Structural levels
One of the main areas of disagreement in the capacity strengthening literature is the classification of the structural levels involved in research capacity strengthening. How these levels are structured and the interconnections between them determine how strategies for capacity strengthening are designed [74, 75]. The framework of Levels and Dimensions that emerged in the mid-1990s indicated that any capacity strengthening initiative should be examined from all of the proposed structural levels [76]. This framework is extensively applied; however, the specific structural levels used vary widely based on the organisation. For instance, the most commonly used structural levels of capacity strengthening, adopted by the United Nations Development Program (UNDP) and DFID, are the individual, institutional and organisational levels [41, 74]. The individual level includes researchers and research teams; the organisational level is composed of university research departments, think tanks and similar organisations; and the institutional level encompasses the regulatory environment and includes governmental bodies and policy makers [74]. Minor modifications to the classification of the structural levels listed above also exist in the literature. For example, LaFond and Brown [43] call these levels personnel, organisation and system, and in Cooke’s [40] framework, the individual level is divided into individuals and teams, and the institutional level is synonymous with the term networks [77, 78]. Meanwhile, Lansang and Dennis [69] add two additional levels: national and supranational, to address investments in capacity strengthening at the national and international levels. Bates, Boyd [18] combine the organisational and institutional levels together under the term “institutional” and add a societal level – similar to the “national” level of Lansang and Dennis’ work – while keeping the individual level that included researchers and research groups. The WHO, however, adopts a framework that has five structural levels that take into account the complexity of the public sector: individual, organisational, networks, institutional context of the public sector and action environment are differentiated from each other [76, 79].
Higher levels of categorisation can lead to unnecessary complexity in conflict settings. In our framework, we decided to adopt the three major levels used by DFID and UNDP: individual, organisational and institutional. However, we mainly focused on exploring the major themes and sub-themes that are related to research capacity strengthening at the individual and organisational levels since, as mentioned earlier, in times of conflict it is more than challenging to have interventions at the institutional level (off-white in Fig. 3) as defence, security and immediate humanitarian response are prioritised over research [30, 80].
External environment
In contexts of prolonged conflict, the external environment is an overarching factor in successful health research capacity strengthening, and should be the point of departure in thinking about the health research capacity strengthening process. Drawing on LaFond and Brown [43], we have used the following six factors: cultural, social, economic, political, legal, and environmental as issues to consider in the overall environment. This conceptualisation of the external environment is also seen in the DFID framework, which places external context and external intervention in the outermost sphere of influence [41]. Similarly, White’s framework also considers the social and cultural environment as the major determinants of research on health [44]. While the external environment certainly plays a role in any capacity strengthening project, it is particularly important in conflict settings, as each of the aspects of the external environment is affected by conflict.
Furthermore, the political and legal situation may be in a state of flux due to conflict that also makes the cultural and social aspects hard to identify due to the complexity and the variability in these determinants among affected populations. Therefore, the environmental situation with regards to the six factors above can greatly advance or delay health research capacity strengthening, especially in conflict [14, 80]. For instance, a recent study conducted by Al-Hamadani et al. [81] stated that the historical, ethical, cultural, political and institutional factors impede the development of health research and systems in Kurdistan, Iraq, with the ongoing conflict in the surrounding area and inter-dependence of these factors accounting for the failure or unsustainability of any efforts.
Funding, community needs and policy environment
Emerging from the external environment are a number of conditions that are critical to successful health research capacity strengthening, namely: the availability of funding, meeting community needs and an enabling policy environment. Many frameworks, especially those targeting LMICs, do not take funding into consideration at the early stage of capacity strengthening but rather consider it as a factor that might later influence the sustainability of the intervention [19]. However, in the MENA region, particularly in conflict settings, the availability of funds to strengthen research is highly limited [82], given the above-mentioned shift in priorities to defence and national security along with the lack of research culture. Finding funding opportunities is also problematic knowing that sources of funding for health research is often separate from funding for humanitarian programs and services. Thus, researchers tend to “tailor” their research to be suitable to funding by external agencies regardless of its social impact, thus rendering both funding and donors’ interests the major driving forces of research [83]. Though this is also common in non-conflict settings, its implications are much more significant in conflict where “useful” research that fits with the community needs is urgently needed, especially on the frontline.
Many frameworks consider policy as a key factor for research capacity strengthening. For instance, Bowen and Zwi [38] present a framework of action which is entirely influenced, if not driven, by policy; but they argue that the latter is mainly determined by evidence and thus can be considered in accordance with community needs. Similarly, Cooke [40] highlights the impact of policy on capacity strengthening on all levels of her framework.
