Breneol et al. Health Research Policy and Systems (2022) 20:64 https://doi.org/10.1186/s12961-022-00865-8

REVIEW

Strategies to adapt and implement health system guidelines and recommendations: a scoping reviewSydney Breneol1,2, Janet A. Curran1,2* , Robert Marten3, Kirti Minocha1, Catie Johnson1,2, Helen Wong1,4, Etienne V. Langlois5, Lori Wozney6, C. Marcela Vélez7, Christine Cassidy1,2, Sanjay Juvekar8, Melissa Rothfus9, Lydia Aziato10, Lisa Keeping‑Burke11, Samuel Adjorlolo12 and Daniel F. Patiño‑Lugo7

Abstract

Background: Evidence‑based health system guidelines are pivotal tools to help outline the important financial, policy and service components recommended to achieve a sustainable and resilient health system. However, not all guidelines are readily translatable into practice and/or policy without effective and tailored implementation and adaptation techniques. This scoping review mapped the evidence related to the adaptation and implementation of health system guidelines in low‑ and middle‑income countries.

Methods: We conducted a scoping review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was implemented in MEDLINE (Ovid), Embase, CINAHL, LILACS (VHL Regional Portal), and Web of Science databases in late August 2020. We also searched sources of grey literature and reference lists of potentially relevant reviews. All findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta‑Analyses Extension for Scoping Reviews.

Results: A total of 41 studies were included in the final set of papers. Common strategies were identified for adapt‑ing and implementing health system guidelines, related barriers and enablers, and indicators of success. The most common types of implementation strategies included education, clinical supervision, training and the formation of advisory groups. A paucity of reported information was also identified related to adaptation initiatives. Barriers to and enablers of implementation and adaptation were reported across studies, including the need for financial sustain‑ability. Common approaches to evaluation were identified and included outcomes of interest at both the patient and health system level.

Conclusions: The findings from this review suggest several themes in the literature and identify a need for future research to strengthen the evidence base for improving the implementation and adaptation of health system guidelines in low‑ and middle‑income countries. The findings can serve as a future resource for researchers seeking to evaluate implementation and adaptation of health system guidelines. Our findings also suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local contexts and health system arrangements in low‑ and middle‑income countries.

Keywords: Health systems, Global health, Scoping review, Implementation science, Evidence‑informed guidelines

© The Author(s) 2022. 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 http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Open Access

*Correspondence: jacuran@dal.ca

1 School of Nursing, Faculty of Health, Dalhousie University, Halifax, CanadaFull list of author information is available at the end of the article

Page 2 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

BackgroundEvidence-informed guidelines are pivotal to reform-ing healthcare and strengthening health systems for healthier communities worldwide [1, 2]. WHO concep-tualizes guidelines as a set of evidence-informed recom-mendations related to practice, public health or policy for informing and assisting decision-makers (e.g. policy-makers, healthcare providers or patients) [3]. In contrast to clinical practice guidelines focused on the appropriate-ness of clinical care activities, health system guidelines outline the required system, policy and/or finance com-ponents recommended to address health challenges [4, 5].

Despite the rigorous systematic synthesis of current research evidence focused on the development of high-quality guidelines, not all guidelines are readily and directly translatable into practice and/or policy [6, 7]. According to Balas and Boren, the small proportion of published evidence (approximately 14%) that does trans-late into practice can take upwards of 17 years from start to finish [8, 9]. Understanding implementation and adap-tation strategies that facilitate the uptake of evidence-informed guidelines and recommendations is an urgent research and policy priority [10–13]. Implementation strategies are often defined as “methods or techniques used to enhance the adaptation, implementation, and sustainability of a program or practice” [14]. Guideline adaptation strategies involve systematically modifying guidelines developed in a specific environment to be suitable for application in other contextual settings (e.g. organizational or cultural) [15].

A review of WHO guidelines by Wang et  al. [16] revealed a lack of implementation strategies that were evidence-based and involved active techniques (e.g. workshops, evaluation surveys, training) within their relevant implementation sections. WHO is currently focused on enhancing the adaptability of guidelines [17] and integrating adaptation strategies into their imple-mentation plans [18]. For successful uptake, even high-quality international guidelines require adapting and tailoring to local contexts or circumstances [19]. To help achieve success, the Alliance for Health Policy and Sys-tems Research (a WHO-hosted partnership) created the Research to Enhance the Adaptation and Implementation of Health Systems Guidelines (RAISE) portfolio, which aims to support decision-making on policy and systems in six low- and middle-income countries (LMICs) [20]. However, much remains to be known about the factors and processes to enhance their adaptation and imple-mentation [16, 20]. Additional evidence is needed to inform good practices, effective methods and evidence-based implementation and adaptation recommendations for the utilization of health system guidelines.

Neglecting to consider the interaction between con-textual factors and guideline uptake is likely to lead to underperformance or failure [21–25]. It is important to recognize political, cultural and socioeconomic contexts and how these intersectional factors can influence health system guideline implementation and adaptation pro-cesses. Several methods have been derived for the selec-tion and tailoring of implementation strategies to address these contextual needs [26]. Various taxonomies have been established as a means to better describe and cate-gorize implementation strategies [27–33] and to concep-tualize context to allow for the analysis of determinants (e.g. barriers and enablers) of implementation outcomes [34]. Frameworks have also been identified for adapt-ing health-related guidelines, but often lack guidance on implementation [18, 35]. Therefore, the best methods for developing tailored implementation strategies and select-ing adaptation frameworks remain to be identified [12, 18].

We conducted a preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports. No reviews were identified that addressed adapting and implementing health system guidelines in LMICs. The search revealed a related overview of systematic reviews examining the effects of implementation techniques for health system initiatives that were deemed relevant to low-income countries (LICs) [36]. Despite this review and the acknowledged contextual differences between LICs and high-income countries (HICs), the findings were derived primarily from studies conducted in HICs, leaving a significant gap in the literature examining any contextual nuances of implementation and adaptation of health system guidelines specifically in LMICs.

The objective of this scoping review is unique, as it provides an overview of available evidence related to the implementation and adaptation of health system guidelines evaluated in LMICs. A focus on adaptation and implementation processes is a novel contribution in the literature by examining both of their strategies, interactions and influences. Recognizing the intricacy of contextual factors, we will only be examining implemen-tation and adaptation strategies that directly happened in LMICs. We adopted an integrated knowledge transla-tion approach by collaborating with a broad range of key informants, including the lead of each partner country in the WHO RAISE portfolio, throughout the review process to help ensure that the findings were relevant to knowledge users. Integrated knowledge translation is an approach to research where researchers and end-users work collaboratively to identify relevant knowledge gaps and ensure the production of actionable knowledge [37].

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The results of this scoping review provide critical insight into the development of evidence-based implementa-tion and adaptation recommendations for health system guidelines in LMICs.

Review aimsThis scoping review assessed and mapped the available evidence related to adapting and implementing health system guidelines and recommendations in LMICs. The following research questions guided the review:

1. What are the common strategies and approaches for implementing health system guidelines and recom-mendations in LMICs?

2. What are the common strategies and approaches for adapting health system guidelines and recommenda-tions in LMICs?

3. What are the commonly reported outcomes or indi-cators of success in adaptation and/or implementa-tion of health system guidelines and recommenda-tions in LMICs?

4. What are the commonly reported barriers and facili-tators with respect to adaptation and/or implemen-tation of health system guidelines and recommenda-tions in LMICs?

MethodsThis scoping review was guided by the methodologi-cal framework outlined by the JBI [38]. The framework includes six phases: (i) identifying the research ques-tion; (ii) searching for studies; (iii) selecting studies; (iv) extracting, charting and appraising data; (v) synthesizing and reporting findings; (vi) consulting with experts and key stakeholders [38].

Inclusion criteriaPopulationIn alignment with the Effective Practice and Organisation of Care (EPOC) taxonomy of health system interventions [39], this review considered articles including any health-care organizations, healthcare professionals or healthcare recipients targeted for change by health system guide-lines within LMICs.

ConceptThe concepts relevant for this review consist of the implementation and adaptation strategies, frameworks, and barriers and/or facilitators related to the adaptation and/or implementation of health system guidelines, poli-cies and/or recommendations. Articles were required to explicitly state their intent to implement and/or adapt any evidence-informed health system guideline to be

considered for inclusion. Health systems were concep-tualized to encompass any system responsible for the provision of health services, finances, and/or governance [40]. Our review considered any evidence-informed (as reported by author) health system guidelines, regardless of the developer. Articles that described their intent to implement and/or adapt clinical practice guidelines were excluded.

Implementation and adaptation, while often under-taken simultaneously, are two distinct concepts being examined by this review. Implementation strategies were defined as any “methods or techniques used to enhance the adaptation, implementation, and sustainability” [14]. Adaptation strategies were defined as a “process of thoughtful and deliberate alteration to the design or delivery of an intervention, with the goal of improving its fit or effectiveness in a given context” [41]. Articles were required to report on the implementation and/or adap-tation of health system guidelines to be considered for inclusion.

ContextContext in this review involved adaptation and/or imple-mentation strategies applied in LMICs at a health system level. LMICs were defined by the World Bank standards based on gross national income for the 2021 fiscal year [42]. Studies or data related to HICs were excluded from this review.

Types of sourcesThis scoping review considered any quantitative, quali-tative or mixed-methods studies that evaluated the implementation and/or adaptation of health system guidelines in any LMICs. Articles that were descriptive in nature (e.g. editorials, commentaries, opinion papers) or did not have evaluation processes for assessing the implementation/adaptation strategy were excluded. Lit-erature reviews that reported on relevant concepts were first reviewed for primary studies and then ultimately excluded. Studies published in English, not restricted by date of publication, were included.

Search strategyThe search strategy aimed to locate both published and unpublished studies. An initial search of MEDLINE (Ovid) was undertaken by a librarian scientist to iden-tify relevant studies of interest. The search strategy was developed using Medical Subject Headings (MeSH) terms and keywords contained in the titles and abstracts of relevant articles. A full search strategy for MEDLINE (Ovid) is included in our Additional file  1. This search strategy underwent peer review by another librarian using the Peer Review of Electronic Search Strategies

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(PRESS) [43] to ensure its accuracy. The search strategy was then adapted for each included information source. Lastly, primary studies from identified literature reviews were scanned for additional studies.

Information sourcesWe employed our search strategy in MEDLINE (Ovid), Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Sciences Literature; VHL Regional Portal), and Web of Science databases. Sources of grey literature included a search of the CADTH (Canadian Agency for Drugs and Technologies in Health) Grey Mat-ters Tool, Google, Google Scholar, and ProQuest Disser-tations & Theses Global. These databases were chosen to capture potential articles across relevant countries.

Study selectionSearch results were uploaded into Covidence system-atic review software [45] for reference management. To ensure that eligibility criteria were uniformly applied by all reviewers, team members independently pilot-tested 20 citations and met to resolve any areas in need of clari-fication. Two reviewers then independently screened all titles and abstracts for assessment against the inclusion criteria. Full-text articles of potentially relevant stud-ies were retrieved, and two reviewers independently assessed the full-text studies for eligibility. Disagreements between reviewers were resolved through discussion at each stage of the study selection process. If consensus could not be achieved, a third reviewer made the final decision. Reasons for exclusion of full-text studies were documented and are reported in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Exten-sion for Scoping Reviews (PRISMA-ScR) flow diagram [46].

Data extractionData were extracted using a predetermined extrac-tion form to collect key findings relevant to the scoping review questions (Additional file  2). The main concepts in the data extraction form included year of publication, country, study aim(s), study population, setting, funding source, use of theoretical/conceptual frameworks, guide-line description, implementation strategies, adaptation strategies, outcomes of interest, study methods, barriers and enablers, key results and stakeholder engagement [38]. Details regarding implementation strategies were extracted based on Proctor and colleagues’ recommen-dations for operationalizing and reporting implemen-tation techniques [14]. This data extraction framework facilitated the collection of specific and pertinent data related to reported implementation strategies, such as

duration, dose and justification. Further, the Framework for Reporting Adaptations and Modifications–Enhanced (FRAME) was used to guide data extraction of adapta-tion strategies to capture the who, where, when, why and how aspects of modifications [41]. As this review seeks to examine implementation and adaptation as two dis-tinct concepts, data on implementation and adaptation strategies were extracted independently of each other. If articles reported on both implementation and adap-tation strategies, concepts related to processes such as barriers, enablers and outcomes were extracted indepen-dently. This could only be accomplished if authors explic-itly stated which indicators (e.g. barriers, enablers and outcomes) related to which concepts (implementation or adaptation). If this level of detail was not provided, the data were still extracted but we were unable to infer which indicators related to which concepts. Data were also extracted if authors reported using a theoretical/conceptual framework to guide/justify their implementa-tion and/or adaptation techniques. Two reviewers inde-pendently extracted details from the included articles, and disagreements were resolved with a third reviewer.

Quality assessmentThe quality of included studies was assessed using the JBI’s critical appraisal tools and the mixed-methods appraisal tool [47, 48]. Two reviewers independently completed the quality assessment. Any disagreements were resolved through discussion. The results of this quality assessment were not used to exclude studies from the review but rather to provide greater insight into the current body of literature on this topic.

Data analysisWe began by categorizing each health system guideline based on the six “building blocks” that WHO identifies as core components to strengthening health systems: (1) service delivery, (2) health workforce, (3) health informa-tion systems, (4) access to essential medicines, (5) financ-ing and (6) leadership or governance [49]. Health system guidelines were categorized into these building blocks based on their primary aim. Subsequently, directed con-tent analysis was used to map implementation strategies according to the list of 73 implementation strategies and definitions outlined in the Expert Recommendations for Implementing Change (ERIC) project [28]. The ERIC framework was developed through iterative consultations with experts and literature to derive a comprehensive list of known implementation strategies [28]. Analysis was completed by two reviewers independently, and disa-greements were resolved through consensus. Guided by the FRAME, thematic analysis was used to examine and group similarities in adaptation strategies and the who,

Page 5 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

what, where, why and when of any modification that took place. Lastly, the Capability, Opportunity and Motiva-tion Behaviour (COM-B) model guided the coding of the reported barriers to and enablers of implementation and adaptation [30, 50]. The COM-B model is a theoretically driven, evidence-based framework that outlines a sys-tematic process to identify and understand barriers and enablers with respect to implementation/adaptation of health initiatives [30, 50]. This model also links the iden-tified barriers and enablers to the required mechanisms needed to enact change [51]. Mapping the findings onto published taxonomies, such as the ERIC framework to classify implementation strategies, the FRAME to detail important considerations to adaptation techniques, and the COM-B model to map barriers and enablers, allows for the identification of possible gaps in current knowl-edge and opportunities for future research [52]. Further, results summaries were stratified per LMIC lending groups (low-, lower-middle and upper-middle-income)

and by using WHO’s six building blocks to assess for potential trends [49].

Descriptive summary tables of all included studies were created to outline extracted data specific to the health system guidelines, implementation strategies, adapta-tion strategies, outcomes/results, and article characteris-tics. Narrative summaries were included to address each research question.

ResultsA total of 8622 unique references were identified from the search strategy. No additional citations were uncov-ered by searching the reference lists of relevant reviews or grey literature sources. After title and abstract screen-ing, 284 papers remained for full-text review. Following this second stage of review, 41 articles were included for data analysis (see Fig. 1 for Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] dia-gram) [53].

Fig. 1 PRISMA diagram

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Article summary characteristicsIdentified articles were published between 2005 and 2010 (n = 6), 2011–2015 (n = 10), and 2016 and beyond (n = 25) (see Fig. 2). Studies were most frequently con-ducted in upper-middle-income countries (n = 21), fol-lowed by lower-middle-income countries (n = 14) and LICs (n = 5) (see Fig.  3). One study reported on case study findings from low-, middle-, and upper-middle-income countries. Twenty-two studies used qualitative methods, 14 studies employed mixed methods, and five used cross-sectional methods to answer their research questions. Sources of funding varied among studies and often included multiple sources (see Fig.  4). Most studies reported funding from an HIC source (n = 21) (e.g. Irish Aid, and United Kingdom’s Wellcome Trust). Other studies reported funding from local country/context initiatives (n = 6) and high-income and local

country partnerships (n = 5). The remaining reported that no funding was received (n = 2) or did not report information on funding (n = 7). Healthcare work-ers and end-users were the most commonly targeted study populations. Settings varied across urban and rural locations and community and hospital sites. Arti-cles reported implementing health system guidelines in urban hospitals (n = 7), both urban and rural com-munities (n = 7), only urban communities (n = 7), and both urban and rural hospitals (n = 5). Only one arti-cle reported on implementation of a guideline in both urban and rural clinics and hospitals. Please refer to Table  1 for a full summary of article characteristics. Any acronyms used in the tables can also be found in Additional file 3.

Fig. 2 Yearly publication trend

Fig. 3 Geographical clustering of health system initiatives

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Health system guidelinesTable 2 summarizes the health system guidelines imple-mented in the included studies. While specific guidelines varied across studies, out of the total 41 studies, three reported on implementation of the Integrated Manage-ment of Childhood Illness (IMCI) guidelines and another three outlined the Prevention of Mother-to-Child Trans-mission of HIV/AIDS guidelines.

Service delivery was the health system building block most frequently targeted by the identified guidelines (n = 24). The remaining building blocks were targeted as follows, in descending order: health workforce (n = 5), financing (n = 4), access to essential medicine (n = 4), health information system (n = 2), and leadership and governance (n = 2).

Adaptation strategiesOnly 14 articles explicitly reported on the concept of adaptation. Rarely did articles specifically comment on the strategies used to determine what and why adapta-tions were necessary. Those that reported how adap-tations occurred often described any modifications as being suggested solutions to identified challenges dur-ing both pre- and post-implementation. Three articles also described a dedicated multidisciplinary working group aimed to gather feedback and identify required

modifications. Six articles reported adaptations to be reactive in nature and another six reported them to be proactively planned. Modifications made were frequently reported as adding, tailoring or tweaking content ele-ments, such as the addition of training sessions, expand-ing scope of practices and restructuring funding sources. None of the included articles reported using a guiding framework to help identify areas where adaptation could be beneficial and/or necessary. A full summary of the adaptation strategies and their related concepts accord-ing to the FRAME is given in Table 3.

Implementation strategiesEleven articles included in our review did not provide sufficient detail to adequately discern the strategies used to implement their health system guideline. 38 out of the 72 ERIC-defined implementation strategies were utilized across all 41 studies. A small number of reported imple-mentation strategies were determined by consensus to fall under two separate ERIC categories and were coded as such. Studies reported a range of one to eight strate-gies to implement their health system initiative, with an average of four distinct implementation strategies. Conducting ongoing training was identified as the most frequent implementation strategy (n = 11), followed by building a coalition (n = 8), use of advisory boards and workgroups (n = 6), conducting educational meetings

Fig. 4 Reported funding sources. *One article may have reported multiple funding sources

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Tabl

e 1

Sum

mar

y of

art

icle

cha

ract

eris

tics

Year

Aut

hor(

s)Co

untr

y (in

com

e br

acke

t)Fu

nded

by

Stud

y m

etho

dsSt

udy

popu

latio

nSt

udy

sett

ing

Qua

lity

appr

aisa

l

2008

Am

aral

et a

l. [8

2]Br

azil

(upp

er‑m

iddl

e‑in

com

e)Bi

ll &

Mel

inda

Gat

es

Foun

datio

nC

ross

‑sec

tiona

l eco

logi

cal

stud

yH

ealth

care

pro

fess

iona

ls,

heal

th s

yste

m o

rgan

iza‑

tion,

fam

ily a

nd c

omm

u‑ni

ty p

ract

ice

Mun

icip

aliti

es w

ith a

po

pula

tion

betw

een

5000

an

d 50

,000

inha

bita

nts

100%

(hig

h)

2011

Blan

co‑M

anci

lla [8

4]M

exic

o (u

pper

‑mid

dle‑

inco

me)

Not

repo

rted

Qua

litat

ive

Med

ical

pro

fess

iona

ls w

ho

inte

ract

with

ser

vice

use

rs

or p

atie

nts

Hos

pita

ls a

nd h

ealth

ce

ntre

s10

0% (h

igh)

2007

Leet

hong

dee

[83]

Thai

land

(upp

er‑m

iddl

e‑in

com

e)Ro

yal T

hai G

over

nmen

tO

ffice

of E

duca

tiona

l A

ffairs

(Kor

‑Por

Lon

don)

Civ

il Se

rvic

e Co

mm

issi

on

Offi

ce (K

or‑P

or T

haila

nd)

Qua

litat

ive

Pers

onne

l who

wor

ked

in th

e pu

blic

hea

lthca

re

syst

em o

vers

een

by th

e m

inis

try

of h

ealth

Publ

ic h

ealth

100%

(hig

h)

2018

Zaku

mum

pa e

t al.

[85]

Uga

nda

(low

‑inco

me)

Cons

ortiu

m fo

r Adv

ance

d Re

sear

ch T

rain

ing

in A

frica

(C

ART

A)

Wel

lcom

e Tr

ust (

Uni

ted

King

dom

)D

epar

tmen

t for

Inte

rna‑

tiona

l Dev

elop

men

t (D

FID

)Ca

rneg

ie C

orpo

ratio

n of

N

ew Y

ork

Ford

Fou

ndat

ion

Mac

Art

hur F

ound

atio

n

Mix

ed‑m

etho

ds s

eque

ntia

l ex

plan

ator

yH

eads

of t

he A

RT c

linic

, he

ad n

urse

s, H

R m

anag

ers,

clin

icia

ns, fi

nanc

e m

anag

‑er

s, st

rate

gy d

irect

ors

Vario

us h

ealth

faci

litie

s in

per

i‑urb

an s

ettin

gs o

r ur

bani

zed

part

s of

rura

l ar

eas

100%

(hig

h)

2020

Mig

uel‑E

spon

da e

t al.

[69]

Mex

ico

(upp

er‑m

iddl

e‑in

com

e)N

o fin

anci

al s

uppo

rt

rece

ived

Mix

ed‑m

etho

ds c

onve

r‑ge

nt s

tudy

des

ign

Serv

ice

user

s re

gist

ered

in

the

heal

th in

form

atio

n sy

stem

(HIS

)

Ten

rura

l prim

ary

heal

thca

re (P

HC

) clin

ics

supp

orte

d by

CES

[Com

‑pa

ñero

s En

Sal

ud]

93%

(hig

h)

2020

Calla

ghan

‑Kor

u et

al.

[86]

Bang

lade

sh (l

ower

‑mid

dle‑

inco

me)

Uni

ted

Stat

es A

genc

y fo

r In

tern

atio

nal D

evel

opm

ent

(USA

ID)

Qua

litat

ive

case

stu

dyM

othe

rs w

ith c

hild

ren

givi

ng b

irth

In h

ospi

tal s

ettin

g—bi

rth‑

ing

units

90%

(hig

h)

2020

Mut

abaz

i et a

l. [8

7]Su

b‑Sa

hara

n A

frica

(low

‑in

com

e)Ca

nadi

an In

stitu

te o

f H

ealth

Res

earc

h (C

IHR)

(C

anad

a)In

tegr

ated

Inte

rven

tion

for D

iabe

tes

Risk

aft

er

Ges

tatio

nal D

iabe

tes

in

Sout

h A

frica

(IIN

DIA

GO

) (S

outh

Afri

ca)

Des

crip

tive

qual

itativ

e st

udy

Preg

nant

wom

en, w

omen

in

labo

ur/d

eliv

ery

and

brea

stfe

edin

g, fr

ontli

ne

wor

kers

Publ

ic h

ealth

faci

litie

s90

% (h

igh)

Page 9 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 1

(con

tinue

d)

Year

Aut

hor(

s)Co

untr

y (in

com

e br

acke

t)Fu

nded

by

Stud

y m

etho

dsSt

udy

popu

latio

nSt

udy

sett

ing

Qua

lity

appr

aisa

l

2018

Sadd

i et a

l. [8

8]Br

azil

(upp

er‑m

iddl

e‑in

com

e)G

radu

ate

Stud

ies

Coor

di‑

natio

n Bo

ard

(Coo

rdin

atio

n fo

r the

Impr

ovem

ent o

f H

ighe

r Edu

catio

n Pe

rson

‑ne

l [C

APE

S])

Braz

ilian

Min

istr

y of

Edu

ca‑

tion

Fede

ral U

nive

rsity

of G

oiás

(U

FG) O

ffice

of t

he D

ean

of

Exte

nsio

n an

d Re

sear

ch

Cont

inge

nt m

ixed

‑met

h‑od

s ap

proa

chFr

ontli

ne h

ealth

wor

kers

; m

anag

ers,

nurs

esH

ealth

care

uni

ts in

G

oiân

ia; p

rimar

y ca

re

sett

ing

86%

(hig

h)

2015

Xia

et a

l. [8

9]C

hina

(upp

er‑m

iddl

e‑in

com

e)Ce

ntre

for E

nviro

nmen

t an

d Po

pula

tion

Hea

lth

(Griff

th U

nive

rsity

)

Mix

ed m

etho

dsPr

egna

nt w

omen

ser

vice

us

ers

Mat

erna

l and

chi

ld h

ealth

‑ca

re h

ospi

tals

86%

(hig

h)

2014

Arm

stro

ng e

t al.

