Identifying implementation science research and policy priorities to advance universal health coverage: a multi-country modified Delphi study

Abstract

Despite efforts to advance universal health coverage (UHC) in different contexts, evidence gaps remain, and implementation science has been underused to address these gaps and determine ‘what works’. The study aimed to establish a research agenda that could guide future research by identifying implementation science research priorities to advance UHC. A three-round modified Delphi study design with a multi-country panel was employed. Initial implementation science research gaps were identified from two scoping reviews conducted by our team, supplemented by 10 papers that we identified through a search of Medline and CINAHL databases. We generated 64 research gaps that were shared with 272 participants in Round I. Round I responses were analysed using descriptive statistics and a cut-off of 75% to move to Round II. Round I qualitative analysis resulted in an additional 15 research gaps and one new topic area. Based on Round I findings, an improved set of research gaps was shared in Round II. Quantitative data in Round II were analysed using the same approach as Round I, using an 85% cut-off point. Open-ended responses were analysed thematically. Round II research gaps were then presented in a virtual workshop. Results from the workshop were analysed using weighted ranking analysis. Round I response rate was 34.9% with 43 research gaps across 12 topic areas. Round II response rate was 77.9% with 42 gaps across 13 topic areas that passed to the virtual workshop. The workshop response rate was 39%. Through this process, the top 10 ranked implementation science research gaps were identified. Identified research gaps are focused on assessing equity in the delivery of health services and financial risk protection interventions. Future research will further contextualise this research agenda with country-level actors.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• There continues to be a pressing need to use implementation science in assessing universal health coverage (UHC) interventions, as implementation science can bridge the knowledge gap between research evidence and real-world settings, and many countries are still far from achieving their UHC targets. Implementation science can generate robust evidence about priority interventions to support equitable progress on UHC globally by identifying barriers and potential paths to overcome them.

WHAT THIS STUDY ADDS

• A three-round modified Delphi approach identified 10 major areas relating to UHC which could be advanced through implementation science research. Most research gaps are focused on assessing equity in the delivery of health services and financial risk protection interventions.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The research agenda can help catalyse multi-institutional partnerships and a critical mass of partners, researchers, knowledge users and trainees to work collectively to embed and use implementation science evidence to achieve UHC and related Sustainable Development Goals.

Introduction

Achieving universal health coverage (UHC) by 2030 requires context-sensitive evidence on the cost-effective implementation, scale-up and sustainability of interventions focused on ensuring that all people receive the health services they need without facing financial hardship. The pursuit of UHC is well aligned with Sustainable Development Goal (SDG) 3 and intersects with multiple other SDGs.^{1 2} While there is growing evidence linking UHC to different health, economic and social outcomes, many people and countries are far from the progressive realisation of UHC that is fair, responsive, resilient and ensures equitable, cost-effective and quality coverage.^{3 4} Faced with competing healthcare needs and resource constraints, countries face difficult policy and programming choices that require evidence-informed guidance on interventions that meaningfully improve health and equity outcomes.³,⁵

The concept of UHC and the related policy articulations, both global and national, have been criticised for being too broad and for the lack of critical interrogation of how these ambitions are being operationalised and realised. For instance, a major criticism has been around how ‘equity’, a key tenet of UHC, has been operationalised in practice, with some arguing that a critical interrogation of the measurement and evaluation of equity in UHC is lacking in the current research.⁶,⁸ When equity was explicitly measured, few studies referred to equity of access relative to UHC goals, and most focused on simplistically using equity of utilisation as a proxy indicator for equity of access.⁶,⁸ Implementation science, with its emphasis on approaches to ‘understand, explain and address problems associated with translating explicit and implicit intentions into desired changes’, we argue, offers the range of methodological and analytical resources necessary to address this criticism and knowledge gap.^{9 10} Implementation science offers robust evidence to inform priority interventions that will progress UHC in ways that enhance health and equity goals within and across global health systems²,⁵⁹

While many definitions exist, implementation science involves synthesising, disseminating, exchanging and applying knowledge to improve the population’s health using research-based evidence to policy and practice processes.¹¹,¹³ Implementation research approaches also explicitly require meaningful engagement of key stakeholders and implementers at all stages of the research process.¹¹,¹³ Thus, an implementation science approach to examining how UHC is being operationalised and realised in practice, both as a concept and as a policy, provides the opportunity to learn from implementation efforts and to generate actionable insights for health systems to deliver on the UHC-related ambitions more effectively.^{9 10 14}

This multi-country modified Delphi seeks to identify implementation research priorities and a research agenda that can progress UHC globally.

