Cross-Cutting Lessons from the Decision-Maker Led Implementation Research Initiative

"Since implementation research focusses on issues of implementation that occur within real-world contexts and systems, there is significant value in engaging the actors involved in implementation in efforts to understand and strengthen it."

Almost 20 million children under one year of age did not receive basic vaccines in 2019, and most of these children lived in low- and middle-income countries (LMICs). To address such issues, the Alliance for Health Policy and Systems Research (AHPSR) within the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) partnered with Gavi, the Vaccine Alliance in an initiative called Decision-Maker Led Implementation Research (DELIR). Through DELIR, 14 decision-maker led implementation research projects have been carried out since 2015 in 10 LMICs with the aim of strengthening the implementation of immunisation interventions and improving coverage. This synthesis paper describes the cross-cutting lessons from the initiative to further understand and develop the strategy of carrying out research as an integrated component of decision-making processes.

As detailed in an introductory editorial accompanying the article, the overall purpose of the DELIR initiative was to support the generation of new knowledge to inform the implementation of immunisation interventions with the aim of improving coverage in LMICs. As conditioned in the call for proposals, decision-makers and researchers had to partner together in the project to be eligible to apply for funding. DELIR was informed by: (i) recognition of the importance of immunisation as an intervention whose implementation and scale-up is critical to move towards universal health coverage, (ii) a felt need for new knowledge to better understand and help overcome health systems barriers to effective scale-up and implementation of immunisation interventions, and (iii) recognition of the added value of engaging decision-makers as principal investigators through an embedded approach informing the generation, dissemination, and use of this new knowledge.

The study of lessons learned from DELIR used qualitative methods of data collection, including a document review and 17 in-depth interviews with decision-makers and researchers engaged in DELIR. Research teams from 11 of the 14 projects participated in the study. Most projects were carried out in countries in Africa and were conducted at the sub-state or sub-district level. Almost all projects were exploratory (n=9; 81.8%); for most, the aim was to identify facilitators and barriers to implementation (n=10; 90.9%). The projects described multiple challenges related to the implementation of immunisation interventions (n=7; 63.6%) and identified both demand- and supply-side barriers (n=6; 54.5%). A few implementation strategies were explored and tested by the projects, such as a tailored communication strategy and participatory action research.

Seven enablers and six barriers to the process of conducting the studies or bringing about changes were identified:

• Key enablers were:
  • Existing relationship (e.g., between decision-makers and researchers) or prior experience in study setting
  • Decision-maker identified the problem or need to be addressed and approached the researcher to collaborate
  • Interest in and support for decision-maker-led research
  • Combination of research and practice
  • External stakeholder engagement and dissemination throughout study
  • Relevant and acceptable findings to inform implementation, in part because the research was carried out with decision makers' ongoing engagement
  • Integration of project(s) into decision-making processes and ongoing or routine work
• Key barriers were:
  • Limited engagement of the decision-maker or researcher throughout study (e.g., due to time constraints or competing priorities)
  • Limited involvement of national-level decision-makers and international partners
  • Insufficient capacity and resources for qualitative research methods
  • Results not supporting a clear action to improve implementation
  • Limited planning or support through the process of making changes
  • Limited role of a single study in informing changes to strengthen implementation

These findings suggest that research done for the purpose of informing decisions and changes to strengthen implementation should be conceptualised and designed in a way that is responsive to the needs, activities, resources, and context in a particular setting. The study also revealed that a collaborative approach to research enabled the projects to leverage existing relationships, networks, and prior experiences in country settings and bring together the perspectives of both decision-makers and researchers, which contributed to their success.

In conclusion: "Decision-maker led research is a promising strategy to facilitate the embedding of research into decision-making processes and contribute to greater use of research to strengthen implementation of proven-effective interventions, such as immunization."