Expert Speak Health Express
Published on Dec 06, 2019
Addressing barriers to achieving Universal Health Coverage through implementation research: Uncovering and understanding context

On September 23, 2019, the United Nationals General Assembly released a declaration renewing the movement towards Universal Health Coverage (UHC) through financial risk protection, access to quality essential healthcare services and safe, effective, and affordable medicines and vaccines for all. 1 Achieving these goals and reaching UHC requires building strong and sustainable health systems that provide quality care for all, leaving no one out.

This declaration brought attention to the barriers limiting progress towards building the strong health systems needed for UHC. These include but are not limited to poor infrastructure, high out-of-pocket payments and catastrophic health expenditures, shortages and inequitable distribution of qualified healthcare workers, poor quality of care delivery, high cost of quality medicines, and lack of innovative technologies appropriate to the range of settings where care is delivered.1 These barriers are significant and overcoming them is a long terms process. However, with the right approaches, there are many improvements that can be made in order to achieve the goal of Universal Health Coverage.

The utilization of implementation research, a discipline which studies how to choose, and support implementation strategies needed to get evidence-based interventions (EBIs) into practice, is one such approach. Implementation research provides methods and tools to plan, adapt, evaluate, and spread implementation of healthcare interventions, producing the knowledge needed to help make significant improvements in the health of vulnerable populations.2  It also informs researchers and healthcare policy makers to determine what makes EBIs successful or unsuccessful when tested in real world settings, how to scale up EBIs in an existing context, what are important outcomes in addition to effectiveness (including fidelity, feasibility, acceptability and coverage of targeted populations), and where and how to adapt an EBI to other countries and contexts.3,4  The new knowledge that implementation research generates allows policy makers, clinicians, program managers, and practitioners from the public, the private, and the non-profit sectors to be better equipped to bridge knowledge gaps between international and regional health services and programmes. 3

A crucial step in implementation research is identifying the contextual factors that serve as facilitators and barriers to improving the implementation of health interventions and their outcomes at the global, national, ministry and individual/community levels. In the case of implementation barriers, these factors can be addressed directly to reduce their impact, by strengthening a health system, or through implementation strategies chosen and adapted to the context, such as task shifting in the setting of limited human resources.

Looking at the different levels:

At the global level, international policies and recommendations as well as donor funding priorities can either support or divert a country’s focus on its own health priorities and strategies. If not aligned, there is a risk of  implementing health interventions or strategies prioritized by the funding sources.

At the national level, strong leadership, economic growth, decentralization of decision making, national healthcare budget, policies and strategies which include an equity lens, as well as championing female empowerment and human rights can facilitate, or in the absence of, be a barrier to effective and equitable implementation of healthcare interventions.

At the ministry level, strong leadership throughout the levels of the health sector in the creation of policies and guidelines, the culture and practice of stakeholder engagement, coordination of partners, multisectoral collaboration and the overall strength of the health system can also be facilitating or limiting factors. Specifically, the presence or absence of integrated primary healthcare services with a patient centered approach, supported by effective supply chain and infrastructure, a focus on community healthcare intervention acceptance, and task shifting in the health system can have major impacts on the ability to implement EBIs effectively.

Finally, at the community and individual level, socioeconomic status, maternal empowerment and education, cultural and religious beliefs and trust in the health system are all factors that can facilitate or hinder implementation. Addressing these factors directly through appropriate implementation strategies can help ensure that effective care reaches all and achieve the health outcomes envisioned by UHC.

In addition to identifying these factors, using this knowledge to develop implementation strategies to leverage the factors facilitating successful EBI implementation and address contextual barriers directly and effectively is critical. For example, in Rwanda, contextual factors at all levels contributed to successful implementation of family planning programs which resulted in the total fertility rate decreasing from 6.2 in 2000 to 4.2 in 2015.5,6

At the global level, prioritization of family planning with the Millennium Development Goals (MDGs) resulted in more international donor funding being directed towards family planning programs. In turn, this  along with population growth led Rwanda to priorities work and use donor funding in this area.

Family planning success also relied on factors at the national level that helped prioritize family planning initiatives in Rwanda. Important factors included high level government support for family planning and other policies to empower and educate women, an equity lens in policy making, and dedication to responding to barriers identified in implementation, including reaching women in inaccessible areas.7

At the ministry level, strong leadership and vision  and a culture of multisectoral collaboration, as well as an understanding of national and community contexts facilitated the success of key implementation strategies . The Ministry of Health was successful in  creating and implementing family planning policies that facilitated the procurement and availability of contraceptive tools at all health facilities, as well as task shifting from doctors to nurses and community health workers for distribution and outreach programs for promotion of family planning.

At the community and individual level, Rwanda identified barriers including cultural  and religious beliefs, such as those associated with having a large family and not using contraceptive measures.   Identifying and addressing these barriers through strategies including leveraging the trusted CHW program and engaging the community and local leaders contributed to increased acceptability and uptake of family planning services.

Integrating these core principles of implementation research is important in identifying and addressing key barriers to UHC locally, nationally, and globally. It allows for a better understanding and identification of barriers and facilitators at the different levels, which can be addressed and drive strategies to guide development and implementation as well as the spread of solutions to succeed in improving health outcomes for all. It equips the relevant stakeholders with a better understanding of global exemplars of successful implementations of EBI’s such as such as thRwanda national family planning program, and to then adapt and utilize transferrable lessons within regional or national contexts.  Used well, implementation research is a crucial tool to make  rapid and sustainable improvements in health outcomes while building health systems that are designed to last, reach the most vulnerable, and ultimately achieve UHC.

Works Cited 

    1. United Nations General Assembly. Moving Together to Build a Healthier World. Published September 23, 2019.

    1. Alonge O, Rodriguez DC, Brandes N, Geng E, Reveiz L, Peters DH. How is implementation research applied to advance health in low-income and middle-income countries? BMJ Glob Health. 2019;4(2):e001257. doi:10.1136/bmjgh-2018-001257

    1. Chambers D. Dissemination and Implementation Research in Health (R01). November 2006.

    1. Proctor E, Silmere H, Raghavan R, et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health Ment Health Serv Res. 2011;38(2):65-76. doi:10.1007/s10488-010-0319-7

    1. National Institute of Statistics of Rwanda (NISR), Ministry of Health (MOH), ICF International. Rwanda Demographic and Health Survey 2014-15. Rockville, Maryland, USA; 2015.

    1. National Institute of Statistics of Rwanda (NISR), Ministry of Health of Rwanda (MOH), ICF International. Rwawnda Demographic and Health Survey 2000. Rockville, Maryland, USA; 2000.

    1. Solo J. Family Planning in Rwanda: How a Taboo Topic Became Priority Number One. Intra Health International; 2008.

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