From local to global: action science in Nairobi
Know the bureacracy, problems and politics of health – and know the frontline of health care. There’s a challenge for science, and it’s being met in Nairobi. Interview of Nduku Kilonzo, Research Director of Nairobi's Liverpool VCT and Care.
(March 06)
Research bringing intimate knowledge of clients and their care in HIV/AIDS clinics, and of the bureacracy, politics and needs of national and international health government – is making Liverpool VCT and Care a scientific force to be reckoned with. Nduku Kilonzo explains.
Nduku Kilonzo is Research Director of Nairobi’s Liverpool VCT and Care, a HIV/AIDS care facilitation and research organization – which began as an operational research project in voluntary counselling and testing (VCT) the Liverpool School of Tropical Medicine. Kilonzo’s speciality is gaining evidence on the role of gender and rape in the AIDS pandemic – and even more powerfully, changing health policy and actions in response to her results. But how do she and Liverpool VCT do it? Here she spoke to Robert Walgate, Editor of RealHealthNews, in Nairobi.
Nduku Kilonzo:“We don’t do biomedical research – there are already enough people doing that very well, from KEMRI to CDC! But there’s a neglected niche, where we work – operational research.
We start by looking at what’s required at policy level – which we learn from discussions, interactions, and meetings with people at that level; and then by studying our own programmes and services. Every year we do an internal assessment, and we look at what are the specific unmet challenges and gaps. So we talk to service delivery people, and government people we work with; and we talk to the programme managers, find out what people think, feel and see – even their predictions for the future.
At service delivery level we look at counsellors, the front-line staff who actually sit down with clients, patients, on a day-to-day basis, and provide a service. At programme level we talk to managers, not front-line providers but ones working very closely with them, facilitating their work.
At policy level I’m talking about governmental partners, and people who work with them. In fact our sense of being, our raison d’être, at Liverpool VCT, is to strengthen our governmental partners, so they in turn can strengthen the national response in HIV/AIDS prevention and care. We don’t have VCT & care services of our own – we work with the government VCT and care services.
RHN:So the idea at the research end is to provide solid evidence that can help the reformulation of policy…
NK: Yes. And practice! We use our research to influence both practice and policy. Our own practice and government practice, in terms of setting standards for service delivery and so on.
RHN:How do you actually use research to change policy and practice? Obviously you can do it in Liverpool VCT, but how do you make change in government?
NK: You have to audit government structures to see where you can best locate your interactions and try to place your influence. For example, when we were doing out post-rape care work, when we started we didn’t have a clue who was mandated [in government] to work on sexual violence. Eventually we found the right people in the division of reproductive health in the Ministry of Health. So we went there and asked if this was part of their work, is this what you should be doing, and so on – and once we’d begun to engage with officers in the division we were able to talk to them about the directions we thought the government should be taking, and saying how we can support your department or division.
RHN:On the face of it this is like NGO lobbying. But the fact that you’ve done research, that you can write down evidenced papers – is that important?
NK: It’s one of the most important things! And this is why Liverpool VCT is working this way.
RHN:So tell me why it’s so important. You interact with the bureaucrat. What happens?
NK: While you are interacting, even bureaucrats will ask questions! Why should I do this? How is it going to help me? What use is it? And what is the cost? What does it mean for me? Unless you’ve got some sort of evidence, indicators, benchmarks to say, ‘actually we have tried it and it doesn’t work the way you are doing it, it works another way – this one, points 1, 2, 3’. If you are responding to national gaps, you are usually responding to something that’s already done, but there are challenges. So you are not coming in from nowhere.
RHN:It’s important therefore that you include the costs in these studies?
NK: We don’t do it all the time, and I have to admit that’s been one of the biggest challenges.
RHN:Because at the political level that’s a crucial issue isn’t it – so I spend my money here or here?
NK: Yes, certainly. So we are being asked right now, ‘you’ve given us this very good model for post-rape care, and how to scale it up, you’ve proved it works, we’ve seen it working – but look, you’ve spent X amount on about 800 survivors in the last two years – what does it mean for the government?!
So right now we are hoping to begin a cost study of that this Spring. And I think it’s going to inform international policy as well, because there’s no study like this for sexual violence interactions anywhere in the world.
RHN:Have you any evidence on the proportion of HIV infections that are caused by rape? Would it be good to have some figures?
NK: Certainly! Because I was with
a nursing NGO in a Nairobi slum village just this morning and they were telling me that they felt that quite a lot of their cases were caused by rape, but of course they had no figures.
It’s something we all hypothesize about, at the global level, but it’s going to be very difficult to get figures.
RHN:There’s privacy and stigma and shame…
NK: Yes, and even if you look at trauma to the vagina or multiple penetrations or perpetrators, but putting all those factors together to calculate a risk is hard.
RHN:To come back to your influence on policy, your studies are local, interacting directly with your government. But do you agree that there’s another role for local research – validating locally international studies proved elsewhere, so bringing them to governments’ notice? Do you do any of that?
