Setting the Health Research Priority Agenda for the Ministry of Health (MoH), Kingdom of Saudi Arabia 2020-2025 Project

Background The Saudi Vision 2030 project recognized the integral role of health research in transforming, modernizing and governing the healthcare system, as well as improving health. The nature of health research prioritization is context-specic, and there is an obligation to effectively allocate resources to initiatives that will achieve the greatest impact, which is discussed in this paper. The best practice for health research prioritization depends on the existing needs and context. The e-Delphi technique was conducted via an online self-administered questionnaire that covered health research topics, topics related to Vision 2030, as well as collaborative research. Criteria used for scoring the selected topics were: appropriateness, relevance, feasibility, urgency, collaboration and impact of research outcome. Research domains were prioritized by ranking the weighted mean aggregate score and all topics of the top ve ranked domains, along with the aggregate scores of the answers of those in leadership positions were pooled together, validated, veried, summarized, rened and then classied into themes. Wellness, Behavior & Lifestyle, Public Health, Family Medicine & Home Care, Trauma and General Management, Environmental Health, Pilgrims’ Health, Women’s Health, Child and Neonatal Health, Geriatric Health, Biomedical Technology Related Fields & Devices, Medical & Devices, and Approaches and &

health and health equity. (7) Finally, broad stakeholder involvement may prevent unnecessary duplication of prioritization efforts and hence wasting of resources. (8) Research Objectives This study aims to identify, empower and support nancing important research projects that can respond to the health needs of the country.

Literature Review
PS plays an important role in health care systems, as it guides investments in health care, health research and respects resource constraints. (9) The public health sector in KSA is led and represented by the MoH. The MoH has concentrated on the National Vision 2030 to focus on a number of objectives to enhance the quality of medical care. These objectives concentrate on health care access, value-based health care, management of road tra c accidents (RTA) and public health. (1) Hence, the MoH needs to set research priorities to meet national and international health needs, as well as funding research domains that match the priority agenda.
In addition, the research priority agenda is targeting researchers who solve health problems, which in turn contributes to improving the life of the Saudi population; it is very important for the MoH to identify and declare their priorities for researchers. PS objectives must consider the following criteria; social justice, equitable allocation, e ciency and burden of disease. (10) The WHO analyzed data in ve developing countries in the Eastern Mediterranean Region, and showed that the explanation behind the wide variation in research PS is accounted for by the fragmented and poorly coordinated status of their national health research system, which should be considered. (11) The assessment of impact and effectiveness of health research PS necessitates the existence of published information on the implementation or evaluation of these researches. (12) The research funding is controlled by the interests of research founders, hence the funded health research do not always serve the interests of health policy and strengthening local health systems. (9) Furthermore, there is a need to make sure that research funds are allocated to high quality research projects. Research enhances the economic competitiveness of a country, increasing e cacy of public services and policy and promoting quality of life and health. Moreover, it can give important predictive information about disease risk factors and trends, outcomes of treatment or public health interventions, functional abilities, patterns of care, and health care costs and use. (13) Without national priorities for health research, countries cannot guide research expenditure, promote science, technology and innovation in health, build research capacity nor negotiate with partners for targeted funding and longterm efforts. (14) No one method is consistently used, however two recent reviews of approaches, tools and methods used to prioritize health research provide interesting insight into the uptake of the various methods. For example, Yoshida (2016) identi ed 165 studies that set health research priorities, noting that only 60% used a de ned method. The Child Health and Nutrition Research Initiative Approach (CHNRI) was most common (26%), followed by the Delphi method (24%). Of the 40% of studies that did not use a de ned method, they listed combinations of expert panel interviews, focus group discussions, literature reviews and questionnaires as an alternative. (15,16) Burden of Disease Approach Global Burden of Disease (GBD) can be used at the national level to assess current and upcoming health challenges by collecting data that help to measure the magnitude of disease burden. In the 1990s, the GBD concept was developed to describe death and loss of health due to disease, injury and risk factors for all regions of the world, (17) and is de ned as the burden that a particular disease process has in a particular area, measured by cost, morbidity and mortality. (18) There are a variety of measures to assess health dimensions such as cause of deaths, health expenditure, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and the Healthcare Access and Quality (HAQ) Index. (19) DALYs is the most commonly used indicator in national burden of disease studies and was the rst comprehensive attempt made to summarize the world's burden of injury, disease and premature death across the world and to make projections for the future. (10) The burden of disease approach relates research to burden of disease and determinants, cost-effectiveness, and nancial ows, however, it requires sophisticated health information systems and high levels of statistical expertise. (14) Using burden of disease data has drawbacks, in particular in uncertainty of estimating the real situation; it is based on historical data which is heterogeneous and can be inconsistent and non-comprehensive. Furthermore, by applying the burden of disease in research PS, we cannot see the whole picture about health status (temporal trends in mortality, incidence and prevalence).

