Status of Routine Immunization Coverage in the World Health Organization African Region Three Years into the COVID-19 Pandemic.

Data from the WHO and UNICEF Estimates of National Immunization Coverage (WUENIC) 2022 revision were analyzed to assess the status of routine immunization in the WHO African Region disrupted by the COVID-19 pandemic. In 2022, coverage for the first and third doses of the diphtheria-tetanus-pertussis-containing vaccine (DTP1 and DTP3, respectively) and the first dose of the measles-containing vaccine (MCV1) in the region was estimated at 80%, 72% and 69%, respectively (all below the 2019 level). Only 13 of the 47 countries (28%) achieved the global target coverage of 90% or above with DTP3 in 2022. From 2019 to 2022, 28.7 million zero-dose children were recorded (19.0% of the target population). Ten countries in the region accounted for 80.3% of all zero-dose children, including the four most populated countries. Reported administrative coverage greater than WUENIC-reported coverage was found in 19 countries, highlighting routine immunization data quality issues. The WHO African Region has not yet recovered from COVID-19 disruptions to routine immunization. It is critical for governments to ensure that processes are in place to prioritize investments for restoring immunization services, catching up on the vaccination of zero-dose and under-vaccinated children and improving data quality.

When a Toolkit Is Not Enough: A Review on What Is Needed to Promote the Use and Uptake of Immunization-Related Resources.

INTRODUCTION: Evidence-based resources, including toolkits, guidance, and capacity-building materials, are used by routine immunization programs to achieve critical global immunization targets. These resources can help spread information, change or improve behaviors, or build capacity based on the latest evidence and experience. Yet, practitioners have indicated that implementation of these resources can be challenging, limiting their uptake and use. It is important to identify factors that support the uptake and use of immunization-related resources to improve resource implementation and, thus, adherence to evidence-based practices. METHODS: A targeted narrative review and synthesis and key informant interviews were conducted to identify practice-based learning, including the characteristics and factors that promote uptake and use of immunization-related resources in low- and middle-income countries and practical strategies to evaluate existing resources and promote resource use. RESULTS: Fifteen characteristics or factors to consider when designing, choosing, or implementing a resource were identified through the narrative review and interviews. Characteristics of the resource associated with improved uptake and use include ease of use, value-added, effectiveness, and adaptability. Factors that may support resource implementation include training, buy-in, messaging and communication, human resources, funding, infrastructure, team culture, leadership support, data systems, political commitment, and partnerships. CONCLUSION: Toolkits and guidance play an important role in supporting the goals of routine immunization programs, but the development and dissemination of a resource are not sufficient to ensure its implementation. The findings reflect early work to identify the characteristics and factors needed to promote the uptake and use of immunization-related resources and can be considered a starting point for efforts to improve resource use and design resources to support implementation.

Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria.

BACKGROUND: The importance of immunization for child survival underscores the need to eliminate immunization inequalities. Few existing studies of inequalities use approaches that view the challenges and potential solutions from the perspective of caregivers. This study aimed to identify barriers and context-appropriate solutions by engaging deeply with caregivers, community members, health workers, and other health system actors through participatory action research, intersectionality, and human-centered design lenses. METHODS: This study was conducted in the Demographic Republic of Congo, Mozambique and Nigeria. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. We analyzed the data using the UNICEF Journey to Health and Immunization Framework. RESULTS: Caregivers of zero-dose and under-immunized children faced multiple intersecting and interacting barriers related to gender, poverty, geographic access, and service experience. Immunization programs were not aligned with needs of the most vulnerable due to the sub-optimal implementation of pro-equity strategies, such as outreach vaccination. Caregivers and communities identified feasible solutions through co-creation workshops and this approach should be used whenever possible to inform local planning. CONCLUSIONS: Policymakers and managers can integrate HCD and intersectionality mindsets into existing planning and assessment processes, and focus on overcoming root causes of sub-optimal implementation.

Integration of a Digital Health Intervention Into Immunization Clinic Workflows in Kenya: Qualitative, Realist Evaluation of Technology Usability.

