Developing countries carry 90% of the global burden\ud
of disease. Infections such as malaria and HIV are\ud
debilitating their economies by killing the young and\ud
economically productive workforce. Research is essen­\ud
tial for health development, yet less than 10% of the\ud
annual global expenditure on health research is\ud
allocated to addressing developing countries' prob­\ud
lems.1 Poor countries must face this challenge seriously.\ud
It is essential that they create strong national research\ud
infrastructures so that they can define priorities for\ud
health research priorities; influence national, regional,\ud
and global health agendas; and lobby for a more equi­\ud
table allocation of resources. This paper discusses\ud
some of the barriers to establishing coordinated health\ud
research programmes in developing countries and\ud
describes how Tanzania has developed a new research\ud
model to try and overcome these

Kitua, A Y

Mashalla, Y J

Shija, J K

Digital Library of the Tanzania Health Community

Coordinating health research to promote action:
the Tanzanian experience
Andrew Y Kitua, Yohana J S Mashalla, Joseph K Shija
Developing countries carry 90% of the global burden
of disease. Infections such as malaria and HIV are
debilitating their economies by killing the young and
economically productive workforce. Research is essen›
tial for health development, yet less than 10% of the
annual global expenditure on health research is
allocated to addressing developing countries’ prob›
lems.1 Poor countries must face this challenge seriously.
It is essential that they create strong national research
infrastructures so that they can define priorities for
health research priorities; influence national, regional,
and global health agendas; and lobby for a more equi›
table allocation of resources. This paper discusses
some of the barriers to establishing coordinated health
research programmes in developing countries and
describes how Tanzania has developed a new research
model to try and overcome these.
Barriers
Lack of a strong research infrastructure is a common
feature of many developing countries and is a major
hindrance to effective health research. Health resources
are often used inefficiently. There is also duplication of
effort and little sharing of knowledge and skill.
Institutional rivalry and intellectual dependence on the
“North” often results in research institutions in the
“South” employing external research consultants at high
cost when appropriate expertise is available locally.
Although a colonial past and financial dependence
on rich donor countries are undeniably important
factors behind the failure to establish effective well coor›
dinated national health research programmes, develop›
ing countries must shoulder some of the blame. Poor
collaboration between research institutions and lack of
strong leadership have resulted in few countries being
able to define clearly their national health needs and
priorities and formulate coherent and comprehensive
research agendas. Many policymakers still believe that
the best ideas only originate from the North.
The fact that health research is conducted within
environments with very different goals is a problem for
all countries but particularly those in developing coun›
tries because superimposed on scarce resources is the
lack of interinstitutional links to allow for the planning
and implementation of research. Academic institu›
tions’ main goal is to produce high numbers of gradu›
ates and good clinical research scientists who will
generate original work that can be published in
prestigious international journals. Publishing in local
journals may arguably be more worth while but is not
seen as a priority because it is often invisible to the
international scientific community and hence less
likely to attract research funds. Medical or health
research institutions regard the number of publica›
tions and researchers produced over time as achieve›
ments. The pharmaceutical industry in turn is driven
by different goals: the need to make products that will
have a market.
Neither academic nor medical and health research
institutions in developing countries regard it as their
responsibility to communicate their research findings to
local policymakers, practising health professionals, or
the public. It is optimistically assumed that key national
decision makers will access the relevant publications;
understand the research language; select useful, locally
relevant results; and use them in planning and
implementing sound health programmes. This laissez›
faire approach to communicating and disseminating
results is in stark contrast to the pharmaceutical
industry, which ensures that its research initiatives are
extended to marketing and advertising products.
The fact that neither the policymakers nor the
public in developing countries are adequately
informed about the scale or nature of local and
national health problems or initiatives to deal with
them means that there is insufficient political and
professional drive to introduce change or follow
“evidence based” policies. Trying to persuade an inad›
equately informed constituency that costly measures in
the short term, such as providing sanitation and safe
water to rural communities, will bring long term gain is
difficult. An essential ingredient for progress, therefore,
is the establishment of a continuous dialogue between
researchers and policymakers (and also the private
sector) to ensure that the latter are better informed and
in a stronger position to be able to formulate and
implement sound health policies.
The Tanzanian approach
Although Tanzania cannot claim to have solved all
these problems, recent moves to coordinate the coun›
try’s health research effort give grounds for some
optimism for the future.
An extra box giving
details of disease
eradication
programmes
appears on the
BMJ’s website
Summary points
The failure of the malaria eradication programme
in some developing countries illustrates the
failure of those countries to coordinate their
health research activities
Coordination is needed to use scarce resources
effectively but also to identify priorities and
