Solving problems – operational research to the rescue

TDR news item
1 July 2013

A new integrated research and training programme for public health workers is helping countries use their data to reduce multi-drug resistant TB and a host of other challenges.

Participants learn that there’s a huge value in analyzing what you’ve done and asking ̶ does this actually work, can we improve this in some way, what are the barriers to our set goals?

Rafael van den Berg, MSF facilitator

National public health programmes often sit on mounds of health data about their citizens – data that could be used to identify health system bottlenecks and critical problems in the control of diseases like multi-drug resistant tuberculosis. TDR is working with health ministries, the World Health Organization (WHO) and other partners on a new operational research and training programme, SORT IT, which provides support to those countries to use that data to improve disease control.

SORT IT stands for Structured Operational Research and Training IniTiative. The programme is based on a proven workshop and mentorship-based model developed by Médecins sans Frontières (MSF) and The Union. Integrated research and training is provided over one calendar year, starting with two weeks of workshop activities, ongoing mentorship, and a final one-week workshop to finalize a research paper and evidence brief for policy-makers.

Participants have to propose a research question where the results can be used to make important changes in healthcare delivery or policy. Their governments and supervisors must agree to support the research, and the WHO regional and country offices help support this process.

“Many of the control programmes are doing what is being prescribed,” says one of the workshop facilitators, Rafael Van den Bergh from MSF, but nobody has time to sit back and ask themselves: ‘does this really work?’ ”

We are doing this huge amount of work, we are doing incentives, different treatment regimens, we don’t know what works, it’s all empirical. Participants learn that there’s a huge value in analyzing what you’ve done and asking - does this actually work, can we improve this in some way, what are the barriers to our set goals? And once you’ve found those barriers, how can we overcome them.”

Eastern Europe workshop on MDR and XMDR TB

A workshop was recently held in Estonia for national tuberculosis (TB) control programme officers from the Eastern European countries, where tuberculosis increased dramatically after the collapse of the Soviet Union. Most countries were able to reduce the numbers of patients by 2005, but then a new problem began with multi-drug resistant (MDR) and extremely multi-drug resistant (XMDR) tuberculosis.

The treatment for tuberculosis is not easy or quick, which is one of the reasons for this rise in drug resistance. At a minimum, it requires daily, supervised treatments of several pills taken orally for 6 months. When treatment is interrupted or disrupted for some reason drug resistance can develop. This can happen because the patient does not take some or all of the drugs as advised, or the supply of drugs to the patient breaks down. Patients with MDR-TB have to take more expensive and more toxic second line drugs for up to 2 years. MDR-TB and XDR-TB can also spread from one person to another. In some countries, MDR-TB rates are high even in people who have never had TB before. “Operational research is quite important to identify the drivers for MDR and prevent them,” says Andrei Dadu of WHO’s European office.

Marge Reinap, the representative of WHO’s Estonia country office, adds, “There are a lot of data and information that can be used for research purposes. During the Soviet time, it was not possible to publish peer reviewed articles in international journals, because it was mostly done in Russian and not English.” So this workshop offers participants an opportunity to mine that data, learn from it and share results beyond Russian-speaking countries.

Twelve people from the Eastern European countries of Armenia, Azerbaijan, Belarus, Estonia, Georgia, Latvia, the Republic of Moldova and Ukraine came to the workshop, which was hosted by the Estonian National Institute for Health Development. One of the participants was Natavan Alikhanova, head of monitoring and evaluation at the Scientific Research Institute of Lung Disease in the Republic of Azerbaijan. The country is one of the 18 high TB priority countries in the region, and among the 27 high multidrug-resistant (MDR) TB burden countries in the world. Dr Alikhanova provides quarterly reports to her health ministry, explaining, “It is important to the government because they buy the first and second line treatments, so they want to know how to spend the money.” She says 2006-2007 figures in one of their cities showed high prevalence rates of MDR – 22% among new patients and 55% among previously treated patients, quite a serious problem. Dr Alikhanova is using SORT IT to analyse a succeeding nationwide survey, which includes both the usual prevalence rates, but also looks at risk factors for drug resistance like age, sex, migration, social status, living condition, smoking, drinking, drug use, prison history, type and category of TB, HIV status, to see what, if any, impact they have on the disease.

In Armenia, Karapet Davtyan from the National Tuberculosis Control Office is looking at why local outpatient units, called cabinets, have different performance. “For example,” he explained, “there is a cabinet with a 90% success rate and another with 50%. Why are these differences? It could be regional, but in the same region we can find one with different rates. It could be because there are younger, more updated doctors, or that the cabinets are farther from where people live and so they stop coming. Or maybe the village ambulatory services are not doing a good job.” Dr Davtyan is mostly using data already collected, and will be presenting findings next year to his director and health ministry, who have supported his training here and are looking forward to learning what they can do to improve the situation.

Many of these countries have received medications free of charge from the Global Fund to Fight AIDS, Tuberculosis and Malaria, and know that this funding will not last forever. They are taking this time to use data already collected to figure out ways to stop this drug resistance, because many of them will have to start paying for the medications out of their already squeezed national budgets.

In the Republic of Moldova, Anna Ciobanu is the deputy director of the national TB programme. She says that one quarter of all new patients are already resistant to the first line drugs, and 10-12% of those who are not resistant stop their treatment before they should, risking resistance for themselves and others later on. The country’s agency for health insurance pays for the drugs, but they want to know which kind of incentives help people stay on treatment until the end. Is it giving 2 Euros a day for 2 months? How about transportation reimbursement for coming to the daily treatment, or €90 Euros at the end of a completed year of treatment, or social assistance, wood for heating, food tickets? These are all examples of different incentives in different parts of the country.

Faster results, customized training

It took me two months to do a similar research project for my master’s degree. Here we did it in one week.

Karapet Davtyan, Armenia National Tuberculosis Control Office

“It took me two months to do a similar research project for my master’s degree,” says Dr Davtyan from Armenia. “Here we did it in one week, and within that week, in two to three days. It was quite tough, it was the first time I did this type of protocol so quickly. After that, I started to believe to myself I could do this faster than before.”

The participants can do more because of the structure of the workshop, which favors one-on-one interactions customized to their needs. There are plenary sessions to teach specific skills, but then they immediately use those to develop their research protocols while in the workshop with a mentor or facilitator.

The courses have been held for 2 ½ years, but already some programme changes are taking place. Dr van den Berg cites a study in Fiji that looked at whether guidelines on rational drug use were being respected, which has led to an evaluation of those guidelines and potential changes to increase compliance with them.

TDR’s SORT IT manager, Andy Ramsay, says “People are very enthusiastic about the course. I think the excitement comes from suddenly getting the skills in 1 - 2 weeks, to learn to start to look at these research questions that many have been asking themselves for years.”

The programme can be applied to a range of diseases and health systems problems. It has already addressed issues of malaria, neglected tropical diseases, maternal and child health, HIV and non-communicable diseases, and TDR is examining ways to expand the scope of both topics and geographic regions where the training is held.

For more information, please contact

Andy Ramsay
E-mail: ramsaya@who.int

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