BACKGROUND: In an effort to increase vaccination coverage in low-resource settings, digital tools have been introduced to better track immunization records, improve data management practices, and provide improved access to vaccination coverage data for decision-making. Despite the potential of these electronic systems to improve the provision of health services, few digital health interventions have been institutionalized at scale in low- and middle-income countries. OBJECTIVE: In this paper, we aimed to describe how health care workers in Kenya had integrated an electronic immunization registry into their immunization clinic workflows and to use these findings to inform the development of a refined program theory on the registry's usability. METHODS: Informed by realist methodology, we developed a program theory to explain usability of the electronic immunization registry. We designed a qualitative study based on our theory to describe the barriers and facilitators influencing data entry and use. Qualitative data were collected through semistructured interviews with users and workflow observations of immunization clinic sessions. Our findings were summarized by context-mechanism-outcome relationships formed after analyzing our key themes across interviews and workflow observations. Using these relationships, we were able to identify common rules for future implementers. RESULTS: Across the 12 facilities included in our study, 19 health care workers were interviewed, and 58 workflow sessions were observed. The common rules developed from our qualitative findings are as follows: rule 1-ensure that the users complete training to build familiarity with the system, understand the value of the system and data, and know where to find support; rule 2-confirm that the system captures all data needed for users to provide routine health care services and is easy to navigate; rule 3-identify work-arounds for poor network, system performance, and too few staff or resources; and rule 4-make users aware of expected changes to their workflow, and how these changes might differ over time and by facility size or number of patients. Upon study completion, we revised the program theory to reflect the importance of the goals and workflows of electronic immunization registries aligning with reality. CONCLUSIONS: We created a deeper understanding of the underlying mechanisms for usability of the registry. We found that the electronic immunization registry had high acceptability among users; however, there were numerous barriers to using the system, even under ideal conditions, causing a misalignment between the system and the reality of the users' workflows and their environment. Human-centered design and human-factors methods can assist during pilot stages to better align systems with users' needs and again after scale-up to ensure that interventions are suitable for all user settings.

Time Utilization Among Immunization Clinics Using an Electronic Immunization Registry (Part 2): Time and Motion Study of Modified User Workflows.

BACKGROUND: Digital health interventions have the potential to improve the provision of health care services through digitized data collection and management. Low- and middle-income countries are beginning to introduce electronic immunization registries (EIRs) into their routine immunization services to better capture and store childhood vaccination information. Especially in Africa, where 25% of children remain unimmunized or underimmunized, technologies that can help identify children due for a vaccination are particularly important for improving vaccination coverage. However, an improved understanding of the effectiveness of these systems is needed to develop and deploy sustainable EIRs in low- and middle-income countries. OBJECTIVE: We conducted an interventional pretest-posttest design study that sought to improve time efficiency through workflow modifications in Kenyan immunization clinics. Our aim was to describe how activity times differed after introducing workflow modifications that could potentially reduce the time needed to perform routine data entry activities. Our intent was to demonstrate changes in efficiency when moving from the existing dual-data entry workflow to a future paperless workflow by health facility size and experience length of health care workers (HCWs). METHODS: We tested how 3 workflow modifications would affect time utilization among HCWs using the EIR at the point of care compared with baseline immunization clinic workflows. Our outcome of interest was the time taken to complete individual activities and a patient's total time in the clinic where we compared the time spent during the baseline workflow with that during the modified workflow. We used a standardized tool to observe and document the immunization clinic workflow. To estimate differences in time utilization, we used bivariate analyses and fit multivariate linear mixed-effects models. RESULTS: Our study found that for HCWs using an EIR, the introduction of modified workflows decreased the amount of time needed to provide services to children seen in the immunization clinic. With a baseline mean time of 10 minutes spent per child, this decreased by about 3 minutes when the preparation modification was introduced and almost 5 minutes for the paperless and combined modifications. Results pertaining to the EIR's performance and ability to connect to the internet were particularly insightful about potential causes of delays. CONCLUSIONS: We were able to conduct a concise clinical simulation exercise by introducing modified workflows and estimating their impact on time utilization in immunization clinics using an EIR. We found that the paperless workflow provided the largest time savings when delivering services, although this was threatened by poor EIR performance and internet connectivity. This study demonstrated that not only should digital health interventions be built and adapted for particular use cases but existing user workflows also need to adapt to new technology.

Changes in on-time vaccination following the introduction of an electronic immunization registry, Tanzania 2016-2018: interrupted time-series analysis.

