Implementation research is important in global health to address the challenges of the know-do gap in real world settings, and the practicalities of achieving national and global health goals.Implementation research is an integrated concept linking research and practice to accelerate the development and delivery of public health approaches. It involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. It uses multiple disciplines and methods, and emphasises partnerships between community members, implementers, researchers and policy makers. Implementation research focuses on practical approaches to improve implementation; to enhance equity, efficiency, scale up and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research, and a range of perspectives on its purposes and appropriate methods.However, there have been limited efforts to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low and middleincome countries (LMICs). The case studies are organized in four categories related to the purposes for using implementation research: impacting people's health, informing policy design and implementation, improving health service delivery, and empowering communities and beneficiaries. Common characteristics of these case studies are the focus on addressing implementation problems, ensuring a partnership approach to the co-creation of solutions, including using tacit knowledge, and commitment of key stakeholders to a pathway towards impact. The case studies reveal the complex adaptive nature of health systems, emphasize the importance of understanding context, and highlight the role of multidisciplinary, rigorous and adaptive processes which allow for course correction to ensure interventions have an impact. This Implementation Research: New Imperatives and Opportunities in Global HealthPanel 1: Key messages 1. Implementation research offers a way to understand and address implementation challenges and make a positive impact on people's health by contributing to building stronger and more responsive health systems within the realities of specific contexts. 2. Implementation research can lead to positive health outcomes, inform policy design, improve health management and service delivery, and support and empower communities and beneficiaries. 3. Implementation research uses multidisciplinary approaches and a range of empirical and systematic methods to document, analyse and address key health problems and test technical health interventions as well as contextually tailored innovative strategies within the foundations of local context. 4. Implementation research can be used to evaluate the feasibility, adoption, and a...

Gender-the socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for males, females and other genders-affects how people live, work and relate to each other at all levels, including in relation to the health system. Health systems research (HSR) aims to inform more strategic, effective and equitable health systems interventions, programs and policies; and the inclusion of gender analysis into HSR is a core part of that endeavour. We outline what gender analysis is and how gender analysis can be incorporated into HSR content, process and outcomes Starting with HSR content, i.e. the substantive focus of HSR, we recommend exploring whether and how gender power relations affect females and males in health systems through the use of sex disaggregated data, gender frameworks and questions. Sex disaggregation flags female-male differences or similarities that warrant further analysis; and further analysis is guided by gender frameworks and questions to understand how gender power relations are constituted and negotiated in health systems. Critical aspects of understanding gender power relations include examining who has what (access to resources); who does what (the division of labour and everyday practices); how values are defined (social norms) and who decides (rules and decision-making). Secondly, we examine gender in HSR process by reflecting on how the research process itself is imbued with power relations. We focus on data collection and analysis by reviewing who participates as respondents; when data is collected and where; who is present; who collects data and who analyses data. Thirdly, we consider gender and HSR outcomes by considering who is empowered and disempowered as a result of HSR, including the extent to which HSR outcomes progressively transform gender power relations in health systems, or at least do not further exacerbate them.

BackgroundTB Control Programmes rely on passive case-finding to detect cases. TB notification remains low in Ethiopia despite major expansion of health services. Poor rural communities face many barriers to service access.Methods and FindingsA community-based intervention package was implemented in Sidama zone, Ethiopia. The package included advocacy, training, engaging stakeholders and communities and active case-finding by female Health Extension Workers (HEWs) at village level. HEWs conducted house-to-house visits, identified individuals with a cough for two or more weeks, with or without other symptoms, collected sputum, prepared smears and supervised treatment. Supervisors transported smears for microscopy, started treatment, screened contacts and initiated Isoniazid preventive therapy (IPT) for children. Outcomes were compared with the pre-implementation period and a control zone. Qualitative research was conducted to understand community and provider perceptions and experiences.HEWs screened 49,857 symptomatic individuals (60% women) from October 2010 to December 2011. 2,262 (4·5%) had smear-positive TB (53% women). Case notification increased from 64 to 127/100,000 population/year resulting in 5,090 PTB+ and 7,071 cases of all forms of TB. Of 8,005 contacts visited, 1,949 were symptomatic, 1,290 symptomatic were tested and 69 diagnosed with TB. 1,080 children received IPT. Treatment success for smear-positive TB increased from 77% to 93% and treatment default decreased from 11% to 3%. Service users and providers found the intervention package highly acceptable.ConclusionsCommunity-based interventions made TB diagnostic and treatment services more accessible to the poor, women, elderly and children, doubling the notification rate and improving treatment outcome. This approach could improve TB diagnosis and treatment in other high burden settings.

