Supporting the Use of Research Evidence (SURE) for Policy in African Health Systems

A Collaborative project funded by the European Commission - Research Seventh Framework Programme to support EVIPNet Africa (Evidence-Informed Policy Network) and REACH (Regional East African Community Health Policy Initiative)

List of partners: Partner organisation name Country Nasjonalt kunnskapssenter for Norway helsetjenesten (KS) Makerere University, Faculty of Medicine Uganda (REACH) Ministère de la Santé Publique (MSP-Cam) Cameroon

Ministère de la Santé (MS-BF) Burkina Faso

Faculté des Sciences de la Santé (FACSS- Centrafrique RCA)

Ethiopian Health & Nutrition Research Ethiopia Institute (EHNRI) Ministéro da Saúde (MISAU) Mozambique

Zambia Forum for Health Research Zambia (ZAMFOHR) Institut Fédératif de Recherche (IFR) France

World Health Organisation (WHO) WHO

Karolinska Institutet (KI) Sweden

McMaster University (MU) Canada

Key Points • Achieving universal and equitable access to health care, improving the quality of health care, and using health care resources wisely require well-informed decisions. • Access to and use of reliable evidence is needed to inform decisions about health systems, as well as for clinical and public health decisions. • SURE will support well-informed policy decisions in African health systems by:
Producing relevant, reliable, accessible and timely research syntheses for policymakers
Developing and evaluating the effectiveness of strategies for improving access to and use of research evidence in policy development
Developing capacity for evidence-informed health policy development in Africa • We will do this in conjunction with the Evidence-Informed Health Policy Network (EVIPNet) and the Regional East African Community Health (REACH) Policy Initiative – two international initiatives that aim to improve the use of research evidence in policy decisions about health systems through partnerships between policymakers, researchers and civil society. • We will evaluate these initiatives to learn systematically from their experience about how best to improve the use of research evidence to inform health policy decisions across different contexts in low and middle-income countries.

Concept and objectives Universal and equitable access to health care, health-related Millennium Development Goals (MDGs) and other national health goals are unlikely to be achieved without evidence-informed health policies and actions. 1-4 Unfortunately, health policies are often not well-informed by research evidence. 4-7 Poorly informed decision-making is one of the reasons why services fail to reach those most in need, health indicators are off track, and it appears unlikely that many countries in Africa will meet the health MDGs. 8 Reasons for this include problems with the production and accessibility of relevant research, and problems with the use of research evidence by policymakers. 4-7

The goal of the Supporting the Use of Research Evidence in African Health Systems (SURE) project is to improve decisions about health systems in Africa by improving policymakers access to and use of research evidence that is relevant, reliable, accessible and timely. The project is linked to the Evidence-Informed Health Policy Network (EVIPNet) 9 and the Regional East African Community Health (REACH) Policy Initiative. 10,11

The specific scientific/technological objectives of SURE are to:
Produce relevant, reliable, accessible and timely research syntheses
Develop and evaluate the effectiveness of five strategies for improving access to and use of research evidence in policy development: • User-friendly formats for research syntheses • Clearing houses for research syntheses and policy relevant research • Rapid response mechanisms to meet policymakers’ needs for research evidence within short time frames (hours or days) • Deliberative forums involving policymakers and researchers with the involvement of civil society and the general public • Supporting civil society’s and the general public’s access to and use of research evidence
Develop capacity for evidence-informed health policy development in Africa
Evaluate collaborative initiatives between policymakers and researchers when using the above and other strategies to support evidence-informed health policy

