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Protecting health workers from infectious disease transmission: an exploration of a Canadian-South African… Yassi, Annalee; Zungu, Muzimkhulu; Spiegel, Jerry M; Kistnasamy, Barry; Lockhart, Karen; Jones, David; O’Hara, Lyndsay M; Nophale, Letshego; Bryce, Elizabeth A; Darwin, Lincoln Mar 31, 2016

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RESEARCH Open AccessProtecting health workers from infectiousdisease transmission: an exploration of aCanadian-South African partnership ofpartnershipsAnnalee Yassi1, Muzimkhulu Zungu2,3, Jerry M. Spiegel1* , Barry Kistnasamy4, Karen Lockhart1, David Jones2,Lyndsay M. O’Hara1, Letshego Nophale5, Elizabeth A. Bryce6 and Lincoln Darwin2AbstractBackground: Health workers are at high risk of acquiring infectious diseases at work, especially in low andmiddle-income countries (LMIC) with critical health human resource deficiencies and limited implementation ofoccupational health and infection control measures. Amidst increasing interest in international partnerships to addresssuch issues, how best to develop such collaborations is being actively debated. In 2006, a partnership developedbetween occupational health and infection control experts in Canada and institutions in South Africa (including aninstitute with a national mandate to conduct research and provide guidance to protect health workers from infectiousdiseases and promote improved working conditions). This article describes the collaboration, analyzes the determinantsof success and shares lessons learned.Methods: Synthesizing participant-observer experience from over 9 years of collaboration and 10 studies alreadypublished from this work, we applied a realist review analysis to describe the various achievements at global, national,provincial and hospital levels. Expectations of the various parties on developing new insights, providing training, andaddressing service needs were examined through a micro-meso-macro lens, focusing on how each mainpartner organization contributed to and benefitted from working together.Results: A state-of-the-art occupational health and safety surveillance program was established in South Africafollowing successful technology transfer from a similar undertaking in Canada and training was conducted thatsynergistically benefitted Northern as well as Southern trainees. Integrated policies combining infection control andoccupational health to prevent and control infectious disease transmission among health workers were also launched.Having a national (South-South) network reinforced by the international (North–south) partnership was pivotal inmitigating the challenges that emerged.Conclusions: High-income country partnerships with experience in health system strengthening – particularly in muchneeded areas such as occupational health and infection control – can effectively work through strong collaborators in theGlobal South to build capacity. Partnerships are particularly well positioned to sustainably reinforce efforts at national andsub-national LMIC levels when they adopt a “communities of practice” model, characterized by multi-directional learning.The principles of effective collaboration learned in this “partnership of partnerships” to improve working conditions forhealth workers can be applied to other areas where health system strengthening is needed.Keywords: Partnership, Community of practice, North–South, North–South-South, Health worker, Occupational health,Infection control, South Africa, Tuberculosis* Correspondence: jerry.spiegel@ubc.ca1Global Health Research Program (GHRP), The University of British Columbia(UBC), Rm. 430, 2206 East Mall, V6T 1Z3 Vancouver, BC, CanadaFull list of author information is available at the end of the article© 2016 Yassi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Yassi et al. Globalization and Health  (2016) 12:10 DOI 10.1186/s12992-016-0145-0BackgroundThe 2013 report of the Third Global Forum on HumanResources for Health (HRH) observed that “in many coun-tries, the employment conditions of health workers are notcompatible with the attainment of universal health cover-age.” It specifically noted that “in some settings, workingconditions are characterized by understaffing, excessiveworkloads, stress, exposure to occupational hazards, unsafeenvironments, occupational ill health and violence, result-ing in inadequate patient care”[1]. In low- and middle-income countries (LMICs) where shortfalls in HRH areespecially severe [2, 3], such circumstances contribute tomigration [4, 5] and departure from public sector facilities[6, 7]. Just as peer-to-peer North–south partnershipsbetween health practitioners promote clinical skill de-velopment of health workers in LMICs [8, 9], similarcollaborations are also desperately needed to build cap-acities for improving LMIC work environments inhealthcare. How to develop, conduct and sustain thebenefits of such international partnerships is the sub-ject of active debate [10–14].The protection of health workers’ health has tendedto be neglected globally, however in high-income coun-tries (HICs) the much lower prevalence of transmissiblecommunicable diseases and better infrastructure hasmitigated the impact of occupational exposure. For ex-ample, the personal protective equipment and neededtraining to prevent occupational respiratory infectionsis often lacking in LMICs [15–17], but generally avail-able in HICs [18, 19]. While the more favourableaccess to resources has created opportunities for tech-nical and organizational innovation, including the de-velopment of information systems [20], it is importantto recognize that expertise and access to technologicalinnovation is rapidly growing within emerging econ-omies as well [13]. Noting the prospects for adaptingsuch experiences for settings of high need, in 2006two World Health Organization (WHO) CollaboratingCentres for Occupational Health (one in South Africaand one in Canada) initiated collaboration with thisobjective.Health workers are especially at risk of exposure toinfectious diseases. Canada took sharp note of this in theSARS outbreak of 2003 when almost half the cases oc-curred in health workers [21]. It has also been estimatedthat 40 % of the Hepatitis B and C cases in health workersare likely due to occupational exposures [22–24]. Healthworkers have a high risk of tuberculosis (TB) [25],and, most recently, a high rate of Ebola was docu-mented in health workers [26]. The elevated risk ofTB in health workers [15, 27, 28] was highlightedby recent TB outbreaks in South African hospitals[28–30], with some studies suggesting that healthworkers are three to ten times more likely to acquireTB [31]. For multiple drug resistant TB (MDR-TB),the risk is even higher- with an estimated incidence of64.8 per 100,000 health workers compared with 11.9per 100,000 general population in South Africa be-tween 2003 and 2008 [25]. Similarly, the estimated in-cidence of extreme drug resistant TB (XDR-TB) was7.2 per 100,000 health workers compared with 1.1 per100,000 general population between 2003 and 2008[25]. Furthermore, there is considerable evidence thatprevention and control of infectious disease amonghealth workers is not only a benefit in itself, but is asignificant contributor to patient safety [32].Exposures are generally preventable with prompt iden-tification and isolation of potentially infectious patients;selection and use of appropriate personal protectiveequipment (PPE); immediate and safe procedures forcleaning up blood and body fluid spills; correctly dispos-ing of contaminated sharps and biomedical waste; adher-ence to routine immunisations; and consistent practiceof respiratory etiquette and hand hygiene. Advisories,notably the Joint WHO-ILO-UNAIDS Policy Guidelineson Improving Health Care Workers’ Access to HIV andTB Prevention, Treatment, Care and Support [33]emphasise the importance of strengthening infectioncontrol programmes and ensuring a safe working environ-ment for health workers. The importance