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REVIEW ARTICLE
Year : 2020  |  Volume : 61  |  Issue : 5  |  Page : 227-236  

Lessons learned from strategies for promotion of evidence-to-policy process in health interventions in the ECOWAS region: A rapid review


1 Department of Health Policy/Systems, African Institute for Health Policy and Health Systems, Ebonyi State University, CAS Campus, Abakaliki, Nigeria
2 Department of Public Health and Research, West African Health Organisation, 175, Avenue Ouezzin Coulibaly, Bobo Dioulasso 01 01 BP 153, Burkina Faso

Date of Submission26-May-2020
Date of Decision04-Jul-2020
Date of Acceptance03-Sep-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Prof. Chigozie Jesse Uneke
African Institute for Health Policy and Health Systems, Ebonyi State University, CAS Campus, Abakaliki, PMB 053
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nmj.NMJ_188_20

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   Abstract 

Context: The West African Health Organization (WAHO) is vigorously supporting evidence-informed policymaking (EIPM) in the countries of West Africa. EIPM is increasingly recognized as one of the key strategies that can contribute to health systems strengthening and the improvement of health outcomes. The purpose of this rapid review is to examine two key examples of evidence-based strategies used to successfully implement health interventions in each of the West African countries and to highlight the lessons learned. Methods: A rapid review technique, defined as a type of knowledge synthesis in which systematic review processes are accelerated and methods are streamlined to complete the review more quickly, was used. A PubMed search was conducted using the combination of the following keywords: Health, policy making, evidence, plus name of each of the 15 countries to identify studies that described the process of use of evidence in policymaking in health interventions. Two examples of the publications that fulfilled the study inclusion criteria were selected. Results: Among the key processes used by the countries to promote EIPM in health interventions include policy cycle mechanism and political prioritization, rapid response services, technical advisory group and steering committees (SCs), policy dialog, capacity-strengthening mechanisms, local context evidence and operational guidelines, multisectoral action and consultative process.Conclusion: Various degrees of success have been achieved in by West African countries in the promotion of EIPM. As the science of EIPM continues to evolve and better understanding of the process is gained among policymakers, more studies on effective strategies to improve the evidence-to-policy process are advocated.

Keywords: Evidence, policymaking, rapid review, West Africa


How to cite this article:
Uneke CJ, Sombie I, Johnson E, Uneke BI. Lessons learned from strategies for promotion of evidence-to-policy process in health interventions in the ECOWAS region: A rapid review. Niger Med J 2020;61:227-36

How to cite this URL:
Uneke CJ, Sombie I, Johnson E, Uneke BI. Lessons learned from strategies for promotion of evidence-to-policy process in health interventions in the ECOWAS region: A rapid review. Niger Med J [serial online] 2020 [cited 2020 Oct 23];61:227-36. Available from: https://www.nigeriamedj.com/text.asp?2020/61/5/227/298091


   Introduction Top


The Economic Commission of the West African States through her specialized health institution, the West African Health Organization (WAHO), is vigorously supporting evidence-informed policymaking (EIPM) among the member states.[1],[2] The importance of EIPM is now widely recognized in West Africa as one of the key strategies that can contribute to health systems strengthening and the improvement of health outcomes through efficient policymaking.[3] In order to achieve continued improvement in health outcomes in an efficient and equitable manner, a number of reports have advocated for the implementation of policies that are evidence informed.[4],[5] The World Health Organization (WHO) has indicated that policies that are informed by robust evidence have higher potential in saving lives, use resources more efficiently, and better meet citizens' needs.[6]

The use of evidence in policymaking is a complicated process. This is because of the multiple definitions of what constitutes an evidence and how their use in policymaking is influenced by contextual factors. Evidence can either be scientific (research/surveys, quantitative/statistical data, qualitative data) or colloquial (economic, attitudinal, behavioral and anecdotal, experts opinion, propaganda, judgments, insight/experience, history, analogies, local knowledge, and culture).[7] The West African region is layered in traditional, ethnic, religious, language, and cultural diversity, which is further heightened by the colonial legacy of fragmentation of the region by official language into Anglophone, Francophone, and Lusophone.[8] The contextual issues, burden of underdevelopment, and weak health systems have combined together and made effective EIPM quite challenging in the region.

