How to improve research capacity strengthening efforts: learning from the monitoring and evaluation of four research consortia in Africa.

Recent efforts to shift the control and leadership of health research on African issues to Africa have led to increased investments for scientific research capacity strengthening (RCS) on the continent and a greater demand for accountability, value for money and demonstration of return on investment. There is limited literature on monitoring and evaluation (M&E) of RCS systems and there is a clear need to further explore whether the M&E frameworks and approaches that are currently used are fit for purpose. The M&E approaches taken by four African RCS consortia funded under the Developing Excellence in Leadership, Training and Science in Africa (DELTAS) I initiative were assessed using several methods, including a framework comparison of the M&E approaches, semi-structured interviews and facilitated discussion sessions. The findings revealed a wide range in the number of indicators used in the M&E plans of individual consortium, which were uniformly quantitative and at the output and outcome levels. Consortia revealed that additional information could have been captured to better evaluate the success of activities and measure the ripple effects of their efforts. While it is beneficial for RCS consortia to develop and implement their own M&E plans, this could be strengthened by routine engagement with funders/programme managers to further align efforts. It is also important for M&E plans to consider qualitative data capture for assessment of RCS efforts. Efforts could be further enhanced by supporting platforms for cross-consortia sharing, particularly when trying to assess more complex effects. Consortia should make sure that processes for developmental evaluation, and capturing and using the associated learning, are in place. Sharing the learning associated with M&E of RCS efforts is vital to improve future efforts. Investing and improving this aspect of RCS will help ensure tracking of progress and impact of future efforts, and ensure accountability and the return on investment. The findings are also likely applicable well beyond health research.

Multi-site comparison of factors influencing progress of African insecticide testing facilities towards an international Quality Management System certification.

BACKGROUND: Insecticidal mosquito vector control products are vital components of malaria control programmes. Test facilities are key in assessing the effectiveness of vector control products against local mosquito populations, in environments where they will be used. Data from these test facilities must be of a high quality to be accepted by regulatory authorities, including the WHO Prequalification Team for vector control products. In 2013-4, seven insecticide testing facilities across sub-Saharan Africa, with technical and financial support from Innovative Vector Control Consortium (IVCC), began development and implementation of quality management system compliant with the principles of Good Laboratory Practice (GLP) to improve data quality and reliability. METHODS AND PRINCIPLE FINDINGS: We conducted semi-structured interviews, emails, and video-call interviews with individuals at five test facilities engaged in the IVCC-supported programme and working towards or having achieved GLP. We used framework analysis to identify and describe factors affeting progress towards GLP. We found that eight factors were instrumental in progress, and that test facilities had varying levels of control over these factors. They had high control over the training programme, project planning, and senior leadership support; medium control over infrastructure development, staff structure, and procurement; and low control over funding the availability and accessibility of relevant expertise. Collaboration with IVCC and other partners was key to overcoming the challenges associated with low and medium control factors. CONCLUSION: For partnership and consortia models of research capacity strengthening, test facilities can use their own internal resources to address identified high-control factors. Project plans should allow additional time for interaction with external agencies to address medium-control factors, and partners with access to expertise and funding should concentrate their efforts on supporting institutions to address low-control factors. In practice, this includes planning for financial sustainability at the outset, and acting to strengthen national and regional training capacity.

Strengthening capacity for natural sciences research: A qualitative assessment to identify good practices, capacity gaps and investment priorities in African research institutions.

BACKGROUND: Strengthening research capacity in low-and-middle-income countries is essential to drive socioeconomic development and to achieve the Sustainable Development Goals. Understanding strengths and weaknesses in institutions' research capacity can guide effective targeting of investments and resources. This study assessed the capacity of institutions undertaking research in natural science topics in Africa to identify priority capacity gaps for future investment. METHODS: Assessments were conducted in eight African institutions that were partners in a UK-Africa programme to strengthen research capacity in renewable energy, soil-related science, and water and sanitation. Assessments involved eighty-six interviews and three focus group discussions to identify institutions' research capacity strengths and gaps against an evidence-informed benchmark. Use of the same interview guides and data collection processes across all institutions meant that findings could be compared. RESULTS: Common research capacity gaps were: lack of, or poorly maintained, equipment; unreliable, slow procurement systems; insufficient opportunities for developing the skills of research support staff such as administrators and technicians; dysfunctional institutional email communication systems; insufficient focus on the development of 'soft' researcher skills such as ethics, academic writing and, in non-Anglophone countries, English language. Programme strengths were the South-South and South-North partnerships for sharing and cascading expertise and resources, joint writing of proposals and publications, and improved individual and institutional visibility. CONCLUSION: There were many similarities in research capacity gaps irrespective of the institutions' natural sciences research focus, and these were similar to those reported in the health sector. Common capacity needs are improving the skills of technicians and administrators to support research activities, soft skills training for researchers, and more effective pan-institutional e-communication systems. These could be strategic investment targets for the joint efforts of national governments and international organisations that fund programmes for strengthening research capacity in low- and middle-income countries.

