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No Development Without Research: A challenge for capacity strengthening © Global Forum for Health Research 2005 Published by the Global Forum for Health Research, August 2005 ISBN 2-940286-37-X Suggested citation: Global Forum for Health Research, Yvo Nuyens, No Development Without Research, 2005 Key words: health research, health research system, capacity development, training, research utilization, health research management Th e reproduction of this document is regulated in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved by the Global Forum for Health Research. Th e report may be freely reviewed and abstracted, with the usual acknowledgement of source, but not for sale or for use in conjunction with commercial purposes. Requests for permission to reproduce or translate the report, in part or in full, should be addressed to the Secretariat where information on any translations or reprints is centralized (see address below). Th e designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Global Forum for Health Research concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Additional copies of No Development Without Research: A challenge for capacity strengthening can be ordered (at no charge) via the website www.globalforumhealth.org or from Global Forum for Health Research 1-5 route des Morillons PO Box 2100 1211 Geneva 2, Switzerland T + 41 22 791 4260 F + 41 22 791 4394 E-mail infoglobalforumhealth.org Th e Global Forum for Health Research is an independent international foundation based in Geneva, Switzerland. It is supported by the Rockefeller Foundation, the World Bank, the World Health Organization and the governments of Canada, Denmark, Ireland, Mexico, Norway, Sweden and Switzerland.NO DEVELOPMENT WITHOUT RESEARCH A challenge for capacity strengthening By Yvo Nuyensii Acknowledgements Th e idea for this publication arose out of the work on research capacity strengthening, which Niall McKee did as an intern at the Global Forum for Health Research during the summer of 2004. His brief literature review and interviewing of a number of stakeholders in the area made it clear that a more systematic review and analysis of key issues in research capacity strengthening was warranted, which resulted in the present document. Th e author would like to thank Stephen Matlin and Abdul Ghaff ar for their guidance and constructive comments on the manuscript. He also gratefully acknowledges the inputs from Narendra Arora and Tina Heiler (INCLEN), Fabio Zicker (WHO/TDR), Ulysses Panisset (WHO/RPC) and Paul Van Look (WHO/HRP) for making available some key information. Finally, the author acknowledges Susan Jupp and Christine Mauroux for review and editorial support. iii Foreword Health research is indispensable for improving health and health equity and contributing to overall development. Many developing countries have made substantial investments in building and enhancing their capacities for research in health and related fi elds, and these eff orts have been supported and extended by programmes of development agencies and research institutions located in high-income countries. Activities have included the education and advanced training of individuals, either through scholarships and fellowships to fund studies overseas or increasingly, as local capacities have improved, through training programmes in their own countries or regions. In parallel, investments have been made in establishing and equipping high quality education, training and research centres in developing countries and in extending their capabilities through international twinning arrangements, networks and collaborative research programmes. Despite decades of such eff orts, and notwithstanding some notable examples of success, the overall picture of progress is a mixed one. Too often, the investments have failed to result in signifi cant impact on health policies and practices in countries and concomitantly there has been an overall failure to see the desired levels of improvements in the health of the targeted population. A mutually reinforcing set of factors, including brain drain, lack of sustained investment in research capacity, lack of alignment of funders’ goals and researchers’ interests with national priorities, and failure by policy-makers and practitioners to use research to inform their decisions, emerge as an interdependent group of cyclical causes and eff ects. Th e result is that members of the research community frequently complain that they are undervalued, their potential contribution ignored and that there is an absence of a culture of utilization of research to inform policy; while their work is often regarded as remote and irrelevant by potential users of evidence and innovation. Th is publication reviews the literature and surveys the successes and failures of research capacity strengthening in the health fi eld, in the context of its potential to contribute to health, development and equity. It points very clearly to the need for all stakeholders in the fi eld – funders, producers, users and benefi ciaries of health research – to be organized into a health research system in which the resources, drivers and priorities are aligned to produce results that are needed, valued and utilized. Th e Global Forum for Health Research is grateful to Yvo Nuyens for conducting this thorough, meticulous and well researched review and synthesis of the fi eld of research capacity strengthening. We hope this will be widely useful in contributing to eff orts to enhance, sustain and utilize research capacities in developing countries to improve the health of their populations. Stephen Matlin Executive Director Global Forum for Health Researchiv Contents Foreword ............................................................................................................................................................... iii List of illustrations ............................................................................................................................................v Abbreviations and acronyms ....................................................................................................................... vi Executive Summary ........................................................................................................................................ vii Introduction ........................................................................................................................................................ 