2.1 The importance of knowledge economies
Development has been conceptualized as a process that creates growth, progress, positive change and/or the addition of physical, economic, environmental, social and demographic components.(43,44) Science and innovation, if well-utilized, may play a core role in realizing sustainable development.(1,45) As seen from the experiences of many industrialized nations, scientific research and linked innovations have been core to economic and social advancement over the past two centuries – be it medical innovations such as vaccines and antibiotics, or industrial innovations in manufacturing, communications, and computation.(46–48)
More recently, questions have been asked as to whether scientific research supports development, or whether it represents a product of development in itself.(49,50) Both these positions have their justifications. In terms of science resulting in development, it is research and knowledge generation, linked with subsequent innovation and application of that knowledge, that can be seen as critical to overcoming key development challenges in LMICs.(49) Therefore, the need to invest in capacity for mobilizing and using science and innovation can be viewed as an essential component of strategies for promoting sustainable development.(51–53) This argument appears to underpin the inclusion of research within the Sustainable Development Goals. Goal 3.B specifically focusses on health research for LMIC needs, calling for “supporting the development of research and development of vaccines and medicines for health conditions which affect LMICS”; goals 9.5 and 12.A call for increased scientific, technical and research capacity more generally in developing countries.(54)
Many calls for the creation of so-called ‘knowledge economies’ are linked to thinking of research activity as an end goal of development. It has been argued that the conceptualization of an economy of knowledge reproduces a growth and market-oriented rationale for knowledge production, accumulation, and diffusion which has particularly influenced the international aid, education, and development agenda.(55,56) For example, the OECD(11) defines knowledge-based economies as those “which are directly based on the production, distribution and use of knowledge and information’’ (p. 7). The World Bank identifies four dimensions of the knowledge economy: economic and institutional regime, education and skills, information and communication infrastructure, and an innovation system – with the agency going so far as to create a Knowledge Economy Index (KEI) as an indicator of a country’s ‘preparedness’ for a knowledge economy.(57)
Asongu and colleagues(58) found the overall trends in African countries’ performance between 1996 and 2010 differed across the World Bank’s KEI dimensions: with Tunisia leading in education, the Seychelles in information and communication technology, South Africa in innovation, and Botswana and Mauritius in institutional regime. Oluwatobi and colleagues(59) have argued that the potential for knowledge production and innovation in Sub-Saharan Africa is mitigated by the level of human capital and quality of institutions. Overall, quality education and strong institutions are held to be imperative for the transformation into a knowledge economy.(59–61) Both educational and economic institutions may create enabling structures for developing knowledge and innovation and for economic growth, but their influence varies according to institutional arrangements, income, and development levels in countries.(61–63) In particular, education plays a vital role in strengthening human capital, which directly influences the ability to create, absorb, transform, disseminate, and use of knowledge and innovation.(59,64–66) Education and training emphasizing the value of traditional knowledge and culture also strengthens human capital to innovate contextually relevant solutions for local development problems.(58,63,67)
2.2 The contribution of health sciences research
Within the broader remit of science for development, health sciences research is vital in its own specific way. There are global examples where health research leads to collective human benefit, development of medical treatments, or better understanding of health risks of activities such as tobacco smoking. At a national level, however, HSR can also specifically generate evidence that is useful for public service planning and program implementation. Local health research is typically seen to provide policy-relevant information, including disease trends, risk factors, outcomes of interventions, patterns of care, as well as health systems and services costs and outcomes.(68)
Authors such as Grant and Buxton have gone so far as to develop a framework to estimate the value that HSR provides to countries.(69) Included as benefits in the framework are cost reduction in the delivery of existing services; improvements in service delivery processes; increased effectiveness of health services; increased population health and equity (achieved through improved allocation of resources, better targeting and accessibility); and contribution to a healthy workforce.
Finally, HSR evidence has also been argued to improve the health policymaking process itself by identifying new issues for the policy agenda, informing decisions about policy content and direction, and through evaluations of policy impact.(70) In many ways, these examples capture the benefits widely seen to follow from a system of evidence-informed policymaking, whereby a more systematic and robust use of research evidence in decision making is seen to improve planning effectiveness and efficiency to serve the broader social good.(18,71)
Health sciences research input and output by national governments are not uniform, with significant disparities between regions or income levels, and also across countries within the same region or at similar levels of income.(72,73) On the African continent, for example, Tanzania and Lesotho had similar levels of GDP (per capita USD 2,365 and USD 2,494 respectively in 2013); however, the percentage of GDP invested in research in Tanzania was more than 3 times higher than in Lesotho (0.28 v. 0.08) while the number of publications per million inhabitants was nearly 50 times higher, at 770 in Tanzania compared to 16 in Lesotho.(74)
One of the most critical contextual determinants of HSR outputs is historical evolution of research systems. For those African nations subject to colonial rule, for instance, modern forms of research were often developed in service to the economic interests of the colonising power. The focus of research thus centred on key exports such as agriculture, forestry and mining related activity, with little interest in HSR to benefit local populations.(75,76) After independence, HSR remained embryonic, with governments often choosing to invest in economies based on the commercialisation of cash products and natural resources rather than in the development of research and technology.(77) Moreover, countries which have experienced conflict, instability, and other socio-political crises, have had to direct resources towards reconstruction and peacekeeping investments, rather than towards scientific research and innovation.(78)
For some nations, the catalyst for investment and development of HSR has only been through the emergence of health crises—new diseases such as HIV/AIDS and Ebola, or the rising incidence of tuberculosis and plague.(79) (Ministère de la santé publique, 2015; MTN, 2017). Outbreaks have also at times inspired new policies calling for investment in HSR by global organisations such as the World Health Organization (WHO) and UNESCO.(80,81) These calls for investment have allowed for a more open dialogue and progress on conceptualising the importance of health research, even within low income African states—with several governments now committed to investing in scientific research in connection with a country's economic and sustainable development priorities.(82–84) Despite these shifts, such as the Bamako initiative, WHO’s efforts to regionalise research efforts, and signs of increased attention to domestic HSR, key drivers of research and research funding in the health sector remain exogenous to African states. Indeed, funding largely reflects global HSR priorities, with limited options for investigator-initiated research on local health concerns.
