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Leadership training to accelerate progress in public health in

sub-Saharan Africa: time for action
COVID-19 has highlighted the deep socioeconomic those findings into scale-up activities with impressive
disparities worldwide. Fragile health systems, chronic public health impact.
lack of access to programmes and services, and Despite academic productivity, there are major gaps in
structural barriers threaten socioeconomic development delivery of disease prevention and health care. The 2015
and good health in sub-Saharan Africa. The pandemic Sustainable Development Goals emphasised the need to
has highlighted the challenges that communities with strengthen implementation science and policy capacity
few resources face, including health-care personnel in low-income and middle-income countries at both
shortages, overcrowded conditions preventing physical institutional and governmental levels. Research capacity
distancing in urban areas, and little access to clean water strengthening models take time to mature and produce
and hand sanitiser. The pandemic has also highlighted a critical mass of independent researchers.4 However,
gaps in preparedness and response; effective leadership few programmes provide public health professionals
within public health programmes could influence in ministries of health or clinicians on the frontline of
outcomes in countries across the globe. health care with the situational analysis skills needed
In 1996, WHO emphasised the need for investments to bring research evidence to scale.8 These skills are
in research capacity strengthening because investments rarely included as part of research or clinical training and
in health research result in better health outcomes in represent an addressable obstacle on the way to closing
high-income countries as well as in low-income and the know–do gap in low-income and middle-income
middle-income countries.1 Funders responded with countries, particularly in sub-Saharan Africa.9
opportunities for individual training ranging from With support from the President’s Emergency Plan
short-term workshops to doctorate programmes.2 The for AIDS Relief (PEPFAR) through the US National
most successful programmes demanded internationally Institutes of Health Office of AIDS Research, and the
recognised scholarship, so that trainees graduated with US Health Resources and Services Administration,
the ability to do research independently and mentor the Afya Bora Consortium was formed between eight
others.3 African and US universities in 2009. This consortium
In the past decade, research capacity building was formed to strengthen health systems through
programmes have evolved to emphasise institutional an interdisciplinary leadership training programme
strengthening in addition to building the capacity targeting African health professionals in medicine,
of individuals.4 Sponsors have encouraged research nursing, and public health from ministries of health,
training models that promote institutional capacity PEPFAR-implementing partners, and universities.10
building and the formation of networks among low- The goal was to train fellows who had competencies
income and middle-income countries.5 This evolution (critical thinking, problem solving, networking, using
has enhanced global partnerships that focus on national data to inform evidence-based practice) and experience
and regional research priorities in disease prevention to lead evidence-based public health programmes
and health-care delivery.6,7 Centres of excellence to fill the gap in African health leadership. The 1-year
have also successfully contributed to strengthening leadership training included didactic in-person and
institutional research capacity, although catalytic start- online modules with core content in leadership skills,
up resources are required and sustainability is not programme management, public health, research, and
guaranteed. Successful centres of excellence such as the policy, and two 4·5-month attachment site placements
Infectious Diseases Institute in Uganda, the Noguchi in ministries of health, PEPFAR-implementing partners,
Memorial Institute for Medical Research in Ghana, and and non-governmental organisations. The goal was not
the Academic Model Providing Access to Healthcare research proficiency, but experience with predetermined
in Kenya have become trusted institutions that build leadership competencies that were tracked. Fellows
national and regional research evidence, and translate developed and implemented projects through which
www.thelancet.com/lancetgh Vol 8 October 2020 e1253