Transfusion Volume for Children with Severe Anemia in Africa.

BACKGROUND: Severe anemia (hemoglobin level, <6 g per deciliter) is a leading cause of hospital admission and death in children in sub-Saharan Africa. The World Health Organization recommends transfusion of 20 ml of whole-blood equivalent per kilogram of body weight for anemia, regardless of hemoglobin level. METHODS: In this factorial, open-label trial, we randomly assigned Ugandan and Malawian children 2 months to 12 years of age with a hemoglobin level of less than 6 g per deciliter and severity features (e.g., respiratory distress or reduced consciousness) to receive immediate blood transfusion with 20 ml per kilogram or 30 ml per kilogram. Three other randomized analyses investigated immediate as compared with no immediate transfusion, the administration of postdischarge micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. The primary outcome was 28-day mortality. RESULTS: A total of 3196 eligible children (median age, 37 months; 2050 [64.1%] with malaria) were assigned to receive a transfusion of 30 ml per kilogram (1598 children) or 20 ml per kilogram (1598 children) and were followed for 180 days. A total of 1592 children (99.6%) in the higher-volume group and 1596 (99.9%) in the lower-volume group started transfusion (median, 1.2 hours after randomization). The mean (±SD) volume of total blood transfused per child was 475±385 ml and 353±348 ml, respectively; 197 children (12.3%) and 300 children (18.8%) in the respective groups received additional transfusions. Overall, 55 children (3.4%) in the higher-volume group and 72 (4.5%) in the lower-volume group died before 28 days (hazard ratio, 0.76; 95% confidence interval [CI], 0.54 to 1.08; P = 0.12 by log-rank test). This finding masked significant heterogeneity in 28-day mortality according to the presence or absence of fever (>37.5°C) at screening (P=0.001 after Sidak correction). Among the 1943 children (60.8%) without fever, mortality was lower with a transfusion volume of 30 ml per kilogram than with a volume of 20 ml per kilogram (hazard ratio, 0.43; 95% CI, 0.27 to 0.69). Among the 1253 children (39.2%) with fever, mortality was higher with 30 ml per kilogram than with 20 ml per kilogram (hazard ratio, 1.91; 95% CI, 1.04 to 3.49). There was no evidence of differences between the randomized groups in readmissions, serious adverse events, or hemoglobin recovery at 180 days. CONCLUSIONS: Overall mortality did not differ between the two transfusion strategies. (Funded by the Medical Research Council and Department for International Development, United Kingdom; TRACT Current Controlled Trials number, ISRCTN84086586.).

Immediate Transfusion in African Children with Uncomplicated Severe Anemia.

