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