Document(s) 13 of 21

What has been learned from the capacity-strengthening initiatives of the past 10 years? The following are five suggested lessons:

• Capacity-development activities should be more country driven;

• The focus has been too narrow, restricted mostly to individuals, groups (critical mass), and institutions (a broader systems approach is needed);

• The supply-side model has predominated, leading the capacity-strengthening activities of the past 10 years to neglect the task of creating a capacity to use (and demand) research;

• Capacity-development programs and policies should pay more attention to the goal of equity in health; and

• Capacity-development initiatives should put more emphasis on fostering broad problem-solving competencies in all aspects of research, to complement the more technical elements.

The importance of country-driven capacity-strengthening is not a new insight. The Commission’s report and many other writings have clearly recognized it. Over the years since the Commission’s report, however, agencies, and particularly external agencies, have failed to sufficiently assimilate or act on this lesson. The recent messages from developing countries are also very definite, as reflected in the snapshots presented above. The first conclusion of the April 2000 WHO meeting on research capacity-strengthening captured this same view:

The health research agenda, including a plan for research capacity strengthening, is primarily the responsibility of the countries themselves. It was recognized that only countries could conduct a situation analysis that was relevant to local conditions and contextually accurate. Countries need to define their own research priorities and conduct locally appropriate operational research. In addition, each country needs to decide on the nature and extent of its contribution to the global research agenda. All of these principles have a direct bearing on the assessment of research capacity within a country, and on the plan and program to strengthen that capacity.

— WHO (2000c, pp. 7–8)

Most of the investment in health-research capacity, illustrated in some of the case studies above, has emphasized building the competencies of individuals, units, and institutions. Of course, these elements are important and essential, but in themselves they are not enough. The broader enabling environment in which individuals and institutions function needs more explicit attention. Although people have recognized this larger element for many years and made suggestions for creating a “research culture,” the specific strategies for doing this remain elusive.

A study initiated by UNDP (Hilderbrand and Grindle 1994) gave some helpful insights concerning a systems approach to national capacity development. The study was conducted in response to a resolution of the United Nations General Assembly (Resolution 44/211), which instructed United Nations agencies to come up with a more coherent strategy for building national capacities. (The World Bank expressed similar concerns, particularly in regard to Africa [World Bank 1991].) The Harvard Institute for International Development conducted the UNDP pilot study, concentrating on public-sector capacity at the national level. It included six country case studies: Bolivia, Central African Republic, Ghana, Morocco, Sri Lanka, and Tanzania. Each case study gave a detailed analysis of national “task networks.” The analysis of findings led to several important contributions, such as Dimensions of Capacity, a broad framework that goes beyond individuals and institutions to include the task networks, the public-sector context, and the national “action environment,” comprising economic, political, and social factors. Based on this work, some intervention guidelines have appeared in subsequent UNDP materials (UNDP 1998). These guidelines consist of tools and models to apply at an individual, organizational, and systems levels.

Over the past 10 years or more, something like a supply-side economic model has been the pervading mode of health-research capacity-strengthening; that is, most of the investment has gone to producing more scientists, creating stronger research units (with an optimal critical mass), and strengthening research institutions. And yet, it is widely recognized in industrialized countries that advances in science and technology are substantially driven by demand for new applications. In low-income countries, public officials, community groups, the media, and industry show a weak demand for new knowledge through research. As a result, developing countries make low investments in R&D. This leaves newly trained researchers with little incentive to remain in universities and research institutes (in part, because of low salaries); those who remain struggle hard to maintain their motivation for life-long learning and innovation. Supply-side capacity-building strategies that ignore the need to stimulate demand for research may actually further distort investment allocations (Bowles and Gintis 1996). But the strategies for stimulating demand must take account of the realities, needs, and culture of the various user groups.

It may be useful to draw a distinction between short-term problem-solving research with direct applications and longer term exploratory research; the terms downstream and upstream are sometimes used to summarize these concepts. Because the needs of low-income countries are pressing, these countries have much to gain from making significant investments in short-term problem-solving research. For some developing countries, less investment in longer term research may be appropriate. In cases in which the linkages between application-oriented research and its use are poor, even “appropriate research” may go to waste. Close links to “where the action is” will create incentives for effective research to address the pressing problems of low-income countries. Ghana gives an encouraging example of this principle (see Box 6.2).

