Camilla Burkot – MPH ‘14, Mailman School of Public Health
In the landlocked southern African nation of Lesotho, researchers from ICAP working on the START Study have been grappling with these questions on a daily basis. With funds from a USAID Implementation Science grant, the purpose of START – which stands for ‘Start TB (patients) on Antiretroviral Therapy and Retain on Treatment’ – is to develop ways to improve initiation of antiretroviral therapy (ART), adherence to HIV and TB medications, and retention in care among people with HIV/TB co-infection. Studies have shown that starting ART early after diagnosis of TB is associated with a decrease in mortality of up to 50%. START is currently four months into enrolling patients and collecting data from 12 primary healthcare clinics and hospitals in Berea District, just north of the capital of Maseru.
As a student at the Mailman School of Public Health, I expected to learn a lot about data collection and management when I joined the START team in Lesotho for my MPH practicum with ICAP, but I did not expect to see the extent to which research is dependent on having a stable health system, well-organized clinics, and motivated healthcare workers already in place.
One challenge that I observed, for example, is inconsistency in the recording and reporting of routine clinical information. When each TB/HIV patient at START’s study sites completes treatment, dies, or is lost to follow-up, START field staff collect a variety of key information about the patient and his/her course of treatment from clinic documents – a task that has turned out to be much simpler in theory than in practice. Because many clinics in Lesotho remain without electricity, recording patient information necessarily remains largely in paper form; as such, medical information for a single TB/HIV patient may be distributed across as many as six different registers, logs, and files. In the face of high patient volume and the absence of a system for checking the accuracy of these documents, records are often incomplete or contain contradictory information. This results in a high volume of data that must be regarded as “missing” for the purposes of research.
Moreover, to access these records in the first place requires good partnerships with nurses and other clinic staff such as counselors and Village Health Workers. While there are many passionate and skilled health professionals in Lesotho’s clinics striving to provide the best care possible for the Basotho people, there are others who are not as motivated and clinics suffer from high staff turnover. At one START study site, for example, the two nurses managing the clinic both resigned in June and have yet to be replaced, which has resulted in chaotic effects on the management of that clinic and patient care.
These are the kinds of challenges that warrant implementation science research in global health – and at the same time the ones which make that research exceptionally challenging to execute on the ground. Despite the initial challenges in rolling out START, innovative thinking and persistence on the part of a dedicated local field staff have demonstrated that these complications are not insurmountable; they are speed bumps, not roadblocks. But above all the process of working through them represents, in my opinion, a powerful argument in favor of a health systems strengthening orientation in global health. From upgrading the physical infrastructure and instituting e-health and supply chain management systems, to introducing updated training programs for healthcare workers and developing mechanisms for supervising and supporting those workers even in the most remote areas. A continued focus on health systems strengthening has the potential to radically change the face of both healthcare provision and health research. Where health systems are strengthened, not only will the possibilities for carrying out research like the START Study be enhanced, but the health challenges which motivate that research in the first place may be significantly reduced.