The Agence Universitaire de la Francophonie (AUF) is today one of the largest university networks in the world. With more than 800 institutions of higher education, and with research members sharing the French language, the agency is present on five continents. It is above all a formidable reservoir of expertise and experience. In the field of health in particular, many of its members work fields such as faculties of medicine, pharmacy and odontology, schools of public health, research centres and laboratories.
The AUF's current policy, validated at its last general assembly held in Marrakech, Morocco, in May 2017, significantly renews the vision of promoting academic Francophonie. Although long focused on the promotion of the French language (i.e. teaching French, or teaching in French in academic environments), the action of the AUF is now focused on how good responses can be provided to the challenges faced by the members of its network. The shared French language is considered more as a powerful lever for the collective solidarity we seek to develop than as an end in itself. This principle of active solidarity is reflected in the services provided to its members thanks to an exceptional network of expertise, which explains the agency's constant attractiveness, including in recent years to institutions that are not very French speaking and are more Francophile than truly francophone (more than a third of the members today).
These challenges are simple to state even though they are difficult to meet in many countries. The first concerns the quality of training delivered, research conducted and modes of governance. The second, which is becoming more and more crucial in all developing countries, is the professional future of its graduates. The third, which in some ways embraces the two preceding ones, is the societal role of institutions of higher education and research, their ability to fully integrate into their environment and their driving role necessarily implied by knowledge-driven globalization. Such challenges are essential to bear in mind because they are at the root of the most important issues in development.
A simple look at francophone Africa is enough to understand the situation. School enrollment in higher education is rapidly developing, to the point where the corresponding rates are now almost everywhere in the double digits, i.e. at levels that France had not reached one or two generations ago. There are many causes for this, such as progress in terms of development and the emergence of a middle class, as well as the aspirations of the younger generations under the effect of globalization.
This dynamic makes higher education more and more a mass education, but its conditions for success are rarely met. Despite some commendable efforts, many institutions are not able to provide the required conditions, namely premises, equipment, organizational methods or human resources. The consequences are terrible. There is a widening gap between the academic world and the territorial reality in which it occurs: that of a country's youth whose most educated part is at the same time having the most difficulty in integrating professionally.
In such a context, health occupies an important and interesting place. Firstly, it is an area of expertise particularly well represented in the AUF by many members, conferences of deans and various professional associations. Secondly, as a field conceived essentially to lead to trades, it integrates in the training course the question of employability as a primary purpose. Thirdly, it appears as a field which can potentially generate new activities thanks to the valorization of research. Finally, this domain corresponds to one of the major challenges of contemporary societies, particularly in developing countries.
One of the objectives of the promotion of academic Francophonie is to become a showcase of reference models in this area, especially on issues that have not always been given sufficient attention. The industrial valorization of research—or, to take a less fraught example, the training of personnel who work in basic health, particularly first-line personnel, who constitute an indispensable framework for any organized public health system—has thus occurred. Some recent studies show how the training of these personnel is rudimentary or totally absent, with their status and remuneration quite random. This example seems far removed from high-level research, but it shows the disarticulation of health systems where research, training and clinical practices are hermetically compartmentalized, leading to a global loss of efficiency and an increase in inequalities.
What place can the university hospital institutes (IHUs) hold in such a landscape, and what original contributions can they make to this vision of Francophonie promotion? The answer to this question can be provided through three elements stemming from the official definition of the IHUs as ‘places of scientific and medical excellence based on research and development.’
The first element is the originality of the model in its desire to link top-level research, care and clinical approach, training and industrial valorization, in response in particular to the shortcomings noted in hospital functioning and in the valuation of health research. The original alliance thus created answers questions regarding the quality of training and research and the employability of graduates, and contributes to solve major societal issues such as the three challenges mentioned above.
The second element is the timely relevance of this model in developing countries where health research, with some exceptions, is poorly structured or even absent and therefore even more estranged than elsewhere from clinical practice, let alone any industrial valorization or job creation. This has considerable qualitative consequences, including in the training and perspectives of the health workforce. This model, which is designed to compensate for the weaknesses of a health system in a rich country, could be a particularly relevant reference for developing countries, allowing them to move faster towards more efficient organizational models.
The third element is the very object of some existing or future IHUs. For instance, the IHU of Marseille is entirely devoted to infectious diseases. As long as the orientations of such IHUs integrate the geography of their research subject, they can constitute a powerful base of support to develop health structures in French-speaking countries of the Global South, contributing at the same time to solidly organize essential research, provide valuable improvements in clinical practice and create new activities that can generate skilled jobs.
The implementation of these three elements obviously supposes that many conditions are fulfilled. The first concerns the existence of a real political will to develop health research in the Global South. This desire, now explicit in many countries, has not yet found its means of realization, either in terms of endogenous financing or by external help. It is a major problem, particularly in Africa, and this real lack of public research policies is due to a blatant lack of resources. The equation is easy to understand. Delays in development are reflected not only in low GDP but also in the budgets of the states concerned, which represent a very small share of their GDP. This double weakness often makes it impossible to finance education and health—to consider two key societal issues—to meet the needs of these countries, especially when they are in the grip of internal or external conflicts, with public security requiring high expenditures. Perhaps a project to create an African Research Council, based on a transposition of the European Research Council (ERC) and the factors that comprise its success, will one day occur.
Whatever the financial solution found, it should lead to the creation of structures that have proven successful and capable of providing responses in the field of health to the challenges of the countries concerned by qualitatively enriching the health systems and existing hospitals, but without involving, at least immediately, the construction of new, significant structures.
The IHU model can inspire a more appropriate answer to this question, provided, however, that the need to link training, clinical research and valorization in areas with a strong development gap, as well as the need to better understand diseases, are taken into account.
We can imagine an IHU generation inspired by the French experience and transposed to the French-speaking countries of the Global South. It would be supported by all the brilliant researchers who originate from these countries and who work in the IHU or other French laboratories but who cannot return home for lack of structures to accommodate them. They would create what could be called university hospital institutes for development, or IHUD, (with the term ‘development’ here having a different meaning than that proposed in the official IHU definition), in which subjects related directly to endemic health problems would be addressed by the fertile alliance between high-level research, doctoral training, clinical practices and economic valuation, as demonstrated by the previous experience of the IHUs.
It would thus be possible to achieve several objectives simultaneously: to allow researchers from the Global South to return to their countries and help them build the health system; to contribute to creating the backbone of public health research; and to qualitatively enrich the supply of care and induce the birth of new activities. In this respect, the countries of the Global South, beginning with the French-speaking countries, could show an example of a new path of development in health, drawing lessons from the historical experiences of the countries of the Global North and at the same time inventing solutions better adapted to their specific contexts.
The experience of the IHU ‘Mediterranée Infection’ could bring such a perspective, its purpose being well adapted to such a transposition in the Global South. Its teams are already working in partnership with African teams, with a regular influx of a number of established and promising researchers from these countries enriching the pool of scientists. These researchers' being all francophones is an additional asset, not only because scientific exchanges are facilitated but also because such spin-offs for development would make Francophonie an example in a major field in terms of societal issues and in a context of a renewed conception of health research.
By creating IHUs, the ambition of the French government was to ‘invent the medicine of tomorrow, future treatments and new practices.’ The perspective opened by the experience of the IHU is to put such an ambition at the service of a new dynamic of active solidarity among French-speaking countries, thus making the French-speaking world a driving force of the medicine of tomorrow.
Conflict of interest
None declared.