of occupationalhealth-infection control collaboration was highlighted inthese [33] and in general infection control guidelines [34].Brinkerhoff observed that while international partner-ships can provide a ‘rational response to complexity’ thatcan build on comparative advantages and divisions oflabour [35], they unavoidably also mirror “dimensions ofpower, participation, trust and sustainability, as well asmutuality” – the latter also emphasized by Johnson andWilson [10]. According to Corbin and colleagues [36],North–South partnerships have replaced older models ofaid and development by giving hope that such a partner-ship would link Northern money and expertise withSouthern know-how and community participation tocreate relevant local health and development initiatives.The opportunities to broaden the notion of “capacity-building” in response to complex challenges are still inearly phases of critical assessment. The challenge tomore comprehensively embrace the concepts of jointlearning and knowledge transfer has encouraged consid-eration of “community of practice” approaches thatactively encompass different types of knowledge andexperience [11]. This approach attempts to reduce thepower imbalances discussed by Holmarsdottir, Desai,Botha, Breidlid and colleagues [12].To contribute to this debate, the research questionswe address in this article are, first, what partnershipmodel characterizes our collaboration linking Canadianand South African infection control and occupationalYassi et al. Globalization and Health  (2016) 12:10 Page 2 of 15health professionals? Secondly, what contributed to thesuccesses we achieved? And thirdly, what lessons can bedrawn about partnership models?Our partnership aimed to build capacity in SouthAfrica as well as in Canada to address the linked area ofoccupational health and infection control. Indeed wetrained dozens of health workers in South Africa; pro-duced guidelines, policies and procedures; and co-developed a health information system (based on onedeveloped in Canada [20, 37]) that has been implementedacross South Africa as part of a process of building cap-acity of healthcare workers and administrators in thatcountry. Notably, re-enforcing the conclusions of Johnsonand Wilson [10] for example related to the mutual benefitof such endeavours, and the importance of learning fromthe Global South (for example, Spiegel et al.,[38]), we alsobuilt capacity of over a dozen Northern research traineesand acquired considerable insights of benefit to theNorthern as well as Southern partners. The usefulness toCanada of this international collaboration was recognizedby an award given by Canada’s top medical authoritiesto two of the Canadian practitioners involved [39, 40]. Ourfindings also support the call (for example, Holmarsdottiret al, [12]) to challenge hegemonic knowledge-productionthat has characterized many previous North–South collab-orations; our experience indeed stresses the importance ofrespecting Southern perspectives and Southern leadershipwithin a North–South-South community of practice.MethodsConceptual approachIn order to address the first question and discern how tocharacterize our partnership, we begin by introducingthe collaboration in Canada between university-basedand hospital-based personnel, analyzing its key featureswith respect to contributing to a global partnership.Next, we describe the context in which this Canadiangroup developed partnerships in South Africa, and,finally we characterize the approach adopted at thenational, provincial, and hospital levels. To address thesecond research question, we present specific activitiesundertaken by the partnership, highlighting challengesas well as outcomes, paying special attention to how thevaried expectations of the different parties within thecollaboration were met. To analyze “what contributes tosuccess” in our partnership, we used a realist review per-spective, namely analyzing the context, mechanism andoutcome of each endeavour we undertook, identifying themicro, meso and macro scale processes involved [26, 38].Specifically our approach examined: i) the micro con-text – ascertaining what mechanisms determined in-dividuals’ preparedness to address potential healthand safety risks, as well as their readiness to participate inprocesses designed to ensure their right to a secureenvironment; ii) the meso context – ascertaining themechanism by which workplace managers were providedwith infrastructural support to meet this challenge in col-laboration with worker representatives; and iii) the macrocontext – especially ascertaining mechanisms used andoutcomes achieved at the level of the provincial and na-tional health departments. We present specific activitiesundertaken by the partnership, highlighting challenges aswell as outcomes, applying our micro-meso-macro frame-work to analyze the mechanisms that led to these, payingspecial attention to how the varied expectations of the dif-ferent parties within the collaboration were met.Each of the specific studies conducted by the partnershiphad its own ethics-approved protocol, with detailed sec-tions on the methodologies employed. Ethics approval forall associated research activity was obtained from the UBCBehavioural Research Ethics Board, University of Free StateEthics Board, Research Ethics Committee, Faculty ofHealth Sciences, University of Pretoria, in addition to theapproval of the National Department of Health (DoH) FreeState DoH, Gauteng DoH and the various hospitalsinvolved. As this article constitutes a meta-analysis of thestudies conducted, a separate ethics approval was notdeemed necessary; we refer readers to each of the separatearticles for elaboration on methodologies and techniquesemployed in the initiatives discussed.The final section of the article responds to the thirdquestion, reflecting on our experience and offering sug-gestions about the pursuit of partnerships to build globalHRH capacity. The methods of data collection and ana-lysis are described below.Data collection and analysisThe data collected for the description of the partnershipwas derived directly from the experience of each memberof the authorship team representing each of the disciplinesand constituencies from within the various organizationsthat participated in the partnership, including managerialstaff and students from both the North and the South. Allof the researchers were themselves active participants inthis collaboration for at least 5 years, and some, for morethan 10 years. As noted by others [41, 42], the use ofparticipant-observation has advantages over second-handaccounts and can provide valuable insights through reflec-tion. As we were the ones most directly involved with allthe components of the research - from the formation ofthe collaboration, to planning the research agenda anddesigning the projects, to collecting and analyzing thedata and synthesizing results for decision-makers andscholarly venues – our own perceptions, synthesizedthrough the process of writing this article, provided themain source of data. The description was aided by referenceto the over 10 publications already published from ourcollaboration [20, 43–52].Yassi et al. Globalization and Health  (2016) 12:10 Page 3 of 15The context-mechanism-outcome method [53] appliedto delineate the mechanisms employed to achieve suc-cess is the general approach used in “realist reviews”[53], which, as described by Spiegel et al. [20], is a strat-egy for synthesizing research that has an explanatoryrather than judgmental focus. In realist evaluation, toinfer a causal outcome (O) between two events, one needsto understand the underlying mechanism (M) connectingthem and the context (C) in which the relationship occurs,with the basic evaluative question of ‘what works?’replaced by ‘what is it about this program that works forwhom in what circumstances?’