Implementation research approaches to promoting universal health coverage in Africa: a scoping review

Background: Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of initiatives promoting the uptake of implementation research in Africa, its role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). Hence, this scoping review aimed to identify and characterise the use of implementation research initiatives for assessing UHC-related interventions or programmes in Africa. Methods: The review protocol was developed based on the methodological framework proposed by Arksey and O’Malley, as enhanced by the Joanna Briggs Institute. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). MEDLINE, Scopus and the Cochrane Library were searched. The search also included a hand search of relevant grey literature and reference lists. Literature sources involving the application of implementation research in the context of UHC in Africa were eligible for inclusion. Results: The database search yielded 2153 records. We identified 12 additional records from hand search of reference lists. After the removal of duplicates, we had 2051 unique records, of which 26 studies were included in the review. Implementation research was used within ten distinct UHC-related contexts, including HIV; maternal and child health; voluntary male medical circumcision; healthcare financing; immunisation; healthcare data quality; malaria diagnosis; primary healthcare quality improvement; surgery and typhoid fever control. The consolidated framework for implementation research (CFIR) was the most frequently used framework. Qualitative and mixed-methods study designs were the commonest methods used. Implementation research was mostly used to guide post-implementation evaluation of health programmes and the contextualisation of findings to improve future implementation outcomes. The most commonly reported contextual facilitators were political support, funding, sustained collaboration and effective programme leadership. Reported barriers included inadequate human and other resources; lack of incentives; perception of implementation as additional work burden; and socio-cultural barriers. Conclusions: This review demonstrates that implementation research can be used to achieve UHC-related outcomes in Africa. It has identified important facilitators and barriers to the use of implementation research for promoting UHC in the region. An a priori protocol for this review, which has been published elsewhere [40], was designed in accordance with the Arksey and O’Malley scoping review methodology [41], as enhanced by the Joanna Briggs Institute (JBI) [42]. The JBI’s enhanced framework expands the six stages of Arksey and O’Malley into 9 distinct stages for undertaking a scoping review: (1) defining the research question; (2) developing the inclusion and exclusion criteria; (3) describing the search strategy; (4) searching for the evidence; (5) selecting the evidence; (6) extracting the evidence; (7) charting the evidence; (8) summarising and reporting the evidence and (9) consulting with relevant stakeholders. The protocol was disseminated throughout the extensive professional networks of the author group and the World Health Organization (WHO) to solicit feedback. Findings of the review are reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [43]. This scoping review used the WHO’s UHC Cube conceptual framework for mapping the processes and outcomes between implementation research and UHC [44]. This framework uses a cube (see Fig. 1) to depict the multidimensional nature and outcomes of UHC. The cube illustrates three core dimensions of conceptualising UHC: population coverage of health-related social security systems, financial protection, and access to quality health care according to need [44, 45]. These dimensions provide an assessment framework for UHC-targeted initiatives, reflecting how many (or what proportion of) people received various needed health services of sufficient quality, while being protected from undue financial risks [44]. Although the framework does not take into account specific contextual factors, it has been widely used globally for conceptualising UHC across diverse health systems and contexts [45–47]. The World Health Organization’s Universal Health Coverage (UHC) Cube Through consultation with the research team and key stakeholders, the overall main research question was defined as: ‘What are the nature and scope of implementation research initiatives for improving equitable access to quality promotive, preventive, curative, rehabilitative and palliative health services in Africa?’ For the purpose of this review, implementation research has been defined within the broader frameworks of implementation science, knowledge translation and evidence informed decision making. Based on the primary research question, the following specific research questions were defined: These were generated using the PCC (Population, Concept and Contexts) framework, proposed by Peters and colleagues [48]. This framework is more appropriate for scoping reviews, compared with the commonly used PICO (Population, Intervention, Comparator and Outcome) framework, as it allows for the consideration of publications that may not feature all of the four PICO elements (e.g. lacking an outcome or comparator/control). Eligible population included evidence producers (health researchers), intermediaries (such as knowledge brokers and implementation research institutions) and evidence users (such as health policymakers, programme implementers like non-government organisations and healthcare providers). There are two concepts of interest for this review, an intervention concept (implementation research) and an outcome concept (UHC). The two concepts of interest are implementation science and UHC. To be considered for inclusion, implementation research initiatives were any activity using a specified implementation research framework or theory design to facilitate the use of research in UHC-related planning, decision making and implementation. Studies with or without comparator between implementation research strategies and control were eligible for inclusion. Outcomes included health service coverage, access (service utilisation and quality of care) and financial risk protection, in line with the UHC Cube framework [44]. Studies that evaluated specific health programme implementation outcomes, barriers or facilitators were included, provided the implementation involved the use of specific implementation research approaches, frameworks or theories. Health systems in Africa were the context of interest. All primary study designs were eligible for inclusion. Further details about the eligibility criteria have been published elsewhere [40]. Literature focused solely or mainly on theoretical and conceptual development of implementation research were excluded, as were those evaluating implementation research knowledge and practice outcomes without interventions, those evaluating implementation outcomes without using specific implementation research frameworks and those discussing implementation research strategies that are not UHC-related. Multinational literature involving African and non-African countries and meeting inclusion criteria were excluded if country-specific information could not be abstracted. The search strategy was developed and applied in accordance with the Peer Review of Electronic Search Strategies (PRESS) guidelines [49]. It was adapted for the different databases using appropriate controlled vocabulary and syntaxes. The search strategy used search terms that are sensitive enough to capture literature relevant to implementation research, with due cognisance of the field’s diverse and overlapping nomenclature and search filters for African countries. An initial exploration of current available literature on implementation research and UHC guided the selection of search terms, ensuring they are inclusive enough to capture any UHC-related implementation research intervention. Details of the search strategies for each database are outlined in Additional file 1. A comprehensive literature search was conducted on the following electronic databases: MEDLINE (via PubMed), Scopus and Cochrane Library (including the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE)). Each database was searched from inception until August 15, 2020. Additionally, relevant grey literature was searched for implementation research-related reports, including the website of the WHO Alliance for Health Policy and Systems Research (AHPSR). Websites of known implementation research institutions, networks and collaborations were explored. We also conducted a hand-search of reference lists of relevant literature to identify for potentially eligible literature. No language restriction was applied. We planned for translation if a potentially eligible literature was published in a language other than English. Further details of the planned search strategies are described in the published review protocol [40]. The review process consisted of two levels of screening: a title and abstract screening to identify potentially eligible publications and review of full texts to select those to be included in the review based on pre-defined inclusion/exclusion criteria. For the first level of screening, titles, and abstracts of all retrieved citations from the search output were screened. Articles that were deemed relevant were included in the full-text review. In the second step, the retrieved full texts were assessed to determine if they met the inclusion/exclusion criteria. A pre-tested data extraction tool was used to extract relevant info from included literature. Extracted information included study characteristics (author, year of publication and country context), study design, implementation research details (platform, framework, strategies and target participants), UHC-related target outcomes as well as identified contextual facilitators and barriers. All extracted data were validated with the full texts before analysis.