"A painstakingly primped coiffure" – that is how a development writer described capacity building recently, illustrating development specialists' expansive jargon around a simple concept: investment that leads to individuals or institutions becoming self-sufficient rather than dependent. Usually used in relation to low- and middle-income countries (LMICs) attaining a level of competency they have not yet reached, it is a rather old-fashioned concept laden with value judgements, but it is probably here to stay.
So what does capacity building consist of? To start with, it is a lot more than training. The endgame for capacity building in health research is individuals, groups, and institutions in LMICs that are globally competitive: carrying out the best possible science to generate new and important research findings; using research effectively to guide research priorities as well as policy; and promoting the demand for research that addresses the needs of their own countries. The Cochrane Collaboration provides a brilliant vehicle for this development, conducting systematic reviews, promoting the use of research evidence, and enhancing research capacity through sustainable networks.
In the world of evidence synthesis, Cochrane's ethos helps build capacity to carry out reviews. The principle of working in inclusive teams, modelled by Iain Chalmers in pregnancy and childbirth, was at the heart of ensuring supportive mentoring and engagement with a broad, non-elitist community from the outset. The Collaboration established multiple efforts to invest everywhere in doing reviews because, let's face it, 20 years ago there was a worldwide capacity gap in research synthesis. So the highly decentralised nature of the Collaboration, built on principles of fairness and equity, was an important grounding. In a narrow sense, part of capacity building in The Cochrane Collaboration is ensuring independence of individuals and groups of people in LMICs completing high-quality Cochrane Reviews, with all the necessary technical and methodological expertise. That in itself is an important goal.
Iain Chalmers and Jimmy Volmink celebrating Cochrane's 20th anniversary
at the Cochrane Indaba, Cape Town, South Africa, May 2013
The Cochrane Collaboration's vision "that healthcare decision making throughout the world will be informed by high-quality, timely research evidence" implies that capacity needs to be enhanced at another level – helping decision-makers find, appraise, interpret, and consider the use of systematic reviews. The Collaboration trains people to understand and interpret reviews, generates advocates for evidence-informed decision making, and supports agents of change. While in the UK systematic reviews are deeply embedded in the whole health system, this cannot be said for many other countries, where traditional models still abound. Now with multiple initiatives worldwide in research translation, a clear focus and embedding of research translation in institutional systems will be important if funders are to get their money's worth. The Collaboration is way ahead of many groups in this area. Authors are contributing to research translation simply by preparing scientifically valid Cochrane Reviews, and Cochrane authors and editors provide a core and unique resource in evidence synthesis globally and nationally, able to advise multilateral agencies, governments, and other decision-makers in the use of best evidence in policy and practice.
Even more broadly, Cochrane's ethos of rigor, scientific integrity, collaboration, and global networking builds the competence of individuals, groups, and institutions in high-quality, relevant research. It is remarkable how good Cochrane Collaboration training is, both directly, for sustaining the learning of research skills, and indirectly, by linking people and institutions into a supportive global research network of many of the best methodologists and leaders. By participating in Cochrane Reviews on important topics, smart authors early in their career can gain international recognition without huge grants or projects. The Collaboration's network provides social capital and support. It also engenders important attitudes around rigor, partnership, a focus on outputs, and value for money. Authors of systematic reviews learn the strengths and weaknesses of primary studies, and in so doing, are in an informed position to themselves carry out high-quality relevant primary research.
Managing and financing capacity building needs care. The Collaboration has valued individual effort and enthusiasm, and that has largely avoided the perverse incentives associated with competitive grants and academia in general. But capacity building and Cochrane Reviews both need investment, particularly as carrying out reviews becomes more demanding. In our own experience as part of a UK Aid programme-funded consortium that supports Cochrane Review production, promotes their use, and is committed to capacity building, we have developed management approaches that have helped us and, in the spirit of the Collaboration, provide a base for others to build on and develop. With support from a strong advisory committee, we have set up a decentralised management structure to allow responsive funding with partners in the Consortium. These partners have discretion on effective use of funds to achieve the programme outputs – to 'get the job done'. Governance is through work plans developed within the explicit strategic priorities of the whole Consortium and negotiated within a management system in the Consortium framework working in line with the expectations from the funders. The work plans are formalised as output-based contracts. Outputs are monitored six-monthly, and the contracts are adjusted when appropriate. This active, transparent management with a focus on high-priority review topics and with performance and year-on-year funding dependent on outputs provides a flexible and effective framework and high value for money. With review engagement, networking, and small scale audit and research projects, the grant aims to build institutional competence, conceptualised around knowledge, skills and attitudes to research, it builds research independence, which is the endgame we all seek (Figure 1).
