Implementation research: From silos to synergy – an emerging story from Pakistan

“Identifying pockets of highest refusal rate for polio vaccination in selected districts of Khyber Pakhtunkhwa province was the starting point of my study – the field workers in my team precisely knew the coordinates of chronic refusal cases…”  “We could not have investigated political patronage and nepotism in human resource management in Balochistan’s health sector without an insider’s support to our research”. “This is one of the easiest data collection exercises of my 25 years of research career – the local health official in our team ensured that we are able to reach the lady health workers and traditional birth attendants (community health workers) in remotest areas of rural Sindh”. “Our study required access to administrative data in four districts in Punjab, we could not have navigated through the cumbersome bureaucratic approval procedures within two weeks without the support of the high-level government official in our team”. These are some of the reflections shared by the research teams during my on-site visits to ten different implementation research projects across the four provinces in Pakistan.

The teams seemed to be surprisingly pleased with the support they were receiving from their partners – the implementers (policy makers, managers and frontline workers) of the Expanded Program for Immunisation (EPI) in Pakistan. 

During my visits, I tried to capture the views of the EPI program implementers as well. “Every year, three to five thick reports with a long list of recommendations are brought on my table, I seldom get a chance to skim through them, but this time, I am co-producing the required knowledge….” remarked a high-level EPI policy maker. “We have tested an intervention in three districts and it seems to be working well, this study is helping me understand the enablers and barriers for scaling up the intervention to all districts in the province…….” stated a program manager. “I always thought that research is for academics…being involved in this study right from identifying a relevant research question to synthesizing findings for policy makers, I am finding the research useful for me too….” commented a front-line vaccinator.

While debriefing the steering committee members of this initiative about my on-site visits, I told them that from the usual experience of working in silos, this partnership is resulting in an effective synergy between the implementers and researchers. This implementation research initiative started in December 2016 with the financial support of Global Alliance for Vaccine & Immunisation (GAVI) and is being technically supported by UNICEF, Alliance for Health Policy & Systems Research (AHPSR) and Health Services Academy, Islamabad. Its aim is to assess health systems bottlenecks in Pakistan’s EPI program. It started with a literature review on knowledge gaps in implementation of the immunisation program in Pakistan. This was followed by orienting, sensitizing, and engaging implementers of the EPI program in implementation research through a policy makers’ led workshop. Based on key areas of research prioritized by the program implementers, a call for research proposals was issued. 10 research teams, each led by an EPI program implementer was selected through a peer review process. The areas of research include, EPI – Polio programs synergy; vaccine supply chain management; scale-up of innovative mobile phone applications being used for improving vaccination coverage data and vaccinators’ performance; behavioral change communication to minimise vaccine hesitancy; ethnic, religious, and cultural barriers for vaccine refusal; supportive supervision to enhance health workers performance; utilising traditional birth attendants (informal healthcare workers) for vaccine related referrals; and governance strategies to strengthen human resource accountability.

After the selection of teams, a protocol development workshop was conducted. Most of the researchers and implementers grappled with working together for the first time. Initially, it was difficult for both sides to balance the need for rigor in research with the time and resources available, and on-ground program implementation challenges. With the facilitation and support from technical partners, the research questions and related methodologies were refined. Since then, I have been technically supporting all the 10 teams and have found the rocky road getting smoother for most of the teams. 80% of them have completed their data collection and are now drafting their final reports.

Acknowledging the need and relevance of implementation research for broader health systems issues in the country, Health Services Academy has recently dedicated a session on preliminary findings of this research initiative in its annual public health conference being held on December 6, 2017. Teams are expected to finalise their reports by the end of this year and a dissemination workshop is being planned by AHPSR and UNICEF in the first quarter of 2018.

The final research findings and their influence on EPI program’s future policies and implementation mechanism is still to be seen. But observing the increasing need for locally generated, timely evidence for the ongoing large-scale health systems reforms in the country and first-hand coordination of interaction among a diverse group of implementers and health systems researchers located in four provinces, I strongly feel that implementation research can effectively bridge the evidence to policy disconnect in Pakistan.