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Background: Research institutions and donor organizations are giving growing attention to how research evidence is communicated to influence policy. In the area of sexual and reproductive health (SRH) and HIV there is less weight given to understanding how evidence is successfully translated into practice. Policy issues in SRH can be controversial, influenced by political factors and shaped by context such as religion, ethnicity, gender and sexuality.Methods: The case-studies presented in this paper analyse findings from SRH/HIV research programmes in sub-Saharan Africa: 1) Maternal syphilis screening in Ghana, 2) Legislative change for sexual violence survivors In Ghana, 3) Male circumcision policy in South Africa, and 4) Male circumcision policy in Tanzania. Our analysis draws on two frameworks, Sumner et al’s synthesis approach and Nutley’s research use continuum.Results: The analysis emphasises the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change – especially in SRH – where there are complex interactions between policy actors.Conclusion: Both frameworks demonstrate how policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximize research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural and practical. © 2011 Tulloch et al; licensee BioMed Central Ltd.
The selected case-studies were presented at a meeting on research engagement with policy and practice in SRH and HIV, which involved researchers, communication specialists and donors working with DFID-funded SRH and HIV Research Programme Consortia. One of the aims of the meeting was to explore and discuss strategies to influence uptake of research into policy and practice in SRH and how context relates to those strategies? Our analysis has been informed by key themes emerging from the meeting, and discussions between all authors. The criteria against which the case-studies were chosen illustrate the role of partnerships, networking and interaction of researchers, with both policy and practice actors in SRH research in Sub Saharan Africa: Criteria 1: The role of research, advocacy and engagement – exploring policy barriers to change in SRH practice. Two case-studies were chosen against these criteria as summarised in Table Table11. Criteria 1 Criteria 2. The role of developing research to policy networks which act on new research evidence –discussing strategies to build partnerships with policy actors and practitioners. Two case-studies were chosen as summarised in Table Table22. Criteria 2 These four case-studies were interrogated using Sumner et al’s synthesis approach [1] and Nutley et al’s research use continuum [4] to identify lessons and the dominant types of research use. Sumner’s framework describes the interrelation of three dimensions through which to understand the process of transferring research evidence into policy and/or practice: 1) political context and institutions; 2) policy actors and networks; 3) policy ideas (for example, use and communication of evidence). The details of each case-study are structured according to these three elements. The order in which the elements are presented varies in response to the chronology of events in different contexts. Yaw Adu-Sarkodie and Baafuor Kofi Opoku. School of Medical, Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Background: Syphilis is easily diagnosed and can be effectively and cheaply treated with antibiotics. Syphilis is known however to be associated with adverse perinatal events, affects between 4% and 15% of pregnant women in Africa and is an important global public health issue. The World Health Organization (WHO) recommends screening during pregnancy and treating infected women with penicillin. Data pertaining to syphilis in pregnancy in Ghana remain either conflicting or unavailable. There is a long-standing syphilis screening policy for pregnant women in Ghana but anecdotal evidence from practitioners suggested that the policy has not been widely practiced. Policy context and institutions: A research agenda, “Maternal Syphilis Screening in Ghana” was developed with the participation of a research team from the Kwame Nkrumah University of Science and Technology and the London School of Hygiene and Tropical Medicine. The research agenda was developed with the DFID-funded RPC for Sexual and Reproductive Health and HIV. Policy makers from the Reproductive Health Unit and the National AIDS Control Programme of the Ghana Health Service, and health staff of user facilities in the country who would implement the findings of the research were also involved. The research assessed the development of the current policy on syphilis in pregnancy and difficulties in its implementation; how much syphilis is seen in pregnant women; the impact on pregnancy outcomes of recent increases in maternal syphilis; existing laboratory diagnostic procedures; and the use of rapid point of care testing in antenatal syphilis screening and potential impact in reducing neonatal deaths. This piece of operational research was largely carried out in health facilities by existing staff, consequently improved research capacities were built in to those facilities. Research data were gathered from over 200 sites. They found that practitioners had not been implementing the maternal syphilis screening protocol, were unaware of the policy and had not been issued with the equipment required to undertake screening. The institutional context in Ghana has a ‘top down’ approach; in this case the administrative structure resulted in a break-down in communications between the policy level and practitioners at health facility level. Policy actors and networks: Stakeholders expected to have findings reported back to them and remained proactive throughout the process; they were dynamic participants in the dissemination discussions that took place in both formal and informal surroundings. Senior members of the research group took a facilitation role between policy and programme staff who could deliver solutions, and implementation staff who could identify barriers at facility level. A central function of the researchers, who were longstanding colleagues with senior members of the Ghana Health Service, was therefore as communicators between policy and practice levels. Policy makers from the Reproductive Health Programme appeared to be more receptive to accepting the credibility of research findings collected by facility level health staff and trusting evidence presented by known colleagues with whom they had existing relationships