The Commission on Health Research for Development, formed in 1987 and based on a global analysis of health conditions and health research, found that research is essential for health action, but also is needed to contribute new insights and alternative interventions . In its final report, presented at the Nobel Conference in Stockholm (Feb 1990), the Commission presented strategies through which the power of research could be harnessed to improve health outcomes and address health inequities, including the strengthening of expertise in research as “one of the most powerful, cost effective and sustainable means of advancing health and development” , p165.
The Council on Health Research for Development (COHRED), which was established in 1993 to promote essential national health research, stated in their Annual Report 2008 that within the last two decades: “there has been a burgeoning of global organisations, partnerships, initiatives and meetings – all focussed on strengthening aspects of health research for development across the globe, and each proposing a different route to this end” , p.2. One of the calls for action from the 2004 Mexico Summit (Ministerial Summit on Health Research) was for research capacity strengthening . The First Global Symposium on Health Systems Research held in Montreux (2010) called for ‘a new international society for health systems research, knowledge and innovation’. This symposium was the launch pad for the now highly active Health Systems Global network (http://healthsystemsglobal.org/) and the fourth global health symposium conferences is due to be held in Vancouver in late 2016. There have been numerous other conferences and summits over the last two decades which have emphasised the importance of health research capacity strengthening, but there is recognition that this is undervalued regarding the role it plays in improving equity of health service delivery and advancing human development . Alongside this and similar other calls for health research capacity strengthening are the divergent opinions on what constitutes research capacity strengthening and how this is to be achieved.
In the last two decades, there has been an expansion in the definitions and types of research capacity strengthening in the published literature [5–9]. Previously, there was a perception of research capacity development as funding studies in Lower and Middle Income Countries (LMIC’s) that focused on the individual researcher (technical skills, technology, career paths, peer reviews, publications). Underpinning many of these projects or initiatives was the assumption that the recipients were ‘empty vessels’.
… that is, the assumption by those who position themselves at the center of some form of knowledge production that there is no knowledge anywhere else, but only empty receptacles waiting to be filled. In other words, to put it bluntly, mistaking one’s own ignorance of what exists elsewhere – knowledge, information systems, practices – for their absence. , p.4
More recent literature relating to individual research capacity strengthening focuses on training models, particularly for MSc and Ph.D programmes. Davies et al.  found that scientists in the UK have nearly 1,000 times more opportunities to study for a Ph.D. than do researchers in LMICs and over half of postgraduate qualifications in LMICs were obtained wholly or partially overseas. The traditional Ph.D. training model involves training abroad at an affiliated institution and working with a researcher whilst maintaining linkages to the country where the student originates . The sandwich Ph.D. (The Swedish International Development Cooperation Agency model http://bit.ly/24jLKT3) has become more popular recently, whereby most of the training occurs in the home country, with short periods of time spent abroad for particular courses.
Though individual capacity development is still recognised as valuable, current understanding of capacity development has moved from the focus on the individual to a more multi-levelled approach where individual researchers, research teams and institutions, and the national research structures and environments in which they operate collectively constitute the national research system . Several authors consider three levels of research capacity: i) environmental and network capacity; ii) organisational/institutional capacity, and; iii) individual level capacity [9, 12, 13]. The importance of linking the various levels of capacity strengthening has been stressed . In addition to the three levels, Manabe et al.,  highlight a foundation level, “local context,” which outlines the need for capacity building to recognise cultural factors, alignment with local and national policies and strategies, trust among development partners, and local ownership. There is also recognition that capacity development goes beyond training and beyond the implicit assumptions of capacity building (where it is assumed that the community does not have any capacity at all to begin with and that the outsider is starting from scratch).
The earlier literature on research capacity strengthening emphasised LMICs’ role in building capacity with researchers at the receiving end, displaying north-south inequities in the process. In recent years, it has been reported that often the Higher Income Countries (HIC) researchers capacity is also enhanced, as they learn from their LMIC colleagues how to deal with different cultural contexts, and how to adapt research methodologies. Here, research capacity strengthening is seen as a two-way process . But knowledge gaps still exist on culture and context in the health research partnership capacity strengthening literature [15–17]. Maher et al.  demonstrate the distinct layers of culture within and between different institutions and disciplines and highlight the importance of learning different organisational cultures and structures, although these layers are not explained in detail in their study.
Thus, within the research capacity strengthening literature, there is recognition of the need for a more collaborative approach to research capacity strengthening, for capacity development to be viewed as a two-way process and for training that is adapted to the context and culture in which it is to be used. For this article the definition of health research capacity of the Global Forum for Health Research in 2004 is used.
