Initiatives supporting evidence informed health system policymaking in Cameroon and Uganda: a comparative historical case study

We conducted a qualitative descriptive and interpretive archival review of both initiatives. All the available documents were requested from the KTPs’ secretariats, the research coordinators of KTPE project at McMaster University in Hamilton, Canada and SURE project at the Norwegian Knowledge Centre for Health Sciences in Oslo, Norway. We searched the websites of EVIPNet (www.​global.​evipnet.​org), EVIPNet Cameroon (www.​cdbph.​org), and the Uganda clearinghouse for health policy and systems research (www.​uchpsr.​org) for any relevant documents or activities. We equally conducted a structured documentary review of poverty reduction/eradication strategic papers and health sector strategic plans produced in Cameroon and Uganda during the period 2001–2012 to capture the political, social and economic contexts and salient features of both health systems. These documents were obtained from the respective ministries of health (Table 1). We extracted relevant data featuring the contexts, the institutional arrangements, the activities and outputs of KTPs.

In both countries, policymakers, researchers and other stakeholders likely to be involved in or affected by policy decisions on the issue addressed by an evidence brief (policy brief) were invited to a deliberative dialogue (policy or stakeholder dialogue). All dialogue participants were surveyed about the evidence brief that was pre-circulated for the dialogue and about the dialogue itself. Seven evidence briefs and five dialogues were concerned in Cameroon. Three evidence briefs and two policy dialogues were concerned in the case of Uganda. The questionnaires available both in French and English were developed as part of the KTPE study. Each questionnaire comprised three or four sections to depict how helpful each of the features of the brief/dialogue were, how well the brief/dialogue achieved its intended purpose, items based on theory of planned behaviour constructs, and questions about respondents’ professional experiences. Further details on the instruments can be accessed online at http://​www.​researchtopolicy​.​org/​KTPEs/​KTPE-overview.

The coding of the features of the brief/dialogue based on the electronic copies of the dialogue summary and/or report was checked with core members of each KTP secretariat. Descriptive statistics were used to examine respondents’ overall assessments of brief/dialogue and their features and to profile the assessments of each feature of the brief/dialogue, each of the brief and the dialogue as a whole, and respondents’ intentions to act on what they had learned.

Cameroon and Uganda political systems are marked by their presidential regimes strongly anchored in traditional ruling systems bolstering the ethnic diversity with 220 and 56 ethnic groups respectively. The Head of State in each country has been in office since the 1980’s. The Parliaments are dominated by a large majority from the Head of State’s political party and technocrats play a pivotal role during health policymaking. The thrust of development policies has been the achievement of MDGs following the Millennium Summit and the African Union resolutions to speed up health investments and align them with health MDGs targets with both countries eligible for grants from a diversity of global health initiatives. Efforts were engaged to strengthen national health research systems leading to establishing a division in charge of health research in the ministry of health in Cameroon since 2002 and increasing financial support to Uganda National Health Research Organization (UNHRO) since 2008.

Since the mid 1990’s, health decentralization was initiated in both countries to align with the health district framework established by the African Regional Office of WHO. The tiered health systems are mixed; state owned health services coexist with private health facilities operating in poorly regulated environments. The ministry of health is the overarching health authority in addition to the inter-sectoral governing bodies of priority health programs established in response to global health initiatives (e.g.; expanded programme of immunization, control programs for AIDS, tuberculosis and malaria, reproductive health, neglected tropical diseases, etc.). The major changes observed include: i)the abolition of user fees in Uganda in 2001 and the promotion of community based health insurance in Cameroon since 2004; ii) the tangible efforts towards actual decentralization of health authority to provincial/regional and district authorities in both countries starting in 2001; iii) the promotion of universal access to HIV/AIDS care including antiretroviral therapy since 2003; iv) the universal access to malaria control interventions since 2002 and; v) the scaling up of reproductive health programs in line with the African Union’s campaign to accelerate the reduction of maternal mortality in 2009.

Table 3 summarizes the political and health systems and main indicators of health MDGs. While Cameroon ranked as lower middle income and Uganda as low income, the maternal mortality ratio (MDG 5) has worsened in the former while improving in the latter. Neither country will reach the health MDGs targets by 2015.

The KTP secretariats are housed within a government entity, a teaching hospital closely linked to the ministry of health in Cameroon and a public university in case of REACH-PI Uganda. Since the beginning, each secretariat is led by the same local champion linked with global ‘evidence to policy’ specialists. Issue networks of policymakers, researchers and other stakeholders were established around priority topics (e.g.; reproductive health, governance for health district development, health financing, malaria control, human resources for health, etc.). The intersection with global funding opportunities for health, the formal and informal connections between the KTP secretariats and national and international players influenced priority setting exercises and resources mobilization to support KTPs operations.

