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Implementation Science at UW

Keywords: Zambia

✪ Strengthening primary care facility management: a systematic review of management interventions, implementation strategies, and outcomes in six sub-Saharan African countries

Authors:

Ermyas Birru, Sandra Urusaro, Aneth Dinis, Stélio Tembe, Teresa Jewell, Steve Gloyd, Kenneth Sherr, & Lisa R. Hirschhorn

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: July 2026

Read the full text in the open access journal BMC Primary Care

Abstract:

Background

Although primary health care (PHC) is central to health system performance, effective facility-level management is a critical determinant of service quality, resource use, and improved health outcomes. We conducted a systematic review to synthesize evidence on interventions, implementation strategies, and outcomes aimed at strengthening PHC facility management in Sub-Saharan Africa (SSA).

Methods

We conducted a systematic review using thematic synthesis. Eight electronic databases were searched for peer-reviewed studies and grey literature published between 2012 and 2022, focusing on interventions targeting PHC facility management in SSA. Implementation strategies were mapped to the thematic cluster areas of the Expert Recommendations for Implementing Change (ERIC) framework. Implementation outcomes were classified using Proctor’s Implementation Outcome Framework, and management effectiveness domains were identified through thematic analysis.

Results

Of 3,752 studies screened, nine met the inclusion criteria. These studies represented six SSA countries: Botswana, Ethiopia, Kenya, South Africa, Tanzania, and Zambia. Four categories of intervention were identified: (1) training and capacity building programs, (2) peer-to-peer learning, (3) audit and feedback-based quality management systems, and (4) supportive supervision. These interventions were delivered through multiple implementation strategies, including training and education, coaching and mentoring, learning collaboratives, interactive continuous learning, and routine data monitoring. Acceptability was the most consistently reported implementation outcome. Improvements in management effectiveness were identified across four domains: financial management, organizational climate and culture, resource management and utilization, and human resource management. Five studies also reported intermediate service-level outcomes including improvements in maternal and child health indicators.

Conclusion

Interventions aimed at strengthening PHC facility management in SSA primarily emphasize skill development, collaboration, and ongoing managerial support, typically delivered through multiple strategies. However, few studies have evaluated these interventions using rigorous experimental or pragmatic study designs. More robust implementation research is needed to identify effective strategies for strengthening PHC facility management and supporting the consistent implementation of national PHC guidelines.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

Authors:

John A.Naslund, Jasmine Kalha, Juliana L. Restivo, Ishmael Amarreh, Tamora Callands, Hongtu Chen, Carlos Gomez-Restrepo, Hesham M. Hamoda, Arjun Kapoor, Sue Levkoff, Jones Masiye, Maria A. Oquendo, Vikram Patel, Inge Petersen, Ozge Sensoy Bahar, Laura Shields-Zeeman, Fred M. Ssewamala, Deepak Tugnawat, José Miguel Uribe-Restrepo, Lakshmi Vijayakumar, Bradley H. Wagenaar, Milton L.Wainberg, Larry Wissow, Haja Ramatulai Wurie, Chifundo Zimba, & Soumitra Pathare

University of Washington affiliated authors are displayed in bold.

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Published: January 2021

Read the full text in the subscription access journal Asian Journal of Psychiatry

✪ How to evaluate the implementation of complex health programmes in low-income settings: the approach of the Gavi Full Country Evaluations

Authors:

Caroline Soi, Jessica C Shearer, Ashwin Budden, Emily Carnahan, Nicole Salisbury, Gilbert Asiimwe, Baltazar Chilundo, Haribondhu Sarma, Sarah Gimbel, Moses Simuyemba, Jasim Uddin, Felix Masiye, Moses Kamya, Dai Hozumi, Julie K Rajaratnam, and Stephen S Lim

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: November 2020

Read the full text in the open access journal Health Policy and Planning

Abstract:

Vaccination, like most other public health services, relies on a complex package of intervention components, functioning systems and committed actors to achieve universal coverage. Despite significant investment in immunization programmes, national coverage trends have slowed and equity gaps have grown. This paper describes the design and implementation of the Gavi Full Country Evaluations, a multi-country, prospective, mixed-methods approach whose goal was to monitor and evaluate processes, inputs, outputs and outcomes of immunization programmes in Bangladesh, Mozambique, Uganda and Zambia.

We implemented the Full Country Evaluations from 2013 to 2018 with the goal of identifying the drivers of immunization programme improvement to support programme implementation and increase equitable immunization coverage. The framework supported methodological and paradigmatic flexibility to respond to a broad range of evaluation and implementation research questions at global, national and cross-country levels, but was primarily underpinned by a focus on evaluating processes and identifying the root causes of implementation breakdowns. Process evaluation was driven by theories of change for each Gavi funding stream (e.g. Health Systems Strengthening) or activity, ranging from global policy development to district-level programme implementation.

