The foremost principle of the Takemi Program’s concept and practice of international health is that seeking new knowledge through research is essential to health improvement. Each Fellow is expected to carry out a research project, based on data collected before arrival at Harvard and using the university’s resources available through faculty members, libraries, and computer facilities. Many mid-career professionals lack adequate time to analyze data, read journals, and write papers for publication. The Takemi Program provides its participants with “protected time” — away from the administrative, teaching, and other obligations at home — and with access to high-quality resources, in people, books, and courses. Each Fellow is expected to produce at least one research paper of publishable quality, on a topic of major importance to health policy.
Research papers completed by Takemi Fellows include: the determination of factors affecting maternal health service utilization in rural Nigeria; a critical assessment of the development of national health insurance in Korea; the role of private physicians in controlling tuberculosis in Bombay, India; the impact of population growth on the demand for health services in Malaysia; analysis of occupational lung diseases in a textile factory in Nicaragua; development of indicators to assess community health needs in urban India; an economic analysis of community participation in malaria control; and air pollution effects on pulmonary function in China.
The principle here is that Takemi Fellows are sharpening their research skills to participate in the world-wide health research system by adding to national and global knowledge on how to allocate resources better, in various countries and on different substantive problems. Some of the research papers use highly sophisticated statistical analysis to uncover unanticipated patterns of association in field data. Other papers employ epidemiologic or demographic modeling techniques learned at Harvard and applied to data sets from home countries. Some papers use policy analysis techniques based on economics, others based on political science. Each of the Takemi Research Papers is a contribution to the essential research needed in every country to assess the nature of health problems and the effectiveness of proposed solutions, as advocated by the Global Forum for Health Research, and each of the Fellows, as a result of his or her year in the Program, is better qualified to conduct research in the future.
A second principle is that the Takemi Program is aimed at producing research that assists in the design, implementation, and evaluation of health policy. From its start, the Takemi Program has concentrated on areas where not much support has gone: the study of health problems from the perspective of policy makers (rather than laboratory research). Individual Fellows, for example, have carried out epidemiological analyses that seek to explicate the contours of specific diseases (such as tobacco-related cancers in India) or economic analyses that show the cost-effectiveness of implementing certain programs (such as the use of deep-well water in China to reduce diarrhea) In presenting their research plans and analyses, Takemi Fellows are pushed by their colleagues and advisors to specify the policy implications of their projects.
Takemi Fellows are encouraged to bring their research results to policy makers in the United States, international organizations, and in their home countries, and to seek changes based on their research results. One Takemi Fellow, Prakash Gupta, testified before scientific commissions in the United States on the health implications of smokeless tobacco; another, Chinyelu Okafor, advised private foundations on the design of programs for improving maternal health in Africa and then helped implement the plans. A third, Boniface Nwakoby, had the opportunity to present his research findings directly to his Minister of Health, Professor O. Ransome-Kuti, in a seminar during the latter’s visit to the Takemi Program. Several Takemi Fellows (from Belgium, Denmark, India and Nigeria) have assumed positions at the World Health Organization. Many Fellows work with international organizations and bilateral aid agencies in their home countries, in the formulation and implementation of health programs and policies.
In addition, the Takemi Program has helped organize a major international meeting (the Takemi Symposium on International Health) on a critical policy issue. These symposia are attended by leading experts concerned with issues of international health, from universities, international agencies, and government ministries. The international meetings lead to published volumes, which include papers by Takemi Fellows. The books so far have addressed issues of: the conceptual bases for health policy in the 21st century; policy responses to health, nutrition, and economic crises in the Third World;the prospects and problems of international cooperation for health; working populations and occupational health in the Third World, and ethical issues in health and development.
The Takemi Program is firmly based on one of Dr. Takemi’s main principles: that interdisciplinary study is necessary if health problems are to be analyzed correctly. Each year of Takemi Fellows includes individuals with an array of disciplinary backgrounds, as noted above, including economics, epidemiology, community health, nutrition, biostatistics, social sciences, and clinical medicine. The Program is based on the conviction that research in public health policy requires a solid disciplinary foundation, but also a broader contextual understanding of the social environment within which health problems arise. Many preventive and therapeutic measures require changes in attitudes and behavior in order to improve health conditions. A narrow disciplinary focus may produce the correct technocratic answer, but one that is impossible to carry out, due to cultural, economic, or social factors.
In this sense, the Takemi Program advocates not only the application of epidemiology and economics to the analysis of public health problems, but also other social sciences — anthropology, sociology, political science, and ethics. Palitha Abeykoon, for example, examined the experiences of several South Asian countries in health manpower policies to identify those factors of policy design that promoted effective implementation. Another Fellow, Lukas Hendrata, analyzed organizational issues affecting the development of primary health care in Indonesia. Another research paper, by Allan Schapira, was written in the form of a teaching case module on how health care systems confront and manage the issues of chloroquine-resistant malaria in Africa.
The Program promotes an interdisciplinary perspective through several mechanisms. By accepting individuals with strong disciplinary training, the Program creates a group with expertise in various fields. Then, the Fellows are placed in closely shared office space, encouraging informal interactions, so that one’s discipline rubs off on one’s neighbors. The weekly research seminar covers a range of disciplines in order to broaden the intellectual horizons of individual Fellows. Finally, the Program recommends that Fellows audit courses in their own disciplines and beyond.
