Health Research Program

What questions should guide the IR?

Formulating the right research question is critical to making sure IR provides the learning you need to take action to address the identified implementation challenge.  Because problems implementing health interventions often result from circumstances specific to a local context, engaging diverse stakeholders will help formulate the right question. This TIP provides guidance on how to formulate and prioritize a question for IR, supporting decision makers to find out how and why a health intervention is not achieving what it set out to do, and how to get better results.

Box 6.1: IR can help to answer questions like… 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 ensure the program is reaching those that need it? How do I ensure the program is sustainable in the long-term?

For instance, in Malawi, policies leading to increased access to and utilization of health facilities for delivery did not produce equivalent gains in newborn survival. Later analyses concluded that facility quality fell substantially short of global standards of evidence-based care.  Higher-quality facilities had substantially few neonatal deaths than other facilities.2,3

IR utilizes real-time data review and reflection to help decision makers to understand why interventions and investments are not achieving their goals in their unique context.  Box 6.1 provides some potential questions IR could help to answer.

How to formulate IR questions

While more traditional research questions focus on the impact of an intervention – for instance, does presence of a skilled attendant at birth reduce maternal mortality? – IR questions focus on:

  • How an intervention is being implemented (implementation strategies),
  • How those implementation strategies affect service outcomes and implementation outcomes (i.e. coverage, feasibility, acceptability), and
  • How contextual factors affect the intervention and its outcomes

IR questions can explore, describe, influence, explain or test (see Table 2 of Peters et al, 2013) how implementation is (or is not) working.1  Additionally, IR questions can try to address challenges  related to program scale-up, sustainability, replication and robustness, program integration, equitability, and real-life effectiveness, including cost.Examples of good IR questions What are the barriers to scaling-up implementation of a vaccine program for children under 5? Is it feasible and acceptable to utilize antenatal care services as a delivery platform to integrate other health services (i.e. HIV, malaria, or nutrition)? How and where at the household/ community level should multiple micronutrient supplements be made available for effective coverage during pregnancy?

Once you have identified some preliminary IR questions, you can refine and finalize those questions with the help of an IR framework (see TIP #7) and input from partners/stakeholders. TIP #5 addresses stakeholder engagement more specifically, but the Robert Wood Johnson Foundation and the Canadian Institutes for Health Research have developed practical guidance on engaging stakeholders in developing research questions.

How to prioritize questions

Health interventions can produce multiple, simultaneous implementation problems and questions. Figure 6.1 illustrates three criteria to utilize when prioritizing IR questions and some questions that will help to establish which IR questions should be prioritized.  Box 6.2 presents how Indonesia utilized a collaborative process to establish IR questions to support scale-up of a national insurance policy.

TIP#6_Figure_Sept 14

 

Box 6.2: How IR was used to Strengthen Financing Reforms in Indonesia4 In 2014, Indonesia began implementing a national health insurance initiative (JKN) aimed at covering the country’s entire population by 2019. IR was undertaken to provide crucial information about whether JKN was being implemented as intended. A consultative process with key stakeholders, including national and local policymakers and implementers, contributed to defining the IR questions. The first one-year cycle assessed how JKN regulations were being interpreted and implemented and implications for effectiveness. The second cycle sought to investigate health worker satisfaction and opportunities to strengthen the links that lead to improved service delivery.


Key resources


References
  1. Peters DH, Tran NT, Adam T. Implementation research in health: a practical guide, 2013. Geneva: World Health Organization.
  2. Godlonton S, Okeke EN. Does a ban on informal health providers save lives? Evidence from Malawi.  J of Development Economics. 2016;118:112-32.
  3. Leslie HH, Fink Gunther, Nsona H, Kruk ME. Obstetric Facility Quality and Newborn Mortality in Malawi: A Cross-Sectional Study. PLoS Med. 2016 Oct; 13(10):e1002151.
  4. Eichler R, Gigli S, LeRoy L.  Implementation Research to Strengthen Health Care Financing Reforms Toward Universal Health Coverage in Indonesia: A Mixed-Methods Approach to Real-World Monitoring.  Global Health: Science and Practice. 2018 Vol 6(4): 747-753.
  5. TDR Implementation Research Toolkit. https://www.who.int/tdr/publications/topics/ir-toolkit/en/