Outflow of Trained Staff

The science and health sectors in Africa, and to a lesser extent Latin America and parts of Asia, suffer from a continuous outward drain of trained staff, a problem that donors have addressed primarily by financing training. But training is only part of the solution to building human capacity, because low salaries, poor and unattractive working conditions and environments, and lack of institutional incentives to allow the development of the individuals' full scientific potential in their own countries also contribute to low morale and high outflow. Technical assistance and training have often proved ineffective in helping to build sustained capacity. What is needed is a comprehensive approach to human resource management as well as a systemic approach to capacity building [21], including recognition of the importance of developing a strong research culture in DECs.

Lack of Governmental Support

A report commissioned by the World Bank showed that with the exception of South Africa and Egypt and a few others, most DECs in Africa (and also in Latin America, with the exception of Brazil and Cuba, and Asia, excepting the People's Republic of China and India) incur very low national investments in research in general, and have a low productivity in science and technology [9]. This generalisation probably masks the fact that scientifically less advanced countries may have reasonable capacity in certain areas, but there is no doubt that the situation of health research in Africa is dire [8]. Another World Bank report [21] found that most capacity support remains fragmented, that the countries do not fully “own” the capacity building agenda, and that the challenges of capacity building vary across sectors within countries as well as across countries. Research capacity building requires the investment of meaningful amounts of funds, which many of the DEC governments are not willing to make because research is considered a long-term undertaking that only rich countries can afford, and because of other perceived pressing needs. Governments are inclined to follow agendas demanded by powerful, well-organised lobby interests more readily than those sought by seemingly weaker or more diffuse, decentralised interests, such as investment in education and health [21]. There is a lack of sufficient funds from the individual governments of DECs to support institutional infrastructure, to fund medium- and long-term research projects, and to create well-remunerated job opportunities for local scientists. Moreover, these are major factors preventing African scholars trained abroad from returning to their home countries to pursue careers in health research. Despite these small national inputs, research capacity development has been identified as an important endeavour that should be fostered in order to obtain the evidence-based knowledge that is relevant to the health concerns of local communities and that policy-makers can use for implementation of adequate practices [22].

Underdeveloped Collaborations and Networks

Establishing and nurturing collaborations in research is undoubtedly one of the best vehicles for building and strengthening research capacity in DECs, and emphasis should be placed on long-term partnerships. Efforts to incorporate as co-workers multinational members of interdisciplinary teams can be of immense value, which should be encouraged and cultivated [10]. Regrettably, the collaborative links between the North and the South are stronger than those between South and South, probably because it is perceived that countries in the North can bring resources and technologies not available in the South. Feeble South–South networking prevents exchange of expertise between countries affected by the same infections and often sharing the same transmission zones, and imperceptibly contributes to the drain of the best researchers in the South towards the North. There is a need to strengthen South–South collaborations and to fund and establish research networks that support, for example, technology transfer aimed at the development and manufacturing of new diagnostic tools and anthelmintics for the management and control of helminthiases.

Funding Issues and Ownership of Programmes

Most research capacity building efforts within and between DECs are supported entirely by external donor agencies, research funding bodies and foundations, pharmaceutical companies, and non-governmental development organisations (NGDOs) such as the World Bank (http://www.worldbank.org/); the Bill & Melinda Gates Foundation (B&MGF, http://www.gatesfoundation.org/); the Carter Center (http://www.cartercenter.org/index.html); Fogarty International Center (http://www.fic.nih.gov/); GlaxoSmithKline (http://www.gsk.com/); Helen Keller International (HKI, http://www.hki.org/); the Japan International Cooperation Agency (JICA, http://www.jica.go.jp/; see Figure S1) and others mentioned in Table S1 and below. For instance, the B&MGF, through a five-year grant to the University of Georgia Research Foundation, is funding the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE), established in December 2008 to answer strategic questions about schistosomiasis control and elimination (http://score.uga.edu/). The challenge is how to ensure that low-income countries create a stable demand for sustainable control, anthelmintic distribution, and the research that supports these activities. In responding to this demand, it is crucial that there is an appropriate supply of trained personnel at various levels, and that the countries are able to raise adequate resources to complement or eventually replace what is already received from external sources, thus sustaining the success of control and elimination efforts made once donor fatigue occurs, or donor funding is diverted somewhere else. An excellent example of such a transition from external donor funding to internal, DEC funding is the African Programme for Onchocerciasis Control (APOC). APOC is funded entirely from voluntary contributions channeled through the APOC Trust Fund, and has fostered North–South, North–South–South, and South–South partnerships (Box 3 and Figure 2).

