Money, People and Institutions: Health Research Capacity for Africa Presentation to the Ministerial Conference for Health Research, Algiers, 23-26 June.

Money, People and Money, People and Institutions: Health Institutions: Health Research Capacity for Research Capacity for AfricaAfrica

Presentation to the Ministerial Conference Presentation to the Ministerial Conference for Health Research, Algiers, 23-26 June for Health Research, Algiers, 23-26 June 20082008

Sara Bennett, PhDSara Bennett, PhDAlliance for Health Policy and Systems Alliance for Health Policy and Systems ResearchResearch

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

Frantz FanonFrantz Fanon

Three ThemesThree Themes

A systemic and institutional approach A systemic and institutional approach to capacity development: not just to capacity development: not just money and peoplemoney and people

A re-think of how we fund research A re-think of how we fund research and development assistance in order and development assistance in order to enhance country leadershipto enhance country leadership

Capacity development throughout the Capacity development throughout the research cycle: not forgetting the research cycle: not forgetting the resources needed to apply evidence to resources needed to apply evidence to policy and actionpolicy and action

Outline of Outline of presentationpresentation Review data on current status of Review data on current status of

research capacity for health – money, research capacity for health – money, peoplepeople

Adopting a systems perspective on Adopting a systems perspective on capacitycapacity

Re-thinking funding of health researchRe-thinking funding of health research Capacity development strategies – Capacity development strategies –

with a focus on evidence usewith a focus on evidence use Lessons and implicationsLessons and implications

The existing state of The existing state of affairs – Money and affairs – Money and PeoplePeople

Funding 1: scale up of Funding 1: scale up of aid for health and aid for health and population activities, population activities, 2002-062002-06

0

2

4

6

8

10

12

14

16

2002 2003 2004 2005 2006Note: 1/ Excludes IDA and GAVI. 2/ Excludes GAVI

Source: OECD, CRS.

US

$ b

illio

ns

Disbursements 1/ Commitments 2/

25 percent per year annual rate of growth

Funding 2: Estimates of Funding 2: Estimates of total expenditure on total expenditure on research for health (US$ research for health (US$ billions)billions)

Source: De Francisco and Matlin 2006

84.992.0

98.0105.9

115.1125.8

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

1998 1999 2000 2001 2002 2003

But inequitably But inequitably distributed - distributed - geographicallygeographically

– OECD countries account for vast OECD countries account for vast proportionproportion

– US the biggest spender (>50% of global US the biggest spender (>50% of global spending)spending)

– Global Forum estimates 5% of research Global Forum estimates 5% of research spending to meet low and middle income spending to meet low and middle income country needscountry needs

– In 2003, just 2 low and middle income In 2003, just 2 low and middle income countries (Brazil and Argentina) met the countries (Brazil and Argentina) met the target of 2% spending on researchtarget of 2% spending on research

And in terms of topicAnd in terms of topic

97% of grants awarded by the 2 97% of grants awarded by the 2 largest research funders for work largest research funders for work relevant to LICs was for the relevant to LICs was for the development of new technologiesdevelopment of new technologies

62.5% of child deaths in LICS could 62.5% of child deaths in LICS could be averted through improved use of be averted through improved use of existing technologiesexisting technologies

Leroy et al 2007Leroy et al 2007

Grant profiles for Health Grant profiles for Health systems researchsystems research LIC compared to HIC LIC compared to HIC institutionsinstitutions

Median Median grant size grant size (US$)(US$)

No. No. grants grants per per annumannum

% % receiving receiving core core fundingfunding

LICLIC 23,50023,500 22 23.5%23.5%

HICHIC 675,000675,000 1212 63.6%63.6%

Source: Bennett et al 2008

Fragmented funding - Fragmented funding - HIV/AIDS, TB and Malaria HIV/AIDS, TB and Malaria research in Uganda 1997-research in Uganda 1997-20022002

