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Inaugural KEYSTONE Course on Health Policy and Systems Research 2015

Implementation Research

Implementation Research

Outline of the Presentation

• Why is it needed? • What is it? • Who should be involved? • What approaches and methods are useful? • Challenges and Critiques

Why is IR needed?

• Improve understanding of barriers/facilitating factors

• Move from phase of innovation to scaling up into large scale systems.

• Study contextual (and outcome) variations of same intervention

• Make implementation more effective

What is IR?

• “Basic intent is to understand not only what is and what isn’t working, but how and why implementation is going right or wrong, and testing approaches to improve it” (Peters et al, 2013)

• "What is happening?" in the design, implementation, administration, operation, services, and outcomes of social programs. And "Is it what is expected or desired?" and "Why is it happening as it is?”

What is IR Contd..

• Deals with strategies needed to deliver products or interventions and spans all of health systems

• Studies process and outcomes as well – processes of change management and institutional arrangements which affect outcomes

• Think of IR as a continuum- Implementation light and implementation heavy

• Monitoring is often the starting point for IR.

Who should be involved?

• Collaborative and challenging • Need to bring commonality between agenda,

understanding, ownership and accountability • Collaboration is not only important for actual research

but for uptake • Clarity on who is responsible for what phase of the

research cycle, without privileging one over the other • Embedding IR into design stage – aligning research

funding with programme needs • Role of Boundary Organizations

Approaches and Methods

• No “one IR method” – • Explanatory versus Pragmatic trials • Effectiveness – Implementation Hybrid trials • Quality Improvement Studies - PDSA • Realist reviews • Participatory Action Research • Mixed Methods

Identifying Research Question

• The question is key • Uses implementation theory – Diffusion of

innovations, SUM, Expand-Net, CFIR; RE-AIM • Requires clarity of research objective • Determines the method of study and tools

used

Group Work

• Four sets of strategies: Maternal Health, Child Health, Tuberculosis and Family Planning

• List three key implementation issues/justify • Define one IR question with method (s)

IR- Challenges and Critique• Big ‘P’ like Policies, Acts are a different animal. Small ‘p’ like

guidelines and Management decisions are more amenable to IR (Nilsen, P et al, 2013)

• Layers in Administrative system needs to be factored into the analysis of the implementation.

• ‘Street level bureaucrats’ can create multiple layers of implementation which might make it difficult to translate IR findings. For eg. Policy at the Union level but implementation at the federal level (Hull & Hupe, 2003).

• Role conflicts – Researchers want to publish and have an eye for detail and rigour whereas the implementer is always under pressure to deliver and solve the problem as soon as possible

IR- Challenges and Critiques• There is a presupposition of ‘learning culture’ of the

organizations • •Immersion of the researcher and the idea of ‘speaking truth

to power’ might create unintended consequences. For eg. Policy makers/Funders might not be open to research which might not show the programme in good light

• Calls for high level of ‘Implementation Fidelity’ • Tacit knowledge • Creating new frameworks • Political processes need consideration • Ethics

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