Financial Resources
Of the six case study institutes, three (the HEI, Bangladesh; HPAU, Uganda and CHeSS, Ghana) received substantial external support (in the range of US$200,000-400,000 per annum) at start up. World Bank support to the HPAU, Uganda was primarily for technical work and had only very limited support for capacity development. In contrast the HEI, Bangladesh received funding from DFID that included support for staff training, the purchase of equipment, and infrastructure development, including the establishment of a resource center. One PhD and seven Masters students were trained through this facility. CHeSS, Ghana also received significant financial support from the Rockefeller Foundation during its start-up phase for capacity development, however it is too soon to determine the effects of this upon the organization.
In Uganda and Bangladesh, the cessation of donor support created major difficulties for the respective institutions. In Uganda the HPAU had only limited success in attracting additional funding after World Bank funding finished, and increases in government funding were insufficient to keep the institute functional. Similarly in Bangladesh, HEI was still highly dependent on DFID funding when the funding ended and was unable to sustain itself from other sources.
"Where HEI failed - or perhaps where the [consulting firm] support did not have sufficient time to support capacity building, was in building capacity within the university to mobilise research and other funds from a variety of different sources. Had the university developed a consulting capacity, there would have been scope for the sort of income generation that is needed to keep this type of unit functioning at a high level, but the level of dependency on the DFID funding was too high, so when the funds were withdrawn..... then there was insufficient capacity to mobilise funds from other sources." (External stakeholder, Bangladesh)
DFID funding to HEI ceased earlier than had originally been anticipated due to a complex set of reasons, including issues of donor aid management, political transitions, institutional rivalry and financial transparency. However the root cause was a change in government, resulting in a regime that was no longer strongly supportive of the health reforms or the role of evidence in driving these reforms, and ultimately was not supportive of the HEI. Unfortunately the limited life of DFID support to HEI and the hostile policy environment that ensued, prevented earlier investments from coming to full fruition.
As noted above, funding at the HEI, Bangladesh and the HPAU, Uganda diminished to levels so low that these institutes were no longer fully functional. While funding for other institutes was better, it was typically modest, and these institutes were still perceived by both internal and external stakeholders to be financially vulnerable. For example, forty-five percent of HEU, South Africa's operating budget was a grant mainly for regional capacity-building which came to an end in 2010. Only HSPI, Vietnam had an operating budget greater than US$1 million per annum (Table
3).
Table 3
Funding of Case Study Institutes
Multilateral agencies (EU, WHO) | 0 | 16 | 22 | 12 | 0 | 18 |
Bilateral agencies (SIDA, DFID) | 0 | 15 | 18 | 67 | 0 | 11 |
Private foundations | 0 | 58 | 20 | 0 | 0 | 13 |
Government (national/provincial) | 0 | | 36 | 6 | 100 | 58 |
NGO (local and international) | 0 | 0 | 0 | 7 | 0 | 0 |
Academic/research organisations | 100 | 11 | 5 | 8 | 0 | 0 |
Approximate Annual Budget (in US$) (where two figures are given this indicates a range of annual funding) | 66,500 | 680,000 | 92,871 -178,500 during past three years | 790,000 | 26,000 | 1,300,000 (2007) |
HSPI, Vietnam, equivalent to a department of the MOH, was the most financially secure: it receives substantial funding from the Ministry of Health (about 60% of total revenues) which covers all basic salary costs, with salary top-ups provided from external projects. The other functional institutions did not receive core financial support from government. In South Africa, the HEU does a substantial amount of advisory work for government, but very little is remunerated as the bureaucratic hurdles in establishing and operating contracts with government were viewed as too cumbersome to typically be worthwhile.
While it might appear that HPAIs hosted by other institutions (such as universities) might gain some financial sustainability from this relationship, in practice the financial responsibilities of the host institution were frequently limited. The HEU, South Africa for example, only received university funding for the Director's position and was otherwise reliant on soft-funding. Funding received by most HPAIs was thus largely project-specific and linked to particular deliverables. Institutes had found it challenging to attract and retain flexible, core, funding. For example, the IHS, India had attempted a few years ago to launch a new Masters program with a view to establishing a steady and reliable revenue stream. The institute had made substantial start-up investments in this program but due to issues regarding agreements on accreditation, the course was never properly launched and this venture undermined the financial viability of the institute for several years.
