CARTA fellows’ scientific contribution to the African public and population Health Research agenda (2011 to 2018)

Africa has a disproportionate burden of both infectious and non-communicable diseases (NCDs) compared with other world regions [1]. Current disease estimates indicate increases in the incidence of NCDs, including cardiovascular diseases (like hypertension and stroke), cancers, and diabetes, which are now major causes of morbidity and mortality and are projected to overtake infectious diseases by 2030 [2]. This is occurring when most African countries are still struggling to control infectious diseases – such as Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (HIV and AIDS) and Tuberculosis (TB), due to weak and overburdened health systems [3]; inadequate resources for scaling up proven interventions; poor management of human resources for health; and recurrent natural and man-made disasters and emergencies [4]. Other contributors to the heavy disease burden on the continent include food insecurity, poor access to safe sanitation, the prevalence of indoor pollutants, increased rates of unemployment, violence and forced migration and access to cheap but unhealthy foods [5]. Tackling these challenges and coming up with pragmatic solutions requires robust research [6, 7].

This need for local research is occurring when Africa has in the recent past been reported to lag behind other regions in research output – producing less than 1% of the world’s research [8], including research in the fields of population and health [9, 10]. The under-performance in research in Africa is partly due to inadequate research funding by African governments [11, 12]. During the first African Ministerial Conference on Science and Technology in 2003, participating countries committed to spending at least 1% of their gross domestic product on research and development by 2010 [12, 13]. Three countries, Malawi, Uganda, and South Africa, had honoured this commitment five years down the line, in 2015 [14]. Other reasons for under-performance include inadequate access to research training [9], poor research infrastructure and technology such as laboratories and computers, insufficient mentorship for junior researchers [11], and limited collaboration or partnerships among research institutions within Africa [10].

There has however been a substantial improvement in the output of researchers in the field of public and population health in many African universities during the past decade [15, 16], a development attributed to advancement in the faculties of public and population health in higher education institutions [16, 17]. Nachega and colleagues [16] reported that between 1991 and 2010, epidemiology and public health research output in the World Health Organization (WHO)/African Region (AFRO) increased from 172 to 1086 peer-reviewed articles per annum, which is a 631% increase over 19 years. During this period, the most commonly research topics published by researchers from African institutions were on HIV/AIDS (11%), malaria (9%), and tuberculosis (7%), which may be motivated by the articulation of the Millennium Development Goals (MDGs) and increased donor funding in specific disease areas [18].

There have been a number of contributions to the development of research capacity on the continent. While not yet adequate, there has been both national and international investment in higher education in general [19, 20]. There has also been a commitment to health-related research. The New African Region Health Research Strategy adopted by the African Union Health ministers in 2015, has prioritised public and population health research [21]. Significant investment in health related research capacity building has also taken place, including the African Institutions Initiative [22], and investments made through the Developing Excellence in Leadership, Training and Science (DELTAS) programme [23], as well as the establishment of the Centre for Disease Control (Africa CDC) by the African Union General Assembly in 2015 [24].

As the disease burden changes on the continent, a comprehensive approach is needed to guide health research capacity in the region, and policies and interventions need to be appropriate to local conditions. The conduct and dissemination of good quality research undertaken by African scientists is central to this [25]. We investigated the research output of a cohort of African scholars to assess the degree to which their research is related to the identified African health priorities.

We focused on one initiative for which we had comprehensive data, the Consortium for Advanced Research Training in Africa (CARTA) [26]. Launched in 2009, CARTA initially brought together nine academic and four research institutions from seven countries in Africa, in partnership with selected non-African universities and training institutes. CARTA aims to develop sustainable health research capacity in Africa through training of PhD fellows in public and population health and promoting research supportive environments. Part of CARTA’s strategy for long term sustainability is that staff of participating African consortium institutions are admitted and supported to obtain their PhD, as a way to build and multiply research capacity in the continent [26]. This study describes the publications authored by CARTA supported PhD fellows and compared them to published consensus on African public and population health research agenda of the sustainable development goals (SDGs), World Bank (WB) and Africa Development Bank (AfDB).

