Global Applications of Implementation Researchconferences.thehillgroup.com/OBSSRinstitutes/TIDIRH2012... · • Examples of IR studies • Overview of IRP ... – Combat HIV/AIDS

Global Applications of Implementation Research

Nhan T. Tran, MHS, PhD Manager, Implementation Research Platform

Alliance for Health Policy & Systems Research World Health Organization

Presentation Overview

• Global Context and rationale for IRP • Framing of IR concepts in global context • Examples of IR studies • Overview of IRP • Discussion

Global Context

• 2015 Millennium Development Goals – End Poverty & Hunger – Universal Education – Gender Equity – Child Health – Maternal Health – Combat HIV/AIDS – Environmental Sustainability – Global Partnerships

Global Context: MDG Coverage Gaps

Global Context: What is there

• Many proven effective health interventions are not being scaled-up in low- and middle-income countries, resulting in failure to achieve health MDGs – routine immunizations, treatment of diarrhea with oral

rehydration salts and zinc, pneumonia treatment, malaria case management, and Vitamin A distribution (MDG 4)

– Prenatal care, emergency obstetric care, third stage management of labor (MDG 5)

– PMTCT, Male Circumcision, PrEP (MDG 6)

IR Definition (IRP)

– Identifies common implementation problems and their main determinants,

– Develops and tests practical solutions to these problems,

– Determines the best way of introducing the solutions into the health system and facilitates their full scale implementation, evaluation, and modification.

Bringing Innovations to Practice

Proof of concept

Proof of implementation

Research to inform

Scale-Up

Innovation

Efficacy Trials-does it work?

how does it work in local settings?

Fidelity? Adaptations

Health systems

integration, sustainability

Bringing Innovations to Practice

Proof of concept

Proof of implementation

Research to inform

Scale-Up

Innovation

Efficacy Trials-does it work?

how does it work in local settings?

Fidelity? Adaptations

Health systems

integration, sustainability

Implementation Outcomes

Effective Implementation

Increased Coverage

Improved Health

DEMAND for Services

Fidelity, Adoption

Bringing Innovations to Practice

Proof of concept

Proof of implementation Scale-Up

Innovation

Efficacy Trials-does it work?

how does it work in local settings?

Fidelity? Adaptations

Health systems

integration, sustainability

Scale up Outcomes

Effective scale up

Improved system

performance

Improved population

health

Support systems for Services

Sustainability

Starting points

• What is the intervention

• Who is the implementer?

• What does/do the implementer(s) need to know to successfully implement or scale up the intervention?

Health Systems

Health Systems

The cutting edge of health research

Epidemiology& Clinical Sciences

Policy & Practice

Social Sciences

IR

What is the nature of the social reality being investigated?

Epidemiology/Clinical science: There are a set of facts to be gathered (one reality)

Social science: Reality is constructed by actors drawing on

their ‘contexts’ (multiple realities)

Positivism Relativism

What are health systems?

Machine-like organisations which can be controlled from the top through rules and incentives

Complex social and political phenomena, constructed through

human action

Purposes of research & related questions

• Normative/evaluative

• Exploratory/ explanatory

• What interventions work best for

scale up?

• What works for whom under what circumstances?

• What are the social processes, including power relations, influencing actors’ understandings and experiences, and shaping impacts of interventions?

Skilled Birth Attendants (SBA)

Implementation barriers

Level of Constraint Types of Constraints

Community/household Perceptions of SBA, decision making

Health services delivery Shortage and distribution of appropriately qualified staff (of appropriate gender) – supervision of SBA and quality assurance

Health sector policy and strategic management

Integration of SBA with existing services

Environmental and contextual characteristics

geographic barriers

Proof of implementation study • Goal – to determine if

CHW model can be implemented in urban slums to increase access to ANC/MNC services

• Cluster randomized trial • Mixed methods study

ANCHUL Study • Explores the fit of CHW in slum

settings (acceptability and appropriateness) and defines adaptations that are necessary to implement

• Outcomes include adherence and delivery of health messages and reminders by CHWs as well as use of services by population

• Testing innovative model of supervision and use of 'heart scale'

IR to inform scale up • Goal: Understand how QI can be used as a

strategy to scale up AMSTL and ENC in Niger • Mixed methods study • Multi-level analysis

– Case studies of decision making at regional and district management levels

– Empowerment and motivation of staff – MNCH outcomes

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Avec SONNE Avant SONNE

Pour l’intimité des femmes

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Pourcentage d'accouchements avec les 3 gestes clésde la GATPA

Pourcentage de cas HPP détectés

2006 2008

2007

Début du collaboratif Fin du collaboratif

2009 2010

Maintien des gains en qualité de soins et résultats - GATPA – Janvier 2006-Avril 2010 dans 20 sites des 7/8 Régions du Niger -

Reflections

• Implementation Research is – An evolving field under development – Draws upon a range of disciplinary perspectives But… – It is not new and has been used effectively by

industry domestically and internationally

Reflections

• IR should respond to the identified needs of those implementing programs and cannot be conducted in isolation

• IR should be more demand driven and priorities should come from implementers

• Need to reconsider relationship between researchers and decision makers (including implementers)

Implementation Research Platform (IRP)

• Launched in 2010 as a collaboration between departments within WHO

• Scope: To promote and support Implementation

Research to accelerate progress on MDGs 4, 5 & 6, especially related to maternal, newborn and child health, and linked to sustainable strengthening of health systems.

IRP 2010-11 Highlights • Provided approximately USD 5 million in support for

programmatic research on IR

• Commissioned systematic reviews to address implementation barriers and facilitate scale-up

• Priority Setting on IR relevant to scale up of effective interventions for maternal and child health

• Development of IR curriculum for researchers

IRP 2012-2013 Progress-to-date • Call for innovations in capacity strengthening for decision makers

• Establishment of regional Nodal Institutes to facilitate capacity

strengthening and regional priority setting

• Development of Guide to Implementation Research

• Established core working group to establish a task force on implementation sciences

• Support for network of research for UNSG Global Strategy for Women and Children's Health

Thank You [email protected]

www.who.int/alliance-hpsr/en/

www.implementationresearchplatform.org