Methods

Study design and planning

We employed a multimethod, three-round modified Delphi study design with a multi-country panel, which combined two online surveys and a repeated virtual workshop. A modified Delphi approach was selected because it: (1) is a rigorous consensus-building method; (2) allows diverse global actors shaping UHC priorities to participate; (3) fosters real-time panellist interaction and (4) is flexible, especially during the COVID-19 pandemic restrictions. A detailed analysis of our use of the modified Delphi approach is presented elsewhere.¹⁵ We report our modified Delphi findings using the Recommendations for Conducting and Reporting Delphi Studies (CREDES) guidelines, so we refer readers to the CREDES checklist discussed further in Junger et al.¹⁶

Figure 1 summarises how we generated a preliminary list of implementation science research gaps from peer-reviewed systematic and scoping reviews. We supplemented two scoping reviews conducted by members of our team^{6 7} with a literature search, and used the Consolidated Framework for Implementation Research and the High-Quality Health System Framework to organise data extraction and synthesis.^{3 17} We identified 64 implementation science gaps across 12 topic areas, which made up the items for Round I of the Delphi survey.

Figure 1. Flow chart of supplementary search strategy to develop the preliminary list of implementation science research gaps (online supplemental file).

Sampling frame for the expert panel

Three sampling techniques were used to identify study participants across five categories. First, global health systems researchers were identified using purposive sampling of authors from the two scoping reviews and supplementary papers.^{6 7} Second, global institutions and national and subnational health system policymakers and programme implementers (e.g., Ministries of Health and Finance policymakers; National Agencies) were identified using convenience sampling in two ways: (a) through the research team’s networks, including in countries where they were currently/previously working and or conducted research and (b) by leveraging University of Toronto and University of Melbourne existing networks. Third, funders or donors and civil society/non-government organisations were identified by the project team using snowballing techniques and through existing networks. For all sampling techniques, the six WHO regions were used to guide purposive sampling of health system policy and programme implementers across low- and middle-income countries to ensure that our sampling approaches did not leave behind important voices for advancing UHC.

A total of 272 participants were identified and invited to participate in the survey. The participants’ names, emails, institution affiliations and titles were captured during the identification process.

Survey design

In Round I, participants were asked to indicate the level of importance of each of the 64 identified implementation science research gaps across 12 topic areas using a 5-point Likert scale (‘extremely important’, ‘moderately important’, ‘neutral’, ‘slightly unimportant’ or ‘not at all important’). Following each of the 12 topic areas, an open-ended response was available to indicate any missing research gaps. An open-ended response option was also provided at the end of the survey to allow participants to comment on or suggest any missing topic areas. Additionally, we collected demographic data including title, primary institution affiliation, years involved in health systems work, subject(s) and region(s) of expertise. We pilot-tested the Round I survey tool with 10 participants knowledgeable in both UHC and implementation science to assess the validity and reliability of the tool. Feedback from the pilot was used to refine the survey tool.

In all surveys, participants received a personalised email with a single-user, unique link to the survey. Participants were assigned a participant number, so multiple rounds could be attributed to each individual while maintaining anonymity. The Round I and II surveys were designed to take approximately 20 min. We sent reminder emails every 2 weeks for up to three reminders to invitees who had not yet responded. We used the REDCap 13.1.27 web-based application to create, administer and manage the surveys in Rounds I and II.

The Round II survey tool was developed iteratively based on Round I responses, and the workshop was developed iteratively from Round II responses (figure 2).

Figure 2. Iterative steps of the three-round modified Delphi study.

For the research gaps that passed from Round I, respondents were provided with both their Round I responses and the average response from the panel. This was not possible for new gaps that arose from open-ended responses in Round I; these gaps were designated as ‘NEW’ gaps within the survey.

Workshop

For the final phase of the Delphi study, we presented Round II research gaps in repeated virtual workshops, inviting all Round I participants who completed the surveys to participate. Given that this was a multi-country study with participants in different time zones, we scheduled an identical, 2 hour workshop for three separate times at varying hours to account for different time zones. We began each workshop with a short debrief of the Delphi study to date, then participants ranked the research gaps in each of the four topic areas using the online platform Alchemer, which allowed real-time ranking analyses. To simplify the ranking process of gaps in the workshop, we collapsed the research gaps from 13 topics into four broader thematic topic areas. Each of the four topics had between 9 and 11 items to be ranked in the synchronous virtual workshop. Following each of the four ranking exercises, we shared the live results and invited panelists to participate in a conversation about the results. The workshops were conducted in November 2023.

