Lessons Learned. from Danida supported Research for Health in Development. 8 Case Stories

Transcription

1 Lessons Learned from Danida supported Research for Health in Development 8 Case Stories

2 Background Research and knowledge management are instrumental in our efforts to better understand the state of health and health systems, and the causes of ill-health. Research generates information and evidence, and knowledge management ensures that the right information is available at the right time for the right purpose and for the right people. Effective communication of research and research results play an important role in ensuring that evidence is made available for policy-makers and can contribute to improving health and well-being. Danida has been funding research activities since the 1970s. The overall objective of the Danida-supported research activities for health is to support the goal of Danish development assistance, namely poverty reduction. To achieve this, it is important that the evidence generated by research is put into practice and becomes an integrated part of development assistance making it more effective and efficient. Growing demands for increased aid effectiveness has led to new policy frameworks such as the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. Such initiatives have also had an impact on Danish research funding. The result being that research is increasingly becoming demand driven with a focus on capacity and ownership of partner countries and that support is given to larger, more strategic research projects. As a consequence of this paradigm shift in health research there is a need to rethink the role and function of research in the health sector. This note aims to facilitate the current discussion and evaluation of the role of health research by documenting some important lessons from 8 existing projects. These 8 case stories sit at the intersection of health research and development policy and can therefore provide valuable insights and inspiration. The case stories chosen represent a myriad of conditions, in terms of thematic scope, scale and approach. Of the many projects Danida has and is funding in this sector, these 8 projects were identified as providing valuable examples by consulting with over 60 researchers working both in the North and the South. Specifically, these were picked due to their relevance for Danish development assistance, the fact that they address important local health issues, their usefulness in terms of operational recommendations for the host country and the ability to influence the global health agenda and research quality. They provide us with interesting experience of some of the key ingredients of what makes a research project work. This note concludes by identifying the generic elements behind these stories. The note is intended to stimulate interest and discussion amongst those with an active interest in health research in the context of international development policy, for example Danida health advisers, embassy staff, partner country health planners and researchers working with Danidasupported health and research programmes. 1

3 Case stories 1. Bandim Health Project In the 1970s, a Guinean mother could expect that half of her children died before the age of five. Although child mortality remains a serious problem, rates have been reduced from 50% to 15% over the past 3 decades, primarily due to the successful implementation of preventive health measures like vaccines and micronutrient supplementations. The Bandim Health Project is one initiative that has made a significant contribution to reducing child mortality rates in Guinea-Bissau. The Bandim Health Project was launched in 1978 as a short-term project focusing on child mortality. The Project soon demonstrated that high child mortality rates were largely due to confined living spaces, resulting in intensive exposure to the infections that caused increased morbidity and higher mortality. This finding contradicted the then generally-held belief, which was that a child would develop the same severity of disease, whether becoming infected with one or 1,000 viral particles. Some of the unique attributes of the Bandim Health Project are the length of engagement, approach to research for health and capacity development at different levels of the government of Guinea-Bissau. For example, data has systematically been collected in the same geographical area for over 30 years, including during the civil war ( ). In addition to monitoring the local effects of global health recommendations and providing evidence for improved actions grounded in the local context, the Project gained experience in assessing the impact of health interventions in crisis during the civil war. Although the published results from the Bandim Health Project have often been challenged, the Project has largely succeeded in influencing policy based on real evidence from the ground. Notable results achieved by the researchers of the Bandim Health Project include: Ensuring that WHO withdrew the measles vaccine (Edmonston Zagreb), introduced in 1989 as it was associated with a two-fold higher mortality rate in girls. Had the vaccine not been withdrawn it would have led to an estimated ½ million additional female deaths in Africa alone. Challenging the WHO recommendation to give Diphtheria Tetanus Pertussis (DTP) vaccine together with vitamin A. Researchers from Bandim found that this practice drastically increases mortality rates of girl children. A conservative estimate suggests that around 100,000 girl children would be lost per year in Africa alone if this practice had been continued. Showing that the effects of Bacillus Calmette-Guerin (BCG) vaccine against TB had a positive effect on survival of the fragile low-birthweight babies. If this vaccine is given at birth rather than at the recommended age of six weeks, mortality in the first month of life can be reduced by 45%. Comments from a researcher: Taking a critical stance is a good Danish value, which we wish to be an integrated part of the training of young researchers from the South. The Bandim Health Project has been given some major grants by Danida which has made a huge difference, and enabled the project to develop and keep a committed core staff. We want to train researchers in partner countries to be more critical towards initiatives from donor countries, asking, for instance, if planned interventions or studies proposed by Northern partners will actually have the desired effect? It is important to take good care of people who have this kind of engagement and commitment. An ongoing financial support from donors, like Danida, fuels the fire. 2