communicate these to policymakers and the public
After years of Tanzanian health research
institutions failing to collaborate they have now
joined in a national health forum
Already the forum has identified research priorities
and is setting out an ethical framework for research
Education and debate
National Institute
for Medical
Research (NIMR),
PO Box 9653, Dar
es Salaam, Tanzania
Andrew Y Kitua
secretary, National
Health Forum
Muhimbili
University College
for Health Sciences,
PO Box 65001, Dar
es Salaam, Tanzania
Yohana J S
Mashalla
member of National
Health Forum
Joseph K Shija
chairman, National
Health Forum
Correspondence to:
A Y Kitua
akitua@twiga.com
BMJ 2000;321:821–3
821BMJ VOLUME 321 30 SEPTEMBER 2000 bmj.com
Tanzania currently has four academic and eight
dedicated research institutions which undertake basic
clinical research. These institutions were created inde›
pendently and until recently had their own mandates
and competed with each other for donor money and
other opportunities. In the past any attempt to forge
links or propose a common action was rejected for fear
of dominance by one centre over another. As a result,
repeated attempts by the National Institute for Medical
Research (NIMR), the government run institution that
was designed to coordinate all medical research in
Tanzania, failed.
In 1998 AYK, the newly appointed director general
of NIMR, persuaded the institution’s management that
the only way to improve the situation was to face the
problem head on by initiating discussions with leaders
of each of the institutions and the Ministry of Health.
From the discussions it was evident that the main
problem was “ownership.” Everyone said they wanted
better coordination, but nobody wanted to be
coordinated by another institution.
After much discussion a proposal was put forward to
create an independent, non›statutory body representa›
tive of all the research institutions to act as a
non›political and non›religious forum for scientific
exchange. It was envisaged that the new body, known as
the national health forum, would also act as a consulta›
tive and advisory body on health research to the policy
and decision makers in the Ministry of Health and wider
government. In addition it would facilitate coordination
and collaboration between different institutes and
promote the dissemination of results and implementa›
tion of research findings. By ensuring that all partner
institutions in health research were involved, the forum
sought to overcome institutional rivalry and provide a
strong independent and impartial collaborative link
between health researchers and health authorities, as
well as relevant national and international agencies.
The proposal was approved at the Fifth African
Essential National Health Research Meeting for Africa
held in Ghana in October 1998 and discussed at
national level at a research strategy workshop in Baga›
moyo in December 1998, where all key national
partner institutions were represented. At a further
workshop in February 1999 a set of terms of reference
for the forum was agreed (see box 1), the first office
bearers were elected, and the newly formed forum sug›
gested a set of national health research priorities.2 3
Details of the process by which the priorities were
developed are given elsewhere.3 Briefly, a question›
naire was sent to all 113 districts in Tanzania asking for
information on the major disease, health service, and
social problems affecting the health of their communi›
ties. The districts were asked to assess the importance
of each problem and provide statistical figures to sup›
port this. Data from 45 of the districts, which
responded with adequate information and were both
geographically and economically representative of
Tanzanian districts, were used to develop the priorities
using criteria developed through consensus in the
workshop (see box 2).
The workshop culminated in the formal launch of
the forum by the Minister for Health in February 1999.
Currently the forum is composed of 20 member insti›
tutions including the ministries of health, education
and community development, women’s affairs, and
children. Although the cost of establishing and
running the forum for one year is modest (about
$50 000 or £33 000), it requires strong leadership and
individual commitment from the representatives of the
participating institutions.
Progress so far
The forum has managed to forge unity among its
members by providing a means by which they can
work together to set the national health research
agenda. Partner institutions are also discussing the
development of common guidelines for conducting
and collaborating on research. For the first time
national health research priorities have been drawn up
G
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Tanzania now has a national forum to determine its health priorities and focus research
Box 1: Aims of the Tanzanian health research forum
• To promote and support health research in Tanzania
• To develop and periodically revise essential national health priorities
• To approve the work of the national health research coordinating
committee and the national health research ethics committee
• To develop and update guidelines for the conduct of scientifically and
ethically sound research in Tanzania
• To promote the establishment of networking and coordination of funds
for health research
• To provide guidelines for partnership in health research
• To promote and enhance the use of health research results for planning,
policy, and decision making
Box 2: Tanzanian criteria for setting research
priorities
• Magnitude of the problem
• Avoidance of duplication
• Feasibility
• Focused
• Applicability of results
• Add to new knowledge
• Political acceptability
• Ethical acceptability
• Urgency
Education and debate
822 BMJ VOLUME 321 30 SEPTEMBER 2000 bmj.com
and national health and social problems identified
(box 3). A draft of guidelines for research ethics are
being discussed.
In addition the forum supports the publication of a
twice yearly bulletin, the Tanzania Health Research Bulle›
tin, which disseminates health research results at a
national level. The bulletin is produced in English, but
