A Conversation with Suleiman Yusuf

In this interview, I speak with Suleiman Yusuf, a Nigerian implementation science researcher and WHO/TDR Fellow whose work sits at the intersection of evidence, equity, and real-world health systems change. Trained in epidemiology with a specialization in implementation science at the University of the Witwatersrand, Suleiman’s research focuses on how evidence-based interventions, particularly for tuberculosis, cancer screening, vaccines, and neglected tropical diseases, can be adapted and sustained in underserved settings across Africa.

His recent work, which formed the basis of his MSc thesis under the supervision of Prof. Latifat Ibisomi and Dr. Abdu A. Adamu, applies the Consolidated Framework for Implementation Research (CFIR) to examine the barriers and facilitators shaping private health providers’ participation in TB control in Nigeria. He currently contributes to global implementation efforts through his volunteer work with the Washington University Light Institute for Global Health and Transformation. His work recently won Best Poster at the Global Implementation Society’s regional gathering in Doha, Qatar.

Together, we discuss his research journey, lessons from the field, and what it takes to move implementation science from theory into impact.

Your study uses the Consolidated Framework for Implementation Research, or CFIR. For people who may not be familiar, how does CFIR help us understand why certain public health strategies succeed or struggle in real-world settings?

Thank you for that thoughtful question. Before diving into the details, it’s important to provide background on the study and its rationale, for better context.  This study utilized the Consolidated Framework for Implementation Research to explore the contextual factors influencing private providers’ involvement in the public-private mix strategy for tuberculosis (TB) control in Bauchi, Nigeria.

To begin, it’s crucial to recognize that in many low- and middle-income countries, most people first seek care from private healthcare facilities. This positions private healthcare providers as critical actors in managing high-priority diseases, including TB. However, in Nigeria— which has the second-highest TB burden in Africa and ranks sixth globally— the potential of these private providers remains largely untapped.

Traditionally, tuberculosis (TB) services in Nigeria have been provided by public facilities. However, to expand access along the TB care cascade, Nigeria adopted a public-private strategic approach. This public-private mix strategy aims to leverage the strengths of both private and public facilities in a collaborative effort to control TB, thereby increasing case detection and ultimately improving health outcomes.

Despite this, implementing this strategy in Bauchi State, Nigeria, faces significant challenges. As implementation scientists, we questioned whether the public-private mix (PP) strategy is not working effectively. While we know that this strategy has proven efficacious in other settings, we are left wondering why it isn’t yielding the same results in Bauchi, Nigeria. We have raised several questions about contextual barriers that may be affecting private providers’ actions.

To achieve our objectives, we conducted a study utilizing the Consolidated Framework for Implementation Research (CFIR) to examine the contextual factors influencing participation.

Now, addressing your question: the CFIR is a significant element in the field of implementation science. In this discipline, various frameworks exist, and the CFIR is classified as a determinant framework. This type of framework is specifically used to explore the contextual factors that determine whether an intervention will be effective in a given setting.

While there are other determinant frameworks, such as the Theoretical Domains Framework, the CFIR stands out. It provides a comprehensive approach to examining the dynamics at play. The CFIR was initially developed by Damschroder in 2009 and updated in 2022, enhancing its relevance and applicability.

So basically, the CFIR framework consists of five major domains: the inner setting, the outer setting, individual characteristics, intervention characteristics, and the implementation process. When talking about the inner setting, it involves factors related to the internal structure, culture, and organizational readiness, and how they shape an intervention’s success.

For instance, in our study, when it comes to the inner setting, we explored issues around the internal structure, having the necessary infrastructure to support implementation, which is quite important. The outer setting domain seeks to examine factors around external policies, incentives, patient needs, and resources, and how we influence the overall success of an intervention.

We also have the individual characteristics domain, which explores individual-level determinants. It focuses on the knowledge, beliefs, and self-efficacy of frontline implementers and how these factors, along with other personal attributes, influence their participation in the intervention. The underlying questions regarding these individual characteristics include: Do the implementers understand how to apply this intervention? Do they believe in its effectiveness? Do they possess self-efficacy? Additionally, what other personal attributes, such as motivation or intrinsic motivation, do they have? Together, these factors shape the individual characteristics of frontline implementers and their level of participation.

Furthermore, we must consider the characteristics of the intervention itself. For instance, what are the costs associated with the intervention? Is it expensive or complex to implement? Understanding these aspects is crucial to evaluating the intervention’s overall impact. Is it adaptable? Does it have evidence, strength, and quality? These factors shape the intervention. As implementation scientists, we understand that, whether an intervention is specific or complex, implementation plays a critical role, especially for frontline implementers. The characteristics of the intervention represent one of the key domains we examine. The final domain focuses on the implementation process itself. This involves reflecting on, evaluating, and engaging with frontline implementers and understanding how these aspects influence outcomes. To guide our assessment, we utilize the CFIR framework, which includes multiple levels of domains. This framework helps us understand why an intervention may be effective in one setting but not in another.

From your perspective, what surprised you most about the barriers that private providers encounter when participating in these public-private mixed strategies?

