The Value of Implementation Research in SupportingEvidence-Informed Health Policy Development

The Value of Implementation Research

Final Report

of

A Workshop on The Value of Implementation Research in Supporting Evidence-Informed Health Policy Development

Bangkok, Thailand 14-16 March 2011

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The Value of Implementation Research

Background As well as drawing on global evidence, the development of effective health policy in countries must draw strongly on local research which is relevant and timely. With increasing recent interest in the new field of ‘implementation science’, implementation research (IR) is seen as a potentially important contributor to development of more effective health policy and, ultimately, to strengthening of health systems. 1 Implementation research can help each step in the process to promote evidence informed decision making. For example, policymakers can use evidence (such as feedback from programmes or changes in health indicators through the scaling up of use of diagnostic kits) in order to clarify and prioritise problems. Likewise, policymakers can use other kinds of evidence (such as results from opinion polls or tacit knowledge from stakeholders) when reviewing and commenting on draft policies. Such a ‘knowledge translation’ process uses research evidence and other information from IR at nearly every stage, both in the development of policies (i.e. setting priorities, clarifying problems, identifying policy options) and in the implementation and monitoring of policies. This offers an integrated approach and continuous interaction between IR and policymaking by incorporating IR in a systems approach that can enhance the uptake of new interventions and the performance of the system.

In an environment of limited resources and competing priorities, the utility and value of IR becomes even more apparent as a key contributor to new knowledge which is directly relevant for strengthening health systems.

Through identification of key lessons which can be applied to health care delivery, including but not limited to diagnostics, this workshop will explore the interface between IR and policy and their contribution to health system strengthening.

Remme JHF, Adam T, Becerra-Posada F, D'Arcangues C, Devlin M, et al. (2010) Defining Research to Improve Health Systems. PLoS Med 7(11): e1001000. doi:10.1371/journal.pmed.1001000 1

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The Value of Implementation Research

Workshop Objectives The overall objective of the workshop was to provide a forum to explore how we should do implementation research which results in more timely policy change and sustainable implementation. The workshop therefore provided a platform for dialogue between policy makers and researchers around three key issues: 1. The importance of developing national policies on the introduction and scaling up the use of point-of-care (POC) diagnostic tests; 2. The challenges of presenting evidence to policy makers to inform policy development and implementation; 3. The contribution of implementation research to health systems strengthening.

Format and Process To achieve these objectives, we brought together researchers and policy makers associated with two ongoing activities in several WHO regions: 1. IR projects ongoing in seven developing countries (Brazil, China, Haiti, Peru, Tanzania, Uganda, Zambia) to determine the feasibility and cost-effectiveness of using novel POC diagnostic tests to prevent congenital syphilis.

2. Evidence to policy initiatives in low and middle-income countries (Africa, Latin America, Western Pacific) strengthening the links between research evidence and health policy development.

Importantly, the value of the exercise extended beyond syphilis diagnostics to diagnostics more generally, and also to other health interventions and processes.

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The Value of Implementation Research

Day 1: Monday 14 March 2011 In the workshop’s opening remarks, Tikki Pang, Director of Research Policy and Cooperation at WHO (WHO/RPC) introduced the “triangle to move mountains,” first proposed in Thailand. This “triangle” connects the three components needed to resolve problems in IR and policy research. All three of these components must be present in order to effect policy change.

Support of policy makers

Research/ Knowledge

Social Movement

Rosanna Peeling introduced the background to the implementation project funded by the Bill & Melinda Gates Foundation to introduce rapid syphilis tests in 7 countries. The WHO estimates that 2 million pregnant women each year are infected with syphilis globally. Approximately 1.2 million of these women transmit the infection to their baby, who may be stillborn, born prematurely or with a low birth weight or congenitally affected as a result. These adverse outcomes are entirely preventable if syphilis in pregnancy is diagnosed and treated before the end of the second trimester.

However, in the developing world, currently only 30% of pregnant women with syphilis are screened and treated, even though universal screening of pregnant women for syphilis is recommended policy in many countries.

