In this section, we first present the summary of the findings from the literature review.
Findings of the literature review
Facilitating factors for KT were identified from reviewed papers and categorized in 8 themes:
1. Institutional strengthening for KT
2. The pre-research phase: research priority setting
3. Research characteristics
5. Contextual issues: politics and economic considerations
6. External influences: global evidence and donor influences
8. Health System Strengthening (HSS) considerations
A summary of the commonly mentioned facilitating factors under each group is shown in Table . Facilitating factors under the themes 'strengthening institutional capacity for KT", research characteristics', 'dissemination', 'political context' and 'partnerships' were mentioned in more than 50% of the retained papers. We present these in more detail as they guided the development of the MRT.
Summary of results (number of reviewed papers mentioning a specific facilitating factor) and themes for the MRT for KT
Institutional strengthening for KT in the health sector
Thirty-nine out of 49 papers reviewed showed that efforts must be made to build relevant capacity among policymakers in research processes, synthesis and application of evidence. Having policymakers with a background in research has been noted to be beneficial to KT. This contributes to ownership of research results and better uptake in policy development and implementation. Institutionalized platforms for engagement between researchers and policymakers right from setting the research agenda to policy development and implementation need to be in place for effective and continuous dialogue. This enables policymakers to appreciate the research processes and ensure their involvement in evidence generation. On the other hand, it enables researchers to appreciate the policy process, implementation challenges and to develop relevant research questions. A supportive policy framework to enable implementation of research findings is also noted to be important.
Forty out of 49 papers reviewed showed that evidence is taken up better, if it is (perceived to be) rigorous, contextualized and provided in a timely manner by credible researchers. Evidence must be comprehensive as much as possible, looking at several dimensions (for example cost implications and implementation feasibility) so as to enable decision making. If recommendations are provided, they must be feasible from an economic and implementation point of view and provide options for short-, medium- and long-term strategies. Local researchers are reported to have the advantage of engaging with policymakers for longer periods and to contextualize findings better as opposed to international researchers.
Thirty-five out of 49 papers reviewed highlight the importance of effective dissemination of evidence. Messages must be simplified, tailored to the different audiences and disseminated using multiple approaches (push efforts). Personal communication and face-to-face interactions between researches and policymakers are mentioned in several papers as effective strategies. Dissemination should be planned for right at the beginning of the research processes, target audiences mapped, dissemination activities agreed and funding provided. Knowledge brokers with the capacity to package evidence in several ways have been shown to facilitate dissemination efforts. Literature however shows that these must be independent and have the capacity to manage conflict of interests among stakeholders. Improving access to internet as ways of improving dissemination was mentioned in 6 papers. Three papers mentioned the use of demand-driven research networks/rapid response units that can respond to the needs of policymakers for evidence in a timely manner. Availability of a champion, who is passionate about KT and gets issues to the attention of policymakers, was found to be an additional facilitating factor.
Twenty-six papers stated that the political environment must be favorable and supportive to adopt and implement the generated evidence. Government stability, openness to change and dialogue provide better chances for KT. Presence of a political window of opportunity and a strong policy momentum are also mentioned as facilitating factors.
Partnerships (exchange efforts)
Thirty-five papers showed that sustained partnerships spanning the whole process, from evidence generation to its application with all relevant stakeholders creates transparency in evidence generation. This subsequently increases the acceptability of evidence among stakeholders, which in turn facilitates KT. Oxman A. et al, however raises the question of how best to engage the different stakeholders in regards to the degree of involvement, forum for communication, method of recruitment and building their capacity for effective involvement [19
Elements of the MRT emerging from the literature review can be summarized along the five themes as follows:
Institutional strengthening for KT
Adequate capacity for knowledge management and institutionalized mechanisms for researcher-policymaker interaction contribute to higher ownership and consequently, better application of evidence.
Timely provision of high quality, contextualized evidence with feasible recommendations and policy options leads to higher adoption and implementation, especially if produced by credible, local researchers and if generated through demand-driven research networks that respond to national decision makers' priorities
Effective provision of research findings is facilitated by using knowledge brokers, audience-tailored formats, and dissemination through multiple channels. Policy champions enable evidence to reach the policy table.
A politically favorable environment open to change and the availability of a political window will make policymakers more receptive for evidence that has the above features.
Partnerships spanning the whole process from setting the research agenda to implementation are important and should include communities and implementing actors. Regional networks may contribute to better exchange of experience.
Figure shows the diagrammatic presentation of the MRT. The figure presents the different elements of the MRT, showing how the elements dealing with research link with the policymaking process.
Diagrammatic presentation of the initial MRT.