4 Showing and raising awareness about the most effective age at which to inoculate against measles. Researchers at the Project published the findings that measles vaccination given at the age of 4½ as well as at the recommended age of 9 months could reduce mortality up to 3 years of age by 50%. Showing and raising awareness about the correlation between the mortality of mothers in cases where they delivered children with low birth weight. Researchers found that mothers were 13 times more likely to die in the first three months after delivery if their children have low birth weight. Fifty percent of the children who lost their mothers would also die. Showing and raising awareness about the continued effectiveness of Chloroquine. The Project researchers found that a higher dose of the old and cheap anti-malarial drug Chloroquine is still effective, despite reported resistance, and despite the fact that national and global institutions favor the more expensive anti-malaria drug Coartem (arthemeter-lumefantrine). Showing and raising awareness about the benefits of adding lime juice to food and drinks to reduce the incidence of cholera. The current focus of the Project is on advocacy in order to ensure that the research findings are applied in such a way as to have a positive and tangible impact on local, national and global health policy. Capacity development: The Bandim Health Project helped to develop local, individual and institutional capacity, both through training and partnerships. One success story is the establishment of the National Institute of Public Health. The Project s current Director of Research, Dr. Amabelia Rodrigues was appointed to lead this new institute and she is the country s first women to receive a PhD degree, trained by the Bandim Health Project. The Project has also gained a noteworthy academic track record, having resulted in over 500 scientific papers being published and initiating and inspiring scientific debates. It has supported 35 PhD students in obtaining their doctoral degrees. Additionally, 12 Guineans have received a Master Degree from an overseas university as a result of the Project, and some 30 Scandinavian students have been associated with the Project to date. The Project is a founding member of the INDEPTH NETWORK, a research collaboration between 37 Health and Demographic Surveillance System and Sites in Africa and Asia. The Project is also an active member of the Enreca Health network 1. Collaborating institutions Denmark: The Danish State Serum Institute Guinea-Bissau: The National Institute of Health. Comments from a researcher: The knowledge sharing between North and South is a win-win situation for all parties involved. To further stimulate this, it would be good to have a forum or network of PhD students from health research development projects from different countries where we could discuss our research. Sidu Biai, PhD student, WHO and Bandim Health Project, Guinea- Bissau The Bandim Health Project maintains an extensive network of research collaborators including the Medical Research Centre, The Gambia; Leiden University Medical Centre, The Netherlands; and the Universities of Århus, Odense, Copenhagen, in Denmark, as well as the University of Lund in Sweden. For more information, see 1 ENRECA programmes, which are now phased, out pursued the goal of enhancing local research capacity and partnership through cooperation on equal terms between Southern and Northern partners. 3

5 2. Health System Reform and Ethics: Private Practitioners in Poor Urban Neighbourhoods in India, Indonesia and Thailand The current global trend to promote public-private partnerships was challenged by the Health System Reform and Ethics Project. Based on case studies from India, Indonesia and Thailand, the Project concludes that access to quality health services for the poor is best achieved through a public health system. The Project contributed also to strengthening of local research capacity and succeeded in engaging policy-makers in a dialogue and influencing policies. Some policy-makers claim that public-private partnerships within the health sector lead to higher standards of services. However, these assumptions are often not based on evidence. The Health System Reform and Ethics research Project was designed to fill this gap. The aim was to identify viable strategies for strengthening ethical practices in the private health sector in urban poor neighbourhoods in India, Indonesia and Thailand. At the same time, the Project explored whether consulting private practitioners instead of using public systems will result in health improvement for poor urban dwellers of these 3 countries. The three case studies provided different contexts, different experiences and findings. However, the general findings give reason to be very cautious when implementing a public-private partnership in health programmes and emphasize that assessment of the local context is of utmost importance. During the project period ( ), a military coup took place in Thailand and an earthquake happened near the project site in Jogjakarta, Indonesia, underlining that the context can also unexpectedly change. This requires flexibility and responsiveness from a project. The Health System Reform and Ethics Project was expanded to include a disaster preparedness and management component to respond to the needs in Jogjakarta. The conclusion of the four-year study was that quality health services for the poor are best achieved through public health systems. However, such a system needs to find an appropriate balance between being of high enough quality to be accepted by the middle class and being cheap enough to be accessible for the poor. Managing this balance is an ongoing challenge but such balance was achieved in Thailand. However recently, the universal health insurance scheme here has been weakened due to the fact that international health tourism boosts the private sector but drain medical specialists from the public sector. In addition, the changing social patterns have decreased access to health care for some groups, such as internal migrants and the elderly who are poor. Comments from a researcher: It is important to link up with the right local South partners. A smaller pilot project is highly recommended in order to test collaboration with new partners as well as to ensure that a project is relevant to the local context. Danida s guidance note on health and development is a positive initiative to align our effort in making a difference in the field of research for health in developing countries, when and if fully adopted - also in-house in Danida As a follow-up of the Project, the findings of the case studies were discussed with the relevant governments and the WHO country and regional offices at an international research-into-policy workshop, held in The outcome of the workshop was a set of jointly developed recommendations for actions. In May 2008, a workshop took place in India to discuss how these recommendations could inform the implementation of the new Indian health reform, and especially the National Urban Health Mission. One of the strengths of the Project was that it provided the needed information at Jens Seeberg, mag.art et PhD, Associate Professor, Head of Section for Anthropology and Ethnography, 4

6 the right time. It emerged as an outcome of a Danida-funded workshop in 2000, which was attended by senior researchers from India, Indonesia, Thailand, Nepal, Norway, WHO and Denmark. Capacity development Capacity development of local partners was an integrated part of the project. The Project strengthened the scientific research base of participating institutions, generating a number of scientific articles, whilst providing systematic training of staff in research methodology. The Project also facilitated the development of a new South-South partnership. This partnership was started as a partnership between universities from Indonesia and Thailand, but it has since then expanded to include Malaysia. This partnership has now developed into a PhD-network. Collaborating institutions Denmark: Department of Anthropology and Ethnography, Aarhus University Indonesia: Centre for Bioethics and Medical Humanities, Faculty of Medicine, Gadjah Mada University; Centre for Health Policy and Management, Faculty of Medicine, Gadjah Mada University. India: Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi; International Council for Iodine Deficiency Disorders, New Delhi. Thailand: Faculty of Medicine, Naresuan University, Muang District, Phitsanulok; Sirindhorn Collage of Public Health, Wang- Thong District, Phitsanulok. Project website: 5

