Perspectives on Implementation Science

Transcript

• 00:00- [Donna] First.
• 00:03This is our first Center on Methods for Implementation
• 00:06and Prevention Science seminar
• 00:08for the academic year,
• 00:10and we're very pleased
• 00:11to see so many people here live in the audience,
• 00:13getting to enjoy a delicious lunch with us,
• 00:16as well as many people on Zoom
• 00:18from literally all over the world.
• 00:20We have colleagues from Nepal visiting us right now
• 00:24and also colleagues from Colombia
• 00:27who are also working on implementation science,
• 00:30especially with respect to infectious disease,
• 00:33representing a longstanding collaboration
• 00:35that the Yale School of Public Health
• 00:36has had with Colombia.
• 00:38But today our focus is our work with Nepal,
• 00:41and I'm very pleased to introduce to you my friend
• 00:45and colleague, Dr. Biraj Karmacharya,
• 00:49who is the administrative director
• 00:51and the director of Public Health Community Programs
• 00:54and associate professor
• 00:55in the Department of Public Health
• 00:57at Dhulikhel Hospital,
• 00:59which I myself visited many times,
• 01:02and Kathmandu University School of Medical Sciences.
• 01:05So, before Biraj gives his talk,
• 01:08I wanted to tell you a little bit about him.
• 01:11He obtained an MBBS,
• 01:14which is sort of the UK version of a medical degree
• 01:17for those of you who don't know that,
• 01:19in 2003 from Kathmandu University.
• 01:23He got his Master's of Tropical Medicine,
• 01:26on a synergy with some of our Colombian colleagues here,
• 01:29in 2006 from Mahidol University in Thailand,
• 01:33and then a PhD in 2015.
• 01:36(attendee chattering)
• 01:39Sally if you could...
• 01:41(attendees chattering)
• 01:51And thank Sally, or whoever did it. (chuckles)
• 01:54As a Fulbright Science and Technology awardee,
• 01:57and an MPH in Global Health in 2017
• 01:59from the University of Washington, Seattle, USA.
• 02:03So, nobody could say he's not well-trained
• 02:05across a diverse range of medical
• 02:08and public health sciences.
• 02:10He was also the founding co-director
• 02:12of Nepal Studies Initiative
• 02:14at the Jackson School of International Studies
• 02:17at the University of Washington.
• 02:19He founded and has been leading
• 02:21the Department of Community Programs
• 02:23and Public Health at Dhulikhel Hospital since 2006,
• 02:27through which he is engaged in developing
• 02:29and setting up innovative community-based health
• 02:32and integrated health and development programs in Nepal.
• 02:36He has also been instrumental
• 02:38in advancing public health training
• 02:40and research in Nepal,
• 02:41leading the pioneering programs,
• 02:44the Master of Science in Public Health,
• 02:46Epidemiology and Global Health,
• 02:48and more recently the PhD program in Public Health
• 02:53at Kathmandu University
• 02:55of Medical Sciences.
• 02:59(alarm clicking)
• 03:00I hope this isn't a fire alarm,
• 03:01which means we have to leave the building.
• 03:04That's what it sort of sounds like.
• 03:06I'm gonna continue in the hope that it isn't.
• 03:08His research interests...
• 03:10(participant chuckling)
• 03:11That's the first time this happened.
• 03:13His research interests span
• 03:15across non-communicable diseases,
• 03:17climate change and health,
• 03:18and health systems and policies.
• 03:20He's been a team member
• 03:23in our Pioneer Worksite Intervention study in Nepal,
• 03:26led by myself and Dr. Archana Shresta,
• 03:29another colleague from Nepal
• 03:31who's visiting us over for the next two days,
• 03:34has continued to collaborate with us
• 03:36in various implementation research studies
• 03:39and training programs.