Use of research evidence to inform health policy decisions needs to be strengthened Available knowledge to improve health systems and services in low and middle-income countries (LMIC) is often not accessed or applied by decision makers. This failure is one of the reasons why services fail to reach those most in need. Sub-Saharan Africa spends on average approximately €80 per person and Asia €190 compared to €2700 for OECD high-income countries. 12 With limited resources and a substantial healthcare burden, it is vital that LMICs spend their healthcare budgets wisely. Sadly, this is all too often not the case. Access to health services is not equitable and is to a great extent frustrated by inefficient health systems. 13 Once individuals do gain access, care is often substandard and expensive. Effective and cheap interventions, such as magnesium sulphate for eclampsia and pre-eclampsia, are often not used, or are simply not available. 14 Meanwhile many ineffective or expensive interventions (e.g. routine episiotomy, bronchodilators for infants, intravenous fluids rather than oral rehydration solutions for diarrhoea in children) continue to be widely used. More account needs to be taken of research evidence when selecting and promoting interventions, and the factors that facilitate their use, including health system capacities.

To make well-informed decisions regarding how best to provide universal and equitable access to health care and health financing, public policymakers need access to robust evidence about interventions and strategies that work and about those that may be potentially useful. They need, too, to understand how to fit these solutions into complex and under-resourced health systems. Evidence is needed to clarify what services and programs to offer or cover, how to deliver those services, financial arrangements, governance arrangements, and how to implement change. 2 Systematic reviews can be used to inform decisions for key questions within each of these domains. 2-5 While policy decisions will always be influenced by factors other than evidence, including political, economic, cultural and sociological factors, strengthening the use of research evidence is a critical challenge that holds the promise of leading to significant health gains.

Research synthesis is a research process to support policy decisions Systematic reviews of research evidence constitute a more appropriate source of research evidence for decision-making than the latest or most heavily publicized research study. 15,16 By systematic reviews, we mean reviews of the research literature with an explicit question, an explicit description of the search strategy, an explicit statement about what types of research evidence were included and excluded, a critical examination of the quality of the studies included in the review, and a critical and transparent process of interpretation of the findings of the studies included in the review.

But policy needs more than a presentation of the best research evidence; it needs to take account of context. For this a research synthesis is required. Research syntheses go beyond systematic reviews, such as Cochrane reviews, 17-20 in that they are intended to support decision-making in a specific context. 21 Thus research evidence needs to be interpreted in relationship to the specific context, and evidence that is specific to this context needs to be incorporated, including evidence of the presence of modifying factors, needs (prevalence, baseline risk or status), values, costs and the availability of resources. 22 Systematic reviews are essential but not sufficient for research syntheses to support health policy decisions. Although policy decisions need to be made in a specific context, much of the evidence that informs health policy decisions, particularly systematic reviews, and the methods used to synthesize evidence and support its use can be shared across countries. LMICs face common challenges, including limited capacity to synthesize and support the use of research evidence. Research synthesis is also used to describe the process that is used to summarise research, which is itself a research process requiring skill and careful judgement. The process includes problem formulation, data collection, data evaluation, analysis and interpretation, and public presentation. 23 More recently the terms “policy synthesis”, “decision support synthesis” and “evidence synthesis” have been used in the context of health care management and policy-making. 24,25 We have chosen to use the term “research synthesis” to emphasize our focus on systematically summarising research evidence relevant to priority health policy decisions in LMIC.

A systematic review of the best research evidence from around the world is the best starting point for the judgements about effects and likely modifying factors required by a research synthesis. Policies based on a subset of the available evidence are more prone to random errors, 26 and judgements about whether to base a conclusion on a subset of observations are better informed if the overall observations are known. 27 Systematic reviews and research syntheses have several advantages. Firstly, they reduce the risk of bias in selecting and interpreting the results of studies. Secondly, they reduce the risk of being misled by the play of chance in identifying studies for inclusion, or the risk of focusing on a limited subset of relevant evidence. Thirdly, systematic reviews provide a critical appraisal of the available research and place individual studies or subgroups of studies in the context of all of the relevant evidence. Finally, they allow others to appraise critically the judgements made in selecting studies and the collection, analysis and interpretation of the results. Similarly, research syntheses differ from regular policy briefs in that they involve systematic and transparent efforts to contextualize the results of systematic reviews and to integrate that evidence with setting-specific evidence to support well-informed policy decisions.

