1. What are the potential barriers to the successful implementation of a new policy?

A useful starting point for anyone wanting to elicit change is the identification of likely barriers to change. Knowing what - and where - the major hurdles are that may affect successful implementation is useful during the planning process. These challenges will often vary from policy to policy, and between different contexts. Both research findings on barriers to policy implementation in other settings, and lessons learnt from previous experiences may be informative, but they may not be sufficient.

There is no standard approach to identifying barriers to change. This process is often done informally by taking perceived barriers into account and in an implicit and unsystematic way. We propose a more structured approach to identifying barriers.

We have adopted a similar approach by focusing on constraints to policy implementation at three levels in the health system:

2. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes among healthcare recipients and citizens?

The behaviour of healthcare recipients and citizens, particularly in relation to the use of health services (e.g. under-utilisation, non-adherence to recommended lifestyle changes or treatment schedules, etc.), may be a potentially significant obstacle to successful policy implementation. It is necessary to understand why the targeted recipients behave in particular ways as this will influence the choices they make in utilising health services. Well-conducted qualitative studies can provide insights into the behaviour of healthcare recipients [10].

One framework that can be used to identify factors that may influence the behaviour of healthcare recipients and citizens was proposed by a WHO working group on adherence to long-term therapies. They suggested five dimensions to consider [11]:

As these factors are related more specifically to clinical interventions, they may be particularly useful when considering barriers to the delivery of care arrangements. For example, some of the socio-economic factors that can affect adherence to treatment among patients with tuberculosis include: a lack of effective social support networks and unstable living circumstances, cultural and lay beliefs, ethnicity, gender, age, the high cost of medication and transport, and the role of criminal justice [11, 12].

The Cochrane Consumer and Communication Review Group has extensively documented the effects of interventions to improve interactions between consumers and healthcare providers and systems, and has developed a taxonomy of interventions that target healthcare recipients and citizens [13]. This may be helpful when conceptualising and considering what kinds of interventions to use. The taxonomy includes:

Several studies and reviews have evaluated the effects of interventions that address constraints to effective health service delivery at the level of healthcare recipients and citizens. In one review, the authors found positive effects from community participation in overcoming such constraints [14]. In this instance, community participation was obtained using a variety of intervention approaches, including: health education (e.g. meetings, group teachings), encouraging a participative approach (mobilising leaders and stakeholders to understand and buy into the intervention), using an outreach strategy (targeting households and high-risk groups), and the training and supervision of providers (e.g. nurses and/or mothers). These interventions resulted in increased health-related knowledge and community empowerment and improved coverage in immunisation and sanitation practices.

If patient-related factors, such as a lack of information appear to be important barriers to policy implementation, interventions to improve information provision might be worth considering. A systematic review has shown that mass media interventions, for example, "can encourage increased utilisation of health services". But this finding should be approached with caution given that the study was based almost exclusively on studies from high-income countries [17] and therefore may not be applicable to other settings.

3. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes in healthcare professionals?

The implementation of a policy or programme will often require changes in the behaviour of those healthcare professionals responsible for implementing the policy on the ground. Changes in professional behaviour do not always necessarily happen automatically. Active and directed approaches may therefore be necessary. The identification of barriers to change or factors that influence professional practice may help to inform the design of interventions for policy implementation. Cabana and colleagues conducted a systematic review of research addressing barriers to guideline adherence among physicians [18] and identified seven main categories of barriers. These can be used as a framework for identifying barriers to policy implementation among healthcare professionals:

The Effective Practice and Organisation of Care (EPOC) Review Group in the Cochrane Collaboration has developed a taxonomy of provider-targeted interventions which provides an overview of the types of interventions that may be considered for implementation purposes [19]. These are:

Several strategies aimed at achieving behavioural change among healthcare professionals have been rigorously assessed [20–23]. Typically, these have taken the form of evaluations of guideline implementation strategies targeted directly at healthcare professionals. Most, but not all, have been conducted in high-income settings [24]. The findings demonstrate that many interventions can influence professional behaviour effectively to a modest or moderate extent. But passive interventions, such as the circulation of guidelines or the hosting of educational meetings, seem only to have smaller impacts. Educational outreach visits and multi-faceted interventions that specifically target identified barriers to change are among the more promising approaches.

