Implementation research is important in global health to address the challenges of the know-do gap in real world settings, and the practicalities of achieving national and global health goals.Implementation research is an integrated concept linking research and practice to accelerate the development and delivery of public health approaches. It involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. It uses multiple disciplines and methods, and emphasises partnerships between community members, implementers, researchers and policy makers. Implementation research focuses on practical approaches to improve implementation; to enhance equity, efficiency, scale up and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research, and a range of perspectives on its purposes and appropriate methods.However, there have been limited efforts to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low and middleincome countries (LMICs). The case studies are organized in four categories related to the purposes for using implementation research: impacting people's health, informing policy design and implementation, improving health service delivery, and empowering communities and beneficiaries. Common characteristics of these case studies are the focus on addressing implementation problems, ensuring a partnership approach to the co-creation of solutions, including using tacit knowledge, and commitment of key stakeholders to a pathway towards impact. The case studies reveal the complex adaptive nature of health systems, emphasize the importance of understanding context, and highlight the role of multidisciplinary, rigorous and adaptive processes which allow for course correction to ensure interventions have an impact. This Implementation Research: New Imperatives and Opportunities in Global HealthPanel 1: Key messages 1. Implementation research offers a way to understand and address implementation challenges and make a positive impact on people's health by contributing to building stronger and more responsive health systems within the realities of specific contexts. 2. Implementation research can lead to positive health outcomes, inform policy design, improve health management and service delivery, and support and empower communities and beneficiaries. 3. Implementation research uses multidisciplinary approaches and a range of empirical and systematic methods to document, analyse and address key health problems and test technical health interventions as well as contextually tailored innovative strategies within the foundations of local context. 4. Implementation research can be used to evaluate the feasibility, adoption, and a...

The relationship of anemia as a risk factor for maternal mortality was analyzed by using cross-sectional, longitudinal and case-control studies because randomized trials were not available for analysis. The following six methods of estimation of mortality risk were adopted: 1) the correlation of maternal mortality rates with maternal anemia prevalence derived from national statistics; 2) the proportion of maternal deaths attributable to anemia; 3) the proportion of anemic women who die; 4) population-attributable risk of maternal mortality due to anemia; 5) adolescence as a risk factor for anemia-related mortality; and 6) causes of anemia associated with maternal mortality. The average estimates for all-cause anemia attributable mortality (both direct and indirect) were 6.37, 7.26 and 3.0% for Africa, Asia and Latin America, respectively. Case fatality rates, mainly for hospital studies, varied from <1% to >50%. The relative risk of mortality associated with moderate anemia (hemoglobin 40-80 g/L) was 1.35 [95% confidence interval (CI): 0.92-2.00] and for severe anemia (<47 g/L) was 3.51 (95% CI: 2.05-6.00). Population-attributable risk estimates can be defended on the basis of the strong association between severe anemia and maternal mortality but not for mild or moderate anemia. In holoendemic malarious areas with a 5% severe anemia prevalence (hemoglobin <70 g/L), it was estimated that in primigravidae, there would be 9 severe-malaria anemia-related deaths and 41 nonmalarial anemia-related deaths (mostly nutritional) per 100,000 live births. The iron deficiency component of these is unknown.

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Undernutrition is the single largest contributor to the global burden of disease and can be addressed through a number of highly efficacious interventions. Undernutrition generally has not received commensurate attention in policy agendas at global and national levels, however, and implementing these efficacious interventions at a national scale has proven difficult. This paper reports on the findings from studies in Bangladesh, Bolivia, Guatemala, Peru and Vietnam which sought to identify the challenges in the policy process and ways to overcome them, notably with respect to commitment, agenda setting, policy formulation and implementation. Data were collected through participant observation, documents and interviews. Data collection, analysis and synthesis were guided by published conceptual frameworks for understanding malnutrition, commitment, agenda setting and implementation capacities. The experiences in these countries provide several insights for future efforts: (a) high-level political attention to nutrition can be generated in a number of ways, but the generation of political commitment and system commitment requires sustained efforts from policy entrepreneurs and champions; (b) mid-level actors from ministries and external partners had great difficulty translating political windows of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional views of undernutrition and disagreements over interventions, ownership, roles and responsibilities; and (c) the pace and quality of implementation was severely constrained in most cases by weaknesses in human and organizational capacities from national to frontline levels. These findings deepen our understanding of the factors that can influence commitment, agenda setting, policy formulation and implementation. They also confirm and extend upon the growing recognition that the heavy investment to identify efficacious nutrition interventions is unlikely to reduce the burden of undernutrition unless or until these systemic capacity constraints are addressed, with an emphasis initially on strategic and management capacities.