Understanding and Bridging Gaps in the Use of Evidence from Modeling for Evidence-Based Policy Making in Nigeria's Health System.

Background. Modeled evidence is a proven useful tool for decision makers in making evidence-based policies and plans that will ensure the best possible health system outcomes. Thus, we sought to understand constraints to the use of models in making decisions in Nigeria's health system and how such constraints can be addressed. Method. We adopted a mixed-methods study for the research and relied on the evidence to policy and Knowledge-to-Action (KTA) frameworks to guide the conceptualization of the study. An online survey was administered to 34 key individuals in health organizations that recognize modeling, which was followed by in-depth interviews with 24 of the 34 key informants. Analysis was done using descriptive analytic methods and thematic arrangements of narratives. Results. Overall, the data revealed poor use of modeled evidence in decision making within the health sector, despite reporting that modeled evidence and modelers are available in Nigeria. However, the disease control agency in Nigeria was reported to be an exception. The complexity of models was a top concern. Thus, suggestions were made to improve communication of models in ways that are easily comprehensible and to improve overall research culture within Nigeria's health sector. Conclusion. Modeled evidence plays a crucial role in evidence-based health decisions. Therefore, it is imperative to strengthen and sustain in-country capacity to value, produce, interpret, and use modeled evidence for decision making in health. To overcome limitations in the usage of modeled evidence, decision makers, modelers/researchers, and knowledge brokers should forge viable relationships that regard and promote evidence translation. Highlights: Despite the use of modeling by Nigeria's disease control agency in containing the COVID-19 pandemic, modeling remains poorly used in the country's overall health sector.Although policy makers recognize the importance of evidence in making decisions, there are still pertinent concerns about the poor research culture of policy-making institutions and communication gaps that exist between researchers/modelers and policy makers.Nigeria's health system can be strengthened by improving the value and usage of scientific evidence generation through conscious efforts to institutionalize research culture in the health sector and bridge gaps between researchers/modelers and decision makers.

Conceptual framework for systemic capacity strengthening for health policy and systems research.

Health policy and systems research (HPSR) is critical in developing health systems to better meet the health needs of their populations. The highly contextualised nature of health systems point to the value of local knowledge and the need for context-embedded HPSR. Despite such need, relatively few individuals, groups or organisations carry out HPSR, particularly in low-income and middle-income countries. Greater effort is required to strengthen capacity for, and build the field of, HPSR by capturing the multilevel and nuanced representation of HPSR across contexts. No comprehensive frameworks were found that inform systemic HPSR capacity strengthening. Existing literature on capacity strengthening for health research and development tends to focus on individual-level capacity with less attention to collective, organisational and network levels. This paper proposes a comprehensive framework for systemic capacity strengthening for HPSR, uniquely drawing attention to the blurred boundaries and amplification potential for synergistic capacity strengthening efforts across the individual, organisational and network levels. Further, it identifies guiding values and principles that consciously acknowledge and manage the power dynamics inherent to capacity strengthening work. The framework was developed drawing on available literature and was peer-reviewed by the Board and Thematic Working Groups of Health Systems Global. While the framework focuses on HPSR, it may provide a useful heuristic for systemic approaches to capacity strengthening more generally; facilitate its mainstreaming within organisations and networks and help maintain a focused approach to, and structure repositories of resources on, capacity strengthening.

Engaging stakeholders to identify gaps and develop strategies to inform evidence use for health policymaking in Nigeria.

Introduction: recent efforts to bridge the evidence-policy gap in low-and middle-income countries have seen growing interest from key audiences such as government, civil society, international organizations, private sector players, academia, and media. One of such engagement was a two-day virtual participant-driven conference (the convening) in Nigeria. The aim of the convening was to develop strategies for improving evidence use in health policy. The convening witnessed a participant blend of health policymakers, researchers, political policymakers, philanthropists, global health practitioners, program officers, students, and the media. Methods: in this study, we analyzed conversations at the convening with the aim to disseminate findings to key stakeholders in Nigeria. The recordings from the convening were transcribed and analyzed inductively to identify emerging themes, which were interpreted, and inferences are drawn. Results: a total of 630 people attended the convening. Participants joined from 13 countries. Participants identified poor collaboration between researchers and policymakers, poor community involvement in research and policy processes, poor funding for research, and inequalities as key factors inhibiting the use of evidence for policymaking in Nigeria. Strategies proposed to address these challenges include the use of participatory and embedded research methods, leveraging existing systems and networks, advocating for improved funding and ownership for research, and the use of context-sensitive knowledge translation strategies. Conclusion: overall, better interaction among the various stakeholders will improve the evidence generation, translation, and use in Nigeria. A road map for the dissemination of findings from this conference has been developed for implementation across the strata of the health system.

