EVIPNet and Evidence-Informed Policy-making: Perspectives ... · EVIPNet and Evidence-Informed Policy-making: Perspectives and Practices, Uganda Harriet Nabudere, MD, MPH College

EVIPNet and Evidence-

Informed Policy-making:

Perspectives and Practices,

Uganda

Harriet Nabudere, MD, MPH

College of Health Sciences

Makerere University, Uganda

REACH – Regional East African Community

Health Policy Initiative

• The Regional East African Community Health (REACH) Policy Initiative was established within the East African Health Research Commission, an organ of the East African Community, to bridge the gap between evidence and health policy and practice.

• Although REACH was not formally established until 2006, it had been under development since 2001 and built on the experience of the Tanzania Essential Health Interventions Project (TEHIP).

EVIPNet

Evidence Informed Policy Network

• EVIPNet built on the experience of REACH and was

assisted by REACH in its establishment, 2005.

• EVIPNet was launched by the World Health

Organization and the ministries of health in several

African and Asian countries to promote the use of

scientific evidence in health policy and systems.

• EVIPNet has expanded to support activities in Latin

America, Eastern Mediterranean region and most

recently, Europe.

• The two initiatives have worked collaboratively

since 2005

Supporting Use of Research Evidence (SURE)

for Policy in African Health Systems

• SURE is a collaborative project that builds upon the

two initiatives – The Regional East African Community Health (REACH) Policy Initiative and the Evidence Informed Policy Network(EVIPNet) Africa.

• Both networks aim to promote the use of evidence in health policy decisions.

• REACH comprises the countries; Uganda, Tanzania, Kenya, Rwanda and Burundi.

• EVIPNet Africa includes the countries of Burkina Faso, Cameroon, Centrafrique, Ethiopia, Mozambique, and Zambia.

• SURE is developing and evaluating KT strategies for EIHP in these LMICs

Overall Strategy: • SURE comprises 8 work packages. • There are 6 work packages with

scientific/technological objectives: WP1: Production of research syntheses (evidence

briefs for policy) to address priority policy questions. WP2: Development and evaluation of strategies for

improving access to research evidence to inform policy decisions, i.e.; user-friendly formats for evidence briefs and clearing house.

WP3: Developing and evaluating mechanisms for a rapid response service to policymaker needs for research evidence.

Overall Strategy (contd)

WP4: Developing and evaluating methods for

conducting deliberative/policy dialogues that are

informed by research syntheses/evidence briefs.

Methods for involving civil society, the general

public, the media in policy development.

WP5: Capacity-building for researchers,

policymakers and civil society in developing and

implementing evidence-informed health policies.

WP6: Comprehensive evaluation of the African

partners initiatives to improve the use of research to

inform health policy decisions.

WP1: Production of research syntheses (policy briefs)

(1)

Policy brief Formats:

Features: description of a policy problem;

description of likely impacts of key options for

addressing the problem; implementation barriers for

the options and strategies to address these

User-friendly packaging:

Key messages (1 page),

Executive summary (3-5 pages),

Full report (25-40 pages)


(contd 2)

Process

Identification of evidence:

National statistics; local data; Systematic reviews of effects) for

impacts (both for benefits and harms) of alternative

organizational arrangements to address the problem, barriers

& strategies for these arrangements; local single studies

Appraisal of evidence:

1. Systematic Review methods

• Check on methods used to search, select and appraise

studies in systematic reviews

• Check on methods used to analyse findings in systematic

reviews


(contd 3)

Appraisal of evidence:

2. GRADE framework for rating quality of evidence

Identification of important outcomes from a systematic

review; Assessment of quality of evidence per outcome

using GRADE framework; Tabulated summary of findings per

outcome; Key messages in plain language

Other Considerations for the evidence:

Systematic reviews and single studies are also assessed for:

applicability to the local context; equity across socio-economic groups; scaling up considerations (costs and

cost-effectiveness); gaps in the research evidence hence

need for monitoring and evaluation


(contd 4)

Merit Review Process

• The policy briefs are reviewed for both scientific

and policy relevance to the Ugandan health

system through an internal review mechanism

consisting of national policymakers, researchers

and other stakeholders.

• An external review process of stakeholders with

similar expertise across the same constituencies

from outside Uganda


(contd 5)

Policy Briefs products

• ‘Task Shifting to optimize health worker roles to improve the

delivery of Maternal and Child healthcare’ from year 1, has

been informative in the development of an international

guideline ‘WHO Recommendations to Optimize Health Worker

Roles to Improve Maternal and Newborn Health’

• ‘Increasing Access to Skilled Birth Attendance’ from year 2, produced for the MOH discussed the evidence for provision of

intrapartum care at first level health facilities, maternal waiting

shelters and working with the private-for-profit sector to

facilitate deliveries in health facilities

• ‘Advancing the Integration of Palliative Care into the National

Health System’ to contribute to the MOH policy process

Evidence brief for Policy:

‘Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare’

The Problem:

• The burden: high maternal mortality ratio

440 per 100,000 live births, under-five

mortality rate 140 per 1000 live births,

• Existing governance, financial & delivery

arrangements: inadequate HRH numbers,

distribution, performance, incentives &

motivation, supervision, informal task shifting

without clear policy, plan, M&E,…



Policy Option 1: Optimising the use of lay health workers: CHWs Use of lay health workers as an add-on to usual care:

(Lewin S et al. 2010) • Probably increases immunisation coverage and

breast feeding • May increase care seeking behaviour for children

under five and reduce morbidity and mortality in children under five and neonates



Policy Option 1 (contd):

Optimising the use of lay health workers: TBAs

Providing as little as two to three days additional training for TBAs: (Sibley L et al. 2004)

• May reduce maternal, perinatal and neonatal mortality and stillbirths

• May have mixed effects on maternal morbidity



Policy Option 2:

Optimising the use of nursing assistants:

• Paucity of information on the impacts of expanding

the use of nursing assistants

• A review found that nurse-aides (assistants) could

provide intrapartum supervision and conduct low

risk deliveries to enable midwives or doctors to

handle obstetric emergencies. (Hofmeyr GJ et al.

