Framework for strengthening the use of evidence, information and research for policy-making in the African Region: report of the Secretariat

AFR/RC71/13 12 July 2021 REGIONAL COMMITTEE FOR AFRICA Seventy-first session Virtual session, 24–26 August 2021 ORIGINAL: ENGLISH Provisional agenda item 17 FRAMEWORK FOR STRENGTHENING THE USE OF EVIDENCE, INFORMATION AND RESEARCH FOR POLICY-MAKING IN THE AFRICAN REGION Report of the Secretariat EXECUTIVE SUMMARY 1. The attainment of the Sustainable Developments Goals and universal health coverage in the African Region is largely dependent on the availability and use of sound data, information and knowledge for health policy formulation. In 2015, Member States endorsed the resolution on “Research for health: a strategy for the African Region, 2016–2025”, calling for country-led research and use of evidence for health policy-making. Indeed, strengthening the links between health policy, practice and products of research was one of the core goals of the research for health strategy. 2. However, while a range of health research evidence is produced and processed for use globally, health policies in the Region are suboptimally informed by it. This has been blamed on the weak capacity of policy-makers to use evidence, information and research in health policy- making in the Region. The situation is made worse by the failure to produce locally relevant health evidence, information and research for the formulation of policies directed at local needs and priorities. 3. A recent assessment of national health research systems in the Region revealed the weak performance of Member States on key indicators such as governance of research for health; developing and sustaining resources for research for health; producing and using research; as well as domestic funding of research for health. The single most popular source of funding for production of research in the Region has been through multilateral/bilateral donors, whose interest is focused more on responding to research needs of a global nature as opposed to local priorities and evidence needs. Hence, the availability of critical, timely and locally contextualized information remains a challenge in the Region. 4. To alleviate these challenges, WHO launched the Evidence-Informed Policy Network (EVIPNet) in 2006 to facilitate knowledge translation and use of evidence for policy-making in countries, but to date, this innovative intervention exists only in 13 Member States. This may be due to the non-existence of an implementation framework that has been formally adopted by Member States to facilitate implementation. The use of research evidence for action involves complex systems of interactions between researchers and decision-makers. This framework provides a guide for strengthening the use of evidence, information and research for health policy- making in the WHO African Region and focuses on clarifying guiding principles and priority interventions that articulate the use of evidence, information and research for health policy- making. The interventions proposed are focused and deliberately inclusive in order to ensure fairness, transparency and gender-equity as well as advocacy for research investments in domestic ii funding and civic participation in health policy-making. 5. The Regional Committee is requested to critically examine and adopt the priority interventions and actions proposed in this framework. iii CONTENTS Paragraphs INTRODUCTION ........................................................................................................................ 1–5 CURRENT SITUATION ............................................................................................................ 6–11 ISSUES AND CHALLENGES ................................................................................................ 12–20 VISION, GOAL, OBJECTIVES, TARGETS AND MILESTONES ....................................... 21–26 GUIDING PRINCIPLES .......................................................................................................... 27–32 PRIORITY INTERVENTIONS AND ACTIONS ................................................................... 33–45 ACTIONS PROPOSED .................................................................................................................. 46 vi ABBREVIATIONS CRVS civil registration and vital statistics EVIPNet Evidence-Informed Policy Network HMIS health management information system ICT information and communication technologies NHIS national health information system NHO national health observatory NHRS national health research system RHIS routine health information system SDGs Sustainable Development Goals UHC universal health coverage WHA World Health Assembly AFR/RC71/13 Page 1 INTRODUCTION 1. Achieving the Sustainable Development Goals and universal health coverage requires the availability of national health information systems with routine health information and research data as their backbone. Access to sound health information facilitates effective and timely monitoring of progress towards the SDGs and UHC, which is critical for efficient interventions. 