The experience of a regional network of health policy and systems actors in translating evidence into policy and action in West Africa.

Objectives: To identify strategies and interventions to strengthen the generation and use of research evidence in health policy and practice decision-making and implementation in the West African sub-region (knowledge translation). Design: The study design was cross-sectional. Data sources were from a desk review, West African Network of Emerging Leaders (WANEL) member brainstorming, and group discussion outputs from WANEL members and session participants' discussions and reflections during an organised session at the 2019 African Health Economics and Policy Association meeting in Accra. Results: Strategies and interventions identified included developing a Community of Practice, a repository of health policy and systems research (HPSR) evidence, stakeholder mapping, and engagement for action, advocacy, and partnership. Approaches for improving evidence uptake beyond traditional knowledge translation activities included the use of cultural considerations in presenting research results and mentoring younger people, the presentation of results in the form of solutions to political problems for decision-makers, and the use of research results as advocacy tools by civil society organisations. Development of skills in stakeholder mapping, advocacy, effective presentation of research results, leadership skills, networking, and network analysis for researchers was also identified as important. Conclusions: To strengthen the generation and use of research evidence in health policy and practice decision-making in West Africa requires capacity building and multiple interventions targeted synergistically at researchers, decision-makers, and practitioners. Funding: Funding for the study was provided by the COMPCAHSS project (#108237) supported by IDRC.

Costs of implementing community-based intervention for HIV testing in sub-Saharan Africa: a systematic review.

BACKGROUND: Community-based interventions (CBIs) are interventions aimed at improving the well-being of people in a community. CBIs for HIV testing seek to increase the availability of testing services to populations that have been identified as at high risk by reaching them in homes, schools, or community centers. However, evidence for a detailed cost analysis of these community-based interventions in sub-Saharan Africa (SSA) is limited. We conducted a systematic review of the cost analysis of HIV testing interventions in SSA. METHODS: Keyword search was conducted on SCOPUS, CINAHL, MEDLINE, PsycINFO, Web of Science, and Global Health databases. Three categories of key terms used were cost (implementation cost OR cost-effectiveness OR cost analysis OR cost-benefit OR marginal cost), intervention (HIV testing), and region (sub-Saharan Africa OR sub-Saharan Africa OR SSA). CBI studies were included if they primarily focused on HIV testing, was implemented in SSA, and used micro-costing or ingredients approach. RESULTS: We identified 1533 citations. After screening, ten studies were included in the review: five from East Africa and five from Southern Africa. Two studies conducted cost-effectiveness analysis, and one study was a cost-utility analysis. The remainder seven studies were cost analyses. Four intervention types were identified: HIV self-testing (HIVST), home-based, mobile, and Provider Initiated Testing and Counseling. Commonly costed resources included personnel (n = 9), materials and equipment (n = 6), and training (n = 5). Cost outcomes reported included total intervention cost (n = 9), cost per HIV test (n = 9), cost per diagnosis (n = 5), and cost per linkage to care (n = 3). Overall, interventions were implemented at a higher cost than controls, with the largest cost difference with HIVST compared to facility-based testing. CONCLUSION: To better inform policy, there is an urgent need to evaluate the costs associated with implementing CBIs in SSA. It is important for cost reports to be detailed, uniform, and informed by economic evaluation guidelines. This approach minimizes biases that may lead decision-makers to underestimate the resources required to scale up, sustain, or reproduce successful interventions in other settings. In an evolving field of implementation research, this review contributes to current resources on implementation cost studies.

Exploring effectiveness of different health financing mechanisms in Nigeria; what needs to change and how can it happen?

BACKGROUND: Various attempts to examine health financing mechanisms in Nigeria highlight the fact that there is no single mechanism that fits all contexts and people. This paper sets out findings of an in-depth assessment of different health financing mechanisms in Nigeria. METHODS: The study was undertaken in the Federal Capital territory of Nigeria and two States (Niger and Kaduna). Data were collected through review of government documents, and in-depth interviews of purposively selected respondents. Data analysis was guided by a conceptual framework which draws from various approaches for assessing health financing mechanisms. Data was examined for current practices, what needs to change and how the change can happen. RESULTS: Health financing mechanisms in Nigeria do not operate optimally. Allocation and use of resources are neither evidence-based nor results-driven. Resources are not allocated equitably or in a manner that minimizes wastage and improves efficiency. None of the mechanisms effectively protects individuals/households from catastrophic health expenditure. Issues with social health insurance cut across legal frameworks and use of Health Maintenance Organisations (HMOs) as purchasers. The concomitant effect is that attainment of Universal Health Coverage is greatly compromised. In order to improve efficiency of health financing mechanisms, government needs to allocate more funds for purchasing health services; this spending must be based on evidence (strategic), and appropriately tracked. The legislation that established National Health Insurance Scheme should be amended such that social health insurance becomes mandatory for all citizens. Implementation of the latter should be complemented by revision of benefit package, strict oversight and regulation of HMOs. CONCLUSION: In order to improve health financing in the country, legal and regulatory frameworks need to be revised. Efficient utilization of resources could be improved through strategic purchasing arrangements and strict oversight.

