“Publish or perish” is a dilemma that scientists in the developing world are only too familiar with. Often, language barriers and little training in how to write grant proposals or science papers means that despite thousands scrambling every day to get into major international journals like The Lancet, Nature and Science, only a tiny percentage make it in. What Africa needs is an expansion of local peer reviewed journals.

Publication in these big journals confers significant prestige, for sure. However, these journals have a global audience. Thus, research from the developing world that makes it into such journals must either contain data so momentous that it cannot be overlooked, or have findings that are applicable to the rest of the world.

Such research can be enormously hard enough to generate, particularly when research institutions in countries in Africa, for example, are under-resourced and understaffed. But by courting global journals so desperately, many African scientists are missing a vital point: research does not need to have global importance for it to be of value to African countries. A point that is rarely mentioned is that while there is no specific formula for publication in a major journal, the editorial staff and boards, and their experiences and knowledge, have a large influence over what gets published. Inevitably, editors on international journals, will not be as well-versed with the details of African scientific challenges as African scientists themselves.

Africa faces its own unique challenges of infrastructure, resourcing, funding, and communication. Some of the nuances of these challenges – that can be determined by local or national governance, for example - may not even be applicable to other developing regions.

All this indicates how vital it is for Africa to have local journals that feature research relevant to local contexts. The ones that exist publish so infrequently – quarterly or biannually, for example – so as not to have enough influence on the research community. Having more local journals would mean that researchers no longer have to struggle to write in a language unfamiliar to them. Not only that, it would mean that other researchers in the region are not forced to read science articles in a language unfamiliar to them, which is vital if researchers are to connect with their peers and understand their work.

This it not to say that African researchers should forget about publishing in global journals – after all, this can be key in getting research out to the worldwide scientific community. High-status publications are also vital for scientists in any part of the world to advance in their career. But publishing locally nurtures a culture of research communication, and can be a crucial arena for younger scientists especially to hone their writing skills. By building up a base of publications, and adding to their scientific credibility, researchers from the developing world might then also find it easier to publish in big journals.

Editors at African science journals might well point out that they simply do not have the funds to publish monthly or weekly because the cost of publication can be hard to recoup in a region where researchers have miniscule budgets and cannot afford large subscription fees.

These issues are not new to anyone working in science in Africa, as was evidenced by the frequency with which this topic was discussed at the Algerian ministerial health conference that will culminate today.

There is a solution. It’s not new, but it is worth reiterating: publish online. Bypassing the costs of publishing on paper, and the inherent challenges of distribution in areas with poor road infrastructure has been proven to work immensely well. The Public Library of Science has shown through its ever-expanding range of journals, including its newest one on neglected diseases, that it can be done. The research published in these journals can then be further disseminated through fora such as TropIKA and SciDev.Net, which keep a close eye on, and are keen to highlight, research from developing countries. There are other initiatives such as Bioline international or SciELO/BIREME in Brazil which could help these journals to publish online.

The challenge now for editors and communicators in developing regions is to forget about making money from print publication and subscriptions. Decades of experience has shown that if it hasn’t worked until now, it’s never going to. The need to spur progress in African science is too urgent not to embrace any new technology or process that would open new channels of communication and mean that scientists in the region learn from each other’s research.

The TropIKA.net team did a quick and informal round of the technical experts attending the Ministerial Conference on Research for Health in the African Region to gather their impressions on the last day of the meeting.

It had been interesting to hear delegates in a sense use the conference to channel their requests to their own governments and ministers. Clearly, there is scope for improving direct channels of communication within ministries. Repeatedly, they had called upon their ministers to commit themselves to the Algiers Declaration. Noting that previous declarations and resolutions had tended to remain on paper only, they expressed the hope that the ministers embark on implementation as soon as they return to their countries.

Asked whether their expectations have been met, some expressed cautious agreement. Yet others who preferred to speak to TropIKA.net anonymously were frustrated, worried that the conference might stop at rhetoric and statement of principles. Curiously though, some of the delegates who requested anonymity during the interview spoke out openly in the plenary. ‘You know that whatever is published will be read by everyone,” said one. Spoken words on the other hand, he added, are seldom recorded and quickly forgotten. “Though I am entitled to my personal views, I don’t want to be seen as a government critic,’ said another delegate.