SURE will support the improvement of health policy in LMICs by increasing their ability to access and use research syntheses by developing, piloting and evaluating strategies designed to strengthen access to and use of relevant research syntheses in policymaking.

The successful development and validation of such strategies across different LMIC contexts would have potentially widespread impacts not only in terms of demonstrating how evidence can be more effectively put to use, but also enhancing the returns to research investments made by major funders. For example, the WHO Commission for Macroeconomics and Health has estimated that the total return on health investments in developing countries is 18% per annum. 28 By collaborating closely with LMIC policymakers and two major LMIC policy networks to develop and evaluate tools to improve the routine use of research evidence in health policy, SURE offers the European Union a potentially large return on both current and future research investment in LMICs.

This collaborative project will build on and support EVIPNet and REACH This collaborative project is linked to and builds upon two existing initiatives - EVIPNet and REACH - that both aim to promote the use of evidence in health policy decisions.

EVIPNet is a demonstration programme launched by the World Health Organization (WHO) and the ministries of health in several African and Asian countries to promote the use of scientific evidence in health policy formulation with the ultimate aim of strengthening health systems and improving service coverage. 9,29 At the country level EVIPNet takes the form of partnerships between policymakers, researchers and civil society focused on facilitating use of high quality research evidence. Launched in 2005 in the Asian region, and supported by a group of international experts, EVIPNet now supports activities in Asia, Sub-Saharan Africa and Latin America. To-date the focus of activities has been on sensitizing and training policymakers and supporting the development of country-specific implementation plans.

REACH was established within the newly formed East African Health Research Commission in the East African Community (EAC) (Kenya, Tanzania and Uganda, with the recent addition of Rwanda and Burundi) to bridge the gap between evidence and health policy and practice. 10,11 Its mission is to access, synthesise, package and communicate evidence required for policy and practice and for influencing policy relevant research agendas for improved population health and health equity. Although REACH was not formally established until 2007, it has been under development since 2001 and builds on the experience of the Tanzania Essential Health Interventions Project (TEHIP). 30 REACH is represented by Makerere University, Uganda (partner 2) in SURE. All five countries in the EAC will be actively involved in the project.

EVIPNet has built on the experience of REACH and been assisted by REACH in its establishment in both Asia and Africa. The two initiatives have worked collaboratively since 2005. Although similar initiatives are emerging in other countries, these initiatives are unique with respect to their focus on supporting governments in LMIC to use research evidence for health policy decisions, the scope of their activities, and their collaborative efforts to develop and evaluate methods for supporting the use of research evidence to inform health policy decisions. 31

These two initiatives already have some activities underway. Specific countries, such as Vietnam in Asia, and Kenya, Tanzania and Uganda (REACH) in East Africa have succeeded in attracting sufficient donor funding support to enable them to launch relatively substantial programmes of activity. Other countries participating in EVIPNet, have lower levels of funding and more modest programmes of work, although there are strong links with the ministry of health in all of the participating countries. If SURE is successful in securing funding, it will build on REACH and EVIPNet, generating new knowledge that will inform their activities and similar activities in other countries. It will thus contribute directly to improved practices and decision making in 11 African countries (six EVIPNet countries and REACH, which includes five countries), and indirectly in these and other LMIC.

