The problem the initiative set out to address is structural. Health policy and systems research is an interdisciplinary field focused on how health systems shape and implement policy, and it is considered critical to achieving the United Nations Sustainable Development Goals. Unlike clinical practice guidelines, which target care for individual patients, health systems guidelines aim to improve the efficiency, equity and quality of care across an entire system. Yet there is a persistent gap in the availability and quality of such guidelines designed within low- and middle-income countries. As a result, health system stakeholders in these settings often rely on guidelines produced by the World Health Organization or by high-income countries — documents that are frequently not adapted to local needs, contexts or political realities, and that often clash with the priorities of the policymakers expected to implement them.

To close this gap, the WHO Alliance for Health Policy and Systems Research funded six research teams from Colombia, Ghana, India, Mozambique, Nigeria and Zambia through the RAISE portfolio. Each team was required to partner with at least one policymaker or knowledge user — someone positioned to use research results to make informed decisions — to support the practical uptake of the guidelines. The projects were strikingly diverse: home visit guidelines in Ghana, prioritization of WHO guidelines in Colombia, antenatal care guidelines in tribal communities in India, cholera control guidelines in Zambia, a WHO digital intervention guideline for mental health system strengthening in Nigeria, and guidelines to reduce primary care waiting times in Mozambique. Selection followed a rigorous peer review process in which 21 eligible proposals out of 27 submissions were scored by 16 reviewers on team qualifications, methods quality, engagement strategy, impact potential, innovation, feasibility and value for money, with scores ranging from 45.00 to 90.67 before an international adjudication panel made the final choices.

Following a competitive process, the Alliance selected the Knowledge Translation Program at St. Michael’s Hospital–Unity Health Toronto, in partnership with the South African Cochrane Centre and the WHO Ethiopia country office, to act as the Technical Support Centre. Crucially, the centre’s approach was rooted in integrated knowledge translation, a methodology in which the knowledge users themselves — the RAISE researchers, trainees and policymakers — were engaged in designing the content and delivery of the support program. This matters because integrated knowledge translation is known to improve buy-in, increase evidence uptake and reduce research waste. It stands in deliberate contrast to the one-size-fits-all or so-called blueprint models that have dominated past capacity-strengthening efforts, which systematic reviews suggest are often driven by high-income country actors pursuing their own spotlight topics rather than the priorities identified by LMIC actors themselves.

The design process began with a needs assessment. In August 2019, 22 participants from the six countries — 10 men and 12 women, including seven principal investigators, six co-investigators, two knowledge users and six research staff — completed a survey with a 63 percent response rate. All teams reported difficulty identifying their specific methods needs before their projects had begun, but six teams requested rigorous training in evidence-based implementation methods, with additional requests covering barrier and facilitator assessments, stakeholder engagement and qualitative analysis. The resulting program had several components: a mandatory three-day in-person inception workshop in Istanbul, Turkey in September 2019; seven pre-recorded webinars delivered between November 2019 and January 2021 through the Canvas online learning platform; online discussion boards; virtual workshops held from April to July 2021 after the COVID-19 pandemic forced the cancellation of planned in-country visits; and ongoing one-to-one coaching calls and email support from methods experts.

The inception workshop covered the full methodological arc of guideline work: introduction to knowledge translation and health policy and systems research, identifying health system gaps, appraising guideline quality using established tools, prioritizing recommendations through Delphi processes, adapting guidelines, mapping barriers and enablers to implementation strategies, and evaluating implementation quality alongside ethical considerations. Participants rated the workshop a mean 6.30 out of 7, praising the quality and applicability of the content and the opportunity to collaborate across teams. The webinars were also well received, rated between 4 and 5 out of 5, with the session on the AGREE II approach to guideline development, evaluation and adaptation drawing the highest engagement. The on-demand format proved essential for teams working across time zones and, as it turned out, through a pandemic.

