OPERATIONAL RESEARCH What is it ? Why is it relevant ? On behalf of many colleagues, it is my pleasure to present Operational researh – what is it and why is it relevant ? Dr. Rony Zachariah MD, PhD Operational Centre Brussels MSF- Luxembourg rony.zachariah@brussels.msf.org

Operational research: historical roots Military & industrial modelling defined as “the application of analytic methods to help make better decisions” Example: Military sector: anti-aircraft artillary efficiency The term operational researach has its historical origins in military and industrial modelling where it is defined as the application of advanced analystic methods to help make better decsions. Better decisons on performance or yield (or profits) on real world problems. It has been used in the military sector to improve anti-aircraft artillary efficiency. For example an antiaircraft gun such as this one needed an average of 20,000 rounds of shells to bring down an enemy plane during the 2nd World War. OR scientists from the British army that worked on this gun reduced the average number of artillary rounds needed to down a plane from that 20,000 to 4000 by the end of 1941…a 5 times increase in the service or performance or service it renders ….if you like quality of the guns performance

Examples: Commercial sector: Englands « Penny Post » – 1840 Efficient scheduling of airline crews In the commercial sector OR has been widely used as early as in 1840 where research by Charles babbage into cost of transporation and sorting of mail that led to Englands universal penny post which subsequently became the royal mail service – seen in commonwealth countries . in the aviation industry its is used for efficient scheduling of airline crews To better designing of waiting lines at disney them parks. All of which have used OR Unfortunately its application to health programming is much less developed.

“What” is operational research for knowledge on interventions, strategies or tools that can enhance the quality, or coverage of health systems and services. So « what » exactly is operational or implementation research in the health sector. There are different definitions of OR but from a progrrame perspective OR can be defined as the search for knowledge on………or if you like the performance of health delivery and services. Importantly research is conducted within the routine health care system

What is not operational research: Basic science research Randomised controlled trials [RCT] – where research is conducted in a strictly controlled environment, with inclusion and exclusion criteria – efficacy is the end point Basic science or fundamental research or product research …and RCT’s are not operational research. In an RCT, research is conducted in a strictly controlled environment with inclusion and exclusion criteria – efficacy is the end point. Because of the controlled environment the conditions are often far from the reality on the ground.

The need for RCT and operational research: a necessary continuum Generates knowledge (Trial conditions) RCT Operational research ‘How to’ apply that knowledge ? (Real world conditions) There is a need for both RCT and operational research which should be done in a continuum. An RCT generates knowledge under trial or controlled conditions OR then shows how to apply that knowledge under real world conditions ( the « How to » ?) And if that can be done, patients and communities can benefit from the generated knowledge…. Patients and communities Benefits +

Excellent evidence but gaps in implementation! Now I will give you 2 examples where we have excellent evidence but where there are major gaps in implementatoion in partly or largely due to the lack of operational research

Malaria Kills 1 to 2 million people each year, Malaria kills between 1 and 2 million people each year, 85% of these deaths occur in children under 5 years of age with one African child dying of malaria every thirty seconds. Even among the hospitalized, one in six will die. Kills 1 to 2 million people each year,

39% reduction in deaths Large clinical trials done in Asia and nine African countries have shown that parenteral Artesunate is much more effective than injectable quinine (which we have been since 1630) with between 23 and 39% reduction in deaths. Quinine too has much more side effects eg these children have paralyis of their left lowe limbs fro Quinine injections. Quinine also produces absesses etc ( due to the acidic nature of quinine).

We estimate that at least 200,000 yearly deaths can be saved with use of artesunate instead of quinine. And despite WHO guidelines to use it in Adults since 2005 and 2011 for children , less than 5 countries in Africa use injectable artesunate. Thus, despite excellent and definitive evidence of an effective intervention against severe malaria, in a certain manner of speaking mosquitos contine to suck the blood of Africa

1988 Another historical example is the delay in implementation of ITBN. As early as the late 1980’s, Snow and colleagues in the Gambia showed that insecticide-treated mosquito bed nets can protect against malaria by 60%, and if children are placed under the bednets it would reduce deaths by 24% in children in Africa, but it took almost 20 years before it was made available on a large scale. In these 2 examples OR could have helped bridge the implementation and coverage gaps at least partly because of lack of down-stream operational research on whether this intervention would be effective outside trial settings and how to enhance and maintain coverage. Even when you implement you still need Or to verify if the netws are in good state or used well or wrongly

