Created in 1963 during the Portuguese colonization, the country’s national flagship university, Eduardo Mondlane University (UEM), is located in Mozambique’s capital city, Maputo. It remained the only public university training physicians for the entire country during the first 41 years after the 1975 independence from Portuguese rule [2, 5].

Mid‑level nurses and other healthcare workers (HCW) received training in schools across the country under the leadership of the Ministry of Health (MOH). As part of the Mozambique governmental strategy for extension of higher education and research development, higher education was expanded to other geographical regions in the country [2].

With 10 branches across Mozambique’s 10 provinces, the Universidade Pedagógica de Moçambique (UPM) was initially created in 1985 to train teachers for the primary and secondary education system [2]. In 2019, UPM was restructured, and the Licungo University (UniLicungo) was created in central Mozambique, with Mozambique’s newest Faculty of Medicine [6].

The Instituto Superior de Ciências de Saúde (ISCISA) was founded in 2003, with two main campuses. One is located in Maputo, and the other in Quelimane, a city located in the Zambeze province in central Mozambique, to support advanced training of mid‑level HCW (nurses, non‑physician technicians) previously trained under the umbrella of the MOH [7].

Lurio University (UniLurio) and Zambeze University (UniZambeze) were created in 2006 and 2007, respectively, based in geographically underserved but highly populated provinces of northern (Nampula) and central (Zambeze) Mozambique, respectively. Each includes a Faculty of Health Sciences to train physicians and other HCW [2].

Private institutions also train HCW. These include the Catholic University (Beira, central Mozambique, created in 1995), and the Instituto Superior de Ciências e Tecnologia de Moçambique in Maputo, created in 1997 [5].

In 2010, through a partnership formed in 2008 between UEM and University of California San Diego (UCSD), UEM received 1 out of 13 Medical Education Partnership Initiative (MEPI) awards from the US President’s Emergency Plan for Acquired Immunodeficiency Syndrome Relief (PEPFAR) and the Fogarty International Center (FIC) of the National Institutes of Health (NIH) of the USA. These awards aimed to increase the number of physicians as critical human resources needed to address human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) control, foster research development within the country by addressing the most pressing health issues, create communities of practice, promote the internationalization of Mozambican universities, and support the development of newly established universities in the country (e.g., UniLurio and UniZambeze), including the creation of research support centers (RSCs) [2, 8–10].

To understand the hurdles and needs to create a robust training and research environment in Mozambique, the MEPI team of investigators, comprising partners from UEM, UniLurio, and UCSD, sought advice from a broad set of key leader institutions, including the MOH, Ministry of Education, Ministry of Science and Technology, Mozambican Medical Council, and UCSD [8].

We also engaged additional universities from Portugal (Universidade NOVA de Lisboa through the Instituto de Higiene e Medicina Tropical, and Universidade do Porto (UP) via the Instituto de Ciências Biomédicas Abel Salazar), as well as from Brazil (Federal University of Bahia) [2, 8].

Major hurdles and weaknesses were identified on the basis of these discussions and of needs assessment. The main barriers included excessively bureaucratic institutional environments, limitations in qualified human resources and research infrastructures, a lack of financial resources, inadequate administrative support for grants, administrative management policies, and weak regulatory structures. Additionally, many investigators had limited access to scientific literature and lacked English proficiency [8].

Based on a multifaceted plan designed to reduce the impact of these barriers and to enhance HCW research capacity in Mozambique, the Mozambique Institute for Health Education and Research (MIHER) was conceived. This was to be a para‑University not‑for‑profit organization conceived in 2010, that was formally instituted in 2011, as the first RSC in Mozambique [8]. Its creation as a not‑for‑profit organization was based on the premise that, to adequately perform their roles, RSCs need to have three key characteristics, namely local ownership, independence, and coordination abilities [11].

Nevertheless, even at the beginning, MEPI‑Mozambique was a consortium of three universities—UEM, UniLurio, and UniZambeze—and aimed also to expand its future activities across the country [8]. MIHER was conceived as the institutional instrument to promote such expansion. MIHER’s major goals were to provide responsive and transparent administrative support, conduct fiscal and project management services for Mozambique’s health and social sciences research communities, and identify funding agencies interested in supporting research and training activities in Mozambique’s public universities training HCW [8].

In this case study, we report on the process of creation of MIHER, as well as its main achievements and effect on developing, implementing and sustaining research capacity‑development activities since its creation in 2011, i.e., 13 years ago. We outline the challenges and lessons learned, and how MIHER is contributing to the transformation of the health research workforce (HRW) landscape in Mozambique, as an example for other African countries.