BACKGROUND: Digital health interventions (DHI) have the potential to improve the management and utilization of health information to optimize health care worker performance and provision of care. Despite the proliferation of DHI projects in low-and middle-income countries, few have been evaluated in an effort to understand their impact on health systems and health-related outcomes. Although more evidence is needed on their impact and effectiveness, the use of DHIs among immunization programs has become more widespread and shows promise for improving vaccination uptake and adherence to immunization schedules. METHODS: Our aim was to assess the impact of an electronic immunization registry (EIR) using an interrupted time-series analysis to analyze the effect on proportion of on-time vaccinations following introduction of an EIR in Tanzania. We hypothesized that the introduction of the EIR would lead to statistically significant changes in vaccination timeliness at 3, 6, and > 6 months post-introduction. RESULTS: For our primary analysis, we observed a decrease in the proportion of on-time vaccinations following EIR introduction. In contrast, our sensitivity analysis estimated improvements in timeliness among those children with complete vaccination records. However, we must emphasize caution interpreting these findings as they are likely affected by implementation challenges. CONCLUSIONS: This study highlights the complexities of using digitized individual-level routine health information system data for evaluation and research purposes. EIRs have the potential to improve vaccination timeliness, but analyses using EIR data can be complicated by data quality issues and inconsistent data entry leading to difficulties interpreting findings.

A realist systematic review of evidence from low- and middle-income countries of interventions to improve immunization data use.

BACKGROUND: The use of routine immunization data by health care professionals in low- and middle-income countries remains an underutilized resource in decision-making. Despite the significant resources invested in developing national health information systems, systematic reviews of the effectiveness of data use interventions are lacking. Applying a realist review methodology, this study synthesized evidence of effective interventions for improving data use in decision-making. METHODS: We searched PubMed, POPLINE, Centre for Agriculture and Biosciences International Global Health, and African Journals Online for published literature. Grey literature was obtained from conference, implementer, and technical agency websites and requested from implementing organizations. Articles were included if they reported on an intervention designed to improve routine data use or reported outcomes related to data use, and targeted health care professionals as the principal data users. We developed a theory of change a priori for how we expect data use interventions to influence data use. Evidence was then synthesized according to data use intervention type and level of the health system targeted by the intervention. RESULTS: The searches yielded 549 articles, of which 102 met our inclusion criteria, including 49 from peer-reviewed journals and 53 from grey literature. A total of 66 articles reported on immunization data use interventions and 36 articles reported on data use interventions for other health sectors. We categorized 68 articles as research evidence and 34 articles as promising strategies. We identified ten primary intervention categories, including electronic immunization registries, which were the most reported intervention type (n = 14). Among the research evidence from the immunization sector, 32 articles reported intermediate outcomes related to data quality and availability, data analysis, synthesis, interpretation, and review. Seventeen articles reported data-informed decision-making as an intervention outcome, which could be explained by the lack of consensus around how to define and measure data use. CONCLUSIONS: Few immunization data use interventions have been rigorously studied or evaluated. The review highlights gaps in the evidence base, which future research and better measures for assessing data use should attempt to address.

Partnership and Participation-A Social Network Analysis of the 2017 Global Fund Application Process in the Democratic Republic of the Congo and Uganda.

Background: The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 as a public-private partnership between governments, the private sector, civil society, and populations affected by the three diseases. A key principle of the Global Fund is country ownership in accessing funding through "engagement of in-country stakeholders, including key and vulnerable populations, communities, and civil society." Research documenting whether diverse stakeholders are actually engaged and on how stakeholder engagement affects processes and outcomes of grant applications is limited. Objective: To examine representation during the 2017 Global Fund application process in the Democratic Republic of the Congo (DRC) and Uganda and the benefits and drawbacks of partnership to the process. Methods: We developed a mixed-methods social network survey to measure network structure and assess perceptions of how working together in partnership with other individuals/organizations affected perceived effectiveness, efficiency, and country ownership of the application process. Surveys were administered from December 2017-May 2018, initially to a set of central actors, followed by any individuals named during the surveys (up to 10) as collaborators. Network analyses were conducted using R. Findings: Collaborators spanning many organizations and expertise areas contributed to the 2017 applications (DRC: 152 nodes, 237 ties; Uganda: 118 nodes, 241 ties). Participation from NGOs and civil society representatives was relatively strong, with most of their ties being to different organization types, Uganda (63%), and DRC (67%), highlighting their collaborative efforts across the network. Overall, the perceived benefits of partnership were high, including very strong ratings for effectiveness in both countries. Perceived drawbacks of partnership were minimal; however, less than half of respondents thought partnership helped reduce transaction costs or financial costs, suggesting an inclusive and participatory process may come with short-term efficiency tradeoffs. Conclusions: Social network analysis can be useful for identifying who is included and excluded from the process, which can support efforts to ensure stronger, more meaningful engagement in future Global Fund application processes.

