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