The politics and practice of initiating a public health postgraduate programme in three universities in sub-Saharan Africa: the challenges of alignment and coherence

Partnership, through its multiple variants, is recognised as one of the mechanisms to bring about development. South-south cooperation is one form of development partnership among a wide range of actors located in LMICs [31, 32].

In year 2009 three of the universities (from Ethiopia, Rwanda and Mozambique) set out to develop a postgraduate programme focusing on health workforce development/management with technical support from the South African university. The support included providing educators from these universities a masters level training in health workforce development/management, development and adaptation of teaching resources, and sharing experience through workshops on delivery of open and distance teaching modalities. Funded by the World Health Organization (WHO) the initiative sought to respond to the twin challenges facing public health training universities of ‘building human resources capacity in ministries and health services while alleviating and improving their own capacity constraints’ [2]. The financial support from WHO sought to enable the implementation of the aforementioned activities led by local programme champions who oversee the development and integration of programme in the three universities [2]. This meant ‘fitting’ the programme into the landscape of programme offerings in each of the universities. The programme had support from the health ministry in each country (Rwanda, Mozambique and Ethiopia) and leadership of the implementing universities. The collaborative project ran from 2009 to 2015.

Overall, the initiative has distinct features of south-south cooperation, which is considered a viable mechanism to facilitate capacity development in developing countries [33, 34] by enabling exchange of knowledge, experience, and resources among Southern partners [35, 36]. This initiative presented an opportunity to explore factors that influence process and outcome of a capacity development initiative across multiple institutional and national contexts, and to explore how contextual or relational factors assisted or undermined coherence and alignment.

The three universities have a wide variety of programmes, with distinct organizational processes regarding how such programmes are initiated, implemented, and sustained. Two broad models of programme introduction prevail in these public health training institutions, i.e. regular and special (See Table 2 below).

Both routes of programme introduction require collaboration with multiple actors within and outside the training institution to fulfil requirements related to feasibility, relevance and quality of curriculum. Regular programmes are fully embedded in the institutional structures and enjoy health ministry’s approval and support, and have a longer life span. Special programmes are introduced through temporary technical and financial arrangements (with respect to funding, level of entry and selection of trainees), with the expectation of gradually transitioning into regular programmes and thus by definition have a temporary life span. Table 3 below summarizes the varying practices in the universities with respect to introducing and sustaining postgraduate programmes.

In the case of University C both regular and special models are common ways of introducing postgraduate programmes. In University B the regular model is the most common, and the special arrangement happens often for certificate or short courses. In University A all postgraduate programmes have a special status.

Ministry of Health is insisting that we start [a new programme] right away. But we responded that we wouldn’t start in a rush, before clarifying how it is going to be operationalized. Is it a regular programme, or what? If it is regular, the registration is done through the university. If it is to be done as special… then you organize special classes, Saturdays, Sundays, or evening. If it is going to be special, then we need to make provision for staff, you can’t just ask them to teach. Time is precious.

[P17, University C]

Prior to introducing a programme, training institutions have to fulfil curriculum requirements, which vary across institutions, with some more protracted than others. With the growing number of programmes and in the context of shortage of capacity in the institutions, stringent curriculum approval processes are put in place to ensure introduction of only priority programmes, e.g. Generic MPH and Field Epidemiology.

With respect to the new training programme on health workforce development/management, none of the three universities had such a programme, which is also distinct from the generic MPH running in all the universities at the time (See Table 4 - Inventory of programmes being offered in the universities at the time of the intervention).

University A effectively integrated the new curriculum in 2014, translating curriculum and teaching resources, and mobilizing resources from external partners to this end. The institution publicized the programme among staff and leadership of the health ministry, which sponsors trainees. At the time of data collection, over 70 trainees of multiple cohorts have been enrolled in the programme.

In University B and C, the envisaged programme did not materialize. The institutions needed an explicit expression of interest, memorandum of understanding, to support integration of programme from the health ministry either through providing funding for the special programme, or making necessary investment on personnel and infrastructure for it to become a regular programme. The south-south partnership did not have funds for these required investments. Trained staff in the short term used the teaching materials designed for the programme to strengthen existing programmes.

In the sections that follow, we unpack these varying developments across universities and explain the contrasting success in implementation of the programme between University A, and the two other universities (B and C).