BACKGROUND: The World Health Organization recommends not performing transfusions in African children hospitalized for uncomplicated severe anemia (hemoglobin level of 4 to 6 g per deciliter and no signs of clinical severity). However, high mortality and readmission rates suggest that less restrictive transfusion strategies might improve outcomes. METHODS: In this factorial, open-label, randomized, controlled trial, we assigned Ugandan and Malawian children 2 months to 12 years of age with uncomplicated severe anemia to immediate transfusion with 20 ml or 30 ml of whole-blood equivalent per kilogram of body weight, as determined in a second simultaneous randomization, or no immediate transfusion (control group), in which transfusion with 20 ml of whole-blood equivalent per kilogram was triggered by new signs of clinical severity or a drop in hemoglobin to below 4 g per deciliter. The primary outcome was 28-day mortality. Three other randomizations investigated transfusion volume, postdischarge supplementation with micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. RESULTS: A total of 1565 children (median age, 26 months) underwent randomization, with 778 assigned to the immediate-transfusion group and 787 to the control group; 984 children (62.9%) had malaria. The children were followed for 180 days, and 71 (4.5%) were lost to follow-up. During the primary hospitalization, transfusion was performed in all the children in the immediate-transfusion group and in 386 (49.0%) in the control group (median time to transfusion, 1.3 hours vs. 24.9 hours after randomization). The mean (±SD) total blood volume transfused per child was 314±228 ml in the immediate-transfusion group and 142±224 ml in the control group. Death had occurred by 28 days in 7 children (0.9%) in the immediate-transfusion group and in 13 (1.7%) in the control group (hazard ratio, 0.54; 95% confidence interval [CI], 0.22 to 1.36; P = 0.19) and by 180 days in 35 (4.5%) and 47 (6.0%), respectively (hazard ratio, 0.75; 95% CI, 0.48 to 1.15), without evidence of interaction with other randomizations (P>0.20) or evidence of between-group differences in readmissions, serious adverse events, or hemoglobin recovery at 180 days. The mean length of hospital stay was 0.9 days longer in the control group. CONCLUSIONS: There was no evidence of differences in clinical outcomes over 6 months between the children who received immediate transfusion and those who did not. The triggered-transfusion strategy in the control group resulted in lower blood use; however, the length of hospital stay was longer, and this strategy required clinical and hemoglobin monitoring. (Funded by the Medical Research Council and Department for International Development; TRACT Current Controlled Trials number, ISRCTN84086586.).

Qualitative study to develop processes and tools for the assessment and tracking of African institutions' capacity for operational health research.

OBJECTIVES: Research is key to achieving global development goals. Our objectives were to develop and test an evidence-informed process for assessing health research management and support systems (RMSS) in four African universities and for tracking interventions to address capacity gaps. SETTING: Four African universities. PARTICIPANTS: 83 university staff and students from 11 cadres. INTERVENTION/METHODS: A literature-informed 'benchmark' was developed and used to itemise all components of a university's health RMSS. Data on all components were collected during site visits to four African universities using interview guides, document reviews and facilities observation guides. Gaps in RMSS capacity were identified against the benchmark and institutional action plans developed to remedy gaps. Progress against indicators was tracked over 15 months and common challenges and successes identified. RESULTS: Common gaps in operational health research capacity included no accessible research strategy, a lack of research e-tracking capability and inadequate quality checks for proposal submissions and contracts. Feedback indicated that the capacity assessment was comprehensive and generated practical actions, several of which were no-cost. Regular follow-up helped to maintain focus on activities to strengthen health research capacity in the face of challenges. CONCLUSIONS: Identification of each institutions' strengths and weaknesses against an evidence-informed benchmark enabled them to identify gaps in in their operational health research systems, to develop prioritised action plans, to justify resource requests to fulfil the plans and to track progress in strengthening RMSS. Use of a standard benchmark, approach and tools enabled comparisons across institutions which has accelerated production of evidence about the science of research capacity strengthening. The tools could be used by institutions seeking to understand their strengths and to address gaps in research capacity. Research capacity gaps that were common to several institutions could be a 'smart' investment for governments and health research funders.

Transfusion research priorities for blood services in sub-Saharan Africa.

Evidence to support many blood transfusion policies and practices in sub-Saharan Africa (SSA) is weak or lacking. SSA cannot extrapolate from wealthy countries' research findings because its environment, users and structures are very different and SSA has critical blood shortages. SSA needs to generate its own evidence but research funds are very scarce and need to be carefully targeted to match need. This study aimed to define this need by determining research priorities for blood services in SSA. Thirty-five stakeholders representing diverse blood services' interests and expertise participated in a workshop. An adapted 'consensus development method' was used to identify, agree and justify research priorities under five themes through small group and plenary discussion, and cumulative voting. Research priorities covered traditional research areas, such as clinical use of blood and infection screening, but also highlighted many new, under-researched topics, mostly concerning blood service 'systems', such as economics, blood components and regulation. Lack of electronic information management systems was an important hindrance to the blood services' ability to generate robust research data. This study has identified and prioritised novel research that will help blood services in SSA to address their own needs including their most urgent problem: the lack of access to adequate blood supplies. To catalyse this research blood services in SSA need to enhance their capacity to conduct, commission and manage research and to strengthen their collaborations within and beyond Africa.

