Health policy and systems research in Ethiopia: current trends and key lessons on how to improve the use of evidence in health policy: technical brief

1 Technical brief July 2021 Health policy and systems research in Ethiopia Current trends and key lessons on how to improve the use of evidence in health policy Evidence intended to inform health programmes in Ethiopia is primarily generated by institutions affiliated to the federal Ministry of Health, although private research firms and professional bodies also produce research. However, there is limited understanding of the role of this diverse set of players in policy-making. This technical brief presents the results of a study that explored the evidence-to- policy process in Ethiopia. It aims to support efforts by the national government, as well as funders, to develop and strengthen existing institutions towards enhanced generation and uptake of research. Due to a lack of capacity; low access to funding and supportive facilities like peer-reviewed journals; and a lack of interaction between decision- makers and researchers, generating health policy and systems research studies is not the primary area of focus for most organizations. As a result, evidence is not a major input into health- related decisions in the country. This is exacerbated by the fact that research is often not aligned to national priorities and that policy- makers are not in the habit of using evidence in the policy-making process. 01 02 03 04 This technical brief draws on research produced by Jimma University, a public research university located in Jimma, Ethiopia. Data collection took place between January and March 2020. The brief is part of a multi-country study commissioned by the Alliance for Health Policy and Systems Research to understand the evidence-to-policy process around health decisions in Ghana, Ethiopia and Mozambique. Support was provided by the Doris Duke Charitable Foundation Key Messages 2Technical brief — Health policy and systems research in Ethiopia Ethiopia’s decentralized health system has progressively increased access to services over the last two decades, putting heavy emphasis on delivering a basic health care package to its large, mainly rural, population. To feed into its national strategic plans, a number of health research institutes and universities were established, some of which date back to the 1950s. They produce material on a diverse set of issues – from clinical and biomedical sciences, to preventative approaches and primary health care. While research organizations in the country are commissioned or even specifically mandated to generate evidence and conduct regular national surveys, little is known about the role their work plays in policy-making. This is particularly the case for health policy and systems research (HPSR), a field that encompasses research on the policies, organizations, programmes and people that make up health systems, as well as how their interaction influences system performance. Using robust evidence to inform public health policy is considered critical to ensuring the greatest and most equitable population health gains (1). Therefore, understanding the culture of research generation, and the extent to which evidence is incorporated into policy-making, is an important part of developing strategies to build capacity to generate and use research going forward. To support these efforts, the World Health Organization’s Alliance for Health Policy and Systems Research commissioned a study to understand the evidence-to-policy process in Ethiopia, and to get a sense of the profile of researchers in the country. Through surveys and in-depth interviews with representatives from 16 local research institutions and 24 health policy-makers, the study explored the entire chain of evidence generation, from conception of the research idea, through to its synthesis and dissemination. This included discussions with key actors involved in two tracer policies – that is, policies that provide concrete examples of the evidence-to-policy process in the country. This technical brief draws on the findings of this study to offer insights into how research feeds into policy and practice in Ethiopia. It also provides an up-to-date snapshot of the range of actors involved in conducting research in the country, as well as their institutional capacities. This learning aims to inform efforts by national governments, as well as funders, to develop and strengthen existing institutions towards enhanced generation and uptake of research. Two complementary studies in Ghana and Mozambique used the same research approach and were undertaken at around the same time to provide the opportunity to do a comparative analysis and distil regional lessons. 3Technical brief — Health policy and systems research in Ethiopia Profile of organizations conducting health policy and systems research in Ethiopia Representatives from a range of Ethiopian research institutions were identified as respondents, including entities that did not have a particularly active HPSR profile within the previous three years. The study team decided to expand the inclusion criteria, to incorporate organizations who also conducted more general health research, in order to better understand the roles and challenges of evidence generation in the country. As a result, a mix of universities, research institutes directly affiliated to the federal Ministry of Health, and professional associations were included as participants (see Box 1). A smaller number of private-for-profit organizations participated as well, but it is worth noting that their work involves regular collaboration with public research institutes. This section provides an analysis of these organizations, including their funding arrangements, capacity levels and main areas of focus. Figure 1 provides an overview of key data. Box 1: List of HPSR institutions operating in Ethiopia » Addis Ababa University » Addis Continental Institute of Public Health » Bahir Dar University » ABH Partners plc » Armauer Hansen Research Institute » Ethiopian Public Health Association » Ethiopian Public Health Institute » Ethiopian Medical Association » Ethiopian Medical Laboratory Association » Ethiopian Midwifery Association » Ethiopian Society of Obstetricians and Gynaecologists » Haramaya University » Hawassa