Bridging the Research to Policy Gap for Effective engagement in policy agenda setting in southern and eastern Africa

Abstract

Increasingly, health conditions exist for which there are high quality local and international data; effective, feasible, and affordable interventions; and strong research communities advocating for attention in low- and middle-income countries (LMICs). Yet these conditions still lack the political priority to make it onto the agenda of health policy makers. Examples include both conditions well-resourced in high income countries, such as surgery and trauma care or most cancers, as well as issues neglected globally, such as access to pain relief and palliative care. The reasons for the persistent absence of these issues from national priority lists in LMICs are still poorly understood. In this dissertation I bring together concepts of implementation science and political science to identify evidence-based, context-appropriate recommendations for improving the effectiveness of research use in driving policy agendas and prioritization. I first focus on assessing the current landscape of theories and frameworks available to researchers interested in building political priority for health conditions in low- and middle-income countries. I then use the frameworks to guide to two case studies looking at commitment to new health technologies in Uganda and the political prioritization of tertiary care in Malawi. In Aim 1, I conduct a scoping review of evidence to policy and agenda setting frameworks and theories that have been applied to health topics in LMICs. In the absence of empirical research, frameworks and theories can provide a useful conceptual foundation for integration of current evidence-based strategies. The search included terms related to health, political priority, and frameworks and theories and looked for studies from 2000-2022. I found a total of 155 studies that applied 41 distinct frameworks and theories to understand the presence or absence of a health topic on the national or global health policy agenda. Theories relevant to political priority came from several academic disciplines, most notably political sciences public health, and vary substantially in complexity, orientation, and the extent to which they are adapted or modified prior to being applied. Of the 44% of studies that assessed health topics in LMICS, one-third were applied to questions of priority in African countries. Aim 2, I used a qualitative case study approach to understand the policy roll out of a web-based electronic medical record designed to facilitate case management of rheumatic heart disease (RHD) in Uganda, called the Active Community Case Management Tool (ACT). RHD is a significant cause of ill-health in young adults in Uganda, but access and adherence to diagnosis and treatment remain low. I combined primary data collection and analysis of interviews with RHD researchers and district health officials with secondary analysis of interviews with health care workers using the ACT software as part of a study to decentralize RHD care to health centers closer to patients in two districts in Uganda. Through mapping the national policy and regulatory approval process, I found strong evidence of expressed political commitment to this new technology, driven in part by trust in the local research community advocating for ACT’s use. However, these expressions have been slow to translate into implementation. The reasons for this are varied, but limitations in the local system available to adapt national strategies into operational policies and guidance is one contributing factor. In Aim 3, I use a process tracing methodology to map ongoing efforts to integrate tertiary care into the Malawi Essential Package of Health Services (EPHS). I draw from Shifffman and Smith framework for determinants of political priority and the SPIRIT action framework to identify determinants of tertiary care’s recent rise and fall on the national health policy agenda in Malawi. The results show that having an available repository of effective interventions, a cohesive political community, and an open political window of opportunity are the strongest predictors a health issues political prioritization. Moreover, for tertiary care, research serves as a catalyst for each of these dimensions in Malawi. This dissertation advances the limited body of literature in policy implementation science at a critical time in the field’s development, by providing a synthesis of relevant frameworks and theories complemented by empirical examples of their application. The focus on applying implementation science concepts to the agenda-setting stage of the policy cycle is particularly innovative, as much of the focus to date has centered on the policy implementation stage of the cycle. I hope that the findings presented here will provide a starting point for researchers interested in better engaging with the policy agenda setting process in southern and eastern Africa.