Status of national health research systems in ten countries of the WHO African Region

Only 10 (21.7%) countries (Cape Verde, Ethiopia, Equatorial Guinea, Guinea Bissau, Malawi, Mali, Mozambique, Rwanda, Senegal, and Sao Tome and Principe) out of the 46 Member States in the Region responded to the questionnaire. Therefore, the analysis reported in this paper is restricted to the ten respondent countries only. The presence or absence of various NHRS attributes per country can be found in Appendix 2 (see Additional File 2).

Table 1 presents the availability of a national health policy (NHP), a strategic health plan (SHP) and a health research policy (HRP) in ten sub-Saharan African countries. Seven (70%) of those countries reported that they had an official NHP. Eight (80%) of them reported that they had a SHP, meaning that one of those countries did not have a NHP. Only three countries (Ethiopia, Mali and Senegal) had an official HRP. Generally, the HRP documents for the three countries that reported to have them had a preamble; a situation analysis of health research in the country; a strategic vision for health research in the country (including vision, goals, underlying values, guiding principles, research priorities, implementation strategies, resource mobilization mechanisms, and modalities for monitoring and evaluation); an organizational or working plan of the national health research system; a strategic vision for the assessment of the national health research system; and a national HRP statement – aims and objectives. Two (Ethiopia and Mali) out of the three countries that had both a NHP and a HRP reported that there were complementarities between the two documents.

Generally, countries that had a HRP reported that faculties of health sciences in national universities, medical research councils or institutes, representatives of nongovernmental hospitals, provincial (or regional) medical officers of health, district medical officers of health, national medical association(s) and administrators of HRP were involved in the process of formulating the HRP. Two (Ethiopia and Senegal) of the countries that reported to have a HRP said that it needed updating. All the seven countries that did not have a HRP reported that policy-makers were interested in developing it. Seven countries reported that WHO support was needed in the development of HRP. Those countries were asked what form of support would be needed from WHO. All of them said that they needed technical support; six countries needed guidelines on the formulation of HRP; six countries needed financial support for undertaking a health research situation analysis; all countries wanted WHO to share experiences and lessons from countries with HRP; and all countries needed support for strengthening their human capacity for implementing HRP.

Only one country (Mali) out of the ten reported to have a law relating to health research; and that country indicated that the law encapsulated ethical concerns. It is unfortunate that the other 9 (90%) countries did not have a research legislation for protecting the integrity, dignity and safety of human research subjects.

Only two (Mali and Senegal) of the ten countries reported to have a strategic health research plan. These countries indicated that their SHRP needed updating, and that they needed WHO's support for this purpose. One of the two countries reported that their plan was being implemented.

Table 2 summarizes the responses to the questions related to the existence and functioning of national research coordination mechanisms. Three countries (Ethiopia, Mali and Senegal) reported that they had a functional national health research system (NHRS) and two of these countries reported that the NHRS had clear terms of reference. Two countries (Mali and Senegal) reported the existence of a functional national health research management forum (NHRMF) with clear terms of reference.

Six (Ethiopia, Malawi, Mali, Rwanda, Mozambique and Senegal) of the ten countries had a functional ethical review committee (ERC) with written terms of reference. When the countries that reported to have an ERC were asked how regularly the committee met, two said monthly, three said quarterly, and one said the committee met whenever there were projects to review.

One-half (Ethiopia, Guinea Bissau, Mali, Senegal, and Sao Tome and Principe) of the ten countries (50%) reported to have a scientific review committee (SRC). When the countries that reported to have an SRC were asked how regularly the committee met, one said monthly, one said quarterly and three reported that it met whenever there were projects to review.

Fifty per cent of the respondent countries (Ethiopia, Malawi, Mali, Mozambique and Senegal) reported the existence of health institutions with institutional review committees (IRC). Only two countries (Ethiopia and Mozambique) reported that they had hospitals with ethics review committees to review clinical research proposals.

Eight countries (80%) reported the existence of a national health research focal point. None of the countries had national guidelines on development of collaboration agreements on health research involving health institutions and agencies outside the country.

Three countries (Mali, Mozambique and Senegal) had a national network of health research and development (NNHRD) that included universities (especially faculties of health sciences), medical research councils or institutes, provincial/regional medical officers of health, district medical officers of health and national medical associations; two of these national networks included representatives of nongovernmental hospitals as well.