Further refining of the MRT through interviews
We sought to further refine the elements of the above MRT using data from KI interviews through assessing the degree of convergence or divergence and also sought to identify new emerging themes. As mentioned in the methodology section, we undertook KI interviews with officials involved in policymaking and holding senior positions in their agencies/institutions. KIs were all senior level officials 15 of whom were policymakers and 2 were researchers. Civil society respondents had been in post for at least 6 years except one who had been in post for 3 years. Ministry of health respondents had been in post for at least 6 years except one (3 years). Donor respondents had been in post for at least 6 years except two (six months and 2 years). In the case of researchers, one had been in post for 14 years and the other 2 years. The private for profit respondents had been in post for 2 years.
The interviews were analyzed along the themes of the MRT.
A summary of the interview results shows that the interviewees focused most on institutional strengthening for KT, research, dissemination, political context and partnerships (Table ).
Summary of results from KI - responses (number of respondents)
Institutional strengthening for KT
Most respondents (11/17) highlighted the need to build the capacity of policymakers in research processes, synthesis and application. A civil society respondent mentioned that "We need leaders who understand the evidence, this is very necessary- enlightened leaders can easily understand evidence and apply it".
Researchers raised the issue of an improved reading culture as a facilitating factor for effective discussion and appreciation of research results. One researcher noted that "The reading culture is poor among the stakeholders. You cannot disseminate through drama for these highly educated people. (...) Some officials come to the workshop when they have not read the research paper. You give them some hours to read and resume the workshop. This is also not good because within that short time, they will not understand everything to contribute new ideas".
Most respondents (12/17) stated that a systematic dialogue and engagement with all stakeholders through institutionalized platforms was one of the ways to ensure that the set research agenda is followed, and evidence is well disseminated and implemented. This helps researchers to participate in policy dialogue and understand the system, while policy makers on the other hand appreciate the research process better. A MoH respondent remarked that "We need to institutionalize a framework of linking policy makers, researchers and implementers. There are weaknesses within the MoH to get in place formation of a research agenda in a consultative manner. The Uganda National Health Research Organization, that should play that role, is very weak. Research undertaken is largely not commissioned. Without a formalized way of using evidence to change policy, KT will continue to be a challenge."
Policymakers, however, stated that these platforms should include more than just policymakers and researchers. They should be broadened to include civil society.
A MoH respondent stated that the MoH should take over overall coordination of evidence generation and dissemination activities and mentioned that a policy analysis unit embedded within the MoH is best placed to coordinate the platform.
A PNFP respondent pointed out the need to reduce the bureaucratic and protracted nature of decision making and policy development and remarked that we need to "Reduce the extent of bureaucracy within the policy making process, reduce the levels of decision making, in this way one can keep track of decisions being made at the different stages and use of evidence in decision making".
Virtually all respondents stated that the scientific soundness, relevance, timeliness, comprehensiveness of the evidence and feasibility of provided recommendations were important. One respondent remarked that "Research must be credible if it is going to drive policy. There is no cause to fear if research has been done by WHO or the School of Public Health, there is no doubt of its credibility. (MoH respondent)
The credibility of researchers was mentioned by 6 interviewees, who specified attributes like researchers of good standing, being reputable and being independent. One responded raised the issue of corruption affecting the research community and research in general: Credibility of researchers matters also. You must get researchers who are respected, otherwise nobody will believe in the results. We, however, have a problem these days. Corruption is also affecting the research process. Some researchers undertake fieldwork and when you look at the data, you really wonder whether they actually went to the field. We are now tending to rely more on Uganda Bureau of Statistics and surveys supported by Macro international, whose quality is undoubtable. (MoH respondent).
Two respondents mentioned that use of local researchers as a favorable factor, because they can easily contextualize research findings and engage more with policymakers. "It is better to use local people in undertaking the research. In that case; results are more likely to be well received and used because they already take into account local context issues" (Donor respondent).
The issue of who commissions the research was raised by a PNFP respondent, who stated that "If research is not commissioned by MoH or WHO, it may not be taken seriously".
One MoH respondent mentioned the need to separate roles between researchers and policymakers. He stated that "We should separate roles, research should be undertaken by researchers who are independent, can assess issues critically and objectively. Policymakers should then receive results, discuss them, understand them and use them in policy development".
The majority of respondents (12/17) raised the issue of better dissemination of evidence through well packaged and adapted messages, using multiple dissemination channels that are tailored to different audiences. One PNFP respondent stated that "All stakeholders must be part of the dissemination. Simplified messages in several forms, policy briefs, report summaries, can be extensively circulated. We need to take advantage of existing fora; people should present their research results in these fora."