The three public health training universities interact and collaborate with a range of external development and training partners, as well as local actors who influence the nature, scope, and success of their own engagement in the countries and beyond, all in the course of implementing their mandate, which encompasses teaching and learning, research, and extension/community outreach service. Table 5 illustrates the various prominent stakeholders in the process of introducing training programme in academic institutions.

These actors that exert distinct influence to enable or constrain the process (either through support, opposition, or inaction) include academics who assume the role of championing the programme, the training institution, relevant government institutions namely health ministry, and external development or training partners.

Any of the aforementioned actors can initiate programme introduction, but the success of the initiative and its sustainability require support from all or most of these actors, which depends on alignment of their respective agendas. The following part of this section describes these actors and their roles and relationships in the context of introducing postgraduate programmes.

The health ministry is a custodian of the health sector and prescribes strategic direction and programmes to public health training universities. The health ministry defines which training programmes are relevant to address national health priority, and outlines core competencies. Even though universities are under the governance of the education ministry, the health ministry assumes the above roles due to its superior expertise of the needs and resources in the sector.

The health ministry often leads the role of initiating new public health postgraduate programmes in the institutions, by working with/through the three institutions, academics, or external partners. The ministry also initiates programmes particularly when those programmes are considered basic in the context of national health priorities such as Masters in Public Health, or Masters in Field Epidemiology.

While in theory academics, training institution, or external partners could initiate a training programme in the three universities, key informants made it clear that successful introduction or sustainability relies on the buy-in and ownership from the health ministry. One senior academic staff explained,

… Our [University B’s] training should contribute to resolve a given problem in [the country] or in the region…. We are free when we identify the need, we can also suggest the introduction of a given programme. But … we are [not] able to start a programme without the approval of the Ministry [of Health].

[P52, University B]

The role of the health ministry in initiating the curriculum varied across the countries, with the ministry playing a more active role in University B and University C than in University A. In the case of University B and University C, it was reported that the ministry is the main stakeholder in training needs assessment and providing a required list of competencies.

In the course of introducing the training programme on health workforce development/management, health ministries in each country endorsed the proposed programme as relevant and expressed support in the early stage of the collaboration in 2009. However, none of the universities received any tangible support from the ministries during the course of the collaboration (2009–2015), which undermined programme introduction particularly in the University B and University C. University A had somewhat better leverage of introducing programme, possibly due to the relative autonomy the university has in its relation to the health ministry.

The lack of support from ministry of health in University B and University C can be attributed to multiple factors. One of the factors is turnover of programme champions based in the universities or turnover of leadership at ministry of health, which resulted in the loss of implementation momentum or loss in institutional memory.

… It [health ministry] did have enough information [about programme]. … We [the local project team] have tried to communicate this with the ministry of health. But since the first communication …there has been a turnover of three ministers.

[P50, University B]

This was further complicated by the advent of parallel processes in the two universities to introduce similar programmes by the health ministries with the backing of other external partners from the North.

Like other academic institutions, the three universities have the mandate to train the next generation of public health professionals to meet national health priorities, but rely on ministries of health for strategic guidance and support when it comes to the programmes they offer.

While all the three universities had complex relationship with the health ministry, these complexities presented differently and impacted on project outcomes in different ways. University A has a relatively high level of autonomy from ministry of health when it comes to introduction of new postgraduate programmes. The programmes are open to private applicants and students working in non-government organizations while staff of the health ministry remain the main clients.

[The postgraduate programmes] emerged in a decentralized [fashion]. Faculties came up with the proposal, waited for approval and started the programme. Neither administrative nor academic management [of the programme] is centralized.

[P31, University A]

In University B the health ministry exerts a great deal of influence when it comes to programme introduction, and sends most of the trainees.

When we started this school [in 2001], it was with the objective … to produce the health professionals for Ministry of Health [which] pays their tuition fees. … [Currently] Most of our students are from Ministry of Health.