0 5 10 15 20 25 30

MRCWHO

USAIDWorld Bank

MoHCDC

UNFPANIH-USA

RockefellerIPHEU

DBLPop Council

PtizerUNICEF

Action AidAMREF

Wellcome

Mean Budget = US$25,945 Source: UNHRO 2002

Number of R&D scientists Number of R&D scientists per million populationper million population

7,318

5,523

1,613

685

608

219

77

65

59

43

0 2,000 4,000 6,000 8,000

Japan

UK

Tunisia

Malaysia

South Africa

Algeria

Madagscar

Burkina Faso

Congo

Niger

Source: UNESCO, 2005 or 2006 data, FTEs

Public Health Training Public Health Training Capacity Capacity (Ijsselmuiden)(Ijsselmuiden)

29 out of 53 (54%) African countries 29 out of 53 (54%) African countries offer no postgraduate training in offer no postgraduate training in public healthpublic health

Largest gap in (i) Lusophone and (ii) Largest gap in (i) Lusophone and (ii) Francophone countriesFrancophone countries

Full time staff of public health Full time staff of public health institutions number about 500 – institutions number about 500 – covering a population of 900 million covering a population of 900 million peoplepeople

Distribution of articles in Distribution of articles in international international epidemiological journalsepidemiological journals (Nchinda)(Nchinda)

0

10

20

30

40

50

60

% p

ub

licati

on

s

1974/75

1989/90

0.6%

3.1%

Authorship of health Authorship of health systems research articles systems research articles 2004-2007 2004-2007 (Bennett 2008)(Bennett 2008)

Affliation of first author by region

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HR Insurance private sector

Other developing countries

Sub-Saharan Africa

Developed countries

3.8% 3.4%

A Systems A Systems Perspective on Perspective on CapacityCapacity

The Health Research The Health Research SystemSystem

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

Research priority-setting

Knowledge generation & dissemination

Evidence filtration &

amplification

Policy making

processes

Research outputs Policy messages

Funding bodies

Research institutions

Advocacy organisations

MediaThink Tanks Government

bodies

Fu

nct

ion

sO

rgan

isat

ion

sO

rgan

isat

ion

alC

apac

ity

Leadership & Governance

Communication & networks

Resources

-Human

-Financial

-Other

Dimensions of Capacity for Health Research and the Application of Evidence to Policy

Source: Sound Choices, Alliance HPSR

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

Human resources for Human resources for Health ResearchHealth Research Researchers need to develop competencies Researchers need to develop competencies

in priority setting, networking and in priority setting, networking and leadership, communication, translation and leadership, communication, translation and dissemination, advocacy, promotion and dissemination, advocacy, promotion and negotiation and partnership development. negotiation and partnership development.

Strong organizations are needed to develop, Strong organizations are needed to develop, motivate and retain health researchersmotivate and retain health researchers– 1986-1996 – 38% of Africans who pursued PhD 1986-1996 – 38% of Africans who pursued PhD

programmes in North America did not return programmes in North America did not return upon completion of programmes. (Sall)upon completion of programmes. (Sall)

– Migration due to salaries but also lack of Migration due to salaries but also lack of supportive environmentsupportive environment

Organizational Organizational CapacitiesCapacitiesResourcesResources IT and internet accessIT and internet access Lab facilities and suppliesLab facilities and supplies Financial systemsFinancial systems HR systems and career development pathwaysHR systems and career development pathwaysLeadershipLeadership Role models for junior researchersRole models for junior researchers Strategic decision makingStrategic decision making Advocates for health researchAdvocates for health researchNetworksNetworks Stimulate innovation, quality and multi-disciplinarityStimulate innovation, quality and multi-disciplinarity With policy makers for evidence-informed actionWith policy makers for evidence-informed action Negotiation skills for fair North-South relationshipsNegotiation skills for fair North-South relationships

Re-thinking how Re-thinking how health research is health research is fundedfunded

Implications of funding Implications of funding patternspatterns Short term, fragmented funding Short term, fragmented funding

undermines long term capacity undermines long term capacity developmentdevelopment

