Equity in research, defined as fair participation, power sharing and benefit across the research process, has become a central ambition in global health. Since 2015, implementation science has sought to place equity at the core of health programmes to benefit patients and health systems. In practice, however, equity is often addressed after interventions have been designed or evaluated. This sequencing can marginalise local expertise, limit opportunities for adaptation and expose interventions to failure at the point of delivery. Health systems shaped by decentralisation, constrained resources and shifting priorities require equity to be integrated earlier in the research lifecycle. The practical challenge lies in embedding equity in ways that are visible, measurable and useful. Limited guidance exists on how to design research with equity in mind or how to track its influence over time, leaving decision makers without clear tools to distinguish symbolic inclusion from substantive change.
From Principles to Measurable Indicators
Existing implementation frameworks, including the Consolidated Framework for Implementation Research and the Theoretical Domains Framework, do not provide clear methods for identifying who shapes decisions, how power is distributed or whether local context meaningfully influences delivery. These gaps make it difficult for policy makers, programme implementers, frontline teams, communities and funders to assess whether equity commitments translate into practice.
A practical approach has been proposed through a set of Equity-in-Implementation Indicators designed to make equity measurable across research and implementation processes. These indicators can be applied before, during and after intervention design, beginning at the planning stage and continuing through delivery and adaptation. They are aligned with four established principles drawn from the Health Equity Implementation Framework and the updated Consolidated Framework for Implementation Research: co-design with affected communities, decentralised and inclusive leadership, contextual adaptation and continuous learning.
Each principle is paired with operational indicators and application prompts that support real-time reflection. Measures linked to co-design examine stakeholder diversity, depth of engagement and the frequency of co-design sessions. Indicators related to decentralised leadership assess local decision-making autonomy, leadership capacity-building and structural equity in governance, including authorship, funding control and resource allocation. For contextual adaptation, metrics track documented adaptations, the balance between fidelity and adaptation and responsiveness to barriers. Continuous learning is assessed through feedback loop functionality, local data interpretation and the frequency of course correction. Together, these measures aim to ensure that equity guides decisions rather than remaining an aspirational objective.
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Application in Large-Scale Research Programmes
The Equity-in-Implementation Indicators have been applied in two research programmes involving more than 80 hospitals in low-income and middle-income countries. In the GIRAFFE study, which aimed to reduce postoperative mortality through locally co-designed interventions, the indicators were used from the outset to inform research design and delivery. Information generated through the indicators enabled local teams to assess decision-making roles, track changes across sites and respond as conditions evolved. Equity functioned as an active process shaping implementation rather than as a retrospective evaluation criterion.
In contrast, the same indicators were applied after the main trial in ChEETAh study, which focused on reducing surgical site infections through changes in operative practice. In that context, the indicators helped identify gaps in staff engagement and supply chains. However, these gaps were recognised too late to prevent their effects. The comparison between these programmes demonstrates that the indicators are most effective when embedded at the design stage and used throughout delivery, rather than applied retrospectively.
These experiences illustrate how structured attention to decision-making, adaptation and accountability can influence implementation processes. By examining who participates, how interventions evolve and whether learning occurs at the point of care, the indicators create transparency around equity-related dynamics that might otherwise remain implicit. Early integration allows adjustments to be made as programmes unfold, whereas delayed application limits corrective potential.
Practical Utility Across Health Contexts
The proposed indicators are described as light-touch, flexible and applicable across diverse health settings. For health professionals, they offer a straightforward method to involve local knowledge and monitor whether adaptations are appropriate and effective. For researchers, they provide a structured approach to designing studies that are both scientifically rigorous and responsive to context. For policy makers and funders, they enhance transparency by clarifying not only whether interventions reach intended populations but also who shapes their design and how they are adapted over time.
The indicators are intended to work alongside established implementation frameworks rather than in parallel. By addressing persistent challenges such as decision-making authority, contextual adaptation and accountability, they contribute a structured mechanism for embedding equity into research governance and delivery. Their relevance extends beyond surgical research to areas including maternal and child health, mental health, chronic disease management and vaccination programmes, where implementation success depends on local ownership and contextual fit. In each of these contexts, the indicators can be used to examine participation, adaptation and learning processes in a systematic manner.
Equity in global health requires deliberate and measurable actions that influence how research is governed, adapted and delivered. A structured set of Equity-in-Implementation Indicators offers a pragmatic means to operationalise equity across the research lifecycle. By aligning with established implementation principles and embedding measurement into planning and delivery, these indicators enable closer examination of decision-making, adaptation and accountability. Experiences from large-scale research programmes demonstrate that early and sustained use strengthens the capacity to distinguish symbolic participation from meaningful power sharing. In doing so, the indicators provide a practical foundation for integrating equity into global health implementation efforts.
Source: The Lancet Global Health
