Towards equity in global health partnerships: adoption of the Research Fairness Initiative (RFI) by Portuguese-speaking countries

Research partnerships between high-income countries (HICs) and low- and medium-income countries (LMICs) often display a set of asymmetries that hinder the development of science, technology and health systems in the LMICs. In practice, this means that research partnerships, instead of addressing local priorities, often result in the appropriation of local data, the relegation of southern scientists to the category of ‘field experts’, the publication of research papers in high-impact journals without LMIC partners as coauthors and the tokenisation of LMIC partners and institutions to obtain competitive funding.^{1 2} There are numerous studies on power imbalances pertaining to research partnerships, often calling for general or specific interventions to improve them, but without apparent actual change in practice.^3–5

Over the past 20 years, only two explicit guidelines have been developed to tackle these imbalances. The Canadian Coalition for Global Health Research (CCGHR) developed a set of recommendations, focused on six main principles, to promote ethical partnerships, including the use of innovative methodologies.⁶ The Commission for Research Partnerships with Developing Countries (KFPE)⁷ has also advocated the use of 11 principles which deal with a wide range of issues, from agenda setting to dissemination. The work of KFPE is 20 years old, but it is not well known outside Switzerland; moreover, it does not provide a practical framework to assess how these principles are implemented in research projects and actual collaborations.

Other agencies involved in the advocacy of ethical research partnerships include the United States Agency for International Development, the Dutch Ministry of Foreign Affairs, the International Development Research Centre (Canada) and the Norwegian Programme for Development, Research and Education (NUFU).⁸ The Sustainable Development Goal (SDG) 17 is focused on partnerships as means to achieve the other SDGs, recognising that joint research in health and other fields is essential.

Funders of research partnerships are struggling with equalising the balance between countries and institutions. The United Kingdom’s Collective on Development Sciences (UKCDS) published a survey of research funder efforts to achieve more equitable research partnerships in 2017⁹ while, in the same year, the UK’s Independent Commission for Aid Impact (ICAI) published a report indicating substantial weaknesses in specifying, assessing and improving equity in research partnerships supported by the UK Grand Challenges Research Fund.¹⁰

While the intentions behind these initiatives are sincere, one may question whether they have practical implications, especially due to the absence of a metric or framework to assess their impact. The Research Fairness Initiative (RFI) was developed through wide global consultation by the Council on Health Research for Development (COHRED) between 2015 and 2017. It is a pragmatic tool that encourages all key stakeholders in global research collaborations to report on their approaches, policies and practices in relation to the partnership components of research. The RFI aims at creating transparency, enabling partners to negotiate before partnerships happen, increasing trust and sense of co-ownership, and building a growing global evidence base of best practices, guidelines and standards.¹¹ The RFI can be understood as a ‘compliance tool’ that promotes knowledge and use of already existing good practices and identifies areas where more work is required or where benchmarks can be developed.

The main difference between the RFI and previous initiatives is the attempt to go beyond ‘good intentions’, as it is a compliance mechanism which builds on a growing body of evidence on all aspects related to partnerships. This tool can be implemented by a wide range of institutions such as government departments, national research and innovation agencies, academic and research institutions, funders, philanthropies and the private sector.

The Special Programme for Research and Training in Tropical Diseases (TDR) was the first institution to prepare an RFI Report, publicly available since early 2018, and the Institute of Hygiene and Tropical Medicine of the NOVA University of Lisbon (IHMT/NOVA) has recently published their RFI Report. IHMT/NOVA was founded in 1902 and has been at the forefront of research on tropical diseases, often within networks and partnership projects, warranting IHMT/NOVA a strong international presence. IHMT/NOVA is particularly active within the Community of Portuguese Speaking Countries (CPLP). Research partnerships are supported by a wide range of national and international funding schemes and institutions. Some of them are specifically focused on the CPLP area, such as the ‘Partnerships for development’ programme of the Calouste Gulbenkian Foundation, as well as the Aga Khan Development Network. The Portuguese Foundation for Science and Technology often supports collaborative projects within the CPLP. In 2013, Portugal and Unesco signed an agreement establishing the International Centre for Advanced Training of Scientists from Portuguese-Speaking Countries in the Areas of Basic Sciences.¹²

Over the years, several networks have been developed within the CPLP to foster health collaboration understood in a broad sense, encompassing aspects related to governance, research, education and training of human resources.¹³ These networks are fundamental in the establishment of research partnerships and priorities, and include PECS–CPLP (Strategic Plan for Health Cooperation within the CPLP) (2009–2016, new edition in preparation); RINSP–CPLP (Network of National Institutes of Health in the CPLP) (2011–); RETS-CPLP (Network of Technical Health Schools) (2009–); Medical Education Network–CPLP; Network of Telemedicine–CPLP.¹⁴ The main difference between the CPLP and other intergovernmental organisations that emerged after the fall of colonial empires—such as the Commonwealth or the International Organisation of La Francophonie—is that it is not led by the Global North country—Portugal—in part due to the socioeconomic, demographic and diplomatic importance of Member States such as Brazil and Angola.¹⁵