Delphi Approach
The Delphi technique is a structured process, which uses a series of questionnaires (known as "rounds") to gather information. Many studies in the literature used the Delphi technique due to exibility of this method. The Delphi technique is useful particularly for di cult topics that can be in uenced by subjective judgments on a collective basis, an acceptable consensus level of 51 to 80% can be achieved from this technique. (20) The e-Delphi technique does not require face-to-face meetings and therefore, is relatively free of social pressure, dominance of individuals or groups, and in addition is inexpensive. (21)

Research Project Design & Methodology
Many different approaches to health research prioritization exist, but there is no agreement on what might constitute gold standard or best practice. Moreover, attempting to produce one best practice is in fact not appropriate, as the optimal approach varies according to the exercise. (3) Therefore, the PS team decided to consider the e-Delphi technique for the online survey of the current research PS cycle, and to conduct the General Directorate of Research and Studies (GDRS)-developed, pilot-tested and self-administered questionnaire in both Arabic and English, which was available online. Involving stakeholders in an explicit manner in PS research can help to: 1) ensure that funding decisions and research meet critical evidence gaps to inform decision making; 2) facilitate shared responsibility and accountability in implementing the research agenda; 3) improve the relevance and legitimacy of research; and 4) ultimately achieve better health outcomes. (22,23) e-Delphi Technique The application of e-Delphi as a foresight methodology brings a useful perspective to more traditional priority-setting methods. The Delphi method is a systematic interactive forecasting method, which uses a panel of experts who answer questionnaires in two or more rounds and the mean or median scores of the nal round determine the results. (14) Several different methods can be used to decide on priorities, which broadly fall into two groups: consensus-based approaches and metrics-based approaches. The former lead priorities to be decided by group consensus, the latter involve metrics or an algorithm that results in pooling of individual rankings of research options. Consensus tends to improve the acceptability of the exercise, while individual ranking prevents dominance of a few participants. Given that all stakeholders are typically not equal and are knowledgeable in different areas, it is especially important for consensus-based approaches to take into account differing values and viewpoints. The Delphi technique is an example of a metrics-based approach. (3,14) Ranking priorities can be performed per research option, with a criteria as guidance. (24,25) Another option is to differentiate between ranking priority issues and priority research questions. The former could be performed by a broad stakeholder group up front and the latter by technical experts. (25) Study Design The most widely reported method used to identify priorities in previous studies is expert consultation. (25) These range from meetings or surveys that collect expert opinion, to more systematic methods that combine a review of the literature, inclusive Delphi surveys of stakeholders and a recognised method for identifying the priorities against weighted criteria. (26) Although objective approaches to health research prioritization that are solely based on burden of disease data or cost-effective analyses do exist, most literature on health research PS that was found as well as the experts that were consulted considered stakeholder involvement to be a fundamental part of the process of research prioritization. (27) Ideally, PS should involve a broad representation of stakeholders, utilize objective and clearly de ned criteria for generating priorities, and be evaluated. (4) The current study was conducted throughout 2019 and applied the Delphi technique via addressing burden of disease approach criteria by its dimensions which include; the magnitude of a health problem, the likelihood of reducing disease burden through controlling its determinants, cost-effectiveness, the present level of knowledge, current resource ows and the degree of equitability. (28) We applied the combined consensus-based and metrics-based approach according to Viergever et al, 2010; as they noted that approaches combining consensus with some form of metrics are common. (3) Study Questionnaire Data was gathered through completion of the online GDRS-developed self-administered questionnaire. The questionnaire was composed of three sections: Section A: Socio-demographic and other characteristics focused on age, gender, nationality, region, professional category and specialty.
Section B: O cial information involved; job/position, a liated institution, job title, years of experience, level of education, administrative quali cation and contribution to research activities and policymaking process. (9) Section C: Research priority topics options covered; questions about health research topics (75), research topics regarding the MoH initiatives to realize Vision 2030 (1), and collaborative research topics.
The questionnaire also included speci c criteria to focus thinking around research priorities and to ensure that important considerations were not overlooked.
The six criteria were further divided into sub-criteria termed 'items'. The list below contains the original six criteria in bold, followed by 'items' used for scoring the selected research topics: 4. Impact of research outcome: opportunity to implement, use of research results, link of research to policy decisions, overall reduction of the problem, including cost.
5. Opportunity to strengthen collaboration with partners: presence of capable partners, available infrastructure and resources, possibility of collaboration and greater research outcome with partner involvement. (29) 6. Urgency: Whether information is not urgently needed, information could be used right away but a delay of some months would be acceptable, or data is very urgently needed for decision-making. (30) From the items under the criteria, we selected a nal 10 to use to score the answers, eight of these items were selected from the rst four criteria, with the remaining two items selected from the fth and sixth criteria. The selected items allowed different research dimensions to be balanced against one another, depending on the identi ed values or principles of the exercise. (24,25,30) The chosen topics were given appropriate scores for each of the selected 10 items and scoring was conducted based on a rating scale of 1 to 3. The total aggregate score out of 30 for the research priority topic was then computed by clicking 'calculate' at the bottom of the page (metric based approach). The criteria can be categorized into one of three dimensions: Public health bene t (should we do it?), feasibility (can we do it?) and cost. (31) Study Questionnaire Development and Evaluation GDRS have developed a pilot-tested online self-administered questionnaire in accordance to Boateng et al, 2018, focusing on three phases (item development, scale development, and scale evaluation). Therefore, the questionnaire passed through the following steps: rst, identi cation of domain and item generation: The study aim is to identify priority areas for research to which funding will be allocated, which is targeted by PHASE 1: ITEM DEVELOPMENT (31). There are many analogous methods used for setting health research priorities (30,32), but adjustments are necessary to be aligned with the context and needs. The

