INTRODUCTION

Article 14 of the Political Constitution of Peru states “to promote the scientific and technological development of the country” as a duty of the State ⁽¹. No. 26842, General Health Law, establishes that “the State promotes scientific and technological research in the field of health, as well as the education, teaching and training of human resources for health care” ²; from which it can be interpreted that the advancement of science derives from education and research, which are the pillars for the development of society, and the State guarantees their promotion.

The Ministry of Health (MINSA), as an agency of the executive branch of the government ³, has the mission of “protecting personal dignity, promoting health, preventing diseases and guaranteeing comprehensive health care for all the inhabitants of the country, proposing and conducting health policy guidelines in consultation with all public sectors and social actors” ⁴. The incorporation of health research and technology under the scope of the competence of MINSA has been established since 2013 with the publication of Legislative Decree No. 1161, which approves the Law on the Organization and Functions of MINSA, ⁵.

Likewise, the vision of the National Institute of Health (INS) is “to be a modern, dynamic and leading institution at the national and international level in the generation, development and transfer of technologies and scientific knowledge in biomedical research [... ]” ⁶. Within this framework, the INS leads the development of the process for the identification of research priorities at the national level, with the objective of generating knowledge in the field of public health in order to guide the formulation, implementation and evaluation of policies and interventions that allocate resources for the attention of prioritized health problems due to the fact that resources in Peru are limited ⁷.

The purpose of this article is to describe the process followed by the Subdirectorate of Research and Laboratories for Noncommunicable Diseases (SUDENT) of the National Center for Public Health (CNSP), with the technical advice of the Directorate of Research and Innovation in Health (DIIS) and in coordination with the Executive Directorate of Oral Health of the General Directorate of Strategic Interventions in Public Health (DGIESP) of MINSA, for the identification of “National Priorities for Research in Oral Health”; as well as to provide recommendations for future processes.

PREVIOUS PROCESSES

Historically, experiences in Peru have been developed since 1974 to identify health research priorities, each of which has guided health policies since then. In the first process, MINSA expressed the intention to support health institutes for research. The National Action Plan was developed during the second process (1983-1984) aimed at achieving “health for all by the year 2000”. During the third process (1991-1994), the National Council for Science, Technology and Innovation (CONCYTEC) and the Pan American Health Organization (PAHO) worked on four priority topics and channeled available resources. In the fourth process (1996-1997), the MINSA Health Research Policy Commission identified new thematic areas and prepared 234 study sheets. During the fifth process (2001-2002), the INS defined the research guidelines through an internal seminar-workshop. Finally, during the sixth process (2006-2007), according to Cabezas et al. ⁸, quoted by the Directorate of Health Research and Innovation ⁹, “the INS deepens the scope and methodology of establishing research priorities” consolidating its participatory methodology.

The process of identification of regional priorities was carried out for the first time in 2019, which established the priorities for the 2010-2014 period, defining “health research” as: “the production of knowledge aimed at studying the health conditions (at the biological, psychological and social levels) of an individual or population and the responses of society to improve them” ⁸.

The process that started in 2009 continued during 2014 with the development of workshops in the 24 regions of Peru and Metropolitan Lima with the participation of regional health authorities, public and private universities, public and private research entities, and other regional governmental sectors convened by the INS to establish the National Research Priorities 2016-2021^7,9. These priorities were implemented in 2019, through the Ministerial Resolution No. 658-2019/MINSA, which approves the National Research Priorities in Health in Peru 2019-2023, identifying the following health problems: (i) Traffic accidents; (ii) Cancer; (iii) Metabolic and cardiovascular diseases; (iv) Respiratory infections and pneumonia; (v) Sexually transmitted infections and HIV-AIDS; (vi) Malnutrition and anemia; (vii) Metaxenic and zoonotic diseases; (viii) Environmental and occupational health; (ix) Maternal, perinatal and neonatal health; and (x) Mental health ¹⁰. It is important to mention that, as stated in the document of the identification process of these National Health Research Priorities, one of the health problems identified was “oral health” ¹¹; however, since the problems that obtained the highest scores were prioritized, oral health did not appear in the final prioritization list.

In this scenario, oral health requires a revaluation in order to gain greater attention regarding research in our country after having been relegated for decades, justifying a specific identification of Oral Health Research Priorities.

In 2021, the National Institute of Health, through SUDENT of the CNSP, incorporated oral health as an area of work, establishing the “Oral Health Plan 2021-2023”, which began with the identification of National Oral Health Research Priorities 2021-2025, and whose process will be described in this article ¹². This prioritization will be fundamental to guide the development of cost-effective research and to optimize the use of the country’s economic resources, taking the previous process as a reference ⁷.

