Presentation is about the uniqueness of Implementation Research and Role of the Government, specially in Indian context of health programme implementation.

1. Implementation Research and
Role of Government
Digvijay Trivedi
MBA (HRM), MA(Eco), PGDRD,PGDCPM
Programme Manager SIfpsa

2. Setting the tone…..
• Ample resources invested in developing effective interventions
to reduce morbidity and mortality, but many are never brought
to scale
• Even when interventions are designed in similar ways,
implementation occurs differently in different contexts, and with
many different effects
• Figuring out how to scale up such interventions is consistently
listed as a top priority during MCH prioritization exercises
• The science of scaling up to optimize the effectiveness of
interventions

3. UNDERSTANDING
IMPLEMENTATION RESEARCH

4. WHAT is IR
Scientific enquiry into questions concerning
implementation
Looking at
constraints
Identify potential
solutions to
constraints
Testing solutions
to constraints
Integrating the
solutions

5. IR: Characteristics
IR is :
• Systematic
• Multidisciplinary
• Contextual
• Complex
IR is NOT :
• Routine, applied
operation research
• Initial or replication of
intervention
• Programme progress
reporting

6. IR: Characteristics
Characteristics Applications for use
Systematic • The systematic study of how a specific set of
activities integrate an evidence-based public health
intervention within specific settings and how health
outcomes vary across communities
Multidisciplinary Analysis of biological, social, economic, political,
system, and environmental factors that impact
implementation. Interdisciplinary collaborations
between behavioural and social scientists, clinicians,
epidemiologists, statisticians, engineers, business
analysts, policymakers, and stakeholders

7. IR: Characteristics
Characteristics Applications for use
Contextual • It is relevant to local specifics and need
• Generates generalizable knowledge that can be
applied across contexts
• Culture, community
Complex • Dynamic and adaptive
• Multi-scale: occurs at multiple levels of health care
systems and community
• practices
• Analyzes multi-component programs and policies
• Non-linear, iterative, evolving

8. IR : Purpose
• Improve Uptake of services
• Efficient Implementation
• Translating research findings into routine common
practice

9. IR: “know-do gap”
• Determine the best ways to implement evidence-based
interventions in real world settings
• Optimize programs that are currently not achieving
adequate coverage or quality
Public Health Knowledge
(what we know)
Public Health Practice
(what we do)
Implementation
Research
IR takes what we know and turns it into what we do

10. IR: Unique features
• Done in real world rather than controlled settings
• Real world settings with existing staff, facilities, and
budgets
• Real world populations rather than select sub-groups
• Focus on context
• Political, social, economic, cultural
• Existing health care system and network of
stakeholders

11. • Central role of stakeholders and end-users
• Health managers, policy makers
• Involved closely in setting agenda
• Goal of efforts is to help them, not publish papers
IR: Unique features

12. IR: Requires Collaboration
Implementers
Policy -
makers
Advocacy
Researchers

13. IR: Implementing Process
Scaling up
Implementation
Efficiency
studies

14. IR: Challenges
• Scale –up the interventions
• Sustainability and health maintenance
• Replication of the evidence based intervention
• Programme integration
• Equitability
• Real-life effectiveness and impact
• Efficiency at all levels
• Unintended consequences

15. IR questions
Challenges IR questions
Scale-up How can coverage and usage of a proven intervention be
improved to meet set targets?
How can a program be scaled up to broader regions or
populations?
Sustainability Why do established programs lose effectiveness over time?
How can sustainability or health maintenance be achieved?

16. IR questions
Challenges IR questions
Replication and
robustness
Why do tested programs exhibit unintended effects when
transferred to a new setting or problem?
Why don’t tested programs work when transferred to new
settings or work in some settings and not others?
How can implementation be improved to assure
replicability?
Program
integration
How can multiple interventions be effectively packaged
and delivered within health systems?
How can interventions be delivered to assure integration?

17. IR questions
Challenges IR questions
Equitability How could program or service delivery be more equitable in
settings where financial and human resources are low, or
/and cultural and social norms affect health-seeking
behavior?
What is the impact across issues of race, class, education,
gender, age, geography (urban-rural) and other relevant
factors?
Real-life
effectiveness
Are there unintended consequences (positive or negative) of
the program?
Under what conditions does the program work?
Is the tool, intervention, or strategy worth it? Is it cost-
effective?
Does the program achieve the intended public health
impact?