Second, content validity
We assessed if the measure adequately captured the concept's full meaning or not, and how accurately an assessment or measurement tool tapped into the various aspects of the speci c construct in question. Our developed questionnaire was revised and formulated based on ve experts' views to ensure clarity of the meaning, relevance to study objectives and easy understanding by participants. Afterwards, the questionnaire was assessed and tested by a sample of target experts, to determine which questions should be included in the survey and which should be not. All the construct questions were assessed, topicrelevant questions were included, and it was insured that the questions were representative of all aspects of the construct, and could fully measure the relevant domain. After that, the experts were agreed on the assessment tool and the Delphi method was used to come to a consensus on which questions were a re ection of the construct we want to measure. The target experts were specialized in research management, health policy implementation, public health and healthcare quality.
Expert judgment was completed, and the nal version was modi ed based on focus group discussions' feedback and on the expert consensus on what items will be accepted, rejected, or modi ed.
Evaluation by the target population was complete through interviews to establish if the items of the assessment tool were appropriate to the topic and a good measure of the topic domains.

PHASE 2: SCALE DEVELOPMENT
Third, pre-testing questions we shared the draft questionnaire with 50 participants over two rounds, in order to validate the pre-tested questions according to their feedback. Following this, we conducted interviews to further re ne and assess item interpretation and nalize the survey.

Fourth, survey administration and sample size
The sample size was calculated through software, the large sample size (2500 participants) was selected to cover a wide range of specialists, and the study included both quantitative and qualitative data.

Fifth & Sixth: Items reduction & extraction
The tool was reviewed to identify items that were not or were the least related to the study domain for deletion or modi cation, subsequently unnecessary variables were deleted.

PHASE 3: SCALE EVALUATION
Test-retest reliability: Test-retest reliability or simply stability testing was computed through correlation, which indicates the degree to which values were consistent through repeated testing. The most direct way of estimating reliability is to manage the test two times with an identical set of themes, and then correlate the two measurements at each time point, with the correlation coe cient (r) between the two sets of values designating the degree of reliability. (33) The correlation magnitude for the administered study questionnaire on two occasions separated by two weeks was 0.95.

