C Uneke, B Ngwu, A Ogbonna, A Ezeoha, P Oyibo, F Onwe
C Uneke, B Ngwu, A Ogbonna, A Ezeoha, P Oyibo, F Onwe. Strategies to enhance the capacity for evidence-informed health policymaking in Nigeria. The Internet Journal of Healthcare Administration. 2009 Volume 7 Number 1.
In Nigeria, there is little interest in transfer and uptake of research into policy and practice. The major constraint to the use of evidence in policy and practice in Nigeria is the grossly deficient capacity development at the individual and organizational levels, particularly the lack of formally trained human resources among public health policy makers. The problem is further compounded by the existence of few relevant studies for many important health policy issues, much less systematic reviews of evidence. The most prominent reason attributed to the limited usability of existing data is that policymakers’ needs do not drive research. Also conflicts over fundamental political values and interest groups can limit the relevance of evidence to the decision-making process and inundate the policy setting with bad-quality evidence, champion poorly designed studies, and limit the critical analysis of information through the social relations they develop with officials. The strategies to enhance evidence-informed policy making include: enhancing supply of policy-relevant research products; enhancing capacity of policy-making organizations to use evidence; establishing new organizational mechanisms to support use of evidence in policy; promoting networking and; establishing norms and regulations regarding evidence use in policymaking.
Policy making has been described as a process that follows a logic that is different from that of the scientific enterprise . The role of evidence based on research is often minimal, and even when it is used by policymakers, such evidence is greatly affected by cognitive and institutional features of the political process . As a result, policymaking is a highly complex process that is difficult to predict or for individual participants to influence, producing stable policies occasionally marked by extreme change [3,4]. In Nigeria, there is little interest in transfer and uptake of research into policy and practice. A few instances where this has occurred are centered mainly on clinical decision-making (evidence-based medicine) and only in a number of tertiary health institutions such as teaching hospitals. Health policy and systems research HPSR is a somewhat new phenomenon in the public health sector in Nigeria and most health researchers, public health policy makers, health service managers and other major stakeholders at government and non-governmental levels are completely ignorant of its value in policy-making and practice (evidence-informed health service management, and evidence-informed policy making).
The major constraint to the use of evidence in policy and practice in Nigeria is the grossly deficient capacity development at the individual and organizational levels, particularly the lack of formally trained human resources among public health policy makers and health service managers . Some of the problem is attributed to the “cultural” differences between those who do research, and those who may be in a position to use it largely due to the absence of opportunities to bring researchers, policymakers and managers together to consider issues around the research to policy and practice interface . There is lack of a HPSR agenda agreed by policy-makers and the research community and the lack of a bridging mechanism between policy-makers and researchers. Inadequate infrastructure in terms of internet access, office and laboratory facilities, coupled with the problem of internal and external brain drain further exacerbates the situation .
T he objectives of this report are to appraise the state of health policymaking in Nigeria, identify the challenges associated with the evidence-informed health policymaking, and how these challenges can be addressed. To achieve the objectives of this report we performed a review of available literature on health policymaking and use of evidence obtained from the Nigeria Ministry of Health databases complemented by information from relevant literature obtained from the Google search.
Health systems research in Nigeria
Health systems research in Nigeria is further burdened with a number of other such challenges including under-investment, lack of human capacity, lack of public demand, inadequate utilization, and poor dissemination of results . Attempts are being made to address the mismatch and gap between need for health research and investment including: research capacity strengthening; promotion of research investment; and the establishment of national health forums . In addition, empirical work on mapping health resource flows and health research systems is in progress in Nigeria. However, there still exists limited capacity to produce knowledge and this is compounded by a dearth of domestic funding and by ‘brain drain’ (emigration of skilled personnel to developed countries), thus domestic research capacity focuses largely on research agendas that are set outside Nigeria . Furthermore policy-makers in Nigeria are either denied access to appropriate evidence, forced to rely on poor-quality research findings, dependent on international research organizations potentially unfamiliar with the country context or reliant on donor agencies for interpretation of the available evidence base. Consequently, these policy-makers often have to draw upon research findings from elsewhere, and thus face complex questions regarding the transferability of conclusions from one setting to another . Another important issue worth mentioning is the fact that Nigeria receives a proportion of her budgets for heath systems from a variety of donor agencies particularly at the State level. These agencies play an important role in influencing government systems and in determining the dominant discourse for discussing systems development. Reform options are therefore often negotiated between officials in government and donor agencies, while other important stakeholders do not fully participate in these processes [7,8,9].