Other chapters in this book discuss strategies for enhancing the demand and use of research by communities (Chapter 4) and policymakers (Chapter 5). To create demand is an important leadership competency for national health-research managers, as described in more detail below.

The title of the 1990 Commission report embodied the bold idea that health research is (or should be) an “essential link to equity in development.” Thankfully, in the last several years the equity goal has gradually gained more currency in the view of funders and in the work of research groups (Gwatkin 2000). Have the capacity-strengthening activities reflected this surge of interest?

In a thoughtful and forward-looking essay, written shortly after the creation of COHRED, Professor Gelia Castillo of the Philippines put forward some proposals on training researchers to pursue the equity goal (Castillo 1993). She suggested that researchers need “extra qualities,” or capacities, such as those of

• Identifying, defining, and addressing the equity dimension in health and development problems;

• Comprehending and internalizing the vision that the best of science is not only in its rigour, but also in its relevance for those who have less in health;

• Exposing and immersing one’s self in field realities and the “facts of life” in the health system; and

• Monitoring, evaluating, and documenting the impact of health research on those for whom ENHR is supposed to make a difference.

A growing number of research initiatives are concentrating on the issue of inequities in health (as described in Chapter 2). Some of these initiatives include a capacity-development component. The World Bank has prepared a helpful guide to multicountry research programs on equity, poverty, and health (Carr et al. 1999), including a listing of projects by country.

If a major goal of health research is to enhance the health and well-being of disadvantaged populations, capacity-strengthening programs must go beyond research methodology, protocol preparation, and expertise in specialized techniques. Yet, most developing-country researchers who acquire training outside their countries will confirm that the greatest part of their training focused on these elements. Relatively little, if any, concerned the skills of advocacy, partnership development, priority-setting, facilitating the research-to-action process, or evaluating impacts. In other words, the capacity repertoire of research institutions and national health-research networks must include all aspects of the research process — from problem identification to the application of results.

The 1996 interim assessment of COHRED emphasized this point (COHRED 1996) and recommended that the elements of the ENHR process (originally identified at the 1990 Pattaya conference) be considered “technologies.” In response to this recommendation, the COHRED Board created the Task Force on ENHR Competencies: the working groups in this task force have focused on specific competencies, including promotion, advocacy, and national mechanisms; priority-setting; research to action and policy; and community participation. Each group has analyzed the available experience from countries that have adopted the ENHR strategy, reviewed the relevant literature and experience from elsewhere, and prepared materials for dissemination (papers, monographs, “learning briefs,” and so on). Organizations and groups, particularly country groups, are using these materials. (A list of some of these materials can be found in Chapter 8, Box 8.4.)

Furthermore, one needs to make integrated use of these competencies to address priority health and development problems at the national and subnational levels. This concept follows from some of the more recent thinking concerning the dynamics of science and research in contemporary societies. For example, in a provocative monograph entitled The New Production of Knowledge, Gibbons et al. (1994) described the emergence of a knowledge system known as “Mode 2.” They discussed several features of Mode-2 research: knowledge production in the context of application, social accountability, transdisciplinarity, and a diversity of organizational arrangements. Both the production and application of knowledge involve many diverse sites and “actors” — the term social distribution describes this feature. Success depends not only on scientific excellence but also on the usefulness (relevance) and efficiency of its mode of production. The new ICTs thus increasingly support Mode-2 activities.

The overall goal for the future remains unchanged. It is to ensure that all countries, particularly low-income countries, have the capacity to apply local and global knowledge to their problems in health and development (especially those of poor and disadvantaged people) and contribute to the development of global knowledge in this field. But this requires a more efficiently designed framework. This section outlines what is, to some extent, “a fresh approach” to the challenge of developing health-research capacity. The four elements of this approach are outlined below: new coalitions, new tools, new leadership, and new North–South partnerships.