[P52, University B]

University C has very close relation with MOH. Students mainly comprise ministry staff and academics from other universities. Lack of alignment in the interests of the health ministry on one hand, and the university and academics on the other hand (over issues of funding or selection of trainees) put a strain on their relationship. This was evident with two prominent but parallel processes of programme introduction prevailing in the university, regular and special. Key informants in University C reported that lately MOH is pushing for regular programmes, as it considers special programmes as unsustainable, as special programmes require additional financial incentives, on top of salaries, for those academics involved in teaching or coordinating the programme. The opportunity cost for academics who participate in new programmes without additional remuneration, as described in a related publication, is time away from engagement in external multiple job holding practice, which offers financial and professional benefits [1]. The training institution on its part claim to operate at full capacity and resist hosting new programmes without the necessary investment in personnel and infrastructure. A senior academic drew attention to the mismatch between MOH expectations and investment towards building capacity of training institutions,

[I] can't really say the support from MOH to university is high or strategic. Because it changes when there is turnover. It also gives you the programme, and does not give you anything [else]. Except for [giving us the] go ahead. No financing.

[P20, University C]

Conversely, MOH representatives contend that the training institution is performing below capacity and should accommodate new programmes that would meet the health workforce need of the sector. One government official described the practice of running special programmes or providing incentives to staff associated with the programme as perverse:

… If it [training programme] is project based [special], … it turns teachers into rent seekers [and] … it won’t have sustainability. It should be part of the [regular] system and integrated, and necessary capacity building, equipment, books should be fulfilled like offering training to teachers. That is when capacity building becomes sustainable.

[P5, University C]

The initiative to introduce the new programme on health workforce development/management had designated programme champions, who were senior academics in the training institutions. In University A the programme champion, a senior academic of the training institution, engaged with MOH about the programme, and was committed to spearhead the implementation of the programme in the university. The university initiated the health workforce development/management programme, with the programme champion ensuring that curriculum approval within and outside the institution was accomplished. Curriculum approval went through various processes at multiple levels (see Table 6 – Process of curriculum approval).

In University C the programme champion, a senior academic staff, faced challenges to advance the programme integration. The implementation process stalled for long periods in the absence of explicit expression of interest to support the programme from the MOH [either provide funding if special programme, or make necessary investment on personnel and infrastructure if regular], and the lack of adequate funding in the existing partnership with external partners to support investment in infrastructure or teaching personnel. This also coincides with the turnover of the programme champion and initiation of a parallel process to introduce a similar programme in the institution with support from the health ministry and external partners. Despite being able to initiate the curriculum approval process, the programme still needed to get approval from the college, external reviewers, and graduate council/senate.

In University B, two senior academic staffs were tasked to champion the introduction of the programme in the institution. They initiated the curriculum development process, but they stopped short of taking the curriculum through all the required levels of approval. This coincided with a change in leadership at MOH, lack of explicit interest and support from MOH, turnover of one of the programme champions, and end of project funding.

A notable difference with respect to programme champions across the three universities is that the designated programme champions in University B and University C vacated their senior leadership positions in the university during the course of the intervention. With the departure of the senior programme champions, institutional memory about the programme, and the momentum and potentiality of securing MOH buy-in were undermined. The programme champion in University A was actively engaged throughout the course of the intervention.

External partners work through or with local actors namely academics, training institutions, or government institutions to initiate programmes to address institutional and national capacity needs in certain areas, by offering financial or technical support. Some of the external development partners (e.g. United States Agency for International Development, Centers for Disease Control, United Nations Population Fund, WHO) and external training partners (e.g. Johns Hopkins Programme for International Education in Gynecology and Obstetrics, Tulane University, Management Sciences for Health, Yale University, University of Rennes) were influential in one or more of the universities.

Engagement of the three universities with external partners can generally be characterized as fragmented. The lack of coordination has led to competition, duplication, and loss of capacity gains, whereby academic institutions or the health ministry choose one initiative over another, or allow both to co-exist, instead of seeking synergy or harnessing partnerships and support around similar initiatives.

Northern training partners dominate the partnership space in the three universities and with MOH (in terms of resource or influence) compared to Southern training partners. In the case of University B and University C, there were reports of parallel processes to introduce a similar programme in human resources management in the institutions in collaboration with Northern external collaborates and led by different academic programme champions within the universities. In the two countries, there were inclinations towards collaborating with Northern external training partners, which are well resourced.

