Discussion
We found that funders aimed to fund implementation research programmes that involved identifying strategies for local contextualisation of the intervention, with the larger goal of effecting policy change. Funders were supportive of programmes that considered the needs of both the population and the stakeholder while developing strategies for scale-up. Funders provided flexibility to plan research according to local needs by deliberately not specifying a definition for scale-up nor required research processes. The individual studies were diverse, comprising varied interventions for diabetes, hypertension, and cardiovascular diseases (CVD) control, and incorporated different prevention and control approaches. Furthermore, the research study plans involved multidisciplinary approaches.
The application of conceptual frameworks in project designs highlights the utility of models as a tool for guiding project thinking, planning and execution,34–37 and in helping to address strategies by systematically identifying factors that affect scale-up.38–41 This study findings highlighted how a combination of theories and frameworks from scaling-up, implementation, evaluation, and social and political science, were used to provide evidence for local contextualisation.
Implementation is the process of integrating an EBI within a setting,42 while scale-up refers to the process of making the intervention reach ‘more people’ and in a sustainable manner.15 16 While implementation and scale-up are similar in their aim to improve current practice and make sustainable changes, they differ in the scale and complexity involved in the change process.43 44 To address scale, implementation researchers must not only consider reaching more people but comprehensively address system level and contextual challenges which affect implementation and sustainability.
A major challenge to sustainability is the availability of research capacity in the implementing country, and building such capacity was central to this call. Local capacity helps ensure that research on programme maintenance is ongoing, extends knowledge of implementation research to other services/disciplines, and improves global equity in NCD-implementation research.44–49 Our study demonstrates that systematic planning and clear governance mechanisms promote reciprocal and collaborative learning. It is through the establishment of such processes that implementation research capacity can be built globally.
Our findings point to three issues concerning scale-up research for local contextualisation, implementation research capacity building, and equity that merit reflection, as outlined below.
Tight funding timelines for consultation and local contextualisation
A funding cycle of 3–5 years is a tight frame for collaborative research that includes genuine stakeholder consultation and codesign for scale-up studies. Current funding timeframes may need to be evaluated to reflect the complexities in undertaking such collaborative research. An alternative is to provide smaller funds to help codesign and test the feasibility of interventions or to develop research programmes with calls for different phases of implementation.
Programmes that promote collaborative efforts between researchers, practitioners, implementors and policy-makers can greatly assist regional, country and international NCD-related commitments and are critical in global health agendas.50–57 Such comprehensive consultation enables researchers to iteratively implement, monitor and evaluate the interventions to improve fit with local stakeholders’ needs.58–60 It is this need for research to be responsive to the contextual determinants of health that was referred to by the funders as being an essential component for this call. However, meaningful collaborative research including stakeholder engagement and consultation that genuinely addresses their needs through codesign and cocreation is a complex and time-consuming process.61–63
Beran et al discuss the challenges involved while conducting research for coproduction which include the need for multidisciplinary approaches, involvement of multiple stakeholders from the early stages and finding suitable research partners.61 Time and investments are essential to conducting collaborative research as are trusting relationships and established linkages. This engagement process often commences once funding is obtained, leaving little time to develop strong partnerships and trust to address the study’s aims. Funders may need to reconsider these time frames based on the complexities involved in conducting implementation research for true local adaptation.64 65
Accelerate global scale-up research capacity, equitably
It is crucial to have more funding opportunities that help build implementation research and scale-up research capacity at a global level. While the importance of developing and implementing locally adapted NCD interventions is essential, the funding of implementation research studies to support this process is underprioritised.10 66 Such funding calls helped bring a spotlight on the need to fund research as a means to improving health outcomes.
Implementation research equips policy-makers with the necessary local evidence that supports national and subnational policy implementation.10 67 The current scale of investments to develop implementation research is nowhere near what is necessary to support the actual processes globally.53 62 There is limited documented evidence of NCD scale-up experiences and the research processes required to support such work, research that is critical for supporting scale-up programmes. This scale-up call represented an investment of US$50 million. With recent estimates that most countries can meet NCD targets with a combined annual investment of US$18 billion annually from 2023 to 2030, this scale-up call comprises 0.28% of the required amount for 1 year.9 If implementation research can accelerate the scale-up of interventions at this stage more funding opportunities to grow scale-up research knowledge, such as that outlined in the GACD scale-up call are urgently required.53 68–70
Equity is an important consideration at all stages of undertaking scale-up research. Addressing equity within the research collaboration will ensure improved global implementation capacity, while developing more equitable funding criteria can empower in-country implementation researchers to support and grow research at a local level. Lead researchers in collaborative studies shoulder the responsibility of ensuring that equity is carefully considered during all stages of the investigation, from early planning to end stages such as publishing.71 Our study provided evidence that while most of the research documents included investigators from both HICs and LMICs listed as Co-PIs, only one-quarter of the funders who funded projects outside of their country were willing to consider a direct application from researchers in LMICs. Actual capacity building and empowerment begin when LMIC researchers can apply for grants directly as a lead researcher.69 72 This is an important consideration for future funding calls.
Improving cohesive action
Better networking between researchers, implementers and funders can facilitate and foster greater sharing of lessons learnt, improving understanding of scale-up research. One of the lessons that can be learnt from the success of large-scale HIV programmes in low-resource settings is the importance of developing a cohesive voice to influence policy priorities and improve international funding.73 74
Funders recognised the important role that joint calls have in aligning global funding priorities, and that the GACD secretariat have in providing extensive networking opportunities to build collaboration between funders, researchers and practitioners. The formal and informal scientific meetings and networking events promoted by the secretariat provide structures and processes crucial to cement relationships. These events encourage conversations, build global partnerships, promote sharing of research learnings and ultimately break down ‘siloed’ thinking. This exchange of ideas and collaborative thinking enables alignment of strategy development, builds advocacy and is essential to spotlight the need for more funding to improve NCD prevention and control.75 76
Strengths and limitations
This study involved the activities of the GACD upscaling working group, providing us the opportunity to examine 21 ongoing projects operating in different contexts. The breadth and applied nature of this work offers a unique grounding for analysis. Nevertheless, our study also has limitations. First, this paper has been written from the point of view of the researchers. Second, the findings rely on the documents shared with us by the study teams, which were diverse but uneven in their comprehensiveness across the studied projects. Third, as we captured these data during the planning phase, there may be some variation between the planning and implementation of the intervention that we have been unable to cover. This study was conducted in the postfunding and early implementation phase of these funded studies and coincides with the rise of COVID-19 pandemic. The study teams likely faced several COVID-19-related challenges in implementing the protocols which are not captured in this study. Further, we interviewed five of the eight funders, so we may have missed some relevant material from the remaining funders. Nevertheless, thanks to the broad reach of the projects studied, we believe the reported findings accurately capture the understanding of the participating NCD-related scale-up projects.