Health research, development and innovation capacity building, enhancement and sustainability

Research, development and innovation (RDI) encompasses undertaking research to contribute to new knowledge, developing policies, and generating products and services. Building health RDI capacity should be informed by the developmental gap, required resources and the impact. Low- and middle-income countries often face barriers to reaching their RDI potential. To address some of the RDI challenges, a framework is presented for building, enhancing and sustaining health RDI capacity at the researcher, department and faculty, institution and government dimensions, which is unpacked at the construct, expand, team, gear and leverage phases. Existing and new health RDI capacity requires building, enhancing and sustaining (constructing) before improving, refining and growing RDI expertise and portfolios (expanding). Collaborative RDI networks and robust partnerships should then be established (teaming) and researchers nurtured, with resources optimized to secure investments for embarking on new activities (gearing). Harnessing the collective RDI collaborations and partnerships leads to greater global competitiveness and sustainability (leveraging). Capacity building, enhancement and sustainability in health RDI addresses health challenges that contributes to improving health, economy and societal outcomes.


Introduction
Global health and development programs, like the Sustainable Development Goals (SDGs), have specific indicators and targets to establish road maps and budgets to mobilize resources in a partner coordination matrix, which could be applied for health research capacity strengthening [1]. Building, enhancing and sustaining health research capacity, viz. medicine, biosciences, public (and global) health and allied disciplines, is critical for growing and gearing (i.e. preparing and equipping) the next generation of researchers and clinicians for discovery and refinement of health solutions. With the aim of investing in research and development (R&D) by allocating ~ 2% gross domestic product (GDP) for building a knowledge economy, many low-and middle-income countries (LMIC) struggle to meet this target, given the allocation of resources for other priorities, such as addressing infrastructural and developmental lags. Funds are also prioritized for health services before filtering to health research. Research, development and innovation (RDI) encompasses undertaking research (R) to develop (D) policies and new products and services (I). Health RDI is the research, development and innovation to address health challenges by generating new knowledge, developing research to progress to the next 2 Health RDI framework for building, enhancing and sustaining capacity Figure 1 presents a conceptual framework that outlines the phases for building, enhancing and sustaining health RDI capacity; which requires constant monitoring, evaluation, input, refinement and maintenance. The key elements of the framework are depicted in Fig. 1 and the key transitions are listed in Table 1. The phases are to (i) construct: build, enhance and sustain RDI capacity; (ii) expand: improve, refine and grow RDI expertise and portfolios; (iii) team: establish collaborative RDI networks and robust partnerships; (iv) gear: nurture researchers and optimize resources to secure investments to pursue new RDI activities; and (v) leverage: harness the collective RDI collaborations and partnerships for greater global competitiveness and sustainability.
The construct, expand, team, gear and leverage phases each have specific actions to build, enhance and sustain research capacity across the researcher, department and faculty, institution, and government dimensions. For constructing, research capacity can be strengthened at the researcher, department and faculty, and institution levels, in alignment with national (government) research and development (e.g. health and economic policy development) priorities and support global initiatives (e.g. the SDGs), while planning for pathways for innovation. For expanding, at the researcher, department and faculty, and institution levels, building RDI capacity identifies and focuses on relevant and impactful RDI activities that can be improved and refined to grow expertise and portfolios. For teaming, identifying and conducting RDI of national priority and global relevance strengthens alignment with governments and global institutions that opens opportunities for collaborations and partnerships to create networks. This translates into greater critical mass and synergies to conduct RDI, and funding options to support future initiatives. Reciprocal complementary teams add value to collaborations and partnerships and leverage synergies. For gearing, the aim is to establish greater independence of researchers, departments and faculties, and institutions i.e. financially which entails greater funding inflows to subsidize research partially or fully. This can be achieved by successful grantsmanship from various funders and also presents an opportunity to attract new collaborators and partners as new RDI avenues present. For leveraging, steady high quality RDI outputs over time enhances reputation and track records,

Application of the health RDI framework
Examples of how the framework may be applied in practice will be presented by unpacking the phases (construct, expand, team, gear and leverage) across the dimensions (researcher, department and faculty, institution, and government).

Construct: build, enhance and sustain RDI capacity
The constructing phase focuses on building existing and new health RDI capacity at the researcher (individual), department and faculty, institution and government levels ( Fig. 1), that is enhanced and sustained by continuous monitoring, evaluation, input, refinement and maintenance. Researchers are broadly defined as research practitioners involved in RDI activities e.g. academic researchers, policy developers and makers, and innovators. Research encompasses RDI where relevant.

