The scale of the unimplemented backlog is striking. Between 2008 and 2016, the Colombian Ministry of Health funded the development of 58 national clinical practice guidelines, produced to high methodological standards and drawing on the research capacity of universities, hospitals, professional societies and patient organizations. Those guidelines collectively contain 3,887 individual recommendations, but implementation remains in its early stages. The researchers attribute the shortfall to the sheer number of recommendations, limited stakeholder experience in implementation science, and a wide range of practical barriers that have never been systematically mapped for Colombian decision-makers.

To decide where to focus, the team engaged representatives of the Colombian Ministry of Health in structured dialogues about which recommendations deserved priority. Using a previously developed visualization tool that ranks pending recommendations, the group selected two clinical areas judged to have significant potential impact on health outcomes, provider experience and health system resources. The first concerned the management of ST-elevation myocardial infarction, the most dangerous form of heart attack, specifically the provision of early fibrinolysis when primary percutaneous coronary intervention cannot be delivered within the recommended time windows. The second concerned rehabilitation services for people with limb amputations, a population that in Colombia includes thousands of victims of antipersonnel landmines left by decades of armed conflict.

The clinical stakes of the first brief are considerable. Early fibrinolysis, the administration of clot-dissolving drugs, is the recommended coronary reperfusion option for patients with ST-elevation myocardial infarction who cannot reach a facility capable of primary percutaneous coronary intervention within 12 hours of symptom onset, or who cannot obtain medical assistance within 90 minutes. The intervention reduces the risk of death and reinfarction by up to 20 percent and improves mid- and long-term outcomes. Given the low availability of catheterization laboratories across Colombia, the country’s challenging geography, and persistent barriers to coronary care, the authors argue that early fibrinolysis may be the best reperfusion option for most Colombian heart attack patients. Between 2011 and 2019, the country recorded 288,169 deaths from myocardial infarction, yet no Colombian study has quantified how many patients lack access to the therapy.

Using the SUPPORT methodology for evidence-informed policymaking, the researchers systematically searched PubMed, Health Systems Evidence and five additional databases, together with grey literature, between February and May 2021. For the fibrinolysis brief, 271 records were screened and 33 studies were included, spanning 48 countries across low-, middle- and high-income settings. Twenty-one of those studies addressed barriers to implementation, ten addressed facilitators and twenty-five described strategies for overcoming obstacles. For the rehabilitation brief, 573 records were screened and 45 studies were included, with 23 studies addressing strategies for adherence to policy recommendations in low- and middle-income countries and 23 covering comprehensive care and continuity of rehabilitation services. Quality was appraised with tools matched to study design, including AMSTAR II for systematic reviews, AGREE GRS for guidelines and Joanna Briggs Institute checklists for other designs.

The barriers identified in the fibrinolysis brief operate at three levels. At the patient level, delayed consultation driven by poor recognition of heart attack symptoms accounts for roughly two-thirds of delays in receiving reperfusion, and low socioeconomic status, low educational attainment, rural residence, transportation difficulties and lack of insurance all reduce access to treatment. At the provider level, clinicians struggle with lengthy guidelines poorly adapted to local contexts, and many lack the training and confidence to interpret electrocardiograms and administer fibrinolytic therapy, a problem especially acute among general practitioners in rural areas where no cardiologist is available. At the system level, the brief documents fragmented care, administrative delays tied to insurance, scarce human resources and equipment, high costs of fibrin-specific drugs, weak audit and feedback mechanisms, and insufficient funding and priority setting for noncommunicable diseases.

The most consequential strategy to emerge from the evidence is the establishment of regional coronary care networks that integrate community facilities with highly complex hospitals along predetermined reperfusion pathways. Such networks, which have driven improvements in countries from Canada to Egypt to India, allow timely fibrinolysis in peripheral settings while opening a 24-hour window for referral to a percutaneous intervention centre for pharmaco-invasive therapy. Complementary strategies include public education campaigns on symptom recognition delivered through mass media and text messaging, training programs for prehospital and hospital staff, quality monitoring between institutions, government-covered insurance for heart attack care, and investment in health information systems that enable reliable audit and feedback.

