PLoS ONEplosplosonePLOS ONE1932-6203Public Library of ScienceSan Francisco, CA USA10.1371/journal.pone.0256099PONE-D-21-06707Research ArticleMedicine and health sciencesMedical conditionsInfectious diseasesViral diseasesCOVID 19Medicine and health sciencesEpidemiologyPandemicsPeople and placesGeographical locationsAsiaIndiaMedicine and health sciencesPediatricsChild healthMedicine and health sciencesPublic and occupational healthChild healthMedicine and health sciencesPublic and occupational healthMedicine and health sciencesMedical conditionsInfectious diseasesResearch and analysis methodsResearch designSurvey researchResearch and analysis methodsResearch designSurvey researchSurveysShifting research priorities in maternal and child health in the COVID-19 pandemic era in India: A renewed focus on systems strengtheningIdentifying MCH research priorities during COVID-19 in Indiahttps://orcid.org/0000-0002-9678-6698MehtaKayurConceptualizationFormal analysisWriting – original draft12ZodpeySanjayData curationWriting – review & editing3https://orcid.org/0000-0002-6129-5020BanerjeePreetikaConceptualizationFormal analysisVisualizationWriting – review & editing12PociusStephanie L.Formal analysisVisualizationWriting – review & editing4DhaliwalBaldeep K.ConceptualizationWriting – review & editing12DeLucaAndreaConceptualizationWriting – review & editing5BhattacharyaSangeeta DasData curationWriting – review & editing6HegdeShailendraResourcesWriting – review & editing7SenguptaParamitaResourcesWriting – review & editing8GuptaMadhuResourcesWriting – review & editing9https://orcid.org/0000-0002-7204-8164ShetAnitaConceptualizationData curationSupervisionWriting – review & editing12*Maternal and Child Health Center India, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of AmericaInternational Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of AmericaPublic Health Foundation of India, New Delhi, IndiaDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of AmericaAmputee Coalition, Washington, DC, United States of AmericaIndian Institute of Technology, Kharagpur, IndiaPiramal Swasthya Management and Research Institute, Hyderabad, IndiaDepartment of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Kalyani, West Bengal, IndiaPostgraduate Institute of Medical Education and Research, Chandigarh, IndiaGoliSrinivasEditorUniversity of Western Australia, AUSTRALIA
The authors have declared that no competing interests exist.
* E-mail: ashet1@jhu.edu12820212021168e025609913202131720212021Mehta et alThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Background
The remarkable progress seen in maternal and child health (MCH) in India over the past two decades has been impacted by the COVID-19 pandemic. We aimed to undertake a rapid assessment to identify key priorities for public health research in MCH in India within the context and aftermath of the COVID-19 pandemic.
Methods
A web-based survey was developed to identify top research priorities in MCH. It consisted of 26 questions on six broad domains: vaccine preventable diseases, outbreak preparedness, primary healthcare integration, maternal health, neonatal health, and infectious diseases. Key stakeholders were invited to participate between September and November 2020. Participants assigned importance on a 5-point Likert scale, and assigned overall ranks to each sub-domain research priority. Descriptive statistics were used to examine Likert scale responses, and a ranking analysis was done to obtain an “average ranking score” and identify the top research priority under each domain.
Results
Amongst the 84 respondents from across 15 Indian states, 37% were public-health researchers, 25% healthcare providers, 20% academic faculty and 13% were policy makers. Most respondents considered conducting systems strengthening research as extremely important. The highest ranked research priorities were strengthening the public sector workforce (vaccine preventable diseases), enhancing public-health surveillance networks (outbreak preparedness), nutrition support through community workers (primary care integration), encouraging at least 4–8 antenatal visits (maternal health), neonatal resuscitation to reduce birth asphyxia (neonatal health) and screening and treatment of tuberculosis (infectious diseases). Common themes identified through open-ended questions primarily included systems strengthening priorities across domains.
Conclusions
The overall focus for research priorities in MCH in India during the COVID-19 pandemic is on strengthening existing services and service delivery, rather than novel research. Our results highlight pivotal steps within the roadmap for advancing and sustaining maternal and child health gains during the ongoing COVID-19 pandemic and beyond.
Johns Hopkins Maternal and Child Health Center - Indiahttps://orcid.org/0000-0002-7204-8164ShetAnitaThe authors acknowledge funding provided by the Johns Hopkins Maternal and Child Health Center - India. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Data AvailabilityAll relevant data are within the manuscript and its Supporting Information files.OutbreaksCOVID-19Introduction
Maternal and child health (MCH) outcomes have been key public health issues in developing countries including India. While the past 25 years have witnessed a concerted global effort to improve MCH in low-and-middle-income countries (LMICs), more progress is needed to meet the targets laid out in the Sustainable Development Goals (SDGs). In India, key MCH indicators remain concerning, as evidenced by partially released results from the National Family Health Survey-5 (NFHS-5), which indicate worsening of maternal and child nutrition indicators in several states [1]. There is an urgent need to identify targeted approaches to improve the state of MCH in India.
While MCH programs in India are weighed down by wide inequities [1, 2], these challenges have been amplified by the ongoing COVID-19 pandemic. In addition to the direct effects of the disease, the indirect effects of the pandemic have been devastating. Limitations in the availability of skilled health workers and health system access barriers have led to lower coverage of antenatal and postnatal care services, and routine childhood immunization services, especially in rural India [3, 4]. A recent modelling paper estimated that the disruption and decreased utilization of routine health services and reduced access to food during the pandemic could lead to an estimated 9.8–44.7% increase in under-5 child deaths per month, and an 8.3–38.6% increase in maternal deaths per month in LMIC settings [5].
Health research is an essential tool for improving health outcomes in LMICs [6]. Amidst limited economic and manpower resources, it is critical to direct research towards the most important gaps. Recent global and national exercises to identify research priorities in maternal and child health that were conducted prior to the COVID-19 pandemic, mainly identified priorities that pertained to implementation sciences and innovation [7, 8]. However, no such exercises have been conducted in the context of the COVID-19 pandemic in India, and it is unknown as to which domains of maternal and child health research are perceived to be most impactful in the context of an unprecedented pandemic. A research prioritization exercise using a methodical and inclusive process could thus guide researchers, policy makers and funding agencies in making informed decisions and improving outcomes. We aimed to undertake a rapid assessment to identify key priorities for public health research in MCH in India within the context of the COVID-19 pandemic, by surveying key stakeholders and experts in India.