2. The national health observatory was introduced as a web-based, open-access and one-stop shop for routine health information and eHealth, including medical informatics, telehealth and mHealth. It facilitates wide and timely dissemination of quality health data and information, and tracking progress towards the SDGs and UHC and other national priorities. 3. In 2013, it was emphasized that research and data for health are crucial in health systems strengthening.1 However, health data and research evidence are of limited value unless they are used for accountability and decision-making. 4. Several international declarations/commitments have articulated the need to channel research toward policy and practice in order to reduce the gap between what is known and what is done to improve health and health care delivery.2,3,4,5,6 The regional Research for health strategy re-emphasized this concept.7,8 Indeed, strengthening the links between health policy, practice and products of research was one of the goals of the Research for health strategy. To improve health outcomes, a combination of knowledge that is both generated and harnessed is key to informing policy and practice. 5. The use of research evidence for action involves a complex system of interactions between researchers and decision-makers and extends beyond the Evidence-Informed Policy Network that was created in response to resolution WHA58.34. CURRENT SITUATION 6. Despite the existence of globally collated, analysed and disseminated public health performance information and research evidence, health policies in the African Region are rarely evidence-based,9 due in part to weak capacity in the use of evidence, information and research in health policy formulation in the Region. A coherent framework to strengthen the capacity of Member States in the use of evidence, information and research for policy-making is required. 1 WHO. Research for Universal Health Coverage: The World Health Report 2013, Geneva, World Health Organization, 2013. 2 WHO. World Report on knowledge for better health. Strengthening health systems. Geneva 2004 3 Mexico Statement on Health Research. Knowledge for better health: strengthening health systems. Ministerial Summit on Health Research, Mexico City, 16-20 November 2004. 4 Resolution WHA58.34. Ministerial Summit on Health Research. In: Fifty-eighth World Health Assembly, Geneva, 16– 25 May 2005. Resolutions and decisions, annexes. Geneva: World Health Organization; 2005 (WHA58/2005/REC/1; http://apps.who.int/gb/or/index.html). 5 Resolution WHA60.27. Strengthening of health information systems. In: Sixtieth World Health Assembly, Geneva, 14– 23 May 2007. Resolutions and decisions, annexes. Geneva: World Health Organization; 2007 (WHASS1/2006– WHA60/2007/REC/1; http://apps.who.int/gb/or/index.html). 6 WHO’s role and responsibilities in health research. Sixty-third World health Assembly. A63/22, Item 11.19 7 AFR/RC65/6. Research for Health: A Strategy for the African Region, 2016-2025 8 WHO. World Report on knowledge for better health. Strengthening health systems. Geneva 2004 9 Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bulletin of the World Health Organization. 2006;84:620–8 (http://www.who.int/ bulletin/volumes/84/8/06-030312.pdf?ua=1, accessed 18 February 2021). AFR/RC71/13 Page 2 7. Priority is not given to research evidence and evidence syntheses as tools for addressing regional health needs, and investments in health research are therefore insufficient.10 Capacity for health research in the Region is low. For instance, a WHO survey in 2018 found poorly functioning national health research systems in the Region, where more than 50% of the Member States lacked a national health research policy, a strategic health research plan, and a dedicated budget to support health research.11 8. Timely availability of context-specific information is rare in the Region. The performance of the routine health information system, especially at the subnational level is constrained by limited institutional and technical capacity. Country capacity for civil registration and vital statistics is poor, with haphazard and low-scale registration of vital events. The national reporting rate and timeliness of HMIS data are poor. Data captured in the NHIS are largely public health facility data with very low coverage of community and private sector data, especially those of private-for-profit health facilities. This has also affected the optimization of eHealth in the Region. 9. The field of eHealth has emerged in the Region, commensurate with the rapid rise in the use of technology, including mobile phones. eHealth can play a significant role in strengthening national health systems towards attaining the SDG and UHC targets by providing critical health information and evidence for health policy- and decision-making. Optimal deployment of eHealth using mobiles phones for sharing information and generating evidence for policy-making has been frustrated by the lack of reliable information and communication technology infrastructure on which to build the national health information infrastructure.12 10. In 2018, the African Region contributed to only 2% of the global health research need, and capacity for evidence synthesis, particularly for systematic reviews, is even lower. The regional research landscape is further characterized by a multiplicity of actors, dispersed efforts and unclear results in relation to impact on local priority health problems and little or no structures in place to track research activities. This is made worse by the lack of African scientific journals, which limits the dissemination and use of Africa-specific information and knowledge. Scientific journals, mostly located in industrialized countries, are more interested in information that attracts global interest. 