SURE focuses on the African region and specifically the countries of Burkina Faso, Cameroon, Centrafrique, Ethiopia, Mozambique, and Zambia; and the Regional East African Community (Kenya, Tanzania, Uganda, Ruanda and Burundi). In terms of objectives, it focuses on developing and evaluating strategies that better enable policymakers to access, assess and apply research evidence in their daily work. 1.2 Progress beyond the state-of-the-art Health policies are influenced by a variety of factors – values and beliefs, stakeholder power, institutional constraints, and donor funding flows, among others. Research evidence is not sufficient, but it is essential if health policies are to be well-informed. Where resources are most scarce, it is arguably even more important that research evidence informs policy-making in order to ensure the wise use of limited resources. Unfortunately, evidence-informed action is rare. Research evidence is lacking for a number of policy questions and impact evaluations still need to be a more integral part of policy implementation. 32 Where research evidence exists for policy questions, it is not always in a form that it is easy for policy-makers and stakeholders (including civil society groups) to acquire, assess, or use. 5 When policymakers seek research evidence it often perceived not to be provided quickly enough for decision-making processes, 5,6,31,33-37 decision making processes may hinder appropriate consideration of research evidence, 38-41 public opinion and civil society may not be well-informed or effectively included in deliberations, 42,43 and mechanisms may not be in place to support collaboration between policymakers and researchers.6,44

Several theories have been put forward to explain the role of research evidence in policy-making and common wisdom about how to improve the appropriate use of research evidence is not hard to find, although empirical evidence to support it is difficult to find, 45 and comes largely from interview studies in high income countries, 5,6 although there is a growing number of studies being undertaken in LMIC. 14,46-50 Systematic reviews of these studies suggest that: 5,6 • interactions between researchers and policy-makers increases the prospects for research use by policy-makers; • timing and timeliness increases (and poor timing or lack of timeliness decreases) the prospects for research use by policy-makers; • policy-makers’ negative attitudes towards research evidence decrease the prospects for research use by policy-makers; • policy-makers’ lack of skills and expertise decrease the prospects for research use by policy-makers; • policy networks, trust in the researcher increases the prospects for research use by policy-makers, while lack of perceived relevance, use of jargon, and only publishing for a scholarly audience decreased the prospects for research use by policy-makers; and • relationships with or involvement of health care staff in the research process increase the prospects for research use by managers, whereas a lack of support by the management and front-line staff who had influence in the area where change is required decrease the prospects for research use by managers.

Activities aimed at improving the use of research evidence to inform policy have been referred to as knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. 51 There is confusion and misunderstanding about these concepts,51 and the literature addressing these concepts is diverse and widely dispersed. 52 Several frameworks have been put forward for organising approaches to improving the use of research evidence by policymakers, including a stakeholder approach, 53 a decision-making framework, 54 a framework for dissemination and utilization, 55 a knowledge translation framework, 56 a framework for knowledge transfer, 57 a framework for context-based evidence-based decision-making, 58 an evidence-informed policy and practice pathway, 59 a knowledge to action process, 51 and a framework for assessing country-level efforts to link research to action. 60 These frameworks have overlapping purposes and concepts.

SURE will use Lavis and colleagues’ framework for assessing country-level efforts to link research to action to describe and evaluate the range of activities in which EVIPNet and REACH are engaged. 60 This framework includes four elements: the general climate for research use, the production of research that is both highly relevant to and appropriately synthesized for research users, the mix of efforts used to link research to action, and evaluation of efforts to link research to action. Efforts to link research to action are considered in four clusters of activities: push efforts (e.g. researchers tailoring their message according to user needs), efforts to facilitate pull (e.g. efforts to train users to access research evidence), user-pull efforts, and exchange efforts.

How SURE will advance the state-of-the-art for supporting the use of research evidence for health policy decisions Although a number of strategies have been proposed to improve the use of research evidence for health policy decisions, 60 and many are supported by reviews of studies that examine factors that influence the use of research, 5,6 they have not been evaluated. 60 SURE will advance the state-of-the-art by evaluating strategies for improving the use of research evidence for health policy decisions prospectively over five years in 11 African countries. In addition, we will build research and practical experience for each of the strategies described below. Each of these strategies has been used, mostly in high-income countries, but to only a very limited extent in the contexts of LMIC. Significant questions remain unanswered concerning how best to adapt these mechanisms to contexts where the nature of policy making, the cultural context, societal expectations and the skills of policymakers, researchers and civil society may be very different and SURE will provide new research data to inform the effective use of strategies that aim to increase the use of evidence in policy. We will adapt these strategies for reducing the gap between research and policy to LMIC contexts, and we will test them across a variety of LMIC settings, as described in the work plan beginning on page 13.

