Need for more and better implementation science in global health

Correspondence to Professor Valéry Ridde; [email protected] ‘We know what we have to do, but we don’t know how to do it’ has been a recurring comment among global health actors for a long time. In 2010, for example, the United Nations affirmed that ‘we know what works’ in taking care of the health of women and children. The WHO Commission on the Social Determinants of Health (2008) has highlighted effective interventions to improve the health of populations and to establish health equity. However, while the content of interventions, which are theoretically effective, are relatively well known, their level of coverage is weak. Furthermore, the conditions of their implementation are less understood. An old meta-analysis shows that the potential effectiveness of interventions is reduced by 50% because of multiple contextual factors which act against the implementation. Therefore, it is not enough to know if a health intervention is effective; it is also necessary to understand why the intervention works, how, for whom and in which contexts. It is here where implementation science is an undeniable aid. In this editorial, the focus will not be on the controversies concerning the definition of implementation science or the academic arguments made in order to appropriate or better sell the training of implementation science. Essentially, what is of interest is to call on the community of students, researchers, implementers and donors to commit themselves to further and a better quality research in order to have a greater understanding of how to implement health interventions. To quote Joseph Durlak, an important author in this field, ‘studying programme implementation is not easy but it is essential’. Implementation is comprised of one or several processes organised in a particular context so as to bring about the desired changes of an intervention (whether policy, programme or project) through the means necessary to deploy it. Implementation science is about mobilising theories, concepts and methods to better ‘understand what, why, and how interventions work in ‘real world’ settings’. There is a movement away from implementation research, which is centred on analysing the way interventions consider evidence, a field that is close to knowledge transfer, which is also not fully developed in low and middle income countries (LMICs). However, we do agree with the fact that ‘research in both fields deals with the challenges of translating intentions into desired changes’. A meeting of major journal editors has been organized by the Canadian Institutes of Health Research Institute of Population and Public Health and the Canadian Journal of Public Health in April 2016 (http://sparkingsolutions.ca). They will soon launch the Ottawa Statement to promote publications in the field of population health intervention research. BMJ Global Health wishes to participate in the development of implementation science but with a focus on equity and on a better adaptation and/or creation of theoretical, conceptual and methodological approaches in the context of LMICs. In fact, a review of writings (1933–2003) concerning research on the implementation of public policies shows that only 4% concerned Africa, 2% Latin America and 15% was on health. The author of this review clearly highlighted ‘the ethnocentric bias in implementation studies’. This observation was confirmed in another analysis (1986–2006) of research in public policies in the field of health promotion: ‘all the most authoritative conceptualizations mentioned here were modelled on Western-style democratic governance systems’. Two rapid bibliographic searches using Pubmed database show an important increase of papers about global health and implementation since 1970, but implementation still concern just around 5% (figure 1). Therefore, there is an urgency to act, since both analyses confirm that we are far from having a body of theories, frameworks and approaches which is sufficient for the in-depth study of the implementation of interventions; 11 12 interventions which still need to be largely ‘tested and operationalised in real-world settings’.