[90]

Tanz

ania

(low

er‑m

iddl

e‑in

com

e)Ev

iden

ce fo

r Act

ion

Tanz

ania

Qua

litat

ive

Hea

lthca

re p

rofe

ssio

nals

, he

alth

sys

tem

coo

rdin

a‑to

rs, d

istr

ict,

regi

on a

nd

zona

l hea

lth a

dmin

istr

ator

s

One

regi

onal

refe

rral

ho

spita

l, on

e go

vern

men

t di

stric

t hos

pita

l and

one

fa

ith‑b

ased

dis

tric

t hos

pita

l

80%

(hig

h)

2011

Ditl

opo

et a

l. [9

1]So

uth

Afri

ca (u

pper

‑mid

‑dl

e‑in

com

e)Iri

sh A

idQ

ualit

ativ

e ca

se s

tudy

de

sign

Polic

y‑m

aker

s, ho

spita

l m

anag

ers,

nurs

es a

nd

doct

ors

Pred

omin

antly

dis

tric

t rur

al

hosp

itals

80%

(hig

h)

2017

Doh

erty

et a

l. [9

2]U

gand

a (lo

w‑in

com

e)Sw

edis

h an

d N

orw

egia

n go

vern

men

t age

ncie

sSo

uth

Afri

can

Med

ical

Re

sear

ch C

ounc

il

Des

crip

tive

qual

itativ

eIm

plem

enta

tion

part

ners

, M

inis

try

of H

ealth

, mul

tilat

‑er

al a

genc

ies

(UN

ICEF

and

W

HO

), di

stric

t man

age‑

men

t, co

mm

unity

‑ and

fa

cilit

y‑ba

sed

heal

th

wor

kers

All

four

regi

ons

of th

e co

untr

y80

% (h

igh)

2019

Love

ro e

t al.

[93]

Sout

h A

frica

(upp

er‑m

id‑

dle‑

inco

me)

Nat

iona

l Ins

titut

e of

Men

tal

Hea

lth (N

IMH

) Wai

nber

g/A

rbuc

kle

Trai

ning

Gra

ntU

nite

d St

ates

Pre

side

nt’s

Emer

genc

y Pl

an fo

r AID

S Re

lief (

PEPF

AR)

Mix

ed‑m

etho

ds e

xplo

ra‑

tory

des

ign

Dis

tric

t‑le

vel p

rogr

amm

e m

anag

ers

(DPM

s)U

rban

and

rura

l prim

ary

care

clin

ics

thro

ugho

ut

dist

rict

80%

(hig

h)

2014

Mko

ka e

t al.

[94]

Tanz

ania

(low

er‑m

iddl

e‑in

com

e)Sw

edis

h In

tern

atio

nal

Dev

elop

men

t Coo

pera

tion

Age

ncy

(Sid

a)

Qua

litat

ive

appr

oach

Dis

tric

t med

ical

offi

cer

(DM

O),

dist

rict n

ursi

ng

office

r (D

NO

), di

stric

t he

alth

offi

cer (

DH

O),

dis‑

tric

t hea

lth s

ecre

tary

(DH

S),

and

dist

rict p

harm

acis

t (D

P)

A ty

pica

l rur

al d

istr

ict

80%

(hig

h)

Page 10 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 1

(con

tinue

d)

Year

Aut

hor(

s)Co

untr

y (in

com

e br

acke

t)Fu

nded

by

Stud

y m

etho

dsSt

udy

popu

latio

nSt

udy

sett

ing

Qua

lity

appr

aisa

l

2016

Mos

hiri

et a

l. [9

5]Ira

n (u

pper

‑mid

dle‑

inco

me)

Scho

ol o

f Pub

lic H

ealth

Re

sear

ch D

eput

y of

the

Tehr

an U

nive

rsity

of M

edi‑

cal S

cien

ces

(TU

MS)

Qua

litat

ive

Des

igne

rs o

f pub

lic h

ealth

fa

cilit

ies,

prov

inci

al h

ealth

m

anag

ers,

com

mun

ity

heal

th w

orke

rs a

nd tw

o fo

rmer

hea

lth m

inis

ters

Rura

l hea

lthca

re fa

cilit

ies

80%

(hig

h)

2020

Mut

hath

i et a

l. [9

6]So

uth

Afri

ca (u

pper

‑mid

‑dl

e‑in

com

e)So

uth

Afri

can

Rese

arch

C

hairs

Initi

ativ

e (S

ARC

hI)

Dep

artm

ent o

f Sci

ence

an

d In

nova

tion

(Sou

th

Afri

ca)

Nat

iona

l Res

earc

h Fo

unda

‑tio

n (S

outh

Afri

ca)

Atla

ntic

Phi

lant

hrop

ies

Nes

ted

qual

itativ

e st

udy

Hea

lth p

olic

y ac

tors

: na

tiona

l gov

ernm

ent,

pro‑

vinc

ial g

over

nmen

t hea

d offi

ce, d

istr

ict,

subd

istr

ict

and

loca

l gov

ernm

ent

Urb

an a

nd ru

ral p

rovi

nces

80%

(hig

h)

2017

Schn

eide

r and

Nxu

mal

o [9

7]So

uth

Afri

ca (u

pper

‑mid

‑dl

e‑in

com

e)Ca

nadi

an In

tern

atio

nal

Dev

elop

men

t Res

earc

h Ce

ntre

(ID

RC)

Fund

ed th

roug

h a

varie

ty

of o

ther

mec

hani

sms

that

w

ere

not r

epor

ted

Qua

litat

ive

case

stu

dyCo

mm

unity

hea

lthCo

mm

unity

car

e, p

rimar

y ca

re c

linic

s80

% (h

igh)

2010

Shei

kh e

t al.

[98]

Indi

a (lo

wer

‑mid

dle‑

inco

me)

Aga

Kha

n Fo

unda

tion’

s In

tern

atio

nal S

chol

arsh

ip

Prog

ram

me

DFI

D TA

RGET

S Co

nsor

tium

at

the

Lond

on S

choo

l of

Hyg

iene

& T

ropi

cal M

edi‑

cine

(LSH

TM)

Uni

vers

ity o

f Lon

don

Cent

ral R

esea

rch

Fund

Qua

litat

ive

case

stu

dyPu

blic

hea

lth a

utho

ritie

s, ho

spita

l adm

inis

trat

ors,

med

ical

pra

ctiti

oner

s

Publ

ic h

ealth

faci

litie

sPr

ivat

e he

alth

80%

(hig

h)

2016

Shel

ley

et a

l. [9

9]Ea

st A

frica

(low

er‑m

iddl

e‑in

com

e)D

FID

(Uni

ted

King

dom

)Q

ualit

ativ

e ap

proa

chH

ealth

care

wor

kers

Rura

l com

mun

ity h

ealth

‑ca

re80

% (h

igh)

2019

Zhou

et a

l. [6

7]C

hina

(upp

er‑m

iddl

e‑in

com

e)C

hina

Med

ical

Boa

rdC

hina

Pos

tdoc

tora

l Sci

ence

Fo

unda

tion

Cent

ral S

outh

Uni

vers

ity

Post

‑Doc

tora

l Sci

ence

Fo

unda

tion

Mix

ed m

etho

dsSe

nior

lead

ers,

depa

rtm

ent

dire

ctor

s fro

m a

tow

n ho

spita

l, fa

mily

mem

bers

of

pat

ient

s

Liuy

ang

Men

tal H

ealth

Pr

even

tion

and

Trea

tmen

t Ce

nter

(MH

C)

80%

(hig

h)

2018

Carn

eiro

et a

l. [1

00]

Braz

il (u

pper

‑mid

dle‑

inco

me)

Not

repo

rted

Cro

ss‑s

ectio

nal q

uant

ita‑

tive

desc

riptiv

ePh

ysic

ians

Isol

ated

prim

ary

care

faci

li‑tie

s in

Mar

ajó

75%

(hig

h)

2014

Cost

a et

al.

[101

]Br

azil

(upp

er‑m

iddl

e‑in

com

e)N

o fin

anci

al s

uppo

rt

rece

ived

Cro

ss‑s

ectio

nal e

valu

ativ

e qu

antit

ativ

e st

udy

Doc

tors

com

plet

ing

hom

e vi

sits

and

nur

ses

prov

idin

g in

divi

dual

car

e

Mun

icip

aliti

es w

ithin

Bra

zil

75%

(hig

h)

Page 11 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 1

(con

tinue

d)

Year

Aut

hor(

s)Co

untr

y (in

com

e br

acke

t)Fu

nded

by

Stud

y m

etho

dsSt

udy

popu

latio

nSt

udy

sett

ing

Qua

lity

appr

aisa

l

2018

Sam

i et a

l. [1

02]

Sout

h Su

dan,

Afri

ca (l

ow‑

inco

me)

Save

the

Chi

ldre

n’s

Savi

ng

New

born

Liv

es p

ro‑

gram

me

ELM

A R

elie

f Fou

ndat

ion

Mix

ed‑m

etho

ds c

ase

stud

yN

ewbo

rns

and

mot

hers

Com

mun

ity/f

acili

ty‑b

ased

se

ttin

gs in

clud

ing

PHC

ce

ntre

, com

mun

ity h

ealth

pr

ogra

mm

e ce

ntre

s, ho

spi‑

tal a

nd c

amps

73%

(hig

h)

2015

Febi

r eta

al.

[103

]G

hana

(low

er‑m

iddl

e‑in

com

e)Bi

ll &

Mel

inda

Gat

es

Foun

datio

nA

CT

[art

emis

inin

‑bas

ed

com

bina

tion

trea

tmen

t]

Cons

ortiu

m

Qua

litat

ive

stud

yH

ealth

care

wor

kers

Dis

tric

t hos

pita

l, he

alth

ce

ntre

s an

d co

mm

unity

‑ba

sed

heal

th s

ervi

ces

70%

(hig

h)

2017

Pyon

e et

al.

[104

]Ke

nya

(low

er‑m

iddl

e‑in

com

e)D

FID

UKA

idQ

ualit

ativ

e m

etho

ds10

nat

iona

l‑lev

el p

olic

y‑m

aker

s, 10

cou

nty

heal

th

offici

als

and

19 h

ealth

care

pr

ovid

ers

10 d

istr

ict‑

and

cou

nty‑

leve

l hos

pita

ls a

nd o

ther

he

alth

faci

litie

s in

sel

ecte

d co

untie

s

70%

(hig

h)

2020

Rahm

an e

t al.

[105

]Ba

ngla

desh

(low

er‑m

iddl

e‑in

com

e)G

laxo

Smith

Klin

e (G

SK)

thro

ugh

PATH

(Sea

ttle

, U

SA)

Qua

litat

ive

desc

riptiv

eKe

y st

akeh

olde

rs, h

ealth

se

rvic

e pr

ovid

ers

and

care

give

rs

At b

oth

the

natio

nal a

nd

dist

rict l

evel

s of

Khu

lna

and

Laks

hmip

ur, s

pe‑

cific

ally

in tw

o su

bdis

tric

t pu

blic

hea

lthca

re fa

cilit

ies

70%

(hig

h)

2008

Stei

n et

al.

[106

]So

uth

Afri

ca (u

pper

‑mid

‑dl

e‑in

com

e)ID

RC (C

anad

a)Q

ualit

ativ

e m

etho

dsPH

C n

urse

sU

rban

and

rura

l PH

C

sett

ings

70%

(hig

h)

2017

Berg

erot

et a

l. [7

9]Br

azil

(upp

er‑m

iddl

e‑in

com

e)N

ot re

port

edM

ixed

met

hods

Psyc

holo

gist

s an

d on

col‑

ogy

staff

; pat

ient

s ag

ed

18 o

r old

er, w

ith c

ance

r tr

eatm

ent p

lan

Hos

pita

ls a

nd c

ance

r cen

‑tr

es fr

om d

iffer

ent B

razi

lian

citie

s

66.6

6% (m

ediu

m)

2010

Hal

pern

et a

l. [7

7]G

uyan

a (u

pper

‑mid

dle‑

inco

me)

Not

repo

rted

Cro

ss‑s

ectio

nal

Doc

tors

, nur

ses

and

data

en

try

cler

ks fr

om e

ach

care

an

d tr

eatm

ent s

ite

Clin

ics

acro

ss th

e na

tion

62.5

0% (m

ediu

m)

2020

Ejet

a et

al.

[107

]Et

hiop

ia (l

ow‑in

com

e)N

ot re

port

edQ

ualit

ativ

e de

scrip

tive

Thre

e ho

spita

ls in

Eth

iopi

aFa

mili

es w

ithin

The

heal

th fa

cilit

y si

tes

loca

ted

in A

ddis

Aba

ba,

Bish

oftu

and

Haw

assa

60%

(med

ium

)

2016

Smith

Gue

ye e

t al.

[108

]Bh

utan

, Mau

ritiu

s, N

amib

ia,

Phili

ppin

es, S

ri La

nka,

Tu

rkey

and

Tur

kmen

ista

n (lo

w‑,

mid

dle‑

and

upp

er‑

mid

dle‑

inco

me)

Bill

& M

elin

da G

ates

Fo

unda

tion

Mal

aria

Elim

inat

ion

Initi

a‑tiv

e of

the

Glo

bal H

ealth

G

roup

(USA

)

Qua

litat

ive

case

stu

dy

revi

ewH

ealth

care

and

pro

‑gr

amm

e st

affM

ostly

in d

ecen

tral

ized

he

alth

sys

tem

s60

% (m

ediu

m)

Page 12 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 1

(con

tinue

d)

Year

Aut

hor(

s)Co

untr

y (in

com

e br

acke

t)Fu

nded

by

Stud

y m

etho

dsSt

udy

popu

latio

nSt

udy

sett

ing

Qua

lity

appr

aisa

l

2020

Ryan

et a

l. [1

09]

Nig

eria

(low

er‑m

iddl

e‑in

com

e)C

BM C

onsu

ltanc

y (A

ustr

al‑

ian

Gov

ernm

ent d

epar

t‑m

ent)

Com

preh

ensi

ve C

om‑

mun

ity M

enta

l Hea

lth

Prog

ram

me

(CC

MH

P)’s

mon

itorin

g an

d ev

alua

tion

budg

et

Mix

ed‑m

etho

ds m

anua

l‑iz

ed c

ase

stud

yPr

ojec

t coo

rdin

ator

, com

‑m

unity

men

tal h

ealth

pro

‑je

ct o

ffice

r, se

lf‑he

lp g

roup

, de

velo

pmen

t pro

ject

offi

cer a

nd s

ix c

omm

unity

ps

ychi

atric

nur

ses

Urb

an a

nd s

emi‑u

rban

m

enta

l hea

lth c

linic

s (s

ome

rura

l)

60%

(med

ium

)

2017

And

rade

et a

l. [7

5]Br

azil

(upp

er‑m

iddl

e‑in

com

e)N

ot re

port

edC

ross

‑sec

tiona

l obs

erva

‑tio

nal c

ase

stud

yPr

egna

nt w

omen

or

wom

en w

ith c

hild

ren

unde

r 2, s

uffer

ing

from

ch

roni

c co

nditi

ons

and/

or

diab

etes

and

hyp

erte

nsio

n

Prim

ary

and

seco

ndar

y he

alth

care

50%

(med

ium

)

2014

Rom

an e

t al.

[66]

Afri

ca (l

ower

‑mid

dle‑

inco

me)

USA

IDQ

ualit

ativ

e ob

serv

atio

nal

case

stu

dyPr

egna

nt w

omen

in A

frica

Hea

lth s

yste

m a

rea

50%

(med

ium

)

2016

Inve

stig

ator

s of

WH

O L

ow

Birt

h W

eigh

t (LB

W) F

eed‑

ing

Stud

y G

roup

[110

]

Indi

a (lo

wer

‑mid

dle‑

inco

me)

WH

O (G

enev

a)M

ixed

‑met

hods

bef

ore‑

and‑

afte

r stu

dyH

ealth

care

pra

ctiti

oner

s an

d pa

rent

s of

LBW

bab

ies

Firs

t‑re

ferr

al‑le

vel h

ealth

fa

cilit

ies

33%

(low

)

2016

Lavô

r et a

l. [1

11]

Braz

il (u

pper

‑mid

dle‑

inco

me)

Not

repo

rted

Mix

ed‑m

etho

ds m

ultip

le‑

case

stu

dyN

urse

sBa

sic

heal

th u

nits

and

four

ou

tpat

ient

clin

ics,

calle

d sp

ecia

lty p

olyc

linic

s

27%

(low

)

2005

Bryc

e et

al.

[58]

Bang

lade

sh, B

razi

l, Pe

ru,

Tanz

ania

, Uga

nda

(low

er‑

mid

dle‑

inco

me)

Bill

& M

elin

da G

ates

Fo

unda

tion

USA

ID

Mix

ed m

etho

dsH

ealth

faci

litie

s w

ith

or w

ithou

t int

egra

ted

man

agem

ent o

f chi

ldho

od

illne

ss

Hea

lth fa

cilit

ies

20%

(low

)

2018

Kihe

mbo

et a

l. [5

7]U

gand

a (lo

wer

‑mid

dle‑

inco

me)

DFI

DW

HO

‑AFR

OCo

ntin

uum

of C

are

for

Repr

oduc

tive,

Mat

erna

l, N

ewbo

rn, A

dole

scen

t and

C

hild

Hea

lth (R

MA

NC

H)

USA

IDU

NIC

EFG

loba

l Pol

io E

radi

catio

n In

itiat

ive

Uni

ted

Nat

ions

Cen

tral

Em

erge

ncy

Resp

onse

Fu

nd (C

ERF)

WH

O (U

gand

a)

Qua

litat

ive

desc

riptiv

e st

udy

Hea

lth w

orkf

orce

Dis

tric

t‑ a

nd re

gion

al‑le

vel

refe

rral

hos

pita

ls20

% (l

ow)

Page 13 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 1

(con

tinue

d)

Year

Aut

hor(

s)Co

untr

y (in

com

e br

acke

t)Fu

nded

by

Stud

y m

etho

dsSt

udy

popu

latio

nSt

udy

sett

ing

Qua

lity

appr

aisa

l

2015

Li e

t al.

[112

]C

hina

(upp

er‑m

iddl

e‑in

com

e)La

w D

epar

tmen

t of

Nat

iona

l Hea

lth a

nd F

amily

Pl

anni

ng C

omm

ittee

Jinan

Sci

ence

& T

echn

ol‑

ogy

Plan

ning

Pro

ject

Mix

ed‑m

etho

ds fi

eld

obse

rvat

ion

Pers

onne

l of t

he h

ealth

de

part

men

t of S

hand

ong

Prov

ince

and

hea

lth

depa

rtm

ents

, dire

ctor

s, m

edic

al p

erso

nnel

of

tow

nshi

p ho

spita

ls

Six

tow

nshi

p ho

spita

ls a

nd

thre

e vi

llage

clin

ics

6.60

% (l

ow)

2015

Win

gfiel

d et

al.

[113

]Pe

ru (u

pper

‑mid

dle‑

inco

me)

Wel

lcom

e Tr

ust

Inno

vatio

n fo

r Hea

lth a

nd

Dev

elop

men

t (FH

AD

) and

th

e Jo

int G

loba

l Hea

lth

Tria

ls C

onso

rtiu

m o

f the

W

ellc

ome

Trus

tU

nite

d Ki

ngdo

m M

edic

al

Rese

arch

Cou

ncil

DFI

DBi

ll &

Mel

inda

Gat

es

Foun

datio

nBr

itish

Infe

ctio

n A

ssoc

ia‑

tion

Impe

rial C

olle

ge C

entr

e fo

r G

loba

l Hea

lth R

esea

rch

Mix

ed m

etho

dsPr

ojec

t tea

m, p

roje

ct p

ar‑

ticip

ants

, civ

il so

ciet

y an

d st

akeh

olde

rs

Two

subu

rbs

of P

eru’

s ca

pita

l, Li

ma

6.60

% (l

ow)

2018

Kavl

e et

al.

[114

]Ke

nya

(low

er‑m

iddl

e‑in

com

e)U

SAID

Qua

litat

ive

Mot

hers

Com

mun

ity c

are

heal

th

faci

litie

s0%

(low

)

Page 14 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

Hea

lth s

yste

m g

uide

line/

reco

mm

enda

tion

over

view

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Am

aral

et a

l. (2

008)

[82]

Inte

grat

ed m

anag

emen

t of c

hild

hood

ill

ness

es (I

MC

I)D

escr

ibe

fact

ors

asso

ciat

ed w

ith th

e im

plem

enta

tion

of IM

CI i

n no

rth‑

east

ern

Braz

il

IMC

I aim

s to

redu

ce m

orta

lity

and

mor

bidi

ty a

ssoc

iate

d w

ith c

hild

hood

di

seas

es b

y im

prov

ing

thre

e ke

y co

mpo

‑ne

nts:

(1) p

erfo

rman

ce o

f hea

lth p

rofe

s‑si

onal

s us

ing

stan

dard

ized

pro

toco

ls; (

2)

impr

ovin

g th

e he

alth

sys

tem

org

aniz

a‑tio

n by

mea

ns o

f ade

quat

e su

ppor

t for

th

e av

aila

bilit

y of

reso

urce

s; (3

) hea

lth

prom

otio

n pr

actic

es th

roug

h fa

mily

and

co

mm

unity

‑bas

ed a

ctiv

ities

Serv

ice

deliv

ery

And

rade

et a

l. (2

017)

[75]

Att

entio

n to

chr

onic

con

ditio

ns m

odel

(A

CCM

) was

ada

pted

to c

reat

e la

b fo

r inn

ovat

ions

in c

hron

ic c

ondi

tions

(L

IACC

)

Add

ress

impl

emen

tatio

n of

LIA

CC

Doc

umen

t the

mai

n ch

alle

nges

and

les‑

sons

lear

ned

to s

ugge

st a

mor

e su

itabl

e ch

roni

c ca

re m

odel

at t

he m

unic

ipal

le

vel

Ada

pted

from

the

seve

n st

eps

of A

CCM

, LI

ACC

impl

emen

ts fo

ur m

acro

pro

cess

es

used

as

a m

anag

emen

t too

l in

prim

ary

heal

thca

re (P

HC

) for

chr

onic

con

ditio

ns:

(1) e

valu

atio

n of

infra

stru

ctur

e; (2

) foc

us

on p

rimar

y ca

re to

acu

te h

ealth

ser

vice

s; (3

) man

agem

ent a

nd m

onito

ring

of

chro

nic

cond

ition

s; (4

) man

agem

ent a

nd

mon

itorin

g of

hom

e he

alth

care

vis

its

Serv

ice

deliv

ery

Arm

stro

ng e

t al.

(201

4) [9

0]M

ater

nal a

nd p

erin

atal

dea

th re

view

s (M

PDR)

Expl

ore

the

curr

ent i

mpl

emen

tatio

n of

M

PDRs

in T

anza

nia

MPD

R en

cour

ages

mul

tidis

cipl

inar

y te

am d

iscu

ssio

ns fr

om s

taff

invo

lved

in

the

patie

nts’

care

as

wel

l as

a re

view

of

the

patie

nts’

docu

men

tatio

n to

iden

tify

avoi

dabl

e fa

ctor

s an

d op

port

uniti

es fo

r im

prov

emen

t

Hea

lth w

orkf

orce

Berg

erot

et a

l. (2

017)

[79]

Psyc

ho‑o

ncol

ogy

prog

ram

me

Cha

ract

eriz

e th

e us

e of

scr

eeni

ng m

eas‑

ures

for p

sych

olog

ists

from

diff

eren

t on

colo

gy s

ervi

ces

Pres

ent t

he p

relim

inar

y re

sults

from

th

is p

rogr

amm

e im

plem

enta

tion

and

deve

lopm

ent

The

prog

ram

me

was

sub

divi

ded

into

six

ac

tions

: scr

eeni

ng o

f dis

tres

s, an

xiet

y,

depr

essi

on, q

ualit

y of

life

; cla

ssifi

catio

n of

ris

k cr

iteria

; dis

cuss

ion

by th

e ps

ycho

l‑og

y te

am; s

ynth

esis

and

dis

cuss

ion

with

he

alth

care

team

; evi

denc

e‑ba

sed

resu

lts

anal

ysis

; tre

atm

ent p

lan

and

reco

rd in

m

edic

al re

cord

s

Serv

ice

deliv

ery

Blan

co‑M

anci

lla (2

011)

[84]

Popu

lar h

ealth

insu

ranc

e (P

HI)

pro‑

gram

me

Und

erst

and

why

hea

lth p

olic

ies

diffe

r ac

ross

Mex

ico

City

Iden

tify

issu

es th

at c

ontr

ibut

e to

the

succ

ess

or fa

ilure

of t

rans

latin

g po

licy

into

pra

ctic

e

Prov

idin

g he

alth

care

cov

erag

e to

pre

vi‑

ousl

y ex

clud

ed p

opul

atio

nsSe

rvic

e de

liver

y

Page 15 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Bryc

e et

al.

(200

5) [5

8]M

CI s

trat

egy

Com

pare

the

prog

ram

me

(IMC

I) ex

pec‑

tatio

n fin

ding

s of

the

Mul

ti‑Co

untr

y Ev

alua

tion

of IM

CI E

ffect

iven

ess,

Cost

an

d Im

pact

(MC

E‑IM

CI)

to th

e fiv

e m

ost

impo

rtan

t pro

gram

me

expe

ctat

ions

fro

m th

e IM

CI i

mpa

ct m

odel

IMC

I is

a st

rate

gy fo

r red

ucin

g m

orta

lity

amon

g ch

ildre

n un

der t

he a

ge o

f 5 y

ears

UN

ICEF

, WH

O a

nd th

eir t

echn

ical

pa

rtne

rs d

evel

oped

the

stra

tegy

in a

st

epw

ise

fash

ion,

see

king

to a

ddre

ss

limita

tions

iden

tified

thro

ugh

expe

ri‑en

ce w

ith d

isea

se‑s

peci

fic c

hild

hea

lth

prog

ram

mes

, and

thos

e ad

dres

sing

di

arrh

oeal

dis

ease

and

acu

te re

spira

tory

in

fect

ions

Serv

ice

deliv

ery

Calla

ghan

‑Kor

u et

al.