11. EVIPNet that was launched in 2006 by WHO exists in only 13 Member States of the African Region.13 These externally funded platforms develop tools and share critical and optimal best-practice lessons learnt, yet more than a decade after its launch, many Member States are yet to embrace the EVIPNet platform. The availability of a formally adopted implementation framework to guide Member States will foster capacities, interests and accountability on fine- tuned information for health policy- and decision-making. ISSUES AND CHALLENGES 12. Inadequate research products: The 2014 and 2018 assessments of national health research systems in the Region reported a 0.34 and 0.59 score for research production in the African Region, highlighting low research output as a major barrier to evidence-informed 10 Nwaka S, Ilunga TB, Da Silva JS, et al. Developing ANDI: a novel approach to health product R&D in Africa. PLoS Med 2010;7:e1000293 10.1371/journal.pmed.1000293 11 WHO, TIBA and EDCTP. Assessing National Health Research Systems in the WHO African Region. Brazzaville, WHO, 2018 12 WHO/AFRO. Health Information and Knowledge Management: eHealth – leveraging IT to strengthen country health systems. (https://www.afro.who.int/health-topics/health-information-and-knowledge-management, accessed 18 February 2021) 13 Burkina Faso, Cameroon, Central African Republic, Eswatini, Ethiopia, Ghana, Kenya, Malawi, Mali, Nigeria, United Republic of Tanzania, Uganda and Zambia. AFR/RC71/13 Page 3 decision-making among Member States and citing inadequate financial resources, capacity to conduct and publish findings from quality research, and insufficient focus of existing research on policy-oriented questions and national priorities as factors that hinder progress in research production in the African Region. 13. Inadequate funding for research: Commencing in 1990, a number of important activities have been pointed out to policy-makers on major issues related to poor health research funding. These include the call to action by the Commission on Health Research for Development for governments to allocate at least 2% of national health expenditure to research and 5% to health research capacity building, and the 2008 Bamako Call to Action on Research for Health.14 In 2018 the NHRS assessment revealed that only Cameroon met the targets of the two Calls while Mali met only the target of the Bamako Call. While funding for health research has generally increased in the Region, over the years, the proportion from domestic sources remains very low relative to the overall gross domestic product of Member States.15 This affects the ability to shape the research agenda and implement research to address local needs and priorities. 14. Weak national health information systems: National health information systems are generally weak and unaligned with the bureaus of statistics and health policies in Member States.16 The 2018 assessment estimated the existence of health research units within the ministries of health at 59%,17 inferring that in almost half of the Member States there is weak alignment between the research and health policy-making structures. 15. Absence of national health research institutes and systems: The 2018 NHRS assessment revealed that at least 11 Member States18 had no national health research institutes/councils. In the absence of these institutes/councils, it is difficult to support the setting and execution of public health priorities in order to obtain context-specific knowledge for health systems strengthening. 16. Low country capacities for the development of evidence-informed policies: The 2018 NHRS assessment revealed that at least 16 Member States19 had no knowledge translation platforms. This implies a limitation in their ability to identify knowledge gaps, summarize and use evidence to inform policy-making and strengthen their health systems. 17. Low utilization of eHealth platforms in the Region: While the use of technology such as the mobile phone has grown in the Region, technology has not been optimally deployed in sharing health evidence and information. This is attributed to several challenges currently being faced in efforts to leverage these information technologies in strengthening national health information systems and policy-making. Some of the challenges include lack of ICT infrastructure on which to build the national health information infrastructure and low private sector investment in health information. Others include weak government structures and 14 WHO. Bamako Call to Action on Research for Health: Strengthening research for health, development and equity. Global Ministerial Forum on Research for Health. Bamako, Mali, 17–19 November 2008 (http://www.who.int/rpc/news/BAMAKOCALLTOACTIONFinalNov24.pdf, accessed 18 February 2021). 