Using evidence to inform decision making
on health systems in LMICs: what evidence
do policymakers need?
Harriet Nabudere, MD, MPH
Knowledge Translation for Health Policy and Systems
College of Health Sciences, Makerere University
Kampala, Uganda
Supporting Use of Research Evidence (SURE) for
Policy in African Health Systems




SURE is a collaborative project that builds upon two
existing initiatives – The Regional East African
Community Health (REACH) Policy Initiative and the
Evidence-to-Policy Network (EVIPNet) Africa.
Both networks aim to promote the use of evidence in
health policy decisions.
REACH comprises the countries; Uganda, Tanzania,
Kenya, Rwanda and Burundi.
EVIPNet Africa comprises the countries of Burkina Faso,
Cameroon, Centrafrique, Ethiopia, Mozambique, and
Zambia.
Overall Strategy:
SURE comprises 8 work packages.
 There are 6 work packages with scientific/technological
objectives:
 WP1: Production of research syntheses (evidence briefs
for policy) to address priority policy questions.
 WP2: Development and evaluation of strategies for
improving access to research evidence to inform policy
decisions, i.e.; user-friendly formats for evidence briefs
and clearing house.
 WP3: Developing and evaluating mechanisms for a rapid
response service to meet policymaker needs for
research evidence.

Overall Strategy (contd)
WP4: Developing and evaluating methods for
conducting deliberative/policy dialogues that are
informed by research syntheses/evidence briefs.
Methods for involving civil society, the general public,
the media in policy development.
 WP5: Capacity-building for researchers, policymakers
and civil society in developing and implementing
evidence-informed health policies.
 WP6: Comprehensive evaluation of the African partners
initiatives to improve the use of research to inform
health policy decisions.

Setting Priorities for Guidance:
Consultations:
Criteria: Important problem, viable options,
opportunity for change, available evidence, etc
 Stakeholder Survey: Parliamentarians,
policymakers, health managers, researchers, civil
society
 Advisory Group: 3 policymakers, 1 researcher, 1
CS practitioner
 Framed and ranked issues that were considered
high priority for the Ugandan health system.

SURE Year 2:
Evidence Brief for Policy
Title
 Authorship
 Problem Description
 Policy Options
 Implementation Considerations
 Completion of the evidence brief
 Dialogues and Evaluation

Evidence Brief for Policy:
Title:
‘Improving Access to Skilled Attendance at
Delivery’
Evidence Brief for Policy:
Authorship:
Contributing Authors:
2 members, REACH Uganda team
1 Senior Policymaker, MOH
Skilled Birth Attendance Working Group:
2 Senior Policymakers (MOH),
1 Obstetrician Consultant/Researcher/
Academician
Evidence Brief for Policy:
The Problem (1):
• Identification of evidence i.e national
statistics & local data from MoH, UBOS,
WHO, UN data etc.
• Advanced draft describing the problem
• Internal reviews by the working group &
external reviews with revision of the
problem section.
Evidence Brief for Policy:
The Problem (2):
The burden: high maternal mortality ratio 435 per
100,000 live births (DHS,2006) from MMR 670
(UN,1990)
 Coverage of Skilled attendance stood at 42%
(DHS, 2006) and under 50% (AHSPR, 2009/2010)
 Maternal and perinatal causes constitute 13.2% of
the total disease burden (WHO,2004)

Evidence Brief for Policy:
Policy Options:
Identification and appraisal of evidence
(preferably systematic reviews of effects)
for impacts (benefits and harms) of
alternative organisational arrangements to
address the problem
• Identification and appraisal of other
evidence: local single studies.

Appraisal of the evidence:
SURE checklist for systematic review methods
1.
Check on methods used to search, select and
appraise studies in systematic reviews

PICOS criteria, data sources, timeframe, explicit selection
criteria,..
2.
Check on methods used to analyse findings in
systematic reviews

Reliable reporting for study characteristics & results,
analysis methods, appropriate combination of findings..
Appraisal of the evidence:
GRADE framework for rating quality of evidence
1.
2.
3.
4.
Identification of important outcomes from
a systematic review
Assessment of quality of evidence per
outcome using GRADE framework
Tabulated summary of findings per
outcome
Key messages in plain language
Evidence Brief for Policy:
Policy Options (contd):
Agreement and development of draft on
3 policy options (organisational
arrangements):
 Providing
Intrapartum Care at first level Health
Centre
 Working with the Private-for-Profit sector
 Maternity Waiting Homes
Evidence Brief for Policy:
Implementation Strategies (1):
Identification and appraisal of evidence
(preferably SRs of effects) on barriers to
implement the policy options & strategies
to address these.
 Identification and appraisal of other
evidence and local information e.g local
single studies, national reports,…

Evidence Brief for Policy:
Implementation Strategies (2):
Agreement on the implementation barriers &
strategies:

Implementation Barriers: poor care seeking behavior from
mothers, social & economic constraints for mothers,
inadequate HRH, inadequate health facilities and financing,

Strategies: VHTs, community mobilisation, community
referral and transport schemes, strengthening health
infrastructure and public-private collaboration
Evidence Brief for Policy:
Implementation Strategies (3):
Advanced draft describing the policy
options, implementation barriers &
strategies
 Internal review and revision of the policy
options, implementation barriers &
strategies

Evidence Brief for Policy:
other considerations Systematic reviews and single studies used were
assessed not only for methodological quality but
also, where possible, for:
◦ applicability to the local context
◦ equity across socio-economic groups
◦ scaling up considerations (costs and costeffectiveness)
◦ gaps in the research evidence hence need for
monitoring and evaluation
Full Evidence Brief for Policy
Draft title and cover page
 Key messages (1 page)
 Executive summary (8 pages)
 Full Report (45 pages)
 Bibliography
 Description of methods
 Acknowledgements
 Conflicts of interest
 External review of the draft policy brief
 Revision of the full policy brief

Evidence Brief for Policy: Evaluation
The evidence brief was the main input for
discussion at two national policy dialogues for
stakeholders including legislators, policymakers,
researchers, civil society and the media
 A survey was conducted with the stakeholders
about the usefulness of the design format of the
brief

Overall assessment of the evidence
brief for policy
‘The purpose of the policy brief was to present the
available research evidence on a high-priority issue in
order to inform a policy dialogue where research
evidence would be just one input to the discussion. How
well did the policy brief achieve its purpose?’ (N=22)
Rating on a scale of 1 (failed) to 7 (achieved)
Mean: 6.6
Median: 7
Range: 2
The need for guidance among decisionmakers
‘I want to use research evidence of the type that was
discussed at the policy dialogue to help work through
what I will say in a briefing, advocate for, or decide.
(N=19)’
Scale of 1 (strongly disagree) to 7 (strongly agree)
Mean: 6.3
Median: 6
Range: 2
The demand for health systems
guidance
------Forwarded Message ----From: xxxxxxxxx
To: harrietnabudere@yahoo.com
Sent: Sunday, October 9, 2011 10:34 AM
Subject: POLICY ISSUES
Greetings my sister. Wish you happy independence.
There many policies we have to work on this year includiing legislative matters.You may have to give us
more time.
The following are pending
- Palliative Care Policy
- Interns Policy
- Human Tissue Bill
- Policy on Emergency Services.
- The Tertiary Health Institutions Bill.
We have to discuss one of these days.
Dr Harriet Nabudere
SURE Project Coordinator
College of Health Sciences, Makerere University
Kampala, Uganda
Email: hnabudere@gmail.com