[54, 55]. As for the firstresearch question, several sources of information wereused for constructing the analysis, supplementing partici-pant observation with information available through themyriad of studies we published.The method of analysis used to address the third ques-tion is analytical induction, whereby tentative hypotheseswere constantly refined, altered or abandoned in light ofthe data collected, in this case, the discussion amongstthe ten co-authors of this article. Specifically, to identify‘lessons learned’ we adopted an iterative reflexive ap-proach that reveals the personal perspectives and socio-political contexts that shape our various constructions ofmeaning [56].Results and DiscussionWhat model characterizes our partnership?Contextualizing the origin of the partnership: A Northerncollaboration with practical experienceThe SARS experience revealed systemic health sectorweaknesses that left health workers, patients and thegeneral public vulnerable. In particular, Canadian occu-pational health and infection control experts learnedthat integrated occupational health-infection controltraining was needed to develop a positive safety culturethat served the workforce and patients alike; and that amore integrated surveillance approach was required.This led to a partnership to develop information andcommunication technology (ICT) tools, including ani-mated training materials and a web-based informationsystem to systematically reinforce surveillance of work-place conditions and workforce health. The researchconducted in line with this concern illustrated the needfor better workplace inspections, and an integratedworkplace audit tool was then developed to supplementworker questionnaires and the ICT innovations. Theproducts developed were heralded as innovative, leadingto their adaptation and use internationally [39]. More-over, the transformations that needed to take place atthe levels of the individual health worker, the healthcarefacility and the health jurisdiction, were documentedand analyzed as a key part of the learning process.This partnering initiative was recognized in 2011 bythe Canadian Institutes of Health Research (CIHR)and the Canadian Medical Association Journal (CMAJ)as one of the six top achievements in Canadian healthresearch that have had a significant impact on health,healthcare and health research [40]. The practical ex-perience and insights gained in addressing a seriousinfectious disease threat gained in this interdisciplinaryuniversity researcher-hospital practitioner collaborationin occupational health and infection in the “GlobalNorth” laid the basis for work in the Global South.Importantly, as discussed below, the experience gainedin the Global South was a key factor in strengtheningthis collaboration in the North, building on insightsgained from South African research colleagues andhealth practitioners.Contextualizing why and how the Canadian-South Africanpartnership developedIn South Africa, HRH is characterised by inequalitiesbetween and within provinces, as well as rural and urbanlocations within the public sectors [57]. In this country,annual per capita expenditure on health ranges from$1,400 USD in the private sector to approximately $140in the public [6]. The national public health sector,staffed by some 30 % of the country’s doctors, remainsthe sole provider of health care for more than 40 millionpeople who are uninsured and who constitute approxi-mately 84 % of the national population [58].In 2010, 49 % of medical practitioner posts and 46.3 %of professional nurse posts were vacant [59], despite thegrowing dual epidemic of HIV and TB increasing thedemand for healthcare [33, 60]. South Africa’s high HIVprevalence [61] has fuelled the epidemic of TB [62];South Africa’s TB incidence is still among the highest inthe world at approximately 860 per 100,000 [63]. Giventhe HRH shortage in South Africa, together with ele-vated infection risks faced by health workers, the needto promote a healthier and safer healthcare work envir-onment is particularly critical [44, 64].When representatives of the South African govern-ment learned about the Canadian health sector efforts ata meeting of the WHO collaborating centres in July2006, they suggested that the Canadian team work withSouth African institutions to improve occupationalhealth and infection control specifically and the healthand safety in the healthcare workplace more generally.The National Institute for Occupational Health (NIOH),a WHO collaborating centre, together with a Depart-ment of Health representative, invited the Canadians toJohannesburg in November 2006, and convened a meet-ing attended by authorities from across the country,including provincial as well as national personnel, andunions.Yassi et al. Globalization and Health  (2016) 12:10 Page 4 of 15The consensus of the Canadian-South African teamwas to pilot a project in one hospital in South Africa,and promote joint learning about the challenges andopportunities for creating desired improvements as wellas for testing materials and processes. Pelonomi Hospitalin the Free State province was chosen, as it met the cri-teria of a) having an existing occupational health unitactive in infection control and eager to take on a newchallenge (including implementing a surveillance sys-tem); b) supportive management; c) a functional jointhealth and safety committee comprising managementand worker representatives; d) strong support from theprovincial Department of Health’s Provincial Occupa-tional Health Unit; and e) a local university that couldserve as a research partner [43, 65]. This hospital be-came the main site for re-engineering of the Occupa-tional Health and Safety Information System (OHASIS)based on the experience of the Canadian web-based sys-tem [20, 45–47].In light of the previously mentioned personal andresource constraints, what made this undertaking feas-ible was the commitment of NIOH, with its technicalexpertise and core capacity to co-develop the neededICT innovations alongside the Canadian partners. Themandate of NIOH is to provide occupational health andsafety technical support across all sectors of the econ-omy to improve and promote worker’s health; to con-duct research to further occupational health; and toprovide teaching and training in occupational health.With OHASIS and related training underway, atten-tion shifted to strengthening the skills of front-lineworkers to prevent their workplace acquired infectionwith HIV and TB. Feasibility and pilot studies werebegun in Free State Province [48], to assess the use ofthe OHASIS information system for this purpose. NIOHalso began to develop a model occupational health pro-gram targeting TB infection control at one hospital inGauteng Province. Furthermore, NIOH quickly seizedthe opportunity to extend the use of the OHASIS systemto the network of 349 laboratories employing 6700 staffat the affiliated National Health Laboratory Service(NHLS) and subsequently began discussions for its fur-ther implementation.Johnson and Wilson [10], examining a partnership be-tween practitioners in the United Kingdom and Uganda,emphasized the mutuality in what they called “North–South/South-North” partnerships. Holmarsdottir (2013)also stresses mutual benefit in North–south-South collabo-rations in which countries from the South enter into part-nership with each other as well as one or more Northernpartner. Our case involves the mutuality of North–South/South-North benefit, but the key aspect of the approach weadopted was a Northern partnership working with a strongSouthern partner, and together working with less well-resourced Southern partner within the same country. Assuch, we characterize our model as a North–south-Southpartnership, albeit only two countries were involved. It ishowever noteworthy that interest has indeed been expressedby additional partners in other African countries, and thiswork is now underway in Zimbabwe and Mozambique aswell, with NIOH continuing to play a strong role.What success was achieved and how? The local projects,their rationale, their mechanisms and their outcomeThe initiatives we undertook are discussed briefly below,highlighting the scale of implementation, as