Unnecessary Caesarean Section (CS) can have adverse effects on women and their newborns. Assisted vaginal birth/delivery (AVB/AVD) using a suction device or obstetric forceps is a potential alternative when delays or complications occur in the second stage of labour. Unlike CS, AVB using a suction device does not require regional or general anaesthesia, can often be performed by midwives, and does not scar the uterus, lowering the risk of maternal mortality and morbidity, in this and subsequent pregnancies. This study examined the appropriateness and outcomes of second stage CS (SSCS), and reasons for low levels of AVB use, in Kenya. Using a mixed methods study design, we reviewed case notes from women having SSCS births and AVB, and conducted key informant interviews with healthcare providers, from 8 purposively selected hospitals in Kenya. Randomly selected SSCS and all AVB case notes were reviewed by a panel of four experienced obstetricians, and appropriateness of the procedure assessed. Semi-structured interviews were conducted with obstetricians, medical officers and midwives, and analysed using a thematic approach. Review of 67 SSCS case notes showed 10% might have been conducted as AVBs, with a further 58% unable to be classified due to inadequate/inconsistent record keeping or excessive delay following initial CS decision. Outcomes following SSCS showed perinatal mortality rate of 89.6/1,000 births, with 11% of infants and 9% of mothers experiencing complications. Non-referred cases of AVB showed good outcomes. The findings of the 20 interviews explored the experience and confidence of healthcare providers in performing AVBs, and adequacy of the training they received. Key reasons for non-performance included lack of functioning equipment, lack of trained staff or their rotation to other departments. Reasons for non-performance of AVB were complex and often multiple. Any solutions to these problems will need to address various local, regional and national issues. Globally, caesarean section (CS) rates continue to rise, with the procedure accounting for 21% of all births in 2021, an increase of 14% since 1990 . Whilst CS are associated with a maternal mortality rate of 10.9 per 1,000 procedures in sub-Saharan Africa compared to 0.3 per 1,000 procedures in LMIC in Europe and central Asia . EmergenBy contrast, in SSA, AVB was found to have taken place within the previous three months, in only 53% of 1728 hospitals and 6% of nearly 10,000 health centres surveyed  since the training of [county], but I’ve done many from when I left medical school, but we were using the old equipment, we were not using the Kiwi. The Kiwi one I’ve used on three patients or so. I’m quite competent actually, personally I am okay, only a bit of refresher then everything will fall in place.” “In-house training was reported in a few of the facilities, with accounts of continuing medical education (CME) sessions, where medical interns tended to present on theoretical aspects of a particular subject, with little or no opportunities to practice skills. Although these seemed to be open to all cadres, limited staffing levels meant that in practice staff were sometimes too busy to attend.During the routine facility assessments, the most common reason given for not performing AVB within a facility was a lack of patients for whom the intervention was indicated. However, this was rarely mentioned by interviewees, with the majority expressing that they thought more AVB should be performed. Several reasons were offered by respondents for not performing AVB, including a lack of functional equipment, insufficient staff, lack of knowledge, skill or confidence, lack of training and fear of complications.The lack of operational equipment was a recurring theme, expressed by the interviewees as a reason for not performing AVB. One of the difficulties described in these settings, was that the preferred device for performing AVB, the Kiwi obstetric suction cup device, is designed to be single-use. However, due the cost of replacements and difficulties in procuring new devices, they are often sterilised and re-used.We sterilize using high level disinfection and we reuse it… I think it can do up to 12 patients” “In some instances, though, this led to problems where the device was no longer functioning properly. On another occasion, an interviewee explained that problems with a dysfunctional device had led to a woman having to undergo a SSCS following a failed AVB, resulting in the loss of the baby.When asked about the use of obstetric forceps, most respondents said that they either did not have them in their facility or that they were not used. One medical officer stated that they had used them once and a consultant admitted that they had never been trained in their use.In two of the hospitals, the staff had requested replacement Kiwi devices, but they were not available, and they had been provided with Malmstrom vacuum extractors instead. Although these are reusable, they require two people to operate and were not favoured by the staff interviewed.The levels of staffing were discussed during the interviews, with almost all interviewees reporting inadequate levels. Interviewees commonly described 1–3 nurses on duty per shift with fewer at night than during the day. These nurses may have covered only the labour ward in the large County Referral Hospitals but in the smaller facilities, they were also expected to cover the antenatal and postnatal wards.This shortage of staff was exacerbated in some instances by the rotation of experienced staff to different departments, either as part of the normal medical training process or because of industrial strike action. The frequency of rotation varied from weekly to 6 monthly resulting in a lack of AVB trained staff.The problem we have is high turnover of the MOs, so the ones we are having currently, I think they are not trained.” “In one instance the rotation of non-specialist medical staff was reported as a reason for non-medically indicated CS, as the rotated doctor was more interested in practising their surgical skills.The combination of low overall staffing levels and the rotation of trained staff was also reported as leading to a lack of support and on-the-job training opportunities for less experienced colleagues.Instances were described where a shortage of MOs, lead to a lack of medical staff on duty at times, resulting in the referral of women who developed complications in the second stage of labour.So, at night it’s always nurses and if we find any difficulty we always refer.” “This was also raised as an issue by receiving facilities, where due to delays caused by the women being transferred from one facility to another (up to 2 hours or more), AVB was not even attempted but the patient was taken straight to the operating theatre for caesarean section.This mother has travelled all the way more than 2 hours during second stage, I don’t wait, because I know, I just go direct and section this mother.” “Another reported effect of low staffing levels was the impact of the quality of patient care. Where a small number of nurses were caring for multiple women in labour, adequate monitoring of interventions such as augmentation of labour with oxytocin infusion was not possible. This resulted in the infusion being stopped, poor progress with failure to reach full dilatation or inadequate contractions and consequently the woman having a CS.“You as a doctor might start the augmentation but then the nurses will stop it because they can’t just monitor. They will call you after four hours that the patient has not progressed…” Where inadequate staffing was experienced, a few healthcare providers described the management of workloads by the juggling of patient care between cadres. Doctors were described as wanting an AVB to be done by the nurse, to avoid them having to take the patient to theatre, whilst the nurse wanted the woman to have a CS so that she was one less patient of labour ward.Varying levels of self-confidence were expressed by study respondents. Some were highly confident whilst others were less so. Levels of confidence were sometimes linked to training received and opportunities to practice. Respondents explained that their lack of confidence stemmed from a lack of any training or refresher training in performing AVB. They thought that with the necessary training they would be able to perform the procedure.Confidence between colleagues was expressed as an issue by some respondents, with a few doctors conveying a lack of trust in some of the nurses’ ability to monitor the progress of labour whilst some of the nurses did not trust the doctors to perform an AVB when it was indicated.A few of the respondents also articulated concerns they perceived colleagues had about potential adverse outcomes relating to the use of AVB, predominantly related to adverse outcomes for