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      Bridging the ‘two communities’: how an emerging primary healthcare global research consortium can help achieve universal health coverage in low and middle-income countries

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          Abstract

          Summary box The quantity of knowledge produced by the research community in Low and Middle-Income Countries (LMICs) has increased substantially in recent years. Knowledge producers may consider their research relevant for the policy and practice community but knowledge consumers often question the utility of this research in real-world policymaking. Bridging the gap between these ‘two communities’ is critical to attaining universal health coverage and sustainable development goals through high performing primary healthcare (PHC) systems. An emerging PHC global research consortium can help bridge this gap and produce acceptable contextual evidence for PHC performance improvements in LMICs. We had done so much work, earned recognition, but solved nobody’s problem.            (Dr Abhay Bang)1 Introduction World leaders reconvened at the 40th anniversary of the 1978 Alma Ata declaration to renew their commitment to primary healthcare (PHC) as the key to attaining Health for All, the goals of universal health coverage (UHC) and the sustainable development goals (SDGs).2 Among affirmations made was the commitment to apply knowledge in order to support multisectoral stakeholder collaborations to strengthen PHC systems. The Declaration of Astana recognised that effective knowledge generation and translation strategies focused on PHC are critical to attaining these global goals. This recognition echoes a global call for evidence-informed healthcare policy and decision-making for over two decades.3 However, one challenge is Nathan Caplan’s theorised ‘two communities’: the research community (knowledge producers) and the policy/practice community (knowledge consumers), each with intrinsically different perspectives and priorities.4 The association between evidence and policy is not always rational or sequential, given that researchers may not produce the evidence and knowledge needed, policymakers may not always choose to take evidence-informed actions, or may choose to use evidence in ways unacceptable to researchers such as to support predetermined positions or decisions.5 The recent World Report on Health Policy and Systems Research also noted that the evidence-policy-implementation continuum is quite fragmented as practitioners operate across various paradigms, organisational structures and tiers, and the evidence produced is not always aligned with priority knowledge gaps.6 This gap hampers the ability of new evidence to be used to address the persisting poor performance of health systems and to achieve the promise of UHC and the SDGs.7 Consequently, improving the relationship between the two communities is critical to encouraging the production of knowledge that is needed and utilisation of this newly produced evidence in policy planning and implementation.5 8 Recently, there have been global efforts to bridge the research-policy-implementation gap but significant work is still needed in how research is prioritised, produced and used.9 The quantity of knowledge produced by the research community in LMICs has increased substantially in recent years, which in theory should accelerate uptake given local production.10 However, while these knowledge producers may consider their research relevant for the policy and practice community, policymakers and implementers often still question the utility of this research in real-world policymaking and not reflecting the need for local contextualisation.6 Therefore, in order to achieve the Astana declaration goals and broader SDG and UHC, it is crucial for the global health community to strengthen existing and develop new models to ensure that the knowledge produced reflects the needs of policymakers and implementers and is translated effectively into action. One approach is improving the partnership and dialogue between PHC researchers, policymakers, providers and other interest groups to produce and apply the new knowledge needed. Another important action is to develop new pathways and communities of researchers needed to prioritise and produce the knowledge needed.11 Bridging the gap: the value of a new global PHC consortium Given the importance of PHC in the attainment of UHC and the SDGs, one of these recent efforts in LMICs has been the work to develop a new global research consortium with the goal of producing prioritised evidence that is relevant to policymakers and implementers seeking to improve PHC systems and delivery. The idea for this proposed PHC measurement and implementation consortium emerged from work by the Primary Healthcare Performance Initiative (PHCPI, www.improvingPHC.org) which recognised the knowledge gaps in how to measure and improve key functions of PHC in LMICs. The