than they would have been of external researchers. Policy ideas and evidence: Important reasons given by staff for not following the policy were poor dissemination of the policy to health facilities, insufficient guidance for staff to implement the strategy, logistical problems and lack of belief in the importance of the policy. Policy makers understood the evidence and recognised the importance of following through the evidence-based policy to practice. In this setting the development of a strategy to communicate the research evidence was therefore found to be less relevant than improving existing links within the health sector to translate the existing policy to a recognised and practicable programme. Outcomes: Two strategies were suggested as a result of the research findings in order to strengthen the maternal syphilis screening policy and help ensure its future implementation: incorporation of syphilis screening and treatment into i) the existing prevention of mother-to-child transmission (PMTCT) of HIV programme, and ii) the free maternal health programme. National roll out of maternal syphilis screening at prenatal clinics using rapid point-of-care diagnostic tests has been initiated, and real progress observed with staff training at facility level and the basis to roll out a functioning maternal syphilis screening nationally. The researchers believed that the involvement of all stakeholders throughout research planning and design, conduct of research and result dissemination gave them ownership of the research and thus increased the likelihood of policy adaptation and implementation. Future challenges lie at programme level rather than in syphilis screening practice per se. Accountability for the maternal screening programme is shared between the maternal health programme (with the greater responsibility but proportionally less funds) and the NACP/STI programme (smaller responsibility but with supplementary financing by external donors). The correct allocation of funds and coordination between the two programmes may remain contentious Nana Oye Lithur. Human Rights Advocacy, INDEPTH network, Ghana. Background: In 2008 the INDEPTH research network in Ghana commissioned an assessment of the laws and policies governing SRH; the work, undertaken by a high profile human rights lawyer, showed that there were deficiencies in laws and that they were not high priorities for government officials. Legislation and policies regarding sexual violence were of particular cause for concern with the research revealing important gaps in policy and insufficient protocols. Important findings in the assessment included evidence that many victims of sexual abuse and domestic violence survivors could not afford the fee they were required to pay for medical reports and examinations. Non-payment of the fee meant that those cases could not be prosecuted; that some health facilities refused to treat survivors who had not been referred to them by the police; and that survivors were unable to access the few post-traumatic stress services available. The study also revealed that HIV post-exposure prophylaxis was not offered to those survivors who did present themselves at health care facilities, thereby exposing them to the risk of HIV infection. Changes in the legislation on sexual abuse and domestic violence reporting would be required to address the barriers faced by survivors. Policy actors and networks: A strategy was devised to share findings of the assessment with key stakeholders: they were shared widely with parliamentarians, regional directors of health, social services, the Commission on Human Rights and Administrative Justice and traditional, religious and women leaders, in the capital Accra and in two regions. The researchers identified parliamentarians as the key targets of their evidence. Recognising they would be difficult to engage with and would be driven by diverse political interests, dissemination of research findings was adapted accordingly. Direct engagement with parliamentarians was necessary, as was respect for their limited time and the need to present them with clearly articulated approaches with which to address the legislative and policy issues. Parliamentarians, particularly those connected to the health sector, were targeted with tailored communication strategies after which meetings were organised by parliamentary clerks at which solutions were presented. The presentations were made by carefully selected and credible message-bearers who were professional, well-respected legal advocates and researchers. At a public level, engagement took place with the media using compelling human stories supported by statistics to generate public interest and to raise the profile of the issues. The media were identified as important allies in complementing the parliamentary lobbying activities as a result of their coverage. Policy context and institutions. The legislature was important in providing an environment in which a comprehensive set of policies and laws that provide for SRH could be developed, and – theoretically – be implemented. Once new legislation was created, however, there were no immediate provisions by policy makers or programme managers to create and disseminate new guidelines to health providers or ensure law enforcement mechanisms were in place. The research team identified that there were insufficient communication strategies, follow-up and monitoring systems to ensure that SRH laws or policies were actually implemented. Policy ideas and evidence: The targeted approach to disseminating research evidence helped to convince politicians of the breadth and seriousness of the issues and encourage decision-making that could address them. Whilst the dissemination of the research assessment was taking place, a Bill on Domestic Violence was also being considered in Parliament. This coincidence created an appropriate opportunity for parliamentarians to amend the proposed domestic violence bill to include a provision that mandates health care providers to provide free medical treatment to survivors of sexual abuse and domestic violence, pending a complaint to the police and the issuance of a report. The clear recommendations were directly related to parliamentary mandate and were easily incorporated in to policy. Outcomes: Legislative change and then inclusion of a provision in the law were instigated. Sexual violence survivors in Ghana should now receive free medical treatment in advance of reporting a sexual violence case to the police. Subsequent feedback to the researchers in 