The evaluation used a mixed-methods design across three phases, applying the Durlak and Dupre process evaluation framework, validated self-efficacy surveys administered at baseline, 12 and 24 months, and semi-structured exit interviews coded thematically with inter-rater reliability checks. The headline quantitative finding was encouraging but nuanced: mean scores for eight of nine research capacity outcomes improved over time, and the improvement in researchers’ ability to develop evidence-based knowledge translation interventions reached statistical significance between 12 and 24 months (Z = −2.93, p < 0.05). The absence of significant change in the other outcomes was attributed to relatively high baseline scores, the small sample size, staff turnover and pandemic-related disruptions to participation. Twenty-one participants responded at baseline, eleven at 12 months and fourteen at 24 months, with only five completing all three time points — an attrition pattern the authors acknowledge as a limitation that may have introduced response bias.

The qualitative findings may prove the most valuable for the field. Teams identified consistent barriers to adapting and implementing health systems guidelines: competing health system structures and stakeholder interests, lack of available data, poorly maintained field equipment for data collection, and insufficient training among staff tasked with implementation. The COVID-19 pandemic compounded these with project delays, reduced human resources, difficulty engaging stakeholders virtually and community fears that study personnel might spread the virus. Yet the enablers the teams identified form a practical playbook. Partnering with health system stakeholders at project inception rather than at study end sustained engagement and buy-in throughout. Employing a multi-sectoral approach that reached beyond the health sector, allocating financial resources for data collection and partnership strengthening, adopting rapid analysis methods to keep qualitative work moving, and building the competencies of the implementation team — a role the Technical Support Centre itself played — all helped projects survive and, in many cases, thrive.

Participants were candid about the program’s friction points as well. Some felt overwhelmed by the sheer number of supports and activities, struggling to balance capacity-strengthening sessions with actual research implementation. Quarterly monitoring templates were seen as helpful for accountability but time-consuming and repetitive. Knowledge user participation in the evaluation was limited by turnover, heavy workloads and pandemic constraints, and internet connectivity varied enough by country that on-demand resources were not equally accessible — page view statistics likely undercount viewership because teams downloaded webinars and watched them together offline. These honest appraisals are part of what makes the study useful: it documents not just what worked but where the model strained.

The authors conclude that the Technical Support Centre offers a replicable model for supporting health policy and systems research capacity in LMICs, with three defining features: a user-driven approach that lets stakeholders determine priorities and activities, flexibility to adapt supports as needs evolve, and multi-modal delivery that extended benefits beyond the core teams to their networks, trainees and associated institutions. Participants recommended sustaining the network of RAISE teams and connecting WHO regional and in-country offices to keep the collaboration alive. As health systems worldwide continue to grapple with pandemic aftershocks and competing priorities, the study’s central lesson resonates well beyond its six countries: capacity strengthening works best when it is not something done to researchers in low- and middle-income countries, but something built with them, on their terms, from the very beginning.

Subject of Research: Implementation and evaluation of a technical support center for health systems guideline research capacity strengthening in low- and middle-income countries

Article Title: Implementation and evaluation of a technical support center for the Research to Enhance the Adaptation and Implementation of Health Systems Guidelines in LMICs [RAISE] initiative

Article References: Fahim, C., Pratt, J., Purewal, A., Marsot-Shiffman, L., de Launay, K. Q., Baddeliyanage, R., Davenport-Huyer, L., Yangchen, S., Gebregiorgis, A. H., Wiysonge, C. S., Tricco, A. C., Puchalski-Ritchie, L., Pham, B., Tuncalp, O., Langlois, E. V., Marten, R., & Straus, S. E. (2026). Implementation and evaluation of a technical support center for the Research to Enhance the Adaptation and Implementation of Health Systems Guidelines in LMICs [RAISE] initiative. Health Research Policy and Systems, 24(S1), Article 73. https://doi.org/10.1186/s12961-026-01462-9

