Improving institutional platforms for evidence-informed decision-making: getting beyond technical solutions.

Purely technical interventions aimed at enhancing evidence-informed decision-making (EIDM) have rarely translated into organizational institutionalization or systems change. A panel of four presentations at the Health Systems Global 2020 conference provides a basis for inference about contextual factors that influence the establishment and sustainability of institutional platforms to support EIDM. These cases include local structures such as citizen panels in Uganda, regional knowledge translation structures such as the West African Health Organization, global multilateral initiatives such as the "One Health" Quadrapartite and regional public health networks in South-East Asia. They point to the importance of political economy as well as technical capability determinants of evidence uptake and utilization at institutional, organizational and individual levels. The cases also lend support to evidence that third-party (broker and intermediary) supportive institutions can facilitate EIDM processes. The involvement of third-party supranational organizations, however, poses challenges in terms of legitimacy and accountability.

Vulnerability of populations to malaria after indoor residual spraying is withdrawn from areas where its use has previously been sustained: a protocol for a systematic review.

INTRODUCTION: With its proven effectiveness, indoor residual spraying (IRS) as a malaria vector control strategy forms one of the reliable vector control strategies, especially when at least 80% of the population is covered. However, to date, there is uncertainty regarding the consequences of IRS withdrawal on malaria control when there is no clear exit strategy in place. Therefore, there is a need to comprehensively update literature regarding malaria burden indicators when IRS is withdrawn following sustained use. METHODS AND ANALYSIS: This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search of studies published between 2000 and 2022 will be performed in CINAHL, Embase, MEDLINE, ProQuest, PsychInfo, Scopus and OpenGrey. Preset eligibility criteria will be used to identify studies for inclusion by two independent reviewers. Title/abstracts will first be screened and potentially eligible ones screened using their full-text publications. Any conflicts/discrepancies at the two stages will be resolved through regular discussion sessions. Included studies will be extracted to capture study and patient characteristics and relevant outcomes (malaria incidence and malaria vector abundance). Relevant tools will be used to assess the risk of bias in the studies measuring the impact of withdrawal. A meta-analysis will be performed if sufficient homogeneity exists; otherwise, data arising will be presented using tables and by employing narrative synthesis techniques. Heterogeneity will be assessed using a combination of visual inspection of the forest plot along with consideration of the χ2 test and I2 statistic results. ETHICS AND DISSEMINATION: Ethics approval is not applicable for this study since no original data will be collected. The results will be disseminated through peer-reviewed publications and conference presentations. Furthermore, this systematic review will inform the design of exit strategies for IRS-based programmes in malaria-endemic areas. PROSPERO REGISTRATION NUMBER: CRD42022310655.

Paper 1: Demand-driven rapid reviews for health policy and systems decision-making: lessons from Lebanon, Ethiopia, and South Africa on researchers and policymakers' experiences.

BACKGROUND: Rapid reviews have emerged as an approach to provide contextualized evidence in a timely and efficient manner. Three rapid review centers were established in Ethiopia, Lebanon, and South Africa through the Alliance for Health Policy and Systems Research, World Health Organization, to stimulate demand, engage policymakers, and produce rapid reviews to support health policy and systems decision-making. This study aimed to assess the experiences of researchers and policymakers engaged in producing and using rapid reviews for health systems strengthening and decisions towards universal health coverage (UHC). METHODS: Using a case study approach with qualitative research methods, experienced researchers conducted semi-structured interviews with respondents from each center (n = 16). The topics covered included the process and experience of establishing the centers, stimulating demand for rapid reviews, collaborating between researchers and policymakers, and disseminating and using rapid reviews for health policies and interventions and the potential for sustaining and institutionalizing the services. Data were analyzed using thematic analysis. RESULTS: Major themes interacted and contributed to shape the experiences of stakeholders of the rapid review centers, including the following: organizational structural arrangements of the centers, management of their processes as input factors, and the rapid reviews as the immediate policy-relevant outputs. The engagement process and the rapid review products contributed to a final theme of impact of the rapid review centers in relation to the uptake of evidence for policy and systems decision-making. CONCLUSIONS: The experiences of policymakers and researchers of the rapid review centers determined the uptake of evidence. The findings of this study can inform policymakers, health system managers, and researchers on best practices for demanding, developing and using rapid reviews to support decision- and policymaking, and implementing the universal healthcare coverage agenda.

Measuring health science research and development in Africa: mapping the available data.

