Contents
Abstract
Health policy and systems research (HPSR), which aims to produce reliable and rigorous evidence to inform the many critical decisions that must be made about health systems, is a new concept in Nigeria. In this study, policy makers and other stakeholders in the health sector identified the challenges and the potential intervention strategies to HPSR evidence use in policy making in Nigeria. The major challenges identified included capacity constraints at individual and organizational levels, communication gaps and poor networking between policy makers and researchers, and the non-involvement of healthcare recipients in identifying and planning care delivery needs. The main solutions suggested included promotion of strategies to encourage partnership between researchers and policy makers, improvement of staff incentives and facilities for research activities, improved budgetary provision for research, and sustainable institutional capacity development. These strategies have been shown to improve evidence-based policy making in developed countries and are likely to produce better outcomes in the developing world.
Résumé
La recherche sur les politiques et les systèmes de santé (RPSS), qui vise à produire des données fiables et rigoureuses pour éclairer les multiples décisions importantes du système de santé, est un concept nouveau au Nigéria. Dans la présente étude, des responsables de politiques et d’autres intervenants du secteur de la santé ont dégagé les défis et les stratégies potentielles d’intervention en matière d’utilisation des données de la RPSS dans l’élaboration de politiques de santé au Nigéria. Les principaux défis repérés comprennent, notamment, les contraintes en matière de capacité aux niveaux individuel et organisationnel, les lacunes en matière de communication, le manque de réseautage entre les responsables de politiques et les chercheurs, ainsi que la non participation des bénéficiaires des services de santé dans l’identification et la planification des besoins en prestation de services. Les principales solutions proposées sont, entre autres, la promotion de stratégies qui favorisent les partenariats entre les chercheurs et les responsables de politiques, l’amélioration des mesures incitatives, la mise en place d’installations pour les activités de recherche, une amélioration des dispositions budgétaires pour la recherche et le développement durable des capacités institutionnelles. Il a été démontré que ces stratégies ont permis d’améliorer l’élaboration de politiques de santé fondées sur les données probantes dans les pays développés; elles permettraient sans doute d’améliorer les résultats dans les pays en développement.
Methods and Materials
Study participants
This research was a subnational study; participants consisted of individuals whose geographical area of operation is southeastern Nigeria, with emphasis on Ebonyi State. Participants included the following: health professionals in charge of the health systems; regional, state and local government directors of the health ministry; health professionals working with specific programs in the health ministry who wish to use HPSR to improve the impact of their strategies; staff and consultants involved in public health issues within the health ministry; and program/project managers under the health ministry.
Data collection
An Evidence-Policy Workshop was organized by the research team in July 2009, and the study participants were invited to it. A total of 73 participants attended. During this forum, a focus group discussion was held, and up to seven discussion groups of between seven to 12 persons per group took part in discussions lasting up to 45 minutes. The issues discussed were categorized into four central themes, with questions within each theme as follows:
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Capacity constraints and challenges that impede the development of HPSR evidence use in Nigeria: (a) What are the individual staff constraints that impede HPSR evidence use in your organization? (b) What are the organizational challenges and constraints that impede HPSR evidence use in your organization?
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Identification of critical gaps in HPSR evidence use, with a focus on improving public health: (a) What are the critical gaps in HPSR evidence use in your organization that have affected efforts to improve public health in your geographical areas of operation? (b) How have the critical gaps identified affected evidence-based healthcare delivery in your geographical areas of operation?
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Identification of barriers to and solutions for translating research into policy and practice via evidence use: (a) What are the barriers to effective utilization of research evidence in policy making and practice in your organization? (b) What possible interventions can be adopted to facilitate the process of translating research evidence into policy and practice?
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Identification of potential strategies and solutions that would address capacity constraints and challenges of HPSR evidence use in Nigeria: (a) What are the possible strategies that can be adopted to improve individual capacity in HPSR evidence use in your organization? (b) What possible strategies can your organization adopt to improve organizational capacity in HPSR evidence use?
