The African medical research environment

There are undoubtedly successful models of international partnership between the global North and South. These have delivered clinically relevant research progress, most notably around communicable diseases (HIV-AIDS, tuberculosis, malaria, and other parasitic and gastrointestinal communicable diseases).3 4 There has been no shortage of recognition of the widespread challenges facing African-led research and health researchers.5 Such is the time frame of progress that the overview written by Whitworth et al in 2008 still has relevance, enumerating the major obstacles to change. A primary recognition by African governments that research funding can be of economic benefit to countries is likely to gain more traction than altruistic goals of improved patient outcomes through research-active clinicians. Nevertheless, fundamental acknowledgement of the principle of public good from research still needs wider political recognition and financial contributions, if practical progress is to be made.

Many of the international initiatives previously set up to move the African research agenda forward have resulted in successful pockets of research excellence, with and within African institutions, such as Medical Research Council The Gambia, Institut Pasteur in Dakar, Sénégal or KEMRI in Nairobi, Kenya. The danger is that without parallel support (including financial contributions) from national governments to drive nationally prioritised research through regional mechanisms, no sustainable support for quality local research can be assured (table 1).

The concept of local and regional networks is not new,6 but building a compelling rationale and implementation plan for such networks, needs to be. Change is driven through crisis. Post-COVID-19, several generational cohorts of clinicians will need to be supported to find motivation and fulfilment in careers which have been impacted by effects of the pandemic. At its most basic, this will require redress of COVID-19’s impact on the training and education of students and postgraduate clinicians. Training this workforce in research skills and supporting development of clinical leaders as clinician-scientists could be driven by early engagement of all doctors in facilitated mentored support, seizing the opportunity post-pandemic to combine need for clinical service expansion and the desire to develop regional research networks: in effect, providing a programme of integrated workforce development.

Clinicians and laboratory scientists could be supported to engage in research either through active academic or clinical service roles. Research-active clinicians and scientists would then create, de facto, responsive ‘functional research units’. This need for responsiveness cannot be overemphasised and there are obvious parallels here with the requisite global preparedness for the next pandemic.7 Successful delivery of this strategy will require national leadership which champions personal/professional development and considers ‘leadership through mentorship’ as valid. Additionally, there needs to be clear separation between development of an engaged clinician-researcher workforce and professional regulation (professional standards, research accreditation and practice) through line management, legal framework and oversight. Most significantly, re-engagement with doctors and researchers at all levels needs to demonstrate genuine care for and professional investment in a workforce which is under extreme pressure. By adopting developmental mentorship strategies, including peer-to-peer, or reverse mentorship partnerships, such a framework for professional and personal reinvestment can be created.

Engagement of all clinicians in elements of research activity, as well as the provision of defined career pathways for clinician-researchers, should embed research culture in clinical practice and improve patient mortality outcomes.8 Supported transition to ground-up models of local and regional research networks will require rapid development of an infrastructure for training support, without creating a burden of destructive bureaucracy.9 Use of e-portfolios to track educational milestones and identify future training needs would support the annual appraisal and regular revalidation of all research-active individuals. The model set out by the Royal College of Physicians (London) and taken up by the East, Central and Southern African College of Physicians is an exemplar in the clinical context which could be transferred to a research environment.

Local networks have potential to deliver much needed standardisation of research practice through skills teaching: study design, grant writing, good laboratory practice, new technologies and research governance. Laboratory accreditation and regulation would need oversight in parallel with people development. Much of this can be delivered online. The validation and assessment of people and processes will be vital for any transition to self-reliance and all of this will require a robust and ‘fit for purpose’ digital infrastructure.

The challenges of cyber-infrastructure and climate change

Adequate digital speed and bandwidth across the continent is fundamental to digital learning, research support and monitoring. While public opinion surveys have confirmed the acceptability of e-health strategies in several African countries, improving access, connectivity and uptake to a reliable digital infrastructure is a prerequisite, if research and clinical services are to be equitably accessed. The South African Research and Education Network acknowledges this principle, although the delivery of its goals remains patchy.10 If existing partners and sponsors in Africa are serious about transitioning to models in which local research networks lead high-quality African-centric research, collaborative funding strategies need to deliver a sustainable cyber-infrastructure for the continent.

The next most important consideration is that of global warming. Establishing a research infrastructure requires a sustainable ‘green‘ framework, as well as developing a medical research focus which mitigates the effects of climate change, including efforts to recycle waste and to reduce use of scare resources such as water. The global South will incur the health impacts of planetary warming disproportionately.11 12 These two strategic approaches—cyber and climate—will be transformative for Africa.

National–international coordination

Local autonomy and research innovation need to be balanced by independent national prioritisation and oversight. The auspices of the African Union could be used to develop and monitor national and regional research centres of excellence providing top-down oversight of governance and research ethics. Other bodies are well placed to encourage and monitor training programmes from the ground-up. The Africa Research Excellence Fund was created to develop the next generation of research leaders through education, mentorship, training and protected research fellowships to promote skills development, including, where necessary, time in the global North.13 Successful examples of existing South–South research collaborations are given in table 2.14 15

Summary

The importance of shared research learning and scientific rigour in publication has been highlighted during the recent pandemic. Acquisition and sharing of knowledge pertinent to local and national health priorities has been a way in which positive steps towards ‘normality’ have been taken. The opportunity to re-engage the clinical workforce in a reinvigorated research approach for the African continent, transitioning from partnership-centric to nationally prioritised agendas, is obvious. If delivered through local and regional networks, research can be newly supported and directed for the benefit of the workforce and for patient outcomes.

Well mentored and led, this will allow a transition from current pockets of research excellence to functional regional research units which penetrate the wider clinical community. At a national level, care will need to be taken to avoid inequity in South–South alliances, while ensuring that the global South continues as an active partner with the global North. This should involve African centres in multinational collaborative partnerships, which particularly emphasise sustainable and digital infrastructure growth.