the mother and baby, particularly where the procedure was applied inappropriately.The thing we fear with the AVDs is the haematoma that sometimes is associated and possible dangers of having brain injuries as you do the AVDs, and I think some of these fears are what many practitioners fear… If you follow the correct guidelines on who qualifies for AVDs nobody should fear.” “Two neonatal deaths were reported following AVB, possibly giving rise to some of the concerns, but it was difficult to determine whether these were because of inappropriate use of AVB itself or as a consequence of the labour complications which necessitated the AVB.Despite the provision of EmONC training, including AVB, in the project supported counties, routine programmatic data showed that the use of AVB remained very low. We reviewed a selection of SSCS and AVB case notes from the included healthcare facilities and found that 10% of SSCS births might have been carried out as AVB, potentially reducing the risk of complications and future morbidity for these women and infants following the procedures. We also found that, whilst many clinicians were in theory appreciative of the benefits of AVB, a complex array of factors impacted on their practice, including staffing, equipment and training.The number of cases in the group categorised as ‘AVB should have been attempted’  suggests that there are women undergoing unnecessary SSCS. If the cases where it was not possible to determine the appropriate method of birth (due to lack of information or delays) are excluded, the proportion becomes even higher n = 7/29, 24%). In this study, although there were complications following both SSCS and AVB, the small number of AVB performed made it impossible to compare the outcomes from the procedures statistically. Both of the AVB cases where complications occurred, may have been compromised due to the duration of referral following full dilatation and thus delays in actually performing the procedure. Furthermore, based on studies by Nolens et al , 24%. In, if SSCSThe qualitative findings from the study clearly demonstrated the complexity of the situations in which many doctors and nurses found themselves. Despite many clinicians expressing support for the performance of AVB, the data collected from the healthcare facilities did not demonstrate this in practice. The barriers to performing AVB described by the interviewees can be categorised at 3 levels, personal (confidence and practice), facility  and national (staffing and pre-registration training), illustrated in the conceptual diagram . These lThe lack of functioning basic equipment was reported as a barrier to the practice of AVB in some instances, and in line with the findings of research in other high, middle, and low-income countries ,23,24. SWe found the lack of performance of AVB was in several cases attributed to a lack of knowledge and skills on the part of the clinicians. This was related to a lack of basic training, not just in AVB, but also in the care and assessment of women in labour, although most of the interviewees had received some AVB training as part of the EmONC programme. Significant improvements in knowledge, skills and clinical practice following competency based EmOC training have been found , howeverWithin this study there also seemed to be a preference for external agencies to provide essential refresher training rather than senior staff within facilities taking a lead in this process, particularly the practical, skills-based aspects. This may have been for a number of reasons including lack of confidence or experience in senior member of staff who might also be reluctant to admit this. The prospect of receiving per diems  and an extended time away from the normal workplace, might all potentially have a bearing on it . The lacThe rotation of staff to different departments was commented on in several of the interviews in this study and is likely to contribute to difficulties for staff in consolidating newly acquired knowledge and skills, such as AVB. While these rotations may be necessary to manage the limited work force, a system is needed at hospital or district level, to ensure that those deployed to maternity wards are trained and competent to provide EmONC.Overall, the quality of medical record keeping was poor, with almost a third  of the cases included in the sample not containing enough information to categorise the appropriateness of the decision for CS. Poor record keeping is not however limited to this study. Similar results have been found in other studies in LMICs . The lacThis study obtained first-hand accounts from healthcare providers of different cadres, who worked clinically on labour wards, providing care for women giving birth. They included obstetricians, medical officers and nurses from eight of the highest volume healthcare facilities, in five counties, across different regions of Kenya. We acknowledge that conducting the interviews remotely might have impacted the findings of this study, although the precise impact is difficult to determine. It is possible that remote interviews gave respondents an enhanced sense of anonymity, and enabled a greater degree of honesty, but conversely face-to-face interviews might have resulted in interviewers building a stronger rapport with respondents. Although questioning healthcare professionals about women’s perceptions of AVB is not a substitute for asking the women themselves, it can give insight into the attitudes and beliefs of the staff who care for the women. Further research into the views of women who have given birth by AVB might provide a broader, first-hand perspective on community level acceptability of AVB, but the scarcity of procedure might make recruitment of sufficient participants difficult.Challenges in obtaining the notes for women who had SSCS resulted in a relatively small sample size for the case note review. In most healthcare facilities, a new set of hospital records was started for each pregnancy. Due to the way in which notes were filed it was not possible to reliably locate the SSCS cases, so it was necessary to retrieve a random selection of emergency CS and identify the SSCS cases at the review stage. Also, a major limiting factor in the interpretation of the SSCS and AVB cases was the quality of the record keeping, including incomplete or missing partographs, or important information on labour progress not recorded. This varied considerably between facilities and in some cases had a notable impact on the reviewers’ ability to assess the need for, and outcomes of, the procedures.An increase in the appropriate use of AVB could avoid unnecessary cases of SSCS and the associated mortality and short- and long-term morbidity, as well as resulting in more efficient use of scarce resources and greater job satisfaction. This study highlighted a variety of issues relating to the under-utilisation of AVB in emergency obstetric care facilities in Kenya. Challenges included the lack of functional equipment, and lack of confident, competent staff on duty in labour wards, within facilities. Other factors included a lack of pre-registration training on the use of AVB, together with inadequate refresher training on practical skills for AVB, for some staff, and the lack of practical leadership in some instances. The complexity of the situation means that there was no single, simple solution to the under-performance of AVB. Interventions to address the problem will need to be comprehensive and sustainable. They will need to address personal, facility-level, local community and national-level barriers, and promote a culture of AVB within facilities.Several of the findings from this study have implications for clinical practice and future research. It is anticipated that implementation of the following could improve clinical practice:Provision of a hand-held, vacuum-extraction device, designed to be reused, and distributed at a price that is affordable to resource-limited health systems.Improvements in family planning provision to avoid unwanted pregnancies.Regular, in-house refresher training and mentorship to help maintain knowledge and skills of all staff working in maternity departments.Avoiding the rotation of EmONC trained staff to non-maternity departments.The use of a pre-formatted, rubber stamp could provide a low cost means of increasing the quality of medical documentation and supported improvement of care quality through standards-based audits.Regular audits of case notes to improve clinical practice and record keeping.A prospective intervention study, that addresses health system challenges, and incorporating a package of evidence-based interventions, could improve the quality of record keeping, prevalence and outcomes of CS and AVB, as well as reducing the risk of adverse outcomes from unnecessary procedures.S1 Text(DOCX)Click here for additional data file.