How to evaluate the implementation of complex health programmes in low-income settings: the approach of the Gavi Full Country Evaluations.

Vaccination, like most other public health services, relies on a complex package of intervention components, functioning systems and committed actors to achieve universal coverage. Despite significant investment in immunization programmes, national coverage trends have slowed and equity gaps have grown. This paper describes the design and implementation of the Gavi Full Country Evaluations, a multi-country, prospective, mixed-methods approach whose goal was to monitor and evaluate processes, inputs, outputs and outcomes of immunization programmes in Bangladesh, Mozambique, Uganda and Zambia. We implemented the Full Country Evaluations from 2013 to 2018 with the goal of identifying the drivers of immunization programme improvement to support programme implementation and increase equitable immunization coverage. The framework supported methodological and paradigmatic flexibility to respond to a broad range of evaluation and implementation research questions at global, national and cross-country levels, but was primarily underpinned by a focus on evaluating processes and identifying the root causes of implementation breakdowns. Process evaluation was driven by theories of change for each Gavi funding stream (e.g. Health Systems Strengthening) or activity, ranging from global policy development to district-level programme implementation. Mixing of methods increased in relevance and rigour over time as we learned to build multiple methods into increasingly tailored evaluation questions. Evaluation teams in country-based research institutes increasingly strengthened their level of embeddedness with immunization programmes as the emphasis shifted over time to focus more heavily on the use of findings for programme learning and adaptation. Based on our experiences implementing this approach, we recommend it for the evaluation of other complex interventions, health programmes or development assistance.

Determinants of Facility-Level Use of Electronic Immunization Registries in Tanzania and Zambia: An Observational Analysis.

BACKGROUND: As more countries transition from paper-based to electronic immunization registries (EIRs) to collect and track individual immunization data, guidance is needed for successful adoption and use of these systems. Little research is available on the determinants of EIR use soon after introduction. This observational study assesses the determinants of facility health care workers' use of new EIRs in Tanzania and Zambia, implemented during 2016 to 2018. METHODS: We used EIR data entered between 2016 and 2018 from 3 regions in Tanzania and 1 province in Zambia to measure weekly EIR system use for a total of 50,639 facility-weeks. We joined secondary data on facility characteristics and applied the Performance of Routine Information System Management framework to categorize characteristics as organizational, technical, or behavioral. We used a generalized estimating equations logistic regression model to assess facility characteristics as potential determinants of system use. RESULTS: In both countries, the estimated odds of weekly EIR use declined weekly after EIR introduction. In Tanzania, health centers and hospitals had increased odds of system use compared to dispensaries. For each additional health care worker trained in a facility during the EIR introduction, the estimated odds of weekly EIR use increased. Tanzanian facilities that had transitioned entirely to paperless reporting had higher odds of sustained use compared to those maintaining parallel electronic and paper-based reporting systems. In Zambia, distance from the district health office was significantly associated with decreasing odds of system use. There were significant differences in EIR use by district in both countries. DISCUSSION: The results highlight the importance of organizational and behavioral factors in explaining sustained EIR use. As EIRs are introduced in new settings, we recommend indicators of engagement and use be built directly into the system so they can be routinely monitored, and course corrections can be implemented as needed.

Perceptions of factors influencing the introduction and adoption of electronic immunization registries in Tanzania and Zambia: a mixed methods study.