Data analysis

Round I closed-ended responses were analysed using descriptive statistics. We set a predetermined cut-off of 75% agreement for items to move into Round II, as previous research has demonstrated that consensus increases after at least a 75% agreement point.¹⁸ We defined ‘agreement’ as 75% of participants considering the research gap item to be ‘moderately’ or ‘extremely’ important. Thematic analysis was used to identify emerging research gaps and topic areas from the open-ended responses.

Quantitative data in Round II were analysed using the same approach. However, given our objective to move towards greater consensus, we found that a 75% agreement cut-off was not sufficiently restrictive (only removing two research gaps from the 58 posed to participants).¹⁵ We, therefore, internally compared how the range of research gaps changed when applying a 75%, 80%, 85% and 90% cut-off point, and we determined that an 85% cut-off point allowed the analysis to move forward with reaching consensus, without too restrictively diminishing the number of research gaps. The open-ended responses were analysed thematically.

21 participants attended the workshops (22.1% participation rate). Results from the workshop were analysed using weighted ranking analysis (where the indicated score is an average of the ranking/performance score) to identify the top-ranked five research gaps from each topic, totalling 20 research gaps, from the virtual workshop results. To account for the three separate workshop sessions, the top 20 research gaps across all sessions were shared via Alchemer for a final 5 min ranking survey with the full panel of 95 panellists between December 2023 and January 2024. A total of 41 participants responded (39% response rate). A weighted ranking analysis approach in Alchemer was used to identify the top 10 ranked gaps across all four topic areas.

Weighted ranking analysis is the approach used for analysing ranking exercises, such as the one employed in the virtual workshop. The process involves assigning the most points to an item ranked as ‘first’ by a participant, and fewer points to each subsequent ranked item. All points are added up per item to arrive at a final ‘score’. This was adapted to get a combination of a rank with a weight as we prioritised items. The system helped us to ascertain the relative importance of each item as scored by participants.¹⁹

Patient and public involvement

Patients and the public were not involved in designing and conducting this study. Participants did not receive any compensation.

Results

We invited 272 individuals to participate in the modified Delphi survey in Round I and 95 individuals for Round II. Round I response rate was 34.9% (n=272), while Round II response rate was 77.9% (n=95). The difference in demographic characteristics was not significant. In both rounds, participants affiliated with academic/research institutions were the majority (Round I 61.1% and Round II 62.2%), and donors were the least represented with 2.1% in Round I and 1.4% in Round II. Participants who self-identified as females were the majority (51.6%) in Round I while males were the majority (51.4%) in Round II. Participants reported expertise across the six WHO regions; the African region had the majority of respondents (43.2% in Round I and 44.6% in Round II). Most participants in both rounds had expertise in health systems, followed by implementation science/research, equity and UHC, policy analysis, health financing and UHC, human resources and UHC, the political economy of health and ‘other’ (e.g., primary healthcare, health economics, epidemiology, health technology assessment) (table 1). The evolving consensus over three rounds is summarised in figure 2.

Table 1. Demographic characteristics of the multi-country Delphi panel, Rounds I and II.

Characteristic	Round I, n=95 (%)	Round II, n=74 (%)
Gender
Male	43 (45.3)	38 (51.4)
Female	49 (51.6)	35 (47.3)
Non-binary	0 (0.0)	0 (0.0)
Prefer not to disclose	3 (3.2)	1 (1.4)
Primary institution affiliated
Academic/research institution	58 (61.1)	46 (62.2)
National policy and health system	12 (12.6)	8 (10.8)
NGO/civil society	7 (7.4)	6 (8.1)
Global institution	7 (7.4)	5 (6.8)
Research funders	2 (2.1)	1 (1.4)
Other	9 (9.5)	8 (10.8)
Years of experience
<5 years	5 (5.3)	5 (6.8)
5–10 years	21 (22.1)	16 (21.6)
10+ years	69 (72.6)	53 (71.6)
Area of expertise (multiple responses permitted)
Health systems	64 (67.4)	48 (64.9)
Implementation science/research	48 (50.5)	37 (50.0)
Equity and UHC	45 (47.4)	35 (47.3)
Health financing and UHC	42 (44.2)	35 (47.3)
Policy analysis	43 (45.3)	34 (45.9)
Human resources and UHC	27 (28.4)	20 (27.0)
Political economy of health	17 (17.9)	14 (18.9)
Other	11 (11.6)	11 (14.9)
Region of expertise (multiple responses permitted)
Africa	41 (43.2)	33 (44.6)
Global (not region-specific)	26 (27.4)	18 (24.3)
Southeast Asia	23 (24.2)	20 (27.0)
The Americas	19 (20.0)	14 (18.9)
Europe	14 (14.7)	7 (9.5)
East Mediterranean	10 (10.5)	8 (10.8)
Western Pacific	9 (9.5)	8 (10.8)

