Speech from the President: Implementation Science Workshop
May 19, 2016
Thank you for providing me the opportunity to speak today at this important forum.
I am here to provide my perspectives, not so much in my capacity as head of a national funding agency, but rather in my capacity as the Chair of the Global Alliance for Chronic Diseases or the G-A-C-D as it is more commonly referred to by its acronym.
Governments around the world have been giving great focus to AIDS, Malaria and Tuberculosis. My own government just made a pledge this month to fund an additional 785 million dollars for these three issues.
While these efforts are very much needed and laudable, chronic diseases, such as cardiovascular disease, cancer, and chronic respiratory conditions, have remained, at least until recently, and in comparison to the “big three”, very marginalized.
This was worrisome for a number of my colleagues and I, especially given that Non-communicable Chronic Diseases account for approximately eighty-five percent of deaths in low- and middle-income countries and approximately thirty-six million deaths per year worldwide.
When we decided to pool our efforts in 2009 in creating the GACD, we had six founding members that included health research funding agencies from Australia, Canada, China, India, the UK and the United States.
This was, and to my knowledge, still is the first and only collaboration of national publicly funded research organizations to specifically address chronic non-communicable diseases.
At the beginning, like with most new endeavours, it wasn’t easy and we experienced a number of challenges in getting the GACD off the ground.
Now, in hindsight, I can honestly say that our progress has been impressive and we are making a significant difference in people’s lives all around the world.
In the short time since its creation, we have doubled the number of countries involved; we have significantly increased the pool of funding for our call for proposals; and, we are in the process of hitting the milestone of a hundred and sixty-million dollars in committed funding under the GACD.
But what’s truly unique about the GACD is that our organization is adaptable and nimble, allowing our collective efforts to evolve. In effect, when we first started the GACD, our attention was focused predominantly on impact. We wanted to focus on interventions where we could see demonstrable change, which is why the first call for proposals was on hypertension. Now, our focus has shifted, while we still seek to have impact, we are now committed to focusing on implementation research and delivery science. Each funded team must demonstrate how their research focuses specifically on the study of interventions that work; and work for whom; under what circumstances; and whether the interventions are affordable and adaptable. In addition, our implementation science focus also means that we are looking at what interventions are scalable in a sustainable and equitable way.
What does this mean in practical terms?
This could be a study in South Asian countries to determine whether a lifestyle intervention program, provided to women with gestational diabetes after delivery, will reduce the incidence of type-two diabetes in a manner that is both affordable and acceptable.
This could be a study in Peru that aims to estimate how an intervention that introduces a low-sodium, high-potassium salt substitute will impact adult blood pressure levels. There are many other examples of GACD funded projects like these that are truly innovative.
But now that the GACD is at full maturity, we are taking the next logical step and devoting our attention to the scale-up aspect of intervention research to ensure the true implementation of evidence into policies and provide impact beyond a local level.
Within the GACD, we explored the option of continuing with identifying new priorities or seeking ways to optimize the international networks that were created and maintaining their expertise and creating something bigger.
Seeing how we have at our disposal approximately eighty percent of the world’s health research organizations, we felt it important to find a way to tap-into the political clout available to us and do more in terms of scaling these impressive research findings, and implementing their findings into true policy and / or change of health care practices needed.
We saw fitting to focus the scale-up strategy on hypertension. The reasons for doing so are obvious. The burden and impact of hypertension in low- and middle-income countries remain significant, with one in three persons affected by the disease. We also know that there are proven inexpensive interventions that are easily available and easily measurable in comparison to other chronic health issues such as mental health for example.
This second phase of the GACD will require working at national levels directly within selected countries that have a dedicated focus on chronic disease prevention and control in their strategic priorities. It also means working with countries that have committed to invest in program implementation towards this selected area.
National ministries of health will be major players in this focused scale-up approach. And our success will directly depend on our ability to make in-roads and obtain the buy-in and uptake of decision-makers and service delivery partners. Indeed – not an easy task!
In sum, this new approach will basically constitute a hybrid system where decision makers, researchers and service providers work collaboratively throughout the entire process from research to service delivery. This constitutes unchartered waters for the GACD and a significant challenge.
But as Herodotus once stated: “It is better by noble boldness to run the risk of being subject to half the evils we anticipate, than to remain in cowardly listlessness for fear of what might happen”.
Given the magnitude of the new direction, we will require the input and guidance from many – including all of you here today.
While we are still at the very early conceptual stages, the vision behind the proposal is to have three or four interventions scaled-up in low- and middle-income countries.
The GACD will play a leadership role in identifying a suite of evidence-based interventions that are ready for scale-up. Research teams will then work in collaboration with participating countries or jurisdictions to select and adapt the right interventions for their context and jointly develop plans for scale-up and evaluation.
The successful intervention will be assessed on specific criteria that include for example:
- Applicability of intervention and appropriateness of the scale-up plan;
- Engagement of local and national governments;
- Inclusion of necessary expertise for scale-up and evaluation phases;
- A realistic evaluation plan that includes evaluation indicators and monitoring capacity.
The GACD is supported by health research organizations and therefore does not have in its mandate, nor does it have the capacity, to fund interventions directly. As such, also new to the GACD model, banks or other funding partners will play an essential role that include for example: supporting the intervention; help assess the financial readiness of the project; confirm eligibility of countries to receive aid or loans; help define the parameters for evaluation and provide their expertise on the economic modelling.
Finally, we see the WHO also playing a role to help assess and provide data on the country or region’s readiness for scape-up; confirm the country eligibility; and facilitate the linkages between the ministries of health, research councils within the implementation countries and research teams.
You can therefore appreciate the number of pieces to the puzzle and the challenging road ahead for the GACD.
To help us succeed, these linkages with international organizations such as the WHO, the World Bank and others will constitute determining factors in our ability in bolstering the work and scope of the GACD to the next level.
But I firmly believe that there is strong value in developing this strategy and linking with other global and regional consortia or organizations that have a similar or complementary mission, as we all strive first and foremost to improve global health. And this strategy helps us all do just that!
While the vision behind this strategy is clear, there are a number of questions that still require our attention. For example, what is the best way to determine which countries to focus on? How to optimally select the appropriate teams? What would be the best approach for evaluation?
As I noted earlier, your guidance and expertise is most welcome.
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