7 3. The Joint Malaria Programme and the Danish Malaria-related Research Malaria constitutes a major challenge to the health and well-being of people in Sub-Saharan Africa. In Tanzania, the Government has ranked malaria research among the top priorities in their programme for Essential National Health Research. The Joint Malaria Programme (JMP) has contributed with new knowledge and improved research capacity. In addition, it has played an important role as a coordinator and mediator in efforts to map and potentially even curb malaria in parts of Tanzania. Every year, 1-3 million people die of malaria, the majority of which are small children in sub-saharan Africa. Deaths are often caused by severe malaria, e.g. cerebral malaria, and malaria in pregnancy complicated by severe anaemia. Malaria and poverty typically go hand-in-hand, not only does it affect the most vulnerable, but it also affects people s ability to earn a living. It is a disease that has a profound effect on society and in itself constitutes an impediment to development. The JMP was established in 2000 to reduce the burden of malaria, by contributing to the provision of better health services through generating knowledge and strengthening research capacity. The Project is a collaboration between various well-respected institutions, including two Tanzanian and five European institutes (see below). Comments from a researcher: The Project builds upon an historic collaboration between the University of Copenhagen and the Tanzanian National Institute for Medical Research, initiated in the early 1990s with the help of ENRECA grants. The Project s history has naturally placed the Danish researchers in the role of a mediator, with the task of ensuring good communication and relations between the different project partners. There are a number of different research programmes under the Project. These involve a wide variety of external collaborators and have received funding from a variety of sources including The European Commission, The Bill and Melinda Gates Foundation and Danida. JMP coordinates the different inputs in a manner that preserves the academic freedom of the individual researchers and at the same time ensures that there is no unnecessary competition for resources, repetition of research work or interference between projects. The Project also has the responsibility to maintain the integrity of the overall programme of research and to liaise with the local communities and external partners. The coordinated approach has been much appreciated by the counterparties. This together with good relationship, mutual trust and respect between the Project and its partners has been the cornerstones of success. The Danish contribution to the Project has mainly been in individual and institutional capacity building. Focus has been on training of local researches to ensure continuity and to maintain local research capacity. This includes improvement of infrastructure and facilities for research, such as offices, data entry facilities, clinical research units, laboratories and rural dispensaries. For example, the three new complimentary laboratories in Moshi, Korogwe, and Tanga are equipped to perform tests which previously had to be sent to Europe. The objectives of a project can best be achieved by joint coordination between all partners during the proposal development and execution. Danida s ENRECA projects have a local identity at NIMR and we appreciate the opportunity given by our collaborators which has lead to new opportunities as our CVs have grown through joint publications of our research findings. Martha Moshi Lemnge, PhD, Chief Research Scientist Centre Director, Tanga Medical Research Centre (NIMR) Tanzania. 6

8 The project portfolio of JMP is large, diverse and evolving. There are a total of 14 sub-projects, ranging from a study to assess the health impact of malarial infection in pregnancy and after child birth on both the mother and her children to a project aiming at vaccinating women against malaria before they become pregnant, thereby possibly avoiding 300,000 deaths annually. Capacity development The annual JMP conference brings together JMP researchers, hospital superintendents, district medical officers, regional medical officers, and representatives from the National Malaria Programme to discuss scientific findings, future priorities, and policy implications, hence promoting the active use of research in future policies and programmes. Numerous papers have been published internationally and locally and equal numbers of Tanzanian, Danish and international PhD students have been awarded degrees. Also numerous master studies have been completed as part of the Tanzanian-Danish research link. Research meetings and courses have been held and technical staff training has been conducted. Collaborating institutions Institutions forming the Joint Malaria Programme Denmark: Centre for Medical Parasitology, University of Copenhagen, Copenhagen University Hospital, Danish State Serum Institute. Tanzania: Kilimanjaro Christian Medical College; National Institute for Medical Research. UK: London School of Hygiene and Tropical Medicine. Netherlands: Radboud University. Other collaborating institutions Faculté des Sciences de la Santé, Université d Abomey Calavi, Benin, Institut de Recherche pour le Développement, France; Stockholm University, Sweden; University of Melbourne, Australia, Seattle Biomedical Research Institute and KEMRI-Welcome Unit, Kilifi, Kenya. Comments from a researcher: Trust between North and South partners is essential for a project to succeed. Partners have different expertise and we should do what we are good at. E.g. the South partners define the research field and project study and we in the North find the funding and adjust the research to what is practicable. We cooperate also through the successful tandem model where a Tanzanian and a Danish PhD student collaborate closely, and through the sandwich model, which implies that a student is working in the South and the North by turns. JMP is a joint programme, managed by a Steering Committee and a Coordinating committee. The Tanzanian/Danish research link within JMP has since been supported though ENRECA and project grants. For more information, see: Ib Christian Bygbjerg, Professor, Department of International Health, Immunology and Microbiology, University of Copenhagen. 7