The major obstacle is the lack of access to laboratories that can offer screening as women often have to travel long distances to reach a hospital or clinic with such services. The goal of the project was to determine the feasibility and cost-effectiveness of increasing access to syphilis screening using rapid syphilis tests. As the project is to provide evidence for policy, the projects need to be country led and tailored to country needs. This was followed by presentations of the seven country projects in which rapid syphilis testing was introduced. Each country presentation was followed by a discussion period. The following points were raised during discussions:

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Country Brazil

Discussion Points

The Value of Implementation Research

The setting in Brazil is unique and there is a special relationship between the Brazilian people and the indigenous. This means the government has been willing to introduce rapid syphilis and HIV screening despite a cost of USD $7000 per women screened and treated. Principal Investigator Adele Bezaken explained that for the Brazilian people, taking care of the indigenous people is a source of pride and the MOH is willing to invest in improving the health of these populations. There is a national policy for screening all pregnant women for syphilis and POC tests have now made it possible to extend these services to indigenous populations in remote areas.

The prevalence of HIV and syphilis have been relatively low in the indigenous populations (around 1%), but failure to implement control measures now could lead to the epidemics spreading out of control. Sexual behaviour across indigenous communities in Brazil permits casual sex during marriage and in order to secure the future of the people, condoms are seldom used.

China

A New England Journal of Medicine (NEJM) article in May 2010 describing the syphilis epidemic in China presented policy makers with evidence and raised an alarm. The Minister of Public Health took an interest in syphilis and HIV control as a result of the controversy raised by the article and the department took responsibility for advocating for syphilis control. The NEJM article had a paragraph highlighting the potential for rapid syphilis tests (RST) to control the syphilis epidemic and on July 7 2010 the MOH introduced a national programme for syphilis screening.

China is one example of a scientific publication having a wider impact on policy, but often good research only reaches a small community of scientists. A suggestion was made for a course on the translation of scientific journals so that key messages reach the public and are accurately represented in mainstream media.

The success of the introduction of syphilis testing to HIV Provider Initiated Counselling and Testing (PICT) was highly variable. In areas with a high HIV prevalence and strong PICT programmes, the introduction of syphilis testing was much more effective than in areas of low HIV prevalence and poor implementation of PICT.

Haiti

The project has been a good example of how to keep syphilis as a priority on the public health agenda despite a cholera epidemic and several natural disasters.

There are two problems when trying to keep a disease as a priority for the MOH. The first is that politicians are always changing and they often have competing priorities for scarce resources. Syphilis is a largely invisible disease and difficult to keep on a list of national priorities unless there is a champion.

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Peru

The Value of Implementation Research Syphilis has not been a priority in Peru, partly because monthly reports show that the prevalence is falling among pregnant women.

The project has shown that prevalence is not falling The baseline survey for the project showed that pregnant women had to make up to 6 contacts to the clinics as part of their first antenatal visit over 27 days before they received the result of their syphilis test. As a result of this project, women now receive their testing, result and, if necessary, treatment in only 1 visit. Plus although rapid HIV testing was implemented in the country, it was done at the laboratory, also after the 27 days. The project has allowed moving HIV testing into the first visit, and it is offered as the “two for one”: one fingerstick two tests, syphilis and HIV. Laboratories were initially opposed to POC testing as they felt that their job was being given to others, but later they realize the value of the rapid tests and their role in the quality assurance (QA) programme QA, and the issuing of certificates to health care workers (HCW) who performed well in the QA programme, were found to be strong motivating factors for HCWs During training, a visual acuity test uncovered that 40-50% of HCW had vision problems and 50% with problems did not wear glasses. Also, 1 in 24 lab technicians were colour blind. This underscores the importance of testing visual acuity and colour blindness during training and ongoing QA/QC during implementation The study team identified several health system failings, raised awareness of these, and has supported the MOH in resolving the problems.

The strategy of using rapid syphilis testing in antenatal care and reproductive health services (labour and abortion), as part of a “two for one” has been taken by the government as policy. The government has bought 300,000 tests from last years’ remaining budget and is in the process of buying 500,000 more with this years’ budget. The strategy will be launched in April 19 th, with the logo “Yes to life, No to syphilis”.

