From operational research to policy and practice The Union, Paris, France MSF, Brussels, Belgium

Operational Research: improving medical care and practice The studyMain findingsImplications for policy and practice Zachariah R et al. VCT and adjunctive cotrimoxazole reduces mortality in TB patients in Thyolo, Malawi AIDS, 2003, 17, VCT and adjunctive cotrimoxazole shown to be feasible, safe and effective in reducing mortality of TB patients under routine programme conditions Provided the evidence to support country-wide expansion of HIV testing and cotrimoxazole within TB Programme in Malawi

Operational Research: showing feasibility of interventions The studyMain findingsImplications for policy and practice van Griensven et al. Success with ART for children in Kigali, Rwanda: experience with health centre / nurse-based care BMC Paediatr 2008; 8, 39 ART successfully offered by nurses at health centre level Demonstrated feasibility and effectiveness of non-physician based HIV/AIDS care for policy makers

Operational Research: advocating for policy change The studyMain findingsImplications for policy and practice O’Brien DP et al. In resource-poor settings, good early outcomes can be achieved in children using adult fixed-dose combination ART – multicentre studies in 8 countries AIDS 2006, 20, Satisfactory ART outcomes in children on split- tablet generic fixed dose combination ART regimens Demonstrated feasibility and effectiveness in resource-limited settings of split-tablet, fixed dose ART regimens compared with branded drugs

What are the principles of getting research into policy and practice?

TB control in Malawi Prisons Programme objectiveEquity in TB control ConstraintMany prisoners admitted to TB registration centres with TB – “vulnerable population” General research question Is the prison setting a “hot spot” for TB transmission Specific research question What is the prevalence of TB amongst prisoners in the largest prison in the country

Important preparation for research and potential policy change Obtain agreement of the Chief Commissioner of Prisons and other relevant authorities to:- conduct the study present the findings on completion

Study in Zomba Central Prison: 20 May – 26 July 1996 MethodsPrisoners with cough > 1 wk submit sputa Active screening of prisoners in their cells Smear-positive = register and treat Smear-negative = follow NTP guidelines ResultsAlready on TB treatment = 14 Screened for TB = 900 (70% of total) Diagnosis smear-positive PTB = 18 Diagnosis smear-negative PTB = 15 75% of TB patients tested = HIV-positive Prevalence of TB = 5% (47/900)

Conclusion High prevalence of TB in the central prison Strong association with HIV No TB control system in prison

Four main steps towards change in policy and practice

Step 1: write up and disseminate findings August 1996Study completed November 1996Study written up as report and as draft paper December 1996Report presented to Chief Commissioner of Prisons; agreement to allow publication; instructions to improve TB control in Malawi prisons November 1997Paper published in Lancet [1997; 350: ]

 Move fast at the end of the study with writing up  Ensure dissemination to the people who make decisions  Publish in a peer-reviewed journal – improves credibility of the findings Activities

Step 2: ensure TB prison control is an important part of TB Programme Objectives Jan-Jun 1997TB Prison control part of the Objectives of TB control under “improving equity” Specify the activities needed Identify specific budget line for Prison TB control Nov 1997First meeting of NTP and Prison Medical Staff. Minutes copied to Chief Commissioner of Prisons and Secretary for Health

 Ensure topic is integrated into Disease Programme planning and objectives  Identify funding lines to support activities  Ensure there is leadership and clarity at all levels so that the new programme work commences well Activities

Step 3: Build monitoring and evaluation and accountability into the new activity monthly meetings between NTP and Prison Medical Staff with data presentation / collation and minutes Incorporate supervision for prison TB control into quarterly NTP activities Invite prison medical staff to annual TB meetings and training sessions Invite NGOs to assist with Prison TB control

 Support the new programme work through routine activities and monitor the outputs Activities

Step 4: publicise the new programme work at meetings and in papers Number of New Prisoners: ,588 Number (%) with cough > 1 week11,863 (9%) Number Smear-positive PTB516 Number Smear-negative PTB603 Number EPTB71 Cure rate (%) in smear-positive PTB62% Int J Tuberc Lung Dis 2003; 8:

Summary of the basic steps for getting research into policy and practice

Before you start the research, think ahead to…  What you would like to see happen  How you think your vision can be made sustainable  Who you will need for support  Who you will need to validate any policy changes  Who you will need to put policy changes into practice

Then, after the study…. 1.Write up and disseminate findings 2.Ensure the topic becomes an important part of the programme objectives 3.Build monitoring and evaluation, and accountability into the new activity 4.Publicise new programme work in meetings and as articles