Why is operational research relevant ? Now I will show you the other side of the coin by giving you 2 examples of OR playing a key role in bridging implementation gaps and scaling up interventions Bridging implementation gaps

MALAWI Early 2000’s Population : 10 Million HIV/AIDS : 1 Million For the first example, let me take you to Malawi. A small country in sub-Saharan Africa. In the early 2000s, Malawi had a population of 10 million inhabitants – 1 million were living with HIV/AIDS

100,000 deaths/ year - no access to antiretroviral treatment Linda is one of such patients and like her 100,000 were dying each year because they had no access to life-saving anti-retroviral treatment (ART). If this was Luxembourg it would mean that the population of the country would dissapear in 5-6 years. But we had ART here in Europe, and our patients were living well.. So why not Africa Photo with permission

MSF-Luxembourg through operational research in rural Malawi showed how to provide universal access to ART by uing use a simple and standardized public healt approach so that it could be delivered by nurses and community workers and non specialists. ART became available in all health facilities to a district population of 500,000. The effect was stunning – 70 % of our hospital beds were occupied by patients such as Phiri - ART brought a miracle – the lazarus effect This model served as evidence for scaling up ART in Malawi and to date, over 650,000 patients in both public and private sectors access ART It was Operational research which showed the “how to” adapt and scale up ART for those in need. Malawi 2013 650,000 on ART

Measuring population Impact of ART on deaths “Coffin sales” We used operational research to assess the population level impact of this ART scale up on reducing deaths by looking at among others at the trend in “coffin sales” – which at the time was a 24 hour thriving business enterprise. ART by preventing deaths cut down this business substantially.

Coffin sales in trouble 10,000 Deaths Averted ! Coffin sales in trouble He results had a major impact in the mass media

BURUNDI – Maternal Deaths Luxembourg 2 /100,000 MDG 5 Reduce deaths by 75% (2015) Let me finish with this example by taking you to Burundi – a country with one of the highest maternal mortality ratios (MMR) in the world 800 deaths per 100,000 live births (compared to Luxembourg or Sweden where it is about 2 deaths per 100,000 live births) – 400 times higher And when a mother dies the child has a 10 times higher chance of dying after becoming an orphan The Millennium development goal 5 sets a target of reducing this maternal mortality by 75% by 2015 but no African country is likely to achieve this African countries – unlikely to achieve MDG 5

Reduced maternal deaths by 74% MSF showed through operational research how an emergency obstetric care package comprising of an ambulance and communicatio network, good antenatal care and acces to emergency obstetrics using national physcians can rapidly reduce maternal mortality by 74% and achieve the MDR 5 in rural Burundi.

Impact in relation to MDG 5 The slide shows the data on mortality reduction in relation to the MDG 5 target.. The X axis shows you the years from 1990 -2015 – MDG target. The Red Bars – Trend in National MMR in Burundi 1990-2011 Dotted lines show the desired reduction in MMR so that we can reach the MDG traget in yellow– the yellow bar. You will note that the red bars lie well outside the dotted line.. Green is what we have achieved in Burundi…clearly showing that we are ahead of the target – Again an example of how OR can help Burundi and other African countries make rapid progress towards MDG5. Reduction in maternal mortality ratio = 74%

40 low-income countries implementing five interventions – up to 27 years after ! Malaria Vaccinations Let me conclude with thius slide taken from the World health report showing the proportion of 40 low income countries implementing implementing five interventions The first 3 lines relate to Malaria – viz ACT about Treatment, Rapid D test and bed nets while the last two lines on the right relate to hae and Hep B vacccination Notice the considerable delay of upto 2-3 decades after regulatory approval for these to be rolled out. -

CONCLUSION Many years pass between ‘definitive’ trial results and policy and practice change EU Research investment 55.8 Billion Euros (2007-2013) Technology/ Drugs/ Clinical trials Support operational research apply knowledge for maximum public benefit. Many years continue to pass between discovery of new innovations , definitive trial results and policy and practice change where it matters most The EU is one of the worlds most prolific funders of global academc output with 55.8 Billion Euros invested in the last 6 years This investment has been focused on upsteam research which results in new Tech …. We call on the EU to support and fund OR so that we can apply the generated knowledge for maximum public health beenfit