Incorporating operational research in programmes funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria in four sub-Saharan African countries

Three of the most devastating communicable diseases in human history, HIV/AIDS, tuberculosis (TB) and malaria, are being fought by affected low- and middle-income countries with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), aiming at eventually ending those epidemics. The Global Fund disburses more than USD 4 billion a year to support programmes run by local experts in more than 100 countries, resulting in an estimated 32 million of lives saved [1]. It is the largest multilateral investor in health systems playing a leading role in global health by its contribution to financing the pathways towards universal health coverage in beneficiary countries. The Global Fund’s approach is multidimensional, shaping the global markets for medicines and technologies, increasing the resilience and sustainability of global health systems and strengthening human rights and gender equality within.

However, multiple challenges are present, especially on the path to disease elimination, including, emerging resistances along the malaria-transmission cycle (vector and agent), TB antimicrobial resistance [2, 3], weak implementation capacities, deficient drug supply systems, limited quality of care or fragmented approaches to health systems strengthening, urging the implementers of disease programmes to improve their efficiency. Operational research (OR) that is designed to increase both implementation efficiency and effectiveness provides evidence on elements that either enhance or impede the performance of established processes within, for instance, disease control activities [1, 4‐7]. OR can therefore support programme managers and policy makers in optimizing and scaling up activities [1, 8, 9]. Also, in contrast to implementation research (IR) that may need more complex data of an intervention in pre-defined groups of patients, (e.g. a randomized control trial), OR often uses routine data to determine how interventions are translated into a benefit in the heterogeneous setting of routine care [4].

The Global Fund has recognized the value of OR and encourages its application by strengthening the capacity of recipient countries to collect high-quality data to maximize the impact of the GF-supported programmes [10]. For instance, OR has shown that gender and age inequities are important drivers of HIV and TB epidemics, the Global Fund has therefore included them as part of its Strategy 2017–2022 as key performance indicators, prompting its beneficiary countries to take actions to reduce those inequities [10]. Yet, OR and other evidence-based approaches are not being routinely embedded in control activities funded by the Global Fund despite the effort and advocacy from different stakeholders such as the Special Programme for Research and Training in Tropical Diseases (TDR) and local research organisations. The reasons for this have been previously explored by Kiefer and colleagues [11] revealing considerable variations from one country to another and between programmes with regards to the needs, demands, absorption capacity and funding for OR related to malaria and TB. The study by Kiefer and colleagues remarked the necessity of the involvement of national research coordination bodies, established research agendas and prioritizing human and technical research capacity to strengthen OR locally.

Building on the findings from Kiefer and colleagues [11], the Swiss Tropical and Public Health Institute (Swiss TPH), commissioned by TDR, undertook a follow-up investigation to find out if and how an OR tool could become an integral feature in the Global Fund grants. The Structured Operational Research and Training IniTiative (SORT IT), a global partnership coordinated by TDR and implemented with partners, was the main OR reference tool for this investigation of four recipient countries in sub-Saharan Africa. SORT IT is a training programme aimed at implementers with little or no prior research experience in which each participant learns practical skills of protocol writing, quality assurance, data collection and analysis, to finalize with a peer-reviewed journal publication [6]. The participants are also trained on the use of their findings to foster evidence informed decision-making in public health [12], as shown by the research by Prasad Tripathy and colleagues in 2018 [13] on how SORT IT Alumni’s work has influenced changes in national policies and practices in TB and HIV programs in Fiji, Moldova, India, and Myanmar, among other countries. For instance, in Myanmar, the national HIV programme routinely assessed creatinine clearance in patients taking Tenofovir, which is a costly procedure. However, based on the OR results by Kyaw and colleagues showing a low incidence of renal toxicity of the drug ([13, 14]), the national HIV programme adopted a low cost screening method for renal dysfunction, saving resources to be allocated elsewhere. The current study, therefore, builds upon Kiefer and colleagues’ previous situation analysis of the extent to which grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) are being utilized to support operational research and implementation research (OR/IR) activities in recipient countries [11]. The objective of this follow-up study was to identify approaches and pathways to implement an OR component into grants to the Global Fund, in four sub-Saharan African countries with a special focus on the SORT IT as a vehicle to increase OR capacity.

