Jovial Thomas Ntawukuriryayo

Background The Exemplars in Under-5 Mortality (U5M) was a multiple cases study of how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, we conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. Methods The cross-country analysis was based on the hybrid mixed methods implementation research framework used to inform the country case studies. The framework included a common pathway of Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS). From the existing case studies, we extracted contextual factors which were barriers, facilitators, or determinants of strategic decisions; strategies to implement EBIs; and implementation outcomes including acceptability and coverage. We identified common factors and strategies shared by countries, and individual approaches used by countries reflecting differences in contextual factors and goals. Results We found the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. We also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs. We found evidence for achieving implementation outcomes in many countries and EBIs including acceptability, coverage, equity, and sustainability. Discussion We found all six countries used a common pathway to implementation with a number of strategies common across EBIs and countries which contributed to progress, either despite contextual barriers or by leveraging facilitators. The transferable knowledge from this cross-country study can be used by other countries to more effectively implement EBIs known to reduce amenable U5M and contribute to strengthening health system delivery now and in the future.

Background Over the last eight decades, many evidence-based interventions (EBIs) have been developed to reduce amenable under-5 mortality (U5M). Implementation research can help reduce the lag between discovery and delivery, including as new EBIs emerge, or as existing ones are adapted based on new research. Rwanda was the first low-income African country to implement the rotavirus vaccine (RTV) and also adopted Option B+ for effective prevention of mother-to-child transmission (PMTCT) before the World Health Organization’s (WHO) recommendation. We use implementation research to identify contextual factors and strategies associated with Rwanda’s rapid uptake of these two EBIs developed or adapted during the study period. Methods We conducted a mixed methods case study informed by a hybrid implementation research framework to understand how Rwanda outperformed regional and economic peers in reducing U5M, focusing on the implementation of health system-delivered EBIs. The research included review of existing literature and data, and key informant interviews to identify implementation strategies and contextual factors that influenced implementation outcomes. We extracted relevant results from the broader case study and used convergent methods to understand successes and challenges of implementation of RTV, a newly introduced EBI, and PMTCT, an adapted EBI reflecting new research. Results We found several cross-cutting strategies that supported the rapid uptake and implementation of PMTCT, RTV, and leveraging facilitating contextual factors and identifying and addressing challenging ones. Key implementation strategies included community and stakeholder involvement and education, leveraging of in-country research capacity to drive adoption and adaptation, coordination of donors and implementing partners, data audit and feedback of coverage, a focus on equity, and integration into pre-existing systems, including community health workers and primary care. The availability of donor funding, culture of evidence-based decision-making, preexisting accountability systems, and rapid adoption of innovation were facilitating contextual factors. Conclusion Implementation strategies which are generalizable to other settings were key to success in rapidly achieving high acceptability and coverage of both a new and an evolving EBI. Choosing strategies which leverage their facilitating factors and address barriers are important for other countries working to accelerate uptake of new EBIs and implement needed adaptations based on emerging evidence.