MethodsSurvey questionnaire and design
A survey to assess research needs in MCH was developed by researchers at the Johns Hopkins Maternal and Child Health Center in India and stakeholders at key Indian institutions such as the Public Health Foundation of India, All India Institute of Medical Sciences, Kalyani, Postgraduate Institute of Medical Education and Research, Indian Institute of Technology, Kharagpur and Piramal Swasthya Management and Research Institute. Specific priority research domains were identified through a review of previous survey results [2], and literature on global priorities in maternal newborn and child health. All key stakeholders reviewed the survey and research domains included, and provided input that was incorporated; the final survey was derived by consensus. The following six broad research domains were identified, according to the principles of thematic analysis: vaccine preventable diseases, outbreak preparedness, primary healthcare integration, maternal health, neonatal health, and infectious diseases. Since this was a rapid assessment, during the survey development process, we did not undertake iterative processes to generate consensus amongst the contributors. The survey consisted of 26 questions which focused on these six broad domains. Under each domain, participants were requested to assign importance to each sub-domain research priority on a 5-point Likert scale, and assign overall ranks to each sub-domain research priority. Open-ended questions were also included to capture other aspects of research priorities. In each domain, participants had the option to nominate a different research topic not included in the prepared list; these could be ranked by importance in the same manner.
Participants
Key stakeholders working in the field of MCH in India were identified through desk reviews, web-based searches, dissemination in professional networks such as the Indian Association of Preventive and Social Medicine, Indian Public Health Association, Indian Academy of Pediatrics and the Federation of Obstetric and Gynaecological Societies of India, and through collaborators. Stakeholders were identified across various domains of maternal and child health, including those primarily engaged in academia, or specific areas such as health systems, policy and economics, nutrition, and tribal health.
Sampling strategy and sample size determination
Since this was a rapid assessment, we employed convenience sampling, based on a snowball sampling strategy. Further, we did not target any specific sample size; we analyzed all responses that we received until the closure of the online survey.
Dissemination of the survey
The survey was administered online using the software platform Qualtrics (Qualtrics, Provo, UT) between September and November 2020. It was disseminated via email, text messages and social media platforms such as WhatsApp. No personal data were collected, although respondents could choose to share their contact information for future surveys.
Ethical considerations
The study was reviewed by the Johns Hopkins Bloomberg School of Public Health (JHSPH) Institutional Review Board (IRB) which classified the proposed activities as “key informants research”, and therefore determined to be exempt from human subjects research oversight. Consent to participate in the survey was highlighted in the introductory portion of the online survey. Participants were informed that responding to the survey request was voluntary; data obtained for the survey analysis would remain anonymous, and that completing the survey and submitting it implied that they had consented to participate in the study.
Data analysis
Descriptive statistics, expressed as frequencies and proportions, were used to examine respondent demographics and Likert scale responses. The Likert scale for each sub-domain research priority was analyzed by tabulating responses based on importance level ascribed. A ranking analysis was conducted by three authors (SLP, PB and KM) using weights that were inversely related to the raw rank from the survey, to obtain an “average ranking score”, which helped identify the top research priorities in each research domain [9]. In this method, sub-domain research priorities that were ranked as “1” would receive the largest weight depending on how many sub-domain research priorities were present in each domain. For example, in the vaccine preventable diseases domain, if individuals ranked “Strengthening the public health workforce” as their “1” priority, the weight would be “10” since there were ten sub-domain research priorities listed underneath this domain. If individuals ranked this sub-domain research priority as “2”, then the accompanying weight would be “9”, and so on. The weights were then multiplied by the count of how many respondents ranked the sub-domain research priority as “1”, “2”, and so on. The total sums of all weighted scores were then divided by the total number of respondents for that sub-domain research priority. Thus, the average ranking score of each sub-domain research priority was then calculated using the formula,
Averagerankingscore=(x1w1+x2w2+x3w3…xnwn)/Totalresponsecount
Where, w = weight of ranked position, and x = response count for each rank.
Responses to the open-ended items were assessed by two authors (SLP and KM). Comments were read independently, and summarized following discussion according to the principles of thematic analysis. The World Health Organization (WHO)’s operational definition for health systems strengthening [10], “any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency” was used to guide the process that categorized responses under the broader theme of “health systems strengthening”.
ResultsParticipant characteristics
The online survey was completed by 84 respondents (key stakeholders) from 15 states and 2 union territories in India. Male respondents constituted 58%, and professional backgrounds were distributed as follows: public health researchers (37%), healthcare providers (25%), academic teaching faculty (20%) and policy makers (13%). An almost equal number of the respondents belonged to non-governmental organizations/private organizations or governmental organizations, and over 65% had work experience of over 10 years in their primary area of expertise. The most common primary areas of work included child health (20%), infectious diseases (17%), health systems and policy (14%), biostatistics and epidemiology (14%), and maternal health (8%) (Table 1).
Across the six domains identified in the survey, most respondents characterised conducting research on systems strengthening priorities as extremely important (Fig 1). In the vaccine preventable diseases domain, over 50% of the respondents considered enhancing vaccination rates among the urban poor, strengthening the public sector workforce and improving vaccination coverage as extremely important. In the outbreak preparedness domain, the proportion who considered the sub-domain research priorities as extremely important ranged from 48% (conducting COVID-19 research for MCH sub-populations) to 76% (enhancing public health surveillance networks). In the primary care integration domain, over 45% of the respondents considered all sub-domain research priorities as extremely important, and 63% felt research on nutrition education support through community health workers was extremely important. In the maternal health domain, systems strengthening was considered extremely important, with 64% considering research on improving facility-based safe delivery outcomes as extremely important. In the neonatal health domain, system strengthening priorities were similarly deemed extremely important, with over 75% considering improving the quality of care during labor and birth, and 67% considering measures to reduce birth asphyxia and improve the initiation of breastfeeding in the hospital as extremely important. In the infectious diseases domain, 63% and 45% of the respondents considered conducting research on diarrhoeal diseases and COVID-19 respectively, extremely important.
10.1371/journal.pone.0256099.g001
Level of importance assigned to individual sub-domain research priorities by respondents across six domains of maternal and child health (n = 84).
