Table 2 Selected Contextual Factors influencing implementation success

Intervention characteristics

Embeddedness in the public system and close integration into national strategies;

“Because it is an opportunity that we have been looking for a long time. We had a program that went through a rigorous research as far back as 1994 that proved the intervention that if you put nurses in the community and work closely with the community members and putting all the structures and equipment, everything, you will improve health outcomes.”

Difficult to adapt to context due to evaluation framework (RCT or other fixed designs)

“Because to actually work through the health system would’ve prevented us from being able to conduct an experiment. That tension was salient throughout the project, even from when we were working with the local government authorities because it was like why are you setting it up this way?”

“The spirit of PHIT is very much one of implementation. Our project is a research project and I sense that that has put us always at a disadvantage compared to other PHIT projects which were directly go in and improve this.”

Innovation

“…that was the situation that we had, this project came as a first project that was looking the entire health system, how do we make the system stronger …this is a project that will sit…right in the middle of the health system.”

Built on existing partnerships

“I think you have to subordinate the global expertise and technocratic input to context about what might work in that setting because to influence a system, you have to have people on board and you have to adapt their perspectives and their perceptions.”

Plan to utilize data and adaptability

“We were in equipoise (questionable vocabulary) [sic] and as researchers the best thing is to put the concept to the test, get results, and then see if it works, start now working towards implementation. I think that it is reasonable to say that it was our scientific intent to generate evidence before we recommend.”

Rigorous evaluation framework

“…based on our understanding of the need to have evidence- based recommendations and adjustments to the system; we didn’t want to say, 'We have this great quality improvement idea, let’s implement!' No, we said, 'We have these great ideas. Do they really work? We don’t know. Can they really contribute to improved quality improvement and improved mortality eventually?'”

Outer setting

Local individual expertise

“The second thing was that we always concentrated on putting nurses in the community. We never talked about midwives…The midwife focuses also to address the inherent cultural practices that every community, every home, every clan in the district, in the community has a midwife.”

Intermittent change in national policies priorities.

“I think one of the challenges of working with the government is they have a lot of priorities and sometimes the national will say on a Monday, “You need to do this by Wednesday!” So all their planning kind of goes out the door. So understanding that they have pressures on their time so that they couldn’t always do it exactly how we had planned to do it. And I think I mentioned before that it just takes longer to do anything with the government. In some ways it’s sometimes easier to do something completely separate, so it takes longer and you have to have more patience, so I think that was a challenge.”

Local policies and management structure strength;

“...it is not our decision, we do not decide where the facilities or nurses should be; it’s the community that decides because we also expect some responsibility from the community.”

Public sector and other funding fluctuations

“The … health system has tremendous logistics and stock out problems. From the very beginning of the study, we were required … to conduct integrated community case management of childhood illness, meaning that the CHWs had to provide antibiotics and antimalarials. There was no way through the health system that they could procure and deliver supplies to CHWs.”

Existing stakeholder capacity

“…this is the program that also deals with a lot of NGOs. For instance, in our community health program the major stakeholder was…who have been already in the community and deal with many issues. So, in training community health nurses to work with the community, they were the people that we used.”

Diseases prevalence

“So, we recognize that the under 5 mortality was dropping but neonatal mortality wasn’t, it’s something that we recognize that a lot of the interventions were not actually addressing the needs of the babies.”

Human resources in the wider health System (attrition and shortage)

“One of the challenges could be that there was a lot of staff movement. Not necessarily people leaving… So a health worker might move from one health center to another. So they would have been exposed to some of the activities but they are now in a different place. We had a couple key leadership people leave the project: the Chief Medical Officer at the provincial level, there was two of them throughout. So that’s a little challenge because you have to re-explain it.”

Inner setting (academic and NGO implementing organizations)

Internal on the job mentorship and Capacity building

“The goal behind that was that because this was a grant that was both implementation and research we really want to grow the capacity of people from…to actually participate in the research part of it but then I think recognizing the value of people being able to consume research and knowledge management and not just necessarily just produce research.”

“I think expediently research capacity building beyond what was focused in the school of public health is something that was much broader. I think that was an adaptation, one [sic] was sort of really remarkable [sic] successful”

Intra PHIT project Leadership Change; and Staff turnover requiring constant training Consistently training new staff due to turnover

“I think changes in the statistical officers at the district level, that was a challenge because you have to keep going and re-training: it’s not linear, you can’t start something and keep gone [sic].”

Interdisciplinary team including National and International staff, and

Expertise in local context

“The institution I work for has been in existence since 2001, so certainly PHIT project was coming to fit into an institution that was already running. In fact, the institution had been doing a lot of health systems work before PHIT, but that was completely focused on ART, anti-retroviral therapy. In fact, my institution, I think it is fair to say that we shared data and championed the introduction of ART in...”

Collaborative research approach

Increased research productivity and local and international collaboration. (Hedt-Gauthier, B. et al. 2017. BMC Health Services Research, 2017. Vol 17 Suppl 3. S3)

Multidisciplinary teams Strong content specific technical skills (PhD and implementation research track record; Academic partners)

“…Strong Technical team. Statisticians and Epidemiologist as well as clinicians…”

Implementation process

Data use to inform iterations on intervention and implementation design

“…the neonatal mortality reduction was definitely something we added on when we recognize [sic] that the under 5 mortality is [sic] dropping but neonatal mortality was not dropping.”

Local intermittent change in data tools and methods.

“It’s amorphous. Then it is in the system, the data systems for the ministry are constantly being updated and changing. So that’s a static thing. So, part of the project was to get, kind of started first making sure the data was okay, and try to figure out how to help them use it to make decisions, that would lead to management decisions is [sic] at the health facility but at the same time the data system will be updated and changed. So we have [sic] constantly kind of re-train people in their system, so it is not very linear.”

Cross intervention peer learning;

“That year limiting was also a platform for us to know what is happening here, what is happening there, not only for the project itself in a hotel discussion but also field visits. I remember very well that the field visit was so exciting for us because we went there, we saw things that were happening, we learned, we pick lessons.”

“We went to the field and we spent a whole day in the field to look at how the CHWs are working in the community. When we came back we had to talk about some of the findings, the challenges, the approach and that was changing the way because we were coming from a background with some experience. So for me, these interactions were not only for the benefit of each country but the entire PHIT program.”