To get a comprehensive picture of the extent of MIHER’s activities, we extracted data from MIHER’s publications (in PubMed, Scopus, and Google Scholar), project progress reports, and activity records, thus offering valuable qualitative and quantitative contributions for analysis through December 15, 2023.

We estimated the following indicators: (a) postgraduate (master and doctoral) programs created and supported, (b) students trained, (c) students sponsored, (d) micro‑research projects mentored, (e) research methods’ courses designed and/or implemented, (f) participants in these courses, (g) research grants written and funded, and (h) publications generated.

Quantitative data such as the number of publications and citations as well as project applications versus those funded were entered into a Microsoft Excel spreadsheet, and exported to the Statistical Package for the Social Sciences (SPSS). Data analysis includes descriptive statistics, tables, and bar and line charts.

The publications retrieved were classified into three groups on the basis of the Scimago Journal & Country Rank (SJR) indicator: (a) publications in high‑citation‑potential journals with a high SJR indicator value (SJR > 1.0), (b) publications in journals with below‑average citation potential (those with an SJR indicator value < 1.0), and (c) publications in non‑SJR indexed journals.

MIHER was initially registered as the “Instituto Moçambicano de Assistência e Apoio à Pesquisa e Ensino em Saúde (IMAPES)” at the Office for Registration of Legal Entities (Conservatória de Entidades Legais) under the authority of Mozambique Ministry of Justice. This was done after fulfilling requirements defined by Mozambican law, which include presentation of the identity of funding members, proof of no criminal record, and the statutes that would guide the organization. In addition, there was a need also to include the composition of MIHER’s social governance bodies, who were elected during an initial General Assembly.

According to MIHER’s statutes, it is mandatory that social governance bodies are chosen from within MIHER’s members [12]. In the same year, IMAPES was renamed as the Mozambique Institute for Health Education and Research (MIHER) to convey its name in English [13]. MIHER’s governance structures initially included 11 MEPI investigators from UEM and Maputo Central Hospital (MCH; 5), MOH (1), Institute Nacional de Saúde (INS) (1), and civil society organizations (CSO) (4). Over the years, other members were admitted, now encompassing 24 members, including honorary members from UCSD (2). MIHER’s General Assembly serves as the highest authority and provides an overarching strategy for the organization’s development. It meets yearly to oversee implementation of activities defined under the institution’s strategic plans and also convenes extra sessions to decide on time‑sensitive issues whenever necessary. The board of directors—with a president, vice president, and general secretary—is responsible for strategic planning and oversight of MIHER´s activities, including seeking any new partnerships. MIHER’s everyday activities are run under the leadership of the executive director. There are two functional units: Research and Training, and Administration. In addition, MIHER has a Fiscal Council of three members: the chair, a secretary, and a third member without a specific portfolio. The Fiscal Council is a supervisory body, independent of the Board of Directors (but also elected by the General Assembly), which seeks, through the principles of transparency, equity, and accountability, to contribute to the organization’s efficient performance.

The organizational structure of MIHER is illustrated in Figure 1. One important feature of the structure—which contrasts with other Mozambican public universities and research institutions—is that the Administration Unit houses the Research Administration Department, which consists of three sub‑units: Pre‑adjudication, Post‑adjudication, and Compliance. The Research and Training Unit plans research and capacity development activities, including advocacy, communication, education, and institutional review board (IRB) compliance.

In terms of human resources, MIHER has 14 full‑time employees engaged in administrative work. Most of its affiliated researchers (approximately 80) are lecturers and health workers from different Mozambican Public Universities, research institutions, and MOH health units.

The MIHER annual budget is approximately $130,000 USD and derives from the administrative and overhead costs of the projects it administers, from donations, and from funds earned by the provision of services (support designing, submission, implementation, and administration of training and research grants and provision of didactic and research method courses and grant and manuscript writing, among others).

On‑site activities took place in only 7 of 10 Mozambican provinces (Figure 2). However, activities conducted using information and communication technology (ICT) tools reached lecturers, researchers, and HCW throughout the country. All public entities training HCW were involved, including Mozambique’s public universities and other higher education institutions, as well as 40 healthcare district and central hospitals.

Altogether, MIHER supported the design and implementation of three masters’ programs at UniLurio: Health Professionals Education, Tropical Medicine and Global Health, and Nutrition and Food Security [4]. At the time of writing, more than 128 master’s students have graduated since implementation in 2013. At least 70% of the students were faculty members in one of Mozambique’s public universities or HCW in other public institutions, including healthcare facilities.