Table 3 shows that only two (Mali and Senegal) countries out of the ten respondent countries reported to have a health research programme. They reported that the programme had a mission statement, clearly defined the terms of reference, and had a clearly defined organizational structure and a plan of action. Three countries responded to the question, which had asked about the number of technical and support staff their health research programme had, to which they said their programme had an average of seven persons.

Three countries responded to the question asking about the number of computers owned by their programme. An average of three computers per country were reported. Two countries reported that their programme was connected to e-mail and Internet. Only one country reported that its health research programme undertook research by itself.

Table 4 presents the national health research institutes' attributes. Three (Ethiopia, Mali and Mozambique) out of ten countries reported to have a national health research institute (NHRI) under Ministry of Health. All the three NHRIs were reported to have telephone facilities, a fax machine and a scanner. Two countries reported that each researcher in the NHRI had a computer and a printer and had access to e-mail and Internet.

The three countries with a NHRI reported the existence of a MoU between Ministry of Health and the institution, and that MOH commissioned the NHRI to undertake operations research from time to time. Two of the NHRIs were reported to have been designated as WHO collaborating centres. The NHRIs disseminated their research through seminars and conferences, in-house seminars, newsletters, institutional publications and international journals, and annual, quarterly and monthly reports.

Countries were asked to name five key enabling and constraining factors for health research in their medical research councils (MRC) or health research institutes (HRI). Their responses are summarized in Table 5. Research policy support was identified as the most important enabling factor in the three countries that had health research programmes. Shortage of research funding was mentioned as the most important setback to health research in MRCs and HRIs.

Table 6 presents the health research enabling and constraining factors in national universities. Only three (Ethiopia, Mali and Senegal) out of ten countries reported the existence of a faculty of health sciences in their national university that conducted health research. They had a MoU with ministries of Health. When asked what the MoU was about, two countries indicated it was for developing human resources for health, one country said it was for technical advice, and two countries said it was for health research. The factors that facilitated national universities' health research included the existence of a school of public health; the fact that research output was a requirement for staff promotion; and the requirement for students to write a research report or dissertation in partial fulfilment of degree requirement. The constraining factors for health research in universities included deficiency in research skills among the teaching staff; inadequacy of research facilities; and lack of research grants.

Four (Malawi, Mali, Rwanda and Senegal) out of ten countries reported that they had a budget line for health research in the Ministry of Health budget document. Table 7 shows the sources of health research funding in order of importance. None of the countries indicated government tax revenues as a very important source for health research. Instead, multilateral and bilateral donor funding was reported to be the most important source of funding for health research. Seven countries reported the involvement of nongovernmental organizations in the provision of health resources.

Countries were asked to indicate actions that should be taken at local and international levels to stimulate health research. Their responses are summarized in Table 8. The five most important actions needed at country level to strengthen national health research systems included: allocation of regular budget for health research and establishment of local health research financing systems; incentives for researchers and clear career development paths for health researchers; establishment of a legal framework (policy and legislation) for health research; clearly-defined structural and institutional arrangements for health research; and strengthening of human health research capacity.

The five main actions, in order of importance, needed at international level to stimulate health research capacity in African countries included: increased access to donations and funding for health research; strengthening of health research collaboration and linkages; provision of technical health research training opportunities; establishment of consultative exchange visits and forums; and promotion of networking and technical support.

The study took stock of national resources for health research in ten countries in the WHO African Region and identified constraints that faced national health research systems.

The key findings were as follows: the response rate was 21.7% (10/46); three countries had a health research policy; one country reported that it had a law relating to health research; two countries had a strategic health research plan; three countries reported to have a functional national health research system; two countries confirmed the existence of a functional national health research management forum; six countries had a functional ethical review committee; five countries had a scientific review committee; five countries reported the existence of health institutions with institutional review committees; two countries had a health research programme; and three countries had a national health research institute and a faculty of health sciences in the national university that conducted health research. Four out of ten countries reported that they had a budget line for health research in the Ministry of Health budget document.

