Moving to Research Partnerships in Developing Countries Anthony Costello, Alimuddin Zumla

Education and debate Moving to research partnerships in developing countries Anthony Costello, Alimuddin Zumla What should be the principles behind investment in Centre for research in developing countries? Does current International Child Summary points Health, Institute of practice overemphasise the results of research and Child Health, ignore issues like ownership, sustainability, and University College, Much foreign-led research in developing London development of national research capacity? We believe countries remains semicolonial in nature and may WC1N 1EH that the research model supported by many funding have negative effects on partner countries Anthony Costello agencies remains semicolonial in nature. Foreign professor of domination in setting research priorities and project international child “Annexed site” research led by expatriates should health management may have negative consequences which be phased out and replaced by a partnership Centre for outweigh the apparent benefits of the research model in which nationals lead research projects, Infectious Diseases findings. National academic leaders and institutions with only technical support from outsiders and International need to be involved if research is to be translated into Health, Royal Free and University practice. The deterioration in academic infrastructure Research funded through national academics and College Medical in many developing countries needs to be reversed as School, Windeyer institutions improves the chances of findings Institute of Medical part of any research investment. A truly cooperative being translated into national policy and practice Sciences, University research partnership, which should be monitored by College, London funding agencies, rests on four broad principles: The principles of an equal research partnership WC1N 6DB x Mutual trust and shared decision making Alimuddin Zumla need monitoring by funding agencies professor of infectious x National ownership disease and x Emphasis on getting research findings into policy international health and practice Correspondence to: compete for the best and brightest local talent. Salaries x Development of national research capacity. A Costello of academics or doctors are five to 20 times greater in an [email protected]. international organisation or research station than in ac.uk Existing research models in developing government or university service. At some stage in their BMJ 2000;321:827–9 countries career these professionals inevitably jump ship. The semicolonial model Research fellows in “annexed sites” may receive good Some styles of research interaction pay little attention training there, but few return to national institutions. to ownership, sustainability and the development of Thirdly, funding agencies have a moral responsibil- national research capacity. “Postal research,” whereby ity not to ignore the appalling problems facing Western researchers request colleagues in Africa to national institutions in developing countries. Over the courier to them biological samples, is still practised, past two decades the effects of economic decline, and though less commonly than in the past. “Parachute of the structural adjustment programmes imposed on research,” whereby researchers travel to Africa or Asia many countries, have led to drastic cuts in numbers of for short periods of time and take back biological sam- academic staff and salary levels, a lack of equipment ples, is still relatively common. Results of both types of and training opportunities, a sense of demoralisation, research are often published with minimal represen- and isolation from international colleagues. Many tation of African or Asian input. researchers must moonlight in other jobs or do private “Annexed sites” for field research, led and managed practice to support their families, with inevitable effects by expatriate staff, still predominate as the model for on time available for research. It seems ethically ques- investment. Undoubtedly, these sites have produced tionable that foreign investment funds should pour some of the most important, influential, and innovative into 10 or so internationally-led independent research research in tropical medicine, and many of the best centres in the poorest countries while national researchers have been trained there. Proponents of academic infrastructure withers on the vine. A merger such a model might argue that tight expatriate control of annexed sites with appropriate national partners increases the likelihood of good quality research find- would be preferable—and mutually beneficial. ings when the work is being done in a difficult environ- Getting research findings into policy and practice ment. We believe these “annexed sites” now represent Research quality should not be the sole criterion for an opportunity cost, attract promising academics away investment. “They’re only interested in the number of from national institutions, and their research findings good quality journal papers you produce,” said one are less likely to be translated into policy and practice. colleague about the criteria used by a funding agency Opportunity costs to judge the success of a research project. High quality Some of the problems with existing research models research obviously tops any list of evaluation criteria. present as opportunity costs. Firstly, expatriates are To conduct poor quality research is bad ethics as well as expensive and should not be used for tasks better run bad economics, but to focus on the quality of research by local staff, especially programme management. results or journal papers alone is clearly insufficient. Secondly, independent foreign research sites may be Transferring funding from expatriate-led research accused of what has been inelegantly termed “donor at annexed sites to national academic leaders and insti- robbery.” Like international agencies, these sites operate tutions is not simply complying with notions of politi- by using inflated local salary scales, and they seek and cal correctness. Lessons learned from research units BMJ VOLUME 321 30 SEPTEMBER 2000 bmj.com 827 Education and debate HIV trials in developing countries. Leading US academics opined that trials without a control arm incorporating full antiretroviral therapy were unethi- cal,45 even in communities where no drug therapies were currently available—a viewpoint vehemently opposed by African researchers, who considered these views overzealous, discriminatory, and impractical.6 Reaching the point of decision making In the United Kingdom interest has been increasing in evidence based health care and how to overcome barriers to getting research findings into practice.78 Haines and Donald highlighted the importance of getting information to the point of decision making, and of overcoming social, organisational, and institutional barriers, through innovative educational strategies, particularly those that ensured better links between ALISON WRIGHT/PANOS PICTURES clinical audit, continuing education, and research pro- Cultural factors greatly influence the interpretation and application of research findings fessionals. Incorporating these ideas at the very start of research project design needs time and money. run by expatriates in developing countries are less Bilateral donors have now built this concept into their likely to be incorporated into policy and practice, and funding applications, but medical research funding foreign researchers tend to favour efficacy trials of charities have still some way to go. novel interventions, rather than applied studies to improve the implementation of proved interventions. Cultural and nationalistic influences play a much Principles of research partnership in greater role in the interpretation and application of developing countries research findings than is widely assumed. Medical A partnership model research, even in the industrialised world, is interpreted A partnership model can produce high quality research differently when France, the United Kingdom, or the at lower cost, with greater influence on national policy 1 United States are compared with each other. Britain and practice (table). In this model the research is line has been the chief proponent of the randomised con- managed by local academic leaders. Senior expatriate trolled trial in medical research, whereas randomised academics visit regularly to provide advice and technical controlled trials underpin very little of French clinical support, and expatriate junior research fellows within practice. Another cultural observation is that most the country work with counterparts under the doctors rarely read the medical literature of any coun- supervision of local academics. No expatriate is try but their own. Most British doctors have no knowl- employed in a position which could be filled by a edge of French medical literature, nor indeed the national, which reduces overhead costs substantially. names of any French journals,2 yet the French health We suggest four broad principles for a truly system is now considered by the World Health Organi- cooperative research partnership between outsider and zation to be the best in the world.3 insider researchers and organisations. These principles In developing countries, populations also prefer to contain and condense many of the excellent guidelines believe ideas generated by their own experts and politi- laid out by the Swiss Commission for Research Partner- cal leaders, and innovations must adapt to local beliefs ship with Developing Countries,

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