9 4. CESA - Cross-Disciplinary Risk Assessment of Taenia Solium Cysticercosis in Eastern and Southern Africa The CESA Project identified the pork tapeworm as an emerging public health and agricultural problem in Eastern and Southern Africa. The Project succeeded in raising awareness about the pork tapeworm throughout all levels of the health system. Providing the pig farmers with knowledge and tools to combat the parasite has made a great difference to the lives of poor smallholders, the majority of whom are women. The pork tapeworm, Taenia Solium, is widely spread in areas with poor sanitation and traditional animal husbandry practices, where pigs range freely. Thus, the disease is strongly associated with poverty and smallholder pig farming. Parasite s eggs are transmitted to pigs via human faeces and develop into larval cysts, cysticercosis. By eating infected pork, humans become infected with the tapeworm, which can affect the muscles, eyes and brain, causing epilepsy and in some instances, death. People who neither raise pigs nor consume pork are also at risk. They can be infected by, for example, eating contaminated food prepared by a tapeworm carrier. The Cross-Disciplinary Risk Assessment of Taenia Solium Cysticercosis in Eastern and Southern Africa (CESA) Project was initiated in 2006, with the goal of raising awareness about the tapeworm, and prevention measures to combat it. The Project builds upon the Livestock Helminths Research Project in Eastern and Southern Africa, an ENRECA-funded project that ran from The CESA Project aims to provide evidence on the presence, distribution and impacts of the pork tapeworm, as well as to identify and recommend intervention strategies for combating the disease in Tanzania and Mozambique. CESA s research activities have raised awareness about the extent of the pork tapeworm problem, including its economic impact. The Project has been used as a model for strengthening capacity and promoting inter-sectoral collaboration and cooperation by both the Tanzanian and Mozambiquan authorities. In addition, CESA has provided knowledge on appropriate and effective control mechanisms and helped to strengthen the veterinary public health infrastructure. The Project s innovative interdisciplinary approach, engaging with both the health and agricultural sectors and local partners, has been one of its main strengths. One of the important results of the Project is that it has inspired new supporting projects, such as Securing Rural Livelihoods through Improved Smallholder Pig Production in Mozambique and Tanzania, commencing in 2010, and the recently initiated Integrated Control of Neglected Zoonoses in Africa. Capacity Development The Project was conducted in close collaboration with the Cysticercosis Working Group for Eastern and Southern Africa, as part of their Regional Action Plan for combating cysticercosis. In addition, an inter-sectoral com- Comments from a researcher: All parties must be actively involved in the process of developing a project i.e. policymakers, users, researchers. This will create a joint ownership and may lead to transformation of research findings into policy and practice. Niels Ørnbjerg, Professor, DSc, Centre Director, DBL- Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen. 8

10 munication and collaboration platform has been created to exchange experiences and share knowledge in Eastern and Southern Africa. Under CESA, a Tanzanian postdoctoral researcher, 3 PhD students (2 in Mozambique, 1 in Tanzania) and 8 Masters Students (5 in Tanzania and 3 in Mozambique) have graduated. Comments from a researcher: The Danish partners serve as a WHO/FAO Collaborating Centre for Parasitic Zoonoses as well as a WHO Collaborating Centre for Integrated Control of Helminth Infections. Also, CESA researchers from Tanzania have served as advisors for a FAO-funded project on situation analysis of cysticercosis in Uganda from Likewise, the CESA researchers in Mozambique have become involved in a cysticercosis-mapping project funded by Portugal. Collaborating institutions Denmark: Project institutions include Danish Centre for Experimental Parasitology* (coordinating institute), and DBL-Centre for Health Research and Development*, Department of Veterinary Disease Biology, Faculty of Life Sciences, University of Copenhagen; Tanzania: Sokoine University of Agriculture (Faculties of Agriculture and Veterinary Medicine), Morogoro, Muhimbili University of Health and Allied Sciences, Dar es Salaam, National Institute of Medical Research, Dar es Salaam, University of Dar es Salaam; Mozambique: Eduardo Mondlane University (Faculties of Health and Veterinary Medicine), Maputo. Co-partner institutions: Institute of African Studies, University of Nairobi; International Livestock Research Institute, Kenya: Medical Faculty, University of Pretoria, South Africa; and School of Veterinary Medicine, University of Zambia, Zambia The pork tapeworm project had a holistic approach recognising that this public health problem had both a health and an agricultural impact. The value of interdisciplinary projects should be more recognised by donors. Arve Lee Willingham, Associate Professor in the Danish Centre for Experimental Parasitology, Department of Veterinary Pathobiology, Life Sciences, University of Copenhagen. *The two centres are recently merged to form a Section for Parasitology, Health and Development. 9