Legend: In a rapid survey conducted to identify the top priorities in maternal and child health research in India during the COVID-19 pandemic, it was found that across the six identified domains, priorities related to systems strengthening received high levels of importance, as seen in this Likert scale distribution.
Overall ranking of research priorities
The highest ranked research priorities identified across domains were strengthening the public sector workforce (vaccine preventable diseases), enhancing public health surveillance networks (outbreak preparedness), nutrition support through community workers (primary care integration), encouraging at least 4–8 antenatal visits during pregnancy (maternal health), neonatal resuscitation to reduce birth asphyxia (neonatal health), and pediatric and maternal screening and treatment of tuberculosis (infectious diseases) (Table 2). While the Likert scale importance assignment and overall ranking exercises were in agreement across most domains, in the infectious diseases domain, a large proportion of respondents felt research on diarrhoeal disease prevention and treatment was extremely important; the ranking exercise, however, yielded pediatric and maternal screening and treatment for tuberculosis as the top priority.
10.1371/journal.pone.0256099.t002
Top 3 ranked research priorities across each domain, by average ranking score.
Average ranking score† Sub-domain research priority
Vaccine Preventable Diseases (maximum score = 10)
8.03
Strengthening the public sector workforce
7.76
Areas of disparity, such as vaccination rates among the urban poor
7.48
Improving vaccination coverage and research opportunities
Outbreak Preparedness (maximum score = 7)
5.63
Enhancing public health surveillance networks
4.91
Developing laboratory capacity and training
4.27
Assisting state government initiatives for disease surveillance
Primary Health Care Integration (maximum score = 6)
4.42
Nutrition education support through community workers
4.22
Supplemental nutrition delivery and effectiveness
4.14
Growth monitoring through regular health visits
Maternal Health (maximum score = 8)
6.45
Encouraging at least 4–8 antenatal visits during pregnancy
5.89
Improving facility-based safe delivery outcomes
5.32
Improving maternal immunization coverage
Neonatal Health (maximum score = 9)
7.38
Neonatal resuscitation to reduce perinatal asphyxia
6.68
Improving quality of care during labor and birth
6.51
Improving initiation of breast feeding in hospital
Infectious Diseases (maximum score = 9)
6.58
Pediatric and maternal screening and treatment for tuberculosis
Where, w = weight of ranked position; x = response count for each rank.
Other research priorities identified
Several additional research topics were also suggested by the respondents across the six domains. Common themes identified were systems strengthening priorities like enhancing vaccine programme surveillance, empowering communities and community health workers, enhancing the quality of antenatal and postnatal care, and health systems strengthening for the infectious diseases domain. Other themes identified included women empowerment, family planning services, early childhood development and behavioural research. Novel research approaches for COVID-19 related research, and the use of technology like telemedicine, geographic information systems and artificial intelligence for the effective delivery of services across domains were also suggested, but these were not considered to be as important as system strengthening priorities during the ongoing COVID-19 pandemic.
Discussion
The key theme that emerged from this study seeking to identify MCH public health research priorities in India within the context of an unprecedented pandemic was the importance of systems strengthening rather than undertaking novel research. The findings of this exercise appeared to signal a shift from those of recent priority setting exercises in MCH, both from India and globally, which were conducted prior to the COVID-19 pandemic. Wazny et al. employed the Child Health and Nutrition Research Initiative (CHNRI) method for research priority setting for child health research in India for the period between 2016–2025, with research ideas crowd-sourced from a network of experts across India [11]. The majority of the top research priorities identified were related to the development of cost-effective interventions and their implementation, impact evaluations, improving data quality and monitoring of existing programs, and improving the management of morbidities [11]. An Indian Council of Medical Research study to identify top research priorities in MCH found that the delivery domain of research which included implementation research, constituted about 70% of the top ten research options [7]. A global exercise to characterize maternal and perinatal health priorities beyond 2015 identified research priorities that were mostly related to implementation research and the innovative development of simplified, cost-effective adaptations of existing interventions [8]. These studies also identified areas for novel or “discovery” research in MCH, such as the development of innovative point of care diagnostics and technological solutions for acute maternal, neonatal and childhood morbidities, which were ranked high in priority lists. These studies employed the CHNRI method, which offers a detailed, systematic algorithm for the identification of research priorities that pools individual scorings of research options based on five weighted criteria, leveraging the collective wisdom of various stakeholders [12]. This method involves several stages, which could take months to complete. Other research priority setting exercises have utilized comprehensive approaches including the Combined Approach Matrix method, the Essential National Health Research (ENHR) method, Council on Health Research and Development (COHRED) method, the James Lind Alliance method and the Delphi method, most of which involve iterative processes which require substantial time and resources to complete [13]. Our study, positioned to fulfill the need for a rapid assessment during the COVID-19 pandemic found that prioritizing research endeavors in MCH to focus on strengthening existing service delivery was most important, and this theme was cross-cutting across the six domains. Further, despite the novelty of COVID-19, “discovery” research such as optimizing COVID-19 diagnostics and clinical management, and the development of an effective vaccine against COVID-19 did not receive high priority, emphasizing the perceived need to strengthen existing health systems to combat the unprecedented pandemic, rather than diverting scarce resources towards discovery research. COVID-19 vaccine research did not feature prominently amongst identified research priorities; we speculate that the most likely reason could be that expectations were low for having a fully developed vaccine within less than a year of virus discovery.
Epidemics in the past have demonstrated that they are highly disruptive to existing health systems. Studies conducted during the West African Ebola outbreak of 2014 have shown that the indirect effects of the pandemic on maternal health were severe, resulting in decreased utilization of antepartum, intrapartum, and postpartum care [14]. Significant decreases in coverage for most vaccines were also observed [15]. A prospective observational study at a tertiary hospital in India reported a reduction in institutional deliveries, increase in pregnancies with complications, and increase in intensive care unit admissions between the months of April-August 2020 [16]. Only a third of women had adequate antenatal care visits during this period [16]. Considering the threat posed by the pandemic on previous gains in MCH, focusing interventions and policies around the identified priority areas would be crucial to steadying the health outcomes of mothers and children.