1 Chapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004): a panorama of players, programmes and issues ................ 3 • Who have been the major players? .......................................................................... 4 – Commission, Task Force, COHRED ................................................................ 4 – World Health Organization .................................................................................. 5 – Global Forum for Health Research ..................................................................... 6 • Players in specifi c areas ................................................................................................. 7 – International Network for Clinical Epidemiology (INCLEN) ................. 8 – Special Programme for Research and Training in Tropical Diseases (TDR) .... 8 – Special Programme of Research, Development and Research Training in Human Reproduction .......................................................................10 – Alliance for Health Policy and Systems Research ........................................10 • Th e donor community .................................................................................................11 Chapter 2 Substantive issues of RCS within a framework: levels, system and process ......15 • Capacity strengthening at various levels ..............................................................15 – individual ...................................................................................................................16 – institutional ...............................................................................................................16 – macro ...........................................................................................................................17 • Capacity strengthening in various functions (of the health research system) ...18 – stewardship ................................................................................................................18 – fi nancing .....................................................................................................................19 – resource generation .................................................................................................20 – production and utilization of research .............................................................21 • Capacity strengthening in various phases of the research process .............21 - managing the research agenda ............................................................................22 - producing evidence .................................................................................................23 - promoting the use of evidence ............................................................................25 - utilizing evidence in policy, practice and action ...........................................28 Chapter 3 A framework for research capacity strengthening: where do we go from here? .............................................................................................35 References ...........................................................................................................................................................37 Select bibliography .........................................................................................................................................41v List of illustrations Figures Figure 1 Yearly publications on RCS .................................................................................................. 4 Figure 2 Examples of eff orts to build research capacity, ranging from individual to global movements ...........................................................15 Figure 3 Research to policy and practice: steps in an iterative cyclical process .................21 Figure 4 Tools and organizations on the cooperation/evidence axis .....................................26 Tables Table 1 Yearly publications on health research and on RCS .................................................... 3 Table 2 INCLEN’s contribution to individual and institutional capacity development ............ 8 Table 3 TDR research capacity building: approved working budget .................................... 9 Table 4 HRP overall output of LID grant recipients by period ............................................10 Table 5 Stakeholder characteristics .................................................................................................26 Table 6 Relative merits of diff erent dissemination pathways .................................................27 Table 7 How to infl uence policy and practice .............................................................................31vi Abbreviations and acronyms CDC Centers for Disease Control and Prevention, USA CHSRF Canadian Health Services Research Foundation COHRED Council on Health Research for Development CTP Collaborative Training Program for Health Research for Policy, Action and Practice DANIDA Danish International Development Agency DFID Department for International Development, UK ENHR Essential National Health Research EXTRA Executive Training for Research Application FUNSALUD Mexican Health Foundation Fundación Mexicana para la Salud GDN Global Development Network GEH Governance, Equity and Health HINARI Health InterNetwork Access to Research Initiative HPSR Alliance for Health Policy and Systems Research HRP UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction IDRC International Development Research Centre, Canada IHPP International Health Policy Program INASP International Network for the Availability of Scientifi c Publications INCLEN International Network for Clinical Epidemiology LAMP Leadership and Management Program (INCLEN) NORAD Norwegian Agency for Development Cooperation ODA Offi cial Development Assistance ODI Overseas Development Institute, UK RAPID Research and Policy in Development (ODI) RCS Research capacity strengthening SARA Support for Analysis and Research in Africa SDC Swiss Agency for Development and Cooperation SDO National Health Service Delivery and Organisation, UK SEARO South-East Asia Regional Offi ce (WHO) SHARED Scientists for Health and Research for Development Sida/SAREC Swedish International Development Cooperation Agency/Department of Research Cooperation TDR UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases ULP User Liaison Program UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNICEF United Nations Children’s Fund USAID United States Agency for International Development WBI World Bank Institute WHA World Health Assembly WHO World Health Organization vii Executive Summary Health research capacity strengthening (RCS) has been high on both national and international agendas, as is evidenced by a steady stream of peer-reviewed and grey literature, training tools, programmes and grants, workshops, task forces and conferences on various issues in the broad and complex area of RCS. Th e nearly unanimous consensus among all stakeholders about the vital role of research capacity in bridging the “know-do gap” and in addressing eff ectively inequities in health research is in sharp contrast with the research capacity reality, where all these actors most of the time seem to be doing their own business and where also equity as an underlying value is getting lost. One programme creates research fellowships for this particular disease; another develops training modules for district staff ; a third organizes skills development workshops for better communication with the media, policy-makers or peers; donor agencies have their own priority programmes and clienteles, and the list goes on. Confronted with this situation of fragmentation, overlapping, incompleteness, selectivity and gaps in research capacity strengthening, this study sets out to identify key issues, problems and challenges in RCS and to bring these pieces together into a conceptual framework or system. Key issues, problems and challenges are identifi ed through a panoramic, but selective overview of some major players and programmes in research capacity strengthening, and this from the Stockholm Conference of the Commission on Health Research for Development (1990) up to the Ministerial Summit on Health Research in Mexico (2004). For each of the players and programmes under review, a short list of key issues is formulated as a fi rst but essential step in clarifying, describing and organizing ideas (as defi ned by these players) about research capacity strengthening. Th e major challenge of this document consisted in bringing these issues into a conceptual framework, which introduces a higher level of abstraction in clarifying, describing and organizing these ideas but at the same time inviting the players to think out-of-the-box. Th e construction of such a framework has been done in a three- step movement, starting with the classical distinction between the three levels for capacity strengthening: individual level (training), institutional level (development and strengthening of institutions) and macro or system level (enabling environment). Th e macro or system level brings as a second step the national health research system with its major functions as an organizing framework. Th e document reviews what capacities and skills are required in support of the functions of governance, fi nancing, creating resources and producing and using research and gives numerous examples from the fi eld to illustrate this. Th irdly, the function of production and utilization of research leads to the notion of the research process as an organizing framework. Th is framework depicts research as an iterative process in phases, starting with managing the research agenda and ending with utilizing evidence in decision-making in policy and practice. For each phase, capacity strengthening needs are reviewed and examples are given to illustrate ways and strategies to address them.viii Th e document makes some preliminary suggestions on how the proposed framework could be used and how it can contribute to a process of dialogue between the various stakeholders. Th is dialogue aims to contribute to a consensus about capacities to be developed and to (re)focus research capacity strengthening on equity as a guiding principle for further action.Introduction Th e Commission on Health Research for Development, an independent international initiative, Capacity was formed in 1987 to recommend how research might improve the health and well-being of building has the people of the developing world. Following a worldwide analysis of health conditions and been a key health research, the Commission concluded that research is essential both to facilitate health action and to generate new understanding and fresh interventions. In its fi nal report, presented instrument in at the Nobel Conference in Stockholm, Sweden (February 1990), the Commission formulated development a set of strategies through which the power of research can be harnessed to accelerate health assistance. improvements and to overcome health disparities worldwide. Building and sustaining research capacity is one of the proposed strategies. In November 2004, the World Health Organization brought together in Mexico City a number of ministers of health, ministerial representatives, international organizations, networks, donor agencies, research programmes and institutions from 58 countries in a Ministerial Summit on Health Research. Th is meeting was held in parallel and partly in common with Forum 8, Research the 2004 annual meeting of the Global Forum for Health Research. Th e two meetings shared the theme of health research to achieve the Millennium Development Goals. Both emphasized capacity in the the crucial but under-recognized part to be played by research in strengthening health systems, South remains improving the equitable distribution of high quality services and advancing human development one of the and recognized the need for a strong, transparent and sustainable national health research world’s unmet system, defi ned as the people, institutions and activities whose primary purpose is to generate relevant knowledge. Statements put out at the end of the Mexico meetings called for action by challenges. all stakeholders in a number of priority areas, one of which was capacity strengthening. Comparing the Report of the Commission in 1990 with the statements made at the Mexico meetings in 2004, one can hardly ignore the remarkable continuity in scope and content of the policies