Problems and Approaches for Blood Transfusion in the Developing Countries.

A safe supply of blood and the knowledge, skill, and resources for the appropriate use of blood are essential for medical services. Many problems are faced in the development of transfusion services in low- or medium-income countries (LMICs). Unfortunately, in many countries, providing safe blood is made more difficult by a lack of blood donors and the high frequency of transfusion-transmissible infections. The problems are compounded by the frequent need for urgent life-saving transfusions. This article examines the problems in supply, safety, and use of blood and how they are being addressed in LMICs, predominantly focusing on sub-Saharan Africa.

Promoting sustainable research partnerships: a mixed-method evaluation of a United Kingdom-Africa capacity strengthening award scheme.

BACKGROUND: Research partnerships between high-income countries (HICs) and low- or middle-income countries (LMICs) are a leading model in research capacity strengthening activities. Although numerous frameworks and guiding principles for effective research partnerships exist, few include the perspective of the LMIC partner. This paper draws out lessons for establishing and maintaining successful research collaborations, based on partnership dynamics, from the perspectives of both HIC and LMIC stakeholders through the evaluation of a research capacity strengthening partnership award scheme. METHODS: A mixed-method retrospective evaluation approach was used. Initially, a cross-sectional survey was administered to all award holders, which focused on partnership outputs and continuation. Fifty individuals were purposively selected to participate in interviews or focus group discussions from 12 different institutions in HICs and LMICs; the sample included the research investigators, research assistants, laboratory scientists and post-doctoral students. The evaluation collected data on critical elements of research partnership dynamics such as research outputs, nature of the partnership, future plans and research capacity. Quantitative data were analysed descriptively and qualitative data were analysed using an iterative framework approach. RESULTS: The majority of United Kingdom and African award holders stated they would like to pursue future collaborations together. Key aspects within partnerships that appeared to influence this were; the perceived benefits of the partnership at the individual and institutional level such as publication of papers or collaborative grants; ability to influence 'research culture' and instigate critical thinking among mid-career researchers; previous working relationships, for example supervisor-student relationships; and equity within partnerships linked to partnership formation and experience of United Kingdom partners within LMICs. Factors which may hinder development of long term partnerships were also identified such as financial control or differing expectations of partners. CONCLUSIONS: This paper provides evidence of what encourages international research partnerships for capacity strengthening to continue past award tenure, from the perspective of researchers in high and LMICs. Although every partnership is unique and individual experiences subjective, this paper provides extension and support of key principles and mechanisms that can contribute to successful research partnerships between researchers.

Indicators for tracking programmes to strengthen health research capacity in lower- and middle-income countries: a qualitative synthesis.

BACKGROUND: The monitoring and evaluation of health research capacity strengthening (health RCS) commonly involves documenting activities and outputs using indicators or metrics. We sought to catalogue the types of indicators being used to evaluate health RCS and to assess potential gaps in quality and coverage. METHODS: We purposively selected twelve evaluations to maximize diversity in health RCS, funders, countries, and approaches to evaluation. We explored the quality of the indicators and extracted them into a matrix across individual, institutional, and national/regional/network levels, based on a matrix in the ESSENCE Planning, Monitoring and Evaluation framework. We synthesized across potential impact pathways (activities to outputs to outcomes) and iteratively checked our findings with key health RCS evaluation stakeholders. RESULTS: Evaluations varied remarkably in the strengths of their evaluation designs. The validity of indicators and potential biases were documented in a minority of reports. Indicators were primarily of activities, outputs, or outcomes, with little on their inter-relationships. Individual level indicators tended to be more quantitative, comparable, and attentive to equity considerations. Institutional and national-international level indicators were extremely diverse. Although linkage of activities through outputs to outcomes within evaluations was limited, across the evaluations we were able to construct potential pathways of change and assemble corresponding indicators. CONCLUSIONS: Opportunities for improving health RCS evaluations include work on indicator measurement properties and development of indicators which better encompass relationships with knowledge users. Greater attention to evaluation design, prospective indicator measurement, and systematic linkage of indicators in keeping with theories of change could provide more robust evidence on outcomes of health RCS.

