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Introduction
This background article discusses the partnership model of the Johns Hopkins University (JHU) Tobacconomics project ‘Accelerating Progress on Tobacco Taxes in Low- and Middle-Income Countries (LMICs)’ (grant number KC 085918), which is part of the Bloomberg Initiative to Reduce Tobacco Use. Over the course of more than 6 years of the project, the JHU Tobacconomics team has partnered with 34 think tanks in 20 LMICs; we have had continual partnerships for over 5 years with half of these think tanks. In that time, our partners’ research has been integral to informing more effective tobacco tax policies in 11 countries, while publishing over 190 research products in total, including reports, policy briefs and scientific journal articles.
In addition to these successes, we have also learnt many lessons. At the core of these lessons is the concept of mutuality and its direct relationship to sustainability. Although the scoping process to identify suitable partners used selection criteria, such as the motivation, capacity, impact and independence, we have learnt that successful partnerships have as much to do with us as with the partner.1 In fact, it is the ability for both partners to connect around shared objectives in mutual effort, respect and trust that have helped to achieve the aims of our project. In other words, getting the relationship right among us, the funding partner, and the research partners has directly affected the quality, reach and ultimate sustainability of the outcomes. Thus, we have learnt that the human element of cultivating relationships built on mutual respect cannot be neglected.
We have also learnt that there should be a natural evolution in healthy partnerships: from ones focused significantly more on capacity building to those based on collaboration as the partnership develops. Both stages are necessary when researchers are faced with a new topic; however, at some point, capacity building should evolve into collaboration. Notably, both stages should be undergirded by mutuality and respect.
This overview article to the third Tobacconomics Supplement traces this evolution and responds to the shortcomings of previous efforts to build research capacity while noting the way forward to increase the flow of high-quality, locally generated research to inform policies in LMICs. The second section reviews the literature on international research partnerships, followed by the application of these findings to the Think Tanks project with a discussion on the lessons learnt over the past 6 years. Finally, the research findings contained in this Supplement are incorporated into a conclusion outlining priorities for future research.
Literature review
Although global research partnerships between organisations in high-income countries (HICs) and those in LMICs are very common, sustainable collaboration which leads to evidence-based policy making can be more difficult to achieve. This requires durable networks of research institutions in LMICs to deeply integrate with local stakeholders and decision makers, as discussed by Siu et al in the overview article to the second Tobacconomics Supplement.2 Funders from HICs can support these connections by supporting LMIC institutions with the necessary resources and skills to produce and effectively disseminate high-quality and timely research.
The literature review below gleans important lessons from the many capacity building experiences of other actors in the field. From the many valuable contributions to build capacity, there have been lessons learnt for improvement, including lessons about the length of commitment and alignment with local priorities, from which our work has benefited. The existing literature examined below assesses these challenges, while offering alternatives and creative solutions.
Capacity building and its shortcomings
Capacity building endeavours require significant commitment from all actors involved. In the past, some of these efforts prioritised research outputs over genuine progress on research capacity building in LMIC countries, as discussed by Chu et al.3 An investment gap in some countries resulted in a limited local infrastructure for research production which continues to be a significant hurdle today. Mansour et al note that this is especially significant in fragile and conflict-affected areas, where staff and participants face the additional burden of navigating political instability.4
Capacity building programmes may consist only of short-term workshops or training programmes. Franzen et al criticise these efforts for concentrating largely on individual researchers, rather than taking a systems approach.5 Enhancing the skills of individuals, typically selecting high-performing ones, is problematic because it makes institutional success dependent on them in the future. Chu et al also note that these programmes oversimplify the complex challenges facing institutions in LMICs as they try to become successfully research-oriented.3 Building capacity on an organisational level requires longer-term investment and involvement from HIC funders that reflects the specific needs of the LMIC grantee, as discussed in Vogel.6
Researchers in many LMICs largely rely on HIC funding. This is one of the main concerns highlighted in Franzen et al.5 Similar themes emerged from interviews of grantees conducted by Van der Veken et al.7 As a result, the output produced may be disconnected from the needs perceived by the local researchers from LMICs. Chu et al emphasise that this practice potentially diverts scarce resources from the provision of other, necessary services.3
Inequitable power dynamics are one of the forces that contribute to the gap between LMIC and HIC research authorship. Kelaher et al found that the LMIC first authorship of global health research funded by HICs proportionally declined between 1990 and 2013.8 At the same time, LMIC first authorship of research funded by LMICs proportionally increased.
