Japan - Egypt - Sub-Sahara Africa
ICCI Story: Networking and Capacity Development for Combating Infectious Diseases
Fayoum University (FU) & Suez Canal University (SCU), Egypt
Countries and Institutions:
Providers in South: Fayoum University (FU) & Suez Canal University (SCU) in Egypt
Co-Sponsor in South: Egyptian Fund for Technical Cooperation with Africa (EFTCA), Ministry of Foreign Affairs of Egypt (MFA)
Recipients (in some cases, collaborators): Medical research institutions, universities, ministries of health, etc. in 27 Sub-Saharan African countries
Collaborators in North: National Hospital Organization Kumamoto Medical Center (KMC), Kumamoto University (KU), National Institute of Infectious Disease (NIID), Japan
Traditional Donor: Japan International Cooperation Agency (JICA)
"International Course for Clinical Immunology (ICCI)" is a unique example of triangular cooperation to accelerate human resources and institutional capacity development in medical sector through expanding network. Initiated by a Southern expert with strong leadership and commitment, ICCI illustrates comparative advantages and complementarities of "North-South" and "South-South" cooperation. The case also highlights the significant role of a spontaneous human network, which functioned as an informal brokering mechanism for demand-supply matching for South-South knowledge exchange.
Background and Set-Up:
a) Expected Goals of South-South Knowledge Exchange
(i) To enhance the capacity of African medical professionals in clinical immunology and laboratory diagnosis of infectious diseases; and
(ii) To strengthen institutional capacity of Egyptian Universities as SSC service providers.
b) A Model – Preceding North-South Cooperation
In 1988, an international training course "Blood Transmitted Disease Seminar - Special Reference to HIV/AIDS, ATL (Adult T Cell Leukemia) and Hepatitis Infections" was launched at Kumamoto Medical Center (KMC) in Japan. The course, which still continues to date, is financed by Japan International Cooperation Agency (JICA) under its global training programme. The lecturers of this course included leading bio-scientists and clinicians in Japan. It soon became one of most popular international medical courses, particularly among researchers in Africa. However, the training opportunities in Japan were limited to senior doctors with only around dozen of trainees accepted annually. KMC alone could not meet the growing demand for such training.
c) Inspiration for South-South Initiative
In 1992, Dr. Ahmed El-Gohary, an Egyptian clinical pathologist from Suez Canal University (SCU), participated in the course in Kumamoto. He was impressed by leading-edge technologies and dedication of Japanese doctors, as well as the quality of course organization and management. He decided to start a similar course in Egypt for Africa. He thought that the support of Japanese experts could ensure the quality of the training while providing more appropriate solutions for preventive health care services in Africa.
d) Complex Negotiations with Northern Donor
In the early 1990's, Japan (JICA) was supporting four triangular cooperation courses in Egypt, jointly implemented with Egyptian institutions. When Dr. el-Gohary brought a new training proposal, he and his university (SCU) had never collaborated with JICA, and its institutional capacity as an implementing partner was unknown. This required some negotiations and adjustment so that the proposal met the donor's basic requirements. Japanese experts involved in the original training played a catalytic role in this process, mediating the negotiation between JICA and SCU. Their support and professional guarantee of the technical capabilities of SCU finally convinced the donor. Egyptian Ministry of Foreign Affairs (MFA) also extended political support for the idea of a new course implemented by SCU.
e) Launching and Implementation of SSC
In 1996, "International Course for Clinical Immunology (ICCI)" was launched by the Faculty of Medicine, SCU, under the partnership agreement between Egypt and Japan. The curriculum was similar to the course in Japan, but it was tailored to focus more on endemic diseases in Africa, basic immunology and molecule biology. Junior doctors, technicians and paramedics were also enrolled in this course. More time was allocated for practical exercises in order to accommodate their needs. Japanese experts were invited as guest speakers, but most of the lecturers were from Egypt or other countries in the region. In this way, the South-South learning course reached more people in need of training with much smaller budgets. The ICCI course still continues to date, with continuous improvements and reinforcements of its curriculum . It has also become a popular course in Egypt with a total of 256 African researchers were trained in 15 years.