BACKGROUND: In recent years there have been calls to strengthen health sciences research capacity in African countries. This capacity can contribute to improvements in health, social welfare and poverty reduction through domestic application of research findings; it is increasingly seen as critical to pandemic preparedness and response. Developing research infrastructure and performance may reduce national economies' reliance on primary commodity and agricultural production, as countries strive to develop knowledge-based economies to help drive macroeconomic growth. Yet efforts to date to understand health sciences research capacity are limited to output metrics of journal citations and publications, failing to reflect the complexity of the health sciences research landscape in many settings. METHODS: We map and assess current capacity for health sciences research across all 54 countries of Africa by collecting a range of available data. This included structural indicators (research institutions and research funding), process indicators (clinical trial infrastructures, intellectual property rights and regulatory capacities) and output indicators (publications and citations). RESULTS: While there are some countries which perform well across the range of indicators used, for most countries the results are varied-suggesting high relative performance in some indicators, but lower in others. Missing data for key measures of capacity or performance is also a key concern. Taken as a whole, existing data suggest a nuanced view of the current health sciences research landscape on the African continent. CONCLUSION: Mapping existing data may enable governments and international organizations to identify where gaps in health sciences research capacity lie, particularly in comparison to other countries in the region. It also highlights gaps where more data are needed. These data can help to inform investment priorities and future system needs.

Governance of health research in four eastern and southern African countries.

BACKGROUND: Health research governance is an essential function of national health research systems. Yet many African countries have not developed strong health research governance structures and processes. This paper presents a comparative analysis of national health research governance in Botswana, Kenya, Uganda and Zambia, where health sciences research production is well established relative to some others in the region and continues to grow. The paper aims to examine progress made and challenges faced in strengthening health research governance in these countries. METHODS: We collected data through document review and key informant interviews with a total of 80 participants including decision-makers, researchers and funders across stakeholder institutions in the four countries. Data on health research governance were thematically coded for policies, legislation, regulation and institutions and analysed comparatively across the four national health research systems. RESULTS: All countries were found to be moving from using a research governance framework set by national science, technology and innovation policies to one that is more anchored in health research structures and policies within the health sectors. Kenya and Zambia have adopted health research legislation and policies, while Botswana and Uganda are in the process of developing the same. National-level health research coordination and regulation is hampered by inadequate financial and human resource capacities, which present challenges for building strong health research governance institutions. CONCLUSION: Building health research governance as a key pillar of national health research systems involves developing stronger governance institutions, strengthening health research legislation, increasing financing for governance processes and improving human resource capacity in health research governance and management.

[Health research in Madagascar: state-of-the-art, challenges and perspectives]. / La recherche pour la santé à Madagascar: état des lieux, défis et perspectives.

The evolution and contemporary challenges of health research (HR) in Madagascar are poorly documented. We aim to gain insights on the factors that shape Madagascar's National Health Research System (NHRS) to better understand their influence. We conducted a qualitative case study, which included a documentary review and semi-structured interviews with 38 key informants. We carried out a thematic analysis and used the WHO/AFRO NHRS Barometer to structure the presentation of the results. There is no legislative framework to support HR activities and institutions. There is, however, a policy document outlining national priorities for HS. Human resources for HR are insufficient, due to challenges in training and retaining researchers. International collaboration is almost the only source of HR funding. Collaborations contribute to developing human and institutional capacity, but they are not always aligned with research carried out locally and the country's priority health needs. Incomplete efforts to improve regulation and low public investment in research training and research implementation reflect an insufficient commitment to HR by the government. Negotiating equitable international partnerships, the availability of public funding, and aligning HR with national health priorities would constitute a solid basis for the development of the NHRS in Madagascar.

Beyond the metrics of health research performance in African countries.

While it is important to be able to evaluate and measure a country's performance in health research (HR), HR systems are complex and multifaceted in nature. As such, attempts at measurement can suffer several limitations which risk leading to inadequate indices or representations. In this study, we critically review common indicators of HR capacity and performance and explore their strengths and limitations. The paper is informed by review of data sources and documents, combined with interviews and peer-to-peer learning activities conducted with officials working in health and education ministries in a set of nine African countries. We find that many metrics that can assess HR performance have gaps in the conceptualisation or fail to address local contextual realities, which makes it a challenge to interpret them in relation to other theoretical constructs. Our study identified several concepts that are excluded from current definitions of indicators and systems of metrics for HR performance. These omissions may be particularly important for interpreting HR performance within the context and processes of HR in African countries, and thus challenging the relevance, utility, appropriateness and acceptability of universal measures of HR in the region. We discuss the challenges that scholars may find in conceptualising such a complex phenomenon-including the different and competing viewpoints of stakeholders, in setting objectives of HR measurement work, and in navigating the realities of empirical measurement where missing or partial data may necessitate that proxies or alternative indicators may be chosen. These findings are important to ensure that the global health community does not rely on over-simplistic evaluations of HR when analysing and planning for improvements in low-income and middle-income countries.

Adherence to the MDR-TB intensive phase treatment protocol amongst individuals followed up at central and peripheral health care facilities in Uganda - a descriptive study.