A number of WAHO-sponsored studies have shown that contextual factors such as culture and health systems' barriers including service delivery organization, the availability and ability of health services, and the quality of care, all act together to increase poor health outcomes in West Africa.[1],[9] Agyepong et al. argued that any attempt at improving health outcomes in West Africa must focus not only on increased investment in health interventions but more importantly on strengthening health systems and implementing lifesaving interventions that are evidence based.[9]

Across the 15 countries of West Africa, various strategies have been implemented to promote evidence-based policies. The purpose of this rapid review is to examine two key examples of evidence-based strategies used to successfully implement health interventions in each of the West African countries and to highlight lessons learned, and their implication for evidence-to-policy link.


   Methods Top


We employed the rapid review technique, defined as a type of knowledge synthesis in which systematic review processes are accelerated and methods are streamlined to complete the review more quickly than is the case for typical systematic reviews.[10] This is with the intention of meeting policymakers' needs to inform policy development in a timely way.[11]

A PubMed search was conducted in the month of April 2020 using the combination of the following keywords: health, policy making, evidence, plus name of each of the 15 West African countries. The search date ranged from 1966 to 2020 and was focused mainly on studies published in English and studies published in French but with titles and abstracts translated in English. The publication entries were initially screened using the following two key study inclusion criteria: (i) must have been conducted in any of the 15 West African countries and (ii) must describe policy components and the process of use of evidence in policymaking in any aspect of the health sector. We did not use gray literature because our emphasis was on peer-reviewed publications.

Two of the authors (CJU and BIU) independently performed the search and data extraction which involved screening of titles, abstracts, and the full texts of publications. Where there were disagreements, resolutions and consensus were reached through discussion between the two authors, with confirmation from the remaining authors (IS and EJ).

Publications that fulfilled these initial inclusion criteria were identified. A second round of screening was conducted to select two publications from each country that best described the mechanism and/or processes used to facilitate evidence-to-policy-to-practice processes in health interventions with some measurable outcomes.

Two of the publications that satisfied the second round of inclusion criteria and adjudged to have excellent examples of country processes that promoted evidence-to-policy processes in health intervention were selected. The selection of two best examples of relevant studies is purely based on convenience. The study is a is a rapid review, designed to present to West African policymakers few excellent examples of successful evidence-to-policy processes across the sub-region. This is for the purpose of initiating further discourse on the subject.


   Results Top


[Table 1] shows the outcome of the publication search. The highlights of the two of the publications adjudged as excellent examples of country processes that promoted evidence-to-policy processes are shown in [Table 2], [Table 3], [Table 4]. A description of the findings is presented below.
Table 1: Description of outcome of the publication search for West African countries

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Table 2: Profile and characteristics of publications reporting the processes that promoted evidence-to-policy processes in health intervention in Francophone countries of West Africa

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Table 3: Profile and characteristics of publications reporting the processes that promoted evidence-to-policy process in health intervention in Anglophone countries of West Africa

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Table 4: Profile and characteristics of publications reporting the processes that promoted evidence-to-policy process in health intervention in Lusophone countries of West Africa

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Benin: Use of policy cycle mechanism and training workshops on evidence-informed policymaking

In Benin, two studies reported the process of EIPM to develop policies on user fees for cesarean sections[12] and nutrition.[13] In the development of the policy on user fees for cesarean sections, the following EIPM steps: agenda setting, policy formulation and legitimation, implementation fidelity, and policy results were adopted.[12] To address possible challenges that could hamper the EIPM process and the development of policy on nutrition, identified capacity gaps were addressed through training workshops on problem-oriented EIPM, systematic reviews, cost–benefit evaluations, and evidence contextualization.[13]

Burkina Faso: Use of rapid response services and steering committees

Rapid response service (RRS) for health policy[14] and establishment and implementation of SCs[15] were the policy issues reported from Burkina Faso. The RRS facilitated the use of research evidence in policymaking. It largely reached the consolidation phase of the institutionalization of the initiative, after project leaders convinced policymakers of the importance of the service.[14] In addition, the implementation of SCs as a collaboration mechanism between researchers and policymakers facilitated the co-production and co-utilization of research findings.[15]

Cape Verde: Use of policy dialog

Two studies[16],[17] from Cape Verde reported how the use of health policy dialog facilitated EIPM. One of the studies highlighted the policy dialog operational process and forum/platform for interactive and evidence-sharing orientation.[16] The study noted that to achieve EIPM, it is imperative to ensure stakeholder participation, improving stakeholder harmonization and alignment, fostering continued institutional learning, providing a guiding framework, and facilitating stakeholder analysis.[16] The second study noted that policy dialogs proved to be an effective tool in health sector management and could be a crucial component of the governance dynamics of the sector.[17]

