In February 2011, the Department of Health Research (DHR), Government of India, came out with a draft National Health Research Policy (1). It is presumed that after due deliberation, the core of this document, with necessary amendments, will become the guideline for future medical and health research in this country.

The point of departure of this document is the recognition that health is an important component of development, and that investment in health research can be a key input in social and economic development. This realisation is a direct consequence of the policy environment created by the "90/10" approach of the Global Forum for Health Research (pointing out that 90% of resources for research are spent on 10% of the global problems, which are more important to the developed world). Tacit in this approach is the admission that this key input into development has been more or less ignored for a long time; in fact this admission is made explicit in many parts of the document. In spite of having perhaps the largest number of medical and allied health training institutions in the world, our research output is pitifully low and it is concentrated in a few well-funded institutions. Many researchers of Indian origin, trained in India, have made their mark in medical and health research working in institutions abroad. All this underlines the absence of a work culture that encourages research, and the paucity of role models for youngsters who would take up research as a career.  On the other hand, as the document itself admits, the "glamour" of a career in curative medicine continues to be powerful enough to attract the brightest young minds.

Nothing new

Introspection along these lines is not new. In fact, reading this document gave me a sense of "djvu". In the 1970s and 80s, under the stewardship of Dr Ramalingaswamy, himself no mean researcher and one-time head of the All India Institute of Medical Sciences, the Indian Council of Medical Research (ICMR) launched a scheme for attracting youngsters into medical research. This too was motivated by the realisation that the best minds in medical colleges opted for careers outside research. Under this scheme, students competed for a national scholarship, which covered their postgraduate education and supported them in the early part of their career; in return, it was expected that they would produce research relevant to the country’s needs and persist in a career in research. I am not aware of many researchers in the medical field in India who have made their mark on the national or international scene who came out of that scheme. (There may be a few; however, it made no palpable impact on the research scene in India.) Then, as now, correcting the lack of pecuniary and career incentives was only a necessary condition, but not sufficient for promoting original research. Now, as then, the need is for creating an environment in medical and research institutions where research is not done as a necessary part of career advancement, but as a highly creative endeavour that satisfies your urge for self-expression.

According to the document, the government now proposes to remedy this by constituting a "national health research management forum" (NHRMF) that will prioritise the areas for research, and channel funds accordingly. It also proposes to restructure the career path of health researchers with adequate incentives built in, so that people choosing a research career will be sufficiently rewarded, both materially and emotionally. The whole edifice of national health research would be under a committee presided over by two ministers and be administered by a career bureaucrat.

If we felt that nationally we were not producing enough young poets or writers, would our government in its wisdom try to solve the problem by creating such a forum as this? Can creativity be "managed" and "monitored" by committees?

Incentives alone are not enough

While many of the things the document says about the importance of health research to development and the need for creating a research culture among medical doctors in India is true, this analysis lacks any real grasp of what motivates researchers. It is true that career prospects and the incentive structure for medical researchers in India need improvement; a national level priority setting may also help in giving the right signals as to where we need to focus. However, what researchers really need in order to produce original work is a more congenial environment for work, as well as a highly transparent and responsive approach to funding and support. It is worth noting that some of the best medical research in India has come from institutions not particularly known for their very attractive salary structure, such as the Christian Medical College at Vellore. Excellent work of international quality has been produced by nongovernmental organisations working among tribal and other marginalised communities, as exemplified by the Society for Education, Action, and Research in Community Health in Gadchiroli. At least a few non-governmental organisations such as the Foundation for Research in Community Health, and Centre for Enquiry into Health and Allied Themes have contributed much to policy and ethics-related research. It is commitment to solving people’s problems, as well as to quality at the highest level, which has led to these. Any researcher with some experience in India will be aware of the delays, lack of transparency, and indifference to quality for which many agencies governing medical and health research in India are known. While the draft document correctly identifies many of the problems plaguing health research in India, we need to introspect a little more into the root causes of the problem and the role that government agencies could play in easing things for health researchers.

The document emphasises the need to move away from the biomedical model and include social and behavioural research as an integral part of health research. There is a wealth of social science research related to health that has come out of India and has been recognised all over the world. We have had a joint panel of the Indian Council for Social Science Research (ICSSR) and the ICMR that has come out with recommendations for an alternate model of healthcare. There are at least a few academic institutions in India that have done commendable work on social science and medicine: the Centre for Social Medicine and Community Health at Jawaharlal Nehru University, the Centre for Development Studies at Thiruvananthapuram, and the Tata Institute for Social Science in Mumbai, to name a few. However, there is no recognition of this in the document; nor is there any plan to nurture such institutions in future. In the light of the establishment of the National Rural Health Mission and the National Health Service Resource Centre, inputs from these institutions become valuable in shaping the future of health research in India. One of the concerns explicitly stated in the document is equity; yet, it fails to mention one important recent international document, the report on the social determinants of health. India is a country with many states performing at different levels in health and yet, policy research into governance and performance does not find a place in the document. How does the DHR or the National Health Research Management Forum see the future integration of the biomedical and the social, economic, anthropological, and policy dimensions of health research if it restricts itself to addressing only medically trained doctors?

Medical and health research in India is now funded and supervised by a broad spectrum of agencies, including the ICMR, the ICSSR, the Department of Science and Technology, the Department of Biotechnology, the University Grants Commission and foreign funders. It is not clear from the document whether the new agency proposes to integrate all these different types of research; in fact, it would be a near impossible task, since the range of approaches covered would be enormous. One suspects that the real motivation for this proposal is the desire for control and that too, of biomedical research in particular. While it is true that biomedical research is on the threshold of unimaginable breakthroughs and while it is equally true that the direction of such research can easily go astray and cause enormous damage, the way to prevent such waywardness is not bureaucratic control. What are needed are systems of peer review and transparency that would discourage research that will not fit into the paradigm of what is desirable.

What about accountability?

What one would have liked to see in such a document is an approach on how the DHR proposes to ensure accountability from the side of the government and the ministry. Researchers want an assurance that their ideas will be discussed seriously and reviewed by competent peers, through a fair process. They want an assurance on the timeframe for such a process, and avoidance of delays. They want the DHR to facilitate and promote inter_disciplinary and inter-institutional research, and not get bogged down in bureaucratic quibbles on who is entitled to what. They would like the whole process of proposal submission to be made easy and painless in these times of electronic communication. They would like an assurance that the data that they have generated would be theirs to analyse and publish, and not be put under strictures about not publishing. Above all they would like the DHR to promote an institutional culture where new ideas are welcomed and given serious consideration, not stifled by the hierarchy of official position.

I wish the document, instead of listing the organisational structures under which research would henceforth have to be done in India, had initiated a discussion on these aspects. As it is, I don’t see this document catalysing path-breaking medical or health research in India. On the other hand, I am confident that such research, though rare, will continue to happen in this country in spite of the document, because of the enormous store of creativity that our youngsters possess.