formulated on both occasions. Indeed, both in 1990 and 2004 research has been clearly defi ned as an important tool and strategy in addressing equity in development. Th is is illustrated by the title of the Commission’s Report (Health Research: essential link to equity in “Building and sustaining research capacity within developing countries is an essential and effective means of accelerating research contributions to health and development. Nurturing individual scientifi c competence and leadership, strengthening institutions, establishing strong linkages between research and action agencies, and reinforcing national institutions through international networks are all important elements of capacity building.” (Commission on Health Research 1 for Development) Introduction2 Introduction development) and the statement by the Global Forum (Health Research for Equity in Global “Strategic Health). Th e same continuity in discourse is further evidenced by the prominent place of capacity and long- strengthening for health research on both occasions. Th ere is an increasing consensus to defi ne term efforts research capacity strengthening as “one of the most important activities in the correction of the 3 ‘10/90 gap’” or, as the SAREC Director, Berit Olsson, put it: “strategic and long-term eff orts in supporting 4 in supporting capacity may contribute to change inequalities in research.” capacity may However, the fact that research capacity strengthening has remained for more than fi fteen contribute years in the spotlights of international and national conferences also means that it is not to change implemented overnight and requires long and systematic eff orts. Th e continuous interest and eff orts in RCS over the last decade is evidenced by a remarkable inequalities infl ux of articles, books and papers, training modules, tools and programmes, conferences, in research” workshops and task forces, all dealing with various issues and aspects in the broad area of (Berit Olsson) RCS. Th is broad character is for instance illustrated by the much quoted defi nition of the United Nations Development Programme (UNDP), which defi nes RCS as “…the process by which individuals, organizations and societies develop abilities (individually and collectively) to perform functions eff ectively, effi ciently and in a sustainable manner to defi ne problems, set objectives and priorities, build sustainable institutions and bring solutions to key national 5 problems”. Th is defi nition makes it clear that RCS refers to a broad and complex area, dealing not only with skills and competencies at various levels and by various actors but also with expected outcomes and impacts on policies and programmes. A comprehensive framework which covers the various dimensions, functions and actors in RCS could therefore be helpful to develop a proper understanding of RCS conceptually and to address its major challenges eff ectively in action terms. Th e current study has four main objectives: • To review some major trends and developments in research capacity strengthening over the last decade, with a focus on developing countries; • To identify from this review some key issues and outstanding challenges in RCS; • To provide a conceptual framework for these issues and challenges, linking RCS in a more eff ective way to the development of a national health research system; • To contribute to a more documented and comprehensive dialogue about priorities and future directions in RCS between the numerous stakeholders, which could make a signifi cant contribution to research capacity strengthening in developing countries.From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004): a panorama of players, programmes and issues Th e search for a conceptual framework to address health research capacity strengthening in a comprehensive and systematic way can begin by examining the practice of capacity building over the last fi fteen years; which actors have been on the playing fi eld between the Nobel Conference in Stockholm and the Ministerial Summit in Mexico; which strategies or programmes were developed and, more important, which key outstanding issues have been identifi ed by those actors. Th ese issues could indeed be used not only as a reality check for the proposed framework, but also as building blocks for its construction. Before drawing this panorama of players, products and programmes, a brief comment is perhaps appropriate on the attention that health research capacity strengthening has received over the last decade within the scientifi c literature – a comment which could give a fi rst indication of the importance of this subject, at least within the scientifi c community. A recent 6 literature search, undertaken by Niall McKee on behalf of the Global Forum, produced two major fi ndings: 1. Th e proportion of peer-reviewed materials on research capacity strengthening in relation to the total amount of peer-reviewed materials on health research is relatively small. Th e results of a search of two databases (Pubmed and Popline) since 1990 are included in Table 1. A possible explanation for this relatively small proportion of materials devoted to RCS is that the majority of publications on it are grey literature, internal reports and documents by UN agencies, international health (research) programmes, bilateral donor agencies, foundations and nongovernmental organizations. It is therefore diffi cult to assess properly the relative importance given to RCS by the scientifi c community. 