In our study, we had 26 contextual factors. Of these, 16 were barriers, while 10 were facilitators. So, within this system, there are many barriers across the five domains of CFIR. But I must say I’m more surprised by “inefficiencies in the diagnostic workflow.” I was so surprised… yes, we want private providers to join this PPM strategy, but does it really make sense if they don’t have access to the GeneXpert machines? This is a core diagnostic tool for TB, which ideally should be easily accessible. Even well designed interventions will struggle to hold if accessibility to key components is poor.  I remember, during the interview with one of the participants, who said they only have one private facility in Bauchi State, Nigeria, that owns a GeneXpert machine. So, you know, it’s crazy.

A state with a population of over five million has only one private facility with a GeneXpert. This highlights a significant readiness gap in the system. I was surprised that, at this stage, we are still discussing the need for GeneXpert. Some private providers mentioned that they have to send samples to another facility, which delays results. Often, when you follow up, they inform you that the results are still not ready. The entire system is disorganized, and when facilities feel that the process isn’t effective, they may choose to disengage from it.

One of the private facilities mentioned that they once collected about 50 suspected tuberculosis (TB) samples. Unfortunately, they were unable to find the proper channel to send these samples to GeneXpert for testing, they had to discard the samples. I was surprised to learn that private providers in this setting still face barriers to accessing GeneXpert services.

TB is, you know, one of many different public health challenges. Is there anything that you’ve learned that you think could be applied to other diseases, like HIV, malaria, or even primary care?

Oh, exactly. I’ve learned a lot of things. <Laugh>

One significant barrier that emerged in the study was the complexity of the reporting system. Private providers noted that they had to complete a considerable number of forms and documentation, most of which is done manually. This challenge is not limited to TB care; I believe that other health systems and programs, such as those for HIV and cancer, as well as educational institutions, are likely facing similar issues. In this context, I think it would be beneficial to implement digital reporting systems as much as possible. This could streamline the submission process, help identify the appropriate reporting bodies, and facilitate the use of these reporting systems.

 Additionally, when discussing stigma, it’s important to recognize that diseases like TB, HIV, and cancer are often stigmatized too. Providers may hesitate to offer services related to these conditions because they fear it will damage their facility’s reputation. For example, some private healthcare providers have expressed that they refrain from participating in this PPM strategy because they don’t want to be labeled as a TB care facility, which could deter potential patients or customers.

In this context, private providers face the challenge of balancing their business interests with the need to contribute to public health. Their primary goal is to make money, and anything that might deter other customers from visiting their facility is a concern for them. To address this issue, it’s crucial to engage with the community and educate them about these diseases. We need to promote the idea that such conditions should not be stigmatized and should be discussed openly. The issue of normalization should be addressed, and society should embrace people with these kinds of diseases.

Also, there is a critical issue regarding feedback in the referral process. Private providers often complain that when they refer a patient, they receive no feedback on what happened to that patient. As a result, patients can become lost in the referral system, with no updates on their status. When a provider refers a patient to a center for diagnosis or treatment, it is important to receive feedback about whether the patient has achieved the desired outcomes. This insight can be directly applied to the HIV referral cascade by ensuring that there is follow-up and feedback whenever a patient is sent for diagnostic purposes. I believe this feedback mechanism is crucial and can be implemented in other health programs as well.

One of the things that really struck me in your findings was how important personal motivation and values were at the individual level. I’ve seen that come up in my own work, too. What can systems do better to support and maintain that kind of motivation?

The truth is that our health system often underestimates personal, genuine motivation. This is a significant issue. Many private providers involved in my study stated that they participate in the PPM strategy not for incentives or personal gain, but because they truly want to help. They feel a strong sense of corporate responsibility to contribute positively to society. There is that intrinsic passion to save life. However, there are ways to improve this situation.

First, public providers should be recognized and respected as legitimate partners in this initiative. It’s essential to acknowledge their contributions to the PPM strategy. Recognition is crucial.

Secondly, there should be meaningful inclusion of private providers in the planning and key decision-making processes. Their involvement is vital for a successful partnership.

Providers feel their contributions to the health system can never be overemphasized, hence they should be included in key decision-making processes. I recall a private provider I interviewed expressing frustration over their exclusion from these important decisions. This presents an opportunity for us to advocate for their involvement.

 In addition to inclusion in decision-making, capacity building is crucial. Providing training to build their confidence will greatly benefit them. Ultimately, when providers feel safe, supported, and valued, their motivation increases, becoming a powerful driver of long-term sustainability in the health system.

If you could recommend a change or two that would strengthen these private-public partnerships, what would they be?

One of the critical barriers that emerged in our study is the complexity of the reporting system. Private providers have noted that the reporting requirements are complex. To address this, I recommend simplifying the reporting system. If feasible, we should create a centralized platform that allows these providers to fulfill their reporting duties easily.

This makes sense because, in implementation science, overly complex interventions, especially for frontline implementers, can affect implementation fidelity. Therefore, we can work towards simplifying the entire reporting process.

Additionally, another barrier identified is the lack of incentives for providers. In implementation science, issues related to incentives and costs are directly linked to the sustainability of interventions. When perceived costs outweigh rewards, engagement among target groups tends to diminish. To address this, we could institutionalize a hybrid incentive model that combines financial and non-financial rewards, such as recognition, certificates, credits, and public acknowledgment. I believe with that we can increase participation in this PPM strategy.

Additionally, it is crucial to strengthen the two-way communication and feedback mechanism. When they refer a patient or send information to a patient, they need timely feedback. This impact group is very important and plays a critical role in the PPM strategy, both in Nigeria and beyond.