An unintended consequence of lockdowns and movement restrictions resulting from the COVID-19 pandemic in LMICs like India is their influence on ongoing transmissions of other non-COVID related infectious diseases. India reports the highest burden of tuberculosis globally, accounting for a quarter of the 10 million global cases and 1.4 million deaths annually [17]. A recent modelling analysis of the impact on COVID-19 related disruptions in tuberculosis services in India showed that even temporary disruptions could cause long term increases in tuberculosis incidence and mortality [18]. In our study, under the infectious diseases domain, conducting research on tuberculosis was ranked as the top research priority, highlighting the fact that tuberculosis continues to remain highly relevant in the Indian setting, despite the emergence of COVID-19. Further, a majority of respondents also felt that conducting research on diarrhoeal diseases was extremely important, emphasizing the need to continue to focus efforts on the prevention and treatment of diarrhoeal diseases in the Indian context. The overall ranking for diarrhoeal diseases, however, occurred below that of tuberculosis, COVID-19, and dengue infections, underscoring the changing patterns of high-burden infectious diseases in India. The identification of non-COVID-19 infectious diseases as leading research priorities in the infectious diseases domain in a survey administered during the unprecedented pandemic highlights the collective opinion of the respondents on the need to sustain research focus on other non-COVID-19 infectious diseases as well.
While there are useful lessons learned from these findings, the study limitations are worth noting. The survey was distributed within a short timeline between September—November 2020, and the results are limited by the small sample size. We acknowledge the potential presence of bias in the selection of key stakeholders for developing the survey, but obtained a final version via consensus, and have taken care to include a large and diverse respondent population. Since this was a rapid assessment, we did not perform specific sample size calculations that could have powered the study adequately to support generalizability of our findings. Additionally, we did not use qualitative methods to capture perspectives, and priorities were identified solely based on overall ranking and Likert scales. Further, the survey did not explore priorities for chronic and non-communicable diseases which have also witnessed an escalating burden in India in recent years. Diagnosis and treatment for such diseases have likely been affected by COVID-19 as well and warrant further research. We advise caution about generalization of these results as regional variations in ranking of priorities may not have been captured due to the small sample size of survey respondents. Despite these limitations, our study has been able to perceive a shift in research priorities for MCH towards systems strengthening during this unprecedented pandemic, and can serve as a valuable resource for donors, researchers and other stakeholders engaged in maternal and child health in India.
The COVID-19 pandemic and its response has significantly challenged health systems globally. It has exposed glaring loopholes in health systems, and has demonstrated that countries’ response to pandemics is ultimately dependent on the resilience of their health systems [19]. Countries such as New Zealand, Sri Lanka, Taiwan and South Korea have been praised for their handling of the COVID-19 crisis; they were able to do so efficiently by investing heavily in their public health systems to improve testing, contact tracing and outreach measures early in the course of the pandemic [20]. Several countries from each of the six WHO regions are demonstrating that investing in stronger health systems is crucial in responding to COVID-19, delivering the best returns on investment and making health for all a reality [21]. In India, the private sector has remained a major player in healthcare delivery for several decades [22], but the ongoing pandemic has highlighted the indisputable role of the public health sector. The public health sector has not only shouldered a vast majority of preventive and outreach services, but also clinical care, with a substantial proportion of critical COVID-19 cases being treated by public health sector services [23]. States with robust, well-staffed and equipped public health systems have been more successful in containing the pandemic, and as a result, public health has reached the forefront of India’s pandemic response and post-pandemic discourse. India’s recent budget has promised substantial increases in healthcare allocation and investment on public health infrastructure [24], and these are welcome steps.
In conclusion, the results of this rapid assessment suggest that in order to build a sustainable future for maternal and child health during and post COVID-19 in India, national authorities should prioritize investments and develop frameworks to strengthen existing public health systems. Governmental investments in health research should be measured against defined benchmarks [25], and central and state governments should invest in building research capacity by developing a local workforce of well-trained and motivated researchers. Stronger collaborations between researchers and policymakers will ensure that research is taken outside the academic institutions and into public health programmes. Further, national research networks could be established to coordinate research efforts by fostering collaboration and information exchange between academic institutions, governmental and non-governmental organizations. Such partnerships could help in optimally tapping the individual sectors’ strengths and contribute to the journey towards achieving the Sustainable Developmental Goals and Universal Health Coverage for all by 2030. Identifying and facilitating roles for public-private partnerships to support public health systems as well as research could further enable the most vulnerable populations to have access to healthcare [26]. General recommendations for establishing research priorities in maternal and child health in India are summarized in Fig 2; these have been informed by the results of this study, and our engagement with key stakeholders, and are in alignment with the World Health Organization’s report on research for universal health coverage [27]. While our results highlight pivotal steps to the roadmap for sustaining and advancing maternal and child health during and after the COVID-19 pandemic in the Indian setting, these learnings are relevant to other emerging global economies as well, given the similarities in their respective health systems.
10.1371/journal.pone.0256099.g002
Recommendations for establishing research priorities in maternal and child health.
Legend: General recommendations for establishing research priorities in maternal and child health in India. These recommendations have been informed by the results of this study, and our engagement with key stakeholders, and are in alignment with the World Health Organization’s report on research for universal health coverage†. † World Health Organization. Research for universal health coverage: World health report 2013. Available at https://www.who.int/publications/i/item/9789240690837.
Supporting information
Research needs in maternal and child health survey: India.
(DOCX)
Raw data: Research needs assessment.
(DOCX)
The authors acknowledge support from the Indian Association of Preventive and Social Medicine (IAPSM).
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12 May 2021
PONE-D-21-06707
Shifting research priorities in maternal and child health in the COVID-19 pandemic era in India: a renewed focus on systems strengthening
PLOS ONE
Dear Dr. Shet,
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Considering the reviewers reports and my own reading of the paper, I reached to a decision of minor revision. Looking forward to read the revised version of this paper.
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'The authors acknowledge funding provided by the Johns Hopkins Maternal and Child Health
Center - India, and support from the Indian Association of Preventive and Social Medicine
(IAPSM).'
We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.
a. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:
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Additional Editor Comments:
Considering the reviewers reports and my own reading of the paper, I reached to a decision of minor revision. Looking forward to read the revised version of this paper.
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Reviewers' comments:
Reviewer's Responses to Questions
Comments to the Author
1. Is the manuscript technically sound, and do the data support the conclusions?
The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.
Reviewer #1: Partly
Reviewer #2: Yes
Reviewer #3: Yes
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2. Has the statistical analysis been performed appropriately and rigorously?