Côte d'Ivoire: Use of technical advisory group and human resources for health monitoring

In Côte d'Ivoire, the evidence-to-policy process was reported with focus on immunization and vaccines[18] and human resources for health (HRH).[19] It was noted that the establishment of National Immunization Technical Advisory Group facilitated the use of evidence in the development and implementation of immunization policy in the country.[18] The second study noted that with increasing experience in assessments for HRH monitoring comes greater need to establish and promote best practices regarding methods and tools for their implementation.[19]

The Gambia: Use of individual-, organization-, and institutional capacity-strengthening mechanisms

The focus of the two studies from Gambia was on vaccine surveillance[20] and on strengthening capacity on the supply and demand sides of evidence production.[21] The first study observed that local institutions play a critical role in making surveillance data available to policymakers. The study noted that documenting the use of surveillance activities can be used as an advocacy tool to convince governments and external funders to invest in surveillance and make it a priority immunization activity.[20] The second study stressed the importance of individual, organizational, and institutional capacity strengthening to facilitate EIPM.[21]

Ghana: Use of technical advisory groups and policy dialog

The two studies from Ghana focused on national immunization[22] and aging and health.[23] The first study examined the functionality of National Immunization Technical Advisory Groups (NITAGs) and noted that NITAG activities facilitated evidence-based decision-making processes with a critical role played by working group data syntheses and assessments.[22] In the second study, stakeholders were engaged in a policy dialog, with the development and presentation of policy briefs to define priority problems and health system responses associated with aging. The framework was useful for engaging stakeholders to develop evidence-informed policies on aging.[23]

Guinea: Use of policy dialog and pro-sustainability investment strategies

The two studies from Guinea focused on policy dialog[23] and on food and nutrition intervention.[25] The first study noted that policy dialog processes were well implemented (i.e., well facilitated, evidence based, participatory, and consisted of recurring meetings and activities)[24] The second study stressed the need to incorporate pro-sustainability investment strategies in food and nutrition programs for child survival. The study concluded that sufficient understanding of the level of complexity being targeted is required to promote evidence-to-policy process.[25]

Guinea Bissau: Use of health research systems and human resources for health costing methodologies

In Guinea Bissau, the assessment of how the health research systems emerged and evolved over time and how the system functions to influence policymaking process were studied.[26] The study noted that if research is to contribute to local decision-making, it is essential to modulate the emerged system by setting national research priorities, aligning funding, building national research capacity, and linking research to decision-making processes.[26] The second study focused on the practice of costing exercises and HRH costing methodologies to improve evidence-to-policy link. The study noted that costing exercises represented an important driver of the human resources development plan (HRDP) elaboration, which lent credibility to the process, and provided a financial framework within HRH policies.[27]

Liberia: Use of policy dialog and health governance and leadership

The two studies from Liberia focused on policy dialog[28] and on health governance and leadership (HGL).[29] The first study assessed how context influences policy dialog, particularly participation of stakeholders before and during the Ebola outbreak. The study observed that the context was instrumental in shaping the dialogs according to the issue of focus, requirements for participation, and the decisions to be made.[28] The second study analyzed national policies and strategies of HGL pertaining to maternal, newborn and child health (MNCH). The study observed that evidence-to-policy link can be facilitated by promoting some aspects of HGL, namely establishing child survival as the top national priority and bringing together donors, strategic partners, health and nonhealth stakeholders, and beneficiaries to collaborate in strategic planning.[29]

Mali: Use of policy analysis and political prioritization

In Mali, the two studies reviewed focused on integrated community case management (iCCM)[30] and on vaccine adoption.[31] The first study reviewed how policy analysis can inform: How iCCM is framed and negotiated, how iCCM is tailored for national health systems, and how to foster accountability and learning for iCCM. The study observed that scaling up of iCCM requires understanding of the political accountabilities involved, how ownership can be fostered and the sustainability of learning for improved policies and programs.[30] The second study explored the processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. The study observed that among the main drivers influencing decisions were the availability of funding and political prioritization.[31]

Niger: Use of health policy development and local evidence in national monitoring data

