Assessing the influence of knowledge translation platforms on health system policy processes to achieve the health millennium development goals in Cameroon and Uganda: A comparative case study

There is a scarcity of empirical data on the influence of initiatives supporting evidence-informed health system policy-making (EIHSP), such as the knowledge translation platforms (KTPs) operating in Africa. To assess whether and how two KTPs housed in government-affiliated institutions in Cameroon and Uganda have influenced: (1) health system policy-making processes and decisions aiming at supporting achievement of the health millennium development goals (MDGs); and (2) the general climate for EIHSP. We conducted an embedded comparative case study of four policy processes in which Evidence Informed Policy Network (EVIPNet) Cameroon and Regional East African Community Health Policy Initiative (REACH-PI) Uganda were involved between 2009 and 2011. We combined a documentary review and semi structured interviews of 54 stakeholders. A framework guided thematic analysis, inspired by scholarship in health policy analysis and knowledge utilization was used. EVIPNet Cameroon and REACH-PI Uganda have had direct influence on health system policy decisions. The coproduction of evidence briefs combined with tacit knowledge gathered during inclusive evidence-informed stakeholder dialogues helped to reframe health system problems, unveil sources of conflicts, open grounds for consensus and align viable and affordable options for achieving the health MDGs thus leading to decisions. New policy issue networks have emerged. The KTPs indirectly influenced health policy processes by changing how interests interact with one another and by introducing safe-harbour deliberations and intersected with contextual ideational factors by improving access to policy-relevant evidence. KTPs were perceived as change agents with positive impact on the understanding, acceptance and adoption of EIHSP because of their complementary work in relation to capacity building, rapid evidence syntheses and clearinghouse of policy-relevant evidence. This embedded case study illustrates how two KTPs influenced policy decisions through pathways involving policy issue networks, interest groups interaction and evidence-supported ideas and how they influenced the general climate for EIHSP.

This was a qualitative comparative embedded case study (Anderson et al. 2005; Yin 2009) combining documentary review and face-to-face semi-structured interviews with key informants. We opted for a case study design admitting health systems as complex adaptive systems comprising several embedded sub systems (Agyepong and Adjei 2008; Paina and Peters 2011). In line with our goal, we selected EVIPNet Cameroon and REACH-PI Uganda, which were launched in 2006 and considered the most active KTPs in sub Saharan Africa with significant but time-limited international financial and technical support (Campbell 2013, Ongolo-Zogo et al. 2014). They are housed in government-affiliated institutions, a teaching hospital linked to the Cameroon ministry of health and a public university in the case of Uganda. Based on their reports of activities, we selected two policy processes (embedded cases) in each country for which the KTPs have prepared evidence briefs and organized stakeholder dialogues in the period between January 2009 and December 2011. Mindful of the duration of the legislative electoral cycle in both countries (5 years) and of the typical HSP cycles (1–4 years), we set a minimum 3-year timeframe for observation after the stakeholder dialogue was organized. There were the efforts to improve governance for health district development and scale up malaria control interventions in Cameroon and, task shifting to optimize the roles of health workers for maternal and child health and improve access to skilled birth attendance in Uganda (Ongolo-Zogo et al. 2014). Standing as insiders leading KTP secretariats (POZ, NKS) and collaborators associated with both KTPs as co-investigators in KTP research and evaluation (JNL, GT), we have combined documents and semi-structured interviews with key stakeholders as data sources (Table 1). Panel 1: Cases description The purpose was to interpret the political context and provide a narrative historical account of each policy process by identifying the actors, describing the key steps in each policy process, and analysing the content of decisions or policies in relation to evidence briefs and stakeholder dialogues. Accordingly, we searched the websites of respective ministries of health for relevant policy documents pertaining to the topics of interest with the support of both KTP secretariats (e.g.; strategic plans, grants, reports of KTPs activities, evidence briefs and summaries of the dialogues including the lists of participants). In addition, we searched peer-reviewed papers from Medline to identify relevant scientific papers on the issues of interest during the period 2004–2014 using the following search terms: Cameroon, Uganda, research, health governance, malaria control, task shifting, maternal child health and skilled birth attendance. We used techniques of stakeholder analysis (Gilson et al. 2012) and contribution mapping (Kok and Schuit 2012) to purposively sample informants from among KTP staff and the participants at the dialogues, based on their characteristics, roles, experiences and involvement in HSP, and their ability to elucidate a range of issues relevant to our research questions. The 54 interviewees were senior officials from the respective ministries of health—permanent secretaries, technical advisors, directors of planning, commissioners, policy analysts and national programme managers—as well as representatives from CSOs, donor agencies, journalists and researchers including KTP staff (Table 2). The interviewees were contacted to request their participation by an email that included an information sheet for the study, and they were then called back to check their availability for an interview. Prior to all the interviews, the explicit consent was obtained in writing using a standardized form. Interviews mostly took place in the interviewee’s office. The interviews, conducted in English in Uganda and in French and English in Cameroon, were audio recorded for 36 participants or recorded in writing for 18 participants declining the audio recording. All audio recordings were transcribed verbatim. Between June and December 2014, one of us (POZ), assisted by a research assistant in each country, conducted all the interviews, each time using the same guiding questions (see appendix one). A two-page summary sheet was prepared soon after each interview so as to capture a concise picture of its context and content, to serve as a checklist of outstanding items and issues, and to triangulate information and reflect on data saturation. Characteristics of the stakeholders interviewed The content analysis of documents and interview transcripts aimed to describe the context in which HSP and decisions to achieve health MDGs occurred and to identify the intersection of KTP activities with contextual factors and, to determine the perceived influence of KTP activities on HSP and country general climate for EIHSP. We used NVivo qualitative data analysis software (QSR International Pty Ltd. Version 10, 2014) to facilitate the documentary review. The framework-guided thematic coding approach was aligned to the logical framework for KTP influence derived from scholarship in political sciences, health policy analysis and knowledge utilization (Figure 1). We conceived of influence as a process guided by history, path dependence and feedback loops, and we described the nature of influence in terms of (1) direct influence on decision to change a policy/program or the decision not to change, (2) indirect influence through the intersection with contextual factors of HSP (e.g. broadening of policy horizons through sense making) (Lindquist 2001; Carden 2009; Paina and Peters 2011; Adam and de Savigny 2012). Institutions were defined as the structures, the political and health system decision-making culture and procedures arising from past decisions (policy legacies), and policy networks inclusive of government, parliament and civil society. Interests were referred to as the organized societal groups, bureaucrats or elected officials with perceived positive or negative incentives relating to the policy process. Ideas were defined as values about ‘what ought to be’ regarding health system and policy and perceptions on problem, as well as research evidence as illustrated in issue clarification, options framing and implementation considerations. External factors were categorized in terms of external donors influence, release of major reports and regional or global focus event or commitment (Campbell 1998, 2002; John 2003; Beland 2009; Lavis et al. 2012). We specifically looked at decisions or changes perceived as directly linked to KTPs activities in terms of institutional arrangements, power struggle amongst interest groups, ideational and external factors. We strived for reliability through a systematic and comprehensive maintenance of records and careful account of the analytical process. Information from interviews was triangulated across interviewees and with information from the documentary review. The influence on HSP was compared within countries and contrasted across cases and countries.

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• ongolo-zogo, pierre
• lavis, john n.
• tomson, göran
• sewankambo, nelson k.