Content validity test
Content validity is an assessment of how tting the factors being measured are according to a panel of assessors with good subject matter knowledge. It speaks of how precisely a measurement tool taps into the various features of the particular construct in question. There is no correlation coe cient, as this method of testing is a logical method rather than empirical one, due to dependence on relevance of the test task with the content of the construct. (33) The developed questionnaire aimed to identify health research priorities for the concerned populations using criteria that allowed different research dimensions to be balanced against one another. The content validity was evaluated as a subjective decision and was highly rated (98%) by a MoH panel of relevant experts.

Data Collection
The data collection process started with sending circular letters by GDRS to invite the enrolled Health Affairs' General Directors & Directors and medical cities' Executive Directors to participate in the survey. Other participants were communicated with via e-mail.
The research team conducted ve workshops for the assigned coordinators, supplied them with information sheets and communicated with them throughout the data collection period.
The designated coordinators facilitated questionnaire ful lment via different hierarchical groups of stakeholders at the MoH headquarters, along with participants a liated to the Health Affairs Directorates, Medical Cities and other key Saudi partner organizations.
The research team reviewed the received ful lled questionnaires, recorded their observations, and provided the coordinators these observations in a timely manner.

Data management and analysis
Data was validated and veri ed according to the ESSnet ValiDat Foundation 2016; they de ned data validation as an activity aimed at verifying whether the value of a data item comes from the given ( nite or in nite) set of acceptable values. According to this de nition, the validation activity referred to single data items, while veri cation related to consistency among different data items. (34) Study variables were summarized in terms of frequency distribution and by computing quantitative measures using descriptive statistics. Bivariate analysis was performed to test the association between variables (Pearson correlation) using the software program Stata version 15, and qualitative analysis was conducted as appropriate.

Results
The study included 2252 participants with a 90% response rate; the majority (68%) were Saudi natives. Their ages varied from (25 to > 60 years), with the majority (76%) aged between 25 and 45 years. Two thirds of respondents were males and the study achieved balanced regional participation. Inclusiveness was attained in terms of participants representing a full range of health specialties and subspecialties (46.5% physicians, 39% health specialists, 10% pharmacists and 3.6% dentists) & related domains (1%).
The kingdom was represented by 16 regions and their contribution was proportional to healthcare providers' density, as (30%) was achieved by Riyadh, Makkah and Jeddah, whereas only (9%) of the total belonged to Jazan, Najran and Al-Bahah. Broad stakeholder involvement was attained as the study covered a wide spectrum of levels of quali cation (from Bachelor degrees [45%] up to Doctoral degrees [18%]) and professional levels (specialist [49%] to consultant [24%]). This mix of speciality from a number of disciplines was included in the study to achieve a fully comprehensive model.    The study clari ed that there was no correlation between contribution to scienti c research, publications and the other studied variables such as regions, age, gender and nationality as correlation coe cient was (r ~ 0).

Discussion
research PS study may strengthen the acceptance and implementation of the research priorities identi ed, so that efforts and funding are invested in generating evidence that is of importance to all stakeholders. Ensuring the transparency of the process can strengthen legitimacy and credibility to support implementation and maximize impact. A reporting checklist for research PS may facilitate more consistent and comprehensive reporting and enable researchers and end-users to better understand the processes taken in developing research priorities. The Reporting guideline for PS of health research (REPRISE) has 31 reporting items that cover 10 domains: context and scope, governance and team, framework for PS, stakeholders/participants, identi cation and collection of priorities, prioritization of research topics, output, evaluation and feedback, translation and implementation, and funding and con ict of interest. (35) However, reviews of published research PS exercises have consistently demonstrated a lack of transparency due to suboptimal reporting. (23) Inadequate descriptions of the stakeholders and the methods used makes it di cult to assess the validity of research priorities identi ed, and limits the ability to aggregate, analyze or compare research priorities that have been previously established. (25) Guidelines are useful for assessing whether the PS process is achieving key constructs relevant to the planning process, deciding on priorities and post-PS work. Ultimately, the implementation of an effective research PS process will facilitate the allocation of resources to research priorities that have the greatest impact on policy or practice. (2) A. Context and Scope

A.2. Health area, eld and focus
The study questionnaire allowed enrolment of research topic options through the following three topics:

A.5. Research area
Public health, health system, clinical research and basic science.

A.6. Type of research questions
The resulting priority agendas included varied types of research options (topics / questions) and covered a broad range of domains as; etiology, diagnosis, prognosis, treatment, behavioural and social science, economic evaluation and implementation.

