Authors: Lauranne Botti, Carel Ijsselmuiden, Katharina Kuss, Eric Mwangi, Isabella E. Wagner
Site of publication: Springer Link
Type of publication: Report
Date of publication: February 8, 2019
In recent decades, governments have increased their collaborations on strategies for global health, and multilateral research programmes have involved partners from high-, middle- and low-income countries. Cooperation on health issues between Africa and Europe reveals the need to address the asymmetries that can affect both global health and health research. The outbreak of Ebola in West Africa in 2014 resulted in over 11,000 recorded deaths. With the disease also threatening Europe and rapidly becoming a global issue, it reminded us of the borderless vulnerability of our populations and of our responsibility to invest in global health and health research. Indeed, the Ebola epidemic did influence the international agenda for global health. The European Union Council, for example, stressed the importance of health security in the European Union (EU) and the need to strengthen preparedness research to address health security. Following a renewed interest in global health, the European Parliament also requested the evaluation of the impact of EU Framework Programmes (FP) funding of research into poverty-related and neglected diseases (PRND) on universal health coverage.
Policy Frameworks and Priorities
The main policy framework that currently guides research cooperation between Africa and Europe at regional level is the Joint Africa–EU Strateg y (JAES) adopted in 2007 by the member states of the African Union (AU) and the EU at the second Africa–EU Summit in Lisbon. Although science is no longer an explicit chapter of the current JAES action plan, the contribution of STI remains embedded in it. The JAES states unequivocally that health research should address global challenges and common concerns related to HIV/AIDS, malaria, tuberculosis (TB) and other pandemics (paragraph 8), while research on vaccines and medicines for major, neglected and water-borne diseases should be supported (paragraph 61) and national health systems strengthened through the development of integrated strategies (paragraph 61).
The JAES stands out as one of the few frameworks that explicitly outline joint priorities for bi-regional cooperation in health research, although many national and international policies, declarations, strategies and agreements do provide guidelines for policymakers to formulate research cooperation priorities. For example, the Sustainable Development Goals are one of the most influential international agreements that guide and feed into bi-regional cooperation strategy and priorities in health research .
These goals directly impacted international strategies and programmes such as the Special Programme for Research and Training in Tropical Diseases hosted at the World Health Organization (WHO), and have led to ambitious initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Global Vaccine Alliance.
A global analysis of the deaths by infectious diseases and non-communicable diseases (NCDs, such as cancer, diabetes or mental health) concludes that there was an increase in HIV/AIDS, malaria and TB deaths between 1990 and 2010. Mortality due to HIV/AIDS reached a peak of 1.7 million in 2006; malaria mortality rose to 1.17 million deaths in 2010 and TB killed 1.2 million people in 2010. In parallel, NCDs rose by just under 8 million between 1990 and 2010, explaining a third of overall mortality worldwide by 2010 (34.5 million).
Bi-regional health research collaboration matches joint priorities particularly on HIV, malaria and TB. Many African countries have built substantial research capacities on these three major diseases. In 2013 the World Health Assembly adopted a resolution that calls for increased investments to improve the health and the social well-being of affected populations.
Africa–EU health research cooperation does address global challenges and common concerns in terms of malaria, TB and, more recently, in terms of NDs. Nevertheless, health research priorities, as mentioned in the JAES, need to be updated to reflect the changing needs and evolving burden of diseases. In the next 10 to 20 years, estimates predict a dramatic increase in the prevalence of NCDs, which will account for nearly 40% of disease burden in Sub-Saharan Africa by 2030.
Although the burden of infectious diseases is similar to the socioeconomic impact of those pandemics, many African countries have built substantial research on research in HIV/AIDS, malaria and TB. Over the long term, research dedicated to NCDs could show positive results that would reduce costs for often lengthy and expensive treatment of cardiovascular diseases, cancers, diabetes or chronic lung diseases, and so could contribute to alleviating the socioeconomic burden of NCDs. The accessibility and affordability of healthcare services and products are also major challenges to be tackled, and so are preventive health services. Ideally, the contribution of research projects to health care, health system services and shaping national R&I systems in low- and middle-income countries should be made an explicit objective of all Africa–Europe cooperative research calls.
