The need for IR

The importance of research in identifying solutions and options for overcoming implementation barriers and bottlenecks (problems) in health systems and programmes is now widely recognized.² These problems are typically identified in the course of implementing a health programme and may be anchored in factors related to the local community, national, regional or health system contexts, for example. Identifying, understanding and characterizing the problem are the foundations of the research methodology and experimental design of IR.

IR is the systematic approach to understanding and addressing barriers to effective and quality delivery of health interventions, strategies and policies. Implementation barriers are best identified by health workers and programme managers, who have direct experiential knowledge of such problems and of the contexts in which they are encountered.The module “developing an implementation research proposal” of this Toolkit describes the process of identifying the problem and formulating corresponding research questions in greater detail.

Many efficacious disease control tools (e.g. bednets and artemisinin-based combination therapies for malaria; praziquantel for schistosomiasis; ivermectin for lymphatic filariasis and onchocerciasis; oral rehydration solution (ORS) for treating diarrhoea; vaccinations for human papilloma virus, polio, influenza, hepatitis B); or strategies (preventing the transmission of HIV from mother to child, testing, tracking and treating malaria) are available. Despite Phase I–III clinical trials that have shown the potential of such tools and strategies to be effective at the community level, impact on health outcomes frequently fall below expectation after scale up and system-wide implementation. In order for a ‘proven’ intervention to be effective, it must be accessible to the target group, health care providers/service providers must comply with the relevant national or local policies, and patients must adhere to the intervention. However, there are several challenges that affect these requirements, including issues related to inequity.

Non-compliance or poor adherence can ultimately render a proven intervention ineffective. There is evidence that after integration into health systems and/or communities, interventions lose impact due to various factors (see Introduction module for example of rapid diagnostic tests for malaria).

IR focuses on identifying the challenges and bottlenecks related to the roll-out of health interventions, as well as on developing and testing effective strategies designed to overcome them, and determining the best way to introduce innovations into the health system, or to promote their large-scale use and sustainability.³

The need to address implementation bottlenecks is often greatest in settings where health systems are weakest or non-existent, as illustrated by studies on health system effectiveness designed to understand reasons for the loss of the impact of a proven intervention. Loss of impact was associated with individual and systemic behaviour, including access to the intervention, diagnostic targeting, provider compliance and patient adherence (Figure 1).