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Figure 2. African Programme for Onchocerciasis Control Trust Fund annual expenditure.

Since the inception of APOC in 1995, expenditure has increased steadily until 2007, mainly with external donor support (listed in http://www.who.int/apoc/about/funding/en/index.html). The orange and dark turquoise portion of the bars represents investment in administration, and the grey and light turquoise portions indicate support for technical activities, operations research, and capacity building. External funding has decreased since 2007 and it is anticipated that from 2015 onwards the programme will be fully devolved to participating countries and their NGDOs. Recently, APOC's mandate has been extended to 2025.

https://doi.org/10.1371/journal.pntd.0001602.g002

Basic and Operations Research and Specialised Training

The successes achieved by control programmes, like the former Onchocerciasis Control Programme in West Africa (OCP), the current APOC, and the Schistosomiasis Control Initiative (SCI), have been partly realised because of the fundamental and operations research carried out within the umbrella of the programmes activities [1]. In most DECs, there is moderate capacity for research in the areas of epidemiology, parasitology, malacology, and entomology, but research capacity is lacking or dwindling in some other specialised areas that are essential to support successful control measures, such as transmission dynamics modelling (see DIMACS/MBI in Table S1), advanced statistical analysis of helminth and NTD epidemiological data, parasite population biology and genetics, vector ecology, and expertise for detection and monitoring of resistance to anti-parasitic drugs and anti-vectorial measures. Expertise in these areas and evidence-based research output are essential for supporting appropriate decisions by policy-makers in the context of implementation and evaluation over time of single and/or integrated helminth control programmes [6], [11]. In this context, authors of this paper (MYO-A, RKP, M-GB) recently organised and taught a course, funded by the Leverhulme–Royal Society Africa Award (Table S1), on “Epidemiology, Transmission Dynamics and Control of Vector-Borne (VBDs) and Neglected Tropical Diseases (NTDs)” at the University of Ghana, including topics on anthelmintic resistance, vector biology, infectious disease modelling, and NTD epidemiology and control.

Insufficient Mentorship

In many DECs, scientists and/or lecturers from research institutions and universities work mainly as individuals rather than as teams. This leaves the new entrant, the young scientist/lecturer, in a place where there is little or no guidance, direction, or an environment that will facilitate his/her career development and progression. Moreover, facilities and inputs for scientific research available to the young scientist are limited. To facilitate research capacity in DECs, there is a need for senior scientists/faculty staff members at higher levels to mentor junior researchers. Having a mentor with expertise, peer esteem, and networking skills provides an invaluable triad function: guidance and direction for the development of a career pathway; research facilities, laboratories, and group support for practical experience; and access to a network of contacts for projection in the national and international arenas. Mentors and role models provide not only exposure to robust and demanding academic and research environments and a vision of what is expected and possible to achieve, but also opportunities to participate and present in international conferences, and obtain feedback on research dissemination activities, manuscripts, oral presentations, and grant preparation. The introduction of the junior fellowships by the European Foundation Initiative for African Research into Neglected Tropical Diseases (EFINTDs) (Table S1) is a step in the right direction, as young scientists will receive mentorship from experienced scientists both from strong research institutions in the North and in the South. This should help raise a generation of young scientists with the required expertise to themselves serve as mentors for the next generation. Mentorship programmes are crucial in DECs, since unlike the institutions of the developed nations, most DECs do not have the period of post-doctoral internship and further training that new PhD graduates often have access to in the North. It will be very helpful to DECs if international funding agencies were able to provide more fellowships with mentorship options for promising junior scientists, just after completing their PhDs, and who are willing to remain in or return to their home countries to build their own career with the intention of focusing in their country's research needs [23].

