In a village in eastern Ghana where Comfort Tetteh grew up, many people thought it was normal for a child to urinate blood. But after studying public health, Tetteh recognized this as a sign of schistosomiasis, one of the many neglected tropical diseases that affect her community.

“In the districts that I’ve worked in, everything is about tropical diseases,” said Tetteh, who became a disease control officer after graduating with a Bachelor of Science degree. “I saw Buruli ulcers, I saw leprosy, I saw schistosomiasis, I saw yaws and many other diseases. My job was to implement disease control measures, and my interest grew to go beyond treatment and help people to apply community-level measures to prevent the appearance of these diseases,” Tetteh said.

Tetteh, now a senior public health officer in Greater Accra, recently had the opportunity to learn how to do exactly that through postgraduate training in implementation research at the University of Witwatersrand in South Africa, with a scholarship from TDR, the Special Programme for Research and Training in Tropical Diseases. The University of Witwatersrand is one of seven universities in low- and middle-income countries partnering with TDR on the Postgraduate Training Scheme.

TDR is a global programme aimed at combating infectious diseases of poverty and is based at the World Health Organization (WHO) headquarters in Geneva. TDR is co-sponsored by the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the World Bank and WHO.

Focusing on infectious diseases of poverty

 Infectious diseases of poverty include tuberculosis (TB), neglected tropical diseases (NTDs), malaria and other vector-borne diseases. These diseases are prevalent in low- and middle-income countries (LMICs), where they mostly affect poor communities and disproportionately affect women and children. The pandemic has also prompted research on how COVID-19 is affecting control efforts for these diseases.

While HIV, TB and malaria have been the priority for two decades of global efforts and billions of dollars in investments, NTDs have often received less attention. And this is despite the fact that these diseases impose a devastating human, social and economic burden on more than 1 billion people worldwide. WHO recently launched a new road map to end this neglect.

Implementation research: the research-to-community link

TDR was established almost 50 years ago, and in the early years, it led the development of critical new NTD treatments – from the first modern treatments for sleeping sickness and river blindness to bednets for malaria.

But with many other agencies now involved in the laboratory development of actual treatments for NTDs, TDR has shifted its focus to implementation research to understand and address barriers to effective implementation of health interventions, strategies and policies.

“The focus of our work is to teach the researchers and scientists in low- and middle-income countries to better address the implementation bottlenecks that prevent the uptake of products and strategies,” said Dr Mahnaz Vahedi, who has been managing TDR’s flagship postgraduate training programme since 2017.

Barriers to uptake include social, political and cultural issues, she points out. These barriers are often grossly underestimated by the innovators of new tests, treatments and vaccines. Thus, there is growing recognition among public health and global health stakeholders that these barriers need to be addressed systematically in order for health programmes to be successful.

Iconic component of TDR’s mission

 Support for postgraduate training in LMICs has been an iconic component of TDR’s mission since the beginning – fostering cadres of skilled professionals in infectious diseases of poverty across Africa, Asia and Latin America, who have become influential in research, public health and policy positions. 

WHO’s Director-General, Dr Tedros Adhanom Ghebreyesus, has spoken out about the importance of such support in building cadres of health professionals and policy leaders from Africa and other developing regions, noting that he himself is “living proof” of the value of such programmes – as the recipient of a WHO scholarship that financed his studies towards his Master’s degree in immunology and infectious diseases, earned in 1992.  

Originally, TDR offered individual scholarships for students to study NTDs – usually in wealthy developed countries. This was expensive and time-consuming – and it also had some unintended consequences.

“The one big lesson we learned is that we weren’t strengthening the capacity of the institutions in the South,” said Dr Pascal Launois, head of TDR’s Research Capacity Strengthening unit.

“This kind of training actually led to a lot of brain drain because people went to do postgraduate training in the UK, Europe or the US and then they didn’t go back to their own countries, and if they did, in many countries there was no institutional commitment for many of them to continue with their work,” he added.

Repositioning to strengthen institutional capacity in the Global South

To correct this, in 2015, TDR issued a call inviting institutions in the Global South to host students for PhD and Masters programmes in implementation research, with TDR providing the course material and full scholarships for the students.

 A flood of institutions applied, and after a careful vetting process, including site visits with independent experts, seven universities were selected: BRAC University (Bangladesh), Universidad de Antioquia (Colombia), the University of Ghana, Universitas Gadjah Mada (Indonesia), American University of Beirut (Lebanon), the University of the Witwatersrand (South Africa) and the University of Zambia. In 2020, Cheikh Anta Diop University in Senegal was added to cater to French-speaking students in Africa.

 “The institutions like it a lot because they get visibility, they are able to host international students and it provides the opportunity for South-South networking, which means we are strengthening the capacity of institutions in the south,” Vahedi said.

The aim is to ensure that the research is done by the researchers based in the disease-endemic countries and for the institutions and students to network.

“The old-fashioned style where research was done by a lead researcher in the North with data collected in the South doesn’t work anymore,” stressed Vahedi.