The ICCI initiative is supported by partnerships at various levels described below:
a) Higher Level Partnership – Macro Context for SSC in Egypt
In the early 1990's when Dr. el-Gohary came back from Japan with an idea of new training, governmental policies both in Egypt and in Japan were generally favorable for such a triangular initiative.
In 1980, the Egyptian Funds for Technical Cooperation with Africa (EFTCA) was established within Ministry of Foreign Affairs. In 1985, Egypt requested Japan for support, in order to expand SSC activities especially for Africa. JICA agreed to partner with Egypt and the first triangular cooperation course was launched in 1985. In 1998, the two countries signed a formal agreement on "Egypt-Japan Triangular Cooperation Programme for Promotion of South-South Cooperation in Africa". In 1999, Egypt started cost-sharing with JICA up to 15% of total training budget under EFTCA.
b) Informal, Individual Level Partnership of Experts
At the project level, an informal partnership among experts from North and South was the driving force to get the process on the ground moving forward. All four on-going triangular courses at that time were proposed by JICA, rather than initiated by Egypt. ICCI was one of the first cases of triangular courses in Egypt which was entirely led by the Southern expert's initiative. As mentioned above, professional guarantee by Japanese experts was critical for JICA in order to finally approve the funding of the project with a new, unknown partner.
This expert level partnership grew stronger over time, involving more people through the implementation process. This stable, long-term partnership is unaffected by frequent personnel changes in governmental agencies. It is one of the factors which made ICCI a long surviving SSC initiative.
c) Institutional Partnership among Implementing Organizations
As more people getting involve and the benefits of mutual learning through SSC were understood, the individual partnership was upgraded to institutional partnership: In 2000, SCU and KMC signed an official academic exchange agreement.
Furthermore, in 2008, SCU established the Scientific Center for Human Resources (SCHR), attached to the Office of Vice President. The Center is staffed with full time administrators working exclusively for SSC courses. The establishment of a permanent structure was an indication of the commitment by the university management. The center played important functions to ensure sustainability of SSC and institutional capacity development. It is a repository of institutional knowledge, including database of international experts/collaborating institutions and the know-how on course management and international partnerships.
d) Intra-African Partnership -Expanding Partnership and South-South Initiatives
As ICCI network continues to grow and expand, many new partnerships and initiatives are emerging. One of the results is a partnership among African institutions.
Among the beneficiary institutions in Africa, for example, Kenya Medical Research Institute (KEMRI) has constantly been sending its staff to be trained in ICCI course. KEMRI itself had received grant aid and technical support from JICA for nearly three decades, and now has also become a provider of SS services to neighboring countries. From 2000 to 2007, KEMRI implemented "Blood Screening for HIV/AIDS and Viral Hepatitis" course for African countries under triangular arrangement with JICA.
Notably, some of course leaders in KEMRI had previously participated in ICCI in Egypt and adopted some elements of ICCI in their own training courses. Realizing the benefits of reciprocal collaboration, KEMRI and SCU later exchanged lecturers in their courses. In 2005, SCU and KEMRI formalized such activities by signing an academic cooperation agreement.
e) Global Network of Alumni - Establishment of a Sentinel Surveillance System
As the training courses in Japan and in Egypt are being implemented parallel, a network of alumni has grown, covering Africa, Asia and Latin America. Drawing upon this human asset, a pilot initiative of sentinel surveillance system, Alumni for Global Surveillance Network (AGSnet), was launched in 1998 by Japanese course organizers. AGSnet was designed to contribute to global surveillance system of emerging and re-emerging diseases. At that time, official global surveillance systems concentrated in industrialized countries. AGSnet proved that such a small and informal network have a potential to supplement global surveillance systems.
SCU played an active role as an advisory member of AGSnet. Laboratory diagnosis practices during ICCI course contributed improving accuracy of data sent by African sentinels. SCU also conducted joint epidemiological research with Japanese researchers.