Across all types of research performers Across all types of research performers funding from “rest of world” is significant:-funding from “rest of world” is significant:-– Independent research inst – 88.5%Independent research inst – 88.5%– Medical schools – 43.6%Medical schools – 43.6%– Hospitals - 36.1%Hospitals - 36.1%– Other eg. NGOs – 39.4%Other eg. NGOs – 39.4%– Govt agencies – 17.1%Govt agencies – 17.1%

Heterogeneity of Heterogeneity of Funding ModelsFunding Models

Consultancy model – local researchers hired Consultancy model – local researchers hired as individual consultantsas individual consultants

Corporate model eg. USAID via northern Corporate model eg. USAID via northern companies/institutionscompanies/institutions

Parachute model eg. EU projects – northern Parachute model eg. EU projects – northern academics contract to local research academics contract to local research institutionsinstitutions

Twinning model – long term collaborations Twinning model – long term collaborations between northern and southern institutionsbetween northern and southern institutions

Overseas field unit model eg. MRCOverseas field unit model eg. MRC Multilateral agency eg. WHO funding via Multilateral agency eg. WHO funding via

local officeslocal offices Capacity development model eg. Sida, IDRC, Capacity development model eg. Sida, IDRC,

Ford – funding straight to southern institutionFord – funding straight to southern institution SWAP models – funding for research flows SWAP models – funding for research flows

via MOH or other government departmentsvia MOH or other government departments

Technical Assistance and Technical Assistance and Domestic CapacityDomestic Capacity OECD estimates that technical assistance OECD estimates that technical assistance

acounts for 25-50% of global aidacounts for 25-50% of global aid In Tanzania average cost of consultant In Tanzania average cost of consultant

US$187,000 per annum – about 40% salary US$187,000 per annum – about 40% salary (OECD)(OECD)

Annual TA spending on health in Cambodia Annual TA spending on health in Cambodia (1997)- US25m compared to US$15m (1997)- US25m compared to US$15m government budget (Godfrey et al)government budget (Godfrey et al)

Criticisms: over-priced, ineffective, tied to Criticisms: over-priced, ineffective, tied to donor country, limits local ownership and donor country, limits local ownership and investmentinvestment

What does TA do to What does TA do to research capacity (Wight research capacity (Wight 2008)?2008)? "…in Makerere you can spend your entire time just "…in Makerere you can spend your entire time just

working on very well paid, short term consultancy working on very well paid, short term consultancy studies for NGOs..who want something done in studies for NGOs..who want something done in three weeks and will pay you very well." (Senior three weeks and will pay you very well." (Senior researcher)researcher)

"Consultancies is not building the capacity of the "Consultancies is not building the capacity of the person who is doing it…(some) have even refused person who is doing it…(some) have even refused scholarships to do PhDs because they were busy scholarships to do PhDs because they were busy doing consultancies" (Faculty dean)doing consultancies" (Faculty dean)

"The culture of institutionalizing is not there. Many "The culture of institutionalizing is not there. Many think the institution is a barrier to them. And…..you think the institution is a barrier to them. And…..you know, many people would prefer to have the money know, many people would prefer to have the money in their own accounts" (Department Head)in their own accounts" (Department Head)

Capacity to apply Capacity to apply research evidenceresearch evidence

Emphases of Capacity Development Emphases of Capacity Development InitiativesInitiatives

Priority Priority settingsetting

Knowledge Knowledge generationgeneration

Filtering Filtering evidenceevidence

PolicymakinPolicymakingg

AllianceAlliance 11 33 11COHREDCOHRED 11 22 33 44EUEU 22 11GFHRGFHR 11 22IDRCIDRC 22 11IHPPIHPP 11 11 44 33INCLENINCLEN 11SidaSida 22 11 33TDRTDR 22 11 44

Capacity Issues among policy Capacity Issues among policy making bodiesmaking bodies

Leadership and governanceLeadership and governance– Lack of incentives for use of evidenceLack of incentives for use of evidence– Need for strong personal leadership for evidence Need for strong personal leadership for evidence

useuse Resources Resources

– Skills to:- identify situations where research can Skills to:- identify situations where research can help, articulate research questions, access and help, articulate research questions, access and assess research findingsassess research findings