(202

0) [8

6]C

hlor

hexi

dine

(CH

X) c

lean

sing

pol

icy

Iden

tify

and

com

pare

faci

litat

ors

of a

nd

barr

iers

to th

e in

stitu

tiona

lizat

ion

and

expa

nsio

n st

rate

gies

of t

he n

atio

nal

scal

e‑up

of C

HX

Prio

ritiz

es s

ever

al n

ewbo

rn h

ealth

inte

r‑ve

ntio

ns s

uch

as k

anga

roo

mot

her c

are,

m

anag

emen

t of n

ewbo

rn in

fect

ions

an

d en

surin

g es

sent

ial n

ewbo

rn c

are

incl

udin

g th

e ap

plic

atio

n of

CH

X to

the

umbi

lical

cor

d

Serv

ice

deliv

ery

Carn

eiro

et a

l. (2

018)

[100

]M

ore

phys

icia

ns fo

r Bra

zil p

rogr

amm

e (M

PBP)

as

part

of t

he F

amily

Hea

lth

Stra

tegy

(FH

S)

To e

valu

ate

the

perf

orm

ance

of t

he F

HS,

th

roug

h th

e de

ploy

men

t of M

PBP

in

Mar

ajó‑

Pa‑B

razi

l

Broa

deni

ng th

e ac

cess

to b

asic

hea

lth‑

care

ser

vice

s an

d co

nnec

ting

the

team

s to

indi

vidu

als,

fam

ilies

and

com

mun

ities

in

the

com

plex

task

of t

akin

g ca

re o

f life

Acc

ess

to e

ssen

tial m

edic

ine

Cost

a et

al.

(201

4) [1

01]

FHS

To re

‑eva

luat

e th

e im

plem

enta

tion

of

the

FHS

in th

e st

ate

of S

anta

Cat

arin

a be

twee

n 20

04 a

nd 2

008

by c

onsi

der‑

ing

indi

cato

rs o

f pot

entia

l cov

erag

e,

evid

ence

of c

hang

e in

the

care

mod

el,

and

the

impa

ct o

n ho

spita

lizat

ions

Cha

ract

eris

tics

of th

e FH

S ar

e te

amw

ork

and

ascr

ibed

dis

trib

utio

n of

pat

ient

s, w

ith a

fore

cast

ed n

umbe

r of f

amili

es/

indi

vidu

als

unde

r its

resp

onsi

bilit

yPr

oact

ive

appr

oach

to th

e he

alth

of t

he

com

mun

ity a

scrib

ed w

hich

relie

s on

ter‑

ritor

ializ

atio

n, fa

mily

regi

ster

s, di

agno

ses

of h

ealth

situ

atio

ns a

nd h

ealth

initi

ativ

es

deve

lope

d in

par

tner

ship

with

the

com

‑m

unity

Serv

ice

deliv

ery

Ditl

opo

et a

l. (2

011)

[91]

Rura

l allo

wan

ce p

olic

yA

naly

se p

olic

y im

plem

enta

tion

and

effec

tiven

ess

and

its in

fluen

ce o

n m

oti‑

vatio

n an

d re

tent

ion

Att

ract

and

reta

in h

ealth

pro

fess

iona

ls to

w

ork

full‑

time

in p

ublic

hea

lth s

ervi

ces

in

rura

l, un

ders

erve

d an

d ot

her i

nhos

pita

‑bl

e ar

eas

iden

tified

by

prov

inci

al h

ealth

de

part

men

ts

Fina

ncin

g

Doh

erty

et a

l. (2

017)

[92]

Prev

entio

n of

mot

her‑

to‑c

hild

tran

smis

‑si

on o

f HIV

/AID

S (P

MTC

T) (O

ptio

n B+

)Pr

esen

t find

ings

from

a ra

pid

asse

ssm

ent

of P

MTC

T O

ptio

n B+

impl

emen

tatio

n in

U

gand

a 3

year

s af

ter p

olic

y ad

optio

n

PMTC

T ev

olve

d pr

ogre

ssiv

ely

from

sin

‑gl

e‑do

se n

evira

pine

pro

phyl

axis

in 2

000

to th

e cu

rren

t rec

omm

enda

tion

that

all

preg

nant

and

bre

astfe

edin

g w

omen

, irr

espe

ctiv

e of

CD

4 co

unt,

shou

ld re

ceiv

e lif

elon

g an

tiret

rovi

ral t

reat

men

t (A

RT),

know

n as

Opt

ion

B+

Serv

ice

deliv

ery

Page 16 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Ejet

a et

al.

(202

0) [1

07]

Stre

ngth

enin

g Et

hiop

ia’s

Urb

an H

ealth

Pr

omot

ion

(SEU

HP)

impl

emen

ted

the

Urb

an C

omm

unity

Hea

lth In

form

atio

n Sy

stem

(UC

HIS

)

Doc

umen

t the

cha

lleng

es a

nd le

sson

s le

arne

d in

the

UC

HIS

impl

emen

tatio

n pr

oces

s

Each

of t

he 1

5 he

alth

ser

vice

pac

kage

s id

entifi

ed c

onta

ined

ser

vice

car

ds a

nd

tally

she

ets

to h

elp

impr

ove

data

col

lec‑

tion

and

stan

dard

izat

ion

Hea

lth in

form

atio

n sy

stem

Febi

r et a

l. (2

015)

[103

]In

tegr

atio

n of

rapi

d di

agno

stic

test

(RD

T)

in IM

CI

Eval

uate

and

repo

rt th

e is

sues

hea

lth

wor

kers

face

d in

inte

grat

ing

RDT

man

‑ag

emen

t int

o th

eir w

orki

ng p

ract

ices

In 2

010

IMC

I was

ada

pted

whe

rein

cas

e m

anag

emen

t of m

alar

ia s

houl

d be

a

test

‑bas

ed a

ppro

ach,

and

ther

efor

e th

e in

tegr

atio

n of

a ra

pid

diag

nost

ic te

st

(RD

T)‑b

ased

inte

rven

tion

was

und

er‑

take

n

Serv

ice

deliv

ery

Gue

ye e

t al.

(201

6) [1

08]

Mal

aria

elim

inat

ion

prog

ram

mes

:G

loba

l tec

hnic

al s

trat

egy

for m

alar

ia

(GTS

)A

ctio

n an

d In

vest

men

t to

defe

at M

alar

ia

(AIM

)G

loba

l Mal

aria

Era

dica

tion

Prog

ram

me

(GM

EP)

Exam

ine

coun

trie

s in

diff

eren

t soc

ioec

o‑no

mic

, pol

itica

l and

eco

logi

cal c

onte

xts

and

eval

uate

how

the

heal

th s

yste

m h

as

oper

ated

with

in th

e co

ntex

t of d

iffer

ent

polit

ical

, fina

ncia

l and

hum

an re

sour

ces

activ

ities

Iden

tify

how

cou

ntrie

s ha

ve im

ple‑

men

ted

elim

inat

ion

prog

ram

mes

, an

d ad

apte

d th

eir m

alar

ia e

limin

atio

n st

rate

gies

GTS

: pro

vide

d th

e fra

mew

ork

for

achi

evem

ent o

f elim

inat

ion

and

esta

blis

hing

an

elim

inat

ion

goal

for 3

5 co

untr

ies.

Prog

ram

me

to re

ach

glob

al

goal

s fo

r mal

aria

con

trol

, elim

inat

ion

and

even

tual

ly e

radi

catio

nA

IM: a

n ac

tion

fram

ewor

k to

redu

ce

mal

aria

thro

ugh

the

Roll

Back

Mal

aria

Pa

rtne

rshi

pG

MEP

: bas

ed o

n ve

rtic

al ti

me‑

limite

d in

terv

entio

ns d

eplo

yed

thro

ugh

cent

ral‑

ized

hea

lth s

yste

ms

at th

e na

tiona

l lev

el

Serv

ice

deliv

ery

Hal

pern

et a

l. (2

010)

[77]

The

patie

nt m

onito

ring

syst

em (P

MS)

for

patie

nts

with

HIV

Des

crib

e th

e pr

oces

s us

ed to

impl

emen

t PM

SPr

ovid

e ex

ampl

es o

f the

pro

gram

me‑

leve

l dat

aH

ighl

ight

ben

efits

for n

atio

nal p

ro‑

gram

mes

PMS

is u

sed

for p

atie

nt c

are

and

data

co

llect

ion

The

phys

ical

com

pone

nts

of th

e W

HO

H

IV c

are

and

ART

PM

S in

clud

e a

patie

nt

char

t, tw

o pa

tient

regi

ster

s, an

d cr

oss‑

sect

iona

l and

coh

ort a

naly

sis

repo

rtin

g fo

rm

Hea

lth in

form

atio

n sy

stem

Inve

stig

ator

s of

WH

O L

ow B

irth

Wei

ght (

LBW

) Fee

ding

Stu

dy G

roup

(2

016)

[110

]

LBW

feed

ing

guid

elin

es in

firs

t‑re

ferr

al‑

leve

l hea

lth fa

cilit

ies

Eval

uate

the

effec

t of i

mpl

emen

ting

WH

O L

BW fe

edin

g gu

idel

ines

Gui

delin

es a

im to

impr

ove

know

ledg

e an

d sk

ills

of h

ealth

wor

kers

Gui

delin

es fo

r opt

imal

feed

ing

of L

BW

infa

nts,

to im

prov

e ca

re a

nd s

urvi

val o

f LB

W in

fant

s

Hea

lth w

orkf

orce

Kavl

e et

al.

(201

8) [1

14]

Baby

‑Frie

ndly

Com

mun

ity In

itiat

ive

(BFC

I)D

escr

ibe

the

impl

emen

tatio

n pr

oces

sD

iscu

ss s

ucce

ss, c

halle

nges

, les

sons

le

arne

d an

d op

port

uniti

es fo

r int

egra

tion

into

oth

er h

ealth

are

as

Thro

ugh

mot

her‑

to‑m

othe

r com

mu‑

nity

sup

port

gro

ups,

BFC

I add

ress

es

brea

stfe

edin

g an

d nu

triti

on c

halle

nges

by

pro

vidi

ng e

duca

tiona

l int

erve

ntio

ns

in c

omm

unity

gar

dens

, wat

er, s

anita

tion

and

hygi

ene

Serv

ice

deliv

ery

Page 17 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Kihe

mbo

et a

l. (2

018)

[57]

Inte

grat

ed D

isea

se S

urve

illan

ce a

nd

Resp

onse

(ID

SR)

Des

crib

e th

e de

sign

and

pro

cess

of

IDSR

revi

taliz

atio

n, h

ighl

ight

ing

the

rollo

ut o

f the

revi

sed

IDSR

gui

delin

es

thro

ugh

stru

ctur

ed tr

aini

ng o

f the

hea

lth

wor

kfor

ce u

p to

the

oper

atio

nal l

evel

na

tionw

ide

Stra

tegy

aim

ed a

t str

engt

heni

ng in

te‑

grat

ed, a

ctio

n‑or

ient

ed p

ublic

hea

lth

surv

eilla

nce

and

resp

onse

at a

ll le

vels

of

the

heal

th s

yste

mFo

cuse

d on

det

ectio

n, re

gist

ratio

n,

conf

orm

atio

n, re

port

ing,

dat

a an

alys

is

and

prov

isio

n of

feed

back

Serv

ice

deliv

ery

Lavô

r et a

l. (2

016)

[111

]D

irect

ly o

bser

ved

trea

tmen

t, sh

ort‑

cour

se (D

OTS

)A

sses

s th

e de

gree

of i

mpl

emen

tatio

n of

th

e D

OTS

str

ateg

y fo

r tub

ercu

losi

s (T

B) in

a

larg

e ci

ty

DO

TS is

bas

ed o

n fiv

e fu

ndam

enta

l co

mpo

nent

s: su

stai

ned

polit

ical

and

fin

anci

al c

omm

itmen

t; di

agno

sis

thro

ugh

qual

ity‑e

nsur

ed s

putu

m‑s

mea

r m

icro

scop

y; s

tand

ardi

zed

shor

t‑co

urse

an

ti‑TB

trea

tmen

t; a

man

agem

ent s

ys‑

tem

for u

nint

erru

pted

sup

ply

of a

nti‑T

B dr

ugs;

info

rmat

ion

syst

em th

at a

llow

s m

onito

ring

and

eval

uatio

n of

act

ions

an

d th

eir i

mpa

cts

Acc

ess

to e

ssen

tial m

edic

ine

Leet

hong

dee

(200

7) [8

3]U

nive

rsal

cov

erag

e (U

C) h

ealth

care

re

form

Und

erst

and

the

fact

ors

influ

enci

ng th

e im

plem

enta

tion

at a

loca

l lev

elBu

ild a

gen

eral

acc

ount

of t

he re

form

s th

at fi

t eac

h of

thre

e in

divi

dual

pro

vinc

ial

case

s

UC

refo

rm o

bjec

tive

was

to re

duce

ge

ogra

phic

al in

equa

litie

s in

fund

ing

and

wor

kflow

dis

trib

utio

n, p

robl

ems

in

reso

urce

allo

catio

n, la

ck o

f pro

gres

s in

de

velo

ping

prim

ary

care

, and

tens

ion

betw

een

cura

tive

and

prev

enta

tive

care

ap

proa

ches

Fina

ncin

g

Li e

t al.

(201

5) [1

12]

WH

O e

ssen

tial d

rugs

pol

icy

Ana

lyse

the

impa

ct o

n vi

llage

‑leve

l and

to

wns

hip‑

leve

l hea

lth s

ervi

ce s

yste

mSu

mm

ariz

e th

e eff

ectiv

enes

s of

impl

e‑m

entin

g es

sent

ial d

rugs

pol

icy;

iden

tify

the

prob

lem

s of

var

ious

asp

ects

Cond

uct a

n in

‑dep

th a

naly

sis

of th

e ca

uses

, and

pro

vide

way

s to

impr

ove

the

esse

ntia

l dru

gs p

olic

y

Esse

ntia

l dru

g po

licy

aim

s to

impr

ove

the

avai

labi

lity

of e

ssen

tial d

rugs

and

to

prom

ote

ratio

nal d

rug

use

Acc

ess

to e

ssen

tial m

edic

ine

Love

ro e

t al.

(201

9) [9

3]Th

e N

atio

nal M

enta

l Hea

lth P

olic

y Fr

amew

ork

and

Stra

tegi

c Pl

an 2

013–

2020

(the

Str

ateg

ic P

lan)

Gai

n kn

owle

dge

on s

tepp

ed‑c

are

proc

e‑du

res

for m

anag

emen

t of m

enta

l illn

ess

in p

rimar

y ca

re s

ervi

ces

Det

erm

ine

the

degr

ee to

whi

ch in

te‑

grat

ed p

roce

dure

s ha

ve b

een

impl

e‑m

ente

dId

entif

y ch

alle

nges

enc

ount

ered

in

coor

dina

tion

of in

tegr

atio

n eff

orts

The

Stra

tegi

c Pl

an a

ims

to fu

lly in

tegr

ate

men

tal h

ealth

ass

essm

ent a

nd m

anag

e‑m

ent s

ervi

ces,

incl

udin

g sc

reen

ing,

m

anag

emen

t of m

enta

l dis

orde

rs, r

efer

‑ra

l pat

hway

s an

d tr

aini

ng, i

nto

all a

spec

ts

of p

rimar

y ca

re, w

ith a

n em

phas

is o

n TB

, H

IV a

nd a

nten

atal

car

e se

rvic

esTh

e st

rate

gic

plan

was

to b

e co

ordi

nate

d at

the

dist

rict a

dmin

istr

ativ

e le

vel

Serv

ice

deliv

ery

Page 18 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Mig

uel‑E

spon

da e

t al.

(202

0) [6

9]Co

mpa

ñero

s En

Sal

ud (C

ES) m

enta

l he

alth

pro

gram

me

Ass

ess

the

impl

emen

tatio

n of

the

CES

pr

ogra

mm

e to

und

erst

and

the

exte

nt

of s

ucce

ss in

inte

grat

ing

men

tal h

ealth

in

to P

HC

Det

erm

ine

stre

ngth

s an

d lim

itatio

ns o

f th

e su

cces

s or

failu

re o

f int

egra

tion

To d

eter

min

e m

anag

ers’

and

prov

ider

s’ pe

rspe

ctiv

es o

n th

e pr

ogra

mm

eD

eter

min

e th

e ke

y st

reng

ths

and

rem

aini

ng c

halle

nges

to th

e im

ple‑

men

tatio

n of

the

CES

men

tal h

ealth

pr

ogra

mm

e

CES

aim

s to

str

engt

hen

the

PHC

sys

tem

to

impr

ove

acce

ss to

qua

lity

heal

thca

reTh

e or

gani

zatio

n fa

cilit

ates

the

deliv

ery

of g

ener

al h

ealth

ser

vice

s (in

clud

ing

men

tal h

ealth

) in

10 P

HC

clin

ics.

For

men

tal h

ealth

, a c

oord

inat

or o

vers

ees

the

deliv

ery

of m

enta

l hea

lth s

ervi

ces

and

capa

city

‑bui

ldin

g ac

tiviti

es a

nd

prov

ides

sup

port

for t

he m

anag

emen

t of

com

plex

cas

esA

ll m

enta

l hea

lth s

ervi

ces

are

deliv

ered

by

med

ical

doc

tors

(MD

s)Se

rvic

es a

re d

esig

ned

acco

rdin

g to

ad

apte

d cl

inic

al g

uide

lines

and

incl

ude

case

iden

tifica

tion,

dia

gnos

is, p

harm

aco‑

logi

cal t

reat

men

ts, i

ndiv

idua

l and

gro

up

talk

‑bas

ed in

terv

entio

ns, a

nd h

ome

visi

ts

Serv

ice

deliv

ery

Mko

ka e

t al.

(201

4) [9

4]Em

erge

ncy

obst

etric

car

e (E

mO

C)

Expl

ore

the

expe

rienc

es a

nd p

erce

ptio

ns

of a

cou

ncil

heal

th m

anag

emen

t tea

m

(CH

MT)

in w

orki

ng w

ith m

ultip

le p

art‑

ners

whi

le il

lum

inat

ing

som

e go

vern

‑an

ce a

spec

ts th

at a

ffect

impl

emen

tatio

n of

Em

OC

at t

he d

istr

ict l

evel

Stra

tegy

aim

s to

str

engt

hen

all d

is‑

pens

arie

s an

d he

alth

cen

tres

thro

ugh

prov

isio

n of

bas

ic E

mO

C (B

EmO

C) b

y st

reng

then

ing

the

capa

city

of d

istr

ict

hosp

ital a

nd u

pgra

de b

y 50

% h

ealth

ce

ntre

s to

pro

vide

com

preh

ensi

ve

EmO

C a

nd s

tren

gthe

ning

hea

lth w

orke

rs

com

pete

ncie

s

Serv

ice

deliv

ery

Mos

hiri

et a

l. (2

016)

[95]

PHC

Inve

stig

atio

n of

con

text

, con

tent

, act

ors

and

proc

ess

of P

HC

impl

emen

tatio

nIn

vest

igat

ion

of th

e re

ferr

al s

yste

m s

itua‑

tion

in Ir

an fr

om 1

982

to 1

989

In o

rder

to ta

ckle

phy

sici

an s

hort

ages

, fo

reig

n do

ctor

s w

ere

bein

g hi

red

en

mas

se to

sup

port

PH

S im

plem

enta

tion

Serv

ice

deliv

ery

Mut

abaz

i et a

l. (2

020)

[87]

PMTC

T Ex

plor

e th

e pe

rspe

ctiv

e of

exp

erts

and

ot

her k

ey in

form

ants

on

the

PMTC

T in

tegr

atio

n in

to P

HC

Stra

tegy

invo

lvin

g th

e in

tegr

atio

n of

te

stin

g to

redu

ce m

othe

r‑to

‑chi

ld

tran

smis

sion

dur

ing

diffe

rent

pha

ses

of

preg

nanc

y

Serv

ice

deliv

ery

Page 19 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Mut

hath

i et a

l. (2

020)

[96]

Idea

l clin

ic re

aliz

atio

n an

d m

aint

enan

ce

(ICRM

) pro

gram

me

Gen

erat

e kn

owle

dge

on th

e po

licy

impl

emen

tatio

nEx

amin

e th

e in

fluen

ce o

f mot

ivat

ion,

co

gniti

on a

nd p

erce

ived

pow

er o

f the

po

licy

acto

rs a

nd h

ow it

influ

ence

d IC

RM

impl

emen

tatio

nEx

plor

e po

licy

cohe

renc

e in

the

ICRM

pr

ogra

mm

eEx

plor

e th

e pe

rcep

tions

of s

take

hold

‑er

s at

the

natio

nal,

prov

inci

al a

nd lo

cal

gove

rnm

ent l

evel

s

The

goal

of t

he IC

RM p

rogr

amm

e is

to

prep

are

all P

HC

faci

litie

s to

mee

t the

qu

ality

sta

ndar

ds s

et b

y th

e O

ffice

of

Hea

lth S

tand

ards

Com

plia

nce

(OH

SC)

An

idea

l clin

ic is

defi

ned

as a

clin

ic

with

goo

d in

frast

ruct

ure,

ade

quat

e st

aff, a

dequ

ate

med

icin

es a

nd s

uppl

ies,

and

good

adm

inis

trat

ive

proc

esse

s, w

ith s

uffici

ent b

ulk

supp

lies;

it us

es

appl

icab

le c

linic

al p

olic

ies,

prot

ocol

s an

d gu

idel

ines

, and

it h

arne

sses

par

tner

and

st

akeh

olde

r sup

port

Hea

lth w

orkf

orce

Pyon

e et

al.

(201

7) [1

04]

Free

mat

erni

ty s

ervi

ces

(FM

S) p

olic

yU

nder

stan

d ho

w th

e po

licy

chan

ged

heal

th s

yste

m g

over

nanc

e in

Ken

ya a

nd

use

the

insi

ghts

to in

form

pol

icy

impl

e‑m

enta

tion

in K

enya

and

in o

ther

LM

ICs

FMS

was

par

t of a

nat

iona

l str

ateg

y to

re

duce

mat

erna

l and

neo

nata

l mor

tal‑

ity, a

llevi

ate

pove

rty

and

achi

eve

the

Mill

enni

um D

evel

opm

ent G

oal t

arge

ts;

abol

ish

user

fees

for a

ll he

alth

ser

vice

s an

d di

spen

sarie

s, an

d pr

ovid

e FM

S in

all

leve

ls o

f car

e of

the

gove

rnm

ent h

ealth

se

ctor

Fina

ncin

g

Rahm

an e

t al.

(202

0) [1

05]

Mat

erna

l, ne

onat

al, c

hild

and

ado

lesc

ent

heal

th (M

NC

&AH

) and

com

mun

ity‑b

ased

he

alth

care

(CBH

C),

repr

oduc

tive

and

adol

esce

nt h

ealth

(MC

R&A

H)

Und

erst

and

key

driv

ers

for i

mpl

emen

ta‑

tion

of W

HO

reco

mm

enda

tions

for t

he

case

man

agem

ent o

f chi

ldho

od p

neu‑

mon

ia a

nd p

ossi

ble

serio

us b

acte

rial

infe

ctio

n (P

SBI)

with

am

oxic

illin

dis

pers

‑ib

le ta

blet

s (D

T)G

ener

ate

evid

ence

to s

tren

gthe

n ne

wbo

rn a

nd c

hild

hea

lth p

rogr

amm

es

in B

angl

ades

h

The

Min

istr

y of

Hea

lth a

nd F

amily

W

elfa

re (M

OH

FW) i

n Ba

ngla

desh

pro

‑vi

des

heal

thca

re s

ervi

ces

for c

hild

hood

pn

eum

onia

and

PSB

I in

the

PHC

set

ting

thro

ugh

both

the

dire

ctor

ate

of h

ealth

se

rvic

es a

nd d

irect

orat

e of

fam

ily p

lan‑

ning

, und

er th

ree

oper

atio

nal p

lans

Inco

rpor

ate

child

‑frie

ndly

am

oxic

illin

DT

for t

he c

ase

man

agem

ent o

f chi

ldho

od

pneu

mon

ia a

nd P

SBI w

hen

refe

rral

for

oral

am

oxic

illin

is n

ot fe

asib

le

Serv

ice

deliv

ery

Rom

an e

t al.

(201

4) [6

6]M

alar

ia in

pre

gnan

cy (M

IP)

Ass

ess

how

thre

e co

untr

ies

in A

frica

w

ere

able

to a

chie

ve g

reat

er p

rogr

ess

in

MIP

con

trol

Iden

tify

the

prac

tices

and

str

ateg

ies

that

sup

port

ed th

e su

cces

s of

the

MIP

pr

ogra

mm

eId

entif

y bo

ttle

neck

s in

MIP

pro

gram

me

impl

emen

tatio

n pr

oces

ses

Shar

e le

sson

s le

arne

d

The

MIP

fram

ewor

k ai

ms

to p

reve

nt

and

cont

rol m

alar

ia d

urin

g pr

egna

ncy

by fo

cusi

ng o

n th

ree

met

hods

that

st

abili

ze tr

ansm

issi

on: (

1) in

term

itten

t pr

even

tativ

e tr

eatm

ent w

ith s

ulfa

doxi

ne/

pyrim

etha

min

e (S

P) a

ntim

alar

ial d

rug;

(2)

use

of p

hysi

cal i

nsec

ticid

e ne

ts; (

3) e

ffec‑

tive

case

man

agem

ent b

ased

on

sign

s an

d sy

mpt

oms

Serv

ice

deliv

ery

Page 20 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Ryan

et a

l. (2

020)

[109

]Co

mpr

ehen

sive

com

mun

ity m

enta

l he

alth

pro

gram

me

(CC

MH

P)A

ims

to h

elp

info

rm th

e ut

iliza

tion

of

publ

ic–p

rivat

e pa

rtne

rshi

ps (P

PPs)

for

men

tal h

ealth

pol

icy

impl

emen

tatio

n in

N

iger

ia a

nd o

ther

low

‑res

ourc

e se

ttin

gs

by d

ocum

entin

g a

prom

isin

g ex

ampl

e fro

m B

enue

Two

com

mun

ity‑b

ased

reha

bilit

atio

n fa

cilit

ies

oper

ate

unde

r CC

MH

PCC

MH

P pr

ocur

es m

edic

ines

from

CH

AN

M

edi‑P

harm

and

set

s up

Dru

g Re

volv

ing

Fund

at e

ach

heal

th c

entr

e to

ens

ure

cons

tant

sup

ply

Refe

rral

s ar

e m

ade

dire

ctly

bet

wee

n th

e co

mm

unity

psy

chia

tric

nur

se (C

PN) o

r co

mm

unity

hea

lth e

xten

sion

wor

ker

(CH

EW) a

nd s

peci

alis

ts a

t Fed

eral

M

edic

al C

entr

e M

akur

di o

r Ben

ue S

tate

U

nive

rsity

Tea

chin

g H

ospi

tal

CPN

s re

ceiv

e fo

rmal

trai

ning

, ret

rain

ing

and

accr

edita

tion,

fund

ed b

y CC

MH

PCC

MH

P tr

ains

peo

ple

as c

omm

unity

‑le

vel m

enta

l hea

lth a

dvoc

ates

for

prom

otio

n, id

entifi

catio

n an

d re

ferr

al.