The Hospital Safety Index is a tool developed by the World Health Organization and the Pan American Health Organization in 2008 and updated in 2015. Although it is the most widely used instrument of its kind to assess the level of hospital preparedness, scientific literature on its application in real life is scarce. This study aimed to investigate the use of the Hospital Safety Index to assess disaster preparedness in healthcare facilities. A retrospective, qualitative study employing semi-structured online interviews was conducted to gather the opinions and perspectives of professionals who have experience in applying the Hospital Safety Index. Authors of scientific publications using the Hospital Safety Index were recruited. A semi-structured interview guide was developed. It addressed different phases of data collection with the Hospital Safety Index, the challenges and facilitators of using it, and recommendations for future adaptations. Data were analysed using inductive thematic analysis. Nine participants who were from three countries  and had different professional backgrounds  participated in this study. A total of 5 themes and 15 subthemes emerged during data analysis. Most of the participants reported their reasons for choosing the Hospital Safety Index as being its comprehensiveness and the fact that it was issued by the World Health Organization. The tool appears to be very specific and allows investigators to spot details in hospitals; however, it is not easy to use, and training is highly encouraged to learn how to navigate the different components of the tool. Governmental support is a crucial facilitator for investigators to be able to enter hospitals and conduct their evaluations. Overall, the tool has a lot of potential, and it should be used to reach a broader audience, such as community members, and assess the preparedness of other facilities that can take part in the response to disasters . Nevertheless, it still needs more adaptations to be tailored to different contexts and settings. Over the last few decades, health systems have witnessed the effects of different types of disasters. As a result, disaster preparedness programs have evolved, adopting a more comprehensive, all-hazard approach . HealthcPreparing HFs for disasters has several benefits, such as the protection of lives; the enhancement of effective response and recovery, including continuity of care; the protection of investments; and the reduction in environmental impacts on the health sector . HoweverTo strengthen the disaster preparedness of HFs, tools and resources have been promoted that support the prioritization of interventions . In the Although it is estimated that the HSI has been used to assess the safety of more than 3500 facilities worldwide , scientiThis study aimed to explore how the HSI has been used to assess disaster preparedness in HFs around the world, understand the challenges and facilitators of its use, and suggest future adaptations for the tool. Specifically, the study aimed to answer the following research questions: How was the HSI used to assess disaster preparedness? What challenges and facilitators did evaluators encounter using the HSI? What future adaptations of the HSI do they recommend?A qualitative study employing semi-structured online interviews was conducted to collect the opinions and perspectives of professionals using the HSI to assess the disaster preparedness of HFs. This design was chosen because it can properly document the experiences of the users applying the HSI and because of the exploratory nature of the study ,22. The The criterion considered for the selection of participants was whether they had published a scientific paper using the HSI. A preliminary review of the literature was performed on Pubmed , using the keyword ‘Hospital Safety Index’. A list of 19 original research papers was retrieved. All of the authors from those papers were contacted via email and were provided with information on the study objective, methodology, and ethical implications. Upon confirmation, the researchers scheduled interviews with participants. Online interviews were conducted in English.An interview guide, made of leading and probing questions, was elaborated see . The guiInterviews were transcribed using Sonix software. The transcripts were manually screened and read multiple times for accuracy. Four researchers  prepared a list of potential codes, using inductive reasoning, after reading all the transcripts and extracting the most important topics addressed by the participants. The four lists were then compared and a unified codebook was devised to analyse interviews. The unified codebook was used to deductively code each of the transcripts, extracting significant quotes related to the generated codes. To ensure the consistency and reliability of the coding, at least three out of the four researchers were present for the coding of each transcript. A time of approximately three hours was allocated for the analysis of each interview. The analysis was conducted over the course of three weeks.The study was conducted according to the principles enunciated in the Declaration of Helsinki. All participants were required to provide oral informed consent prior to data collection. Sufficient details about the study aims and processes were provided at the beginning of each interview. The collected data were anonymized, and access to the data was restricted to the co-authors of this paper only. This study was ethically approved by the ethical committee of Habib Thameur Teaching Hospital, Tunisia, under the reference number HTHEC-2021-09.More than 40 potential participants from 5 countries  were identified; out of these, only 21 contacts were found, and those 21 people were invited by means of email. Nine participants (randomly re-named as A1-9) were accepted for recruitment into this study. A total of 5 themes and 15 subthemes emerged during data analysis. An overview of the demographics of the participants, alongside information about their research, is presented in Participants predominantly used the 2015 version of the HSI. Of these, five did not introduce any modifications to the original version. The distribution of HFs assessed with the HSI is shown in Most of the participants (6 out of 9) stated that the reasons for which they had chosen the HSI over other tools were twofold: it was issued by a trustworthy organization  and because of its comprehensiveness. Conversely, other participants reported that the HSI was recommended by their supervisors. Additional reasons for choosing the HSI over other instruments were its use in nearby countries, its availability in the local language, and its relevance to the researchers’ background and objectives.Investigating hospitals’ and public buildings’ disaster preparedness was the most mentioned purpose for using the HSI (5 out of 9). Additionally, respondents mentioned having used the HSI to test its appropriateness in a specific setting , to investigate the possible need for a hospital renovation, or to pursue hospital accreditation.Almost all participants (8 out of 9) stated that they performed a literature review to gain knowledge about the HSI, and 7 out of 9 participants formed a multidisciplinary team  and had peer discussions to analyse the tool in depth. Some participants conducted mock assessments under supervision, while others translated the measure into their local language to facilitate its utilisation.We took pictures. We went to the whole area of the building. We were literally going to every space within the building’ (A3). Seven out of nine participants conducted interviews with hospital staff to gain information about hospital safety. Interviews were mostly conducted in person, though some were conducted through mobile phones or an online platform. One participant adopted focus group discussions, while another one conducted additional interviews with individuals living around the hospital. Some authors used the HSI as a self-administered checklist for the hospital staff.The methods of data collection varied between participants. Visual inspection was the most common method of data collection reported by respondents: ‘‘HSI is a really good guideline, you can be in a hospital a hundred times, but when you have the guideline with you, you can actually see many invisible things that you didn’t see before’ (A2). Indeed, all participants agreed that being comprehensive and a user-friendly tool were the most important strengths of the HSI. Some participants stated that its flexibility (4 out of 9), ease of adaptability to different contexts (3 out of 9), conciseness, and cost-effectiveness (3 out of 9) were other considerable strengths. Further, 5 participants mentioned the easiness of analysis using the Excel calculator as an additional strength of the HSI assessment. you don’t see in HSI so much connection between the modules, you cannot understand how the characteristics of natural hazards that a building is prone to (in module 1), is related to elements of the other modules ’ (A1).Many participants (6 out of 9) highlighted that the HSI is tailored around the US context and might, therefore, be inadequate for