NGO, Non-Governmental Organization.

Delphi survey Round I

A total of 95 panellists responded to the Round I survey (34.9% response rate). The 64 research gaps posed to them in this round spanned 12 topic areas: (1) the impact of financial risk protection (FRP) interventions on health; (2) utilisation and equity; (3) properties and features of FRP interventions; (4) achieving equitable outcomes in UHC interventions; (5) equitable access to healthcare; (6) effectiveness of UHC interventions; (7) role of state and non-state actors; (8) role of the private sector in UHC service delivery; (9) task-shifting for UHC, interventions on recruiting and retaining health workers in underserved areas; (10) health information infrastructure; (11) patients’ and providers’ perceptions and experiences and (12) implementation science research capacity and ecosystem. Using the 75% cut-off point of 75%, 43 research gaps across 12 topic areas passed from Round I to Round II.

The qualitative analysis resulted in adding 15 new research gaps and one new topic area (determining infrastructure, governance, leadership and management for UHC) for the next round. We also used open-ended comments to revise some of the original research gaps. Revisions to original research gaps typically involved merging research gaps and adding a clarifying example. A detailed description of the analysis of open-ended comments is described in our methodological paper;¹⁵ all research gaps and their modifications are shared in online supplemental file 1.

Delphi survey Round II

A total of 74 panelists responded to the Round II survey (77.9% response rate). The open-ended suggestions did not bring up new gaps. Using a cut-off of 85%, 42 gaps across 13 topic areas were passed to the workshop. We reorganised the 42 gaps under four overarching topic areas for discussion at the virtual workshop. The four topic areas were: (1) examining health workers’ roles in advancing UHC; (2) FRP interventions; (3) achieving equitable access and outcomes from UHC interventions and (4) determining infrastructure, governance, leadership and management for UHC with one research gap.

Virtual workshop and follow-up survey

A total of 21 participants (n=95) joined one of the synchronous virtual workshops (22.1% response rate), and 41 participants (n=95) responded to the follow-up survey (43.2% response rate). A weighted ranking analysis approach was used to identify the top 10 ranked gaps traceable in three of the four workshop topic areas, including ‘Financial risk protection interventions’ with four research gaps, ‘Achieving equitable access and outcomes from UHC interventions’ with five research gaps and ‘Determining infrastructure, governance, leadership and management for UHC’ with one research gap. Table 2 outlines the top 10 research gaps.

Table 2. Top 10 implementation science research gaps by topic area with weighted scores.

Topic area	Research gap	Score*
Understanding/characterising features of financial risk protection (FRP) interventions and impacts on health, health systems and equity	The health impacts of FRP interventions on patient and/or population outcomes, including, for example, (1) the health impacts of FRP interventions that prioritise proportionate Universalism approaches and (2) the impact of FRP intervention payment mechanisms on health outcomes (e.g., capitation, fee-for-service schemes for provider payment).	593
	The extent to which FRP interventions reach those who stand to benefit the most.	508
	The impact of different financing models for financial risk protection (FRP) interventions on UHC (e.g., focusing on estimating resource requirements and input cost; examining approaches to mobilising resources for FRP interventions; examining tiered insurance schemes).	505
	The impact of essential/minimum healthcare benefit packages on achieving financial protection.	502
Achieving equitable access and outcomes from UHC interventions	The impact of UHC implementation strategies on quality-related outcomes over time, and within and between subpopulations.	474
	The equity effects of integrated service delivery models on patient and/or population outcomes.	473
	The effects of integrated service delivery models on access to care (e.g., the factors that underpin ‘successful’ integrated service delivery models).	466
	The impact of prevention and health promotion interventions to advance UHC, including: (1) Interventions that address the social determinants of health and (2) intersectoral interventions.	450
	Approaches for accounting for and measuring equity (e.g., in priority-setting processes and in assessing quality of care).	403
Determining infrastructure, governance, leadership and management for UHC	The impact of different governance approaches on UHC (e.g., decentralised modes of governance, social accountability mechanisms like social audits, governance approaches that minimise corruption), including how to create government structures that systematically seek and address feedback from patients, populations and providers.	451