• 03:40It's been a very productive collaboration
• 03:43with around 16 papers published
• 03:45or submitted to date in which Biraj
• 03:47and I are co-authors,
• 03:49and many more expected in the future
• 03:51as we continue to apply implementation science methods
• 03:54to end cervical cancer in Nepal
• 03:57and mitigate the growing non-communicable disease epidemic
• 04:00in the country, particularly with respect
• 04:02to hypertension and the consequences of it,
• 04:06cardiovascular disease and stroke mortality,
• 04:08the major causes of mortality in Nepal
• 04:11and around the world.
• 04:13So that's our introduction
• 04:14to our friend and colleague Biraj.
• 04:17And now, he requested that he will speak
• 04:21for maybe about 45 or so minutes,
• 04:23and then please write down
• 04:25and note your questions,
• 04:27and those in the chat as well,
• 04:28and then we'll take questions.
• 04:29(attendee speaking foreign language)
• 04:31I think we've got someone else unmuted.
• 04:33(Biraj harrumphing)
• 04:35- [Biraj] Good afternoon everyone
• 04:37and thank you Dr. Spiegelman Donna
• 04:41for a very extensive introduction,
• 04:44you made a little bit nervous.
• 04:46(Biraj laughing)
• 04:48I was already nervous, you know,
• 04:50but I'm supposed to present in this forum-
• 04:53(attendee speaking foreign language)
• 04:56- [Donna] Sorry, Biraj, why don't you, let's take a second.
• 04:58- [Sally] I got it.
• 04:59- [Donna] You got it?
• 05:00All right then.
• 05:01- [Biraj] It's a-
• 05:01- [Donna] It's chaotic, people come in
• 05:03and then they're not muted.
• 05:04all right, sorry Biraj, please-
• 05:06- [Biraj] Yeah, I've been closely
• 05:07following Dr. Spiegelman's work along
• 05:11with my colleague Dr. Archana's work
• 05:13and also what is happening in the center,
• 05:16and I was already very nervous
• 05:18because it's a team that
• 05:19is really highly technicality
• 05:22in terms of implementation science,
• 05:24and I'm not an expert in that field,
• 05:27but I thought that,
• 05:29take this opportunity to share some
• 05:31of the on-the-ground experience from Nepal,
• 05:34especially in relation to my own work
• 05:37and collaboration from academia with the government
• 05:41and also with the community, so,
• 05:45I just want to warn that you'd be disappointed
• 05:47if you were expecting a very technical talk
• 05:49on implementation science from me. (chuckles)
• 05:57So.
• 06:07So, I just made my disclaimer
• 06:09that I don't consider myself
• 06:12as an expert in implementation science
• 06:15or a scientist in it,
• 06:16but maybe, you know, I'm more closer to say I'm one
• 06:20of the users of implementation science research, so.
• 06:28So, for many of you who have not been in Nepal
• 06:31or do not know about Nepal,
• 06:33it's a tiny country sandwiched between India
• 06:37and China with a population
• 06:40of about 30 million people.
• 06:45In terms of health,
• 06:47you know, it stands out as a unique country
• 06:51in many respects.
• 06:52It was one of the few countries
• 06:53that met the Millennium Development Goals,
• 06:56and it's one of the countries
• 06:58that had one of the highest increases
• 07:00in life expectancy in the last 40 years.
• 07:03So, the average life expectancy
• 07:05in Nepal increased by about 20 years
• 07:08in the last 40 years time.
• 07:11So, that means we have been seeing,
• 07:14and we will be seeing more
• 07:16of this double burden of disease
• 07:19where we see the infectious diseases problems,
• 07:21but at the same time pretty high problems related
• 07:24to non-communicable diseases as well.
• 07:29This is also a country which I think would be
• 07:33an ideal lab for those who are working
• 07:36in health systems and policies.
• 07:39Until around a few years back,
• 07:41it was a heavily centralized,
• 07:43we had a very heavily centralized health system
• 07:46where the Ministry of Health outlined, governed,
• 07:49and dictated all the different activities until
• 07:53the rural communities and even at the household level.