non-US settings, given the different health systems and disaster profiles. According to some participants, the HSI is too detailed, and it relies too much on information collected from the staff. Other weaknesses identified by respondents were the non-applicability of the tool to all hazards (such as COVID-19), the inadequate grading system, and the discrepancies between the tool’s modules and the initial hazard assessment, as explained by one participant: ‘are afraid that if they have a low classification, it will alter their reputation’ (A7). Third was the unavailability of data/documents for preliminary review and the lack of similar research against which to compare results. Three main challenges before collecting data using the HSI were expressed by the participants. First, the lack of interest from the hospital staff in conducting the assessment. In the participants’ opinion, staff did not perceive the assessment of hospital safety as a priority. Second was the difficulty of obtaining necessary permissions to access the healthcare facility, since public hospitals ‘According to the participants, most challenges during data collection were related to the quality and accessibility of data. In fact, up-to-date data were either unavailable; inaccessible; considered confidential by hospital staff and, hence, not shared; or not properly archived. This made the task of collecting data even more challenging. At times, the data collection process was regarded as time-consuming because of the amount of data to be collected. Some challenges were related to the hospital staff—mainly due to their lack of availability to take part in the assessment and their lack of trust towards the research team. Lastly, some challenges were related to the healthcare facility. Participants mainly complained about restricted access to some parts of the building—a fact that sometimes made the data collection harder or even impossible.Once the hospital staff knows that this is under the purview of the ministry as well as the hospital directors, it is not that difficult to get the information’ (A4). A good example of governmental support was the use of the HSI for hospital accreditation in Indonesia. Raising awareness for the importance of such an assessment amongst the facility’s staff, gaining the trust of the hospital staff, having someone on the team who is a staff member, and the availability of the tool in the local language were mentioned as other facilitators for using the HSI. Many participants (7 out of 9) mentioned support via the endorsement of the government health authorities as a facilitator of the conduct of assessments using the HSI: ‘Many participants implemented changes to the HSI, either by removing or adding questions. For example, two participants reported that they removed non-applicable questions, while another participant added new questions related to the involvement of the community. Some participants used a different technique of data collection. While the HSI is a checklist to be filled in by evaluators, some participants (2 out of 9) used it as a self-administered questionnaire to be filled out by the hospital staff. Lastly, one participant preferred using R programming  to analyse data instead of the available Excel calculator. The HSI needs fine-tuning to the local conditions’. Similarly, other participants suggested adding elements regarding spatial data or staff preparedness. Many participants suggested having two different tools for public and private hospitals because of the differences they have in terms of governance and aims. Furthermore, improvements in the grading system of the HSI were also suggested: ‘Instead of just three grades, maybe we could have from zero to five or zero to ten’ (A2). Lastly, the use of new technologies in the assessment methods, such as a web-based tool or a mobile application, was suggested. Three participants stated that ‘Everyone who collects the data should be trained and have the same perception on how to collect the data’ (A5). Regarding the facility, participants recommended notifying the staff and asking for documentation beforehand, having good communication with the hospital and, having written consent from the hospital director. Lastly, considering the data collection process, participants suggested allowing plenty of time and using new technologies (such as smartphone apps) or, alternatively, combining interviews, document analysis, and field visits. Moreover, some participants suggested comparing results with other studies that used HSI. Participants’ suggestions addressed three elements: the team, the facility, and the data collection process. Regarding the team, participants suggested that researchers prepare their teams, either by creating a multidisciplinary team or by training data collectors: ‘Recommendation must be implemented. Otherwise, there is no point’ (A4). Moreover, some participants (3 out of 9) recommended conducting the HSI assessment periodically and organizing training sessions for the staff regarding the use of the tool.Participants suggested using the HSI as a guide to enhance the safety of the facility, rather than using the tool merely for assessment: ‘Elements concerning the use of HSI in PHC facilities emerged during some interviews. These elements touched on/revolved around the barriers and facilitators of the use of HSI in such facilities. Among the most relevant barriers, the lack of interest in studying PHC facilities was frequently mentioned, as well as the PHC staff’s lack of knowledge about many elements of the HSI. Additionally, some items in the HSI were not relevant to the PHC facility; thus, some participants decided to skip them. On the other hand, as a facilitator, the use of a medium/small version of the HSI was an option for adapting the tool to the PHC context.This study explored how the HSI has been used to assess disaster preparedness in HFs in different settings and countries, examined the challenges and facilitators of the use of the HSI, and formulated suggestions for future adaptations of the HSI. This work examined the methodological implications of using the HSI and provided practical recommendations to enhance its use. The main findings of this study represent the perspectives of nine participants using different versions of the HSI in different types of facilities.The HSI proved to be the first choice for assessing hospital disaster preparedness, complementing the findings of Heidaranlu et al. . This isAmong the most prominent obstacles is the difficulty for researchers to receive approval for conducting assessments of disaster preparedness in hospitals. This is not related to the HSI itself, but rather, it results from the scarce awareness of the importance of disaster preparedness among hospital staff and management boards. It is interesting to note that, in countries where the HSI is used to obtain hospital accreditation, this type of assessment is easier. This indicates that a national hospital accreditation system that considers hospital safety could facilitate the use of the HSI and, thus, increase the chances of hospitals measuring their preparedness level and possibly acting upon it .Hospitals are known to be complex systems that play many roles, such as providing health care, laboratory analysis services, hotel services  and maintaining their buildings . Some of the study’s participants noted this complexity as a challenge. Indeed, it has been demonstrated that the complexity of hospitals in the United Kingdom has adversely affected their ability to respond to emergencies, such as COVID-19, and has made it more challenging to gauge their level of preparedness ,27,28,29It is noteworthy that all interviewees involved in the current study used the HSI as a tool to meet specific security standards or for accreditation purposes rather than to monitor HF preparedness levels and safety. It is, thus, necessary to increase awareness of the importance of monitoring preparedness via the HSI as well as the benefits that are derived from this among healthcare workers, health managers, and public health experts. This can be done by educating healthcare professionals on the basic principles of disaster medicine and disaster management, promoting the use of the HSI via workshops and webinars, and advocating for institutional pressure on hospital safety, considering the projected increase of disasters in the future ,31,32.Overall, the need for effective and evidence-based training of healthcare personnel at all levels, including the development of standards and guidelines for training in multidisciplinary health responses to major events, has been identified as a priority by the disaster response community. Despite training and education being considered integral, findings demonstrated that they were not yet standardized ,34,35. On a positive note, the WHO, and its regional offices, particularly the East Mediterranean and Europe Regional Offices, collaborated to train local assessors on how to use the HSI. Numerous assessors have emerged because of these activities, many of whom have developed strategic plans to carry out national assessments, thus indicating significant interest in the