010, which is four times below the average for Latin American and Caribbean countries, estimated at 0.78% of GDP. Official data indicate that Panama’s cumulative public investment in research and development, awarded through competitive grants from SENACYT between 2004 and 2012, was $18.6 million dollars. These funds have been assigned to 340 research projects in all knowledge areas, of which 63 (18.5%) correspond to health sciences [
19]. The ICGES and the Institute for Scientific Research and Technology Services (INDICASAT) are the leading research institutions in the country and are the main recipients of these research funds, as indicated in Table
1.
Table 1
Distribution of public fund for health research during the years 2004 to 2012
Gorgas Commemorative Institute of Health Studies (ICGES) | 26 | 38.0 |
Institute for Scientific Research and Technology Services (INDICASAT) | 20 | 39.9 |
University of Panama (UP) | 6 | 9.3 |
Health Ministry (MINSA) | 2 | 6.2 |
Social Security (CSS) | 2 | 2.8 |
Others | 7 | 3.8 |
Total | 63 | 100 |
According to the World Health Organization, a health research prioritization process is defined as a scheme to build consensus on a set of research issues that require urgent attention [
20]. A priority is defined as an element or condition judged to be more important than another, which involves an exercise in “judgment” and the use of “values” that sustain the quality of a priority [
21]. Simultaneously, there is a local context and a series of criteria, such as benefits, evidence, cost-efficiency, equity, and severity, which compete in order to establish this judgment. Finally, stakeholders, who act individually in representation of pluralist society, make decisions by consensus, making an ethical framework necessary to sustain the legitimacy of the prioritization process [
2,
20]. This group of stakeholders includes individuals from the governmental sector, non-governmental organizations, the private sector, academia, health service providers, and healthcare recipients. The intention of this plurality is to encourage equal participation among the different sectors involved and to allow constructive debate for conflict resolution between different areas and interests [
2]. An explicit prioritization process strategy and a description of follow-up plans are other key elements that guarantee the process’ transparency and legitimacy [
2]; transparency refers to the extent to which it is clear how decisions were made and legitimacy refers to the moral authority of decision makers [
22,
23].
Daniels and Sabin [
22,
24] established the process of “accountability for reasonableness” (AR) with the aim to prevent errors that can be committed by legitimate authorities. AR represents the ethical framework of a legitimate prioritization process as it encourages democratic deliberation through four conditions based on justice theory: relevance, publicity, review, and enforcement. The condition of “relevance” is met if prioritization decisions are based on importance as recognized by legitimate decision makers. In order to meet this condition, careful selection of a representative group of decision makers who are responsible for the elucidation of values, criteria, methods, and information that will guide the prioritization process is necessary. The condition of “publicity” is achieved if the decisions and reasons for the prioritization are made available to encourage public debate. To meet the condition of “review”, mechanisms for the reevaluation of decisions based on new evidence should exist. Finally, to ensure a just process, the leaders must guarantee the three previous conditions are met, therefore meeting the fourth condition of “enforcement” [
1,
25]. Recently, the AR approach has been implemented in priority-setting for health care services [
26,
27] and health research [
28,
29], relying on the belief that fair, deliberative procedures yield acceptable results [
26].
The principal objective of establishing research priorities for health at the domestic or international level is to align investments with the population’s health needs in an efficient way to improve health and quality of life. However, prioritization represents one of the greatest challenges confronted by decision makers, particularly in less developed countries where there are obstacles, including limited economic resources, insufficient official health indicators, socioeconomic inequity, political instability, and inefficient health institutions and systems [
1,
30]. At the same time, one of the largest challenges is the lack of equal participation among decision makers and the shortage of systematic strategies for adequate prioritization processes [
31]. As a result, at times, countries set priorities based on historical precedents or by forming
ad hoc committees [
31]. These prioritization practices frequently generate results that are not in line with reality or that are influenced by the preferences and scientific autonomy of researchers [
31].
Systematic prioritization process experiences of low- and middle-income countries in Africa, Asia, and Latin America have been documented [
2,
5,
6]. Authors report high heterogeneity among the different countries examined in areas such as the context, methods used, criteria included, information used, involvement of different stakeholder groups, results obtained, and prioritization processes [
2]. In the Latin American context, the leadership of Brazil has been recognized for the transparency of its processes, the inclusion of broad stakeholder groups, and the maturity of its health research system. Brazil’s prioritization is based on a high degree of public consultation throughout the process, which was led by the Ministry of Health in 2003 and followed the Combined Approach Matrix methodology. The first draft of the agenda was written by a group of 510 professionals from five different regions [
32], and it was available for public comment over 45 days on the Ministry of Health’s official website. A series of municipal, state, and national conferences constituted the preparatory phase with the community before the agenda was approved during the Second National Conference on Science, Technology, and Innovation in 2004. The event included the participation of 431 conference delegates and 213 observers and invited guests. Six basic principles guided the construction of the agenda: 1) improve public health in the short, medium, and long term; 2) eliminate all forms of inequality and discrimination; 3) respect the life and dignity of people; 4) ensure the implementation of high ethical and gender standards in research; 5) respect methodological and philosophical pluralism; and 6) strive for social inclusion and environmental respect [
32]. Thus, if evaluated with the AR principles in mind, the described country experience illustrates the establishment of a comprehensive national agenda with a high level of legitimacy based on deliberative practices for consensus building and transparency.