Here are some of the comments we collected:

We need the political will to do all this. At the end of the day, it’s our own people who will benefit. People are dying of avoidable diseases because we don’t have the knowledge and are not doing the research. Now we African countries are exchanging ideas and are supporting each other, which will be good for Africa.
Professor Sule, Nigerian Ambassador to Algeria.

I came here to gather some data which would help me in preparation for the Bamako Conference. I can say that some of my expectations have been met, as I have met some of the key individuals I wanted to talk to. The conference has brought together researchers from different backgrounds, a fact that I deeply appreciate. However, some of my expectations have not been met, given that I expected to hear more on research for health as opposed to health research. The discussions have been too general. Besides, the issues discussed here have also been the subject of discussion at previous conferences. There was not much new really. I would have preferred to network and share new ideas with fellow researchers.
John Arido, Kenya.

My expectation was that at the end of this conference, ministers would commit themselves to the Declaration which they are going to sign today. Therefore, I cannot say that my expectations have been met until the ministers go back to their countries and begin implementing the resolutions reached. I hope they will follow up in earnest and act upon their commitments.
Ali Gubio, Nigeria.

Anonymous comments:

‘Since we are going to Bamako, my expectation was that more issues would be discussed in depth. I think we are used to talking too much and doing very little. I am disappointed. I hope I’m wrong but won’t be surprised if the Declaration to be signed today just remains on paper’.

‘I fear the Declaration will be left to gather dust on the shelves but I don’t want to be quoted on this, especially now that the minister is around’, said a delegate who has been active during plenary discussions.

‘A most noble endeavour! Most of the processes and arrangements have gone on well, as I anticipated; however, I am a bit disappointed with some of the discussions. I am not too sure whether some of the critical discussion points were not lost during the translation process.’

‘Well, since my minister is here, I have got to be careful about what I say, in order not to stray too far from official viewpoints’.

‘The expectations of donor agencies also have to be taken into consideration in the debate’.

‘There seem to be relatively fewer younger people in this conference, presumably because it is supposed to be a “ministerial conference”; however, I wonder if the ordinary (and young) people out there in our countries identify with the opinions and recommendations being made in their name. What about including some representatives who do not necessarily represent the “official” viewpoint(s)’?

Of course I like “TropIKA.net” and what it is doing! I am impressed by the team’s “quiet visibility”.

‘I only wish that the recommendations being made will be pursued further’.

‘I am surprised by the number of people who took the trouble to make the journey here for this meeting. It is good to know that there are a lot of people who are passionate about the knowledge gap in our countries and are committed to making a contribution- albeit only “discussions” so far. I am also impressed by the number of the many already existing initiatives that are working towards ameliorating some of the issues being discussed at this very forum’.

‘Today, the Algiers Declaration was signed. The onus is now on the ministers attending this meeting to use their considerable powers and influence to steer the implementation of this Declaration and prove the skeptics wrong. They have the unique opportunity to make this Declaration come live’.

Commenting on the regular daily reports on Tropika.Net, Dr Tolu Inyang of Nigeria said Tropika was meeting its objectives because the awareness is increasing about its usefulness for promoting knowledge sharing in developing countries around the world.

“It is doing its job to enhance networking among South-South countries and link them up with facilitation that can gain from northern countries. The daily reports have enabled thousands of those not here in Algiers to share the experience of what we’ve been going through. Tropika is a great idea!”

According to Professor Rose Leke, head of the Faculty of Medicine & Biomedical Sciences, University of Yaounde1, Cameroon, just getting all the experts together, both researchers and policy-makers, to discuss research and the way forward in the African region is a remarkable achievement.

“I believe that we really should be able to move forward with the recommendations that came out if people go back home and are committed to working on getting funding and systems in place. This meeting was very good because it’s not often you’ll find this level of people getting together. We hope strong messages will go home and I’m very optimistic that with high level government support, we will be able to move health research forward.”

“This meeting was very important for advancing the cause of health research in the region. If we all subscribe to the belief that knowledge and research and development are important, then the delay in Africa being able to catch up can be obliterated through advances in research. I’m optimistic that our leadership will take this seriously and adopt the notion that research is crucial to development in Africa, so our common goal can be realised,” said Dr Tolu Fakeye, Head: Division of Research and Statistics, Federal Ministry of Health, Nigeria.

He suggested that between now and the Bamako meeting in November, countries should make inventories of capacities that already exist. “From this conference, we’ve found out that there are quite a number of institutions whose capacities we didn’t know much about, which have been doing a lot, so we should focus attention on what already exists.”

