Even though some progress has been achieved on the millennium Development Goal (MDG) four, MDG five has been identified as one of the MDGs with the least progress. Slow progress has been linked to the slow uptake of clinical research findings and evidence-based practices into routine care, weakened health systems across all key functions (including under-financing, insufficient health workforce). Health services in both public and private sectors can benefit from improved quality of care (effectiveness, reliability, safety, appropriateness, equity, efficiency)
The large scale implementation of effective service-delivery interventions could potentially induce significant improvements in health outcomes in low and middle-income countries. However, the development and implementation of effective implementation strategies can be a major challenge. Accomplishing these tasks requires rigorous interdisciplinary research involving experts in program operations, health systems/operations/implementation research, SRH service delivery, clinical interventions, health sector development policy, the behavioural and organizational sciences, and monitoring and evaluation. The Department adopted the following definition that is currently used by the journal Implementation Science: 'Implementation Research is the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, and hence to improve the quality (effectiveness, reliability, safety, appropriateness, equity, efficiency) of health care. It includes the study of influences on healthcare professional and organizational behaviour.'
The Department is currently building a portfolio of implementation research projects. The projects are at different stages of development and are briefly introduced below:
HL-EBM clinically integrated e-learning
HRP is currently evaluating an EBM teaching programme for obstetrics and gynaecology trainees that combines e-learning with bedside learning through facilitation by senior staff in seven developing countries (Argentina, Brazil, Democratic Republic of Congo, India, Philippines, South Africa and Thailand). The main endpoints in this trial are knowledge, attitude and competency of junior trainees.
Enhancing coverage of focussed antenatal care through implementation research
Antenatal care (ANC) is an essential element of the MNCH continuum of care and is considered an MDG 5B tracking indicator. Many developing countries have introduced health policies prescribing the delivery of the full package of effective antenatal care practices and their integration with key health interventions such as prevention and treatment of HIV and malaria, detection and management of anaemia, and screening and treatment of syphilis. Unfortunately, implementation bottlenecks and health system constraints often limit the full adoption of these policies at health facility level.
A meeting of experts convened in Maputo in 2009 by the Ministry of Health of Mozambique and HRP highlighted similar constraints to the implementation at facility level of Mozambique’s recently introduced ANC package. In response, HRP obtained funding from the Government of Flanders to support a four-year project to evaluate a strategy to increase the delivery of evidence-based practices included in the ANC package by midwives (and other health professionals), and promote the integration of key interventions into routine antenatal care. The ultimate goal of the project is to improve maternal and newborn outcomes as well as the detection, treatment and prevention of major health-related conditions in pregnant women (e.g., anaemia, and infectious diseases such as HIV/AIDS, malaria, and congenital syphilis). The project will be conducted as a cluster randomized trial at ten health facilities in different regions of Mozambique and will be carried out by a team including the Ministry of Health, HRP and international and national experts from the Institute for Clinical Effectiveness and Health Policy, the Johns Hopkins Bloomberg School of Public Health and the International Centre for Reproductive Health.
Magnesium Sulphate for eclampsia
Magnesium Sulphate is relatively easy to administer at hospital level and is an effective, inexpensive, and safe intervention to treat women with eclampsia/pre-eclampsia. Estimates indicate that a 50% increase in the use of Magnesium Sulfate would prevent 10-15 maternal deaths per 100,000 live births in low resource countries. However, its implementation rate is low. Barriers limiting its use include: lack or inappropriate dissemination of clinical guidelines, non-inclusion in local essential medicines lists, lack of training and limited interest of the industry to market the drug.
HRP, NIH and the Canadian Institute for Health Research recently developed a plan for a collaborative implementation research effort to evaluate a strategy that could increase the use of Magnesium Sulphate and contribute to decrease mortality and morbidity due to hypertensive disorders of pregnancy. The strategy will include: Magnesium Sulphate ready-to-use boxes, guidelines, training, reminders and interventions aimed at supporting the health system. The evaluation will be done through a hospital-based cluster randomized trial that will be conducted in 3-4 low and middle income countries. The research collaboration includes HRP; The Institute for Clinical Effectiveness and Health Policy, Argentina; The Johns Hopkins Bloomberg School of Public Health, USA; The Norwegian Knowledge Centre for the Health Services, Norway; The Medical Research Council of South Africa, South Africa; The Ottawa Hospital Research Institute, Canada and The University of Toronto, Canada.
Delivery strategy to increase the use of antenatal corticosteroids in developing countries
Preterm birth is the leading cause of the four million neonatal deaths per year, 99% of which occur in low-middle income countries. The administration of antenatal corticosteroids to mothers at high risk of preterm birth is a highly effective intervention reducing neonatal deaths between 25%-50%. However, in low and middle income countries, only 10% of preterm babies are currently receiving antenatal corticosteroids. This figure contrasts sharply with the more than 70% of preterm babies that receive the intervention in high income countries.
HRP, in collaboration with the Institute for Clinical Effectiveness and Health Policy, Argentina and the NICHD Global Network for Women´s and Children´s Health Research, will conduct a cluster randomized trial to test whether a multi-component intervention designed to increase the use of antenatal corticosteroids among mothers at risk of preterm birth in African, Asian and Latin American countries is safe and will reduce neonatal mortality in comparison to the existing standard of care. The intervention will consist of implementing the following at all health care levels: 1) diffusion of guidelines to healthcare providers; 2) improving the identification of women needing corticosteroids by measuring uterine height with a color-coded tape to estimate gestational age in women at risk of birth in the following seven days; and 3) providing antenatal corticosteroids kits containing Betamethasone ampoules, syringes and instructions for administration.
Enhancing coverage of focussed antenatal care through implementation research
HRP is carrying out a cluster randomized controlled trial in Ngorongoro district, northern Tanzania in collaboration with the London School of Hygiene and Tropical Medicine and Johns Hopkins Bloomberg School of Public Health. The aim of the trial is to determine the effectiveness of introducing birth plans into routine antenatal care on increasing the use of skilled delivery and immediate postpartum care. The study is designed to detect an absolute change in improvement in skilled delivery care utilization of at least 10% (from the current 7% to 17%) as statistically significant (P<0.05, two sided) with power of 80% and an attrition rate of at most 20%.
UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction Department of Reproductive Health and Research: (last revised: June 2010). World Health Organization.