BACKGROUND: As technology has become cheaper and more accessible, health programs are adopting digital health interventions (DHI) to improve the provision of and demand for health services. These interventions are complex and require strong coordination and support across different health system levels and government departments, and they need significant capacities in technology and information to be properly implemented. Electronic immunization registries (EIRs) are types of DHI used to capture, store, access, and share individual-level, longitudinal health information in digitized records. The BID Initiative worked in partnership with the governments of Tanzania and Zambia to introduce an EIR at the sub-national level in both countries within 5 years as part of a multi-component complex intervention package focusing on data use capacity-building. METHODS: We aimed to gather and describe learnings from the BID experience by conducting a framework-based mixed methods study to describe perceptions of factors that influenced scale-up of the EIR. Data were collected through key informant interviews, a desk review, EIRs, and health management information systems. We described how implementation of the EIRs fulfilled domains described in our conceptual framework and used cases to illustrate the relationships and relative influence of domains for scale-up and adoption of the EIR. RESULTS: We found that there was no single factor that seemed to influence the introduction or sustained adoption of the EIR as many of the factors were interrelated. For EIR introduction, strong strategic engagement among partners was important, while EIR adoption was influenced by adequate staffing at facilities, training, use of data for supervision, internet and electricity connectivity, and community sensitization. CONCLUSIONS: Organizations deploying DHIs in the future should consider how best to adapt their intervention to the existing ecosystem, including human resources and organizational capacity, as well as the changing technological landscape during planning and implementation.

The impact of an integrated electronic immunization registry and logistics management information system (EIR-eLMIS) on vaccine availability in three regions in Tanzania: A pre-post and time-series analysis.

BACKGROUND: Since 2016, the Government of Tanzania has been implementing TImR, an integrated Electronic Immunization registry-logistics management information system (EIR-LMIS) that includes stock notifications. The objective of this study is to estimate the impact of this intervention on vaccine availability. METHODS: Monthly stock-out data were collected from paper registers at facilities, an Excel-based system at districts, and the new system (TImR) across all 924 health facilities in Arusha, Tanga and Kilimanjaro Regions. Six months of stockout rates pre- and post-introduction, by antigen, were compared via a two-way analysis of variance (ANOVA). A mixed-effects logistic regression model with the TImR data identified predictors of vaccine availability across antigens. FINDINGS: Post-introduction, ANOVA models estimated that overall stock-out rates declined from a monthly average of 7.1% to 2.1% (p < 0.01). Three specific vaccines had fewer stock-outs; OPV's monthly average dropped from 12.5% to 2.1% (p < 0.01), MR from 9.4% to 1.0% (p < 0.01) and DTP-HepB-HiB from 8.1% to 1.7% (p < 0.01). In the mixed-effects logistic regression model, controlling for antigen, odds of stock-out were 4.1% (95% CI: 3.3 - 4.9) lower for each week of tenure. Compared to DTP-HepB-HiB vaccine, odds of BCG vaccine being stocked out were 4.31 as high (95% CI: 3.1 - 5.0). The odds of being stocked-out were 29.7% lower for PCV (95% CI: 8.8 - 45.8) and 26.6% (95% CI: 3.4 - 44.1) lower for rotavirus vaccines compared to DTP-HepB-HiB. The odds of stock out were 37.7% lower for MR vaccine than DTP-HepB-HiB (95% CI: 18.1 - 52.6). CONCLUSIONS: Tanzania's integrated EIR-eLMIS may increase vaccine availability compared to its paper and Excel based system. Post-introduction of an eLMIS, the odds of a vaccine stock-out reduced over time. Further research could determine the impact of this intervention on vaccine wastage and replenishment response times.

Redefining vaccination coverage and timeliness measures using electronic immunization registry data in low- and middle-income countries.

Vaccine coverage is routinely used as a performance indicator for immunization programs both at local and global levels. For many national immunization programs, there are challenges with accurately estimating vaccination coverage based on available data sources, however an increasing number of low- and middle-income countries (LMICs) have begun implementing electronic immunization registries to replace health facilities' paper-based tools and aggregate reporting systems. These systems allow for more efficient capture and use of routinely reported individual-level data that can be used to calculate dose-specific and cohort vaccination coverage, replacing the commonly used aggregate routine health information system data. With these individual-level data immunization programs have the opportunity to redefine performance measures to enhance programmatic decision-making at all levels of the health system. In this commentary, we discuss how measures for assessing vaccination status and program performance can be redefined and recalculated using these data when generated at the health facility level and the implications of the use and availability of electronic individual-level data.

Childhood vaccines in Uganda and Zambia: Determinants and barriers to vaccine coverage.

