Practical lessons for bringing policy-makers on board in sexual and reproductive health research

We selected 18 academic articles answering a number of our selection criteria described above. The objective of the selection was to uncover existing literature’s main themes to relate them with the experience of project coordinating teams in four ICRH-coordinated projects. Therefore our search was not systematic, a choice reinforced by the following elements. Literature on translating research into policy is extensive, however few references are discussing it in the specific context we were looking at (SRH outside of North American and European contexts, particularly in LMICs). When literature looks at this context, it tends to look at stakeholder involvement with a focus on community and religious leaders and societal change rather than policy-makers and policy change. Only three references answered all four selection criteria [5‐7]. Therefore, we had to consider the extent to which other references were approaching the context we wanted to examine, or were discussing translation processes without linking them specifically to other contexts, even when they did not answer all four selection criteria. We were careful to select studies which could inform translatable dynamics to our context. References included were used to answer objective 1 and give an overview of the currently available knowledge on policy-makers’ involvement in our specific context.

Our literature review results show that knowledge management is now recognized as a key component of health system research; it can be defined as the creation and management of linkages between research and action [8]. It was particularly put under the spotlight at the 2004 World Health Organization Ministerial Summit on Health Research in Mexico, which sought to address the so-called “know-do” gap by exploring ways of translating research into action. The final statement of the meeting stresses the need to base “health policy, public health, and service delivery (…) on reliable evidence derived from high quality research [because] research evidence comes from various sources (…) and measures the benefits and potential risks of health interventions” [9]. Others call on moral and ethical considerations to support such statements [3].

In the context of knowledge management, ‘action’ is primarily understood as policy change resulting ideally in improved service delivery and ultimately in improved well-being for the populations. Policy change is thus a major objective of research translation efforts. As stated in the introduction, a number of individuals and organizations may be involved in policy change processes. Therefore, depending on the research context, such efforts should target a wide range of these actors, including policy-makers [2, 3, 5]. Because policy change is an increasingly complex and chaotic process [5], influenced by multiple factors (social, economic, political or cultural) [10, 11], researchers should be aware of the competing priorities of policy-makers in their decision-making processes [6]. This has implications in deciding which policy-makers to target, depending on the kind of policy change aimed at: changes in agenda-setting, narratives, institutions, policy or implementation [6, 12]. Ultimately, the objective of this process is to foster advocacy for SRH “supportive policies” [13].

Research results being taken up by policy-makers is not an automatic process. It requires a sustained investment since producing scientific evidence, however strong, is often not enough to ensure it is considered in future policy-making [7]. Therefore, strategies have to be proposed in order to “establish a conducive environment in terms of organizing regular meetings and consultations with key policy bodies” [6]. Those strategies might consist of push and/or pull efforts to create an “appetite” [14] for research in policy-makers and to encourage them to take up evidence when changing policy [14, 15].

To create such enabling fora, significant work should be carried out in order to identify the relevant institutions, networks or individuals [6] and to be prepared to address potential conflicts of interest [2]. Communication is essential to maximize the uptake of research results and framing is its cornerstone, as presenting the results in a clear and concise way increases their responsiveness to policy-makers’ needs [5]. An understanding of those needs and of policy-making processes is critical in order to ensure the best translation of research results. Because of its complexity, the process is particularly challenging. It means that all actors involved need to make efforts in terms of access to data, results framing and dissemination, network strengthening, which means investments in financial, time and human resources [7, 16, 17].

The research community is paying increasingly attention to these processes; however the literature rarely touches upon their specifics in the field of SRH. Because SRH interrogates a number of social norms and goes far beyond a simple public health paradigm, the uptake of even the most technical SRH research can meet significant obstacles [6]. Acknowledging sexual and reproductive health rights remains sensitive and researchers may face specific resistance from policy-makers on topics such as abortion, gender identity and sexual orientation, or sex work [5].

Little also exists on translation processes outside North American and European contexts and more particularly in LMICs [12, 14]. However, researchers wanting to bring their evidence into policy-making do face additional challenges in LMICs, notably because of the “limited critical mass and absorptive capacity (…) to undertake multiple and competing initiatives” [8] as well as rapidly evolving social environments [16]. In addition, LMICs offer fewer opportunities to engage with policy-makers in dedicated fora and fewer resources are attributed to SRH [5, 6]. When SRH is targeted in those settings, the literature rather focuses on other stakeholders, especially community and/or religious leaders. Thus, how to engage policy-makers outside North American and European contexts in the field of SRH is rarely touched upon.

Besides those gaps, criticism has been raised about the current paradigm in which translation of research outputs is considered. Academics have warned that although framing results in an understandable way is important, the sole needs of policy-makers should not dictate health system research as they are influenced by public opinion and electoral opportunities [18]. Funding agencies have sometimes been criticized for expecting quick and clear returns on investments in translation activities, a demand that might jeopardize future funding opportunities for SRH research [3, 6].

