How do we better engage national-level voices in research prioritisation in fragile and conflict-affected contexts?

We at the International Rescue Committee (IRC) recently conducted two research studies with R2HC’s support: one, a prospective cohort study on a combined protocol for acute malnutrition treatment in Somalia, and two, a four-country policy study around drivers of decision-making surrounding acute malnutrition treatment protocols in food-insecure contexts.  We pursued the second question to understand dynamics for health policy change in fragile and conflict-affected contexts, but also additionally to understand pathways for research uptake.  Given the extensive global discussions around adapted protocols to better treat the 50 million under-five children suffering from acute malnutrition, the findings from the policy study have been of great interest to actors working in this space.

We report a few key findings here:

• The rationale for allowing adaptations to national acute malnutrition treatment guidelines varied significantly by context. In more severely affected contexts like Somalia and South Sudan, “saving lives” and concerns about capacity of health staff to take weight-for-height z-scores accurately were brought up as reasons for adaptations while not raised in Niger or Nigeria.  The need to treat moderate acute malnutrition (MAM) cases to prevent severe acute malnutrition (SAM) cases was raised in Niger and Nigeria very strongly, and slightly less strongly in Somalia and South Sudan.
• There was general openness toward the idea of adapting protocols, but many reported waiting for more evidence. The emphasis on scientific evidence differed by context, with greater emphasis on field realities and practical needs emphasized by Somalia and South Sudan respondents.
• Confusion at the national level around adapted protocols appeared to be partially driven by global actors. Global stakeholders admitted themselves that lack of clarity around the vocabulary of adapted protocols (e.g. Combined Protocol vs. Expanded Criteria vs. Simplified Protocol) was largely driven by them.
• There was wide awareness of ongoing research studies on adapted protocols, including the Somalia study and its sister study I mention above. However, there were several respondents who warned that research and pilot projects are not always aligned with national priorities.

As a researcher, I took to heart the last point around researchers failing to sufficiently incorporate national priorities, this study being an example of research that was driven mainly by global, and not national, priorities. This speaks to the need to invest in local research institutions that have consistent links and access to national dialogues and priorities. Elrha has already embraced this through the addition of a prerequisite of including a local academic institution for the current R2HC call.  However, there is a need for longer-term time and financial investment for research capacity building in fragile and conflict-affected contexts to bring about meaningful change to the concerns raised about the national-level priorities and voices being excluded.

Commitment to local capacity building is also only one piece of the puzzle; simultaneously, there needs to be pathways for high-income public health institutions that boast world-class expertise to engage meaningfully with local actors to come to a communal understanding of impactful research questions. This may mean more financial and time investment in research co-design, something often difficult to do under usual proposal development procedures. In many stable contexts, high-income country academic institutions have long-standing relationships with low-income country governments or academic institutions, supported by long-term funding, but those relationships are fewer and farther between in the context of instability, driven by funding length and high turnover.  The humanitarian health research community needs to do some reflection on what meaningful national engagement could look like within the challenges and limitations of insecure contexts.

Naoko Kozuki, International Rescue Committee