BACKGROUND: Improving childhood vaccine coverage is a priority for global health, but challenging in low and middle-income countries. Although previous research has sought to measure determinants of vaccination, most has limitations. We measure determinants using a clearly-defined hypothetical model, multi-faceted data, and modeling strategy that makes full use of the hypothesis and data. METHODS: We use linked, cross-sectional survey data from households, health facilities, patients and health offices in Uganda and Zambia, and Bayesian Structural Equation Modeling to quantify the proportion of variance in childhood vaccination that is explained by key determinants, controlling for known confounding. RESULTS: We find evidence that the leading determinant of vaccination is different for different outcomes. For three doses of pentavalent vaccine, intent to vaccinate (on the part of the mother) is the leading driver, but for one dose of the vaccine, community access is a larger factor. For pneumococcal conjugate vaccine, health facility readiness is the leading driver. Considering specifically-modifiable determinants, improvements in cost, facility catchment populations and staffing would be expected to lead to the largest increase in coverage according to the model. CONCLUSIONS: This analysis measures vaccination determinants using improved methods over most existing research. It provides evidence that determinants should be approached in the context of relevant outcomes, and evidence of specific determinants that could have the greatest impact in these two countries, if targeted. Future studies should seek to improve our analytic framework, apply it in different settings, and utilize stronger study designs. Programs that focus on a particular determinant should use these results to select an outcome that is appropriate to measure their effectiveness. Vaccination programs in these countries should use our findings to better target interventions and continue progress against vaccine preventable diseases.

Researcher and policymaker dialogue: the Policy BUDDIES Project in Western Cape Province, South Africa.

Dialogue and exchange between researchers and policy personnel may increase the use of research evidence in policy. We piloted and evaluated a programme of formalised dialogue between researchers and provincial health policymakers in South Africa, called the buddying programme. An external evaluation examined implementation and short-term impact, drawing on documents, in-depth interviews with policymakers, a researcher buddies focus group and our own reflection on what we learnt. We set up buddying with seven policymakers and five researchers on six policy questions. Researchers knew little about policymaking or needs of policymakers. Policymakers respected the contact with researchers, respected researchers' objectivity and appreciated the formalised approach. Having policymaker champions facilitated the dialogue. Scenarios for policy questions and use were different. One topic was at problem identification stage (contraceptives and HIV risk), four at policy formulation stage (healthy lifestyles, chronic illness medication adherence, integrated care of chronic illness and maternal transmission of HIV to infants) and one at implementation stage (task shifting). Research evidence were used to identify or solve a policy problem (two scenarios), to legitimise a predetermined policy position (three scenarios) or the evidence indirectly influenced the policy (one scenario). The formalised dialogue required in this structured buddying programme took time and commitment from both sides. The programme illustrated the importance of researchers listening, and policymakers understanding what research can offer. Both parties recognised that the structured buddying made the dialogue happen. Often the evidence was helpful in supporting provincial policy decisions that were in the roll-out phase from the national government.

Why do policies change? Institutions, interests, ideas and networks in three cases of policy reform.

Policy researchers have used various categories of variables to explain why policies change, including those related to institutions, interests and ideas. Recent research has paid growing attention to the role of policy networks-the actors involved in policy-making, their relationships with each other, and the structure formed by those relationships-in policy reform across settings and issues; however, this literature has largely ignored the theoretical integration of networks with other policy theories, including the '3Is' of institutions, interests and ideas. This article proposes a conceptual framework integrating these variables and tests it on three cases of policy change in Burkina Faso, addressing the need for theoretical integration with networks as well as the broader aim of theory-driven health policy analysis research in low- and middle-income countries. We use historical process tracing, a type of comparative case study, to interpret and compare documents and in-depth interview data within and between cases. We found that while network changes were indeed associated with policy reform, this relationship was mediated by one or more of institutions, interests and ideas. In a context of high donor dependency, new donor rules affected the composition and structure of actors in the networks, which enabled the entry and dissemination of new ideas and shifts in the overall balance of interest power ultimately leading to policy change. The case of strategic networking occurred in only one case, by civil society actors, suggesting that network change is rarely the spark that initiates the process towards policy change. This analysis highlights the important role of changes in institutions and ideas to drive policymaking, but hints that network change is a necessary intermediate step in these processes.

Epistemic communities in global health and the development of child survival policy: a case study of iCCM.