The rehabilitation brief tells a parallel story of systemic failure. Colombia’s armed conflict has left 8,451 people amputated by antipersonnel mines between 1990 and July 2021, and the World Health Organization and United Nations have both called on member states to strengthen rehabilitation services. Yet preliminary Colombian data cited in the study reveal the depth of the access problem: among 85 individuals with amputations studied in ongoing research, prostheses were prescribed for only 15 patients, or 17.6 percent, and just 3 patients, or 3.5 percent, actually received one. The average wait between amputation and prosthesis prescription was 147 days, and the interval between amputation and delivery of the device ranged from four to eight months. Barriers include inadequate funding, fragmentation in which each rehabilitation intervention occurs in a different location, deficient information systems, and insufficient training among health workers in amputee care.

The evidence points to concrete remedies. Telehealth, telerehabilitation and tele-education programs were accepted by patients and improved follow-up, knowledge and outcomes, an important finding for rural populations far from rehabilitation centres, and trials in other chronic conditions suggest telerehabilitation is not inferior to in-person care. Home-based training by community volunteers improved independence, mobility and social integration, while structured programs with clear goals and feedback improved the rehabilitation experience. At the provider level, multidisciplinary teams, better care pathways and economic incentives reduced major amputations and improved service delivery. One review found that patients who received prostheses were more likely to receive extensive outpatient therapy and experienced fewer hospitalizations and emergency visits.

The unifying conclusion of both briefs is that Colombia’s implementation challenge is fundamentally one of access, continuity and coordination. Nineteen percent of Colombians live in rural areas and nearly 40 percent of the rural population lives in poverty, making strategies that improve timely access for rural and low-income communities essential. The authors conclude that networks integrating community facilities and hospitals, with clear healthcare pathways that help patients navigate the system and clarify each stakeholder’s role, could positively and significantly affect outcomes and care experience for both heart attack patients and amputees. They also emphasize that the education sector is central, since building the knowledge and skills of both patients and providers is a precondition for any of these reforms. As a methodological contribution, the study demonstrates that evidence briefs, though less rigorous than formal systematic reviews, are a practical tool for translating a backlog of 3,887 dormant recommendations into prioritized, actionable implementation plans.

Subject of Research: Development of evidence briefs to support implementation planning for early fibrinolysis in myocardial infarction and rehabilitation services for amputee patients in Colombia

Article Title: Using evidence briefs to support future implementation planning: the case of early fibrinolysis for myocardial infarction and rehabilitation for the amputee patient in Colombia

Article References: Vélez, M., Vélez-Marín, V., Lugo-Agudelo, L. H., Patiño Lugo, D. F., Velásquez-Salazar, P., Mesa Franco, L. F., Vera-Giraldo, C. Y., Velásquez-Correa, J. C., Fahim, C., Marten, R., Yangchen, S., & Straus, S. (2026). Using evidence briefs to support future implementation planning: the case of early fibrinolysis for myocardial infarction and rehabilitation for the amputee patient in Colombia. Health Research Policy and Systems, 24(S1), Article 70. https://doi.org/10.1186/s12961-026-01466-5

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01466-5

Keywords: evidence briefs, implementation science, clinical practice guidelines, early fibrinolysis, ST-elevation myocardial infarction, rehabilitation, amputee care, Colombia, health policy, coronary care networks, telerehabilitation, health systems

The editorial introducing the special issue, authored by Seraphine Zeitouny, Christine Fahim, Robert Marten and colleagues, sets out the rationale with unusual candour. Health guidelines have traditionally concentrated on clinical practice and service delivery, but there is growing recognition that the most consequential guidance now addresses structural and policy-level challenges: governance, financing, and the organization of care across whole systems. When such guidance is integrated into policy and practice, studies have linked it to significant improvements in health outcomes for target populations, and effective implementation is widely seen as critical for strengthening health systems and advancing the Sustainable Development Goals. Yet empirical knowledge about the factors shaping the adaptation and implementation of health system recommendations remains thin, particularly in low- and middle-income countries, where most of the world’s population receives care. The new studies are an attempt to fill that evidence gap with real-world, policy-relevant data rather than theoretical frameworks alone.

