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The role of brain-drain and inequitable partnerships in perpetuating Africa’s weak health systems

17 Nov 2008

Greer van Zyl

Source: TropIKA.net

Sub-Saharan Africa has a huge burden of disease, estimated by some to be five times higher than that of established market economies (1). At the Ministerial Conference on Research for Health held in Algiers, it was clear that Africa’s health systems are weak and under stress, and increasingly cannot keep up with this burden. Although cost-effective strategies do exist, health problems are not adequately addressed for a range of reasons, among them lack of capacity and incentives, brain-drain, and under-investment in research. It has been said that inequalities in health research translate to inequalities in health.

Health research has generated knowledge with enormous potential to improve people’s health through drugs, vaccines and diagnostics, but research needs to be translated into policy and action by sharing of results. According to one speaker at the conference, 97% of grants awarded by the two largest research funders for work relevant to low income countries (LICs) was for the development of new technologies – yet 62.5% of child deaths in LICs could be averted through improved use of existing technologies (2). In Africa, the emphasis needs to shift to health systems research and developing human and health research capacity.

To assess where the continent stands, the WHO’s regional office for Africa (AFRO) undertook the first-ever mapping survey on human capacity, training for research, and staff movement in Africa. The research was conducted in 2007 using questionnaires, with a 96% response rate (44/46 countries). The results were released during the Algiers meeting.

From the data it is clear that there is a dearth of information identifying actual health research capacity. What has emerged is that Sub-Saharan countries do not have sufficient resources – financial, human capacity or infrastructural – to train sufficient numbers of health researchers. Just 3% of the world’s health workers are in Africa, and there are not enough institutions to train the number of staff needed to meet the continent’s health research needs. The institutions are unable to meet the huge needs for training, there is a shortage of senior staff for mentoring, and there is a serious shortfall in qualified staff engaged in research in most countries. Fulltime staff of public health institutions number about 500, covering a population of 900 million people. Increased international/bilateral funding initiatives are also drawing experienced scientists away from research institutions.

Brain drain

In the absence of training facilities, many health scientists pursue education in developed countries and opt to stay there. Those who return home often become frustrated because of poor salaries, infrastructure and the lack of prospects for career advancement. Some of the brain drain is internal: most of the research institutions lose staff to other sectors within their home countries every year as well. There is virtually no data on the movement of African health researchers, an area which needs to be researched.

This paucity of workers is reflected in the numbers of African-authored publications in peer reviewed journals – as little as 1% of health scientific publications from Africa make it into internationally indexed journals, while 60% of the papers that do are from three countries, South Africa, Nigeria and Egypt. The number of local journals needs to be increased to broaden the scope for publication, and it was suggested that publications could be increased if researchers had help in translating their findings for scientific papers, analysing data, and writing quality papers.

According to Dr Sara Bennett, Manager of the Alliance for Health Policy and Systems Research (WHO), poor pay and lack of incentives have driven some of the best brains out of their countries. The situation, Dr Bennett said, has been compounded by low public health training capacity. She noted that only 29 out of 53 African countries offer postgraduate training in public health.

‘Apart from poor salaries, most African scientists working in their home-base have to cope with constraints prevalent in resource poor settings and have no incentives such as career development to persuade them to continue working in Africa. The brain drain occurs due to lack of a supportive environment and insufficient key resources such as online libraries. We sorely need capacity building for health research, as well as knowledge translation,’ said Dr Bennett.

According to Dr Njeri Wamae of the Kenyan Medical Research Institute, the issue of training overseas and deciding either to come back home or stay out there is very personal. ‘I trained overseas in the United States and would come back to Kenya and work, and then go back to the graduate schools. There was not a single time I considered living abroad permanently because I had a fulfilling job in Kenya. But for someone who can’t find a fulfilling job, it’s unfair to expect them to remain at home without any prospects. Besides, the world is a global village and even those who have been trained whether locally or overseas, wherever they go, they apply their skills for the common good,’ she believes.

‘Another thing we should not lose sight of is the feeling of wanting to give back. Kenya and my community invested in training me. I also received training from TDR, WHO’s special programme for research and training in tropical diseases. I want to give back and do some good in the area of neglected tropical diseases because I don’t think it is TDR’s plan to train people for them to jump on the ‘gravy train’ and leave their own countries where they are needed most, at least initially,’ asserted Wamae.