Evaluating the sub-national fidelity of national Initiatives in decentralized health systems: Integrated Primary Health Care Governance in Nigeria.

BACKGROUND: Policy making, translation and implementation in politically and administratively decentralized systems can be challenging. Beyond the mere sub-national acceptance of national initiatives, adherence to policy implementation processes is often poor, particularly in low and middle-income countries. In this study, we explore the implementation fidelity of integrated PHC governance policy in Nigeria's decentralized governance system and its implications on closing implementation gaps with respect to other top-down health policies and initiatives. METHODS: Having engaged policy makers, we identified 9 core components of the policy (Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Structure, and Office Establishment). We evaluated the level and pattern of implementation at state level as compared to the national guidelines using a scorecard approach. RESULTS: Contrary to national government's assessment of level of compliance, we found that sub-national governments exercised significant discretion with respect to the implementation of core components of the policy. Whereas 35 and 32% of states fully met national criteria for the structural domains of "Office Establishment" and Legislation" respectively, no state was fully compliant to "Human Resource Management" and "Funding" requirements, which are more indicative of functionality. The pattern of implementation suggests that, rather than implementing to improve outcomes, state governments may be more interested in executing low hanging fruits in order to access national incentives. CONCLUSIONS: Our study highlights the importance of evaluating implementation fidelity in providing evidence of implementation gaps towards improving policy execution, particularly in decentralized health systems. This approach will help national policy makers identify more effective ways of supporting lower tiers of governance towards improvement of health systems and outcomes.

An estimate of the prevalence of hypertension in Nigeria: a systematic review and meta-analysis.

BACKGROUND: Hypertension is a leading cause of morbidity and mortality in Africa, and Nigeria, the most populous country in the continent, hugely contributes to this burden. OBJECTIVE: To provide an improved estimate of the prevalence and number of cases of hypertension in Nigeria based on the cut-off 'at least 140/90  mmHg', towards ensuring better awareness, control and policy response in the country. METHODS: We conducted a systematic search of Medline, EMBASE and Global Health from January 1980 to December 2013 for population-based studies providing estimates on the prevalence of hypertension in Nigeria. From the extracted crude prevalence rates, we conducted a random-effects meta-analysis, and further estimated the overall awareness rate of hypertension in Nigeria, expressed as percentage of all hypertension cases. We applied a meta-regression epidemiological modelling, using United Nations population demographics for the years 2010 and 2030, to determine the prevalence and number of cases of hypertension in Nigeria for the 2 years. RESULTS: Our search returned 2260 publications, 27 of which met our selection criteria. From the random-effects meta-analysis, we estimated an overall hypertension prevalence of 28.9% (25.1, 32.8), with a prevalence of 29.5% (24.8, 34.3) among men and 25.0% (20.2, 29.7) among women. We estimated a prevalence of 30.6% (24.5, 36.6) and 26.4% (19.4, 33.4) among urban and rural dwellers, respectively. The pooled awareness rate of hypertension was 17.4% (11.4, 23.3). The overall mean SBP was 128.6 (125.5, 130.8) mmHg, and the DBP was 80.6 (78.5, 82.7) mmHg. From our modelling, we estimated about 20.8 million cases of hypertension in Nigeria among people aged at least 20 years in 2010, with a prevalence of 28.0% (24.6, 31.9) in both sexes - 30.7% (24.9, 33.7) among men and 25.2% (22.7, 31.9) among women. By 2030, we projected an increase to 39.1 million cases of hypertension among people aged at least 20 years with a prevalence of 30.8% (24.5, 33.7) in both sexes - 32.6% (27.3, 38.2) among men and 29.0% (21.9-32.2) among women. CONCLUSIONS: Our findings suggest the prevalence of hypertension is high in Nigeria, and the overall awareness of raised blood pressure among hypertension cases is low in the country. We hope this study will inform appropriate public health response towards reducing this burden.