Mixing of methods increased in relevance and rigour over time as we learned to build multiple methods into increasingly tailored evaluation questions. Evaluation teams in country-based research institutes increasingly strengthened their level of embeddedness with immunization programmes as the emphasis shifted over time to focus more heavily on the use of findings for programme learning and adaptation. Based on our experiences implementing this approach, we recommend it for the evaluation of other complex interventions, health programmes or development assistance.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ A targeted systematic review of cost analyses for implementation of simulation-based education in healthcare

Authors:

Daniel S Hippe, Rachel A Umoren, Alex McGee, Sherri L Bucher, Brian W Bresnahan

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2020

Read the full text in the open access journal SAGE Open Medicine

Abstract:

Over the past two decades, there has been an increase in the use of simulation-based education for training healthcare providers in technical and non-technical skills. Simulation education and research programs have mostly focused on the impact on clinical knowledge and improvement of technical skills rather than on cost. To study and characterize existing evidence to inform multi-stakeholder investment decisions, we performed a systematic review of the literature on costs in simulation-based education in medicine in general and in neonatal resuscitation as a particular focus.

We conducted a systematic literature search of the PubMed database using two targeted queries. The first searched for cost analyses of healthcare simulation-based education more broadly, and the second was more narrowly focused on cost analyses of neonatal resuscitation training. The more general query identified 47 qualified articles. The most common specialties for education interventions were surgery (51%); obstetrics, gynecology, or pediatrics (11%); medicine, nursing, or medical school (11%); and urology (9%), accounting for over 80% of articles. The neonatal resuscitation query identified five qualified articles. The two queries identified seven large-scale training implementation studies, one in the United States and six in low-income countries. There were two articles each from Tanzania and India and one article each from Zambia and Ghana. Methods, definitions, and reported estimates varied across articles, implying interpretation, comparison, and generalization of program effects are challenging.

More work is needed to understand the costs, processes, and outcomes likely to make simulation-based education programs cost-effective and scalable. To optimize return on investments in training, assessing resource requirements, associated costs, and subsequent outcomes can inform stakeholders about the potential sustainability of SBE programs. Healthcare stakeholders and decision makers will benefit from more transparent, consistent, rigorous, and explicit assessments of simulation-based education program development and implementation costs in low- and high-income countries.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Implementation science and stigma reduction interventions in low- and middle-income countries: A systematic review

Authors:

Christopher G. Kemp, Brooke A. Jarrett, Churl-Su Kwon, Lanxin Song, Nathalie Jetté, Jaime C. Sapag, Judith Bass, Laura Murray, Deepa Rao & Stefan Baral

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: February 2019

Read the full text in the open access journal BMC Medicine

Abstract:

Background

Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions.

Methods

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR).

Results

A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven.

Conclusion

Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

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✪ Mentorship and coaching to support strengthening healthcare systems: lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa

Authors:

Anatole Manzi, Lisa R. Hirschhorn, Kenneth Sherr, Cindy Chirwa, Colin Baynes, John Koku Awoonor-Williams and the AHI PHIT Partnership Collaborative

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2017

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Despite global efforts to increase health workforce capacity through training and guidelines, challenges remain in bridging the gap between knowledge and quality clinical practice and addressing health system deficiencies preventing health workers from providing high quality care. In many developing countries, supervision activities focus on data collection, auditing and report completion rather than catalyzing learning and supporting system quality improvement. To address this gap, mentorship and coaching interventions were implemented in projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) as components of health systems strengthening (HSS) strategies funded through the Doris Duke Charitable Foundation’s African Health Initiative. We report on lessons learned from a cross-country evaluation.

Methods

The evaluation was designed based on a conceptual model derived from the project-specific interventions. Semi-structured interviews were administered to key informants to capture data in six categories: 1) mentorship and coaching goals, 2) selection and training of mentors and coaches, 3) integration with the existing systems, 4) monitoring and evaluation, 5) reported outcomes, and 6) challenges and successes. A review of project-published articles and technical reports from the individual projects supplemented interview information.

Results

Although there was heterogeneity in the approaches to mentorship and coaching and targeted areas of the country projects, all led to improvements in core health system areas, including quality of clinical care, data-driven decision making, leadership and accountability, and staff satisfaction. Adaptation of approaches to reflect local context encouraged their adoption and improved their effectiveness and sustainability.