CPN

s an

d C

HEW

s co

nduc

t com

mun

ity

outr

each

for f

ollo

w‑u

p

Serv

ice

deliv

ery

Sadd

i et a

l. (2

018)

[88]

Braz

ilian

nat

iona

l pro

gram

me

for i

mpr

ov‑

ing

prim

ary

care

acc

ess

and

qual

ity

(PM

AQ

)

To d

eter

min

e fro

ntlin

e w

orke

r adh

eren

ce

to P

MA

Q a

nd th

eir p

erce

ptio

n of

the

impa

ct o

f the

pro

gram

me

Det

erm

ine

the

rela

tions

hip

betw

een

the

impa

ct o

f the

PM

AQ

as

perc

eive

d by

fron

tline

wor

kers

and

the

way

they

ev

alua

te th

e or

gani

zatio

nal c

apac

ity o

f th

e FH

S at

the

front

line

This

pro

gram

me

was

ado

pted

in 2

011

to im

prov

e th

e qu

ality

and

per

form

ance

of

PH

C in

Bra

zil,

whi

ch is

bro

adly

kno

wn

thro

ugh

its m

ain

polic

y: th

e FH

SPM

AQ

obj

ectiv

es a

re (1

) to

prom

ote

qual

ity a

nd in

nova

tion

in p

rimar

y ca

re

man

agem

ent,

stre

ngth

enin

g se

lf‑as

sess

men

t, m

onito

ring

and

asse

ssm

ent,

inst

itutio

nal s

uppo

rt a

nd p

erm

anen

t ed

ucat

ion

proc

esse

s; (2

) to

impr

ove

the

use

of in

form

atio

n sy

stem

s as

a p

rimar

y ca

re m

anag

emen

t too

l; (3

) to

inst

itu‑

tiona

lize

a pr

imar

y ca

re a

sses

smen

t and

m

anag

emen

t cul

ture

; (4)

to s

timul

ate

the

focu

s of

prim

ary

care

on

the

serv

ice

user

, pro

mot

ing

man

agem

ent p

roce

sses

an

d tr

ansp

aren

cy

Serv

ice

deliv

ery

Sam

i et a

l. (2

018)

[102

]W

HO

sta

ndar

ds fo

r com

mun

ity‑ a

nd

heal

th fa

cilit

y‑ba

sed

new

born

car

eEx

amin

es th

e fe

asib

ility

of i

mpl

emen

ting

a pa

ckag

e of

com

mun

ity‑ a

nd fa

cilit

y‑ba

sed

neon

atal

inte

rven

tions

WH

O s

tand

ards

for c

omm

unity

‑ and

he

alth

faci

lity‑

base

d ne

wbo

rn c

are

prio

r‑iti

zed

the

mos

t crit

ical

ser

vice

s (n

eona

tal

inte

rven

tions

for r

educ

ing

mor

talit

y)

durin

g a

hum

anita

rian

cris

is

Serv

ice

deliv

ery

Page 21 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Schn

eide

r and

Nxu

mal

o (2

017)

[97]

War

d‑ba

sed

outr

each

team

(WBO

T)

stra

tegy

—ad

apta

tion

for c

omm

unity

he

alth

wor

ker p

rogr

amm

e

Und

erst

and

the

lead

ersh

ip a

nd g

over

n‑an

ce s

truc

ture

Ass

ess

the

prov

inci

al e

xper

ienc

es w

ith

adop

tion

and

impl

emen

tatio

n of

the

WBO

T st

rate

gy

Esta

blis

hed

set o

f pro

posa

ls fo

r the

reor

‑ga

niza

tion

of c

omm

unity

‑bas

ed s

ervi

ces

Lead

ersh

ip/g

over

nanc

e

Shei

kh e

t al.

(201

0) [9

8]H

IV te

stin

g po

licie

sIn

vest

igat

e pr

oble

ms

in th

e im

plem

en‑

tatio

n of

sta

ndar

dize

d pu

blic

hea

lth

prac

tice

guid

elin

es fr

om th

e pe

rspe

ctiv

e of

the

part

icip

ant a

ctor

s

Focu

sed

on th

e fo

llow

ing

aspe

cts

of

the

polic

y: (1

) inf

orm

ed c

onse

nt; (

2) H

IV

test

ing

as a

pre

cond

ition

to p

refo

rmin

g a

med

ical

pro

cedu

re; (

3) s

tric

t con

fiden

‑tia

lity

Hea

lth w

orkf

orce

Shel

ley

et a

l. (2

016)

[99]

Nat

iona

l com

mun

ity h

ealth

wor

ker

(NC

HW

) str

ateg

yEv

alua

te im

plem

enta

tion

proc

ess

Det

erm

ine

barr

iers

and

faci

litat

ors

Ass

ess

how

evi

denc

e w

as u

sed

to g

uide

on

goin

g im

plem

enta

tion

and

scal

e‑up

de

cisi

ons

A s

trat

egy

deve

lope

d to

recr

uit c

omm

u‑ni

ty h

ealth

ass

ista

nts

for a

ssis

tanc

e w

ith

dise

ase

burd

en th

roug

h a

com

preh

en‑

sive

PH

C c

urric

ulum

Stra

tegy

aim

ed to

redu

ce m

ater

nal a

nd

child

mor

talit

y by

pro

vidi

ng P

HC

ser

vice

s as

clo

se to

the

fam

ily a

s po

ssib

le

Hea

lth w

orkf

orce

Stei

n et

al.

(200

8) [1

06]

Prac

tical

App

roac

h to

Lun

g H

ealth

in

Sout

h A

frica

(PA

LSA

) PLU

S pr

ogra

mm

eEx

plor

e th

e va

lue

of P

ALS

A P

LUS

guid

e‑lin

e tr

aini

ng a

ppro

ach

from

a P

HC

nur

se

pers

pect

ive

Eval

uate

the

stra

tegi

es u

sed

for a

dopt

ion

Hea

lth s

yste

m‑b

ased

app

roac

h to

trai

n‑in

g fo

r prim

ary

care

pro

vide

rs w

ith tw

o co

mpo

nent

s: (1

) a c

ompr

ehen

sive

set

of

algo

rithm

‑bas

ed s

yndr

omic

gui

delin

es

for P

HC

nur

se c

linic

al m

anag

emen

t of

resp

irato

ry d

isea

se a

nd H

IV/A

IDS;

(2) a

tr

aini

ng p

rogr

amm

e to

faci

litat

e gu

ide‑

line

impl

emen

tatio

n

Serv

ice

deliv

ery

Win

gfiel

d et

al.

(201

5) [1

13]

CRE

SIPT

: com

mun

ity ra

ndom

ized

eva

lu‑

atio

n of

a s

ocio

econ

omic

inte

rven

tion

to

prev

ent T

B

Eval

uate

a s

ocio

econ

omic

inte

rven

tion

to s

uppo

rt p

reve

ntio

n an

d cu

re o

f TB

in

TB‑a

ffect

ed h

ouse

hold

sD

escr

ibe

the

chal

leng

es o

f im

plem

enta

‑tio

n, le

sson

s le

arne

d an

d re

finem

ent o

f TB

inte

rven

tion

The

CRE

SIPT

pro

ject

aim

ed to

eva

luat

e a

soci

oeco

nom

ic in

terv

entio

n (v

ia c

ash

tran

sfer

s) to

sup

port

pre

vent

ion

and

cure

of T

B in

TB‑

affec

ted

hous

ehol

ds

and,

ulti

mat

ely,

impr

ove

com

mun

ity T

B co

ntro

l

Fina

ncin

g

Xia

et a

l. (2

015)

[89]

PMTC

T; p

rena

tal H

IV, s

yphi

lis a

nd h

epat

i‑tis

B te

stin

g (P

HSH

T)Ex

amin

e th

e ch

alle

nges

and

effe

ctiv

e‑ne

ss o

f int

egra

ting

PHSH

T se

rvic

esA

prio

rity

stra

tegy

(pro

mot

ed b

y W

HO

) in

volv

ing

the

inte

grat

ion

of s

ervi

ces

incl

udin

g te

stin

g to

redu

ce m

othe

r‑to

‑ch

ild tr

ansm

issi

on (M

TCT)

Serv

ice

deliv

ery

Zaku

mum

pa e

t al.

[85]

ART

sca

le‑u

pEx

plor

e ho

w d

iffer

ent h

ealth

sys

tem

co

mpo

nent

s in

tera

ct in

influ

enci

ng th

e su

stai

nabi

lity

of A

RT s

cale

‑up

impl

emen

‑ta

tion

Prov

isio

n of

free

ant

iretr

ovira

l dru

gs,

wor

kfor

ce tr

aini

ng in

ART

man

age‑

men

t, en

hanc

ing

labo

rato

ry c

apac

ity

and

stre

ngth

enin

g A

RT p

rogr

amm

e re

port

ing

Acc

ess

to e

ssen

tial m

edic

ine

Page 22 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 2

(con

tinue

d)

Aut

hor/

year

Gui

delin

e/re

com

men

datio

n na

me

Stud

y ai

m a

nd o

bjec

tives

Des

crip

tion

Hea

lth s

yste

m b

uild

ing

bloc

k

Zhou

et a

l. (2

019)

[67]

The

mid

‑ and

long

‑ter

m p

olic

y an

d de

velo

pmen

t pla

n fo

r men

tal h

ealth

in

Liuy

ang

Mun

icip

ality

(Liu

yang

pol

icy

and

Liuy

ang

plan

)

Add

ress

the

gap

in C

hina

’s m

enta

l hea

lth

polic

y lit

erat

ure

with

resp

ect t

o lo

cal‑

leve

l pro

mot

ion

and

impl

emen

tatio

nPr

ovid

e a

deep

er u

nder

stan

ding

of

Chi

na’s

prob

lem

s an

d ge

nera

l les

sons

for

impl

emen

ting

men

tal h

ealth

pol

icy

at

the

loca

l lev

el

The

four

mai

n ob

ject

ives

of L

iuya

ng

polic

y an

d Li

uyan

g pl

an in

clud

e (1

) es

tabl

ishi

ng a

lead

ersh

ip a

nd c

oord

ina‑

tion

mec

hani

sm fo

r men

tal h

ealth

wor

k;

(2) c

onst

ruct

ing

a th

ree‑

leve

l net

wor

k of

men

tal h

ealth

ser

vice

s; (3

) man

age‑

men

t and

inte

rven

tion

for p

atie

nts

with

ps

ycho

sis

(PW

P); a

nd (4

) im

prov

ing

the

publ

ic’s

awar

enes

s an

d kn

owle

dge

of

men

tal h

ealth

Lead

ersh

ip/g

over

nanc

e

Page 23 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 3

Hea

lth s

yste

m g

uide

line/

reco

mm

enda

tion

adap

tatio

n st

rate

gies

(FRA

ME)

Aut

hor

Ada

ptat

ion

stra

tegi

esJu

stifi

catio

nW

hen

the

mod

ifica

tion

occu

rred

; was

ad

apta

tion

plan

ned

Who

par

ticip

ated

in th

e de

cisi

on to

mod

ifyW

hat w

as m

odifi

ed;

cont

ent o

f mod

ifica

tion

Leve

l of d

eliv

ery

And

rade

et a

l. (2

017)

[75]

Att

entio

n to

chr

onic

con

‑di

tions

mod

el (A

CCM

)La

ck o

f res

ourc

esN

ot re

port

ed; p

lann

ed

proa

ctiv

eSt

eps

wer

e co

nditi

oned

fo

r the

abi

lity

of h

ealth

pr

ofes

sion

als

to u

nder

‑st

and

the

seve

n m

acro

pr

oces

ses

and

thei

r en

gage

men

t bas

ed o

n av

aila

ble

reso

urce

s

The

seve

n st

eps

of th

e A

CCM

(the

y cu

t thr

ee o

f th

e st

eps

to a

dapt

to th

is

heal

th s

yste

m);

rem

ovin

g/sk

ippi

ng e

lem

ents

Hea

lth p

rofe

ssio

nals

are

the

prim

ary

and

seco

ndar

y le

vel

of c

are

Arm

stro

ng e

t al.

(201

4)

[90]

Mat

erna

l and

per

inat

al

deat

h re

view

s (M

PDR)

sy

stem

impl

emen

tatio

n

Ada

ptat

ions

bas

ed o

n ch

alle

nges

that

wer

e id

entifi

ed th

roug

h a

case

re

view

incl

udin

g la

ck o

f tr

aini

ng

Thes

e ar

e su

gges

ted

solu

‑tio

ns to

cha

lleng

es th

at

wer

e id

entifi

ed—

may

or

may

not

hav

e be

en p

ut

into

pra

ctic

e; re

activ

e

Det

erm

ined

thes

e du

ring

an M

PDR

mee

ting

Trai

ning

and

eva

lua‑

tion—

prov

idin

g sk

ills

and

educ

atio

n to

mat

erni

ty

staff

and

wom

en in

the

com

mun

ity, r

espe

ctiv

ely;

ad

ding

ele

men

ts—

trai

n‑in

g an

d ed

ucat

ion

Com

mun

ity (w

omen

) and

cl

inic

/uni

t lev

el (m

ater

nity

st

aff a

t hos

pita

l/rep

ro‑

duct

ive

and

child

hea

lth

coor

dina

tor)

Bryc

e et

al.

(200

5) [5

8]IM

CI g

ener

ic g

uide

lines

ca

n be

ada

pted

by

any

coun

try

or a

rea

to re

flect

th

eir s

peci

fic e

pide

mio

‑lo

gica

l pro

file

and

heal

th

syst

em c

hara

cter

istic

sW

HO

wor

ked

to d

evel

op

guid

elin

es fo

r the

cou

ntry

ad

apta

tion

proc

ess,

incl

udin

g ev

iden

ce fo

r in

terv

entio

n ch

oice

s, m

odel

s fo

r how

to

inco

rpor

ate

addi

tiona

l di

seas

es a

nd c

ondi

tions

in

to th

e tr

aini

ng m

ater

ials

, an

d ho

w to

con

duct

loca

l st

udie

s to

iden

tify

term

i‑no

logy

and

loca

l foo

dsCa

dres

of “

IMC

I ada

ptat

ion

cons

ulta

nts”

wer

e tr

aine

d at

regi

onal

and

glo

bal

leve

ls

Revi

ew o

f the

gui

delin

e ex

pect

atio

nsPr

e‑im

plem

enta

tion

and

early

impl

emen

tatio

n;

proa

ctiv

e

Coun

trie

s th

at im

plem

ent

this

pro

gram

me

adap

t it

to fi

t the

ir lo

cal c

onte

xt

Cont

extu

al—

sett

ing;

ta

ilorin

g to

thei

r loc

al

cont

ext

Targ

et in

terv

entio

n gr

oup

Page 24 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 3

(con

tinue

d)

Aut

hor

Ada

ptat

ion

stra

tegi

esJu

stifi

catio

nW

hen

the

mod

ifica

tion

occu

rred

; was

ad

apta

tion

plan

ned

Who

par

ticip

ated

in th

e de

cisi

on to

mod

ifyW

hat w

as m

odifi

ed;

cont

ent o

f mod

ifica

tion

Leve

l of d

eliv

ery

Carn

eiro

et a

l. (2

018)

[100

]Th

e m

ore

phys

icia

ns in

Br

azil

prog

ram

me

(MPB

P)

has

resu

lted

in c

hang

es

in th

e w

ork

proc

esse

s of

th

e Fa

mily

Hea

lth S

trat

egy

(FH

S), i

nclu

ding

cha

nges

to

the

man

agem

ent a

nd

cont

rol m

odel

s us

ed in

th

e re

gion

Mun

icip

aliti

es e

xper

ienc

ed

stro

ng a

scen

ding

tren

ds

in th

e nu

mbe

r of p

rena

tal

cons

ulta

tions

and

lack

of

acce

ss to

reso

urce

s

Impl

emen

tatio

n; re

activ

eM

inis

try

of H

ealth

(MoH

)Co

ntex

tual

—ho

w

trea

tmen

t is

deliv

ered

; ta

ilorin

g/tw

eaki

ng/r

efin‑

ing—

reor

gani

zatio

n of

th

e pr

enat

al c

are

Targ

et in

terv

entio

n gr

oup

Gue

ye e

t al.

(201

6) [1

08]

Stra

tegi

es w

ere

adap

ted

to

impl

emen

t man

agem

ent

of m

alar

ia p

rogr

amm

eIn

trod

ucin

g ne

w o

r ada

pt‑

ing

stra

tegi

es, f

rom

inse

cti‑

cide

rota

tion

to le

ssen

the

risk

of in

sect

icid

e re

sist

‑an

ce, t

o an

incr

ease

in

para

sito

logi

cal s

cree

ning

in

dev

elop

men

t are

as to

cu

rtai

l the

risk

of t

rans

mis

‑si

on, t

o co

llabo

ratio

ns

with

the

priv

ate

sect

or

Non

e re

port

edEa

rly im

plem

enta

tion;

re

activ

eSt

affCo

ntex

tual

; tai

lorin

g to

lo

cal c

onte

xtO

rgan

izat

ion

Hal

pern

et a

l. (2

010)

[77]

Ada

ptat

ion

of a

sta

ndar

d‑iz

ed H

IV p

atie

nt m

onito

r‑in

g sy

stem

(PM

S)W

HO

pro

vide

d tr

aini

ng o

n th

e H

IV c

are

and

antir

etro

‑vi

ral t

reat

men

t (A

RT) P

MS,

an

d th

e te

chni

cal w

orki

ng

grou

p ad

apte

d ea

ch c

om‑

pone

nt fo

r Guy

ana

Syst

em to

ols

and

func

‑tio

ns w

ere

mod

ified

ba

sed

on fe

edba

ck fr

om

the

trai

ning

ses

sion

pa

rtic

ipan

ts, a

nd a

pilo

t PM

S w

as s

ubse

quen

tly

impl

emen

ted

at o

ne s

ite

Non

e re

port

edPr

e‑im

plem

enta

tion;

pl

anne

d/pr

oact

ive

Tech

nica

l wor

king

gro

upCo

ntex

tual

—pa

tient

cha

rt

data

ele

men

ts a

nd fu

nc‑

tiona

lity

to P

MS

syst

em;

tailo

ring/

twea

king

, add

ing

elem

ents

to p

atie

nt c

hart

Clin

ic‑u

nit l

evel

—H

IV c

are

ART

Page 25 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 3

(con

tinue

d)

Aut

hor

Ada

ptat

ion

stra

tegi

esJu

stifi

catio

nW

hen

the

mod

ifica

tion

occu

rred

; was

ad

apta

tion

plan

ned

Who

par

ticip

ated

in th

e de

cisi

on to

mod

ifyW

hat w

as m

odifi

ed;

cont

ent o

f mod

ifica

tion

Leve

l of d

eliv

ery

Kihe

mbo

et a

l. (2

018)

[57]

Impl

emen

t nat

ionw

ide

ISD

R tr

aini

ng to

hea

lth

faci

litie

s ba

sed

on th

e re

vise

d gu

idel

ines

dev

el‑

oped

Post

‑tra

inin

g su

ppor

t th

roug

h in

tegr

ated

su

perv

isio

n

Two

chal

leng

es fr

om th

e fir

st im

plem

enta

tion:

Lack

of f

undi

ng re

sulte

d in

a la

ck o

f res

ourc

es a

nd

capa

citie

s at

the

oper

a‑tio

nal l

evel

A n

eed

for a

har

mon

ized

ou

tbre

ak re

spon

se a

nd

info

rmat

ion

flow

at t

he

dist

rict l

evel

Pre‑

impl

emen

tatio

n;

plan

ned

Min

istr

y of

hea

lth a

long

w

ith k

ey p

artn

ers

Aim

ed to

enh

ance

the

capa

city

of d

istr

icts

to

prom

ptly

det

ect,

acce

ss

and

effec

tivel

y re

spon

d to

pu

blic

hea

lth e

mer

gen‑

cies

; add

ing

elem

ents

—tr

aini

ng

Hea

lth w

orkf

orce

all

the

way

up

to th

e op

erat

iona

l na

tiona

l lev

el

Leet

hong

dee

(200

7) [8

3]G

over

nmen

t dec

ided

to

fund

the

sche

me

by p

ool‑

ing

the

Min

istr

y of

Pub

lic

Hea

lth (M

oPH

) bud

gets

fo

r pub

lic h

ospi

tals

, oth

er

heal

th fa

cilit

ies,

and

Med

i‑ca

l Wel

fare

Sch

eme

(MW

S)

and

volu

ntar

y he

alth

car

d sc

hem

e an

d pr

ovid

ing

addi

tiona

l mon

ey

The

initi

al p

lan

met

resi

st‑

ance

from

qua

rter

s su

ch

as th

e ci

vil s

ervi

ce a

nd th

e la

bour

uni

ons

Pre‑

impl

emen

tatio

n;

reac

tive

Civ

il se

rvic

e an

d la

bour

un

ions

reje

cted

the

initi

al

plan

, gov

ernm

ent t

hen

had

to re

asse

ss

Impl

emen

tatio

n an

d sc

ale‑

up a

ctiv

ities

; su

bstit

utin

g th

e fu

ndin

g st

ruct

ures

Targ

et in

terv

entio

n gr

oup

Mut

abaz

i et a

l. (2

020)

[87]

Ove

r the

yea

rs, t

he p

re‑

vent

ion

of m

othe

r‑to

‑chi

ld

tran

smis

sion

of H

IV/A

IDS

(PM

TCT)

gui

delin

es h

ave

been

ada

pted

, but

no

stra

tegi

es re

port

ed

Non

e re

port

edN

one

repo

rted

Non

e re

port

edN

one

repo

rted

Non

e re

port

ed

Ryan

et a

l. (2

020)

[109

]Co

mpr

ehen

sive

com

‑m

unity

men

tal h

ealth

pr

ogra

mm

e (C

CM

HP)

A s

cale

‑up

initi

ativ

e fo

r th

e ge

nera

l men

tal h

ealth

po

licy

impl

emen

tatio

n in

N

iger

ia th

roug

h pu

blic

–pr

ivat

e pa

rtne

rshi

p in

he

alth

care

del

iver

y

Abs

ence

of m

ore

clin

ical

re

sour

ces

Scal

e‑up

; rea

ctiv

eN

one

repo

rted

Phon

e ps

ychi

atris

ts a

s ne

eded

; add

ing

elem

ent

Com

mun

ity p

sych

iatr

ic

nurs

es (C

PNs)

and

com

‑m

unity

hea

lth e

xten

sion

w

orke

r (C

HEW

s)

Page 26 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 3

(con

tinue

d)

Aut

hor

Ada

ptat

ion

stra

tegi

esJu

stifi

catio

nW

hen

the

mod

ifica

tion

occu

rred

; was

ad

apta

tion

plan

ned

Who

par

ticip

ated

in th

e de

cisi

on to

mod

ifyW

hat w

as m

odifi

ed;

cont

ent o

f mod

ifica

tion

Leve

l of d

eliv

ery

Schn

eide

r and

Nxu

mal

o (2

017)

[97]

Re‑e

ngin

eerin

g of

prim

ary

heal

thca

re (P

HC

)To

mee

t the

nee

ds a

nd

dem

ands

of e

ach

com

mu‑

nity

hea

lth p

rogr

amm

e

Not

repo

rted

; pla

nned

pr

oact

ive

Dis

tric

t man

ager

s, se

nior

pr

ovin

cial

man

ager

s, PH

C

faci

lity

man

ager

s, ou

t‑re

ach

team

lead

ers,

seni

or

dist

rict o

ffici

al, s

ubdi

stric

t m

anag

ers,

PHC

faci

lity

supe

rvis

ors,

prof

essi

onal

nu

rses

, env

ironm

enta

l he

alth

offi

cers

Hea

lth p

osts

vs

PHC

re‑

engi

neer

ing

Role

s of

non

gove

rnm

en‑

tal o

rgan

izat

ions

wer

e re

defin

edC

hang

e in

the

met

hod

of

paym

ent o

f CH

WN

ew c

urric

ula

and

trai

ning

pr

oces

ses;

tailo

ring

lead

er‑

ship

and

gov

erna

nce

chan

ges

Hea

lthca

re w

orke

rs—

spe‑

cific

ally

com

mun

ity‑b

ased

w

orke

rs

Stei

n et

al.

(200

8) [1

06]

Inco

rpor

atin

g co

unse

lling

sk

ills

into

the

Prac

tical

A

ppro

ach

to L

ung

Hea

lth

in S

outh

Afri

ca (P

ALS

A)

PLU

S m

odel

Ong

oing

ons

ite tr

aini

ng

prov

ides

em

otio

nal s

up‑

port

Giv

en th

e lim

iting

un

ders

tand

ing

of n

urse

co

unse

lling

ski

lls (i

.e.

they

oft

en th

reat

ened

pa

tient

s in

stea

d of

mak

ing

reco

mm

enda

tion)

, nur

ses

conc

eive

cou

nsel

ling

as

“adv

ice”

that

mus

t be

com

‑pl

ied

with

rath

er th

an th

e pa

tient

feel

ing

empo

wer

‑m

ent i

n de

cisi

on‑m

akin

g

Dur

ing

the

impl

emen

ta‑

tion

of th

e PA

LSA

PLU

S pr

ogra

mm

e an

d th

is

eval

uatio

n; re

activ

e

Not

repo

rted

Ong

oing

site

trai

ning

and

co

unse

lling

; add

ing

ele‑

men

ts—

inco

rpor

atio

n of

a

pray

er in

to n

urse

‑tra

in‑

ing

sess

ions

, as

a m

eans

of

acc

essi

ng s

pirit

ual

rese

rves

for e

mot

iona

l su

ppor

t

Prim

ary

heal

thca

re n

urse

s

Win

gfiel

d et

al.