In Niger, the two studies reviewed focused on the examination of processes of health policy development in iCCM of childhood illness[32] and on how and why evidence influenced policy formulation for iCCM.[33] In the first study, it was noted that the policymakers possessed skills and capacities to negotiate with donors and deliberate and weigh conflicting considerations but lacked capacity and resources to formally evaluate and document programs.[32] In the second study, national monitoring data were used to identify the issue of children dying in the community prior to reaching health facilities.[33] The study concluded that while evidence from research studies and other contexts can be critical to policy development, local evidence is often needed to answer key policymaker questions.[33]

Nigeria: Multisectoral action in policy development and consultative process

In Nigeria, the two studies reviewed focused on multisectoral action (MSA) in policy development[34] and on maternal, newborn and child health (MNCH).[35] The first study provided descriptions of policy contents, processes, and actors as well as contextual factors related to the policies around the major noncommunicable disease (NCD) risk factors. The study observed that there was some degree of application of MSA in NCD prevention policy development and noted that stronger coordination mechanisms with clear guidelines for sector engagement are required.[34] The second study assessed the extent EIPM mechanism was employed in the MNCH policy formulation process. The study observed that policy documents focused on maternal health improvements and the use of a consultative process involving multiple stakeholders for policy development.[35]

Senegal: Use of landscape of policy environment and evidence-based guidance

The two studies from Senegal focused on immunization supply chains[36] and on family planning (FP).[37] The first study conducted a landscape of policy environment around immunization to identify relevant policies and administrative and technical roles and responsibilities, affecting the supply chain for immunization. The study observed the need for better coordination and planning for all aspects of immunization programs and better, more timely data for decision-making.[36] The second study assessed the use and perceived impact of WHO's evidence-based FP guidance and tools and ways to strengthen their use. The study observed that the WHO materials are evidence based and, when adapted to the country context, will improve evidence-to-policy process.[37]

Sierra Leone: Use of multisectoral efforts and leadership capacity improvement

The two studies from Sierra Leone focused on strengthening multisectoral efforts to effectively address anemia[38] and on HRH.[39] In the first study, some factors that can improve evidence-to-policy link to address anemia included agenda setting; establishment of a cohesive coordination structure; strong, committed leadership; and representation of diverse stakeholders.[38] The second study assessed the patterns and drivers of postconflict policymaking, and observed that windows of opportunity for change and reform depend on a constellation of leadership and capacity improvement.[39]

Togo: Use of operational guidelines and local context evidence

The two studies from Togo focused on access to HIV prevention, care, and treatment services[40] and on tobacco control.[41] The first study observed that several policy barriers restrict men who have sex with men (MSM) and sex workers from accessing services and result in harassment and arrests, but development of operational guidelines can improve policy implementation and service uptake.[40] The second study assessed the use of a multisectoral approach (MSA) in developing and implementing tobacco control policies. The study observed that the formulation of tobacco control policies was driven locally by the political, historical, social, and economic contexts.[41]


   Discussion Top


The outcome of this rapid review has shown that the countries of West Africa have evolved various strategies to promote evidence-to-policy processes in health interventions to improve health outcomes. A discussion of the vital lessons that have been learned from these strategies is presented below.

Policy cycle mechanism and political prioritization

The use of policy analysis and policy cycle mechanisms including agenda setting, policy formulation and legitimation, implementation fidelity, and policy results has been shown to enhance evidence-to-policy process.[12],[42] It is, however, vital to consider the use of policy cycle within the lens of political prioritization if policy implementation will be very successful and achieve the set objectives. In Benin, the policy development process suffered from inadequate uptake of evidence because the policy content and process were not completely in harmony with political goals.[12] It is important to state that the process of EIPM is not only a technical matter of knowledge translation but can be much more a political process.[43],[44] In a previous study, it was argued that the social determinants of health are amenable to political interventions and therefore the policy development processes which drive health interventions are largely dependent on political action.[45] Studies from West African countries have demonstrated how politics played major contributory roles in the success and failures of the development and implementation of some policies on health intervention.[12],[18]

Rapid response services

The RRS has been described as an innovation that aims to support the policy and decision-making process, providing relevant and timely research evidence when it is needed.[46] The use of RRSs to promote EIPM is gaining increased attention in a number of low- and middle-income countries.[14],[46],[47],[48] The study from Burkina Faso is an example of how RRS was successfully used to facilitate the use of research evidence in policymaking.[14] In a previous study from Uganda, it was reported that RRS received policy and decision questions and responded to these with the best available research evidence in summarized and contextualized forms within short periods of time.[47] RRS has the potential of enhancing the timeliness and relevance of research evidence for policymaking and will likely improve contact and interaction between policymakers and researchers when available.[46]