Tanzania

To address the lack of national technical committee for diagnostics, decision makers and individuals with technical expertise were called together to create such a committee This national committee developed an algorithm to guide decision making for the selection of which diagnostics would be used in Tanzania before the project began.

Early engagement of the MOH led to the government donating supplies for the project. Ongoing stakeholder engagement led the MOH to commit itself to scale-up the use of rapid syphilis tests. Rapid tests are now recommended in the national guidelines for syphilis screening.

The national Institute for Medical Research (NIMR) will work with the MOH to assist in the scale-up of rapid syphilis tests.

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Uganda

The Value of Implementation Research MoH were consulted re site selection and regularly briefed throughout the project. A study team was seconded to the project by the MoH and has worked with the technical group responsible for procuring lab supplies. A local supplier of rapid syphilis tests has been identified in Uganda The programme worked well because of the excellent HIV PMTCT programme already in place at study sites Syphilis screening motivated more male partners to come for testing A question was asked about the long term effect of syphilis treatment on MTC HIV transmission. Although the project team in Uganda would have liked to conduct a follow-up and compare rates of HIV infection among children born to women tested and treated for syphilis to the general population, this was not possible in the time-frame of the project. The key aim of the project was to study the feasibility of introducing RST, not their impact on disease (HIV or syphilis) prevalence or incidence.

Zambia

At the end of the project, the MOH is planning to revert to a laboratory based test, RPR, even though the project showed that rapid syphilis tests were more cost-effective and increased accessibility. This is because test kits were only procured for the duration of the study and although the study team is hopeful that the government will change from laboratory-based to rapid tests and expand it to all PMTCT sites, this decision has not yet been finalized.

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The Value of Implementation Research

Following the country presentations, Patty Garcia summarised the activities from the country projects that contributed to effective implementation research. The activities were not conducted in a linear manner. Indeed, the seven project sites often had to do them repeatedly to achieve their goals.

Stage of IR 1. Advocacy for Research Problem

Activities Engaging stakeholders, corporations, agencies/ donors, societies, the public Identify champions

2. Study Design

Engage stakeholders Perform baseline assessment including providers knowledge and willingness Address country needs and local infrastructure in study design

3. Preparation

Make plans based on data collected during the baseline study Engage stakeholders Outline timing requirements, and training and material needs

4. Implementation

Engage stakeholders Involve other partners Evaluation of the acceptability of the rapid test to health care providers and patients Identify more champions Motivate and provide recognition to HCW (for example using certificates)

5. Monitoring and Evaluation

Set up a system for monitoring and timely feedback for corrective action on results Engage stakeholders Provide technical support

6. Cost-effectiveness evaluation

Engage stakeholders Evaluate in a variety of different settings (best and worst case scenario, changes to patient flow) and whether there are Page 8 of 28

The Value of Implementation Research economies of scale Note: this data is highly valued by policy makers but often not presented because of problems with collection. A costing guide has been developed by the project economist to assist with data collection.

7. Communicating Results

Engage stakeholders Share data and information and help with interpretation Use simple messages and different formats (powerpoint, web based, phone calls, reports, SMS messages) to get the message across

8. Include a phase to help with policy development

Identify policies (local, regional and national level) Work on changing policy Help with the dissemination of policy Champions can be a great help with this stage

9. Media Involvement

Involve the media Help the media with the story Give the protagonist role to the MOH in order for the MOH to adopt the project as theirs and to encourage ownership

10. Assure transference and scale-up

Host training of trainers workshops Share tools, guidelines and FAQs Provide support to the development of a national RST programme

In summary, the top ten recommendations for effective IR were: 1.

2.

3.

4.

5.

6.

Engagement of stakeholders as peers, throughout entire study period Share and communicate results Use clear compelling messages Identify champions Train and offer technical assistance Positive feedback Page 9 of 28

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7. Involve other partners 8. Leverage results 9. Make cost-effectiveness analysis user friendly 10.Keep motivation high These recommendations for effective IR research, based on the experiences of the project teams, kicked off a panel discussion. Two brief presentations

by Manju Rani and Luis Gabriel Cuervo provided meeting participants with the experience of the WHO Regional offices in the Western Pacific and the Americas illustrating a systems approach where knowledge translation supports health systems and is a catalyst for the development of national health research systems. The discussion that followed touched on a wide range of issues related to implementation research from the importance of working with policy makers and champions throughout the entire research process to the need for systems research before the transition from pilot project to scale-up.