^*Weighted scores assign the most points to an item ranked highest by a participant, and the fewest points to the item ranked lowest (e.g., in the workshop ranking exercise, an item ranked as number 1 out of 20 items would receive 20 points, and an item ranked as number 20 would receive 1 point). The scores here represent the total points received by each item by all participants’ rankings.

Discussion

This study aimed to advance knowledge in implementing UHC interventions by co-creating an impactful implementation science research agenda to address UHC and health equity. We used a modified Delphi approach to identify a ‘top 10’ list of implementation science priority research gaps spanning three topic areas.

The first topic area, ‘FRP interventions and impacts’, included the four research gaps that were the highest-ranked items. FRP is central to achieving UHC. Standard FRP metrics include out-of-pocket (OOP) expenditure, catastrophic OOP spending and poverty lines. The financial protection dimension of UHC is attained when people face no financial barriers to accessing healthcare services.^{7 20} However, the 2023 global monitoring report—tracking UHC—shows that since the launch of the SDGs in 2015, financial protection has worsened for those who accessed health services.²¹ Implementation science research can give insights into the progress and impacts of FRP interventions, and what works where and why, which is a shift from traditional economic evaluations that leave out important contextual factors. Consistent with the research gaps identified as high priority by our Delphi panel, researchers have highlighted the need to measure the equity impacts of interventions that aim to eliminate catastrophic expenses or avoid impoverishment due to OOP expenses, and to understand the barriers faced by people forgoing needed care for financial reasons.^{22 23} One of the scoping reviews used to generate the preliminary list of implementation science research⁷ indicated clear literature gaps on the impact of FRPs. Specifically, it highlighted a lack of evidence on the influence of health services that contribute to OOP expenditures, the impact of chronic conditions and multimorbidity on elevated OOP expenses, the contribution of non-medical services such as transportation and meals to overall health-related OOP costs and the potential role of insurance premiums or entry fees—currently excluded from standard OOP expenditure calculations—in shaping FRP outcomes.

The second topic area, ‘Achieving equitable access and outcomes from UHC interventions’, had the highest (five) number of research gaps. Advancing equity in the delivery of essential health services is paramount to achieving UHC.^{6 11} Pursuing UHC implies trade-offs that might not be favourable to populations made structurally vulnerable.^{24 25} The research gaps ranked as highly important by our Delphi panellists acknowledge the importance of understanding the effects, impact and outcomes of UHC interventions on population health and equity through implementation science approaches. The provision of equitable quality care requires an understanding of the multifaceted interplay of factors that influence patients’ health and their experience of healthcare services,²⁶ and health systems cannot improve health without providing quality healthcare.³ Throughout the SDGs, health-related targets suggest the need for intersectoral interventions to address population health challenges.¹ Many of the research gaps ranked highly by participants in this section exemplify, for example, ‘the impact of prevention and health promotion interventions to advance UHC, including interventions that address the social determinants of health and intersectoral interventions’. Previous studies highlighted that assessing unmet needs and forgone care is key to promoting equity in service coverage.^{21 27 28}

The third topic area, ‘Determining infrastructure, governance, leadership and management for UHC’, included one research gap about the impact of different governance approaches on UHC. Building strong health system governance to speed up progress towards UHC requires focusing on specific countries and global-level collaboration.²⁹ Several governments have implemented health system governance reforms and interventions,³⁰ but the question of whether those governance structures could be effectively translated to other contexts, what worked and why can be answered by applying implementation science approaches to assess the implementation processes and outcomes and their impacts on health and equity. Decentralisation, for example, has been lauded in some cases for improving accountability and stakeholder participation, but its impact on equity is not clear.^{29 31} Moreover, decentralisation is not always aligned with UHC reforms, and as such, its benefits are unequal and favour urban populations, constraining progress in OOP expense reduction and expansion of coverage.³¹ Although health system governance does not explicitly feature strongly within UHC dimensions, SDG #16 underlines the need for ‘effective, accountable and inclusive institutions at all levels’.¹