– Relatively few policy makers with research trainingRelatively few policy makers with research training– Financial resources (eg. for commissioning studies)Financial resources (eg. for commissioning studies)– IT infrastructureIT infrastructure

Communications and networksCommunications and networks– Mechanisms to engage researchers, eg. committee Mechanisms to engage researchers, eg. committee

structuresstructures Lack of empirical evidence as to what worksLack of empirical evidence as to what works

Strategies to enhance Strategies to enhance capacity to use evidence in capacity to use evidence in policy makingpolicy making1.1. Enhance supply of policy relevant research Enhance supply of policy relevant research

products eg. support systematic reviews & products eg. support systematic reviews & policy briefspolicy briefs

2.2. Enhance capacity of policymaking Enhance capacity of policymaking organisations to use evidenceorganisations to use evidence eg. training for eg. training for staff, incentives for evidence usestaff, incentives for evidence use

3.3. Establish new organisational mechanisms to Establish new organisational mechanisms to support evidence use eg. establish knowledge support evidence use eg. establish knowledge broker organizations, broker organizations,

4.4. Promote networking eg. shadowing Promote networking eg. shadowing arrangements, regional networks, arrangements, regional networks,

5.5. Establish norms and regulations eg. require Establish norms and regulations eg. require publication of evidence base for reforms, publication of evidence base for reforms, mandatory evaluations.mandatory evaluations.

Knowledge TranslationKnowledge Translation

EVIPNet - Evidence-informed policy EVIPNet - Evidence-informed policy networksnetworks– Country networks of policy makers and Country networks of policy makers and

researchers that seek to promote the use of researchers that seek to promote the use of evidence in policyevidence in policy

– Support development of research syntheses, Support development of research syntheses, policy briefs, policy dialoguespolicy briefs, policy dialogues

Other knowledge translation platforms eg. Other knowledge translation platforms eg. REACH – East African Community and REACH – East African Community and Zamfor in ZambiaZamfor in Zambia

Need for innovation – but also monitoring Need for innovation – but also monitoring and evaluationand evaluation

Lessons and Lessons and ImplicationsImplications

Building system-wide Building system-wide capacitycapacity Institutions are key – but don’t Institutions are key – but don’t

forget the need for trained forget the need for trained individualsindividuals

Don’t forget what motivates Don’t forget what motivates people – money, but also career people – money, but also career development, respect etc.development, respect etc.

Need for strong African leadership Need for strong African leadership in developing long term capacity in developing long term capacity development plansdevelopment plans

Re-thinking FundingRe-thinking Funding

Stronger African leadership of capacity Stronger African leadership of capacity development may mean more development may mean more investmentinvestment

Also means re-thinking aid modalities: Also means re-thinking aid modalities: funding for short term consultancies funding for short term consultancies redirected to longer term research redirected to longer term research capacitycapacity

Funding models that foster equitable Funding models that foster equitable North-South and South-South North-South and South-South partnershipspartnerships

Capacity development Capacity development for Knowledge for Knowledge TranslationTranslation Highly neglected area of capacity Highly neglected area of capacity

developmentdevelopment Needs much greater investmentNeeds much greater investment Development and assessment of Development and assessment of

innovative strategies that enable innovative strategies that enable policy makers, managers, policy makers, managers, clinicians, media and civil society clinicians, media and civil society to better apply evidence in their to better apply evidence in their workwork

Measuring, and Measuring, and learning from our learning from our actionsactions Lack of reliable data on capacity for Lack of reliable data on capacity for

health research – current initiative health research – current initiative welcomedwelcomed

Limited knowledge about where the Limited knowledge about where the real bottlenecks arereal bottlenecks are

Need more institutional and system Need more institutional and system assessments (eg. IDRC)assessments (eg. IDRC)

More serious evaluations of capacity More serious evaluations of capacity development initiativesdevelopment initiatives