Decisions to scale-up an intervention are made based on results from a pilot project. Pilot sites often benefit from additional support from the research team or funding from the donor agency which go unreported in publications and communications with policy makers. Each of the countries has been documenting the process from the beginning and the London team is finalising a generic toolkit based on country experiences and the process of implementation. Country project outcomes and implementation tools have been shared with policy makers and champions through an ongoing process of stakeholder engagement. Frequently asked questions leaflets were developed to enhance messages. This should improve the transition from pilot project to national programme.

The day concluded with presentations by Don de Savigny and Maimunah Hamid discussing the essential elements for creating a framework for an IRpolicy interface with a systems approach. One very important component of this transition is to ensure long-term sustainability and effectiveness through health systems research. Researchers and policy makers often overlook this intermediate step in scaling up a project which can result in fragmentation of the health care system into disease oriented interventions. Any intervention introduced to the health system has an effect on the entire system including financing, service delivery, human resources, and logistics. Scaling up is not simply a multiplication of what Page 10 of 28

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was learned during the implementation research and will be faced with unexpected challenges and obstacles unless systems research is undertaken.

A common thread in each of the success stories presented is the early engagement with policy makers and ongoing engagement with stakeholders. Early engagement with policy makers can foster country and local ownership, and aid in the transition from implementation research to programme. Consumers and champions can also assist in advocating for an intervention. Consumers and the public can demand services from local health care facilities and from their government. Champions are non-biased advocates, whereas researchers may have a vested interest in the success of a project. Publishing peer-reviewed articles in scientific journals keeps researchers accountable and should ensure advocacy is based on sound scientific evidence and not personal opinion.

One of the policy makers attending the meeting offered his perspective on IR and effecting policy change. First it was noted that policy makers are constantly changing and the policy environment is a very dynamic one. For research to be successful in changing policy and practice in the long-term, it is important to have the stability of an academic institution involved in the research which would outlive the turnover of politicians. Since most politicians’ terms of office are short, it is important that outcome measures from IR be collected periodically and reported to policy makers. Politicians would be less willing to support an intervention if the impact will not be realized for another 5 years, long after s/he has left office.

The two main messages from the afternoon session were: 1. To work with a number of partners (policy-makers, consumers and champions) to gain an understanding of the needs of policy makers and the health system before initiating implementation research.

2. To develop clear concise messages and communicate in a language the audience is able to understand.

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The Value of Implementation Research

Day 2: Tuesday 15 March 2011 The morning of the second day of the workshop focused on policy initiatives in low- and middle-income countries (Africa, Latin America, Western Pacific) on strengthening the link between research evidence and health policy development.

In the first presentation of the day, Tikki Pang made several insightful observations about the bumpy road from research to policy. He observed that research is conducted by scientists who have pre-existing opinions, views, and beliefs. Though often overlooked, this needs to be taken into consideration when presented with research findings. Dr. Pang also raised the issue of mistrust between researchers and policy makers and noted that this is one factor contributing to the know-do gap. Another challenge confronting policy makers is lack of data in developing countries. Many studies included in systematic reviews are conducted in well resourced settings and do not translate to resource constrained settings. For policy makers, there are three key questions when considering an intervention: Can it work? Will it work? Is it worth it?

Don de Savigny presented his experience working on the Tanzania Essential Health Intervention Project (TEHIP) which sought to improve health by providing districts with additional funding and tools to map local health needs and spending. The introduction of tools allowed the district to match resources allocation to health needs and implement changes in an integrated manner. TEHIP marked a paradigm shift in research methodology. It was a new type of research with a new type of ethics allowing for longer project duration, local ownership and a systems approach to health improvement. Don emphasised the importance of continuous surveillance at sentinel sites to monitor the impact of new interventions. Externally funded vertical disease programmes can have an adverse impact on health systems which is too rarely documented.