A key informant expressed exasperation about proliferation of similar initiatives often led by Northern external training partners as a case of, “…. the funder tail wagging the capacity development dog.” [P22] Recounting the ambivalence surrounding the scenario in University C in relation to decision about the choice of partners or programmes, a key informant stated,

… I can see that [this south-south] programme is the first [to be initiated]. … How do we go about it? Do we merge [it with a similar programme initiated with northern partners]? … were we supposed to accept [just this programme] … or did we do the right thing [to choose the programme supported by northern partners]?

[P17, University C]

The figure below summarizes the aforementioned analysis, and highlights the prominent actors, processes and mechanisms that influenced the introduction of the postgraduate programme in public health in the three universities (Fig. 2).

The above figure shows the link between intervention, and associated resources and expertise, towards introduction of a postgraduate programme, and state of curriculum integration and training rollout in the target universities, and future changes in terms of development of critical mass of leaders, and improved national leadership and training capacity. It is evident in the above analysis that this transition is mediated by dynamic set of factors associated with multiple actors (external development and training partners, universities, programme champions, health ministries) and contextual factors within the university and beyond. Hence, curriculum integration or training roll out is contingent on seniority, role and motivation of programme champions, and opportunities and support at their disposal. Factors associated with the target universities and health ministries including recognition and support of programme or its champions, and incentive arrangements impact on motivation and opportunities of programme champions to spearhead integration of programme. Contextual factors such as national policies and procedures have a bearing on successful implementation of intervention. Interaction across these individual, institutional and context level factors further determine retention of programme champions in the target universities. Overall, the degree of alignment across these multiple actors and processes enable or constrain the success of the capacity development intervention resulting in the short-term outcomes of partial or non- integration in two universities (B and C), and full integration in University A.

When it comes to programme introduction, the study established that success of initiatives depends on the degree of alignment achieved among the agendas and expectations of the various actors within and outside the institutions, who have varying influence on availability of resources for programmes, their legitimacy, implementation, and sustainability. The process is embedded in contestations over issues of programme feasibility, relevance, and need. The financial feasibility of programmes is contested between institutions and MOHs, institution and external partners, or institution and academics. The issues include academics’ workload and financial incentives, the training institution’s capacity to rollout the programme, or resources at the MOH’s disposal to support the initiative in the institutions.

With respect to programme relevance and need, in all the three countries MOH has the discretion in deciding whether a programme meets a national priority, which is also influenced by the national and international priorities and interests, through the roles played by external partners. Future research needs to examine more closely the perception about global or local orientation of existing programmes, and practice of priority setting within the health ministries with respect to core competencies or training programmes.

Cancedda et al. (2015), based on assessment of training initiatives originating through North-South collaboration in sub-Saharan Africa, recognized the confluence of factors influencing such initiatives and underlined the importance of, among others, adaptability, local ownership and funding, coherence between training and country health priorities, long term engagement, and integration and continuity of programmes [10]. Our analysis of the experience of the three universities resonates with these lessons, even though in the very different context of a south-south collaboration. The successful integration of programme in University A is down to convergence of the aforementioned issues, while University B and University C fell short of embedding programme due to lack of the crucial elements namely, inadequate ownership or funding, and short-lived engagement of key actors like programme champions and MOH.

One of the challenges observed, in the case of University B and University C, which undermine programme introduction or sustainability was the lack of coordination of efforts, and the resulting presence of parallel initiatives. There were reported instances of local and external partners of public health training institutions working in silos in their respective collaborations with the in the case of University B and C, which pose challenges of competition, duplication, and resource wastage. On the same note, a study drawing from four major initiatives in LMICs, highlighted the barriers in on-going practices of training initiatives for health professionals. In the face of poor coordination and communication about these training initiatives among stakeholders, including MOH and regulatory bodies, ‘low-income countries have been on the receiving end of a disorderly patchwork of small-scale, insufficient quality, short-term, and unsustainable health professional training initiatives … created unnecessary gaps or overlaps in resources, and failed to help meet long-term national health workforce needs’ [10]. The authors argue for a more prominent role by health ministries to coordinate these efforts [10]. However, a concern with such an arrangement, which represents the position of health ministries, is the widely prevalent practice of choosing and supporting Northern partnership over Southern ones, and crowding out of some programmes that are not considered high priority by MOH.