2. Th e number of articles devoted to RCS in three leading international medical/health journals is constantly growing, but slowly over the last decade. Figure 1 gives the number of articles on RCS published over the last ten years in the British Medical Journal, the Journal of the American Medical Association and Social Science and Medicine. Results for health Results for RCS % of RCS-related Table 1 research articles Yearly publications on health research Pubmed 12,696 799 6.29% and RCS Popline 534 16 2.99% Source: Niall McKee, Review of research capacity strengthening (2004) Whilst the results are not clear cut or defi nite due to the nature of the selected data, they indi- cate nevertheless that RCS has been taking a more central place in the production of scientifi c ar- ticles over the last decade, at least as refl ected by the analysis of three leading scientifi c journals. Chapter 14 Chapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004) 40 Figure 1 35 30 Yearly publications BMJ 25 on RCS 20 JAMA 15 Soc Sci+Med 10 5 0 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year Parallel with a (slowly) growing interest in research capacity strengthening in the scientifi c literature, an increasing number of actors at national, regional and international level have been initiating and/or expanding short-, medium- and occasionally also long-term activities, projects and programmes in research capacity strengthening in developing countries. Th ese players include UN agencies, such as WHO, UNICEF and UNAIDS, international health research programmes, such as the Alliance for Health Policy and Systems Research, the International Network for Clinical Epidemiology (INCLEN), WHO’s Special Programmes; global health research advocacy groups, such as the Global Forum for Health Research and the Council on Health Research for Development; regional research networks, such as the African Health Research Forum and the China Health Economics Research and Training Network; donor agencies, such as the International Development Research Centre and Sida/SAREC – and these are only a few examples, not even including the numerous country actors and activities in RCS. Although it could be an interesting learning experience to draw a complete picture of the trees in the RCS forest, the major aim here is to identify key issues to be addressed in RCS and to place these issues into a framework, allowing for a more systematic and synergetic approach. By looking briefl y at documents, initiatives and activities of a selected number of players in the fi eld of RCS, some of these key issues can be uncovered and brought to the surface for further analysis and integration within a framework. A distinction has been made between some major players and some actors in specifi c areas of RCS. Th is overview will be concluded with a brief comment about the role of the donor community in RCS. It goes without saying that the following panoramic overview does not pretend to be complete or representative of what happened in RCS during the last fi fteen years, nor is it aiming to give a historical analysis of RCS eff orts during this period. Th e gradual uncovering of the complex reality of RCS in its major components and key issues is its single objective. Who have been the major players? Commission and Task Force on Health Research for Development Th e independent, international Commission on Health Research for Development noted in its 1990 report that capacity building for research has not been a priority with most donor agencies because it is costly and time-consuming and does not seem to produce immediate results. Th e Commission therefore included in its Action Agenda “building and sustaining in both developing and industrialized countries individual and institutional research capacity concerned with third-world health problems” as one of its four major components. Furthermore it recommended “that building and sustaining research capacity be integrated as a key objective and powerful instrument for all health and development investments. Primary commitment must come from developing country governments to accord priority and provide sustained support … Donor-assisted health projects should commit at least 5% of the project budget to 7 research capacity strengthening and research activities”. Established to carry forward the recommendations of the Commission and to support pilot activities at country level, the Task Force on Health Research for Development (1991) evolved a “Strategy for Action in Health and Human Development” or the Essential National Health Number of publicationsChapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004) 5 Research (ENHR) strategy and included strengthening research capacity as one of the seven elements in this strategy. It was noted that many developing countries still lack the capacity to implement a national plan to conduct research on both country-specifi c and global health problems “because of defects in their institutions, shortages of trained researchers, limitations 8 of funding, and poor logistic support”. Th e goal of RCS is to ensure that each country develops the research capacity needed to analyse its health situation, to respond to new challenges and to develop better interventions for prevention, control and treatment. In view of the enthusiasm with which developing countries and also but to a lesser extent donor agencies embraced the ENHR strategy, the second International Conference on Health Research for Development decided to establish in 1993 the Council on Health Research for Development (COHRED) as an international mechanism to facilitate the further implementation of ENHR. From its inception, COHRED placed research capacity strengthening high on its agenda and covered it in a number of publications, organized training and orientation activities on various capacities, such as priority setting, tracking of resource fl ows, research management and dissemination of research fi ndings. Its Interim Assessment (1997) identifi ed capacity strengthening as one of the four major areas where COHRED should make its next steps. Capacity strengthening, together with advocacy for equity in health research, continues to take a prominent place in COHRED’s Strategic Framework for Action (2003-2007), which emphasizes that “all countries should have the capacity to identify their priorities, to conduct essential research that guides their health policies and practice, and to 9 manage a system through which the eff orts of all players can be harmonized”. Key points: • capacity strengthening at individual, institutional and system level • capacity strengthening of various stakeholders, including researchers, policy-makers and health-care providers • capacities to produce, utilize and manage research • capacity development to be driven by countries • need for an integrated capacity strengthening plan • need for long-term investments in capacity development, from both national and international sources. “The regions where disease burden is greatest, and changing most rapidly, are severely disadvantaged by the small numbers of their scientists, the invisibility of the work of their scientists, and the lack of incentives for excellence and productivity.” 