Although programmes supported by the Global Fund for AIDS, TB and malaria are supposed to spend 15% of their budget on monitoring and evaluation, few if any have done so.

Le van Hoi and Jorge Maia Barreto presented the experiences of the Western Pacific and Latin American regions with knowledge translation and

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the role that the Evidence-Informed Policy Network (EVIPNet) takes in this process.

The morning presentations were followed by a fruitful discussion on knowledge translation to improve trust between policy makers and researchers, enhance policy and improve research relevance, and the need for continuous evaluation of programmes.

Researchers are often unaware of burning policy needs and policy makers are often unaware of compelling research results, even if the research highlights an opportunity for a very simple, highly cost-effective intervention to be introduced. David Mabey raised the question of using the example of Tanzania where less than 50% of pregnant women are screened and treated for syphilis despite two papers being published in 2002 clearly showing the link between maternal syphilis infection and adverse birth outcome and the effectiveness of a single dose of benzathine penicillin in preventing adverse birth outcomes in Tanzania. The disconnect between researchers and policy makers can be overcome by using a simple, clear message, presented at an opportune time. The process of putting together a communication tool and document targeting policy makers can be a timely process and policy brokerage may help to overcome some of the delays.

Although evidence is first needed to change policy, a robust evaluation of policy can generate evidence on its effectiveness and help with identifying ineffective components or faults in the implementation. Post policy research should include health systems research to evaluate the impact an intervention has on a health system.

The EVIPNet programmes in the Western Pacific and Latin America regions are too young to have undergone a formal evaluation and assessment of their impact in the health systems, but both networks share resources and meet regularly to review the activities of regional networks and participating countries. Networks can be difficult to evaluate and it was suggested by Gรถran Tomson that outcome indicators complement the country evaluation by EVIPNet, in addition to the pre-and post intervention programme evaluations. The network is preparing at this time for the implementation of its monitoring and evaluation.

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The Value of Implementation Research

In the afternoon of Day 2, participants were divided into two break-out groups: Group 1 discussed creating a Framework for IR to Systems to Policy Interface and Group 2 discussed the Dissemination and Communication of Key Findings and Plans for Future Research. A rapporteur from each group presented the results of the group discussions on the morning of Day 3.

Day 3: Wednesday 16 March 2011 On the final day of the workshop, the outcomes of the two break-out groups were presented and discussed by participants.

Group 1 discussed the Framework for IR to Systems to Policy Interface. The participants described a continuum between implementation and systems research. They noted that while there may not be a clear distinction between IR and systems research, systems analysis could become part of IR. The group highlighted several issues with knowledge production in IR including a lack of information on the following: How to scale up implementation experiences?

How to integrate an intervention into the broader health system?

How to determine if the ‘intervention’ is system-ready?

How to effectively expand and scale-up an intervention?

Whether to focus on vertical or horizontal health systems research?

How to situate the problem in terms of a systems question instead of an intervention question?

Group 1 also discussed how rapid point of care (POC) tests have been a ‘game changer’ for the health system, enabling researchers to probe all aspects of the health system with a disease oriented intervention. The introduction of rapid tests raised issues with governance including regulatory issues, the harmonization/ regionalization of regulatory bodies, ethical concerns and transparency and accountability. Introducing POC tests led to human resource concerns being considered by researchers and the MOH including training standards, workload concerns, task shifting, continuing education, and rational use of supplies.

The result of the group’s discussion was the drafting of a framework for IR to systems to policy interface which highlighted the issues at each stage of Page 14 of 28

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the critical pathway, as identified by the rapid syphilis test introduction project.

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Group 2 discussed how to best communicate and disseminate the results of the rapid syphilis testing project to have an impact beyond the STI community. They also brainstormed a list of future research opportunities.

The dissemination/communication plan is a multi-faceted one involving: scientific publications policy briefs presentations at conferences interactions with the media to disseminate to the wider public drafting case studies development of a toolkit based on the experiences of the seven countries. The toolkit will be made available to any country with an interest in introducing rapid syphilis tests.

