Elsevier

The Lancet

Volume 392, Issue 10160, 17–23 November 2018, Pages 2214-2228
The Lancet

Health Policy
Implementation research: new imperatives and opportunities in global health

https://doi.org/10.1016/S0140-6736(18)32205-0Get rights and content

Summary

Implementation research is important in global health because it addresses the challenges of the know–do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.

Introduction

In global health, many specific interventions can be effective at low cost in relatively controlled environments, in short-term studies, or on small scales.1 However, building strong and responsive health systems that promote health and wellbeing through sustainable strategies that work on a large scale remains an important challenge, particularly in low-income and middle-income countries (LMICs).

Internationally, the need for implementation research could not be greater or more timely. The Sustainable Development Goals (SDGs) and national commitments for universal health coverage require effective implementation of proven interventions to improve health outcomes and ensure that no communities are left behind and all benefit from improved health and wellbeing. Implementation research provides a set of approaches, methods, tools, and ways of bridging research and practice to address these issues. Implementation research offers a renewed focus on how to accelerate the development and delivery of services that improve and sustain health and wellbeing for all people, including those who are most disadvantaged.

The aim of this Health Policy is to present the characteristics that define implementation research and their application in global health through case studies. We show how evidence can inform practice, and the potential of implementation research to make a positive impact on health across different contexts and implementation problems using a range of research methods in LMICs. The case studies highlight contexts in which achieving SDGs and universal health coverage presents heightened challenges.

Section snippets

Defining implementation research

Implementation research builds on several research traditions (panel 1), and each of these research traditions has developed its own set of core disciplines, primary audiences, and typical sets of research questions (table 1).1, 2, 3, 4 In part because of the so-called invisible colleges that have formed from the different traditions, the field of implementation research in health has yielded considerable debate over its scope, theories, methods, terminology, and areas of emphasis (panel 2).

Methods to synthesise learning on implementation research

We selected and analysed numerous case studies of implementation research projects in differing LMIC contexts within a framework of core characteristics of implementation research. The framework and selection of case studies was informed by a set of five structured and consultative international meetings that were held between 2012 and 2016 (panel 3), bringing together researchers, donors, and policy makers to identify problems and opportunities related to implementation research, build

Smallpox eradication

The smallpox eradication campaign remains the only successfully completed global health eradication campaign to date. One of the most dramatic and effective uses of implementation research involved testing a new implementation strategy for smallpox eradication using real-time data. The purposeful application of different research approaches was crucial to the success of the smallpox campaign. These approaches included research on different ways to deliver vaccines, such as the bifurcated needle

Ghana

The Community Health and Planning Services (CHPS) is the most local level at which public health services are delivered in Ghana. CHPS started as a family-planning research project and then transformed into an initiative aimed at locating primary care services in communities and involving them in the decision making process. The CHPS example shows the practicality of scaling up a successful pilot programme throughout the country, and what is required to put evidence into action through

District health systems strengthening

A growing body of implementation research shows that the use of participatory research processes to support learning and district health systems strengthening. In the cases described in this section, the participatory action learning strategies have been assessed using a range of qualitative, participatory, and quantitative methods, and have shown promising results, identifying the probable pathways of effect.

The Improving Health Workforce Performance (PERFORM) project43 has involved

People at risk for HIV infection and discrimination

The government of India developed the National AIDS Control Programme, which involves the implementation of targeted interventions to reduce HIV for key populations, including female sex workers (FSWs). A qualitative process evaluation was done in two Indian states, Andhra Pradesh and Karnataka, to assess the ways in which targeted interventions are appropriately adapted to FSW needs and changing contextual and programmatic factors.68 Establishing outreach activities for FSWs, many of whom were

Conclusion

The case studies show the wide range of implementation research processes in terms of scale, topics, methods, and range of impacts in global health. The effects of implementation research do not always fit neatly into the categories we have used to describe them. The same research can affect health outcomes while also informing policy, improving health management and service delivery, and empowering communities and beneficiaries. Many of the case studies illustrate how implementation research

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