Working Towards More Balanced Bi-regional Collaboration
Investments in research on poverty-related diseases (PRDs) on the one hand, and the increasing burden of non-communicable disease (NCDs) on the other, remain disproportionate. The CAAST-Net Plus study of joint co-publications by authors affiliated to institutions in Europe and SSA shows an increase in publications on NCDs in the period 2004–2015 while the total volume of co-publications remains relatively low. A similar picture results from analysis of research projects funded by the different FPs within the health societal challenge area. Such observations call into question the balance (regarding the scientific and geographical scope, the funds, as well as the ownership and leadership over cooperative project) within bi-regional cooperation.
Africa–EU health research cooperation does address global challenges and common concerns in terms of malaria, TB and, more recently, in terms of NDs. Nevertheless, health research priorities, as mentioned in the JAES, need to be updated to reflect the changing needs and evolving burden of diseases. In the next 10 to 20 years, estimates predict a dramatic increase in the prevalence of NCDs, which will account for nearly 40% of disease burden in Sub-Saharan Africa by 2030
Nevertheless, EDCTP (European & Developing Countries Clinical Trials Partnership)
is a remarkable example of balanced cooperation in terms of governance and participation. Legally, EDCTP is an association established under Dutch law in the Netherlands, which currently counts 28 partner states as full and equal members—14 African and 14 European. Focusing on the development of indispensable research infrastructure, EDCTP has been contributing substantially to the Africa–Europe partnerships, because of its focus on the development of new and improved drugs, vaccines, microbicides and diagnostics against HIV/AIDS, TB, malaria and neglected infectious diseases. Among the results achieved by the programme are the Kesho Bora Study, which demonstrated a 43% reduction in HIV infections in infants and more than 50% reduction of mother to child transmission during breastfeeding and influenced WHO 2010 guidelines on prevention of mother-to-child transmission of HIV, and the Malaria Vectored Vaccine Consortium which found that the volunteers receiving the T cell-inducing vaccine had a 67% reduction in the risk of malaria infection during eight weeks of follow-up.
The EDCTP programme, with its comparatively large funding for African institutions, has also become a success story from the perspective of balanced funding. The first phase of the EDCTP lasted from 2003 to 2013 and in this programme, 70% of funding went to African institutions and 62% of all projects were led by African researchers. A significant portion of the funding was aimed at capacity building and support for the ethical and regulatory environment for clinical research in Africa that includes, for example, the African Vaccine Regulatory Forum (the network of ethics committees), National Ethics Committees (NECs), the Mapping of Research Ethics Committees in Africa and the Pan-African Clinical Trials Registry (PACTR).
Depending on the nature, risks and burdens of the collaborative research, mutual negotiations should culminate in agreements or memoranda of understanding (MoU) aimed at providing a fair level of benefits to the host country, research institutions and communities. All clinical trials should be performed in compliance with local ethical and regulatory requirements. Nevertheless, research ethics committees cannot be made solely responsible for preventing unethical or exploitative conduct. Lack of staff, time and resources for follow-up restrain the agency of such research ethics committees. Access to adequate research infrastructure and equipment is critical for the quality of research too—in 2016, South Africa launched the Research Infrastructure Roadmap to improve researcher’s access to world-class scientific knowledge and facilitate long-term planning to establish competitive national system of innovation.
Assessing the extent to which research outputs are translated through innovation into goods and services or new and revised policies and processes is a difficult task given the lack of validated measuring tools. Linking social, health and economic impacts to health research, investments and collaboration is all the more necessary given the considerable challenges facing health research, such as the discovery of new vaccines for HIV/AIDS, malaria and TB, or the achievement of a UHC. Although results in these fields remain fragmented, they do gradually improve health systems and healthcare services in Africa and Europe. Nevertheless, recent research development and health research programmes tend to signal positive trends regarding the measurement of progress and impacts made.
