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

bstract 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. (Continued on next page) © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( data made available in this article, unless otherwise stated in a credit line to the data. * Correspondence: 1 Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa 2 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa Full list of author information is available at the end of the article Nnaji et al. BMC Health Services Research (2021) 21:414 Content courtesy of Springer Nature, terms of use apply. Rights reserved. (Continued from previous page) 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 mixedmethods 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. Keywords: Implementation research, Evidence, Universal health coverage, Access, Equity Background The need for health decision making to be informed by empirical evidence has been identified as a vital step for achieving universal health coverage (UHC) and equitable access to high quality health care [1, 2]. It has been recognised that decisions informed by research evidence have the potential to promote equitable service delivery and improve health outcomes at population level, while strengthening health systems [2]. The World Health Organization (WHO) defines UHC as “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship” [3]. Since the 1978 Alma-Ata Declaration and the 1986 Ottawa Charter for Health Promotion, the right to the highest attainable standard of physical and mental health has gained increasing attention [4]. As a result of this prioritisation, UHC was adopted as a target of the Sustainable Development Goals (SDG), with the aspiration that countries will achieve this by 2030 [5]. With the increasing momentum of global efforts towards the attainment of UHC, countries are often faced with difficult choices regarding the most effective use of available health resources, particularly in contexts of resource limitation, competing healthcare needs and political priorities [6]. Given this inherent complexity, UHC decision making requires adequate consideration of best available and contextually applicable research evidence [6, 7]. While investment in health research and research outputs have grown considerably in Africa over the years, there remain enormous gaps in translating available research evidence into health policy and practice [8]. This so-called ‘know–do gap’ has resulted in suboptimal gains from allocated health resources, in spite of growing investment towards the actualisation of UHC in Africa [2, 9]. The gap is accentuated by the region’s high burden of communicable and non-communicable diseases [10, 11]. Implementation science has emerged in response to this critical gap [12]. Implementation science is an integral part of the broader Evidence-informed Decision Making (EIDM) enterprise. EIDM involves processes of distilling and disseminating the best available evidence from research, practice and experience and using that evidence to inform and improve public health policy and practice [13, 14]. Knowledge translation, knowledge transfer and translational research are EIDM concepts that are closely related to implementation science, used to refer to the processes of moving research-based evidence into policy and practice, through the synthesis, dissemination, exchange and application of knowledge to improve the health of the population [13, 15–17]. Although there may be nuanced differences in their conceptualisation, these terms essentially have similar goals and practical implications for improving health outconmes [15–17]. There has been no clear consensus on the definition of implementation science [18]. In 2015, Odeny and colleagues published a review of the literature that found 73 unique definitions [19]. Broadly, implementation science has been defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services.” [16] Since the field of implementation science has cogent applications for both clinical and Nnaji et al. BMC Health Services Research (2021) 21:414