THE PROCESS

The identification of Oral Health Research Priorities, which took place from June 2 to June 25, 2021, was led by the SUDENT technical team, which was made up of four professionals (one physician and three dental surgeons) who had experience in research and academic training in fields related to Public Health, Epidemiology and/or Health Services Management. The DIIS technical team (the office that has led the National Research Priorities process and validated the methodology during the application of this research prioritization process) also provided advice, and worked in close coordination with the technical team of the Executive Directorate of Oral Health (DSABU) of the DGIESP of MINSA. The activities were developed through virtual workshops via the Zoom platform based on the participatory methodology adopted from the “Guide for the identification of Regional Health Research Priorities” prepared by the DIIS of the INS ^9,13.

Three key actors were identified based on the following characteristics (Table 1):

1. Researchers/specialists, who met at least two of the four conditions: i) being a researcher recognized by the National Scientific, Technological and Technological Innovation Registry (RENACYT) (via DINA-CONCYTEC platform ¹⁴ at the date of download as of March 30, 2021; ii) having published two or more research articles with relevance in oral health (letters to the editor were not considered) in national or international peer-reviewed journals; iii) teaching in a public or private university; and iv) being a specialist in a dental area. The SUDENT technical team was able to access the telephone numbers and/or email addresses of 78 professionals from the list of identified professionals who met the above conditions, which were used to contact them through social networks, telephone calls and/or WhatsApp in order to ask them to participate in the process; of the 78 contacted professionals, 46 (59.0%) responded and accepted. This call took place between May 18 and 28, 2021.

2. Decision-makers, made up of the three members of the team of the Executive Directorate of Oral Health (due to availability in some phases 2 were involved) and the 29 Coordinators of the oral health program belonging to the Regional Health Directorates (DIRESAS), Regional Health Managements (GERESAS) and Integrated Health Networks Directorate (DIRIS). The list of coordinators of the national oral health program was provided by the DSABU, which provided logistical support to manage the call via email; this call took place between May 18 and 28, 2021. All coordinators responded and accepted, for a total of 32 decision makers.

3. Experts in Oral Health, formed by ad honorem members of the Committee of Experts of the DSABU of the DGIESP through Ministerial Resolution No. 571-2017/MINSA ¹⁵. DSABU provided the contacts of the seven members of the referred committee, who were summoned by phone calls and/or WhatsApp between May 18 and May 28, 2021. After the call, three experts (42.9%) responded and accepted the invitation.

The phases of the process are described below:

RESULTS AND COMPARISONS

Research priorities are defined by the INS as “research needs prioritized on the basis of the health problems that most affect the population and that require effective and efficient responses” ²¹. This important work has been carried out by the INS in several opportunities, which materialized in Ministerial Resolutions such as Ministerial Resolution No. 262-2022/MINSA ¹⁸ that approves the “National Research Priorities in Oral Health” (Table 5), which are the subject of this article.

The National Institute of Dental and Craniofacial Research of the United States, known as NIDCR, developed its 2021-2026 Strategic Plan based on four guiding principles and five strategic priorities with their respective objectives ²². Similarly, the National Institute for Health Research (NIHR) in England has established 10 oral health priorities ²³. When reviewing the plan and the questions identified by the English community, some similarities were found between their objectives and the priorities identified in Peru, ¹⁸; the main difference between both processes and ours being the participants. This process was carried out with researchers/specialists, decision-makers and experts (there was no participation of the civil society); while in the USA, several entities related to the scientific community, federal agencies and industry participated; and in England, the NIHR group participated in collaboration with the dental schools and public health in England to identify unanswered questions related to oral health research for patients, the public, caregivers and oral health professionals.

On the other hand, the 2018 priority identification study in Iran, a developing country like ours, reported 171 topics in six areas related to Oral Health, obtaining 44 topics on “dental clinical care and treatment”, 37 topics on “health and prevention”, 19 topics on “health promotion and education”, 37 topics on “management of dental care delivery”, 16 topics on “policies and their requirements” and 18 topics on “dental materials, equipment and technologies” ²⁴, topics that largely coincide with those identified in Peru ¹⁸.

Among Latin American countries, Brazil considered oral health in its National Health Research Priorities Agenda in 2015, whose subagenda coincides with the National Oral Health Research Priorities of Peru in the topics related to epidemiology, risk factors, development of the epidemiological system, development of strategies for oral health promotion, innovations for treatment and supply of oral health services ²⁵.

The Oral Health Research Priorities identified in Peru are in line with the research priorities for strengthening the Global Health Action for Oral Health, which are rooted in the knowledge gaps in: i) Epidemiology and health information systems for the surveillance of oral conditions; ii) Collection, harmonization and rigorous evaluation of evidence for equity in the prevention and treatment of oral conditions; and iii) Strategies to provide essential quality oral health care without financial barriers ²⁶.

