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Introduction: Health system strengthening initiatives in low and middle-income countries are commonly hampered by limited implementation readiness. The Maximizing Engagement for Readiness and Impact (MERI) Approach uses a system “readiness” theory of change to address implementation obstacles. MERI is documented based on field experiences, incorporating best practices, and lessons learned from two decades of maternal, newborn, and child health (MNCH) programming in East Africa. Context: The MERI Approach is informed by four sequential and progressively larger MNCH interventions in Uganda and Tanzania. Intervention evaluations incorporating qualitative and quantitative data sources assessed health and process outcomes. Implementer, technical leader, stakeholder, and policymaker reflections on sequential experiences have enabled MERI Approach adaptation and documentation, using an implementation lens and an implementation science readiness theory of change. Key programmatic elements: The MERI Approach comprises three core components. MERI Change Strategies (meetings, equipping, training, mentoring) describe key activity types that build general and intervention-specific capacity to maximize and sustain intervention effectiveness. The SOPETAR Process Model (Scan, Orient, Plan, Equip, Train, Act, Reflect) is a series of purposeful steps that, in sequence, drive each implementation level (district, health facility, community). A MERI Motivational Framework identifies foundational factors (self-reliance, collective-action, embeddedness, comprehensiveness, transparency) that motivate participants and enhance intervention adoption. Components aim to enhance implementer and system readiness while engaging broad stakeholders in capacity building activities toward health outcome goals. Activities align with government policy and programming and are embedded within existing district, health facility, and community structures. Discussion: This case study demonstrates feasibility of the MERI Approach to support district wide MNCH programming in two low-income countries, supportive of health outcome and health system improvements. The MERI Approach has potential to engage districts, health facilities, and communities toward sustainable health outcomes, addressing intervention implementation gaps for current and emerging health needs within and beyond East Africa.
We will continue to refine the MERI Approach to overcome challenges in adoption and uptake. Full MERI Implementation requires a significant commitment to quality, detail, and specific activity order requirements. However, based on our own experiences, SOPETAR steps and application across all levels and entire districts are key for maximum impact. For example, extensive time and resource investment in orientation activities within our first Mama na Mtoto district in Tanzania initially met with hesitation by funders, government officials, and implementation team members accustomed to more rapid start up. However, by implementation start in the second intervention district, the purposeful and intense orientation process was better understood and its quality and added value appreciated. We learned that ensuring good understanding of the MERI Approach and its rationale by implementation teams and stakeholders is critical to implementation success. Additionally, time and resources intense steps during and after the intervention are balanced by utilizing available human and tangible resources within existing systems, reducing long-term maintenance costs for embedded activities. MERI’s very structured process may be challenging to implement in certain contexts. For example, flexibility in timing maybe limited when dealing with humanitarian situations and critical deliverables. However, based on our recent adolescent SRHR programming experiences during an unpredictable novel coronavirus-19 pandemic, general commitment to MERI principles including quality and order can still be feasible. If readiness, especially motivation, is truly stimulated, there are dividends in district health systems who, with a strong foundation, can pivot to meet emerging, unpredicted needs without significant external support. Packaging the MERI model requires thoughtfulness, creativity, and adaptation for context. Implementers require early and in-depth orientation and guidance, whilst integrating their own valuable experiences and expertise. This requires dedicated time and investment. At the community level, explaining a complicated “implementation science” process may seem improbable, but with adaptation, it can be achieved and effective. Recently with local stakeholders, a modified community-friendly version of the MERI Approach was developed, using a widely understood analogy of a fruit tree (Figure 2). This image is posted and discussed at the orientation sessions with every participant group during our current HAY! initiative. It generates conversation and common understanding about roles, expectations, and priorities amongst stakeholders and beneficiaries, regardless of role or literacy level, prior to activity implementation. Another example of adaptation for broad implementation engagement occurs during “plan” sessions where different stakeholder groups use a “rose” and “thorn” activity (i.e., rose = facilitator; thorn = barrier) to identify locally relevant barriers and enablers. MERI Approach tree (community version). In both Tanzania and Uganda implementation delivery teams use English during meetings and plan to have access to paper handouts and computer-assisted presentations. In contrast, in the community context, sharing of implementation concepts and tools (adapted HAY! Tree “rose/thorn” activity mentioned above) often requires translation into local dialect, visual representation of concepts, and posting on locally available materials (e.g., rice bags) to accommodate audience literacy, language, and venue. At all levels, participants show interest in engaging and understanding implementation concepts. Within our current Ugandan adolescent health initiative, such adaptations are overseen by a dedicated “implementation coaching team” whose members mentor implementing district leaders, monitor processes, assess implementation strength and progress, and identify and address emerging implementation gaps. Additionally, this team considers incorporation and articulation of macro-level factor management, especially multi-sectoral engagement within MERI, which is critical in adolescent health and wellness. Further research and documentation opportunities include comprehensive MERI evaluation within a full project cycle. To date a priori evaluation has only occurred for the SOPETAR model and MERI Change Strategies; the MERI Motivational Framework was articulated and added following the Mama na Mtoto intervention and its fuller evaluation is pending. Additionally, the extent of readiness to change amongst stakeholder groups has yet to be prospectively documented. The MERI Approach also warrants further testing in settings where there are no prior established relationships. In our settings, in-country institutional partners (universities) had clinical working relationships with district health leaders prior to implementation start. What additional MERI adjustments might be required for success where no prior relationship exists or at the national scale-up level?
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