Real-world implementation challenges in low-resource settings

27 August, 2021

Citation and selected extracts from a new paper in The Lancet Global Health.

CITATION: Real-world implementation challenges in low-resource settings (Comment)

Kathryn M Chu, Thomas G Weiser

Lancet Global Health

Open Access Published: August 18, 2021



Postoperative mortality is disproportionately high in low-income and middle-income countries (LMICs)... ASOS-2, a cluster-randomised controlled trial [], developed earlier work to assess an intervention aimed at reducing postoperative mortality. A package of five interventions were applied to patients at high risk on the basis of the clinical concept of failure to rescue — ie, that postoperative complications require active intervention and that hospitals with high rates of mortality fail to rescue deteriorating patients. This package included admitting the patient to a higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to say in the ward, and placing a postoperative surveillance guide in a visible position at the bedside...

The 160 hospitals allocated to the intervention group struggled to implement the package, with only 40·0% (64 hospitals) able to include the bedside surveillance guide plus one additional component, and only 59·4% (95 hospitals) able to implement two or more items in the package...

Even simple solutions, such as putting patients at high risk in close proximity to the nursing station and providing a surveillance guide at the bedside, could not be implemented uniformly, and less than a fifth hospitals allocated to the intervention group delivered all five components of the enhanced postoperative surveillance package to patients at high risk.

An implementation science approach is essential in resource-limited settings to leverage effective, novel solutions that work under resource variability. Implementation challenges tend to fall into five concrete categories: the specifics of the intervention; material, intellectual, and administrative support for implementation; the knowledge and behaviours required to enact change; the measurement, oversight, and feedback mechanisms to identify progress; and how interventions are systematised...

This study, powerful in its breadth and scope, should serve as a wakeup call for clinicians and investigators interested in improving surgical safety and quality.,,


Neil Pakenham-Walsh, HIFA Coordinator,