(201

5)

[113

]In

nova

tive

soci

oeco

nom

ic

inte

rven

tion

agai

nst

TB (I

SIAT

) str

ateg

y w

as

eval

uate

d un

der t

he c

om‑

mun

ity ra

ndom

ized

eva

lu‑

atio

n of

a s

ocio

econ

omic

in

terv

entio

n to

pre

vent

TB

(CRE

SIPT

) pro

ject

Regu

lar s

teer

ing

mee

tings

, fo

cus

grou

p di

scus

sion

s an

d co

ntac

t in

the

heal

th

post

s

Incr

ease

adh

eren

ce a

nd

part

icip

atio

n in

the

pro‑

gram

me

Pre‑

impl

emen

tatio

n an

d im

plem

enta

tion;

pro

activ

eSt

akeh

olde

rs +

reci

pien

tsCo

ntex

tual

—in

crea

sed

the

spee

d of

ban

k tr

ansf

ers;

subs

titut

ing

the

fund

ing

stru

ctur

es

Targ

et in

terv

entio

n gr

oup

Zaku

mum

pa e

t al.

[85]

ART

sca

le‑u

pN

onph

ysic

ian

cadr

e w

ere

pres

crib

ing

antir

etro

vira

l th

erap

y

The

shor

tage

of p

hysi

cian

‑le

vel c

adre

was

iden

tified

as

a c

onst

rain

t

Scal

e‑up

; rea

ctiv

eIn

divi

dual

pra

ctiti

oner

sIm

plem

enta

tion

and

scal

e‑up

act

iviti

es; t

wea

k‑in

g—no

nphy

sici

an c

adre

w

ere

pres

crib

ing

ART

du

e to

rapi

dly

expa

ndin

g pa

tient

vol

umes

Clin

ic/u

nit l

evel

, ind

ivid

ual

prac

titio

ner

Page 27 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

(n = 6) and developing educational materials (n = 5). The least prevalent ERIC-defined implementation strategies included, but were not limited to, revision of professional roles (n = 2), alterations of incentives/allowance structure (n = 2), assessments for readiness and identification of barriers and facilitators (n = 1), and tailoring of strategies (n = 1). A full breakdown of all 38 implementation strate-gies and their frequencies can be found in Table 4. None of our included studies explicitly reported the use of a theoretical/conceptual framework to guide their selec-tion of implementation strategies.

Outcomes of interestTable  5 summarizes the outcomes of interest and key results of included studies. Nineteen articles reported the involvement of key stakeholders in various aspects of their design and implementation processes. Stakehold-ers varied from frontline healthcare workers to policy-makers, government organizations and nongovernmental organizations (NGOs). Outcomes of interest were related primarily to documenting and evaluating the implemen-tation process, as well as the impact of the guideline on the health system (n = 39). These included assessing the barriers to and enablers of implementation, eliciting end-users’ experiences and perspectives, monitoring system and service changes, evaluating resource use, identify-ing future steps and comparing guideline expectations to real-world impacts. Additionally, one article explic-itly specified the documentation of an implementation framework as an outcome of interest. Patient-level out-comes were noted as an indicator of success and included measuring health outcomes and quality of care delivery (n = 3). While many outcomes of interest were indicators of the overall success of the health system guideline inte-gration, there were no outcomes of interest specifically reported as related to adaptations.

Outcome measuresOutcome measures included interviews/focus groups (n = 29), document/policy analysis (n = 10), surveys/questionnaires (n = 9), health administrative data and medical records (n = 8), field visits/observations (n = 4), secondary data from literature/guideline reviews (n = 2), individual case studies (n = 2), clinical assessment tools (n = 1), performance assessment tools (n = 1) and patient observations (n = 1). A full breakdown of outcomes is presented in Table 5.

Barriers and enablers related to implementationReported barriers to and enablers of implementation of health system guidelines were coded using the COM-B framework [54]. Barriers and enablers that were most frequently reported by identified studies were associated

with physical (n = 36) or social (n = 22) opportunity. Physical opportunities are defined as the environmental context and resources, whereas social opportunities refer to the social influences, such as norms and cultural fac-tors [54]. Financial constraints, access to resources, and training (or lack thereof ) were persistent physical oppor-tunity factors described. Language and communication, political instability and power imbalances are all exam-ples of reported barriers or enablers related to social opportunities.

Implementation barriers and enablers related to psy-chological (n = 15) and physical capabilities (n = 19) were the second most frequently coded category in the COM-B framework. Physical capabilities describe the skills and abilities required, while psychological capa-bilities refer to the concepts of knowledge, memory, decision-making and behavioural regulation [54]. Identi-fied articles reported barriers and enablers related to the knowledge about implemented guidelines, the emotional toll on frontline workers and the resistance to change. Physical capabilities included adapting training materials specific to the needs of end-users and ongoing training/mentorship with supervision.

Reflective (n = 4) and automatic (n = 10) motivations were the least often coded barrier and enabler in our review. Reflective motivation refers to the roles, iden-tities and beliefs about consequences [54]. Resistance to or acceptance of change, trust in the guidelines, and defining role and responsibility attributes are all exam-ples noted among the reflective motivation category. Automatic motivation refers to the emotion and rein-forcement influencing target behaviour [54]. Dedicated commitment, enthusiasm and motivation to implement health system guidelines were reported as a barrier and/or enabler. A summary of the COM-B analysis can be found in Tables  6 and 7. A full breakdown of extracted and analysed data can be found in Additional file 4.

Barriers and enablers related to adaptationEight articles reported barriers and enablers related to adaptation of the health system guidelines. Of these, physical opportunities were the most commonly reported barriers and enablers, with articles describing the use of technical working groups to adjust and manage unexpected changes, ensure flexibility in initiatives, and create new structures/systems to facilitate local adapta-tion (n = 6). Strong multisectoral collaboration, proac-tive leadership and culturally appropriate support are all examples of barriers and enablers related to social oppor-tunities that were reported (n = 3). Reflective motivation (n = 2) was the only other COM-B category captured in reported barriers and enablers with respect to adaptation by this review. This related to a lack of available evidence

Page 28 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Table 4 Implementation strategies coded using the ERIC framework

ERIC category Occurrences Implementation strategies (author/year)

Conduct ongoing training 11 Conduct ongoing training (Ejeta et al. 2020 [107]; Lovero et al. 2019) [93]Training sessions (Xia et al. 2015) [89]Education and retraining (Callaghan‑Koru et al. 2020) [86]Training (Kavle et al. 2018 [114]; Rahman et al. 2020 [105])Clinical training (Sami et al. 2018) [102]Staff in primary care settings to receive training and supervision for basic men‑tal health screening, diagnosis and treatment (Lovero et al. 2019) [93]Trained in key modules of WHO’s Mental Health Gap Action Programme Inter‑vention Guide (Ryan et al. 2020) [109]Capacity‑building of medical doctors (MDs) through high‑intensity training and onsite supervision (Miguel‑Esponda et al. 2020) [69]Develop and conduct tailored training for nurse midwives and clinical officers at dispensaries (Mkoka et al. 2014) [94]

Build a coalition 8 Establishment of task teams, appointing leaders and NGO partnerships to lead and manage change (Schneider and Nxumalo 2017) [97]The programme proposal was presented and discussed with the staff. With the approval of the team, the process was gradually implemented (Bergerot et al. 2017) [79]Mutual promotion between national and local policies (Zhou et al. 2019) [67]Partnering with community associations (Lavôr et al. 2016) [111]Support for referrals to specialist services (Miguel‑Esponda et al. 2020) [69]Collaboration and support from international development partners; national procurement planning and coordination (Rahman et al. 2020 [105])Establish primary healthcare (PHC) network in one district of each province in the first year (Moshiri et al. 2016) [95]Integrated into curative health services provided by the national government (Gueye et al. 2016) [108]

Develop educational materials 7 Develop educational materials (Ejeta et al. 2020 [107]; Andrade et al. 2017 [75])Standardization of materials (Roman et al. 2014) [66]New training methods to create a more harmonized and educated workforce (Kihembo et al. 2018) [57]Written policy statement that is routinely communicated (Kavle et al. 2018) [114]Designed training materials (self‑reading, teaching aids and videos) based on the principles of participatory learning (investigators of WHO Low Birth Weight [LBW] Feeding Study Group, 2016) [110]Treatment guidelines (Rahman et al. 2020) [105]

Use of advisory boards 6 Stakeholder engagement (Roman et al. 2014) [66]Community groups and activist and healthcare professional acceptance and support; obtaining assistance from community health workers (Mutabazi et al. 2020) [87]Development of a chlorhexidine technical working group (Callaghan‑Koru et al. 2020) [86]Promote collaboration between healthcare staff, support groups and local community; orientation of national policy‑ and decision‑makers, management and community committees (Kavle et al. 2018) [114]Strategic planning workshops (Sami et al. 2018) [102]Elicited feedback on any site‑specific concerns not addressed by the proposed system (Halpern et al. 2010) [77]

Conduct educational meetings 6 Education to healthcare providers (Roman et al. 2014) [66]Health education sessions (Kavle et al. 2018) [114]A national training and feedback session (Halpern et al. 2010) [77]Participatory community meetings for information (Wingfield et al. 2015) [113]Conducting educational activities for adherence to directly observed therapy (DOT ; Lavôr et al. 2016) [111]Countries conducted orientation meetings (Bryce et al. 2005) [58]

Distribute educational material 5 Distributed educational material (Ejeta et al. 2020) [107]Routinely distributed policy statement (Kavle et al. 2018) [114]Designed training materials (self‑reading, teaching aids and videos) based on the principles of participatory learning (investigators of WHO LBW Feeding Study Group, 2016) [110]Printed educational materials for clinical decision‑making (Miguel‑Esponda et al. 2020) [69]Treatment guidelines (Rahman et al. 2020) [105]

Page 29 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Table 4 (continued)

ERIC category Occurrences Implementation strategies (author/year)

Promote network‑weaving 5 Leading and managing change—establishment of task teams, appointing leaders and NGO partnerships (Schneider and Nxumalo 2017) [97]Collaboration between national reproductive health programmes and national malaria control programmes (Roman et al. 2014) [66]Coordination of Community Cadres within the health system (Shelley et al. 2016) [99]Multi‑department participation and collaboration to better implement the national essential drugs policy (Li et al. 2015) [112]Targeted interactions of PHC designers with local actors shaped a wide net‑work of friends before the implementation phase (Moshiri et al. 2016) [95]

Conduct educational outreach visits 4 Education to healthcare providers (Roman et al. 2014) [66]Ongoing onsite training provides emotional support (Stein et al. 2008) [106]Monthly visits from a member of the working group to validate reports and address any implementation issues (Halpern et al. 2010) [77]Developed management and training capacity in a limited number of districts (Bryce et al. 2005) [58]

Access new funding 4 Ensuring financial stability (Roman et al. 2014) [66]Financial guarantee from the central government (Zhou et al. 2019) [67]Distribution of amoxicillin by UNICEF (Rahman et al. 2020) [105]Programme financing (Miguel‑Esponda et al. 2020) [69]

Stage implementation scale‑up 4 Implementation scale‑up (Callaghan‑Koru et al. 2020) [86]Pilot project was evaluated first; when it was deemed successful, the guideline was implemented at all existing care sites, one site at a time (Halpern et al. 2010) [77]End of one phase was marked with a review meeting with the objective of synthesizing early implementation experience and planning for expansion (Bryce et al. 2005) [58]Policies were implemented in a series of stages (Leethongdee, 2007) [83]

Develop and organize monitoring systems 4 Surveillance system and performance and monitoring framework (Kihembo et al. 2018) [57]Programme monitoring (Kavle et al. 2018 [114]; Bryce et al. 2005) [58]Following each assessment, quality improvement plans are generated and provided to facility managers to guide their improvement actions (Muthathi et al. 2020) [96]

Develop resource‑sharing agreements 4 Management of resource availability; commodities/resources availability (Roman et al. 2014) [66]Distribution of medical commodities (Sami et al. 2018) [102]Ensuring medication supply (Miguel‑Esponda et al. 2020) [69]Supply and distribution of amoxicillin dispersible tablets (Rahman et al. 2020) [105]

Provide clinical supervision 4 Provide clinical supervision (Sami et al. 2018 [102]; Lovero et al. 2019 [93])Staff in primary care settings to receive training and supervision (Lovero et al. 2019) [93]Capacity‑building of MDs through high‑intensity training and onsite supervi‑sion (Miguel‑Esponda et al. 2020) [69]

Develop a formal implementation blueprint 3 Five‑year strategic plan with workplans (Kihembo et al. 2018) [57]Planning and early implementation, developed national strategy and plan (Bryce et al. 2005) [58]Network expansion plan; required budget was estimated and suggested to government; establish PHC network in one district of each province in the first year (Moshiri et al. 2016) [95]

Develop and implement tools for quality monitoring 3 Develop and implement tools for quality monitoring (Ejeta et al. 2020) [107]Standardization of materials; performance assessments (indicators); monitor‑ing and evaluating (Roman et al. 2014) [66]Monitoring through a health information system (Miguel‑Esponda et al. 2020) [69]

Change physical structure and equipment 3 Provide essential equipment and supplies; build/improve infrastructure for service delivery (Mkoka et al. 2014) [94]Availability of basic equipment (Rahman et al. 2020) [105]Providing containers to collect sputum and other inputs in the laboratory (Lavôr et al. 2016) [111]

Use train‑the‑trainer strategies 2 Train‑the‑trainer strategies (Ejeta et al. 2020 [107]; Kihembo et al. 2018) [57]

Page 30 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

influencing choices and end-users valuing additional (and adapted) components to the initiatives.

Quality appraisalTwenty-seven articles ranked high (67–100%) in their quality assessments. Seven articles ranked medium (33–66%) and seven ranked low (0–32%) (see Table 1). Those with medium- and lower-quality scores often lacked details related to their study methods, resulting

Table 4 (continued)

ERIC category Occurrences Implementation strategies (author/year)

Recruit, designate and train for leadership 2 Recruit, designate and train for leadership (Ditlopo et al. 2011) [91]Top‑down supervision from the central government (Zhou et al. 2019) [67]

Promote adaptability 2 Development and adaptation of guidelines to make them specific for low‑income contexts (Callaghan‑Koru et al. 2020) [86]Adapted the guidelines to their national context (Bryce et al. 2005) [58]

Alter incentive/allowance structures 2 Conditional cash transfers to reduce TB vulnerability; incentivize and enable care (Wingfield et al. 2015) [113]Alter incentive/allowance structures (Ditlopo et al. 2011) [91]

Centralize technical assistance 2 Centralize technical assistance (Andrade et al. 2017) [75]Development of new systems (integrating human resources, financing, etc.) that provided alignment across various departments (Schneider and Nxumalo 2017) [97]

Conduct local consensus discussions 2 Stakeholder engagement (Roman et al. 2014) [66]Targeted interactions of PHC designers with local actors shaped a wide net‑work of friends before the implementation phase (Moshiri et al. 2016) [95]

Involve executive boards 2 Trained key decision‑makers and built government commitment (Bryce et al. 2005) [58]Integrated care into health services provided by the national government (Gueye et al. 2016) [108]

Involve patients/consumers and family members 2 Initiated groups/forums such as Mother to Mother service—where trained mothers living with HIV provided psychosocial support to pregnant women and mother of babies diagnosed with HIV (Mutabazi et al. 2020) [87]Participatory community meetings (Wingfield et al. 2015) [113]

Obtain and use patients and family feedback 2 Obtain community acceptance (Shelley et al. 2016) [99]Community dialogue and action days (Kavle et al. 2018) [114]

Organize clinical implementation team meetings 2 Support groups; mentorship and support (Kavle et al. 2018) [114]Elicited feedback on any site‑specific concerns not addressed and encouraged system buy‑in among the individuals who would ultimately implement the system (Halpern et al. 2010) [77]

Revise professional roles 2 Reallocation of roles and responsibilities (Schneider and Nxumalo, 2017) [97]Stream linking tasks and roles to expand treatment and care for HIV (Mutabazi et al. 2020) [87]

Provide ongoing consultation 1 Supervision/support system (Shelley et al. 2016) [99]

Capture and share local knowledge 1 Capture and share local knowledge (Andrade et al. 2017) [75]

Use other payment schemes 1 A new public health insurance scheme which provides treatments within a defined “core” benefits package to registered members for a co‑payment (Leethongdee 2007) [83]

Provide local technical assistance 1 Between visits, throughout the implementation process, working group mem‑bers were available for technical consultation (Halpern et al. 2010) [77]

Make training dynamic 1 Training as a facilitated, interactive and more hands‑on approach to learning; integrating learning and practice clinical work allow for feedback/revisions/clarifications (Stein et al. 2008) [106]

Make billing easier 1 Institution flow for timely funding (Lavôr et al. 2016) [111]

Inform local opinion leaders 1 Built government commitment to move forward (Bryce et al. 2005) [58]

Assess for readiness and identify barriers and facilitators 1 Baseline assessment (Kihembo et al. 2018) [57]

Change record systems 1 Change record systems (Ejeta et al. 2020) [107]

Create new clinical teams 1 Deploy health workers (Mkoka et al. 2014) [94]

Tailor strategies 1 Tailor strategies to local context (Andrade et al. 2017) [75]

Page 31 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

Sum

mar

y of

resu

lts a

nd o

utco

mes

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Am

aral

et a

l. [8

2]N

one

repo

rted

Fact

ors

asso

ciat

ed w

ith th

e po

licy

adop

tion

Dat

a fro

m s

tate

sec

reta

riats

of

heal

thN

ew h

ealth

inte

rven

tions

tend

to

be

initi

ally

ado

pted

by

thos

e w

ho n

eed

them

Smal

ler a

nd m

ore

dist

ant

mun

icip

aliti

es w

ere

less

like

ly

to h

ave

IMC

I

It is

nec

essa

ry to

defi

ne h

ealth

po

licie

s in

eac

h st

ate

that

pro

‑m

ote

the

stra

tegy

in h

ighe

r‑ris

k m

unic

ipal

ities

And

rade

et a

l. (2

017)

[75]

Pan

Am

eric

an H

ealth

Org

aniz

a‑tio

n co

nsul

ted

on d

ata

colle

c‑tio

n m

etho

dsSt

akeh

olde

rs in

volv

ed in

im

plem

enta

tion

incl

uded

; G

over

nmen

t of t

he S

tate

of

Min

as G

erai

s; G

over

nmen

t of

Sant

o A

nton

io d

o M

onte

; The

N

atio

nal C

ounc

il of

Hea

lth

Secr

etar

ies

Mac

ro p

roce

sses

of a

tten

tion

to c

hron

ic c

ondi

tions

mod

el

(ACC

M)

Hea

lth o

utco

mes

ass

ocia

ted

with

prim

ary

heal

thca

re (P

HC

)

Hou

seho

ld s

urve

ys a

nd m

edi‑

cal r

ecor

dsIn

terv

iew

sFo

cus

grou

ps

Incr

ease

in c

omm

unity

hea

lth

agen

t vis

itsIn

crea

se in

indi

vidu

als

usin

g pu

blic

hea

lth s

ervi

ces

only

am

ong

thos

e w

ith d

iabe

tes

A d

ecre

ase

in d

octo

r vis

its fo

r in

divi

dual

s w

ith d

iabe

tes

Hav

ing

a un

ified

hea

lth s

yste

m

as th

e m

ain

prov

ider

of p

rimar

y ca

re in

sm

all m

unic

ipal

ities

was

im

port

ant

Esta

blis

hing

a P

HC

net

wor

k in

sm

all m

unic

ipal

ities

was

im

port

ant

Impo

rtan

ce in

impl

emen

tatio

n of

the

mac

ro p

roce

ssSc

reen

ing

patie

nts

to re

ceiv

e tr

eatm

ent a

t diff

eren

t car

e le

vels

Arm

stro

ng e

t al.

(201

4) [9

0]Re

prod

uctiv

e an

d ch

ild

heal

th c

oord

inat

ors,

a di

stric

t la

bora

tory

tech

nici

an, a

dis

tric

t nu

rsin

g offi

cer,

dist

rict m

edic

al

office

r (D

MO

s), h

ealth

sec

reta

r‑ie

s, an

d zo

nal m

ater

nal a

nd

perin

atal

dea

th re

view

s (M

PDR)

m

edic

al o

ffice

rs w

ere

info

rm‑

ants

who

wer

e pr

ofes

sion

ally

in

volv

ed in

MPD

R

The

role

and

pra

ctic

es o

f M

PDR

in d

istr

ict a

nd re

gion

al

hosp

itals

Key

stak

ehol

ders

’ invo

lvem

ent

in a

nd p

ersp

ectiv

es re

gard

ing

the

MPD

R pr

oces

s

Inte

rvie

ws

Impl

emen

tatio

n of

MPD

R w

as

dysf

unct

iona

lTh

e sy

stem

stil

l fac

es a

num

ber

of c

halle

nges

, mos

t of w

hich

m

ay b

e re

late

d to

a la

ck o

f cla

r‑ity

in it

s in

tend

ed p

urpo

se

It is

unw

ise

for p

rovi

ders

to

dise

ngag

eFa

cilit

y‑le

vel r

evie

ws

are

an

impo

rtan

t ite

rativ

e le

arni

ng p

ro‑

cess

that

sho

uld

rem

ain

the

core

of

any

effo

rt to

impr

ove

care

in

heal

th fa

cilit

ies

Shou

ld T

anza

nia

wis

h to

cha

nge

the

MPD

R sy

stem

at t

he lo

cal

leve

l, ev

alua

tion,

trai

ning

and

su

perv

isio

n ar

e re

com

men

ded

Berg

erot

et a

l. (2

017)

[79]

Non

e re

port

edPa

tient

s’ di

stre

ss, a

nxie

ty,

depr

essi

on a

nd q

ualit

y of

life

Dis

tres

s th

erm

omet

erH

ospi

tal a

nxie

ty a

nd d

epre

s‑si

on s

cale

Func

tiona

l ass

essm

ent o

f ca

ncer

ther

apy

Stru

ctur

ed q

uest

ionn

aire

The

prev

alen

ce o

f dis

tres

s w

as

high

com

pare

d w

ith d

evel

‑op

ed c

ount

ries

Prom

ote

the

deve

lopm

ent o

f st

rate

gies

that

favo

ur e

quity

in

canc

er c

are

and

that

offe

r int

er‑

vent

ions

in a

tim

ely

man

ner

Mea

sure

s us

ed w

ere

adeq

uate

fo

r the

iden

tifica

tion

of p

atie

nts’

need

s th

roug

hout

the

con‑

tinuu

m o

f can

cer

The

deve

lopm

ent o

f thi

s sc

reen

ing

prog

ram

me

achi

eved

th

e go

al o

f bet

ter m

eetin

g th

e ps

ycho

soci

al n

eeds

of c

ance

r pa

tient

s

Page 32 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Blan

co‑M

anci

lla (2

011)

[84]

Non

e re

port

edEff

ectiv

enes

s of

pol

icy

impl

e‑m

enta

tion

Inte

rvie

ws

New

spap

er a

rtic

les

Offi

cial

doc

umen

tsO

nlin

e ne

ws

serv

ices

and

pu

blic

atio

ns

Effec

tive

impl

emen

tatio

n in

te

rms

of a

cces

s an

d ca

paci

ty

show

s ve

ry d

iffer

ent e

xper

i‑en

ces

betw

een

the

polic

ies

anal

ysed

Mor

e th

an h

alf o

f the

tota

l nu

mbe

r of p

rimar

y he

alth

ce

ntre

s m

anag

ed b

y th

e de

part

men

t of h

ealth

wer

e st

ill n

ot c

ertifi

ed to

trea

t pol

icy

bene

ficia

ries,

serio

usly

affe

ct‑

ing

acce

ss to

ser

vice

s

Thes

e po

licy

reco

mm

enda

tions

m

ay h

elp

to im

prov

e im

plem

en‑

tatio

n of

the

polic

ies,

as w

ell a

s ot

her n

ew o

r cur

rent

pol

icie

s ei

ther

in M

exic

o or

in o

ther

co

untr

ies

Bryc

e et

al.

(200

5) [5

8]N

one

repo

rted

Com

pare

find

ings

of t

he M

ulti‑

Coun

try

Eval

uatio

n of

IMC

I Eff

ectiv

enes

s, Co

st a

nd Im

pact

(M

CE‑

IMC

I) re

lativ

e to

the

pro‑

gram

me

expe

ctat

ion

refle

cted

in

the

IMC

I im

pact

mod

el

12 c

ount

ry a

sses

smen

tsIn

‑dep

th s

tudi

es a

t five

site

sC

ross

‑ site

ana

lysi

s

The

qual

ity o

f tra

ined

IMC

I w

orke

rs w

as b

ette

r tha

n th

at

of th

e un

trai

ned

wor

kers

, eve

n w

ith n

o su

perv

isio

nIm

prov

ing

the

qual

ity o

f car

e in

fir

st‑le

vel g

over

nmen

t hea

lth

faci

litie

s w

as n

ot s

uffici

ent t

o in

crea

se lo

w u

tiliz

atio

n le

vels

The

mod

el re

flect

ed is

sues

di

rect

ly re

late

d to

ser

vice

del

iv‑

ery,

but

sho

wed

insu

ffici

en‑

cies

with

oth

er a

spec

ts o

f the

he

alth

sys

tem

suc

h as

tran

si‑

tion

path

way

s fro

m p

olic

y an

d st

rate

gy to

ope

ratio

ns, h

uman

re

sour

ce is

sues

incl

udin

g su

p‑po

rtiv

e su

perv

isio

n, fi

nanc

ing

and

ensu

ring

an e

quita

ble

cove

rage

of i

nter

vent

ions

New

att

entio

n to

chi

ld s

urvi

val,

new

lead

ersh

ip in

key

org

aniz

a‑tio

ns, a

nd a

focu

s on

ach

ievi

ng

the

Mill

enni

um D

evel

opm

ent

Goa

l of r

educ

ing

child

mor

talit

y by

two

third

s al

l pro

vide

the

impe

tus

to m

ove

quic

kly,

forc

e‑fu

lly a

nd in

new

way

s to

ach

ieve

un

iver

sal c

over

age

with

pro

ven

child

sur

viva

l int

erve

ntio

ns

Page 33 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Calla

ghan

‑Kor

u et

al.