10 (Ad Hoc Committee) World Health Organization Th e same year (1990) in which the Commission released its report, the World Health Organization rd focused its Technical Discussions at the 43 World Health Assembly on the “Role of Health Research in the Strategy for Health for All by the Year 2000”, with research capability strengthening as one of the four major themes. Th e subsequent resolution by the Assembly on “Th e role of health research” urged Member States, particularly developing countries, “to build and strengthen national research capabilities by investing resources in national institutions, by providing appropriate career opportunities to attract and retain the involvement of their own 11 scientists, and by creating environments that will foster scholarship and creativity”. Stimulated by this recommendation and also challenged by the work of the Commission on Health Research for Development, WHO intensifi ed its eff orts in capacity strengthening, both in its health systems and science and technology programmes, and also at its various organizational levels. Training materials for various stakeholders were developed, specifi c capacity strengthening programmes, for instance in the areas of tropical diseases, human Introduction6 Chapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004) reproduction (see below) and health systems, became stronger and more investments were The report allocated to RCS. emphasizes the At the strategic and policy level of the organization, research capacity strengthening importance of was recognized as a vital and essential investment in health and development and received high priority in key policy documents, such as the health research strategy developed by the strengthening 12 Advisory Committee on Health Research (1997) and in the recommendations of the Ad human Hoc Committee on Health Research Relating to Future Intervention Options (1996). As capacity, one of the institutional responses to the challenges, the Ad Hoc Committee made the following fostering fi rm statement: “Investors may increase the effi ciency of R&D by strengthening national and regional research capacity, through, for example, focusing eff orts on areas of comparative an enabling advantage, on improvements in the quality of training, and on explicit initiatives to translate environment results into relevant policies and interventions; by off ering incentives to reverse the brain drain, and the by promoting policies that require research posts to be competitive and based on peer-reviewed 13 allocation of funds; and by making core support for institutions competitive”. promotion of More recently, WHO published the World Report on Knowledge for Better Health: collaboration Strengthening Health Systems, which was a major input to the Ministerial Summit on Health in health Research (Mexico, 2004). In taking stock of health research the document highlights a series research. of inequities in the research process, including in the fi nancing of research (the ‘10/90 gap’), in setting the research agenda (predominance of biomedical and clinical research as well as the infl uence of pharmaceutical and biotechnology companies), gender bias in health research and inequities in knowledge publication. Focusing strongly on the development of a national health research system, the report identifi es health research capacity strengthening as one of the four major functions of the health research system. As key strategies, the report emphasizes the importance of strengthening human capacity, fostering an enabling environment and the promotion of collaboration in health research. Key points: • capacity strengthening of individuals and institutions in combination with promoting an enabling environment • not only capacity strengthening, but also capacity retention • capacity strengthening, not just in technical aspects of research • capacity strengthening for the demand-side of research • importance of funding and fi nancial incentives • need for a more system-oriented and long-term approach. Whilst the above events, documents and issues all refer to the World Health Organization at the global or headquarters level, it should be recognized that similar or parallel observations could be made at the regional level. Th e important role of the WHO Regional Offi ces in RCS is for instance illustrated in the regional building up and planning process towards the International Conference on Health Research for Development in Bangkok (Th ailand, 2000), whereby most of these offi ces played a catalytic role in channelling the country voices towards this international event. Global Forum for Health Research Th e Global Forum attaches much importance to RCS to help correct the ‘10/90 gap’ and seeks to explore ways in which it could contribute to the greater effi ciency and eff ectiveness of RCS eff orts. To this end the Global Forum has devoted special sessions on RCS during its annual meetings (Forums), where various capacity strengthening initiatives have been presented and discussed, together with more overall policies and perspectives on RCS. Th e three editions of Th e 10/90 Report on Health Research (2000, 2001-2002, 2003-2004) also give considerable attention to RCS by identifying major challenges, reviewing progress made and drawing an action agenda for the coming years. Th e 10/90 Report 2003-2004 formulated the following major lines for RCS: design a framework for defi ning RCS needs and impact, establishment of Chapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004) 7 14 a network of RCS partners, funding and enabling health research systems. It should be noted that the equity dimension in general and the gender dimension in particular cut across the Global Forum’s overall strategy, including research capacity strengthening. Key points: • need for evaluation of RCS • RCS agenda at national, regional and global levels • funding of RCS • strengthening of macro-environment/national health research system. The Action Plan, adopted by the International Conference on Health Research for 15 Development (Bangkok, 2000), jointly organized by the Council on Health Re- search for Development, the Global Forum for Health Research, the World Bank and the World Health Organization, recommended for capacity development the following actions (at national level): • Research