Despite the important role that policy plays in driving research in stable settings, it has a secondary role in research capacity strengthening in conflict compared to other factors like funding, partnership with international institutions and the willingness of local populations to participate, all of which contributes to initiatives that have direct impact on research on health. Thus, we argue that while policy is often paralysed in conflict settings, community needs become a contributing factor to research. This is not to exclude the role that governments can play in promoting/hindering research and its capacity strengthening. For instance, health interventions in Lebanon are not strongly monitored by the government where international agencies have established parallel systems in response to the Syrian refugee crisis [84]. Similarly in Iraq, there are limited regulations on the private healthcare sector [85]. On the other hand, research is strongly regulated and monitored in Egypt [86] and Yemen, where any health intervention is highly controlled by armies or militias, depending on the site of the intervention, and is politically instrumentalised [87, 88].
Assessing existing capacity and needs
The immediate response to most emergency situations is a humanitarian impulse to act, and urgently. However, it is important to identify actual needs and priorities, especially in conflict where human and physical resources are already stretched [89, 90]. Thus, a comprehensive needs assessment to determine the actual gaps in research in conflict settings is crucial and should be considered as part of the planning process for research capacity strengthening [91]. Since such an assessment provides more upfront knowledge regarding research needs, especially on the frontlines, it can also be considered as a tool for evaluating ongoing interventions. As a result, our framework includes a feedback loop from this section to the one above (funding and community needs) so that interventions that meet community needs are prioritised for funding in an attempt to bridge the gap between evidence and practice, a problematic issue even in non-conflict settings [37, 92]. While the quality and quantity of data in conflict is usually limited, recent reports indicate improved data quality in conflict due to, to a large extent, needs assessments and research conducted as part of the humanitarian response [82, 93,94,95].
Infrastructure and communication
In spite of its importance, communication is rarely mentioned in the literature as a stand-alone factor for research capacity strengthening as it is mainly considered as one of the core concepts of partnership [96]. However, in conflict settings, communication – even on the local level – is challenging. So, providing access to reliable internet and other communication tools is crucial to conduct rapid and high-quality community-based research and to have effective capacity strengthening on both institutional and individual levels [97,98,99].
Infrastructure is a basic pillar in any health research capacity strengthening framework. For instance, Baillie, Bjarnholt [36] place resourcing, including infrastructure, at the very bottom of the pillars for research capacity strengthening for public health. In Cooke’s framework, principle number six focuses on “investing in infrastructure” as a specific intervention for successful research capacity strengthening. That said, physical infrastructure is not given much attention compared to other components like project management and annual appraisal [40]. In frameworks focusing on research capacity strengthening in the global North, much emphasis is placed on improving individual skills and governance over physical infrastructure that, despite its importance, is counted as an antecedent [43, 45, 65].
However, infrastructure is a main consideration and often a limiting factor in health research capacity strengthening in conflict settings. The availability of safe and accessible buildings to conduct primary research and training is crucial [49, 84]. Yet, we have seen ample evidence of how healthcare infrastructure has been a target of attacks during conflicts in Syria, Yemen and Iraq in recent years [100]. Hence, considering the challenges of providing safe physical surroundings, distance learning capabilities and communication with other locations is critical. This has been shown to be useful in conflict settings like Yemen where SMS text messaging was used for education and health promotion in a project conducted by UNICEF [101]. Similarly, tele-medicine was successfully used for mentoring medical doctors and providing clinical decision support in intensive care units in different parts of Syria and in operation rooms in Gaza [102, 103].
Similarly, a major entity that should be established and continuously monitored is the Institutional Review Board (IRB) for ethical review of research protocols. IRBs are often not well-prepared to provide rigorous and rapid reviews of health research protocols in conflict settings and with conflict-affected populations. As for the MENA region, there is a large disparity when it comes to the presence of regulatory bodies for ethics and their adherence to international guidelines. For instance, in Lebanon, a unified system of research governance does not exist, and hence research regulation is greatly influenced by the policies of individual institutions and their IRBs [104]. Syria and Iraq also do not have specific guidelines for research ethics but refer to international guidelines like the Helsinki Declaration, and International Ethical Guidelines for Biomedical Research Involving Human Subjects (CIOMS). Palestine and Yemen, however, have no documents that refer to any national or international guidelines for research ethics [105]. Thus there is an urgent need to strengthen the research ethics capacity at both the institutional and individual level in the region by having programs which are similar to Middle East Research Ethics Training Initiative (MERETI) and Salim El-Hoss Bioethics and Professionalism Program (SHBPP) [106].