Researcher capacity
Researchers should identify the RDI gaps and their needs for building, enhancing and sustaining capacity (Table 1). Enablers of HRCS are to provide quality and relevant training for researchers, to recognize and empower research leadership (in departments, faculties and institutions), to build collaborations in support of career progression (that is equitable and transparent), and to provide tailored supervision, management and mentorship [10]. Researchers are equipped to plan and conduct research, to develop and apply methods to address health challenges, to establish and develop cohesive internal collaborations to be leveraged externally at the provincial (state or sub-national), national, regional, continental and global levels; and to advise, guide, support, supervise, manage and mentor early career researchers, particularly at national and regional levels [14]. General skills and training are important to develop holistic researchers who can apply project management tools, design excellent proposals, write robust grant applications, learn time and people management skills, and how to lead, train, motivate, mentor and coach researchers and teams. Early career researchers are the foundation for successful research institutions [15], and for maintaining continuity and excellence, and therefore need to be trained and mentored to become established scientists that drive their own health RDI activities in alignment with institutional and national (government) priorities. Effective and efficient health RDI capacity requires research and support personnel optimally embedded in the pipeline [16] to enable translation and discovery [15] (i.e. policies, products and services). At the researcher level, capacity development often intensifies during postgraduate training-at the masters, doctoral and postdoctoral career stages. However, researchers can also gain experience horizontally e.g. undergo training in policy development and practice, technology transfer, research administration; or in specific techniques such as specialized and advanced training in gene editing; all for the transfer and application at their host institutions. Placement in industry is important, particularly for innovation (e.g. biotechnology R&D) and broader health skilling (e.g. pharmaceutical production and quality control). The horizontal integration across departments and faculties in institutions with a good understanding of their vertical lines (their RDI discipline and specialty) will set individual researchers apart as they will gain a competitive advantage. The immersion of researchers in the RDI pipeline (conducting RDI) and across delivery platforms (supporting RDI) enhances process understanding, fosters creativity, and guides towards holistic systems thinking. To foster the development of national RDI systems that translates into enhancement and discovery, adequate support is required for researchers operating across the pipeline [15].

Department and faculty research capacity
Departments and faculties should support researchers in alignment with their RDI strategies, priorities and goals (Table 1). With critical mass in a department, growth can be fostered to build expertise in specific diseases e.g. a program in obesity can feed into diabetes, cardiovascular disease and specific types of cancer. The allocation of department resources should be assigned to grow certain aspects of RDI that will lead to a competitive advantage, with oversight from faculty leadership and management. For example, access to unique clinical samples (e.g. specific ethnic samples and rare disease samples), indigenous extracts, drug resistant patients (e.g. resistance to TB and other anti-microbial medications), and multimorbid patients (e.g. HIV/AIDS and TB patients afflicted with a non-communicable disease) often treated by polypharmacy, will elevate a department's research profile as they hold valuable assets and the requisite knowledge and expertise for conducting specialized, relevant and responsive research. This equates to research currency that attracts collaborators, partners and investors. With good research outputs and track records, their faculty, department and researcher reputations will be augmented. This will grow faculty and department capacity and stature that will attract collaborators who seek access to valuable samples, knowledge and expertise and will bring additional knowledge and expertise to grow and/or pursue different RDI directions. This translates into greater economies of RDI scale that elevates the team's global competitiveness. Multidisciplinary (additive) research harnesses the knowledge and expertise, within specific boundaries, in collaborative RDI teams (from different fields who investigate a similar but broad research topic); interdisciplinary (interactive) RDI analyzes, synthesizes and harmonizes the disciplinary interlinkages in a coordinated and coherent manner (researchers inform and compare perspectives by knowledge transfer across disciplines); whereas transdisciplinary (holistic) RDI transcends and integrates health, social, natural and other sciences (to blend diverse perspectives to understand complex research questions and challenges). To foster and develop the values and skills in collaborating multi-, inter-and transdisciplinary research teams, specific competencies are often required [17,18]. Complementary competencies should be harnessed to enrich the collaborating research team for greater productivity through driving knowledge generation, policy development and innovative health solutions.

