versión On-line ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.102 no.4 Cape Town abr. 2012
C IJsselmuidenI; D L MaraisII; F Becerra-PosadaIII; H GhannemIV
IMD, MPH, FFCH (CM) (SA). Council on Health Research for Development, Geneva, Switzerland, and University of KwaZulu-Natal, Pietermaritzburg, South Africa
IIMA, MA. Council on Health Research for Development, Pietermaritzburg
IIIMD, MPH. Council on Health Research for Development, Mexico City, Mexico
IVMD, MSc. Department of Epidemiology, University Hospital Farhat Hached, and Council on Health Research for Development (North Africa & Middle East), Sousse, Tunisia
Building the skills for doing, managing and delivering health research is essential for every country's development. Yet human resources for health research (HRHR) are seldom considered in Africa and elsewhere. Africa's health research capacity has grown considerably, with potential to increase this growth. However, a systemic way of defining, co-ordinating and growing the HRHR needed to support health systems development is missing. Reviewing the status of HRHR in Africa, we assert that it consists of unco-ordinated, small-scale activities, primarily driven from outside Africa. We present examples of ongoing HRHR capacity building initiatives in Africa.
There is no overarching framework, strategy or body for African countries to optimise research support and capacity in HRHR. A simple model is presented to help countries plan and strategise for a comprehensive approach to research capacity strengthening. Everyone engaged with global, regional and national research for health enterprises must proactively address human resource planning for health research in Africa. Unless this is made explicit in global and national agendas, Africa will remain only an interested spectator in the decisions, prioritisation, funding allocations, conduct and interpretation, and in the institutional, economic and social benefits of health research, rather than owning and driving its own health research agendas.
Limited capacity in low-resource regions hampers quality research, and building human resources for health research (HRHR) capacity is critical for system strengthening. Little has been written about the complex topic of HRHR,1 and this is the first attempt to position the potential of HRHR for Africa. It is important to include HRHR in 'no health without research' debates and to mobilise the international community to support Africa's potential to address the gaps in this area.
The capacity for health research in Africa has grown considerably,2-10 with great potential to build on this growth. However, a systemic way of defining, co-ordinating and growing the HRHR needed to support health systems development is missing. We reflect on the status of HRHR capacity in Africa, highlighting the absence of an overarching framework, strategy or body focused on building African HRHR capacity. Resources should be directed towards building HRHR capacity at all stages of the research process, at all levels in the system, and across multiple national sectors.
No health without research
High-quality research is critical for identifying, prioritising and addressing the health needs of a population. The World Health Report 2012 will centre on the essential role of research in improving health outcomes. Health research drives development, as it generates the knowledge needed to improve health systems performance and, ultimately, health and health equity.11,12 Strengthening the capacity of health research systems therefore directly affects the ability of nations to improve their health outcomes.13,14 Despite this awareness, a mismatch remains between the increased disease burden in low- and middle-income countries (LMICs),15 and their technical and human capacity to use existing knowledge or generate new knowledge to address major health challenges.16,17
The Commission on Health Research for Development produced its report, Health Research: Essential Link to Equity in Development in 1990.18 Work leading up to this report demonstrated that health research was not given its proper role in improving health, equity and development in LMICs. The Commission recommended that LMICs should spend 2% of their health programme budgets on health research, and that donors should match this with an allocation of 5% of their (externally provided) health programme funding. These percentages have repeatedly been recommended in subsequent publications, forums and declarations, but allocation of these funds has been difficult to measure and has rarely been achieved.19
No research without capacity
Four global commissions18,20-22 have extensively referred to the need for research to prioritise and address the health problems they were mandated to examine. Despite this, all but one of the reports18 fail to explicitly refer to the need for enhanced research capacity in LMICs. Capacity is defined here as the ability of people, organisations and societies to manage their affairs successfully.23 A framework for capacity strengthening may focus on different levels, systems, or processes involved in the broad activity of research.24 Human resource development is an essential building block to strengthen capacity at all levels within the research system, and at all stages during the research process.25