Cultivating more equitable relationships
Global research models have varied significantly over the last several decades. Initially, vertical research projects were commonly used to build an evidence base in LMICs, as described in Franzen et al.5 Under this model, researchers from HICs came to LMICs to conduct their research without considering local priorities, involving local researchers or assessing their impact on already-scarce resources. Engaging in this type of ‘extractive research’, which did not sufficiently benefit LMICs, faced criticism from local governments and other stakeholders. Chu et al note examples of such critiques, and highlights the Ministry of Health in Rwanda, which began requiring local authorship of publications when local data are being used.3
Increasingly, discourse surrounding global research has focused on equity in partnerships between organisations in LMICs and HICs. Faure et al present 10 domains, which are essential to consider when pursuing international health research.9 These domains include: funding, capacity building, authorship, sample ownership, research agreement, local health priorities, trust, acknowledging inequalities, recognition of stakeholders and communication. By taking each of these domains into consideration when establishing and continuing relationships with LMIC institutions, HIC funders can promote equitable and collaborative research. Ward et al go further to argue that ethical guidelines should be established specifically for global research to protect LMICs from harmful research practices.10
Even outside of the ethical considerations, LMIC institutions are better situated to reach the target audience in their countries and inform policy than their HIC counterparts. Franzen et al’s review of relevant literature concludes that evidence produced by local researchers is more likely to align with the existing political and cultural context which increases its uptake.5 Similarly, Kasprowicz et al discuss the benefits of African-led research in the continent, specifically.11 Local researchers are most familiar with the needs of their countries and are essential to the translation of research to policy. Organisations in LMICs contribute this unique and necessary expertise to global research.
An effective relationship between partners from HICs and LMICs is critical to facilitate evidence-based policy making in the long term. Resources and guidance from HICs can help to build and strengthen the flow of knowledge from research to policy makers. As Vogel discusses, the demand for evidence from the government may be limited at first, due to a lack of understanding of the value of research in the policy making sphere.6 Shifting attitudes of policy makers in LMICs takes time, requiring longer-term engagement on the part of local researchers, and thus, longer-term funding commitments from HIC institutions. Establishing ongoing and substantive communication and trust among global partners can also ensure that HIC institutions are able to fund research on relevant and time-sensitive topics in LMICs, overcoming a significant challenge identified by Van der Veken et al. 7
Application to this project
To address these challenges and to ensure the success of our endeavour, we integrated the following seven strategies into our work. Of course, these are not comprehensive solutions, nor are they silver bullets, but we believe these aspects of the project have helped to steer us away from the common pitfalls in international research capacity building and will hopefully ensure long-term sustainability of tobacco economics in the countries where we have worked.
Careful selection
Siu et al set out the partner selection process for capacity building partnerships.1 Motivation, capacity, impact and independence of the institution are systematically assessed through desk research, interviews and inperson visits. Typically, partnerships are institution-to-institution, so that the depth and breadth of capacity extends beyond individual researchers. Some situations have required flexibility with the scoping process, but the evaluation criteria have remained the same. Researchers with institutional backing need to exhibit genuine motivation to engage in high-quality research on tobacco. Given that the topic is specific in the field of economics, this is usually easy to assess. However, we did not always get this assessment right. In the partnerships that turned out to be less fruitful, it was almost always due to a lack of motivation, either to complete the work in a timely way, actively disseminate the research or meet the standards of quality set out by the research mentors. We acknowledge that there may have been a failure to inspire this motivation on our part as well, either through unclear expectations or other failures in communication. The lessons documented here came about in an iterative process, which means that we learnt many of these lessons through our own mistakes.
