Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda

Abstract

Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) – deaths preventable through health system-delivered evidence-based interventions (EBIs) – in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification and testing of strategies, work to achieve sustainability at scale and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda’s actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country’s success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.

Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000–2015

“…exemp lars. health/ topics/ under-five-morta lity), with methodological details of the country case studies published elsewhere [15]. Briefly, six low-and middle-income countries -selected to represent a range of locations and population sizes -were identified as having experienced greater U5M drops between 2000 and 2015 in relation to the gross domestic product per capita than countries in their regions with similar socioeconomic development.…”

“…From 2000 to 2015, these countries dropped U5M by more than 50%, and all but Senegal achieved MDG4, defined as more than two-thirds decline in U5M during that period [5]. The case studies focused on the implementation of the health system-delivered EBIs known to reduce amenable U5M, defined as deaths preventable through quality in healthcare delivery [15]. In every country we studied, work in other sectorsincluding female empowerment and education, economic growth, and water, sanitation, and hygiene -also served as facilitators or barriers to the implementation strategies or their adaptation, in and beyond the health system, and the overall impact of the EBIs in reducing U5M.…”

An Implementation Research Approach to Reorient Health Supply Chains Toward an Equity Agenda in the COVID-19 Era

“…Within healthcare, evidence-based interventions can include health activities such as community nutrition education sessions, prenatal check-ups, or facility-based deliveries of babies [8]. Within the supply chain context, evidence-based interventions could include the procurement and distribution of vaccines or personal protective equipment.…”

“…In implementation research frameworks, contextual factors are understood to impact evidence-based interventions. In successful implementation, strategies should be adjusted to accommodate for these factors [8]. Contextual factors that could facilitate successful supply chains include: strong partnerships between governments, donor institutions, manufacturers, access to seaports, and extensive road networks to ease transport and delivery of goods.…”

“…Implementation strategies are understood as the approaches used for successful and sustained application of interventions [9]. These strategies should be adapted based on the contextual factors that either limit or facilitate an intervention's ideal implementation [8].…”