Research capacity strengthening (RCS) enables LMICs to identify health research priorities and develop strategies relevant to local contexts.12,26 If countries are to achieve their own and international health and development goals such as the millennium development goals (MDGs), there must be substantial investment in the capacity to carry out multidisciplinary research in the context of national health research systems.23,27,28 However, evidence of impact or returns on investment in HRHR are not immediately tangible29,30 (or easily measurable31-34) and, given the magnitude of the challenges facing under-resourced LMICs, the attention of national governments and international donors has largely been directed elsewhere.35
As research and innovation is increasingly recognised as important for development, it is not surprising that debates in science, technology and innovation (STI) have focused on strengthening human resources for research.17,36-43 Capacity building efforts have similarly been directed at the health sector, where much work has been done to address the shortage of human resources for health (HRH) in LMICs.44-46 There have been similar calls to increase health research system capacity12,14,28,47 and strengthen the knowledge base required to address local health needs. However, there are limited calls to action, recommendations, or planning specifically for resources for those who must capacitate this system or help create this particular knowledge base.8,48
Where is the capacity for health research?
The health research system interfaces with both the health and the research systems. However, other than disparate discussions on migration and curbing the brain drain,49 the need to capacitate health research is often neglected. Furthermore, health research is typically dealt with by three different ministries - health, science and technology (S&T), and higher education - further exacerbating the fragmentation of health research capacity. While most academic health research falls under ministries of higher education, research conducted by medical research councils and other national bodies is mandated to ministries of health. The separation of research in the health sector from that conducted in the STI domain is becoming increasingly irrelevant and unproductive. Health research is more usefully conceptualised in systematic terms, allowing for more effective communication between stakeholders in all sectors and at each end of the research process.
Health research capacity is defined as the ability to identify problems, set priorities, build sustainable institutions, and identify solutions to key national health problems.50 Capacity building efforts in HRHR are marked by their absence, and there is little understanding of how capacity is weak.25 This is partly because much health research conducted in LMICs is problem-specific ('vertical approach') and typically concerns only conditions for which international funding is available. While capacity building is often included as a component of many development programmes, it is seldom the primary objective.14,24,51-53 Nonetheless, there is increasing potential for evaluating the impact of such investments because of efforts towards measuring the effectiveness of sustainable capacity building.13,31,33,54 Such initiatives will hopefully encourage greater national and international investment in capacity building in LMICs.
Strengthening HRHR capacity: From individual training to system growth
Analysis and strengthening of research capacity must appreciate the different levels (individual, institutional and macro), functions and enabling variables within the system.25,28 Previous capacity building strategies have focused on individual skills development, knowledge transfer and training,15,23,47 but there is increasing recognition that capacity building must be approached in systemic terms.12,14,24,28,47 This necessitates capacitating the system with people who have skills including administration and management, priority setting, networking and leadership, translation into policy and action, dissemination, advocacy, and ethics. An enabling environment for research is important,12,16 along with the political will and leadership to mobilise a sustainable system.28,55
We know of no framework that brings all these dimensions together to assist with decisions regarding the forms of capacity strengthening needed within the health research system. As a starting point, the Council on Health Research for Development (COHRED) has developed a simple model for mapping capacity at all levels of the system to identify areas in need of strengthening. Recognising the dynamic and complex nature of health research systems, it is possible for many capacity building actions to contribute to more than one box in the grid. The Research Capacity Strengthening (RCS) grid (Table I) is a 2x2 table in which the level of development of a nation's research system is related to the level at which capacity building or strengthening needs to be undertaken.
Where are the human resources for health research in Africa?