15 Røttingen JA, Regmi S, Eide M, Young AJ, Viergever RF, Ardal C, et al. Mapping of available health research and development data: what's there, what's missing, and what role is there for a global observatory? Lancet, 2013; 382(9900):1286–1307 16 Mbondji, PE., Kebede, D, Soumbey-Alley, EW, Zielinski, C, Kouvividila, W, & Lusamba-Dikassa, PS: Health information systems in Africa: descriptive analysis of data sources, information products and health statistics. Journal of the Royal Society of Medicine, 2014; 107(1 suppl), 34–45. (https://doi.org/10.1177/0141076814531750, accessed 18 February 2021) 17 WHO, TIBA and EDCTP. Assessing National Health Research Systems in the WHO African Region. Brazzaville, WHO, 2018 18 Botswana, Burundi, Côte d’Ivoire, Eritrea, Eswatini, The Gambia, Lesotho, Namibia, Seychelles, Sierra Leone, South Africa 19 Angola, Benin, Burkina Faso, Burundi, Cabo Verde, Côte d’Ivoire, Congo, Democratic Republic of the Congo, Eritrea, Eswatini, Gabon, Mauritania, Namibia, Nigeria, Sierra Leone, South Sudan. AFR/RC71/13 Page 4 mechanisms to ensure that accountability, transparency and effective leadership are in place; inadequate human resources; and insecure electronic information exchange across national geographical and health sector boundaries. 18. Low utilization of evidence during health policy formulation: The regional average barometer score for use of research in policy formulation was 55% in 2018.20 This is attributable to the low level of interaction between researchers who respond to the priorities of research funders, and health policy-makers who are focused on local needs and priorities. There is no platform for such interaction, given the low utilization of these research findings by the policy- makers. The NHRS assessment21 cited donor dependence which responds to donor research interests and issues of global interest, as opposed to the need for local evidence as a challenge in the utilization of evidence during policy formulation. 19. Strong health information and research systems, together with the availability of quality health data from all the relevant sources, their analysis, synthesis, interpretation and dissemination, hold promise for achieving the SDG and UHC goals. They provide the necessary information on health status and trends, health determinants, health system strengths, tools and interventions, and facilitate an evidence-based, systematic approach to policy- and decision- making and programming. 20. Strengthening health research systems will ensure availability of quality health data from different sources: This will facilitate the achievement of the SDGs through the provision of important information on health status and trends and the development and evaluation of new tools and interventions to address health needs.22,23 VISION, GOAL, OBJECTIVES, MILESTONES AND TARGETS 21. Vision: More evidence-driven policy-making in the African Region. 22. Goal: A well-functioning health research and information system that supports the generation, compilation, analysis, synthesis and dissemination of good quality health data, and communication of information from all relevant sources for health policy-making. Objectives 23. The objectives of this framework are to: (a) Strengthen national health information systems in order to generate quality gender disaggregated data; (b) Establish or strengthen national health research systems to undertake relevant research and analyses of policy-relevant data and information; (c) Ensure fully-functional national health observatories; (d) Increase country capacities to establish effective guideline-development committees and health technology assessment units for the development of evidence-informed health policies; and 20 WHO, TIBA and EDCTP. Assessing National Health Research Systems in the WHO African Region. Brazzaville, WHO, 2018 21 WHO, TIBA and EDCTP. Assessing National Health Research Systems in the WHO African Region. Brazzaville, WHO, 2018 22 WHO. Research for Universal Health Coverage: The World Health Report 2013, Geneva, World Health Organization, 2013. 23 UN: Document A/69/700. The road to dignity by 2030: ending poverty, transforming all lives and protecting the planet. Synthesis report of the Secretary-General on the post-2015 sustainable development agenda. United Nations General Assembly, 4 December 2014. New York: UN; 2014. AFR/RC71/13 Page 5 (e) Mainstream the use of evidence in the formulation of policies, targets, and indicators addressing the SDGs and UHC. Targets 24. By 2030, all Member States should: (a) have a well-functioning facility-based health information system, with an overarching system of governance that supports effective data collection and management, data quality analysis, and data dissemination and use; (b) have a functional national health observatory; (c) have a health information system performance of over 80%; (d) have a national health research system barometer performance of over 66%; and (e) have EVIPNet or other knowledge translation team established and funded; (f) show evidence of research and databases for policy direction. Milestones 25. By 2024 (a) Every Member State should have a functional national health observatory; (b) At least 50% of Member States should show a health information system performance of over 80%; (c) At least 50% of Member States should have a national health research system barometer performance of over 66%; (d) At least 50% of Member States should have EVIPNet or other knowledge translation team established and funded; (e) At least 50% of Member States should show evidence of research and databases for policy direction. 