programs and science: seeking the academic mission in global health james blanchard, md, mph, phd...

Programs and Science:Seeking the Academic Mission in

Global Health

James Blanchard, MD, MPH, PhDProfessor and Director

Centre for Global Public HealthDepartment of Community Health Sciences

University of Manitoba

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?

“Research driven” approach to intervention design and

assessmentTheoretical Basis

Intervention Design

Demonstrate efficacy / effectiveness

Implement and Scale UpWith “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.

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

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.

“Know-Do Gap” orClashing 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

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

Same Epidemic, Different Prevention Strategies?

Epidemic typology

India-Canada HIV/AIDS Project – ICHAP (2001-6)

Design overview:c. 1999

NACO TRGs

Karnataka Rajasthan

CEA

Program planning andimplementation cycleCEA

Program planning andimplementation cycle CEA

CEA Local level projects

e.g. community-based care

enhancedsurveillance

targetedinterventions

operationalresearch

UM

UMUM

UM

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

“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

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

“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 / CoverageImprove Quality

Critical MNCH Interventions

Planning Phase

Knowledge Translation

Karnataka India

Implementation Phase

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

Overview of Program Science issues in HIV/STI

Strategic Planning

ProgramImplementation

ProgramManagement

• 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 Knowledge Spheres of Practice Intended Outcomes

• Select the intervention mix• Implement interventions effectively

• Achieve high coverage• Maximize efficiency• Alter programs when appropriate

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

A final word…(from Michael Gibbons1)

• 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.