All sentinels participated AGSnet on a voluntary basis without any financial incentives. They were motivated by mutual trust and professional responsibility believing that they were making contributions for global infectious disease control. Follow up visits to sentinels also worked as encouragement for their continued contributions. AGSnet showed the importance of personal connections in surveillance network, especially for many laboratory professionals working in isolated conditions in developing countries.
Complementarity with North-South Cooperation:
a) Comparative advantages of Egypt
Egypt has comparative advantages over Northern donors in some aspect: It has relatively advanced medical care facilities and epidemiological research levels compared to many developing countries. With its proximity of epidemiological setting, it can offer appropriate technologies and replicable solutions easily adapted in Sub-Saharan Africa. Moreover, training in Egypt is much cost-efficient compared to that in Japan. However, this doesn't mean that South-South cooperation is an alternative to North-South cooperation. The ICCI case demonstrates that these are rather complemental. Each has different roles to play with different advantages.
b) Roles of North-South Cooperation
In the ICCI case, the preceding North-South cooperation presented "a model" to be followed by southern experts. Many aspects of the original course were reflected in the curriculum and management of the new course. In addition to financial and administrative assistance of the donor agency (JICA), support by northern experts was essential in materializing the SSC course. Their continued support during the implementation stage, as visiting lecturers, facilitated "learning-by-doing" of Egyptian course managers.
c) Mutual Learning – Attitudinal Changes of Sothern Experts
In this regard, northern experts observed attitudinal changes of Egyptian lecturers over the years of SSC. Initially, many Egyptian lecturers tended to have rather patronizing lecturing approach toward African trainees. This tendency was especially apparent among younger researchers who have less experiences and international exposures. One of young lectures mentioned to the author, that he had a preconception that Egypt was much advanced and that SSC was a one-way knowledge transfer to less advanced countries. This was wrong, he admitted. South-South knowledge exchange opportunity had completely changed his perception about Africa and he did learned many things from African researchers.
The observations by Japanese experts and the personal reflection of a young Egyptian explain that SSC offers eye-opening experiences for the service providing side too. Through knowledge exchanges and direct interaction with African and other international researchers, they realized that development cooperation was a mutual learning process. Many Egyptian lecturers were inspired by the experiences and decided to seek study opportunities abroad, or to start joint research projects with international expert. Some of them are now emerging as new course leaders to continue SSC initiatives at SCU.
d) Synergy Effect Enhancing Complementarities
Parallel implementation of North-South and South-South training courses is also beneficial for ensuring synergies between the two. Feedback information from both reduced duplications and strengthened comparative advantages of respective courses. The targets and focuses of two courses were clearly demarcated: The training in Japan is targeted to senior medical doctors, while training in Egypt is designed to accommodate laboratory technicians and paramedics. According to the observation by a Kenyan doctor who participated in the two courses in Japan and Egypt, the former was more lecture-based on advanced technology, while the latter was a basic immunology course with more focus on hands-on laboratory work.
How to Share – Lessons Learned:
a) Mechanism-Driven vs. Informal Network-Driven
South-South initiatives can be divided into two categories based on how they are identified and formulated. Some of SSC are facilitated through a carefully designed matching mechanism. A typical example is JARCOM case (Matsumi 2010. Ref: First Generation Case Story for Bogota HLE). Let us tentatively call it "mechanism-driven SSC". Under such a mechanism, demand-supply matching is made through a structured framework designed by central aid coordination agencies, often facilitated by northern donors with funding readily available. Achievements and lessons learned can be easily accumulated and documented under such structure, but the cases of such a mechanism are limited in number.
On the other hand, the ICCI initiative has been facilitated through informal and spontaneous networking of experts at the field level. Let us call it "informal network-driven SSC". It is estimated that the majority of South-South knowledge exchanges, including TCDC (Technical Cooperation among Developing Countries), are initiated through such informal networking. Though largely unrecorded because of its informal nature, they also offer real life lessons that can be reflected into global policy making.
