How Foundations Can Make Covid Research Grants More Equitable

As our nation grapples with its greatest public-health crisis in a century, every day it seems we are confronted with more questions than answers. When will Covid-19 “peak” in the United States? How does a person’s social, economic, or immigration status affect that individual’s survival rate? How do we address racial and ethnic data gaps in reporting Covid test results, hospitalizations, and fatalities? How do we effectively protect rural communities, whose citizens tend to be older and less healthy?

There is an important field of research that aims to ask, and answer, these kinds of questions. Known as health-services research, it has helped us understand how the health system works, what health care costs, who pays for it, how we access it, and how it can be more equitably delivered.

Over the past 50 years, health-services research has been responsible for many important outcomes for patients. It has the power to sharply improve the health of Americans, especially those who typically lack access to medical care. It can show us how to improve health outcomes for low-income patients; help curb the disproportionate rates of pregnancy-related mortality among African American women; and increase access to prenatal and preventive care among Latinas and Native Americans.

Indeed, research is, and can continue to be, a catalyst for greater health for all of us, but key parts of the research enterprise are broken — including the way foundations award health-services research grants.

At the same time, as the Covid crisis shows us, the health care landscape is changing, and related research must keep pace.

This is why I’m serving as co-chair of the Paradigm Project, a multiyear effort led by AcademyHealth, to redesign the way health-services research is awarded, conducted, communicated, and used. The project brings together 120 volunteers from diverse disciplines to brainstorm solutions to some of the field’s thorniest issues.

Bias in Decision Making

One issue that tops that list includes rethinking how philanthropists and others make funding decisions to ensure that research addresses the most pressing needs of a diverse array of people. The Paradigm Project’s first background paper, “Innovating in the Research Funding Process,”provides critical lessons not just for foundations that fund health services research, but for any area of philanthropy supporting scientific inquiry.

The report takes a close look at how research grants are assessed and awarded. It finds that despite being widely used by the scientist and foundations, the process leaves a lot to be desired — especially when the goal is greater equity.

Grant “peer review” is a process in which experts — typically people working in the same or similar field as the proposed research topic — inform funding decisions based on their assessment of those applications. While it has been a helpful gauge in discerning solid grant proposals, evidence suggests that it is too often hindered by bias, burden, and unreliability. For example, some experts estimate that as much as 85 percent of funding for medical researchis directedtowardstudies that are poorly designed, go unpublished, or demonstrate bias.

Bias is a pressing concern, since by its very nature, involving peer review in the awarding of grants limits a diversity of perspectives. And diverse perspectives are not just a nice thing to strive for. Evidence shows that including wider perspectives in peer review can result in increased awareness of real-world challenges, more acceptance and uptake of research findings by patients and the public, and more effective use of resources spurred by the research.

Alternative Approaches

So, what are some alternatives for foundations that want to ensure the most optimal and equitable conditions for funding health-services research?

One option is broadening participation in the peer-review process. Organizations like the Robert Wood Johnson Foundation, for which I served as president, are looking at innovative approaches. For example, the foundation now has national advisory committees that better represent the races, ethnicities, and perspectives of the diverse population it aims to serve. Crowdsourcing is another way to diversify funding allocation, with sites like Experiment.comgiving anyone the opportunity to review applications and openly comment on them.

Other opportunities for guarding against bias in funding allocation include randomly allocating funding by lottery; offering innovation prizes for answering a particular challenge or problem, in an effort to inspire creative solutions; and incorporating new technologies, especially those that can ensure quality is not lost when including a wider range of reviewers in the peer-review process.

Foundations that support science have a critical role to play in addressing issues of equity and access related to funding and awarding research grants. As we seek to overcome the Covid crisis, issues of equity become critically more important. By acting with innovation and inclusion, funding for health-services research to help us understand the impact of pandemics like Covid can be allocated in a sustainable, fair, and equitable way to ensure every person has an opportunity to be healthy.