Students are selected both from health ministries and academia, as the aim is to bolster the country’s capacity in government and its research capacity in institutions.

More than 400 students – with an equal number of men and women – have been trained in Southern institutions since 2015 in programmes lasting from one to two years, and the second phase of the programme is due to start this year after a new call was issued in 2021 for new partners.

There are a few changes in the second phase. The India Institute of Health Management in Jaiphur has joined the group. If funds allow, the University of Technology of Science in Bamako in Mali will also be included to provide back-up for Senegal given the high demand from French-speaking African countries. And BRAC University in Bangladesh will now also train students from the Eastern Mediterranean Region.

Close-up on Wits School of Public Health

 Professor Tobias Chirwa, Dean of the School of Public Health at the University of Witwatersrand (Wits) in South Africa, said that hosting the postgraduate training programme has been a boost for both his institution and sub-Saharan Africa.

“The Wits School of Public Health has benefited from the long-term investments from TDR, including the recent funding on implementation research capacity building to support sub-Saharan African postgraduate students,” Chirwa said.

“Through its extensive network and rich postgraduate programmes, the School will continue to provide regional training on implementation research and collaborate with research and academic institutions in Africa and beyond to develop and implement interventions that are relevant and contextual.”

Professor Latifat Ibisomi, the academic coordinator of the training programme at Wits University, said that TDR has enabled the school to “host outstanding students from multi-disciplinary backgrounds across 12 sub-Saharan Africa countries.”

“These students have conducted country-specific implementation research, thereby transferring their skills to several countries across the continent,” Ibisomi said. “We are thus contributing to the building of a critical mass of implementation researchers who are working to unblock implementation barriers that abound in the region.”

Lymphatic filariasis – why so high despite years of interventions?

Alfred Manyeh recently graduated with a TDR-sponsored PhD focused on lymphatic filariasis, a parasitic disease transmitted by mosquitoes that he became fascinated with back in 2015 when he was first exposed to it.

“I conducted my study in the northern part of Ghana in a district called Bole, where the transmission of lymphatic filariasis is highest in the country, although a lot of interventions happen there,” said Manyeh, who is currently a research fellow at the University of Health and Allied Sciences at Ho in Ghana.

Through his research, Manyeh wanted to uncover why the transmission of the disease was still so high despite years of interventions in the area.

“Based on the findings of my initial assessment, I put an intervention in place with strong stakeholder engagement. Then I went in there to evaluate the process and the impact of the intervention on the people’s knowledge about the disease and then their willingness to participate in the mass drug administration,” Manyeh said.

He found that the programme implementers – drug distributors and health workers – were not following protocols and that local people had various misconceptions about both the disease and its treatment.

Driving real change from implementation research findings

“We dealt with this by organising videos, community meetings and social mobilisation programmes in the community to educate the people about the disease and also about the medication, as well as training for the implementers,” Manyeh said, adding that people were more willing to take the drug after the intervention.

While the impact of his PhD research has only been felt in one area of Ghana, Manyeh is teaching a new generation of young scientists how to do implementation research and is confident that this will improve the uptake of health products in his country.

Meanwhile, Charity Hungu, a Masters graduate from Wits, has taken her new skills back to Kenya’s Kenyatta University Teaching Referral and Research Hospital, where she is a research officer.

 “The main focus of the hospital is on cancer. My work entails coordinating research projects within the hospital as well as with partner institutions from our region and internationally,” Hungu said.

“Sub-Saharan Africa has a great need for implementation scientists to address the daunting health issues that have set us back over the decades,” added Hungu. “We need to effect a turnaround, making our health systems work better and change the reality and narrative of our continent to one of healthier and more vibrant communities.”

 Adapting for COVID times

During the pandemic, more than  400 TDR-trained researchers and programme officers have adapted the research skills they have learnt to help their countries to combat COVID-19, according to a recent survey of graduates.

The activities they have been involved in include pandemic preparedness and response, situation analysis, surveillance, infection control and clinical management.

 As the senior public health officer in Greater Accra, Tetteh has been involved in the COVID-19 case management and vaccination rollout activities in her district.

Although the Kenyan hospital where Hungu is based focused on cancer, it also served as one of the main COVID-19 isolation centres in the country in the earlier part of the pandemic, and she has been drawn into some of the COVID-19 studies.

TDR has also developed several online implementation research tools to assist students who can’t travel to their universities to study during the pandemic.

“The pandemic created an opportunity for us to adapt our programme by providing hybrid and virtual training,” Vahedi said. “We are also looking forward to embarking on the development of a Masters degree in implementation research as well as a postdoctoral programme,” Vahedi said.

Developed in collaboration with TDR, as the first in a series of stories on strengthening implementation research capacity in low- and middle-income countries to tackle infectious diseases of poverty. For more information on TDR’s Postgraduate Training Scheme, please contact Dr Mahnaz Vahedi.

Image Credits: Cheikh Anta Diop University.