This study evaluated the usefulness of KT tools (policy brief and policy dialogue) in enabling policy-makers in Ebonyi State to contextualize and operationalize a national policy document (AFRIN).
The approach used was informed from the 2018 report of the Global HIV/AIDS Initiatives Nigeria, which recommended that policy briefs be included as part of any comprehensive communication strategy and used for engaging both policy-makers and researchers at the subnational and national levels towards contextualization and operationalization. A key reflection on the role of the policy dialogue in contextualizing the policy options created by the policy brief is seen in the outcome of the policy dialogue, where the stakeholders recommended volunteerism instead of recruitment of skilled workers, nonmonetary compensation of health workers serving in rural communities (such as through conferment of state honours and chieftaincy titles by communities they have served well), optimal use of available solar freezers and other cold chain equipment instead of buying and installing new equipment, and refraining from frequent transfer of skilled health workers away from rural areas by making it statutory that every such worker would have served for at least 3 years before such transfer. These decisions were taken bearing in mind certain realities of the state. First was the financial constraints the state faces as one of the states receiving the smallest allocations from the monthly Federal Account Allocation Committee (FAAC) meeting. This committee decides the amount of funds that each of the 36 states of Nigeria receives from the federal account based on certain fixed criteria. This is compounded by the fact that the state has low internally generated revenue as a result of a weak tax base due to the near absence of industry and other commercial ventures. Second, the health sector both nationally and in the state faces chronic under-funding. The state has never achieved the recommendation of the Abuja Declaration in 2001 by African heads of government that every country should allocate a minimum of 15% of their annual budget to the health sector . Finally, there has been no recruitment of staff into the health sector for about 10 years despite the fact that workers have been retiring from service and dying, so there is an acute shortage of skilled manpower sector-wide.
The use of the policy brief in this study allowed career policy-makers, researchers and other stakeholders in the RI programme to identify the most feasible policy options of the AFRIN for implementation in Ebonyi State. Studies have demonstrated the usefulness of policy briefs and policy dialogue in policy-maker and researcher engagement .
Our study is similar to that of Yehia et al. , which evaluated the usefulness of KT tools (policy brief and policy dialogue) in the development of mental health policy in Lebanon. In that study, a policy brief developed from a comprehensive evidence synthesis and findings from key informant interviews of 10 policy-makers and key informants defined the problem and suggested three policy options as solutions. This policy brief guided a policy dialogue on mental health services development in Lebanon. Evaluation of the policy dialogue showed that integrating mental health services into primary healthcare was the option most frequently suggested by the 24 participants, thus validating the evidence in the policy brief. A post-dialogue survey conducted 6 months later showed that stakeholders had undertaken many implementation steps including the establishment of a national task force on mental health, training primary healthcare staff on mental health services and updating the national essential drug list to include psychiatric medicines. They concluded that the use of KT tools to help generate evidence-informed programmes was promising in Lebanon.
Johnson et al.  reported on the lessons learned from an initiative called Nigeria Research Days (NRD), using policy dialogue in supporting the use of evidence for establishing maternal, newborn and child health policy. The paper described the conceptualization, implementation and conduct of the first edition of the NRD policy dialogue framework. The framework for KT in that study was “the knowledge value chain” framework, a nonlinear concept based on the management of five dyadic capabilities: knowledge mapping and acquisition, knowledge creation and destruction, knowledge integration and sharing/transfer, knowledge replication and protection, and knowledge performance and innovation. The Department of Family Health of the Nigerian Federal Ministry of Health initiated and organized the NRD to serve as a platform for exchange between researchers and policy-makers for improving maternal, newborn and child health. In the first edition of the NRD, a cross-sectional study was designed to assess the effectiveness of a policy dialogue during the NRD. A descriptive analysis of the data collected from the workshop evaluation survey showed that the participants rated the content and format of the meeting positively and made suggestions for improvement. They were willing to implement the recommendations of the final communiqué and concluded that the lessons learned from this first edition would be used to improve future editions. However, unlike in our study, that study did not employ the use of a policy brief; rather, researchers who were implementing grants from the Canadian initiative Innovating for Mother and Child Health in Africa (IMCHA) were mapped and invited to present the outcomes of their studies to the audience of researchers, policy-makers and non-state actors involved in maternal and child health.
Unlike a previous policy dialogue on the control of infectious diseases of poverty in Ebonyi State , which involved participation from two institutions, the present study had an interesting feature of having participation from across many sectors. All of the participants were mid-level to senior officers in their respective organizations (career policy-makers), with 86.7% directly or indirectly influencing the policy-making process. As envisaged by Bammers et al. , deliberate targeting of such career policy-makers through the kind of enterprise employed in this study will help in bridging the “know–do gap”, as many career civil servants neither recognize nor accept their roles in policy-making. This is despite the high level of influence on policy-making reported by these participants. Anecdotal evidence suggests that career policy-makers, in contrast to their elected and appointed counterparts, tend to be well versed and familiar with routine decision-making processes given their length of time in service, experience, cross-sectoral exposure and continuity in office across various political regimes. This highlights the need for more focus on engaging these career policy-makers on policy-related issues. It is anticipated that with the additional skill enhancement through the workshop on policy dialogue they received, they will realize that they are policy-makers and thereafter play a greater role, both directly and indirectly, in policy-making.