Reviewer #1: N/A
Reviewer #2: Yes
Reviewer #3: Yes
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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.
Reviewer #1: No
Reviewer #2: No
Reviewer #3: No
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Reviewer #1: No
Reviewer #2: Yes
Reviewer #3: Yes
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5. Review Comments to the Author
Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)
Reviewer #1: How shifting research priorities in MCH could be the new focus on systems strengthening? It would be beneficial to explain or include in the introduction section as this could direct your focus. Perhaps this could highlight or give a better picture of overall intention of doing this survey?
Any form of survey technique was used to get consensus from the stakeholders or key participants?
Do the survey questions developed be tested or validated? And how do the stakeholders were approached asking them to take part in a survey. Any form of sampling technique was used?
Authors have mentioned how they analyzed the survey response. But who and how
Participant characteristics: why 84 respondents from 15 states in India. Should it be the main stakeholders? or does it refers to stakeholders from each state in India. Has it been mentioned?
I would say the primary area of work for others, 16 is many. Would it be any way to regrouped the primary area of work, so it provides more representative towards those work related to MCH?
Overall ranking of research priorities: the word 'concurrent' to explain the overall ranking exercise may not be suitable, suggest to rewrite
Authors have listed out the common themes identified as other research priorities. However, these rather similar to priorities identified in the 6 domains except those considered as not important as system strengthening priorities.
The second last paragraph of discussion: this paragraph mainly described or explained how countries responding on covid-19 which found not appropriate. How this relate to the top research priorities? It may be valuable to include the steps further, would the results of this survey be disseminated? to enhance systems strengthening require a coorporation between researchers and stakeholders. So, would it be any engagement with the stakeholder afterwards?
How the general recommendations (Figure 2) arised?
Reviewer #2: Thank you for sharing the paper for review. The topic is important and relevant.
General comments:
The authors emphasized health system strengthening in relation to COVID-19 pandemic, which only highlights the shortcomings of the existing health system facing a crisis. There was neither elaboration on why the earlier studies on research priority setting paid limited or no attention to health system domains for priority setting nor there were any indications that these priorities will be institutionalized irrespective of the COVID-19 or other emerging diseases or crisis. Some statements like importance of public health systems or importance of public-private partnership are made with limited supportive evidence. The reader would benefit from more evidence supporting statements. In addition, it would be informative for reader to provide rationale for six domains for research priority and how they link to health system strengthening, including their operational definition of health system strengthening.
I recommend for publication subject to revision and addressing comments raised.
Method:
a) Representative sample – The paper would benefit by describing how various stakeholders were selected to have representative sample, despite being a convenient sample.
b) Sample size: There is no mention of how sample size was calculated or what was the expected response rate? There is no justification given on total number of respondents (N-84) is good for generalizability of results. The authors could elaborate further on it.
c) Sampling: No sampling design is mentioned. If it is a convenience sampling, it should still be mentioned, and a justification would be helpful.
Data analysis:
a) The authors could provide some information on how they increased the reliability and validity of the collected data. Were there any significant differences in ranking by respondents’ characteristics? Were there regional variations in responses when 15 states are grouped into regions? These comparative analyses could help in shedding light on reliability and validity of the data as well their generalization.
b) The reader would benefit with a specific example of a domain on how formula of average ranking score is applied (Table 2) rather than just describing the formula.
Discussion
a) The authors could elaborate the added value of their rapid method over Child Health and Nutrition Research Initiative (CHNRI) method for research priority setting and why it should be used over CHNRI method. They can add other methods for comparison as well.
b) The author could clarify if COVID19 was not the reference point then: a) will be the priorities remain the same or be different as reflected by other studies? b) How valid will be the findings if the reference to COVID 19 is not made especially for health system strengthening research?
c) Health system resilience was mentioned in relation to a study (Page 22), as “...has exposed glaring loopholes in health systems, and has demonstrated that countries’ response to pandemics is ultimately dependent on the resilience of their health systems (17).” However, the authors did not explain why resilience had not been made part of research domains for research priority ranking. Given the debate whether the resilience is an emergent property of the system arising from the interactions of the systems components or a health system capacity, has important policy, program, and research implications, therefore, a rationale exists for putting it for research priority setting and ranking. The authors could clarify their perspective for not considering resilience as a research priority category.
d) There is no discussion on how these recommendations based on survey will be disseminated to relevant authorities for policy and program development and further research
e) The rationale for how India’s research priorities are relevant for emerging economies need further elaboration/justification.
Reviewer #3: The paper reports on research priorities for MCH in India following the COVID-19 pandemic. The study used CNHR approach to summaries research priorities and input was sought from research, academia, policy makers, and programmes. The study found research on health system strengthening and delivery of existing intervention received highest ranking. The findings are line with expectations during the pandemic when there we few novel interventions that we thought efficacious at the time of the study and optimization of existing interventions are/were most beneficial. The paper is well written and arrives at appropriate conclusions.
Minors Comment
• In the discussion the authors should comment on why research on COVID-19 vaccines did not receive high priority ranking. This is likely because most did not expect an efficacious vaccine to be developed within a year of the pandemic and research could add this to their discussion section.
• The authors should acknowledge potential limitations to the research methodology especially on the self-selected nature of responders, which may bias findings.
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Reviewer #3: Yes: Samuel Akech
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10.1371/journal.pone.0256099.r002Author response to Decision Letter 0Submission Version1
14 Jun 2021
Journal Requirements:
When submitting your revision, we need you to address these additional requirements.
1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at
https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and
We have ensured that the revised manuscript meets PLOS One’s style requirements.
2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.
We have reviewed the reference list in the revised manuscript to ensure that it is complete, current and meets PLOS One’s requirements.
3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.
We have attached the questionnaire used for this survey during the resubmission process.
