Building the capacity of users and producers of evidence in health policy and systems research for better control of endemic diseases in Nigeria: a situational analysis

Endemic tropical diseases continue to impose a tremendous health burden in resource-poor countries throughout the world, claiming millions of lives annually and inflicting severe morbidity that results in significant losses in economic productivity and social progress [1]. Nigeria did not meet the Millennium Development Goals (MDG) targets for malaria which was to halt and reverse the spread of malaria and some other communicable diseases such as HIV/AIDs, tuberculosis by 2015. The baseline assessment for the health-related Sustainable Development Goals (SDGs) highlights the weaknesses of the Nigerian health system in controlling of endemic diseases [2, 3]. A significant weakness is the scarcity of scientists and health professionals in low and middle-income countries (LMICs) with relevant infectious disease research knowledge and expertise to generate health policy and systems research evidence [4]. A second weakness is the limited use of relevant research evidence for policy and decision making, which essentially hinders well-designed disease control programs from achieving desired goals [5]. There is also the gap in evidence of complex interventions in health to improve knowledge of what works for whom and in what context [6, 7].

As policy-makers and communities increasingly demand better returns on investments in health, HPSR+A has the potential to enable health system interventions to achieve better value for money. However, the current capacity to undertake HPSR+A and teaching is low in developing countries [7]. Health policy and systems research has been defined as “an emerging field that seeks to understand and improve how the societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to health policy outcomes” [8]. It enables the identification of gaps in capacity, barriers to efficient functioning, and effective performance of the health system and methods by which the existing resources can be optimally utilized [9, 10]. Capacity building programs bring on additional resources, i.e. knowledge, skills and experiences in organizational settings [11]. HPSR is typically context-specific, and to apply research evidence to policy, national-level capacity is needed [7]. The success of efforts to build capacity in developing countries will ultimately depend on political will and credibility, adequate financing, and responsive research, capacity, strengthening (RCS) plan that builds on a thorough situational analysis of the resources needed for health research and the inequities and gaps in health care [12].

In order to strengthen health systems using evidence, there is a current need to build the capacity of HPSR+A in LMICs as this encompasses the processes of actual decision-making at all levels of the health system [8]. Capacity building programs are critical for prioritizing health programs in resource-constrained countries where poor health outcomes have been linked with poor health services [11]. There is a rising importance to build capacity in HPSR+A in both the ‘pull and push’ domains of research in Nigeria [13]. This includes capacity to analyse, evaluate, and develop context-specific strategies to strengthen the fight against neglected tropical diseases (NTDs) and malaria. It also encompasses capacity to demand for and use research, so that research knowledge contributes to improvements in health and health equity [13]. Several factors contribute to poor demand for research evidence. First is that there is little appreciation of the value of research and its potential to contribute to policy development. Another critical contributor is that many LMICs do not have an environment or a culture conducive to health research [13]. These environmental factors include governance, socio-political influences and attitude of key stakeholders.

In Nigeria, Universities are central to strengthening and sustaining HPSR+A capacity. They not only produce knowledge through research but are also mandated to teach the next generation of policy-makers, health professionals, and researchers [7]. However, there is limited capacity amongst these groups due to the long-standing culture of not making research a priority and poor funding towards research [1]. The Health Policy Research Group (HPRG), College of Medicine University of Nigeria, Enugu campus (COMUNEC) is currently striving to bring HPSR to the fore in the country by collaborating with policymakers and international partners. They have made some progress, especially in the field of knowledge management for getting research into policy and practice (GRIPP) HPRG comprises public health physicians, medical doctors, epidemiologists, and health economists who are primarily lecturers but use their teaching time to subsidize research [14].

Strengthening the capacity of producers and users of research is arguably a sustainable strategy for developing the field of HPSR+A in Africa than relying on training in high-income countries [10]. As both policy-makers and communities increasingly demand better returns on investments in health, HPSR has the potential to enable health system interventions to achieve better value for money. To reach this potential, producers and users of HPSR evidence need training and local empowerment to be more context useful. World Health Report called for renewed efforts to strengthen health research capacity towards universal health coverage [12], for which capacity building interventions have been identified to bring in new resources (skills, knowledge) in the organization. There is a need for adequate research and analytical capacity in a range of organizations including ministries of health, health policy analysis institutes, think-tanks, academia and civil society in Nigeria. The long-term goal is to strengthen individual and institutional capacity to initiate and lead research activities in disease-endemic countries while developing national and international partnerships. This is timely as there is yet no national policy on the control of NTDs.