there are plans to produce it in both English and
Kiswahili. Copies are sent to all regional and district
medical officers, the Ministry of Health, members of
the forum, and district and child health coordinators.
In the future we hope to publish some abstracts in local
newspapers and make the bulletin available to the
general public.
Getting research into practice
Two disease eradication programmes—one a success
and one only a partial success—show why mechanisms
of implementation at a national level are so important.
Both onchocerciasis and malaria were given global pri›
ority for eradication, with global, regional, and national
commitment in the form of political backing and finan›
cial and technical resources. Yet, while onchocerciasis
eradication is a success and children born in the 1990s
have no risk of river blindness, malaria is still a problem
in developing countries (see extra box on the BMJ ’s
website). A key reason for this has been the failure of
some countries to coordinate the malaria programme.
As a result industry and the private sector have not been
engaged in the programme. The fact that insecticide
impregnated bed nets have been proved to be effective
in reducing deaths from malaria4–8 has not been enough
to ensure their use.
In Tanzania recent concerted efforts by the
scientific community, including the forum, and the
Population Services International Social Marketing
Group as well as other partners has resulted in the
removal of taxes for bed net materials. This has
promoted the local production and distribution of bed
nets and there are now two companies producing 2.3
million bed nets annually. In addition 23 million nets
are treated with insecticide in the community every
year.5 The price of bed nets has been reduced by half,
and the current challenge is to provide sufficient insec›
ticide to maintain impregnation.
Conclusion
To ensure that research results are translated into action
national and regional mechanisms must be put in place
to determine national research priorities, coordinate
research, and promote the effective dissemination of
research results (box 4). The mechanism must also be
able to exert leverage at national and international level.
Onchocerciasis control had all these elements and has
become a success,9 10 whereas malaria control lacked
national commitments and sustainability.11 The promo›
tion of use of bed nets in Tanzania is gaining ground
because it has all the above elements. We hope that the
national health forum will provide a sustained
mechanism for Tanzania and promote the uptake of
research findings into practice.
1 Global Forum for Health Research. Promoting research to improve the health
of poor people. Geneva: Global Forum for Health Research, 1999.
2 Kitua AY. “Let the debate begin”: priority setting by, and for, Tanzania.
Research into Action, COHRED Newsletter 1999;17:7›8.
3 Tanzania essential national health research, priority setting workshop, 15›21
February 1999, Arusha, Tanzania. Dar es Salaam, Tanzania: National Insti›
tute for Medical Research, 1999.
4 Lengeler C, Cattani J, De Savigny D, eds. Net gain: a new method for prevent›
ing malaria deaths. Geneva: World Health Organization, International
Development Research Centre, 1996.
5 Alonso PL, Lindsay SW, Armstrong JRM, Konteh M, Hill AG, David PH,
et al. The effect of insecticide treated bed nets on mortality of Gambian
children. Lancet 1991;337:1499›502.
6 D’Alessandro U, Olaleye BO, McGuire W, Langerock P, Bennett S, Aikins
MK, et al. Mortality and morbidity from malaria in Gambian children
after the introduction of an impregnated bednet programme. Lancet
1995;345:479›83.
7 Nevill CG, Some ES, Mung’ala VO, Mutemi W, New L, Marsh K, et al.
Insecticide treated bednets reduce mortality and severe morbidity from
malaria among children on the Kenyan coast. Trop Med Int Health
1996;1:139›46.
8 Binka FN, Kubaje A, Adjuik M, Williams L, Lengeler C, Maude GH, et al.
Impact of permethrin impregnated bed nets on child mortality in
Kassena›Nankana District, Ghana: a randomized controlled trial. Trop
Med Int Health 1996;1:147.
9 Summanen P, El›Sheikh H. Eye disease and blindness. In: Kari L,
Lenkinen S, Bergstrom S, Makela PH, Peltomaa M, eds. Health and disease
in developing countries. London: Macmillan, 1994:248›353.
10 World Health Organization. The world health report. Life in the 21st century.
A vision for all. Geneva: WHO, 1998.
11 Bradley JD. Malaria›whence and whither? In: Targett GAT, ed. Malaria.
Waiting for the vaccine. Chichester, Wiley, 1991:11›29.
Box 4: Essential elements for putting research into action
• Strong national research promoting and coordinating mechanism
• Establishment of updated national health research priorities
• Strong national political, financial, and technical commitment
• Effective strategies for dissemination of research results
• Involving the private sector and industry in health research and
advertising (learning from commercial publicity)
Box 3: Main health and social problems
identified for Tanzania
Diseases
1 Malaria
2 Upper respiratory tract infections
3 Diarrhoeal diseases
4 Pneumonia
5 Intestinal worms
6 Eye infections
7 Skin infections
8 Sexually transmitted diseases
9 Anaemia
10 Trauma and accidents
Health service problems
1 Lack of trained staff
2 Lack of equipment and drugs
3 Lack of transport
4 Underfunding
5 Ignorance and low health education
6 Impassable roads
7 Lack of rehabilitation facilities and buildings
8 Lack of water supply
9 Poor environmental sanitation
10 Inadequate health facilities
Social and cultural problems
1 Food taboos in pregnancy
2 Poor latrine use
3 Poor economic status due to alcoholism and laziness
4 Polygamy
5 Ignorance and high illiteracy
6 Sex inequality
7 Witchcraft
8 Inheritance of widows
9 Low acceptance of family planning and high fertility
10 Use of local herbs
Education and debate
823BMJ VOLUME 321 30 SEPTEMBER 2000 bmj.com


Malaria, burden, HIV, Poor countries, Research Infrastructure, Tazania

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Malaria, burden, HIV, Poor countries, Research Infrastructure, Tazania

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