1.2.1 Research syntheses Although it has become commonplace to use systematic reviews to inform health technology assessment (HTA) and clinical practice guidelines, 31,61 systematic methods are rarely used to prepare research syntheses for health policy decisions. 2-7 The methods that are used for systematic reviews of health systems questions are also less well developed. 25,61 The Cochrane Effective Practice and Organisation of Care (EPOC) Group has developed methods for policy relevant systematic reviews, 62 and continues to develop those methods. The Norwegian satellite of EPOC based at the Norwegian Knowledge Centre for the Health Services, (a partner in SURE) was recently established with the aim of supporting the production of reviews that are relevant to health policy decisions in LMIC, 63 and will support the African partners in undertaking policy relevant research syntheses.

As noted earlier, research syntheses go beyond systematic reviews, such as Cochrane reviews, in that they are intended to support decision-making in a specific context. In the research syntheses prepared as part of SURE, research evidence from systematic reviews will be contextualised and interpreted in relationship to the specific contexts in which decisions will be made and evidence that is specific to that context will be incorporated, including evidence of the presence of modifying factors, needs (prevalence, baseline risk or status), values, costs and the availability of resources. 22 In addition, considerations that are critical to policy decisions will be incorporated, including considerations of equity, monitoring and evaluation of new policies, and scaling up. 64

SURE will advance the state-of-the-art with respect to research syntheses by testing approaches that are both scientifically rigorous and pragmatic across 11 African countries and evaluating the practical usefulness of these syntheses.

As secondary research, SURE syntheses will use scientific methods to summarise and contextualise the best available research evidence. The syntheses will address priority health policy questions in Africa and will inform answers to these. In addition, they will be used to develop and evaluate strategies for improving access to and use of research evidence in policy development, and contribute to building capacity, as described below.

1.2.2 User friendly formats for policy briefs and clearing houses Lavis and colleagues systematically reviewed studies of decision-making by health care managers and policy-makers, conducted interviews with a purposive sample of them in Canada and the United Kingdom, and reviewed the websites of research funders, producers/purveyors of research, and journals that include them among their target audiences. 5 Their systematic review and interviews suggest that removing jargon from research syntheses would increase prospects for their use by policymakers and managers. Their interviews with policymakers and managers in that study suggest that presenting systematic reviews using something like a 1:3:25 format is preferred over current approaches; i.e. one page with key messages, a three page structured summary, and a 25 page report + a longer technical report, if needed. Their analysis of websites suggested that reports using a 1:3:25 format are rare. Lavis has subsequently investigated the design of user friendly formats for HTA by interviewing policymakers in Canada (unpublished data). We are unaware of any research that has focused on the design and evaluation of user friendly formats for policymakers in LMIC. Research evidence presented in formats that are not user-friendly will not be read and will not influence policy. Prof Lavis, a partner in SURE, will work with our African partners to significantly advance research into the most effective format for research summaries aimed at policymakers in LMIC. This work has the potential to dramatically improve the chances that policymakers will read, consider and apply where appropriate the contents of research summaries when reaching policy decisions.