A publication strategy was discussed at a principal investigators’ meeting in London (January 2011). At the meeting it was decided that a publication committee would be created to review all draft papers prior to submission.

This would ensure that the messages communicated to the scientific community were consistent. High impact journals would be targeted in addition to national or regional journals to allow each site to describe their project and results in more detail. Publications in scientific journals would create an evidence base and communicate the project results within the scientific community.

To reach policy makers, policy briefs would need to be drafted. It was suggested that policy makers be involved the preparation of the documents as part of a continuing process of stakeholder engagement. It was suggested that two forms of briefs be drafted, a short communication, to target policy makers and ministers and a technical document to target technical decision makers and staff working in the ministry. Ayoude Oduola from WHO/TDR suggested involving individuals within the MOH in the drafting of policy briefs to help encourage ownership within the ministry.

Conference presentations will be given at the following meetings: VIII Brazilian STD Society Congress and the IV AIDS Brazilian Congress, Curitiba, Brazil, May 18-21 2011. The First Congress of ALAC/ IUSTI Latin America will also be held at the same time Page 17 of 28

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AFRO workshop on Congenital Syphilis, Dar es Salaam, Tanzania, June 21-23 2011 Meeting of the 19th Meeting of the International Society for STD Research (ISSTDR), Quebec City, Canada, July 10-13 2011 International Congress of Health Economics, Toronto, Canada, July 10-13 2011 Engaging the media will be a key component of the communication strategy. Media coverage is important to inform the general public and policy makers. Publication in high impact journals should be accompanied by a press release and press conference in each country. At the same time as the press conference, PIs should work with knowledge brokers preparing information to distribute to policy makers to maximize the impact of the media coverage. MOH representatives should also be invited to speak at the press conference.

It was noted by the Latin America investigators that it takes time to build an effective relationships with journalists. Workshops for journalists have been useful in Peru and Brazil to help build a relationship with media contacts and develop the industry’s knowledge of scientific research. It was also suggested that researchers make themselves available to journalists to answer questions so that the information reported is as accurate as possible, and where possible to work with knowledge brokers.

The message that will be disseminated with the results needs further crafting. Several suggestions were made during the breakout group including healthy babies and the silent killer. Past experience with HIV supports the use of a positive message instead of a scare campaign. Several messages may be needed for targeting different audiences. The medium used to communicate the final message might differ depending on the audience as well.

Recently, there has been a lot of international attention on the Millennium Development Goals. Researchers should capitalize on this and highlight the impact this intervention has on newborn survival and its contribution to countries achieving MDG 4. This message is highly timely and will be influential among policy makers and funders.

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The Value of Implementation Research

Case studies may assist in the communication of results. It will be difficult to develop individual case studies because nobody seems willing to become a public “syphilis champion� and represent the cause. Instead, case studies could focus on happy midwives or healthy families, delivering an effective and positive message. The most appropriate message, and medium, will again depend on the context and audience.

Another component of the communication strategy is the publication of a toolkit based on country experiences, through each stage of the implementation process. The toolkit consists of guidance documents and manuals on Policy & Planning, Implementation and Advocacy & Communication.

Several ideas were suggested for future research, including: - Impact evaluation (impact on perinatal mortality, incidence of congenital syphilis, cost analysis from the society’s perspective) o Could be done in a high prevalence country that was not part of the feasibility study o Would be expensive and require long-term follow-up - Use this study as a model to evaluate introduction of new technologies into health systems (new diagnostic tests for typhoid) - Studies on health system strengthening o Improved supply chain management o Incentives and empowerment of HCW by POC tests - Health economics: explore the cost-effectiveness of this intervention and its comparative advantages from a systems approach - Syphilis elimination and the impact of falling prevalence rates on the test performance and QC programmes - Evaluation and implementation research on new POC tests for syphilis and other STIs - How to increase the involvement of male partners - New business models for the provision of screening - Health systems research on the barriers to scale up and how to overcome them - Strategies for syphilis control in high risk groups In addition to the dissemination plans presented by Group 2, Tikki Pang informed the participants of an open call for papers from PLoS Medicine to Page 19 of 28

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coincide with the publication of the World Health Report in May 2012.

