Enhancing implementation research within Canada’s investments in the health of women and children globally
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* Renee Sharma
* Helen Scott
* Zulfiqar A. Bhutta

Few issues have received as much global attention in recent years as maternal, newborn and child health and survival, a cornerstone of the United Nations’ Millennium Development Goals.

Recent research has focused on defining and developing a range of evidence-based interventions across the continuum of care for maternal, newborn and child health; as a result of the implementation of many of these initiatives, global maternal and child mortality fell from about 13 million deaths in 1990 to just over 6 million in 2015.1 Yet, progress has been uneven. Disparities between countries, as well as between populations within countries, are evident. These gaps in coverage of essential interventions are related to marginalization of some groups, social inequities and geographic issues.1

There has been comparatively little research on strategies to reach those in greatest need. We need to move from “what” to “how best” to package and scale up interventions to address maternal, newborn and child health, and to integrate these within existing programs, which remains a global challenge.1 If we are to achieve high, sustainable and equitable coverage of life-saving interventions, addressing this gap with good implementation research is essential, and Canada must contribute to such efforts.

The relatively new field of implementation science refers to “the study of methods to promote the integration of research findings and evidence into healthcare policy and practice,” i.e., exploring the ways in which key players influence and interact with the uptake, adoption and implementation of evidence-based interventions, to try to improve delivery and scale up of interventions in specific local contexts.2 Related to this is the concept of implementation research, which was defined by Peters and colleagues as the “scientific inquiry into questions concerning implementation — the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions).”3 The intent of implementation science and related research is to investigate and address major bottlenecks that impede effective implementation of interventions, to test new approaches to improve health programming and to determine a causal relationship between interventions and their impact.4 There are few systematic exercises exploring the relationship of implementation research to major global priorities, and they are limited to specific areas such as the health care work force,5 community drivers of intervention uptake6 and demand-side financing.7 However, an increasing number of exercises are focused on specific implementation questions within countries or programs,8,9 in an attempt to strengthen implementation of evidence-based strategies.

Global gains in the health of women and children were made possible by concerted investments and efforts by many national governments, including Canada’s, as well as other global organizations offering development assistance, with almost 19% of development assistance targeting maternal, newborn and child health in 2015.10 Many of these investments are focused on evidence-based strategies and essential interventions. However, mere consensus on evidence-based interventions and action plans is insufficient to influence policies or, more importantly, for tangible impact on the ground, unless it is accompanied by robust implementation that is guided by sound and relevant research.

Canada’s funding of interventions to improve maternal, newborn and child health through the $6.35 billion Muskoka Initiative on Maternal, Newborn and Under-Five Child Health, over the last five years11 has been criticized for missing opportunities to invest in reproductive health and family planning. It is also unclear if the investments made across a range of approaches to maternal, newborn and child health had a substantial impact on the outcomes related to Millennium Development Goals 4 and 5, and the exact proportion of overall funding for health systems, implementation research and accountability.12

A recently undertaken multistakeholder review of Canada’s investments in maternal, newborn and child health, and public consultations represent a unique opportunity to assess the impact and relevance of appropriate research to address implementation and impact. The review should consider priorities for Canadian investments in the health of women and children, and target strategies for scaling up and enhancing the effectiveness of key interventions in at-risk populations. Interventions and innovations to improve the health of marginalized populations at risk, those living in fragile states and active conflict zones, and displaced populations should be key priorities.

Given the range of possibilities for research and investment in the health of women and children, some focus and prioritization is needed. Which interventions should be targeted for implementation research and scale up? We suggest a multistep process that starts with an evaluation of the allocations of existing funding to health research, especially implementation research. This evaluation should be followed by consultations with funding bodies and country stakeholders to identify core priorities in the face of finite resources for implementation and research.

Notwithstanding the previous statements, some generalizations can be made about current areas of focus in implementation research. A focus on development, deployment and retention of adequate and well-trained human resources is key to reaching populations who are at risk. Of these, the major opportunity of reducing inequities might relate to working with community strategies and delivery platforms such as community support groups, health care workers and innovations that facilitate delivery of quality services. Major barriers to care seeking and impact also relate to poor quality of services in most midlevel referral health facilities.13 Strategies for improving quality of care, incentivizing care seeking, and using technology for monitoring and evaluation in such settings must be prioritized for research.

Because of finite resources and the need to set priorities, research into cost-effective approaches for scale up must receive attention. A Canadian strategy for investment in the Sustainable Development Goals for improved health of women and children that is guided by the best research for prioritizing implementation at scale will likely ensure impact, value for money and enhancement in global knowledge for reaching every woman and every child.

KEY POINTS
*   Limited research is available on packaging and scaling up interventions to best address global maternal, newborn, child and adolescent health, and their integration within existing programs.

*   Good implementation research is essential to achieving high-level, sustainable and equitable coverage of life-saving interventions. Canada must contribute to these research efforts and undertake a review of investments in implementation research within the Muskoka Initiative to date and opportunities moving forward.

*   Key areas for implementation research may include developing, deploying and retaining adequate and well-trained human resources; overcoming barriers to intervention access and uptake through community-based strategies and delivery platforms; improving detection and care seeking for childhood illnesses; improving quality of care and monitoring and evaluation; and identifying cost-effective approaches for scale up services.

## Footnotes

*   **Competing interests:** None declared.

*   **Contributors:** Zulfiqar Bhutta wrote the initial draft, with substantial input from Renee Sharma and further comments from Helen Scott. All of the authors revised the manuscript critically for intellectual content, approved the final version to be published and agreed to be accountable for all aspects of the work.

*   **Funding:** The Centre for Global Child Health at The Hospital for Sick Children, Toronto, received funding from the Canadian Partnership for Women and Children’s Health to conduct the research prioritization exercise and prepare a final report.

*   This article has been peer reviewed.

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