Existing sources that provide one-stop shopping (clearing houses) for quality-appraised systematic reviews, such as The Cochrane Library, contain a small but growing stock of systematic reviews that address one of the most important types of questions asked by health care managers and policymakers – what are the likely benefits and potential harms of a policy decision? The Library includes Cochrane reviews that have met the standards of a Cochrane review group as well as structured summaries of other systematic reviews. The reviews increasingly provide (even if they do not always highlight) some of the information most relevant to health care managers and policymakers (e.g. differential effects across different groups or settings). The reviews typically do not provide information about the contextual factors that may influence applicability in other contexts, which leaves health care managers and policy-makers to struggle through assessments of applicability to their settings on their own. Moreover, as befits a global resource, these sources of systematic reviews do not include reviews that have been adapted in ways that enhance their applicability in particular contexts. There is a growing number of efforts that provide one-stop shopping for clinical information aimed at healthcare professionals that builds on systematic reviews, contextualizes the evidence and incorporates other evidence, such as Clinical Evidence (http://www.clinicalevidence.com ), UpToDate ( http://www.uptodateinc.com ), and Evidence-Based Medicine Guidelines ( http://ebmg.wiley.com/ebmg/ltk.koti ). There are also a variety of services that are designed to provide user friendly front ends for clinicians seeking relevant evidence, including the Turning Research Into Practice (TRIP) Database (http://www.tripdatabase.com ), SUMSearch (http://sumsearch.uthscsa.edu ), and BMJ Updates (http://bmjupdates.mcmaster.ca/index.asp ). We are unaware of any comparable databases or services for policymakers and managers. 5

SURE will advance the state-of-the-art for making research evidence accessible to policymakers by refining and testing user-friendly formats for research syntheses across 11 African countries, and by developing and testing clearing houses (one stop shopping) for policy-relevant research evidence.

1.2.3 Mechanisms for responding rapidly to policymakers’ needs for research evidence Policymakers frequently face tight time frames in responding to issues that arise, for example in parliament, in the media or in relationship to real or perceived crises. Frequently they need access to research evidence that has been appraised and contextualised in a matter of hours or days, if it is going to be of value to them. Many HTA agencies have established rapid assessment processes, particularly for new technologies. 65-68 There is no common definition of “rapid assessment” and there is variation in the scope, methods and time to complete assessments. Milne and colleagues have described a range of HTA responses available in the UK, including 2-3 page assessments that take six weeks, rapid systematic reviews that take 8-10 weeks, technology assessment reviews that take six months, Cochrane reviews, and full HTA reports that can take 3 years. 69 We are not aware of any evaluations of rapid response mechanisms that are designed to respond to policymakers needs for research evidence within hours or days. Although policy development rarely needs to be undertaken so quickly, there are several reasons for considering a mechanism for responding so quickly; including developing a better understanding of policymakers needs for research evidence in their daily work, potential impacts on decisions that are made urgently when there is a real or perceived need to respond, and potential impacts on attitudes and the general climate in which policy is developed.

SURE will advance the state-of-the-art for responding rapidly to policymakers’ needs for research evidence by prospectively studying their daily needs for research evidence and by developing and evaluating mechanisms for responding rapidly to those needs, as described in WP3 (see page 22).

1.2.4 Deliberative forums that support the use of research evidence and involvement of civil society and the general public Public policymakers and stakeholders draw on research and many other types of evidence and values to inform their decision-making. 2,39 Facilitating this process could involve soliciting the other types of evidence and values by engaging those locally involved in or affected by a decision: • in the research synthesis process (e.g., setting the context, establishing the question or interpreting the results) • in a research study that examines their views and experiences in parallel with the review • in a deliberative process (such as “safe harbour forums”) that draws on the research synthesis as one input among many.

Interactions between researchers and policymakers emerged with some consistency in systematic reviews of the factors that increased the prospects for research use by policymakers, 5,6 so the first and third approaches could also increase the prospects that the research synthesis would be used. Deliberative processes are starting to be seen as providing a promising type of locally contextualized “decision support” for public policymakers as well as a way to give voice to stakeholders such as patients and the public. 39,70 While a great deal of attention and some evaluation has been paid to using deliberative processes in clinical practice guideline development, 38-41 little attention has been paid to using such processes to inform policymaking. 38,39,70

Moreover, the importance of involving patients and the general public at all levels of the health services is widely recognised. They are the ultimate beneficiary of public policies, and many governments and organisations have acknowledged the value of involving them in policy development, often through civil society. The potential benefits of this include: policy that includes their ideas or addresses their concerns; improved implementation of policies; better health services; and better health.

