Thursday, 2 October 2014

A Fork in the Road in Implementation Research: Swerving towards people centeredness

Mistakes are guaranteed. Learning from mistakes is not guaranteed. Implementation research is an attempt to maximize the chance to learn from our own and others' mistakes. Several forces array against successful learning from mistakes:
  1. Mistakes create benefits to small groups who will fight attempts to detect or correct them.
  2. Mistakes embarrass the leaders because infallibility is mistakenly presumed to be a leader's birthright.
  3. Mistake detection is an extra expense, and dollars spent to monitor don't obviously save lives the way direct services do.
Health systems researchers face a fork in the road. One path leads to implementation research as big science which can anoint a priestly caste of implementation experts pursuing universal truths and codifying best practices in mistake correction. The experts' business model is to sell expertise to clients and research foundations.

Another path leads to implementation research as small science — a cottage industry practiced by every district health officer, clinic manager, and MoH official. As small science, implementation research would become a widely prevalent skill in systematic and organized mistake detection. Everybody has to muddle through. Some keep repeating the same mistakes. There is a better way to muddle through, and we need health system functionaries at all levels to be experts at mistake detection and correction. The forces that perpetuate mistakes need to be engaged on local battlefronts one small sub-district, province, or ministry at a time.

The crucial choice for implementation research is whether it is to be identified as an epic search for universal solutions or as a platform to spread established methods of finding local solutions. The proliferation of self-identified global health experts and an organization calling itself "Health Systems Global" speaks to the seduction of searching for universal solutions. The latest seduction has been systems science. Many, myself included, have approached the construction of health systems models and simulations as a search for distilling eternal truths about health systems. After the "Eureka moment" the systems scientist announces a new universal principle and thereby changes the world. Right? Wrong!

What follows is the predictable disjunction between the researchers' distilled knowledge and implementation. Shortcomings in the small, local manifestation of policy research are a prevalent block to big science implementation research. For a discipline committed to mistake detection it would be unseemly for implementation research to perpetuate the myth that global decontextualized knowledge is readily recontextualized. This is not a false dichotomy, it is a real one. The more we push a paradigm that implementation research is the province of rigorous scholarship, the more we disable practitioners from accessing readily available approaches to doing their jobs better.

There is a different version of implementation research called participatory modeling, and even if some doubt how participatory the approach truly is, it is at least designed to engage the implementers themselves from the very beginning of the problem solving journey. A partnership forms where stakeholders and systems scientists convene to use the symbolic tools to identify and diagram the way a small system of interest to a planner can support the implementation of new policies.

A shared understanding of how organizations work can focus attention on where mistakes should be anticipated and how system reforms may lead to other mistakes. Here, implementation research is more a practice of mindful implementation. Indeed it is a style of managing one's implementation using practical research than it is a quest for universal principles.

To embark on the pathway to spread implementation research as a practical learning technique to be practiced broadly will rain on the ambitions of many would-be heroes of global health knowledge. Don't fear, they won't go away. Proof that big ambitious policy research is inert doesn't seem to slow it down. Luckily the evidence that building universal capacity in small and local systems thinking helps change policy for the better does appear to be leading to enthusiasm and growth.

Miraculously, there is a groundswell of interest in taking the small narrow road to powerful ignominy rather than the broad glorious road to powerless notoriety. More and more health systems researchers are focusing on moving skills in mistake detection and mistake correction closer to the people affected by mistakes. This approach epitomizes people centeredness. It can involve people in an ongoing cycle of vigilance to make their local health policies autonomously mistake-correcting.

Academicians who feel threatened by turning over control and authority to the people affected will object that deep complexity of health systems requires brainiacs and super computers. These guys don't get it. The utopian health system guided by global best practices is a pipe dream.

What is in our reach are real health systems everywhere in which more people are more involved in mistake detection and correction. The spread of the practice of small, local implementation research can spread the word on the necessity of people's involvement and watchful scrutiny every time one implements. This is a radical idea, powered by truth. It is exciting to see health systems researchers shed laurels and roll up sleeves to share the word that everyone makes mistakes and everyone should work on fixing them. This is the future of implementation research.

By David Bishai, Professor, Johns Hopkins Bloomberg School of Public Health