Access to Literature and Unedited Databases

Strict open-access publication policies, subsidies by the research funders of wealthier nations, and the growth of prestigious and high impact open-access journals (for instance in the Public Library of Science and BioMed Central families) have ameliorated the access of scientists in DECs to high quality and updated peer-reviewed research. In particular, BioMed Central has recently launched “Open Access Africa”, a collection of initiatives designed to increase the output and visibility of scientific research published by African learning institutes. The Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi, Ghana, is the first African Foundation Member to participate in BioMed Central's free membership scheme (http://www.biomedcentral.com/developingcountries/events/openaccessafrica). However, a considerable amount of investment by higher education and research institutions is needed to maintain the necessary funding for electronic journals, digitised archives, bibliographic databases, and printed literature that are not easily available in DECs. Furthermore, fast and reliable Internet access is sometimes lacking in DECs, which in turn limits the access of researchers in those countries to open-access information via the Internet. For a compilation of web-based bibliography databases of epidemiology, parasitology, and tropical medicine resources from the Spanish-speaking Latin America and Caribbean regions, see [24]. Without affiliation to a strong library in an academic institution, individual Internet access even at broadband speed is not sufficient. This hampers research and research capacity. As a positive example, the Brazilian Federal Agency for the Support and Evaluation of Graduate Education (CAPES) subscribes to all major peer-review journals, a remarkable effort to make scientific publications available to all academic and educational institutions in Brazil. In addition, CAPES works with the Cambridge Overseas Trust to offer the CAPES Cambridge Scholarship, which welcomed its first recipients (Brazilian nationals) for PhD training in October 2011 (http://www.cambridgetrusts.org/partners/capes-brazil.html).

The issue of open access to helminth epidemiology databases for the purposes of mathematical modelling is more fully discussed in [6]. This ongoing issue has been an important hurdle in developing collaborative programmes and has been addressed in the preparatory meetings for the Bamako Call to Action [25]. While several institutions would like to have all data collected from countries where diseases of the poor are prevalent placed on open-access databases, this proposal has not had general acceptance because it appears to give countries with highly structured, efficient institutions, access to data at apparently no cost, which have been generated, at great cost, by low- and middle-income countries. The analysis of these data should be conducted and shared between the latter before it is open to the former, or password-protected access could be granted after mutually beneficial agreements or memoranda of understanding for joint analysis and publication of hard-earned data have been signed by participant institutions and researchers [25]. There are also intellectual property issues needing further discussion [26], [27]. Investment in data collection and curation can be substantial, and there has been little mutual collaboration between the developed countries of the North using data from developing countries of the South. It is clear that capacity building for data analysis and translation of findings for improving health, together with new research questions to be addressed, need further discussion. A system needs to be developed where different stakeholders will participate and share findings [25].

Lack of Advanced Enabling Technology Tools

DECs face challenges in research capacity for helminthiases and other infectious diseases, especially in areas that require the application of advanced technology for disease control such as functional genomics and bioinformatics research. This may be either due to the lack of trained personnel in such specialised areas, the lack of appropriate infrastructure and equipment, or the brain drain of the few local scientists and health professionals who may have such expertise. Research capacity building in DECs faces the greatest challenge in areas requiring the application of advanced technologies such as genetics for disease control, genomics, functional genomics (and other “omics”), bioinformatics, and computational biology that can, in the medium and long term, have a major impact on disease control or elimination [28], [29]. There is a lack of expertise in DECs for the development of new reagents, products and approaches for diagnosis, anthelmintics, vaccines, and integrated vector control, which are crucial for the sustained success of current programmes for the control and elimination of helminthiases [30]. If DECs had the adequate research capacity for the development of effective functional genomics tools and bioinformatics, areas like the study of gene function could be applied for the development of novel drugs based, for instance, on locally available natural products (see the LANBIO and ANDI initiatives described in Text S1).