tool’s adoption by nations and regions. In addition, the Disaster Risk Reduction (DRR) community is increasingly considering hospital preparedness by developing new tools and frameworks, such as the CADRI tool. By doing so, this community is bringing a new perspective of hospital sustainability into hospital preparedness for disasters, and it is being given more and more consideration ,37,38,39Another important finding concerns the lack of space for cultural considerations in the HSI. Findings highlighted how some participants had to adapt the tool to their cultural context and country-specific disaster profile to perform a meaningful assessment. This is relevant considering the different types of health systems and facilities worldwide, as well as different disaster profiles. Moreover, of relevance is the fact that hospitals take on different forms in different societies, constituting a space where core cultural values come into view . It follFollowing a bottom-up approach in assessing disaster preparedness, some respondents emphasized the importance of expanding the spectrum of responses to collect data not only by consulting medical doctors, nurses, and hospital managers, but also by consulting other workers, such as cleaning staff or maintainers. Other respondents consulted nearby communities to retrieve information. These considerations are key for proper Health Emergency and Disaster Risk Management . OverallThe scoring system of the HSI has been criticized because of its narrow grading scale, using only three grades   A wider Additionally, taking into consideration that HFs are contributing to climate change, and thus, to a possible future health emergency, it is the authors’ belief that the sustainability of HFs needs to be factored in as well—whether within the HSI or any assessment of HFs’ preparedness, security, or resilience .In addition to hospitals, the HSI has been used in PHC facilities. Those facilities are inherently different, which is why a modified version of the HSI with fewer elements exists and is documented in the literature. However, it is not well known worldwide and has only recently been used more frequently. Despite the recognized importance of strengthening disaster preparedness at all levels of the health system, literature supporting primary healthcare disaster preparedness is scant and lacks rigour ,44. TherSeveral recommendations emerged from this study that can be categorised as recommendations for hospitals’ decision-makers, recommendations for researchers, and recommendations for HSI reviewers from the WHO.Awareness of the importance of assessing hospitals’ disaster preparedness should be raised in hospitals, and decision-makers should promote the use of the HSI to facilitate the identification of weaknesses and inform the allocation of resources. Training, workshops, and awareness-raising campaigns for the importance of performing disaster-preparedness assessments with the HSI should be carried out in hospitals, and incentives should be provided to hospitals that routinely perform disaster-preparedness assessments. This could ultimately facilitate receiving approval for assessments conducted by academic researchers, WHO investigators, or internal hospital boards.The use of the HSI as a guide for the routine monitoring of disaster preparedness in HFs should be promoted. This can be done by establishing trained teams in hospitals that carry out the evaluation and using this as an opportunity to improve hospital preparedness. Overall, the HSI should become a tool for enhancing proactive preparedness strategies rather than an instrument used merely for preparedness evaluations. This could ultimately favour the production of up-to-date reports on the preparedness of HFs and inform policymakers and hospitals’ decision-makers of intervention strategies aimed at strengthening hospital preparedness.More research should be conducted on how to overcome the current limitations of the HSI, including limitations of the scoring system and cultural barriers encountered when using the tool in non-US settings. Those performing disaster preparedness assessments with the HSI are encouraged to highlight, in their publications or reports, the operational challenges that were encountered while using the tool. In turn, HSI reviewers from the WHO are encouraged to take such recommendations into account to improve the tool and facilitate its utilisation. This could ultimately inform HSI reviewers of the most important issues to address when elaborating future versions of the HSI.Research should highlight differences in the preparedness of hospitals, smaller facilities, and primary care centres. Given the variety of different health systems’ infrastructures, it is important to diversify disaster-preparedness assessments by considering peculiar elements of different levels of care. The HSI can be used as a guiding framework for the development of secondary tools that can be used to assess the preparedness of other components of the health system. This could ultimately stimulate the development of secondary tools that allow investigators to assess the preparedness of different health system components.Future versions of the HSI should take technology into account to ease data collection. For example, a mobile phone application could facilitate data collection and calculations, increasing the chances of the HSI being routinely used. In addition, an online platform monitoring the disaster preparedness of hospitals worldwide can have added value in promoting cross-country comparisons. This could be an incentive for performing assessments with the HSI, even in low-resource settings or by internal hospital staff having limited resources  to deploy for such an assessment. An online platform reporting the results of hospitals’ assessments worldwide could be a key resource for monitoring global improvements in disaster preparedness and sharing best practices.Given the increased attention on hospital sustainability and climate change mitigation worldwide, it is recommended that elements of sustainability are incorporated into the HSI. Considering that the health sector is a major contributor to climate change, integrating disaster preparedness and sustainability principles might lead to several co-benefits. This could ultimately enrich disaster preparedness assessments, rendering them more relevant for environmental scientists and contributing to decreasing hospitals’ environmental impacts.The HSI could be used beyond the health sector to reach a broader audience (such as community members) and to assess preparedness not only for HFs but also facilities that can take part in the response to disasters, such as hotels, stadiums, or schools. When disasters strike, hotels or stadiums can, indeed, be chosen as urban disaster shelters, as they may offer refuge to the affected communities. City buildings, such as hotels or schools, can also be used to store medical equipment and materials when disasters hit hospitals’ infrastructures. It might, therefore, be useful to include in the HSI an evaluation of the preparedness of secondary buildings for a comprehensive assessment of hospital disaster preparedness in a given area.The main limitation is the small sample size, as only nine individuals accepted the invitation to take part in this study. Furthermore, the interviewees came from a small number of countries; thus, results cannot be considered generalisable to the world population. It must be said, however, that the duration and depth of the interviews allowed us to reach data saturation and comprehensively answer the research question. The extensive expertise of the research team in hospital disaster preparedness, previous experience using the HIS, and the scientifically sound methodology based on the COrEQ guidelines are strengths that characterise this study. This is the first qualitative study exploring the methodological implications of using one of the most important tools for assessing hospital disaster preparedness and, therefore, has the potential to provide useful insights for future adaptations and modifications of the tool.This study demonstrated that the use of the HSI is broad and diverse, depending on the context, the final goal, and the methodologies used. Since it has been 7 years since its last update—and for it to be used in an optimal way—the HSI still needs more adaptations to be tailored to different contexts and settings. Some of the adjustments could be to incorporate new technologies that facilitate data collection and handling; to re-evaluate the grading system to make it broader (from 1 to 5 or 1 to 10); and to make the tool flexible enough to be updated autonomously in accordance with the context and the facility being assessed, by giving the assessor the freedom to remove elements that are unnecessary or to construct their own pool of elements. The HSI has shown its effectiveness in assessing HFs’ preparedness in many settings around the world, yet the users of this tool are still facing challenges in using the tool to its full potential. The authors encourage future revisions of the HSI to take the recommendations elaborated on in this study into account.