The next element of the scoping process is the assessment of research capacity within the think tank. Researchers must show a demonstrated ability to use economic models to analyse fiscal policies (and not necessarily related to tobacco). Publications, preferably peer-reviewed, are good indicators of this capacity. Additionally, the research produced by the institutions must show the potential for impact. A solid track record in policy change related to past research is a helpful indicator, as well as participation on economic councils, or other types of efforts to inform policy.
Finally, the independence of the institution protects the independence and credibility of the research findings. As a partner in the Bloomberg Initiative To Reduce Tobacco Use, this project has strict requirements against tobacco industry funding for all partners. Following the obligations set forth in Article 5.3 of WHO Framework Convention on Tobacco Control (FCTC), the first international public health treaty, research partnerships should be protected from the vested interests of the tobacco industry. Given that this initiative involves institutional capacity building, a thorough vetting process was implemented to ensure that the institution is free of any tobacco industry funding or influence.
The next stage of collaboration is also a deliberate and careful endeavour. Researchers on both sides have the option of continuing to work within the capacity building structure. Collaborations are encouraged only where both sides feel they would be beneficial, with substantive and agreed-upon contributions from each author.
Longer-term investment
Contracts of shorter duration are appropriate in limited situations, where capacity already exists, and a specific outcome is required. However, where capacity needs to be built, along with a progressive body of evidence in which one finding builds on another, longer-term partnerships are more effective. For example, estimates of the price elasticity of demand are often needed before researchers can take on other in-depth economic studies. The duration of the contract also affects the incentives for production. Usually, a longer timing extends the space between the project inception, where motivations are high, and delivery, where the anticipation of future work is connected with the successful delivery of current deliverables. This ‘space-between’ can allow researchers and funders freedom to learn and experiment in the research, but it also has the potential to create a lag in project momentum (and thus delivery), especially when researchers are juggling multiple projects, which most are. These incentives must be acknowledged to mitigate the risk of lag, either through shorter-duration contracts, or by interim deliverables and presentation or publication opportunities, so that the researcher’s attention and incentives are aligned with the expectations of the funding institution.
The incentives usually become a shared enterprise during the next stage of collaboration. Collaboration with our partners has involved applying for joint funding on several research projects as well as beginning to establish regional hubs where a selected partner takes over our capacity building role for new partners in new countries, while our team provides advice in the transition of management (and funding) of the project in that region. Working ourselves ‘out of the job’ enables the project to grow in that region and allows us to explore new regions and research. It also places leadership and funding in the hands of LMIC research institutions.
Cultural and environmental sensitivity
In the first overview article, Siu et al explain the project team structure, which includes Site Leads for each think tank.1 Typically, each Site Lead hails from the country or region and at the very least has spent substantial time living or working there. This type of structure has been essential to cultivating understanding and respect. Site Leads also become critical to growing multicultural understanding among other team members from the Global North. This understanding is not just limited to behaviour or social norms of communication, but also relates to other common challenges faced in LMICs, such as political instability, frequent electrical power outages, and increasingly devastating weather events due to climate change. Understanding the realities and global inequities fuelling these challenges has been critical to developing our ability to balance flexibility with the need to accomplish project objectives. This sensitivity has been an essential element in both stages of capacity building and collaboration.
Flow of funds
While the North-South flow of funds is a reality in our project, we also emphasise the contractual basis for the relationship. Contracts impose mutual obligations as well as benefits for both parties. Allowing the necessary time for genuine negotiation of the terms of a Scope of Work that outlines a detailed and concrete set of deliverables and budget, along with deadlines for drafts and final versions of the research, eliminates the ambiguity of unstated expectations. Importantly, the Scope of Work also establishes the time limits for review and comment on the funder side and outlines the research mentoring and technical assistance which will be provided, whether remotely or inperson.