26. By 2027 (a) Every Member State should have a functional national health observatory; (b) At least 80% of Member States should have a health information system performance of over 80%; (c) At least 80% of Member States should have a national health research system barometer performance of over 66%; (d) At least 80% of Member States should have EVIPNet or other knowledge translation team established and funded; (e) At least 80% of Member States should show evidence of research and databases for policy direction. GUIDING PRINCIPLES 27. Government leadership: The ministry of health shall provide leadership and take decisions for the provision of knowledge translation services such as evidence synthesis units and support evidence-informed stakeholder dialogues during health policy-making. 28. Evidence comes first: Although decisions are influenced by several factors, interventions need to be informed first and foremost by the latest, best available evidence and best practices as well as cost-effectiveness. AFR/RC71/13 Page 6 29. Local knowledge for local-decision making: Researchers should be encouraged to explore solutions to national health problems using local data derived from national health information and research systems to complement supranational evidence. 30. Partnerships: Partnerships should be based on trust and commitment within and outside the health sector, and between researchers and policy-makers working together to close the ‘knowledge and action’ gap. 31. Ethics: All the activities and operations will be conducted in a transparent, ethical and accountable manner. 32. Citizen participation: Health policy-making shall value citizen participation that embodies fairness, transparency, gender-sensitivity and equity. PRIORITY INTERVENTIONS AND ACTIONS 33. Strengthen national health information systems, align with national statistics bureaus and policies, harmonize health indicators and establish an integrated health information system: Information and evidence are the foundations of sound decision-making and resource allocation. There is need to create an integrated national HMIS that provides regular high-quality and timely evidence that is used to report on priorities and targets. Priority interventions are to: (a) establish national governance mechanisms for the integration and management of health information and eHealth; (b) ensure the availability of sustainable financial, technical and human resources for health information systems and eHealth; (c) develop, and where they exist, embed national strategies for health information and eHealth, and apply intersectoral approaches among ministries responsible for health, information, technology and other sectors; (d) strengthen the national technical infrastructure for health information; (e) promote the coordination of research, including clinical trials and implementation research in institutions using registries. 34. Establish and promote national health research institutes and systems: Support the setting and execution of public health priorities in order to obtain context-specific knowledge for health systems strengthening. Priority interventions are to: (a) develop a national strategy and plan of action for strengthening and funding national health research institutions and systems; (b) establish and/or strengthen national and institutional ethics review boards to promote accountability and coordination. 35. Increase country capacities for the development of evidence-informed policies: Map and analyse decision-making processes and ensure that knowledge transfer processes are in place to identify knowledge gaps, and summarize and use evidence to strengthen the health system. Priority interventions are to: (a) support national initiatives to increase capacity in knowledge translation, including evidence gathering, analysis, synthesis and dissemination; (b) adopt and conduct implementation science to facilitate and institutionalize evidence-based practice in health; (c) constitute and institutionalize national and subnational evidence services for health policy- making such as knowledge transfer teams that are multidisciplinary and multisectoral to AFR/RC71/13 Page 7 stakeholders and actors. The team should be led by the ministry of health and should foster interaction between researchers and decision-makers and encourage the systematic use of research findings in decision-making; (d) define objectives, workplans and projects that take local interests into account; (e) monitor the activities of the knowledge transfer platforms in order to provide feedback for the national research agenda and health information management; (f) advocate for and allocate resources for creating the proposed work and required networking. 