The path forward is not impossible, however. Some DECs in South America, the Caribbean, and the African regions, despite similar challenges, have been able to develop adequate research capacity. For example, Brazil, Cuba, and South Africa have made major technological advancements in the field of functional genomics, bioinformatics, and vaccine development. Notably, the scientific output and impact of these countries' researchers have increased internationally, and consequently the brain drain has been reduced or halted [31]. Such progress is mostly due to the financial investments made by the governments of such countries to build and support adequate research capacity in their national institutions. This is now yielding expertise in new technologies, leading to the development of innovative interventions and effective management of various diseases, with resultant progress in infectious disease control. For instance, the first effective meningitis B vaccine was developed at the Cuban Finlay Institute (http://www.finlay.sld.cu/english/eindex.htm), and was recently licensed to GlaxoSmithKline [32]. The FIOCRUZ/Bio-Manguinhos and Butantan Institutes of Brazil and other collaborative institutions are full members in the product development partnerships (PDPs) for the Human Hookworm Vaccine Initiative [33]. The People's Republic of China is one of the world's leading producers of penicillin, and together with India and Brazil, produces praziquantel for schistosomiasis treatment. The National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention in Shanghai, following a collaborative effort between Chinese, European, and African scientists, has investigated the effects of artemether, singly or in combination with praziquentel, against the major human schistosome species [34]. The Serum Institute of India is the world's leading manufacturer of diphtheria-pertussis-tetanus vaccine. Over 60% of the United Nations Children Fund's vaccine requirements for the Expanded Programme on Immunization are met by Brazil, Cuba, India, and Indonesia [35].

Scarce Evaluation of Capacity Building and Research Partnership Coalitions

A further challenge hampering the effective development of research capacity building is the lack of application of the same rigorous monitoring and evaluation (M&E) practices to capacity building work that are implemented in other areas, with most activities lacking standard quality assurance processes at the design stage, and not being routinely tracked, monitored, and evaluated [21]. Scientific training and outputs could, for instance, be measured in terms of abundance and quality of research dissemination activities; numbers of peer-reviewed papers published by authors from DECs; number of grants in which the principal investigator and research instigator are based in DECs; number of trainees at undergraduate and post-graduate levels who receive education in DECs or return to their home countries to pursue health research careers; and number and impact of courses, workshops, internships, or academic visits hosted or organised in DECs, among others. Sustainability outputs could be assessed in terms of having created a demand for sustainable parasite control and for trained, local personnel to conduct and supervise it as well as a corresponding supply and retention of such personnel; impact of research findings on policy and practice, and in terms of the countries' capacity to assume ownership of and co-finance control programmes implementation and M&E [23], [36].

North–South Partnerships

Given the lack of political will and financial commitment by most DECs to support research capacity building, the role of global and regional efforts has become crucial in supporting and sustaining the control of helminth infections. These efforts include various established research partnerships between the developed countries and the developing nations. Establishing these North–South partnerships in the form of consortia, networks, and collaborations between research institutions has made valuable contributions to research capacity and should be encouraged, although this requires significant financial investments [31], [37], [38]. These partnerships are essential for the training of skilled personnel in research methods and dissemination, the translation of the results of research into tangible actions, products, or improved practices and policies for the benefit of communities and individuals [31], [39], [40], and the deployment of current interventions or the development of novel strategies within national, regional, and global control programmes [38]. Text S1 describes examples of such partnerships for the research and control of helminthiases, the investigation of infectious diseases of poverty, poverty elimination, and environmental sustainability (see also Figure S1). For a more comprehensive and general account of international initiatives for building research capacity in the South, the reader is referred to [41].

For such partnerships to work effectively, they should include major players such as local research institutions, universities, and researchers on infectious diseases of poverty, managers of control programmes, and policy-makers. They should also provide a forum for an active involvement of the DECs and their scientists to ensure that the priority needs of these countries, as well as the training of local human resources, are met. For a more comprehensive account of “desirables” in establishing “win-win” partnerships between the North and the South, readers are referred to the “11 Principles for Research in Partnership with Developing Countries” prepared and published by the Swiss Commission for Research Partnerships with Developing Countries (KFPE) [42], and more recently extended to 12 principles [43], [44]. Bonfoh et al. [40] discuss how the application of these principles, and the evolution of the partnerships from a very basic field station, driven by external projects, to a fully fleshed research centre, partnered with other African institutions, have ensured that research at the Swiss Centre for Scientific Research (CSRS) in Côte d'Ivoire has survived a decade of serious civil unrest.