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01462-9

Keywords: health policy and systems research, capacity strengthening, LMICs, knowledge translation, guideline adaptation, implementation research, WHO Alliance for HPSR, RAISE initiative, technical support centre, integrated knowledge translation, health systems guidelines, COVID-19

The guideline in question is the WHO Guideline: recommendations on digital interventions for health system strengthening, known as WHO-GRDI. Released in 2019, it distils the global evidence on nine categories of digital health intervention, from birth and death notification and drug stock management to telemedicine, targeted client communication, patient tracking, health worker decision support and digital training. The problem, the researchers argue, is that guidelines like this are written for the world in general, not for any particular health system in particular. In countries where electricity is unreliable, networks drop and health workers are already stretched thin, an unadapted guideline can sit on a shelf. Guideline adaptation — a systematic, participatory process that preserves the integrity of the original recommendations while customising them for local laws, resources and culture — is widely seen as a faster and cheaper alternative to developing new guidelines from scratch, yet detailed accounts of how to do it for mental health systems have been scarce.

The team structured the entire project around the Knowledge to Action cycle, a widely used implementation science framework that moves from identifying a problem, through adapting knowledge to local context, to implementing, monitoring and sustaining change. Lagos was a deliberately pragmatic choice. The state already runs the Mental Health in Primary Care programme, or MeHPriC, which operationalises the WHO’s mhGAP strategy in 57 designated flagship primary health centres, each staffed with doctors, nurses, midwives, community health extension workers, pharmacy technicians and counsellors. MeHPriC had already demonstrated clinical and cost-effectiveness in treating depression, anxiety, substance use disorders and epilepsy, but its processes were largely manual, with only scattered use of SMS messages, WhatsApp and emergency phone lines.

The project unfolded in four phases: planning, adaptation, implementation and evaluation. In the planning phase, the researchers established a Local Steering Committee of project members and independent local experts in digital intervention, guideline development, programme implementation and qualitative research, alongside a separate Stakeholders’ Forum drawing in psychiatrists, psychologists, primary care workers, technology providers, policymakers and nongovernmental organisations. Early dissemination through existing unions of nurses, midwives, community health workers and general practitioners helped secure cooperation from the outset. Ethics approval came from both the Lagos State University Teaching Hospital and the WHO itself.

The adaptation phase began with a hard-nosed assessment of whether Lagos was even ready. The team reviewed Nigeria’s mental health law, national mental health policy, task-shifting policy and National Health ICT Strategic Framework, and mapped existing digital health projects through the WHO’s Digital Health Atlas and a Nigerian digital health dashboard. The connectivity picture was surprisingly strong: by August 2021 Nigeria had more than 188 million active mobile lines, over 140 million people accessing the internet by phone, 48 percent broadband penetration and a call setup success rate of 98.9 percent. Notably, of 12 reviewed digital health projects in Nigeria, none focused on mental health — confirming the unmet need. Five independent raters then appraised the WHO-GRDI itself using the AGREE-II instrument, the international standard for guideline quality, scoring it 79.3 percent overall, with particularly strong marks for editorial independence and clarity. An 11-member Contextualization and Adaptation Panel of mental health specialists, primary care experts, policymakers, technology providers and linguists then worked through multiple rounds of structured feedback and formal consensus to produce a locally tailored draft, which was externally reviewed by professional bodies and 60 consulted stakeholders.

The adapted guideline emerged with eight rather than nine recommendations. Birth and death notification were merged into a single recommendation, since Lagos facilities record live deliveries, stillbirths and deaths with the same staff and systems. The word telemedicine was dropped entirely as ambiguous to local workers, and health worker decision support was relabelled clinical decision support. During planning workshops, stakeholders used the Theoretical Domains Framework to surface barriers and facilitators, then ranked the recommendations using a modified Delphi technique. Five were judged feasible for a pilot within the project’s timeline: drug stock notification, client-to-health-provider communication, health worker supervision and communication, targeted client communication and clinical decision support. The rest were set aside for want of infrastructure or priority.

