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Operational and implementation research: From IAS/Rome to ICASA/Addis Ababa Nicolas MEDA, MD PhD Centre MURAZ, Burkina Faso Objectives • To summarize major findings reported at the 6th IAS Conference in Rome on operational and implementation research issues • To discuss the major lessons learned from the conference on operations research and their implications for Africa • To propose some recommendations on the way forward Major topics covered by presentations on Operations Research in IAS 2011 Rome • Expanding testing, counseling and HIV knowledge • Delivering better diagnostics • Closing gaps in the cascade of retention in prevention and care programmes • Human resources needs & constraints • Decentralization and integration HIV testing: Innovation and Scale-up • Home-based testing accepted by 84% of households (Otieno et al.) and linkage to combination HIV prevention and care programme successfully managed (Tumvesigye et al.), all, in rural Uganda • Uptake of routine testing in health care settings high in California (Mahajan et al.) • Routine testing in Emergency Care Departments feasible and very productive in New Jersey (Martin et al.) Diagnostics: Innovation, CostEffectiveness and Scale-up Retention in the care cascade • Country ART and PMTCT programmes present wide variation in retention rates (M. Fox) • In Malawi, only 37.5% of confirmed HIV+ children are placed on ART in urban settings (Dube et al.) • Using trained Community Health Workers (Tingathe Project, rural Malawi) and Patients Advocates (South Africa) can improve access and retention in HIV prevention and care programs for children and adolescents Human Resources: a Critical Factor for Success • Task-shifting for nurse-initiated management of ART equivalent to doctor-initiated management of ART (STRETCH trial, South Africa) • Devolving more responsibility to nurses is considered in many other countries (Kenya, Swaziland, Malawi) • Blood exposure episodes are not rare in health care settings and many depend on technologies used for blood sampling or for medical injections (Brazil and Tanzania Studies) Decentralization and Integration • Decentralization is key for scaling-up prevention and care programmes and for reducing attrition (Marinucci et al. seven years experience in six African countries) • Without close supervision and support for quality management, decentralization ends with mixed results (Lambdin et al.) • Sometimes down-referral from urban doctor to rural nurses are not valued by patients on ART (Moshabela et al. REACH Project, South Africa) Decentralization and Integration • In Uganda, after integration of HIV & TB services, both survival and retention in care improved significantly, with 25% dying before ART initiation compared to 75% before integration (Hermans et al.) • Reproductive Health and HIV can also be integrated. But client needs for dual protection something very low and providers complain with high workload (Green et al. in Tanzania and Heffron et al. in Malawi) Lessons learned • Delivering efficient services with good uptake and retention even in rural settings is possible for routine HIV testing, PMTCT and ART programs • Decentralization with task-shifting & integration need more research to understand how best to maximize efficiencies, quality and health impact • Many confusions persist on definitions, scope and questions about operational and implementation research • No information shared in implementation science Definitions OPERATIONAL RESEARCH IMPLEMENTATION RESEARCH The search for knowledge on interventions, strategies, or tools that can enhance the effectiveness, efficiency, quality, access, coverage, or sustainability of programmes in which the research is being done The scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence to improve the quality and effectiveness of heath services Zachariah et al. Lancet 2009 12 Eccles & Mittman, Implementation Science 2006 The way forward for Operational research Supply-side barriers Demand-side barriers • Human resources • Infrastructure • Commodities/Supply chain management • Behaviours of providers • Clinical services organisation, management and delivery • Patients & community behaviours • Payments (informal+++) • Integrated communication programme • Communty mobilisation and involvement Governance, leadership, health financing, programme performance management, strategic information Operational research & Implementation Science From IAS Rome to ICASA Addis Ababa, 2011