Nepal Public Health Foundation, Kathmandu, Nepal.
University of Global Health Equity, Kigali, Rwanda.
BMC Pediatr. 2024 Feb 28;23(Suppl 1):645. doi: 10.1186/s12887-023-03889-3.
Health system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal's adaptation and implementation of IMCI.
We conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000-2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI.
Strategies chosen and adapted to meet Nepal's specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained.
Nepal's story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.
医疗体系提供的循证干预措施（EBIs）对于降低可避免的 5 岁以下儿童死亡率（U5M）非常重要。实施研究（IR）可以缩小知识差距，并减少新知识与其在实际环境中的实施之间的滞后。IR 还可以帮助理解对 EBI 及其实施进行调整以适应当地环境有用的背景因素和策略。尼泊尔一直是降低 U5M 的领导者，包括通过采用儿童疾病综合管理（IMCI）等 EBI。我们利用 IR 来确定尼泊尔在适应和实施 IMCI 方面所采用的策略。
我们使用实施研究框架进行了一项混合方法案例研究，该框架旨在了解尼泊尔在 2000-2015 年期间如何通过实施已知可降低可避免的 U5M 的医疗体系提供的 EBIs，从而超越其同行。我们结合了对现有文献和数据的审查，并辅之以 21 次与政策制定者和实施者的关键信息访谈，以了解影响实施结果的实施策略和背景因素。我们从案例研究中提取了相关结果，并使用解释性混合方法来理解尼泊尔在适应和实施 IMCI 方面的成功和挑战的原因和方式。
为满足尼泊尔的具体情况而选择和调整的策略包括利用当地研究为国家决策者提供信息、试点测试、合作伙伴参与，以及利用和整合现有的社区卫生系统。这些跨领域的策略得益于以下促进因素：社区卫生系统和结构、数据使用文化以及当地研究能力。地理位置是一个关键障碍，尽管在最富有和最贫穷的五分位数中都看到 U5M 大幅下降，从 2001 年到 2016 年，每 1000 例活产的财富公平差距从 73 减少到 39，但仍存在很大的地理不平等。
尼泊尔的故事表明，在不同背景下可用的实施策略是采用和调整 IMCI 并实现可接受性、有效性和覆盖范围等结果的关键。选择利用投资于社区和机构方法等促进因素的策略以及解决地理等障碍的价值，对于努力加快实施 EBIs 的策略的适应和实施以继续实现儿童健康目标的国家来说，是有用的经验教训。