There is, however, little evidence of the effects of involving civil society or the general public in health policy. 72-74 Of 42 papers identified in a systematic review of involving patients in the planning and development of health care, 31 (74%) were case studies. Papers often described changes to services that were attributed to involving patients, including attempts to make services more accessible. Changes in the attitudes of organisations to involving patients and positive responses from patients who took part in initiatives were also reported. This evidence suggests that their participation may have contributed to changes in the provision of services, but the evidence is limited and almost entirely from high-income countries.

Oliver and colleagues have developed a useful framework for describing and considering different dimensions of consumer involvement, 75 and Telford and colleagues have developed a set of principles and indicators for consumer involvement. 76 While both of these have been developed in the context of consumer involvement in research, they provide useful frameworks for considering public involvement in health policy development as well. The UK National Institute for Health and Clinical Excellence (NICE) has adopted a comprehensive approach to involving patients and has a patient involvement unit aiming to involve patients and carers in the development of clinical guidelines. 77 We are not aware of any similar efforts in LMIC or in relationship to the development of health policy.

Reporting in the mass media can influence health policy, and one way in which the general public may become involved in health policy development is through the mass media. Nonetheless, HTA agencies, guideline developers and units supporting the use of research evidence in health policy have generally made negligible efforts to communicate evidence to the wider public via the mass media. 31 Although journalists are likely to agree that accurate reporting of research that is relevant to health policy is important, they have many constraints on their ability to do this. 78 Mutual efforts of researchers and journalists employing a variety of strategies are likely to be needed to address those constraints, including training and innovations such as structured press releases. 79

SURE will address these knowledge gaps by developing and evaluating methods for conducting deliberative processes that are informed by research syntheses (see WP4 on page 24). In addition, it will develop and evaluate methods for informing and involving civil society and the general public in policy development, including through the mass media. Beyond generating new knowledge, this work will lead to practical guidelines and tools that can be used in both partner and non-partner countries.

1.2.5 Initiatives to support evidence-informed health policy WHO issued the World report on knowledge for better health, with a chapter devoted to linking research to action, in 2004. 80 The Ministerial Summit on Health Research held that year in Mexico City issued a statement on the importance of research for better health and strengthening health systems. 81 In May of 2005 the 58 th World Health Assembly passed a resolution acknowledging the Mexico Statement on Health Research and urged member states “to establish or strengthen mechanisms to transfer knowledge in support of evidence-based public health and health-care delivery systems, and evidence-based health-related policies.” 82 EVIPNet arose from discussions at the Ministerial Summit in Mexico and the recognition that information about how to achieve evidence-informed health policy is limited, especially in LMIC. 9 Important questions remain unanswered about how best to improve access to and use of research evidence to inform health policy decisions in resource poor settings.

Organisations have been established in many countries and internationally to support the use of research evidence for health care decisions. These include HTA agencies, organisations that produce clinical practice guidelines (CPGs), and units that directly support the use of research evidence in developing health policy on an international, national, and state or provincial level (“government support units”). While there are important differences among these organisations, there are also commonalities and opportunities for existing and new initiatives to learn from this collective experience. In 2005 a review of this experience was undertaken for the WHO Advisory Committee on Health Research. 31 This review particularly sought out government support units (GSUs) in LMIC, using networks, personal contacts and snowballing. Thirty-eight such units were found in LMIC. The review collected data about these units using a combination of a mailed questionnaire, followed by telephone interviews and site visits with selected units.

