HIV programme sustainability in Southern and Eastern Africa and the changing role of external assistance for health.

High human immunodeficiency virus (HIV)-prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability. Our respondents described HIV systems' vulnerability to donor departure, as well as how development partner priorities and practices have created challenges to promoting long-term HIV control. The challenges exacerbated by EA patterns include an emphasis on treatment over prevention, limiting effects on new infection rates; resistance to service integration driven in part by 'winners' under current EA patterns and challenges in ensuring coverage for marginalized populations; persistent structural barriers to effectively serving key populations and limited capacity among organizations best positioned to respond to community needs; and the need for advocacy given the erosion of political commitment by the long-term and substantive nature of HIV EA. Our recommendations include developing a robust investment case for primary prevention, providing operational support for integration processes, investing in local organizations and addressing issues of political will. While strategies must be locally crafted, our paper provides initial suggestions for how EA partners could change operational approaches to support long-term HIV control and the achievement of universal health coverage.

Strategies to promote evidence use for health programme improvement: learning from the experiences of embedded implementation research teams in Latin America and the Caribbean.

BACKGROUND: To achieve global health targets, innovative approaches are needed to strengthen the implementation of efficacious interventions. New approaches in implementation research that bring together health system decision-makers alongside researchers to collaboratively design, produce and apply research evidence are gaining traction. Embedded implementation research (EIR) approaches led by decision-maker principal investigators (DM PIs) appear promising in this regard. Our aim is to describe the strategies study teams employ in the post-research phase of EIR to promote evidence-informed programme or policy improvement. METHODS: We conducted a prospective, comparative case study of an EIR initiative in Bolivia, Colombia and Dominican Republic. Guided by a conceptual framework on EIR, we used semi-structured key informant interviews (n = 51) and document reviews (n = 20) to examine three decision-maker-led study teams ("cases"). Focusing on three processes (communication/dissemination, stakeholder engagement with evidence, integrating evidence in decision-making) and the main outcome (enacting improvements), we used thematic analysis to identify associated strategies and enabling or hindering factors. RESULTS: Across cases, we observed diverse strategies, shaped substantially by whether the DM PI was positioned to lead the response to study findings within their sphere of work. We found two primary change pathways: (1) DM PIs implement remedial measures directly, and (2) DM PIs seek to influence other stakeholders to respond to study findings. Throughout the post-research phase, EIR teams adapted research use strategies based on the evolving context. CONCLUSIONS: EIR led by well-positioned DM PIs can facilitate impactful research translation efforts. We draw lessons around the importance of (1) understanding DM PI positionality, (2) ongoing assessment of the evolving context and stakeholders and (3) iterative adaptation to dynamic, uncertain circumstances. Findings may guide EIR practitioners in planning and conducting fit-for-purpose and context-sensitive strategies to advance the use of evidence for programme improvement.

How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean.

Innovative strategies are needed to improve the delivery of evidence-informed health interventions. Embedded implementation research (EIR) seeks to enhance the generation and use of evidence for programme improvement through four core features: (1) central involvement of programme/policy decision-makers in the research cycle; (2) collaborative research partnerships; (3) positioning research within programme processes and (4) research focused on implementation. This paper examines how these features influence evidence-to-action processes and explores how they are operationalized, their effects and supporting conditions needed. We used a qualitative, comparative case study approach, drawing on document analysis and semi-structured interviews across multiple informant groups, to examine three EIR projects in Bolivia, Colombia and the Dominican Republic. Our findings are presented according to the four core EIR features. The central involvement of decision-makers in EIR was enhanced by decision-maker authority over the programme studied, professional networks and critical reflection. Strong research-practice partnerships were facilitated by commitment, a clear and shared purpose and representation of diverse perspectives. Evidence around positioning research within programme processes was less conclusive; however, as all three cases made significant advances in research use and programme improvement, this feature of EIR may be less critical than others, depending on specific circumstances. Finally, a research focus on implementation demanded proactive engagement by decision-makers in conceptualizing the research and identifying opportunities for direct action by decision-makers. As the EIR approach is a novel approach in these low-resource settings, key supports are needed to build capacity of health sector stakeholders and create an enabling environment through system-level strategies. Key implications for such supports include: promoting EIR and creating incentives for decision-makers to engage in it, establishing structures or mechanisms to facilitate decision-maker involvement, allocating funds for EIR, and developing guidance for EIR practitioners.

Pathways to high and low performance: factors differentiating primary care facilities under performance-based financing in Nigeria.

