Learning health system for implementation, scale-up, and sustainment: a systematic review to consolidate guidance for...

Learning Health Systems (LHSs) link research and health service delivery by generating evidence to guide decision-making and continuous improvement. Although various LHS frameworks exist, there is limited practical guidance for how LHSs can improve implementation. This systematic review aimed to consolidate existing guidance to identify the infrastructure (pillars) and improvement processes (steps) required to support a LHS cycle that improves the implementation (including scale up or sustainment) of health programs, policies, or practices.

We searched five databases and grey literature for documents describing an LHS model, or a process, or process model, guideline, or tool (i.e., guidance) intended to improve the quality of implementation, scale-up, and/or sustainment of health interventions. Title, abstract, and full-text screening were conducted independently by two reviewers. Data were synthesised separately for pillars and steps. Framework synthesis identified pillars and steps, informed by an existing LHS framework and refined iteratively; thematic synthesis explored patterns within each.

From 12,151 records and 25 websites, 96 guidance documents were included. Six Pillars were identified as important to operationalise LHS improvement processes: 1-Interest holder engagement, 2-Workforce development and capacity, 3-Evidence surveillance and synthesis, 4-Data collection and management, 5-Governance and organisational processes, and 6-Cross-cutting infrastructure. The improvement process was comprised of 10 'Steps' across three LHS phases: Phase 1) Knowledge to Practice -Identify and understand the problem; Decide and plan for action; Assess and build capacity; Pilot; Phase 2) Practice to Data-Execute the action; Collect data; Monitor and respond; Phase 3) Data to Knowledge- Analyse and evaluate; Disseminate; and Decide (continue, adapt, or cease improvement efforts). Despite the diversity in purpose and context across included documents, the consolidated steps and pillars were conceptually consistent, suggesting a shared foundation. Some contextual variation in emphasis and operationalisation was noted, particularly among guidance focused on scale-up or sustainment.

This review consolidated LHS pillars and improvement steps to better implement, scale or sustain health interventions. Findings provide a structured yet adaptable approach for operationalising implementation-focused learning cycles within LHSs. It informs forthcoming WHO guidance, and supports more systematic, responsive use of evidence in health systems.

The review protocol was prospectively registered on Open Science Framework ( https://doi.org/10.17605/OSF.IO/V4JRC ).