BackgroundThe ‘Sponsoring National Processes for Evidence-Informed Policy Making in the Health Sector of Developing Countries’ program was launched by the Alliance for Health Policy and Systems Research, WHO, in July 2008. The program aimed to catalyse the use of evidence generated through health policy and systems research in policymaking processes through (1) promoting researchers and policy advocates to present their evidence in a manner that is easy for policymakers to understand and use, (2) creating mechanisms to spur the demand for and application of research evidence in policymaking, and (3) increased interaction between researchers, policy advocates, and policymakers. Grants ran for three years and five projects were supported in Argentina, Bangladesh, Cameroon, Nigeria and Zambia. This paper seeks to understand why projects in some settings were perceived by the key stakeholders involved to have made progress towards their goals, whereas others were perceived to have not done so well. Additionally, by comparing experiences across five countries, we seek to illustrate general learnings to inform future evidence-to-policy efforts in low- and middle-income countries.MethodsWe adopted the theory of knowledge translation developed by Jacobson et al. (J Health Serv Res Policy 8(2):94–9, 2003) as a framing device to reflect on project experiences across the five cases. Using data from the projects’ external evaluation reports, which included information from semi-structured interviews and quantitative evaluation surveys of those involved in projects, and supplemented by information from the projects’ individual technical reports, we applied the theoretical framework with a partially grounded approach to analyse each of the cases and make comparisons.Results and conclusionThere was wide variation across projects in the type of activities carried out as well as their intensity. Based on our findings, we can conclude that projects perceived as having made progress towards their goals were characterized by the coming together of a number of domains identified by the theory. The domains of Jacobson’s theoretical framework, initially developed for high-income settings, are of relevance to the low- and middle-income country context, but may need modification to be fully applicable to these settings. Specifically, the relative fragility of institutions and the concomitantly more significant role of individual leaders point to the need to look at leadership as an additional domain influencing the evidence-to-policy process.

This article presents the enablers and barriers to the scaling-up of results-based financing (RBF) programs. It draws on the Alliance for Health Policy and Systems Research's multicountry program of research Taking Results Based Financing From Scheme to System, which compared the scale-up of RBF interventions over four phases-generation, adoption, institutionalization, and expansion-across ten countries. Comparing country experiences reveals broad lessons on scale up of RBF for each of the scale-up phases. Though the coming together of global, national, and regional contextual factors was key to the development of pilot projects, national factors were important to scale up these pilots to national programs, including a political context favoring results and transparency, the presence of enabling policies and institutions, and the presence of policy entrepreneurs at the national level. The third transition, from program to policy, was enabled by the availability of domestic financial resources, legislative and financing arrangements to enhance health facility autonomy, and technical and political leadership within and beyond the Ministry of Health. The article provides lessons learned on RBF policy evolution, emphasizing the importance of phase-specific groups of actors, the need to tailor advocacy messages to enable scale-up, the influence of political feasibility on policy content, and policy processes to build national ownership and enable health system strengthening.

IntroductionNon-communicable diseases (NCDs) have become a major public health challenge worldwide; they account for 28 million deaths per year in low-and-middle-income countries (LMICs). Like many other LMICs, India is struggling to organise quality care for a large NCD-affected population especially at the primary healthcare level. The aim of this study was to assess local health system preparedness in a south Indian primary healthcare setting for addressing diabetes and hypertension.MethodsThis paper draws on a mixed-methods research study on access to medicines conducted in Tumkur, Karnataka, India. We used quantitative data from household and health facility surveys, and qualitative data from focus group discussions and in-depth interviews with health workers and patients. We identified systemic drivers that influence utilisation of services at government primary health centres (PHCs) using thematic analysis of qualitative data and a systems framework on access to medicines to assess supply and demand side factors.ResultsMajority of households depend on private facilities for diabetes and hypertension care because of the lack of laboratory facilities and frequent medicine stockouts at PHCs. Financial and managerial resource allocation for NCDs and prioritisation of care and processes related to NCDs was suboptimal compared to the prominence of this agenda at global and national levels. Primary healthcare has a limited role even in the activities under the national programme that addresses diabetes and hypertension.DiscussionThe study finds critical gaps in the preparedness of PHCs and district health systems in organising and managing care for diabetes and hypertension. Due to the lack of continuous care organised through PHCs, patients depend on expensive and often episodic care in the private sector. There is a need to improve managerial and financial resource allocation towards diabetes and hypertension (and other NCDs) at the district level.Trial registration number CTRI/2015/03/005640; Pre-results.