Language can also be a barrier to conducting research in conflict, especially in the MENA region where along with Arabic fus’ha there are 16 other Arabic dialects which differ significantly from each other [107]; not to mention other languages that are widely spoken in MENA like Farsi, Turkish, Hebrew, Kurdish, along with several minority languages [108]. The interaction of local researchers with international partners and the dissemination of research findings also necessitates a knowledge of the English language by local researchers. As a result, infrastructure to mitigate language barriers like translators and presence of adequate language facilities in conflict are indispensable [109]. Despite being a common feature in both general and conflict settings, language barriers can have drastic consequences in conflict as the timely critical local narratives and qualitative data require rapid and accurate accurate interpretation.
In conflict-affected regions, funding, communication, and infrastructure are thus the main limiting factors for capacity strengthening and tend to be cross-cutting and interdependent. Consequently, infrastructure was incorporated into our model in a triangular shape that shows the additive nature of the factors included: physical infrastructure and a safe location is the top requirement for research capacity strengthening which can then feed into more advanced infrastructure building (labs, IT, etc.). The investments needed in infrastructure are usually larger than any single capacity strengthening activity or program, often needing large financial and technological investment, not to mention additional safety and security measures which could be challenging in conflict [49, 110, 111].
Training, leadership and partnership
Another framework that emerged in the mid-1990s with the Framework of Levels is the Framework of Partnership that focuses on the need for equitable and effective partnership between donors and beneficiaries or local and international bodies when strengthening capacity, so that sustainable development would eventually be locally owned [76, 112, 113]. Building partnerships is widely adopted in most of the health interventions in LMICs [75, 76, 114, 115], however the level of collaboration between researchers and relief agencies is still underdeveloped and challenging [116, 117]. To overcome this aspect, ELRHA’s Research for Health in Humanitarian Crises (R2HC) programme provides funding for partnerships between academic institutions and humanitarian NGOs. Between 2013 and 2019, seven funding calls have resulted in more than 50 studies being funded. A recent report by ELRHA highlighted the importance of strong collaboration between the different stakeholders involved in a project in a humanitarian setting as it facilitates data collection and thus leads to well-designed and contextualised interventions [118].
For Baillie, Bjarnholt [36], ‘leadership’ and ‘resourcing’ lie at the heart of the capacity strengthening process. In our model, training, leadership, and partnership are major research capacity strengthening activities. Training is part of the individual capacity strengthening process while partnerships takes place at the organisational and institutional levels. Leadership fits in the middle of these two categories. Similar to the research capacity strengthening levels, we modelled training, leadership, and partnerships as a Euler diagram, due to the overlap between these categories.
Farmer and Weston [45] discuss disciplinary diversity in partnerships, something we captured in the model in two ways: partnerships between researchers of different disciplines and those between different academic institutions and practitioner groups (e.g. from NGOs). This is critical to health research capacity strengthening in conflict-affected contexts since knowledge of different disciplines in sciences, social sciences, and medicine are required. Partnerships with practitioners are key in conflict settings as they will often have better access to affected populations [52]. Partnerships therefore help to bridge the gap between research and practice by involving practitioners in primary research.
We also included North/South partnerships in our model, as these can be crucial in many ways, such as providing distance learning, increased lab capacity, training, mentorship, and so on [69]. However, despite the potential benefits of such partnerships, there is a risk of inequality between local and international partners where research topics are specified by the Northern partners and the external funders, along with inequality in the distribution of the benefits of research [96, 119,120,121,122,123]. Endeavouring to overcome these inequities should be at the heart of any partnership.
For leadership, we focused on governance and mentorship. Governance or management is more of an organizational aspect and is necessary to build strong research projects, strengthen partnerships, and manage funding. Mentorship focuses more on the individual side of capacity strengthening and is crucial for increasing the number of young researchers in the pipeline. It can take multiple forms, but primarily serves early career researchers and students. Mentorship is often local, but can take place in North/South partnerships as well. We also note the overlap between mentorship and training: while mentors certainly provide training, there is some training needed for mentors/leaders to be effective [124]. This is an often overlooked aspect of capacity strengthening but can improve relationships between mentors and mentees and increase the number of researchers focusing on health in conflict and establish sustainable working groups [124]. Equally overlooked is reverse mentoring where early career researchers provide new skills and ideas to more established researchers. A great example of the establishment of such a working group is the International Working Group on Reproductive Health, which contributed to capacity strengthening in the MENA region by supporting and creating a research community that included early career researchers and seniors with multidisciplinary backgrounds [50].
