The Global Fund and global goals: the role of implementation and operational research

The Global Fund to Fight AIDS, Tuberculosis and Malaria has transformed the financing and delivery of health interventions in countries to meet Millennium Development Goal (MDG) 6, to combat human immunodeficiency virus/acquired immunedeficiency syndrome (HIV/AIDS), malaria and other diseases (mainly tuberculosis [TB]). At the United Nations General Assembly in New York, 25–27 September 2015, governments are due to adopt the new Sustainable Development Goals (SDGs) for 2016–2030. One of the proposed 17 goals is on health (Goal 3). This goal comprises 13 targets, including HIV/AIDS, malaria and tuberculosis, among a broader array of health problems. Leaving aside the important question as to whether the mission of the Global Fund may embrace a broader health agenda in the future, it is useful at this turning point to review the role of implementation and operational research in reducing the burden of HIV/AIDS, malaria and tuberculosis, looking back at the MDG era and looking forward towards the SDG era.

Science and technology have generated tools to address HIV/AIDS, malaria and tuberculosis, and implementation and operational research have taken these tools out of the research and development laboratories and into communities. The development of HIV tests and drugs counts as one of the greatest modern achievements in health science and technology. Implementation and operational research have contributed to the global scale-up of access to antiretroviral drugs. By June 2014, 13.6 million people living with HIV infection were receiving antiretroviral therapy (ART) globally, an increase from just 800 000 in 2003. Successful scale-up of ART has had a dramatic impact on the estimated number of people dying of HIV-related illnesses: the number of HIV deaths declined by 35% from a peak of 2.4 million in 2005 to 1.5 million people in 2013.¹

Despite a lack of progress for many years in developing new TB diagnostics, drugs and vaccines, implementation and operational research have maximised the impact of the available tools. The data systematically collected by national TB programmes on people diagnosed with TB and the outcomes of their treatment have not only enabled evaluation of programme performance, they have also fuelled operational research, which has been the hallmark of effective TB control in a wide variety of settings. Globally, the TB mortality rate fell by 45% between 1990 and 2013.¹ The prospects for large-scale access to new diagnostic tests, such as nucleic acid amplification tests, and new drugs, such as delamanid and bedaquiline, depend on implementation research to realise their potential to contribute to a further decrease in the TB burden.

Implementation research has taken the technologies for malaria control, including indoor residual spraying, long-lasting insecticidal nets, point-of-care diagnostic tests and artemisinin-based combination therapies, into communities and contributed to a significantly decreased burden of malaria: between 2000 and 2015, the global malaria mortality rate has decreased by 58%.¹

The SDGs are to build on the lessons learned from progress towards the MDGs and setbacks. Progress towards the SDG years depends on maximising the gains from the health interventions that are currently available and from those that will become available (undoubtedly including new drugs and potentially new vaccines against HIV, TB and malaria). For HIV, extending access to ‘test and treat’ using currently available HIV diagnostic tests and treatment, and in the future making an effective HIV vaccine widely available, both depend on implementation research to bring these interventions to scale. For TB, the dramatic increase in the rate of decline of TB incidence that is needed to realise the ultimate goal of TB elimination will depend not only on science and technology for the development of new drugs and vaccines but also on implementation research to make these widely available. Finally, for malaria, the use of mass drug administration in the contribution to malaria elimination raises the question of how effective and feasible methods of delivery through community engagement can be developed.

In the SDGs era, we need to maximise the potential of implementation and operational research to make the benefits of science and technology available to at-risk individuals and communities and to help achieve the ambition of ending the epidemics of TB, HIV and malaria. Implementation and operational research involve modest costs, but they have the potential for a huge magnifier effect in extending the impact of health interventions delivered by programmes supported by the Global Fund. The challenge arises for the Public Health Action community: how can we engage with the wide range of stakeholders involved in Global Fund grant activities to promote the inclusion of implementation and operational research as a key activity for funding under a Global Fund grant?