She has encouraged graduate students pursuing doctoral and masters degrees over her 25 years as a researcher and lecturer. ‘I do some fishing in my own lectures when I’m teaching because we do need a new crop of disease control experts who we can pass the mantle on to. I engage them in various fields of control of parasitic diseases, while asking them to have the mindset of tomorrows’ disease control experts. I’m happy to report that I’ve seen new recruits who joined KEMRI with only a basic degree, undergo my mentorship and today they have PhDs from local and international universities and have identified solid biomedical career pathways,’ she said.

Funding of health research

‘The scarcity of financial resources has led to choices between research and health development, but the real choice is the change of paradigm of translating research into health policies,’ said WHO’s regional director for Africa, Dr Luis Sambo, at Algiers.

One of the highlights emerging from the Algiers meeting was a commitment by ministers in the final declaration to allocate at least 2% of national health expenditures and at least 5% of health external project and programmed aid to research and research capacity building.

This will help to develop capacity throughout the research cycle, particularly as resources are needed to apply evidence to policy and action. To stem the brain drain, suggests Bennett, African governments need to have long-term development plans that would lead to increased funding and thus better pay for researchers.

‘There’s a need for strong African leadership in developing long-term capacity building plans, and that stronger leadership in capacity development could mean more investment. Africa has a clear opportunity to take the lead in proposing aid modalities and funding models that foster equitable North-South and South-South partnerships.’ She added that short-term, fragmented funding undermines long-term capacity development.

According to Dr Tikki Pang, while there has been a massive influx of money into health, this is not necessarily a good thing at country level, because countries don’t always have the capacity to handle it. ‘A small country like Malawi with three million people can’t absorb $100 million in foreign aid; the health systems just can’t cope with this sort of funding, so the potential disruptive effect is tremendous.’

He gave an example of a vaccine trial in Malawi which required 17 dedicated nurses for the trial. These nurses were withdrawn from the health system to undertake this work with dramatic implications for the healthcare system in a country which ‘only produces about 17 – 20 nurses per year.’ Malawi then recruited South African nurses to prop up its folding health system, which South Africa could ill afford. WHO recommends a minimum of one nurse per 1000 population. Malawi 0.59 nurses/1000, compared with 9.37 nurses/1000 in the United States (3).

‘I would always posit that if you go into a country to do a clinical trial, you should also set aside money in your grant to train local people to compensate against the parachute effect. I don’t see much of this happening. Perhaps this is due to countries’ lack of capacity or the power imbalance. I think it is an ethical issue for a donor to come in and disrupt the health system to such an extent that affects healthcare to the nation – to me that’s unethical practice,’ said Dr Pang.

Equitable partnerships

WHO is working on guidelines for equitable partnerships between northern institutions and institutions in developing countries following appeals from certain developing countries following inequitable contracts in terms of benefit-sharing.

‘Contracts have in some cases been drawn up in such a way the developing country institution was ‘taken for a ride’. There appears to be exploitation in terms of ownership of research at the end of the process, authorship of publications, intellectual property, even sharing of royalties of patents,’ remarked Pang.

This resonates with a recent article in Science by Tucker and Makgoba on public-private partnerships and scientific imperialism (4), which asserts that while health-related public-private partnership organisations (PPPOs) have been important in generating resources and novel products, the authors argue that they have not been able to change the prevailing imperialist paradigm or to involve African researchers as equally empowered participants and leaders.

‘However well-intentioned these individuals and organizations are, the traditional imperialist power dynamics remain in which African researchers have very limited executive decision-making ability with public-private partner organisations (PPPOs) and Africans are only able to access resources that (predominantly) non-Africans decide are appropriate. African scientists and clinicians also need to address power imbalances when establishing their own individual relationships with the large PPPOs. Although many African researchers are desperate for any funds that become available, others who are relatively well-resourced appear to perpetuate the power imbalances by accepting contractual relationships with PPPOs that are continuing the old dependency paradigms.’

They urge that those who fund and control PPPOs change the way in which the PPPOs operate, including their structures, personnel and systems, so that Africans will not remain relatively disempowered participants.

According to Dr Pang, the Swiss, Australians and the Wellcome Trust have developed guidelines of their own volition in terms of conduct by their institutions when partnering with developing countries. ‘But I’ve not seen anything from some of the bigger donors. Countries look up to WHO for guidance and it is incumbent on the organisation to do something about this.’

According to Dr Pierre Ongolo-Zolo, senior lecturer at the Medical School, University of Yaounde I in Cameroon, one of the most interesting developments at the Algiers meeting was the announcement by the Dr Elias Zerhouni, Director of the National Institutes of Health (NIH) in the United States USA, who openly declared the NIH’s support and its readiness to work with all of the countries represented at the meeting.