Financial incentives may be used as a means of influencing professional behaviour but these have been evaluated almost entirely in high-income settings. These can be effective in influencing individual healthcare professionals when simple and well-defined behavioural goals are provided, such as increases in the delivery of immunisations - at least in the short term [25]. However, several potentially negative consequences of such programmes have been identified and the use of financial incentives may not necessarily be cost-effective.

Regulatory measures are inexpensive and potentially effective means of eliciting changes in professional behaviour but may be poorly received by professional groups [26]. The impact of regulations per se as a means of achieving behavioural change among healthcare professionals has not been reviewed systematically, therefore available knowledge about their effectiveness is limited [27].

4. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary organisational changes?

Many organisational change strategies see the measures that should be taken as steps in a process that leads to change. Defining why there is a need for change and identifying barriers to change are tasks that are typically included in this process.

Pexton has proposed a list of the most common barriers to organisational change and this can also be used as a framework for barrier-identification [30]:

Examples of the tools and approaches often recommended to organisations assessing preparations for change include [31]:

Most commonly used organisational change strategies are based almost entirely on theory, or else on one-off applications and opinion. Sometimes these are supplemented with case studies or anecdotes, mainly from high-income settings [31]. Evidence about the effectiveness of these strategies is hard to come by, making it difficult to predict whether or not a specific method is likely to lead to the desired organisational change.

Although the impacts of such change management strategies are uncertain, they may still be useful as processes allowing for active reflection on how change in an organisation can be facilitated.

5. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary systems changes?

When a policy is to be implemented, changes at the general level of a health system may be necessary. These may include changes to governance arrangements, financial arrangements and delivery arrangements [32]. For example, when considering the financing of a policy option, should all costs be incurred by the government, or are additional sources of funding needed? Can the current system cope with the additional bureaucratic or logistical workload, or is a new mechanism needed to deliver the service? The body of evidence on how to implement such changes is small: those making decisions will usually have to draw on case studies and experiences in other jurisdictions. For particular policy implementation issues systematic reviews may be useful, such as those related to the costs of scaling up interventions [33] or factors that may affect the sustainability of health programmes [34]. In a recent overview, the authors summarised the evidence from systematic reviews on the effects of governance, financial and delivery arrangements, and implementation strategies that have the potential to improve the delivery of cost-effective interventions in primary health care in LMICs [27].

Useful documents and further reading

Shared decision-making in health care. Achieving evidence-based patient choice (2^nd edition, Edited by Edwards A and Elwyn G). Oxford University Press, 2009.

Changing Professional Practice (Edited by: Thorsen T and Mäkelä M) Copenhagen: Danish Institute for Health Services Research and Development, 1999. http://www.dsi.dk/projects/cpp/Monograph/DSI9905.pdf

Grol R, Wensing M, Eccles M. Improving Patient Care: The Implementation of Change in Clinical Practice. Oxford: Elsevier, 2005.

Fretheim A, Schünemann HJ, Oxman AD. Improving the use of research evidence in guideline development: 15. Disseminating and implementing guidelines. Health Research Policy and Systems 2006, 4:27. http://www.health-policy-systems.com/content/4/1/27

NorthStar - how to design and evaluate healthcare quality improvement interventions. The ReBEQI Collaboration 2005: http://www.rebeqi.org/?pageID=34&ItemID=35

Iles V, Sutherland K. Organisational Change. A review for health care managers, professionals and researchers. 2001. London, National Co-ordinating Centre for NHS Service Delivery and Organisation R & D http://www.sdo.nihr.ac.uk/files/adhoc/change-management-review.pdf.

Links to websites

Cochrane Consumers and Communication Review Group Resource Bank: http://www.latrobe.edu.au/chcp/cochrane/resourcebank/index.html - The Cochrane Consumers and Communication Review Group is part of the Cochrane Collaboration, an international, non-profit organisation that aims to help people make well-informed decisions about healthcare. The Consumers and Communication Review Group co-ordinates the production of systematic reviews of interventions which affect consumers' interactions with healthcare professionals, services and researchers. This resource bank is a list of Cochrane systematic reviews relevant to people's health communication and participation needs, and has been produced by manually searching The Cochrane Library.

Cochrane Effective Practice and Organisation of Care (EPOC) Review Group: http://www.epoc.cochrane.org/en/index.html - EPOC is a Collaborative Review Group of the Cochrane Collaboration and produces systematic reviews of educational, behavioural, financial, regulatory and organisational interventions that are designed to improve healthcare professional practice and the organisation of health care services.