At UEM, MIHER supported the design and implementation of the first master’s program in Biosciences in the country, starting in 2020; this program comprises three main fields of concentration: Parasitology, Microbiology, and Neurosciences [2]. The program currently enrolls 48 students. In 2017, MIHER also supported the implementation of a Ph.D. program in Biosciences and Public Health [2]. Of the 42 students enrolled to date in this Ph.D. program, 40% were directly sponsored by MIHER‑generated grants. So far, three students have successfully completed their Ph.D. degrees, with dissertation research of the remaining students still ongoing.

In 2023, MIHER supported the design of another master’s program in Health Sciences at UniLicungo; this program includes three areas of concentration: Clinical Investigation, Tropical Medicine and Climate Changes, and Health Professionals Education. The first cohort of students (60) was expected to enroll in September 2024.

These postgraduate programs also led to more than 300 micro‑research projects for students, lecturers, and researchers, who were mentored in multidisciplinary areas across communicable and non‑communicable diseases and health professionals education [2, 14–25]. More than 60 student and faculty micro‑research grants were also provided to lecturers via their participating institutions [2].

Table 1 summarizes the number and type of research and development (R&D) short courses developed and their participants. During the reporting period, MIHER designed and implemented 260 short courses, which enrolled 9,514 participants. The bioethics and responsible conduct of research (RCR) courses (101) attracted the highest numbers of attendees (5,804 participants).

Curiously, average participation rates were highest during the coronavirus disease 2019 (COVID‑19) pandemic years (2020–2022), probably because the adoption of distance learning facilitated students’ attendance.

MIHER supported the writing and submission of 116 grants, of which 98 (84%) were awarded, totaling US $29,940,086. This represents an extraordinary success rate. By way of comparison, the most recent success rate (Fiscal Year 2023) for individual research project grants awarded by the US National Institute for Allergy and Infectious Diseases (NIAID) is only 17% (https://report.nih.gov/funding/nih-budget-and-spending-data-past-fiscal-years/success-rates; accessed October 25, 2024). Of the support facilitated by MIHER, $20,067,045 (67%) was generated through the UEM–UCSD partnership. Of the $24,630,770 in US federal funds, $19,193,807 was awarded directly to MIHER, and $5,436,963 was in the form of sub‑awards. Going forward, MIHER has secured $2,614,914 for research and training activities through 2027 from 13 sources (Supplemental File 1). These grants involved, in total, 27 Mozambican researchers as principal investigators and co‑investigators (an average of 3.4 grants/researcher) whose primary institutions were UEM (8), MCH (12), MOH(3), INS (2), and CSO (2) in partnership with 34 researchers from various partner universities in the USA, Europe, Africa, and Oceania. Eight principal investigators and co‑investigators had a dual affiliation with UEM and MCH.

Figure 3 presents the annual amount of funding administered by MIHER.

Figure 4 illustrates the proportion of grants awarded to MIHER by various funding organizations. The major funders have been PEPFAR (39%) and NIH (43%). In terms of geographic representation by continent, most funds came from North America ($27,449,734; 91.7%), followed by Europe ($2,316,504; 7.7%), Oceania ($54,150; 10.2%), and, lastly, Africa ($119,699; 0.4%).

Table 2 presents detailed information of the awards generated through the UEM–UCSD partnership, totaling $20,067,045. Of these funds, 58% came from PEPFAR, and 40.5% came from NIH–FIC. There were also 19 pilot grants for early‑career investigators from the UCSD Center for AIDS Research (CFAR), totaling $592,526.

MIHER trained 16 research administrators by providing professional development opportunities, such as participation in international networking events, including both in‑person and online conferences organized by the NIH along with the International Society of Research Administrators. MIHER also trained 30 lecturers and researchers from UEM and UniLurio in principles of research administration.

Research work mentored and/or supported through MIHER’s grants resulted in the publication of 170 articles, of which 151 (89%) were in journals indexed in PubMed (see Supplemental File 2 for details). The publications were on diverse topics, including communicable diseases (e.g., HIV and its co‑morbidities, tuberculosis, hepatitis, neglected tropical diseases, COVID‑19), non‑communicable diseases (e.g., stroke and mental health), antimicrobial resistance, health professionals education, health system strengthening, nutrition and food security, ethnobotanies, and digital technologies.

Figure 5 presents a graphical representation of the number of publications and citations per year. Over the years, there has been a steady increase in the publication output of about 13 per year. In December 2023, MIHER’s indexed publications had accumulated 3,860 citations. Out of 170, 96 (57%) manuscripts were published in high‑citation potential journals, while 52 (31%) manuscripts had a lower SJR rank (< 1.0).

