A narrative review of health research capacity strengthening/building literature was carried out. The narrative review methodology (specifically that of a hermeneutic review) was chosen instead of a systematic review methodology, with the understanding that the topic of research capacity strengthening in conflict is one that requires incorporating a diverse range of sources and knowledge-bases, and interpreting these based on judgment and expertise in order to offer insight into a complex and multi-faceted process [
13‐
15]. Furthermore, as the aim of this piece is to draw lessons for capacity strengthening in conflict-affected LMICs (on which there is little evidence) from the evidence base for capacity strengthening in LMICs
in general, an ‘interpretive and discursive synthesis’ through the means of a narrative review was deemed most appropriate [
13].
To find literature for the review, peer reviewed articles published from 1990 onwards were searched by GB between April and September 2018 using two main databases; Ovid Global Health, and Ovid Medline. Keywords used in the review were; health* research*, capacity building*, capacity strengthening*, course delivery*, capabilities*, conflict*, post-conflict* and LMICs. Searches were completed using individual keywords and further filtered by two criteria; English language literature and combinations of keywords. Abstracts were screened first using broad inclusion criteria (i.e. relevance to health research capacity strengthening in LMICs); studies meriting inclusion at this stage were then read in full before the final determination of relevance was made. Both qualitative and quantitative studies were included.
Subsequently, a search for grey literature was conducted on the World Health Organization (WHO) Global Health Observatory (GHO), Reliefweb and the Social Science Relief Network. Further sources, found and/or recommended by AP, NEA, AE, and PP, and by experts on the theoretical background to health research capacity strengthening (such as the Capacity Research Unit at the Liverpool School of Tropical Medicine), were also included. A final search was undertaken using Google Scholar to assess for any key omissions during the search process. Studies reviewed were published between 1992 and 2018.
Articles were mainly included if they described health research capacity strengthening interventions in conflict, post-conflict, or LMIC settings (See Table
2 for definitions of settings). Interventions were included whether they were delivered by domestic organisations, North-South partnerships or international non-governmental organisations (NGOs), research consortia and private philanthropic organisations. Health research capacity strengthening was interpreted broadly to include general skills development programmes, as well as subject specific initiatives for targeting established research gaps. Interventions constitute any initiative delivered at the individual, organisational and institutional level with the overall goal of increasing the capacity for health research in these settings. Further studies were eligible if they encompassed the stated geographic contexts and described health research skills gaps, or challenges and opportunities for research capacity strengthening whether related to specific interventions or not.
Table 2
Definitions of types of settings
Conflict and conflict-affected: Conflict, as used here, refers to violent armed struggle between hostile groups, resulting in over 25 battle-related deaths per year [ 16]. We use conflict-affected to indicate areas that may not be bearing the brunt of violence, but still experience social and political upheaval as a result of conflict, e.g. in the form of an influx of refugees or internally displaced populations. |
Post-conflict: Post-conflict is highly difficult to conceptualise and may refer to the period following a formal surrender, negotiated end of hostilities, or peace talks. It is a period with increased security and peace, although there may be violence and insecurity in certain regions; political and economic reforms and the influx of large-scale private investment and development aid. Some countries are described as post-conflict for up to two decades or more after the end of hostilities; however, this tends to be very context-specific depending on the typology of conflict. Post-conflict peace is typically fragile: nearly half of all civil wars are due to post-conflict relapses [ 17, 18]. |
LMIC (Low and Middle-Income Country): According to the World Bank’s definitions, drawing on 2017 figures, low-income economies have a gross national income (GNI) per capita of $995 or less; the GNI per capita of lower middle-income is between $996 and $3895; and upper middle-income economies have a GNI per capita of between $3896 and $12,055 [ 19]. |
Articles were analysed by GB using the DFID framework [
1] for three levels of intervention of research capacity strengthening, which occur at the individual, organisational and institutional levels. Analysis of the studies determined the distribution of interventions across this framework. Further analysis examined all articles for descriptions of the facilitators and challenges encountered by health research capacity strengthening programmes using a grounded coding methodology. Themes from the papers were manually categorised in two cycles: the first cycle used open coding to generate categories and themes; the second cycle used focused coding to confirm, consolidate, and re-organise categories based on conceptual similarity. AP contributed to further consolidation of themes. Hence, the themes used emerged through the review, while the domains that capture the themes are based on an adaptation and refinement of those used by Pang et al. [
20], as discussed in more detail below.
This paper forms part of the Research for Health in Conflict in the Middle East and North Africa (R4HC-MENA) [
21] project and – in the interest of validation – drafts were shared with a number of colleagues at the American University of Beirut. Findings were also presented at the executive board meeting of the project in Ankara in December 2018, where colleagues from Lebanon, Jordan, the Occupied Palestinian Territories and Turkey were present, and subsequently verified with research partners in the RECAP project which also focuses on humanitarian health research capacity building in conflict-affected areas [
22].