• 07:56But now from a very centralized health system,
• 07:59now it has changed into
• 08:01a highly decentralized health system
• 08:04where there is quite substantial authority
• 08:08at the local level, as you can see,
• 08:10the local levels, primarily the municipalities,
• 08:12are responsible for the basic health services,
• 08:16urban health services.
• 08:18They are responsible for running
• 08:20a lot of centrally approved health programs.
• 08:23They are also responsible
• 08:25and also have the authority
• 08:27to run locally contextual programs,
• 08:31community-based programs.
• 08:33And also, they have the freedom to promulgate lots
• 08:38of local-level health policies and regulations.
• 08:40So we have had a sort of a complete u-turn
• 08:43in our health policy.
• 08:45There's of course quite a bit of mess,
• 08:47but also it opens a lot of opportunities in collaboration,
• 08:51you know, not just with other sectors
• 08:53but also with academia and communities as well.
• 08:56We also now have a completely new structure,
• 08:59the provincial structure.
• 09:01We have seven provinces which run
• 09:04the provincial hospitals,
• 09:06they also run district-level health offices and so on.
• 09:09And also central ministry
• 09:11that is still responsible for a lot of activities.
• 09:15And very importantly, you know,
• 09:17a sort of landscape changer in our health system
• 09:21is the National Health Insurance Program
• 09:24that the government announced just a few years back
• 09:26and is rapidly scaling up throughout the country.
• 09:29So what I mean is there are lots of things happening
• 09:32in the country in the context of health,
• 09:35and I tried to shed some light
• 09:37on how we can fit in or, you know,
• 09:40cannot fit in in some of these activities.
• 09:44So, this is the town where I work
• 09:48and I also live there.
• 09:51I like to show this picture, you know,
• 09:53to persuade some of you to visit us.
• 09:55It's a beautiful town,
• 09:58small town of about 15,000 people,
• 10:01not very far from the capital,
• 10:03it's just an hour drive from the capital Kathmandu.
• 10:06And this is the institution
• 10:08where I work at Dhulikhel Hospital,
• 10:11also, it's the University Hospital
• 10:13of Kathmandu University
• 10:14and runs the Kathmandu University School
• 10:17of Medical Sciences.
• 10:21We also have
• 10:23a pretty extensive community-based health program
• 10:27at our institution.
• 10:28So, this is the first community-based hospital in Nepal.
• 10:32It's a very unique model,
• 10:34it is not a typical private hospital
• 10:36or a public hospital,
• 10:37so it's somewhere in between.
• 10:40Even now the highest board
• 10:42of the hospital comprises of the members
• 10:46from the local community.
• 10:48So it has a very different governance structure,
• 10:50a not-for-profit non-governmental hospital,
• 10:53which serves as a tertiary-level hospital
• 10:56of almost a population of 2.3 million people in Nepal.
• 11:00And we also have a pretty extensive network
• 11:04of rural community-based outreach centers
• 11:07through which we run a range
• 11:08of community-based health programs in the country.
• 11:11These are also the sites
• 11:13for a lot of our implementation research work
• 11:16that we are currently doing.
• 11:18And Donna has been to a couple of them
• 11:21and also was there recently,
• 11:23now, few months back, right. (laughs)
• 11:28So, you know, these are just some examples
• 11:31of our implementation science works
• 11:35in our institution.
• 11:37It started with
• 11:38the Nepal Pioneer Worksite intervention study led
• 11:41by Dr. Donna and Dr. Archana.
• 11:43And then you can see we have had
• 11:45a pretty wide spectrum
• 11:47of implementation research works going on
• 11:50in our institution,
• 11:52also, in the communities that we serve.
• 11:54And we are also very closely working
• 11:56with the Ministry of Health
• 11:58in various health systems-level
• 12:00implementation research programs.
• 12:04So I'm going to talk,
• 12:07share some of my own very personal experience
• 12:10around how we have evolved over the course of time
• 12:14in trying to understand
• 12:17how these three entities,
• 12:19you know, can align or cannot align together.