Although progress has been made, the disparity in research capacity among countries and between regions is wide, and unfavourably weighted against LMICs.56-58 As elsewhere, health research is seen as separate from STI in most African countries,59,60 and the ways in which the poorest African countries can develop their fragile health systems and their own capacity to do health research is rarely discussed.9,61,62 Despite this, much health research is happening in Africa, and the building of research capacity over the last three decades has left the continent increasingly capable and self-assured in the context of research and innovation for health.2-10 Nonetheless, even in countries, like South Africa, that are leaders in STI on the continent,63,64 deficits remain in human resources for health research.48
While attempts have been made to map international initiatives aimed at strengthening research capacities in Africa generally,24 knowledge about capacity building support for health research and research uptake in Africa is fragmented or non-existent.15,24,62 Overall the African effort is unco-ordinated, small-scale, and largely driven from outside Africa. Nevertheless, the lack of information on current strategies is not a reflection of what is happening, as many activities are under way to strengthen HRHR capacity in Africa (Table II).
The listing here focuses on those programmes supporting the capacities of African countries and institutions to manage health research. However, it shows that many efforts are geared towards individual capacity building, with indirect benefit to institutions. For example, one donor or bilateral agency may fund several institutions in their own country, all of which will have individual projects in African countries.52 Local research institutions, scientific academies and universities rarely receive any direct support. Separation by language regions persists, and attention to co-ordinating mechanisms is rare.
Currently there is no way to accurately map all these externally driven initiatives. Therefore it is close to impossible to list the individual research projects that focus on specific diseases or conditions, or that are interested in health systems evaluation and performance. However, it is increasingly possible to map African institutions for health research through COHRED's Health Research Web (HRWeb) and, in future, through NEPAD's African Science, Technology and Innovation Indicator (ASTII) project.
HRHR is a key component of national research capacity and national health systems. Until recently, LMICs have largely been spectators in research for health that is essentially about their own countries. But considerable progress has been made in Africa in research for health in the past three decades, and the spectator phase is giving way to active participation in research that is for and about the health and development needs of African countries.
Despite this, HRHR is not being explicitly addressed by global efforts to improve the number and expertise of human resources for health in LMICs. Because HRHR straddles different domains (health, S&T, and higher education), it falls between the gaps. Major potential is lost by not systematically addressing HRHR and not viewing it in collaboration with the STI domain. Tapping into such potential can contribute significantly to health and health systems development.
Why is it acceptable that health care and human resources for health should be built up within African countries themselves, but that health research can be provided for and driven from outside Africa? Health systems strengthening, currently high on the agendas of international and national partners, cannot happen without adequate HRHR. Africa needs many more HRHRs to improve its own health systems and address its own health needs.
- Africa needs data - on research, on research for health, and on human resources for both.
- Based on these data, Africa must develop a co-ordinated strategy to build HRHR capacity.
- The commitment by African ministries of health to spend 2% of health budgets on health research following the Bamako Declaration must be reiterated. Data on how well African governments are faring on this measure are sparse because research for health is often funded out of budgets in ministries other than The Ministry of Health. The World Health Report 2012 will further highlight the need for co-ordinated efforts in this regard.
- Responsible vertical programming (RVP) should become the norm. This means restructuring disease-focused research programmes in ways that support national capacity for health research and health research management. HRHR must be seen as integral to development, and not only as a short-term, crisis-solving tool.
- Harmonisation and partnership. There must be greater communication and collaboration among international funders to support for capacity building efforts in health research.24,54,66 Dedicated funding is needed for explicit capacity building initiatives for HRHR, while health research programmes should have built-in capacity building components, with a focus on developing HRHR.
- Diversification of capacity building. Capacity building efforts must focus on knowledge transfer and generation and also on human resources for policy development and advocacy, research management, governance and stewardship.
- Monitoring and evaluation is an area requiring urgent attention. While several RCS initiatives have been undertaken, systematic learning from them has been weak.13,24 Establishing indicators to measure the effectiveness of HRHR capacity building would strengthen the case for investing in such efforts.
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Accepted 30 October 2011.
Corresponding author: D Marais (firstname.lastname@example.org)