consortium is designed to be an interdisciplinary global research network prioritising LMIC leadership and including researchers and policymakers from academic institutions, government agencies, international organisations and non-governmental organisations. The diverse nature of a consortium based in LMICs partnering with researchers across high-income, middle-income and low-income countries, creates an opportunity to close this research-policy-implementation gap in PHC. Further, it creates a platform for harnessing the resources needed to generate and translate country-prioritised, policy-relevant evidence to support better measurement, implementation and improvement efforts for PHC in LMICs. The consortium also has the potential to build needed capacity in LMICs to increase leadership and capacity for future work. Building on the PHCPI framework and a scoping review of existing PHC research,12 the effort identified four priority research areas where there were gaps in measurement and improvement knowledge. Quality, safety and performance Management; PHC policies and governance; organisation and models of care; PHC financing. Work was funded to complete evidence gap maps and a multi country prioritisation process described in the introduction to this supplement. This supplement is a compendium of outcomes of these foundational processes. It presents findings on knowledge gaps relating to PHC from diverse LMIC contexts such as sub-Saharan Africa and the Asia-Pacific regions and Central and Latin America. The findings presented and the questions raised in the articles are important to catalyse a contextual agenda for the consortium as well as inform broader research efforts targeting PHC improvement. For example, a systematic scoping review by Bresick and colleagues revealed a paucity of validated measures and fit-for-purpose instruments, as well as poor suitability of identified evidence base to inform the design of performance measurements and management policies and programme in LMICs (Bresick et al, 2019). Another study conducted by Angell et al seeking to generate a stakeholder-led research agenda in the area of PHC financing revealed a disparity between research questions prioritised by stakeholders and existing questions addressed by current research (Angell et al, 2019). The findings from the articles included in this supplement reinforce the necessity for consortium that can drive evidence-informed decision making and PHC performance improvements through a better and more inclusive approach to determining what research is needed as well as how it should be done. Also importantly, the series of studies set a foundational agenda for the consortium to focus on context-specific evidence related to the most effective approaches for improving PHC performance in LMICs. The issues raised in this supplement reflect my thoughts and experiences as an actor in both the knowledge producing and the knowledge consuming communities. Working in Nigeria’s PHC policy space, I have been concerned that policy decisions are often made without utilisation of contextual evidence. On the other hand, being affiliated with research institutions across the sub-Saharan Africa, I also find that knowledge being produced is often skewed to address areas of interest to funders and researchers rather than the priority knowledge needs of the research consumers. It is therefore important that stakeholders across the knowledge production to consumption spectrum interact effectively to harmonise and contextualise priority areas so as to streamline funding accordingly. For the consortium to be effective, focus must also be given to improving capacity within and across countries given the diversity in resources and research experience; ensuring an appropriate interdisciplinary/functional mix (such as academia, service providers, policymakers and implementers); as well as to the importance of an LMIC driven prioritisation and production. If successful, this research consortium can produce the knowledge and insights needed by policymakers and implementers to know how to better identify and address the quality gaps in PHC and accelerate the work needed to ensure that UHC has the quality, effectiveness, equity and sustainability needed. Conclusion The emerging research consortium seeks to answer key questions on how to understand and overcome both cross-cutting and context specific bottlenecks to PHC. While serving as a knowledge translation platform, it should also address the capacity to implement evidence-informed strategies, which is noted to be a deficiency in many PHC delivery systems.7 13–15 Thus, a system is desired that not only translates the ‘science-derived knowledge’ from researchers to evidence users, but also converts this to the ‘practical art of implementation’ required to make the impact. In this way, actual problems will be solved following the interlocking activities of knowledge producers and knowledge users: the two becoming one community.