11 5. Linking Human Nutrition and Fisheries Research in Bangladesh The research collaboration between the Department of Human Nutrition of Copenhagen University and the Bangladesh Agricultural University linking human nutrition to fisheries research has led to recommendations on how to preserve the nutritional value from fish. This has had a significant impact on the health and economy of the poor in Bangladesh and India. Fish and fisheries are essentials for food and livelihoods in rural Bangladesh. Maach Bhhat Banaye Bangali means fish and rice make a Bengali, an old saying illustrating the importance of fish in the Bangladeshi food culture. However, changing agricultural patterns and increasing population pressure have resulted in declining number of fish being captured, and now aquaculture is contributing to half of the fish consumed in Bangladesh. Since the mid-1980s, Danida and other donors have supported aquaculture extension projects in Bangladesh with the aim of improving food security through education on carp aquaculture in small ponds belonging to poor farmers. A research group based at the Department of Human Nutrition (IHE) has been coordinating a number of relevant research and research capacity building projects since the mid-1990s. Specifically, these have examined the nutritional contribution of fish in local diets in the context of declining fish captures. IHE has developed a production model which combines the need for local production of fish for sale and for consumption. IHE has worked in collaboration with fisheries researchers at Bangladesh Agricultural University (BAU) in Mymensingh, thereby establishing an innovative and successful link between human nutrition and fisheries research. Quote: Research projects should be develop in parallel tracks of "hard core" science, capacity building and interaction with stakeholders. The collaboration must be based on trustful personal contacts between the South and North partners which is a cornerstone for success in all aspects of development research. Bangladesh is home to over 250 freshwater fish species, most of them small indigenous fish species (SIS). Rural families typically rely on fish as the primary source of protein, and fish consumption mirrors the local freshwater fish diversity. In a number of collaborative research and PhD projects, the Project has linked human nutrition with fisheries research to give recommendations on how to preserve the nutritional value from fish, rich in micronutrients such as Vitamin A, in diets when a diverse fish fauna is substituted by a few cultured fish species with lower nutrient contents, typically those which are already deficient in the diet. IHE and their counterparties found that the mola species had the highest vitamin A content - twenty fold that of other SIS living in the same environment, and exceptionally high iron and zinc contents. Like other SIS, mola is eaten with its bones and is therefore also an important source of calcium. The BAU team found that mola had a feeding and reproduction biology which made it very suitable to combine with carp in fish ponds, and that with optimal pond management the total fish production was increased when mola was added to the polyculture. The added benefit is that the Mola s reproductive cycle means that it can be partially harvested throughout the production season, while the carp are harvested at the end of the season, mainly for sale. The carp-mola combination improved the economies of households relying on aquaculture as the mola were an additional revenue stream and / or a direct source of food for the households. Mola aquaculture is also compatible with farming of prawns, which are of high commercial value. The research has been disseminated through publications and interactions with stakeholders. The carp-mola combination production model has been piloted since 2004, and is now included in the government s strategy for dissemination of improved aquaculture practices. In order to increase awareness about the model, the Department of Fisheries has requested BAU to issue production manuals, to implement a pilot-scale dissemination project, and to contribute to the training of extension staff and interested NGOs in the carp-mola production model. The production model has also been transferred to West Bengal, India 10

12 through a pilot project, and has been taken up by a local NGO there. As an indicator of the Project s success, the Indian Government s interest in the production of nutrient-dense indigenous fish has increased, leading to a recent declaration by the Inland Fisheries Society of India based in Barrackpore, India inviting Indian fisheries-related research and extension institutes to develop and implement production strategies for indigenous nutrient-dense fish including mola. IHE initiated a similar link between human nutrition and fisheries research in Cambodia in Cambodia has an even higher diversity of local fish fauna than Bangladesh. As a result of research by and support to the Institute of Fisheries Post-Harvest Technologies and Quality Control under the Ministry of Agriculture, Forestry and Fisheries, general attention has been drawn to the nutritional contribution of freshwater fish species. On-going research under the WinFood Project ( supported by Danida is investigating the potential of improving child nutrition by using mola and other nutrient dense indigenous foods to improve the nutritional quality of complementary food for young children (age 6-24 months). Capacity building: The IHE-BAU collaborative research between human nutrition and fisheries has been complemented by support to research capacity building through training activities and joint supervision of students. One of the initial challenges in establishing the link between the human nutritionists from IHE and the fisheries researchers at BAU was to communicate the perception that small fish could be potentially a valuable contribution in aquaculture rather than being an undesired weed hampering carp production. Research on small indigenous fish species has been the basis for three PhD. and 16 M.Sc. theses from BAU, and two PhD and eight MSc and BSc theses from IHE. Collaborating Institutions: Denmark: Institute for Human Nutrition, Life Sciences, University of Copenhagen. Institute of Food Safety and Nutrition, Danish Veterinary and Food Administration, Mørkhøj; Danish Institute of Agricultural Sciences, Foulum. Bangladesh: Faculty of Fisheries, Bangladesh Agricultural University (BAU), Mymensingh; Mymensingh Aquaculture Extension Project (MAEP), Mymensingh; International Centre for Diarrhoeal Disease Research, ICCDR,B, Dhaka; Institute of Nutrition and Food Science, University of Dhaka. Cambodia: Institute of Fisheries Post-Harvest Technologies and Quality Control, Ministry of Agriculture, Forestry and Fisheries, Phnom Penh and World Food Program. 11