The identified research priorities advance knowledge in implementation science to strengthen UHC in various contexts, thereby impacting key SDG addressing poverty (SDG1), health and well-being (SDG3), gender equality (SDG5) and reducing inequalities (SDG10). FRP is covered by SDG indicator 3.8.2 and is one of the core components of UHC. FRP interventions have the potential to reduce OOP payments, lower catastrophic health expenditures and prevent families from falling into deeper poverty as a result of paying for healthcare.^{7 32} By reducing financial barriers, FRP interventions contribute to improving health outcomes and equitable access to needed healthcare services. This is crucial in reducing maternal mortality (SDG#3.1), ending preventable deaths in newborns and children (SDG#3.2) and reducing premature mortality from non-communicable diseases (SDG#3.4), making FRP a driver for other SDG3 targets.³³ Additionally, the impact of FRP extends beyond health to other SDGs.³⁴ First, by preventing households from falling into poverty, effective FRP interventions reduce poverty levels, thus contributing to SDG#1. Second, effective FRP interventions contribute to achieving equitable access outcomes for the marginalised and disadvantaged groups, impacting the achievement of gender equality and empowering all women and girls (SDG#5) and reducing health-related inequalities within a country (SDG#10).^{35 36} Further, achieving UHC necessitates a multidimensional and integrated approach that encompasses the formulation and execution of effective policy frameworks, the establishment of robust accountability mechanisms and the equitable allocation of resources. These components are underpinned by strong health system governance, which serves as the foundation for sustainable and inclusive health reforms. This governance framework is applicable across a broad spectrum of stakeholders, including national governments and policymakers, ministries of health, healthcare providers, civil society organisations, international development partners, academic and research institutions, and community representatives, each of whom plays a critical role in advancing the UHC agenda. Effective health system governance advances inclusive societies and strengthens institutions by fostering policies that ensure equitable distribution and access to healthcare for all, contributing to achieving SDG#16.^{36 37}

Our study has several strengths. To arrive at the research gaps, we used two scoping reviews supplemented by a targeted literature review and deployed two conceptual frameworks to organise our list of research gaps. We used multiple strategies to identify the expert sample. The study also has some limitations. Given that the majority of participants were from Africa, there is some geographical bias in our findings, and there might be confirmation bias risks, considering that we had a high representation from academia/research institutions compared with funders. These patterns are similar to those in other modified Delphi studies.³⁸ It is difficult to assess whether the overrepresentation of certain groups in our participant sample may affect the uptake of the research agenda. It is undetermined how the final top 10 research agenda represents the views of those who had been selected to be part of the Delphi study, since we registered a high drop-off rate (43.2% response rate). The response rate for Round I and the final survey is low compared with the average Delphi studies for health research.³⁹ This may be due to the ‘wide net’ approach employed to recruit global experts in implementation science and UHC. The techniques we employed to increase participant response rate are reported in our methodological paper.¹⁵ To incorporate participants’ qualitative feedback from Round I, we thematically reorganised, consolidated, shortened, reformatted and paraphrased the topic areas and research gaps. It is possible that inadvertent changes to the underlying theme were made during this process. However, our approach to involving multiple members of the team in developing these themes should have mitigated this.

Conclusion

To the best of our knowledge, this is the first global study to identify implementation science research gaps for UHC. A three-phased modified approach was used to rank the top implementation science research gaps. The majority of the research gaps are focused on assessing equity in the delivery of health services and FRP interventions. There continues to be a pressing need to use implementation science in assessing UHC interventions. Apart from directly informing the research and training directions at individual institutions, this research agenda can deepen multi-institutional partnerships and establish a critical mass of partners, researchers, knowledge users and trainees to work collectively to use implementation science evidence to achieve UHC and the SDGs. The results provide a framework to stimulate further discourse and collaborative research among key stakeholders involved in UHC within and between countries. The research agenda may require further discussion with country-level actors (e.g., policymakers, policy implementers, patients, communities, Non-Governmental Organization (NGOs)) to contextualise them further. By improving our understanding of what works, where and why, researchers can leverage implementation science to improve progress towards UHC for all.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.