Research capacity development is the process by which individuals, organizations and societies develop abilities (individually and collectively) to perform functions effectively, efficiently and in a sustainable manner to define problems, set objectives and priorities, build sustainable institutions and bring solutions to key national problems., p.150
There is also an expanding debate on the role of technology in teaching and training that is also relevant to strengthening research capacity. The benefits of using web-based tools (commonly defined as online tools and other network resources and technologies) include overcoming temporal/geographic or physical access barriers; providing searchable content and encouraging interactivity; achieving greater student focus, as learners can have greater control over timing and sequence of learning; and obtaining higher retention and improved student satisfaction [19–24]. Pedagogical advantages that are suggested include supporting constructivist approaches to learning (whereby learners construct their understanding and knowledge through experience and reflection) and socialising online learning to a greater extent than previously possible . Web-based tools also offer greater flexibility in the learning process, easier publication and reusing of study content by students and teachers/trainers , and; facilitating more active learning and collaborative knowledge building .
While recognising the potential of electronic learning and the explosive growth of the Internet as important drivers of education transformation, the challenge for many educational institutions and individuals of poor information technology infrastructure needs to be addressed . Given that it may not be feasible to offer fully online programmes in many parts of the world due to inadequate internet connectivity, low bandwidth and limited computer ownership, blended learning approaches may be the most appropriate [29, 30]. A blended learning programme is a combination of face-to-face instruction with computer-mediated instruction .
Technology enhanced learning can also be seen as a means for resource constrained countries to improve access to medical education and overcome a shortage of teachers/trainers . Ellaway and Masters  noted that e-learning has become mainstream in medical education (e-learning covering broadly ‘the educational uses of technology’), and the amount of e-learning resources available to an educator has increased dramatically . However, a recent survey of courses in health policy and systems research reported that the use of online education or technology enhanced learning was minimal, both in LMIC and HIC settings . Therefore, although the transformation of medical education through e-learning has started, it needs to be adapted and tested in new areas such as research capacity strengthening; and it needs to be supported to meet the growing demand and the need for greater access to it, especially in the global south where institutional and other resource shortages are greatest.
The information society  with the corresponding explosion in technology choices and available information requires changes in how we educate or teach. In transforming education to strengthen health systems Frenk et al.  note that there needs to be explicit links made between the education of health professions and the health systems where they will practice, which requires the design of new instructional and institutional strategies. They argue that this requires a move away from "… inward-looking institutional preoccupations to harnessing global flows of educational content, teaching resources, and innovations” , p.6. Additionally, they note the need for new competencies to be developed to deal with the explosive increase, not just in the volume of information, but also in the ease of access to it.
Working within this information society requires new skills in aggregating and analysing vast amounts of information and in the extraction and synthesis of knowledge that is necessary to researchers for professional practice . This point is echoed by Ruiz et al.  who emphasise that new skills are needed by the educators to transform from traditional teacher to a curator of information and facilitator of learning. “We must embrace, adapt to, and harness technology in order to meet the needs of present and future health professionals” , p.439. Just as technology enhanced learning is becoming essential for the health professional and the health systems practitioner, it can play a role in strengthening research capacity in ways that are cost effective and culturally appropriate, through allowing researchers to remain in and develop their skills in LMIC settings and while on-the-job.
This article explores the use of technology enhanced learning in the delivery of a collaborative postgraduate blended Master’s degree in Malawi that focused on research capacity strengthening in community health systems research and addresses two research questions:
Can technology enhanced learning be used to develop health research capacity?
How can learning content be designed that is transferrable across different contexts?
MSc in community health systems research
The Community Systems Strengthening for Equitable Maternal, Newborn, and Child Health (COSYST-MNCH) project was funded by Irish Aid/ Higher Education Authority (of Ireland) 2012–2015 as part of the Programme of Strategic Cooperation between Irish Aid and Higher Education and Research Institutes . The project was a partnership of experienced development workers, researchers and practitioners in the Royal College of Surgeons in Ireland (RCSI – lead); College of Medicine (CoM), University of Malawi; Concern Worldwide (CWW), Ireland and Malawi, and; Dublin City University (DCU), Ireland. The goal of COSYST-MNCH was to achieve a better understanding of community systems factors underpinning maternal, newborn and child health (MNCH) services in Malawi, focusing on the health dimensions of the first 1000 days of life.
COSYST-MNCH had two components. The first was research case studies of districts and community settings where CWW Malawi was already implementing projects. A central aim was to understand how community systems influence MNCH service utilisation. Inherent in this approach was an understanding that broader intersectoral factors such as hunger, nutrition, and poverty are major determinants of MNCH service utilisation. The second component involved the development and delivery of a Masters in Community Systems Health Research in Malawi. This component offered capacity development opportunities to all the country partners in the form of blended learning – combining new technology enhanced modules and face-to-face training.
