Health Policy and Planning Advance Access originally published online on July 6, 2005
Health Policy and Planning 2005 20(5):290-301; doi:10.1093/heapol/czi034
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Original article |
Implementing global knowledge in local practice: a WHO lung health initiative in Nepal
1 Institute of Medical Technology Assessment/Institute of Health Policy and Management, Erasmus Medical Centre, Erasmus University Rotterdam, the Netherlands, 2 Department of Social Medicine, Academic Medical Center – University of Amsterdam, the Netherlands, 3 previously: Stop TB, Communicable Diseases Cluster, World Health Organization, Geneva, Switzerland; currently: Family and Community Health Cluster, World Health Organization, Geneva, Switzerland, 4 Department of Community Media and Family Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal, 5 National Tuberculosis Centre, Thimi, Nepal, 6 World Health Organization, Nepal and 7 Netherlands Institute of Health Services Research, Utrecht, The Netherlands
Correspondence: AHA ten Asbroek, MSc, Department of Social Medicine, Academic Medical Center/University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, the Netherlands. Tel: +31 20 5667440/5664892; fax: +31 20 6972316. E-mail: g.tenasbroek{at}amc.uva.nl
Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases.
We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level.
This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the ‘implementability’ of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.
Key Words: quality of care, implementation, guidelines, stakeholder analysis, social system, low-income countries, Nepal
1The Practical Approach to Lung Health (PAL) was initially titled Adult Lung Health Initiative. The name was changed in 2001.
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