Introduction by Croakey: Governments and other research funders have a long history of neglecting research focused on the prevention of health problems, instead ploughing most support into biomedical and clinical research that is primarily focused on treatments and related interventions.
An important new study investigating the Medical Research Future Fund’s allocation of funds suggests that the problem is even bigger than this: it found that many MRFF grants allocated for public health and prevention are being awarded to projects that are actually more about clinical interventions.
The study, published this week in The Australian and New Zealand Journal of Public Health, is believed to be the first such evaluation of the MRFF’s public health research funding. It investigated 249 projects funded by six MRFF initiatives that addressed public health and prevention from 2018 to July 2023.
The authors defined public health “as an interdisciplinary approach to promote health and wellbeing, and to protect against and prevent disease, illness, injury, disability, and premature mortality related to any systemic or structural determinants of health (social and cultural, environmental and ecological, occupational, economic, commercial, and political) affecting the whole population or population sub-groups”.
The projects were categorised into one of six prevention levels: “not prevention” (not having preventive features), “primordial prevention” (improving societal conditions), “primary prevention” (modifying health-compromising behaviours or exposures), “secondary prevention” (detecting and dealing with disease early), “tertiary prevention” (treating, managing, and rehabilitating health conditions), or “quaternary prevention” (protecting individuals from potentially harmful medical interventions).
Limitations of the study included that it evaluated only six out of 22 MRFF Initiatives and also evaluated only successful grant applications, and not unsuccessful ones. It did not include the COVID-19 Research Response grants.
Meanwhile, Croakey columnist Dr Lesley Russell, who has written extensively on the MRFF and concerns about transparency and accountability, responds to the findings below, using a selection of adjectives that include “disturbing”, “troubling”, and “perplexing”.
Beneath her article are links to further commentary.
Lesley Russell writes:
As this paper points out, research funding in Australia has long prioritised biomedical and clinical research over public health research, despite the improvements in health that public health initiatives have delivered.
The situation is further complicated because there is no clear definition of public health research and because the downstream issues such as the social determinants of health are rarely seen by the relevant policy makers as integral to health and healthcare.
In recent years, most specifically during the Morrison Government era, public health and prevention research has been discriminated against because of the focus on research leading to commercial benefits.
In the years since the MRFF was established, I have made several efforts to analyse how these funds are spent. There is now a reasonable amount of information available online, but it takes considerable time and effort to bring this together and see the overall funding picture.
The authors of this paper have tackled this difficult task and – at a time when public health and prevention have never been more important – their findings are disturbing.
While some might argue with their selection criteria and classifications, there are no other (better) guidelines to facilitate this.
Findings
A summary of their findings:
- Six of the 22 MRFF Initiatives and Missions were categorised as public health related: the Indigenous Health Research Fund; Primary Health Care Research; Million Minds Mental Health Research Mission; Global Health; Dementia, Ageing and Aged Care Mission; Preventive and Public health Research.
- Of the 249 research projects funded under these Initiatives and Missions which were evaluated, 57 percent were categorised as “public health research”.
- The highest proportion of “public health research” was found in the Indigenous Health Research Fund Initiative (92.6 percent). This is encouraging.
- The lowest proportion was in the Preventive and Public Health Research Initiative (47.9 percent). This is troubling and perplexing.
- Tertiary prevention emerged as the most common prevention level in the six evaluated MRFF Initiatives and Missions (32.1 percent) and this also received the most funding.
- Primary prevention at 27.7 percent was the next most common level.
- The majority of funding in the Preventive and Public Health Research and Primary Health Care Research Initiatives was allocated to tertiary prevention (27.1 percent and 43.1 percent respectively) and non-prevention research (41.5 percent and 25.7 percent respectively). That’s discouraging.
- Public health research projects received 50.3 percent of the total funding in the six evaluated Initiatives and Missions.
- The Global Health Initiative had the highest proportion of funding allocated to public health research projects (90.6 percent).
- The Preventive and Public Health Research Initiative had the lowest proportion of funding allocated in this category (38.9 percent). This makes me think (with no evidence to support this) that the people making the priority and funding decisions for this Initiative are not prevention and public health experts.
- The Indigenous Health Research Fund Initiative had the highest proportion of projects categorised as public health research (92.6 percent) but had a substantially lower proportion of funding allocated to public health projects (45.3 percent). Why?
Taken together, these data highlight how research on the treatment and management of chronic diseases is masquerading as preventive and public health research.
This approach is that of the ambulance at the bottom of the cliff – if more research was spent on primary prevention, then there would (ultimately) be less need for tertiary and quaternary “prevention” activities.