4. During our internal checks, the in-house editorial staff noted that you conducted research or obtained samples in another country. Please check the relevant national regulations and laws applying to foreign researchers and state whether you obtained the required permits and approvals. Please address this in your ethics statement in both the manuscript and submission information. In addition, please ensure that you have suitably acknowledged the contributions of any local collaborators involved in this work in your authorship list and/or Acknowledgements. Authorship criteria is based on the International Committee of Medical Journal Editors (ICMJE) Uniform Requirements for Manuscripts Submitted to Biomedical Journals - for further information please see here: https://journals.plos.org/plosone/s/authorship
This study was reviewed by the Johns Hopkins Bloomberg School of Public Health (JHSPH) Institutional Review Board (IRB) which classified the proposed activities as “key informants research”, and therefore determined to be exempt from human subjects research oversight. As a result, as per relevant national regulations, we did not need to obtain any additional approvals to administer this survey to stakeholders engaged in maternal and child health in India. This information has been added to the ethics statements as requested. We further acknowledge our local collaborators, from the Indian Academy of Preventive and Social Medicine (IAPSM) in the acknowledgements section of our revised manuscript.
5. Thank you for stating the following in the Acknowledgments Section of your manuscript:
'The authors acknowledge funding provided by the Johns Hopkins Maternal and Child Health
Center - India, and support from the Indian Association of Preventive and Social Medicine
(IAPSM).'
We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.
a. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:
'The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.'
We have removed references to funding information in the acknowledgements section, and would like to revise the funding statement thus:
“The authors acknowledge funding provided by the Johns Hopkins Maternal and Child Health
Center - India, and support from the Indian Association of Preventive and Social Medicine
(IAPSM). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript”.
b. Please include your amended statements within your cover letter; we will change the online submission form on your behalf.
We have included the above amended statement within our cover letter submitted at the time of submission of the revised manuscript.
Additional Editor Comments:
Considering the reviewers reports and my own reading of the paper, I reached to a decision of minor revision. Looking forward to read the revised version of this paper.
[Note: HTML markup is below. Please do not edit.]
Reviewers' comments:
Reviewer's Responses to Questions
Comments to the Author
1. Is the manuscript technically sound, and do the data support the conclusions?
The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.
Reviewer #1: Partly
Reviewer #2: Yes
Reviewer #3: Yes
________________________________________
2. Has the statistical analysis been performed appropriately and rigorously?
Reviewer #1: N/A
Reviewer #2: Yes
Reviewer #3: Yes
________________________________________
3. Have the authors made all data underlying the findings in their manuscript fully available?
The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.
Reviewer #1: No
Reviewer #2: No
Reviewer #3: No
________________________________________
4. Is the manuscript presented in an intelligible fashion and written in standard English?
PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.
Reviewer #1: No
Reviewer #2: Yes
Reviewer #3: Yes
________________________________________
5. Review Comments to the Author
Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)
Reviewer #1: How shifting research priorities in MCH could be the new focus on systems strengthening? It would be beneficial to explain or include in the introduction section as this could direct your focus. Perhaps this could highlight or give a better picture of overall intention of doing this survey?
Thank you for this suggestion. We have added these points in the introduction section of the revised manuscript, Briefly, these lines capture the essence of the findings of similar previous studies (conducted prior to the COVID-19 pandemic). Further, we clarify that there was a knowledge gap regarding the priority areas in maternal and child health research in India during the pandemic era, necessitating this rapid assessment, which then revealed the new focus of the shifting research priorities in MCH to be predominantly health systems strengthening needs.
Any form of survey technique was used to get consensus from the stakeholders or key participants?
Our survey was jointly developed by researchers at the Johns Hopkins Maternal and Child Health Center in India and key stakeholders at Indian institutions engaged in maternal and child health that included the Public Health Foundation of India, All India Institute of Medical Sciences, Kalyani, Postgraduate Institute of Medical Education and Research, Indian Institute of Technology, Kharagpur and Piramal Swasthya Management and Research Institute. Research domains were identified through a review of previous survey results, and literature on global priorities in maternal newborn and child health in consultation with key stakeholders in important Indian institutions. All key stakeholders reviewed the survey and research domains included, and provided input that was incorporated; the final survey was derived by consensus. As this was intended as a rapid assessment, we did not conduct iterative consensus building exercises, and this has been clarified in the Methods section of the revised manuscript.
Do the survey questions developed be tested or validated? And how do the stakeholders were approached asking them to take part in a survey. Any form of sampling technique was used?
Since we aimed to conduct a rapid assessment to identify top research priorities in maternal and child health, we piloted the survey questions among key stakeholders prior to disseminating the survey among potential respondents. The survey tool was novel and was not validated. Key stakeholders working in the field of MCH in India were identified through desk reviews, web-based searches, dissemination in professional networks such as the Indian Association of Preventive and Social Medicine, Indian Public Health Association, Indian Academy of Pediatrics and the Federation of Obstetric and Gynecological Societies of India, and through collaborators. It was a convenience sample based on a snowball sampling strategy. We have added this information to the methods section in the revised manuscript. We acknowledge in the limitation section the potential presence of bias, but have taken care to include a large and diverse respondent population.
Authors have mentioned how they analyzed the survey response. But who and how
We have discussed the methodology we employed for data analysis in greater detail in the revised manuscript. Specifically, we have included the formula we used to calculate the “average ranking score” and substantiate this further with an example to make it easy for our readers. Ranking analysis was conducted by three authors, and we have added these details to the methods section of the revised manuscript.
Participant characteristics: why 84 respondents from 15 states in India. Should it be the main stakeholders? or does it refers to stakeholders from each state in India. Has it been mentioned?
All our respondents were key stakeholders working in the space of maternal and child health in India. They were located in 15 states and 2 union territories in India. Thank you for this suggestion, we have added this information to the participant characteristics in the results section of the revised manuscript.
I would say the primary area of work for others, 16 is many. Would it be any way to regrouped the primary area of work, so it provides more representative towards those work related to MCH?
We took a closer look at the primary area of work listed by the respective respondent, and have updated table 1 in the revised manuscript. Following appropriate regrouping, as well as the addition of two new categories, namely, environmental and occupational health, and clinical research, we are now left with only 4 areas listed under “other”. This will make for clearer understanding for the readers.
Overall ranking of research priorities: the word 'concurrent' to explain the overall ranking exercise may not be suitable, suggest to rewrite
We have replaced the word “concurrent’ with “in agreement”, signifying that the priority research domains identified by the Likert scale importance assignment and overall ranking exercises were in agreement in all domains, except the infectious disease domain.
Authors have listed out the common themes identified as other research priorities. However, these rather similar to priorities identified in the 6 domains except those considered as not important as system strengthening priorities.
We agree that the “other research priorities” identified by the respondents are similar to the broader sub-domain themes, and fall within the wider area of systems strengthening. We clarify this further in the results section of the revised manuscript, and have further added other non-systems strengthening themes identified by the respondents in the revised manuscript.