Through these two components, COSYST-MNCH aimed to:
establish an international and cross sectoral research partnership to enable learning by the partners and generate knowledge on and for strengthening community systems for MNCH;
improve the evidence base on the community systems obstacles and enabling factors underpinning MNCH service utilisation in Malawi within the first 1000 days of life, and;
enhance capacity amongst key development partners (i) to identify, measure and analyse health problems and services at the community level, using both quantitative and qualitative methods, and/or (ii) in designing and delivering technology enhanced education.
It is within the second component – the blended learning Masters – that, as reported here, a range of e-learning technologies and applications were used with varying success and acceptability.
The MSc in Community Systems Health Research was a blended Masters programme, comprising a modular taught course and research dissertation. The MSc targeted practitioners and students with a background, experience or interest in community development, who wished to develop and/or build on existing expertise in health research. An objective of the partnership – by undertaking the pilot in conjunction with and located in CoM – was to introduce an innovative e-learning educational programme which could be taken over, adapted and accredited through the University of Malawi, once the pilot phase was complete. The MSc was launched in March 2014 in Malawi and was tested and evaluated over the period 2014–2016. RCSI led the project with DCU providing technical and academic support, and academic and logistical input provided by CoM and CWW. The MSc was accredited by RCSI.
The MSc combined technology enhanced online modules with face-to-face sessions delivered in Malawi. Approximately 80 % of the Masters was provided online. The learning technologies used in the programme included Padlet (https://padlet.com/), Twitter (www.twitter.com), Wikispaces (www.wikispaces.com), Google Docs (docs.google.com) and Wordpress (https://wordpress.org) - tools specially selected to enhance learner-content, learner-learner, and learner-instructor communications. In computing terms these web-based tools that were used are not particularly new or novel, but it can be argued, due to their limited application in educational context, that they are new and novel in the field of education. Downes  argues that the emergence of the newer web-based tools is a social revolution rather than a technological revolution – a culture referred to by Bryant  as the ‘always on’ culture.
The structure and outline of the modules were agreed at a 2013 cross-country workshop that involved all the partners, where there was consensus on the need for a balanced mix of quantitative and qualitative research methods. The MSc comprised six modules, with two delivered in each of 3 semesters in an 18 month period. Each module was taught over a period of 8–9 weeks. The modules covered health systems, community systems, epidemiology and statistics, research methodologies and methods, and measuring health. An orientation module was designed to acclimatise learners to an online learning environment, introduce them to the programme and to some of the tools that would make up their future educational journey. Students were required to complete this non-credit bearing module before commencing the six core modules. Each semester, a one week intensive course was delivered mainly by RCSI and DCU staff with support from CoM, covering the two modules in the forthcoming semester. After the six modules were completed students continued with a research project and thesis write-up over an 18 month period. The teaching materials and supporting activities were hosted in Moodle (https://moodle.org), an online virtual learning platform that is widely used by higher education institutions worldwide, and a CD version of these materials was created to provide offline access to content. Pre-paid internet access cards were arranged for the students, allowing them five free online hours per week, which was deemed to be the amount of time necessary for completion of the weekly online activities. Development workers/practitioners employed by two Non-Governmental Organisations (NGOs) working in development in Malawi comprised the first intake to the MSc (5 students).
The use of web-based tools requires a pedagogical shift on the part of academics - a change from ‘teacher-centred knowledge-transfer’ models to a more active and constructivist approach to problem solving: ‘A new educational culture and mind-set as well as overcoming considerable organisational barriers are important prerequisites’ for this approach , p.265. However technology alone will not deliver the educational benefits, which: “only becomes valuable in education if learners and teachers can do something useful with it” , p.24.
Improving the technical competencies of students, teachers/trainers and the wider programme team across institutions was a key aim of the project. Professional development for educators lowers technology anxiety and discomfort and therefore encourages adoption of learning technologies . Formal information and learning technology training sessions were conducted in Ireland and Malawi to share plans, experiences and best practices across institutions, and to extend technology enhanced learning competence beyond project members. These were supplemented by tailored, one-on-one training for individual teachers/trainers, delivered by a learning technologist, as they initially developed online content.
The Masters programme, by seeking to directly build the research capacity of NGO staff – rather than just involving them in the collecting of data for the research element of the project – aimed to achieve a more equitable partnership between academics and NGOs, by enabling NGO staff to work towards academic awards, while also facilitating the completion of the larger project. It also offered experienced RCSI staff, most of whom had limited or little experience of technology enchanced teaching methods and approaches, opportunities to spend time on creating content and reflecting on modes of delivery in new and often challenging ways. The benefits of technology enhanced learning were not limited to the development of online content and extended to the design and delivery of existing face-to-face education programmes in RCSI and CoM.