1. Programs and Science: Seeking the Academic Mission in Global Health James Blanchard, MD, MPH, PhD Professor and Director Centre for Global Public Health Department of Community Health Sciences University of Manitoba

2. What is the academic mission? University of Manitoba “To create, preserve and communicate knowledge, and thereby, contribute to the cultural, social and economic well-being of the people of Manitoba, Canada and the world.” In global health, how do we create, preserve and communicate knowledge?

3. “Research driven” approach to intervention design and assessment Theoretical Basis Intervention Design Demonstrate efficacy / effectiveness Implement and Scale Up With “Fidelity” “Getting research into policy and practice (GRIPP)”* * Parkhurst et al. Lancet 2010. “Getting research into policy and practice (GRIPP)”* * Parkhurst et al. Lancet 2010.

4. Constraints to the research-driven model (1) “Magic bullet” thinking –Focus on single interventions and technologies, rather than on combination interventions “Tyranny of the proven” –Interventions with “clear agreed-on evidence” displace interventions with less evidence but higher population impact potential

5. Constraints to the research-driven model (2) Mismatching intervention and context: epidemiological, sociological, cultural, economic, political. Lack of attention to complexity: –Unintended consequences –Synergies and antagonism between interventions –Recursive (feedback) loops between interventions, individuals and contexts.

6. “Know-Do Gap” or Clashing Paradigms? Research that answers unasked questions Leaving critical knowledge gaps Inconsistent standards of “evidence” Cacophony of “technical” guidance Failure to invest resources and intellectual capital to build knowledge out of programs and practice

7. The example of HIV prevention and control… Lack of clarity about epidemic assessment and strategic implication Few interventions with clear, agreed-upon evidence about effectiveness Lack of clarity about the appropriate intervention mix Limited theoretical and empirical knowledge on scaling up

8. Same Epidemic, Different Prevention Strategies? Epidemic typology

9. India-Canada HIV/AIDS Project – ICHAP (2001-6) Design overview: c. 1999 UM

10. Architecture… “Embedded scientist” model: –In programs, with government and private sector Partnership with local academic and program organizations: –St. Johns Medical College, NIMHANS, PHFI... –NGOs Establishment of local organizations: –Karnataka Health Promotion Trust: established in partnership with the Govt. of Karnataka to assist in the development and scaling up of health programs –India Health Action Trust: established to provide technical assistance across India, Asia and globally

11. “Knowledge” outcomes… Strategic information: –Rural epidemic, transmission dynamics –Understanding sex work (organization, practice, migration) –Mapping health services – configuration of STI/HIV care among private/public providers Implementation strategies: –Integrating programs / services at the district level –Scaling up targeted interventions Management approaches: –Training and mentoring systems –Monitoring and evaluation systems

12. Knowledge translation… Strategies: –Rural integrated outreach and program delivery –Scaling up programs and services for FSWs and high risk MSM –Training / mentoring systems for STI / HIV care providers and counselors –Building capacity in community-based organizations (collectivization of FSWs) Methods / tools: –Data triangulation and epidemic appraisal –Mapping vulnerable populations –Micro-planning tools for targeted interventions –Monitoring systems

13. “Technical assistance to improve maternal, neonatal and child health outcomes through the National Rural Health Mission in Karnataka, India” Package of Critical MNCH Interventions Implementation Model Health System Preparation Improve Availability / Accessibility Increase Utilization / Coverage Improve Quality Critical MNCH Interventions Planning Phase Knowledge Translation KarnatakaIndia Implementation Phase

14. Program Science: a new initiative With Sevgi Aral, CDC (Atlanta) Improve the science base for programs (focusing initially on HIV / STI programs) Close the “Program-Science” gap

15. Overview of Program Science issues in HIV/STI Strategic Planning Program Implementation Program Management Define prevention objectives Prioritize the right populations Match strategy to epidemic phase Epidemiology Transmission dynamics Policy analysis Efficacy / effectiveness Operations research Surveillance Monitoring/evaluation Operations research Health systems research Spheres of KnowledgeSpheres of PracticeIntended Outcomes Select the intervention mix Implement interventions effectively Achieve high coverage Maximize efficiency Alter programs when appropriate

16. Process Build the concept from programmatic and scientific perspectives –Focused meetings, consultations Initiate vanguard “Program Science” initiatives through partnerships of academia with programs at the country, state and district levels

17. A final word… (from Michael Gibbons 1 ) Need to move from “scientifically reliable” to “socially robust knowledge”, which: –“… is superior to reliable knowledge both because it has been subjected to more intensive testing and retesting in many more contexts…. and also because of its malleability and connective capability.” –“…. is the product of an intensive (and continuous) interaction between data and other results, between people and environments, between applications and implications.” 1. Gibbons M. Nature 1999.