Table 4 outlines a comparative historical account in relation to global focusing events. EVIPNet Cameroon can be traced from the creation of a division of health operations research in the ministry of health in 2002 whose mission includes linking research and action. The division responded to a call for letters of intent by the WHO which led to its establishment as the KTP secretariat in May 2006 before its relocation in June 2008 at the centre for the development of best practices in health at Central Hospital Yaoundé. REACH-PI Uganda came to existence through a longer incubation period starting in December 2001 with the Lake Duluti regional consultation under the auspices of the East African Health Research Council and concluded in December 2006. As a consequence of the regional consultation, several activities to link health research and action were conducted such as the successful completion of Tanzania Essential Health Interventions Project in 2003 and national workshops in 2004 and 2005 in Kenya, Tanzania and Uganda. The UNHRO agreed to have the Makerere University College of Health Sciences establish the Uganda REACH country node which marked the beginning of the Uganda KTP which has also served as the base for Makerere University’s participation in the SURE project.

Table 5 outlines the KTPs’ infrastructure. EVIPNet-Cameroon secretariat has been operating with a multidisciplinary group of part-time researchers and research assistants (e.g.; public health, economy, anthropology, sociology, epidemiology, clinical sciences) trained as brokers. While two scientists have remained engaged the whole time, a turn-over was noted amongst researchers and assistants. REACH-PI Uganda has been operating with a smaller group of full time staff of public health experts trained as brokers. A social scientist trained as broker left after 12 months and the number of brokers went from one to six between 2009 and 2012. The initial stakeholder analyses during grant preparation laid the groundwork for participatory priority setting exercises and validation of the respective programs of work thus creating the enabling environment for mutually beneficial exchange amongst knowledge brokers, policymakers, researchers, and other stakeholders. Both KTPs were established as demonstration projects informed by existing theoretical frameworks and were guided by a monitoring and evaluation framework that has enabled this description. They were conceived as problem solving enterprises, operating under the “learning through doing” principle. The same technical and scientific support from the EVIPNet resource group was provided to both initiatives for their operations including grant writing, developing and testing new resources and tools for EIHP. A vibrant collaboration was established with the McMaster Health Forum at McMaster University, the Norwegian Knowledge Centre for health services and the South African Cochrane Centre in Cape Town, South Africa (SACC). Several visits of scientists and knowledge brokers were organized across countries and in both directions.

The initial funding in Cameroon was obtained from the global EVIPNet secretariat and the Canada’s Global Health Research Initiative through a Global Health Leadership Award. The initial funding for REACH-PI EAC was obtained from IDRC, the Swiss Tropical Institute and the Alliance for Health Policy and Systems Research (AHPSR). For the remaining period, financial resources for both KTPs were obtained from IDRC, the European Commission Seventh Framework Program (EC-FP7), the global EVIPNet secretariat and AHPSR. National governments provided mainly in-kind support. The EC-FP7 funded the five-year SURE project which was instrumental for building capacity, developing and testing resources and tools for EIHP. The Canadian Institutes for Health Research funded the KTPE. The estimated annual budget has varied from $US 40,000 to 180,000 between 2006 and 2012 in Cameroon with a total of 720,000 during the whole period. The change of the hosting institution in the case of REACH-PI prevented tracing the total investment during the period 2006–12, as from 2009 to 2012 the overall budget approximates US$ 640,000 non inclusive of the International Research Chair Initiative supporting the doctoral program in health policy and knowledge translation.

Table 6 provides an account of the activities and outputs in terms of capacity building, knowledge management and linkage and exchange. The human capital for EIHSP was increased by more than thirty training workshops in Cameroon, Uganda and other countries (Kenya, Tanzania, Burkina Faso, Mali, Zambia, and Mozambique) to jointly build capacity for policymakers, researchers, civil society groups and media on EIHSP. Almost five hundred stakeholders were sensitized or trained by both KTPs including five Africans and four Canadians enrolled in the joint doctoral program in health policy and knowledge translation at Makerere University and McMaster University respectively.

Following the priority setting exercises, both KTPs have produced 15 evidence briefs for policy. Preparing evidence briefs was very labour intensive as few evidence briefs have required two full time equivalent knowledge brokers during one year. Between 2008 and 2012, EVIPNet Cameroon prepared 12 evidence briefs and REACH-PI Uganda prepared three evidence briefs. In line with the SURE grant plans, a mechanism to prepare rapid evidence syntheses in response to stakeholders’ urgent needs within days or weeks was piloted in Uganda starting 2010 and has required at least one full time equivalent knowledge broker. In 2012, the same mechanism was launched in Cameroon informed by the Uganda pilot. In total, six rapid evidence syntheses were prepared in Cameroon in 2012 versus 73 in 2010–2012 in Uganda. Under the effective health care research consortium collaboration with the SACC, EVIPNet Cameroon has prepared 12 bilingual summaries and translated into French 24 abstracts of Cochrane reviews in 2011–2012. Evidence products generally aligned with priorities to achieve health MDGs. EVIPNet Cameroon has maintained since 2009 a website providing access to evidence briefs and syntheses complementing the national electronic database of health documents housed by the division of health operations research. REACH-PI Uganda has established in 2012 a Uganda clearinghouse for health policy and systems research operating as a “one-stop shop” of health policy-relevant evidence. Informed by evidence gaps identified during the preparation of evidence briefs, both platforms applied for and received funds for building capacity to conduct policy relevant trials and Cochrane reviews in collaboration with the SACC. EVIPNet Cameroon has contributed to Cochrane Collaboration’s efforts to translate its products into French.