Colombia offers the most systematic case. Researchers led by Claudia Marcela Velez at the Universidad de Antioquia analysed the country’s implementation of clinical practice guidelines alongside thirteen World Health Organization health systems guidelines covering governance, financial and delivery arrangements. Through document analysis, the team identified access to care as the single largest obstacle to effective implementation. Even where guidelines explicitly endorsed approved and publicly funded technologies and services, those resources remained inaccessible or unavailable to significant segments of the population, especially people living in rural areas or on low incomes. The finding is a blunt reminder that a recommendation on paper is not the same as a service on the ground, and that equity gaps can persist even when policy language promises universal access.

The Colombian team then moved from diagnosis to action. Working with the country’s Ministry of Health, the researchers prioritized two groups of health system recommendations for implementation and, using the SUPPORT methodology’s systematic process for searching and synthesizing evidence, developed evidence briefs to inform planning. The first brief addressed early fibrinolysis for patients with ST-elevation myocardial infarction, a time-critical intervention for heart attacks. The second examined rehabilitation services for patients with amputations, where the brief highlighted the urgent need to improve timely access, particularly for people in rural areas and low-income settings. Barriers included patient sociodemographic characteristics and a scarcity of trained clinicians. Notably, the analysis suggested that establishing integrated healthcare networks linking community facilities with hospitals could be a promising strategy for improving both health outcomes and patient experiences, offering a concrete structural remedy rather than a vague exhortation to do better.

In Ghana, Samuel Adjorlolo of the University of Ghana and colleagues turned their attention to home visits, a foundational but often invisible component of primary healthcare. Studying practice in a rural-urban setting in the Greater Accra region, they documented the challenges nurses and other health professionals face when delivering care to people in their homes. The obstacles were mundane but debilitating: transportation difficulties, poor road infrastructure, fragmented residential address systems that make it hard to locate households, a lack of basic logistics such as home visit bags and essential medical tools, inadequate financing, and sociocultural practices that complicate service delivery. These are barriers familiar across many low- and middle-income countries, and their persistence undermines one of primary care’s most valuable functions. In developing and piloting future home visit guidelines, the team proposed multifaceted measures including targeted training, allocation of human and financial resources, and provision of safety and security measures for both male and female staff, recognizing that workforce protection is a precondition for community-based care.

Nigeria’s contribution tackles one of the most topical questions in global health: how to adapt guidance on digital health interventions without losing its universal applicability. Abiodun Olugbenga Adewuya of Lagos State University College of Medicine and colleagues contextualized the World Health Organization’s 2019 guideline recommendations on digital interventions for health system strengthening to the specific needs of mental health services in Lagos State. They then piloted implementation across five randomly selected primary care centres, assessing perceived effectiveness, acceptability, appropriateness and feasibility among clients, health workers, mental health professionals and health managers, while also measuring readiness for implementation change. The results were instructive in their nuance. Recommendations such as drug stock notifications, health worker supervision and targeted client communication appeared effective and feasible for strengthening digital mental health services. But health workers expressed reservations about client-to-provider communication and clinical decision support, revealing that stakeholders’ readiness to accept changes varies considerably even within a single health system. The study underscores a key tension in guideline adaptation: the balance between preserving the integrity of evidence-based recommendations and reshaping them to fit local needs.