The review of project documents of the four ICRH-coordinated projects showed that the four research consortia put into place a range of strategies to enhance policy-makers’ involvement at different stages of the projects.

A first step all the projects took was to identify existing policies and potential gaps at national and study site levels through a policy analysis. Although the focus at this initial stage was more on policy content and thus not strictly speaking a translation activity, the policy analysis allowed to identify areas where policy change is needed as well as to map which policy-makers should be approached. The characteristics of policy-makers approached for each project are described in Table 2. These policy-makers were interviewed as key informants (DIFFER, INPAC) or consulted in the frame of causal analysis workshops (MOMI), which constituted a first contact with the projects. All projects invited policy-makers to kick-off meetings (DIFFER, MOMI, INPAC), annual consortia meetings (INPAC), or a first individual meeting (CERCA).

Throughout the projects, policy-makers have been provided with fora to give feedback on the project objectives and/or on the design, selection and implementation of the interventions at study sites. DIFFER, INPAC and MOMI formed Policy Advisory Boards (PABs) at each study site, meeting at least yearly (DIFFER, MOMI) or bi-yearly (INPAC). The main objective of PABs is to maximize involvement, which is key for the sustainability of project outcomes. PABs also provide ethical and methodology guidance. CERCA chose to convene individual or small group meetings with policy-makers rather than forming boards. In addition to their PABs, DIFFER and MOMI organized stakeholders’ workshops, specifically to collect policy-makers’ (among other stakeholders) feedback on the results of their initial situation analysis and the implications for the interventions.

The four projects also implemented mechanisms to reflect on the translation process and share the research results with policy-makers at the end of the project. As such, the CERCA consortium organized a conference primarily attended by policy-makers, with the objective of disseminating results on teenagers’ SRH. Additionally, three national reference documents were developed by CERCA in which the most important project results and recommendations are mentioned. These were distributed amongst policy makers of the three involved countries (Bolivia, Ecuador and Nicaragua). An evaluation workshop is to be conducted in the frame of DIFFER at the end of the project to discuss opportunities to translate the project outcomes into policy and guidelines to improve female sex workers’ SRH. INPAC aims at developing three specific tools to inform the translational process in the context of SRH (particularly abortion and family planning) in China: a list of potential barriers to translation, recommendations on communicating with PABs, and a strategy for translating INPAC results into actual policy. MOMI will similarly produce policy recommendations in a format adapted to policy-makers’ needs.

Key informant interviews provided additional information on challenges, solutions and lessons learned regarding policy-makers involvement in project design and implementation.

Key informant interview results show that there is a consensus that involving policy-makers is critical to improve both local ownership and scientific knowledge and to ensure ultimately that health outcomes improve for the target populations. They also show that participating policy-makers were selected based on their familiarity with the project topics and their responsiveness to the first contact.

All interviewees agreed that policy-makers have to be involved early in the project. This is considered the best (although not automatic) guarantee that the involvement remains steady throughout the project, that needs and opportunities are correctly identified, and that the implementation of the interventions would not be met with resistance. Providing information to policy-makers is not considered enough and all projects searched to create effective ways of collecting inputs. This is illustrated by the different strategies described above (workshops, advisory boards, etc.…).

Involving policy-makers proved strenuous. Table 3 shows the main obstacles met and the corresponding solutions experimented in the four projects.

The projects all experienced similar challenges in policy-makers’ attitudes and the consortia worked on improving motivation and interest of policy-makers whether in the project itself (CERCA) or in research findings in general (DIFFER). Two projects faced additional obstacles of policy-makers worrying the project would go against national regulations on abortion (INPAC) or being reluctant to participate in a project aiming at sex workers (DIFFER). MOMI was received more positively by policy-makers who recognized the need for enhancing post-partum care.

Geographical distance and high levels of policy-makers’ turnover were the two main structural challenges cited by project coordinators. This required from local consortium partners to regularly repeat efforts to involve policy-makers at a distance or to seek new appointees, which is reflected in local consortium partners feeling that translational activities are time-consuming and rarely rewarding. The strategies to make and keep contact with policy-makers were dependent on the existing networks at the different sites: if in some countries CERCA had to rely on individual mailing because of the lack of such networks, INPAC worked extensively with them, using the presence of local consortium partners in the national and/or local decision-making processes.

Experiences with policy-makers could also be positive, particularly when they agreed with the project objectives, recognized the needs at stake, and were thus eager to participate. This was not only beneficial for the projects but also rewarding for the teams (DIFFER, MOMI, INPAC). In some cases, policy-makers facilitated contacts or provided financial support for local adolescent SRH networks (CERCA).