summarizedin Table 1. It should be noted that this collaboration, fromits onset, had a strong research component, in line withthe commitments of the Canadian and South Africanpartners who initiated it. From this perspective, the role ofresearch trainees has been central, with a distinct focus onimplementation science i.e. what contributes to practicesworking and why. Important to the success of these initia-tives has been the strong role played by students bothfrom Canada and South Africa – with each project tightlylinked to student-led initiatives for dissertations or majorpapers for their respective academic projects. This aspectis highlighted in the descriptions below.a) Building infrastructure: The Occupational Healthand Safety Information System (OHASIS)Despite legislation that establishes processes (e.g.joint management-worker committees) to overseethe creation of safe and healthy working conditions,the information and capacities needed to take onthis challenge have remained sorely lacking. Tostudy the usefulness of applying a computerizedinformation system to reinforce health and safetypractices, OHASIS modules [66] were refined andco-developed in workshops and then introduced foruse in three hospitals in Free State. Workplace as-sessments (audits) to record deficiencies and modelpractices, as well as to formulate recommendationsfor action, were conducted initially by joint North–South teams as a key capacity-strategy, resulting inthe preparation of a collaboratively developed paper-based and electronic “Workplace Assessment FieldGuide for Health Care”[67] which became the basisfor report forms and future training.Challenges were of course experienced in pursuingthis initiative. For example, limited technicalcapacities to support computerized systems(including inadequate bandwidth) and restricted staffaccess to computers were frequent sources offrustration. Nevertheless, most occupational healthnurses, infection control personnel, health and safetycommittee representatives and managers interviewedindicated that the introduction of the “system”Yassi et al. Globalization and Health  (2016) 12:10 Page 5 of 15served to draw attention to the processes needingattention, with the anticipation that the full value ofthe integrated system will be realized with time.While local capacities for supporting OHASIS werelimited in the Free State hospitals, the roll-out of thesystem throughout NHLS actively supported by theNIOH, went quite smoothly, progressing from apaper based to an online system with more than 300employees trained and accessing the system.Recognizing this, an agreement was enacted betweenthe host Canadian institution and NHLS/NIOH fora transfer of the computer code without cost, undera Creative Commons Licensing agreement, ensuringthat further development could be led directly bySouth Africans. Shortly thereafter, NIOH prepared alighter and updated version with the assistance ofthe original developers.At NHLS, the information system was found to beeffective and efficient in capturing and usinginformation on worker health [68] and the relatedinvestigation and reporting of health and safetyincidents, as substantiated by surveys of randomlyselected employees in 2012 and 2015, revealingincreases in feeling “always comfortable reportinghealth and safety problems to their manager” (up17 %) and “encouraged to report injuries and illnessin the workplace” (up 16 %). This observed efficacyprovided impetus for NIOH/NHLS to develop a newmodule for waste management with newinternational (WHO) funding that it was able toattract. Agreements are now being finalized tointroduce the integrated OHASIS system acrossGauteng province, led by NIOH which has takenover updating and improving OHASIS by creating astreamlined version that is easier to run in the SouthAfrican context (responding to technical challengesidentified in Free State) as well as training materialsto support implementation scale-up.1 The system isalso about to be introduced in one hospital inWestern Cape as well and discussions are underwayfor further roll-out in Free State. To refine theimplementation of the system, two South Africangraduate students are playing a major role. AMaster’s of Business Administration student who isdirectly involved in the project roll-out in Gautengis conducting a study on how to design reporting tomeet the needs of managers and a Medical Residentin Occupational Medicine is focusing on how toimplement a surveillance system to decreaseoccupational TB in a hospital in Western Cape;while a Canadian doctoral student is also involvedin studying the factors determining successfulimplementation in each of the settings across SouthAfrica. Notably, co-development of OHASIS,involving Canadian and South African developersis continuing, with the explicit agreement that mod-ules developed or improved upon will be sharedfreely with all parties internationally.Table 1 Projects within this South African-Canadian partnership: Interventions implemented for impact at different scalesaScale project MICRO outputs- health workere.g. Professionals, allied workersMESO outputs- workplacee.g. Hospital, laboratory, clinicMACRO outputs -jurisdictione.g. Province, national entity1. OccupationalHealth and SafetyInformation System(OHASIS)Health workers familiar withprocedures to protect theirhealth & safety; healthworkers better able topromote healthy workenvironments.System established in numeroushospital workplaces, clinics &laboratories to provide informationto OH professionals & facilitydecision-makers to support ahealthy work environment.Policies & technical supportprovided to provincial decision-makersfor sustainably maintaining healthywork environment; & technologytransfer to national partner forongoing work with provinces.2. Certificate programmefor training healthworkers (see Table 2 for details)Health workers more skilledand confident to prevent &manage HIV and TB risk inthe workplace, includinghow to conduct & evaluateworkplace interventions.Systems and innovationsimplemented to betterprevent and manageblood-borne and airborneinfectious disease(especially TB)in workplaces of the trainees.Policies, support and oversight foractions to prevent & control TB riskin the workplace conveyed to provincialauthorities through presentations bytrainees.3. TB infection control tools,policies and proceduresHealth workers more skilledand confident in taking stepsto prevent and control TB riskin the workplace, includinghow to conduct workplaceinterventions.Policies to prevent and controlTB workplace risk; & systemsimplemented (pilot in 28 hospitalsin Free State, plus one in Gauteng &one in Western Cape)Policies and technical support foractions to prevent & control TB riskin the workplace directly discussedwith Provincial executive to beimplemented beyond the hospitallevel, and with direct coordinationwith national policies. (See Table 3for Free State policies developed)aThe scale where primary emphasis for each project is targeted is noted by bold; i.e. for project #1, while all levels were affected, the primary focus of interventionis at the meso (workplace); project #2 the focus was on training health workers, so the scale is micro (individual) although clearly with the intent of having impactat the workplace and ultimately provincially and nationally; project #3 targeted both the hospital and provincial level in its implementationsYassi et al. Globalization and Health  (2016) 12:10 Page 6 of 15b) Multi-directional learning and the training ofhealthcare workers to implement occupationalhealth and infection controlTo improve local capacity to conduct and evaluateworkplace-based HIV and TB prevention interventions,and to empower healthcare workers to serve as “agentsof change” within high-risk workplaces, a 1-yearcertificate program was collaboratively developed bythe Canadian infection control and occupational healthpartners together with colleagues from NIOH andpersonnel from the Free State Department ofHealth and the University of Free State.Thirty-one participants - mostly occupationalhealth nurses, infection control practitioners, andhealth managers - formed eight groups with thetask of designing and conducting projects forimproving occupational health and infectioncontrol in their workplaces. Each group wasassigned Canadian and South African mentors.Table 2 outlines the various projects that wereundertaken. Many of the program’s “graduates”continued to play an active role in the largerresearch program that subsequently developed[47]. A South African graduate student assisted inimplementation in Free State; several Canadiangraduate students worked with each of thevarious projects [48–51] helping to implementthis program, with one Canadian graduate studentwriting his Master’s thesis about this programoverall [48]. One of the South African traineeprojects (Table 2 row 6), led by a nurse from arural hospital in Free State, was subsequentlypublished in a peer-reviewed journal [50].Stigma and concerns about confidentiality are oftencited as barriers to uptake of HIV counselling andtesting (HCT) by health workers, but without muchdata to reveal underlying reasons [69]. This lack ofempirical evidence hinders efforts to improveutilisation of such services. Spurred by the SouthAfrican trainees’ finding that between January andMay 2011 only 121 of its more than 1900 healthworkers had accessed the HCT service, a traineegroup project (see Table 2 row 7) addressed this issue,as did a Canadian Masters student’s thesis [49]. Morethan one-third of health workers surveyed (38.5 %)indicated they believed that there was HIV stigma inthe workplace. Additionally, nearly 40 % of allsurvey participants indicated they would not use theoccupational health unit at their workplace due to fearthat confidentiality might not be maintained [49].Building on the work of the South African trainees,another Canadian student – working on his Master’sin Health Administration - conducted a best–worstscaling choice experiment to quantify attributes thatmay influence a health worker’s choices as towhether and where to be screened for TB. Thisstudy included 2 focus groups, key informantinterviews, and distribution of a questionnaire at twohospitals in Free State. Analysis of results found thatto improve uptake of TB screening by healthworkers, programs should be free, guaranteed,confidential, with minimal waiting times, andavailable at the workplace [52].With documentation that stigma is a major issue,yet another Canadian Masters student worked withlocal staff to inform the development of a stigmareduction intervention as part of a largemulticomponent trial being planned. Relevantresults of four feasibility studies conducted [47] wereanalyzed along with the literature. The findingsstressed that a stigma reduction campaign mustaddress community and structural level drivers ofstigma, in addition to individual level concerns [46].The North–South partnership at the GautengHospital (described below) is giving rise to at leasttwo further academic projects at the Doctoral andMasters levels – for South African students. Theprocess of involving Canadian graduate students aswell as South African graduate students to workwith healthcare worker trainees in LMICs facilitatedmulti-directional learning – and is an aspect of North–South collaborations that we believe is extremelyimportant to explicitly recognize as a mutual benefit.c) Implementing occupational health infection controlprograms in a high TB-burden hospital in Gautengand in Free StateNIOH took on responsibility for implementing aworkplace health programme to protect heathworkers at a hospital in Gauteng province, with theNorth–South partnership collaboratively designingand implementing a TB infection controlprogramme (ICP) in this hospital. The TB ICP hasthree major components: 1) training of hospitalpersonnel and implementation of a TB workplaceassessment (audit) to identify hazards for airbornediseases, as well as identify best practice whereapplicable (recommendations are being implementedand will be reassessed); 2) a survey of healthcareworkers’ experience and perceptions about TBinfection control at the hospital which revealed highTB exposure risk, lack of TB infection controltraining and a threefold greater risk of TB comparedto the general population [45]); and 3) methodologyfor quantifying TB bacilli in the air [51] with thefindings then used to sensitise management to theneed to implement control measures.The partnership succeeded in elevating attention toTB infection control and occupational health andYassi et al. Globalization and Health  (2016) 12:10 Page 7 of 15Table 2 Synthesis of projects implemented through the training programme in Free State, South Africa aProject title Trainees Setting Objective Methods Key findingsInvestigating TB infectioncontrol practices in OutpatientDepartment (OPD)(http://med-fom-ghrp-spph.sites.olt.ubc.ca/files/2012/09/FINAL_group-5-powerpoint-presentation_May15.pdf)SE Mmutle,MRMorake,ME Moea,NF JacobsOPD at PelonomiHospital (largeregional referralcentre, Bloemfontein)- To makerecommendationsto managementregarding TB infectioncontrol- Self-administered questionnairesassessing TB infection controlknowledg & practice- Workplace assessmentchecklist to assess hazards andbest practice- Only 24 % of HCWsreported that they arescreened annually for TB- 47 % answered questionsrelated to personal protectiveequipment correctly- 84 % reported askingcoughing patients to practicerespiratory etiquette- Sputumcollection area was inaccessibleReducing the risk of DOTSsupporters acquiring TBduring home visits(http://med-fom-ghrp-spph.sites.olt.ubc.ca/files/2012/09/Group-2-final-presentation.pdf)N Nyembe,N Jacobs,DMofokengNeighbourhoodcommunities(Bloemfontein& Welkom)- To identify and assessstrategies used by DOTSsupporters from NGOsto reduce TB transmission- To assess the impact of aTB infection control trainingintervention- Pre & post questionnairesassessing TB knowledge, attitudes& beliefs- Interviews assessing TB knowledge& practice- 2-day training programme- Infection control practices audit- Overall improvement in levelsof knowledge, attitudes beliefsregarding TB- Lack of administrative controls& use of personal protectiveequipment identified- No N95 respirators available- Health & safety problemswere reported to coordinatorsbut not followed upCreating a safe environmentfor patients and staff in thebronchoscopy theatre(http://www.ghrp.ubc.ca/files/2012/09/Group-4-presentation-function-17h-may-16th.pdf)HM Madiehe,MLMagerman,MJMorweng,MEMotloheloa,A Smuts,TCWalaza,EA WieseBronchoscopytheatre at UniversitasAcademic Hospital(large tertiary hospital,Bloemfontein)- To assess compliancewith TB infection controlguidelines- To make recommendationsto minimize TB exposuresfor staff and patients- Structured observations toevaluate infection controlpractices in the bronchoscopytheatre & waiting room- Checklist-based environmentalrisk assessment of the theatre- Improvement rate in infectioncontrol compliance from46 % to 83 %- Environmental risks identifiedincluded overcrowding,poor ventilation, lack ofhand-washing supplies &cluttered surfacesStrengthening the OHC forthe management of TB inthe health care workplace(http://med-fom-ghrp-spph.sites.olt.ubc.ca/files/2012/09/Group-7_May16_5-30pm.pdf)L Benson,DAKololo,NJ Sidyiyo,MW Moliko,JNkhatho,NWPhandle,H LangfootUniversitasAcademic Hospital- To strengthen theworkplace TBprogramme inthe OHC- A feasibility study wasconducted to inform developmentof a cough registry- Occupational health & safetytools were developed: the coughregistry, permission slips,a plan for diagnosis andtreatment of HCWs with TB- Operational managerswere trained on the useof the cough registry- These activities led to anincrease in utilisation of theOccupational Health Clinic- Confidentiality was identifiedas a barrierImproving infection controland safety practices in theCentral Laundry: A baselineassessment (http://med-fom-ghrp-spph.sites.olt.ubc.ca/filesMM Litsoane, KDMoeketsiFree State ProvincialLaundry Facility(Bloemfontein)- To assess