Our study explores if there are the necessary conditions in the GF beneficiary countries to integrate OR elements into the programmes implementation, and what is the best way to do it. The conceptual framework was based on a behavioural change assessment and an analysis to identify elements supporting and blocking the integration of OR, namely force filed analysis. The assessment included the identification of opportunity, motivation, capability, and triggers within the specific country contexts as these elements are pointed out as necessary for a specific behaviour to be present [15, 16]. The force field analysis was used to assess the current situation within the selected countries because it has proven to be useful identifying both driving and blocking forces contributing to the actual behaviour equilibrium at a given time that are affecting a problem [17, 18]. The force field analysis also assists in the identification of the factors that can be dealt with to achieve a behaviour modification [19].

We used the SORT IT programme as the vehicle of OR because it represents a tried and tested approach to making use of routinely collected programme data to better understand how to improve programme performance [12, 20]. For instance, two of the most relevant papers published in the integration of OR to Global Fund grants are from Pakistan [21] and India [22]. These papers point out the effect of the SORT IT programme as an element that assists stakeholders coordination within the countries’ health system, which is a key element for successfully integration of OR into the disease programmes.

Four sub-Saharan African countries with high burden of malaria, TB or TB/HIV co-infection and that indicated interest in OR were included. The countries assessed in the current study were Ghana, Sierra Leone, the United Republic of Tanzania (Tanzania hereinafter) and Zimbabwe. The country selection was based on the following criteria: (i) high burden of malaria, TB and/or TB/HIV co-infection; (ii) having participated in the National Strategic Plan workshop organized by the Global Fund and the World Health Organization (WHO) in Hammamet, Tunisia in June 2019; (iii) having expressed interest in integrating OR into their national disease programmes funded or to be funded by GF grants; and (iv) Swiss TPH was not acting as a local fund agent in the country.

The interviewed stakeholders not only recognized the benefits of OR implementation but also manifested interest in integrating it into the relevant health programmes. The explored countries seem to have all the necessary elements to initiate the integration of OR into their health systems under the behaviour change assessment. However, no clear actions were identified towards this goal. Based on this insight, the behavioural aspects of OR adoption were taken into consideration assuming that a framework of incentives may be present preventing stakeholders to take any action. As mentioned before, the desire to enhance efficiency of programme implementation was found to be omnipresent across stakeholders. It is therefore surprising that those stakeholders barely recognized OR as an implementation tool, if at all.

Given that the main opportunity for countries to integrate OR elements into their programmes funded by GF is the country’s needs assessment, and the most influential stakeholder in this step is the MoH, we explored its role in this step. It is important to note that the country’s need assessment is the first step to elaborate the National Strategic Plan. Both the country’s need assessment and the MoH’s decisions seem to be greatly shaped by two factors: scarcity and tangibility. This favours the acquisition of tangible resources, e.g., drugs or bed nets, over non-tangible ones such as OR training which also results into a strong prioritization creating a perpetuating cycle that does not favour OR investments. Given the limited contributions of domestic funds to the country responses, the priorities of the national programmes are influenced by the requirements of the major donors. A change aiming to increase OR as a tool to increase value for money within the investments would require the involvement of both national and international stakeholders.

The options to break the negative dynamics of scarcity and low prioritization of OR include donors earmarking funds to develop OR, either as part of the current commitments or as additional ones. Another option is to conduct a bottom-up approach with simultaneous sensitization among the in-country decision makers on the mid- and long-term benefits of OR with sound examples and data showing efficiency gains for national disease programmes. There are additional steps to consider in developing this option such as the coordination of the main stakeholders. For instance, there is a need for OR advocates to have strong links at country level so to engage with the national programmes thereby relying on the support of WHO country offices to effectively influence their approach to OR and their decisions in the country funding request. CCMs would be instrumental in this engagement as CCM could influence MoH decisions and strategy if a coordinated body of stakeholders backs it up. The crucial steps identified during our investigation are shown in Fig. 3.

Despite the differences in involvement, culture and local characteristics in the countries under review, the dynamics between the different stakeholders and the opportunities to integrate OR into GF grants were similar. This is probably due to the magnitude of the Global Fund financial support to health system and service development and derived structures, which homogenizes the particularities of Global Fund funded programmes among all countries. This opens the possibility that SORT IT could indeed work as a vehicle to integrate OR into the disease programmes funded by the Global Fund. Our recommendations to achieve this integration are presented in Table 1.

The necessary elements to integrate OR into the Global Fund funded programmes in Ghana, Sierra Leone, Tanzania and Zimbabwe seem to be in place. For instance, there is willingness from the stakeholders and opportunities to develop OR and integrate it into the Global Fund funded programmes. The SORT IT programme could be instrumental in the integration of OR into GF funded programmes by coordinating the CCM and other stakeholders to break the tendency of the MoH to favour the acquisition of tangible goods over OR training.