Improving and Harmonizing Operational Research
in Tuberculosis
Anthony D HarriesThe Union, Paris, France
1. Agree on what we are talking about
“What” is operational research
Research into
strategies, interventions, tools or knowledgewhich
can improve health care delivery
Guiding principles in setting operational research agendas
• Define program / health system objectives
• Identify constraints to meeting objectives
• Ask research questions around constraints
Research questions
Three themes:
• Lack of knowledge?
• Lack of a tool or intervention?
• Inefficient use of a tool or intervention?
Theme – “inefficient use of a tool”sputum smears for diagnosing PTB
• Objective of NTP = high quality sputum smear diagnosis using three sputum smears per patient
• Constraint = three smears per patient are demanding for the laboratory technicians
• Research question = are two smears as efficient as three smears for diagnosing smear-positive pulmonary TB
• Answer the question in a number of different ways
Research methodology
• Descriptive or cross-sectional studies
• Case-control studies
• Cohort studies (prospective, retrospective)
Research is carried out within the routine system
What is not operational research:
• Basic science research
• Randomised controlled clinical trials [RCT] – where research is conducted in a strictly controlled environment, with inclusion and exclusion criteria – efficacy is the end point
The need for RCT and Operational Research
RCT
Provides information onefficacy of interventionin special groups ofpatients
Operational Research
Provides information onthe effectiveness of theintervention in theheterogeneous world ofroutine patient care
Routine TB quarterly data monitoring system on cases and outcomes
Data used for operational research
2. Recognise the challenges and barriers to operational research
The needs of Operational research:
Protocol development
Searching for funds
Collecting and analysing data
Writing the papers
Dealing with peer review revisions
TIME
There is no dedicated time available
The first problem
The second problem
I don’t have the SKILLS to do research
What data do I collect?
How do I collect data?
How do I make sense of the data?
How do I analyse the data? I cannot write
I cannot get started
I have too many good ideas
I spend all my time re-writing
There is no logic to my thoughts
The editorial demands are too much
Programme managers do NOT recognise the relevance of
operational research
The third problem
The fourth problem
Individuals return to RLS with MPH or PhD
Why are they not involved in operational research?
Appointed to senior-level management posts
No infrastructure for research
“I have no mentor”
No opportunities
No support for research back home
3. Find real solutions
1. Involve Programmes• Involve programme staff right at the start
• Ensure that research questions are relevant to programme implementation and connected to health service delivery
• Set up a good coordination mechanisms to provide clear strategy about setting of research priorities
International Expertise
WHO
The Union
LSTM / LSHTM / KNCV
NTP Malawi Institutions
Medical School
NGOs
National AIDS Programme
Research Ideas
Malawi TB Programme Management Group
Implementation of research by the various groups
NTP programme investment
• Appoint research officer, who can work alongside NTP manager
• Support in-service training • Work with partners in developing research
training workshops, writing skills workshop• Annual review meetings to present
research• Emphasize publications in national and
international journals
2. Build the capacity
• Training symposia• Training courses• In-service training• Masters degrees• Doctorates
BUT…………….
Japan International TB Course:2001 - 2007
• 28 participants developed ORP
• 11 (39%) started ORP on return to home
• 1 wrote a paper
• 0 published a paper
Ohkado A et al, IJTLD 2009 – in press
Union / MSF paradigm for operational research training course
Purpose: • To develop the practical skills for conducting and
publishing operational research
Approach: • Careful selection of participants• Need to achieve milestones to remain in the course• Target-oriented – success of the course judged on
whether participants complete research and submit a scientific paper
Three modules
• Module 1: research questions, protocol development, ethics ( 5 days) – August 2009
• Module 2: Data management and data analysis (5 days) – October 2009
• Module 3: Paper writing, includes data presentation, interpretation and policy implications (5 days) – March 2010
Operational Research Fellows
• Careful selection of fellows• Employed full-time / part-time through Union• Mentors identified• Attached to programmes or linked institutions• 12-month contracts• Deliverables= 2 papers submitted each year• Linkage to PhD programme (under
development)
4. Invest in Research
NTP Programme level
• Clear objectives and activities around operational research
• Clear targets – number of projects implemented, projects completed, papers written, papers published, program policy and practice changed
• Well defined budget line including research allowances, internet connectivity, conference attendances
International Support for Research
• GFATM – 10% of country proposal can go for M&E and operational research
• The Union – two mechanisms for support (Treat-TB and Centre for Operational Research)
• The Wellcome Trust African Institutions Initiative (seven consortia of 18 African countries partnered with 6 Northern hemisphere countries)
• European & Developing Countries Clinical Trials Partnership
5. Develop Partnerships and Harmonize the efforts
Ministry of Health
NTP
WHO
NGOs
The Union
MSF
Schools of Tropical Medicine
LSTM, LSHTM
ITM
TB Associations
KNCV
HIV Associations
IAS
Governmental Bodies
Local country (MRC)
CDC, USA
Medical Colleges International Universities
Johns Hopkins
Harmonisation
• Should we develop an international TB operational research agenda?
• Should we keep a database of what research is taking place, where and by whom?
• Who should take the international lead?
“Learn by Doing”
Partner with colleagues and friends, and realise that we may not always have it initially correct