Using the WHO Health Systems Framework in IR

As stated, during the IR process health personnel are involved in the development of the research questions, the data collection as well as the interpretation of results and identification of recommendations. At the same time, they are responsible for the delivery of the intervention, whether it be mass drug administration for onchocerciasis, promoting better sanitation to reduce transmission of intestinal helminths or other health interventions. For reasons of operational feasibility, human resources and funding, IR is often conducted in only a selection of districts or health centres. However, the implications of the IR might apply to the wider health system. How then, do we ensure that these results are integrated and sustained within the health system?

The WHO Health Systems Framework (Figure 6) provides a guide to IR practitioners on how the wider health system can be involved in implementation research. Before the IR project begins, the IR team can review the framework to assess how each of the building blocks might be implicated in the health intervention under study as well as in the solutions to identified barriers.

Let's consider an example to understand how the six building blocks in the WHO framework can serve as a guide for integration of IR into the health system:

Your IR project aims to understand and reduce barriers to uptake with insecticide-treated bed nets (ITN) in families with children under the age of 5 in two districts using a mixed methods study. Barriers to ITN use included: fathers were not supportive of bed net use for children; and mothers needed more understanding and skills to ensure their children slept under a net every night. The IR project tested two solutions to these barriers: 1) text messaging to fathers; and 2) the use of counselling to mothers in MNCH clinics. IR results demonstrated the utility of both actions to improve compliance with ITN use in two districts, confirmed with a reduction in cases of malaria in children < 5 years as treated by local health staff. These results and actions are applicable to several other districts in the health system, so how will you ensure that these new practices are integrated into existing health service delivery so that they can be sustained over time?

With this example, each health system building block contributes to integration of results and increased sustainability:

Service delivery: These IR recommendations provide a solution to reduce the cases of malaria in children under the age of 5 by improved use of ITNs. These actions have been shown to be effective, safe and with a minimum of additional resources. As a result, these IR actions can be recommended for improved service delivery in more than the two districts under study.
Health workforce: In order to ensure that mothers are counselled in each district, appropriate health personnel working in MNCH clinics need to be identified for training so that they can provide counselling to mothers. These activities can be added to the regular staff training programmes as well as supervision checklists to ensure that staff have the resources and skills they need to carry out the activities. Consider if further upstream training is required to sustain the activities, e.g. at nursing or midwifery schools.
Health information systems: How can the recording of these activities be integrated into the routine data collection at the health centre and/or the district health office?
Medical products, vaccines and technologies: If the IR project demonstrated the use of a job aid (e.g. brochure, poster, Frequently Asked Question sheet) to guide the health staff as they counselled mothers, how can this be reproduced and distributed on a wider scale?
Health financing: Can the training of health personnel be integrated into existing training activities to reduce financial pressure on the health system? How can routine text messages to fathers be financially maintained?
Leadership and governance: In order to ensure effective oversight of these activities, regular monitoring and evaluation of the counselling, text messaging and reported malaria cases can demonstrate the impact of these activities over time.

Without considering the health system, IR risks producing results that have limited and time-bound implications. Sustainability in IR is efficient. Without sustainability, the same IR question may be researched again in several years, as the barrier or bottleneck may have only been temporarily removed. Working within the health system improves the equity of the reach of IR so that those areas not originally in the research project may also benefit from its results. Health interventions need to benefit all those in need. Considering sustainability, equity and the rational use of resources should be a part of all IR projects.