University » International Institute for Primary Health Care in Ethiopia » Jimma University » Mekelle Universityniversity of Gondar 4Technical brief — Health policy and systems research in Ethiopia The study found that health research in the country is primarily conducted by public sector entities, but that producing timely, policy-relevant studies to inform decision-making is not their main area of focus. Rather, research organizations perform a variety of functions and participate in a wide range of different activities. All respondents reported providing training or running workshops, for example, and a large proportion said they engage in advocacy activities. Only half said they conduct specific HPSR studies, and when they do the main focus is on maternal and child health, as well as reproductive health issues. In general, however, organizations concentrate on broader health studies, including national or subnational surveys, as well as clinical and biomedical research. The capacity of most research organizations is modest and there are limited supportive mechanisms in place. Respondents reported that there is a general lack of experienced researchers in Ethiopia, which results in reliance on junior staff to undertake critical research activities. This was evidenced by the poor response to vacancy announcements, and the weak skills profile of many researchers. What is more, most of the senior researchers that do operate in the country are concentrated in just a few universities, making the distribution of skills uneven. Interviews across categories of respondents revealed that inadequate human resource development and supportive facilities make it difficult to easily solve these problems. For example, less than half of research organizations have full access to international peer-reviewed journals and tracking of staff progress through work plans is rare, although almost three quarters do provide some training. Due to low salaries and a lack of career progression opportunities, retention of quality staff is also a major issue that compromises the kind (and scope) of activities that research organizations can take on. Respondents feel that the overall level of funding allocated to health research is low and report an absence of core funding for HPSR work, although only 11 out of 16 study participants provided financial information. Almost half of organizations (45%) said that they rely entirely on government funding, with the remainder drawing on both government and external sources (through collaborative and competitive grant applications). No specific funding for HPSR was reported. Limited transparency and bureaucratic issues around the use of resources, as well as short funding periods, present additional difficulties. In terms of the perceived quality of outputs, researchers feel they perform well, but most policy-makers contest this assessment. Across four dimensions of quality – timeliness, policy relevance, feasibility and completeness – research organizations scored themselves an average of 4, on scale of 1 to 5. A large proportion also reported prioritizing their activities based on national or subnational research agendas, although over half said they considered global priorities and the same proportion were guided by funding conditions. However, none of the participating organizations could clearly articulate how prioritization happens in practice, for example, through formal mechanisms for selecting research themes involving key stakeholders. Policy-makers were not particularly positive about the quality of locally-generated research, with some reporting that studies lack quality and actionability. Ethiopia Sources of funding Domestic Only Mix of international and domestic International Only 9 Years working on HPSR 14 2 0 Public Private not-for- profit Private for-profit Organizational affiliation or status Level of focus on HPSR activities* Priority functions of HPSR institutions Top HPSR themes† Average across all organisations Average across all organisations * Institutions gave themselves a score on each activity between 1-5. For each activity, their relative level of focus is provided † The yellow area represents the proportional focus on HPSR themes Conduct policy-relevant research Networking with domestic and international partners for mutual support Communicating and publishing research findings Building capacity to use evidence for policy-makers Profile of organizations conducting HPSR in Ethiopia Senior Researchers Research staff experience level 20 Mid-level Researchers 56 Research Assistant30 Doctorate level Research staff education level 18 Master’s level66 Bachelor’s level30 Prioritizing HPSR research in response to country needs Developing and sustaining a critical number of HPSR researchers with multi-disciplinary skills 0 6 Universal health coverage Reproductive health Communicable diseases Service delivery Activity Percentage (%) Conduct HPSR 50 Conduct research other than HPSR 8894 Policy advocacy/ communication 44 Monitoring and evaluation 100 Training/workshop/ short course 50 Formal education Allocate funds to others 6 5 Non-communicable diseases Influence policies through advice based on evidence Technical brief — Health policy and systems research in Ethiopia 6Technical brief — Health policy and systems research in Ethiopia Issues affecting evidence-informed policy and practice in Ethiopia The study revealed that evidence plays a less than optimal role in informing health policy and practice in Ethiopia, with several critical factors affecting the demand, generation and use of research. Issues raised by researchers and policy-makers fell into three key themes: lack of focus on HPSR by research institutions; limited interaction between researchers and policy-makers; and inadequate packaging and dissemination of research in formats appropriate for policy audiences. Generating HPSR studies is not a primary area of emphasis for most research organizations in Ethiopia, nor is developing and sustaining adequate multi- disciplinary research capacity. Much heavier focus is placed on running training for stakeholders and engaging in advocacy than on generating rigorous evidence. It is therefore unsurprising that policy-makers feel that the quality of research studies is low, and that there are marked skills gaps across many