(202

0)

[86]

Min

istr

y of

Hea

lth a

nd F

amily

W

elfa

re (M

OH

FW)’s

IMC

I uni

t ac

ted

as th

e re

sour

ce te

am

coor

dina

ting

scal

e‑up

A g

roup

com

pose

d of

sta

ke‑

hold

ers

from

gov

ernm

ent,

acad

emia

and

NG

Os

to m

ade

polic

y re

com

men

datio

ns a

nd

prov

ided

gui

danc

eA

loca

l pha

rmac

eutic

al

com

pany

sup

plie

d si

ngle

‑dos

e bo

ttle

sLo

cal N

GO

s w

ere

cont

ract

ed

to c

oord

inat

e th

e tr

aini

ng o

f pr

ovid

ers

in e

ach

dist

rict

Faci

litat

ors

and

barr

iers

with

re

spec

t to

the

inst

itutio

naliz

a‑tio

n an

d ex

pans

ion

stag

es

Inte

rvie

ws

Focu

s gr

oups

Doc

umen

ting

faci

litat

ors

and

barr

iers

with

resp

ect t

o sc

ale‑

up o

f chl

orhe

xidi

ne (C

HX)

po

licy

(see

Bar

riers

/Ena

bler

s Ta

ble)

Stro

ng le

ader

ship

was

a h

uge

succ

ess

fact

orPu

blic

sys

tem

was

not

eva

lu‑

ated

giv

en th

e co

mpl

exity

and

lim

ited

regu

lato

ry c

ontr

ol in

th

is s

ecto

rSc

ale‑

up b

ench

mar

ks w

ould

be

use

ful a

ppro

ache

s fo

r ide

n‑tif

ying

key

inst

itutio

naliz

atio

n ch

ange

sC

hang

es s

houl

d be

ada

pted

to

refle

ct th

e fu

ll st

ruct

ure

of th

e he

alth

sys

tem

CH

X co

unse

lling

and

dis

trib

u‑tio

n ha

ve n

ot b

een

rout

inel

y im

plem

ente

d in

ant

enat

al c

are

expa

nsio

n, s

ugge

stin

g th

at

dist

inct

pla

ns a

nd im

plem

enta

‑tio

n st

rate

gies

are

nee

ded

to

achi

eve

goal

s w

ithin

the

two

scal

e‑up

dim

ensi

ons

The

scal

e‑up

of C

HX

in B

angl

a‑de

sh w

as in

fluen

ced

by a

rang

e of

fact

ors

from

all

five

CFI

R do

mai

ns

Carn

eiro

et a

l. (2

018)

[100

]N

one

repo

rted

Stra

tegy

per

form

ance

Popu

latio

n co

vera

ge e

stim

ated

by

prim

ary

care

team

sPr

opor

tion

of li

ve b

irths

to

mot

hers

with

/with

out p

rena

tal

cons

ulta

tions

Hos

pita

lizat

ion

rate

s du

e to

pri‑

mar

y ca

re‑s

ensi

tive

cond

ition

Infa

nt m

orta

lity

rate

Resu

lted

in c

hang

es to

the

man

agem

ent a

nd c

ontr

ol

mod

els

used

in th

e re

gion

, and

in

trod

uced

uni

vers

ities

to th

e pr

oces

sTh

e pr

opor

tion

of li

ve b

irths

to

mot

hers

with

/with

out p

rena

tal

cons

ulta

tions

incr

ease

d by

97%

on

ave

rage

, pre

dom

inan

tly

with

sev

en c

onsu

ltatio

ns o

r m

ore

and

redu

cing

the

prop

or‑

tion

of li

ve b

irths

to m

othe

rs

with

out p

rena

tal v

isits

The

infa

nt m

orta

lity

rate

ac

hiev

ed a

dow

nwar

d tr

end

The

resu

lts in

dica

ted

the

cont

ri‑bu

tion

of th

e m

ore

phys

icia

ns

in B

razi

l pro

gram

me

(MPB

P)

tow

ards

impr

ovin

g pr

imar

y ca

re

base

d on

the

sele

cted

indi

cato

rs

Page 34 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Cost

a et

al.

(201

4) [1

01]

Non

e re

port

edIn

dica

tion

of c

over

age

Evid

ence

of c

hang

e an

d im

pact

Hom

e vi

sits

mad

e by

doc

tors

Requ

este

d ex

ams

of c

linic

al

path

olog

yRe

ferr

als

to s

peci

alis

ts, a

nd

indi

vidu

al c

are

prov

ided

by

nurs

esN

umbe

r of h

ospi

taliz

atio

ns

due

to c

ondi

tions

that

wou

ld

resp

ond

to o

utpa

tient

car

e (i.

e.

indi

cato

r of i

mpa

ct)

A m

ajor

ity o

f mun

icip

aliti

es

mai

ntai

ned

the

cove

rage

leve

l ve

rified

in 2

004

One

mun

icip

ality

pre

sent

ed

stro

ng in

dica

tions

of c

hang

e in

200

8 an

d w

as re

clas

sifie

d as

m

oder

ate

so a

s to

allo

w th

e co

nduc

tion

of th

e st

atis

tical

te

stA

n in

crea

se o

f 50%

in th

e pr

opor

tion

of m

unic

ipal

ities

cl

assi

fied

as h

igh‑

impa

ctM

ore

cove

rage

com

pare

d w

ith

prev

ious

per

iods

Low

er ra

tes

of m

orbi

dity

The

prop

ortio

n of

mun

icip

ali‑

ties

with

the

expe

cted

num

ber

of re

ques

ts re

mai

ned

smal

l

Ther

e sh

ould

be

revi

sion

of

wor

k pr

oces

ses

in F

amily

Hea

lth

Stra

tegy

(FH

S) u

nits

, and

a m

ore

in‑d

epth

inve

stig

atio

n of

the

fac‑

tors

driv

ing

the

smal

l num

ber o

f m

edic

al h

ome

visi

ts, r

efer

rals

to

a sp

ecia

list,

requ

ests

for c

linic

al

path

olog

y ex

ams,

and

limite

d nu

rsin

g ca

re in

rela

tion

to th

e nu

mbe

r of m

edic

al c

onsu

ltatio

ns

Ditl

opo

et a

l. (2

011)

[91]

Non

e re

port

edTh

e im

plem

enta

tion

and

per‑

ceiv

ed e

ffect

iven

ess

of a

rura

l al

low

ance

pol

icy

The

mot

ivat

ion

and

rete

ntio

n of

hea

lthca

re p

rofe

ssio

nals

(H

CPs

) in

rura

l hos

pita

ls

Inte

rvie

ws

Polic

y re

view

Part

ial e

ffect

iven

ess

of ru

ral

allo

wan

ce in

recr

uitm

ent

Alm

ost a

ll po

licy‑

mak

ers,

hosp

ital m

anag

ers

and

HC

Ps

cons

iste

ntly

per

ceiv

ed th

e ru

ral a

llow

ance

to b

e di

visi

ve

beca

use

it ex

clud

ed ju

nior

nu

rses

Rem

oten

ess

of th

e ar

ea n

ot

cons

ider

edFi

nanc

ial i

ncen

tives

alo

ne w

ere

insu

ffici

ent

Rete

ntio

n st

rate

gies

that

com

‑bi

ned

finan

cial

and

non

finan

cial

in

cent

ives

are

like

ly to

be

mor

e eff

ectiv

e th

an in

crea

sed

rem

u‑ne

ratio

n al

one,

but

thes

e w

ould

ne

ed to

be

tailo

red

to in

divi

dual

co

untr

y co

ntex

ts

Doh

erty

et a

l. (2

017)

[92]

Stak

ehol

ders

wer

e in

volv

ed in

de

term

inin

g th

e re

ason

s an

d su

stai

nabi

lity

of th

e po

licy

Impa

ct o

f Pre

vent

ion

of

mot

her‑

to‑c

hild

tran

smis

sion

of

HIV

/AID

S (P

MTC

T) O

ptio

n B+

impl

emen

tatio

n on

the

Uga

nda

heal

th s

yste

m

Inte

rvie

ws

Focu

s gr

oups

Fina

ncia

l sus

tain

abili

ty o

f the

pr

ogra

mm

e w

as a

recu

rrin

g th

eme

beca

use

of fu

ndin

g in

secu

rity

Seni

or s

take

hold

ers

voic

ed

conc

erns

abo

ut th

e he

alth

sy

stem

’s re

adin

ess

to a

dopt

the

polic

y an

d th

e ra

pid

pace

of

scal

e‑up

Uga

nda

has

achi

eved

suc

cess

in

sca

ling

up a

cces

s to

ART

and

re

duci

ng th

e nu

mbe

r of c

hild

ren

new

ly in

fect

ed w

ith H

IVIf

ongo

ing

inve

stm

ents

and

te

chni

cal s

uppo

rt fo

r the

HIV

/A

IDS

resp

onse

in U

gand

a ar

e no

t allo

cate

d to

str

engt

hen

the

heal

th s

yste

m a

cros

s pr

ogra

mm

e ar

eas,

a si

gnifi

cant

op

port

unity

may

be

lost

Page 35 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Ejet

a et

al.

(202

0) [1

07]

City

/tow

n he

alth

offi

ces

Sub‑

city

and

dis

tric

t offi

ces

Com

mun

ity le

ader

sRe

gion

al h

ealth

bur

eaus

Ethi

opia

n Fe

dera

l Min

istr

y of

H

ealth

Mem

bers

of t

he S

EUH

P pr

o‑gr

amm

eH

ealth

cen

tres

Less

ons

lear

ned

Cha

lleng

es to

impl

emen

tatio

nIn

terv

iew

sD

ocum

ent r

evie

wTh

e pi

lot t

est e

nabl

ed th

e ur

ban

heal

th e

xten

sion

pro

fes‑

sion

als

(UH

E‑Ps

) to

com

pre‑

hens

ivel

y fo

cus

on th

e 15

he

alth

ser

vice

pac

kage

sU

se o

f tal

ly s

heet

hel

ped

colle

ct h

igh‑

qual

ity d

ata

and

repo

rt it

to c

ity/t

own

heal

th

office

sSy

stem

atic

cat

egor

izat

ion

of

hous

ehol

ds, b

ased

on

thei

r ec

onom

ic s

tatu

s an

d he

alth

se

rvic

e ne

eds

allo

wed

for

effec

tive

time

man

agem

ent

and

deliv

ery

of s

ervi

ces

to

vuln

erab

le p

opul

atio

ns

Plan

s ar

e m

ade

to s

cale

up

the

prog

ram

me

to m

ajor

citi

es

Febi

r et a

l. (2

015)

[103

]N

one

repo

rted

Perc

eptio

ns o

f hea

lthca

re

wor

kers

(HC

Ws)

rega

rdin

g th

e is

sues

face

d

Inte

rvie

ws

Impl

emen

tatio

n fa

ced

chal

‑le

nges

giv

en th

e w

eak

heal

th

syst

ems

in m

ost d

evel

opin

g co

untie

sTh

e pe

rcep

tions

of f

ront

‑lin

e H

CW

s on

the

accu

racy

an

d ne

ed fo

r the

gui

delin

e to

geth

er w

ith th

e ca

paci

ty

of h

ealth

sys

tem

s to

sup

port

im

plem

enta

tion

play

ed a

cr

ucia

l rol

eG

uide

lines

on

finan

cing

of

diag

nost

ics

and

trea

tmen

ts a

re

influ

enci

ng c

linic

al d

ecis

ion‑

mak

ing

in th

is s

ettin

g

Furt

her r

esea

rch

is n

eede

d to

un

ders

tand

the

impa

ct o

f the

N

atio

nal H

ealth

Inte

rvie

w S

urve

y (N

HIS

) on

the

feas

ibili

ty o

f int

e‑gr

atin

g te

st‑b

ased

man

agem

ent

for m

alar

ia o

f the

IMC

I gui

delin

esFi

ndin

gs s

ugge

st th

at th

e pr

oble

m is

hei

ghte

ned

by

belie

fs a

nd h

abits

of f

ront

line

heal

th s

taff

in h

ealth

faci

litie

s in

de

velo

ping

cou

ntrie

s th

at a

re

used

to p

resu

mpt

ive

trea

tmen

t an

d pe

rcei

ve e

very

feve

r to

be

mal

aria

Gue

ye e

t al.

(201

6) [1

08]

Non

e re

port

edW

ays

in w

hich

cou

ntrie

s ha

ve

impl

emen

ted

elim

inat

ion

prog

ram

mes

The

deve

lopm

ent a

nd a

dop‑

tion

of p

rogr

amm

esH

ow p

rogr

amm

es o

pera

ted

with

in th

eir c

onte

xt

Revi

ew o

f cas

e st

udy

repo

rts

Mal

aria

pro

gram

mes

did

not

sh

ow a

hig

h le

vel o

f cap

acity

fo

r ant

icip

atio

n of

thre

ats

to

elim

inat

ion

Ther

e w

ere

man

y ex

ampl

es o

f m

ajor

dev

elop

men

t pro

jec‑

tions

that

com

bine

d a

pote

n‑tia

l for

incr

ease

d re

cept

ivity

an

d vu

lner

abili

tyM

onito

ring

and

eval

ua‑

tion

incl

uded

mon

itorin

g pr

ogra

mm

e ou

tput

s an

d ev

alu‑

atio

n of

impa

ct

Glo

bal m

alar

ia e

radi

catio

n w

ill re

quire

wel

l‑man

aged

m

alar

ia p

rogr

amm

es p

rovi

ding

hi

gh‑q

ualit

y im

plem

enta

tion

of e

vide

nce‑

base

d st

rate

gies

, fo

unde

d up

on s

tron

g su

rvei

l‑la

nce

and

resp

onse

str

ateg

ies

tailo

red

to th

e su

bnat

iona

l lev

el

tran

smis

sion

con

text

Ade

quat

e fu

ndin

g an

d hu

man

re

sour

ces

to s

usta

in m

alar

ia

elim

inat

ion

and

prev

entio

n of

re

intr

oduc

tion

is a

lso

requ

ired

Page 36 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Hal

pern

et a

l. (2

010)

[77]

Stak

ehol

ders

agr

eed

on th

e id

eal s

yste

m fo

r Guy

ana

Impl

emen

tatio

n st

rate

gyBe

nefit

s of

mon

itorin

g na

tiona

l pr

ogra

mm

es

Cro

ss‑s

ectio

nal r

epor

tsCo

hort

ana

lysi

s re

port

sM

onth

ly v

isits

from

a m

embe

r of

the

wor

king

gro

upPa

tient

cha

rts

and

regi

ster

s

A la

rge

disc

repa

ncy

was

foun

d be

twee

n th

e da

ta p

rovi

ded

in th

e cr

oss‑

sect

iona

l rep

orts

su

bmitt

ed p

rior t

o th

e us

e of

th

e PM

S an

d th

e da

ta fr

om

thos

e su

bmitt

ed a

fter

its

impl

e‑m

enta

tion

79%

of a

com

bine

d na

tiona

l co

hort

who

sta

rted

ART

wer

e al

ive

and

on fi

rst‑

line

ART

re

gim

ens.

Aft

er 6

yea

rs, 5

8% o

f th

e fir

st c

ohor

t of A

RT p

atie

nts

in th

e co

untr

y w

ere

aliv

e an

d on

ART

, with

onl

y 8%

pat

ient

s on

sec

ond‑

line

regi

men

s

The

less

ons

lear

ned

durin

g im

plem

enta

tion

can

be u

sed

to

bett

er in

form

oth

er c

oun‑

trie

s in

the

regi

on in

nee

d of

in

form

atio

n sy

stem

s th

at c

an

both

impr

ove

patie

nt c

are

and

prod

uce

high

‑qua

lity

data

to

info

rm p

rogr

amm

atic

and

pol

icy

deci

sion

s

Inve

stig

ator

s of

WH

O L

ow

Birt

h W

eigh

t (LB

W) F

eedi

ng

Stud

y G

roup

(201

6) [1

10]

Non

e re

port

edA

sses

smen

t of f

acili

ties,

sup‑

plie

s an

d eq

uipm

ent

Ass

essm

ent o

f qua

lity

of c

are

Ass

essm

ent o

f kno

wle

dge,

cl

inic

al s

kills

and

cou

nsel

ling

skill

s of

HC

Ps

Obs

erva

tion

visi

t by

expe

rt

paed

iatr

icia

nW

ritte

n te

stFi

ve o

bjec

tive

stru

ctur

ed c

lini‑

cal e

xam

inat

ions

Inte

rvie

ws

with

HC

Ps fo

r fee

d‑ba

ck (i

n po

st‑im

plem

enta

tion

phas

e on

ly)

30%

of n

urse

s re

port

ed a

si

gnifi

cant

incr

ease

in th

eir

wor

kloa

d fo

llow

ing

impl

emen

‑ta

tion

of th

e gu

idel

ines

No

sign

ifica

nt c

hang

e in

key

pr

actic

es li

ke e

arly

initi

atio

n of

bre

astfe

edin

g, e

xclu

sive

br

east

feed

ing

and

prel

acte

al

feed

ing

Resu

lted

in s

igni

fican

t im

prov

e‑m

ent i

n th

e kn

owle

dge

and

skill

s of

HC

Ps a

nd m

othe

rs a

nd

wer

e in

stru

men

tal i

n pr

omot

‑in

g po

sitiv

e he

alth

beh

avio

ur

at h

ospi

tal d

isch

arge

Nee

ded

addi

tiona

l effo

rts

on

part

of H

CW

s/ad

ditio

nal s

taff

and

effor

ts to

pro

mot

e ge

neric

ea

rly fe

edin

g pr

actic

e

Kavl

e et

al.

(201

8) [1

14]

Min

istr

y of

Hea

lthU

NIC

EF K

enya

Par

tner

ship

sN

GO

Impl

emen

tatio

n ex

perie

nce

of B

aby‑

Frie

ndly

Com

mun

ity

Initi

ativ

e (B

FCI)

Succ

esse

s, ch

alle

nge,

and

les‑

sons

lear

ned

Opp

ortu

nitie

s fo

r int

egra

tion

Dis

cuss

the

futu

re a

nd n

ext

step

s

Revi

ew o

f key

gov

ernm

enta

l pr

ogra

mm

e do

cum

ents

Impl

emen

tatio

n m

onito

ring

Cove

rage

of B

FCI w

as h

igh

and

it su

rpas

sed

the

gove

rnm

ent

targ

et o

f 28%

of a

ll “co

mm

unity

un

its im

plem

entin

g BF

CI”

by

2016

/201

7Im

prov

ed e

arly

initi

atio

n of

br

east

feed

ing

and

excl

usiv

e br

east

feed

ing

(EBF

) wer

e no

ta‑

ble

durin

g an

d af

ter i

mpl

emen

‑ta

tion

for a

3‑m

onth

per

iod

Buy‑

in fr

om n

atio

nal l

eade

rs is

ke

yM

ento

rshi

p by

trai

ners

pla

yed

a ke

y ro

leSo

cial

mob

iliza

tion

effor

ts

prom

ote

EBF

Impl

emen

tatio

n ca

n m

otiv

ate

early

and

freq

uent

ant

enat

al c

are

(AN

C) a

tten

danc

e, e

ncou

rage

at

tend

ance

to h

ealth

faci

lity

for c

hild

birt

h an

d m

ay im

prov

e im

mun

izat

ion

upta

ke

Page 37 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Kihe

mbo

et a

l. (2

018)

[57]

UKA

id D

epar

tmen

t for

Inte

rna‑

tiona

l Dev

elop

men

tU

nite

d N

atio

ns C

entr

al E

mer

‑ge

ncy

Resp

onse

Fun

d (C

ERF)

New

born

, ado

lesc

ent a

nd c

hild

he

alth

Uni

ted

Stat

es A

genc

y fo

r Int

er‑

natio

nal D

evel

opm

ent (

USA

ID)

Cent

ers

for D

isea

se C

ontr

ol a

nd

Prev

entio

n (C

DC

)

Doc

umen

t the

IDSR

impl

e‑m

enta

tion

fram

ewor

kEv

alua

te p

lann

ing

and

mon

i‑to

ring

Und

erst

and

the

desi

gn a

nd

orga

niza

tion

Und

erst

and

the

logi

stic

s an

d re

sour

ces

depl

oyed

in th

e pr

oces

s

Pre‑

and

pos

t‑tr

aini

ng s

core

sRe

view

of p

ublis

hed

and

unpu

blis

hed

guid

elin

esRe

view

of p

repa

redn

ess

and

resp

onse

pro

toco

lsRe

view

of t

rain

ing

docu

men

tsIn

terv

iew

sM

eetin

g m

inut

es

Thro

ugh

a co

ordi

nate

d pa

rtne

r su

ppor

t and

resp

onse

, fun

d‑in

g, w

hich

was

not

prim

arily

ea

rmar

ked

for I

DSR

impl

emen

‑ta

tion,

was

mob

ilize

d an

d ha

r‑ne

ssed

to a

chie

ve n

atio

nwid

e eq

uipp

ing

of m

ultid

isci

plin

ary

dist

rict t

eam

s w

ith s

kill

sets

and

to

ols

nece

ssar

y fo

r per

form

ing

rele

vant

func

tions

A c

olla

bora

tive

effor

t res

ults

in a

co

ordi

nate

d si

gnifi

cant

impa

ct

on p

ublic

hea

lthTh

e re

vita

lizat

ion

of th

e ID

SR

prog

ram

me

high

light

s un

ique

fe

atur

es w

hich

can

be

easi

ly

adop

ted

and

appl

ied

by o

ther

co

untr

ies

that

wis

hed

to

stre

ngth

en th

eir I

DSR

pro

‑gr

amm

es

Lavô

r et a

l. (2

016)

[111

]N

one

repo

rted

Deg

ree

of im

plem

enta

tion

Inte

rvie

ws

with

nur

ses

Reco

rd b

ook

of s

ympt

omat

ic

resp

irato

ry p

atie

nts

Reco

rd b

ook

and

mon

itorin

g of

TB

case

sPa

tient

cha

rts

Trea

tmen

t for

mM

onth

ly re

port

act

ivity

In b

acte

riolo

gica

l dia

gnos

is,

clas

sific

atio

n w

as p

artia

lly

impl

emen

ted

Onl

y ba

cillo

scop

ies

for f

ollo

w‑

up tr

eatm

ent a

re c

arrie

d ou

t in

100

% o

f bas

ic h

ealth

uni

ts

(BH

U)

Ther

e w

as n

o re

latio

nshi

p be

twee

n th

e de

gree

of i

mpl

e‑m

enta

tion

and

effec

tiven

ess

of

the

prog

ram

me

Polit

ical

org

aniz

atio

n in

the

impl

emen

tatio

n of

the

dire

ct

obse

rvat

ion

of th

erap

y (D

OTS

) st

rate

gy w

as im

paire

d an

d w

eake

ned

by it

s im

plem

enta

‑tio

n

Mob

ilize

d co

mm

unity

par

tner

s w

ith H

CPs

can

be

orga

nize

d in

su

ppor

t of a

cau

se a

nd b

uild

th

eir o

wn

stra

tegi

es o

f act

ions

to

str

engt

hen

publ

ic h

ealth

pol

i‑ci

es, t

hrou

gh th

e in

clus

ion

in th

e fo

rmal

soc

ial c

ontr

ol a

genc

ies

The

DO

TS s

trat

egy

was

cla

ssifi

ed

as p

artia

lly im

plem

ente

d in

the

BHU

stu

died

Page 38 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Leet

hong

dee

(200

7) [8

3]N

one

repo

rted

Influ

ence

s of

impl

emen

tatio

nIn

terv

iew

sFo

cus

grou

psD

ocum

enta

ry a

naly

sis

Mai

n ch

ange

s fo

cuse

d on

the

role

of p

ublic

org

aniz

atio

ns,

and

tens

ions

bet

wee

n th

e ol

d an

d ne

w a

dmin

istr

ativ

e st

ruct

ures

The

choi

ce o

f fun

ding

mec

ha‑

nism

was

an

impo

rtan

t are

a of

lo

cal d

iscr

etio

nM

any

resp

onde

nts,

espe

‑ci

ally

at l

ower

leve

ls, h

ad a

po

or u

nder

stan

ding

of t

he

purc

hase

r/pr

ovid

er s

plit

abou

t to

be

impl

emen

ted

in th

e Th

ai

syst

em, w

hich

hig

hlig

hted

th

e hu

ge s

hift

in c

ultu

re th

at

wou

ld b

e re

quire

d in

the

new

sy

stem

Ther

e w

as a

mac

ro‑le

vel

prob

lem

con

cern

ing

the

dist

ribut

ion

of fi

nanc

e an

d th

e w

orkf

orce

acr

oss

the

natio

nTh

ere

was

a m

icro

‑leve

l pr

oble

m c

once

rnin

g th

e di

strib

utio

n of

reso

urce

s by

co

ntra

ctin

g un

its fo

r prim

ary

care

(CU

Ps) t

o ho

spita

ls a

nd

heal

th c

entr

es

Ther

e w

as a

cyc

le o

f pol

icy

pres

crip

tions

, loc

al a

dapt

atio

ns

and

high

er‑le

vel p

olic

y re

visi

ons

that

affe

cted

sev

eral

asp

ects

of

the

refo

rms

and

part

icul

arly

the

finan

cing

mec

hani

sm, w

hich

re

sulte

d in

the

low

er‑le

vel a

ctor

s ha

ving

the

mos

t im

pact

Li e

t al.