2.3 How can we measure health sciences research?
While there is a strong case that HSR in LMICs is important at national and global levels – for improving health, preventing epidemic spread, supporting health policy and systems, and as an influential factor of national development more broadly – there is no single framework or consensus method to assess HSR capacity across countries. Indicators for measuring and monitoring HSR generally include standard output indicators of knowledge production and innovation, such as scientific journal articles per million inhabitants or patents per million inhabitants (57), and input and process indicators of health research and development. Such process indicators can include gross domestic research and development expenditure on health as a percentage of GDP (GERD), number of clinical trials per million inhabitants, research grants, and full-time equivalent health researcher per million inhabitants.(37) From the perspective of decision-makers in national agencies, these indicators of knowledge production and human resources for research are helpful for benchmarking performance against regional and global comparators and for informing policy and strategy to strengthen research and development.(85)
Researchers and international organisations have attempted to compile indicators and measure HSR capacity in different ways. For example, the WHO has created a Global Observatory on Health Research and Development which aims to “consolidate, monitor, and analyse relevant information on health research and development activities”.(86) This uses a logic model perspective to assessing HSR, tracking a range of indicators to monitor health R&D inputs, processes, and outputs as identified and defined by Røttingen and colleagues.(37) While these indicators are useful for monitoring and benchmarking the state of HSR and development activities, funding, and performance at the national level, they do not provide information to assess overall capacity of national health research systems as a set of “people, institutions and processes” for HSR. Moreover, there are incomplete or missing data for many of these indicators.
A second approach takes a systems perspective to assessing HSR capacity, recognising that research and development funds and personnel represent but two components of a nation’s HSR capacity. In this vein, Pang and colleagues(19) defined a national health research system within a conceptual framework of four functions: stewardship, financing, creating and sustaining resources, and producing and using research. This framework has been operationalised under the Research for Health unit at the WHO Regional Office for Africa and used to assess the evolution of national health research systems, with data collected from individual researchers for health focal points in 2003, 2009, and 2014.(87–90) These key informants within national Ministries of Health and other institutions replied to survey questions about whether HSR policies, institutions, or other resources were currently in place in the country (e.g. national health research policy, national research ethics committee, national health research institute, national budget line for health research)(87).
In applying this approach, Kirigia and colleagues(88) analysed trends between 2003 and 2014 to show that although there have been positive gains across many functions, there are still considerable gaps in many African countries. For example, fewer than half of the countries in Sub-Saharan Africa have an official health research policy, a national strategic health research plan, a law regulating HSR, or a budget line for HSR within the health budget; and only about half of them have a national health research institute or council, a health research programme at the Ministry of Health, or a health research management forum. Public financing for HSR is also typically measured to be very low, with minimal progress towards the goal of 2% of the national health expenditure allocated to HSR. Instead, most funds for HSR come from external sources such as international organisations, NGOs, or multilateral/bilateral partners. Within the systems approach, Kirigia and colleagues attempted to quantify the performance and capacity of national HSR systems in the African national health research systems barometer.(89) Based on their operationalisation of Pang et al.(19) framework, with 4 main functions and 17 sub-functions, Kirigia et al. calculate an index for each sub-function and propose a score for the region, and for each country and function using the 2014 survey data.(89) According to Kirigia et al, the weakest elements of African health research systems are human resources for HSR, government spending on HSR, publications in peer-reviewed journals, and research institutions to conduct HSR.(89)
Overall, there have been a variety of attempts to identify various elements of HSR activity, performance, and capacity in Africa. Some have assessed R&D potential, measured funding inputs, or identified gaps in national HSR systems. These efforts shed light on where strengths and weaknesses lie, but currently do not provide a comprehensive review and synthesis of data on which to comparatively evaluate HSR knowledge and innovation, HSR and development activities, and HSR systems at the national level across Africa.
The aim of this paper is thus to develop this work by collecting and aggregating data on a range of variables to consider HSR activity, performance, and capacity in all African countries. We propose a framework for evaluating a country’s capacity for HSR based on publicly available data sources. This framework incorporates and expands on indicators from previous studies. Using this framework, we present data on HSR capacity in each of the 54 UN-recognised African states to map current capacity across the region for health sciences research – providing one of the first analyses to systematically outline the contribution of African countries to HSR across such a wide range of indicators.