Can innovation in sexual and reproductive health drive evidence-based change?

As Head of the R2HC programme, I’m interested in the ‘last mile’ challenge of evidence use: driving change in policy, practice and programmes to improve the lives of people affected by crises. In humanitarian settings, using evidence to create change is especially challenging, as documented in our learning paper From Knowing to Doing.

Sexual and reproductive health knowledge gaps well-documented

The sexual and reproductive health (SRH) sector is no exception. Priority SRH evidence gaps in humanitarian settings have been well documented in literature searches. The knowledge gaps are wide-ranging, from interventions for maternal and neonatal care, to family planning, safe abortion, gender-based violence prevention and care; and from strengthening implementation of the Minimal Initial Service Package (MISP) to providing appropriate information and services for adolescents, and marginalised groups such as disabled people and LGBTQIA.

What we know less about is why existing policies and guidelines to improve SRH in emergencies aren’t being routinely implemented. Cost-effective, evidence-based SRH interventions that are routinely delivered at the lowest levels of health care systems in lower and middle-income countries (LMICs), are often not introduced in humanitarian settings. When we already have so much evidence-based knowledge about effective SRH interventions, why aren’t these approaches being utilised?

Why the gap between evidence and practice?

It occurs to me that one of the reasons for the gap between evidence and practice might be because of the specific challenges of delivering SRH services in complex humanitarian settings. Perhaps we need more nuanced solutions for specific populations or contexts. As COVID-19 and the Ebola crises have shown us, understanding context and people’s behaviour matters. Generalisable evidence can’t always be effortlessly transferred across from one setting to another. Interventions benefit from being fine-tuned and adapted for different people and places. But, what if the gap between evidence and practice is rooted in something deeper? We know that gender biases have influenced the prioritisation and delivery of GBV programming in humanitarian contexts. Are biases contributing to the lack of transition from evidence to practice in SRH?

Regardless of the drivers behind the evidence to practice gap, might innovations, or innovative approaches adapted from other settings, therefore be a solution to some of the biggest barriers to SRH in humanitarian settings? Our new report Innovation for SRH in Humanitarian Crises sheds light on the role innovation can play in addressing such challenges.

Innovation could be the solution

Over the past ten years there’s been a proliferation of innovations seeking to address critical SRH problems facing practitioners in humanitarian settings, with mobile apps receiving particular attention. It’s never been clear to me whether such innovations are targeted at the most intractable challenges where evidence alone has failed to drive change, or whether innovations are being introduced opportunistically, using more of a scatter gun approach.

For someone like me who isn’t an innovation specialist, understanding what’s meant by innovation in the humanitarian sector can be confusing. But this report has helped unpack the meaning, by shedding light on the sectors’ understanding of innovation, and providing useful and clear examples of SRH innovations currently being implemented or introduced.

Based on the inputs of the SRH community of practice, the authors define innovation as “an iterative, co-creative process that leads to improved, inclusive and sustainable solutions to pressing SRH challenges faced by women, girls, marginalised populations and humanitarian practitioners.” SRH practitioners see innovation as being both the invention of new interventions, and the adaptation of existing ones to new contexts or users. So, an innovation can be either a new solution (invention), or the adaptation of an existing solution to a new humanitarian context or user group. Other key elements are also necessary. The process of innovating must involve end users and other stakeholders, and it must be an iterative process, with the potential for other solutions to be simultaneously explored. Successful innovations are also sustainable, with potential for scaling up. Critically, innovations should generate learning and evidence and, in common with research in humanitarian settings, must be conducted ethically.

Most of the innovations identified through our review are not new inventions but have been adapted from approaches that have worked in other settings. The majority address maternity care, with others focusing on family planning, safe abortion and post-abortion care, and neonatal mortality. Others address the specific needs of marginalised SRH population groups. A point-of-care ultrasound training for health care providers, using cloud-based monitoring to detect pregnancy complications, pneumonia and trauma, is an example of an invention. This innovation is completely new and is currently being tested in Yemen. Digital innovations, on the other hand, such as apps to empower adolescents to make informed contraceptive choices, or to train healthcare providers on newborn health guidelines, fall into the category of adaptations as they are using pre-existing technology. Similarly, menstrual hygiene approaches and dignity kits specifically targeting different user groups, are also adaptations.

Complemented with research

Encouragingly, all the identified innovations overlap with evidence gaps highlighted in literature reviews and research priority settings. Most of them are still in their early stages, having only recently been introduced. Gaps remain though, including in relation to some of the most challenging SRH problems. For example, harmful practices such as child marriage and FGM, which are at risk of increasing during humanitarian crises, remain particularly difficult to address. Personally, I think it’s unlikely that innovative solutions can be found to address such sensitive issues, although there’s a possibility that innovative approaches — co-created and iterative — might reveal more culturally-sensitive ways to address such practices.

Generally speaking, I think innovation is perhaps best suited to finding solutions where SRH service provision, modes of delivery or training need to be changed; where policy needs to be formulated or adapted; or where new products are needed.

Our review has provided me with the opportunity to think more closely about the overlap and linkages between research and innovation, and the part each can play in addressing challenges specific to SRH in humanitarian settings. Evidence alone is not always enough, especially when it is not applied. Critical challenges might be best solved through innovation, rather than persisting with solutions that aren’t working or being utilised. At some stage in every innovation, research plays an important part in examining and measuring effectiveness. Research and innovation complement each other, and one thing our report has shown is that there is definitely scope for more collaboration between these different fields of expertise when tackling critical SRH problems.