A.7. Time frame
The current PS cycle is scheduled to take place over a 5-year period, with the next PS cycle planned to take place in 2025.

A.8. The previous PS process
The previous research priority agenda of the MoH was set in 2013 following two expert consultation workshops. The selected priority topics were: cancer, accidents, diabetes mellitus and health system research. As the research priority agenda should be regularly updated, the GDRS undertakes the responsibility of setting the current priorities for health research in the MoH under a national umbrella, in order to rationalize use of health research resources and to achieve health system transformation goals.
Selection, structure, characteristics of the leadership and management team and experience relevant to conducting PS According to "The Research and Studies by Law", issued by the Saudi Ministerial Council Decree, (36) GDRS is the structure responsible for proposing the health research priority agenda. Following this, the suggested agenda should be shared with the "MoH Research Priority Adoption Committee" for approval. This was put into practice following the application of both the 1st and 2nd rounds of the e-Delphi technique.
The GDRS team was led by the General Director and guided by the MoH Advisory Authority who initiated, developed, and carried out the PS process. The PS team included a public health consultant and a specialist, in collaboration with highly quali ed managers of health research departments in the involved MoH health affairs directorates and medical cities. Additionally, a group of quali ed cooperators helped in the facilitation of online questionnaire ful lment as well as data validation and veri cation.

C. Framework for PS
The 1st and 2nd rounds of the e-Delphi technique were applied according to the process outlined by COHRED in 2010 (14) and modi ed to accommodate the national governance context.

