N. Ilona Varallyay: Ilona Varallyay is a health systems research and evaluation consultant; co-writer of the IR TIPs; and lead investigator for the case study evaluation of embedded IR.
Health system decisionmakers—including national policymakers, regional health directors, health administrators, program managers and district health officers, and in some cases frontline health workers—can use a range of different problem-solving strategies when faced with challenges in service or policy implementation. Implementation research (IR) is one approach that can help decisionmakers understand and address those problems in a way that is systematic, rigorous, and sensitive to the local context.
New international technical recommendations for newborn survival [related to management of possibly severe bacterial infection (PSBI)] had just been published. They were in line with the national agenda, but we know that there are unique implications for a given country when implementing these recommendations—so how do we decide how to proceed in our country? During the orientation meeting, the group made a decision to move forward with implementation research.
– MOH Policymaker, Ethiopia
In Ethiopia, the Ministry of Health saw a natural role for IR to inform scale-up of PSBI management in order to maximize its effectiveness; however, cases such as these are more the exception than the rule, particularly in low-resource contexts. Globally there is still limited knowledge about IR among decisionmakers, and where it exists it is often driven by external donor funding.
Emerging evidence about decision-maker leadership in IR
A growing number of initiatives are focused on creating opportunities for decisionmakers to actively engage throughout the research process, alongside researchers, and other key implementation stakeholders. We recently led a multiple case study evaluation1 of one approach to IR that supports health system decisionmakers in a lead role—as Principal Investigators—to investigate an implementation problem of concern to them. The evaluation demonstrated the critical role of decisionmakers in ensuring the evidence generated is relevant and useful for local decision-making. In addition, decisionmakers were pivotal in driving the evidence use processes that led to policy and program improvements. Real-world IR experiences such as these can help decisionmakers better understand the potential benefits (and challenges) of IR—possibly even motivating them to try it out.
“I see [my engagement in implementation research] as highly strategic, because in the end, the one who is going to make the decision is the Ministry of Health. If the Ministry of Health participates in generating the evidence, it is much easier. You do not have to go raise awareness, you do not have to go convince the Ministry of Health [to pursue] a good strategy—the Ministry of Health is [already] seeing it. If the Ministry department head is involved in the investigation, it will definitely push for your investigation to have a positive response in practice.”
-MOH Policymaker PI, Dominican Republic
The IR TIPs: New resource to support decisionmakers in IR
With increasing evidence about the value of health system decisionmakers’ role in IR, the Health Research Program is developing guidance targeting decisionmakers – TIPs for implementation research for decisionmakers in low- and middle-income countries (IR TIPs). Intended to complement existing resources on research methodology, the IR TIPs focus on practical considerations for decisionmakers in their routine work environments as they: decide whether or not to use IR, plan for the research, interpret findings, strategize for dissemination, use evidence to inform solutions to implementation challenges, and assess their improvement efforts.
Design and development of IR TIPs
To ensure that IR TIPs content was both based on available evidence as well as suitable for our target audience, the team drew on several strategies. We reviewed published and grey literature on a range of topics, many of which are not specific to IR alone (e.g. stakeholder engagement, setting up a research partnership), but are critical principles of the approach. Drawing on the literature we wove in practical lessons learned, illuminating case studies, and also included links to existing guidance documents. This process also allowed us to compile a repository of ‘vetted’ resources for almost all aspects of research generation and evidence use processes that will be useful beyond just IR. As we wanted to ensure that the IR TIPs reflected the needs and perspectives of our target audience, we also conducted a series of formative in-depth qualitative interviews with decisionmakers and researchers in the Africa and Asia regions. Throughout this development process we obtained feedback from experts internal and external to USAID.
Creating demand for IR among decisionmakers
The IR TIPs are just one step toward advancing decisionmaker involvement in IR. This was echoed in our formative qualitative interviews with decisionmakers. Multiple efforts are needed, particularly to create demand for IR among government actors in LMICs and ensure these efforts are locally owned and driven. There is still a long road ahead before IR becomes one of the standard problem-solving approaches for decisionmakers, especially in LMICs where resources are more limited. However, promising advances are being made and worth building on.
Join the conversation
To learn more about what we learned in the formative qualitative interviews with key stakeholders, and how we used that learning to inform the development of the IR TIPs, please join us at the 6th Global Symposium on Health Systems Research (Stakeholder Voices: Strengthening national-level stewardship of IR in LMIC, Abstract #2544).
We are continuing to expand upon and adapt the existing IR TIPs based on expressed need and identification of new resources and examples, but we welcome input from potential users. Please take a look at our IR TIPs and share your feedback, any other useful resources, or requests for additional content directly on the website.
1See: Varallyay NI, Bennet S, Kennedy C, Ghaffar A, & Peters DH (2020). How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean. Health Policy and Planning Journal Supplement: Innovations in implementation research. Forthcoming launch on Nov. 10, 2020 at the 6th Global Symposium on Health Systems Research.