occupationalhealth & infection controlknowledge & practice- To minimize workplaceexposures/hazards- Self-administered questionnaireassessing occupational health &infection control knowledge &practice- Hepatitis B vaccinationreported by 85 %- 90 % reported no trainingwas received on needle-stickinjury preventionYassietal.GlobalizationandHealth (2016) 12:10 Page8of15Table 2 Synthesis of projects implemented through the training programme in Free State, South Africa a (Continued)/2012/09/Group-8-presentation_-16-May.pdf)- 72 % reported never usingeye protection- 82 % knew how tocontact the health &safety representative,but only 56 %reported doing soReducing blood and bodyfluid exposure in theworkplace (http://med-fom-ghrp-spph.sites.olt.ubc.ca/files/2012/09/revised-Litsitso_Nkoko.2012.Graduation_presentation.pdf)L Nkoko Thebe DistrictHospital in ThaboMofutsanyana(mid-sized ruralhospital)- To determine knowledge,attitudes & practices ofHCWs regarding exposureto blood and body fluids- A questionnaire investigatingBBF exposures, reporting ofexposures, & HCWs’ knowledgeof infection control andoccupational health resources wasdistributed to all HCWs in 11high-risk departments in thehospital- Many respondents did notknow enough about BBFexposures actions.- HCWs take immunisationfor Hepatitis B seriously- Most take precautions toavoid BBF exposures; mostreport exposures.- OHS representatives need tobe more proactive within theirunits.- More training is needed onsharps disposal & theimportance of using personalprotective equipment.Improving utilisation ofworkplace HIV and AIDSprogramme for healthcareworkers at Pelonomi Hospital(http://www.ghrp.ubc.ca/files/2012/09/Group-1-presentation-for-graduation-working-copy-11.FINAL_.pdf)N Brandsel,MNtlola,N Myeko,FTlhapuletsaPelonomi Hospital(large tertiary hospitalin Bloemfontein)- To understand why theOccupational Health Service(OHS) is under-utilised for theHIV & AIDS program inorder to determine whatcan be done to improvethe service.- Self-administered questionnairesconsisting of both closed &open-ended questions.- The questionnaire was piloted,translated & back translatedbefore distribution to a stratifiedsample of HCWs representing allcategories of occupation, sex,race & age- 57.6 % knew that HIVtreatment is available atthe OHS- 71.3 % agreed thatoccupational health (OH)practitioners are well trainedto offer HCT, while 70.4 %agreed that OH practitionersencourage people to use theORS unit for HIV and AIDSservices- 71.2 % believed thatconfidentiality is maintainedat the OHS unit most or all ofthe time, however, whenasked what factors explainwhy HCWs do not access HIVservices at OHS unit, moststated that they feared thatconfidentiality will not bemaintained (37.3 %)a For more information on the Certificate Programme offered at the University of Free State, through the assistance of the partnership details see Liautaud A, Yassi A, Engelbrecht M, O’Hara L, Rau A, Bryce E, SpiegelJ, Uebel K, Zungu M, Roscoe D, et al.: Building Capacity to Design, Implement and Evaluate Action Research Projects to Decrease the Burden of HIV and TB in the Healthcare Workforce: A South African- CanadianCollaboration. Open Medicine 2013, 7:s33 [48]. For Abstracts and presentations for each project see the weblinks noted. For Project #6, see L. Nkoko et al. 2014 [50]Yassietal.GlobalizationandHealth (2016) 12:10 Page9of15safety overall, with occupational health and safetynow reporting directly to the hospital CEO. As well,the partnership has increased the knowledge andconfidence among infection control andoccupational health workers, highlighted the plightof healthcare workers at the hospital, and assistedhealthcare workers to advocate for their right to ahealthy and safe working environment.While the Gauteng project was underway, newintegrated policies and standard operatingprocedures were also developed in Free StateProvince, with the North–South partnershipengaged in implementing and evaluating impact at28 hospitals across the province [47]. Table 3summarizes the new policies that were developedand implemented, with comments regardingchallenges encountered and accomplishments.Importantly, while progress was made, inadequatestaffing remains a challenge that will requireongoing attention. We are also undertaking furtherwork to address stigma [70], experimenting with newparticipatory including arts-based methods [46, 71].What are the lessons about determinants of success inpartnerships?Our partnership aimed to strengthen capacities for im-proving working environments of health workers, withemphasis on reducing workplace TB transmission as ahigh priority. As was shown in Table 1, at the micro level,our projects targeted personal knowledge and skills ofhealth workers to not only follow proper procedures tobetter protect themselves and fellow workers from harm –but to develop skills for advocating for change at themeso (workplace infrastructure) and macro (governmentpolicy and resources) levels. At the workplace level, weattempted to strengthen information systems for provid-ing active surveillance, reporting and prevention. At themacro level, we focused attention on the establishment ofpolicies and procedures to enable effective and sustainableprovision of healthier workplaces and successfully advo-cated for increased resources to be allotted to meet identi-fied needs.Valuing experiential understanding as well asscientific-technical expertise, we relied on fosteringpeer-to-peer interactions in complex interdisciplinaryand inter-professional processes in both the Northernand Southern settings. The priority that was assignedto research throughout the exercise facilitated atten-tion to developing and disseminating innovations. Wealso explicitly acknowledged that partners had differingalbeit complementary expectations. Table 4 summa-rizes these differences with respect to research andproducing new insights; teaching and learning; andservice and practice.In recognizing the complexities in successfully imple-menting interventions at different scales, our attentionwas drawn to different types of partnership. As shown inTable 5, a traditional model for North–South partner-ships is characterized by Northern experts working withlocal Southern practitioners in resource-limited settings.This model allows for direct assistance but is limited insustainability; also Northern experts may not have suffi-ciently in-depth understanding of the local reality, andmay be more focused on addressing scientific-technicaldimensions than practical implementation process chal-lenges- particularly those at the macro level. Here cau-tions about hegemonic knowledge production [12] areparticularly warranted.A second model links Northern experts with a strongSouthern partner that, in turn, works with local Southernless well-resourced communities. This is a more sustain-able option than the first, as the capacity-building with thestrong Southern partner is more likely to result in the abil-ity to implement appropriate and feasible policies and sys-tems. However, the lack of direct involvement of theNorthern experts with the local Southern communitieslimits the extent to which bi-directional learning canoccur, to strengthen the overall effort. Here cautions aboutmaintaining mutuality [10] need to be recalled.The model we adopted can be characterized as a com-munity of practice in which the members of the Northernpartnership work directly not only with the strongerSouthern partner but also with their local counterparts. Inthis model, the value of peer- to-peer interactions can befostered not only at the micro and meso levels but also atthe macro scale - essential for effectively addressing imple-mentation challenges. The consciousness-raising thatoccurred through this partnership has already led to callsto improve the way global health is taught in medicalschools in the North [72].Johnson (2007)’s conceptualization of communities ofpractices as “an action learning space [with] mutualengagement, shared enterprise and shared repertoire asdynamic processes subject to a range of social relationsand differences between actors” provides a useful per-spective for considering how the partnership principle of“joint learning” that is put forward by the Tropic Healthand Education Trust (THET) can be operationalized,especially recognizing the different scales that must beaddressed for sustainability (another THET principle)[11].In considering the mechanisms and outcome achievedin different contexts in which we worked, we identifiedfive key features of the partnership that we see as havingbeen essential in what we accomplished:First, the Northern HIC partners’ practical experience inaddressing similar issues was invaluable in establishing apeer-to-peer partnership in which both HIC and LMICYassi et al. Globalization and Health  (2016) 12:10 Page 10 of 15colleagues had “real world” experience. In our case, theCanadians developed considerable collaborative experi-ence in addressing SARS, then later H1N1, and created arange of training materials, information systems and inte-grated policies. This was not only important in buildingthe expertise of the Northern partners to apply in the col-laboration with Southern partners, but highlighted therelevance of the Southern-based experience to alsoaddressing problems in HICs.Secondly, the active leadership of a strong nationalSouthern partner with experience in training, surveil-lance and policy development for the healthcare sector,and a mandate to work with local partners for imple-mentation, was crucial. In our case, NIOH and theNHLS fit this criterion perfectly. This enabled not onlyNorth–South collaboration, but sustained South-Southcollaboration, in that the “national” Southern partner hasbeen able to continue the work with “local” Southernhealthcare partners. While there is a growing literatureon North–South-South collaborations, this generally re-lates to a strong Southern country working with aweaker Southern country; our experience illustrates thatthe same principles apply within a single Southern part-ner country.Table 3 Impact of the partnership on policies and practices in Free StateBefore the partnership Since the partnership became actively involved in the Free State Province1. Management involvement was limited, andnot in compliance with legislationa• CEOs of hospitals recognized their legal obligation and new policies were approvedby the Free State Head of Department and Member of the Executive Council forHealth in 2013, starting with the establishment of health & safety representativesand committees2. Policies were not based on evidence. • New policy on management of TB at the workplace developed• New policy on workplace assessment developed3. Inadequate staff resources were allocatedto this area• Four new Occupational Health Nurse Practitioners (OHNPs) were appointed to provideimproved health services for the workforces.4. Programme coordination was a gap, withlimited working together of different professionals• The Partnership established programme coordination and working together of differentprofessionals (Infection Control [IC] practitioners, TB Coordinators and OHNPs),• There are regular meetings at Provincial level of these different professional groups whoare now working together5. TB and HIV management at OHC was not wellutilised by healthcare workers; OH nurses were nottrained or authorized to prescribe TB and HIVtreatment nor other PHC treatment• All OHNPs are now authorised to prescribe TB and HIV treatment as well as other PrimaryHealth Care (PHC) treatment and medication issues by hospital Pharmacy• Improved healthcare workers usage of TB and HIV management at OH clinics (OHCs) -now free treatment available• Health workers can get medication at own GP if preferred, come for follow-up and getservice free at OHCs.• Perception among OH staff that there has been decreased disability leave and staffleaving due to disability, and fewer employees suffering work related diseases andinjuries (although this is in the process of being ascertained more rigorously)6. No reliable electronic database for capturinginformation; no standardised medical surveillancetool; and no standardized approach to identifyingand recording workplace hazards• OHASIS brought easy-to-use system, which specified data to be collected to informManagement of need for future policy reviews and/or implementation measures to betterprotect health workers.• Training on OHASIS for OH/IC professionals as well as health and safety representatives,using a structured approach to code risks/hazards, made it easy to understand typesof hazards7. Very limited research capacity for occupationalhealth and infection control intervention studies.• Research capability improved through 1-year Certificate course for OH and IC personnel• Research output of short course gave evidence base of workplace conditions atdifferent facilities• Workplace conditions were perceived to have been improved through specific targetedefforts and reports to Managers and CEOs resulting in approvals for further research.aThe Occupational Health and Safety Act, 1993, states that occupational health and safety is the legislated responsibility of every employer including the publichospitals and clinics (OH&S Act, 1993). A National Health Plan for South Africa was prepared by the African National Congress (ANC) with the technical support ofWorld Health Organization and (United Nations Children’s Fund) in May 1994. The ANC initiated a process of developing an overall National Health Plan based onthe Primary Health Care Approach; occupational health and safety (OHS) was included in the Plan. Specifically, Chapter 14 of the White Paper for theTransformation Of The Health System In South Africa (1997) was entirely devoted to Occupational Health; this document later became the National Health Act no.61 of 2003, with Chapter 4 section 25 (2)(r) stipulating that the Head of Health in the province must provide occupational health. The key strategy for deliveringOHS services for the Department of Health is through Occupational Health Units attached to health facilities. It was also indicated that Provincial OHUs should beestablished as part of provincial health services to coordinate and monitor OHS, and to oversee training, information, surveillance, assessment of compensationfor occupational disease and injury, advice on workers’ rights to compensation, research, and specialised medical servicesYassi et al. Globalization and Health  (2016) 12:10 Page 11 of 15Thirdly, the mutual nature of the learning was anexplicit goal of the activities undertaken – a feature wethink has been important in our success. Northernersalways learn and gain from such experiences as much asthey teach and offer the Southern partner. In our case,the extensive involvement of both Canadian and SouthAfrican graduate students working with South Africanhealthcare trainees played a large role in all activitiesundertaken. The interdisciplinary community-universitypartnerships in both the HIC and LMIC combinedresearch, service and training; mutual appreciation ofthe varied needs was an essential part of the knowledgeexchange.Fourthly, our partnership recognized that it was notsufficient to provide training and other measures tostrengthen individual knowledge and skills, but that wealso had to address organizational infrastructural needsand governmental policies. As such, the recognition ofthe need for interventions at micro, meso, and macrolevel was of critical importance. Indeed, we believe thatTable 4 Different expectations in North- South-South collaboration for building HRHExpectedoutputsactivity areaExpected outputs for NorthernpartnerExpected outputs for leadingSouthern partner institutionExpected outputs for local Southernhealth system/hospital partnersResearch &New Insights∎ Scholarly publications(peer reviewed)- withlead authorship on some andco-authorship on others∎ Further grant funding∎ Scholarly publications(peer reviewed)- with leadauthorship on some andco-authorship on others∎Manuals and working papersfor local implementation,promoting problem-solvingand surveillance, withpotential for scale-up∎ Participation in scholarlypublications usually as co-authors∎Manuals and working papersfor local implementation,promoting problem-solvingand surveillance∎ Receipt of simple knowledge-translationproducts that can be usedfor local impactTeaching &Learning∎ Training of graduate and postgraduate students leading tosuccessful project papers/thesesof Northern students∎ Professional mentoring ofSouthern leaders∎ Respectful bi-directionalcapacity-building∎ Training of graduate andpostgraduate studentsleading to successfulproject papers/thesesof Southern students∎ Development of localhealth professionals andparaprofessionals intrain-the-trainer approach∎ Respectful bi-directionalcapacity-building∎ Training of healthcare workersleading to greater confidencein fulfilling their healthcare responsibilities∎ Development of local healthprofessionals and paraprofessionalsand trained trainerswho can continue the work∎ Respectful bi-directional capacity-buildingService & Practice ∎ University/hospital service(curriculum development,sharing lessons)∎ Participation in professionalassociations - national (Northern)and international∎ Insights from applyingpolicies and proceduresin high risk circumstances∎ Fulfilling institutional mandate∎ Participation on national committeesfor policy development and implementation∎ Professional associations - national(Southern), international∎ Surveillance of overalleffectiveness of policies and procedures∎ Fulfilling hospital/health system mandate,with improved policies and practicesimplemented in the workplace∎ Participation on local committees forpolicy development and implementation∎ Professional associations - local∎ Documentation on effectivenessof policies and proceduresTable 5 Characteristics, strengths and challenges of different partnership modelsType of partnership Characteristics Strengths ChallengesModel 1: Northern experts– Local Southern partners(North–South)Northern experts work directlywith local health practitionersin resource-constraintsettingsPotential for knowledge fromthe North to be made directlyavailable to practitioners onthe frontlines;Practical contextual understandingof the Southern reality may belimited and sustainability uncertainModel 2: Northern experts workingwith strong lead institution basedin the South that has a mandateto work to build capacity in itsjurisdiction (North–South)Northern experts work directly withcounterparts at the national levelor in lead Southern institutions,who, in turn, work with localhealth practitioners in localresource-constraint settingsSustainability enhanced withleadership reinforced inSouth jurisdiction; capacitiesfor technology transfer enhancedMutuality limited by uncleargrounding in practical realitiesof Northern partner; with limitedability for mutuality at practitionerlevel; limits to bi-directionallearningModel 3: North–South-SouthCommunity of practicePractitioners and researchers fromthe North and South work togetherwith local practitionersAbility to develop, share and analyseimplementation at different scales;enhanced bi-directional(or actually tri-directional) learningComplexities in sustainingtripartite relationship.Yassi et al. Globalization and Health  (2016) 12:10 Page 12 of 15emphasizing the social determination of health [38] atall levels is paramount.Finally, the model adopted - of establishing a communityof practice, involving HIC researchers and practitionersalong with LMIC researchers and practitioners working atdifferent scales (training individuals, strengthening work-place infrastructure, achieving improved policies andresource allocation from government) - synthesizes the les-sons learned. The key message, therefore, is that investingin developing a multi-scalar community of practice, cen-tered on strengthening a key LMIC institution that can sus-tainably work with local partners, is thus especially useful;we believe this model and these key features can be appliednot only to improving occupational health and infectioncontrol, but sustainable health systems strengthening moregenerally.ConclusionsWorking conditions for health workers worldwide havebeen undergoing rapid change, with new methods fordiagnosis and treatment of diseases, combined withrapid communication technology, improving global abil-ity to disseminate new knowledge remarkably effectively.On the other hand, economic globalization is severelystraining healthcare resources, preferentially benefitingricher countries [73, 74]. Health worker migration [74],trends to deregulation [73, 75] and weak health systemsalso impact human resources for health, with the recentEbola outbreak representing only the tip of the iceberg.Thorsteinsdottir and colleagues [13], drawing on theirown experience, emphasize the urgent need for inter-national collaboration to address the ever-faster spread ofinfectious diseases and outline some of the challengesencountered, including lack of research resources inSouthern public sector institutions and technologicalchallenges. The five key aspects we identified as cru-cial to success add to some of the proposed actionsthey articulate, with our experience highlighting theusefulness of a bi-national North–South-South model.We believe that this approach can have widespreadapplicability, providing mutual benefit to all partiesinvolved.Endnotes1Training material and an introduction to the OHASISsystem are available at http://ghrp.ubc.ca/products/ andwill be available on an NIOH site.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionAY, Principal Investigator on most of the grants enabling the partnership,and JS, Principal Investigator for one of the research projects discussed,collaboratively prepared the initial manuscript, summarizing the collectivework over the past 9 years. MZ & EB then reviewed and modified themanuscript at the initial stage of preparation. KL and LO then elaborated onspecific experiences and conducted additional literature reviews for theteam. MZ, LN, DJ and LD elaborated on details on specific projects and theSouth African context. BK, as Executive Director of NIOH for the period whenthe collaborations were established and conducted until late 2014, furtherrefined the analysis of how the collaboration was established andconducted, as well as vision for the scale up. Drafts of the manuscript inprocess were shared amongst the entire team and revisions iterativelyprepared. All authors read and approved the final manuscript.AcknowledgementsThe authors wish to thank all the healthcare workers and laboratory workerswho participated in the projects described, as well as the managers, unions,and senior executive members who offered their support. We are grateful tocolleagues within NIOH and UBC who contributed to this work, as well as tocolleagues from Vancouver Coastal Health and from the various SouthAfrican Departments of Health and other organizations (includingDepartment of Public Service and Administration in South Africa, and theWorld Health Organization and International Labour Organization) whosupported and actively participated in these activities. At NIOH, we especiallyacknowledge with much appreciation the ongoing support of the ExecutiveDirector Dr. Sophie Kisting. The authors also thank colleagues at theUniversity of Free State, especially Dr. Michelle Engelbrecht and others at theCentre for Health Services Research and Development (CHSR&D), as well asDr. Rodney Ehrlich and the trainees, staff and other colleagues at theUniversity of Cape Town. We acknowledge the generous funding of thiswork provided by the Canadian Institutes of Health Research (CIHR) undergrants ROH-115212 and MOP-102669, as well as the funding for training inFree State provided to CHSR&D and UBC from Canada’s Global HealthResearch Initiative, a program funded by CIHR, the Canadian InternationalDevelopment Agency, the Public Health Agency of Canada and theInternational Research Development Centre. 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