13 6. TORCH - Tororo Community Health Community and Health System: Interaction and Change in Uganda In the early 1990 s, Uganda began decentralising the public administration and the service sectors, including the health sector. District Health Teams faced difficulties in carrying out the decentralisation as they often lacked people s respect and trust. The TORCH Project succeeded in strengthening the relationship between the users and providers of health care services in Uganda s Tororo District. The decentralisation process in Uganda gave District Health Teams the responsibility for planning and ensuring good quality health care in all facilities and within their catchment area. However, locals were often not willing to use government facilities claiming that the quality of health care was not appropriate. Thus, the District Health Teams faced two major challenges: first, to strengthen people s confidence in and utilisation of government health facilities, and second, to gather and use information about the population they served in order to effectively plan and improve local health services. The health care research project, Tororo Community Health - Community and Health System: Interaction and Change in Uganda (TORCH) helped to meet these challenges. The TORCH researchers provided new evidence for training and support to the District Health Teams and conducted studies of the health systems, involving the communities themselves. The TORCH Project contributed to better health by building trust, confidence and knowledge among health workers and local communities over a period of 15 years ( ). Comments from a researcher: The Project adopted a multi-disciplinary approach, and included analyses of health systems, health economics, medical anthropology, epidemiology, and data collection methods, with a primary focus on women and children. The broad-based approach, long-term engagement, capacity development, good communication and good relations with both the communities and the staff in the health facilities provided the foundation for the Project s success and impact. TORCH researchers sat with the District Health Team at their regular planning meetings and in later evaluations and follow-up processes. They provided training in the information technology necessary to handle data from the health units and developed a training package to strengthen the Health Management Information System, which was later adopted by other districts. The research teams went out to communities and listened to people s concerns, experiences, needs and expectations. This method of working with district planners, health staff and communities has also continued after the TORCH Project ended. A long timeframe and a generational perspective are necessary. Finding the right local researchers is crucial as well as strong administration in both South and North. It can be difficult to find the time and resources for knowledge sharing. To this end, the ENRECA Health Network is very valuable and it is to the credit of Danida that they continue to support the Network. Susan Whyte, Professor, Institute Department of Anthropology, University of Copenhagen. 12

14 The most important outcome of the Project has been the individual and institutional capacity developed at the local and central level, especially the Child Health and Development Centre at Makerere University. The Centre is now in a much stronger position to attract national and international funding and, most importantly, the Centre s staff continues to work with other districts throughout the country and to train the next generation of health care and social science professionals in community-oriented approaches. During the time of the Project, staff at the local health centres became less isolated, partly because of overall general development that contributed to better infrastructure such as roads and public transportation and partly because of the introduction of mobile phones, which in many ways revolutionised communication. Capacity development The TORCH Project has produced 65 scientific papers and four books. It has supported six Ugandan PhD degrees and 43 Ugandan Diploma and Master Degrees. Four Danish PhD and 14 Master students have been affiliated with the Project. The Project has inspired establishment of several active networks, such as a Working Group on Social and Political Aspects of HIV/AIDS in Uganda, which is based at the Child Health Development Centre, and a network of Danish anthropologists conducting research in East Africa. In addition, several TORCH researchers are key actors in the Network on Religion and HIV/AIDS in Africa, based at the Centre of African Studies, Leyden University. Collaborating institutions Denmark: Department of Anthropology, Copenhagen University, the Department of Epidemiology and Social Medicine, Aarhus University and the Department of Anthropology and Ethnography, Aarhus University. Uganda: Child Health and Development Centre, Makerere University The TORCH Project was an Enreca Health Project. For more information see Comments from a researcher: I think it is very important to have a participatory collaboration i.e. bottom-up approach where the Southerners participate from the outset in developing the objectives of the project so that is does not remain a foreign project. Some projects come with already developed objectives and intentions, which becomes hard to implement and when the project closes, it just disappears. Not so with the Danida funded health research project TORCH. TORCH has left a landmark at the Child Health Development Centre, Uganda. Jenipher Twebaze, a Ugandan PhD student at the University of Copenhagen 13

15 7. Oral Health Systems Research and Development of Oral Health Promotion in Madagascar A third of all African people suffer from pain due to oral disease. The key to improving oral health and quality of life lies in ensuring that effective oral health promotion and oral disease prevention are incorporated into public health programmes. Building on the existing capacity in Madagascar, the project Oral health systems research, development and implementation of oral health promotion has established the first Public Health Research Department, a PhD school, and a Master of Public Health Programme in the University of Majunga, Madagascar. Poor oral health is a growing public health problem in Africa. The occurrence of tooth loss, dental caries and gum diseases has increased markedly due to the introduction of sweets and soft drinks, the lack of exposure to fluoride for prevention of dental caries, and a poor tradition of oral hygiene. Other increasing problems are oral cancer caused by a heavy consumption of tobacco, particularly among the elderly, and oral health problems caused by the HIV/ AIDS pandemic. Some of the reasons for this are the insufficient health systems infrastructure and limited number of dentists trained in public health. Comments from a researcher: Poor oral health has an overall impact on people s lives and well being. Missing, discoloured, or damaged teeth affects one s ability and wish to communicate and smile, in addition, poor dentition reduces capacity of biting and chewing food. Oral health problems are also socially stigmatising and restrict activities such as attending school and work. The Madagascar Oral Health Project has contributed to better health in the country by strengthening local research capacity in prevention of oral disease and by putting more focus on community oral health promotion. A comprehensive national epidemiological investigation of major oral disease conditions has been carried out as a platform for extensive community and health systems research projects. During its lifetime, the Project ( ) trained a whole generation of oral health researchers, empowering them to educate and train their peers in public health science. The Project also succeeded in putting prevention and promotion on the national health policy agenda. As a result, Madagascar has developed its national oral health promotion programme and a school health programme for children, teachers, community and family. The Project s success is based on the strengthened research capacity at the Faculty of Odonto-Stomatology, University of Majunga and successful training and skill transfer. To date, 16 workshops for Malagasy oral health researchers have been conducted with the active participation of local staff, community leaders, dentists, medical doctors, and school teachers, and the involvement of representatives from the Ministry of Health and the local WHO office. Through problem-based learning and applied research, participants have gained knowledge and skills to set up public health and school health programmes. Selected senior researchers were also trained at the School of Dentistry, University of Copenhagen, Denmark. The training focused on training of We have to actually solve health problems not merely describe them it is our duty to help the under-privileged. To succeed we need to stimulate enthusiasm and global awareness. And most importantly, as partners, we must create a personal commitment, this commitment also implies that partners from the South stay and work in home countries. The personal relations and commitments within the country will secure the project for the future. Poul Erik Petersen, Professor. Odontological Institute, Centre for Health and Society, University of Copenhagen; Chief, WHO Global 14