2009)



Policy Option 3: Optimising the use of nurses, midwives: A systematic review evaluated the impact of doctor-nurse

substitution in primary care: (Laurant M et al. 2009) • Nurse practitioners compared to doctors probably have

longer consultations and order more laboratory investigations • Patients are probably more satisfied with nurse practitioners • There is probably little or no difference in the number of

prescriptions, return consultations or referrals • There may be little or no difference in the quality of care or

patient outcomes



Policy Option 4:

Optimising the use of drug dispensers:

• A review on expanding the roles of outpatient pharmacists:

(Beney J et al. 2000) found that expanded use of outpatient

pharmacists targeted at patients may decrease the use of

specific health services – such as hospital admissions and

ambulatory care visits – and may improve patients’

compliance with drug therapy

• The impacts of expanding the use of drug dispensers to

promote and deliver cost-effective MCH interventions are uncertain.



Implementation Considerations: Agreement on the implementation barriers &

strategies: Implementation Barriers: poor care seeking

behavior from mothers, inadequate HRH skills, inadequate HRH incentives, poor referral processes,

Strategies: outreach by CHWs, community mobilisation, mass media for public education, in-service training for HRH, improved remuneration for HRH, community referral and transportation schemes,


‘Increasing Access to Skilled Birth Attendance’

The Problem: • The burden: high maternal mortality ratio 435 per

100,000 live births (DHS,2006) from MMR 670

(UN,1990)

• Coverage of Skilled attendance stood at 42% (DHS,

2006) and under 50% (AHSPR, 2009/2010)

• Maternal and perinatal causes constitute 13.2% of

the total disease burden (WHO,2004)



Policy Option 1: Providing Intrapartum Care at first level Health Centre Country case studies by Koblinsky et al. (1999) suggest that an efficient intrapartum care intervention is to provide for

mothers to routinely deliver in a primary level or first level health facility (e.g. Health Centre II) with midwives as providers but with other attendants working with them in a team.

• Efficient models of care reducing MMR to >50



Policy Option 2:

Working with the Private-for-Profit sector

Systematic Review by Patouillard et al. (2007) found many interventions involving the private-for-profit sector that could be implemented successfully in poor communities with potential improvements in equity particularly for those providers frequently used by low income groups.

• Provision of vouchers

• Franchising

• Contracting-Out



Policy Option 3:

Maternity Waiting Homes

A systematic review by van Lonkhuijzen and

colleagues (2009);

Maternity waiting facilities may be a relevant

option in rural populations with limited access to

emergency obstetric care.



Implementation Considerations:

Agreement on the implementation barriers & strategies:

Implementation Barriers: poor care seeking behavior from

mothers, social & economic constraints for mothers,

inadequate HRH, inadequate health facilities and financing,

Strategies: VHTs, community mobilisation, community referral

and transport schemes, strengthening health infrastructure

and public-private collaboration

WP4: National Policy Dialogues

Objectives

Structured discussions using the policy briefs as background

documents for consideration of health systems issues to inform

health policy decisions

Participation

Stakeholders with the relevant expertise including; legislators,

policy makers, health managers, researchers, civil society,

professional organisations and the media

Moderation & Environment

Facilitation is provided by a neutral, knowledgeable

moderator. Discussions do not aim for a consensus. Records

are kept, however, participant contributions are not attributed

to the individual or institution they represent. Records of stakeholder views and experiences are shared with MOH

together with the policy briefs

WP4: National Policy Dialogues

contd… Dialogues held

REACH Uganda has held six policy dialogues for the policy

briefs on ‘Task Shifting’ and ‘Increasing Access to Skilled Birth

Attendance’ and ‘Palliative Care’.

Evaluation

Surveys conducted with the stakeholders regarding the design

of the policy briefs and dialogues yielded high ratings for both

products and processes as useful communication

mechanisms for research evidence to support decision-

making

Stakeholder Perceptions Results from Baseline Outcomes Survey

Graduate scale of 1 (never), 5 (frequently), 7 (always)

Question Mean Median Mode

To what extent do you agree or disagree with

these statements about REACH Uganda

(SURE)’s contributions over the last two years.

REACH Uganda (SURE) has contributed to

enhancing the availability of relevant

research evidence on high priority issues.

4.8 5.5 6.0


strengthening relationships among

policymakers and researchers.

4.9 6.0 6.0


strengthening policymakers’ capacity to find

and use research evidence in health systems

policymaking.

4.5 6.0 6.0

REACH Challenges

• Core funding for REACH – government,

external partners

• Human resource capacity – numbers, skills

• EA sub-regional linkages – weak leadership

Thank You!

EVIPNet and Evidence-Informed Policy-making: Perspectives ... · EVIPNet and Evidence-Informed Policy-making: Perspectives and Practices, Uganda Harriet Nabudere, MD, MPH College

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