What is implementation science, and what can it do for the field of global health?
Earlier this month, FHI 360 brought together over 150 public health specialists, researchers, scholars and donors in Washington, DC, for a day-long symposium to wrestle with these questions.
One clear conclusion emerged: There is no single definition for implementation science. Symposium speakers used definitions including: the scientific study of methods to promote the integration of research findings and evidence-based interventions into health care practice and policy (U.S. National Institutes of Health); the application of systematic learning, research and evaluation to improve health practice, policy and programs (U.S. Agency for International Development); and the study of methods to improve the uptake, implementation and translation of research findings into routine practices (U.S. President’s Emergency Plan for AIDS Relief).
Despite the lack of consensus on definitions, symposium participants agreed that implementation science can make essential contributions to global health. Setting implementation science apart from other research disciplines is its focus on how to implement proven interventions in real-world contexts, delivered at scale. Noting that implementation occurs within complex systems, Greg Aarons of the University of California, San Diego, introduced participants to frameworks that help us consider the interaction of factors that affect the success of the implementation process. (View the symposium’s presentations and webcast.)
Pierre Barker of the Institute for Healthcare Improvement explained that implementation science begins where efficacy trials leave off. Typically, health service innovations are initially tested under carefully managed conditions, using designs like a randomized controlled trial. Once research has generated evidence of an intervention’s potential impact, the effectiveness under typical circumstances is evaluated. Implementation science serves that purpose, embracing the messy complexity of the real world, often in the context of a fragile health system. Laura Guay of the Elizabeth Glaser Pediatric AIDS Foundation showed how weak data management systems limit our capacity to evaluate health service effectiveness. Kate Ramsey of Columbia University discussed how culture clashes between researchers who devise innovations and providers who work at the frontline of health care delivery lead to interventions that produce unintended consequences. Implementation science confronts complexities like these, supporting the global health field in developing evidence-based implementation strategies for proven public health practices.
What, then, do we do with the evidence that is generated from implementation research? Theoretically, such evidence will fuel more widespread implementation of interventions that work. Bryan Weiner of the University of North Carolina argued that implementation science studies should tell us how to succeed in replicating an intervention in another setting by revealing the drivers and barriers to effective implementation. Symposium participants were excited to learn that peer-reviewed publications of implementation science studies tend to offer more detail about the intervention and the context in which it was implemented than do traditional research papers, which often contain minimal information on these two elements, thus limiting the potential for replication.
However, even when armed with “how to” evidence, the scale-up of a proven intervention will not necessarily happen spontaneously. Evidence does not put itself into widespread practice; it often requires advocacy, stakeholder engagement, technical assistance and other deliberate efforts to promote evidence use.
Kirsty Newman of the United Kingdom’s Department for International Development discussed how implementation research has the potential to improve the supply of evidence, thereby leading to more evidence-informed policy and practice. But, she also said that efforts to improve the supply of evidence need to be balanced with those to build the capacity of policymakers and practitioners to systematically access, appraise and use evidence in decision making. Such demand-side efforts will enable policymakers and practitioners to determine if the scale-up of a particular intervention is an appropriate investment in their context and will foster more long-term use of evidence in policy and practice. (To learn more, read Kirsty’s blog on the symposium.)
Still an emerging field, implementation science’s greatest body of experience has occurred in sophisticated health systems. It is time to bring implementation science to the rest of the world. Core implementation science concepts — like coping with real-world contexts, delivering interventions at scale and achieving maximum population-level health outcomes from the investment of limited resources — are at the heart of global health practice. Expanded application of implementation science to global health, therefore, holds great promise for advancing this research discipline. In turn, implementation science offers the global health field a new set of evaluation approaches and tools that can close the gap between what we know works and what we actually do.