NK: Because it seems to me that so often we get some breakthrough in the international journals, even social interventions like home-based care
of malaria, which everyone says is immensely successful, there’s a big noise in the media, but then it’s all forgotten – and maybe just adopted in the researcher’s home country, if he or she is lucky enough to be well-connected. But maybe if there were local studies, showing that this intervention is relevant to your own administration, these successes would take wider root.
Yes. And I think it goes both ways. It’s important to localise results, and it’s equally important to be able to use local studies to influence international policy – it should go back and forth.
RHN:So how do you do that?
NK: Have great result, I suppose! That’s one way of doing it! But also it’s a matter of identifying the issue. When I look at national gaps, I prefer not to look at them from a very closed perspective. We have a huge list of questions to study, about eight pages of them! So one key thing to help us choose has been that we do a lot of reading, we make searches on the international literature search. So one of our criteria in selection is what resonates globally, what’s the challenge for international HIV prevention and care?
RHN:After all we are working in an international framework in terms of response, the three ones, the 3 by 5 – everything has some international pivot about which it turns. So you work locally, but you need to be able to resonate with that. So what’s the way you do that? Is it to get in to the international journals?
NK: Yes! That’s important. We have access to those.
RHN:Through academic quality.
NK: Yes.
RHN:But how do you get to the international policy agenda?
NK: I’m not sure that we have a clear strategy. We don’t. Except that in sexual violence we’ve been able to strategize for international policy, once we’d realized that what we were doing was important for that. So we began to feed a lot of our results back.
RHN:To whom?
NK: To WHO – to the gender and HIV/AIDS group, to the gender, women, and health group.
RHN:So this was quite apart from the publications.
NK: Yes. And word got around and we began to be asked questions.
RHN:And you speak at meetings…
NK: Yes we do quite a bit of that! And currently we are doing quite a bit of work with WHO as part of the team doing international guidelines for PEP [post-exposure prophylaxis, to try to stop or slow an early HIV infection, such as in rape]. We’re working on international guidelines for care and support of violence survivors. And once we had the call from WHO, we started to think what evidence we need to inform the policy-making.
RHN:Aren’t there very few academics willing to do this kind of research? How do you create the research team in Kenya?
NK: I have to be honest! We create them! It’s a matter of looking at interest, intelligence… We advertise. We’ve not been a big research institution with huge research grants. Which is something we are just beginning to think about, realizing we need a clear research strategy and so on; but so far we’ve advertised for mid-level, not highly-paid, researchers, and got people like graduates, people interested in reading, and people who have a basic idea of what is going on in HIV prevention and care, from an academic perspective. That we find out at interviews.
RHN:You have many applicants?
NK: Applicants we have to cut down there are so many! Many are people who’ve been out of university for two or three years in a first job, and want to do something interesting. And once you’ve made your selection, you try and make researchers out of them!
RHN:Do they have a career path, a path out into research elsewhere?
NK: We are too young to think of that! But I got my own PhD through that. I came in as a researcher, did my first piece of work, got into a PhD programme…
RHN:No kidding! So where did you come from?
NK: My first degree was in education – I’m a teacher by profession. And I was employed as a research assistant just after college and thought ‘that’s interesting’! I had a huge interest in gender issues, and I moved to UNDP, and in everything I was always looking for that little bit of research to do. Then Liverpool VCT was a lucky break for me because they had a job for a research student on gender and health.
Now we have two huge studies in mind, and are looking for more research students and funding.
RHN:What studies are they?
NK: One is looking at HIV counselling and testing in diagnostic settings. So we aim to develop systems and protocols that can inform government. Because it’s a mess, to say the least, very ad hoc. So it’s a huge challenge, but we are working quite closely with NASCOP, the National HIV/AIDS and STD Control Programme, who are very interested.
In fact we did the first needs assessment in collaboration with them, and we are discussing the way forward with them and other partners.
We deal sometimes with NASCOP, sometimes the Divison of Reproductive Health, both under the Ministry of Health, and NAC, the National AIDS Commission, a completely independent body.
RHN:I understand NASCOP is rather a strong programme, but what about other parts of the bureaucracy? I was just attending a two day meeting of the World Economic Forum here in Nairobi which was demonstrating the weakness of the health systems and bureaucracies in Africa, and trying to galvanise new solutions. You seem to be dealing with quite an active, responsive bureaucracy. Or do you face these problems too?
NK: You do, but you have to willing to negotiate and navigate around them! And perhaps that is one of the challenges of policy-oriented research, because where do you draw the line between engagement with health policy, and actually using research results? To what extent are you an advocate, and to what extent are you a resear-cher who’s getting your research used? It’s a very delicate grey area.
RHN:But you really have to understand the bureaucracy.
NK: Certainly. I think you have to be local, to be honest with you, and have a keen sense of the underlying dynamics and politics.
RHN:So you become a politician as well…
NK: Gosh! I would never ever see myself as a politician!
RHN:Changing the activities of government, that’s political! But of course you are doing it through evidence… that’s a different game.
NK: Certainly it is! RW top
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