Conclusion

We found that incorporating mentorship and coaching activities into HSS strategies was associated with improvements in quality of care and health systems, and mentorship and coaching represents an important component of HSS activities designed to improve not just coverage, but even further effective coverage, in achieving Universal Health Care.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Data-driven quality improvement in low-and middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia

Authors:

Bradley H. Wagenaar, Lisa R. Hirschhorn, Catherine Henley, Artur Gremu, Ntazana Sindano, Roma Chilengi and the AHI PHIT Partnership Collaborative

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2017

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Well-functioning health systems need to utilize data at all levels, from the provider, to local and national-level decision makers, in order to make evidence-based and needed adjustments to improve the quality of care provided. Over the last 7 years, the Doris Duke Charitable Foundation’s African Health Initiative funded health systems strengthening projects at the facility, district, and/or provincial level to improve population health. Increasing data-driven decision making was a common strategy in Mozambique, Rwanda and Zambia. This paper describes the similar and divergent approaches to increase data-driven quality of care improvements (QI) and implementation challenge and opportunities encountered in these three countries.

Methods

Eight semi-structured in-depth interviews (IDIs) were administered to program staff working in each country. IDIs for this paper included principal investigators of each project, key program implementers (medically-trained support staff, data managers and statisticians, and country directors), as well as Ministry of Health counterparts. IDI data were collected through field notes; interviews were not audio recorded. Data were analyzed using thematic analysis but no systematic coding was conducted. IDIs were supplemented through donor report abstractions, a structured questionnaire, one-on-one phone calls, and email exchanges with country program leaders to clarify and expand on key themes emerging from IDIs.

Results

Project successes ranged from over 450 collaborative action-plans developed, implemented, and evaluated in Mozambique, to an increase from <10% to >80% of basic clinical protocols followed in intervention facilities in rural Zambia, and a shift from a lack of awareness of health data among health system staff to collaborative ownership of data and using data to drive change in Rwanda.

Conclusion

Based on common successes across the country experiences, we recommend future data-driven QI interventions begin with data quality assessments to promote that rapid health system improvement is possible, ensure confidence in available data, serve as the first step in data-driven targeted improvements, and improve staff data analysis and visualization skills. Explicit Ministry of Health collaborative engagement can ensure performance review is collaborative and internally-driven rather than viewed as an external “audit.”

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries

Authors:

Felix Cyamatare Rwabukwisi, Ayaga A. Bawah, Sarah Gimbel, James F. Phillips, Wilbroad Mutale, Peter Drobac and the AHI PHIT Partnership Collaborative

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2017

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Achieving the United Nations Sustainable Development Goals in sub-Saharan Africa will require substantial improvements in the coverage and performance of primary health care delivery systems. Projects supported by the Doris Duke Charitable Foundation’s (DDCF) African Health Initiative (AHI) created public-private-academic and community partnerships in five African countries to implement and evaluate district-level health system strengthening interventions. In this study, we captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions.

Methods

We used qualitative data from key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through AHI in Ghana, Mozambique, Rwanda, Tanzania, and Zambia.

Results

Four major overarching lessons were highlighted. First, variety and inclusiveness of concerned key players (public, academic and private) are necessary to address complex health system issues at all levels. Second, a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Third, inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Fourth, five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects.

Conclusion

The AHI experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

Measuring health systems strength and its impact: experiences from the African Health Initiative

Authors:

Kenneth Sherr, Quinhas Fernandes, Almamy M. Kanté, Ayaga Bawah, Jeanine Condo, Wilbroad Mutale and the AHI PHIT Partnership Collaborative

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2017

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Health systems are essential platforms for accessible, quality health services, and population health improvements. Global health initiatives have dramatically increased health resources; however, funding to strengthen health systems has not increased commensurately, partially due to concerns about health system complexity and evidence gaps demonstrating health outcome improvements. In 2009, the African Health Initiative of the Doris Duke Charitable Foundation began supporting Population Health Implementation and Training Partnership projects in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze significant advances in strengthening health systems. This manuscript reflects on the experience of establishing an evaluation framework to measure health systems strength, and associate measures with health outcomes, as part of this Initiative.

Methods

Using the World Health Organization’s health systems building block framework, the Partnerships present novel approaches to measure health systems building blocks and summarize data across and within building blocks to facilitate analytic procedures. Three Partnerships developed summary measures spanning the building blocks using principal component analysis (Ghana and Tanzania) or the balanced scorecard (Zambia). Other Partnerships developed summary measures to simplify multiple indicators within individual building blocks, including health information systems (Mozambique), and service delivery (Rwanda). At the end of the project intervention period, one to two key informants from each Partnership’s leadership team were asked to list – in rank order – the importance of the six building blocks in relation to their intervention.

Results

Though there were differences across Partnerships, service delivery and information systems were reported to be the most common focus of interventions, followed by health workforce and leadership and governance. Medical products, vaccines and technologies, and health financing, were the building blocks reported to be of lower focus.

Conclusion

The African Health Initiative experience furthers the science of evaluation for health systems strengthening, highlighting areas for further methodological development – including the development of valid, feasible measures sensitive to interventions in multiple contexts (particularly in leadership and governance) and describing interactions across building blocks; in developing summary statistics to facilitate testing intervention effects on health systems and associations with health status; and designing appropriate analytic models for complex, multi-level open health systems.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**