Money, People and Institutions: Health Research Capacity for Africa

1. Money, People and Institutions: Health Research Capacity for Africa Presentation to the Ministerial Conference for Health Research, Algiers, 23-26 June 2008 Sara Bennett, PhD Alliance for Health Policy and Systems Research

2. If man is known by his acts, then we will say that the most urgent thing today for the intellectual is to build up his nation. Frantz Fanon

3. Three Themes • A systemic and institutional approach to capacity development: not just money and people • A re-think of how we fund research and development assistance in order to enhance country leadership • Capacity development throughout the research cycle: not forgetting the resources needed to apply evidence to policy and action

4. Outline of presentation • Review data on current status of research capacity for health – money, people • Adopting a systems perspective on capacity • Re-thinking funding of health research • Capacity development strategies – with a focus on evidence use • Lessons and implications

5. The existing state of affairs – Money and People

6. Funding 1: scale up of aid for health and population activities, 2002-06 25 percent per year annual rate of growth

7. Funding 2: Estimates of total expenditure on research for health (US$ billions) Source: De Francisco and Matlin 2006

8. But inequitably distributed - geographically • OECD countries account for vast proportion • US the biggest spender (>50% of global spending) • Global Forum estimates 5% of research spending to meet low and middle income country needs • In 2003, just 2 low and middle income countries (Brazil and Argentina) met the target of 2% spending on research

9. And in terms of topic • 97% of grants awarded by the 2 largest research funders for work relevant to LICs was for the development of new technologies • 62.5% of child deaths in LICS could be averted through improved use of existing technologies • Leroy et al 2007

10. Grant profiles for Health systems research LIC compared to HIC institutions Source: Bennett et al 2008

11. Fragmented funding - HIV/AIDS, TB and Malaria research in Uganda 1997-2002 Source: UNHRO 2002 Mean Budget = US$25,945

12. Number of R&D scientists per million population Source: UNESCO, 2005 or 2006 data, FTEs

13. Public Health Training Capacity (Ijsselmuiden) • 29 out of 53 (54%) African countries offer no postgraduate training in public health • Largest gap in (i) Lusophone and (ii) Francophone countries • Full time staff of public health institutions number about 500 – covering a population of 900 million people

14. Distribution of articles in international epidemiological journals (Nchinda) 0.6% 3.1%

15. Authorship of health systems research articles 2004-2007 (Bennett 2008) 3.4% 3.8%

16. A Systems Perspective on Capacity

17. The Health Research System The people, institutions and activities whose primary purpose is to generate high quality knowledge that can be used to promote, restore and/or maintain the health status of populations. It includes the mechanisms adopted to encourage the utilization of research.

18. Dimensions of Capacity for Health Research and the Application of Evidence to Policy Research priority-setting Knowledge generation & dissemination Evidence filtration & amplification Policy making processes Research outputs Policy messages Media Funding bodies Research institutions Think Tanks Government bodies Advocacy organisations Functions Organisations • Resources • Human • Financial • Other Organisational Capacity Leadership & Governance Communication & networks Source: Sound Choices, AllianceHPSR

19. "What distinguishes the successful from the unsuccessful national health innovation system is its capacity to promote constructive interactions among these many elements to overcome lack of policy coherence, deep fragmentation of research and innovation effort and often enormous inefficiencies in the allocation an use of resources." Mugabe 2005

20. Human resources for Health Research • Researchers need to develop competencies in priority setting, networking and leadership, communication, translation and dissemination, advocacy, promotion and negotiation and partnership development. • Strong organizations are needed to develop, motivate and retain health researchers • 1986-1996 – 38% of Africans who pursued PhD programmes in North America did not return upon completion of programmes. (Sall) • Migration due to salaries but also lack of supportive environment

21. Organizational Capacities Resources • IT and internet access • Lab facilities and supplies • Financial systems • HR systems and career development pathways Leadership • Role models for junior researchers • Strategic decision making • Advocates for health research Networks • Stimulate innovation, quality and multi-disciplinarity • With policy makers for evidence-informed action • Negotiation skills for fair North-South relationships

