Aid in the third millennium: marrying relief with development

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SPEED READ

– the international community should marry emergency relief interventions with solid system building capabilities. Complementarity is the real answer

 – research and innovation for health should be seen as key drivers for development – also in lower income countries

 – countries can begin and further optimize their research and innovation systems by defining research and innovation priorities; creating a policy framework to act on these priorities; and develop a national research and innovation management office – so, decisions can be taken and communication can be done. COHRED’s core competence is supporting countries in achieving these – and more

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Africa calls

Armauer Hansen Research Institute (AHRI) is a government biomedical research institution in Addis Ababa, Ethiopia. Founded in 1969 through the initiative of the Norwegian and Swedish Save the Children organizations, AHRI was erected next to a large hospital for leprosy patients, with the specific mission of developing tools for the prevention, control and treatment of mycobacterial infections. Current research activities focus on tuberculosis, HIV, malaria, leishmaniasis, and other diseases of public health importance in Ethiopia.

Notwithstanding these apparently clearly defined goals, AHRI is admittedly in a transitional phase, “undergoing reform to transform itself to be an institute embracing research agenda which will have direct impact in development and transformation of population in Ethiopia and Africa” (sites/ahreaccr.org/i/).

Africa calls, COHRED answers

COHRED, the Council on Health Research for Development, is a global, non-profit organisation with a unique approach to development problems of people living in low- and middle-income countries. COHRED strongly believes research and innovation are potent drivers of sustainable development, for everyone and everywhere, and strives to provide leadership and effective solutions to support low- and middle-income countries to build their own research and innovation systems for health, equity and development.

Very recently, the Ministry of Health of Ethiopia has requested COHRED to define a strategy for the positioning of AHRI in the Ethiopian research system for health, following a detailed analysis of the national situation and after profiling AHRI and its competencies.

Unaligned aid, fragmented landscapes

The AHRI case is by no means an isolated one. Developing countries host a multitude of research institutions that have been set up in the past thanks to the financial, scientific and managerial guidance provided by donors. Needless to say, in most cases activities within these research centres reflected donors’ priorities rather than those of national health research systems, that in many instances were simply non-existent. In other words, the classic stand-alone, vertical programme approach. But as the years went by, and the global research agenda shifted towards different diseases or health-related issues, so did donors’ interest and attention. As a result, many research centres in developing countries – some of which of very good level and with well educated workforce– ended up being disconnected by national health systems. These, one their side, have not been able in many cases to integrate health research into a systems approach, with research continuing to be fragmented, uncoordinated, and based on small-scale activities.

Bobo-Dioulasso, Burkina Faso. Credit: Gabriela Montorzi, COHREDBodo-Dioulasso, Burkina Faso. Credit: Gabriela Montorzi, COHRED

Burkina Faso, were a number of health research structures are present, is a paradigmatic example of this widespread situation. A few years back, COHRED performed a so-called ‘Alignment and Harmonization Study’ for the country . Alignment refers to the donor commitment to base development assistance on partner countries’ strategies, institutions and processes, while harmonization is the commitment by donors to rationalize their multiple activities in ways that maximize the collective efficacy of aid under country ownership. The study acknowledged the positive initiatives undergone in recent years to strengthen the country’s national health research system, but also highlighted the standing poor coordination among health research actors. “There is health research in Burkina Faso but there is no health research system,” the study reports quoting an interviewee, and what you have on the ground is “A fragmentation of health research with each research institution undertaking research activities according to its own priorities, donor’s priorities and/or researchers’ field of interest without any coordination with the Ministries and other research institutions.” On the other hand, the study stressed, in the absence of a well-defined agenda for health research at the country level, it is currently difficult for donors to effectively align their interventions with countries’ policies and strategies.

What you find in the African context in particular, is that research is really driven by vertical programmes. This way you create a fragmented health system of institutions that, when donors’ enthusiasm wanes off or the money stops, find themselves left-behind and isolated.

Beyond relief

The gist of the matter is the need to move beyond the aid model of knights coming from the rich north in their shining armours and shields, bringing expertise and money to solve the problems of the poor south. That time is over, is gone forever. Countries need to come into control, building and managing their own systems. And research and science must be a key part of the development agenda. Thus, strengthening innovation systems – including all those ‘leftover’ research institutes, that must be aligned with countries’ health priorities and could be transformed to attract partnerships with northern institutions and grants from abroad – becomes the key to achieve equity and national development.

Think about the GAVI Alliance for a moment. This partnership is committed to increasing access to immunisation in poor countries, and has done a magnificent work in the field, saving an incalculable number of lives. But, after more than a decade working in Africa, which consumes most of the resources GAVI has recruited and mobilized so far, there is still not a single WHO-prequalified vaccine laboratory in the continent, except for a small yellow-fever outfit attached to the Institut Pasteur in Dakar, Senegal. So, ten years later we are exactly in the same dependency situation for Africa as we were at the beginning of GAVI. Now, for me this is not development. This is relief.

Of course, relief is important, and this is therefore the dilemma: were do we go with aid? It must be relief or development? Clearly, COHRED is on the side of development, but complementarity is the real answer. The international community should marry the emergency relief stuff with solid system building capabilities. And strengthening research systems could really help countries.

The way forward

How is then possible to stimulate science and technology as drivers of development? When people speak about capacity building they mean we train PhD students in London and then we send them back. In reality, if you really want to be able to start taking charge of research and innovation as strategies for development in your country, you need three things in place: credibly set and regularly updated health research priorities; a policy framework to activate the country on these priorities; and some research management capability, such as a medical council or alike. We call these the ‘Holy Trinity’. COHRED can then support country partners, following a comprehensive approach that integrates fundamental national principles into an ‘ideal national research and innovation’ system (www.cohred.org/approaches/).

Bobo-Dioulasso, Burkina Faso. Credit: Gabriela Montorzi, COHRED
Bodo-Dioulasso, Burkina Faso. Credit: Gabriela Montorzi, COHRED

But, above all, there must be readiness to engage in all this. If there is no political commitment to R&D or to making funding available to improve health for everyone, nothing is going to happen. “It really depends on what countries are interested in doing. We don’t go there to work for them. We work in partnership. We don’t impose. They need to ask for it. They need to drive it. We cannot write a policy for them, for instance. It has to come from them. There has to be a leadership,” said Gabriela Montorzi, Manager of Country Support at COHRED.

Although many stories can be mentioned that point to the effectiveness of this approach, the process can be very long, and success is difficult to measure on the short term, Montorzi remarked. However, this is not always the case. “A project COHRED helped to draft along these lines in the recent past, has allowed Liberia to set up a research unit within the Ministry of Health that did not exist before. So it’s already giving a specific place to research. And it’s likely that the unit will continue. So, that’s a short-term result that is quite tangible,” Montorzi said.

Carel IJsselmuiden