Comment
they could practise newly acquired skills, overseen and capacity building is needed to change the course of such
honed with on-site mentorship as well as facilitated health emergencies in low-income and middle-income
in-country monthly meetings, during which fellows countries.
discussed progress and solutions to implementation We declare no competing interests. All authors are members of the Afya Bora
Consortium Fellowship in Global Health Leadership Working Group and present
barriers. this on behalf of its members and all public health professionals, faculty, staff
Afya Bora has resulted in a vibrant network of and fellows who continue to support the mission of the Afya Bora Consortium.
young leaders who have continued to excel post- Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY 4.0 license.
fellowship in the public health arena, with more than
80% spearheading new initiatives and taking on Yukari C Manabe, Yohana Mashalla, Carey Farquhar,
enhanced leadership roles within their institutions, *Nelson K Sewankambo
sewankam@infocom.co.ug
and approximately two-thirds receiving promotions
Division of Infectious Diseases, Department of Medicine, Johns Hopkins
or moving to new positions at local, national, and University School of Medicine, Baltimore, MD, USA (YCM); Infectious Diseases
international public health organisations. All 161 fellows Institute, Makerere University College of Health Sciences, Kampala, Uganda
(YCM); Faculty of Medicine, University of Botswana, Gaborone, Botswana (YM);
stayed in their countries of origin after completing Departments of Global Health, Medicine and Epidemiology, University of
the programme. The programme also empowered Washington, Seattle, WA, USA (CF); and Makerere University College of Health
Sciences, Kampala, Uganda (NKS)
partnering universities to offer leadership training
1 WHO. Investing in health research and development: report of the Ad Hoc
directly relevant to the needs of ministries of health and Committee on Health Research Relating to Future Intervention Options.
https://apps.who.int/iris/handle/10665/63024 (accessed Aug 8, 2020).
PEPFAR-implementing partners. Many of the fellows 2 Dean L, Gregorius S, Bates I, Pulford J. Advancing the science of health
involved in the programme support the public health research capacity strengthening in low-income and middle-income
countries: a scoping review of the published literature, 2000–2016.
sector and are now on the frontline of the response to BMJ Open 2017; 7: e018718.
COVID-19. 3 Manabe YC, Katabira E, Brough RL, Coutinho AG, Sewankambo N, Merry C.
Developing independent investigators for clinical research relevant for
By moving beyond research capacity strengthening, Africa. Health Res Policy Syst 2011; 9: 44.
leadership programmes such as Afya Bora accelerate 4 Bates I, Taegtmeyer M, Squire SB, et al. Indicators of sustainable capacity
building for health research: analysis of four African case studies.
effective research use, prioritise public health problems, Health Res Policy Syst 2011; 9: 14.
5 Omaswa F, Kiguli-Malwadde E, Donkor P, et al. The Medical Education
and foster links between ministries of health, non- Partnership Initiative (MEPI): innovations and lessons for health
governmental organisations, and academic institutions. professions training and research in Africa. Ann Glob Health 2018;
84: 160–69.
Africa-centric leadership training that rapidly forges 6 Matenga TFL, Zulu JM, Corbin JH, Mweemba O. Contemporary issues in
a network of young leaders who can identify locally north–south health research partnerships: perspectives of health research
stakeholders in Zambia. Health Res Policy Syst 2019; 17: 7.
relevant health priorities, scale up evidence-based 7 Walsh A, Brugha R, Byrne E. “The way the country has been carved up by
researchers”: ethics and power in north–south public health research.
solutions, and communicate and marshal resources Int J Equity Health 2016; 15: 204.
is key to improving public health. Through rapid 8 Kalibala S, Nutley T. Engaging stakeholders, from inception and
throughout the study, is good research practice to promote use of findings.
situational analysis and broad exposure to programmatic AIDS Behav 2019; 23 (suppl 2): 214–19.
skills, future leaders must be able to design, implement, 9 Izugbara CO, Kabiru CW, Amendah D, et al. “It takes more than a fellowship
program”: reflections on capacity strengthening for health systems
scale up, evaluate, and iteratively improve evidence- research in sub-Saharan Africa. BMC Health Serv Res 2017; 17 (suppl 2): 696.
based research for policy and practice during health 10 Farquhar C, Nathanson N. The Afya Bora Consortium: an Africa–US
partnership to train leaders in global health. Infect Dis Clin North Am 2011;
crises such as COVID-19. Future pandemics are inevitable 25: 399–409.
and, therefore, investment in leadership beyond research
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Leadership training to accelerate progress in public health in

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