22. Re-thinking how health research is funded

23. Implications of funding patterns • Short term, fragmented funding undermines long term capacity development • Across all types of research performers funding from “rest of world” is significant:- • Independent research inst – 88.5% • Medical schools – 43.6% • Hospitals - 36.1% • Other eg. NGOs – 39.4% • Govt agencies – 17.1%

24. Heterogeneity of Funding Models • Consultancy model – local researchers hired as individual consultants • Corporate model eg. USAID via northern companies/institutions • Parachute model eg. EU projects – northern academics contract to local research institutions • Twinning model – long term collaborations between northern and southern institutions • Overseas field unit model eg. MRC • Multilateral agency eg. WHO funding via local offices • Capacity development model eg. Sida, IDRC, Ford – funding straight to southern institution • SWAP models – funding for research flows via MOH or other government departments

25. Technical Assistance and Domestic Capacity • OECD estimates that technical assistance acounts for 25-50% of global aid • In Tanzania average cost of consultant US$187,000 per annum – about 40% salary (OECD) • Annual TA spending on health in Cambodia (1997)- US25m compared to US$15m government budget (Godfrey et al) • Criticisms: over-priced, ineffective, tied to donor country, limits local ownership and investment

26. What does TA do to research capacity (Wight 2008)? • "…in Makerere you can spend your entire time just working on very well paid, short term consultancy studies for NGOs..who want something done in three weeks and will pay you very well." (Senior researcher) • "Consultancies is not building the capacity of the person who is doing it…(some) have even refused scholarships to do PhDs because they were busy doing consultancies" (Faculty dean) • "The culture of institutionalizing is not there. Many think the institution is a barrier to them. And…..you know, many people would prefer to have the money in their own accounts" (Department Head)

27. Capacity to apply research evidence

28. Emphases of Capacity Development Initiatives lity.

29. Capacity Issues among policy making bodies • Leadership and governance • Lack of incentives for use of evidence • Need for strong personal leadership for evidence use • Resources • Skills to:- identify situations where research can help, articulate research questions, access and assess research findings • Relatively few policy makers with research training • Financial resources (eg. for commissioning studies) • IT infrastructure • Communications and networks • Mechanisms to engage researchers, eg. committee structures • Lack of empirical evidence as to what works

30. Strategies to enhance capacity to use evidence in policy making • Enhance supply of policy relevant research products eg. support systematic reviews & policy briefs • Enhance capacity of policymaking organisations to use evidence eg. training for staff, incentives for evidence use • Establish new organisational mechanisms to support evidence use eg. establish knowledge broker organizations, • Promote networking eg. shadowing arrangements, regional networks, • Establish norms and regulations eg. require publication of evidence base for reforms, mandatory evaluations.

31. Knowledge Translation • EVIPNet - Evidence-informed policy networks • Country networks of policy makers and researchers that seek to promote the use of evidence in policy • Support development of research syntheses, policy briefs, policy dialogues • Other knowledge translation platforms eg. REACH – East African Community and Zamfor in Zambia • Need for innovation – but also monitoring and evaluation

32. Lessons and Implications

33. Building system-wide capacity • Institutions are key – but don’t forget the need for trained individuals • Don’t forget what motivates people – money, but also career development, respect etc. • Need for strong African leadership in developing long term capacity development plans

34. Re-thinking Funding • Stronger African leadership of capacity development may mean more investment • Also means re-thinking aid modalities: funding for short term consultancies redirected to longer term research capacity • Funding models that foster equitable North-South and South-South partnerships

35. Capacity development for Knowledge Translation • Highly neglected area of capacity development • Needs much greater investment • Development and assessment of innovative strategies that enable policy makers, managers, clinicians, media and civil society to better apply evidence in their work

36. Measuring, and learning from our actions • Lack of reliable data on capacity for health research – current initiative welcomed • Limited knowledge about where the real bottlenecks are • Need more institutional and system assessments (eg. IDRC) • More serious evaluations of capacity development initiatives