For Dr Immanuel Idigbe, Director General of the Nigerian institute of Medical Research, the meeting was important in focusing health research for development, and from Dr Ridley presentation, delegates could see how important health findings over time were translated into policies.

“We’ve had these meetings before, and the bottom line for this one is that it shouldn’t be a talk show – we have taken decisions and we have a resolution; our next steps now are on implementation. I am very optimistic.”

The head of the Bamako Secretariat, Dr Ania Grobicki, feels strongly that the Algiers meeting was a really positive step forward.

“Its clear that health research is being taken very seriously by the dignitaries present here and this is going to enable the whole process to move to the next level. We really need to move to implementation. The initial targets were proposed in 1990 in terms of 2% of the budget of health ministries to go towards research, and the idea has been around for a long time. Now is a unique moment because it’s being recognised both within the health sector and beyond that Africa needs to develop research and innovation. This applies to research in general, as reflected at the AU summit last year where there was a commitment to science, technology and innovation for Africa’s development, as well as research in the health sector which is an integral part of that.”

“In terms of ministerial commitment, I think the needs of Africa are going to come through very strongly at the Bamako global conference, and the priorities of Africa are going to have a high profile at that meeting. This is really driving the motivation for the messages to come across very clearly of what Africa is looking for from the rest of the world and what the continent expects of itself.”

The Regional Director for the WHO Eastern Mediterranean Region, Dr H A Gezairy, had the delegates spellbound when he related his own personal experience of how the longwinded process of translating research into policy was fast-forwarded with dramatic results.

“There is a difference of 11 days every year between the lunar and solar year, and this has an impact on pilgrimages to Mecca. In 1975/6 we were coming closer to the pilgrimage occurring during summer, and one of the problems during pilgrimage is heat- or sunstroke. The original treatment was to put the comatose person in ice-cold water. This didn’t have the desired effect because those who didn’t die from heat, died from shock.

“We realised we needed to reduce the temperature of these patients quickly, so we approached the London School of Tropical Medicine. They sent us a student from Sudan – one of the first examples of south-south collaboration. We studied different ways to reduce the temperature, and tried everything, including balloons in the stomach filled with water. We were racing against time. It may seem obvious to look at physiology, but the problem with sunstroke is that the body’s thermostat shuts down and you don’t sweat anymore, you keep the heat inside. We had to find something that simulated the heat regulator.

“In the end, technology came to the rescue: we came up with the Mecca-bed, a bed with nozzles which sprinkled water on the patient, along with hot air. This was so effective that within half an hour – more usually within four minutes - the comatose patient is revived.

“The Mecca-bed was an example of the shortest time between the research and implementation, and it worked because decision-makers were involved. It is very important for every one of us to communicate in such a way that decision-makers understand what is possible.”

Algiers – How researchers can interface with policy makers for the implementation of research was an issue raised time and again in different sessions during the Conference.

The Regional Director for the African Region, Dr Luis Sambo, urged researchers to create a demand for evidence, and to examine how this evidence is presented to policy-makers. He commented that a significant amount of grey literature bearing significant outcomes of research was stored at research institutions, but there was a missing link between the research projects and the ministries of health and other health sectors.

If some of the most important public health problems in Africa can be solved with existing knowledge, we have to ask why we don’t make significant progress. The conference has highlighted some reasons why, ranging from poor health information systems, human and institutional capacity gaps, and funding. It may be more useful to look at what has worked. The African Programme on Onchocerciasis Control (APOC) could provide some clues. Following initial research on the drug Ivermectin which proved effective in preventing Onchocerciasis, the drug was distributed to communities on a large scale. This community approach to distribute Ivermectin was unique, proving that a community-directed approach could work: 70 million people are currently covered by this drug, with the aim of reaching 100m by 2010. APOC was asked to see whether this community directed approach could be used in multi-interventions for other diseases.

APOC launched a multi-country study at seven country sites, in 35 health districts, covering 2.4 million people. The most complex of the interventions was the co-treatment with malaria. The result was that anti-malarial treatment for children doubled in 24 hours, proving that - contrary to expectations - the uptake of Ivermectin was not negatively affected, because it was linked with malaria control which communities felt passionate about as it addressed their immediate need. After APOC established that this approach could be used for other interventions, countries have developed policies to scale up interventions. (This work on how public health could gain from the Onchocerciasis approach is available on the TDR website) .

