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...

In Tanzania, the coverage of four or more antenatal care (ANC 4) visits among pregnant women has declined over time. We conducted an exploratory analysis to identify factors associated with utilization of ANC 4 and ANC 4 decline among pregnant women over time. We used data from 8035 women who delivered within two years preceding Tanzania Demographic and Health Surveys conducted in 1999, 2004/05 and 2010. Multivariate logistic regression models were used to examine the association between all potential factors and utilization of ANC 4; and decline in ANC 4 over time. Factors positively associated with ANC 4 utilization were higher quality of services, testing and counseling for HIV during ANC, receiving two or more doses of SP (Sulphadoxine Pyrimethamine)/Fansidar for preventing malaria during ANC and higher educational status of the woman. Negatively associated factors were residing in a zone other than Eastern zone, never married woman, reported long distance to health facility, first ANC visit after four months of pregnancy and woman's desire to avoid pregnancy. The factors significantly associated with decline in utilization of ANC 4 were: geographic zone and age of the woman at delivery. Strategies to increase ANC 4 utilization should focus on improvement in quality of care, geographic accessibility, early ANC initiation, and services that allow women to avoid pregnancy. The interconnected nature of the Tanzanian Health System is reflected in ANC 4 decline over time where introduction of new programs might have had unintended effects on existing programs. An in-depth assessment of the recent policy change towards Focused Antenatal Care and its implementation across different geographic zones, including its effect on the perception and understanding among women and performance and counseling by health providers can help explain the decline in ANC 4.

This paper examines the characteristics of implementation research (IR) efforts in low-income and middle-income countries (LMICs) by describing how key IR principles and concepts have been used in published health research in LMICs between 1998 and 2016, with focus on how to better apply these principles and concepts to support large-scale impact of health interventions in LMICs. There is a stark discrepancy between principles of IR and what has been published. Most IR studies have been conducted under conditions where the researchers have considerable influence over implementation and with extra resources, rather than in ‘real world’ conditions. IR researchers tend to focus on research questions that test a proof of concept, such as whether a new intervention is feasible or can improve implementation. They also tend to use traditional fixed research designs, yet the usual conditions for managing programmes demand continuous learning and change. More IR in LMICs should be conducted under usual management conditions, employ pragmatic research paradigm and address critical implementation issues such as scale-up and sustainability of evidence-informed interventions. This paper describes some positive examples that address these concerns and identifies how better reporting of IR studies in LMICs would include more complete descriptions of strategies, contexts, concepts, methods and outcomes of IR activities. This will help practitioners, policy-makers and other researchers to better learn how to implement large-scale change in their own settings.

Our results suggest that the two alternative antibiotic regimens for outpatient treatment of clinical signs of severe infection in young infants whose parents refused hospital admission are as efficacious as the standard regimen. This finding could increase treatment options in resource-poor settings when referral care is not available or acceptable.

BackgroundShort birth intervals are associated with an increased risk of adverse perinatal outcomes. However, reduction of rates of short birth intervals is challenging in low-resource settings where majority of the women deliver at home with limited access to family planning services immediately after delivery. This study examines the feasibility of integrating a post-partum family planning intervention package within a community-based maternal and newborn health intervention package, and evaluates the impact of integration on reduction of rates of short birth intervals and preterm births.MethodsIn a quasi-experimental trial design, unions with an average population of about 25 000 and a first level health facility were allocated to an intervention arm (n = 4) to receive integrated post-partum family planning and maternal and newborn health (PPFP-MNH) interventions, or to a control arm (n = 4) to receive the MNH interventions only. Trained community health workers were the primary outreach service providers in both study arms. The primary outcomes of interest were birth spacing and preterm births. We also examined if there were any unintended consequences of integration.ResultsAt baseline, short birth intervals of less than 24 months and preterm birth rates were similar among women in the intervention and control arms. Integrating PPFP into the MNH intervention package did not negatively influence maternal and neonatal outcomes; during the intervention period, there was no difference in community health workers’ home visit coverage or neonatal care practices between the two study arms. Compared to the control arm, women in the intervention arm had a 19% lower risk of short birth interval (adjusted relative risk (RR) = 0.81, 95% confidence interval (CI) = 0.69-0.95) and 21% lower risk of preterm birth (adjusted RR = 0.79; 95% CI = 0.63-0.99).ConclusionsStudy findings demonstrate the feasibility and effectiveness of integrating PPFP interventions into a community based MNH intervention package. Thus, MNH programs should consider systematically integrating PPFP as a service component to improve pregnancy spacing and reduce the risk of preterm birth.