Institutional research capacity
Institutional research capacity depends on the researchers, research support personnel and an enabling environment (i.e. supportive processes, systems and culture) [12] to build, enhance and sustain research capacity through harnessing the collective economies of RDI scale within the institution. Therefore, institutions should coordinate RDI activities by providing an enabling environment (systems, processes and support) ( Table 1). Designing RDI capacity strengthening programs in health, at institution level, requires clear goal setting, defining the capacity required to achieve the goal, determining baseline capacity and identifying the gaps towards achieving the desired capacity, delivering implementation and action plans to address the gaps, and learning by adapting and refining the plan and indicators [7]. Building institutional capacity is required to establish and sustain RDI that is aligned with a shared vision [19], mutual goals and focused on delivering improved health outcomes. To enable RDI, adequate infrastructure e.g. equipped laboratories and clinics, dedicated time and support should be provided by institutions [14] concomitant with sufficient personnel; and there should be freedom to conduct policy-and innovation-focused research. There should also be a shift where clinical and translational implementation is the required output; or alternatively, newer, cheaper and better treatments or improved processes for health service delivery. To maintain health RDI capacity, institutions should devise strategies and policies to grow and develop, retain and attract researchers by continuously improving and refining training, support and mentoring, and also provide access to resources [20][21][22]; i.e. to maintain and continuously make the environment enabling and geared to respond to health challenges. Sharing agile and mobile teams, responsibility and accountability is required with vested interest in making progress and reaching milestones. With virtual teaming applications becoming more frequently adopted and utilized, collaborations and partnerships are more easily managed to advance RDI.
RDI capacity should be integrated to meet the institutional demands. For a research institution that focuses on select diseases in response to national health priorities, there should be the assurance of internal cohesion for better outputs and impact. Focusing on infectious diseases such as HIV/AIDS and TB that burden citizens will lead to research outputs e.g. publications and graduated students. But ultimately the impact should lead to better health outcomes for citizens afflicted by diseases of high national prevalence i.e. institutional research should be aligned and converge to reduce morbidity and mortality from the most prevalent diseases. With a compromised immunologic and metabolic state, and the greater likelihood of living longer, HIV/AIDS patients are susceptible to opportunistic pathogens e.g. TB but may also later develop non-communicable diseases such as cardiovascular disease and diabetes as they age or due to adverse reactions to multiple types and/or more frequent treatments. This requires a necessary shift in focus as future research should be responsive to health needs. This also reflects a major health and economic burden i.e. the complex and high cost of treatment of chronic diseases, multimorbidity and polypharmacy afflicting an increasing number of patients over a longer duration as they age. Hence the integration of departments e.g. epidemiological, clinical and basic research should all mutually inform and reinforce each other and be supported by an enabling research environment (faculty and institution) that aims to realize translational research i.e. policies that introduce or improve practices and innovation that leads to products and services that bring in revenue. This configuration lends itself to making an impact with its focused relevance and responsiveness. However, silos and fragmentation often need to be overcome as non-collaborative mindsets may exist and research domains may be fiercely guarded.
Some institutions face infrastructural RDI capacity challenges. RDI and general operations capacity are necessary to support researchers. Institutions need a critical mass of researchers; adequate research support personnel (e.g. grant, financial, human resources and operations management); board and advisory committees (for institutional governance, review and strategy); and research, data and innovation management systems [14] to deliver RDI outputs. RDI capacity and capabilities are highly variable inter-and intra-country, particularly in LMIC, but need to be adequate to maintain fidelity to research protocols [14], that incudes harmonization of protocols for reproducibility of research at different sites intra-and inter-country. Other institutional challenges are budgetary constraints and no or limited access to timely information and data [14]. The strengthening of financial systems is integral for high performing institutions to facilitate better management of RDI income. Funders should offer training and share insights on financial management [23] and incorporate experiences that are conveyed to researchers. Following international ethics, grant funding and management standards is important to ensure that relevant topics are adequately addressed and that funds are not incorrectly allocated or misused but are used cost-effectively to gain the best possible value for RDI outputs and impact.