In terms of linkage and exchange, EVIPNet Cameroon organized seven policy dialogues informed by pre-circulated evidence briefs. The policy dialogues were jointly convened by the KTP secretariat and the Ministry of Health. The selection of participants was informed by the stakeholder analysis. Participants deliberated on scaling up access to artemisinin-based combination therapy (ACT), scaling up malaria control interventions, improving governance for health district development, retention of human resources for health in rural areas, scaling up community-based health insurance, improving antenatal care services coverage, improving access to and quality of care in the accident and emergency departments. REACH-PI Uganda organized three dialogues on scaling up access to ACT, task shifting for maternal and child health and, improving skilled birth attendance. EVIPNet Cameroon and REACH-PI Uganda played a central role organizing the first international forum on EIHP in LMICs (27–29 August 2012, Addis Ababa, Ethiopia) whose 121 participants were from 27 countries including 17 African countries. Participants were policymakers, international bureaucrats, knowledge brokers, researchers, civil society groups, and media.

Table 7 summarizes the results of the survey of readers of ten evidence briefs. The respondents largely agreed that the briefs achieved their purpose of presenting the available research evidence on a high-priority policy issue in order to inform a policy dialogue where research evidence would be just one input to the discussion. The different design features of the brief were highly appreciated but respondents expressed lower satisfaction with the brief not concluding with any recommendations.

Table 8 features the results of the survey of participants attending ten dialogues. All respondents felt the dialogues achieved their purpose of a full discussion of relevant considerations about a high-priority policy issue in order to inform action and the different features of how the dialogues were designed were considered very helpful including that the dialogue was informed by a pre-circulated evidence brief.

Both initiatives are equipped with research units operating as national knowledge brokering institutions with regional influence. Within the two health systems, a network of local and global experts has created new spaces for inclusive evidence informed deliberations amongst policymakers, researchers and stakeholders on high-priority health policy topics related to MDGs. The interaction between the KTP secretariats and ministries of health and other stakeholders enabled the identification of priorities for evidence briefs as well as evidence gaps. Both initiatives have progressively expanded to cover the array of operations of a knowledge brokerage enterprise namely capacity building, knowledge management, and linkage and exchange. Applications to funders and advocacy meetings have enhanced their visibility and provided enabling resources towards institutionalization and sustainability.

The evidence briefs and rapid evidence syntheses prepared generally aligned with health policy and systems priorities to achieve the health MDGs. The technical and consensual natures of the topics addressed and the problem-driven approach have contributed to a high level of satisfaction amongst all categories of stakeholders. The mechanisms to address stakeholders’ urgent needs of evidence within days and weeks were well received. The briefs and syntheses have provided evidence-based problem frames, policy options and implementation strategies yielding potential changes in two of driving forces in policymaking namely interests and ideas.

This historical account illustrates how the convergence of local and global factors and agents has enabled the implementation of in-country efforts to support EIHSP related to health MDGs. It also illustrates how the differences in historical background, institutional anchorage, contexts and funding sources have led to differences in activities and outputs of these KTPs. The diversity of grant arrangements and the differences in institutional arrangements and planning cycles as well as the stability of health technocrats explain the differences in evidence outputs and the contrasted uptake of the rapid response mechanism. EVIPNet Cameroon was more prolific in preparing evidence briefs and organizing policy dialogues because of the closer ties with the ministry of health thus allowing working concurrently on several evidence briefs. REACH-PI Uganda prepared more rapid evidence syntheses and aligned the production of evidence briefs to the SURE project arrangements.

This historical account equally illustrates the unpredictability of the course of events during the initial decade of these initiatives conceived of as demonstration projects. Initial priority settings have been readjusted to align with changes in leadership within ministries of health and global funding opportunities (e.g. in Cameroon shifting from nutrition and chronic non communicable diseases to health district governance and health financing based on the grant from the AHPSR). Contributions from governments have remained in kind. In this documentary review, we failed to identify any empirical evidence on the influence or impact of the KTPs on the country climate for research use or on specific policy processes beyond the policy deliberations.

