Strengthening the core health research capacity of national health systems helps build country resilience to epidemics: a cross-sectional survey

Introduction

One of the lessons that should have been learned from the 2014–2015 Ebola epidemic in West Africa, the largest and longest Ebola outbreak in history, was “the need to be better prepared for the next epidemic”¹. “The next epidemic” is happening now in 2020 and is the COVID-19 pandemic. This pandemic, of unprecedented global scale and impact, has tested the preparedness and resilience of every country. Among the many factors that contribute to preparedness and resilience, the capacity to undertake health research is a vital component of the response to infectious disease outbreaks. As we have seen from the current pandemic, all countries are at risk of infectious disease outbreaks and need to strengthen their capacity for a timely and effective research response. Capacity to undertake research varies widely among countries, reflecting the extent of investment and efforts to build and retain that capacity, usually over a long period of time. TDR, The Special Programme for Research and Training hosted at the World Health Organization (WHO), has long supported Low- and Middle-Income Countries (LMICs) in strengthening research capacity, through the range of activities needed to develop the necessary institutional base, research infrastructure, training programmes, career development pathways, research portfolio, regulatory frameworks and networks.

Fortunately, most countries, most of the time, do not have such outbreaks, so the opportunities for developing capacity for research through “on the job” learning during an outbreak are limited. This has two key implications. Firstly, developing capacity for research on infectious diseases, including: outbreaks takes place to a large extent before an outbreak (or between outbreaks) and is blind to the next specific infectious agent. Secondly, developing adaptable capacity for research on other health problems contributes to generic research capacity, which becomes applicable during infectious disease outbreaks. TDR supports a number of long-term programmes to strengthen capacity for research on infectious diseases: the Postgraduate Training Scheme (PGTS) on implementation research, the Clinical Research and Development Fellowship (CRDF) scheme on clinical research, and the Structured Operational Research Training InitiaTive (SORT IT) on operational research, a partnership-based initiative led by TDR and implemented in collaboration with various partners (Box 1).

Stimulated by examples of people who trained on these programmes and used the skills they gained to contribute to the COVID-19 response, we were interested to assess this more systematically. We therefore assessed whether those trained were involved in the COVID-19 response and if so, in which area(s) of the emergency response they were applying their skills.

Methods

This was a cross-sectional survey that used three online questionnaires in English (one per programme, see Extended data³; pre-tested on four selected trainees, following which minor changes were made to improve clarity) to gather information from the individuals who had been trained through the three programmes.

From the records of each training programme, we identified individuals who had completed training during the relevant timespan of each programme: 1999–2018 for the CRDF scheme, 2015–2020 for the PGTS, and 2009–2019 for SORT-IT. For those people with available contact details, we sent online questionnaires by e-mail (in March 2020 for SORT-IT and in April 2020 for the CRDF and PGTS) asking if they were currently involved in the COVID-19 response. We asked about the nature of their involvement, and if they were applying their acquired skills in responding to various key areas for tackling the pandemic.

The survey data was exported to Microsoft Excel for data analysis.

As part of monitoring and evaluation of TDR supported training programmes, routine online surveys are conducted to gather information for improving the quality and performance of such trainings. Participation in this survey was voluntary and individual consent was obtained for use of anonymized data for reporting and dissemination, including through publications, via the use of a yes/no tick box question within the questionnaires. As this study was part of routine monitoring and evaluation of a training programme, and potential ethical concerns were addressed (responders were all adults, response was voluntary, data were anonymized, personal identifiers were removed and no sensitive personal questions were included that could risk psychological or social harm), this was thus considered a minimal risk study and specific ethical approval for sending questionnaires was not required.

Results

A total of 1143 individuals out of 1254 trained could be contacted; 699 responded to the survey. Table 1 shows the number of participants who reported involvement in the COVID-19 response, the number applying their acquired skills and the number of countries involved. Of 699 individuals who responded to the survey, 411 (59%; 152 female) reported involvement in the COVID-19 response, with 315 (77%) of the latter applying their acquired skills in 85 countries around the globe. With some overlap between programmes, 84% of those trained through CRDF were applying their skills in 27 countries, 91% of those trained through PGTS were applying their skills in 47 countries, and through SORT IT, this was 73% in 62 countries.

Table 2 shows that trainees are applying their skills in a range of critical areas of the COVID-19 pandemic response. In terms of research, 74% of those trained through the CRDF scheme, were involved in clinical research, most commonly as a clinical trial manager. For PGTS, 45% were involved in implementation, operational research or clinical research, while 26% of trainees from the SORT IT programme were involved in implementation and/or clinical research.

Discussion

The survey findings show that substantial numbers of health workers who were trained to improve their research capacity prior to the COVID-19 pandemic are currently involved in a wide range of emergency response activities.

This suggests that the respondents have used the specific skills they gained through trainings in combination with their abilities and knowledge as transferable competencies in responding to COVID-19 through a range of research and health system areas. This reinforces the value of TDR’s emphasis on developing core competencies (i.e. sets of skills combined with abilities and knowledge) through research training^4,5. It also underscores the longer-term gains of investing in research capacity building programmes.

Regarding contribution to the research response to COVID-19, the high involvement of those trained through the CRDF scheme in clinical research (74%) is a practical example of applying the recommendation in the 2018 World Bank report “Money and microbes: strengthening clinical research capacity to prevent epidemics” concerning leveraging capacity-building from the private sector⁶.

The significant involvement of trainees from PGTS and SORT IT in implementation and operational or clinical research shows that strengthening of core national research capacity before (or between) epidemics can make an important contribution to the timely mobilization of research resources during an epidemic.

The role played by TDR in supporting LMICs to strengthen capacity for clinical and implementation/operational research is in line with the WHO R&D blueprint¹ (the global strategy and preparedness plan that allows the rapid activation of research and development activities during epidemics). The development of the R&D blueprint in the aftermath of the 2014–2015 Ebola epidemic in West Africa was a recognition of the need to galvanize research, with the aim “to fast-track the availability of effective tests, vaccines and medicines that can be used to save lives and avert large scale crisis”¹. The focus on R&D needs to be complemented by efforts to promote implementation research, which helps to make sure that as new diagnostics, drugs and vaccines emerge from R&D pipelines they are evaluated in clinical trials and approved, they are made available to all who could benefit from them. Resources are needed to strengthen capacity for implementation/operational research, as well as for clinical research, in the LMICs where outbreaks are likely to occur⁷.

Regarding contribution to the broad health system response to COVID-19, the survey results show that more than seven-in-ten of all trained prior to the COVID-19 pandemic are currently involved in a range of health system areas. These areas include: critical preparedness and response, situation analysis/surveillance, infection control and clinical management, data generation, analysis and reporting, and mitigating the effect of COVID-19 on other diseases. The research training has thus had wider benefits going beyond research, to provide generic skills that can be applied to a range of areas needed to tackle the pandemic. Limitations of this study are that we had no comparison group and we are unable to know the influence of non-response and social desirability bias. The extent and quality of contribution to the COVID response could also not be clearly defined.

In conclusion, the three TDR-supported training programmes have strengthened the health research capacity of health workers, thereby contributing not only to research but also to emergency preparedness and the broad health systems response to COVID-19. Such training programmes help build country resilience to epidemics.

Data availability