The best medical treatment option in the world can’t save a single patient unless it is delivered at the proper time, with the proper plans and processes in place.
That’s why implementation science for health matters. It can best be described as a collection of principles that, if applied, will ensure the best possible health care is delivered to a specific community. It involves using evidence-based research to identify the obstacles to delivering health services, and the best ways to overcome them. The research must take into account things like geographical limitations, the social and economic make up of a community as well as cultural practices. Once established for one community, the methodology can be reused in others.
Through my own experience – as an academic and as former health minister of Rwanda – I am convinced that, unless we adopt this approach we won’t be able to achieve universal health coverage and other United Nation’s Sustainable Development Goals. This is particularly true for Africa where health services are stretched because of a lack of resources.
If we incorporate efficient, evidence-based practices into our service delivery models in Africa we’ll save millions of lives, as well as millions of dollars.
A vaccination programme rolled out in Rwanda illustrates what I mean.
The Rwandan example
In 2011 Rwanda began a vaccination programme for human papillomavirus (HPV) – the most common sexually transmitted disease in the world. 33 countries had rolled out vaccination programmes, but few of them were in developing countries and none were in Africa.
In 2010, when we were preparing our first campaign, Rwanda seemed an improbable candidate for achieving near-universal HPV vaccination coverage. After all, we were ranked the 15th poorest nation in the world. International skeptics argued that developing countries couldn’t manage because of their weak scientific base, poor infrastructure, economic difficulties and overemphasis on curative, rather than preventative, medicine.
At the time even the developed world had achieved only moderate coverage of HPV vaccinations. The US had less than 35% of its adolescent female population fully vaccinated, and France also had a low coverage. If countries like this couldn’t realise HPV universal vaccination roll-outs, how could low and medium income countries manage?
But we weren’t deterred. We convinced HPV vaccine producers to ignore the global disapproval by presenting our evidence-based strategy of how we would roll-out a programme across the country. They listened, and then signed a public private partnership agreement, which funded the programme.
What is the secret to Rwanda’s success? The answer is simple. We put our trust in implementation science.
Implementation science in action
For the rollout we collected evidence, adapted distribution methods to our setting and set clear targets and outcomes.
Every step of HPV distribution was evidence-based. To analyse the cultural implications of our program, the Ministry of Health conducted a series of interviews and discussions with community members. We set up a task force which included all stakeholders - religious, educational, political, parliamentary, and community leaders - and designed a strategy of nationwide community education to spread awareness of cervical cancer, the benefits of the vaccine, and the proper time to receive it. Since almost all types of cervical cancer are caused by the human papillomavirus, it was important first to explain the link with cancer.
Using the same focus groups, we developed a method of defining and reaching the target population. Since HPV is a sexually transmitted disease, we wanted to vaccinate girls before they became sexually active. The task force researched the proper age bracket for this. Its conclusion was that a school-based vaccination scheme of 12-year-old girls would be most effective. Over 97% of female Rwandan pre-teens are enrolled in primary school and few have sexual intercourse at that age.
Another research component was on the cold chain management. We needed to know how much vaccine to procure, how much storage space and money this would require, how many transport vehicles we would have to mobilise and where to send them. We also drew from our experience in rolling out other vaccination programs to create a rotating decentralized storage system.
Once all the evidence had been evaluated, we put a detailed delivery plan in place. We organised a distribution system to transport the vaccine from the cargo plane, to Kanombe International Airport, to the national warehouse, to the 30 district hospitals, to the 436 health centres – at that time, to the primary schools.
We also collaborated with Rwanda’s 45000 community health workers and all the teachers concerned. They identified girls who were absent from school on the day of vaccination to make sure they were covered too. And teachers were taught how to monitor students in the days after the vaccination so that they could report any adverse side-effects and be a key pillar of the HPV vaccine pharmacovigilance system.
The principles of implementation sciences applied for the success of the HPV vaccination roll-out have been used in other vaccination campaigns. Today in Rwanda we have more than 90% of all children fully vaccinated for 11 vaccines, with an additional HPV vaccine for all girls.
The need for research and education
As Vice Chancellor of the University of Global Health Equity in Rwanda we are introducing researchers to implementation science.
Like any science, it requires research. At the moment, the global focus (and therefore global funding) is on clinical research and fundamental sciences. Last year less than 2% of all research grants offered by the National Institute of Health, the largest funder of health research in the world, have been dedicated to implementation science.
But to improve health care we must also invest in implementation research to improve service delivery. Sure, we need basic science to create cheaper, more effective technology. But we also need implementation science to provide cost-effective ways of delivering and promoting universal health coverage.