The exclusive focus of universities on so called basic programmes, a common pattern in MOH’s programme selection, can be detrimental to the needed mix in the range of public health professionals, in the context wherein only a few public health programmes and training institutions exist in the countries. This can also undermine internationalization of academic institutions with respect to the diversity of global programmes in public health. What is evident in this study is that universities or academics lack autonomy in this regard.

Contestation between health ministries and universities over issues of quality, relevance or alignment of training programmes with national priorities can be located in the debate about internationalization of higher education in Africa, wherein institutions engage in exchange of global knowledge and know-how towards executing their academic and research mandates [14, 45]. Academic institutions partnership with external partners can be characterized as having an internationalization agenda, whether it is training of academics abroad or adapting a new programme. Internationalization, which has an outward approach and emphasizes quality and standard, may not be aligned well with an inward focus of meeting local priorities. Jowi (2009) noted that the internationalization of higher education in Africa is motivated mainly by the need to revamp the academic and management capacity of the institutions, in the face of inadequate support from government. This explains predominance of well-resourced northern partners in internationalization initiatives in Africa compared to partners from south or the African region in particular despite a growing interest in the later types of cooperation [14]. Finding coherence in the internationalization agendas is thus a daunting challenge that higher education institutions and governments in Africa grapple with in the context of lack of clarity regarding roles that the various actors play in the implementation of internationalization [46].

Despite the increasing demands put on universities to meet national health workforce needs, it was apparent in this research that there was not enough input to strengthen capacity of the public health training universities regarding personnel and infrastructure. The institutions are often expected to seek and get by with short-term solutions.

The findings of this investigation complement those of earlier studies that attributed the lack of diversity in training programmes in LMICs to the multifaceted shortage of resources facing training institutions including faculty and support staff, funding, capacity to develop teaching material and curriculum, and teaching spaces [10, 11, 13, 47, 48]. This has been evident particularly in the context of University A, where the institution has fewer programmes than University B or University C due to lack of resources and support.

The successful introduction of the postgraduate programme on human resource management in University A suggests the important contribution that a south-south partnership can make. Literature on south-south cooperation reports on the fragile nature of such partnerships due to overreliance on funding from the North and capacity challenges to sustain partnership [34] despite their potential benefits in promoting Southern knowledge and experience, adaptability across partners, and non-hierarchical relationship [14, 49, 50] compared to north-south partnerships, whose success is undermined by “fundamentally unequal resource endowments and incentive structures” [51]. The literature on partnership further maintains that a host of factors pertaining to environment, membership, process and structure, communication, purpose, and resources determine success of partnerships [31, 32].

Literature emphasizes the value of backing programme champions if they are to make progress in fulfilling their roles, and that they need to have qualities like seniority, credibility, personality, and leadership [52‐54]. Literature further highlights the significance of selecting the right personnel to execute the role of champion and support at their disposal [52, 55]. Our analysis also showed that programme champions’ success in enabling introduction of programme and building coherence across the different actors depends on seniority, sustained engagement, or availability of resource and institutional backing.

Programme champion’s role is as much political as technical. Their responsibility requires more than meeting curriculum approval standards, as they need to work towards securing endorsement from health ministries and other stakeholders to give the new programme legitimacy and required resources.

Taken together, the experiences of the three public health training universities resonate with other studies that recognize partnership and collaboration as key strategies for tackling complex challenges such as fostering innovation or improving performance [53, 54, 56]. Our analysis further shows that partnerships to introduce postgraduate programmes in public health training universities are fraught with contested interests and priorities around what is feasible or relevant; and potentiality of success in embedding and sustaining programme depends on alignment, coherence and harmonization of differences among the various players.

The findings from this study cannot be extrapolated to all public health training universities within the countries or the sub-Saharan region. The limited evidence suggests that universities within countries and in the region work with different set of actors, and have quite distinct experiences and relationships.

The study has two main limitations. First, determining impact and sustainability of new programmes, which are key but long-term aspects of capacity development, was not feasible within the limited period of this research. The focus of the research was thus limited to investigating processes, and short and medium-term outcomes of the intervention. Second, due to social desirability bias [57], and tensions between accountability and learning [58], participants may have been inhibited from fully disclosing failures that might reflect badly on themselves or their institution. We acknowledge the issue and strove to address it through long-term engagement, building trust and confidence with research participants to enable opportunities for open reflection and learning.