management and leadership training programmes should be estab- lished. Funds should be designated for research capacity development in its broadest sense. • Viable research careers should be developed where they do not exist. • Capacity development efforts should include all stakeholders – communities, health-care providers, researchers and institutions – but should focus primarily on institutional development. Players in specifi c areas Over the last decade the number of players in the health research fi eld and therefore also indirectly in RCS has been increased in a signifi cant way. Th e latest available 10/90 Report by 16 the Global Forum lists, in addition to a number of information networks in health research (e.g. HINARI, INASP-Health and SHARED), 17 networks in the priority research areas, of which most have some capacity strengthening component on their agenda. International agencies like the World Bank, UNAIDS, UNICEF and the Global Fund are dealing with some specifi c aspects in RCS. Th e World Health Organization has numerous research programmes with research capacity strengthening as a key component or strategy. Most of these programmes are targeting either a specifi c group (e.g. managers, clinicians, social scientists, district staff ) or a specifi c topic area (e.g. specifi c disease, human resources, health systems, social determinants). Beside the classical examples of the Special Programmes on tropical diseases research (TDR) and human reproduction research (HRP), there are some more and recent examples of research capacity strengthening in specifi c areas, like human resources, tuberculosis, operational research in support of “3 by 5” and equity. Th ere are also an increasing number of nongovernmental organizations active in the fi eld of research capacity strengthening for research, which focus also most of the time on specifi c groups, topical areas or particular capacities, like the International Network for Clinical Epidemiology (INCLEN), the International Forum for Health Social Science, the Alliance for Health Policy and Systems Research (the Alliance), the Equity Network (EQUINET), the Field Epidemiology Training Program (CDC) and so on. Rather than trying to establish an anthology or even a glossary of all these RCS initiatives, four health research programmes which have RCS as one of their major fl agships – INCLEN, TDR, HRP and the Alliance – are briefl y reviewed here with the aims of identifying further issues and challenges in RCS and constructing a more comprehensive framework for analysis and action. Chapter 18 Chapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004) International Network for Clinical Epidemiology (INCLEN) INCLEN was established in 1980 as an initiative to improve health care in developing countries by promoting a population-based framework among health care professionals in the planning, measurement and evaluation of health systems. Its original mission was to train faculty at medical schools in developing countries to think more broadly about the determinants of health, but gradually the programme evolved to include a wide range of health professionals involved in clinical care, preventive care and promotional health, who investigate important issues of equity, effi ciency and quality in health care. Clinicians, social scientists and biostatisticians from leading medical institutions in the developing world were trained (at Master’s level) to create Clinical Epidemiology Units (CEUs) in their own countries that could serve as agents for change. Th is training was initially done in Clinical Epidemiology Research and Training Centers (CERTCs) in medical schools in Australia, Canada and the United States, but was gradually transferred to developing world CEUs. As many of these CEUs reached a level of maturity and stability with a full faculty training complement, a selected number were upgraded to research and training centres (CERTCs) to train fellows in their respective regions. INCLEN’s contribution to individual and institutional capacity development of the last 25 years is illustrated in the following table: • Number of professionals trained: 724 in 28 countries Table 2 • 71 Clinical Epidemiology Units (CEU) in 28 countries INCLEN’s contribution to • 24 Clinical Epidemiology Research & Training Centers (CERTC) in 15 countries, offering the following individual and institutional or similar MSc programmes : 17 capacity development o MSc in Clinical Epidemiology o MSc in Epidemiology and Biostatistics o MSc in Health Policy and Management o MSc in Clinical Medicine Source: INCLEN, International Network for Clinical Epidemiology “A Forum 6 workshop on clinical trial capacity in low- and middle-income countries identifi ed several areas where substantial capacity development is sorely needed including the areas of planning, good clinical practice norms, ethical reviews, data management and statistical analysis, the ability of indigenous researchers to compete successfully for research funding, even on issues dealing with essential 18 national or regional public health conditions.” (INCLEN) In its present strategic plan 2003-2007, the INCLEN Trust, established in 2000 and registered as an international nongovernmental organization, has defi ned strengthening of its “global, regional and national research and capacity building functions” as one of its four major 19 strategies. Special Programme for Research and Training in Tropical Diseases (TDR) “While researchers in disease-endemic countries are closer to the problems and may hold the key to solutions, all too often they are handicapped by the lack of essential skills, equipment, access to information, and opportunities to participate in the global research agenda.” (WHO/TDR, Research capacity building in 20 developing countries)Chapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004) 9 Established in 1975 and currently co-sponsored by UNICEF, UNDP, the World Bank and WHO, the Special Programme for Research and Training in Tropical Diseases (TDR) aims to improve existing and develop new approaches for preventing, diagnosing, treating and controlling neglected infectious diseases which are applicable, acceptable and aff ordable by developing endemic countries, which can be readily integrated into the health services of these countries, and which focus on the health problems