Findings
Returned searches indicated 281 papers eligible for review; after further screening 74 results merited inclusion. Of these, 43 studies detailed specific interventions, while the remaining publications dealt with research capacity strengthening more generally. Three studies (7% of interventions) explicitly examined post-conflict settings in Somalia, Somaliland and Liberia; none examined a zone of ongoing conflict. Over half (53%) of the described interventions take place in Sub-Saharan Africa and 14% in South Asia. Four studies (9% of interventions) engage with health research capacity in the Middle East and North Africa (MENA) region, encompassing the United Arab Emirates, Qatar, Iran and Turkey. Only one study examines an intervention in the North African sub-region – specifically Tunisia, Algeria and Morocco. Two studies (4.5%) examined South American interventions, specifically in Brazil and Latin America and its diaspora.
Levels of intervention
The UK’s DFID [
1] have outlined three levels of intervention at which research capacity strengthening activities occur; the individual, organisational and institutional level. The individual level primarily includes the delivery of workshops, online teaching, and personal mentorship for the development of skills in selected researchers. The organisational level is the level at which the university or NGO operates and includes such activities as funding system development, curriculum development and research process development, such as Institutional Review Boards (IRBs) and ethics committees. The institutional level refers to broader dynamics that influence the research context, such as the regulatory context, incentive structures and political motivation towards research resource base development (Table
3).
Table 3
Studies Addressing the DFID Research Capacity Levels of Intervention
Individual n = 24 | Strengthening individual capacities through: ■ Mentorship of researchers ■ Research methodology workshops ■ Policy and influence training | |
Organisational n = 11 | Improving organisational structures, processes and procedures related to research through: ■ Developing capacity for research programme coordination, grant applications, teaching delivery in universities, think tanks, NGOs, etc. ■ Funding system development ■ IRB system development ■ Curriculum development | |
Institutional n = 8 | Creating an environment where research can be conducted by setting political, economic, and technical standards and regulations, by addressing: ■ ‘Rules of the game’ ■ Incentive structures ■ Political and regulatory context ■ Resource base development | |
The majority of efforts have been directed towards the building of individual skills in health professionals – individual training/workshops and seminar interventions examined in this review account for 56% of programmes (Table
3). It is assumed that capacity strengthening at one level leads to increased capacity at others; however this notion is increasingly under contestation, and the literature suggests that a systems approach that cuts across the levels can produce greater capacity dividends [
23‐
26]. The International AIDS Vaccine Initiative (IAVI) represents an important programme in this respect, given its system-wide approach. As part of a global consortium targeting vaccine development, research capacity strengthening in Africa was a specific goal and associated initiatives were integrated across the domains of scientific skills and training, research infrastructure, community engagement and advocacy [
27]. Successfully ascending the DFID framework from the individual to the institutional levels requires increasing investment for system development, and the existence of political will within organisations and across national and international domains.
Institutional intervention necessarily demands high levels of political engagement in the process of capacity strengthening and research prioritisation, but such concerted coordination is both resource intensive and demanding of professionals and key stakeholders. The need to convene around shared goals requires a stable and robust political system able to assert its own objectives without imposing undue influence on research organisations. One such example is the Thai public health community’s efforts at strengthening capacity for tobacco control research, which is unusual globally for its comprehensive approach including taxation and corporate regulatory reforms [
28]. In Thailand a tobacco control research community has been built during three phases; 1) discovery of the value of research; 2) development of capacity strengthening processes alongside research governance systems; and 3) undertaking of locally determined research responding to local needs [
28]. Essential to this process has been “buy in” from the Thai government and external donors in order to adapt foreign research to domestic requirements and to support greater regional collaboration to build research networks and address the influence and power of the tobacco industry [
28]. Clearly initiatives such as this require the mobilisation of a great number of scarce resources, and the challenges inherent in producing what Shiffman and Smith [
29] describe as ‘issue attention’ require careful management when establishing a more system-wide intervention. For this reason, it is not surprising that only 19% (Table
3) of reviewed interventions occur at the institutional level.
Factors influencing research capacity strengthening
The identification of core practices that support the establishment of strong health research systems is an important area for interventions. A strong health research system should comprise of systems and processes that synthesise interventions informed by broader set of determining principles. Pang et al. [
20] have argued that strong financing, production and utilisation of research, resources and stewardship are four cardinal features of a well-functioning sustainable health research system. Within these domains can be seen a great variety of practice across health research systems. To better capture the broad range of influences determined from the literature reviewed here, Table
4 breaks their features down into more specific categories that emerged from our thematic analysis. These categories, and the positive and negative influences within them, may guide further undertakings in capacity strengthening initiatives.