Many clinical trials address improvements and adaptations of existing treatments for specific, vulnerable target groups, such as newborns and infants, pregnant women and HIV-infected individuals, who benefit not only from the medicine, vaccine or technology being tested but also from better and more accessible preventive and curative health care. Similarly, research on neglected tropical diseases, which mainly affect populations living without adequate sanitation and in close contact with infectious vectors and livestock, is increasingly showing positive outputs. Under FP6 and FP7, several projects were funded on leishmaniasis, trypanosomiasis, schistosomiasis, Buruli ulcer, filariasis and sleeping sickness. Results of these projects contributed to integrated diagnostic-treatment platforms and to several publications, constituting the evidence base for WHO policy revisions. This in turn contributed to the extended scope of the EDCTP programme and is also in line with the JAES.
The EDCTP programme, with its comparatively large funding for African institutions, has also become a success story from the perspective of balanced funding. The first phase of the EDCTP lasted from 2003 to 2013 and in this programme, 70% of funding went to African institutions and 62% of all projects were led by African researchers. A significant portion of the funding was aimed at capacity building and support for the ethical and regulatory environment for clinical research in Africa that includes, for example, the African Vaccine Regulatory Forum (the network of ethics committees), National Ethics Committees (NECs), the Mapping of Research Ethics Committees in Africa and the Pan-African Clinical Trials Registry (PACTR)
Long-lasting partnerships between African and European member states and research institutions seem to be a key factor for successful collaboration and continued access to funding from national and multinational programmes. All three institutions have this in common: over 20 years of continuing and intense cooperation with European countries and research institutions—Wellcome Trust and Oxford University with KEMRI, University of Munich with Mbeya Medical Research Centre and the University of Barcelona with Manhiça Health Research Centre in Mozambique. In addition to increased institutional capacities for basic research and for conducting clinical trials, African countries also benefit from the establishment of the PACTR, increased ethics capacity through the RHInno Ethics platform and through the establishment of NECs in four countries—all through EDCTP funding.
The Unique Potential of the RFI to Improve Research Collaborations Between Africa and Europe?
Research partnerships (or formalised research collaborations) do not apply only to high-income countries: they are not merely a luxury afforded by those with the financial means to pay for them. Research partnerships are an essential component of sustainable development of low- and middle-income countries as well. Partnerships are recognised as key to sustainable development in general (through the Sustainable Development Goal 17), while research collaborations and research networks are becoming the essential components of a strategy to deal with global or local challenges and to build national research system capacities
However, the potential of research collaboration, partnerships and networks to build sustainable national research systems (especially in low-income countries) can only be realised if such partnerships are “fair”. If all partners can derive benefits commensurate with their contributions—or perhaps even more than their contributions in the case of support for research systems in low-income countries—and if these benefits concern all aspects of the “research enterprise” and not simply sharing in a publication, then the full potential of research collaboration could be fully realised. Partners and countries (especially, again, low-income countries) should not only benefit from access to a final product or technology but also share in research system capacity strengthening and spin-off economic activities. The research enterprise is so much larger than publications: it includes the creation of jobs, increasing social capital, increasing reliability of local finance and communication facilities, sharing in intellectual property rights and the benefits deriving from these and much more.
Research partnerships (or formalised research collaborations) do not apply only to high-income countries: they are not merely a luxury afforded by those with the financial means to pay for them. Research partnerships are an essential component of sustainable development of low- and middle-income countries as well
Most, if not all, stakeholders in research are well aware of this—and many have tried and continue trying to improve the way partnerships are created and maintained, and how benefits (and costs) are shared more equitably. This applies to research collaboration between high-income countries as much as to collaborations between high- and low-income countries.
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