16 trainers in public health research and programme development and on translation of knowledge and skills, including in areas such as project supervision and management. The Project has provided the needed infrastructure for the development of a sustainable research environment. A physical research library as well as an access to relevant databases via the Panum Institute Library in Copenhagen, Denmark was established. In addition, the Faculty of Odonto-Stomatology received basic research equipment, such as computers, LCD projectors, printers and scanners to support effective teaching and training. Capacity development The Project has contributed to awarding 3 PhD degrees and 65 Master of Public Health degrees by Scientific articles have been produced and the first public health research journal, Journal de Santé Publique Madagascar has been published. The project s South-South dimension includes extension of the work in co-operation with the Faculty of Dentistry, University of Dar-es-Salaam, Tanzania. The Project was involved in developing teaching materials and training in public health, oral disease preventive and oral health promotion practises. Collaborating institutions Madagascar: Faculty of Odonto-Stomatology, University of Majunga. In Denmark: School of Dentistry, Faculty of Health Sciences, University of Copenhagen. Oral health systems research development and implementation of oral health promotion in Madagascar was an Enreca Health Project. For more information see 15

17 8. FIBOZOPA - Fish Borne Zoonotic Parasites in Vietnam In Vietnam, the parasites in fish that can be transmitted to humans are a severe public health problem. It is a threat to food security as well the fishery sector, impacting the local economy and export. The Fish-borne Zoonotic Parasites Project in Vietnam (FIBOZOPA) has built general awareness about fish borne zoonotic parasites as well as generated specialised knowledge about the infection, its prevention and control. The Project has also been successful in transferring evidence from research into policy. Practically, every individual in Vietnam is at risk of both carrying and transmitting the fish borne zoonotic parasite. People are usually infected when eating raw or inadequately cooked fish. The FIBOZOPA Project was established when North and South Vietnamese project partners from several universities and government institutions, together with the Danida Fishery Sector Programme Support, recognised the need to investigate the problem and build research capacity to prevent and control the parasites. FIBOZOPA has been a pioneer in providing documentation on the incidence and significance of fish borne zoonotic parasites. In 2002, it was estimated that 15-20% of the population living in the Red River Delta Provinces were infected. Since the start of the Project in 2004, the general awareness level of the food sellers, and the health risks of fish borne zoonotic parasites has been raised through health education and promotion. National television has on two occasions broadcasted documentaries about the parasites and the Project, and local newspapers have highlighted the findings and recommendations important for safe food handling and hygiene. They have also stressed the importance of improved aquaculture practices to control the parasite. Recommendations based on on-going field trials provide information to the institutions responsible for developing policies, guidelines as well as training manuals for control mechanism. The close cross-sectoral cooperation has been crucial for the successful building of research capacity and dissemination of the Project s research results. Comments from a researcher: Our experience shows that crosssector research has the biggest impact. We are also having success because the Vietnamese government early recognized a need to build research to manage the problems that these parasites cause to human health and the aquaculture industry. A way forward to make projects like FIBO- ZOPA sustainable is to establish large platforms both practically and logistically, building-up research capacity and thus making the projects sustainable. So in the future, these parasites should be seen as a larger effort to strengthen the capacity of Vietnam to deal with food safety and other biosecurity problems, e.g. caused by climate change, in the aquaculture sector. Another key element has been the successful transfer from a research project to a capacity building project. Especially, strengthening of the institutional research capacity has ensured the sustainability. The FIBOZOPA Project has not only had a positive impact on the livelihood of the individual fish farmer and on the aquaculture sector in Vietnam, it has continued to raise awareness of major risks in the country as well as internationally and thereby contributed to improving the health and the wealth of the Vietnamese people. Anders Dalsgaard, Professor, Faculty of Life Sciences and FIBO- 16

18 The findings of the FIBOZOPA Project have been disseminated to Cambodia and Laos and there is an ongoing dialogue with WHO and FAO to ensure that the experience from the Project will be used in other countries to control the parasites. The FIBOZOPA Project is in its second phase that will run until Core funding comes from Danida/Council for Development Research. The first phase ( ) was co-funded by the Danida-funded Fishery Sector Programme Support. Capacity development Twelve publications have been published in international peer reviewed journals and a number of papers has been accepted for publication (May 2009). Several abstracts and oral presentations have also been presented at national and regional research workshops and conferences. Thirteen Master of Science students from Vietnam (5 internationally and 8 nationally enrolled) have completed their studies within the FIBOZOPA Project. Six students from Vietnam and two from Denmark are currently engaged in PhD studies within the framework of the Project. In addition, the Project has produced training material, epidemiological and risk assessment studies, held training courses, and contributed to Master programmes at partner institutions and provided expertise and advice to FAO and WHO. Collaborating institutions Denmark: Department of Veterinary Disease Biology at Faculty of Life Sciences, University of Copenhagen Vietnam: Research Institute of Aquaculture No. 1, No. 2 and No. 3; National Agro-Forestry-Fisheries Quality Assurance Department; National Institute of Malariology, Parasitology and Entomology; Institute of Biotechnology; Institute of Ecology and Biological Resources, National Institute of Veterinary Research, and Fisheries Sector Programme Support. FIBOZOPA - Fish borne zoonotic parasites in Vietnam is an Enreca Health Project. For more information, see: fibozopa2.ria1.org and 17