An important goal of MIHER was to facilitate domestic research outputs that describe findings from projects completed in Africa (and Mozambique specifically). In fact, consistent with this, Africans served as first or last author for 55% and 34% of the publications, respectively. Of these, 44% had a Mozambican first author. Last authors were most often from the USA (46%), followed by Africans (34%), of whom 23% were Mozambicans. Females were the majority of first authors (58.2%) and served as last authors of 46.4% of publications. Africans outside Mozambique, representing 24 countries, collaborated on 42 publications (see Supplemental Table 1 for details).

Investments made in infrastructure to support development of research included the rehabilitation or acquisition of research equipment for the Parasitology and Pathology laboratories of the UEM Faculty of Medicine (FoM‑UEM). Advanced training was also provided by laboratories at UCSD and South Africa [8] to three laboratory technicians and three lecturers on topics such as molecular biology, bioinformatics, immunohistochemistry, cell culture, cultivation of parasites, and techniques to assess microbial resistance.

ICT rooms were installed at FoM‑UEM, MCH, UniLurio [2, 4, 26], and the Instituto de Ciências de Saúde de Quelimane. In addition, MIHER supported the installation of a SEACOM fiber optic terminal at UEM, the extension of internet connectivity to the FoM‑UEM and MCH, and an internet connection at UniLurio [2, 4]. MIHER´s projects and fees collected from master’s students supported the installation of a Center for Graduate Studies at UniLurio. Fees from students also helped to pay supplements to lecturers and administrative staff, as well as other institutional expenses [2]. MIHER also supported the development of an Institutional Bioethics Committee at the FoM‑UEM and MCH [8].

MIHER participated in the creation of AFREhealth in 2016, a pan‑African community of practice established to enhance training and research capacity development for HCW in the African continent [27]. MIHER representatives occupy 2 of the 23 available seats within the AFREhealth Governing structure.

MIHER has also played a critical role in organizing 11 international scientific events, including the IV MEPI annual Symposium and the VI Annual AFREhealth symposium, held in August 2014 and 2023, respectively, in Maputo. The VI Annual AFREhealth symposium had 500 participants from 131 universities. Speakers from sub‑Saharan institutions (184) were from 23 countries that were Anglophone (71.2%), Lusophone (16.3%), and Francophone (11.4%). Mozambique had the highest number of abstracts submitted (34), followed by Uganda (31) and Zambia and South Africa (17 each). National scientific events at the UEM (1), FoM‑UEM (3), and ISCISA (5) were also supported by MIHER.

Dealing with multiple funding agencies, with different research infrastructures and with particularities concerning grant requirements and fiscal management, has been a major challenge, mostly because these requirements are far from standard Mozambican national operating procedures. In general, solutions acceptable for both parties emerged from open dialogue and thorough discussions.

Without question, the training opportunities inherent in MIHER enabled more researchers to apply for advanced (MSc and Ph.D.) studies, while feeling confident to pursue parallel research careers. In this context, both MIHER and other Mozambican universities and research institutions now face a new challenge in dealing with a shortage of qualified mentors and research funds to meet the training needs of the continuously increasing number of early‑career researchers. A focus on increasing the development of mentors should be an important follow‑up priority.

Intense competition for international grants, combined with financial constraints faced by funding agencies in their own countries, may undermine prospects for raising research funds. Mozambique’s own internal threats, such as terrorism in the north and the increasing number of extreme climate events, including cyclones and floods [1, 43, 44], make it difficult for the public sector to consistently fund research and training activities. This situation may also negatively affect MIHER’s efforts to build and consolidate an advanced research network in the country.

The lessons one can take so far are that MIHER’s continuous efforts, strategic vision, mission, perseverance, and funding diversification have paid off and should be prioritized.

In summary, the foundation of MIHER contributed to a unique pillar of research and training sustainability, which was built on a network platform involving national and international research and funding partnerships. As such, RSC’s of Excellence, such as MIHER, should be replicated in Mozambique and elsewhere. By nurturing local talent; fostering resource sharing, partnerships, and collaborations; and advocating for research‑driven policies, these centers can further contribute to the development of robust research ecosystems, a motivated HRW, improved healthcare systems, and ultimately, better health outcomes for the global population.

MIHER has enabled local academic capacity to make significant contributions, which will dramatically change the RHW and the research landscape in Mozambique and ultimately in Africa. Above all, these achievements were possible because of the scientific engagement and vision of our collaborators, from UCSD and elsewhere, who value shared goals, mutual respect, coordination, and transparency as critical elements of success in global health research [35, 37]. We are also grateful for similar reasons to our primary funding agencies, PEPFAR and NIH‑FIC. Both entities supported south–south collaboration and leadership and ownership by Mozambicans and Africans to define activities according to their priorities and context.

Moving forward, MIHER aspires to establish itself as a regional research administration training hub especially to serve the Lusophone community in Africa, Latin America, and Asia.