The data presented in this paper suggest that the health research output from India is not commensurate with the magnitude and distribution of disease burden. The research output in public health is particularly meagre, which is a major concern as public health sciences are a necessary tool to facilitate improvement in population health. Within this low research output, several diseases/conditions contributing substantially to the disease burden and several major areas of public health importance have relatively less representation. Without dynamic, relevant, good quality and adequate original research in the various aspects of public health it is difficult to imagine how the sub-optimal health status of the Indian population would improve on rhetoric or theoretical concepts alone [14, 15].
In this paper we used impact factors for journals as a measure of the quality of papers published in those journals. Although impact factors are not without their limitations, they still offer a tangible, and perhaps the best available, option to compare the quality of publications in journals [6].
We explored several sources where information about health research output from India could be available in the public domain, as the utilisation of research findings is facilitated most if they are readily accessible in the public domain. However, we did not find any source that would add substantially to the information available in the PubMed database. Indeed, there are more Indian health journals than are included in PubMed, but their quality in general is not as high as those included in PubMed with none of them having an impact factor above zero. Non-inclusion in our analysis of the papers published in these journals, therefore, did not bias our assessment of quality-adjusted research output based on impact factors. The relative low quality and impact factor of a large proportion of Indian journals has been discussed previously [16, 17]. PubMed lists affiliation of the first author only, and therefore, the analysis presented in this paper includes only those publications in which the first author had Indian affiliation. There would be other publications with non-Indians as first author and Indians as co-author(s), which we estimate to be a very small fraction of those with Indians as first author. In the general context, the PubMed/MEDLINE database has been used previously to assess the health research output from several countries [18–25].
We used the disease burden in India as estimated by the Global Burden of Disease Study [2]. Although the limitations of this Study have been debated previously in the literature, we could not find a better alternative for use for our study, as these were the most comprehensive estimates available for India. In any case, these estimates can be taken only as indicative, and therefore, we highlight only gross deviations of health research output from these trends.
There has been a previous attempt to assess the health research output from India using the Science Citation Index of 1981–85 and relating the number of papers published in journals of various medical/health specialities with the perceived areas of major disease burden [26]. However, review of all published abstracts to classify each paper in various categories, the approach used by us, has not been used previously to assess health research output from India to our knowledge. Systematic tracking of health research output, and its relation to the estimated trends in disease burden, are necessary for guiding further appropriate development of health research in India. In addition to the overview of research needs identified in this paper, more in-depth assessment of research needs for major diseases/conditions would also be necessary, as was reported recently for the evidence base needed to control HIV/AIDS in India [27].
Since public health sciences seem to be the weakest link in improving health in India currently, it is imperative that a strategic framework for developing original public health research in India be evolved. To do so, the demand, supply and environment issues would have to be addressed:
Demand. Among the multitude of factors that influence the demand for relevant public health research, the role of policy makers and senior health academics is of particular importance. This is seriously sub-optimal in India at present. Political compulsions push many policy makers into short-term gains instead of investments in comprehensive research for long-term benefits. Although there has recently been an increasing trend in India towards commissioned research by government and international agencies in some aspects of public health, this by itself is not enough to boost comprehensive public health research in India, and the reports of such studies are many times not available in the public domain which reduces the chance of their widespread utilisation. Many senior health academics in India continue to disregard public health research as a less-respectful cousin of basic and clinical research. Systematic efforts are needed to demonstrate to these groups the linkages between all aspects of health research (basic, clinical and public health), and the linkages between public health research and improvements in population health, in order to boost the demand for relevant and good-quality public health research in India.
Supply. Enhancing the output of public health research will require effort on various fronts. Establishing schools of public health and other institutions to train quality scientists in public health is a priority, as India has a surprisingly few number of institutions that can provide proper training in public health research. Another area that needs quick attention is to make public health exposure in medical and paramedical colleges more practical to encourage hands-on investigative thinking, as currently it is so theoretical that it rarely inspires enthusiasm in young professionals towards public health research. Setting higher standards for the research dissertations currently required for post-graduate degrees in preventive and social medicine would also encourage better quality and practically relevant public health research. It is also necessary to systematically develop performance-based opportunities to public health research scholars for career enhancement. Another element that would help develop public health research capacity in India is evolving mechanisms to encourage contribution to this effort by the many Indian public health researchers living abroad.
Environment. A conducive environment is necessary for the demand and supply of public health research to function optimally. Efforts are needed to develop this by attempting to develop broad-based coalitions, that include health care providers, civil society and non-governmental sector, for-profit private sector and industry, and national and international agencies providing financial support, which would understand and support the need for vibrant public health research as a vital element of societal development. This is a necessary element that has so far received scant attention, which must be addressed if sustainable development of public health research to improve population health is to become possible in India. An environment of good-quality and comprehensive public health research in India would also infuse the much-needed originality in teaching public health sciences and their practical application to the local context.
Evolving such frameworks would require building up a critical momentum for this effort through perseverance and wisdom. One such opportunity is provided by the recent initiative of the Indian Ministry of Health and Family Welfare to develop more effective institutes of public health in India, with relevant public health research and its utilisation an important key to improving population health [28].
The recent attention towards revitalising the academic aspects of health care / medicine through evidence [29] and evidence-based global health [30] is particularly relevant for developing nations. Evolving a strong, dynamic and locally-relevant evidence base is even more important for developing nations as this is likely to yield relatively higher returns by contributing to improvements in the health, lives and economy of a larger proportion of the world's population. For this to happen, theoretical concepts alone would obviously be not enough. The practical solutions for this effort would have to be developed wisely. The data and its interpretation presented in this paper are, we hope, an example of how the deficiencies in the evidence-base needed for adequate health care in developing nations can be understood objectively in order to plan its strengthening.