A fourth principle that underlies international health as understood in the Takemi Program is a non-hierarchical relationship of mutual respect among Takemi Fellows and also between Fellows and faculty members, with an emphasis on collegiality and equality. As mid-career health professionals, who have advanced careers in research, service, and education, and who are selected from an international competition, Takemi Fellows occupy a position of some prestige within the Harvard community. Many Fellows lecture on their research and other topics in courses and seminars at Harvard University and other institutions. The Fellows enrich the educational environment at the School of Public Health, through their experiences and their expertise in particular fields. The Fellows also enrich each other’s lives; their shared existence opens their minds to new ideas and perspectives. From personal friendships, Fellows gain international understanding. They come to appreciate basic similarities in health problems and policies, as well as national differences.
A Takemi Fellow’s relationship with the Faculty Advisor critically affects the quality of the fellowship and the research. The Program assures that the research relationship is based on mutual respect. Most Takemi Fellows carry out their research and complete the analysis and writing on their own. In some cases, faculty members contribute sufficiently to the research paper to be recognized as coauthors, but the Takemi Fellow is the first author in the published version. The principle of mutual respect recognizes the existence of different skills between Fellows and advisors and also among Fellows; the principle also reflects the objective of promoting the intellectual development of advisors as well as Fellows. After the Takemi year, Fellows are encouraged to continue their relationships with Harvard faculty members and other researchers met at Harvard, all on the basis of mutual respect as colleagues.
Concomitant with the principle of mutual respect is the principle of individual freedom for Takemi Fellows. The Program imposes only minimal requirements on Fellows: to attend one group seminar each week, to join in an informal luncheon each week, and to produce a high quality research paper by the close of the academic year. Beyond that, Fellows are free to act as they please: to audit courses throughout the University; to sit in the library and read; to stay at home and write; to consult their advisor regularly or to ignore the advisor resolutely. Each Fellow is encouraged to use the rich resources of Harvard to achieve his or her individual research objectives, and the Program assists the Fellow in navigating the University’s resource map.
The principle of individual freedom is based on the assumption that each Fellow knows what he or she best needs or wants at this critical midpoint in one’s career. The array of activities is minimally structured, to allow each Fellow to chose the most appropriate particular blend. Similarly, the Program’s weekly seminar does not seek to impose a specific doctrine of health policy, but rather exposes the group of Fellows to a panoply of researchers, some already eminent and some still emerging, and all grappling with serious questions of resource allocation in health. In the words of one Fellow, the Program provides “a privileged moment for learning.” This freedom for Takemi Fellows represents a social good, intended to be used in the Program’s overall mission of improving health conditions on a global scale. Fellows accept the freedom in exchange for an implicit acceptance of responsibility in advancing the Program’s mission.
The community of Fellows, while at Harvard and thereafter, represents the sixth key principle for the Takemi Program. Each year, the Program seeks to create a community out of the group of Fellows, to bridge the cultural and intellectual boundaries created by geographic, disciplinary, and language differences. The Fellows share offices in close proximity, and the Program sponsors informal social occasions for both Fellows and families. By mid-year, the community has gelled to the point where Fellows strong in particular disciplines — often statistics and economics — are helping others in new skills, a form of TC/TF or Technical Cooperation among Takemi Fellows. The candid critique of research proposals and draft papers depends on a sense of communal trust and confidence, which is created through the weekly research seminars and luncheons and through the informal interactions among Fellows. The Fellows experience this community spirit, with its mutual support and exchange, as a positive outcome of the Program.
Promoting the broader community of Fellows, across different years, is accomplished through the international meetings held every two years and through networking activities. In countries with more than one Takemi Fellow, the individuals meet on both a professional and social basis. These linkages are now beginning to evolve, as the number of Fellows is reaching a critical mass. The possibility of collaborative research projects at the regional level was actively discussed at the last Symposium in September 1990. In addition, a number of Fellows, after returning home, have continued to work with Harvard faculty members on projects related to their Takemi Research Papers. How to harness the potential of the network of Takemi Fellows remains a question for both Fellows and the Program. At the same time, this question reflects the Fellows’ recognition that they have gained a long-term relationship with an international network.
Individual capacity building:
The final principle of the Takemi Program emphasizes the importance of individual capacity building as an instrument for strengthening institutions and improving health conditions in the Third World. Enhancing the skills and experiences of individuals with leadership qualities is expected to contribute, both directly and indirectly (through research, teaching, and administrative positions), to the effectiveness of the institutions in which the individuals work. While more than one Takemi Fellow has been accepted from three institutions ( in Nigeria, Japan, Brazil, South Africa, India, and China), the Program does not have a strategy of institution strengthening, as adopted by some foundations and international agencies. This emphasis on individuals rather than institutions resulted in part from limited resources within the Program, and also from a strategic choice at the Program’s start.
To date, most Takemi Fellows have returned to their home institutions, although some subsequently have changed positions due to severe political instability or evolving career objectives. The choice of mid-career professionals as Takemi Fellows increases the likelihood that individuals will return to their institutional positions at home. But the Program has no written or legal requirement on returning; it is rather an implicit expectation. At the same time, the Program recognizes that in some cases, individual development may depend on not returning.