As the project stage advances into collaboration, the flow of funds, although admittedly still North-South, involves pursuit of joint-funding opportunities from various funders, and sometimes even involves the LMIC research institution receiving the direct funding with our team standing on the sidelines in an advisory capacity as the leadership role transitions to the LMIC institution. While this is often a daunting undertaking, we believe it is a necessary step in actualising equity and mutuality, and ultimately growing the body, quality, relevance and impact of the evidence produced.
Regular communication
Once the contract is executed, regular communication is necessary. In addition to regular communication with the Site Lead—via email, text, chat, videoconferencing and so on—at each opportunity for an inperson meeting with leadership and the Site Lead, the partners have ‘one-on-one’ meetings, where we ask the important question: How can we do better? Some of the best recommendations for improvements to the relationship and the contractual terms have come through these regular, face-to-face meetings. This form of openness and humility has been critical to capacity building and to collaboration, as well as the transition between the two.
Local research priorities
In both the capacity building and collaboration stages, it is vital to give sufficient space for the think tank priorities within their local context. This means that sometimes the negotiation of the research topics in the Scope of Work takes longer, or that its development must align with the timeline of the institutional leadership’s research agenda setting for the coming year. To accommodate this aspect, we have learnt to begin developing the research agenda well in advance, sometimes as far as a year before the close of the previous grant period. If the research is part of the organisation’s overall priorities, the quality and reach of the outputs improve substantially.
Another way to ensure that the research fits with local research priorities is to work towards integration of the institution’s research team with local stakeholders, whether they are governmental or non-government organisations. Holding joint policy dialogues to understand divergent and shared interests helps inform research questions and their relevance to policy priorities. It also helps increase the uptake of their research, and ultimately, the contribution to more effective policy making.
Authorship
During the capacity building stage of the project, all of the deliverables were authored solely by the researchers in the LMIC research institution, including scientific publications. This was by intention, as we were engaged in a capacity building effort, which encouraged local ownership and dissemination of their research products. The Site Leads provided step-by-step guidance on the development of the research questions and protocol; training on the application of methodologies; review of the results; and development of the research product drafts and finals. This research mentoring was time and resource intensive, but the final products were owned by the think tank partners.
In 2022, however, once our team determined that many of the partners were already conducting research on their own footing, the Site Leads and the think tank partners now have the option to collaborate on coauthored publications with the think tank researchers serving as lead author as the preferred (but not rigid) arrangement. This partnership model had been requested explicitly by several of the think tanks who now conceptualise the partnership as peer collaboration. In the current Supplement, 8 of the 23 articles by project think tanks are coauthored collaborations and all are lead-authored by LMIC researchers.
Research in this supplement
The Research contained in this Supplement reflects the growing research competency of the think tank researchers in this area. In addition to assessing consumer responses to price increases broadly, the studies examined differences among population groups (Huque et al,12 Merkaj et al,13 Shimul et al 14) and regional trends in the affordability of cigarettes (Zubović et al 15). Several papers estimated the impact of tobacco on household spending and poverty (Macías Sánchez et al,16 Mugosa et al,17 Swarnata et al,18 Vladisavljevic et al 19) as well as the overall burden on health care systems and economies (Gligorić et al,20 Memon et al 21). Other research analyzed the macroeconomic impacts of tobacco taxes (Bella et al,22 Cicowiez et al 23) and the illicit tobacco market (Divino et al,24 Szklo et al 25).
Conclusion
This background paper has described seven important lessons learnt in the transition of this project from capacity building to collaboration on tobacco economics research. Further work should include an independent review of the project to understand whether the participants’ benefits and overall policy impact measured up to the design and intentions of the project team.
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Footnotes
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Contributors All authors contributed substantially to this article.
Funding This study was funded by Bloomberg Philanthropies (Bloomberg Initiative To Reduce Tobacco Use).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.