• 12:26So let me talk a little bit about
• 12:29the government perspective.
• 12:31So I'm sure we all believe that the government,
• 12:35especially the Ministry of Health should be a major,
• 12:37(attendee chattering)
• 12:38should be the major stakeholder
• 12:41and the user of implementation research in health,
• 12:44because what we are aiming
• 12:45for in implementation research is trying
• 12:47to see how
• 12:49(attendee chattering)
• 12:51proven interventions can be implemented
• 12:53and scaled up in a larger setting.
• 12:56So definitely most of the time-
• 12:57(attendee chattering)
• 12:59And most of the time it would be,
• 13:02it would be the government
• 13:03and the Ministry of Health
• 13:05that is responsible for scaling it up.
• 13:07So if we cannot bring onboard government
• 13:10in implementation research, you know,
• 13:13we really need to think twice,
• 13:14what would be the implications of the, you know,
• 13:17of the extensive scientific work that we are doing?
• 13:21Now, what are the major challenges in that?
• 13:24So, let me, go into some of the very basics on this.
• 13:29So, from the perspectives
• 13:31of academia, generally,
• 13:34we tend to think that of course policies
• 13:37and programs should be evidence-based,
• 13:39you know, should look into data findings,
• 13:42research, and so on.
• 13:44But how does policymaking happen
• 13:49in most of the places in the world?
• 13:50And also, you know, not an exception
• 13:53in a country like Nepal.
• 13:55And we all need to acknowledge
• 13:58that it's not always
• 14:01a process that follows,
• 14:03that strictly follows an evidence-based approach.
• 14:07So if the policymaking happens, you know,
• 14:12through other drivers
• 14:14than the evidence base,
• 14:16then that itself becomes a major barrier
• 14:20in terms of utilizing
• 14:21the research findings for policymaking.
• 14:24So that's one of the major challenges
• 14:31in up taking the implementation science research
• 14:34in the government system.
• 14:35In the same way, a lot of programmatic decisions
• 14:39in health are also
• 14:41not directly linked to evidence.
• 14:45There are lots of,
• 14:46you know, political interests,
• 14:47lobbying groups, advocacy and so on
• 14:50that are happening.
• 14:51And the role of evaluation
• 14:53and iterative process in health system is also,
• 14:56you know, pretty challenging.
• 14:58It is lot less than ideal, I would say,
• 15:03you know, in Nepal and I guess in most
• 15:05of the countries around the world.
• 15:07So in this backdrop,
• 15:09how is it that we can help permeate, you know,
• 15:13the knowledge skills related
• 15:16to implementation science research
• 15:18in the health system?
• 15:19I think that's, you know,
• 15:20that's a question we have to,
• 15:21we have to navigate.
• 15:24And there are also other concerns
• 15:27from the perspectives of the government,
• 15:31and in our own relationship
• 15:33and conversation with the government,
• 15:36it is very difficult to navigate a path
• 15:40in which the government
• 15:42and academia can connect
• 15:44for national-level policies and programs.
• 15:47We do not have a very clear way,
• 15:50or a platform, or a structure
• 15:53that brings on board the, you know,
• 15:55the academia science
• 15:59into the government activities.
• 16:02And so the, there are also concerns
• 16:04from the government sides
• 16:06in terms of the accountability
• 16:07and also many times capacity of academia.
• 16:13There are also challenges related
• 16:15to lack of clarity on roles, responsibilities,
• 16:17- [Attendee] In control.
• 16:18- [Biraj] And authorities,
• 16:20and also unclear mechanism of collaboration.
• 16:22So these are some of the challenges
• 16:24that we face when we collaborate with academia.
• 16:27I'll give you some examples on that.
• 16:31So, one of the most common, I would say,
• 16:36complaints from the government side
• 16:38when we work with them is regarding time.