Zambia’s case demonstrates how implementation science frameworks can be applied to epidemic control. Chanda Mwamba of the Centre for Infectious Disease Research in Zambia and colleagues evaluated the country’s multi-sectoral cholera elimination plan using the knowledge-to-action framework, a widely cited model for translating research into practice. Following a comprehensive review of the plan and engagement with key stakeholders, their analysis found that appointing a coordinator and establishing technical working groups enhanced coordination and strengthened the case for increased investment. Yet implementation remained fragmented by slow institutionalization, weak coordination, inadequate funding and poor infrastructure. The authors argued that commitment from all stakeholders, genuine political will and dedicated funding could help eliminate cholera, and they recommended developing a collaborative, multi-sectoral strategy rooted in national guidelines and policies to empower communities in eradication efforts. The message is that global elimination targets depend less on new science than on the unglamorous machinery of coordination and finance.

Running beneath the country studies was an explicit investment in research capacity itself. Christine Fahim of the Knowledge Translation Program at St. Michael’s Hospital-Unity Health Toronto and colleagues described the implementation and evaluation of a technical support program designed to strengthen the RAISE teams’ ability to conduct guideline adaptation and implementation research. The program used an integrated knowledge translation approach, emphasizing a user-driven model in which study teams determined their own priorities and support needs. Its components included an in-person capacity-strengthening workshop, personalized coaching sessions with methods experts, and a virtual ecosystem of webinars, discussion boards and workshops. Teams rated the program highly and identified significant barriers impeding guideline work: conflicting health system and stakeholder interests, scarcity of available data, inadequate equipment for data collection, and limited capacity and knowledge. They also identified enablers, including forging partnerships with health system stakeholders at a project’s inception, employing multi-sectoral approaches to implementation, and investing in the competencies of implementation teams.

Taken together, the studies converge on several lessons that the editorial authors argue should reshape how guidelines are produced and used. Engagement with policymakers, beginning at project initiation and continuing throughout the research process, emerged as a decisive factor regardless of the guideline’s focus area. Effective implementation requires contextualization through early and meaningful stakeholder engagement, and the research repeatedly encountered the same structural barriers: limited resources and contested resource allocation, weak coordination, and inadequate infrastructure. Facilitators were equally consistent, including the use of evidence briefs to translate recommendations into policy-ready formats, appraisal of international guidelines to ensure local adaptability, and user-driven capacity building. Multi-sectoral governance and collaboration surfaced as essential ingredients in every setting studied, from cholera control in Zambia to digital mental health in Nigeria. Many teams also called for sustained efforts to strengthen research capacity and to synthesize insights from diverse user perspectives, recognizing that one-off projects rarely change systems on their own.

The implications reach well beyond the six countries involved. As health systems worldwide grapple with pandemic preparedness, aging populations and the integration of digital tools, the demand for guidance that actually functions in resource-constrained environments will only intensify. The RAISE findings point toward a future research agenda built on co-creation and co-production with policymakers, sustained partnerships rather than transactional consultations, strengthened implementation capacity, and genuinely multi-sectoral support for guideline adoption. They also highlight a growing recognition that health policy and systems research itself needs capacity strengthening, so that the countries facing the toughest implementation challenges are equipped to generate, adapt and apply the evidence they need. Guidelines, the special issue ultimately argues, are essential tools, but their effectiveness depends entirely on context-specific integration into policies and practices, collaborative multidisciplinary approaches, and the willingness to treat adaptation not as an afterthought but as the core of the scientific enterprise.

Subject of Research: Adaptation and implementation of health systems guidelines in low- and middle-income countries

Article Title: Adapting and implementing health systems guidelines: learning lessons from countries

Article References: Zeitouny, S., Fahim, C., Adewuya, A. O., Adjorlolo, S., Mwamba, C., Velez, C. M., Straus, S. E., & Marten, R. (2026). Adapting and implementing health systems guidelines: learning lessons from countries. Health Research Policy and Systems, 24(S1), Article 69. https://doi.org/10.1186/s12961-026-01460-x

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01460-x

Keywords: health systems guidelines, guideline adaptation, guideline implementation, RAISE initiative, Alliance for Health Policy and Systems Research, low- and middle-income countries, knowledge translation, health policy, digital health interventions, health systems strengthening, evidence briefs, capacity strengthening