The key, believes TDR’s Robert Ridley, is that if the research output is owned by the policymakers, then policy development is rapid. APOC engaged policymakers from the outset, and gave feedback about research results on an ongoing basis so the decision-makers knew what was coming down the pipeline. “Engage them from the start of the process, and set agendas,” was his advice. 

South Africa’s Lindiwe Makubalo suggested that since many researchers do work closely with ministries and policy-makers, we should look at models and tools on how to influence ministers. “We need to share lessons on how we have been able to influence policy and being the interface as senior officials by working closely with researchers and policy-makers. We do have a voice; we need to think about how we can leverage this.” 

Agreed, says Dr Edwin Muguti, a specialist consultant surgeon from Zimbabwe. Usually technocrats have the answers to health problems but they are unable to effectively communicate that knowledge to help policy-makers translate it into action.

We need a new breed, a “transgenic” or hybrid between pure politician and scientist,  who is both technically trained and politically orientated so the gap between implementation of policy and research is narrowed. 

“Our policies need to be guided by research, but I suspect that half the time some politicians don’t understand what it’s all about. A transgenic person would help solve this problem.”

So it seems the answers are multifaceted: we need to convince policy-makers of the importance of evidence in a way they will understand; we should scratch them where they’re itching from the start so they have a sense of ownership of the results. And possibly the best way to achieve this is for health ministries to be populated with “transgenics”. 

Underpinning all these pragmatic suggestions is communication. Insular scientists need to adapt to changing environments and embrace new ways of working through which their work can be appreciated, understood and implemented. The world is shifting, and the African research agenda is moving inexorably forward with political and donor commitment. Researchers can no longer afford the luxury of isolation; we have to communicate effectively. In Africa, it is a matter of life and death.

Money is power. The relationship between aid donors and recipient countries has often been characterised by tensions attributable to the imbalance of power. A frequent lament from recipient countries is that, as holders of the power, donors have set the countries’ agenda by choosing to fund some projects and not others. Many in the donor community now realise, however, that funding research that are misaligned with the country’s needs or priorities does not benefit the donor’s primary goal – that of supporting science and health in developing countries.

Not only that, over the past decade or so, the sums of money funnelled into international aid has grown at a staggering pace. With big players like the Gates foundation on the scene, money for HIV/AIDS for example has leapfrogged from millions to billions in just a few years. Given the vast amount of money at stake, it’s imperative that it is being spent wisely.

Several donors – such as SIDA/SAREC in Sweden and DFID in the UK - are now working hard to shed this paternalistic image by aligning their funding decisions with countries’ priorities. The fact that a lot of donor money has gone to AIDS/TB/malaria but little towards chronic diseases or health systems research indicates that funding priorities could do with some realignment.

Efforts in the past few years to increase the effectiveness of aid spending have included the high-profile 2005 Paris Declaration, which saw over 100 ministers, aid agency workers and other key officials commit to harmonizing and managing aid for results with a set of monitorable actions and indicators. For example, by 2010, 85 per cent of aid going to developing countries should show up in developing country budgets. This should make it transparent that the aid is aligned to poverty reduction priorities. Stakeholders in this area are to meet in Accra this September to assess progress to meeting the Paris goals and to assess how to go forward.

So, what do donors want from recipient countries? Delegates at the AFRO/WHO ministerial meeting in Algiers have been vocal. They want them to take the lead – to get out of the habit of perenially criticising donors for being the ones to set the agenda. Arguably, in the absence of recipient countries stating their priorities, donors have had to allocate funding to areas where there is data to show where money is needed and for issues that have key political support.

On Day 2 of the meeting, participants to the session on financial flows highlighted these points, and more. Countries need their own means of gathering health data, and of measuring how donor and governmental money is spent. This will be crucial for evidence-based policies on what the health research priorities are.

The message is clear: donors want countries to tell them what they need. It’s time for the countries themselves to speak up.END

Following ten years of bloody civil war, the health system in Sierra Leone was literally devastated. Paradoxically, it was this collapse that spurred the country’s progressive health leadership to embrace health information technology and systems in a way never imagined during the years when the country was burning.

What the end of the conflict did was to create two opportunities: to address this unmet need of a health information system, and to acknowledge that – paradoxically – when there is nothing, it is sometimes easier to get this kind of work done. Harnessing their energy around a common theme, the country’s health officials announced in June that they had developed an integrated data warehouse to capture information from districts for national use.