• 16:41And I remember very clearly
• 16:43in one of the meetings, you know,
• 16:45not long ago, you know,
• 16:46one of the very senior officials,
• 16:48government officials said very straight, like,
• 16:50"If you do a research,
• 16:52it takes a couple of years to come up
• 16:54with your research results.
• 16:56By that time we would have changed our policies
• 16:59at least four or five times."
• 17:01So in no way, the research that you are going to do
• 17:05can be used very easily in our system
• 17:08and we have time constraint,
• 17:09and there are lots of pressures regarding, you know,
• 17:11the program implementation,
• 17:14budget, reporting, and so on.
• 17:17And it is very difficult to align time, you know,
• 17:20with the government programs
• 17:22and the research activities
• 17:24that go in parallel.
• 17:26So, that was one of the major problems.
• 17:29The second thing that we face,
• 17:33the second problem that we face very often
• 17:37is regarding the people,
• 17:38who are we going to collaborate in the government?
• 17:40Especially in our setting when
• 17:42there are so many changes happening
• 17:45at all levels of government health system,
• 17:48it is very difficult.
• 17:49Unless, it is the collaboration is institutionalized,
• 17:53the individual level relationship
• 17:54and collaborations are very vulnerable to changes.
• 17:59We work with somebody and we plan with somebody,
• 18:02the person is changed, and then again,
• 18:04we have to go back to the same drawing board.
• 18:08That's the second big challenge we face
• 18:11in collaboration with the government.
• 18:14The third is scope of engagement,
• 18:17to what detail we should be working,
• 18:20to what extent we should be collaborating
• 18:22with the government,
• 18:24and the government should be collaborating with academia?
• 18:26That's also not well defined.
• 18:28So what happens is,
• 18:31what happens is there's a lot of confusion in that
• 18:34and, you know, the two entities end up going
• 18:37in their own track without much
• 18:39of a complementary function.
• 18:41So that's a challenge that we face very often
• 18:44with the government system.
• 18:46And another, the fourth point is,
• 18:48especially in terms of, you know,
• 18:50when we think from the lens of researcher,
• 18:55a lot of time government entities
• 18:57are not interested
• 19:01in the full spectrum of research
• 19:03that we are planning.
• 19:04And some of the time they're just looking
• 19:06into cost-effectiveness.
• 19:07Some of the time they want to see the effectiveness,
• 19:11reach, adoption, you know,
• 19:13it's all day they might be interested
• 19:15in only some of the components.
• 19:16And so as researchers,
• 19:18how do we make ourselves available
• 19:21to the government without losing scientific rigor?
• 19:24I think that would be the, you know,
• 19:26that is one of the most difficult questions
• 19:28we need to answer.
• 19:33In the same ways,
• 19:38I think that in the context
• 19:39of implementation science,
• 19:41bringing onboard communities is also very important.
• 19:45And because especially in the context
• 19:48of implementation science,
• 19:50in communities, you know,
• 19:52a lot of communities are not just research subjects,
• 19:55but they function more as partners in our study,
• 19:58but most of our studies are not designed like that.
• 20:01So we we need to be creative enough
• 20:06to build more, you know,
• 20:09in-depth partnerships with the communities
• 20:11while we are implement planning
• 20:14and implementing implementation research.
• 20:16And another experience that we had
• 20:19was about identifying the interventions
• 20:22for the communities.
• 20:24Most of the times, we tend to jump,
• 20:28you know, into identifying interventions,
• 20:30proven interventions through other settings
• 20:32and then try to see, like,
• 20:34how do we implement that in our community?
• 20:35What are the barriers and facilitators to that?
• 20:40But it is also very likely
• 20:44that we might miss the opportunity
• 20:47of co-creating with the communities that,
• 20:50you know, nowadays it is becoming more and more,
• 20:55I would say accepted
• 20:59and popular among among researchers
• 21:03to co-create interventions with the communities.
• 21:05But that is an area
• 21:07that I strongly believe needs significant improvement
• 21:12and expansion in coming days.
• 21:14So, these are some aspects of the communities.
