Implementation research addressing strategies to strengthen health systems for equitable high-quality care and health outcomes in the context of non-communicable diseases (GACD)

This topic aims at supporting activities that are enabling or contributing to one or several expected impacts of destination “Tackling diseases and reducing disease burden”. To that end, proposals under this topic should aim to deliver results that are directed, tailored towards and contributing to some of the following expected outcomes:

• Healthcare practitioners and providers in low- and middle-income countries (LMICs)^[1] and/or those in high-income countries (HICs) serving disadvantaged populations have access to information allowing to strengthen health systems for equitable high-quality care and health outcomes in the context of non-communicable diseases (NCDs).
• Public health managers and authorities have access to improved insights and evidence on how to decrease the fragmentation of care for patients living with NCDs and ensure continuity of care across all stages of disease progression, including prevention, risk reduction, and timely diagnosis of NCDs. They use this knowledge to design policies to reduce health inequities and to promote equitable health outcomes.
• Researchers, clinicians and authorities have an improved understanding how the proposed interventions for strengthening health systems for equitable high-quality care and health outcomes in the context of NCDs could be adopted in LMICs and/or disadvantaged populations of HICs setting, taking into account specific social, political, economic and cultural contexts.
• Communities, local stakeholders and authorities are fully engaged in implementing and taking up interventions that strengthen health systems for equitable high-quality care and health outcomes in the context of NCDs and thus contribute to deliver better health, improve quality of life across the life course and extend healthy life expectancy.

The European Commission is a member of the Global Alliance for Chronic Diseases (GACD)^[2]. The GACD specifically addresses NCDs and supports implementation science to improve health outcomes. This topic is launched in concertation with the other GACD members (international funding agencies) and aligned with the 10^th GACD call.

Health systems in many countries have not kept pace with the rapid emergence of NCDs that require costly long-term care and treatment. Resilient, fit for purpose health system should provide high-quality, safe, equitable, accessible healthcare, that reflects the needs of the population, and enables the integration of healthcare across the care continuum, encompassing prevention, screening, diagnosis and long-term management of NCDs^[3]. While health systems across the world struggle with these challenges, this is a particular problem in LMICs that have relatively overburdened, poorly resourced and fragile health systems that struggle to cope with the burden of NCDs. Health inequalities (e.g. linked to geographical location, socioeconomic status, sex and/or gender, ethnicity, disability) are often accentuated by structural and/or systemic weaknesses such as lack of staff and appropriate medicines.

The increasing burden of NCDs on healthcare systems has spurred a greater interest in exploring strategies to tackle these conditions, including a move from a healthcare system focused on disease and hospital-based care, to a more holistic model, involving communities and primary care, and focused on maintaining health^[4],[5]. These include interventions addressing the integration of and access to care, screening, access to medicines and technologies, task shifting and digital health interventions. Implementing these strategies while retaining a focus on equity is challenging and health systems need to account for geographical disparities as well as reach communities that have traditionally suffered health inequalities. Equity in health requires that resources and processes are designed to promote equalisation of health outcomes for populations experiencing health disparities, to ensure similar health outcomes for all of society^[6].

Evidence for how to strengthen health systems to improve services and ensure equitable health outcomes is emerging, mostly from research in HICs. However, implementing equity-oriented interventions for transformation and/or strengthening of health systems remains challenging and largely unexplored in underserved populations, especially in LMICs. Providing evidence on implementation strategies that can enable effective adaptation and scaling of programmes will be critical to improving survival and quality of life as well as reducing disability, the burden of caretaking on (typically female) family members and costs of healthcare falling on households.

This implementation research topic is therefore focused on strategies to support health system transformation and/or strengthening using evidence-based interventions in the context of NCDs that can be adapted to and implemented in LMICs and/or disadvantaged populations experiencing health disparities in HICs to encourage equitable health outcomes.