External financial aid to blood transfusion services in sub-Saharan Africa: a need for reflection.

Jean-Pierre Allain and colleagues argue that, while unintended, the foreign aid provided for blood transfusion services in sub-Saharan Africa has resulted in serious negative outcomes, which requires reflection and rethinking.

Towards building equitable health systems in Sub-Saharan Africa: lessons from case studies on operational research.

BACKGROUND: Published practical examples of how to bridge gaps between research, policy and practice in health systems research in Sub Saharan Africa are scarce. The aim of our study was to use a case study approach to analyse how and why different operational health research projects in Africa have contributed to health systems strengthening and promoted equity in health service provision. METHODS: Using case studies we have collated and analysed practical examples of operational research projects on health in Sub-Saharan Africa which demonstrate how the links between research, policy and action can be strengthened to build effective and pro-poor health systems. To ensure rigour, we selected the case studies using pre-defined criteria, mapped their characteristics systematically using a case study development framework, and analysed the research impact process of each case study using the RAPID framework for research-policy links. This process enabled analysis of common themes, successes and weaknesses. RESULTS: 3 operational research projects met our case study criteria: HIV counselling and testing services in Kenya; provision of TB services in grocery stores in Malawi; and community diagnostics for anaemia, TB and malaria in Nigeria. Political context and external influences: in each case study context there was a need for new knowledge and approaches to meet policy requirements for equitable service delivery. Collaboration between researchers and key policy players began at the inception of operational research cycles. Links: critical in these operational research projects was the development of partnerships for capacity building to support new services or new players in service delivery. EVIDENCE: evidence was used to promote policy dialogue around equity in different ways throughout the research cycle, such as in determining the topic area and in development of indicators. CONCLUSION: Building equitable health systems means considering equity at different stages of the research cycle. Partnerships for capacity building promotes demand, delivery and uptake of research. Links with those who use and benefit from research, such as communities, service providers and policy makers, contribute to the timeliness and relevance of the research agenda and a receptive research-policy-practice interface. Our study highlights the need to advocate for a global research culture that values and funds these multiple levels of engagement.

Impact of introducing integrated quality assessment for tuberculosis and malaria microscopy in Kano, Nigeria.

BACKGROUND: The World Health Organization (WHO) has recommended the integration of malaria microscopy quality assessment (QA) with that of other microscopically diagnosed diseases, but there is no evidence that it has been attempted. We assessed the feasibility of linking malaria microscopy into the existing tuberculosis (TB) microscopy QA system in Kano, Nigeria. METHODOLOGY: Five TB microscopy centres were selected for implementing the integrated TB and malaria microscopy QA scheme in the state. A model system was designed for selecting and blinded rechecking of TB and malaria slides from these laboratories. Supervision and evaluation was conducted at 3-month intervals for 24 months. RESULTS: TB microscopy QA was strengthened in four laboratories. Full integration of the QA for TB and malaria microscopy was achieved in two laboratories, and partial integration in two other laboratories. The programme resulted in an increase in the specificity of both TB and malaria microscopy results. At the final assessment, 100% specificity was achieved for TB microscopy results in four laboratories. There was an increased concordance rate and decreased false positivity and false negativity rates of TB microscopy results in all five laboratories. CONCLUSIONS: It is feasible to integrate the QA system and training for TB and malaria microscopy for assessing and improving quality of both services. However, the integrated system needs testing in different settings in order to be able to develop sound recommendations to guide the complex scaling-up process.

Household cost of malaria overdiagnosis in rural Mozambique.