36. Mainstream the use of evidence in health policy formulation and setting of targets and indicators pertaining to the SDG and UHC agenda: (a) stimulate interaction among stakeholders by convening evidence-informed stakeholder dialogues to deliberate on priority health challenges; (b) prepare policy briefs according to identified gaps and opportunities that draw on available synthesized research evidence and on local data, including viable options and key implementation considerations embodying the equity lens; (c) use relevant evidence from non-health sectors and disciplines in formulating health policies; (d) promote accountability for policies by defining and using targets and indicators and adding them to relevant policies where they are missing; (e) demonstrate the consistent use of information and research evidence in the formulation of health strategies and policies by developing methods for gathering and analysing such explicit knowledge; (f) establish health sector review mechanisms at national and subnational levels for sound monitoring and evaluation of health system performance. 37. Develop and strengthen national regulatory frameworks: (a) legislate for health management information systems; (b) promote the creation of institutional review boards (IRBs) in Member States or subregional health institutions. The IRBs should join international networks; (c) legislate for health research including ethical considerations, priority setting; and (d) promote the development and use of research laws and research plans to drive evidence- informed policy-making. 38. Establish and build the capacity of EVIPNet country teams for improved evidence uptake into policy and practice: (a) establish knowledge translation platforms; (b) establish health research and evidence management forums; and (c) ensure regular training and retraining of country teams. 39. Strengthen health research infrastructure: (a) map research institutions and human resources for research in each country; (b) identify areas of strength of the different institutions; (c) provide human and financial resources to empower the selected ones to become centres of excellence based on previous work, expertise, and/or prevalent diseases in the locality. AFR/RC71/13 Page 8 40. Engage in research that meets country needs: (a) map disease profiles and burden in each country; (b) prioritize diseases prevalent in the country as targets for research; (c) draw up an inventory of ongoing research funding details. 41. Develop a research and development coordination mechanism between the ministry of health and other relevant ministries: (a) coordinate research activities and periodically consolidate research products in the country; (b) review, monitor and periodically issue guidelines on procedures for selecting research evidence for use in policy-making; and (c) periodically review policies and practices regarding the use of evidence in health policy- making. 42. Ensure adequate financing: (a) create a budget line for health research equal to at least 2% of national health expenditures and at least 5% of external aid for health projects and programmes aimed at NHRS strengthening; (b) track expenditures for health research. 43. Develop monitoring and evaluation tools: (a) review targets and make them smart to allow for a fine-tuned response; (b) assess the implementation and progress in the use of evidence and research data in policy- making; (c) track the mechanism and schedule for the implementation processes. 44. Key responsibilities and proposed commitments for the World Health Organization and partners; (a) provide advice and support to Member States in the establishment of governance mechanisms and in building sustainable capacity for knowledge transfer, health information systems and eHealth; (b) advocate and provide guidance for strengthening national health research systems and institutions, promote implementation research to address challenges affecting wider coverage of health interventions; (c) promote intercountry interactions and networking of the knowledge translation platforms to share experiences, harmonize procedures and strengthen capacity in processes such as evidence briefs, policy dialogues, situation analysis, developing clearing houses (repositories of knowledge), and monitoring and evaluation frameworks; (d) organize periodic capacity building workshops for EVIPNet teams to develop their skills in finding and using research evidence; (e) collect and disseminate best practices and lessons learnt from national, regional and global knowledge transfer activities; (f) establish WHO collaborating centres on knowledge translation to support the generation, use and uptake of evidence for policy-making in the Region; (g) convene forums of national health observatories to share experiences and strategies; AFR/RC71/13 Page 9 (h) track progress in the implementation of this framework in the Region using the NHRS barometer24 and other appropriate monitoring and evaluation tools developed in consultation with Member States. 45. The Regional Director shall report to the Regional Committee on progress in the implementation of this framework after every three years. The first report will be presented three years after its adoption by the Regional Committee. ACTIONS PROPOSED 46. The Regional Committee is invited to examine and adopt the actions proposed in this framework. 24. Kirigia JM, Ota MO, Senkubuge F, Wiysonge CS, Bongani MM. Developing the African national Health research systems barometer. Health Res Pol Syst, 2016; 14(1):53. doi: 10.1186/s12961-016-0121-4.