Describing the evolution of Iran’s health research system over 50 years, understanding the profile of its publications, and setting the national health research priorities

Introduction: Health research is essential towards improvement of population health and development. Hence, it is of much interest to study the low- and middle-income countries (LMICs) that have improved their health research performance. A substantial growth has been reported in the number of Iran’s research publications over the past three decades, throughout the times of socio-economic and political instability. Some criticise this growth for having had led to a decline in citation impact of health research in Iran. The overall aim of my PhD was to obtain a better understanding of the changes in different components of Iran’s health research system (HRS) over 50 years and investigate different patterns in the growth of its health research publications. As a way to move forward, I also aimed to identify Iran’s health research priorities for achieving its long-term health targets. The policy recommendations raised from the findings of this PhD should provide lessons to share with other LMICs. Notably, the priority-setting study provides a model on how to implement a systematic and inclusive method towards improving health research governance at the national level. Methods: My PhD consisted of four studies. For the first study, I conducted a narrative review of the literature on HRS in Iran. My search strategy was guided by the HRS framework developed by the World Health Organization (WHO). I searched MEDLINE and Google Scholar; after removing the duplicates, 805 articles were retrieved, of which 601 were irrelevant. I categorised and reviewed the remaining 204 records according to the WHO HRS framework. For the second and the third studies, I undertook bibliometric analyses of Iran’s biomedical, clinical, and public health research publications for the period 1965-2014. I used Web of Science Core Collection and its different tools for retrieving and analysing the publications and used Journal Citation Reports® to find information about the journals. I also investigated different types of collaborations across the highly-cited papers based on the affiliations, the characteristics of the language of the authors’ names, and the authors’ study and work backgrounds. In the last study, using the Child Health and Nutrition Research Initiative (CHNRI) method, I engaged 48 prominent Iranian academic leaders in the areas related to Iran’s long-term health targets, a group of research funders and policymakers, and 68 stakeholders from the wider society to set Iran’s health research priorities. Results: Iran’s number of health research publications has substantially increased since 2000: a surge was seen in 2007, and the figure reached a peak in 2011. The first surge could be the result of an increased visibility, due to the addition of new Iranian medical journals to international bibliographic databases, while the peak could be due to increased financial and infrastructural resources and incentives that had promoted publications. H-index of publications has also increased (almost doubled between 2000 and 2010). 30.9% of the mostcited publications had only relied on Iranian resources (including 48 publications); of which the majority were original basic sciences research; and had been published in journals with impact factors ranging between 0.4 and 8.3. In general, it does not seem that the growth of the quantity and the citation impact of Iran’s publications has led to a significant impact on decision making and practice. Iran has made some progress in different functions of its HRS over the last 50 years, such as starting a discourse surrounding health research ethics, prioritysetting, and placing monitoring mechanisms while increasing the capacity for conducting and publishing research. However, significant improvements are still required to address the gap between the knowledge producers and users. In the prioritisation study which I conducted, 128 proposed research questions were scored independently using a set of five criteria: (i) feasibility, (ii) impact on health, (iii) impact on economy, (iv) capacity building, and (v) equity. The top-10 priorities were focused on: health insurance system reforms to improve equity; integration of non-communicable diseases (NCDs) prevention strategy into primary healthcare; cost-effective population-level interventions for NCDs and road traffic injury prevention; tailoring medical qualifications; epidemiological assessment of NCDs by geographic areas; equality in the distribution of health resources and services; current and future common health problems in Iran’s elderly and strategies to reduce their economic burden; the status of antibiotic resistance in Iran and strategies to promote rational use of antibiotics; the health impacts of water crisis; and research to replace the physician-centred health system with a team-based one. Conclusions: A great capacity for health research lies in Iran. This capacity can be strengthened with further investment in national priorities; fostering collaboration with Iranian diaspora who have shown interest and capacity in collaboration with peers at home; supporting institutions that are lagging behind while ensuring allocation of adequate resources to academics in Iran with proved capacity; and avoiding excessive use of bibliometrics in health research assessment practices. Furthermore, the findings highlighted consensus amongst various prominent Iranian researchers and stakeholders over the research priorities that require investment to generate information and knowledge relevant to the long-term health targets. Finally, it was concluded that the CHNRI method is an appropriate tool to use in the contexts where participants have limited freedom to express opinions on a panel of experts; and/or where the macro-level decision-making system is highly centralised and stakeholders from the wider society are rarely engaged in decision-making processes