To quote the authors: “Given that the primary aim of public health is to prevent diseases and other health hazards from occurring (as a priority over managing disease and ill health), research should focus on primordial and primary prevention to prevent the occurrence of disease, and to a lesser degree secondary prevention where early detection is able to prevent progression of disease.
“As tertiary and quaternary prevention are concerned with limiting the consequences of disease, they do not meet the spirit of the public health definition, even if tertiary prevention technically can…protect against…premature mortality.”
The authors also attempt to explain these findings as due to the pervasiveness of the “deficit model of health” within Western healthcare systems and policies, which focus on sickness as opposed to health and wellbeing.
A recent report from a standing Lancet Commission makes the case superbly. It finds that nearly half of all dementia cases could be prevented or delayed by tackling 14 risk factors, starting in childhood.
The risk factors are: less education, hearing loss, hypertension, smoking, obesity, depression, physical inactivity, diabetes, excessive alcohol consumption, traumatic brain injury, air pollution, social isolation, untreated vision loss and high LDL cholesterol.
Recommendations
The recommendations at the end of the paper make a cogent case for working to achieve an appropriate balance within funding and grant opportunities in Australia that will foster public health research in addition to biomedical and clinical research.
In particular, the authors argue that: “An overemphasis on biomedical treatments could also raise equity concerns, as the benefits of advanced treatment options often remain accessible primarily to the wealthy, owing to the associated higher out-of-pocket medical costs.”
To these recommendations I would add the following:
- While most, if not all, of the MRFF funding initiatives and missions have an advisory body, there is little indication that these interact, let alone coordinate with each other.
- There should be strong links between the health funding bodies (the NHMRC and the MRFF) and the newly established Australian Centre for Disease Control.
- These lessons we learned and are still learning from the COVID-19 pandemic should be used to inform priorities in funding for prevention and public health research.
- Australia needs a change in culture to increase the focus on prevention and public health. To date there is widespread acceptance of this in documents and strategies, but this does not translate into action and – importantly – funding.
Further reading
In an article published at the Public Health Association of Australia’s Intouch blog, two of the researchers, Honorary Associate Professor Leanne Coombe and Dr Saman Khalatbari-Soltani, write:
“We want to be clear – our research doesn’t show that the MRFF is wasting money. We suspect that many of the projects funded through the MRFF Initiatives we analysed, while not fitting the definition of public health, are still important (who doesn’t want a new cancer cure or treatment?)…
“But what our research does show is that Government public health research funding is not transparent or clear – and it should be. Likewise, when Government research funding is allocated under a public health and prevention banner, it should genuinely reflect a public health approach.
“It is crucial to prioritise public health projects that target the root causes of ill health and health inequities, such as our living conditions, our work, and our social supports, to enhance the health and wellbeing of all Australians.
“That’s why we need the MRFF to adopt a better, clearer definition of public health research so that funding can be allocated appropriately.
“Similarly, we need to see a proper Government commitment and investment in public health and prevention. To date, the National Preventive Health Strategy has yet to receive any real funding for implementation.
“In Australia today, there are unfair and avoidable differences in health between different population groups, and this is one of our biggest public health challenges. At the same time, the numbers of Australians living with chronic diseases is exploding, while the cost of treatments and cures is skyrocketing.
“We will be paying for the lack of investment in prevention for years to come.
“It’s clear that the Australian health system is struggling and will continue to do so unless our governments act now.
“We must stop parking the ambulance at the bottom of the cliff, and make sure we are properly and transparently funding public health research that will stop people falling from a great height.”
In a related PHAA media statement, CEO Adjunct Professor Terry Slevin said a lack of genuine transparency around public health research in Australia is just part of the problem.
“Across the board health prevention initiatives are grossly and outrageously underfunded, while treatment and clinical initiatives attract billions of dollars. For example, Australia has an 85-page National Health Prevention Strategy with virtually no funding attached to it,” Slevin said.
“Everyone wants effective accessible treatment for existing disease. But the cost of treating them, particularly chronic diseases, is skyrocketing. If we do not boost investment in prevention, we will continue to suffer from, treat and pay for preventable chronic diseases for generations to come. Proper commitment to prevention research is a step in that direction.
“Australia has a Pharmaceutical Benefits Scheme and Advisory Committee that determines which proven medical treatments are funded by government to make sure Australians can benefit from them. It’s time Australia revisited how we fund public health research and programs, and created a similar model to ensure that proven, effective public health initiatives get the funds they need.”
See Croakey’s archive of articles on prevention