• 21:18And from the perspective of academia,
• 21:22we generally tend to think academia
• 21:25as the traditional role of academia
• 21:27as the generator and disseminator of knowledge.
• 21:30And we tend to think
• 21:33that our responsibility ends there.
• 21:35We generate knowledge,
• 21:37we disseminate knowledge through various platforms.
• 21:40We are not trained inherently
• 21:43to think as the implementer of knowledge.
• 21:47But in the context of implementation science,
• 21:49I think we need to redefine a bit of our role
• 21:52in how we can be part
• 21:54in the implementation of knowledge
• 21:56with other stakeholders as well.
• 21:59This is also very relevant in our settings,
• 22:02and something that we are currently doing
• 22:04is working with communities
• 22:06in designing these interventions
• 22:10and implementing them,
• 22:11and creating some models of success
• 22:13that we hope will be adopted
• 22:15and scaled up in other settings.
• 22:17So at least being part in the implementation
• 22:21in creating some models of success
• 22:24should be a goal of academia.
• 22:28But there are inherent challenges
• 22:29in collaborating mainly with the government,
• 22:32there are conflicting priorities,
• 22:34we have other tasks besides research
• 22:36and being a, you know,
• 22:38being a collaborator.
• 22:39The timing is, as I said, very important.
• 22:42Aligning, as researchers and academicians,
• 22:45aligning our timing and deadlines
• 22:49with government priorities,
• 22:50programs, and policies,
• 22:52and is another big challenge,
• 22:54we need to be creative in doing that.
• 22:58And also creating structures within academia,
• 23:02maybe a wing within our departments or centers,
• 23:05that would be exclusively involved
• 23:07in collaborating with the government
• 23:10in building the whole implementation science component
• 23:13within the system.
• 23:15So, these are some of the perspectives from academia,
• 23:18and this is also something
• 23:20that we have been experiencing.
• 23:24So what do we do?
• 23:27And I'm mentioning this based
• 23:29on our own experience, small experience.
• 23:32The first thing is we like to say we have
• 23:36to build upon existing programs and projects.
• 23:38We should not be waiting
• 23:41for a grant take off to happen.
• 23:43So whatever we are doing in a small scale,
• 23:45medium scale, large scale,
• 23:47with whatever teams we are collaborating,
• 23:49whether it is a local government,
• 23:52provincial government, central government,
• 23:54one program, larger program,
• 23:57and we have to build upon existing programs
• 23:59and projects, you know?
• 24:01Another very important part
• 24:03that we have felt over the course of time
• 24:07is to create institutionalized entities,
• 24:12some consortium networks, institutes,
• 24:14or collaborating centers.
• 24:16So when the collaborations happen only
• 24:19on a project or program level,
• 24:22at the level of programs and projects stuff,
• 24:26the life of those collaborations tends to be limited.
• 24:30So if we can think of establishing
• 24:33these platforms, institutionalized platforms,
• 24:38you know, that would be a very strong point
• 24:41in collaborating with government and communities.
• 24:44That is something we have been trying to do
• 24:48in Nepal as well.
• 24:50The third is creating communication
• 24:52and coordination of forums.
• 24:57As researchers and academicians,
• 25:00we generally, you know,
• 25:03by default tend to communicate when we need,
• 25:06you know, when we need to get an approval,
• 25:08when we need to get a letter of support,
• 25:10when we need to get a partner,
• 25:12you know, to be kept on board
• 25:15in our new grant or application.
• 25:18But, you know, that should not be the approach.
• 25:22I think we have to create
• 25:24a system of communication
• 25:26and coordination that is more regular
• 25:28and that is not just need-based,
• 25:30but also developing a, you know,
• 25:34a stronger relationship should be our goal.
• 25:38Then the fourth one,
• 25:41which is what I'm most passionate about,
• 25:44is trying to design our academic programs,
• 25:48research training programs, fellowships,
• 25:51which are a little more progressive
• 25:54and innovative in embracing the team members
• 25:58from the government and also communities,
• 26:01particularly from the government.
