Closing the Know-Do-Gap in Global Health through Implementation Science

~Written by Sarah Weber (Contact: sarahkweber@gmail.com)

An area that has gained increased recognition in the past few years is the challenge of the ‘know-do-gap” or bridging the gap between what we know through research and what is implemented. The field of implementation science aims to bridge this gap by getting evidence-based findings out into practice in a timely manner. This is especially important for developing countries facing a shortage of resources and challenging health care systems. Donors, such as USAID, PEPFAR, The Bill and Melinda Gates Foundation, and others have started looking at implementation science as an effective tool and begun funding programs to specifically address the know-do-gap. Implementation science is a fairly new field and has gained greater momentum in developed countries among their domestic health fields than in developing country settings. However, it is a strategy that aligns very well with global health goals and will likely gain greater attention and focus within the global health community over the coming years.

Understanding Implementation Science 

The gap between learning effective strategies/interventions and implementing them is far too large. On average, it takes 17 years for 14% of research to translate to practice (an astonishingly long process which results in only a small percentage actually being implemented). This shows that there is a significant delay between learning effective solutions, strategies, and products through research and translating/implementing them to meet the local needs and produce positive health impacts for specific populations. 

Implementation science, still being a relatively new area of science, has multiple definitions and terminology including knowledge translation, knowledge to action, implementation and dissemination, and implementation research. These definitions are relatively similar as they demonstrate the intention of studying how to efficiently push research into the field as evidence-based solutions. The definition of implementation science from the National Institute for Health Fogarty International Center fits well within the global health context: “the study of methods to promote the integration of research findings and evidence into healthcare policy and practice. It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions”. In simple terms, implementation science means implementing proven interventions in real world settings by modifying them based on the local context and incorporating scale-up processes to meet the local needs. Implementation science is a multi-faceted, non-linear process which requires communication with multiple stakeholders throughout the process and the need for evaluation throughout to ensure that strategies are producing the intended results.

Why should we pay attention to implementation science?

Disparities exist between the developed and developing world

All of us in the field of public health recognize the significant health disparities between high income and mid to low income countries. Although there are effective solutions, there is a gap between knowing effective solutions and successfully implementing them in diverse, low-resources settings. The following statistics from the World Health Organization demonstrate this:

• Developing countries account for 99% of annual maternal deaths in the world.
• In Chad, every fifth child dies before they reach the age of 5, while in the WHO European Region, the under-five mortality rate is 13 out of 1000.
• Women in the richest 20% of the global population are up to 20 times more likely to have a birth attended by a skilled health worker than a poor woman. Closing this coverage gap between rich and poor in 49 low-income countries could have saved the lives of more than 700,000 women between 2011 and 2015

We have the knowledge to solve most health problems in the developing world

Knowledge exists to address and treat preventable illnesses and health problems, yet preventable diseases continue to affect large segments of the global population. Perhaps one of the best examples is the use of childhood vaccinations, one of the most successful public health interventions of all time. The technology exists to prevent over a dozen childhood diseases with routine vaccinations, yet there were still 1.5 million child deaths in 2011 from diseases preventable by routine vaccinations. Programs need to address the bottlenecks and local barriers preventing comprehensive implementation of immunization programs so all children can be reached.

Increasing the number of interventions translated into practice positively impacts health

It is critical that we close the know-do-gap globally and implement proven interventions in developing countries to be efficient with money and resources. Recipients are currently not able to benefit from the latest evidence-based solutions as old ineffective “solutions” are still utilized during this lag time. For the developing world, the know-do gap has widened, as there is the added challenge of how to best implement evidence-based solutions, without utilizing strategies developed from high income countries with sophisticated health systems. This is difficult and requires modifications based on the local context and resources. 

Increasing access to approaches which have demonstrated effectiveness in diverse populations will lead to improved health. We need to go beyond just learning what is needed and actually implement it. This requires engaging stakeholders, evaluating strategies and measuring impact to ensure the strategies and solutions are meeting local needs. We need to reduce the know-do-gap so that more effective strategies can be utilized to create health impacts, and ineffective strategies and solutions can be retired quickly. Implementation science is not a one-size approach and scaling up evidence-based programs and practices to meet the needs of the target population is of utmost importance.