Theoretical foundation underlying the methodological approach
The target participants in this study were health service/policy providers because we anticipated a supply-driven outcome that would address capacity constraints in HPSR evidence use in policy making and policy implementation by these individuals. According to AHPSR (2004), the supply-driven model has been used extensively to design capacity-strengthening initiatives in developing countries, based on the assumption that if the skills of the main actors (researchers and policy makers) are enhanced via training and enough institutional capacity is built, research outputs will be put to good use. Although this argument has intensified in HPSR circles with a focus on the demand side, the supply-driven approach has a stronger tendency to accomplish a high level of ownership of policies, an outcome that has been witnessed in Nigeria and other developing countries. The reason is that health policies are better implemented when those charged with this responsibility are made to identify the capacity challenges and the solutions required to address these challenges.
Capacity constraints at the individual level are perceived as major impediments in HPSR evidence use in the health policy making process in most developing countries, including Nigeria (Gonzalez-Block and Mills 2003; Uneke et al. 2009). Green and Bennett (2007) have noted that evidence is needed about how capacity constraints, particularly among policy makers in various countries, inhibit evidence-informed health policy, and which strategies are effective in addressing these constraints. No other category of individuals is in the best position to identify the capacity challenges of service/policy providers in HPSR evidence use in policy than the service/policy providers themselves. This assumption informed the adoption of our methodological approach. Our intention, however, was not to restrict the investigation to the supply-driven model. The goal was first to generate information using the supply-driven model, and then to use it to stimulate the demand-driven aspect, which is also key to achieving evidence-based policy making and practice. A number of earlier reports provided evidence proving that supply-side capacity-building strategies that do nothing to stimulate the demand for research are unlikely to achieve expectations, and may actually further distort allocations (Bhagavan 1992; Acemoglu 1997). The essence of our approach was to address the uncoordinated “pushing” of research results by scientists and “pulling” of research results by market-oriented users (AHPSR 2004).
We employed a focus group discussion because our study was intended to draw upon respondents’ attitudes, feelings, beliefs, experiences and reactions with respect to capacity constraints in HPSR evidence use in policy making. A focus group was seen as the most feasible method of accomplishing this aim, as other methods such as observation, one-to-one interviewing and questionnaire surveys do not enhance social gathering and interaction the way a group discussion does. The approach that we took to elicit information from key informants in the focus groups has been described by Kitzinger (1995). The theoretical foundations underlying this approach were based on the work of Thomas and colleagues (1995), who described the focus group as “a technique involving the use of in-depth group interviews in which participants are selected because they are a purposive, although not necessarily representative, sampling of a specific population, this group being ‘focused’ on a given topic.” Richardson and Rabiee (2001) have noted that individuals participating in a focus group are usually selected based on the fact that they have a working knowledge of issues addressed, are within a similar age range, have similar socio-demographic characteristics and are likely to be comfortable talking to the interviewer and with one another. According to Burrows and Kendall (1997; cited in Rabiee 2004), “this approach to selection relates to the concept of ‘Applicability,’ in which subjects are selected because of their knowledge of the study area.”
Data analysis
The responses from the focus group discussion were noted and were analyzed based on Giorgi’s (1985) phenomenological approach, which has been elaborated by Albert and colleagues (2007). The analysis followed the following steps: (a) going over all the textual data to gain an overall impression; (b) identifying all comments that appeared significant to the research and extracting these meaning units; (c) independent abstracting of the meaning units, followed by discussion and consensus; (d) independent categorization and summarization of abstractions into challenges of HPSR evidence use in policy making and the solutions as perceived by policy makers, followed by discussion and consensus; and finally (e) returning to the extracted text to ensure a good fit with the final list of challenges and solutions.
Results
The participants’ attributes are presented in Table ; the responses from the focus group discussion are summarized in Table .
TABLE 1.
Participant attributesNo. (%) of participants
N=731. Gender Male44 (60.3) Female29 (39.7)2. Age 25-3410 (13.7) 35-4444 (60.3) ≤4519 (27.1)3. Official designation Program officers17 (24.3) Managers/Heads of departments39 (55.7) Directors17 (24.3)4. Years of experience in current designation (in years) <324 (32.9) 3–524 (32.9) 5–1018 (24.7) >107 (9.6)5. Highest academic qualification Diploma13 (17.8) Bachelor40 (54.8) Master’s18 (24.7) Doctorate2 (2.7)Open in a separate window
TABLE 2.