The quality and relevance of the policy brief developed for this study was rated very highly (moderately useful to very useful), which is similar to the finding reported by Uneke et al. . This is probably because similar methods for policy brief preparation as recommended by Lavis et al. and Jones and Walsh [19, 24] were utilized in both studies. Likewise, the participants considered the policy dialogue process and brief to be very useful. Again, this can be explained by the fact that well-established guidelines [24, 32, 33] for the conduct of policy dialogues were followed.
This research compared the policy options in AFRIN as stated in the policy brief and the context-driven suggestions provided by the participants. The key implementation strategies listed centred on supply and logistics, proper budgeting and funding, human resource management, and intersectoral/organizational collaboration and creation of accountability interest/advocacy groups. Proper budgeting and availability of funds has a role in effective implementation of policies/programmes. Regarding human resource management, the gap can be bridged by considering task-shifting, which is less expensive and can contribute to better implementation. Studies have shown the value of task-shifting and equitable urban–rural distribution of health workers in various aspects of health programmes .
Policy dialogues provide the much-needed opportunity for policy-makers to review suggested policy directions and proffer revisions and implementation considerations relevant to the particular context. The contextualization of policy options stated in the policy brief during the policy dialogue is an invaluable takeaway from the policy dialogue, as demonstrated in our study. Evidence has shown the usefulness of policy dialogues in promoting stakeholder involvement in translating evidence to policy [17, 18, 35, 36].
To improve future policy dialogues, the participants recommended retention of some features. In descending order of importance, these were the participatory and interactive engagement, involvement of all stakeholders, fair representation of stakeholders in the various subgroups during the deliberations, and well-itemized problems and policy recommendations. This differs from the findings of Lavis et al. , where the design features to be retained were, in descending order, skilled facilitation using an outside agent, bringing together all parties who could be affected by the outcome (as it allowed for a variety of perspectives and open dialogue), pre-circulation of packaged evidence summaries, alternative ways of addressing a policy issue, and the adoption of the Chatham House Rule. However, in a study by Boyko et al. , participants wanted all the design features in the deliberative dialogue retained in future dialogues.
With regard to what should change in future policy dialogues on the same issue, the most frequently demanded design feature change was the nonparticipation by the apex (political) policy-makers in the ministries such as the commissioners and permanent secretaries. Participants suggested that the participation of such political policy-makers should be made mandatory.
It is possible that this group of stakeholders could not attend the dialogue due to low prioritization of RI in the state and busy schedules. This is cause for concern considering the fact that the apex policy-makers are often too busy with other political engagements, making it difficult for them to sit in for such activities, and even when they attend they are distracted with many calls. One of the strategies used to ensure good attendance was early notification of the meeting followed by frequent calls and reminders. This highlights the need for continued advocacy to policy-makers to ensure they fully understand the importance of these KT processes.
As Boyko et al.  suggested, “fair representation among policy makers, managers, stakeholders and researchers” is a challenge for deliberative dialogues that address low-priority policy issues (i.e. those that are not on the “radar” of government decision-makers). For political officeholders, gains in RI may be considered as non-vote-catching given its nonphysical form compared to huge, more visible works like roads, bridges and buildings. This in turn could pose an implementation barrier to the policy at hand.
Participants’ written comments on important action they would personally do better or differently to address the featured policy issue reflects their different roles in the policy process but can be summarized to mean that they intend to use what they learned during the dialogue to improve RI service delivery. This is similar to the findings of other studies . For example, some frontline health workers were willing to improve supportive supervision for the immunization programmes, civil society organizations suggested optimizing community resources and advocacy for RI, and the media committed to placing RI in the public domain. Thus the policy dialogue was an effective KT vehicle enabling policy actors to take responsibility to improve accountability in RI service delivery. This interesting finding highlights the value of personal responsibility in implementation of health programmes. Furthermore, the dialogue could potentially enhance evidence uptake, as has been demonstrated and advocated for by previous studies [25, 26, 38].
Another interesting finding was that stakeholders wanted the brief circulated further in advance. This is surprising because, in our context, people do not tend to read materials sent to them in advance.
A major misgiving about implementing AFRIN in the state that was expressed by the health worker participants in this study was health worker-specific sanctions for poor RI performance without considering the failure of the government to budget for and/or release funds for RI services in a timely manner. They also wondered who would sanction the government when it defaults on its own responsibility. Research evidence has shown that non-budgeting and/or non-release of budgeted RI funds have been the most difficult bottleneck in RI service delivery in states and local government areas in Nigeria [2, 12, 13]. To mitigate this issue, the stakeholders suggested transforming the multi-stakeholder group into an RI “ombudsman”, in addition to prioritizing effective RI coverage as a political campaign issue in future elections.
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