Healthcare effectiveness measurement and value in health have been common topics in public health literature since 2006 when value-based healthcare (VBHC) was first defined by Porter and Teisberg. The aim of this study was to identify the barriers and challenges related to the implementation of VBHC solutions in the example of Poland. A case presentation was used as a method. The national integrated care programs  were used to present general challenges, along with the Integrated Care Model (ICM) for patients with advanced chronic obstructive pulmonary disease (COPD), to determine specific difficulties. ICM has been operating since 2012 in Gdańsk and gradually adapted the value-based integrated care (VBIC) approach. An analysis of the available data showed that the greatest difficulties related to the implementation of the VBHC and VBIC concepts are a lack of legal and reimbursement solutions, staff shortages, a lack of educational standards for some members of the multidisciplinary team, and insufficient awareness of the role of integrated care. As the level of preparation to implement VBHC policies varies between individual countries, the conclusions drawn from the experience of ICM and other Polish projects may be a valuable voice in discussion. Value in healthcare, first defined in 2006 by Michael Porter and Elizabeth Teisberg, is understood currently as a relation between patient-centered outcome measures and the cost of achieving improvement in these results . The proPersonal—effective care enabling the achievement of patients’ personal goals;Allocative—fair distribution of resources between each group of patients;Technical—achievement of best possible results with available resources .The broader approach was proposed by Gray, who presents the concept of value in three respects : This concept was primarily introduced in Great Britain; however, in 2019, the European Commission proposed to complete the Triple Value approach with a fourth dimension, which is social value. This dimension is understood as the contribution of healthcare to social participation and connectivity . The justification for introducing the value-based healthcare (VBHC) approach is to give more value to patients expectations and put them at the center of interest. Reducing the cost of care matters but is not the most important outcome in the process . Thus, cFrom the very beginning, the integration of care has been included in VBHC proposed by Porter; however, VBHC and value-based integrated care (VBIC) are not the same processes. VBIC is not a simple combination of integrated care and VBHC. VBIC was initially defined by Valentijn and Vrijhoef in 2016 as “patients’ achieved outcomes and experience of care in combination with the amount of money spent by providing accessible, comprehensive and coordinated services to a targeted population” ,8.To introduce VBIC, the general (population) understanding of health must be included in those elements of VBHC that already exist in the health system. Implementation of VBIC includes, for example, shifting (where possible) from the hospital-centric to more patient-accepted types of care. Availability of home care may result in better adherence to treatment, improved physical activity , and betMacro scale—a comprehensive set of political and systemic arrangements that ensures the provision of care for the general population;Meso scale—a partnership established by various stakeholders, mainly for the sake of joint accounting and management that enables the provision of integrated care (IC) to selected groups at risk. It can also be understood as building partnerships between different groups of professionals to better understand their individual roles in providing IC for selected target groups;Micro scale—also called patient-centered or clinical care, it is an integrated form of care, but most often limited to individual, specific health condition cases; a single process carried out at a specific time and place.In terms of the scale of organization, the macro , meso (targeted sub-groups), and micro  levels can be distinguished. Similarly, when analyzing the type of integration, we can identify: Functional and normative integration are related to the context of enablers of integration . AccordiA case study approach was used to determine the barriers and challenges related to the implementation and provision of the Integrated Care Model that would meet the criteria of value-based integrated care (VBIC). This study provides a broad context of national programs with which to identify general barriers and challenges. For discussing specific difficulties, the Integrated Care Model for patients with advanced COPD  was chosen due to its unique elements of: (1) Multiannual functioning in the Polish healthcare system with only single features consistent with the concept of value-based healthcare; (2) Experience with gradual adaptation of the value-based integrated care (VBIC) approach; (3) Offering a wide range of support for patients, including home care, treatment tailored to individual patients’ needs, patient and family education, multidisciplinary team care , and access to a care coordinator. Limitations to this case study include the lack of publications that could be used as comparative material and the fact that individual countries are not equally prepared to implement VBHC. Thus, VBIC models may face slightly different challenges.Health programs which include VBHC elements have been more frequently financed by the Polish public payer  in the last few years. Nationally coordinated care projects using VBHC elements include, among others, coordinated specialist care for the patient after a heart attack (KOS-Infarction), coordinated care in primary healthcare (POZ Plus), and comprehensive treatment of chronic wounds (KLRP-1 and KLRP-2 services). A particularly interesting example is the KLRP, which introduced modern services with advanced IT tools based on performance bonuses (degree of wound closure) . The KOSIn Poland, in addition to national programs, regional initiatives are also undertaken. Despite being less known, they are characterized by a high degree of advancement in terms of VBHC and, at the same time, serve as an example of integrated care, entering the area of the VBIC concept. One such program is ICM, which is dedicated to patients with chronic obstructive pulmonary disease (COPD), the disease known to be the third leading cause of morbidity and death .The presented model (ICM) has been operating continuously since 2012 and uses a recommended scheme of implementing services in healthcare  after education provided within ICM [ICM was presented in detail back in 2012 and later years ,29. In tthin ICM . ICM is a home-based coordinated intervention for patients suffering from advanced COPD with frequent exacerbations. It is worth underlining that COPD exacerbations are associated with the irreversible loss of lung function . TherefoApart from home support, ICM provides the integration of the medical team with social assistance and the assistance of a coordinator. Individual patients’ treatment plans are tailored according to COPS and their individual health needs. In addition, compliance with medical recommendations is monitored and discussed during regular interdisciplinary team meetings. Entry to the program is preceded by qualification conducted by a team of physicians from the Department of Allergology and Pneumonology of the University Clinical Centre in Gdańsk. Consent to enter ICM is obtained from the patient during hospitalization due to an exacerbation of COPD. Afterwards, the coordinator conducts an interview with the patient and arranges appointments with a specialist physician, a psychologist, a physiotherapist, and a dietician. Patients are provided with instructional materials—a book with exercises and a video, including a set of general rehabilitation and breathing exercises. Further, at one of the regular meetings, the team assesses whether including the patient in ICM is advisable. After qualifying, the patient is visited at home by assistants during regular two-hour visits (every two weeks). Assistants check whether the patients have the prescribed drugs and are using them correctly. They also accompany the patients during exercises and assess whether they need the additional support of volunteers or social care institutions. Each visit ends with the preparation of a structured report that is presented to the coordinator at the regular meeting of the team. This report includes information on compliance (including regularity of taking medications), patient needs and satisfaction with care and