Nature and processes of informal networks are diverse and not always replicable in different settings: It is not possible to make a single model or manual to proceed. Reports are available on outputs and results of SSC, but most of conventional studies do not tell who, how and in which context. Qualitative case story approach, focusing more on the process and context is an effective tool to understand how such informal network actually works and how it is contributing horizontal learning and capacity development. Some of the lessons come out of ICCI process are listed below:
b) Some Lessons Learned
- Triangular arrangement is an effective approach to facilitate South-South knowledge exchange. Preceding North-South cooperation can sometimes provide a model for Southern partners to adopt. Much longer-term mentors are often needed to support sustained institutional capacity rather than just promoting one-time knowledge exchange.
- Nontransparent and complex procedures and regulations of traditional donors often work as obstacles for new Southern partners to enter into triangular arrangement. In ICCI Case, experts from North can play significant role as a mediator.
- Strong leadership and commitment of individual change makers is still essential in many Southern institutions for starting up South-South learning. But it should be followed institutionalization of SS programme within the implementing organization. It is a critical step to guarantee sustainability and long-term capacity development.
- Past 60 years of North-South cooperation has created substantial stock of international cooperation experts. Many of them are from the South, who are often the "products" of preceding North-South cooperation. They are potential broker agents for South-South Cooperation.
- Mobility of such experts is very high and they often have up-to-date information on field level development needs and the best available southern resources to be matched with such needs. They are "living resource database".
- Projects, training events, international conferences/workshops and professional societies all could function as informal matching venue for South-South knowledge exchanges.
- Effective use of informal networks would substantially reduce transaction and coordination costs of demand-supply matching, and could produce unexpectedly positive outcomes.
- Informal networks are self-sustaining and proliferating. It can also mobilize additional resources/funding. Thus, it is often more sustainable than formal networks.
- Higher level actors, i.e. bilateral and multilateral donors, northern and southern governments, also have roles to play to facilitate such networking through creating enabling environment and providing policy level support.
- Capacity development is a long-term process and cannot produce discernible impacts even after several years of South-South training events. Governments/donors need to have longer term vision for supporting CD process. Large amount of investment is not necessarily essential, rather, longer-term, low-profile support could, in some cases, nurture local CD and partnerships.
c) A Case Story that Appeals to People
Real life case stories are powerful tools that can appeal to people. The life story of Dr. el-Gohary, who initiated ICCI from scratch, communicates strong messages and inspires young scientists involved in ICCI. A project always has an end, but people's stories continue. A comment of a young Sudanese resident doctor participated in ICCI in 2010 sums up:
"It still costs us a lot of money to come to Egypt. And so many of my colleagues desperately need such training. If we have a similar course available in Sudan, many people will benefit. Someday, I want to start a new course someday like Dr. el-Gohary".
On-going since 1996 (Each training course is five weeks)
Budget (Division of Responsibilities):
In ICCI Process, responsibilities are divided and shared by all partners involved in order to maximize financial, human and institutional resources mobilized:
1. Financial resources
Approximate costs for one training course for five weeks in Egypt (including honoraria and travel costs of two international lecturers from Japan) : USD 8,200/pax
(Ref: Similar clinical training course held in Japan costs USD 13,000/pax for three weeks)
The training budget (excluding honoraria and travel costs of two international lecturers) is shared by JICA (85%) and by Egypt under the Egyptian Fund for Technical Cooperation with Africa (EFTCA) (15%).
2. In-kind contributions
Egyptian implementing institutions (Fayoum and Suez Canal Universities) provide training facilities, lecturers and administrative services.
3. Other contributions
In addition to this, SCU and FU mobilized external resources (lecturers) from other medical research institutions, universities and international organizations (such as WHO, Pasteur Institute, Federation African Immunological Society (FAIS) and other professional societies, universities and research institutes from Africa and Middle East, etc.). In many cases, the honoraria and travel costs of these external lecturers are born by these cooperating institutions, adding to more resources to the triangular arrangement.
Name of Primary Contact Person:
Ms. Yasuko Matsumi (author of the case story)
Dr. Ahmed El-Gohary, M.D.
President, Fayoum University, Fayoum, Egypt
Dr. Isao Arita, M.D.
Director Emeritus, Kumamoto Medical Center, Kumamoto, Japan
Dr. Fumio Kawano M.D.
Deputy Director, Kumamoto Medical Center, Kumamoto, Japan