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Background: The need for evidence-based decision-making in the health sector is well understood in the global health community. Yet, gaps persist between the availability of evidence and the use of that evidence. Most research on evidence-based decision-making has been carried out in higher-income countries, and most studies look at policy-making rather than decision-making more broadly. We conducted this study to address these gaps and to identify challenges and facilitators to evidence-based decision-making in Maternal, Newborn and Child Health and Nutrition (MNCH&N) at the municipality, district, and national levels in Mozambique. Methods: We used a case study design to capture the experiences of decision-makers and analysts (n = 24) who participated in evidence-based decision-making processes related to health policies and interventions to improve MNCH&N in diverse decision-making contexts (district, municipality, and national levels) in 2014-2017, in Mozambique. We examined six case studies, at the national level, in Maputo City and in two districts of Sofala Province and two of Zambézia Province, using individual in-depth interviews with key informants and a document review, for three weeks, in July 2018. Results: Our analysis highlighted various challenges for evidence-based decision-making for MNCH&N, at national, district, and municipality levels in Mozambique, including limited demand for evidence, limited capacity to use evidence, and lack of trust in the available evidence. By contrast, access to evidence, and availability of evidence were viewed positively and seen as potential facilitators. Organizational capacity for the demand and use of evidence appears to be the greatest challenge; while individual capacity is also a barrier. Conclusion: Evidence-based decision-making requires that actors have access to evidence and are empowered to act on that evidence. This, in turn, requires alignment between those who collect data, those who analyze and interpret data, and those who make and implement decisions. Investments in individual, organizational, and systems capacity to use evidence are needed to foster practices of evidence-based decision-making for improved maternal and child health in Mozambique.
This study is based on a combination of case studies that capture the diversity of experiences of evidence-based decision-making processes about MNCH&N at different levels where decisions about health policy and interventions are made in Mozambique (national, district and municipal), and at different performance levels on select maternal and child health indicators over time. The indicators were maternal and under-five mortality ratios between 1997 and 2011, because those were used in the most recent analysis published by the NEP in Mozambique [18]. We selected six cases: the NEP; Maputo City, two districts of Sofala Province (Caia and Chemba) and two of Zambézia Province (Alto Molócuè and Gilé). The NEP is an example of efforts to improve evidence-based decision-making at the national level, while Sofala is a similar example at the provincial, district and facility levels. Maputo City has consistently had lower maternal and under-five mortality rates compared to other provinces, is a municipality and the capital city of the country. Zambézia has consistently had the highest maternal and under-five mortality rates [18]. Our analysis period ranged from 2014 to 2017, the period of the first phase of the NEP, which overlaps with PHIT project activities. Study investigators relied on Sofala and Zambézia Provincial Directorates of Health (DPS) to select one district they regarded as a good example of evidence-based decision-making and one that had challenges with that process. We sampled key informants who had participated in the generation of evidence and decision-making for planning and implementation of interventions aimed to improve reproductive maternal and under-five survival in each of the case studies, between 2014 and 2017, and continued in their institutions or were still associated with NEP activities at the time of interview. Although NEP activities were formally concluded in 2016 when the National Health Observatory was created [20], in practice, activities continued well into 2017–2018. We focused on key informants responsible for the production or assessment of evidence (analysts) and for decision-making (decision-makers) in the health sector and local government (districts and municipality). Often decision-makers in the Mozambican health sector are also program implementers. Therefore, this categorization of key informants is mostly for analytical convenience. Over three weeks, in July 2018, two study investigators conducted in-depth individual interviews with key informants and reviewed documents on evidence-based decision-making about policy design, planning and implementation of interventions to reduce maternal and under-five mortality in each of the case studies, in the study reference period (2014–2017). Key informants were contacted through official letters and telephone and were interviewed at a place and time of their convenience, after obtaining their written informed consent. Interviews were audio-recorded whenever participants consented for the procedure. Study investigators documented each interview through notes, regardless of whether the interview was being recorded or not. Each participant was asked to share existing documents that could help understand evidence-based decision-making in their case study. Study investigators conducted interviews using interview guides (Additional file 1: interview guides) tailored to each key informant category (decision-maker or analyst) and to each governance level (district or municipality and national level). Key domains in interview guides included describing decision-making processes (typology, regularity and key participants in decision-making, whether decision-making is evidence-based or not, and how those were documented), barriers and facilitators of evidence-based decision-making, and discussing examples of good practices of evidence-based decision-making. The document review guide helped prepare short annotations of each document (about 150 words), that described the document typology, key issues addressed in the document, institutions involved in decision-making or in the analysis and generation of evidence. To keep track of emerging themes, before leaving each site, study investigators prepared case-specific memos, using interview notes and document review annotations. Thematic analysis was conducted in ATLAS.ti, version 8.4 (Scientific Software Development GmbH), using constructs from the conceptual framework for the Ministry of Health’s capacity to demand and use research evidence (Fig. (Fig.1)1) [6]. The framework defines “[Ministry of Health] capacity to demand and use research evidence to inform policy and management decisions operating on three levels, namely, individual, organizational and systems levels” [6]. Whereas the framework focuses on research evidence, we focus on evidence both from population-based surveys and routine data from the HIS, because those are the main types of evidence that are mostly used in the Mozambican National Health System. We also apply the framework to the Ministry of Health at the central level and to the health portfolio at the local level (district and municipality). The framework breaks-up demand and use of evidence into seven sequential steps, namely, “recognition, acquisition, cognition, discussion, reference, adaptation, and influence”. Recognition refers to “individual motivation to use evidence and [ability] to identify questions that can be answered by [ …] evidence”. Acquisition describes individual knowledge about where and how to search for evidence. Cognition refers to the ability to “assess the quality of evidence and understand results”. Discussion relates to sharing and discussing “evidence with colleagues, researchers and others”. Reference describes the “ability to interpret and synthesise [ …] evidence”. Adaptation is the “ability to adapt results to local context or current questions”. Influence describes people having “sufficient latitude within their role to use evidence to influence decisions” [6]. Demand of evidence encompasses recognition and acquisition, while the use of evidence covers the remainder steps. Individual capacity is expressed through individual skills to identify, assess and interpret evidence, distributed across the seven steps of evidence demand and use. Organizational capacity is manifest in Ministry of Health (and the health portfolio at various levels) “structures, practices, and resources that support the demand and use of research evidence in its decisions”. Systems capacity is reflected in “processes through which the [Ministry of Health] addresses the broader policy environment, and influences society and organizations beyond the [Ministry of Health]”. Individual and organizational capacity are reflected in all seven steps, while systems capacity is reflected in recognition, discussion and influence [6]. This thematic analysis process, followed a case-oriented approach [21] that focused on describing the characteristics of each case study and an extended case-study approach that captured similarities and differences across the cases [22]. Preliminary findings from the case-oriented approach were used to prepare case-specific reports that were shared with key informants for feedback. Findings presented in this manuscript reflect the extended case study approach. The study was approved by Mozambique’s National Bioethics Committee for Health (CNBS) and the Ministry of Health, after endorsement from the Directorates of Health of Maputo City, Maputo Municipality, and Sofala and Zambézia Provinces. Interviews were conducted after obtaining written informed consent from key informants. They consented separately for documenting the interviews using field notes and audio-recording. Audio-recordings and fieldnotes were protected using alphanumeric individual codes that replaced the identification of each key informant. Before preparing this manuscript, study investigators obtained key informants’ feedback on preliminary study findings, and that feedback was incorporated into the current manuscript.
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