(201

5) [1

12]

Non

e re

port

edIm

pact

of e

ssen

tial d

rug

polic

y on

prim

ary

care

ser

vice

sEff

ectiv

enes

s of

impl

emen

ting

esse

ntia

l dru

g po

licy

Fiel

d ob

serv

atio

nM

ain

oper

atio

n in

dica

tors

Impl

emen

tatio

n w

as v

ery

stab

leTh

e he

alth

adm

inis

tra‑

tive

depa

rtm

ents

sho

uld

stre

ngth

en th

e ch

oice

, co

nfirm

atio

n, a

sses

smen

t and

co

ntro

l of d

istr

ibut

ion

com

‑pa

nies

, est

ablis

h th

e in

dust

ry

stan

dard

s of

dru

g di

strib

utio

n in

dust

ry a

s so

on a

s po

ssib

le,

and

impr

ove

the

acce

ss

thre

shol

d

Thro

ugh

the

inve

stig

atio

n of

gr

assr

oots

med

ical

inst

itutio

ns,

we

can

dete

rmin

e th

e pr

inci

ples

, va

rietie

s an

d pr

ices

of s

peci

fical

ly

supp

lied

drug

s, an

d th

e st

ate

can

desi

gnat

e sp

ecia

lized

man

u‑fa

ctur

ers

for d

rug

man

ufac

turin

g an

d go

vern

men

t can

pro

vide

fin

anci

al s

ubsi

dies

Page 39 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Love

ro e

t al.

(201

9) [9

3]N

one

repo

rted

The

proc

edur

es fo

r ste

pped

ca

re m

anag

emen

tPe

rcei

ved

chal

leng

es to

impl

e‑m

enta

tion

HC

P tr

aini

ngH

CP

expe

rienc

es o

f man

agin

g m

enta

l illn

ess

Inte

rvie

ws

Que

stio

nnai

res

Men

tal h

ealth

scr

eeni

ng

shou

ld b

e co

nduc

ted

by

nurs

es fo

r all

patie

nts

at P

HC

fa

cilit

ies

Men

tal h

ealth

care

refe

rral

s sh

ould

be

mad

e w

ithin

clin

ic

to M

HPs

and

/or t

o ot

her f

acili

‑tie

s ba

sed

on c

ase

seve

rity

and

avai

labi

lity

of m

enta

l hea

lth

pers

onne

l with

in c

linic

Ther

e is

a la

ck o

f tra

inin

g an

d co

nsis

tenc

y in

the

upta

ke o

f ro

les

and

resp

onsi

bilit

ies

by

nurs

es a

nd M

HPs

Impr

oved

dis

tric

t‑le

vel a

dmin

‑is

trat

ive

coor

dina

tion,

men

tal

heal

th a

war

enes

s an

d fin

anci

al

reso

urce

s ar

e cr

itica

l to

the

suc‑

cess

of i

nteg

ratio

n eff

orts

Mig

uel‑E

spon

da e

t al.

(202

0)

[69]

Non

e re

port

edTh

e ex

tent

to w

hich

the

pro‑

gram

me

activ

ities

hav

e be

en

inte

grat

ed in

to th

e or

gani

za‑

tion

and

the

PHC

clin

ics

Soci

odem

ogra

phic

and

clin

ical

ch

arac

teris

tics

Inte

rvie

ws

Cha

lleng

es to

del

iver

y of

se

rvic

es w

ithin

the

prog

ram

me

incl

uded

tim

e co

nstr

aint

s co

u‑pl

ed w

ith th

e m

any

com

petin

g pr

iorit

ies

pres

ent a

t the

clin

ics,

and

the

limite

d av

aila

bilit

y of

sp

ecia

lists

to p

rovi

de m

ento

r‑sh

ip to

MD

sA

ll M

Ds

and

clin

ical

sup

ervi

‑so

rs p

erce

ived

a n

eed

for

mor

e in

volv

emen

t of e

ither

ps

ycho

logi

sts

or p

sych

iatr

ists

to

impr

ove

the

trai

ning

and

su

perv

isio

n an

d al

so to

adv

ise

on d

ifficu

lt ca

ses

Inte

grat

ion

of m

enta

l hea

lth‑

care

ser

vice

s in

PH

C w

ill

requ

ire im

prov

ed fi

nanc

ing

and

reso

urce

man

agem

ent

of P

HC

and

spe

cial

ist s

ervi

ces,

ongo

ing

capa

city

‑bui

ldin

g, th

e de

velo

pmen

t of e

ffect

ive

refe

rral

sy

stem

s, fu

rthe

r dev

elop

men

t of

com

mun

ity‑b

ased

ser

vice

s, an

d lin

king

of P

HC

with

loca

lly

rele

vant

soc

ial i

nter

vent

ions

Mko

ka e

t al.

(201

4) [9

4]In

volv

ed in

impl

emen

tatio

nEx

plor

ing

the

expe

rienc

e of

re

spon

dent

s in

impl

emen

t‑in

g em

erge

ncy

obst

etric

car

e (E

mO

C)

Perc

eive

d ro

le o

f par

tner

s in

Em

OC

impl

emen

tatio

n

Inte

rvie

ws

Focu

s gr

oups

Faci

lity

surv

eyD

ocum

enta

ry re

view

s

Coun

cil h

ealth

man

agem

ent

team

(CH

MT)

took

the

lead

and

w

orke

d w

ith te

am s

pirit

Ther

e w

as in

crea

sed

dem

and

for s

ervi

ces

Ther

e w

as re

sour

ce s

carc

ity in

te

rms

of s

kille

d H

CPs

, fun

ds

and

time

Wor

king

with

com

petin

g ne

eds

Ack

now

ledg

ing

impo

rtan

ce o

f pa

rtne

rs, p

artia

lly b

ecau

se th

ey

play

diff

eren

t rol

esA

nee

d fo

r cle

ar w

orki

ng

arra

ngem

ents

A d

esire

for c

omm

unity

par

‑tic

ipat

ion

Prog

ress

ing

tow

ards

bet

ter

serv

ice

Adv

ocat

es w

orki

ng to

geth

er in

pa

rtne

rshi

ps to

gov

ern

impl

e‑m

enta

tion

To h

ave

effec

tive

part

ners

hips

, th

e ro

les

and

resp

onsi

bilit

ies

for e

ach

acto

r sho

uld

be c

lear

ly

stip

ulat

ed in

a c

lear

wor

king

fra

mew

ork

with

in th

e di

stric

t he

alth

sys

tem

Page 40 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Mos

hiri

et a

l. (2

016)

[95]

Beca

use

the

impl

emen

ta‑

tion

requ

irem

ents

, inc

ludi

ng

staffi

ng, s

truc

ture

and

fund

ing,

w

ere

in th

e ha

nds

of th

e de

puty

for h

ealth

, the

re w

as

limite

d co

llabo

ratio

n w

ith th

e ot

her s

ectio

ns o

f the

MO

H

Det

ails

of i

mpl

emen

tatio

nIn

terv

iew

sTh

e im

plem

enta

tion

appr

oach

be

tter

cor

resp

onde

d w

ith

a to

p‑do

wn

appr

oach

that

re

aliz

es p

olic

y ch

ange

ver

sus

a hi

erar

chic

al p

roce

ss

Exis

tenc

e of

a w

orki

ng P

HC

ne

twor

k se

rved

as

prop

er in

fra‑

stru

ctur

e fo

r its

impl

emen

tatio

n

Mut

abaz

i et a

l. (2

020)

[87]

Stak

ehol

ders

incl

uded

the

Uni

ted

Stat

es P

resi

dent

’s Em

erge

ncy

Plan

for A

IDS

Relie

f; G

loba

l Fun

d to

Fig

ht

AID

S, T

uber

culo

sis

and

Mal

aria

; U

SAID

; CD

C; I

nter

natio

nal

NG

Os

Expe

rienc

es in

volv

ed in

dai

ly

activ

ities

Inte

rvie

ws

Self‑

adm

inis

tere

d qu

estio

n‑na

ire

Agr

eem

ent o

n th

e im

port

ance

of

gui

delin

e in

tegr

atio

nFr

ontli

ne H

CPs

exp

erie

nced

hi

gh w

orkl

oads

, hig

h st

aff

turn

over

and

lack

of i

nfra

stru

c‑tu

reA

dditi

onal

ass

ista

nce

from

HC

P an

d nu

rses

was

ess

entia

l for

su

ppor

tIn

crea

sed

test

ing

from

the

impl

emen

tatio

n of

PM

TCT

prog

ram

me

show

ed a

redu

c‑tio

n in

dia

gnos

ed H

IV/A

IDS

in

child

ren

Add

ress

ing

the

chal

leng

es o

f in

tegr

atio

n of

PM

TCT

will

hel

p in

elim

inat

ing

mot

her‑

to‑c

hild

tr

ansm

issi

on o

f HIV

/AID

S

Mut

hath

i et a

l. (2

020)

[96]

Invo

lved

in d

esig

n an

d im

ple‑

men

tatio

nPo

licy

cont

ext,

ratio

nale

and

ph

iloso

phy

Inte

rgov

ernm

enta

l rel

atio

n‑sh

ips,

perc

eptio

ns o

f rol

es a

nd

resp

onsi

bilit

ies

in im

plem

enta

‑tio

nIC

RM p

rogr

amm

e re

sour

cing

Impl

emen

tatio

n pr

ogre

ss, c

hal‑

leng

es a

nd c

onst

rain

ts

Inte

rvie

ws

The

cent

ral t

hem

e w

as th

e im

pera

tive

to im

prov

e th

e qu

ality

of P

HC

in p

repa

ratio

n fo

r im

plem

enta

tion

Four

them

es e

mer

ged

rela

ted

to s

truc

tura

l con

text

: co

ntes

tatio

ns a

bout

role

s an

d re

spon

sibi

litie

s; w

eak

inte

r‑go

vern

men

tal r

elat

ions

hips

; en

ablin

g lo

cal l

eade

rshi

p; a

nd

insu

ffici

ent r

esou

rcin

g of

the

ICRM

pro

gram

me

Thre

e th

emes

em

erge

d re

late

d to

spe

cific

con

text

: gap

s in

th

e ex

istin

g N

CS;

insu

ffici

ent

polic

y co

here

nce;

dis

junc

ture

be

twee

n th

e N

CS

and

ICRM

pr

ogra

mm

e

The

desi

gn o

f any

hea

lth re

form

sh

ould

con

side

r pol

icie

s or

initi

a‑tiv

es th

at e

nsur

e co

here

nce

and

the

avai

labi

lity

of re

sour

ces

Maj

or c

hang

e in

itiat

ive

requ

ires

invo

lvem

ent o

f all

rele

vant

pol

icy

acto

rs in

des

ign

and

impl

emen

‑ta

tion

Cle

ar c

omm

unic

atio

n st

rate

gies

an

d on

goin

g m

onito

ring

and

eval

uatio

n ar

e pr

ereq

uisi

tes

for

the

succ

ess

of p

olic

y im

plem

en‑

tatio

n

Page 41 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Pyon

e et

al.

(201

7) [1

04]

Qua

litat

ive

rese

arch

was

car

‑rie

d ou

t usi

ng s

emi‑s

truc

ture

d in

terv

iew

s w

ith 3

9 ke

y st

akeh

olde

rs fr

om s

ix c

ount

ries

in K

enya

The

impl

icat

ions

of t

he

impl

emen

tatio

n of

the

free

mat

erni

ty s

ervi

ces

(FM

S) p

olic

y on

hea

lth s

yste

m g

over

nanc

eSt

reng

th o

f the

impl

emen

ta‑

tion

prog

ram

me

Sem

i‑str

uctu

red

inte

rvie

ws

Inst

itutio

nal a

naly

sis

as a

theo

‑re

tical

fram

ewor

k

The

new

ly in

trod

uced

form

al

inst

itutio

nal (

re)a

rran

gem

ents

w

ere

uncl

ear

Impl

emen

ters

face

d ch

alle

nges

of

acc

ount

abili

ty, e

spec

ially

ad

here

nce

to th

e FM

S po

licy

Whe

n re

sour

ces

wer

e co

n‑st

rain

ed, H

CPs

wer

e le

ss li

kely

to

be

acco

unta

ble,

as

they

w

ere

not p

rovi

ded

with

the

reso

urce

s to

wor

k

Ther

e w

ere

disc

repa

ncie

s be

twee

n fo

rmal

and

info

rmal

ru

les

whi

ch c

reat

ed a

mis

alig

n‑m

ent o

f inc

entiv

es fo

r pol

icy

impl

emen

tatio

nA

ligni

ng th

e ob

ject

ives

of t

he

impl

emen

ters

with

new

pol

icie

s, co

rres

pond

ing

inst

itutio

nal (

re)

arra

ngem

ents

, enf

orce

men

t m

echa

nism

s an

d in

cent

ives

is

cruc

ial

Rahm

an e

t al.

(202

0) [1

05]

Stak

ehol

ders

dis

cuss

ed th

e ch

alle

nges

and

opp

ortu

nitie

s fo

r im

plem

enta

tion

of th

e W

HO

reco

mm

enda

tions

that

em

erge

d fro

m th

e st

udy

Faci

litat

ors

and

barr

iers

to

impl

emen

tatio

nIn

terv

iew

sD

ocum

ents

ana

lysi

sA

dvoc

acy

initi

ativ

es s

houl

d be

un

dert

aken

to p

rom

ote

polic

y re

visi

ons

Trai

ning

and

inst

ruct

ions

sh

ould

be

prov

ided

Inco

mpl

ete

polic

y ad

optio

n ca

n be

att

ribut

ed to

insu

ffi‑

cien

t coo

rdin

atio

n am

ong

divi

‑si

ons;

lack

of c

entr

al p

rocu

re‑

men

t of a

mox

icill

in d

ispe

rsib

le

tabl

ets

(DT)

; and

per

cept

ions

of

the

effica

cy o

f ant

ibio

tics

and

form

ulat

ions

at t

he n

atio

nal

and

dist

rict l

evel

s

Sign

ifica

nt p

rogr

ess

occu

rred

, bu

t key

cha

lleng

es re

mai

n at

the

natio

nal a

nd s

ubna

tiona

l lev

els,

cont

ribut

ing

to s

low

ado

ptio

n of

th

e W

HO

reco

mm

enda

tions

for

the

case

man

agem

ent o

f chi

ld‑

hood

pne

umon

ia a

nd p

ossi

ble

serio

us b

acte

rial i

nfec

tion

(PSB

I) us

ing

amox

icill

in D

T

Page 42 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Rom

an e

t al.

(201

4) [6

6]St

akeh

olde

rs h

elpe

d in

form

th

e de

velo

pmen

t of k

ey

info

rman

t int

ervi

ew g

uide

sQ

ualit

ativ

e da

ta w

ere

colle

cted

th

roug

h in

‑dep

th in

terv

iew

s am

ong

key

stak

ehol

ders

at t

he

natio

nal l

evel

Prom

isin

g pr

actic

es/s

trat

egie

s th

at h

ave

supp

ort p

rogr

am‑

min

g su

cces

sIm

plem

enta

tion

barr

iers

Less

ons

lear

ned

Seco

ndar

y da

ta (l

itera

ture

re

view

)In

terv

iew

s

Inte

grat

ion—

stre

ngth

enin

g an

d cr

eatin

g na

tiona

l gro

ups

(sta

keho

lder

s)Po

licy—

in li

ne w

ith W

HO

gu

idel

ines

and

als

o in

terp

rete

d in

a s

imila

r man

ner a

cros

s he

alth

sys

tem

sCo

mm

oditi

es—

avai

labi

lity

in

drug

reso

urce

s an

d st

ock

Qua

lity

assu

ranc

e—as

sess

men

t to

ols

to m

onito

r pro

gres

s an

d al

levi

ate

barr

iers

at t

he ti

me

Capa

city

-bui

ldin

g—su

cces

sful

w

hen

focu

sed

on p

re‑t

rain

ing

and

in‑s

ervi

ce tr

aini

ngCo

mm

unity

invo

lvem

ent/

enga

gem

ent—

linki

ng c

om‑

mun

ity‑ w

ith fa

cilit

y‑le

vel c

are

and

prom

otin

g co

mm

unity

en

gage

men

t and

kno

wle

dge

abou

t MIP

pro

gram

me

Mon

itorin

g an

d ev

alua

t-in

g—th

ree

case

stu

dies

did

im

plem

ent t

his

and

caus

ed

chal

leng

es fo

r nat

iona

l syn

the‑

sis

and

repo

rtin

gFi

nanc

ing—

mor

e de

dica

ted

supp

ort f

or M

IP p

rogr

amm

e by

adv

ocat

ing

build

ing

of

in‑c

ount

ry a

war

enes

s fro

m

com

mun

ity to

nat

iona

l lev

el

The

timin

g aff

ords

cou

ntrie

s th

e op

port

unity

to re

prio

ritiz

e M

IP p

rogr

amm

ing

to e

nsur

e eff

ectiv

e te

chni

cal o

vers

ight

and

pr

ogra

mm

e m

anag

emen

t

Page 43 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Ryan

et a

l. (2

020)

[109

]M

eetin

gs w

ith th

e C

BM m

enta

l he

alth

adv

isor

for N

iger

ia; w

el‑

fare

offi

cers

from

com

mun

ity‑

base

d re

habi

litat

ion

cent

res,

the

Bish

op o

f the

Met

hodi

st

Chu

rch

Dio

cese

of O

tukp

o in

Be

nue

Stat

e, th

e Be

nue

stat

e he

alth

man

agem

ent i

nfor

ma‑

tion

syst

ems

office

r, th

e Be

nue

stat

e di

rect

or o

f pub

lic h

ealth

an

d ot

her s

tate

and

loca

l go

vern

men

t offi

cial

s

Envi

ronm

ent a

nd h

ealth

sys

‑te

m in

whi

ch th

e pr

ogra

mm

e fu

nctio

nsH

isto

ry o

f the

pro

gram

me

Pro

gram

me

mod

el a

nd c

on‑

cept

ual f

ram

ewor

kEn

gage

men

t with

bro

ader

sy

stem

s P

rogr

amm

e re

sour

ces

and

man

agem

ent

Clie

nt c

hara

cter

istic

sPa

thw

ays

to c

are

Clin

ical

inte

rven

tions

Med

icat

ions

Psy

chos

ocia

l int

erve

ntio

nsA

cces

sibi

lity

of s

ervi

ces

Info

rmat

ion

syst

ems

used

Fiel

d vi

sits

Serv

ice

utili

zatio

n da

taIt

is p

ossi

ble

to le

vera

ge a

pub

‑lic

–priv

ate

part

ners

hip

(PPP

) w

ith n

ot‑fo

r‑pr

ofit p

artn

ers

to

rapi

dly

expa

nd m

enta

l hea

lth

serv

ices

in p

rimar

y ca

reCo

ordi

nate

d eff

orts

acr

oss

prim

ary,

sec

onda

ry a

nd te

rtia

ry

care

is n

eede

d

Mor

e re

sear

ch is

nee

ded

to

docu

men

t and

eva

luat

e PP

Ps fo

r m

enta

l hea

lth in

LM

ICS,

with

a

focu

s on

sus

tain

abili

ty

Sadd

i et a

l. (2

018)

[88]

Non

e re

port

edPe

rcep

tions

abo

ut p

rimar

y ca

re

acce

ss a

nd q

ualit

y (P

MA

Q)

Org

aniz

atio

nal b

arrie

rs to

the

impl

emen

tatio

n of

FH

S

Sem

i‑str

uctu

red

inte

rvie

ws

Que

stio

nnai

res

Low

org

aniz

atio

nal c

apac

‑ity

influ

ence

d th

e pe

rcei

ved

impa

ct o

f the

doc

tors

, nur

ses

and

com

mun

ity H

CPs

Adh

eren

ce to

PM

AQ

at t

he

front

line

follo

ws

a to

p‑do

wn

patt

ern;

46%

of H

CPs

repo

rted

th

at a

dher

ence

was

the

resu

lt of

the

PMA

Q b

eing

impo

sed

by th

e m

unic

ipal

hea

lth s

ec‑

reta

ry (S

MS)

, and

26%

of H

CPs

re

port

ed a

dher

ence

was

due

to

tryi

ng to

impr

ove

serv

ice

qual

ity

Mor

e co

ntex

tual

ized

pub

lic

polic

y or

hea

lth p

olic

y re

sear

ch,

focu

sing

on

front

line

wor

kers

, co

uld

be im

plem

ente

d

Sam

i et a

l. (2

018)

[102

]N

one

repo

rted

Expl

ain

the

mai

n he

alth

sys

tem

bo

ttle

neck

s fo

r im

plem

enta

‑tio

nBa

rrie

rs a

nd fa

cilit

ator

sRe

com

men

ded

solu

tions

Focu

s gr

oups

Dire

ct o

bser

vatio

nsCo

llect

ion

of v

arie

ty o

f doc

u‑m

ents

See

barr

iers

and

ena

bler

s in

Ta

ble

7Fu

rthe

r res

earc

h to

impr

ove

the

impl

emen

tatio

n of

com

mu‑

nity

‑ and

faci

lity‑

leve

l new

born

in

terv

entio

ns in

set

tings

with

on

goin

g co

nflic

tU

nder

stan

ding

the

feas

ibili

ty

of g

uide

lines

reco

mm

ende

d in

co

ntex

t wou

ld a

llow

for s

peci

fic

adap

tatio

ns a

nd in

nova

tions

Page 44 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Schn

eide

r and

Nxu

mal

o (2

017)

[9

7]N

one

repo

rted

Polic

y fo

rmat

ion/

adop

tion

Real

loca

tion

of ro

les

and

resp

onsi

bilit

ies

Dev

elop

men

t of n

ew s

yste

ms

How

cha

nge

is le

d an

d m

an‑

aged

Inte

rvie

ws

Obs

erva

tions

Doc

umen

t rev

iew

Rout

ine

and

audi

t dat

a

Neg

otia

ting

a fit

bet

wee

n na

tiona

l man

date

s, pr

ovin

cial

an

d di

stric

t his

torie

s an

d st

rate

gies

of c

omm

unity

‑bas

ed

serv

ices

Defi

ning

new

org

aniz

atio

nal

and

acco

unta

bilit

y re

latio

n‑sh

ips

betw

een

CH

Ws,

loca

l he

alth

ser

vice

s, co

mm

uniti

es

and

NG

Os

Revi

sing

and

dev

elop

ing

new

al

igne

d an

d in

tegr

ated

pla

n‑ni

ng, h

uman

reso

urce

s, fin

anc‑

ing

and

info

rmat

ion

syst

ems

Lead

ing

chan

ge b

y bu

ild‑

ing

new

col

lect

ive

visi

ons,

mob

ilizi

ng p

oliti

cal s

uppo

rt

and

desi

gnin

g im

plem

enta

tion

stra

tegi

es

Cont

ribut

ed to

an

unde

rsta

nd‑

ing

of le

ader

ship

and

gov

ern‑

ance

func

tions

in s

tren

gthe

ning

C

HW

pro

gram

mes

Sugg

est t

he n

eed

for m

ultil

evel

fra

mew

orks

that

pro

vide

bot

h di

rect

ion

and

flexi

bilit

y, a

llow

ing

for e

mer

genc

e an

d ne

gotia

tion

Hig

hlig

hted

the

mul

tifac

eted

, ne

gotia

ted

and

dist

ribut

ed

natu

re o

f the

se fu

nctio

ns,

span

ning

ana

lytic

al, m

anag

eria

l, te

chni

cal a

nd p

oliti

cal r

oles

Futu

re w

ork

incl

udes

eva

luat

ing

the

impl

icat

ions

of a

sses

sing

or

stre

ngth

enin

g th

e le

ader

ship

an

d go

vern

ance

of n

atio

nal

CH

W p

rogr

amm

es

Shei

kh e

t al.

(201

0) [9

8]N

one

repo

rted

Pers

pect

ives

of d

iffer

ent

grou

ps o

f act

ors

on th

eir o

wn

part

icip

atio

n in

the

impl

emen

‑ta

tion

proc

ess

Inte

rvie

ws

Info

rmed

con

sent

was

see

n as

un

wel

com

e ob

stac

les

Phys

icia

ns ty

pica

lly fo

llow

ed

unw

ritte

n ru

les

that

wer

e ba

sed

on th

eir o

wn

clin

ical

ju

dgem

ent a

nd th

e be

st in

ter‑

est o

f the

pat

ient

, not

nec

essa

r‑ily

the

guid

elin

eLa

ck o

f priv

ate

room

s re

sulte

d in

phy

sici

ans

disc

losi

ng c

onfi‑

dent

ial r

esul

ts in

fron

t of o

ther

pa

tient

s

Cont

ribut

ed a

n un

ders

tand

ing

of h

ealth

pol

icy

impl

emen

tatio

n in

Indi

a fro

m th

e “e

mic

” per

spec

‑tiv

es o

f the

var

ious

par

ticip

ant

acto

rs

Shel

ley

et a

l. (2

016)

[99]

This

pro

cess

eva

luat

ion

utili

zed

inte

rvie

ws

with

a v

arie

ty o

f st

akeh

olde

rs to

exp

lore

per

‑sp

ectiv

es a

nd le

sson

s fro

m th

e fir

st 6

mon

ths

of c

omm

unity

he

alth

ass

ista

nt (C

HA

) dep

loy‑

men

t

Less

ons

lear

ned

Barr

iers

to a

nd fa

cilit

ator

s of

fid

elity

Inte

rvie

ws

Com

mun

ity a

ccep

tanc

e is

es

sent

ial t

o su

cces

sful

pro

‑gr

amm

e im

plem

enta

tion

Effec

tive

and

relia

ble

supe

rvi‑

sion

is c

onsi

dere

d a

corn

er‑

ston

e to

suc

cess

Find

ings

allo

wed

the

gove

rn‑

men

t to

mak

e in

form

ed d

eci‑

sion

s an

d ad

just

men

ts p

rior t

o se

cond

dep

loym

ent o

f CH

As

Page 45 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Stei

n et

al.