Comparison between Delphi technique and burden of disease approach
The Delphi approach was preferred and adopted as opposed to the burden of disease method for the current PS study. This was based on the Delphi The study clusters were composed of the highest 14 health affairs regions with regard to the overall percentage of physicians (3% and more). The remaining regions where physician percentages were less than 3% were merged to form two strata, each of them was represented by 5% of the total MoH physicians. Northern borders and Hafr Al-Baten represented the two merged categories as they had the highest physician density within their clusters.
Strategy for surveying and sampling technique: The survey team decided to consider "Major City-based sample" as a comprehensive approach rather than "Hospital-based sample".
1. The MoH regional sample was estimated for professional categories and regions through online sample size calculator, which is accessible via the following website: (www.surveysystem.com,https://www.checkmarket.com/sample-size-calculator/). (37) Due to wide range of specialties for the physicians and allied health professionals, the estimated samples were multiplied by 300% and 150% respectively to cover the varied strata. Health system research by necessity is highly multidisciplinary, with a strong emphasis on social sciences, economics, and anthropological investigations.
Much ongoing research consists of descriptive, comparative and evaluative studies and secondary analytical research. Although experimental studies are less common, partly because of the operational and ethical challenges in experimenting at the health system level, they can be very informative and provide convincing evidence on the bene ts of innovations in health system e ciency and health impact. (42) The proposed goals of the KSA Health Sector Transformation Strategy are; rstly, to improve health: increase the length, wellbeing and quality of life of Saudi citizens, which includes the Vision 2030 goal of increasing the life expectancy of citizens to 80 years by 2030. Secondly, to improve healthcare: by improving the quality and consistency of services and the performance and accountability of healthcare organizations and staff to deliver care that is safe, effective, patient-centered, timely and equitable. Thirdly, to improve value: by containing costs, improving outcomes, controlling public healthcare expenditure and guiding new investment. All three transformation goals conform with, and are enablers of, the Vision 2030 strategic objectives for health: access, value and public health. (1) Health systems are already struggling to meet current demands and the challenges facing society over the next 40 years will add further stress. As a result, solutions may require more innovative approaches that address the wider determinants of health and require multi-disciplinary partnerships, which are traditionally outside the remit of health policy-makers. The environmental determinants, which include climate change, disasters and emergencies, interact with and potentially have an impact on the social and economic determinants of health, including an ageing population and economic decline in many parts of the world. (43) The WHO framework describes health systems in terms of six core components or "building blocks", as shown in Fig. 19: (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) nancing, and (vi) leadership/governance. The six building blocks contribute to the strengthening of health systems in different ways. Some wider spanning components, such as leadership/governance and health information systems, provide the basis for the overall policy and regulation of all the other health system blocks. Key input components to the health system include nancing and the health workforce. A third group, namely medical products and technologies and service delivery, re ects the immediate outputs of the health system, i.e.
the availability and distribution of care. (44) Fig. 5 The WHO has addressed improving the quality of health services, and highlights research as an adaptable tool and resource that can support local quality improvement efforts. It aims to support implementation of quality improvement approaches to make health services more effective, safe and people-centric.
There is an increasing collective recognition that quality health services should be; effective, safe, people-centric, timely, equitable, integrated and e cient. (45) Health system research provides evidence that, when applied, it can make healthcare affordable, safe, effective, equitable, accessible, and patient-centric. The Agency for Healthcare Research and Quality invests in research to generate new evidence to help healthcare systems and healthcare professionals improve the lives of the patients they serve. (46) Good service delivery is a vital element of any health system. Service delivery is a fundamental input to population health status, along with other factors, including social determinants of health. The network of service delivery in any well-functioning health system should have the following key characteristics; comprehensiveness, accessibility, coverage, people-centricity, continuity, quality, coordination, accountability and e ciency. (44) The Framework for action for health workforce development in the Eastern Mediterranean Region has been developed in response to the health workforce challenges facing the Region, in line with Sustainable Development Goal (SDG) target 3.C to increase the recruitment, development, training and retention of the health workforce. It is imperative that the Region strives towards institutionalizing strategic planning as an approach in responding to health workforce challenges. The framework aims to guide country and regional action to strengthen the health workforce to ensure access for all people to an adequate, competent, well-balanced, motivated and responsive health workforce which contributes to health systems strengthening and progress towards universal health coverage in the Region. (47) A health information system refers to a system designed to manage healthcare data. This includes systems that collect, store, manage and transmit a patient's electronic medical record, a hospital's operational management or a system supporting healthcare policy decisions. Health information systems also include those systems that handle data related to the activities of providers and health organizations. Data is analysed to improve patient outcomes, inform research, and in uence policy-making and decision-making. (48) Health information technology (health IT) involves the exchange of health information in an electronic environment. Widespread use of health IT within the healthcare industry will improve the quality of healthcare, prevent medical errors, reduce healthcare costs, increase administrative e ciencies, decrease paperwork, and expand access to affordable healthcare. It is imperative that the privacy and security of electronic health information be ensured as this information is maintained and transmitted electronically. (49) eHealth has been de ned by the European Commission as "the use of Information and Communication Technologies (ICT) in health products, services and processes combined with organizational change in healthcare systems and new skills, in order to improve health of citizens, e ciency and productivity in healthcare delivery, and the economic and social value of health". (50) eHealth is an umbrella term that covers a wide range of health and care services delivered through ICTs, such as electronic health records (EHRs), health information systems, remote monitoring and consultation services (e.g. telehealth, telemedicine, telecare), tools for self-management, and health data analytics. Health is a subset of eHealth that is linked to mobile telephony and applications.