In a multi-sectoral year-long project involving over 10 key partners from the international community, the central data storage system will link six data sources including outpatient data, based on 25 core indicators. Special low energy hardware was sourced as the country has power supply problems. In addition, a massive training effort was launched to upskill the human chain of data capturing, analysis, management and dissemination.

However, training proved not to be sufficient in this case; data capturing in the first months improved, but not significantly. The motivation mantra of this week’s health systems meeting was again the root of poor delivery. Inspired, motivated and involved, the Sierra Leone government promptly upped the salaries of the health workers by a third. Not that this will work in every case, but the data capturing in the country improved exponentially. Questioning the integrity of data collected when there are sweeteners involved, I was told that ironically, the problem is not about over-reporting or the possible artificial creation of data, but of under-reporting. I was assured that there are ways to analyse data for consistency, but it needs to be collected first!

I think Sierra Leone deserves all the accolades. The country is showing the rest of Africa that it is possible to build health information systems under very difficult circumstances. Congratulations to all concerned on the birth of this new “baby”!

We know there is a gulf between potential health gain and inequalities in Africa, which can be narrowed with research an infrastructure. We also know there is a correlation between the greatest number of avoidable deaths and weak national health systems because they are less able to generate new knowledge, monitor healthy system performance, develop new technologies or put existing interventions to use.

What are the critical issues that limit translation of research and evidence into policy in Africa? Why has it taken Africa so long to realise or commit to knowledge generation? Is there a poor perception of the value of research?.

These are some of the issues delegates at the Ministerial Conference on Research for Health in the African Region currently underway in Algiers will grapple with over the next three days. Over 200 delegates from countries throughout Africa are at this meeting to prepare an African response for the Global Conference on Health Research and Policy, taking place in Bamako, Mali in November 2008.

Ground-breaking surveys – the first ever in Africa – have formed the basis of the discussions and deal with vexing issues such as governance and stewardship, research ethics, expenditure on health research in the region, human capacity, institutional facilities, the use of evidence for policy and decision-making, health information systems, and the state of health information in Africa.

While the surveys may have limitations in their methodology and representation, they are a formative and substantial body of work undertaken by the WHO’s Regional Office in Africa. This was done in response to the request of all 46 ministers of health to collect core information and indicators on the current status of health research, information and knowledge systems. The mapping exercise represents a departure point for countries to commit to investing in health research and capacity.

We have crossed the Rubicon; Africa now has data with which to motivate additional funding, relationships with donors, capacity enhancement, and critically, health systems research based on the gaps identified from the surveys. With the political will, there is no going back…

Getting the balance right for individual countries in terms of models of governance was one of the key discussions during a session on governance and stewardship by Dr Tikki Pang of WHO. According to him, there are generally two views, one based on a centralised system with a single institution co-ordinating research, while the other is “to let 1000 flowers bloom,” ie. not have any co-ordination, as is the case in the United States.

However desirable, this latter model is really only possible when countries have strong health research infrastructure or plenty of money. In developing countries it is more common to establish a national health research council which can include not only the public sector but also academic researchers from universities, NGOs, and members of professional societies. These models of governance are contextual to individual countries, and priority setting is an essential component.

But it emerged during the discussion that these are not the only two roads to take. Mauritius gave examples of how it has been able to allow “at least three flowers to bloom” with research being undertaken at various institutes of research, medical research and at the university. These resulted in interventions which improved health outcomes, and was carried out within an administrative framework, with each institution following their own ethical guidelines. Now, after 30 years of decentralised research, the government is due to pass legislation shortly regulating clinical trials.

“You don’t have to only have one model – you can have a mixture of both,” said the Mauritian delegate. With institutional capacity, he believes centralisation of governance is probably desirable for policy decisions and ethics, but in terms of undertaking research and mobilising resources, institutions should be able to function autonomously under the law.

From the surveys, it appears the key decision-makers of what research gets done are institutional heads (61%) about a third of whom had been in the post for less than two years, and many of whom are appointed by a political process. This raises some questions: how – and for what ends – are decisions made on what research is conducted, by whom and on whom? How autonomous are the decisions? To what extent does politics drive the health research agenda? Why does research not translate to policy if at least half of people heading these institutions are politically appointed?