(200

8) [1

06]

Non

e re

port

edPe

rcep

tions

of t

hose

invo

lved

in

the

prog

ram

me

Valu

e of

the

trai

ning

app

roac

h

Part

icip

ants

’ obs

erva

tions

Inte

rvie

ws

Focu

s gr

oups

Trai

ning

was

inte

ract

ive

and

effec

tive

Inte

grat

ive

trai

ning

app

roac

h al

low

ed fo

r sup

ervi

sory

fe

edba

ckA

hor

izon

tal t

rain

ing

appr

oach

fa

cilit

ated

the

impl

emen

tatio

n pr

oces

sTr

aini

ng w

as e

ffect

ive

and

mor

e lik

ely

to b

e eff

ec‑

tive

with

in a

hea

lth s

yste

m

fram

ewor

k w

hich

con

sist

ently

pr

ovid

es P

HC

ser

vice

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prov

ed q

ualit

y of

car

e w

as

seen

in a

rang

e of

illn

esse

sN

urse

s w

ere

over

stre

tche

d an

d m

any

PHC

clin

ics

wer

e un

ders

taffe

d

All

leve

ls o

f hea

lthca

re s

yste

m

team

s sh

ould

be

enga

ged

in

prog

ram

me

impl

emen

tatio

n

Win

gfiel

d et

al.

(201

5) [1

13]

Form

ativ

e ac

tiviti

es in

clud

ed

cons

ulta

tions

, foc

us g

roup

di

scus

sion

s an

d qu

estio

nnai

res

cond

ucte

d w

ith th

e pr

ojec

t te

am, p

roje

ct p

artic

ipan

ts,

civi

l soc

iety

and

key

NG

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stak

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ders

Cash

del

iver

y st

rate

gyCa

sh tr

ansf

er s

ize

Cash

tran

sfer

tim

ing

Cash

tran

sfer

con

ditio

ns, l

evel

s an

d re

spon

sive

ness

Perf

orm

ed a

n ac

cept

abili

ty

asse

ssm

ent

Qua

ntita

tive

and

qual

itativ

e da

ta fr

om p

artic

ipan

ts, a

civ

il so

ciet

y gr

oup

of e

x‑pa

tient

co

mm

unity

repr

esen

ta‑

tives

, CRE

SIPT

[com

mun

ity

rand

omiz

ed e

valu

atio

n of

a

soci

oeco

nom

ic in

terv

entio

n to

pre

vent

TB]

pro

ject

sta

ff an

d lo

cal a

nd re

gion

al P

eruv

ian

TB

prog

ram

me

staff

and

coo

rdin

a‑to

rs

A n

ovel

TB‑

spec

ific

soci

oeco

‑no

mic

inte

rven

tion

prov

ed to

be

feas

ible

in a

n im

pove

rishe

d,

urba

n en

viro

nmen

t and

is n

ow

read

y fo

r im

pact

ass

essm

ent,

incl

udin

g by

the

CRE

SIPT

pr

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tO

f pot

entia

l cas

h tr

ansf

ers,

74%

w

ere

achi

eved

, 19%

wer

e no

t ac

hiev

ed, a

nd 7

% w

ere

yet t

o be

ach

ieve

dO

f tho

se a

chie

ved,

92%

wer

e ac

hiev

ed o

ptim

ally

and

8%

su

bopt

imal

lyCa

sh tr

ansf

er s

trat

egy

shou

ld

be ta

ilore

d to

hou

seho

ld n

eeds

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ons

from

CRE

SIPT

will

aim

to

assi

st T

B co

ntro

l pro

gram

mes

to

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tivel

y im

plem

ent t

he re

cent

gl

obal

pol

icy

chan

ge o

f inc

lud‑

ing

soci

oeco

nom

ic s

uppo

rt a

s pa

rt o

f TB

cont

rol a

ctiv

ities

Page 46 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

Tabl

e 5

(con

tinue

d)

Aut

hor/

year

Stak

ehol

der i

nvol

vem

ent

Out

com

es o

f int

eres

tO

utco

me

mea

sure

sKe

y re

sults

Aut

hor c

oncl

usio

ns/f

utur

e di

rect

ions

Xia

et a

l. (2

015)

[89]

Stak

ehol

ders

wer

e in

terv

iew

ed

and

surv

eyed

Serv

ice

user

vie

ws

on in

te‑

grat

ed p

rena

tal H

IV, s

yphi

lis

and

hepa

titis

B te

stin

g (P

HSH

T)

serv

ices

Serv

ice

user

s’ kn

owle

dge

and

satis

fact

ion

of P

HSH

T se

rvic

esFa

ctor

s aff

ectin

g ho

w th

e in

tegr

atio

n of

ser

vice

s w

as

coor

dina

ted

Surv

eyRo

utin

e m

onito

ring

Inte

rvie

ws

Focu

s gr

oups

Preg

nant

wom

en h

ad li

ttle

kn

owle

dge

of P

HSH

T se

rvic

es

and

foun

d th

e se

rvic

e pr

oces

s to

be

long

and

com

plic

ated

HIV

test

s w

ere

abov

e th

e na

tiona

l sta

ndar

d, u

nlik

e sy

phi‑

lis a

nd H

ep B

Lack

of r

efer

ral n

etw

ork

betw

een

lab

resu

lts re

sulte

d in

si

gnifi

cant

del

ays

Cond

uctin

g re

gula

r mee

tings

be

twee

n he

alth

age

ncie

s co

uld

impr

ove

info

rmat

ion

exch

ange

Esta

blis

hing

a p

rope

r clie

nt re

fer‑

ral s

yste

m w

ith a

n in

tegr

ated

in

form

atio

n sy

stem

s co

uld

help

re

duce

redu

ndan

cyD

ecen

tral

izat

ion

of s

ervi

ces

coul

d he

lp s

impl

ify p

roce

ssFa

cilit

ate

task

‑shi

ftin

g an

d co

m‑

mun

ity p

artic

ipat

ion

Zaku

mum

pa e

t al.

[85]

Non

e re

port

edSu

stai

nabi

lity

of A

RT s

cale

‑up

impl

emen

tatio

nA

cces

s to

ART

med

icin

esIn

terc

onne

ctio

ns in

hea

lth

syst

em s

ubco

mpo

nent

s

Nat

iona

l sur

vey

of h

ealth

fa

cilit

ies

Org

aniz

atio

nal c

ase

stud

ies

Acc

ess

to A

RT m

edic

ines

at

the

leve

l of f

ront

line

heal

th

faci

litie

s w

ere

influ

ence

d by

in

form

atio

n sy

stem

s, hu

man

re

sour

ces,

gove

rnan

ce a

nd

lead

ersh

ipFa

ilure

to m

aint

ain

basi

c A

RT

prog

ram

me

reco

rds,

owin

g to

he

alth

wor

kfor

ce s

hort

ages

, co

ntrib

uted

to c

hron

ic A

RT

med

icin

es s

tock

‑out

s

Hea

lth s

yste

m s

tren

gthe

n‑in

g in

terv

entio

ns, e

spec

ially

ta

rget

ing

low

er‑le

vel a

nd

rura

l‑bas

ed h

ealth

faci

litie

s, ar

e re

com

men

ded

to p

rom

ote

ART

pr

ogra

mm

e su

stai

nabi

lity

Zhou

et a

l. (2

019)

[67]

Cons

ulta

tions

with

sta

keho

ld‑

ers

Form

ulat

ion

proc

ess,

cont

ent

and

impl

emen

tatio

n is

sues

Inte

rvie

ws

Ope

n‑en

ded

surv

eys

Stra

tegi

es to

ach

ieve

the

four

pol

icy

obje

ctiv

es w

ere

unev

enly

cov

ered

Two

actio

n ar

eas,

nam

ely

“qua

lity

impr

ovem

ent”

and

“pro

cedu

re a

nd d

istr

ibut

ion

of

esse

ntia

l med

icin

es”, w

ere

not

cove

red

The

limite

d hu

man

reso

urce

s m

ade

wor

king

par

t‑tim

e ve

ry

com

mon

Cons

ider

ing

polic

y op

erat

ion‑

ality

, tar

gets

, tim

e fra

mes

and

ev

alua

tion

indi

cate

d w

ere

cons

iste

nt w

ith n

atio

nal o

nes,

but m

ainl

y se

t for

prio

rity

stra

tegi

es

Solid

evi

denc

e, h

igh‑

leve

l ap

prov

al, i

nvol

vem

ent o

f mul

‑tip

le s

take

hold

ers,

deta

iled

and

com

preh

ensi

ve a

rran

gem

ents

in

ope

ratio

nal i

ssue

s, an

d cl

ear

polic

y fo

cuse

s w

ill p

rom

ote

succ

essf

ul im

plem

enta

tion

of

men

tal h

ealth

pol

icy

Page 47 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

in an unclear understanding of the implementation and initiative fidelity. Results from these studies should be considered with this in mind.

DiscussionThis scoping review located, mapped and codified pub-lished literature exploring the adaptation and implemen-tation of health system guidelines in LMICs to assess trends and identify potential gaps. Through the synthesis of available evidence, we were able to identify common strategies for adapting and implementing health system guidelines, related barriers and enablers, and indicators of success.

Overall, the most common type of implementation strategies used to facilitate the integration of health system guidelines involved education, training, clinical supervision and the formulation of working groups and advisory boards. Examples of education and training include the development of standardized educational materials, as well as national training and feedback sessions (see Table  4 for a breakdown of all exam-ples). While this review can comment on the types of implementation strategies utilized, specific details such as the duration and dose of these techniques were largely underreported by the authors of the included studies (e.g. 1-day vs month-long workshops). The reported educational and collaborative implementation

Table 6 Implementation barriers and enablers coded using the COM‑B framework (summary table)

COM-B category COM-B subcategory COM-B definition Frequency of occurrence

Examples of barriers and enablers

Opportunity Physical Environmental context and resources 36 ○ Financial constraints and budgets○ Physical resources to support guideline implementation (water lines, lack of transpor‑tation, etc.)○ Need for extensive human resources○ Stakeholder support and buy‑in○ Site check‑ins○ Training for end‑users and stakeholders○ Supportive policies and laws○ Ensuring basic needs are met for workers to support motivation and reduce attrition○ Local leadership○ Incentives○ Strategic implementation and operation plans

Social Social influences, norms, cultural, social pressures, conformity

22 ○ Cultural context○ Political instability/stability○ Political commitment○ Stigma (e.g. HIV+ mothers counselling other HIV+ mothers)○ Power imbalances

Capabilities Psychological Knowledge, memory, decision‑making, behavioural regulation

15 ○ Knowledge of the guideline and its practices○ Emotional toll on frontline clinicians work‑ing with vulnerable populations○ Resistance to change

Physical Skills and abilities 19 ○ Adapting training materials for all (e.g. adapting materials for those who are illiterate)○ Hosting training meetings○ Continued implementation through train‑ing, mentorship, supportive supervision and follow‑up documentation

Motivation Reflective Roles and identity, beliefs about conse‑quences and optimism

4 ○ Resistance to/acceptance of change○ Trust in guidelines○ More clear definition of roles and respon‑sibilities

Automatic Emotions and reinforcement 10 ○ Enthusiasm and commitment to imple‑mentation○ Motivation to implement and perform duties

Page 48 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

strategies are in direct alignment with current literature and support similar emerging themes in other health-care and income settings [55, 56]. A recent review of techniques used to implement nursing practice guide-lines across different health settings reveals that educa-tion-based strategies were almost always incorporated in the implementation plan [55]. Our findings are consistent with other works in LMICs cited in Imam-arua et  al.’s (2017) literature synthesis of implementa-tion strategies to deliver maternal practice guidelines [56]. While these reviews identified the involvement of local opinion leaders in their implementation tactics, the formal creation of advisory groups (such as devel-oping technical working groups) appears to be more common in health system-based implementation ini-tiatives than in clinical practice guidelines. This could be reflective of the complex nature of health systems, social norms and values in local communities regard-ing decision-making, and the various actors that need to be thoughtfully and proactively engaged to facili-tate implementation. Furthermore, included studies used an average of four implementation strategies, and less than half of potential strategies available to them (38/73 techniques defined by ERIC). Thus, our review highlights the potential need to leverage and combine a

wider variety of implementation techniques to address known barriers to changes and to achieve policy/pro-gramme goals.

Though most of the included articles detailed ration-ales for implementing their targeted health system guidelines, the selection of implementation strategies did not appear to be guided by foundational knowledge, theory or conceptual frameworks. Further, only three studies applied a formal implementation plan [57–59]. Implementation science literature highlights the criti-cal importance of identifying and tailoring implementa-tion techniques to successfully transition evidence into real-world practice [60, 61]. Conducting behavioural analyses to identify barriers and facilitators can then be used to guide the selection of evidence-based strategies and to mitigate potential challenges while simultaneously amplifying promising facilitators [54, 60, 61]. Differing levels of available human and physical resources, politi-cal structures, professional roles and responsibilities, and cultural and religious practices are all salient and intersectional factors that need to be considered within an implementation plan for health system initiatives [62, 63]. These contextual factors are of particular importance to consider in potentially resource-limited settings to optimize strengths and attend to weaknesses [63]. One

Table 7 Barriers and enablers related to adaption (COM‑B analysis—opportunities, motivation)

Author (year) Opportunities

Physical Social

Andrade et al. (2017) [75]

○ Unable to implement an electronic system (enabler) ○ None reported

Bryce et al. (2005) [58] ○ Adapting guidelines to context (enabler) ○ None reported

Gueye et al. (2016) [108]

○ Programme showed flexibility over time, as it was able to mobilize a large number of staff

○ None reported

Halpern et al. (2010) [77]

○ A technical working group is crucial to help develop the country‑specific systems, oversee implementation, and adjust or deal with unexpected changes (enabler)

○ None reported

Leethongdee (2007) [83]

○ Created a new catchment area which increased the budget (enabler)

○ None reported

Rahman et al. (2020) [105]

○ Readiness of the health system to execute the policy (ena‑bler/barrier)

○ Proactive leadership from national programmes, advocacy, technical and resource support from international develop‑ment partners (enabler)

Stein et al. (2008) [106] ○ None reported ○ The spiritual adaptation/incorporation provided culturally appropriate support (enabler)

Wingfield et al. (2015) [113]

○ None reported ○ Strong multisectoral collaboration (enabler)

Motivation

Automatic Reflective

Stein et al. (2008) [106]

○ None reported ○ Nurses valued counselling skills that were built as an adapta‑tion to the guideline (enabler)

Wingfield et al. (2015) [113]

○ None reported ○ Lack of available evidence, and thus deciding on the transfer amounts and timing was difficult (barrier)

Page 49 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

component necessary for building a resilient health sys-tem is an awareness of the current strengths and weak-nesses within existing structures to inform practice and policy planning [64]. There are various evidence-based frameworks and taxonomies that provide structured and systematic processes to identify existing barriers and enablers in specific contexts [26, 28, 54, 65]. Exist-ing tools such as the COM-B model can be used to help identify and map known implementation barriers and enablers and assist in selecting targeted techniques to influence change at the health system level [54]. The use of evidenced-based conceptual and theoretical frame-works could help to improve the selection of individual-ized implementation techniques and ultimately improve the successful integration of health system guidelines in LMICs.

Lack of consistent funding was a noted barrier to the implementation of health system guidelines. Despite this, only a handful of articles reported accessing new fund-ing sources as part of their implementation plan [66–69]. While seven studies were conducted in an LIC setting, reports of financial constraints were not limited to those within LICs. Our findings suggest that securing imple-mentation research funding is arduous, irrespective of a country’s income level. Recent work from Ritchie et  al. [62] explored the challenges experienced among LMICs when translating maternal health evidence into practice and revealed that lack of health system funding was one of the most common barriers to evidence implementa-tion in LMICs. This barrier, however, may not be unique to LMICs, with sustained funding being challenging even among high-income contexts [70]. As highlighted in the implementation science literature, this is of particular importance when considering the ability to sustain the delivery of health system guidelines beyond their ini-tial implementation [71]. Partnering with NGOs was one strategy utilized by some of our included articles to help fund initiatives. However, while initial finan-cial support may provide the necessary seed money and resources to help launch initiatives, projects with-out sustained sources of funding risk being shut down [70]. It is also noteworthy that over half of the included studies reported funding sources stemming solely from high-income funding initiatives (e.g. Irish Aid, Austral-ian government funding, Canada’s International Devel-opment Research Centre), with only 11 studies utilizing funds from their local country (i.e. Brazilian Ministry of Education, China’s Medical Board). Financial commit-ments and sustained funding from health ministries is essential to supporting implementation efforts and facili-tating the longevity and sustainability of moving evidence into practice and strengthening implementation of health system guidelines into the real-world context.

When stratifying our findings by WHO’s health sys-tem building blocks, it became clear that change at the health system level is often dependent on addressing all intersecting concepts. For example, a majority of our identified health system guidelines targeted the service delivery building block, and yet their related barriers included lack of financing, resources and/or leadership and government commitment. Guidelines that targeted the health workforce building block reported barriers specific to the lack of knowledge about the guidelines, human resources and funding. These findings highlight the intersectional nature of all health system building blocks and the critical need to look across components to facilitate successful system-level change. When exploring Rwanda’s great success in improving health outcomes, Sayinzoga and Bijlmakers [72] discovered that one of the key factors influencing their successes was the recogni-tion of the need for multiple and interconnected health system initiatives to achieve set goals. Without account-ing for this intersectional nature, initiatives are unlikely to be successful, resulting in wasted time and efforts [63]. Strengthening health systems requires purposeful plan-ning and action across building blocks to enact reform across all health, social and political structures [73, 74]. Researchers and decision-makers are encouraged to incorporate WHO’s health system building blocks as a framework to identify essential elements that may require additional support during the implementation and adap-tation of health system guidelines.

Our review revealed a dearth of reported information related to the adaptation of health system guidelines in comparison to implementation strategies. We could find only one study that reported having tailored its guidelines to the needs of the local context as an implementation strategy [75], and only 14 studies reported adaptation techniques. Adapting both health system and clinical practice guidelines is critical to enhancing applicability to the specific setting and to account for differing cultural, organizational and environmental factors [76]. Adapta-tion of these initiatives can lead to increased local uptake by engaging stakeholders and end-users throughout the process [76]. However, this customization must be car-ried out carefully to ensure the correct application of evi-dence and recommendations. Utilizing evidence-based adaptation frameworks provides systematic guidance to ensure that the required modifications are made while still honouring the authenticity of the guideline [76]. Unfortunately, the use of adaptation frameworks was not reported in any of our included articles. While some articles reported on their adaptation techniques, such as Halpern et  al.’s [77] detailed description of the crea-tion of a technical working group to adapt each guide-line component, most articles did not provide sufficient

Page 50 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

detail of their processes or reasoning. Rigorous research is needed to explore and identify the most effective adap-tation strategies to enhance a guideline’s applicability and uptake at the health system level and support the use of these strategies in practice.

The most frequent indicators of success when imple-menting and adapting health system guidelines were related to assessing contextualized barriers and facili-tators, end-user experiences, and monitoring system changes. Choosing outcomes and indicators is still a debated topic within implementation science literature [8]. As this review identified, many distinguish imple-mentation success by evaluating the process itself (i.e. challenges and successes). Limited studies reported on cost as a critical implementation outcome. Without evaluating implementation cost, sustainability of the health system change is difficult to discern. Conduct-ing cost–benefit analyses and verifying areas of poten-tial cost savings could provide decision-makers with further evidence to support the granting of sustainable funding for implementation of health system guide-lines—a major barrier identified in this review.

An alternative ideology asserts success as being related to a health system guideline’s ability to achieve its recommended target and improve care [78]. Only a small proportion of studies included in our review compared guideline targets with real-world changes or leveraged patient-level outcomes to identify improve-ments in quality of life and health outcomes [75, 79]. The integration of patient- and population-level out-comes may be an important component in the evalu-ation of health system guidelines in LMICs, as an ultimate goal of a resilient and sustainable health sys-tem is to better serve patients and families. There are also a variety of evaluation frameworks that can help guide researchers in the selection of outcomes and indicators of success at the health system level [49]. While flexibility is necessary in evaluation plans, uti-lizing these frameworks can provide structure and evi-dence-based processes to ensure comparable outcomes are being selected and reported. This would allow for the streamlined comparison and shared learning across LMICs and could facilitate a more transpar-ent understanding of key factors that drive successful implementation of health system guidelines.

The findings from our quality appraisal and the lack of detail that we were able to extract related to certain concepts (i.e. adaptation strategies) highlight the need to improve adherence to reporting guidelines within this body of literature. By following reporting guide-lines in the dissemination of study findings, we can help increase the transparency and completeness of research initiatives [80], ensuring that articles contain

the important components and active ingredients for their implementation and adaptation strategies, evalu-ation methods and health system initiatives. Without this information, it is difficult for readers to discern how implementation and adaptation plans were devel-oped, the techniques employed, and the trustworthi-ness of findings [81].

LimitationsIt is important to consider our findings considering potential limitations. First, our search strategy was lim-ited to reports published in English. We consulted with our knowledge users, who advised that they did not believe this would influence our review findings; how-ever, we acknowledge that not all initiatives conducted in LMICs are reported in this language. This may also partly explain our finding that most initiatives were funded by HICs. Second, given the variation in how authors describe health system guidelines (e.g. recommendations, policies), we may not have captured all potentially rele-vant studies. Further, it is worth noting that authors may not uniformly use the term “adaptation” when referring to the concept definition adopted in this work. Variations in terminology could have impacted our identification and/or extraction of data. However, our search strategy was carefully developed by an experienced library scien-tist to mitigate such challenges and comprehensively cap-ture pertinent studies.

ConclusionsIdentifying evidenced-based strategies to successfully move evidence into practice continues to be a growing and critical area of research. Health system guidelines are pivotal tools to optimize, strengthen and develop resilient healthcare infrastructures and provisions. This scoping review provides a comprehensive overview of published literature examining the adaptation and implementa-tion of health system guidelines in LMICs. Our findings revealed the most common strategies for implementing health system guidelines in LMICs, including education, training, clinical supervision and formation of advisory groups. There is a need to explore the impact of lever-aging and combining a wider variety of implementa-tion techniques to achieve policy/programme goals. The reporting of adaptation strategies was an evident gap in this body of literature, highlighting the need for more primary research aimed at identifying effective adapta-tion techniques to enhance a guideline’s applicability and uptake at the health system level. Given the lack of theoretical frameworks identified in included studies, research teams can turn to established implementation and adaptation frameworks as a starting point to help

Page 51 of 54Breneol et al. Health Research Policy and Systems (2022) 20:64

guide their work. Furthermore, while the absence of sus-tained funding and financial commitments was identified as a salient barrier to the implementation of health sys-tem guidelines, there was a lack of studies reporting cost as an evaluation outcome. Future researchers are encour-aged to consider conducting cost analyses to create a case for decision-makers to support the granting of sustain-able funding for health system guidelines. Our findings suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local con-texts and health system arrangements in LMICs.

AbbreviationsLMICs: Low‑ and middle‑income countries; LIC: Low‑income country; HIC: High‑income country; EPOC: Effective Practice and Organisation of Care; COM‑B: Capability, Opportunity and Motivation Behaviour model; RAISE: Research to Enhance the Adaptation and Implementation of Health Systems Guidelines.

Supplementary InformationThe online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12961‑ 022‑ 00865‑8.

Additional file 1. Search strategy.

Additional file 2. Data extraction form.

Additional file 3. Acronyms.

Additional file 4. Barriers to and enablers of implementation categorized by the COM‑B framework (opportunities category).

AcknowledgementsWe would like to acknowledge and thank those who helped us during the citation screening and/or data extraction phases: Benjamin Rose‑Davis, Kiyana Kamali, Zohra Khatoon, and Daniel Crowther.

Author contributionsSB performed citation screening, data extraction and data analysis, and wrote the initial draft of this manuscript. JAC directly supervised all phases of the work, provided substantial content expertise, contributed to data interpreta‑tion, and provided substantial revisions on the initial and final manuscript. RM supervised all phases of the work, provided substantial content expertise, con‑tributed to data interpretation, and provided substantial revisions on the initial and final manuscript. KM and CJ performed citation screening, data extraction, data analysis and provided significant revisions to the manuscript. HW helped draft the initial protocol for this work, performed citation screening, and provided significant revisions to the manuscript. LW, CC, MR and LK‑B pro‑vided methodological expertise during all phases of the work and provided significant revisions to the manuscript. EV, MV, SJ, LA, SA and DP provided methodological expertise, provided key stakeholder and content expertise to ensure the relevancy of this work, and provided significant revisions to the final manuscript. All authors read and approved the final manuscript.

FundingThis work was jointly funded by the SPOR Evidence Alliance (Award Number: 201705GSR‑386588‑GSR‑CEAJ‑157857) and WHO Alliance for Health Policy and Systems Research.

Availability of data and materialsAll data generated or analysed during this study are included in this published article and its additional files.

Declarations

Ethics approval and consent to participateNo ethical approval was required, as this work is a secondary analysis of published literature.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Author details1 School of Nursing, Faculty of Health, Dalhousie University, Halifax, Canada. 2 Strengthening Transitions in Care Lab, IWK Health Centre, 8th Floor Chil‑dren’s Site, 5850/5980 University Ave, Halifax, NS B3K 6R8, Canada. 3 Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland. 4 Faculty of Health, Dalhousie University, Halifax, Canada. 5 Partner‑ship for Maternal, Newborn & Child Health (PMNCH), World Health Organiza‑tion, Geneva, Switzerland. 6 Nova Scotia Health Authority Policy and Planning, Dartmouth, Canada. 7 Facultad de Medicina, Universidad de Antioquia, Medellín, Antioquia, Colombia. 8 Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India. 9 W.K. Kellogg Health Science Library, Dalhousie University, Halifax, Canada. 10 School of Nursing and Midwifery, University of Ghana, Legon, Accra, Ghana. 11 Department of Nursing & Health Sciences, University of New Brunswick, St. John, Canada. 12 Department of Mental Health Nursing, University of Ghana, Legon, Accra, Ghana.

Received: 21 December 2021 Accepted: 9 May 2022

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