How is it possible to create and sustain effective national health-research mechanisms and networks? The last 10 years have seen much more attention paid to this question. The underlying assumption is that many organizations and groups need to work together to strengthen the research capacities of developing countries. All these organizations and groups are stakeholders in the task of producing and using equity-oriented, priority-driven health research. But the process that leads to effective interactions among stakeholders is complex, and the participating organizations themselves need to be strong enough to contribute effectively to a national network or “system.” An equally important need is to ensure that the interactions of these organizations and groups are well-coordinated and efficient.

The UNDP capacity-development study, described above (UNDP 1998), paid particular attention to national task networks (where the public sector was included). Based on a number of country case studies, UNDP specified some of the characteristics of successful national networks, including

• Policies defining goals for coordinated action;

• Specific mechanisms to facilitate frequent interaction across organizational boundaries; and

• Clarity of organizational responsibilities.

In a recent publication, the COHRED Working Group on Promotion, Advocacy and the ENHR Mechanism, reviewed and summarized the experience of several low- to middle-income countries with experience in creating or altering national mechanisms to promote ENHR (COHRED 1999). This review suggested four factors (“tough tasks”) that influence the effectiveness of such mechanisms: promoting equity in health, acting as an agent for change, providing research-system support, and responding to changing circumstances. For each of these four factors, the review identified “key messages” and illustrated them with examples from low- to middle-income countries. It described several types of coalition arrangements and reported the experience of countries such as Bangladesh, Kenya, Jamaica, Nicaragua, the Philippines, South Africa, and Uganda. The snapshot from Tanzania (presented above) describes the recent creation of a Tanzanian National Health Research Forum, which has brought together all the major stakeholders in a new collaborative structure to coordinate health research.

In addition, one sees more of a focus on health-research and action coalitions at the district and subdistrict levels. Two examples illustrate this development: the Tanzania Essential Health Intervention Project (TEHIP) and the Initiative for Sub-District Support (ISDS) in South Africa.

TEHIP was established in 1997 to test innovations in evidence-based planning, priority-setting, and resource allocation at a district level (TEHIP News 1999). Consistent with Tanzania’s process of health-sector reform, which features decentralization to the district level, TEHIP is conducting the project in two districts. The project is still in progress, but experience to date has confirmed that district planning coalitions can strengthen their capacities and that districts can use local evidence of various kinds in practical year-by-year decision-making and resource allocation. Ongoing research is determining the cost of this process and its impact on the burden of disease.

It is noteworthy that TEHIP takes a virtual centres-of-excellence approach, drawing on an interdisciplinary and interinstitutional consortium of Tanzanian researchers to apply their talents in addressing these practical issues. In effect, this represents a “meta-experiment” in capacity-building. As well as achieving cost-effectiveness, TEHIP has provided the additional benefit of decreasing long-standing mutual prejudices between researchers and ministry officials. Researchers learn about the realities and constraints on the health system; and government officials learn to respect the researchers’ efforts to address these pressing system problems. Gradually, a climate of trust is strengthened between officials and researchers as they share data, resources, and administrative responsibilities.

Another example of the emphasis on coalitions at the district level is ISDS, which was created in 1996 to demonstrate how systematic and sustained support could improve primary health care at various sites (ISDS 1998). For example, in Mount Frere (one of the poorest districts in South Africa), ISDS established a problem-solving coalition with a clear research agenda. This involved the government health services, a local development nongovernmental organization (NGO) (Isinamva), and community members. They agreed on three research priorities: to determine who was getting sick and dying in the district and at what rate, why the death rate among children admitted to Mount Frere Hospital with malnutrition was 50%, and why drugs were not getting to the clinic shelves. All three partners participated in the community-survey design, collection of data, and analysis (McCoy 1997).

Several important lessons have emerged from the experience in the eight ISDS sites in South Africa, including the value of

• Using an initial situation-analysis exercise to establish an evidence base and to serve as a coalition-building process and;

• Having external facilitators to serve as an “honest broker”;

• Tackling only a small number of common problems at any one time; and

• Using training workshops to develop and strengthen teamwork.

In essence, the new “critical mass” should be national and subnational research and learning networks focused on specific health problems and firmly linked to other relevant regional and international research efforts. These networks recognize and support various sites of knowledge generation, facilitate communication among these sites, initiate problem-oriented collaborative actions, and foster the practice of learning while doing as the model for ongoing monitoring and evaluation.

