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.

Lessons Learned From Implementing Prospective, Multicountry Mixed-Methods Evaluations for Gavi and the Global Fund.

INTRODUCTION: As global health programs have become increasingly complex, corresponding evaluations must be designed to assess the full complexity of these programs. Gavi and the Global Fund have commissioned 2 such evaluations to assess the full spectrum of their investments using a prospective mixed-methods approach. We aim to describe lessons learned from implementing these evaluations. METHODS: This article presents a synthesis of lessons learned based on the Gavi and Global Fund prospective mixed-methods evaluations, with each evaluation considered a case study. The lessons are based on the evaluation team's experience from over 7 years (2013-2020) implementing these evaluations. The Centers for Disease Control and Prevention Framework for Evaluation in Public Health was used to ground the identification of lessons learned. RESULTS: We identified 5 lessons learned that build on existing evaluation best practices and include a mix of practical and conceptual considerations. The lessons cover the importance of (1) including an inception phase to engage stakeholders and inform a relevant, useful evaluation design; (2) aligning on the degree to which the evaluation is embedded in the program implementation; (3) monitoring programmatic, organizational, or contextual changes and adapting the evaluation accordingly; (4) hiring evaluators with mixed-methods expertise and using tools and approaches that facilitate mixing methods; and (5) contextualizing recommendations and clearly communicating their underlying strength of evidence. CONCLUSION: Global health initiatives, particularly those leveraging complex interventions, should consider embedding evaluations to understand how and why the programs are working. These initiatives can learn from the lessons presented here to inform the design and implementation of such evaluations.

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.

Evaluating Global Health Partnerships: A Case Study of a Gavi HPV Vaccine Application Process in Uganda.

BACKGROUND: Global health partnerships have grown rapidly in number and scope, yet there has been less emphasis on their evaluation. Gavi, the Vaccine Alliance, is one such public-private partnership; in Gavi-eligible countries partnerships are dynamic networks of immunization actors who work together to support all stages and aspects of Gavi support. This paper describes a conceptual framework - the partnership framework - and analytic approach for evaluating the perceptions of partnerships' added value as well as the results from an application to one case in Uganda. METHODS: We used a mixed-methods case study design embedded in the Gavi Full Country Evaluations (FCE) to test the partnership framework on Uganda's human papillomavirus (HPV) vaccine application partnership. Data from document review, interviews, and social network surveys enabled the testing of the relationships between partnership framework domains (context, structure, practices, performance, and outcomes). Topic guides were based on the framework domains and network surveys identified working together relationships, professional trust, and perceptions of the effectiveness, efficiency, and legitimacy of the partnership's role in this process. RESULTS: Data from seven in-depth interviews, 11 network surveys and document review were analyzed according to the partnership framework, confirming relationships between the framework domains. Trust was an important contributor to the perceived effectiveness of the process. The network was structured around the EPI program, who was considered the leader of this process. While the structure and composition of the network was largely viewed as supporting an effective and legitimate process, the absence of the Ministry of Education (MoE) may have had downstream consequences if this study's results had not been shared with the Ministry of Health (MoH) and acted upon. The partnership was not perceived to have increased the efficiency of the process, perhaps as a result of unclear or absent guidelines around roles and responsibilities. CONCLUSION: The health and functioning of global health partnerships can be evaluated using the framework and approach presented here. Network theory and methods added value to the conceptual and analytic processes and we recommend applying this approach to other global health partnerships to ensure that they are meeting the complex challenges they were designed to address.