other important factors that may affect the quality of care. The entire integrated care team meets regularly every 4–6 weeks where they prepare a treatment plan and provide the necessary support for patients. The coordinator organizes the work of the team, enables the patients to stay in contact with the therapeutic team, and ensures contact between the team members. Patients and their families are educated during individual consultations and regular patient gatherings. The topics of the educational meetings focus on the essence of the disease, the principles of the therapy, including the use of individual inhalers, the treatment of exacerbations, the role of rehabilitation, and diet. The team will also look for ways to provide effective non-medical care when the difficult socio-economic situation of the patient is an additional challenge. Participation in ICM ends when the patient’s consent is withdrawn or the disease progresses to the terminal phase, requiring the care of palliative support centers .ICM is carefully analyzed in terms of effectiveness. The types of outcome measures used to assess ICM have been gradually extended with additional areas . This caAs can be seen in All analyses of costs and changes in demand for health services have been established as before–after type and included two consecutive 6-month periods—in the first 6 months, patients received standard care, followed by integrated care. It should be emphasized that all available results clearly indicate that the ICM is a cost-effective intervention, regardless of the type of indicator used in the assessment of effectiveness, which is also presented in A study by Lewis et al. showed that the instability of state health policy can be a key obstacle to the implementation of integrated care models . This maThe initial attempts to implement projects based on VBHC and VBIC in Poland revealed several barriers and challenges. Recalling the previously described wound treatment services, few service providers are interested in conducting them. In 2021, the KLRP-2 service was delivered by only three healthcare providers in two voivodships in Poland (out of 16). The reasons for this include the high staff and organizational requirements, a lack of adequate financial incentives, and actual (not only declarative) incentives to shift the burden from inpatient to outpatient care. There are also many difficulties in conducting ICM. This is mainly due to the lack of a stable source of financing and dedicated forms of payment that would take into account the specificity of integrated care. In addition, the healthcare system is not organizationally prepared to provide patients with advanced COPD with full coverage of their needs. A project is currently underway under the ICM leadership to improve the integration of activities between the GP and the specialists  through the use of an online platform. Using these modern techniques might improve the patient’s “pathway” between medical centers and may increase the availability of different professionals. Barriers to the implementation of integrated care also include the lack of staff, including coordinators and nurses, among others. In particular, the position and role of the coordinator requires formal regulation; so far, it is a function, not a profession. For the purposes of ICM, the authors prepared individual training sessions for all team members, which were carried out during monthly meetings. The ICM coordinator has no medical education, which additionally emphasizes the need to popularize and standardize training in this area. At the moment, there are no systemic solutions in this regard in Poland. Although a few universities train coordinators, the educational offers are very scarce. Additionally, the role of interprofessional communication is seldom present in study programs. It seems that many implementations outpaced the training of personnel.The barriers identified in Poland based on experience from conducting national programs are systemic and concern various stakeholders, starting with society itself, which must be ready to accept the new form of care and to demonstrate a more active and responsible form of participation in the provision of health services. A good global example of where patients are active in VBHC is their involvement in ICHOM’s development of standard sets of outcome measures .The next group is healthcare providers, who need to engage additional resources to transit to VBHC, which often involves the need to reorganize work and retraining. This may require cutting the provision of many different services off, which raises the risk of fragmentation of care and makes it challenging to implement package payments. It is also associated with the need to perform new activities, e.g., entering data into dedicated registers, measuring new outcome measures, and others . The criIntegrated care based on VBHC also requires a change within social care, which must cooperate more widely with, for example, healthcare providers ,41.However, key challenges remain in the decision-making area of the government, as a creator of general conditions necessary for implementation of VBHC and VBIC. Above all, it is necessary to remove the remaining legal barriers and actively support the introduction of new value-based reimbursement models. Regarding integrated care itself, it is crucial to remove organizational, financial and legal barriers, and to introduce an incentive system for smaller centers to jointly initiate integrated care in partnership with larger entities. It is also necessary to develop the already-active solutions towards the implementation of payments dependent on the outcome. This would require obliging service providers to report outcome measures, creating a national framework for registries in the area of outcome measures dedicated to individual medical conditions and preparing cost reporting standards. All these activities require the refinement of existing and functioning IT systems. Some actions are also needed on the part of the public payer. In terms of implementing integrated care, the main one is to introduce incentives, including financial ones, dedicated to service providers who operate in the form of an integrated practice unit (IPU) and support the coordination of patient care throughout the treatment pathway. Concerning the reimbursement process itself, developing reimbursement structures for entire care cycles is still a challenge . VBIC remains an important topic that is constantly challenging and which can help optimize healthcare . During The presented study has some limitations. The most important is the limited number of publications dealing specifically with VBIC, not VBHC in general. The small number of VBIC programs that are sufficiently well described is considered to be the main reason for the lack of knowledge in this area and presents limited possibilities with which to conduct comparative analyses. ICM, shown in this article as a real world case, operates in a healthcare system that does not fulfill all the principles of VBHC. Therefore, the ICM itself faces some challenges that may not be present in other projects and countries. However, as the degree of preparation for the implementation of the VBHC concept is varied and the discussion on opportunities and challenges is important, the experiences from conducting ICM can be helpful in selecting the most significant goals and ways of solving already-identified problems . The lessons learned from the multiannual operation of ICM, including the gradual adaptation of the value-based integrated care (VBIC) approach, may be valuable in international discussions on this subject.The ICM presented in this article is a rare proof that, even without systemic solutions enabling the implementation of VBHC, it is possible to implement effective projects fitting the VBIC concept. However, they have to face many challenges and difficulties, which are the result of the lack of necessary action on the legislative side, in particular concerning reimbursement methods. The lack of systemic solutions is tantamount to the lack of standards that would help initiate such activities in the future and correct programs already in place. The lessons learned from multiannual operation of ICM, including the gradual adaptation of the value-based integrated care (VBIC) approach, may be valuable guidance on how to build such projects and prioritize activities. It seems that, at the moment, it is critical to clearly embed integrated care in the healthcare system as a separately reimbursed service and to further train staff—especially integrated care coordinators.