organizations. Researchers say that lack of adequate funding has a huge impact on their ability to recruit and retain qualified staff, produce quality research and engage with relevant stakeholders. Respondents from universities in particular strongly argue that the chronic underinvestment in research – especially by the government – is a critical bottleneck to the consistent generation of quality evidence in the country. What is more, limited core funding prevents research organizations from improving their overall research processes through investments at the institutional level. Policy-makers and researchers operate in their own spheres and do not come together consistently around key issues. This affects the relevance and timeliness of evidence and, by extension, the likelihood that it will be used in decision-making. While some researchers again attribute this to a lack of funding, which prevents them from involving stakeholders throughout the research process, the absence of formal structures or platforms to link research organizations with policy-makers at different levels also makes it difficult for the two groups to meaningfully come together. This disconnect has resulted in two specific challenges. First, it has led to a lack of appreciation and awareness by researchers of the health policy environment, thereby preventing them from feeding into and influencing key policy processes. Second, it has resulted in limited interest in, or demand for, research due to the low value that is attached to it as part of the decision-making process, with some policy-makers going as far as to say that research represents a “waste of resources”. As a result, policies continue to be designed and implemented on the basis of opinion, political motivations, past experiences (both programme and international) and global declarations. 7Technical brief — Health policy and systems research in Ethiopia Although researchers collaborate with ministries and participate in workshops at the national level, evidence is not systematically or actively disseminated nor is it tailored to policy audiences. Only respondents from professional associations said they repackage their research into policy briefs/recommendations and undertake advocacy to promote evidence uptake, and even they do not z do so routinely. Universities and research institutes reported that they rely on more traditional avenues to publicize their work, such as academic publications and annual research conferences. In short, while research organizations list research communication as one of their core functions, insights from the qualitative component of the study reveal that research findings are often not disseminated as well as they could be leading to low uptake of the limited evidence that is produced. Conclusions and policy implications HPSR in Ethiopia does not appear to systematically influence policy-making. As in other parts of sub-Saharan Africa, access to evidence in the country is relatively low and the capacity of researchers to translate their findings into appropriate formats and link into policy processes is often limited. This hinders efforts to strengthen health systems and improve health outcomes. To overcome this, the study provides the following recommendations for consideration: 1. Greater domestic funding should be considered for institutional development of research organizations as well as for policy-relevant research. This may help attract and retain more skilled researchers thereby improving the quality of studies and their dissemination. To complement this, international donors should also consider increasing the proportion of funds they allocate to support HPSR in order to further build the evidence base on how to configure stronger health systems. 2. National and subnational research forums could provide an opportunity to regularly bring together research institutions, donors, non-governmental organizations and other stakeholders. These could play a role in promoting and cultivating research leadership and making sure that studies are demand-driven and linked to programme and operational challenges. Regular interaction between researchers and policy-makers may also help promote a more positive culture with regards to research in the policy-making process, and make recommendations more feasible, tailored and timely. 3. Research organizations could work to consolidate the wide range of functions they undertake in order to strengthen the rigour and credibility of research outputs, as well as the way they are communicated. As part of this, formal quality assurance mechanisms such as advisory groups may need to be set up. At the same time, they could establish or improve systems to make the use of resources more transparent and effective, especially those related to finance, procurement and human resources. 8Technical brief — Health policy and systems research in Ethiopia 4. Research organizations could consider putting greater focus on strengthening research communications capacity through regular skill-based training for their staff. A focus on summarizing evidence through short presentations and policy briefs is particularly important as these are preferred formats for policy-makers. Another consideration may be to include more communications staff on their research teams. References 1. van de Goor I, Riita- Maija RM, Syed A, et al. Determinants of evidence use in public health policy making: Results from a study across six EU countries. Health Policy, 2017; 121(3): 273-281. The Alliance is able to conduct its work thanks to the commitment and support from a variety of funders. These include our long-term core contributors from national governments and international institutions, as well as designated funding for specific projects within our current priorities. This brief, in particular, received support from the Doris Duke Charitable Foundation and from Alliance core funds. For the full list of Alliance donors, please visit: https://ahpsr.who.int/about-us/funders. Health policy and systems research in Ethiopia: current trends and key lessons on how to improve the use of evidence in health policy. Technical brief ISBN 978-92-4-003030-5 (electronic version) ISBN 978-92-4-003031-2 (print version) © World Health Organization 2021. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence.