February 03, 2011 Daniel G. Datiko How to integrate operational and implementation research into a National Tuberculosis Programme? February 03, 2011 Daniel G. Datiko 1

Outline of presentation Background and definition What is expected of operational research What is the current status Why is such research possible to do in some settings? How can we do it? Conclusions

Background Variation in the use of terminologies Mismatch: Size of health problem and resource constraints Recognition of the problem Increased interest to fill these gaps Increased awareness of research needs Variation in the use of terminologies

Defining research to improve health systems, PLoSMed 7(11):e1001000

Definition: Operational research Pragmatic: search for knowledge on interventions, strategies, or tools that can enhance the quality, effectiveness, or coverage of programmes in research area. Aim: find solutions for problems Origin: demand driven identified during routine monitoring and evaluation Operational research in low-income countries: what, why, and how? Lancet Infect Dis 2009; 9: 711–17

Definition: Implementation research A research that focuses on how to promote the uptake and successful implementation of evidence-based interventions and policies Aim Identify implementation problems and find solution Identify ways of introducing into the health system Characteristics Involves the systematic and critical investigation and analysis of the dynamic, contextual processes that influence how individuals, populations and health systems change to adopt new interventions. Operational research in low-income countries: what, why, and how? Lancet Infect Dis 2009; 9: 711–17

The Global Fund definition Operational research Any research producing practically-usable knowledge which can improve program implementation regardless of the type of research falls within the boundaries of operations research. Framework for Operations and Implementation Research in Health and Disease Control Programs

The scope of operational research Defining research to improve health systems, PLoSMed 7(11):e1001000

What is expected of operational research? Using TB as an example For example, it is important to Improve access to TB Diagnosis and treatment Adapt DOTS strategy to Improve programme performance Evaluate: feasibility, effectiveness or impact of new strategies or interventions Provide evidence and change policy

What is the current status? In the past, it shaped modern TB control It is not much used in developing countries From 1997 - 2006 Africa contributed only 7% of research on tuberculosis However, the number of reports increased from 49 in 2006 to 89 in 2008 The impact on TB may be questioned Generally, it remains underutilized! Operational research for improved TB control: the scope, the needs and the way forward, INT J TUBERC LUNG DIS 15(1):6-13 A bibliometric analysis of tuberculosis research indexed in PubMed, 1997–2006, INT J TUBERC LUNG DIS 12(12):1461–1468

Why was it not done? Failure to recognize its significance Inadequate and high turnover of staffs Lack of research capacity Inadequate funding or use of funds Little support from decision makers Lacks coordinating mechanisms NTPs not included = not implemented It is not part of NTPs

How can it be done? Increasing opportunities More staffs Increasing funding Understanding the significance of research Increasing operational challenges Experiences from different settings

Why was it possible in Malawi? They did operational research for many years Identify research priorities and objectives A Central Unit for coordinated research activities They had budget for research Developed capacity building programs Scientific reviews and dissemination + booklets Example of operational research

Assessing the diagnostic process of patients labeled as TB suspects who had been admitted to general hospital wards 25 TB officers trained 19 TB officers collected satisfactory data 11 TB officers submitted research paper 5 TB officers presented reseach paper and data used for collating the results Developing operational research capacity in hospital tuberculosis control officers in Malawi, INT J TUBERC LUNG DIS 2003,7(3):266-270

Recognition by the NTPs

How was it done in China? High burden of tuberculosis They identified operational problems They set research priorities Epidemical survey Socio-economic study on TB patients Conducted researches and audited reports They translated research findings into actions

Epidemiological survey Application of the results Main results Prevalence of TB = 367 per 105 Estimated no of TB = 4.51 million The annual prevalence reduction 3.8% from 1979 - 2000 3.2% from 1990 - 2000. Informed the central government Budget by central government $5 million in 2001 $76 million in 2009 Harmonization of resources

Socio-economic study on TB patients Results Application… Among 1278 TB patients 80% earn below the average income 92% did not have medical insurance Financial problem result in Escape consultation Poor treatment adherence Government fund Increased to support Diagnosis x-ray films AFB Treatment

Taken from Cancun presentation by Jing Shiwen

Experiences from Ethiopia There is limitted interest in research Among managers of TB programme some research done by academicians Currently increasing interest because of Increasing health interventions Community based initiatives

Experiences from Ethiopia... We reviewed programme performance Involved HEWs in case finding and treatment Demonstrated its cost-effectiveness Important questions How was the message carried across? Who should be involved?

Experiences from Ethiopia... How should it be communicated? Involved the Ministry of Health Reported our finding at review meetings Build common understanding Supervised by Ministry of Health and WHO Endorsed suspect form, specimen referral and treatment

Research: Suspect referral sheet Ministry of Health: Suspect referral format Research: Suspect referral sheet

Experiences from Ethiopia... Who should we involve? Understand the context National Part of NTP Understands operational challenges Good connection with the health system

The continuum…. Now with full support from NTPs Started implementation at larger scale Completed baseline activities Decentralized smear preparation

Filling referral form Labelling … Smearing … Fixing smears….

Slide referral…. Examination ….

How can we do it? Planning for operational research NTP outline their challenges Resources: time, offices, training,… Improve fund allocation and utilization Research capacity building Provide sustained mentorship Develop trained researcher Build institutional capacity Establish functional partnership Managers, decision makers, partners Coordinating mechanism and shared responsibility Ways of communicating the research findings

The Union’s operational research support package.

Conclusion Evidence based decision making Low research productivity: < 7% Contrasts with the morbidity and mortality Still it is possible….irrespective of limits OR and implementation might not happen at once, it is a continuous process!!!

NO RESEARCH NO HEALTH ‘ It seems astonishing that in the 21st century decisions on health care can still be made without a solid grounding in research evidence’ 2012 WHR REPORT THEME January 25, 2011 , A Call for Papers. PLoS Med 8(1): e1001008. doi:10.1371/journal.pmed.1001008

Thank you!