Committing to implementation research for health systems to manage and control non-communicable diseases
Authors: Robert Marten, Bente Mikkelsen, Ruitai Shao, Livia Dal Zennaro, Nino Berdzuli, Thushara Fernando, Asmus Hammerich, Anselm Hennis, Hai-rim Shin, Steven Shongwe, Abdul Ghaffar
Journal: The Lancet Global Health (2020)

A 2020 WHO survey found that the ongoing COVID-19 pandemic was disrupting non-communicable disease (NCD) services in 122 (77%) of 159 countries surveyed. COVID-19 is disproportionately affecting people living with NCDs, exacerbating inequalities1Sheldon TA Wright J Twin epidemics of COVID-19 and non-communicable disease.BMJ. 2020; 369m2618Crossref PubMed Scopus (44) Google Scholar and limiting interventions to control tobacco and alcohol use, create healthy diets, and promote physical activity. NCDs are already responsible for more than 70% of deaths worldwide, three-quarters of which occur in low-income and middle-income countries (LMICs). The combination of COVID-19 and NCDs also has devastating consequences for people's access to health systems. COVID-19 underscores an urgent need to invest in NCD management as part of primary health care and universal health coverage. Although countries face unique challenges in implementing NCD programmes, better research that is grounded in local settings and context could help overcome barriers and accelerate implementation. More specifically, implementation research—defined as the scientific study of the processes used to implement policies and interventions, and the study of contextual factors that affect these processes—could improve the effect of NCD prevention, early diagnosis, screening, and treatment management programmes. There are three reasons why implementation research is a crucial and necessary priority. First, implementation research improves the adoption of health policies and accelerates policy action. Ongoing NCD policy implementation in many countries is weak; for example, one study found, across an average of 151 countries, not even half (49·3%) of WHO-recommended NCD policies are implemented.2Allen LN Nicholson BD Yeung BYT Goiana-da-Silva F Implementation of non-communicable disease policies: a geopolitical analysis of 151 countries.Lancet Glob Health. 2019; 5: e50-e58Google Scholar Implementation research can help to investigate how policies or interventions are implemented, and identify and surmount policy barriers.3Theobald S Brandes N Gyapong M et al.Implementation research: new imperatives and opportunities in global health.Lancet. 2019; 392: 2214-2228Summary Full Text Full Text PDF Scopus (258) Google Scholar It determines where and how successful policies have been implemented, and provides insights to improve the delivery of services and policy adoption. It is also a way to narrow the gap between research and practice; WHO has developed a practical guide, a toolkit, and a 2016 guide to implementation research for NCD prevention and control.4WHOA guide to implementation research in the prevention and control of noncommunicable diseases. World Health Organization, Geneva2016Google Scholar More recent analyses have also helped conceptualise a continuum of NCD research questions.5Peters DH Peters MA Wickramasinghe K Osewe PL Davidson PM Asking the right question: implementation research to accelerate national non-communicable disease responses.BMJ. 2019; 365l1868Crossref PubMed Scopus (11) Google Scholar These guides and tools can be combined with multidisciplinary research approaches (eg, from political science and behavioural sciences) to better understand policy barriers and develop strategies to overcome these blockages.6Reich MR Political economy of non-communicable diseases: from unconventional to essential.Health Syst Reform. 2019; 5: 250-256Crossref PubMed Scopus (19) Google Scholar Second, implementation research accelerates the local adaptation of best practices, empowers local communities, and improves service delivery. WHO has developed a list of best buys for NCDs with affordable, feasible, and cost effective intervention strategies. However, these strategies have not yet been widely adopted, and most best buys are vastly underutilised. For example, one study found research only considered 11 of the 24 best buys for NCDs in LMICs.7Allen LN Pullar J Wickramasinghe KK et al.Evaluation of research on interventions aligned to WHO 'best buys' for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015.BMJ Glob Health. 2018; 3e000535Crossref PubMed Scopus (76) Google Scholar There is still a knowledge gap in how to adapt these interventions for LMIC settings, and how to overcome more traditionally reductionist, linear understandings of policy making, and engage communities and populations. This need for adaptation is true for many health policies, but is particularly true for NCDs, which have generally been overlooked within the broader global health agenda. The ongoing COVID-19 pandemic highlights the crucial contributions that communities make in response to public health emergencies; managing and responding to NCDs is no different. Implementation research can help engage communities and provide insights on how to best develop approaches and policies for NCDs. Having a better understanding of local needs, applying a more systems-based approach, and engaging communities will improve existing efforts to deliver services and, ultimately, develop better health policies. Third, a broader, shared commitment to implementation research can enhance the adoption of national NCD strategies, create healthier populations, and accelerate progress on the Sustainable Development Goals (SDGs). Leveraging implementation research can support civil-society actors and policy makers to improve efforts to deliver services, as well as advocate for, develop, and implement more effective policies. To make this happen, health ministries can collaborate with academic and civil-society actors to assess data and consider policy options. Moving policy implementation beyond the health sector, and working with other actors, can lead to more tailored support to accelerate and overcome implementation obstacles.8Jackson-Morris A Nugent R Tailored support for national NCD policy and programme implementation: an over-looked priority.BMJ Glob Health. 2020; 5e002598Crossref PubMed Scopus (6) Google Scholar This means that increased attention to the institutionalisation of local capacity for knowledge generation and its application is required. Increased attention is particularly important given heterogeneity of cardiovascular diseases, cancer, diabetes, and lung diseases across and between different contexts and over a person's life-course.9Bente M Julianne W Ivo R et al.Life course approach to prevention and control of non-communicable diseases.BMJ. 2019; 364l257PubMed Google Scholar It is crucial that the best available data sources are used to identify and set priorities. The ongoing COVID-19 pandemic demands a new lens to focus on NCDs. Closing the gap in research and adapting evidence-based interventions to understand how to implement and improve programme and service delivery is a complex challenge, but an absolute necessity to achieve the SDGs. SDG target 3.4 commits countries to reduce premature mortality from NCDs by a third by 2030 (relative to 2015 levels). A new analysis shows that no LMIC is on track to meet this target if their 2010–16 average rates of decline for both men and women are maintained or exceeded; however, this same analysis shows that effective and integrated health systems interventions, combined with tobacco and alcohol control, could transform NCD control such that most countries could achieve the SDG target.10NCD Countdown 2030 collaboratorsNCD Countdown 2030: pathways to achieving Sustainable Development Goal target 3.4.Lancet. 2020; 396: 918-934Summary Full Text Full Text PDF PubMed Scopus (224) Google Scholar If SDG target 3.4 is to be reached in LMICs, policy makers must evaluate, monitor, and improve NCD programmes, and a new commitment to building local and national capacities for implementation research is urgently needed to manage NCDs. We declare no competing interests.