­­Eleven tips for operational researchers working with health programmes: our experience based on implementing differentiated tuberculosis care in south India

Abstract

Due to the workload and lack of a critical mass of trained operational researchers within their ranks, health systems and programmes may not be able to dedicate sufficient time to conducting operational research (OR). Hence, they may need the technical support of operational researchers from research/academic organisations. Additionally, there is a knowledge gap regarding implementing differentiated tuberculosis (TB) care in programme settings. In this ‘how we did it’ paper, we share our experience of implementing a differentiated TB care model along with an inbuilt OR component in Tamil Nadu, a southern state in India. This was a health system initiative through a collaboration of the State TB cell with the Indian Council of Medical Research institutes and the World Health Organisation country office in India. The learnings are in the form of eleven tips: four broad principles (OR on priority areas and make it a health system initiative, implement simple and holistic ideas, embed OR within routine programme settings, aim for long-term engagement), four related to strategic planning (big team of investigators, joint leadership, decentralised decision-making, working in advance) and three about implementation planning (conducting pilots, smart use of e-tools and operational research publications at frequent intervals). These may act as a guide for other Indian states, high TB burden countries that want to implement differentiated care, and for operational researchers in providing technical assistance for strengthening implementation and conducting OR in health systems and programmes (TB or other health programmes). Following these tips may increase the chances of i) an enriching engagement, ii) policy/practice change, and iii) sustainable implementation.

The First Differentiated TB Care Model From India: Delays and Predictors of Losses in the Care Cascade

“…TN-KET is an initiative of the state health system with the involvement of all 3 key directorates. 10 The Directorate of Medical Education provides tertiary-level care through teaching hospitals (1 per district). The Directorate of Medical and Rural Health Services provides secondary-level care through district headquarter and subdistrict hospitals.…”

“…We introduced a paper-based triage tool (to be used at TB diagnosis) in all the public PHIs (Box, Supplement 1). 10 Triaging was done by health staff at the public PHI, which could include the laboratory technician, TB health visitor (if present), STS (if based at the public PHI), staff nurse, or the medical officer. Even on their own, very severe undernutrition, respiratory insufficiency, and poor performance status are known risk factors for death and have a strong association with TB mortality.…”

“…[16][17][18][19][20][21][22][23][24] Referral and Appropriate Care For people with high risk of severe illness, the diagnosing TB unit STS facilitated the referral (using public ambulance service) to nodal TN-KET inpatient care facilities for comprehensive assessment, confirmation of severe illness, and inpatient care. 10 Table 1 contains the criteria for confirmation of severe illness after comprehensive assessment. 5 Tamil Nadu earmarked roughly 150 nodal TN-KET inpatient care facilities and about 900 TB beds (10% being in high-dependency units).…”

“…Respiratory rate more than (>) 24 physician. 10 The State TB Cell of Tamil Nadu prepared the Inpatient Care Guide for Adults With TB Who Are Severely Ill with clinical guidance to assist the nodal physicians. 10,25 This includes management of TB complications, management of comorbidities, and discharge criteria.…”

“…Statewide in routine program settings, we triaged people with TB at diagnosis (Box), followed by referral for comprehensive assessment, confirmation of severe illness (Table 1), and inpatient care. 10 Globally and nationally, there are limited examples of implementing such a strategy in routine TB program settings. Before evaluating the impact on TB deaths, it was crucial to understand the retention and delays in the TN-KET care cascade, as well as predictors of losses (especially during the early stages of implementation).…”