This paper provides information on the levels of involvement in HPSR+A (among producers of research evidence) and use of research evidence for decision making (among users of evidence) for the control of endemic diseases in two states in Nigeria. It also highlights potential interventions for improving capacity to undertake and use HPSR+A in policy and decision making.

The personal characteristics of respondents are presented in Table 1. Majority of them were males, 58% of producers and 56.5% of users. Academics (lecturers and professors) accounted for 55.6% of the producers of research evidence, while malaria control was the area of greatest experience for the highest proportion of users of evidence, 26.1%. With respect to job role, half of the producers of evidence were lecturing, and 34.8% of users of evidence reported they were heading departments in their organizations.

The rest of the findings are reported separately for producers and users of evidence.

The higher proportion of producers of research evidence involved in HPSR+A in Enugu state could be explained by the influence of Health Policy Research Group which is a foremost organization known for generating research evidence in health policy and systems analysis, as well as training potential HPSR+A researchers. Enablers for involvement in HPSR+A include personal interest, mentorship, promotion and availability of research grants. On the flip-side, respondents reported that lack of funds, lack of interest, lack of mentorship and lack of educational resources were major constraints to getting involved in HPSR+A. These results are in concordance with other studies that have highlighted funding, mentorship and opportunities for training as key drivers for building capacity of researchers in the field of HPSR+A [7, 9, 12‐14].

Majority of the users of evidence (decision/policymakers) in both states were aware that research evidence should inform policy decisions, and a few reported they had in the past requested for research evidence or initiated research for policy/strategy development and program implementation/review. This could be attributed to increasing global attention and support for evidence-informed decision making in health. The proportion of users who reported actually using research evidence in decision making was not as robust, and their reasons were mainly lack of awareness of HPSR evidence and lack of autonomy in decision making. The former reason is irrespective of the fact that considerable numbers of producers of research evidence in both States reported that their research is informed by health policy and program priorities of users of evidence. Poor access to research evidence and limited decision space have been previously reported as constraints to evidence-based decision making [16, 17].

There seemed to be a clear channel for gathering evidence for decision making in both States. Whereas producer of research evidence preferred journal publications, conferences and feedback workshops for dissemination of research findings, users of evidence appeared to value policymaker workshops, partners’ meetings and short courses as important channels for communicating/receiving research evidence. The preference for journal publication among producers of evidence is due to high visibility and academic staff appraisal requirements which are both critical for career progression of university lecturers. The observed mismatch in communication of research evidence has been underscored as a major constraint to GRIPP [14]. Hence communication of research evidence should occupy a major part of interventions for improving capacity in HPSR+A in LMICs.

Finally, although, users of evidence in both States perceived research dissemination and GRIPP activities to be very important, their capacity to participate in these activities was poor, and has been linked to low demand for high-quality research outputs [18]. This underlines the importance of bridging the gap between research and policy making. Decision makers need capacity building in order to, i) better understand the field of HPSR+A, ii) be able to initiate and commission health systems research that are relevant for policy and decision making, iii) be able to source for, synthesize and use research evidence for policy making. Similarly, because HPSR+A is a relatively new field, there is a need to continue building a critical mass of researchers that will be able to undertake such studies and have the skills for GRIPP.

There are gaps in capacity to produce and use evidence for decision making in control of endemic diseases in Nigeria. Involvement of researchers in HPSR+A is constrained by lack of funding, limited numbers of mentors and inadequate training opportunities. Poor uptake of research evidence in policymaking is hindered by poor access to research evidence and lack of autonomy in decision making. There is the need to invest in capacity building activities in order to develop a critical mass of users and producers of evidence in HPSR+A for better control of endemic diseases.