Figure 1. Conceptual framework for capacity development from the Effective Health Care Research Consortium
www.evidence4health.org RPC = Research Programme Consortium
For the Collaboration as a whole, a strategic approach to capacity building makes sense. In particular, building on the existing centre and branch infrastructure and expertise, and building on current authors and their institutions is important, as well as drawing in new individuals, groups and institutions that sign up to the principles and high standards expected. Helping prospective Cochrane authors to engage with their audience, to be responsive to current information needs, and to become familiar with existing systematic reviews is central to identifying relevant new review topics. This, together with promoting the use of best evidence in decision making, should be done through maintaining Cochrane principles, and high standards of quality, while advancing sustained efforts to build infrastructure, lobbying for institutional support, and providing technical, methodological, and financial support.
And for all the experienced authors and editors in the Collaboration – you need to be part of this: how many people in LMICs have you supported in conducting a Cochrane Review in the last 12 months? Mutual support and strong networks are what makes Cochrane powerful, so let's use them even more in fulfilling what the development specialists like to call 'capacity building'.
Taryn Young1, Paul Garner2, Tamara Kredo3, Lawrence Mbuagbaw4, Prathap Tharyan5, Jimmy Volmink6
1Taryn Young (firstname.lastname@example.org), Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, and South African Cochrane Centre, South African Medical Research Council, South Africa; 2Paul Garner (email@example.com), Effective Health Care Research Consortium, Department of Clinical Sciences, Liverpool School of Tropical Medicine, UK; 3Tamara Kredo (firstname.lastname@example.org), South African Cochrane Centre, South African Medical Research Council, South Africa; 4Lawrence Mbuagbaw (email@example.com), Centre for the Development of Best Practices in Health, Cameroon; 5Prathap Tharyan (firstname.lastname@example.org), South Asian Cochrane Network & Centre, Christian Medical College, Vellore, India; 6Jimmy Volminck (email@example.com), Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, and South African Cochrane Centre, South African Medical Research Council, South Africa.
How to cite: Young T, Garner P, Kredo T, Mbuagbaw L, Tharyan P, Volmink J. Cochrane and capacity building in low- and middle-income countries: where are we at? [editorial]. Cochrane Database of Systematic Reviews 2013;11:ED000072. dx.doi.org/10.1002/14651858.ED000072
1. Roopanarine L. Development jargon decoded: capacity building. www.theguardian.com/global-development/poverty-matters/2013/aug/26/development-jargon-decoded-capacity-building (accessed 7 October 2013).
2. Bates I, Akoto AYO, Ansong D, Karikari P, Bedu-Addo G, Critchley J, et al. Evaluating health research capacity building: an evidence-based tool. PLoS Medicine 2006,3(8):e299. dx.doi.org/10.1371/journal.pmed.0030299
Competing interests: TY co-ordinates the work of the Effective Health Care Research Consortium (EHCRC; www.evidence4health.org) in the African region and heads the Centre for Evidence-based Health Care (www.sun.ac.za/cebhc) at Stellenbosch University, South Africa; one of the Centre's aims is to build and enhance capacity in evidence-informed decision making. TY is also employed by the South African Cochrane Centre (www.mrc.ac.za/cochrane) as a consultant to support training and other Cochrane initiatives. PG is director of the EHCRC, which receives money to increase the number of evidence-informed decisions by intermediary organisations that benefit the poor in LMICs. The funder assesses him and the Consortium against outputs that include Cochrane Review production and capacity building in LMICs. PG is also the co-ordinator of a WHO Collaborating Centre for Evidence Synthesis for Infectious and Tropical Diseases (UNK234; apps.who.int/whocc); one of the Centre's aims is to help WHO build capacity in research synthesis. TK is employed by the South African Cochrane Centre and is one of the African partners receiving support from the EHCRC to support evidence synthesis, capacity development, and evidence use in Africa. One of the Centre's mandates is to support Cochrane Review authors to initiate, complete, and disseminate their Cochrane Reviews. LM works with the Centre for Development of Best Practices in Health (www.cdbph.org) in Yaoundé, Cameroon, a partner to the EHCRC, and receives payment for work that aims to produce summaries of health evidence and improve stakeholder capacity to use evidence in health care. PT is employed by the Christian Medical College at Vellore in South India. He is Director of the South Asian Cochrane Network and Centre (www.cochrane-sacn.org), which has received funding for capacity-building activities from many non-commercial organisations involved in health care and health policy; this funding has facilitated research synthesis activities, including the EHCRC. Since August 2012, PT has been a recipient of The Cochrane Collaboration's Global Capacity Building Initiative, which partly funds his salary for a two-year sabbatical from his regular employment. JV has been an ECHRC partner for many years. He is Dean of the Faculty of Medicine and Health Sciences at Stellenbosch University, Director of the South African Cochrane Centre, and a member of the Academy of Science for South Africa, which aims to generate evidence-based solutions in response to high-priority national problems.
Image credit: The Cochrane Collaboration
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