New tools are required to ensure that health research decreases inequities in health and development. These tools should promote systems thinking to help participants in the health-research process see the whole picture, rather than component parts, and see patterns of change, rather than individual events. Examples of such tools are described below.

Tools for setting health-research priorities

The COHRED Working Group on Priority Setting has examined the experience of developing countries engaged in setting health-research priorities (COHRED–WGPS 2000). These countries have opened their priority-setting processes to several stakeholders: researchers, policymakers, health-care providers, community representatives, and sometimes funders (both national and international). Although some similarities appear across countries, each country has created its own distinctive process for determining and using priority-setting criteria. The experience to date has revealed that multistakeholder health-research priority-setting is a complex and challenging process. A frequently cited problem is moving from the identification of priorities to their actual implementation. Another is aligning the interests of external donors with stated national and local priorities. A recently published manual (“tool kit”) incorporates much of the experience to date (Chongtrakul and Okello 2000).

Tools for assessing health equity

As described in Chapter 2, there is a rapidly growing interest in the issue of health inequities, and many groups are involved in designing tools and systems to describe and monitor equity in health. Most of this activity is summarized in a useful publication prepared by the World Bank (Carr et al. 1999).

Tools for monitoring resource flows

As described earlier, several countries (Malaysia, the Philippines, and Thailand) have recently undertaken studies to trace the flow of health R&D resources (COHRED 2000a). As a result of this work, COHRED is developing a training package to assist other countries in doing similar analyses.

Tools for assessing capacity development

Arising from the larger UNDP-initiated study on capacity development described earlier (Hilderbrand and Grindle 1994), ongoing work is being conducted by the Harvard Institute for International Development to develop indicators to measure investments in research capacity-strengthening. This work is addressing four levels of capacity-strengthening: individual researchers, groups, institutions, and national research communities. A progress report for this initiative was presented at the recent Annecy meeting, including a description of pilot projects currently under way to refine the indicator tools (Simon 2000).

There has been a growing interest in the role of leadership as a distinctive and important ingredient in the process of change. Some of the research and analysis of “the leadership factor” has been applied in various aspects of health-sector reform (Neufeld et al. 1995). Much of the leadership research to date, however, tends to limit itself to the private sector in industrialized countries. Nevertheless, some relevant shifts in thinking about leadership are the following:

• From thinking primarily about individual qualities to considering the specific context for leadership (in other words, less emphasis on the attributes of individual leaders and more on the leadership needed in a specific situation);

• From a focus solely on individuals to considering the importance of leadership teams (including a shift from a preoccupation with control to a focus on more participatory practices); and

• From a focus on uniformity to one on diversity, valuing differences.

Research managers in developing countries have also expressed their need for enhanced skills in research management. In response, several organizations have developed training modules and conducted seminars on this issue (IDRC and WHO 1992).

What are the special leadership competencies (both individual and collective) required to enable national health-research systems in low-income countries to reduce health inequities? This section proposes some of these special competencies in addition to the general attributes required for any leadership, such as the ability to articulate a collective vision, inspire, and “seize the day.”

Knowledge management

There is an increasing emphasis on the importance of the “knowledge economy” in economic and social development (World Bank 1999). What does this mean for health-research managers in low-income countries? Given the remarkable progress in the development and use of ICTs, potentially all countries should have ready access to a global knowledge base. More specifically, health-research managers should be able to apply all the available knowledge, both local and global, to specific local health problems. But the transaction costs of communication are high in low-income countries. The reasons for this include poor communication infrastructures and limited access to global knowledge sources. Busy health managers in low-income countries are often also doing work that in industrialized countries would be that of support staff and have little time and even less opportunity to acquire the necessary skills and habits to use ICTs.

Given the potential of the available ICTs, a special opportunity currently presents itself to the global health-research community — an opportunity for international agencies and partners in the North to facilitate the development of the knowledge management capacities of health-research managers in the South. There are several encouraging examples of agencies responding to this opportunity. One is the Scientists for Health and Research for Development project. This project has developed an interactive Web-based system for storing and accessing information concerning research projects, funding agencies, networks, and research documentation (for more information, visit http://www.shared.de/). Another is the Health Information for Development project, launched in January 2000; it is preparing a global directory of Health Information Resource Centres, among its other activities (see http://www.iwsp.org/).