The infrastructure, activities, outputs and outcomes of both initiatives encompass the full array of activities of knowledge brokerage enterprises and they have experimented at various levels the three key functions of such enterprise: capacity building, knowledge management and, linkage and exchange [8],[28]. Indeed, both KTPs have trained almost 500 policymakers, researchers and stakeholders to facilitate researcher push and user pull [9]. More than 100 tailored evidence syntheses were produced, disseminated and made openly available online. Inclusive consultations were organized to identify high-priority policy issues related to health MDGs and structured stakeholder mappings laid the ground work to convene 10 deliberative dialogues informed by research evidence.

The historical account and the critical analysis of actors of these social experiments feature the influence of policy learning/diffusion in the establishment of policy networks and epistemic communities [31]-[33]. Leading researchers from northern universities linked with African researchers to create a new momentum for EIHSP, developing and testing new resources and tools to popularize knowledge translation activities across Anglophone and Francophone Africa. They exemplify the relevance of the recommendations formulated based on analysis of similar institutions in other settings [35].

This is the first historical account of what is constitutive of two KTPs housed in government institutions in sub Saharan Africa. It contributes empirical knowledge on the feasibility and practicality of enhancing the technical capacity of policymakers, researchers and stakeholders; preparing evidence briefs, syntheses and summaries; providing evidence related services; convening dialogues and creating space for evidence informed deliberations on high-priority health policy topics. This investigation complements the lessons learned from the Zambian Forum for Health Research (ZAMFOHR) case study [36], a national nongovernmental organization spearheading knowledge translation efforts in Zambia. It also enriches the recent gathering of lessons learned on KTPs by providing a longitudinal perspective on what constitutes a KTP and how it operates in two LMICs [18]. The study offers an insiders’ perspective as two authors have a deep knowledge and understanding of the context in Cameroon and Uganda and the authors have been involved with both KTPs from the inception phase through the current state of operations. This study also provides a grounded feedback to the chorus of voices calling for support to EIHSP and the recommended strategies for facilitating the uptake of research into policy in LMICs [37]-[42]. Finally, by providing an historical insight on institutional arrangements of KTPs, this study contributes empirical evidence to the call for new conceptual frameworks and methods to orient evaluation of efforts to support EIHSP in LMICs [20]. In that regard, the analytical framework used for this study lays the ground work for further political sciences informed perspectives on KTPs to comprehend their influence and impact.

This study presents three main limitations. First, the study is restricted to describing what is constitutive of the two KTPs since their inception; an assessment of their influence on specific policy processes and the climate for EIHP is still awaited to empirically inform the efforts to explicate KTPs using sound political sciences perspectives. Second relates to the nature of retrospective qualitative archival review, the exclusive use of official documents might have overlooked challenges experienced by the KTP implementers particularly the informal networks to navigate the health bureaucracies, to engage with officials and gain their support over time. The restriction to the KTPs’ archives might have prevented the capture of the external players’ views and perspectives and particularly the funding agencies. Last relates to the insiders’ narrative as recall bias and social desirability yield potential negative effects on neutrality and objectivity.

This empirical documentation can inform the development of new initiatives with three implications: (i) those planning to establish initiative to support EIHSP in LMICs should carefully consider opportunities for national and international collaborations to mobilize political support from government officials and funding agencies; (ii) the critical role of participatory processes during priority setting exercises, stakeholders dialogue and needs assessment so as to secure commitment from both national policymakers and global players investing in health sector development; (iii) establishing an initiative to support EIHSP requires committed and skilled human resources to cope ably with intense and somehow stressful endeavour and to navigate the complex interfaces of knowledge to policy and action with a long term perspective.

This study equally provides a strong basis on which researchers can attune their efforts in developing and validating robust methods and tools to evaluate the effects and influence of KTPs [20].Indeed, the framework developed by Lavis and colleagues [9] to assess country efforts to link research to policy and used elsewhere [18] provide descriptive categories for efforts (e.g.; climate, research production, push efforts, facilitate user-pull, user-pull, exchange, and evaluation) engaged by a given country but doesn’t provide tools to assess the influence of such efforts. Further, the framework developed by Ward and colleagues [28] on what constitutes a knowledge brokering enterprise while accounting for the three main functions (e.g.; capacity building, knowledge management, and linkage and exchange) fails to account either for the effects and influence on drivers of policymaking (e.g.; institutions, interests and ideas) or the intersection with contextual factors during policymaking in environments permeate by cross jurisdictional learning. The need to have further reflection on the appropriate evaluative framework of KTPs remains valid [20].

The rising numbers of skilled individuals in EIHSP and the availability of contextualized evidence resources imply that national and global players investing in health sector development in Africa should create the enabling environment (e.g.; new rules and regulations, incentives) for and foster effective management and use of the human capital for policy analysis and research during health system planning and programming.