EXPECTED IMPACT

The oral health situation in Peru is a public health problem, as it ranks second among the 10 leading causes of morbidity in the three natural regions (coast, highlands and jungle) of the country ²⁷. The health emergency caused by the COVID-19 pandemic has aggravated the oral health of the Peruvian population. The restrictions on access to health services, especially dental care, adopted to mitigate contagion ^28-31 showed the need for the identification and implementation of new health interventions, guidelines and public policies in the field of oral health, taking into account the current context. Therefore, the “National Oral Health Research Priorities 2022-2026” ¹⁸ have a transcendental role in guiding future research on oral health and will in turn serve to redefine policies and establish and/or reformulate more effective programs ³² that will contribute to the improvement of the health system ³³, in accordance with Law No. 31540, which declares the formulation and implementation of the national oral health policy to be of national interest and public necessity ³⁴.

LESSONS LEARNED, PERSPECTIVES AND RECOMMENDATIONS

It should also be noted that during this process, decision-makers in the public management of oral health at both central and regional levels, who may change according to the political context, were considered as actors; therefore, it was important to have the vision of the academia, represented by professionals who evidence the conduct of research.

It is relevant to understand the social context in which the process was carried out, since there were some restrictions for face-to-face coordination due to the COVID-19 pandemic. All coordination and activities were carried out virtually, which did not guarantee full participation of the initially considered actors; however, all actors in all stages and phases of the process participated, which allowed having different points of view.

Regarding the conduct of the process by the SUDENT team, it should be noted that all actions involving changes in the proposals were carried out under consensus and subsequently reviewed in the subsequent stage for acceptance.

The process complied with the guidelines established in the Methodological Guide of the DIIS ⁹ under the technical advice of the DIIS (which has carried out previous processes of identification of national health research priorities). Therefore, pre-publication of the list of priorities was not possible because throughout the process, criticism and recommendations were received from the invited key actors, whose contributions and comments were openly valued. However, the omission of pre-publication, as well as the declaration of conflicts of interest, could be considered as limitations.

Another limitation in this process was related to the difficulties of the key actors to continually participate in all phases and activities, which was related to aspects of time availability; however, it should be noted that this difficulty was mitigated to a greater extent by conducting the process virtually. Regarding the varying participation rate, we must recognize potential participation bias due to voluntariness, which could represent a potential motivation that was not declared as a conflict of interest and could not be identified or noticed.

Selection bias is also a possibility, given that although the list of researchers with RENACYT code (30 researchers according to the download date) was used to contact the key actors of the group that represents the researchers, and although most of them provided their email address, not all of them could be reached. Therefore, they were contacted through their contact network, social networks and/or WhatsApp; however, some did not respond, the line was out of service, or they were not available. In view of this situation, dental surgeons who work as teachers and direct the development of research protocols at universities were included. Specialists, who apply the results of the research directly on the patient were also included. Therefore, the representativeness of the oral health scientific community may have been affected.

In conclusion, this article has described the process followed for the identification, for the first time, of the Oral Health Research Priorities in Peru, which are valid from 2022 to 2026 and will guide the development of research that will be used as evidence for decision-making in oral health, in the hope that this process will serve as a model for the identification of a new list of research priorities in this field, being perfected each time.

After identifying priorities on the basis on the National Multisectoral Health Policy 2030 ³⁵, the published report on Global Oral Health by the World Health Organization ratified that oral health requires urgent action and highlights the challenges and opportunities for oral health ³⁶ that should be considered for research aligned with the priorities identified during this process.

We call on all oral health research professionals to contribute to the development of Peruvian scientific production framed within these priorities, thus contributing with scientific evidence that will support solid public policies for the benefit of Peruvian society. In addition, we recommend the DIIS to evaluate the relevance of incorporating the pre-publication of results and the declaration of conflicts of interest as part of the methodology for future processes.

Similarly, it is necessary to promote the implementation of the National Priorities for Oral Health Research in the academia, in order to encourage its development in universities throughout the country; this will also allow the competent bodies to include the topic of oral health in the competitive funds encouraging researchers to develop research that require a larger budget, such as clinical trials and technological innovations, considering the importance of funding for research of the highest quality, taking the National Institutes of Health as a model ³⁷. The priorities identified in terms of their approach represent a macro level for the planning and management of oral health research, which should help public and private institutions, as well as the academia, in order to formulate research topics/lines/ideas, which in a more specific way will promote the formulation of research questions that are aligned with the needs to generate evidence and guarantee an adequate use of the limited resources available.