In addition to needing the skills to use ICTs, knowledge managers must also be able to critically appraise the validity of the evidence base for health interventions and interpret it for appropriate application. The Cochrane Collaboration is an international coalition of clinicians and consumers working mainly through the Internet to design, conduct, report, disseminate, and criticize systematic reviews in all areas of health care (more information is available at http://hiru.mcmaster.ca/).

Creating demand

As noted earlier, efforts to build research capacity have had a preoccupation with the supply side and paid insufficient attention to fostering a demand for research. What does this mean in terms of specific competencies for health-research leadership in developing countries? Stimulating a demand for research may mean targeting user groups more than researchers. User groups may include legislators, the media, district development committees, and the private sector. In South Africa, for example, national legislators helped in designing a country-wide survey of health facilities, including a mechanism to monitor progress in provision of equitable services (HST 2000).

Coalition-building

If research and learning networks and coalitions are to become an increasingly important feature of national health-research systems, this can be expected to create greater demand for coalition-building skills. These skills are particularly important in developing countries, where intersectoral collaboration is required for research and effective action on most health problems. Several important analyses of intersectoral collaboration are available, and they offer insights into the role of facilitators in collaboration (“coalition-builders”) (Harris 1995; Burdach 1998).

Developing leadership

All too often, new health-research managers and management teams find themselves unprepared to meet the responsibilities they are taking on. Typically, senior researchers are thrust into leadership positions based primarily on seniority and past scientific or academic performance. Although some managers already use informal methods to prepare future leaders, it would be useful to pay more attention to specific strategies for developing leadership. These may include a program of reading and discussion on effective leadership, explicit succession planning, and systematic mentoring (Pegg 1999).

Despite the good intentions of developing countries in creating and maintaining self-sustaining health-research systems, the fact remains that many highly depend on resources from the North. This applies to the support of health-sector reform generally and to health-research activities within the health sector. The reality is that North–South interactions will remain an important feature of health research in many developing countries for the foreseeable future. How well do these partnerships contribute to strengthening national health-research capacities in low-income countries? What can be learned in this regard from the experience of the past 10 years?

Some insights into these questions are available in the recent self-assessments of some bilateral agencies. In a thoughtful compilation of essays, the Swedish Agency for Research Cooperation with Developing Countries (SAREC) reviewed its experience of 20 years (SAREC 1995). A focus on strengthening the capacities of university departments has been a particular feature of the support for research (including health research) offered by SAREC (now the Swedish International Development Cooperation Agency [SIDA] SAREC). Its strategy for the 1990s was to continue with this emphasis, but with the additional element of measures to support the university as a whole, including research training and university administration. It began using an increasing share of the total allocation to strengthen the conditions for research at the universities, such as support for reforms, research management, libraries, Internet connectivity, and laboratories. A relatively new feature, at that time, was the contribution to university funds for research, which was intended to stimulate systems for peer review and decision-making on research. The concluding essay summarized the overall thrust of this volume: “research and researchers should play an active and proactive role in the process of change. This may be at variance with a more traditional view of the researcher as an ‘objective’ and detached scholar, whose hands should not be tainted by personal participation in actual events” (SAREC 1995, p. 187). Current SIDA–SAREC policies and programs are described in a more recent publication (SIDA–SAREC 2000).

In 1997, Norway’s Ministry of Foreign Affairs commissioned a comprehensive study of institutional development in Norwegian bilateral assistance, examining the experience of three development-assistance channels used by the Norwegian Agency for International Development (NAID): the public sector, private commercial firms, and NGOs (GON 1998). The report found that in general there was an increasing awareness and commitment to institutional development (capacity development) among public institutions and NGOs. It found, however, that policy objectives were unclear, that overall development perspectives were missing, and that the empirical base for assessing results was weak. It put forward a comprehensive set of recommendations with application at three levels: the Ministry of Foreign Affairs, NAID, and Norwegian organizations. The recommendations for the latter included putting “a stronger emphasis on developing competence and capacity for problem-solving in developing countries” (GON 1998, p. 49), that is, on the capacity for learning.