Malaria research initiatives are good examples of such integrated successes. Although it is a large and highly competitive field, a number of networks exist to foster collaboration, communication, and interactions not only amongst international members, but also among local members. An example is the Biology and Pathology of Malaria Parasite (BioMalPar), a network of excellence funded by the European Commission, which has been successful in establishing and strengthening malaria communities and laboratories in both Europe and malaria-endemic countries [45]. A more recent example, described in Text S1, is the creation of International Centers of Excellence for Malaria Research (ICEMR), which has established a global network of independent research centres in malaria-endemic settings to provide knowledge, tools, and evidence-based strategies to support researchers working in a variety of endemic areas, especially within governments and health care institutions.

South–South Partnerships

In addition to these North–South partnerships, research capacity building can be reinforced by facilitating and providing more opportunities for South–South collaborations [17], [18]. Text S1 also describes some of these initiatives. For instance, in the Latin American and Caribbean region, Brazil and Cuba have made major research investments resulting in a calibre of research expertise and research institutions that are recognised internationally [18], [32]. These well-established institutions could play a major role as regional and inter-continental focal points for South–South collaborations and capacity strengthening for other endemic countries such as the Brazil–Africa programmes previously described [17], [18]. In Africa, only a few countries, such as South Africa, have developed sound fiscal policies supporting knowledge-based development and leading to wealth creation. This has enabled them to invest in science and technology, build substantial research capacity [9], and importantly, to provide attractive remuneration packages to keep their scientists and other expertise in the country. With such expertise and infrastructure, South Africa could also serve as a regional focal point for South–South collaborations within Africa and between other DECs.

Since such partnerships involve considerable financial commitment, extended and continued support will still be needed from global and regional donors, including the WHO, TDR, and other major agencies, schemes, research and development institutions, and funding bodies committed to capacity building such as the Health Programme of the European Commission (http://ec.europa.eu/health/programme/funding_schemes/index_en.htm); the training and capacity building programmes of the Section for Parasitology, Health and Development (SPHD, http://www.ivs.life.ku.dk/English/Sections/SPHD.aspx) of the former Danish Bilharziasis Laboratory (DBL–Centre for Health Research and Development), and of the former Swiss Tropical Institute (now Swiss Tropical and Public Health Institute [Swiss TPH)] in Basel, http://www.swisstph.ch/); the US Agency for International Development (USAID, http://www.usaid.gov/), and in particular the USAID's Neglected Tropical Disease Program (http://www.neglecteddiseases.gov/index.html); the Neglected and Other Infectious Diseases Program of the B&MGF (http://www.gatesfoundation.org/topics/Pages/neglected-diseases.aspx); the New York-based Ford Foundation International Fellowships Program (http://www.fordifp.net/); the International Development Research Centre of Canada (IDRC, http://www.idrc.ca); AusAID (http://www.ausaid.gov.au/) in Australia; the Institut de Recherche pour le Développement (IRD, http://www.ird.fr/) in France; the Department for International Development of the United Kingdom (DFID, http://www.dfid.gov.uk/); the Wellcome Trust (http://www.wellcome.ac.uk/), and the Medical Research Council (MRC, http://www.mrc.ac.uk/index.htm) also in the UK, as well as other foundations, initiatives, and programmes (such as those listed in Table S1, summarised in Text S1, and described in [41], which also provide awards to support candidates from DECs for post-graduate studies at master's and doctoral levels, post-doctoral careers, and research projects). However, these funding opportunities are highly competitive, and therefore for nationals of DECs to access such funds, local scientists should establish strong networks and collaborations and also strengthen their publication and proposal-writing skills to enable them to tap into such opportunities for research capacity building [23].

An important need to be addressed by both North–South and South–South partnerships is that of improving the graduate-level training for students in DECs. Unfortunately, the NTD knowledge base in DECs is often not extensive and the investigators who are involved in intervention programmes are usually associated with ministries of health rather than with national universities. Although this still would entail a great deal of involvement by partners from the North, if external universities could provide support for investigators to provide in-country training within DECs to build up a critical mass of able personnel, the ability to carry out and evaluate NTD control without relying on external direction will one day become a reality. Often, for good training, DEC students must travel elsewhere, which contributes to the exit of qualified scientists who stay in their country of training rather than returning to their home countries (but see Text S1 and Table S1 for examples of current initiatives aiming to remedy this very problem).