BACKGROUND: Following initiation of MDR-TB treatment, patients have a choice to receive follow up DOT supervision at either the central initiating facility or at a peripheral facility. OBJECTIVES: We describe the adherence patterns of MDR-TB patients undergoing DOT supervision at the two health facility categories during intensive phase of treatment. METHODS: We used a retrospective cohort of patients initiated on MDR TB treatment at Mulago National Referral Hospital between 2014 and 2016. We extracted data from the National Tuberculosis and Leprosy Program records and analysed these using STATA V14. RESULT: Majority (84.01%) of the patients received their DOT supervision from the peripheral facilities. Males made up 62.1% of patients, and 91.2% had had their household contacts screened for MDR-TB. 26.5% of the patients on peripheral DOT supervision had good adherence to treatment protocol compared to 0% among patients on central initiating health facility DOT supervision. Among the patients with good adherence, 24.1% had contacts screened for MDR-TB as compared to 3.6% with poor adherence. CONCLUSION: More patients preferred MDR-TB DOT supervision at peripheral facilities, which had better adherence to the treatment protocol compared to the central initiating facility. Younger people and those with household contacts screened had better adherence to the treatment protocol, highlighting areas for targeted interventional programs for MDR-TB in resource limited settingsMore patients preferred MDR-TB DOT supervision at peripheral facilities, which had better adherence to the treatment protocol compared to the central initiating facility. Younger people and those with household contacts screened had better adherence to the treatment protocol, highlighting areas for targeted interventional programs for MDR-TB in resource limited settings.

Pre-diagnostic drop out of presumptive TB patients and its associated factors at Bugembe Health Centre IV in Jinja, Uganda.

BACKGROUND: Drop out of presumptive TB individuals before making a final diagnosis poses a danger to the individual and their community. We aimed to determine the proportion of these presumptive TB drop outs and their associated factors in Bugembe Health Centre, Jinja, Uganda. METHODS: We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis.We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis. RESULT: Among the 216 registered presumptive TB patients who were less than 1% of patients visiting the outpatients' department, 40.7% dropped out before final diagnosis was made. Age and HIV status were significantly associated with pre-diagnostic drop out while gender and distance from the health center were not. CONCLUSION: A high risk to individuals and the community is posed by the significant proportion of presumptive TB patients dropping out before final diagnosis. Health systems managers need to consider interventions targeting young persons, male patients, HIV positive persons.

A Process Evaluation to Assess Contextual Factors Associated With the Uptake of a Rapid Response Service to Support Health Systems' Decision-Making in Uganda.

BACKGROUND: Although proven feasible, rapid response services (RRSs) to support urgent decision and policymaking are still a fairly new and innovative strategy in several health systems, more especially in low-income countries. There are several information gaps about these RRSs that exist including the factors that make them work in different contexts and in addition what affects their uptake by potential end users. METHODS: We used a case study employing process evaluation methods to determine what contextual factors affect the utilization of a RRS in Uganda. We held in-depth interviews with researchers, knowledge translation (KT) specialists and policy-makers from several research and policy-making institutions in Uganda's health sector. We analyzed the data using thematic analysis to develop categories and themes about activities and structures under given program components that affected uptake of the service. RESULTS: We identified several factors under three themes that have both overlapping relations and also reinforcing loops amplifying each other: Internal factors (those factors that were identified as over which the RRS had full [or almost full] control); external factors (factors over which the service had only partial influence, a second party holds part of this influence); and environmental factors (factors over which the service had no or only remote control if at all). Internal factors were the design of the service and resources available for it, while the external factors were the service's visibility, integrity and relationships. Environmental factors were political will and health system policy and decision-making infrastructure. CONCLUSION: For health systems practitioners considering RRSs, knowing what factors will affect uptake and therefore modifying them within their contexts is important to ensure efficient use and successful utilization of the mechanisms.

Policymaker experiences with rapid response briefs to address health-system and technology questions in Uganda.

BACKGROUND: Health service and systems researchers have developed knowledge translation strategies to facilitate the use of reliable evidence for policy, including rapid response briefs as timely and responsive tools supporting decision making. However, little is known about users' experience with these newer formats for presenting evidence. We sought to explore Ugandan policymakers' experience with rapid response briefs in order to develop a format acceptable for policymakers. METHODS: We used existing research regarding evidence formats for policymakers to inform the initial version of rapid response brief format. We conducted user testing with healthcare policymakers at various levels of decision making in Uganda, employing a concurrent think-aloud method, collecting data on elements including usability, usefulness, understandability, desirability, credibility and value of the document. We modified the rapid response briefs format based on the results of the user testing and sought feedback on the new format. RESULTS: The participants generally found the format of the rapid response briefs usable, credible, desirable and of value. Participants expressed frustrations regarding several aspects of the document, including the absence of recommendations, lack of clarity about the type of document and its potential uses (especially for first time users), and a crowded front page. Participants offered conflicting feedback on preferred length of the briefs and use and placement of partner logos. Users had divided preferences for the older and newer formats. CONCLUSION: Although the rapid response briefs were generally found to be of value, there are major and minor frustrations impeding an optimal user experience. Areas requiring further research include how to address policymakers' expectations of recommendations in these briefs and their optimal length.