Proliferation of multiple small scale projects was problematic. For example, HSPI Vietnam's research portfolio from 2005 to 2009 comprised a total 64 projects, with 70% being short-term projects of less than one year. This led to a high administrative burden. Similarly, observers of the HEU, South Africa thought that substantive effort was expended by the Unit to secure relatively limited amounts of funding.
"They survive but they spend a lot of time chasing money......it's just silly that a Unit as successful as this has to spend so much time looking for a bit of money here and a bit of money there" (External Observer, South Africa)
Staff at the HEU, South Africa noted that initially they had been almost entirely reliant on small, short-term project funding, but had managed over time to secure a number of larger, longer term programs that provided greater financial security. While the HEU, South Africa is strongly committed to internal capacity development it has received only limited funds dedicated to this purpose and these only materialized relatively late in its development. Furthermore, it is frequently viewed by external partners as a mechanism through which to build regional capacity rather than needing such support itself.
None of the institutes had a clear financial or fund-raising strategy, and none had professionalized the fund raising role. Researchers and policy analysts undertook fund-raising as an "add on" to their core roles. While some institutes were relatively sophisticated in terms of understanding and responding to the funding environment, fund-raising at many institutes remained passive and lacked strategic direction.
Human resources
With the exception of CHeSS, Ghana (which is still relatively young and facing an unpredictable workload), all of the institutes relied primarily on in-house research staff, though external consultants were sometimes used to fill particular gaps.
Table
4 shows the number of staff by qualification. The question of how to attract and retain well qualified staff was perceived to be a key challenge particularly for the HEU, South Africa and the IHS, India. The IHS has struggled to hire and retain senior and experienced health researchers: only four of the current staff have substantive (at least 3-4 years) research experience. Interviews with current and past staff members found that as researchers gained in experience and recognition, the financial position of the IHS could not provide them with financial security and so they left for better paying jobs. Equally importantly, the small pool of senior staff remaining in the organization carried a heavy burden including fund-raising, mentoring new researchers and overseeing an increasing number of small grants while having insufficient opportunities to specialize and develop their own skills. Burn-out of good researchers was a major problem faced by the Institute. As one former staff member said:
Table 4
Staffing at case study institutes, 2009
PhD | 5 | 1 | 0 | 4 | 0 | 7 |
Masters | 6 | 1 | 12 | 5 | 1 | 14 |
Bachelors | 0 | 3 | 4 | 1 | 0 | 9 |
Administrative & other staff | 4 | 2 | 10 | 4 | 0 | 12 |
TOTAL
| 15 | 7 | 26 | 14 | 1 | 42 |
"When I was there, I worked long hours and enjoyed it; but then I found it difficult to carry on due to financial and family needs". (Former staff member, IHS, India)
Recruitment of senior staff was also identified as a critical issue at the HEU, South Africa. The institute had not been able to recruit an additional person with a PhD for seven years prior to the study. Respondents attributed this to the global shortage of health economists (particularly senior people with experience in low and middle income countries) combined with the University salary structure. The University has a relatively compressed salary structure meaning that junior researchers are well paid compared to government, but senior people earn salaries that, until very recently, were 40% lower than market value. As a consequence, the HEU has found itself mentoring and training a large number of more junior people, who having gained experience, then leave to better paid positions in government. Like the IHS, the difficulties in hiring more senior level staff mean that existing senior staff bear a very heavy workload, and there is a real danger of burnout.
Problems of staff retention at the HSPI, Vietnam appeared less significant than elsewhere. All the staff trained under the long-standing Vietnam-Sweden Research Cooperation Programme had returned to serve in Vietnam. HSPI staff are not highly paid but non-financial incentives are important. Low staff turnover was attributed by respondents to high morale and commitment: staff said they are well recognized by high level officers, proud of their work and their contribution to society, have a good working environment, and are adequately paid. Respondents at the HEU, South Africa also noted that the very positive work culture at the institute made it an appealing and supportive place to work.