Governmental health research agendas
National, state (provincial or sub-national), municipality (city) and district (suburb) government departments should align their RDI strategies and priorities and identify challenges that need to be addressed (Table 1). Governments should set priorities, plan and coordinate research, support governance, enable regulation, facilitate knowledge translation and dissemination [24][25][26] and provide resources for the academic, policy and innovation health research tracks. Without country-level planning, action and guiding documents and policies in LMIC, health RDI is more likely to be influenced by international funders' agendas instead of focusing on the priorities of LMIC [27]. LMIC researchers should inform and lead their RDI agendas and foreign investors should be cognizant of the tacit knowledge held by LMIC researchers. Governments need to ensure that their health RDI priorities are being addressed and remain protected from external influences with potential conflicting agendas. Therefore, national health strategies should be lucid, integrated and preserved, and distinctive in alignment. There should be allowance for some deviations from global health strategies and standards to favor the development of LMIC RDI capacity specific to their own health priorities. In LMIC, particularly in Africa, adding value to health RDI requires evidence-based actions that are adopted by national and provincial governments to bring health to the forefront of development agendas [14]. Further, adding value to health RDI is realized by defining, financing and monitoring lucid national plans for a future health research [14] from which the outputs and impact emanate.

Expand: improve, refine and grow research expertise and portfolios
In the expanding phase, the focus shifts to improving, refining and growing RDI expertise and portfolios (Fig. 1).

Researcher expansion
Researchers should undergo relevant training and skilling, and identify projects to grow their RDI expertise and portfolios (Table 1). Investment in early career researchers and developing leaders, concomitant with building and providing technical, managerial and administrative support, will encourage and motivate researchers towards greater productivity [8] to generate RDI outputs and contribute to their development as researchers and principal investigators in preparation for leading teams. LMIC researchers are best informed to identify and tackle health challenges that afflict their countries and to generate high quality and relevant evidence to decision makers [28]. At a researcher level, refinement of research projects should occur in line with market information and research developments. From a health perspective, market information refers to disease burdens that are high, emerging or dissipating and will therefore inform resource allocation. Research developments, in a health market sense, refers to the expiry of patents or lost efficacy and drug side effects that could initiate research to discover and introduce new agents to the market. Researchers need to take ownership of their expansion pathways towards enhancing their RDI outputs and for advancing their career trajectories as they grow their research expertise and enterprise.

Department and faculty expansion
Departments and faculties should provide an enabling RDI environment, prioritize areas and grow their teams (Table 1). Individual researchers form teams that feed into departments, managed by faculties, that operate across institutions. Each team member is tasked to grow their research expertise and portfolios to contribute and align to robust department and faculty research expertise. For example, with an obesity epidemic, that presents a market (or target group) in countries with a high obesity prevalence, departmental teams can define their contribution along the RDI pipeline i.e. team members can be assigned to health promotion and disease prevention, or patient enrollment, others to conducting the research, others to data analyses and interpretation, others to research dissemination e.g. articles and theses that follow the conventional academic research route, or policy development and innovation outputs, and others can program or project manage the entire RDI process (i.e. provide governance (compliance, monitoring and evaluation) and scientific oversight). This reflects the collaborative nature of RDI in departments within faculties and institutions, but team members should also be conversant in all aspects of the pipeline, with expertise in one or more aspects for greater capacity and coverage. Innovation creation should be embedded from inception, through duration, to completion of projects. Essentially, better health outcomes should be the main deliverable, not articles or theses, for RDI outputs to have greater impact. Innovation can be initiated by identifying and pursuing leads from a study. For example, a subset of participants may be more resistant to the benefits of physical activity, healthy nutrition and/or treatments. Their genetic and molecular signatures may reveal insights into factors in signaling pathways that are modulated by specific lifestyle interventions and/or treatments; what accounts for unusual variability; which factors present in early, stable and advanced states of diseases; or novel factors may be identified to explain variability in responsiveness. Precision medicine can then be pursued to contribute to healthier patients as more customization per target group enables better overall health outcomes.

Institutional expansion
The alignment of the right fit of researchers across departments and faculties to address major RDI challenges is an institutional function to realize expansion and can be advanced by adopting multi-, inter-and trans-disciplinary approaches ( Table 1). For institutions, their overarching RDI strategy should focus on identifying, conducting and supporting activities that align with the national burden of disease (i.e. addresses the diseases that lead to the most morbidity and mortality in the country and can be further investigated at sub-national levels) but remains globally relevant and aligned e.g. diabetes, cardiovascular disease and cancer are global health challenges.

