Programs and Science:
Seeking the Academic Mission in
Global Health
James Blanchard, MD, MPH, PhD
Professor and Director
Centre for Global Public Health
Department 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 assessment
Theoretical Basis
Intervention Design
Demonstrate efficacy /
effectiveness
“Getting research into policy
and practice (GRIPP)”*
* Parkhurst et al. Lancet 2010.
Implement and Scale Up
With “Fidelity”
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” or
Clashing 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)
NACO
TRGs
CEA
UM
Design overview:
c. 1999
Program planning and
UM
implementation cycle CEA
CEA
UM
Program planning and
implementation cycle
Karnataka
Rajasthan
CEA
UM
e.g.
communitybased care
enhanced
surveillance
Local level projects
targeted
interventions
operational
research
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”
Planning Phase
Package of
Critical MNCH
Interventions
Implementation Phase
Improve Availability / Accessibility
Implementation
Model
Critical MNCH
Interventions
Health System
Preparation
Improve Quality
Increase Utilization / Coverage
Knowledge Translation
Karnataka
India
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
Spheres of Knowledge
Spheres of Practice
Intended Outcomes
• Epidemiology
• Transmission dynamics
• Policy analysis
Strategic Planning
• Define prevention objectives
• Prioritize the right populations
• Match strategy to epidemic phase
• Efficacy / effectiveness
• Operations research
Program
Implementation
• Select the intervention mix
• Implement interventions effectively
• Surveillance
• Monitoring/evaluation
• Operations research
• Health systems research
Program
Management
• 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.