Rosanna Peeling also suggested drafting a concept note to be sent to some high impact journals to propose the publication of papers on the overall project findings from all seven countries. This concept note would focus on the main project outcomes: rapid tests as tools for transforming policy (to make it implementable), strengthening health systems and saving lives. A second over-arching paper discussing the challenges to introducing rapid tests and how they were overcome could be submitted to journals such as Health Policy and Systems or Implementation Science. More in-depth country-specific papers could also be submitted for publishing in an open access journal or in national journals.

A list of conferences to share the results of the syphilis IR project was drafted. In addition to ISSTDR held in Quebec City (July 2011), and regional meetings in Africa and Latin America, this included: VIII Brazilian STD Congress and IV Brazilian AIDS Congress: Brazil, May 18-21, 2011 Global Health Council: USA, June 13-17, 2011 (may be too late to submit abstracts) Annual Meeting of the Global Forum for Health Research: Cape Town, 1st quarter, 2012 Second Global Symposium on Health Systems Research: China, 2012 Global Health Council: Mumbai, June 2013 Health Technology Assessment Annual Conference: Brazil, June 2011 Health Technology Assessment Annual Conference: Mumbai, June 2012 When disseminating results, the wording of a message will be critical. It will be important to draw parallels between the syphilis rapid test and other diagnostics and discuss more generalizable outcomes. Somsak Chunharas reiterated a point made earlier by Don De Savigny that technology interventions do not exist in a vacuum but within a system and there is a need to improve our understanding of health systems so IR can be taken forward. In part, this will be done through the toolkit which should take a broader systems approach rather than a technical or disease specific approach.

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Though the project set an example of how a simple intervention can strengthen health systems, and could be used as a model and applied to other diseases, Goran Tomson suggested that what is first needed is mapping of (1) diseases for which POC tests are available and scale up is needed, (2) a data base of diseases for which rapid tests exist, but where further test development is needed, and (3) diseases for which information and basic research is needed to identify a target before test development can begin. The suggestion of mapping the landscape of POC tests by Tikki Pang was complemented by Luis Gabriel Cuervo’s suggestion of publishing a systematic review of the knowledge gaps in public health to lay the road map for funding agencies and researchers with a particular focus on diagnostics. Even with a map of health needs, diagnostic companies would be reluctant to invest in developing a test for low-income countries because of a perceived lack of return for investment. Rosanna Peeling told the participants about WHO/TDR’s African Network for Drugs and Diagnostics Innovation (ANDI) and it counterparts in Asia, in which scientists in developing countries are provided with funding and network support to develop drugs and diagnostics for diseases that are of public health importance in their own region. This initiative should encourage young scientists to take a serious interest in a career in diagnostics research and development.

Somsak Chunharas summarized the morning’s discussion by highlighting two critical research questions which need to be addressed in diagnostics: 1) how do we integrate existing technologies? 2) how do we motivate people to develop new technologies?

Day 3: Meeting Summary The seven country projects have shown the value of rapid tests in increasing access to diagnostics, which are critical in the detection of STIs as most STIs are asymptomatic. Increased access to syphilis diagnostics will allow countries to make progress in achieving Millennium Development Goal 4 (reducing mortality under 5), 5 (improving reproductive health for women) and 6 (reducing prevalence of HIV) There is also a broader value to the project which is the potential impact on building blocks of the health systems (health provider motivation, quality assurance, financing, supply Page 21 of 28

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chain management) where the impact will carry on beyond the timeframe of the project. Firstly, what has been done for syphilis can be used as a tracer to probe various parts of the health care system. Secondly, the multicountry project can also be used as a model for other diseases and the experiences of the group will extend beyond syphilis. Finally, the work of the country investigators has the potential to fill gaps and address some of the key issues raised during the project including neglected laboratory systems, the desirability of an essential diagnostic list, the desirability of better governance and processes, and the necessity for standards.

Although the focus of the project was syphilis, its outcomes have implications that extend far beyond a single disease.

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Appendix 1: Workshop agenda

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Appendix 2: List of Participants

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