The proposed implementation research should be focused on one or more evidence-based interventions (or complex interventions) focused on building equity-orientated health systems change to tackle the growing burden of chronic conditions, including NCDs. The choice of intervention(s) and provision of existing evidence of the intervention’s effectiveness, cost-effectiveness, sustainability, scalability and potential for long-term health and other impacts should be justified (and in what context this evidence has been generated). As the evidence underpinning strategies to transform and/or strengthen health systems in the context of NCDs is still emerging, particularly in LMICs, a limited period of testing the effectiveness of an intervention that the applicant’s team has adapted for local implementation is therefore usually appropriate.

Applicants should explore the implementation of proposed intervention(s) for a selected study population(s) taking into account the unique social, political, economic, and cultural context(s) in which the study will take place. Applicants should justify why any adaptation will not compromise the known effectiveness of the selected intervention(s).

Proposals should address all the following activities^[7]:

• Provide a research plan using validated implementation research frameworks or hybrid design research;
• Have an appropriate strategy for measuring implementation research outcomes and real-world effectiveness outcomes and indicators. Other health or non-health outcome measures, especially those identified as important by patient participants and/or critical for advancing Universal Health Coverage (UHC)^[8], are also welcome;
• Specifically address health equity and the principles of UHC;
• Engage an appropriately expert and skilled research team which can ensure a suitable multidisciplinary approach and that demonstrates equitable partnership and shared leadership between HIC-LMIC, and/or non-Indigenous-Indigenous members of the project team and external stakeholders through a clear governance strategy;
• Provide a stakeholder engagement strategy with evidence of support/engagement from key stakeholders for delivering patient-centred care;
• Ensure that project partners are engaged from the beginning to contribute to the sustainability of the intervention after the end of project. Proposals should demonstrate sustainability of the strategy, beyond the lifespan of the project;
• Provide opportunities for implementation research capacity building for early career researchers and team members from lower resourced environments, such as LMICs or disadvantaged communities;
• Ensure meaningful involvement of early career team members, including at least one early career member as a co-investigator.

The study population may include the general population, people with one or more existing NCDs, those currently without NCDs, or a combination of both. The study population may also include patients with NCDs and chronic infectious disease(s) (e.g., studies that focus on integrating NCD management into an HIV or tuberculosis clinic). With regard to NCDs, applicants are encouraged to explore any chronic non-communicable condition (or combination of conditions), including mental health disorders, neurological disorders and sleep disorders.

Proposals are expected to use an appropriate implementation research design and frameworks for feasibility studies, cluster randomised control trials (cRCTs), before and after studies, and additional implementation science classifications of study designs (e.g. hybrid designs)^[9],[10].

Applicants are not limited to use any particular design, however a validated implementation research framework should underpin the study.

Proposals would be expected to generate evidence that is of direct relevance to policymakers, communities and practitioners. Also, proposals will require a strategy to include the relevant policymakers, local authorities, as well as other stakeholders such as community groups, or other individuals or organisations involved in the implementation of the intervention, with co-creation from the development of the project through to the implementation knowledge translation phase. Applicants should also provide a clear plan for continuing to engage with stakeholders.

Stakeholders also include patients, their family members and carers. Their contributions should be nurtured through meaningful engagement from the outset, not only as participants in the research undertaken. Patient engagement throughout the research project is critical to developing patient-centred models of care.

All stakeholders should be engaged at every stage of the research project, from initial ideation of research questions, throughout the duration of the project, and afterwards during the knowledge translation phase. It is also important to include stakeholders who can help sustain the project’s implementation, facilitate scale up, and use the knowledge generated from the project after the grant ends.

Poverty, racism, gender inequality, ethnic discrimination, and other inequities are directly associated with reduced potential for equitable access to quality care. Proposals should consider the social determinants of health and discuss their potential impact on the effective implementation of the intervention(s). If there is a focus on a particular population (e.g., gender, race and/or ethnicity), then the reason for this should be justified.