In the Netherlands, the Directorate General for International Cooperation developed a “demand-driven, research cooperation programme for health in Africa” (Wolffers et al. 1998, p. 1654). This initiative focused on three countries: Benin, Ghana, and Mozambique. The first phase of this exploration found that “conventional research cooperation is often counterproductive for development of a sustainable research environment” (Wolffers et al. 1998, p. 1654). This initiative has led to a cooperative health-research program involving Ghana and the Netherlands, which genuinely attempts to “put Southern requirements first” (Wolffers et al. 1998, p. 1653). It will be important to monitor this and similar experiments and to continue to disseminate the lessons learned to the global health-research community.

Multilateral agencies, too, have reviewed their role in capacity development at the country level. WHO recently conducted a review of its contributions (Lucas et al. 1997). On national capacity for managing health services, the report found that top management is often unstable, with high turnover rates of senior officials (such as Ministers of Health and professional and administrative heads). Although the study did not specifically examine the issue of national health-research capacity, it did review the development of health services more generally and recommended a new approach, which the investigators named “the essential presence,” tailoring WHO’s contribution to the needs and capacity of individual countries and to the contributions of other external agencies. The principle author of the report later called on WHO to improve its own analytic capacity to adequately function in this new mode (Lucas 1998).

With the recent creation of the Department of Research Policy and Cooperation (described in Chapter 1), WHO is assigning higher priority to health research in its profile of work. Importantly, the challenge of research capacity-strengthening has been a major focus of attention of this new department. Evidence of this is the consultative process of the Relevant Research Excellence Accelerates Complete Health initiative, with its emphasis on promoting a new paradigm for research capacity-strengthening. The criteria for the International Health Research Awards (to be presented at the October 2000 conference in Bangkok) also reflect this invitation to innovate. Similarly, the April 2000 meeting in Annecy had some welcome features signaling a new beginning (WHO 2000c). Although initiated by WHO, this meeting was cosponsored by several other groups. Most of the participants were from developing countries. It gave the highest priority to in-depth discussions among “working teams” to analyze country experiences, integrate other inputs into the context of country realities, and put forward “action ideas.” The outputs of the meeting consisted of two sets of conclusions: a description of “key strategies and principles” for research capacity-strengthening; and “action ideas” to be assimilated into WHO’s new framework and vision for research capacity-strengthening.

A recent special issue of the journal Health Policy and Planning examined the question of coordination and management of external resources in the health sectors of low-income countries; it included several country case studies (Walt et al. 1999b). Much of this analysis derived from projects funded through loans from the major development banks. Although the focus was not specifically on the production and use of health research, some important insights from the analysis are applicable to the issue of North–South partnerships. They include the importance of both formal and informal relationships and the inherent instability of the process of managing external resources. It also stressed the importance of paying particular attention to the context-specific conditions of each country.

A helpful description of important principles of North–South partnerships for research appears in a recent publication of the Swiss Commission for Research Partnerships with Developing Countries (SCRPDC 1998). These principles are summarized in Box 6.3.

The American poet Robert Frost once wrote, “I have promises to keep; and miles to go before I sleep.” So it is with the hopes and prospects for health-research capacity-strengthening articulated 10 years ago. At best, progress in the intervening decade has been modest. To more effectively build a national capacity for equity-oriented health research, we will need to make dramatic shifts in our conceptualization of the challenge and take steps to meet it. Current supply-side strategies too often reinforce the prevailing market and peer incentives that focus research on the problems of the rich. In fact, the predominant international emphasis on new-product development can work against equity.

We need to make a major shift to demand-driven capacity development, taking guidance from the needs and realities of developing countries. National leaders should have support for their efforts to forge problem-oriented research and learning coalitions and networks. It will be important to develop and apply new purpose-specific tools. To exploit the promise of the information-technology revolution, strategies will be needed to reduce the costs of communication for research producers and users in low-income countries. And leaders in research in both the North and the South must strengthen their capacities to participate effectively in truly collaborative partnerships, based on mutual respect and shared goals.

Document(s) 13 of 21