Implementation Science

Implementation Science - POLICY FORUM CORRECTED 25 JANUARY...

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14 DECEMBER 2007 VOL 318 SCIENCE 1728 CREDIT: INTERAMERICAN DEVELOPMENT BANK W e face a formidable gap between innovations in health (including vaccines, drugs, and strategies for care) and their delivery to communities in the developing world. As a result, nearly 14,000 people in sub-Saharan Africa and South Asia die daily from HIV, malaria, and diarrheal dis- ease ( 1 ), even though scientific advances have enabled prevention, treatment, and, in some cases, elimination of these diseases in devel- oped countries. Many evidence-based innovations fail to produce results when transferred to commu- nities in the global south, largely because their implementation is untested, unsuitable, or incomplete. For example, rigorous studies have shown that appropriate use of insecti- cide-treated bed nets can prevent malaria ( 2 ), yet, in 2002, fewer than 10% of children in 28 sub-Saharan African countries regularly slept with this protection ( 3 ). Newer studies have shown that malaria incidence is decreased by distribution of free nets, but further research is needed to promote cost-effective, sustained access—particularly for the poor living in rural areas ( 4 ). The same is true of strategies to prevent mother-to-child transmission of HIV. Al- though interventions like prophylactic anti- retroviral therapy and replacement feeding have worked well in hospitals and clinics, increasing coverage in rural areas (where women have limited access to clean water and formal health care) may require testing of novel approaches, such as self-administration of drugs ( 5 , 6 ). Similarly, the scale-up of male circumcision, which has been shown to pro- tect against HIV transmission in recent clini- cal trials ( 7 ), will require development of safe, culturally acceptable, and accessible methods for surgery and care ( 8 ). The Implementation Research Gap Why is effective implementation, particularly in resource-poor countries, such an intractable problem? The reasons are complex. First, sci- entists have been slow to view implementa- tion as a dynamic, adaptive, multiscale phe- nomenon that can be addressed through a research agenda. Although randomized, con- trolled experiments are the gold standard for testing safety and efficacy of pharmaceuti- cals, health delivery schemes are less likely to be subject to rigorous scientific analysis. Second, people living in poverty face a bewildering constellation of social constraints and health threats that make prevention and treatment more difficult. They often have lim- ited knowledge of preventive health practices and insufficient or sporadic access to quality care. Their health systems are underfinanced, underregulated, and crippled by health-worker shortages. Even for those with access to care, health is routinely undermined by heavy pathogen loads, environmental exposures, inadequate sanitation infrastructure, and socio- economic barriers to behavior change. Faced with such challenges, it is not surprising that
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This note was uploaded on 04/05/2010 for the course SSH 494 taught by Professor Hurtado during the Fall '09 term at ASU.

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Implementation Science - POLICY FORUM CORRECTED 25 JANUARY...

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