Training, meanwhile, is important for expanding the number of researchers and improving their research and language skills. For health research capacity strengthening, it is aimed at two groups: students (undergraduate and postgraduate) and practitioners [125]. This is important in conflict settings where we primarily look to involve practitioners. These individuals may not have prior research training or experience so courses and workshops can be very effective at increasing the prospects and potential of joint projects. The trainings for both students and practitioners should include topics like qualitative and quantitative research skills, research ethics, and data analysis, all of which help in mentoring individuals who wish to conduct research during humanitarian crises [126].
Gender equity in academia is already a challenge even in the most developed countries [127]. As for the MENA region, gender gap is normalized but varies from country to country depending on culture, social norms, policies, and stability [128]. Ongoing conflicts and patriarchy have restricted the progress in women rights and their political roles. Yet following the Arab spring many countries are in a transition state, and deeply-embedded institutional and cultural barriers to gender equity are being questioned and reconsidered. Positive developments regarding gender equity in general, and women in academia in specific, can thus be achieved in the near future [129]. Capacity building interventions should promote gender equity, especially in conflict settings, by training, mentoring and empowering local female researchers to become leaders in the field of health research. Hence, “Gender Equity” as a theme in the framework is expanded to cover all aspects of capacity strengthening at the individual and institutional levels.
However, the extent to which training, partnerships and leadership can be implemented depends highly on the availability of infrastructure and communication which, as mentioned before, can be hindered in conflict unless advanced technology and innovative approaches are used to overcome these challenges.
Adaptability and sustainability
Sustainability is a crucial component of capacity strengthening, yet is a major challenge. Consequently, it is an essential part of frameworks for health research capacity strengthening, and is considered as part of the feedback loop within these frameworks [5, 37, 40, 41, 43, 130]. Sustainability is usually attained when the newly acquired skills and facilities following a certain intervention are well maintained and put to use, i.e. individual researchers and teams continue to conduct health research with improved quality [131, 132]. However, “uncertainty is the only certainty there is” in conflict and thus sustainability is challenged by many factors like funding, scarcity of resources, political and economic instability, the downward spiral of fragility including the collapse of educational and health systems. In conflict, the flight of health workers, researchers and skilled administrators is one of the key barriers to sustainability [133]. For example, thousands of health practitioners have left Syria since 2011, which has led to a severe shortage in health workers, especially in the most severely affected areas of the country, such as Aleppo where 96% of medical doctors had fled by 2014 [134, 135].
In our model, adaptability is purposefully placed before sustainability. In conflict, the whole setting is fragile and subject to changing dynamics. Capacity strengthening should thus align with humanitarian work with respect to preparedness and adaptability to changes, such as through the use of tools that can be set up and dismantled easily, data collection tools that could be used in emergencies like District Health Information Software (DHIS)Footnote 1 and KoBo,Footnote 2 and modifying the content of training to be more suitable to the current situation [136]. One example is MSF’s application that was launched in 2017 and is used by MSF fieldworkers and by organizations like WHO and UNICEF. The application is seen as a tool for training the fieldworkers as it provides the latest medical guidelines [137]. Another example is the MENA Youth Capacity Building in Humanitarian Action (MYCHA) programme, which conducts training to youth from the MENA region. It aims to empower youth in conflict settings by preparing them to be involved in response and conflict resolution and by providing six-month mentorship and support for their own humanitarian projects that they implement within their local contexts. The content of such trainings are regularly refined in order to address the realities faced in the field [138] This element is also the beginning of a feedback loop in our model. Capacity strengthening is a continuous process, and our feedback loop relates back to both the external environment and assessment of needs and priorities.
Monitoring and Evaluation
Another factor that feeds into the feedback loop is monitoring and evaluation [67]. The targets in our model are aimed at health research in conflict settings including evidence-based practice, auditing, and effective dissemination. Long-term impacts like changing institutional and policy norms to support conducting research with a social impact are also included within the monitoring and evaluation process. Such long-term objectives are in accordance with the strategies addressed in the DFID and Cooke frameworks that consider changing the rules of the game as desired long-term ends for capacity strengthening [40, 41].
In an unstable and high-risk setting, where even daily activities have to be negotiated and adapted, it is difficult to implement monitoring and evaluation activities, and to predict both long-term and short-term impact. Thus, in such settings, real-time evaluation for capacity strengthening, as a tool of continuous improvement and development, is more beneficial compared to the conventional thematic evaluation approach for frameworks of capacity strengthening due to the lack of knowledge and stability [49].
Another question that also arises is whether capacity strengthening in conflict should be considered as an end or as a process to an end [40]. Since long-term objectives are less likely to be achieved in fragile settings, it would be more realistic to consider capacity strengthening, with its standard indicators of dissemination and number of trainings conducted, as an end in the context of conflict when evaluating the intervention.