2009 and 2010 suggested that despite the amended legislation there was little practical change: participants in regional workshops stated that fees were still being demanded by health providers who were not aware of the new law; the police continued to issue forms which did not reflect the new Domestic Violence Act to rape victims; health care providers took advantage of the old forms to charge fees for medical reports. There is a need for engagement between policy makers and the Ghana Health Service to develop strategies to ensure the laws on free medical treatment are followed and to address incidences of corrupt practice. To address this challenge a secretariat has been created at the Ministry of Women and Children tasked with the dissemination of the legal amendment, the coordination of its implementation and educational training. On-going engagement between the researchers, advocates and government officials has been instrumental in addressing the disconnect between policy development and practice. Eugene Sickle and Sinead Delany-Moretlwe. Reproductive Health & HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa. Background: The incontrovertible evidence in support of adult male circumcision as a strategy for the reduction of HIV transmission means that South Africa has a human rights and ethical duty to develop a national male circumcision policy. (10-12). For a variety of complex reasons translation of research into policy and then into practice has been slow. The initial “research to policy” drive lost momentum because of poor in-country communication of the research, coupled with weak public understanding of, and engagement with, science. Researchers continued to drive the creation of an adult male circumcision (AMC) policy, working with the World Health Organization (WHO) and UNAIDS to recommend it “as a new, additional prevention strategy for HIV prevention in men” (13). Policy context and institutions: The “research to policy” activity was re-invigorated by the reconstitution in 2008 of The South African National AIDS Council (SANAC) as the pre-eminent national advisory body, providing strategic and political guidance to government on issues of policy on HIV/AIDS. SANAC endorsed the National Strategic Plan for HIV/AIDS [13], lists male circumcision as an “add-on” prevention strategy, thereby giving impetus to the development of a national policy. As the creation of a comprehensive male circumcision policy gathered momentum activity was once again stymied by contestation from within SANAC by traditional leaders. SANAC is a body created by the Department of Health; it is a broad forum which represents 17 sectors. As a broadly representative forum, they were seen as an honest broker in the consultations around this policy because they were an inclusive body which sought to get input from a broad range of stakeholders about issues. Researchers as part of this body were in a position to be able to negotiate for policy change as part of a broader grouping that included the Department of Health. Policy actors and networks: For many South Africans, male circumcision is an integral part of culture and an important step in the initiation of boys into manhood. The practice is the domain of traditional leaders and traditional healers within the South African context. Researchers, through SANAC structures, engaged traditional leaders, recognizing that the development of a policy must be respectful of the important roles played by traditional and religious practices regarding male circumcision. This requires an on-going dialogue with traditional leaders and healers and faith-based sectors about what circumcision may mean for amending and improving the practice of traditional interventions as well as for the evolution of effective AIDS prevention strategies. The translation of research on male circumcision into policy has required key stakeholders to navigate a complex set of relationships and interactions. Researchers have been required to engage at all stages of this process, often beyond their traditional roles. Through broad-based consultation a deeper understanding of the benefits of male circumcision in the context of HIV prevention has been achieved and ultimately, the development of a comprehensive policy has been realised. Policy ideas and evidence: When SANAC took over the policy consultations there was substantial investment of time in stakeholder meetings to explain the scientific rationale for the policy and to reassure concerned groups that this would not infringe on cultural practices or women’s rights. Thus the final policy was framed as a package of interventions around improved sexual and reproductive health. In this setting, science was used to explain policy and was an important aid to stakeholders’ appreciation of the policy. Evidence was presented in a way that tried to explain the hierarchy and strengths of currently available evidence. Dialogue was valuable as it enabled SANAC members and policy makers to receive and respond to feedback and concerns from those groups that did not support male circumcision. Scientists were able to interpret data for stakeholders and work with other like-minded groupings to address concerns in a way that was acceptable. For example, presentations that addressed key concerns of adult male circumcision safety, women’s risk and rights, were conducted. As more evidence emerged it was incorporated into discussions and used to respond to concerns that were raised. The dialogue between SANAC and stakeholders was framed as a rational discussion – the data served to move the discussion away from extreme views and into the realm of what was known or what still needed to be determined. This was important as part of a broader trend to make research and science more accessible to people and to change perceptions that research is not useful. Outcomes. This positive engagement allowed researchers, SANAC and WHO to set a comprehensive policy agenda with input from key figures in civil society, traditional leadership structures and government. It was a collective effort but the participation of scientists in civil-society government structures has facilitated “change from within”. The result was the development of broad-based advocacy and community-messaging campaigns under the auspices of SANAC and constitution of an expert working group tasked with policy development and the National Department of Health embarking on a nationwide situational analysis as to the feasibility of introducing adult male circumcision into the public healthcare