eHealth has experienced a period of signi cant growth and maturity in recent years. Such investments are most often seen in the context of achieving health system reform, providing new and innovative modes of healthcare delivery or offering e cient methods of access and exchange of health information. Most notable, however, is the transition of eHealth to a subject of strategic importance for policy-makers. (52) debilitating diseases, will increase the ability to address the growing healthcare challenges. Countering antibiotic resistance will be crucial to ensure effective drug treatment overall, and technologies such as those countering anti-microbial resistance will be important to minimise and stop the spread of antimicrobial resistance. (39) Pharmaceutical products are a fundamental component of both modern and traditional medicine and it is essential that such products are safe, effective and of good quality, and are prescribed and used rationally. (71) Innovation in medical devices as a research priority area aims to contribute to the continued improvement of patient safety and outcomes at an affordable cost; developing medical device technologies will provide affordable transformative solutions for chronic diseases such as heart disease, diabetes and musculoskeletal diseases. The diagnostics research priority area should focus on the development of next-generation biomedical diagnostic devices for diagnosing diseases and sustaining human health. Diagnostic products form a critical part of healthcare delivery, as enabling the early and accurate detection is vital in ensuring successful treatment, and reducing health costs. (39) Equitable access to health products is a global priority, and the availability, accessibility, acceptability, and affordability of health products of assured quality need to be addressed in order to achieve the SDGs, in particular target 3.8.
Every disease management strategy requires access to health products for prevention, diagnosis, treatment, palliative care and rehabilitation. (53) EHRs are real-time, patient-centred records that provide immediate and secure information to authorized users. EHRs typically contain a record of the patient's medical history, diagnoses and treatment, medications, allergies and immunizations, as well as radiology images and laboratory results. They expand on the information in a traditional paper-based medical record by making it digital and thus easier to search, analyze and share with other authorized parties. An EHR system plays a vital role in universal health coverage by supporting the diagnosis and treatment of patients through provision of rapid, comprehensive and timely patient information at the point of care. (52) All around the world, acutely ill and injured people seek care every day. Frontline providers manage children and adults with medical, surgical and obstetric emergencies, including injuries and infections, heart attacks and strokes, asthma and acute complications of pregnancy. Prioritising an integrated approach to early recognition and resuscitation reduces the impact of all of these conditions. (58) In the coming years, there is expected to be an increasing emphasis on primary care in order to improve the common problem of the ER being treated as the gateway to the hospital. Moreover, promising trends in the development of simulation-based education, improvements in residency programs and curricula, and diversi cation of healthcare providers indicate that the rapid progress experienced over the last decade is to continue for the next decade and beyond. Roadmaps like the National Transformation Plan 2020 and the Saudi Vision 2030 have also begun to pave the way for future developments. It is now the task of Saudi emergency medicine physicians and healthcare policymakers to conduct practical research and implement data-driven, evidence-based policies and procedures, to guide efforts to move towards a more preventive and primary care healthcare-based model. Collaborative practices take considerable time and effort to mature, and to deliver effective results. Therefore, the current agenda is an effort to support successful research collaborations. Healthy collaboration built upon shared goals, interests and enthusiasm, provides added value to the process and ensures a higher potential to achieve a project's goals. (73) There is a clear need to adopt a "collaborative research agenda" as complex health problems should be addressed in a comprehensive way. The confronted complexity requires input from multiple expert areas, pooling scienti c, technological, human capital resources and the associated data.
Moreover, institutions reported that their research activities are largely evaluated in terms of inputs and outputs such as the grants received, the number of publications produced, and the number of training activities delivered. Meanwhile, evaluation of the actual outcomes (as perceived by their communities) is rare, with limited formal connection to the research bene ciaries. Effective collaboration at both micro (among professionals) and macro (participation of public and other stakeholders) levels is important to achieve impact and deliver bene t. (73) The COVID-19 pandemic is a public health emergency of international concern. Hence, there is an urgent requirement for conducting academic research on several aspects of this highly contagious disease, to nd effective means of containment and treatment of the disease, for now, and in the future. Signi cant areas have been identi ed for academic research to contain, prevent and treat this viral infection, and extensive research is required for the development of a vaccine for the prevention of COVID-19. There is an urgent need for early production and manufacturing of essential items such as personal protective equipment, medicines, and ventilators to combat this pandemic, and all measures to maintain social distancing by the public must be ensured. In addition to the healthcare measures to deal with the pandemic, there is also an imminent requirement for research to improve the global economy, which has been negatively impacted. COVID-19 has posed new challenges to the global research community, as there is a need for a better understanding of COVID-19 and its socio-economic rami cations on society. Future research needs to promote multi-disciplinary and international approaches, particularly in the biological and Several health research priority exercises have been conducted. These were context-speci c and need-driven, so are variable in focus, scope and extent (national, sub national, institutional, speci c health service delivery level as Primary Health Care etc.). (14) With regard to the locally available information about the previous research priority themes of the MoH, the previous priorities were set in 2013 through two expert consultation workshops, and the selected priority topics were cancer, accidents, diabetes mellitus and health system research. The planned strategy is to declare the established priority via online publication of a peer reviewed journal article and issuing the "Bulletin of MoH Research Priorities". In addition, there will be communication by means of MoH internal communication announcements and engagement on social media.
I. Implementation

I.1. Strategy or action plans for implementing priorities
For attaining a feasible and sustainable implementation of the established research priorities, the following actions were achieved: The involvement of policymakers, researchers and funding organizations from the beginning increases the opportunity for research priorities to be translated into actual research.
Classi cation of priorities into themes and adaptation of global research priorities facilitate implementation.
Moreover, supporting written evidence of informed policy briefs and making effective use of health research evidence in policymaking will be considered to maximize the impact of the established priorities.
It is planned to declare priorities via announcements and calls for proposals by the GDRS. Subsequently, the submitted research proposals' arbitration,