Advancing Implementation Research
USAID’s Health Research Program supports and promotes an implementation research approach as a means of accelerating the research-to-use process and facilitating the introduction, uptake and scale-up of new or adapted health interventions. The Health Research Program and its partners have adopted a set of operating principles intended to guide programs to use implementation research. The following conditions are conducive to advancing an implementation research approach:
Stakeholder engagement: jointly identifying problems and solutions among implementers, researchers and decision-makers in a co-design process, with an expanded role for partners in low- and middle-income countries (LMIC) and fostering of multisectoral, multidisciplinary partnerships.
Applied iterative research: Utilizing a process of learning and adapting throughout program implementation, as a means of accelerating the research-to-use process and facilitating the introduction, uptake, and scale-up of new or adapted health interventions.
Adaptive implementation and scale: embracing the implementation research process to support roll-out and diffusion of interventions, programs and policies into routine and sustained use at the country level.
Research uptake: accelerating research uptake through systematic real-world use of evidence embedded into service delivery platforms.
Knowledge management and collaborative learning: developing and refining intentional process documentation, knowledge management and translation of findings from the beginning of projects to facilitate adaptive implementation in real time among a broad group of stakeholders.
Why Implementation Research?
The last century has seen a boom in new evidence for interventions proven to reduce maternal, newborn and child mortality and improve health among women and children. The greater challenge is expanding evidence-based interventions to everyone, everywhere with sufficient quality, efficiency and appropriateness. Even when research shows that an intervention can and does work, the impact achieved in real-world settings often differs. Why?
Implementation research helps to bridge the gap between what research shows to be effective and what is happening when countries work to implement effective interventions. Efficacy research tells us that a given intervention will work under controlled circumstances. Effectiveness research tells us that same intervention does work under “real-world” conditions. Implementation research tells us why or how the intervention works.1
The figure below tells the story of how management of possible severe bacterial infection (PSBI) has been moving along the research-to-use continuum over the past decade. To learn more about PSBI, please visit our PSBI Community of Practice.
“Many interventions found to be effective in health service research studies fail to translate into meaningful patient care outcomes across multiple contexts. In fact, some estimates indicate that two-thirds of organizations’ efforts to implement change fail.”2
The Program’s approach to implementation research is supporting countries on their journey to self-reliance by contributing to the evidence-informed policies and programs necessary to improve the health status of women and children.
Definitions and Characteristics
Implementation research helps to understand what, why and how specific policies, programs or individual practices work in “real world” settings and tests approaches to improve them.1
Asking the Right Questions
Implementation research can help to answer the following questions:
- Why am I not seeing the results I expected from my program?
- How can I develop solutions to the challenges I’m seeing?
- How can I help my program get better results?
- How can I adapt or improve my program as it is being implemented?
- How can I make sure my program is reaching those that need it?
- How do I make sure my program is sustainable in the long-term?
To answer the questions above, consider certain core components related to the program.
- Intervention: What is the project planning to do (and why)?
- Implementation Strategies: How will the intervention get done?
- Implementation Outcomes: What was actually done and how?
- Systems/Process: What was changed?
- Intervention (service/client) Outcomes (including unintended): Did it make a difference/have the planned effect?
- Contextual Factors: What else affected the implementation and intervention outcomes?
- Stakeholders: Who are the key users and beneficiaries and when and how to engage them?
Developing a theory of change and utilizing existing conceptual frameworks can help to define these core program elements, understand how they interact, and decide how they can be measured.
Understanding the Theory of Change
A theory of change provides a visual explanation of how and why specific relationships lead to specific events – for instance, how a given intervention will effect change.3 A theory of change describes the steps along the pathway toward a goal and the assumptions about why they occur. These steps and assumptions are then the subject of research for verification, testing, or further explanation.
Implementation Research Frameworks
One indication of a strong implementation research design is utilization of a conceptual framework. A framework is a strategic or action-planning model that provides a systematic way to design, implement and evaluate interventions
Implementation outcome variables are the building blocks of implementation research and serve as indicators of how and why a given implementation is actually working.