www.thelancet.com/infection Vol 12 May 2012 415 Personal View Lancet Infect Dis 2012; 12: 415–21 Published Online February 9, 2012 DOI:10.1016/S1473- 3099(11)70309-7 This online publication has been corrected. The corrected version first appeared at thelancet.com/ infection on March 9, 2012 Operational Centre Brussels, Medical Department, Médecins Sans Frontières, Luxembourg, Luxembourg (R Zachariah PhD, R Van den Bergh PhD, W van den Boogaard MPH, T Reid FCFP, B Draguez MD); Access to Medicines Unit, Médecins Sans Frontières, Geneva, Switzerland (N Ford PhD); London School of Hygiene and Tropical Medicine, London, UK (D Maher DM, Prof A D Harries FRCP); International Union against Tuberculosis and Lung Disease, Centre for Operational Research, Paris, France (K Bissell PhD, Prof D A Enarson MD, A D Harries); Department of Molecular and Cellular Interaction, Vlaams Instituut voor Biotechnologie, Brussels, Belgium (R Van den Bergh); Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium (R Van den Bergh); Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA (K G Castro MD); Department of Public Health, Division of Global Health (IHCAR), Karolinska Institute, Stockholm, Sweden (J von Schreeb PhD); Kenya Medical Research Institute, Ministry of Health, Nairobi, Kenya (J Chakaya PhD); Global Fund to Fight HIV, Tuberculosis and Malaria, Geneva, Switzerland (Prof R Atun FRCP); Imperial College London, Is operational research delivering the goods? The journey to success in low-income countries Rony Zachariah, Nathan Ford, Dermot Maher, Karen Bissell, Rafael Van den Bergh, Wilma van den Boogaard, Tony Reid, Kenneth G Castro, Bertrand Draguez, Johan von Schreeb, Jeremiah Chakaya, Rifat Atun, Christian Lienhardt, Don A Enarson, Anthony D Harries Operational research in low-income countries has a key role in filling the gap between what we know from research and what we do with that knowledge—the so-called know–do gap, or implementation gap. Planned research that does not tangibly affect policies and practices is ineffective and wasteful, especially in settings where resources are scarce and disease burden is high. Clear parameters are urgently needed to measure and judge the success of operational research. We define operational research and its relation with policy and practice, identify why operational research might fail to affect policy and practice, and offer possible solutions to address these shortcomings. We also propose measures of success for operational research. Adoption and use of these measures could help to ensure that operational research better changes policy and practice and improves health-care delivery and disease programmes. Introduction The scientific knowledge available on communicable and non-communicable diseases should, in theory, have ushered in a golden age of health care in low-income countries. 1,2 The reality, however, is different and the gap between what we know from research and what we do with this knowledge is huge. Operational research has a key role in bridging this so-called know–do 2,3 or implementation gap, 4,5 particularly in low-income countries, and is essential to ensure that scarce resources invested in research produce results that can be used to strengthen health services and benefit communities. 6 All research starts with an appropriate research question. Clinical research often involves a journey that ends in a publication and presentation at a national or international conference. For operational research, this process is long and passes through four essential stages after completion of the research project: effective dissemination to stakeholders to ensure that findings are accepted and adopted, a peer-reviewed publication (a milestone in the dissemination process, as well as an important indicator of successful completion of a research study), changes to policy and practice, and positive effects of programme results—the most important end-measure of success. Guidance and indicators to measure progress along this road do not exist and are needed urgently. In this Personal View article, we draw on our experience of operational research mainly in tuberculosis and HIV over many years in Malawi and other low-income countries and propose ways to redress this deficiency. We define operational research and its relation to policy and practice. We then identify why findings can fail to affect policy and practice and offer possible solutions. Finally, we propose parameters and a checklist for measuring success of operational research to assess progress along the journey. Relation with policy and practice Many definitions of operational research exist, 7 but from a disease-control perspective it is the search for knowledge on strategies, interventions, or technologies that can improve the results of the health programmes under investigation. 8 Thus, by this definition, operational research should affect policy and practice and improve health-care delivery systems. 9 Operational research questions should address issues that impede achievement of programme objectives and implementation of activities (eg, prevention, care, or treatment). This research should provide answers of direct, practical relevance to improvement of health-care delivery and should ensure that investments are used wisely to maximise health returns. Operational research needs to demonstrate relevance and value to programme managers, health-care workers, and the community by showing that it improves policy, practice, and the results of the programme. Demonstration of success also prevents research being perceived as an unwanted and unnecessary burden on services. 10–12 We are in an era of rapid technological innovation where new technologies such as drugs, diagnostics, and vaccines are under development with potential to change substantially the way that diseases such as HIV, tuberculosis, and malaria are managed (eg, the intro- duction of GeneXpert for the diagnosis of drug-resistant tuberculosis 13 ). Operational research programmes are crucial to assess how new technologies can be integrated into routine health systems to improve diagnosis and treatment outcomes. Why operational research might fail to affect policy and proposed solutions Development of the research question The study question must be of direct relevance to the programme, and decision makers should be involved from the start to promote a sense of ownership and responsibility. In an investigation of the burden and control of tuberculosis in a Malawi central prison by Nyangulu and colleagues, 14 the study question was formulated by senior staff from the Malawi National Tuberculosis Programme and the subject of the study was discussed thoroughly with the chief commissioner of prisons. Prior agreement was obtained from the commissioner to do the study and report back the findings when completed. The study noted a high