Government expansion
Enabling factors for RDI capacity building, enhancing and sustainability are shared visions and goals, collaborations, partnerships, training (including building skills and providing education), institutional support and leadership, monitoring and evaluation [29] and government buy in to protect and advance the health interests of society [30,31]. Government departments refine, build and integrate prioritized RDI activities that will have a positive social, education, economy and health impact (e.g. policy development for best practice and products and services derived through innovation) ( Table 1). LMIC led research capacity building, when coordinated at government level, will be better aligned to address the relevant health challenges, with enhanced ownership and the opportunities for building skills [32] at researcher, department and faculty, and institution levels. With scarce resources in some LMIC, it is important to focus on where the greatest health impact can be realized [33] despite the emerging diseases, outbreaks, multi-morbidities, polypharmacy and drug resistance that complicate disease treatment and management. Plague may be important in a few countries, but globally it will not be a priority. It cannot be ignored though; at the very least, there should be sufficient capacity to deal with domestic threats and outbreaks that transcend globally. The Covid-19 pandemic disrupted the global health landscape and highlighted the need for better preparedness for diseases that expand rapidly and globally. Further, education, the economy, employment and society were adversely impacted by the Covid-19 pandemic. The recovery post-pandemic is challenging, and some countries will lag even further as they navigate their disease burdens which have been shifted and exacerbated by the pandemic. Not all diseases can be investigated, thus the diseases require prioritization, and the practice is to allocate skills and funding, and to build critical mass to respond by reducing the disease burden that will have the most impact. For example, in countries with the highest non-communicable diseases morbidities and mortalities, focusing research, policy development and implementation, and innovation, to reduce the burden will translate into better population health outcomes, with healthier people contributing to greater economic activity. Governments need to selective expand key RDI areas and partner with high performing institutions that can deliver by conducting RDI activities that address the prioritized health challenges for better health outcomes for their citizens.

Team: form collaborative research networks and robust partnerships
In the teaming phase, collaborative research networks and robust partnerships are established (Fig. 1).

Researcher teaming
Researchers should be immersed in multi-, inter-and trans-disciplinary teams to realize synergies from their collective and complementary RDI activities (Table 1). Within a team, each researcher should strive to learn and reciprocate that learning, with other team members. Teams work in departments, across faculties, to elevate institutional RDI outputs, through harnessing their diversity and synergies.

Department and faculty teaming
Building expert teams in and across departments and faculties will foster multi-, inter-and trans-disciplinary RDI (Table 1). External drivers shape researchers' perspectives on the socioeconomic and political context and need to be understood to determine RDI priorities before establishing collaborations [34]. Research collaborations build capacity by pooling resources and sharing knowledge and need to function effectively to achieve greater RDI quality and impact [35]. For effective collaboration, reciprocity is key for enhancing RDI capacity and exchanging knowledge and skills [34]. If diabetes is being tackled, then data are required i.e. epidemiological data such as prevalence, incidences and rate of progression, subtypes; and clinical data on the treatments coupled to anthropometrical data. If treatment is not optimally efficacious, basic science studies could be designed to investigate drug interactions, gene editing experiments could be conducted, or loss/gain of function studies undertaken to reveal targets; informed by patients' samples that are sequenced, and precision medicine applications will provide accurate and holistic detail. Therefore, an overarching department and faculty research theme(s), with teams focusing on specific RDI activities to contribute to that theme, will build department and faculty capacity and expertise, address more complex challenges and elevate institutions' global statures towards greater excellence.

Institutional teaming
RDI capacity building thrives through supportive collaboration, mentorship, and the provision of training to develop management, financial and communication skills [36] to equip support teams to provide an enabling environment. RDI administrators, managers and leaders should collaborate with researchers to guide them on processes and systems, and inform them of funding and collaboration opportunities (Table 1). Institutions can form consortia with other compatible and complementary institutions. Integrated partnerships between the universities and health sectors accelerate RDI activity, capacity and readiness [34], which can be extended by partnerships with industry to drive RDI and be supported by the philanthropy sector. A strong consortium that covers the key components of the RDI pipeline, that can meet academic and innovation criteria, will be competitively placed to deliver outputs and attract further funding, collaborations and partnerships on a pathway towards sustainability. Reciprocal, complementary and value added institutional partnerships will enable the leveraging of synergies.

Government teaming
Task teams should be established to liaise, monitor, evaluate and convene RDI committees that identify researchers and institutions that can address prioritized government challenges ( Table 1). Committees that are constituted by diverse and knowledgeable members that represent the key stakeholders in health and related sectors should be led by governments for setting, monitoring and evaluating priorities, reaching consensus on the relevance and responsiveness of RDI being conducted, championing RDI, and mobilizing resources rapidly respond to existing and emerging health challenges.