We have the tools through implementation science to close the gap and get more efficient interventions into practice. The global health community must keep moving the bar from evidence to action, and implementation science can help.  

Resources

Canadian Institute for Health Research.  Knowledge Translation of Low and Middle Income Countries: A Learning Model http://www.cihr-irsc.gc.ca/e/44240.html

National Institute for Health, Fogarty International Center. http://www.fic.nih.gov/News/Events/implementation-science/Pages/faqs.aspx 

FHI 360. Perspective on how Implementation Science can Improve Global Health http://degrees.fhi360.org/2014/09/perspectives-on-how-implementation-science-can-improve-global-health/

UNICEF. Immunization Facts and Figures 2013 http://www.unicef.org/immunization/files/UNICEF_Key_facts_and_figures_on_Immunization_April_2013%281%29.pdf

World Health Organization. Fact File on Health Inequalities. http://www.who.int/sdhconference/background/news/facts/en/

Inequality within those who Call for it the Loudest

~Written by  Mikael Ashorn (Contact: mikael.ashorn@gmail.com)

Last March I had the chance to be part of a team representing our graduate program in the annual Emory Global Health Case Competition in Atlanta. We were given the not-so-easy task of transforming the World Health Organization (WHO) to the 21st century (http://www.globalhealth.emory.edu/what/student_programs/case_competitions/pdfs/2014_international_cc_case.pdf).

As we pondered this thrilling case among our group there was a lot of discussion around the fundamental core structure of the WHO and about the politics surrounding it. How could it serve better those in need – and as equally as possible? Among other things the WHO, as well as other United Nations (UN) branches, try to promote equity among the world's population. Health is listed as a fundamental human right, which everyone should have equal access to, already in the Universal Declaration of Human Rights in 1948. But do these large organizations promote equity also within their own system?

A Swiss newspaper writes (http://lenews.ch/2014/11/20/the-united-nations-more-consultants-fewer-rights/) on how the UN has started to save by using short-term consultants on a long-term basis. The Joint Inspection Unit (JIU) has already noted this negative trend. According to the JIU this trend creates inequality and a two-tier structure among the workers: consultants with next-to-none social benefits and full-time employees.

About half a year later I was attending Youth & Student UN-days in Finland. The theme was human rights. No one seemed to be talking about the equal rights of the employees within the UN. Among other presentations, I heard a former intern give a talk on how much she had learnt during her internship in the UN. However, in the same breath she spoke about how hard it was to make it through this unpaid internship financially.

Yes – you heard me right. Unpaid.

The UN does not pay any of its interns, nor does it help them financially in any other way. Does this provide equal opportunities for everyone to participate? Brilliant students from developing countries already struggle with tuition fees more than students coming from more prosperous countries. However in this field of work a good education is usually not sufficient to land a job. All employers expect work experience, which is usually gained through internships.

Some organizations, like the International Federation of Red Cross and Red Crescent Societies (IFRC), seem to have noticed this. For instance the IFRC claims to be “an equal opportunity employer”. With almost identical competences required as for internships for the UN, they pay all the interns expenses as well as a nominal salary.

A Washington Post article claims, that poor kids who do everything right are still worse off than rich kids who do everything wrong (http://www.washingtonpost.com/blogs/wonkblog/wp/2014/10/18/poor-kids-who-do-everything-right-dont-do-better-than-rich-kids-who-do-everything-wrong/). They claim that this is because of the different opportunities they get in life. These are the kinds of differences the UN promotes with non-paid internships. My fellows and I from developed countries are fortunate enough to have social-networks that we can rely on during the internship without a salary. However others are not so fortunate.

When the JIU published its report, the UN responded that changing the systems is very much in their interest, as they “need to have the best people possible”. By continuing these unpaid internships, the UN not only creates inequality between candidates but also might rule out some very competent prospective employees, whom are not fortunate enough to be able to work unpaid.

As an employer, the UN seems to pay rather high salaries (https://careers.un.org/lbw/home.aspx?viewtype=SAL). Could these be scaled back so that at the very least, interns' living expenses can be paid? This way, the UN would also be promoting equity within the organization. It would give more people the opportunity to get their careers kick-started through an internship, which future employers would appreciate.