The solution designed as part of phase 2 (Design the solution) will achieve impact only if implemented on a large scale and as intended. The concept of scaling up is useful here and can be defined as “deliberate efforts to increase the impact of successfully tested health innovations so as to benefit more people and to foster policy and programme development on a lasting basis” [107].
An innovation in this context refers to a new intervention or set of interventions to achieve health impact. Implementation of an intervention requires consideration of its essential components, who will deliver it, with what outcomes and how. In addition, the implementation plan developed at the “design implementation” step should consider the resources for implementation, the need for capacity-building for implementation, and how the intervention can be integrated within the particular setting or organization [108],[109].
A monitoring and evaluation (M&E) plan should be developed and put into action prior to implementation to measure whether the solution has been implemented as planned (process evaluation) and is resulting in the expected outputs, outcomes and impact. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) is a useful model to guide the evaluation, as it considers the different stages of implementation (reach, adoption, implementation, maintenance) and multilevel (individual, setting) indicators [108],[110]. The M&E plan should consider indicators related to equity and cost. M&E allows early identification of problems and facilitates adjustments to be made to improve performance. The results of the evaluation can be disseminated/published to contribute to the evidencebase and help others who are designing and implementing similar solutions (Fig. 2.7).
Sustain change
In EIDM, sustainability “describes to what extent an evidence-based intervention can deliver its intended benefits over an extended period of time after external support from the donor agency is terminated” [108]. Sustainability is achieved when there is maintenance of the programme’s initial health benefits, integration of the intervention within the culture of the setting or community in which it is implemented (institutionalization) and a focus on capacity-building to ensure continued delivery of the intervention [108],[109]. Achieving sustainability also requires a continuing alliance of stakeholders.
Planning for sustainability is an essential component of implementation and should begin before the programme is implemented, ideally at the “design implementation” step [107]. While research in the area of sustainability is limited [111], sustainability has been conceptualized as a dynamic process that involves continued learning and problem-solving, and ongoing adaptation of interventions [112]. If interventions are adapted to improve the fit of the intervention within the multilevel contexts (including the practice setting and the system within which it sits), ongoing improvement as opposed to diminishing outcomes over time1 can be expected [112]. However, achieving optimal fit requires consistent tracking of the characteristics of the intervention, practice setting and ecological system using valid, reliable and relevant measures.
Ideally, the M&E plan developed as part of the previous step incorporates consideration of longer-term monitoring to support the process of ongoing adaptation and achievement of optimal fit of the intervention. Further, results of the evaluation of this adjustment process should be disseminated to contribute to the evidence base for achieving sustainability. Sustainability of interventions requires a “learning organization” that uses rapid learning cycles to allow adaptation of evidence-based interventions followed by ongoing assessment and feedback loops [65],[111],[113]. The characteristics of a learning health system include the following:
• it is data- and evidence-driven (the system captures, links and shares relevant data and produces timely research evidence);
• it has the appropriate system supports (the system supports informed decision-making at all levels with appropriate data, evidence and decision-making frameworks);
• it promotes a culture and the acquisition of competencies for rapid learning and improvement (e.g. data and research literacy, co-design, scaling up, leadership) [112].
This kind of system collects data as a basis for generating new evidence, which is then transferred into practice for implementation. Data generated from practice as well as experience from implementation are again fed back into the learning cycle to change or refine policies and practice (Fig. 2.8) [114].
In EIDM, sustainability describes to what extent an evidence-based intervention can deliver its intended benefits over an extended period of time after external support from the donor agency is terminated.
Global health and equity
Achieving an impact on global health and equity is the ultimate aim of better use of research evidence in health decision-making. The WHO policy strategy to achieve impact, outlined in WHO’s Thirteenth General Programme of Work, 2019–2023 (GPW13), are the Triple Billion targets, an ambitious initiative to improve the health of billions of people by 2023 [2], with the goals of:
•1 billion more people benefiting from UHC;
•1 billion more people better protected from health emergencies;
•1 billion more people enjoying better health and well-being.
The Triple Billion targets act as both a measurement and a policy strategy. The results framework includes 46 indicators, the Triple Billion targets, and healthy life expectancy (HALE) to quantify expected years of life in good health as a measure of the overall health of populations [11],[12]. Measurement of the targets is aligned with those of the SDGs to streamline data collection and implementation efforts, and accelerate progress towards achieving key targets [12].
Impact measurement includes a cross-cutting commitment to improving equity in health [12]. Health equity is defined as the absence of unfair and avoidable differences in health [115]. Monitoring health inequalities, i.e. observable differences in health, is essential for achieving health equity. It allows the identification of vulnerable groups at risk of being left behind and provides evidence for equity-oriented decision-making to close existing gaps [12]. Vulnerable groups can be identified using the PROGRESS-Plus tool [116],[117]. Further, incorporation of equity considerations at all levels of the evidence creation funnel and policy/action cycle will be fundamental to the achievement of health equity [118],[119].
The Triple Billion targets focus on the execution and delivery of significant improvements in the health of the world’s population through evidence-based interventions, strengthened health information systems, and support for transformational public health policy [2].
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