The second last paragraph of discussion: this paragraph mainly described or explained how countries responding on covid-19 which found not appropriate. How this relate to the top research priorities? It may be valuable to include the steps further, would the results of this survey be disseminated? to enhance systems strengthening require a coorporation between researchers and stakeholders. So, would it be any engagement with the stakeholder afterwards?
These are very helpful observations. In our study, we found that across various domains of maternal and child health, the overall focus was on strengthening existing services and service delivery mechanisms during the COVID-19 pandemic era. As a real-world example, in the penultimate paragraph we discuss how certain countries that invested heavily on their health systems early in the course of the pandemic, experienced early success in coronavirus control, substantiating the fact that health system strengthening is of utmost importance, as was identified by the respondents in our study.
How the general recommendations (Figure 2) arised?
The general recommendations in figure 2 have been derived from the World Health Organization’s report on research for universal health coverage, and they have also been informed by the findings of our study and discussions with key stakeholders. We have added these details to the discussion section of our revised manuscript, and also to the figure’s legend.
Reviewer #2: Thank you for sharing the paper for review. The topic is important and relevant.
General comments:
The authors emphasized health system strengthening in relation to COVID-19 pandemic, which only highlights the shortcomings of the existing health system facing a crisis. There was neither elaboration on why the earlier studies on research priority setting paid limited or no attention to health system domains for priority setting nor there were any indications that these priorities will be institutionalized irrespective of the COVID-19 or other emerging diseases or crisis. Some statements like importance of public health systems or importance of public-private partnership are made with limited supportive evidence. The reader would benefit from more evidence supporting statements. In addition, it would be informative for reader to provide rationale for six domains for research priority and how they link to health system strengthening, including their operational definition of health system strengthening.
I recommend for publication subject to revision and addressing comments raised.
In the introduction section of the revised manuscript, we explain how results from similar research priority setting exercises, undertaken both globally and nationally had identified research priorities that were mostly related to implementation research; several of which pertain to health systems strengthening as well. However, these exercises had also identified areas of novel “discovery” research, and data were lacking regarding the relevance of such priorities during the era of an unprecedented pandemic. We undertook this rapid assessment to further understand and inform this data gap, and found that the overall focus for research priorities in MCH in India during the COVID-19 pandemic is on strengthening existing services and service delivery, rather than novel research.
Since we designed our rapid assessment to determine research priorities in maternal and child health in India during the COVID pandemic, it would be difficult for us to predict how the identified priorities would change if the reference for COVID-19 would not be made. While it is likely that the focus will continue to remain on health systems strengthening, given that the pandemic has exposed glaring loopholes in health systems, this question motivates us to conduct a follow up exercise to identify top priorities in maternal and child health research once the pandemic subsides.
With regards to the importance of public health systems and public-private partnerships, we have added relevant references to substantiate the statement.
Following the reviewer’s observations and suggestions, in the revised manuscript, we have further explained how the six research domains were identified, and in the results and discussion sections, we address how the top priorities identified are related to health systems strengthening. We used the WHO’s operational definition for health systems strengthening to thematically analyze responses that would be categorized into the broader theme of “health systems strengthening”; and have included this information in the methods section of the revised manuscript.
Method:
a) Representative sample – The paper would benefit by describing how various stakeholders were selected to have representative sample, despite being a convenient sample.
In the methods section of the revised manuscript, we have now discussed our sampling strategy in greater detail. To clarify, stakeholders were identified across various domains of maternal and child health, including those primarily engaged in academia, or specific research areas such as health systems, policy and economics, nutrition, and tribal health. Since this was a rapid assessment, we employed convenience sampling, based on a snowball sampling strategy, and we have added these details in the methods section of the revised manuscript.
b) Sample size: There is no mention of how sample size was calculated or what was the expected response rate? There is no justification given on total number of respondents (N-84) is good for generalizability of results. The authors could elaborate further on it.
Since this was a rapid assessment, we did not target a specific sample size; we analyzed responses from this that we received until the closure of the online survey. We have added this information to the methods section of the revised manuscript, and further acknowledge this approach as a limitation in the discussion section of our revised manuscript.
c) Sampling: No sampling design is mentioned. If it is a convenience sampling, it should still be mentioned, and a justification would be helpful.
We have described our sampling strategy in greater detail in the revised manuscript. To clarify, stakeholders were identified across various domains of maternal and child health, including those primarily engaged in academia, or specific research areas such as health systems, policy and economics, nutrition, and tribal health. Since this was a rapid assessment, we employed convenience sampling, based on a snowball sampling strategy, and we have added these details in the methods section of the revised manuscript.
Data analysis:
a) The authors could provide some information on how they increased the reliability and validity of the collected data. Were there any significant differences in ranking by respondents’ characteristics? Were there regional variations in responses when 15 states are grouped into regions? These comparative analyses could help in shedding light on reliability and validity of the data as well their generalization.
The results obtained here were obtained from a rapid assessment to identify top research priorities in maternal and child health across India during the COVID-19 pandemic, and included 84 expert respondents from across 15 states and 2 Union Territories in India. While all the regions of India had some representation, the sample size was small and may preclude assessments of rankings by region. However, this is a valid comment by the reviewer, and we examined our data to see if there were regional variations, and unsurprisingly we did not find any significant differences. We will explore if differences exist in future work. We acknowledge these limitations in the Discussion section of the manuscript, advising caution about generalization of these results as regional variations in ranking of priorities may not have been captured due to the small sample size of survey respondents.
b) The reader would benefit with a specific example of a domain on how formula of average ranking score is applied (Table 2) rather than just describing the formula.
We have included an example to illustrate how the average ranking score was calculated in the methods section of the revised manuscript. Specifically, in this method, sub-domain research priorities that were ranked as “1” would receive the largest weight depending on how many sub-domain research priorities were present in each domain. For example, in the vaccine preventable diseases domain, if individuals ranked “Strengthening the public health workforce” as their “1” priority, the weight would be “10” since there were 10 sub-domain research priorities listed underneath this domain. If individuals ranked this sub-domain research priority as “2”, then the accompanying weight would be “9”, and so on. The weights were then multiplied by the count of how many respondents ranked the sub-domain research priority as “1”, “2”, and so on. The total sums of all weighted scores were then divided by the total number of respondents for that sub-domain research priority. Thus, the average ranking score of each sub-domain research priority was then calculated using the formula,
Average ranking score = (x1w1 + x2w2 + x3w3 ... xnwn)/ Total response count
Where, w = weight of ranked position, and x = response count for each rank.
a) The authors could elaborate the added value of their rapid method over Child Health and Nutrition Research Initiative (CHNRI) method for research priority setting and why it should be used over CHNRI method. They can add other methods for comparison as well.