Governance and management
Governance structures at the institutes differed according to the nature of institute ownership. The two NGOs, CheSS, Ghana and IHS, India both had their own Boards. The HEI, Bangladesh was self-governing and reported to the syndicate of the university through its own Board of Governors. However the other university-based institute, the HEU, South Africa had no independent advisory or governance structure but was accountable through the usual university channels. Respondents at the HEU perceived the governance arrangements to be satisfactory, although stable leadership of the Department in which the HEU is located and good personal relations amongst Departmental staff had clearly played a part in making this arrangement effective.
For the two institutes based in Ministries of Health (HSPI, Vietnam and HPAU, Uganda) issues related to management and governance appeared critical: neither institute had a separate governing body and both reported directly through ministry channels. Originally, the HPAU in Uganda was created as an independent unit reporting directly to the Permanent Secretary, well above the heads of departments. This reporting structure was intended to give the unit autonomy and power to influence policies coming from technical departments. However many officials senior to the head of HPAU were effectively bypassed by this arrangement, and given the bureaucratic and hierarchical nature of government this proved problematic. Initially staff managed to make the arrangement work through employing informal channels of communication, but as the resources available for HPAU support declined, the unit's authority was undermined and its level within the bureaucratic hierarchy downgraded through organizational reforms.
HSPI, Vietnam does not have a Board but it has a Scientific Committee (responsible for maintaining quality standards) and an Advisory Committee responsible for strategic direction. Some respondents suggested however that both these committees were dominated by government officers, and consequently the ability of HSPI to provide truly independent advice was circumscribed.
In contexts where strong boards were in place they were perceived to play a very positive role. At IHS India, while the Board only meets once a year, Board members often interact with individual staff members on a one-to-one basis in the interim, and respondents stated that the Board was critically important both in terms of setting long term strategy, and with respect to fund raising. IHS has a complex board structure with both charter members of the board and regular members. Of the original founding charter members in 1990, seven continue in their roles thus providing a substantial degree of stability for an entity that has suffered from relatively high staff turnover.
In none of the institutes were routine management systems perceived by respondents to be problematic, but host institutions' regulation of reimbursement was thought to be problematic in cases where the institute was dependent upon the management policies of a parent organization. In Vietnam, Bangladesh, Uganda and South Africa the prevailing salary levels were thought to be too low to attract and retain qualified staff. Vietnam addressed this by using grants with external agencies to "top up" salaries. The HEU, South Africa was also exploring a special university provision allowing certain professions to be paid "above-rate-for-job" and recently succeeded in negotiating this.
Organizational networks
Within their country contexts, the more successful institutes benefitted from strong links to policy makers which affected not only their ability to influence policy, but also supported their research capacity. As discussed in the companion article [
19], frequently these links were derived from the individual reputations of institutional leaders. At the HSPI, Vietnam there were concerns about how best to institutionalize these networks. HEU, South Africa also works closely with another South African policy analysis institute, the Center for Health Policy, which has enabled both institutes to participate in, and even lead, much larger, multi-partner projects than would have been possible on their own.
Three of the institutes - HSPI, Vietnam; HEU, South Africa; and IHS, India - had benefitted from longer term institutional collaborations with organizations outside their own country. These linkages had been particularly beneficial for capacity development. HSPI was a key beneficiary of the Vietnam-Sweden Research Cooperation Programme that has been active since the 1990s. In addition to training, this program helped build institutional links with the Karolinska Institute in Stockholm. Staff at the HEU in South Africa also noted the importance of linkages to universities outside of the country. Strong and long term links had been cultivated with the London School of Hygiene and Tropical Medicine (LSHTM) and the Karolinska Institute. As the relationship with LSHTM has evolved into a broader consortium, HEU's role has also evolved into one which both benefits from and contributes to capacity development efforts to countries in the region. IHS, India has multiple links and partnerships, although the majority of these are with in-country institutions. At the HEI, Bangladesh, university politics proved difficult to navigate, resulting in few networks and few links to other universities being established.
While HSPI Vietnam has strong links to the Karolinska Institute and strong professional networks with researchers at provincial and district levels within Vietnam, it seemed that its international research networks are relatively narrow and ad hoc. Respondents recognized the importance of developing such networks:-
"There should be an official way of collaboration, maintaining and sustaining such collaborations, wider partners and more official arrangement. Now HSPI invites them on a project basis, [there is] no continuity and [it is] not sustainable. HSPI need more hands, and spend time for thinking and policy interface." (government official, Vietnam)