19 Conclusion Developing People Developing Societies Danida s support to research for health aims at achieving coherence between development research, development assistance policy and practical cooperation as a means to improve health in low-income societies. The projects introduced in this report have been successful in communicating the research results and initiating the process of translating research-based evidence into policy and practice. All the projects have contributed to individual and institutional capacity development, underlining that national research capacity is vital to a nation and its development. Their driving force has been the commitment of partners in the South and the North. The chosen projects represent the diversity of research projects funded by Danida. Although their context, design and results differ from each other, it is possible to identify some core elements that have paved the way for these projects to run successfully and to reach their goals. These are: 1. Agree on a clear vision and strategy It is essential that the project has a clear vision and strategies developed in a participatory manner and aligned with the national health and development agenda. This has enabled the projects to gain a local identity and contributed to equal partnerships. While the vision in many instances has remained the same throughout the life of the projects, the strategies for achieving these visions have changed over time. Flexibility to accommodate the changing environment and the changing needs and demands of the involved partners has been key to success. 2. Invest in committed people and institutions Choosing the right partners, with the right skills, at the right time, together with a commitment to making a positive difference, has been one of the strong suits of the Danish funded ENRECA health research projects. Currently some key positions in the South are being filled with individuals educated through a Danish research project. They continue training and education of the next generation of professionals and have the capacity and possibilities to influence policy at local, national, and global level. Capacity building is now an integrated part of Danida s support to research for health. However, capacity building does not simply mean funding PhD students from the South but it implies that both the South and the North are engaged in a learning process. At the project level, it is essential to keep investing in institutions and continuous education of staff throughout the project period and create an enabling environment for this to happen. In the end, it is the commitment and dedication of each individual, and the relationships between them, that are the backbone of the projects. Issues such as the creation of ownership, mutual respect, trust, continuity and consistency, and fulfilment of realistic expectations are critical. Disputes and conflicts that are dealt with positively can potentially be an inspiration to change rather than obstacle for reaching the goals. 3. Employ good administrators Sound local administration in the South, together with professional administration in the North, often makes all the difference to the success of a project. Resources invested in the training of administrative staff can be of significant benefit to a project. Longterm planning and budgeting is a challenge and it is easy to underestimate resources and time, including finances. 4. Get to know the needs of the involved partners 18

20 Experience has shown that it is important to know the project s end users, their assumptions and expectations from the beginning of the project. It is also important to determine how to reach and listen to end users opinion leaders and service-providers as they can make a project succeed or fail. 5. Use your networks and connections Getting to know the country and involve partners prior to the start of the project is crucial for its success. In some cases, this has been achieved through initial pilot projects and workshops. In other cases, building on the existing relationships and the past experience has provided the needed knowledge and contacts to develop a sustainable project. Likewise, ensuring that all stakeholders are involved and continuously informed has proven to be beneficial. 6. Communicate strategically and effective Effective communication and strategic use of communication platforms have ensured that research results have had influence on policy-making. Such communication does not only involve scientific journal articles, newsletters, websites and local media but also interpersonal communication, advocacy and lobbying. Targeting the right people at a strategically appropriate time has made a difference. It is therefore important to prepare a communication strategy as part of the formulation of a research project. Such strategy could cover project communication with local and national government bodies, the media, and the research community. Knowledge management and sharing, including with fellow researchers in Denmark, creates synergy between current projects and new initiatives. 7. Ensure sustainability Several of Danida s health research projects have managed to forge lasting South-South networks. This is highly desirable and ensures the continuity of capacity development. Exchange of knowledge and experience between countries and institutions dealing with the same challenges will carry the agenda. Leaving behind a well-functioning management and logistics support system furthermore secures sustainability in the South. The continuous commitment of the Northern institutions to provide moral, administrative and financial support to the researchers and their projects contributes to the building of research capacity and initiation of new relevant projects. 8. Ensure an appropriate long-term timeframe Long-term commitment and funding are needed to ensure a project s success. Research takes time and a minimum project period is often four years. The first step of the research process will most likely involve exploratory work that is very time consuming but does not produce actual results. Building strong capacity in the research institutions and developing research capacity that will generate new knowledge and new professionals takes a long term commitment. 9. Collaborate across cultures, disciplines and institutions It is important to support global health research priority-setting in order to enhance the strengthening of essential national health research systems and the creation of effective research environments. In addition to diverse stakeholders, involving different academic fields or sectors add to the success of a project. Such broad-based, intersectoral interdisciplinary research programmes score best when measured in positive impact on government policies, sustainable and functioning partner institutions, trained women and men, published articles as well as in additional funds and support through separate funding proposals. 10. Vision for the future building on the lessons learned 19