Doing embedded development and research – reflections on the start of the Results4TB programme

Sophie Witter, Professor of International Health Financing and Health Systems at Queen Margaret University, Edinburgh, shares her reflections on the gains and pains of the first 18 months of the Results4TB programme in Georgia.

Georgia has a high overall tuberculosis (TB) treatment success rate, but with wide geographical variation, and a high loss to follow up. Treatment success rate of drug-sensitive patients varies from 50% to 100%. Even more worrying has been the relatively low treatment success rates for multi-drug resistant TB patients, at around 56% (compared to 70% in most other countries).

As a research team (including Curatio Foundation, Queen Margaret University, Edinburgh, London School of Hygiene and Tropical Medicine and Antwerp Institute of Tropical Medicine), we have had the privilege of working with local policy-makers and specialists in TB care to understand the factors behind these challenges and develop potential solutions.

In workshops in May and July 2017, we worked in groups with national and local level participants to understand what might work to improve adherence to TB treatment, considering bottlenecks for patients and providers. We used a lot of sticky pads and developed complex diagrams! No intervention can tackle all of the challenges in one go, but in the end, we decided to address two core emerging problems: 1) the lack of integration of primary and TB care and 2) the lack of motivation of providers in the area of TB services (where TB doctors face low salaries and are an aging cohort).

Since then, we have worked closely with the Ministry of Health, the National Centre for Disease Control and Public Health, the National TB centre and other relevant partners to develop a pilot programme which will incentivise facilities and providers to increase patient-centred and effective treatment for TB. (Patients also face barriers but already receive some financial support to help them continue with treatment.)

Piloting will start early in 2019 and we are excited to see how much difference this new approach makes. Our research plans include a cluster randomised trial, with qualitative analysis to understand what drives or impedes performance for different areas and groups, and a cost-effectiveness component to see whether the programme offers value for money.

Normally, researchers focus on relatively ‘simple’ tasks such as evaluation of programmes. Of course, these are not simple at all – and especially when you add in multiple components, with lots of tools, which require careful planning for data collection, analysis and integration, as we have!

But in this case, what has been especially interesting and challenging has been working on the development of the programme, as well planning its analysis. This meant developing concept notes, budgets, guidelines for providers, training materials, and working to bring all parties on board, amongst other things. 

This is called embedded development and research, and it is an increasingly recognised way of working to ensure that research changes the world, rather than just ending up in papers in journals.

What is striking is how many skill-sets and qualities are needed for researchers to work in this way – including political skills, and having the resilience to negotiate blockages in the development, funding and implementation process. (Plus the more traditional skills, like getting the sample size calculations right!)

This is stretching us all in the research team, but we are working well together and learning to share insights from our different disciplinary backgrounds. I think this is the future for applied health system researchers. But watch this space as we report back on our successes and failures over the next two years!

Read more about Results4TB