The pilot itself ran for three months in five randomly selected flagship primary health centres, one from each administrative district. In each clinic, 11 health workers already involved in MeHPriC received mobile phones or tablets preloaded with project materials, and 55 health workers plus five supervising mental health specialists were trained over two weeks. Evaluation used validated implementation science instruments: the Acceptability of Intervention Measure, Intervention Appropriateness Measure and Feasibility of Intervention Measure, each scored on five-point Likert scales, supplemented by a perceived effectiveness rating and the 12-item Organizational Readiness for Implementing Change scale completed by health workers and managers. Altogether, 150 clients, 50 health workers, a five-member mental health team and five health managers participated in the assessment.

The headline results were encouraging. Recommendations on drug stock notification, health worker supervision and communication, and targeted client communication scored high across the board — perceived effectiveness between 80.0 and 92.0 percent, acceptability between 80.5 and 91.0 percent, appropriateness between 84.0 and 90.0 percent and feasibility between 81.0 and 90.0 percent. Organizational readiness was uniformly high, with a mean ORIC score of 55.62 out of 60, and no significant difference between frontline workers and managers. But two recommendations fell short. Client-to-health-provider communication scored between 65.6 and 73.4 percent, and clinical decision support between 78.0 and 79.0 percent on acceptability and effectiveness. The qualitative data explain why. Workers felt that emergencies such as suicidal crises demand face-to-face contact, worried about guilt and clinical liability if a remote patient deteriorated, and resented unpaid work extending beyond their capacity. On decision support, many found the electronic mhGAP guide too prescriptive and felt that checking a device in front of a patient undermined the patient’s self-esteem and the therapeutic relationship. Practical complaints about electricity, network connectivity, device safety and the need for more training rounded out the concerns.

The authors draw three main lessons for anyone attempting similar work in a low- or middle-income country. First, robust stakeholder engagement before, during and after adaptation is essential, and existing professional networks are the most efficient conduit for it. Second, policymakers should ensure a digital strategy, supporting infrastructure, legislation, governance frameworks and training plans are in place before attempting implementation of guideline recommendations. Third, integrating new recommendations into an already functioning programme — as the team did with MeHPriC’s existing mobile phone backup — makes the manual-to-digital transition far smoother. The team has prepared evidence briefs for Lagos policymakers and plans continued policy dialogues. The study does carry limitations: Lagos is Nigeria’s most developed state, the pilot was short at three months, and not all WHO-GRDI recommendations were implemented. Still, the authors argue the work offers valuable information for adapting and implementing the WHO-GRDI and other health systems guidelines, and they call for further research embracing the views and experiences of end-users to understand the balance between the generalizability and local adaptability of health systems guidelines. An ongoing feasibility trial of the electronic mhGAP app in Nepal and Nigeria is expected to inform the next round of implementation decisions.

Subject of Research: Adaptation and pilot implementation of the WHO guideline on digital interventions for strengthening mental health systems in Lagos State, Nigeria

Article Title: Adaptation and pilot implementation of the WHO guideline on digital intervention to strengthen mental health systems in Lagos state, Nigeria

Article References: Adewuya, A. O., Abdulmalik, J., Abimbola, S., Oladipo, O. E., Dahiru, A., Shettima, F., Fasawe, A., Fahim, C., Marten, R., Yangchen, S., & Straus, S. (2026). Adaptation and pilot implementation of the WHO guideline on digital intervention to strengthen mental health systems in Lagos state, Nigeria. Health Research Policy and Systems, 24(S1), Article 74. https://doi.org/10.1186/s12961-026-01463-8

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01463-8

Keywords: WHO-GRDI, digital health, mental health systems, Nigeria, Lagos, guideline adaptation, implementation science, primary health care, mHealth, mhGAP, low- and middle-income countries, health policy

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