Building and sustaining research capacity has been advocated as a leading strategy to overcome health disparities in Africa [25]. Our analysis showed a steady increase in the annual number of articles published by CARTA fellows in the 8 years studied, a finding that has been reported elsewhere [27]. The year-on-year increase in publications is likely to be as a result of the corresponding increase in the number of CARTA fellows each year. In 2011 there were 20 fellows in the programme and by 2018, 185 fellows had been admitted in the fellowship. The areas of study were likely a reflection of the increased global response to infectious diseases such as HIV and AIDS, TB and malaria through funding programs such as the Global Fund and the investments by the National Institute of Health and the United States Agency for International Development reported in the fellows' publications. Increased funding in these areas may have influenced the selection of research topics by CARTA fellows. Studies have reported that HIV/AIDS, malaria and tuberculosis (TB) continue to attract the greatest investment from external funders, a trend that influences current research being conducted in sub-Saharan Africa [16, 28].

In our analysis, the subject areas addressed by CARTA PhD fellows are mostly aligned with the SDGs, World Bank and AfDB priority areas, addressing research gaps in infectious diseases, maternal and child health, and sexual and reproductive health. These research areas are in line with the burden of disease and health system priorities in the region. Studies show that 90% of children who die from malaria are from sub-Saharan Africa (SSA), and 72% of deaths in the region are attributed to infectious diseases including HIV/AIDS, TB, and Malaria, and from complications related to pregnancy and childbirth [26].

Despite the increasing number of NCDs including cancers, diabetes and hypertension – that are now co-occurring alongside infectious chronic diseases (such as HIV and TB) [29], findings from this study show less research is conducted in this field. In addition, in the face of high burden of neglected tropical diseases, such as helminth infections, hookworms, and other protozoa amongst the poorest in SSA [30], our analysis showed that while this is being studied, very few papers were found in this area. The same trend was observed in infectious diseases such as hepatitis B and C, despite the substantial burden that these diseases have in Africa [31, 32]. Notably, only a few fellows researched violence and injury. This finding concurred with earlier research indicating that despite violence and injury-related morbidity being at the top of the list of disease burden in Africa, the field remains under-researched [33]. In addition, there were no studies on mental health and substance abuse among children and adolescents; this is in spite of their correlation and burden in the continent [34, 35]. In light of these findings, we recommend that African universities broaden their research priorities in tandem with the change in disease burden taking place in Africa. Contextually focused research would provide appropriate evidence-based information to guide policies and decisions aimed at addressing disease burden and future epidemics in Africa [2].

Our analyses also show that most articles were published by fellows from or affiliated to consortium universities in Kenya, Nigeria, and South Africa. The three countries are also home to five of the nine host institutions in the consortium. This finding is similar to earlier studies that revealed that health research productivity in Africa is skewed, with countries like South Africa, Nigeria, and Kenya contributing more than half of all research papers indexed in PubMed between 2000 and 2014 [17]. This could also be due to differences in economic development and education levels (including epidemiology or public health programmes), which vary widely between and even within countries [11, 26]. Thus, it is paramount to keep developing research capacity in partner institutions with low research output by ensuring an enabling environment for conducting research and training more PhDs in such institutions.

The increase in the number of articles published by CARTA fellows contributes to improved health research output of African academic and research institutions. Whereas externally supported researchers from sub-Saharan Africa have often undertaken postgraduate degrees at institutions in high-income countries [9], CARTA has demonstrated a mechanism to increase PhD training in African institutions. Local enrolment is supplemented by additional PhD training – CARTA’s Joint Advanced Seminars (JAS) to ensure PhD students are internationally competitive and also orients them towards locally relevant research [36]. Such initiatives could be supported by African governments (in respective countries) by prioritising research funding and considering the needs of young researchers in Africa. Only if African governments invest in young researchers will the continent be able to come up with innovations that are relevant to solving the public health problems affecting the population of the region.

This study demonstrates the full range of topics that CARTA fellows are researching on. The evaluation has shown that investments by CARTA in supporting doctoral training at African training institutions has been beneficial to the region as the programme has provided the PhD fellows sufficient motivation and skills to publish their research in the broad fields of public and population health. There is a need to keep developing research capacity in countries with low research output by training more PhDs in such institutions and by facilitating enabling environments for research. Further and broader exploration of nature and the drivers of public and population health research output remains an imperative to address gaps, promote alignment and sustainability of public health training, research and practice in sub-Saharan Africa.