Over 250 delegates from 30 countries met in the beautiful city of Dhaka, Bangladesh, for the Global Conference on Implementation Science (GCIS) between 28th June to 1st July of 2019. This was the first time that such a global conference on implementation science was organized in a low-income country. The conference was co-hosted by the Centre for Science of Implementation and Scale-up (SISU) at BRAC James P Grant School of Public Health at BRAC University and UNICEF Bangladesh, and co-sponsored by TDR. The event convened public health practitioners, policy-makers, researchers, implementers, students, funders etc. to share learnings on health and related programmes in resource-poor settings including conflict areas, urban poor and on how implementation research (IR) could tackle implementation challenges and scale-up a programme successfully. Given the relatively recent emergence of IR, this global conference was a timely attempt to synthesize our current understanding of the field, challenges faced and the way forward.
IR for effective health and non-health programming and scaling-up
We need IR to close know-do gaps in public health. The lack or delay of implementation and scale-up of proven interventions can lead to death and disability. For example, it took 42 years until the provision of Vitamin C for sailors was scaled up to prevent scurvy. An inspiring success story was the implementation and scale-up of Oral Rehydration Therapy (ORT) in our host country of Bangladesh by BRAC, icddr,b, the government of Bangladesh and others. ORT, tested effective by icddr,b researchers, was implemented and scaled-up nationally (hands on training to 14 million mothers) by BRAC, making it a part of the Bangladeshi culture. It is successes like these that highlight the importance of IR, research uptake and scale-up.
Making IR meaningful
To ensure that IR is meaningful to the populations we are intending to serve, researchers must include decision-makers, programme implementers and community members into the research process.
“Answer their questions – not yours.” – Dr John Reeder, Director of TDR
This statement reminds us of the often ‘neglected populations’ and of the need to ensure that IR is truly multidisciplinary. While sharing experiences in conducting IR, Mr. Asif Saleh, acting Executive Director of BRAC, reflected on the importance of keeping solutions simple and working closely with decision-makers in the entire IR process. This facilitates the translation of lessons learnt from IR projects into policy and practice.
Understanding IR: Emphasize the commonalities rather than fragmentation
Despite having several definitions and approaches of IR followed by different organizations or groups, it is crucial that instead of fragmenting, all IR actors focus on the commonalities and work together. The question should not be how sophisticated IR is compared to other research methods. Instead, we have to critically evaluate the quality of IR projects. High-quality IR is systematic, rigorous, multidisciplinary and answers real world questions. Some good examples of IR projects shared at GCIS and guidelines included the new training course on ethics in IR by WHO-TDR, the DELIR Initiative by UNICEF and AHPSR, GACD implementation science workshops, ENCORE, Arise, MNSP of FHI360, the COUNTDOWN NTD project, HEARD project, TB and Tobacco, Tobacco control etc. It was clear that we need to be flexible to adapt and understand implementation on a continuum from evidence-based practice to practice-based evidence.
“We do IR not just because we like it, or we want to get published. Instead, it is needed because, ultimately, it has a benefit. Benefit of the people who are involved and benefit of the people we all serve.” – Professor Rohit Ramaswamy
IR entails an art of working with people and the science has both ‘soft’ and ‘hard’ aspects which cannot be done individually or by a group of researchers sitting in a room. IR needs to happen in the field, with partnerships among several players who seek to address questions related to implementation. Instead of being obsessed with the outcome of an intervention, IR is deeply embedded in the process. Through IR we are able to understand what works, what does not work, for whom, in what context and why. IR often deals with complex interventions and multi-component interventions in a complex system which is adaptive and non-linear. Therefore, IR should embrace the complexity, deal with those complexities and keep solutions simple and innovative. We need to work together to find strategies, develop good local experimentation methods, co-design methods and harvest issues of ethics, dignity and equity deeply rooted in local wisdom. Implementation science is embedded in the everyday act of implementation and scalability should be considered right from the conception to design and execution of any IR project.
Areas to explore further and way forward to get to a glorious era of IR
Research is just another spanner in the toolbox of an implementer. By making IR research engaging, accessible and useful to decision-makers and implementers, we can democratize research. As Professor Malabika Sarker highlighted, it is important to build IR literacy and a critical mass of well-trained implementation researchers. Participants highlighted several critical areas where IR could support and come up with potential solutions. Professor Debra Jackson, Chief of Implementation Research and Delivery Science (IRDS) Unit at UNICEF HQ New York, emphasized to consider ‘political economy’ as one of the areas of IR. IR could investigate how policy makers take decisions and develop budgets and explore avenues to ensure a regular budget for IR. The need of IR for effective health service delivery in fragile and emergency settings and to develop IR guidelines for such settings was emphasized by several participants. Professor Kaosar Afsana, former Director of the BRAC Health programme, recommended applying IR to understand the accountability mechanism of the health systems. Especially, when health care expenditure is too high in low-income countries. In addition, panelists emphasized that questions around ethics and inequity should be at the center of IR. The outcome of the Dhaka GCIS and key strategies for a glorious future of IR were summarized by Professor Sally Theobald:
All in all, DHAKA GCIS brought hope and expectations from different stakeholders to work together, practice and promote IR to achieve the SDGs. Building a critical mass of well-trained implementation researchers, collaborations and networks to help learn and scale will be crucial to take forward the agenda of IR. One such network which made this blog possible is the Emerging Voices for Global Health (EV4GH) network. The authors are thankful to the networks and friendships formed across different editions of the program.
A big thank you to the organizers! And check out #sisuGCIS for more about the conference on Twitter.