The GSUs that were identified were based both in academic institutions (37%) and government agencies (39%). A high proportion of these GSUs provided service on many facets of policy issues: characterizing problems (74%), identifying potential solutions (82%), fitting solutions into health systems (75%), and bringing about change in health systems (88%). They were most focused on public policymakers in health departments, followed by public policymakers in central agencies (77%), stakeholders (79%) and public policymakers in other departments (63%). Only four GSUs reported having a manual describing the methods that they used. Only three GSUs described using or doing systematic reviews. Three described using non-systematic methods to review the literature. Several reported doing economic analyses and using a variety of methods, including surveys, epidemiological studies and qualitative studies.

The GSUs identified a range of different types of research or evaluation methods as strengths, including systematic reviews, measurement of health system performance, economic analyses and surveys. Other strengths noted by GSUs were having a small unit that can respond quickly, publishing drafts for public comments, close links with policymakers, independence and financial stability. The GSUs consistently described their close links with policymakers as a strength, particularly those based in government. Weaknesses that were identified by GSUs were limitations of the methods used, including: not usually providing an exhaustive literature search or critical appraisal, and use of “vote counting” instead of a more rigorous approach. GSUs also identified inadequate human resources and time as weaknesses.

Key messages from this review are that initiatives that aim to support the use of research evidence to inform health policy should: • Establish relationships with and access to policymakers and stakeholders and seeking secure public funding; • Foster the professional development of people with adequate qualifications to bridge research and policy; • Become involved in international networks both to learn from others’ experiences and to avoid duplication of effort; • Be independent and transparent about their approach and methods; and • Start small.

In addition to advancing the state-of-the-art for specific strategies for improving access to and use of research evidence in policy development, SURE will undertake a comparative evaluation of seven Africa initiatives (involving 11 countries) and an impact evaluation of two of these. In this way it will test hypotheses such as those above and broadly advance the state-of-the-art for initiatives that aim to support the use of research evidence to inform health policy decisions.

1.3 Science and technology and associated work plan

1.3.1 Overall strategy SURE comprises eight work packages. Our plans for project management are described in WP8 on page 34 and section 2.1 on page 40, and our plans for disseminating the results of this collaborative project are described in WP7 on page 31. There are six work packages with scientific/technological objectives. These six work packages and their deliverables are summarised in the figure below. WP1 focuses on the production of relevant research syntheses to address priority policy questions. Work packages 2-4 focus on the development and evaluation of strategies for improving access to and use of research evidence to inform policy decisions. WP5 focus on building capacity for evidence-informed health policy and the development and evaluation of resources for building policymakers’ capacity for accessing and using research evidence. WP6 focus on a comprehensive evaluation of the African partners’ initiatives to improve the use of research to inform health policy decisions.

The scientific/technological work required for work packages 2-6 will be managed by a research team based at REACH. A full-time researcher responsible for this work and a part-time senior coordinator will be based there. All of the partners will contribute to this work and each of the country teams in Africa will be involved in the development and evaluation of the strategies that will be delivered, as well as the comparative evaluation. Each country team in Africa will, in addition, deliver a minimum of one research synthesis per year that will be used in the development and testing of these strategies. The Coordinator Partner 1 – Nasjonalt kunnskapssenter for helsetjnesten) will be responsible for overall coordination of the project and WHO will be responsible for dissemination of the project results. All of the European partners and the Canadian partner will provide technical expertise and support.

SURE will run over five years, with the aim of all of the country teams becoming self- sustaining by the end of the five-year project. Additional reasons for proposing a five year project include providing sufficient time for: • Development, pilot testing and evaluation of strategies for improving access to and use of research evidence in policy development, • Testing these strategies on a minimum of five research syntheses per African partner, • Building capacity among the African partners, and Packaging and wide dissemination of the results of the project.

A five-year time plan will help to ensure that the strategies that are developed through this collaborative project are practical and that their use can be sustained. The collaborative project is designed to build on the combined technical expertise of the partners and to test the methods that are developed in diverse real world settings over time, to ensure that the results are both scientifically rigorous and pragmatic.

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