One respondent mentioned the importance of face-to-face dissemination, especially to senior people in their offices, while 6 mentioned use of radio and politicians as the best way to reach the community. One donor respondent pointed out the need for multiple channels: "We need to use various opportunities, formal and informal to disseminate research results. Radios can be used but must be repetitive short massages. Most important is to use various channels. One misses this one, but catches another channel."
Four PNFP and 1 donor respondents mentioned the significant role that civil society can play in disseminating evidence, although they again noted the challenges that need to be addressed for this to be effective. One PNFP respondent stated that "A well informed and knowledgeable civil society can play a role in dissemination, because we have roots in the community, advocacy, and community mobilization. We can put pressure on policymakers to implement evidence, but we are largely left out. The challenge is that we have to go through that middleman, the government. The government to some extent blocks civil society by putting restrictions on "who" should undertake dissemination".
Two respondents mentioned use of electronic media although they acknowledged its limited accessibility and thus the need to assess its usefulness. One researcher remarked: "Media and IT are not accessible by all. A lot of research is disseminated through electronic media, but some areas have no such infrastructures, same do not have e-mail, we need to evaluate its usefulness"
One PNFP respondent mentioned the creation of a team within government structures to be charged with the responsibility of disseminating evidence and remarked that "There must be a team in government unit who handle dissemination other than leaving to individual programmes and researchers. They should move quickly and reach out to the researchers and make sure that available evidence informs policy quickly".
Four respondents stated that dissemination is a process that should be planned for at the very beginning of the research process, and that a communication strategy needs to be developed and funded.
One donor pointed out the importance of having a champion within the MoH who links up with higher-level officials who actually make policy decisions. Such champions are able to go and see the different officers and engage in face-to-face dissemination. The respondent stated that "It helps a lot to have a champion within MoH who links up with higher officials, who actually make policy decisions. He can spend more time with senior officials and ensure that results are shared in important fora".
Seven respondents mentioned the need for a favorable political environment that is open to dialogue and a political window that presents an opportunity for change. A PNFP respondent stated that "The best time to disseminate results is when there is a political window like at the time of elections, then politicians pick it to their advantage. But if the research result is affecting the incumbent government, it may not be a good time for you to disseminate such a result".
Specific mention by 9 respondents was made of getting politicians' involvement in research and among suggested strategies is targeted dissemination as stated by a MoH respondent that "Politicians are very important, they should be a targeted group because they are in the community, and there are top policymakers so they should be given high consideration".
Almost all respondents cited the importance of involving all relevant stakeholders throughout the process, right from setting a research agenda to policy development and implementation. Six respondents mentioned the need to involve communities who are often neglected. One PNFP respondent stated that "The community is not involved at all. It's only policymakers and researchers, the community is neglected, yet they are the main beneficiaries who know their problems too well".
Ranking of facilitating factors by key informants
We asked respondents to rank the facilitating factors in order of importance (Table ). The top 3 facilitating factors were 'strengthening institutional capacity for KT' (12 respondents), 'research characteristics' (9 respondents) and 'partnerships' (9 respondents). No respondent ranked political context among the top three facilitating factors. MoH and PNFP respondents emphasized the importance of institutional strengthening for KT. Donors emphasized research characteristics, while researchers emphasized partnerships.
Number of respondents ranking facilitating factors among the top 3
Refining the MRT
Taking into account what is stated as most important by policymakers in Uganda, we refined the initial MRT that was based on the literature review under three themes as follows.
Institutional strengthening for KT
- Institutionalized platforms for engagement between researchers and policymakers including civil society
- Mainstreamed mechanisms (within MoH) to coordinate evidence generation synthesis and dissemination
- Build capacity of policymakers in knowledge management (central depository, research processes, interpretation, evidence based culture, ownership of results, synthesis and application
- Reduced bureaucracy in policy making
Expected outcome: higher ownership and better application of evidence
- Timely provision of high quality and contextualized evidence with recommendations that are economically feasible and offering policy options
- Credibility of researchers
- Use of local researchers
- Separation of roles between researchers and policymakers
Expected outcome: higher adoption and implementation
- Involvement of all relevant stakeholders throughout the process to improve trust and build interest
- Community involvement in evidence generation and KT
Expected outcome: higher adoption and implementation
Figure presents the modified MRT with the elements confirmed by the interviews now underlined and new elements in blue italic type. This shows that policymakers, researchers and other actors involved in policymaking in the health sector in Uganda believe that particular attributes of the research and the dissemination process influence the uptake of research and knowledge into decisions on health policies, but that this requires sound institutional capacities. They believe that several factors can facilitate such uptake: the presence of political windows of opportunity and the involvement of knowledge brokers and policy champions.
Diagrammatic presentation of the refined MRT.