This paper highlights the major challenges and considerations for addressing COVID-19 in informal settlements. It discusses what is known about vulnerabilities and how to support local protective action. There is heightened concern about informal urban settlements because of the combination of population density and inadequate access to water and sanitation, which makes standard advice about social distancing and washing hands implausible. There are further challenges to do with the lack of reliable data and the social, political and economic contexts in each setting that will influence vulnerability and possibilities for action. The potential health impacts of COVID-19 are immense in informal settlements, but if control measures are poorly executed these could also have severe negative impacts. Public health interventions must be balanced with social and economic interventions, especially in relation to the informal economy upon which many poor urban residents depend. Local residents, leaders and community-based groups must be engaged and resourced to develop locally appropriate control strategies, in partnership with local governments and authorities. Historically, informal settlements and their residents have been stigmatized, blamed, and subjected to rules and regulations that are unaffordable or unfeasible to adhere to. Responses to COVID-19 should not repeat these mistakes. Priorities for enabling effective control measures include: collaborating with local residents who have unsurpassed knowledge of relevant spatial and social infrastructures, strengthening coordination with local governments, and investing in improved data for monitoring the response in informal settlements.

BackgroundCommunity health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs.MethodsWe searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized.ResultsFew studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes.ConclusionsResearch on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-015-0001-3) contains supplementary material, which is available to authorized users.

No abstract

BackgroundGlobally, there is increasing interest in community health worker’s (CHW) performance; however, there are gaps in the evidence with respect to CHWs’ role in community participation and empowerment. Accredited Social Health Activists (ASHAs), whose roles include social activism, are the key cadre in India’s CHW programme which is designed to improve maternal and child health. In a diverse country like India, there is a need to understand how the ASHA programme operates in different underserved Indian contexts, such as rural Manipur.MethodsWe undertook qualitative research to explore stakeholders’ perceptions and experiences of the ASHA scheme in strengthening maternal health and uncover the opportunities and challenges ASHAs face in realising their multiple roles in rural Manipur, India. Data was collected through in-depth interviews (n = 18) and focus group discussions (n = 3 FGDs, 18 participants). Participants included ASHAs, key stakeholders and community members. They were purposively sampled based on remoteness of villages and primary health centres to capture diverse and relevant constituencies, as we believed experiences of ASHAs can be shaped by remoteness. Data were analysed using the thematic framework approach.ResultsFindings suggested that ASHAs are mostly understood as link workers. ASHA’s ability to address the immediate needs of rural and marginalised communities meant that they were valued as service providers. The programme is perceived to be beneficial as it improves awareness and behaviour change towards maternal care. However, there are a number of challenges; the selection of ASHAs is influenced by power structures and poor community sensitisation of the ASHA programme presents a major risk to success and sustainability. The primary health centres which ASHAs link to are ill-equipped. Thus, ASHAs experience adverse consequences in their ability to inspire trust and credibility in the community. Small and irregular monetary incentives demotivate ASHAs. Finally, ASHAs had limited knowledge about their role as an ‘activist’ and how to realise this.ConclusionsASHAs are valued for their contribution towards maternal health education and for their ability to provide basic biomedical care, but their role as social activists is much less visible as envisioned in the ASHA operational guideline. Access by ASHAs to fair monetary incentives commensurate with effort coupled with the poor functionality of the health system are critical elements limiting the role of ASHAs both within the health system and within communities in rural Manipur.

Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs' relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs' relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling CHWs to perform well and responding to the opportunities offered by their unique intermediary position.