Gear: nurture researchers, departments and faculties, and institutions
In the gearing phase, researchers are nurtured (i.e. prepared and equipped) and resources are optimized (at department, faculty and institutional levels) to secure investments to embark on new activities (Fig. 1).

Researcher gearing
Researchers are prepared, equipped and nurtured, in teams, to seek and secure funding (e.g. seed funding) and generate new projects (Table 1). In the research team matrix, there are typically new, emerging, established and/or prominent researchers. A critical mass of established independent researchers could develop sufficient new and emerging researchers to meet department, institution and faculty RDI demands. Sustainable independence refers to researchers who secure funding to conduct RDI, that is fully subsidized externally, and may cover a reasonable infrastructural overhead of 10-15%. Full sustainable independence is achieved when all RDI, operations and salaries are financed externally e.g. from grant income, providing training and/or revenue from products and services. This is realized by researchers making discoveries that are patented to yield products and services that generate income, with revenue reinvested to sustain current RDI and feed into future discoveries. Venture capitalism, philanthropy and crowd funding are sources to start up. More conventionally, multiple grant funding, and multiplier funding (where secured awards are leveraged to attract co-investment from existing funders and additional investment from new funders), awarded to researchers within a department from various funders can be used to start up. Successful grantsmanship from diverse and multiple sources to fund RDI activities often attracts new collaborations and partnerships.

Department and faculty gearing
Faculties should convene interdepartmental planning and strategy meetings to inform RDI directions, priorities and funding opportunities (Table 1). This will encourage researchers from different departments to collaborate on a shared faculty vision e.g. secure a five-year grant that will fund the full RDI costs for early career researchers to work across the faculty to address a major multimorbidity (health challenge) or build critical and scarce skills that can be applied across departments (e.g. biostatistics and bioinformatics). This is also an opportunity to monitor, evaluate, provide input, refine and maintain RDI activities at the department and faculty levels, that can be conveyed to the institution for oversight.

Institutional gearing
Institution managers and leaders should monitor and evaluate RDI to identify opportunities for growth and to invest and disinvest in activities based on outputs, relevance and responsiveness (Table 1). With institutional oversight, leaders play a role in identifying RDI opportunities when networking with national and international stakeholders and guiding researchers to form new collaborations, particularly by increasing their footprint in new countries. Further, some funding should be allocated for researchers to pursue high risk research, within a realistic time frame, that could yield high rewards e.g. a new income generating health product (e.g. a diagnostic, device or treatment).

Government gearing
RDI activities with the potential to inform policy or generate revenue through innovation should be prioritized (Table 1) and may lead to more rapid uptake by governments [32], especially when government stakeholders are involved and informed of the initiatives from inception, which may garner buy in and further support. Funders should collaborate with institutions to improve job security for researchers by setting fair employment contracts [36] and incentivize researchers to secure further grants.
For collaborations (researcher, department and faculty) and partnerships (institution and government), there are two broad concepts. The complementary principle is where each researcher, department and faculty, institution or government contributes expertise and resources that are complementary, and not duplicated but may be supplementary, to conduct and support RDI activities that are scalable and deliver mutually beneficially outputs that improve outcomes. The currency principle refers to the collaborator or partner i.e. their value as a contributor, i.e. what they offer, and what they can gain (reciprocity). For medical insurance, better data on their patients for more accurate forecasting of costs, and the opportunity to treat diseases earlier, even prior to onset (e.g. incentivizing obese and/or insulin resistant people to adopt healthier lifestyles to prevent diabetes), that will result in savings, reflects their potential gains. For companies, an opportunity to demonstrate that they value their employees and gain insight (collective and anonymous) on employees' health and personal challenges are gains. RDI teams in turn will benefit from receiving funding and/or support (e.g. data analysis or project management) and contribute to the well-being of medical insurance companies' patients and employees. Ultimately, people will benefit from better health and quality of life.

Leverage: harness collective RDI collaborations and partnerships for greater global competitiveness and sustainability
In the leveraging phase (Fig. 1), harnessing the collective RDI of skilled researchers who constitute excellent departments and faculties that constitute highly reputable institutions enables greater global competitiveness and sustainability. This drives and sustains RDI excellence.