The determinants of primary health facility performance in developing countries have not been well studied. One of the most under-researched areas is health facility management. This study investigated health facilities under the pilot performance-based financing (PBF) scheme in Nigeria, and aimed to understand which factors differentiated primary health care centres (PHCCs) which had performed well, vs those which had not, with a focus on health facility management practices. We used a multiple case study where we compared two high-performing PHCCs and two low-performing PHCCs for each of the two PBF target states. Two teams of two trained local researchers spent 1 week at each PHCC and collected semi-structured interview, observation and documentary data. Data from interviews were transcribed, translated and coded using a framework approach. The data for each PHCC were synthesized to understand dynamic interactions of different elements in each case. We then compared the characteristics of high and low performers. The areas in which critical differences between high and low-performers emerged were: community engagement and support; and performance and staff management. We also found that (i) contextual and health system factors particularly staffing, access and competition with other providers; (ii) health centre management including community engagement, performance management and staff management; and (iii) community leader support interacted and drove performance improvement among the PHCCs. Among them, we found that good health centre management can overcome some contextual and health system barriers and enhance community leader support. This study findings suggest a strong need to select capable and motivated health centre managers, provide long-term coaching in managerial skills, and motivate them to improve their practices. The study also highlights the need to position engagement with community leaders as a key management practice and a central element of interventions to improve PHCC performance.

Do academic knowledge brokers exist? Using social network analysis to explore academic research-to-policy networks from six schools of public health in Kenya.

The potential for academic research institutions to facilitate knowledge exchange and influence evidence-informed decision-making has been gaining ground. Schools of public health (SPHs) may play a key knowledge brokering role-serving as agencies of and for development. Understanding academic-policymaker networks can facilitate the enhancement of links between policymakers and academic faculty at SPHs, as well as assist in identifying academic knowledge brokers (KBs). Using a census approach, we administered a sociometric survey to academic faculty across six SPHs in Kenya to construct academic-policymaker networks. We identified academic KBs using social network analysis (SNA) in a two-step approach: First, we ranked individuals based on (1) number of policymakers in their network; (2) number of academic peers who report seeking them out for advice on knowledge translation and (3) their network position as 'inter-group connectors'. Second, we triangulated the three scores and re-ranked individuals. Academic faculty scoring within the top decile across all three measures were classified as KBs. Results indicate that each SPH commands a variety of unique as well as overlapping relationships with national ministries in Kenya. Of 124 full-time faculty, we identified 7 KBs in 4 of the 6 SPHs. Those scoring high on the first measure were not necessarily the same individuals scoring high on the second. KBs were also situated in a wide range along the 'connector/betweenness' measure. We propose that a composite score rather than traditional 'betweenness centrality', provides an alternative means of identifying KBs within these networks. In conclusion, SNA is a valuable tool for identifying academic-policymaker networks in Kenya. More efforts to conduct similar network studies would permit SPH leadership to identify existing linkages between faculty and policymakers, shared linkages with other SPHs and gaps so as to contribute to evidence-informed health policies.

Analyzing the sources and nature of influence: how the Avahan program used evidence to influence HIV/AIDS prevention policy in India.

BACKGROUND: Major investments by development partners in low- and middle-income countries (LMICs) often seek to develop a supportive policy environment. There is limited knowledge about the mechanisms that development partners use to influence government policy, or which mechanisms are effective. This study assessed the influence of Avahan, a large HIV/AIDS prevention program in India supported by the Bill and Melinda Gates Foundation, on the development of HIV/AIDS policies in India, particularly the National AIDS Control Program III (NACP III). METHODS: A retrospective assessment of the contributions of Avahan to the development of NACP III was conducted based upon document review and in-depth interviews with key informants, including Avahan staff and staff of implementing partners. This assessment was carried out within a framework centered on three domains: evidence considered by policy and decision-makers; the channel through which influence is exerted; and the target audience for influence. RESULTS: Respondents identified a number of respects in which Avahan influenced NACP III policy, notably, Avahan influenced perception of the feasibility of scaling up services (through a demonstration effect) and Avahan, along with others, helped ensure a strong focus on targeted interventions. Overall Avahan's influence was greatest during policy implementation. While the extent to which research evidence generated by Avahan influenced NACP III was limited, best practice evidence generated by Avahan, including the lessons learned from routine implementation and management, contributed significantly to NACP III. This was largely due to the credibility Avahan had established and strategic 'inside track' communications. CONCLUSION: While studies of knowledge translation typically focus primarily on scientific evidence, this study suggests that other forms of evidence, notably best practice evidence derived from program experience, and disseminated through personal communication, were particularly influential. The framework developed for the paper provides a useful tool to analyze how evidence-based influence is exerted.

Priority setting and health policy and systems research.

Health policy and systems research (HPSR) has been identified as critical to scaling-up interventions to achieve the millennium development goals, but research priority setting exercises often do not address HPSR well. This paper aims to (i) assess current priority setting methods and the extent to which they adequately include HPSR and (ii) draw lessons regarding how HPSR priority setting can be enhanced to promote relevant HPSR, and to strengthen developing country leadership of research agendas. Priority setting processes can be distinguished by the level at which they occur, their degree of comprehensiveness in terms of the topic addressed, the balance between technical versus interpretive approaches and the stakeholders involved. When HPSR is considered through technical, disease-driven priority setting processes it is systematically under-valued. More successful approaches for considering HPSR are typically nationally-driven, interpretive and engage a range of stakeholders. There is still a need however for better defined approaches to enable research funders to determine the relative weight to assign to disease specific research versus HPSR and other forms of cross-cutting health research. While country-level research priority setting is key, there is likely to be a continued need for the identification of global research priorities for HPSR. The paper argues that such global priorities can and should be driven by country level priorities.