Table 4
Influencing Factors on Health Research Capacity Strengthening
Financing & Sustainability | Access to Funding | | Inability to access funding | |
Continuity of funding | | Short-term research funding | |
Resources | Adequate and appropriate infrastructure | [ 23, 28, 30, 31, 38, 39, 46, 74, 94, 95, 99, 101, 102] | Demands of clinical service delivery limiting staff participation in research | |
Stewardship & Leadership | North-South Partnerships | | Weak scientific leadership | |
Capable leadership | | Integrating new initiatives into existing systems | |
| | Strong external (political) influence on institutions | |
Mentorship | Sustained mentorship | | Absent mentorship | |
Partnerships | Creating networking opportunities | | Differing expectations of partners | |
Equity in collaboration/shared decision-making | [ 2, 3, 23, 26, 30, 33, 37, 39, 45, 88, 106, 111, 113‐ 115] |
Sustained collaboration over time | |
History of collaboration/pre-existing relationships | |
Production & Utilisation of Research | Ability to attract young dedicated scientists | | Poor incentives to conduct research | |
Research addressing policy gaps and local needs | | Culture/attitude barriers | |
Local leadership and claim-making | | Difficulty publishing in international journals/scarcity of local journals | |
Research governance structures | | Low staff and stakeholder retention | |
Favourable political conditions | | Neglect of skills | |
| | Failure to link research to policy | |
Financing is regularly cited as the critical factor limiting the development of health research systems in LMICs, as indicated in Table
4. Access to sufficient, sustainable and long-term funding was a key determinant of research capacity strengthening success. Yet, the ability to access financial resources is curtailed by several factors, such as levels of public expenditure on research and the disbursing structures of funding bodies. For example, the review by Ismail et al. [
30] of health research in the Eastern Mediterranean region details evidence that this region counts among the lowest investors globally in research and development activities, averaging around 0.3% of gross domestic product (GDP) compared to 1.8% in the UK, and 2.8% in Japan. Meanwhile, the ability of LMIC researchers and research groups to access financial resources from international funding bodies and donors is hampered by asymmetries in how grants are allocated, requirements for partnerships with Northern institutions, and the disbursement of funds
within such partnerships [
31‐
33].
Relatedly, stewardship emerged as a further influencing factor on health research capacity strengthening. North-South partnerships, in particular, offer a means to consolidate the benefits of knowledge and resource transfer at the individual level, whilst capitalizing on organizational learning in order to generate onward systemic and procedural benefits [
34]. There are several examples of such international collaborations such as the Task force on Malaria Research Capability Strengthening coordinated by the WHO, which disburses grants to African research groups to work in partnership with US and European groups, as well as facilitating networking and educational activities for graduate and postdoctoral researchers [
34]. The US National Institutes for Health has also promoted stewardship in research capacity by linking US institutions with leading research centres in LMICs such as India, Mali and Uganda [
35]. Leading initiatives from the UK include the £1.5 billion Global Challenges Research Fund that explicitly addresses the development needs of overseas development assistance (ODA) recipient countries; the Wellcome Developing Excellence in Leadership, Training and Science Initiative (DELTAS) for research and training programmes led by African scholars; and the £735 million Newton Fund, which includes partner countries in both decision-making and financial contributions. These innovative models need to be studied – major funding schemes from resource-rich settings should be designed to encourage and leverage local LMIC co-funding that leads to better ownership and sustainability of research programmes [
36].
A caveat to the benefit of North-South collaboration is that to be effective, these collaborations need to be equitable. The way partnerships are established, whether there is clarity and alignment on expectations, how funds are managed and by whom, how research priorities are identified, and how benefits for both sides are distributed
and perceived can all have bearing on both the equitability and success of research partnerships [
26,
33,
37]. We have included ‘partnerships’ as a stand-alone category in the table above to reflect the importance of this domain.
Mentorship is a critical interpersonal theme and is a recurrent element of effective programmatic work in health research capacity strengthening [
25,
30,
38‐
40]. Mentorship can take place between students of health research and their teachers; a lack of effective doctoral supervision has been cited as a barrier to the development of broader national health research systems [
40]. Equally the importance of international linkages with researchers in other institutions with more established research cultures, has been found to be a beneficial form of mentoring for East African clinical research trainees, and is thought to enhance the quality of research output [
38]. Mentorship is also an important dynamic as programmes are deployed on an organisational basis, facilitating the transfer of knowledge between groups delivering training programmes and their Northern or Southern partners [
25,
30,
39].