Researcher leveraging
Researchers should harness collaborative networks to secure funding from diverse and multiple sources, grow networks and consistently deliver high quality and relevant RDI outputs with impact (Table 1) to maintain and improve excellence. Researchers require personal, frequent and flexible support from committed supervisors and mentors to guide them to produce quality, relevant and timely outputs [28] and to become more established by securing funding to sustain their RDI activities. Sustainability is achieved with financial independence and autonomy in decision making [7] which will contribute to global competitiveness.

Department and faculty leveraging
With overarching departmental and faculty research themes, building the collective RDI expertise and leveraging networks and consortia to secure larger funding awards will translate in generating more quality outputs (Table 1). Foundational excellence at the unit i.e. individual researcher level with competitive and marketable skills will grow successful departments and faculties that deliver quality research and innovation outputs frequently such as articles, graduates and products (new diagnostics, devices and treatments) and services (training, editing, scientific writing and mentoring) to further elevate their institutions' stature. This charts the path towards creating a sustainable RDI enterprise.

Institutional leveraging
Existing and new institutional partnerships are leveraged to harness RDI economies of scale for further elevation of institutional stature, competitive advantage and excellence (Table 1). Institutions should align and selectively partner with compatible and high performing institutions, and with shared interests and goals, identify and harness their collective RDI expertise, capabilities, funds and other resources to further elevate their global competitiveness. This should grow in a phased, timely and responsible manner, to apply resources where the most value and impact can be derived through RDI activities. Institution leaders can demonstrate that they value their researchers by endorsing the RDI, ensuring that systems and processes are enabling and adaptive to advance RDI, and by prioritizing and (re)aligning RDI with institutional goals [37]. Institutional sustainability can be realized by securing research grants, frequently publishing quality and relevant articles, developing policies (for implementation and best practice), and generating patents for products (innovation) [10] and providing services.

Government leveraging
Policies are introduced, refined or revised that lead to improved practices in government departments to realize greater effectiveness and efficiencies (e.g. systems, processes and costs), and revenue generated from innovation is reinvested in RDI with specific funding ringfenced for addressing government priorities (Table 1). Governments should mobilize funds, informed by their RDI priorities that address their health challenges, and, with philanthropy partners, incentivize the private sector (industry) to contribute to developing, marketing and sustaining innovation [38]. Public-private-philanthropy partnerships should be cohesive to address potential mismatches in national and global RDI priorities [38,39]. Further, governments should collectively coordinate and support the co-creation of a global RDI roadmap by analyzing the capacities in countries, and collectively, charting the steps for each country to enhance capacity and calculate the costs [38]. A global RDI roadmap should encompass the entire RDI life cycle, from laboratory to implementation science to innovation, and be monitored and evaluated [38]. It is imperative to prioritize and integrate RDI findings into practice [37] and to realize products and services for positive societal impact.

Limitations
The conceptual health RDI framework presents a guide for building, enhancing and sustaining capacity, but was informed by selective literature, a LMIC perspective, and limited by the paucity of relevant studies-e.g. some studies focus on building capacity to address specific diseases. The definitions of research, development and innovation may differ, and often only one of these aspects are the focus in studies, despite the need for greater integration. The framework can be reinforced and adapted by adopting principles and best practices from countries with advanced RDI track records. For some countries, the challenges to conduct and support RDI varies, due to resourcing constraints and conflicting priorities. Thus building, enhancing and sustaining RDI may only be realistic at researcher and/or department and faculty levels and progress may be gradual. Building, enhancing and sustaining capacity are separate, albeit interlinked, phases for advancing RDI researchers, departments and faculties, and institutions may struggle to shift from building to enhancing RDI. In addition, sustaining RDI is challenging in a competitive global arena, with changing priorities, under-resourcing, and competition for researchers. Future research can focus on the inputs for realizing RDI building, enhancing and sustaining (such as quality researchers), as each presents a direction for further development. To test the framework, indictors could be assigned that are specific per researcher, department and faculty, institution and government and be informed by the activities required to progress from building to enhancing to sustaining RDI.

Conclusion
Constructing, expanding, teaming, gearing and leveraging RDI are phases that advance global competitiveness, stature and lead towards greater sustainability. Building, enhancing and sustaining research capacity requires constant monitoring, evaluation, input, refinement and maintenance. Capacity building, enhancement and sustainability-across the researcher, department and faculty, institution, and government dimensions-that applies RDI to address health challenges contributes to improving health, economy and societal outcomes.
Author contributions MC wrote the main manuscript text, prepared the figure and table and reviewed the manuscript.

Competing interests The authors declare no competing interests.
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