Nearly all African countries have recently implemented some form of integrated community case management of childhood illness (iCCM), a strategy aimed at reducing child mortality by providing curative care for common yet fatal childhood illnesses. This case study describes the evolution of iCCM at the global level using the theory of epistemic communities first outlined by Haas, which explains how international policy coordination on technical issues takes place via transnational expert networks. We draw from in-depth interviews with global policy-makers (n = 25), a document review (n = 72) and co-authorship network analysis of scientific articles on iCCM. We find that members of the iCCM epistemic community were mainly mid- to upper-level technical officers working in the headquarters of large norm-setting bodies, implementing partners, funders and academic/research groups in global health. Already linked by pre-existing relationships, the epistemic community was consolidated as conflicts were overcome through structural changes in the network (including or excluding some members), changes in the state of technology or scientific evidence, shifting funding considerations, and the development of consensus through argument, legitimation and other means. Next, the epistemic community positioned iCCM as a preferred solution via three causal dynamics outlined by Haas: (1) responding to decision-makers' uncertainty about how to reduce child mortality after previous policies proved insufficient, (2) using sophisticated analytic tools to link the problem of child mortality to iCCM as a solution and (3) gaining buy-in from major norm-setting bodies and financial and institutional support from large implementing agencies. Applying the epistemic communities framework to the iCCM case study reveals the strengths and weaknesses of a focused policy enterprise with highly specialized and homogenous disciplinary origins, allowing for efficient sharing of complex, high-level scientific information, but possibly excluding voices with relevant methodological, operational or country-level perspectives.

Policy entrepreneurs and structural influence in integrated community case management policymaking in Burkina Faso.

Policy entrepreneurs are individuals who attempt to influence the policy process and its outcomes through their opportunistic or incremental actions. Their success in the policy-making process has been associated with the convergence of four factors: behavioural traits; institutional factors; network position and political capital. Policy entrepreneurs have received little study in low- and middle-income country policy research despite observations of individualized decision-making, informal institutions and the unequal distribution and exercise of power in policymaking. This article aims to identify whether policy entrepreneurs were present in the policy process around integrated community case management (iCCM) in Burkina Faso, whether they were successful in achieving policy change, and whether success or failure can be explained using existing policy entrepreneur frameworks from high-income polities. This mixed methods policy study collected data from in-depth qualitative interviews and social network surveys of actors involved in iCCM policymaking [known locally as C-integrated management of childhood illness (IMCI)]; data were analysed based on the framework categories. Interview data pointed to one key individual who played a significant role in the inclusion of pneumonia treatment into the country's iCCM policy, an issue that had been a point of contention between government policy elites and development partners. Social network data confirmed that this actor was strategically located in the policy network to be able to reach the most other actors and to be able to control the flow of information. Although some development partner actors were as strategically located, none had the same level of authority or trust as was imbued by being a member of the government civil service. The entrepreneur's mid-level rank in the health ministry may have encouraged him/her to invest political capital and take risks that would not have been feasible or attractive to a more senior actor. This study highlights the convergence of factors needed to be an entrepreneur, as well as the role of development partner actors in creating a facilitating environment.

Exchanging and using research evidence in health policy networks: a statistical network analysis.

BACKGROUND: Evidence-informed health policymaking is a goal of equitable and effective health systems but occurs infrequently in reality. Past research points to the facilitating role of interpersonal relationships between policy-makers and researchers, imploring the adoption of a social network lens. This study aims to identify network-level factors associated with the exchange and use of research evidence in policymaking. METHODS: Data on social networks and research use were collected from seventy policy actors across three health policy cases in Burkina Faso (child health, malaria, and HIV). Networks were graphed for actors' interactions, their provision of, and request for research evidence. Exponential random graph models estimated the probability of evidence provision and request between actors, controlling for network- and individual-level covariates. Logistic regression models estimated actors' use of research evidence to inform policy. RESULTS: Network structure explained more than half of the evidence exchanges (ties) observed in these networks. Across all cases, a pair of actors was more likely to form a provision tie if they already had a request tie between them and visa versa (θ=6.16, p<0.05; θ=2.87, p<0.05; θ=2.31, p<0.05). The child health network displayed clustering tendencies, meaning that actors were more likely to form ties if they shared an acquaintance (θ=2.36, p<0.05). Actors' use of research evidence was positively associated with their centrality (i.e., connectedness). CONCLUSIONS: The exchange and use of research evidence in policymaking can be partly explained by the structure of actors' networks of relationships. Efforts to support knowledge translation and evidence-informed policymaking should consider network factors.