Failures to link existing health funding to the production and utilization of research has resulted in strikingly low publication outputs in various LMIC settings [
30]. The most effective programmes at generating rapid increases in research output are interventions delivering thematically focused operational research training programmes such as the SORT-IT model. MSF, Partners in Health, the International Union against Tuberculosis and Lung Disease, and the American Thoracic Society have all reported successful programmes delivering multi-national operational research programmes in LMIC settings, with clearly linked research outputs including publications numbering in the 1000s over a combined 20-year period [
41‐
44]. Delivery of these programmes has been facilitated by the fact that they are spearheaded by organisations with secure funding sources with the means to bypass the difficulties of working within national systems.
However, at times these programmes are found lacking in their scope for scale-up and integration into sustainable long-term national and regional research governance systems [
30]. A number of important issues arise in relation to this finding including limited institutional and individual financial incentives for conducting research, political sensitivity towards findings, and a poor connection of research to policy activities [
30]. Key to sustainable capacity strengthening in this domain is a shift in ethos towards strong local involvement in leadership, policy-making and priority setting [
26,
45,
46]. Such an ethos requires reflexivity in programmatic design, coupled with a shift from focus on end outcomes measured only as publication outputs and number of training workshops, to a greater emphasis on quality, sustainability and utility of research [
10,
24]. One potential approach to a better linkage between the stewardship, financing and production and utilisation of research domains is that of ‘embedded research’ which brings together researchers, implementers and policy-makers to set research priorities
and conduct the research as a way of bridging the gap between knowledge production, policy uptake and implementation [
47,
48].
Health Research capacity in conflict
Despite growing global interest in health system strengthening in conflict, there is very limited specific literature on health research capacity strengthening in this context [
11,
49]. Of the studies identified for this review, none discussed research capacity strengthening interventions in an active conflict zone. Three took place in conflict-affected areas (Somalia, Somaliland & Liberia), all of which are now in various phases of post-conflict reconstruction. In these environments all the usual challenges of capacity strengthening processes are present, however the conditions of political precarity, resource scarcity and instability are intensified [
50]. So too are the healthcare demands on limited services, accentuating the gulf between research needs and gaps. Study populations can be difficult to reach, and building sustainable partnerships that recruit and retain research staff can be a challenge [
51]. Previous reviews have established that capacity strengthening efforts have focused on settings with at least some existing capacity rather than those where it is almost entirely lacking [
10].
This is not to say that capacity strengthening efforts are not taking place, but rather that they are ad hoc and/or understudied. Examples of such efforts include responses to the Syrian conflict and the influx of Syrian refugees to Lebanon by academic institutions like the American University of Beirut [
52], which have been engaged in redesigning and delivering modules and trainings to address the extant health situation. Moreover, there are ongoing partnership projects between the North and South like the Research for Health in Conflict in the Middle East and North Africa R4HC-MENA [
21] and RECAP [
22] projects that this study forms part of, that aim to support preparedness and response to conflict by strengthening research capacities. Since these projects have started relatively recently, research outputs are forthcoming. Meanwhile, NGOs at the frontline in humanitarian settings are generally more concerned with implementation rather than knowledge production, and much of their work and experience remains understudied, or at best is found in grey literature [
8,
53,
54]. As a result, the literature is sparse.
In part, this is because the challenges of conducting research in conflict environments have militated towards the delivery of training programmes via local actors with limited stewardship, high financial and resource costs and weak research capacity strengthening [
50]. The sparse literature does indicate certain key influencing factors and tactics for successful research capacity strengthening in conflict-affected areas. For example, as in research capacity strengthening for health more generally, the importance of thinking beyond the individual level and adopting a systems approach is also emphasised by a report for Elrha – which provides funding for improving humanitarian outcomes through partnership, research and innovation [
55] – on research for health in humanitarian crises [
51]. Of course, system-wide approaches can be very challenging in many conflict-affected countries and environments given political constraints and the existence of conflict, but might be possible in regional hubs such as Lebanon, Jordan, Turkey, Brazil, and Kenya, for example.
Furthermore, novel approaches such as web-based learning via online platforms as a means of crossing geographical and political boundaries have emerged as potential modes of knowledge transmission and evidence accumulation [
56,
57]. The adoption of technologies for research in conflict has been proposed as a potential tool for teaching research skills in the Palestinian territories as a means of overcoming the barriers imposed by professional groups being separated by checkpoints and bureaucratic delays [
58]. Local ownership has again been identified as an essential priority; a longstanding initiative between the Swedish Agency for Research Cooperation with Developing Countries and the Somali Academy of Science and Art (SOMAC) has emphasised the importance of long-term locally directed programmes supported by well-resourced international partners in the aftermath of conflict and during the process of rebuilding during ongoing fragility [
45]. Work is also being undertaken to examine how to best encourage translation of research in humanitarian crises into the policies and practice of humanitarian organisations by linking research, policy-making, and humanitarian communities together, for example by the Advancing Health Research in Humanitarian Crises project of the Fogarty Center for Global Health Studies [
59].