Implementation research (IR) has proved to be a potential catalyst in facilitating the uptake of evidence-based innovations into routine practices and thereby maximizing public health outcomes. IR not only focuses on the effectiveness of the innovations but also identifies and addresses the barriers and facilitators to maximize their uptake into routine practices. This article describes the processes undertaken to implement a research project aimed at promoting access and rational use of antibiotics for children (PARAC). It also provides an overview of the lessons learnt during its implementation in Tanzanian hospital and community settings. Drug-resistant bacteria have greatly contributed to this.3 A considerable number of evidence-based measures have been documented to curb the problem of AMR, but their successful implementation still remains a challenge.4 To address this, Tanzanian AMR stakeholders designed implementation research (IR),5 firstly to assess the implementation of stewardship programmes in 14 tertiary hospitals, and secondly to assess the contributions of accredited drug-dispensing outlets (ADDOs) to the access and rational use of medicines, particularly antibiotics.AMR, especially resistant bacteria, is a public health threat that requires serious action to prevent the predicted post-antibiotic era.6 The implementation of the project for PARAC followed the steps as presented in Figure This was a stakeholder-driven project, kicked off by UNICEF and funded by Wellcome where stakeholders were invited to discuss and formulate the research questions. Various stakeholders were engaged, from the government, the private sector, associations, non-government organizations (NGOs), multilateral agencies, academic agencies and beneficiaries.Stakeholders designed the research questions based on the implementation challenges and research gaps that were identified by the same stakeholders and evidence from literature and implementation experience. The formulation of the research questions was guided by the stakeholders with experience in research (e.g. research and academic institutions). Two research questions were formulated to target hospitals and community settings.After having two approved research questions by stakeholders, the team of researchers from Muhimbili University of Health Sciences (MUHAS) had the role of developing the study protocols. From the two formulated questions, one protocol targeted the hospital settings  and the other targeted the community settings, the so-called ADDOs. The two protocols were submitted to the MUHAS Research and Ethics Committee for ethical approval.Data were collected from the 14 administrative regions  of Mainland Tanzania. A mixed-methods approach was used to study the questions designed by stakeholders. Before starting data collection, the approved protocols were submitted to the appropriate national and local authorities for granting of permissions. According to country regulations, ADDOs are regulated by the President’s Office—Regional Administration and Local Government. For the hospital-based study, permissions were requested from the medical officers in charge. The collected data were submitted to the experienced biostatisticians for quantitative analysis while for the interviews the qualitative research experts analysed the data. Two reports were prepared for dissemination to the funder and the stakeholders.MUHAS researchers in collaboration with the Pharmacy Council (PC), prepared two research project reports. The reports were communicated and presented to the funder through the UNICEF country office for reviews and suggestions. The MUHAS team of researchers responded to the comments and suggestions. Following reviews from the funder reports, MUHAS and PC prepared workshops for stakeholders to validate the findings, formulate and prioritize actionable recommendations and to develop an action plan to include the recommendations into longer-term implementation plans. After the workshops, the research findings, actionable recommendations and their action plans were communicated to the Permanent Secretaries Ministry of Health and President’s Office—Regional Administration and Local Government.During the first workshop conducted in Dar es Salaam city, stakeholders spent 2 days validating the research findings and formulating actionable recommendations and the action plan. The participatory approach was used to formulate the actionable recommendations and the action plan from the validated findings. In this workshop, stakeholders reviewed the findings and developed actionable recommendations to address the gaps that were reported from the research findings. In the end, a plenary session was held where each of the actionable recommendations formulated by the groups were discussed. For both studies, the plenary session came up with 12 actionable recommendations plus their action plans.About a month after the first workshop, stakeholders were invited to attend the second workshop in Dodoma city (Government city). The first workshop was researcher focused, and the second one was more policymaker focused on how these findings would translate into practice, and which findings had a greater likelihood of actually changing practice. The second workshop was organized after the team had time to share and discuss the recommendations from the first workshop with their representing organizations/institutions. During the second workshop, the actionable recommendations were prioritized and only six actionable recommendations were retained. For further actions, the six actionable recommendations were communicated to the Government Chief Medical Officer from the Ministry of Health and the Director of Health, Social Welfare and Nutrition Service—President’s Office Regional Administration and Local Government, and National Multi-sectoral Committee on Antibiotic Use and Resistance.A third workshop was convened in Dar es Salaam city to hear about the progress of implementation from the government and other implementing partners such as NGOs, professional associations and international organizations (e.g. UNICEF). In this workshop, stakeholders received updates from the government through the Committee of National Action Plan on Antimicrobial Resistance (NAPAR: 2017–22). During the third workshop, the government through NAPAR were already implementing one of the six recommendations of the ‘review of the 2017–22 NAPAR’ (the first recommendation). Additionally, the Government of Tanzania is formulating a policy on ‘health insurance for all’. Our study recommended that people should be sensitized to join health insurance schemes. It was realized that to take the other recommendations into action, more stakeholder engagement was needed. It was proposed that we should hold another stakeholders’ workshop, this time targeting donors.During the workshop discussions, especially when the stakeholders were formulating actionable recommendations, there were always facilitator (in favour) and barrier (against) sides. However, conflict of interest among the stakeholders is something that needs to be clearly stated (noted) at the beginning of the IR process. For example, during the discussion on whether to include rapid diagnostic tests (RDTs) in the community pharmacies, there were conflicting interests between different professionals . Some stakeholders thought that including RDTs in the community pharmacies was shifting the role of pharmacies from being dispensing outlets to health centres.Implementation of the PARAC project posed two challenges; when the same stakeholders were involved in the different workshops, the discussions became easier as the stakeholders had the knowledge on the discussed topic/subject. On the other hand, using the same stakeholders across different workshops ensured the bringing up of new and diverse ideas.7 For example, including policymakers and implementers at different levels of the health system as co-investigators during the implementation of the research8 will enhance the ownership of the research findings, which may ultimately facilitate the policy change and uptake.The universities and research institutions may play the leading role, but the research team should be composed of a diverse number of stakeholders including those who are not representing academic and research institutions.With the current funding system, the maximum budget is planned before conducting research. However, IR is an iterative process that may need the revision of study protocol to accommodate the new things arising while conducting it or accommodate suggestions from the stakeholders. Securing an additional budget to implement a new proposed item may became challenging. The best approach for this is to include a reasonable percentage of contingency at the beginning of the process.Traditionally, the funding of IR focuses on identification of relevant questions, subsequent development of an IR protocol and conducting the IR, analysis and write up of study results, and dissemination thereof. With strong and explicit support from Wellcome and UNICEF, timelines of the original study were extended, and the development of actionable recommendations and a prioritized action plan requested. This allowed greater uptake of the actionable recommendations into action plans and, in the future, their embedding into longer-term implementation plans. Another lesson learnt should be the ownership by the government mainly for the implementation of actionable recommendations.IR is a growing field when it comes to the Tanzanian context. Involvement of a range of stakeholders  is crucial to develop IR capacity, and develop and execute a research agenda that is needs-based and responds to local implementation problems. IR funding, rather than stopping at dissemination of IR findings, needs to allow for the development of a subsequent action plan, which is based on prioritized actionable recommendations.