National policy development for cotrimoxazole prophylaxis in Malawi, Uganda and Zambia: the relationship between Context, Evidence and Links

Abstract

BackgroundSeveral frameworks have been constructed to analyse the factors which influence and shape the uptake of evidence into policy processes in resource poor settings, yet empirical analyses of health policy making in these settings are relatively rare. National policy making for cotrimoxazole (trimethoprim-sulfamethoxazole) preventive therapy in developing countries offers a pertinent case for the application of a policy analysis lens. The provision of cotrimoxazole as a prophylaxis is an inexpensive and highly efficacious preventative intervention in HIV infected individuals, reducing both morbidity and mortality among adults and children with HIV/AIDS, yet evidence suggests that it has not been quickly or evenly scaled-up in resource poor settings.MethodsComparative analysis was conducted in Malawi, Uganda and Zambia, using the case study approach. We applied the ‘RAPID’ framework developed by the Overseas Development Institute (ODI), and conducted a total of 47 in-depth interviews across the three countries to examine the influence of context (including the influence of donor agencies), evidence (both local and international), and the links between researcher, policy makers and those seeking to influence the policy process.ResultsEach area of analysis was found to have an influence on the creation of national policy on cotrimoxazole preventive therapy (CPT) in all three countries. In relation to context, the following were found to be influential: government structures and their focus, donor interest and involvement, healthcare infrastructure and other uses of cotrimoxazole and related drugs in the country. In terms of the nature of the evidence, we found that how policy makers perceived the strength of evidence behind international recommendations was crucial (if evidence was considered weak then the recommendations were rejected). Further, local operational research results seem to have been taken up more quickly, while randomised controlled trials (the gold standard of clinical research) was not necessarily translated into policy so swiftly. Finally the links between different research and policy actors were of critical importance, with overlaps between researcher and policy maker networks crucial to facilitate knowledge transfer. Within these networks, in each country the policy development process relied on a powerful policy entrepreneur who helped get cotrimoxazole preventive therapy onto the policy agenda.ConclusionsThis analysis underscores the importance of considering national level variables in the explanation of the uptake of evidence into national policy settings, and recognising how local policy makers interpret international evidence. Local priorities, the ways in which evidence was interpreted, and the nature of the links between policy makers and researchers could either drive or stall the policy process. Developing the understanding of these processes enables the explanation of the use (or non-use) of evidence in policy making, and potentially may help to shape future strategies to bridg...

Contextual influences on the role of evidence in health policy development: what can we learn from six policies in India and Nigeria?

“…Our findings suggest that context forms an important set of influences on evidence-informed health policy development, which is consistent with other similar studies (Dobrow et al, 2006;Hutchinson, 2011;Hutchinson et al, 2011;Mirzoev et al, 2013). Although most influences reported by our respondents appear to be facilitators, we also found that similar factors can both strengthen or undermine the role of evidence: for example, availability of resources can facilitate generation of evidence, whereas resource constraints were referred to as a barrier thus limiting communication of evidence in both Nigeria and India.…”

“…Final manuscript (NOT anonymised) development in different countries (de Savigny et al, 2012;Hutchinson et al, 2011;Ricketts, 2010), despite a growing interest in improving the understanding of facilitators and constraints to evidence-informed health policymaking in different contexts.…”

Is operational research delivering the goods? The journey to success in low-income countries

“…The role would include raising awareness of decision makers to important fi ndings and bringing stakeholders together to begin the decision-making process. For example, after the national policy development on co-trimoxazole prophylaxis for HIV-positive individuals in Malawi, Uganda, and Zambia, 16 a policy entrepreneur was used in Malawi to help bridge the gap between operational research and policy networks. In Malawi, research evidence was swiftly translated into policy and practice, 53 whereas in the other two countries this translation was slow.…”

“…11 Similar examples of engagement of stakeholders at the outset of research include a study showing the benefi ts of co-trimoxazole prophylaxis for people with HIV and another noting the negative eff ect of user fees on patients' outcomes in HIV programmes. [15][16][17] The key message from these experiences is that, at the outset, the most important people needed to support and implement the study fi ndings should be identifi ed and engaged.…”

Health research systems: promoting health equity or economic competitiveness?

“…45 Recent findings also indicate that results from local operational research on cotrimoxazole preventive therapy for HIV were put into national policy in Malawi and Uganda faster than the results of randomized-controlled trials testing the same therapy in Zambia. 46 Thus, health policy and systems research improves health care by, first, generating evidence informed by local constraints on the best delivery methods for interventions and then linking this evidence to changes in treatment practice and policy. 13 Ultimately, research on product development and on health policy and systems are complementary.…”