‘The NIH welcomes the goals of this conference and wants to reinforce the belief that sustainable programmes in countries require built-in institutional capacity. We researchers are no longer able to be independent of each other, not only at the fundamental level of discovery, but also managing that knowledge in a culturally sensitive way. This is a great moment because for the first time, we are all aligned in the sense that health research has to be developed at local and regional levels where best knowledge is applied for best results. We’re looking forward to Bamako, and you have our support.’ – Dr Elias Zerhouni, Algiers, 26 June 2008

‘Now maybe things will change,’ said Ongolo-Zolo. ‘One of the big issues that has to be sorted out is the issue of fairness between northern institutes and partners from Africa which is very imbalanced. I hope to see this real partnership whereby research is conducted on priority issues of Africa with researchers earning the same salaries as those coming from the north to work in our institutions. We need to have the same benefits in terms of patents and authorship in scientific papers.’

This sentiment was echoed by many countries during the Algiers conference. ‘How can we coordinate donor funding to help solve national problems rather than satisfy donor needs? How can we suggest to donors rather than have them prescribe? The question is: are we helping donors to make propaganda or are we ensuring that donors are making an impact on our problems at country level? How do we build up mutual trust?’

Several participants referred to pressure and bias on the part of donors in their selection of health research priorities for funding. ‘Health research policies need to be in place; the best strategy to convince donors is to have a national health plan’. This point was reinforced by the Namibian delegate who said that unless countries can show specific budget lines for research, it would be impossible to talk about research priorities.

One crucial determinant of success with donors, as stressed by Dr Andrew Kitua of Tanzania’s National Institute for Medical Research in a panel discussion, was for partners share common goals, no matter which sector, geographic or economic group they belonged to. (Read more about Dr Kitua’s successful engagement with donors on page…). Negotiation and communication skills were regarded as valuable tools for researchers in all cases, at national, intersectoral, and global levels, while being part of a multinational network added leverage.

The mapping exercise on collaboration of outputs which represented feedback from 44 out of 46 countries and over 700 institutions found that almost half of all easily accessible journal articles from the region had no collaboration, indicating untapped potential. Some institutions received a large share of their funds from foreign sources. Institutions belonging to a multinational group were more likely to report more access to professional networks and have acceptable levels of funding. Institutions not belonging to a multinational group were more likely to undertake national priority research and collaborate with other national institutions, but have lower salaries. Institutions across the region identified fundamental issues for achieving more balanced research partnerships which included deciding on priorities together, increasing research capacities and improving negotiating skills.

Communication

Many participants spoke on the lack of communication between African countries as a limiting factor in effective collaboration. ‘To strengthen collaboration, we need to know what countries are doing,’ they urged. There are currently few incentives encouraging collaboration, which would help ensure good quality research and strengthened capacity. WHO’s AFRO office is planning to establish an African ‘observatory’ for research which will house all the data from the mapping surveys and act as a repository for regional research.

The mapping results found that the most common format for the dissemination of knowledge on health policy was through printed documents and publications. Education and networking among health service providers was mainly through local communication, medical education conferences, and by communication with peers abroad. There was a gap in monitoring and evaluation in both policy formulation and the provision of clinical services.

Researchers need to communicate far more effectively between themselves and other stakeholders. Disseminating knowledge is crucial, particularly in a manner which made decision-makers aware of the possibilities. ‘What appeals to policy makers is not scientific papers. They listen to the radio and read newspaper. The best way to convince policy makers is to give them real stories where research has made a difference, and particularly where it saves money,’ suggests Dr Tikki Pang.

Delegates highlighted the role and inclusion of the media and other stakeholders in bridging the gap between researchers, policymakers and the population, as well as simplifying often complex research findings. They acknowledged that different elements of society needed to be involved to have an impact. It was seen as increasingly important that scientists talk to policy makers who in turn talk to the private sector to have the desired impact.

References

1. Murray CJL, Lopez AD (1996). Global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston, MA: Harvard School of Public Health, World Health Organization, World Bank.

2. Dr Sara Bennett, Ministerial Conference for Health Research, Algiers, 23 – 26 June 2008, referring to: Jef L. Leroy et al. (2007). Current Priorities in Health Research Funding and Lack of Impact on the Number of Child Deaths per Year. American Journal of Public Health; 97(2):219-223. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17194855

3. The World Health Report – Working together for health. Geneva, World Health Organization, 2006. Available from: http://www.who.int/whr/2006/en

4. Tucker TJ, Makgoba MW (2008). Public-private partnerships and scientific imperialism. Science; 320:1016-1017. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18497279