Implementation Science for Family Planning and Reproductive Health

Implementation science is gaining ground in the family planning and reproductive field as a systematic approach to improving policies, programs, and practice.

Karen Hardee

Karen Hardee, Director of the Evidence Project and Population Council senior associate, answers questions about how the project is using implementation science in generating, translating, and using evidence to improve programming.

What do you see as the goal of the Evidence Project?

The goal of the Evidence Project is to increase access to quality family planning and reproductive health services in order to reduce unintended pregnancies. Our contribution to that goal is to use implementation science to provide evidence about how programs and policies can be designed and implemented better—and to promote use of the evidence by decision-makers to improve programming.

What is implementation science?

In the Evidence Project, implementation science consists of the strategic generation, translation, and use of evidence to improve family planning/reproductive health programs, policies, and practices. We start with generating new evidence through primary research or consolidating existing evidence through synthesis papers, case studies, landscape reviews, or expert meetings. Then we translate the evidence into key messages and formats tailored to decision-makers at different levels—district, national, regional, global—as appropriate. The translation process is followed by working directly with the decision-makers on how to use and apply the evidence to strengthen programming in their particular context.

Of course, the process is not always linear. To me, implementation science is an iterative and interactive process that shines a spotlight on how programs are implemented. In addition to measuring outcomes, implementation science emphasizes documenting and measuring the strength of implementation. Sometimes we get an outcome from a study suggesting that something does not work. Unless we have a solid description of the implementation, it is hard to say why the program did not work. Implementation science involves making sure you really understand and measure how the implementation was done—not only looking at the family planning/reproductive health outcomes, but also looking at implementation outcomes.

Implementation science gives wide scope for using different research methods to answer questions. In other words, the method might be policy analysis, or secondary analysis, or a case-control study. Implementation science incorporates a range of methodologies to study how to improve implementation; it is complementary to monitoring and evaluation.

Another part of what we are doing is studying what evidence is, how it is used by policymakers, program managers, and providers, and how we can enhance the use of evidence in programs. We are asking what evidence there is to show that decision-makers actually use evidence in making decisions. And what are the facilitating factors and challenges that decision-makers face in making evidence-informed decisions? This will help guide our knowledge translation and use activities and will inform our research.

How is the Evidence Project unique in its use of implementation science? Doesn’t the family planning field have a history of doing this?

The family planning field has a rich tradition of conducting operations research. We have always had a strong philosophy of engaging users from the start so that research answers critical questions that are relevant to programs.

Many people are now asking what implementation science compared with operations research. To me, there are very close ties. Two distinguishing features of implementation science are its focus on implementing what has been shown to work, particularly around scaling up family planning/reproductive health programming within health systems, and using implementation science to address implementation bottlenecks and challenges.

In past research we tended to look just at the health outcomes and concluded whether the program worked or did not work. We based our conclusions only on the health outcomes rather than examining whether there were some real problems in the implementation, such as the training did not go well, or there was not good supervision, or the commodities did not make it in time.

As we generate evidence and conduct studies, we will focus on making sure we document the implementation successes and shortcomings to better understand and explain the outcomes that emerge.

In what other ways is the project unique?

I hope the Evidence Project can help demonstrate how evidence on family planning can be used within the health system—in other words, how family planning services can be integrated into larger health systems. It is not enough to say to a family planning manager that a strategy works—it can work as an isolated pilot—but then you have to get it into the system. So who prints the job aids, who provides training on how to use them, who updates them—all of these things have to be institutionalized. Also, how do we scale up practices that work within health systems and what does this cost? The process of scale up has included monitoring and some evaluation, but there has been less emphasis on implementation research, including costing.

Another unique feature is the project’s potential ten-year time frame, which opens up possibilities for longitudinal studies. One of our partners, INDEPTH Network, has demographic surveillance sites that offer an opportunity to add questions about family planning and to link the longitudinal data collection to family planning interventions.

Additionally, the project covers almost the whole FP2020 time period. That gives us a huge opportunity to make sure we are answering key questions to move forward the FP2020 agenda of reaching an additional 120 million users with quality information and services.