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          Most cited references 12

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          The Two-Communities Theory and Knowledge Utilization

           N. Caplan (1979)
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            Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries

            Primary health care (PHC) has been recognized as a core component of effective health systems since the early part of the twentieth century. However, despite notable progress, there remains a large gap between what individuals and communities need, and the quality and effectiveness of care delivered. The Primary Health Care Performance Initiative (PHCPI) was established by an international consortium to catalyze improvements in PHC delivery and outcomes in low- and middle-income countries through better measurement and sharing of effective models and practices. PHCPI has developed a framework to illustrate the relationship between key financing, workforce, and supply inputs, and core primary health care functions of first-contact accessibility, comprehensiveness, coordination, continuity, and person-centeredness. The framework provides guidance for more effective assessment of current strengths and gaps in PHC delivery through a core set of 25 key indicators (“Vital Signs”). Emerging best practices that foster high-performing PHC system development are being codified and shared around low- and high-income countries. These measurement and improvement approaches provide countries and implementers with tools to assess the current state of their PHC delivery system and to identify where cross-country learning can accelerate improvements in PHC quality and effectiveness.
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              Need for more and better implementation science in global health

               Valéry Ridde (2016)
              ‘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’1 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.2 However, while the content of interventions, which are theoretically effective, are relatively well known, their level of coverage is weak.3 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.4 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’.5 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’.6 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).7 However, we do agree with the fact that ‘research in both fields deals with the challenges of translating intentions into desired changes’.8 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.9 The author of this review clearly highlighted ‘the ethnocentric bias in implementation studies’.9 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’.10 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;9 11 12 interventions which still need to be largely ‘tested and operationalised in real-world settings’.13 Figure 1 Global health and implementation science papers from 1970 to 2015. Two rapid bibliographic searches using PubMed database were performed. Search 1, in order to obtain all references about global health, the following was used: [Global health (MeSH, major topic) OR international health (title / abstract)], given that the MeSH term was introduced only recently. In order to exclude interventions studies about pharmaceutical treatment, the following terms were added: NOT [pharmaceutic (Title/Abstract) OR drug (Title/Abstract) OR vaccine (Title/Abstract)]. Results of search 1 are presented with the black line (left axis) per year since 1970. Search 2, in order to extract in these results, studies focusing on implementation science, the following terms were added: AND [implementation (Title/Abstract)]. Results of search 2 are presented with the red line (left axis) per year since 1970. In the blue dotted line (right axis) the calculated percentage of references focusing on implementation science (search 2) in the global health area of research (search 1).Data analysis performed by Stéphanie Degroote. This urgency should not be taken lightly. It is important that implementation studies in LMICs adhere to what is often called the third generation, which uses more rigorous research design.14 While global health actors appear to have discovered implementation science recently,15 it was actually mobilised at least more than 30 years ago by political science researchers.9 It is not necessary in this editorial to discuss the history of the analysis of intervention implementation8 9 11 which should be better understood (and thus better taught16) and used by those who study implementation. However, research on global health implementation should better exploit the theories, conceptual frameworks and approaches of the social sciences.12 As essential as the inductive and empirical approaches may be, recourse or contribution to theoretical and conceptual development is as important, if not even more.17 As a reminder, among the health promotion studies which analysed public policy, only 18% made reference to a theoretical framework.18 Studies showed that Kingdon's stream theory19 along with Lipsky's street-level bureaucrats20 and Rogers’ innovation theory,21 which were all developed in the USA, could also have been adapted in the context of certain LMICs in order to better understand implementation. Additionally, the role of ideas in the implementation (rather than the emergence) of interventions in LMICs have not really been tackled,22 whereas the writings on high-income countries in this regard have been abundant.23 Implementation science clearly cannot be developed alone without considering the effects of interventions (or the principles of effectiveness, to borrow from Patton's words24), because it risks falling into ‘type 3 error’, where an intervention is evaluated even though it has not yet been implemented as anticipated.25 Thus it is important to better describe the content of interventions using available tools26 27 and to report on the (classic) fidelity and intensity of implementation. It is also necessary to update the adjustments of interventions—inevitable in a natural context—and the fidelity of the theory.28 29 It is in this contextual and holistic research approach that we should conduct and report implementation science. The recurrence of several types of interventions in many settings, the links between the effects (expected or not), the processes, the actors and their context should be brought to light, notably with the theoretical approach of critical realism, which is still not well-tested in LMICs.30 Critical theory could be used to better understand power relations. Individual relations and the role that context plays in the matter should be studied to understand, for example, the heterogeneity of effects in the implementation of interventions.31 When not forgotten, contextual analysis specifically associated with interventions is often the poor parent.32 The use and presentation of methods should also be considered in developing this field by making it more credible to those who think that qualitative research or the flexible approach to research design,33 34 which are integral parts of implementation science, are not rigorous enough. For this, it is necessary that authors are more precise in the description of their methods of qualitative sampling and of their analysis procedures. Beyond these interdisciplinary, boundary-spanning approaches, which are necessary in global health,35 36 the recourse to mixed methods and to multiple case studies, if longitudinally possible, would be a major benefit for implementation science.14 It is certainly time to seriously consider the charge which was made almost 10 years ago on policy research in LMICs: ‘more work on implementation, and specifically, the challenges of implementing equity-oriented policies, as well as more examination of successful policy change experiences’.37 We invite authors to participate in this by proposing and submitting implementation science articles to BMJ Global Health.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2019
                16 August 2019
                : 4
                : Suppl 8
                Affiliations
                [1 ] departmentDepartment of Planning, Research & Statistics , National Primary Healthcare Development Agency , Abuja, Nigeria
                [2 ] departmentCentre for Health Policy , University of the Witwatersrand , Johannesburg-Braamfontein, South Africa
                Author notes
                [Correspondence to ] Dr Ejemai Amaize Eboreime; ejemaim@ 123456gmail.com
                Article
                bmjgh-2019-001573
                10.1136/bmjgh-2019-001573
                6703297
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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