In the discussion section of the revised manuscript, we mention other methodologies used to identify top research priorities, and describe why we chose our rapid method over the CHNRI method in the discussion section of the revised manuscript. Other research priority setting methodologies such as the CHNRI method, Combined Approach Matrix method, the Essential National Health Research (ENHR) method, Council on Health Research and Development (COHRED) method, the James Lind Alliance method and the Delphi method, are comprehensive methods, but they involve iterative processes which require substantial time and resources to complete. We therefore adopted our rapid method since we aimed to undertake a brisk assessment to identify key priorities for public health research in MCH in India within the context of the COVID-19 pandemic.
b) The author could clarify if COVID19 was not the reference point then: a) will be the priorities remain the same or be different as reflected by other studies? b) How valid will be the findings if the reference to COVID 19 is not made especially for health system strengthening research?
We designed our rapid assessment to determine research priorities in maternal and child health in India during the COVID-19 pandemic, with the goal of understanding what, if any, changes in research priorities were perceived by the larger scientific and public health community. If COVID-19 were not a central event during the period of this research, or if this research were conducted prior to the pandemic, it is likely that our findings would be similar to previous studies to identify research priorities in maternal and child health that were conducted prior to the COVID-19 pandemic by Arora et al, 2017 and Souza et al, 2014, that mainly identified priorities that pertained to implementation sciences and innovation.
It is likely that as the pandemic has exposed gaps and weaknesses in the health systems, there is a heightened awareness that these gaps need to be addressed, and hence we believe our findings from this rapid assessment carry immense relevance and urgency.
c) Health system resilience was mentioned in relation to a study (Page 22), as “...has exposed glaring loopholes in health systems, and has demonstrated that countries’ response to pandemics is ultimately dependent on the resilience of their health systems (17).” However, the authors did not explain why resilience had not been made part of research domains for research priority ranking. Given the debate whether the resilience is an emergent property of the system arising from the interactions of the systems components or a health system capacity, has important policy, program, and research implications, therefore, a rationale exists for putting it for research priority setting and ranking. The authors could clarify their perspective for not considering resilience as a research priority category.
We agree with the reviewer that health system resilience would have been a domain area to be considered. At the time of the design of the survey, we considered specific topic areas rather than cross-cutting concepts such as health system resilience. Our cross-sectional survey, conducted a few months into the COVID-19 pandemic identified that focusing on research on strengthening existing health systems and service delivery was most important for maternal and child health during the ongoing pandemic. Since health system resilience is the ability to prepare for, manage (absorb, adapt and transform) and learn from shocks such as pandemics, it is likely that a follow up exercise conducted during the post-pandemic period would be well positioned to identify research priorities pertinent to health system resilience. This comment has prompted us to plan to explore health systems resilience further in our future work.
d) There is no discussion on how these recommendations based on survey will be disseminated to relevant authorities for policy and program development and further research.
Our rapid assessment to identify top priorities in maternal and child health research in India during the COVID-19 pandemic era has led to important learnings, and we have shared the results of our study with the stakeholders who participated in the study. In addition, we have shared it with the leadership of the premier body of public health professionals in India, the Indian Academy of Preventive and Social Medicine (IAPSM). We hope that by publishing our findings in a reputed journal such as PLoS One would enhance our ability to disseminate these important findings to relevant authorities for policy and program development and further research.
e) The rationale for how India’s research priorities are relevant for emerging economies need further elaboration/justification.
Conducting research priority setting exercises is usually an expensive and time-consuming process, and difficult to conduct in other low- and middle-income (LMIC) settings, especially during the ongoing pandemic. The findings of our rapid assessment to determine top research priorities in maternal and child health in India have identified systems strengthening as most important during the pandemic. Other emerging economies such as Sri Lanka and Bangladesh, that have strong primary health systems have fared much better in the pandemic, especially during the second wave, although these data are still emerging. Given the similarities in health systems, populations served and limited resources across other LMIC settings, we believe that policymakers and stakeholders from other emerging economies could also benefit from these findings.
Reviewer #3: The paper reports on research priorities for MCH in India following the COVID-19 pandemic. The study used CNHR approach to summaries research priorities and input was sought from research, academia, policy makers, and programmes. The study found research on health system strengthening and delivery of existing intervention received highest ranking. The findings are line with expectations during the pandemic when there we few novel interventions that we thought efficacious at the time of the study and optimization of existing interventions are/were most beneficial. The paper is well written and arrives at appropriate conclusions.
Minors Comment
• In the discussion the authors should comment on why research on COVID-19 vaccines did not receive high priority ranking. This is likely because most did not expect an efficacious vaccine to be developed within a year of the pandemic and research could add this to their discussion section.
We agree with the reviewer and are equally surprised to note that research on COVID-19 vaccines did not receive high priority ranking. The most likely reasons are that expectations were low for having a fully developed vaccine within less than a year of virus discovery. We have discussed this further in the discussion section of our revised manuscript.
• The authors should acknowledge potential limitations to the research methodology especially on the self-selected nature of responders, which may bias findings.
We discuss the limitations of our study in the discussion section of the revised manuscript, and specifically allude to selection bias, as has been rightly pointed out.
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Submitted filename: Responses to reviewers comments.docx
10.1371/journal.pone.0256099.r003Decision Letter 1GoliSrinivasAcademic Editor2021Srinivas GoliThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Submission Version1
2 Aug 2021
Shifting research priorities in maternal and child health in the COVID-19 pandemic era in India: a renewed focus on systems strengthening
PONE-D-21-06707R1
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10.1371/journal.pone.0256099.r004Acceptance letterGoliSrinivasAcademic Editor2021Srinivas GoliThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
4 Aug 2021
PONE-D-21-06707R1
Shifting research priorities in maternal and child health in the COVID-19 pandemic era in India: a renewed focus on systems strengthening
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