Discussion issuesSummary of responses from discussion groups1.Capacity constraints and challenges that impede the delivery of HPSR evidence use in NigeriaIndividual Staff Constraints
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Inadequate funding for research programs
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Inadequate facilities
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Lack of access to information (and specifically, Internet services)
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Poor incentives/lack of motivation
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Lack of interest in research (individuals think it is not their responsibility to initiate/conduct research)
Organizational Constraints
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Poor capacity to collaborate with partnersx
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Inadequate funding
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Political interference
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Inadequate manpower
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Inconsistency in policy formation processes
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Lack of capacity development programs
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Inadequate involvement of the appropriate health personnel in policy making
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Non-continuity of health programs due to change in government
2.Critical gaps in HPSR evidence use, with a focus on improving public healthCritical Gaps in HPSR Evidence Use
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Dearth of qualified personnel (experts)
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Non-integration of efforts in planning and in decision-making
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Non-involvement of health recipients in identifying and planning healthcare delivery needs
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Non-use of multiprofessional approach in formulating health policy and initiating health research works
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Poor networking
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Lack of functional database
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Top-down policy making approach that excludes critical agents at the primary level
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Communication gap between the policy makers and the researchers
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Non-availability of research units/departments in most health organizations
How the Factors (Gaps) Affect Evidence-based Healthcare Delivery
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Lead to poor/substandard health services delivery
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Hinder the achievement of health sector goals/targets
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Lead to process/implementation failure, and so can disrupt priority-setting
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Lead to inefficiency in the use of available resources
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Lead to service duplication and the generation of irrelevant services
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Increase mortality and morbidity rates
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Affect planning for healthcare delivery
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Create gaps between the policy makers and the implementers, giving rise to non-involvement of grassroots in ownership and participation
3.Barriers to and solutions for translating research into policy and practice via evidence useBarriers to the Use of Evidence in Policy Making Process and Practice
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Dearth of existing relevant research data
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Interdisciplinary conflicts (i.e., lack of interdisciplinary teamwork)
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Poor logistics system
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Lack of knowledge on the part of policy makers to appreciate the relevance of evidence-based research
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Political interferences or influence
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Socio-cultural barriers
What Can Be Done to Facilitate the Process of Translating Research Evidence into Policy and Practice
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Increase funding provision for building and maintenance of research evidence database
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Ensure institutional/personnel capacity development
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Undertake advocacy campaigns
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Educate policy makers on the importance of evidence use in health policy making
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Promulgate relevant legislation to back up implementation of research results
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Fund health research projects
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Train health personnel to carry out research
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Equip planning and research centres at state and local government levels
4.Potential strategies and solutions that would address capacity constraints and challenges of HPSR evidence use in NigeriaStrategies and Solutions for Improving Individual Capacity
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Train personnel to enable them to know more in their area of specialization
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Provide Internet facilities and reference materials
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Improve staff incentives for research activities
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Motivate personnel through incentives
Strategies and Solutions for Improving Organizational Capacity
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Enhance collaboration and networking among stakeholders in the health sector (including private sector participants and donor agencies)
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Initiate and undertake political advocacy on critical health issues
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Ensure adequate resource mobilization (especially on how to optimize internal sources)
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Improve funding and incentives; provide research budgets
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Ensure widespread dissemination of research results and feedback
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Develop sustainable institutional capacity
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Fund research and utilization of results in decision-making and policy implementation in the health sector
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Utilize research findings in quarterly/annual meetings where research evidence can be presented to policy makers
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Ensure proper data management
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Minimize political interests in the development of HPSR
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Introduce effective monitoring and evaluation programs
Open in a separate window
Concerning capacity constraints and challenges that impede the delivery of HPSR evidence use in Nigeria, some participants identified individual-level constraints as follows: “There are inadequate facilities for health policy and systems research in our health ministry”; “We lack access to reliable electronic information systems, especially Internet services”; “There are poor incentives and lack of motivation for health policy and systems research”; “I do not have much interest in research since it is not encouraged by my organization,” etc.
