How service delivery implementation strategies can contribute to attaining universal health coverage: lessons from polio eradication using an implementation science approach

(2022) 22:1271 Olateju et al. BMC Public Health https://doi.org/10.1186/s12889-022-13681-0 Open Access RESEARCH How service delivery implementation strategies can contribute to attaining universal health coverage: lessons from polio eradication using an implementation science approach Adetoun Olateju1, Michael A. Peters1, Ikponmwosa Osaghae2 and Olakunle Alonge1* Abstract Background: Improving service delivery is a key strategy for achieving service coverage, one of the two components of universal health coverage (UHC). As one of the largest global public health initiatives, individuals involved with the Global Polio Eradication Initiative (GPEI) have learned many important lessons about service delivery. We identified contributors and challenges to delivering health services at national and subnational levels using experiences from the GPEI. We described strategies used to strengthen service delivery and draw lessons that could be applicable to achieving UHC. Methods: Online cross-sectional surveys based on the Consolidated Framework for Implementation Research (CFIR) domains and socioecological model were conducted from 2018–2019. Data were analyzed using an embedded mixed methods approach. Frequencies of the contributors and challenges to service delivery by levels of involvement were estimated. Chi-square tests of independence were used to assess unadjusted associations among categorical outcome variables. Logistic regressions were used to examine the association between respondent characteristics and contributors to successful implementation or implementation challenges. Horizontal analysis of free text responses by CFIR domain was done to contextualize the quantitative results. Results: Three thousand nine hundred fifty-five people responded to the online survey which generated 3,659 valid responses. Among these, 887 (24.2%) reported involvement in service delivery at the global, national, or subnational level with more than 90% involved at subnational levels. The main internal contributor of strengthened service delivery was the process of conducting activities (48%); working in frontline role had higher odds of identifying the process of conducting activities as the main internal contributor (AOR: 1.22, p = 0.687). The main external contributor was the social environment (42.5%); having 10–14 years of polio program implementation was significantly associated with identifying the social environment as the main external contributor to strengthened service delivery (AOR: 1.61, p = 0.038). The most frequent implementation challenge was the external environment (56%); working in Eastern Mediterranean region was almost 4 times more likely to identify the external environment as the major challenge in service delivery strengthening (AOR:3.59, p < 0.001). *Correspondence: 1 Department of International Health, Bloomberg School of Public Health Johns Hopkins University, 615 N Wolfe Street, E8140, Baltimore, MD 21205, USA Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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BMC Public Health (2022) 22:1271 Page 2 of 13 Conclusion: Priority actions to improve service delivery include: adopt strategies to systematically reach hard-toreach populations, expand disease-focused programs to support broader primary healthcare priorities, maximize community outreach strategies to reach broader age groups, build community trust in health workers and develop multisectoral leadership for collaboration. Achieving UHC is contingent on strengthened subnational service delivery. Keywords: Service delivery strengthening, Universal health coverage, Polio eradication, Implementation contributors, Primary health care, Implementation science Background Achieving Universal Health Coverage (UHC) is one of the Sustainable Development Goals (SDG) targets aimed at ensuring healthy lives and well-being for all ages [1]. It emphasizes access to effective and quality health care by all people and communities without financial hardship [2]. The UHC target has two components: first is the effective coverage of essential health services, and second is preventing health-related catastrophic financial expenditure [3]. The essential health service coverage component of UHC highlights the need for effective health service delivery for all people. Strengthening service delivery involves a two-pronged approach on both the supply-side and demand-side of the health system. The supply-side focuses on capacity building of health workers and improving service readiness, availability, and quality at health facilities. The demand-side involves increasing access of individuals and communities to health services, ranging from social mobilization to create demand for services to bringing health services to beneficiaries in their communities. Progress towards effective service delivery within UHC is monitored using the service coverage index (SCI) which is computed from selected tracer indicators covering four main categories including reproductive, maternal, newborn and child health, infectious diseases control, non-communicable diseases, and service capacity and access [1]. Globally, SCI increased across all regions between 2000 and 2017, however disparities persist in countries and regions towards attainment of UHC [4]. In 2015, Eastern Asia, North American, and European regions had the highest SCI for essential services while sub-Saharan Africa reported the lowest coverage [4]. Although development assistance for disease-specific global health initiatives have more than quadrupled in the last 20 years (from $6.7B to $29.2B between 2000 and 2019), specific funding for health system strengthening which includes UHC barely doubled (from $2.7B to $5.6B) in the same period [5], and the evidence on the contribution of vertical global public health programs, [6] to support countries in reaching UHC goals is ambig (...truncated)