In order to promote health equity, proposals should aim to address differences in intervention access, uptake, and effectiveness in socially disadvantaged groups and develop strategies for reducing inequities. To facilitate this process at the data analysis stage, studies should be designed to address such differences. At a minimum, studies should capture and disaggregate data on sex and/or gender differences. If feasible, a plan for capturing intersectional impacts on health outcomes should be included in the analysis strategy.

This topic requires the effective contribution of social sciences and humanities (SSH) disciplines and the involvement of SSH experts, institutions as well as the inclusion of relevant SSH expertise, in order to produce meaningful and significant effects enhancing the societal impact of the related research activities.

All projects funded under this topic are strongly encouraged to participate in networking and joint activities, including internationally, as appropriate. These activities could, for example, involve the participation in joint workshops, the Annual Scientific Meetings of the GACD, the exchange of knowledge, the development and adoption of best practices, or joint communication activities. Therefore, proposals are expected to include a budget for such activities and may consider covering the costs of any other potential joint activities without the prerequisite to detail concrete joint activities at this stage. The details of these joint activities will be defined during the grant agreement preparation phase.

Applicants envisaging to include clinical studies^[11] should provide details of their clinical studies in the dedicated annex using the template provided in the submission system.

[1] As defined by the World Bank.

[2] https://www.gacd.org

[3] Kruk ME, Pate M, Mullan Z. Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era. Lancet Glob Health. 2017 May;5(5):e480-e481.

[4] Hunter DJ, Bengoa R, Meeting the challenge of health system transformation in European countries, Policy and Society, Volume 42, Issue 1, March 2023, Pages 14–27.

[5] The WHO has produced a series of recommendations for strengthening health systems, to improve capacity and services to tackle NCDs, with an eye to understanding how the service improvement will be scaled up system-wide; https://apps.who.int/gb/ebwha/pdf_files/WHA66-REC1/A66_R1_ANX4-en.pdf

[6] Health equity is achieved when everyone can attain their full potential for health and wellbeing.

[7] The following types of proposals are not in the scope of this topic: i) proposals with the primary aim of informing the development and/or selection of an intervention for a given context, where the implementation component will be explored in a future project (i.e. standalone feasibility projects);ii) epidemiological cohorts; iii) etiological work, mechanistic, or epidemiological research, unless an essential component of a focused study to develop implementation research approaches; iv) clinical trials, validation studies, or intervention efficacy studies for a new or established pharmacological agent or behavioural intervention.

[8] https://www.who.int/health-topics/universal-health-coverage

[9] Examples of frameworks include (this list is not exclusive): i) Consolidated Framework for Implementation Research (CFIR); ii) the context enhanced (RE-AIM) Reach, Effectiveness, Adoption, Implementation, Maintenance); iii) Practical Robust Implementation and Sustainability Model (PRISM) frameworks.

[10] The following are potential interventions or strategies that applicants may consider in their implementation plan (please note that this is not an exhaustive list): i) Strengthening within the workforce including: training; task shifting within healthcare services; multi-disciplinary teams; community outreach; and the care continuum; ii) Changes in health or related facilities, including relationships, engagement and linkages between facility levels (primary, secondary, tertiary), regional specialist care, pharmacies, and community healthcare; iii) Digital or information technologies in health systems to improve condition management; shared records; coordination in continuum of care; self-management and equitable health outcomes; iv) Implementation of new technologies, innovations for screening, earlier diagnosis and better management of NCDs; v) Ensuring equitable access to good quality medicines (priority medicine lists and financing, monitoring; procurement and distribution; charging and fees); vi) Health policy entrepreneurship linked to solving or capitalizing a policy or practice issues/innovations that have a clear link with service delivery or health promotion with NCDs.

[11] Please note that the definition of clinical studies (see introduction to this work programme part) is broad and it is recommended that you review it thoroughly before submitting your application.