Academic journal article Bulletin of the World Health Organization

The Research Agenda for Improving Health Policy, Systems Performance, and Service Delivery for Tuberculosis Control: A WHO Perspective

Academic journal article Bulletin of the World Health Organization

The Research Agenda for Improving Health Policy, Systems Performance, and Service Delivery for Tuberculosis Control: A WHO Perspective

Article excerpt

Voir page 475 le resume en francais. En la pagina 475 figura un resumen en espanol

Introduction

Operational research offers significant gains at relatively low cost, and in a time frame of months or, at the most, a few years, but its application to tuberculosis (TB) has been relatively neglected (1). In this context, we mean operational research specifically aimed at developing interventions that result in improved policy-making, better design and implementation of health systems, and more efficient methods of service delivery. It is rooted in national and local experience, but can be applied at the global, national, or community level. Murray has given wider definitions of operational research (2). The present paper argues for greater investment in operational research and indicates some needs and opportunities for this, focusing on the approach to operational research taken by WHO following the development of its new recommended control strategy for TB, the "DOTS" strategy (3). The marketing of this strategy began in 1995 (4). Previously, WHO's efforts in applying operational research to TB control had been restricted by relatively low levels of funding to a patchwork of small-scale studies that were poorly focused and difficult to conduct in settings without a clear control strategy. Since 1996 WHO's operational research on TB has been concentrated in countries that have begun implementation of the DOTS strategy, and has focused on global and regional issues through relatively large-scale multicentre projects.

Progress in operational research in some key areas

A rational framework is necessary to develop a research agenda and select priorities when resources are scarce. We have based out framework on a global analysis, made in 1998, of the reasons for the persistence of TB and the factors preventing its better control (5). What follows draws on the results of several meetings convened by WHO since 1990 with controllers and researchers from countries with high TB burdens. The aims were to arrive at an improved definition of the priorities for research on TB, to develop strategies for addressing them (6), and to implement programmes of work.

Lack of political will and commitment

The lack of political commitment in governments, development agencies, and donors was seen as the principal factor hindering TB control. This matter has to be dealt with primarily at the political level. However, the priority research response is the development of convincing arguments for the adoption and expansion of the DOTS strategy. Because economics is the driving force of the political process in most countries, national or provincial studies of the cost-effectiveness of the DOTS strategy are essential. In India, for example, a relatively straightforward analysis of this type (7) demonstrated a net annual potential gain to the economy of ca US$ 500 million.

Arguments in favour of health interventions that alleviate poverty are increasingly deployed with a view to raising health expenditure (1). Direct evidence is often lacking, although the association of TB with poverty has been noted and debated for centuries (8). However, now that DOTS programmes have been in place for several years in various communities it should be possible to demonstrate their impact, if any, on social and economic indicators. This could be undertaken, for example, in China, where DOTS programmes cover roughly half the country. Specific studies may need to focus on disadvantaged groups such as women and ethnic minorities.

Studies of peoples' perception of the importance of TB are important, since politicians depend, to a greater or lesser extent, on support from their populations. Such work is also crucial for the design of advocacy campaigns seeking to raise awareness and stimulate political action, i.e. to achieve social mobilization. A study of the perceived priority of TB in India (9) showed that its control was severely underfunded, stigma was common, and the public were ignorant of the causes of and proper remedies for the disease. …

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