The questionnaire used in this study provided a "check-list" of attributes that should be found in a functional NHRS, and the way forward re-states what was not found. Therefore, the following actions need to be taken by the ten sub-Saharan African countries to increase functionality of NHRS:

The study reported in this paper had a number of limitations. Firstly, we did not make any attempt to evaluate the extent to which NHRS achieved their intrinsic goals of advancement of scientific knowledge and promotion of its utilization to improve health and health equity [12, 20]. Thus, our study is a partial study of NHRS.

Secondly, this study was restricted to the NHRS functions of stewardship, financing and creating and sustaining resources or health research inputs. The questionnaire did not have any questions on the production and use of health research outputs. In addition, it did not assess the availability of non-ICT equipment used in health research (e.g. laboratories and reagents), functioning motor vehicles for fieldwork, office space, supportive supervision, human resources for health research motivation and retention, among others. This information was missed partly due to our ignorance full range of the functions of NHRS at the time of developing the questionnaire and also because the questionnaire was not pilot-tested prior to administration.

Thirdly, the health research focal person in each of the countries Ministry of Health bore the responsibility for completing the questionnaire in consultation with the national health research institutes, national universities with faculties of health sciences, non-governmental organizations that undertake health research, etc. We do not know how many people were interviewed in each of those organizations/institutions in the process of completing the questionnaire. Thus, it is not clear how representative the views of the persons interviewed were of the entire NHRS in each country. In order to increase validity, future NHRS studies in the African Region should consider drawing lessons from the approaches employed in the Council on Health Research for Development (COHRED) – and the World Health Organization Regional Office for South-East Asia (SEARO) – sponsored case studies on national health research. Those case studies constituted groups of individuals with different perspectives or contributions to national health research activities and capacities, collectively discussed and responded to the questionnaire [29, 30]. D'Souza and Sadana [29] and Sadana et al [30] reviewed the existing case studies and found that there was need for refinement and better documentation of methods used to develop case studies.

Fourthly, only 10 out of 46 countries in the Region responded. Thus, whereas the results reported in this paper may be representative of the 10 countries that responded, they cannot be generalized for the 46 WHO Member States in the African Region. In preparation for the second global ministerial conference on Research for Health in 2008, the World health Organization in collaboration with COHRED, UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and health research networks in the Region among others, are planning to undertake an in-depth comprehensive assessment of national health research, health information and knowledge systems in the African Region. The assessment will describe the stewardship, financing, research inputs and outputs, dissemination and impact of NHRS; describe the resources, indicators, data sources, data management, information products, dissemination and use of health information; describe how knowledge from research, health information and other sources is created, captured, disseminated, applied and used for improving, protecting, or restoring health; based on the findings of the mapping, develop national and regional strategic plans for advocacy, resource mobilization and implementation [31]. The proposed assessment intends to map the full range of stakeholders (sectors, organizations/institutions, disciplines, networks and users) in different stages of research, information and knowledge generation, synthesis and use within each country and across the region.

A number of actions may enable the new proposed assessment in all the 46 countries to achieve a higher response rate than that reported in this paper: (i) the WHO management should hold individual WHO Country Representatives fully accountable for country-level follow-up to ensure completion of the data collection instrument(s); (ii) the WHO management should give written assurance to Member States that the outcomes of the study would help WHO and partners to tailor their technical and financial support to the specific country needs; (iii) the WHO management should apprise the countries that the results from the study will constitute Africa's contribution to the 2008 Global Ministerial Conference on Research for Health; (iv) WHO Country Representatives should negotiate with the relevant national authorities to constitute multi-stakeholder research for health steering committees to oversee the data collection, preliminary analysis and dissemination (through country-based workshops); (v) use remunerated national professional researchers to administer the data collection instrument(s); (vi) organize workshops at the regional economic communities headquarters to train the researchers on the purpose of the proposed study, data collection instruments, field methodology, and potential usefulness of the research outcomes in the development of NHRS, health management information systems, and knowledge management systems; (vii) involve the African Health Research Forum in undertaking the study.

Fifthly, the respondent countries did not provide estimates of the total government allocation to research. Thus, it was not possible to know whether countries were making concerted efforts to achieve the target for investing at least 2% of national health expenditures in research and research capacity strengthening, as recommended by the Commission on Health Research for Development [27].