Health Research Program

Identifying problems to solve with IR

IR seeks to answer an implementation question that explores, defines, or tests solutions for an implementation problem that has been identified by service providers, program managers and/or policymakers.  But how are implementation problems identified, clarified, and prioritized?  Figure 4.1 illustrates the basic ways a problem is brought to attention, what that problem might look like, and suggestions for clarifying the magnitude of the problem.

TIP #4_Figure 4.1_Sept 14

Systematic identification, clarification, and prioritization of implementation problems is best done during regular data, health sector or program reviews. These reviews are most complete if they have included opportunities for problem identification feedback from frontline workers or facility managers through observation of delivery challenges.

Some key steps to successfully identify implementation problems include:A good problem statement answers: Who is affected? How big is the problem? What contributes to the problem? When and where is the problem most likely to occur?

  • Involving technical experts and other relevant stakeholders to help define the problem
  • Involving technical experts and other relevant stakeholders to help define the problem
  • Reviewing existing research and information about the problem
  • Collecting new data from stakeholders if necessary, to help identify root causes and other contextual information.
  • Framing the problem in a way that will help to identify possible solutions for testing

Widely supported by many low and middle-income countries, processes such as Joint Annual Reviews (JAR) or Mid-term Reviews of Health Sector Plans provide an opportunity to:

  • review trends related to key MNCH indicators (see Box 4.1),
  • assess constraints or challenges encountered, and
  • solicit recommendations for implementation improvement.

Establishing priority challenges

As part of the review process, multiple challenges will likely arise, and priorities for action will need to be identified.  National (or sub-national) priority-setting processes are an important means of ensuring dialogue and engagement between researchers, policymakers and managers that turns health system and policy problems into researchable questions, identifies priorities among them and, ultimately, supports the uptake of research findings.5 There are many tools available for establishing an effective priority-setting process6, including the Essential National Health Research,  priority setting  Child Health and Nutrition Research Initiative (CHNRI), Combined Approach Matrix (CAM), and the James Lind Alliance Method.

Box 4.1: Where to get the information to help identify your implementation problem A good first place to start assessing and identifying your implementation challenge is by reviewing your country’s Countdown to 2030 (Countdown) Country Profile and Equity Profile. Using data accessible to the public from UNICEF and WHO, Countdown tracks: progress in the 81 countries that account for the majority of under-five and maternal deaths; implementation of interventions that have been scientifically proven to reduce mortality among mothers, newborns, or children AND that are feasible for implementation in LMIC; service delivery platforms that support delivery of multiple effective interventions; interventions and approaches that can be associated with a valid coverage indicator that is reliable, comparable across countries and time, nationally representative, clear and comprehensible by policymakers and program managers, and available regularly. While Countdown provides the most up-to-date snapshot of national (Country Profiles) and regional (Equity Profiles) data, access to district-level data is critical. Investigation of routine monitoring data (i.e. health facility and other administrative data) compiled through your district health information system (DHIS2) can provide important (and continuous) statistics to help in identifying the implementation challenge. Health facility data can be used (if the quality is sufficient) at the district-level to understand the extent to which facilities are functioning as intended, and at the state/national-levels to review policies and allocation of resources.

As many countries are increasingly moving toward decentralization of health system management, it is essential, whatever review processes and priority-setting tool(s) are employed, to support sub-national decision makers (e.g., District Health Officer) to utilize routine monitoring data to detect implementation problems and advocate for investigation of questions to support solving them.  Following the principles below will help to ensure that all stakeholder voices are heard throughout the problem identification and prioritization process. These include8:

  • Capacity and quality assurance all along.
  • Prioritization based on evidence, reasons and principles accepted as relevant.
  • Transparency ensured through documentation and communication of decisions and actions, reflecting the concerns of stakeholders at national and local levels.
  • Inclusiveness by ensuring that all interested parties are represented throughout the process.
  • Promotion of equity in health and development by ensuring the maximization of health for the greatest number of people, independently of individual financial resources, with special focus on the poorest.

The Kampala Slum Maternal Newborn Implementation Research Study (MaNe Project) In Uganda, an effort to generate evidence on the most feasible and value for money approaches for improving maternal and newborn health (MNH) for the urban poor brought implementers, researchers, government partners, donors, and program beneficiaries and other stakeholders such as community leaders, health providers, and others together for a four-day co-design workshop to review formative research findings to support understanding of the contextual issues for those living in informal settlements of Kampala. The workshops utilized participatory methods to engage stakeholders in interpreting and synthesizing the formative phase research findings, identifying gaps and underlying issues, and generating ideas for possible implementation strategies to be tested using IR. When can an IR approach be most useful?

Health interventions are complex largely because of many unpredictable factors that can lead them off track. A systematic way to collect and use evidence to identify and act on implementation problems is the first step in the IR process. An IR approach is useful when11:

  • answering the research question will lead to:
    • positive population health outcomes, and
    • improved delivery of the target health intervention, and
    • a strengthened health system, and
  • there is capacity to put results into practice to create change, and
  • there is political and community support, and
  • results can be measured.

Once the implementation problem has been identified and clarified, you are ready to engage the key stakeholders to jointly formulate an IR question to help you address the problem (see TIPs #5 and TIP #6).

Key resources

Clarifying Implementation Problems

Priority-setting Resources

  1. Bhattacharya AA, et al. (2019) Quality of routine facility data for monitoring priority maternal and newborn indicators in DHIS2: A case study from Gombe State, Nigeria PLoS One 14(1).
  2. Leroy JL, Habicht JP, Pelto G, Bertozzi SM. (2007) Current Priorities in Health Research Funding and Lack of Impact on the Number of Child Deaths per Year. American Journal of Public Health 97, no. 2: 291-223.
  3. Kanmiki EW et al. (2019) Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana. PLoS ONE 14(2): e0211956.
  4. Lavis JN, Wilson MG, Oxman AD, Lewin S, Fretheim A. (2009) SUPPORT Tools for Evidence-Informed Health Policymaking (STP) 4:  Using Research Evidence to Clarify a Problem.  Health Res Policy 16;7 Suppl 1(Suppl 1):S4.
  5. Gilson L (Ed). (2012) Health Policy and Systems Research: a methodology reader. APHSR, WHO.
  6. Council for Health Research for Development (COHRED) Collaborative Paper. (2006) Priority Setting for Health Research: Toward a management process for low and middle income countries (Working Paper 1).
  7. Green A and Bennett S. (2007) Sound Choices: Enhancing capacity for evidence-informed health policy. AHPSR, WHO.
  8. COHRED (August 2010) Priority Setting for Research for Health: a management process for countries.
  9. Rudan I, et al. Setting Priorities in Global Child Health Research Investments:  Guidelines for Implementation of the CHNRI Method.  Croat Med J. 2008 Dec; 49(6): 720-733.
  10. Hindin MJ, Christiansen CS and Ferguson BJ. (2013) Setting research priorities for adolescent sexual and reproductive health in low-and middle-income countries.  Bull World Health Organ; 91: 10-18.
  11. Peters D, Tran N, Taghreed, A. (2013) Implementation Research in Public Health: a practical guide.  AHPSR, WHO.