IHMT/NOVA spearheaded RFI’s adoption by the Ministers of Health of CPLP Member States at their biennial meeting in Brasilia, Brazil, in October 2017.¹⁶ This led to the recommendation that the guiding principles and mechanisms of the RFI should be built into the scientific work of RINSP (Network of Public Health Institutes of the CPLP) and RIDES (Health Research and Development Networks of the CPLP). In April 2018, at the second joint meeting of RIDES, representatives of all Member States reiterated that “the guiding principles and mechanisms of the Research Fairness Initiative (RFI) should become ‘structuring scientific principles’ within RIDES”.¹⁷

The adoption of the RFI by IHMT/NOVA and the CPLP is an opportunity for the users of the RFI and for the RFI System itself. First, for IHMT/NOVA, the writing of its own RFI Report led to an institution-wide reflection on its own relationships with research partners. The first finding is a confirmation that IHMT/NOVA has taken substantial steps to overcome its own colonial past in the way it constructs and manages its research partnerships. For instance, IHMT/NOVA’s Administration Board, Advisory Council and Scientific Advisory Board include members from partner institutions from several countries from the Global South, and there are numerous institutional partnerships with Universities in Angola, Brazil, Cape Verde and Mozambique.¹⁸ IHMT/NOVA also incorporates academic staff from those Universities as Invited Professors. One of the outcomes of this change is that several training programmes were moved from Portugal to Angola, Brazil and Cape Verde. IHMT/NOVA has also participated in several collaborative research projects coordinated by LMIC institutions. However, the systematic nature of the RFI also indicated areas for further improvement, the main one being the lack of guidelines and clear policies on data sharing, public engagement with science and dissemination of IHMT/NOVA’s research.

Second, for the CPLP, the implementation of the RFI is likely to lead to a greater institutional awareness towards issues of fairness between partners and institutions with greatly differing research capabilities. The CPLP fosters cooperation between Portugal and a group of countries in Africa, South America and Southeast Asia that were once its former colonies. The CPLP was founded in 1996, 22 years after the Carnation Revolution in Portugal—the Fascist elite was removed from power, bringing an end to colonial rule. The CPLP is characterised by a sense of togetherness and solidarity and is focused on the promotion of the Portuguese language, a common ground to establish partnerships and cooperation in various fields, such as culture and health.¹⁹

Third, because the RFI is an open and evolving system, use of the RFI within CPLP will enable adaptation to its cultural and epistemological characteristics. As Jasanoff²⁰ argued, there are numerous ‘civic epistemologies’ which characterise national models of knowledge production and public accountability. The recent adoption of the RFI by the CPLP may contribute to further development and expansion of this mechanism, incorporating new methodological approaches and historical work related to public engagement with science, technology and health in Latin America and Africa.²¹ This could be interpreted as a form of ‘reverse innovation’,²² as experiences and approaches from LMICs can be mobilised to reconfigure compliance tools themselves, thus contributing to an ecology of knowledge and practices. A good example of ‘reverse innovation’, especially in the field of vector-borne infectious tropical diseases, is the fact that clinicians from LMICs usually have a much richer empirical experience than their HIC counterparts, as they work in regions where those diseases are endemic—their experience is of major importance to address these diseases as they emerge in countries like Portugal, France, Italy and Greece.

It is too early to state whether the RFI will be an opportunity to transform institutional practices, eventually leading to stronger research partnerships, but IHMT/NOVA’s expectation is that CPLP-wide implementation of the RFI will substantially support the research capabilities of all member states. The adoption of the RFI allows institutions to include the RFI Logo on their websites, reports and other relevant materials, thus enhancing their ‘ethical capital’. Notions such as ‘corporate social responsibility’, ‘responsible business’, ‘sustainability’ and recent debates linked to UK’s Research Excellence Framework(REF), focusing on ‘impact’,²³ illustrate how ethical capital is mobilised by public and private organisations as part of their brand management strategies.²⁴ Funding agencies themselves increasingly require researchers to frame their research proposals according to SDGs, and it is possible that in the near future certain compliance tools—such as the RFI—will be mandatory to ensure the ethical/moral integrity of a given institution.

The RFI Logo is valid for an initial period of 2 years, and it can be extended if RFI principles and guidelines are put in place by the adhering organisation—this process is monitored by COHRED, which aims at involving all relevant stakeholders in global health research. The preparation of an institutional RFI Report by any of the key stakeholder groups—government departments with responsibilities in research and science, national research and innovation agencies, research and academic institutions, corporations engaged in research, research funders, and international agencies and non-profits—can provide transparency in terms of their own role in generating equitable partnerships, also creating a global evidence base of good practices and, possibly, future benchmarks and standards. We are still in the early days of the RFI, and wider implementation and further research will be necessary to assess whether the adoption of the RFI by the CPLP will contribute to the empowerment of local institutions and to the transformation of the RFI itself.

Some of the indicators that could be used to assess the impact of the RFI on partnerships might include, for instance, the number of collaborative research projects coordinated by LMIC institutions; the number of peer-reviewed articles where the first author belongs to a LMIC institution; the number of patents registered by LMIC partner institutions or the number of new PhDs awarded to LMIC candidates stemming from collaborative research projects. These indicators may illustrate how the RFI benefits LMIC institutions, but a more comprehensive and systematic protocol still needs to be developed. Nevertheless, the experience at the IHMT/NOVA shows that preparing an RFI Report fosters greater awareness of all aspects of research partnerships, demonstrating that institutional ethics are deeply entwined with research management systems.