How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries

Abstract

Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies towards UHC. Yet despite resource mobilization towards this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries. Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision-making, as well as evidentiary needs related to community health data for decision-making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context, and second, much existing economic evidence does not deal with what decision-makers value when it comes to community health systems—i.e. coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision-maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision-making, empowering national decision-makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.

SEEP-CI: A Structured Economic Evaluation Process for Complex Health System Interventions

“…Its development was informed by discussions with consortium researchers and other stakeholders, such as national and district level health workers and officials, in each of the participating countries. That process involved identifying the challenges described above and eliciting qualitative data from policymakers on what they perceived to be the uses and shortcomings of conventional economic evaluations [ 17 ]. While those discussions were helpful in identifying the shortcomings of conventional economic evaluation approaches for decision-making, the SEEP-CI was developed by the authors with no formal input from external experts, thus no formal procedure for reaching consensus about the steps involved (e.g., the DELPHI method [ 18 ]) was conducted or required, and the steps of the SEEP-CI, described below, solely reflect the views of the authors.…”

Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya

“…At global, national and subnational levels, decision-makers often cite concerns about whether existing economic research can be generalised to their setting and describe structural and capacity barriers to economic evidence commissioning and use. 56 Koon et al 57 described the process embedding health systems research in decision-making in LMICs, emphasising both health system or contextual factors as well as factors about the evidence-generating organisation that increase trust in the evidence produced. This work focuses on evidence generated in a given context for the same context.…”

COVID-19 information dissemination in Uganda: Perspectives from sub-national health workers

“…This is particularly important in light of the widespread dissemination of misinformation regarding COVID-19 causes and cures from unreliable sources, where health workers are in positions to potentially combat the inaccuracies and promote healthy behaviours. While previous work has shown that sub-national health workers are likely to rely on personal communications to inform their decisionmaking [10,11], this has not been studied amongst subnational health workers in the context of COVID-19 in Uganda specifically.…”