BackgroundEvidence-informed decision-making for health is far from the norm, particularly in many low- and middle-income countries (LMICs). Health policy and systems research (HPSR) has an important role in providing the context-sensitive and -relevant evidence that is needed. However, there remain significant challenges both on the supply side, in terms of capacity for generation of policy-relevant knowledge such as HPSR, and on the demand side in terms of the demand for and use of evidence for policy decisions. This paper brings together elements from both sides to analyse institutional capacity for the generation of HPSR and the use of evidence (including HPSR) more broadly in LMICs.MethodsThe paper uses literature review methods and two survey instruments (directed at research institutions and Ministries of Health, respectively) to explore the types of institutional support required to enhance the generation and use of evidence.ResultsFindings from the survey of research institutions identified the absence of core funding, the lack of definitional clarity and academic incentive structures for HPSR as significant constraints. On the other hand, the survey of Ministries of Health identified a lack of locally relevant evidence, poor presentation of research findings and low institutional prioritisation of evidence use as significant constraints to evidence uptake. In contrast, improved communication between researchers and decision-makers and increased availability of relevant evidence were identified as facilitators of evidence uptake.ConclusionThe findings make a case for institutional arrangements in research that provide support for career development, collaboration and cross-learning for researchers, as well as the setting up of institutional arrangements and processes to incentivise the use of evidence among Ministries of Health and other decision-making institutions. The paper ends with a series of recommendations to build institutional capacity in HPSR through engaging multiple stakeholders in identifying and maintaining incentive structures, improving research (including HPSR) training, and developing stronger tools for synthesising non-traditional forms of local, policy-relevant evidence such as grey literature. Addressing challenges on both the supply and demand side can build institutional capacity in the research and policy worlds and support the enhanced uptake of high quality evidence in policy decisions.

BackgroundGovernments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented.MethodsWe used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically.ResultsThe institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania’s long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements.ConclusionsTanzania’s central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.

Background: Nearly every nation in the world faces shortages of health workers in remote areas. Cameroon is no exception to this. The Ministry of Public Health (MoPH) is currently considering several rural retention strategies to motivate qualified health personnel to practice in remote rural areas. Methods: To better calibrate these mechanisms and to develop evidence-based retention strategies that are attractive and motivating to health workers, a Discrete Choice Experiment (DCE) was conducted to examine what job attributes are most attractive and important to health workers when considering postings in remote areas. The study was carried out between July and August 2012 among 351 medical students, nursing students and health workers in Cameroon. Mixed logit models were used to analyze the data. Results: Among medical and nursing students a rural retention bonus of 75% of base salary (aOR= 8.27, 95% CI: 5.28-12.96, P< 0.001) and improved health facility infrastructure (aOR= 3.54, 95% CI: 2.73-4.58) respectively were the attributes with the largest effect sizes. Among medical doctors and nurse aides, a rural retention bonus of 75% of base salary was the attribute with the largest effect size (medical doctors aOR= 5.60, 95% CI: 4.12-7.61, P< 0.001; nurse aides aOR= 4.29, 95% CI: 3.11-5.93, P< 0.001). On the other hand, improved health facility infrastructure (aOR= 3.56, 95% CI: 2.75-4.60, P< 0.001), was the attribute with the largest effect size among the state registered nurses surveyed. Willingness-to-Pay (WTP) estimates were generated for each health worker cadre for all the attributes. Preference impact measurements were also estimated to identify combination of incentives that health workers would find most attractive. Conclusion: Based on these findings, the study recommends the introduction of a system of substantial monetary bonuses for rural service along with ensuring adequate and functional equipment and uninterrupted supplies. By focusing on the analysis of locally relevant, actionable incentives, generated through the involvement of policymakers at the design stage, this study provides an example of research directly linked to policy action to address a vitally important issue in global health. Implications for policy makers• Based on a Discrete Choice Experiment (DCE) analyzed using mixed logit and Willingness-to-Pay (WTP) analysis, we recommend substantial monetary bonuses for rural service along with ensuring supplies and equipment for at least a basic package of health services to motivate health workers • Classification of posts based on remoteness and tying level of bonuses to this may be necessary to attract health workers to the most rural areas • Offering specialist training and housing, as proposed by the Ministry of Public Health (MoPH) were less popular incentives across health worker cadres examined • Focusing on actionable incentives and conducting locally relevant research are vital if findings are to influence policy-making Implications for publicAttracting and retaining qu...

The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.

BackgroundThe need for sufficient and reliable funding to support health policy and systems research (HPSR) in low- and middle-income countries (LMICs) has been widely recognised. Currently, most resources to support such activities come from traditional development assistance for health (DAH) donors; however, few studies have examined the levels, trends, sources and national recipients of such support – a gap this research seeks to address.MethodUsing OECD’s Creditor Reporting System database, we classified donor funding commitments using a keyword analysis of the project-level descriptions of donor supported projects to estimate total funding available for HPSR-related activities annually from bilateral and multilateral donors, as well as the Bill and Melinda Gates Foundation, to LMICs over the period 2000–2014.ResultsTotal commitments to HPSR-related activities have greatly increased since 2000, peaked in 2010, and have held steady since 2011. Over the entire study period (2000–2014), donors committed a total of $4 billion in funding for HPSR-related activities or an average of $266 million a year. Over the last 5 years (2010–2014), donors committed an average of $434 million a year to HPSR-related activities. Funding for HPSR is heavily concentrated, with more than 93% coming from just 10 donors and only represents approximately 2% of all donor funding for health and population projects. Countries in the sub-Saharan African region are the major recipients of HPSR funding.ConclusionFunding for HPSR-related activities has generally increased over the study period; however, donor support to such activities represents only a small proportion of total DAH and has not grown in recent years. Donors should consider increasing the proportion of funds they allocate to support HPSR activities in order to further build the evidence base on how to build stronger health systems.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-017-0224-6) contains supplementary material, which is available to authorized users.