Nelson Sewankambo - A view from the south

THE VALUE AND CHALLENGES OFINSTITUTIONAL PARTNERSHIPS INGLOBAL HEALTHA VIEW FROM THE SOUTHNelson K. SewankamboPrincipal, Makerere University College of Health SciencesUganda

Outline of the Presentation• The context• Benefits• Risks / Challenges• Improving partnerships

Context: Global Health• Interest in global health by HIC• Increased funding globally• A new era for LMIC institutions• Insufficient funding from LMICs

Context: Power ImbalanceHICLMICSome Reasonsa) Inadequate institutionalcapacityb) Very unequal resourcesc) Often initiated from thenorth, externally driven andnot in sync with localpriorities

Academic Partnerships betweenRich and Poor CountriesLancet 2008; 371:1055-6• “Partnerships in the context of an unevenplaying field and massive disparities inresources are clearly difficult, despite thebest intentions”– Competitive pressures and financial demands– Should we shape our institutions in the imageof partner institution– Need for partners in the south to have a realvoice, ownership & in management

Inequities In Collaboration• Very unequal relationships– Decision making process• Publication rights• Ownership: Data, specimens, equipment, authorship• Intellectual property rights• Dispute settlement• Lack of transparency / opaque transactions

Just Health: Meeting Health Needs FairlyNorman Daniels, Cambridge University Press, 2008.

What Do We Owe Each OtherGlobally• “If we are one global Community shouldwe not care about global healthinequalities as much as we care abouthealth inequalities within our own setting”?• If, however, we are self-contained nationstates, what business is it of ours if othershave worse health?Norman Daniels

Benefits of Partnerships• Depend on what point of view onelooks at the partnership• Need convergence of views and corevalues e.g. minimizing inequities• Capacity development: Personnel,institutional, environment• Improvements in academic / serviceperformance (quantity and quality)

Makerere-Case Western ResearchCollaboration• Improving careand preventionof TB

Benefits for All• Mutual benefit: A must– Mutual accountability, trust & respect– Joint products• Mutual learning• Effective communication a pre-requisite

Elements for a SuccessfulCollaboration• Good Leadership,..…… at all times• Shared passion, commitment by all. Itmust come and be driven from the heart• Built on the principle of mutual reciprocalbenefit creating a win-win situation for all• Understanding the economic, social,cultural & political realities of the hostenvironment• Long term partnership is critical

MU-JHU Research collaboration

Other Ingredients for a SuccessfulCollaboration• Mutual respect and accountability• Adequate resources matching the task• Sensitivity & responsiveness to local needs• Equitable distribution of risks and benefits

Makerere and Karolinska Institutet Sign forJoint PhD 2003

Distribution of PhD Applicants by Countryand Gender: Merit Vs EquityCountryCategoryPhDApplicants bygenderMalen (%)Femalen (%)No. ofapplicantsShortlisted n (%)Shortlisted bygenderMalen (%)Femalen (%)AllCountries197 127(64.5)70(35.5)Kenya 68 38 (55.9) 30(44.1)28 (14.2) 16 (59.3) 11 (40.7)4 (5.9) 2 (50.0) 2 (50.0)Rwanda 6 5 (83.3) 1 (16.7) 0 (0) 0 (0) 0 (0)Tanzania 33 21 (63.6) 12(36.4)Uganda 90 63 (70.0) 27(30.0)8 (24.2) 5 (62.5) 3 (37.5)16 (17.8) 10 (62.5) 6 (37.5)

Requirements for Success as aNetwork• Have a common purpose and work together• Complex institutional and personal relationships• Regular attention to the network to be effective• Need structures & decision-making mechanisms• Work-plan with timelines and deliverables• Good communications & engagement strategies• Manager(s) to ensure work plan implementation

Risks of Partnerships• May become a free enterprise, not strategic• Cost of managing partnerships• Cannibalizing the core and retard growth• Distorting institutional structure, governance• Divert staff from what they should be doing• Political, legal & ethical risks

Ethical Issues• Well recognized in research• Ethical validity in education• Ethical considerations for short-termexperiences by trainees in global health• Ethical coherency when medical studentswork abroadLancet 2008; 371: 1133, JAMA 2008; 300: 1456• Impact on student, patient and sendingcommunities

Many Partnerships: A ManagementChallenge• How to fully harness positive energies• Inadequate institutions framework(s)• Creation of parallel systems• Mini-institutions within the institution• Duplication of & competition for resources

Mitigating Risks is Critical• The Swiss principalshttp://www.kfpe.ch/download/KFPE_ImpactStudy• RAWOO principlesNetherlands Development Assistance Research Partnership2001, Meeting Report 1999• Costello and ZumulaBMJ (312) 827-829The above lack a strong southern voice• Partnership Assessment Toolkitwww/ccghr.ca

More Towards Mitigation of Risks• Short term funding cycles lead to uncertainfuture, threaten sustainability• Capacity building as essential element• Lack of core funding• Huge differences in overheads allowed• Differences in work cultures

Institution-to-Institution Partnerships:A Preferred Approach• Definition of purpose e.g partnership• Engaged top leadership of JHU schools• Long-term engagement approx 30 yrs• Better coordination, Better resource use• Jointly raise resources for defined tasks• MoUs

Improving International ResearchContractingDavid A Sack a , Vanessa Brooks a , Michael Behan a ,Alejandro Cravioto a , Andrew Kennedy b , CarelIJsselmuiden b & Nelson Sewankambo ca. International Centre for Diarrhoeal Disease Research,Bangladesh, Dhaka, Bangladesh.b. b. Council on Health Research for Development, 1-5 Routedes Morillons, 1211 Geneva, Switzerland.c. Faculty of Medicine, Makerere University, Kampala,Uganda.Bulletin of the World Health Organization 2009;87:487-487.doi: 10.2471/BLT.08.058099

Monitoring & Evaluation (M&E)M&E should occur at all stages ofpartnerships: Inception, implementation anddissemination and wrapping up (“Good Endingand New Beginnings”)www/ccghr.ca

Maximizing Value• Inequitable partnerships are common – needfor improvement• Using lessons from N-S to build S-S• An ethics model• Working towards more equitablepartnerships

Maximizing Value of Partnerships:Issues for Consideration• How to choose partnerships?• How to measure success of a partnership?• When to say no in the face of scarcity?• How to ensure equitable partnerships so thatthe weaker ones ALSO emerge winners?• Need a platform for effective negotiation

Equitable Partnerships? What dothey look like?Need to be defined clearly