BACKGROUND: It is estimated that over 70% of patients with suspected malaria in sub-Saharan Africa, diagnose and manage their illness at home without referral to a formal health clinic. Of those patients who do attend a formal health clinic, malaria overdiagnosis rates are estimated to range between 30-70%. METHODS: This paper details an observational cohort study documenting the number and cost of repeat consultations as a result of malaria overdiagnosis at two health care providers in a rural district of Mozambique. 535 adults and children with a clinical diagnosis of malaria were enrolled and followed over a 21 day period to assess treatment regimen, symptoms, number and cost of repeat visits to health providers in patients misdiagnosed with malaria compared to those with confirmed malaria (determined by positive bloodfilm reading). RESULTS: Diagnosis based solely on clinical symptoms overdiagnosed 23% of children (<16y) and 31% of adults with malaria. Symptoms persisted (p = 0.023) and new ones developed (p < 0.001) in more adults than children in the three weeks following initial presentation. Adults overdiagnosed with malaria had more repeat visits (67% v 46%, p = 0.01-0.06) compared to those with true malaria. There was no difference in costs between patients correctly or incorrectly diagnosed with malaria. Median costs over three weeks were $0.28 for those who had one visit and $0.76 for > or = 3 visits and were proportionally highest among the poorest (p < 0.001) CONCLUSION: Overdiagnosis of malaria results in a greater number of healthcare visits and associated cost for adult patients. Additionally, it is clear that the poorest individuals pay significantly more proportionally for their healthcare making it imperative that the treatment they receive is correct in order to prevent wastage of limited economic resources. Thus, investment in accurate malaria diagnosis and appropriate management at primary level is critical for improving health outcomes and reducing poverty.

Laboratory costs of a hospital-based blood transfusion service in Malawi.

BACKGROUND: Despite policies advocating centralised transfusion services based on voluntary donors, the hospital-based replacement donor system is widespread in sub-Saharan Africa. AIMS: To evaluate the cost of all laboratory resources needed to provide a unit of safe blood in rural Malawi using the family replacement donor system METHODS: Full economic costs of all laboratory tests used to screen potential donors and to perform cross-matching were documented in a prospective, observational study in Ntcheu district hospital laboratory. RESULTS: 1729 potential donors were screened and 11,008 tests were performed to ensure that 1104 units of safe blood were available for transfusion. The annual cost of all transfusion-related tests (in 2005 USdollars) was USdollars 17,976, equivalent to USdollars 16.28 per unit of transfusion-ready blood. Transfusion-related tests used 53% of the laboratory's total annual expenditure of USdollars 33,608. CONCLUSIONS: This is the first study to provide prospective economic costs of all laboratory tests associated with the family replacement donor system in a district hospital in Africa. Results show that despite potential economies of scale, a unit of blood from the centralised system costs about three times as much as one from the hospital-based "replacement" system. Factors affecting these relative costs are complex but are in part due to the cost of donor recruitment in centralised systems. In the replacement system the cost of donor recruitment is entirely borne by families of patients needing a blood transfusion.

Malaria and urbanization in sub-Saharan Africa.

There are already 40 cities in Africa with over 1 million inhabitants and the United Nations Environmental Programme estimates that by 2025 over 800 million people will live in urban areas. Recognizing that malaria control can improve the health of the vulnerable and remove a major obstacle to their economic development, the Malaria Knowledge Programme of the Liverpool School of Tropical Medicine and the Systemwide Initiative on Malaria and Agriculture convened a multi-sectoral technical consultation on urban malaria in Pretoria, South Africa from 2nd to 4th December, 2004. The aim of the meeting was to identify strategies for the assessment and control of urban malaria. This commentary reflects the discussions held during the meeting and aims to inform researchers and policy makers of the potential for containing and reversing the emerging problem of urban malaria.

Malaria misdiagnosis: effects on the poor and vulnerable.

CONTEXT: Effective and affordable treatment is recommended for all cases of malaria within 24 h of the onset of illness. Most cases of "malaria" (ie, fever) are self-diagnosed and most treatments, and deaths, occur at home. The most ethical and cost-effective policy is to ensure that newer drug combinations are only used for true cases of malaria. Although it is cost effective to improve the accuracy of malaria diagnosis, simple, accurate, and inexpensive methods are not widely available, particularly in poor communities where they are most needed. STARTING POINT: In a recent study in Uganda, Karin Kallander and colleagues emphasise the difficulty in making a presumptive diagnosis of malaria, and highlight the urgent need for improved diagnostic tools that can be used at community and primary-care level, especially in poorer populations (Acta Trop 2004; 90: 211-14). WHERE NEXT? Health systems need strengthening at referral and community level, so that rapid accurate diagnosis and effective treatment is available for those who are least able to withstand the consequences of illness. Indirect evidence strongly suggests that misdiagnosis of malaria contributes to a vicious cycle of increasing ill-health and deepening poverty. Much better direct evidence is needed about why and how misdiagnosis affects the poor and vulnerable.