• 26:03Most of the time what we feel is that
• 26:06the people working in the government are not,
• 26:11they do not get on-the-job training programs
• 26:15or orientations on the areas of research,
• 26:18which we, from the academic perspective,
• 26:20we feel would be most relevant to them.
• 26:23So how do we bridge that?
• 26:25You know, trying to create certificate-level programs,
• 26:28fellowship programs which are on the job
• 26:30where the government,
• 26:32the government personnel can learn
• 26:34as well as practice in their own work,
• 26:37would be something that we think
• 26:40would be more impactful
• 26:42than just training pure academicians or researchers.
• 26:46And we have been experimenting on that,
• 26:48recently my colleague Archana
• 26:51also launched implementation science fellowship program
• 26:54in Nepal, the first implementation science fellowship
• 26:57in Nepal, which actually called
• 26:59for applications in peer.
• 27:01So each applicant had to find a peer,
• 27:04so it's a government and academia peer.
• 27:07The peers apply and, you know,
• 27:09when they are awarded,
• 27:10it's the peer that work together.
• 27:11So that, you know, something like that, so.
• 27:13We need to think about that.
• 27:15And we are also trying to redesign some
• 27:18of our academic curricula to fit more
• 27:21into government personnel and so on.
• 27:25And we also need to create dedicated entities
• 27:28in government and academia
• 27:30for these types of collaboration.
• 27:32If we come up with a new finding or new idea,
• 27:35there's no designated platform
• 27:37or structure in the government
• 27:40where we go and say, "These are our findings,
• 27:42these are the strengths and limitations of our studies,
• 27:44and this is how you may use it for policy."
• 27:48There's no structure for that.
• 27:51So a lot of time from academia,
• 27:54we take rest after the publication
• 27:58or presentation in a big conference
• 28:00and it doesn't go further.
• 28:02So we need to create some structure like that.
• 28:06And forging partnership between academia, government,
• 28:10and community is not a question
• 28:13of whether we should do it or not,
• 28:15it's a moral imperative now.
• 28:17The resources that we spend
• 28:20in all of these activities,
• 28:23it would be unfair if the findings
• 28:27and the learnings are not utilized properly.
• 28:30So this is a moral imperative as well,
• 28:33it's not something that we can skip.
• 28:36I think we are morally bound to be able
• 28:40to at least try to get the, you know,
• 28:44get the collaboration going on.
• 28:48And we are mindful
• 28:51that it is not an easy task,
• 28:54there are challenges,
• 28:56there'll be lots of disappointments,
• 28:59and we won't need to aim right away
• 29:01to change the world, to change the nation.
• 29:03But at least if we can create
• 29:06a small model of success in our setting,
• 29:08others will follow.
• 29:12And there are reasons for hope.
• 29:14Especially in Nepal, we are seeing
• 29:17a complete generational shift
• 29:19in the leadership in the ministry as well.
• 29:23So a lot of new personnel
• 29:24that are leading in the Ministry of Health
• 29:27and at all levels,
• 29:29there's a complete new generation coming up
• 29:32who are traditionally more educated
• 29:34than people in the earlier generation,
• 29:38more progressive, more informed,
• 29:40and more open to collaboration.
• 29:42We need to tap that.
• 29:43And from academia also,
• 29:45there's a new, I'll say,
• 29:50understanding and approach
• 29:57to open up
• 29:58and not just remain within our own silos of academia.
• 30:03So there are lots of reasons for hope.
• 30:06The new calls and research grants
• 30:08also specifically seek participation of communities
• 30:12and government, which is very good.
• 30:15And I hope that in coming days,
• 30:18a lot of conferences and forums bring together,
• 30:21not just researchers and academicians,
• 30:23but also, you know, participants from government
• 30:26and communities, and other beneficiaries as well.
• 30:29So with that, I end my short presentation here.
• 30:33Thank you.