18. The Government

19. Government : Key stakeholder
Government
and
Healthcare
Policy and
programmes
Resource
allocation
Institutional
arrangements
Programme
Management

20. Governments: Centre viz a viz State
• Health : responsibility of state, local and also
Central government
• Service delivery: more concerned with state
government
• Regulations and standards: more concerned with
centre government
• Both centre and state are jointly responsible for
programme listed in concurrent list

21. Government Institutions
• Primary health care
• Primary health centres
• Sub centres
• Hospitals/ health centres
• Community health centres
• Rural hospitals
• District hospitals
• Teaching hospitals

22. Government Institutions
• Health insurance service schemes
• Employees State Insurance scheme
• Central government health scheme
• Other agencies
• Defense
• Railways

23. Milestones
NFPP
1952
UIP
1985
RCH
1996
NHP
2002
NRHM-
2005
Primary
Health
Centre
National
Health
Programe
1957
National
Health Policy
2002

24. • Reducing burden of disease
• Infectious
• Chronic
• Life style diseases
• Family Health :
• IMR, MMR TFR, malnutrition
• Healthcare finance mechanism
• Health inequality : Universal access to health
Challenges

25. Burden of
diseases
•Poor implantation of public health programs
• Lack of access to diagnostics
•Poor living conditions
•Lack of specialists
Family Health •Population explosion
•Gender inequality
•Poor nutrition
•Weak service delivery system
Why Do Challenges Exist

26. Why Do Challenges Exist
Health care
finance
•Expensive curative care
•Limited and expensive health
insurance
•Inadequate vaccination coverage
Health
equity
•Sharp rural and urban divide in service
access
•Economics of scale works in urban
setting only
•Dearth of qualified medical
practitioners

27. Government viz a viz
Implementation Research

28. Key Points
• IR results can be used to help make informed policy
decisions to improve the effectiveness of public health
programs.
• Knowing what the research shows about program
effectiveness can help to make better decisions on how
and where to spend state funds.

29. Process Barriers
• Implementation seldom succeeds perfectly when it is first
attempted
• Achieving sufficient programme fidelity
• Moving more quality benefits to more people over wider
geographical area more quickly
• Addressing conflicting orientation, mandates and capacities
of stakeholders
• Right size scaling to sustain.

30. Where Government use IR
(prevention paradox)
Option A: • An intensive clinical smoking cessation program
for 100 smokers with a 100% quit rate.
• Expected outcome: 100 people stop smoking.
Option B • A mass media anti-smoking education campaign
targeting 10,000 people with a 2 percent quit
rate.
• Expected outcome: 200 people stop smoking.
Conclusion • The less effective option (2percent success) is
twice as cost-effective as the most effective
option (100 percent success)

31. Legislating
• Identify key program and policy options to address
problems. Use the evidence to identify the actions most
likely to succeed
• ‚Identify the locations that best fit the program by
considering the characteristics of communities where IR
indicates the programs and policies are successful.
• ‚Specify expected costs of a program or policy, as well as the
goals, expected benefits and potential savings.

32. Appropriating resources
• Assure best use of limited resources by funding the most
effective policies and programs
• ‚Provide necessary funding to achieve expected health
outcomes
• ‚Target and specify communities best suited for the program
for funding opportunities.

33. Oversight/ Supervision
• ‚Compare actual outcomes with expected outcomes, and
determine if programs are being implemented effectively
and efficiently.
• ‚Describe the community characteristics where the program
achieved desired results.
• ‚Clarify why desired health gains were, or were not,
achieved.

34. Evaluate Policy Alternatives
• ‚If specific outcome are known, cost comparison of alternative
programs that can be done to accomplish the outcome.
• If program you want to fund is known, comparison of
effectiveness at different funding levels can be done.
• If available funding is known, comparison of programs with
similar goals to determine which alternative will achieve the
best outcome for the available funds

35. Who can do IR for the Government
• ‚Universities
• State government policy centers
• ƒState departments of health, education and other
agencies
• ƒPublic and nonprofit policy centers
• ƒState and national associations

36. • IR results can be used to make informed policy decisions to
improve the effectiveness of public health programs.
• Knowing what IR shows about program effectiveness can help
in decisions on state funds utilisation.
• Public health policies and programs are increasing and IR
results on effectiveness translate the evidence into public
health policy recommendations.
• IR can do careful comparison of state’s population with
populations included in controlled group to determine
programs or policies that likely will work in state.
The way forward: suggestions

37. The way forward: suggestions
• IR assess the success of policies and programs by measuring
cost and effectiveness and gauging the strength of results that is
useful in recommending public health policies as cost-saving,
cost-effective, and/or ideas based on the evidence.
• IR results can be used to develop policy strategy, draft
legislation and monitor program progress. By working with an
advisory group that includes researchers and public health
experts, government will be able to consider the research
available throughout the process.

38. • Deciding to propose or support a legislative proposal,
government can weigh the strength of the IR results
supporting the proposal as well as the political and spending
priorities
• Funding IR as part of public health programs, government can
play a key role in establishing the evidence to improve
effectiveness of programs and to reap maximum benefits from
state public health efforts.
The way forward: suggestions

39. Discussion

40. • Fundamentals of Implementation Research:
USAID and Measure Evaluation
• Implementation research in TDR: conceprual and operationa
framework :
UNDP/World Bank/WHO: Special programme on Research and Training in
tropical diseases
• Using Research in Public Health Policymaking:
Council of State Governments‘ (CSG) Healthy States Initiative
References

41. Thanks & Be Happy….