environment. The consultations resulted in broad acceptance of the policy and there are roll-out programmes in provinces that traditionally did not circumcise. The culmination of these activities saw the creation of a comprehensive policy, the aim of which is to improve male sexual and reproductive health, and reduce new HIV infections through the provision of safe, accessible, sustainable and voluntary clinical male circumcision services in South Africa. There are several demonstration sites including one that has been trying to mobilise the whole community for male circumcision. In KwaZulu-Natal King Goodwill Zwelithini, a traditional leader announced and endorsed the male circumcision programme in selected sites. Despite some controversy in this traditionally non-circumcising province, there has been strong political and traditional endorsement of programmes. Mwita Wambura, Joseph Mwanga, Jackline Mosha, Gerry Mshana, Frank Mosha, John Changalucha. National Institute for Medical Research, Mwanza, Tanzania. Background: HIV/AIDS remains the most important public health problem in Tanzania) [14]. Promoting effective interventions that prevent new infections and control of the epidemic is a policy priority. Adult male circumcision (AMC) is effective in mitigating the acquisition of HIV infection in men [10-12]. The Tanzanian government was keen to introduce AMC on a large scale from 2007, but it was felt that there was limited information on cultural attitudes and practices towards circumcision, the safety of the procedure, techniques used in both clinical and traditional settings and the capability of the existing health service infrastructure to deliver safe male circumcision services. Policy context and institutions: Two AMC relevant policies have been in place for several years, The National HIV/AIDS Policy of 2002 and the Traditional and Alternative Medicine Act of 2002. Rather than formulating a new policy it was agreed to adapt them to accommodate AMC as an intervention against HIV infection. Strong political will to create a forum to develop AMC policy was in existence. In order to provide national leadership, coordination, resource mobilisation and advocacy, the Tanzanian Ministry of Health and Social Welfare (MoHSW,) following WHO guidance, therefore formed two bodies (a Taskforce Committee and Technical Working Group) to oversee the scaling up of circumcision services in the country. These bodies were formed through a consultative and inclusive process involving all stakeholders. Among the decisions taken by the two oversight bodies were designating a focal person at the MoHSW to coordinate day-to-day work, drafting AMC guidelines for health practitioners and using these to train service providers. The two bodies also approved the implementation of a situation analysis of male circumcision in Tanzania and the on-going male circumcision demonstration projects in four Regions. The National Institute for Medical Research (NIMR) had conducted earlier studies on the topic [15,16] and was tasked to carry out the situation analysis to ensure that decisions are based on sound evidence. Its involvement to provide evidence for the policy development process was a natural progression of the previous research work that NIMR had conducted. Policy actors and networks: Momentum was given to the process from policy actors at all levels. The president of the United Republic of Tanzania was enthusiastic for AMC to be introduced as an additional strategy against HIV infection. Members of the oversight bodies were selected from several sectors, their selection based on, amongst other criteria, experience in policy formulation, implementation and advocacy issues and technical competence in AMC issues. Actors with a range of expertise contributed, including those from the donor community, NGOs, policy makers, researchers, advocacy groups and AMC practitioners in the policy process all of whom were crucial in the scale up efforts The lobby and advocacy group led the advocacy and mobilisation campaigns, the donor community funded the situation analysis study through the government of Tanzania and funded the development of a costed action plan and AMC demonstrations sites. Researchers conducted the situation analysis study, whilst AMC demonstration sites are staffed by AMC practitioners and NGOs. The introduction and scaling-up of AMC services exemplifies the necessity of co-ordinated action from multiple stakeholders. The Tanzanian experience of planning and rolling out male circumcision services illustrates the potential of an inclusive, interconnected and on-going relationship required between policymakers, donors, advocacy groups, researchers and AMC practitioners within a national health programme. Policy ideas and evidence: The policy development process started after evidence that emerged from trials conducted in South Africa, Kenya and Uganda showed that AMC provided partial protection against HIV infection. There was however a lack of locally relevant information required to inform the policy development process. Locally specific research was therefore undertaken as part of the situation analysis study; local research findings informed the development of the Tanzanian strategy and the planning of AMC demonstration sites. Experience gained from demonstration sites further informed the policy features such as ensuring that services are affordable; and defining the minimum quality of care provided to those who undergo AMC as an intervention against HIV infection. Findings from the situation analysis showed a high level of acceptability of male circumcision in both traditionally and non-traditionally circumcising populations. Traditional leaders play a key decision making role in circumcision and should have a role to play in the national strategy for the national programme to be successful in traditionally circumcising areas. Health systems need strengthening for effective delivery of circumcision services. NIMR presented these findings to the two oversight bodies and an implementation strategy was developed. Outcomes: AMC scale-up is under-way and there is enabling environment regulated by policy. New policy was not developed but existing policies were adapted to include provision of safe male circumcision procedures for the prevention of HIV infection. Several challenges remain such as the integration of traditional and clinical based circumcisions and how limitations within the public health system will affect the national AMC programme.
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