of the poor. Building research capacity has been a major component of TDR since its inception. In its most recent strategy, TDR has been placing research capacity strengthening at the heart of the programme “underpinning everything it does, from the discovery of new basic knowledge, to the 21 development of new tools, new intervention methods, and new policies for disease control”. Two main tracks in its approach to capacity building have been established. One track (R&D-driven capacity building: RCS-plus) is driven by the R&D output, i.e. leading research institutions, from least as well as more advanced developing countries, are invited to compete for participation in R&D work contributing directly to TDR’s R&D agenda and to build capacities to become more internationally competitive. Th e other track (Researcher-driven capacity building) has an individual component with “open calls for applications” both for postgraduate degree or specialized training and leadership class, and an institutional component with a support package which is expected to develop research leadership, promote the development of infrastructure and research environment and to foster opportunities for collaboration with more advanced countries. Th is new strategy also involved a shift in the allocation of resources for research capacity strengthening. While prior to 2000 funding for individual capacity building (through research and training projects) accounted for nearly half of capacity strengthening activities and budget, this share went sharply down after 2000 and the lion’s share of the budget shifted gradually to strengthening existing research capacity in more developed countries to support research and development in TDR priority areas. Th is shift in priority in capacity strengthening eff orts is illustrated by the following table: 2000-2001 (%) 2002-2003 (%) 2004-2005 (%) Table 3 TDR research Research 932 7.1 1,817 16.2 1,746 17.1 capacity building: environment 22 approved working budget Individual (In US thousands) academic 4,800 36.7 2,652 23.7 1,618 15.9 training Institutional 2,677 20.5 2,669 23.8 2,234 21.9 grants R&D-related capacity 4,680 35.8 4,062 36.3 4,587 45.0 building Total 13,089 100.0 11,200 100.0 10,185 100.0 includes MIM/TDR grants Source: F. Zicker As far as key issues are concerned, a SWOT analysis (strengths, weaknesses, opportunities, threats) which was done in relation to the new TDR research capability strengthening strategy, identifi ed the following threats or issues: • “continued global focus on quick-fi x and operational solutions to public health problems gives research low priority; • development of research self-reliance is a multifaceted task and it is diffi cult to measure and attribute impact to investment; • poor economies of most disease-endemic countries (DECs) maintain public R&D investments at a less than viable level; • globalization makes high level DEC researchers extremely mobile in search of better 23 opportunities (RCS Strategy 2002-2005) ”.10 Chapter 1 From the Commission in Stockholm (1990) to the Ministerial Summit in Mexico (2004) Special Programme of Research, Development and Research Training in Human Reproduction (HRP) “An integral part of development support is the building-up of national and regional self-reliance through research capacity strengthening” (WHO/HRP, An Investment 24 for the future) Th e Special Programme of Research, Development and Research Training in Human Reproduction (HRP) was established by the World Health Organization in 1972, as the main instrument within the United Nations system for the coordination, promotion, conduct and evaluation of international research in human reproduction. Since the beginning, HRP has established a network of institutions, which are involved in both global and national reproductive health research and research training. HRP uses a system of grants to build and strengthen the capacity of developing countries to conduct research on reproductive health and to apply the fi ndings of that research to policy and practice. Th e main instrument is the long- term institutional development (LID) grant, which off ers a technical support package including training, equipment, expert advice and other resources to support a research programme in line with the country’s needs. Other instruments include research training grants, which allow scientists from developing countries to undertake training in an institution other than their own, and grants for resource maintenance, courses, workshops, seminars, and advocacy for best practices through centres of excellence. 25 Th e following table gives an idea of the overall output of LID grant recipients by period: OUTPUT 1990-1994 1995-1998 Difference (%) Table 4 HRP overall output of LID Years spent on research projects 2871 1989 -30 grant recipients by period Staff trained abroad 287 211 -25 Staff trained in the totality of centres 30527 42717 +40 Publications and presentations 3178 3423 +8 Source: UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Report of the In-depth Review of Research Capacity Strengthening (2002) Among the lessons learned, the most recent External Evaluation report (2003) noted: • “… it remains a challenge to bridge the gaps between research, policy and action… • reproductive health research capacity strengthening can be enhanced by supporting 26 leading reproductive health research centres…” In addition to these lessons, the Report of the In-depth Review of Research Capacity Strengthening recommends that for the period up to 2010 HRP’s research capacity strengthening programmes should be targeted mainly to: • assist least-developed countries with an expressed commitment to improve the reproductive health status of their populations; • introduce and strengthen strategies to facilitate the dissemination and utilization of research results to improve programmes and services; • develop effi cient and eff ective monitoring and evaluation mechanisms that allow a more objective assessment of the impact of the proposed RCS mechanisms. Alliance for Health Policy and Systems Research As an initiative of the Global Forum for Health Research, the Alliance for Health Policy and Systems Research (HPSR) was launched in early 2000 to promote the generation, dissemination and use of knowledge for enhancing health system performance in developing countries. To