Technical advisory group and steering committees

The use of technical advisory groups (TAGs) and SCs facilitated the EIPM process in Burkina Faso, Côte d'Ivoire, and Ghana.[15],[18],[22] A TAG or an SC has been defined as a group of health policy actors/experts who meet on a regular basis to decide on, guide, and evaluate a project's implementation, and to recommend strategies on how to best to achieve the project's goal and objectives.[15],[49] Available reports have shown that both TAG and SC have played vital roles in bridging the divide between research and policy and promoting EIPM. Such groups and committees have functioned as health coordination mechanisms and have strengthened the development of a sector-wide approach in facilitating EIPM.[50],[51]

Policy dialog

Policy dialog has emerged as a key strategy for the promotion of EIPM in the West African sub-region as can be seen from the examples in Cape Verde,[16] Ghana,[23] Guinea,[24] and Liberia.[28] Policy dialog is a vital interactive knowledge-sharing platform. It follows a deliberative process aimed at strengthening the quality of policy thinking, identifying context-specific issues, and exploring ways in which end users and policy actors can explore strategic policy options for health system reform.[52],[53] In Cape Verde, policy dialog enhanced health sector management, and the success factors included the use of innovative approaches, good facilitation, availability of resources for dialogs, good communication, and consideration of different opinions.[16] The report from Guinea showed that policy dialog improved harmonization in terms of fostering information exchange among partners.

Capacity-strengthening mechanisms

The establishment of capacity-strengthening mechanisms on EIPM including the use of specialized workshops and other forms of training programs has been advocated.[21] The United Nations Development Programme[54] defined capacity as the ability of individuals, institutions, and societies to perform functions, solve problems, and set and achieve objectives in a sustainable manner. In the Gambia, strengthening capacity at individual, organizational, and institutional levels was identified as a key strategy for facilitating EIPM.[21] The study added that sustainability of EIPM requires strengthening institutional capacity and addressing the incentives facing policymakers that support the use of evidence in policy cycles.[21] In a previous study, Lavis et al.[55] identified four areas that capacity-strengthening mechanism to improve EIPM can focus on, including: (i) the ability to acquire research evidence; (ii) reviewing the strength and generalizability of evidence; (iii) adapting research findings to make them relevant in a local context; and (iv) evaluating the feasibility of different policy options.

Local context evidence and operational guidelines

The consideration of local context evidence and their use in operational guidelines has been shown to improve the EIPM process in Niger,[33] Senegal,[37] and Togo.[40] The health system of the West African region is highly influenced by its complex and multidimensional contextual issues such as tradition, religions, language, and culture.[8] This explains why the use of local context-specific evidence can facilitate the EIPM process. In a study in Ghana on the health policy agenda setting and formulation on free antenatal care in government facilities, Koduah et al.,[56] while studying the Ghanaian health policy agenda setting and formulation on free antenatal care, observed that contextual factors such as political ideology, economic crisis, historical events, social unrest, and change in government served as bases for policymaking process.

Multisectoral action and consultative process

Among the key strategies to facilitate EIPM as highlighted by studies reviewed are MSA and consultative process. MSA and consultative process were successfully used to promote EIPM in Nigeria[34] and Sierra Leone.[38] MSA has been defined as actions that are undertaken by sectors outside the health sector – with or without the collaboration with the health sector – to attain health-related outcomes or influence health determinants.[34],[57] Because the health of the population is influenced by socioeconomic factors that often lie outside of the health sector, MSA contributes to improvements in the health of the population by addressing these social determinants of health.[34] Consultative process, also known as stakeholders' engagement, has been described as key toward tailoring best evidence for policy and practices.[58]


   Conclusion Top


This review has provided insight into what has worked in the West African region as the researchers and policymakers make efforts to promote EIPM for improved health outcomes. As the science of EIPM continues to evolve and better understanding of the process is gained among policymakers, more effective strategies to improve the evidence-to-policy link will be developed. One of such vital strategies can be the development of an EIPM guidance, which will provide step-by-step approaches that can be employed to promote evidence-to-policy-to-practice link.

Acknowledgments

The authors wish to thank all the policymakers from West Africa who participated in the study.

Financial support and sponsorship

This study was a component of the “Moving Maternal, Neonatal and Child Health Evidence into Policy in West Africa” (MEP) project funded by the West African Health Organization and the International Development Research Centre Canada (Reference: IDRC 107892_001).

Conflicts of interest

There are no conflicts of interest.

 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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