At the organizational level, participants identified a number of capacity constraints: “Our organization has poor capacity to collaborate with partners and other organizations/institutions”; “There is inadequate funding for any research activity including health policy and systems research”; “There is a lot of political interference in our operations, which are not in favour of research”; “We lack sufficiently trained manpower”; “The policy formation processes in our organization are very inconsistent”; “Our organization does not have established capacity development programs,” etc.
Participants identified the critical gaps in HPSR evidence use, with a focus on improving public health: “There is non-integration of efforts in planning and in decision-making”; “Non-involvement of health recipients in identifying and planning healthcare delivery needs”; “Non-use of multiprofessional approach in formulating health policy and initiating health research works”; “The existence of poor networking”; “There is a huge communication gap between the policy makers and the researchers,” etc.
Participants also described how these gaps affect evidence-based healthcare delivery: “These critical gaps have led to poor and substandard health service delivery”; “They have hindered the achievement of health sector goals/targets”; “These gaps can lead to the failure of policy process and implementation and so can disrupt priority setting”; “They lead to inefficiency in the use of available resources”; “They lead to service duplication and the generation of irrelevant services”; “They increase mortality and morbidity rates,” etc.
Concerning barriers to translation of research into policy and practice via evidence use, the policy makers commented: “There is [a] dearth of existing relevant research data”; “There are often interdisciplinary conflicts, that is, lack of interdisciplinary teamwork”; “We have [a] poor logistics system”; “There is lack of knowledge on the part of the policy makers to appreciate the relevance of evidence-based research,” etc.
To facilitate the process of translating research evidence into policy and practice, the participants commented: “There should be increased funding provision for building and maintenance of research evidence databases in various health organizations”; “Mechanisms should be put in place to ensure institutional and personnel capacity development”; “It is important for the promulgation of relevant legislations to back up implementation of research results”; “Efforts should be made in equipping planning and research centres at state and local government levels,” etc.
The potential strategies and solutions that would address capacity constraints and challenges of HPSR evidence use in Nigeria were identified as follows: “There should be the provision of functional Internet facilities in health-based organizations”; “Each organization should ensure the improvement of staff incentives for research activities”; “It is vital to establish processes that are capable of enhancing collaboration and networking among stakeholders in the health sector”; “Establish ways of ensuring adequate resource mobilization, especially on how to optimize internal sources”; “The organizations should improve budgetary provision for research”; “It is vital to ensure that there is widespread dissemination of research results and feedback, particularly to health ministries”; “There should be sustainable institutional capacity development”; “Funding research works and utilization of results in decision-making and policy implementation in the health sector should be made mandatory”; “There should be minimization of political interests in the development of health policy and systems research,” etc.
Acknowledgements
The authors are grateful to the World Health Organization for its provision of financial support for this investigation through the Alliance for Health Policy and Systems Research (research grant no. 2009/25025-0; PO-No. 2 00072059). We are also grateful to all organizations, policy makers, researchers and other stakeholders for their participation in this research.
Contributor Information
Chigozie J. Uneke, Lecturer/Research Director, Health Policy & Systems Research Project, Department of Medical Microbiology/Parasitology, Faculty of Clinical Medicine, Ebonyi State University, Abakaliki, Nigeria.
Abel E. Ezeoha, Lecturer/Researcher, Department of Banking and Finance, Faculty of Management Sciences, Ebonyi State University, Abakaliki, Nigeria.
Chinwendu D. Ndukwe, Consultant Community Physician, Department of Community Medicine, Faculty of Clinical Medicine, Ebonyi State University, Abakaliki, Nigeria.
Patrick G. Oyibo, Consultant Community Physician, Department of Community Medicine, Faculty of Clinical Medicine, Ebonyi State University, Abakaliki, Nigeria.
Friday Onwe, Lecturer/Researcher, Department of Sociology/Anthropology, Faculty of Arts, Ebonyi State University, Abakaliki, Nigeria.