Special report Capacity-building for health research in developing countries: a manager’s approach Franklin White1 ABSTRACT Research may be viewed as rigorous inquiry to advance knowledge and improve practices. An international commission has argued that strengthening research capacity is one of the most powerful, cost-effective, and sustainable means of advancing health and development. How- ever, the global effort to promote research in developing countries has been mostly policy dri- ven, and largely at the initiative of donor agencies based in developed countries. This policy approach, although essential, both contrasts with and is complementary to that of research managers, who must build capacity “from the ground up” in a variety of health service set- tings within countries and with differing mandates, resources, and constraints. In health or- ganizations the concept of research is broad, and practices vary widely. However, building re- search capacity is not altogether different from building other kinds of organizational capacity, and it involves two major dimensions: strategic and operational. In organizations in the health field, if reference to research is not in the mission statement, then developing a relevant re- search capacity is made vastly more difficult. Research capacities that take years to develop can be easily damaged through inadequate support, poor management, or other negative influences associated with both internal and external environments. This paper draws from key interna- tional research policy documents and observations on the behavior of research and donor agen- cies in relation to developing countries. It examines capacity-building primarily as a challenge for research managers, realities underlying operational effectiveness and efficiency, approaches to resource mobilization, and the need for marketing the research enterprise. Selected examples from South Asia and Latin America and the Caribbean are presented. Key words Research, developing countries, health resources, health manpower, staff development. Building research capacity is similar practices.” In management terms, gation, problem analysis, and external to building other kinds of organiza- building such a capacity reflects a com- audit. In this holistic sense, research is tional capacity. A utilitarian definition mitment to “quality improvement” as basic to effective and efficient health of research is simply “rigorous inquiry and characterizes a “learning organi- care as financing. to increase knowledge and improve zation” (1). Health research is therefore Effectiveness and efficiency in health best viewed as a broad and robust con- services were highlighted in the 1970s cept that includes not only biomedical by Archie Cochrane in his analysis of and clinical research but also epidemi- the British National Health Service (2). 1 The Aga Khan University, Department of Com- munity Health Sciences, Karachi, Pakistan, and ological and related community health In the 1980s “health as a resource” was also Dalhousie University, Department of Com- research, health systems research, recognized in the health promotion munity Health & Epidemiology, Halifax, Nova Scotia, Canada. Send correspondence to: Franklin health services research, operational movement (3), and “investing” in this White, Department of Community Health Sci- research, and so on. Research is also resource by the World Bank in 1993 (4). ences, The Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan; e-mail: implicit within other functions: plan- This evolution reflected the growing [email protected] ning, evaluation, surveillance, investi- recognition of an “evidence-based” ap- Rev Panam Salud Publica/Pan Am J Public Health 12(3), 2002 165 proach to health issues, especially as knowledge and improve practices” of goals and objectives. This “manage- applied to policy, programmatic, and must come from the top. The quality of ment cycle” applies to organizations, clinical decision-making. management can make or break re- systems within organizations, and par- According to a 1990 report of the in- search capacity. This starts with a vision ticular functions within those systems. ternational Commission on Health Re- and/or mission statement. For exam- If reference to research is not in the search for Development (5), “strength- ple, during the early 1990s, the Carib- mission statement (at least implicitly), ening research capacity in developing bean Epidemiology Center (CAREC) developing a relevant research capac- countries is one of the most powerful, developed the following mission state- ity is made vastly more difficult. cost-effective, and sustainable means ment, which explicitly includes a com- In developing countries one often of advancing health and develop- mitment to research (8): hears that the health sector cannot de- ment.” That this applies to countries at velop research due to a lack of man- all stages of development is illustrated To advance the health status of agerial support, time, and funding. If by the World Health Organization Eu- Caribbean people by advancing the we look carefully, we may also find lit- ropean Regional Office statement in capabilities of member countries in tle or no reference to research in mis- 1997 that “there is little research-based epidemiology, laboratory technology sion statements. Some organizations and related public health disciplines evidence about the components of ef- may not even have a statement. Devel- through technical cooperation, service, fective hospital management” (6). training, research and a well–trained oping or revising a mission statement The challenge of promoting health motivated staff. enables the role of research to be ad- research in developing countries was dressed or updated and will help to recently addressed by the Global Illustrating a similar commitment develop a learning organization. Forum on Health Research (7), with from South Asia, the Aga Khan Uni- particular origins in the international versity (AKU) President’s Order num- perspective of the United Nations and ber 3 states (9): Prioritizing research other development agencies. How- ever, this approach is mostly policy– Whereas His Highness Prince Karim Responsibility for developing a re- driven and contrasts with (although Aga Khan and the Aga Khan Founda- search-friendly environment applies it’s complementary to) that of the re- tion have established in Pakistan a beyond health issues to public policy search manager, who must build ca- Health Sciences Complex whose pro- as a whole, and it brings us to the issue pacity “from the ground up” within a grams will promote human welfare of priorities, which is also relevant to given context. Furthermore, like all in general and the welfare of the peo- capacity-building. National priorities ple of Pakistan in particular and have managers, the research manager must for education and for health services— expressed the desire to establish an manage change, for example, adjust- autonomous University . for the including related research—are re- ing the capacity of a research organi- promotion and dissemination of flected in the level of public sector in- zation to the rapidly evolving patterns knowledge and technology and for vestment, especially when compared of health and disease, such as the providing instruction, training, re- with other expenditures or with coun- emergence of the AIDS pandemic and search, demonstration and service in tries experiencing similar resource con- the now-burgeoning impact of non- the health sciences . straints. All of the countries of South communicable diseases in virtually all Asia spend far more on their military developing countries. Departments may also have mission establishments than on health, while statements, and in Community Health the converse holds for Latin America Sciences at Aga Khan University this is: (10). For example, in India and Pak- CAPACITY-BUILDING istan during the period of 1996–1998, To train young people for leadership public expenditures on health were, re- In addressing research capacity- in addressing health problems of the spectively, only 0.6% and 0.8% of gross building, there are two main levels: people of Pakistan, particularly those domestic product (GDP) while military of the more deprived populations, strategic and operational. The strategic spending amounts were, respectively, through the primary care approach, level is more fundamental because, in and to contribute to improvements 2.1% and 4.2% of GDP. This was in order to be effective operationally, one in the health services of Pakistan, par- sharp contrast to the nations of Latin must first be sure of the philosophical ticularly through the development America, where the median expendi- basis and must operate within a strate- of prototypes that are effective and ture on health was 2.5% of GDP and gic framework. affordable. on the military was 1.25% of GDP. The only exception in Latin America is Planning cycles flow from mission Colombia, with military spending The strategic management context statements, and the cycles incorporate being 2.6% of GDP in this period and goals, objectives, strategies, action health outlays being 1.5% of GDP. Like other good management prac- plans, monitoring, and evaluation. In While Colombia’s share for health is tices, “rigorous inquiry to increase turn, they lead to the periodic revision below the median for Latin America, it 166 White • Capacity-building for health research in developing countries is still double the