The nature of health policy making in Nigeria
The current health policy making process in Nigeria is embodied in the National Health Policy and Strategy to Achieve Health for All Nigerians, introduced in 1988 and subsequently revised in 2004 [10,11]. Founded on egalitarian principles, the policy making process seeks to improve the health of all Nigerians by devising a sustainable health system based on primary health care (PHC), that is promotive, protective, preventive, restorative and rehabilitative and which will ensure a socially and economic productive and fulfilling life to every individual. The policy process adopts WHO’s strategy for realizing PHC as elaborated in the Declaration of Alma Ata . The main focus of the National Health Policy is on the National Health System and its Management; National Health Care Resources; National Health Interventions and Services Delivery; National Health Information Systems; Partnership for Health Development; and Health Research and Health Care Laws. Though they are still in embryonic stages, each of these areas represents important components of an effective health system and would, if fully developed and implemented, go a long way in plugging the gaps and inadequacies of the current policy making system in Nigeria .
The policy provides for a health system with three levels: primary, secondary and tertiary. According to the National Health Policy, the federal government is responsible for policy formulation, strategic guidance, coordination, supervision, monitoring and evaluation at all levels . It also has operational responsibility for disease surveillance, essential drugs supply and vaccine management.
The National Health Policy is based on the fundamental principles of the second National Development Plan 1970–1974 which describes five national goals: a free and democratic society; a just and egalitarian society; a united, strong and self reliant nation; a great and dynamic economy; a land of bright and full opportunities for all citizens. The policy states that health development shall be seen not solely in humanitarian terms but as an essential component of the package of social and economic development as well as being an instrument of social justice and national security . Under the leadership of the current democratic government, the Health Sector Reform (HSR) Plan of Action is being developed to guide investments and actions by all levels of government, the private sector, donors and all development partners in health. The Plan of Action maps out medium term objectives in seven strategic intervention areas: primary health care, disease control, sexual and reproductive health including STIs/HIV/AIDS, secondary and tertiary care, drug production and management, coordination of development partners, organization and management . A dynamic policy process involving extensive consultation among all the levels of government is already being pursued in order to build consensus around health policies.
How research evidence is incorporated in the policy process in Nigeria
In Nigeria there are three strata of policy-making: (i) governance policies which relate to organizational and financial structures; (ii) service policies for resource allocation and patterns of services and (iii) practice policies on how practitioners use resources to deliver patient care. The decision-making “actors” in Nigeria are mainly politicians (including elected officials), managers and civil servants and those scientific and technical professionals who know health and medical disciplines. Support may emerge from unexpected quarters, such as other decision-makers who have relied on research to formulate policies in the past but who have moved on to posts in other sectors. Then there are “mediators” who facilitate communication, institutions as well as individuals, both inside and outside the research community, in academics, the bureaucracy or international agencies [5,11]. In Nigeria, political, economic and social factors all affect how research evidence is incorporated in policy making process, and who makes them, at all levels: national, state and local. The use of research evidence in policy environment is also affected by political traditions, and economic and social conditions within the country [12,13]. Social differences, both class and ethnic, and beliefs and values affect who becomes a policy-maker and which policies they pursue based on available evidence. For example, elite families may seek to retain power to influence policy by nominating family members to stand for government; policy-makers from particular ethnic groups may promote policies from evidence that favor their own group; or members of a government may be unwilling to introduce legislation around family planning and abortion because of the strong religious views .
Challenges of Evidence-Informed Health Policymaking in Nigeria
In Nigeria health policymaking is highly influenced by politics and some of the characteristics of the political setting pose a great challenge to evidence-informed decision making. Both administrators and legislators play active roles in the policy making processes. Unfortunately, among the administrators there is limited organizational capacity to collect and evaluate research, there are also limited research skills among the legislators, which has led to a general lack of understanding about how evidence can be used properly. This is also reported in some studies in other countries [ 14,15]. The problem is further compounded by the existence of few relevant studies for many important health policy issues, much less systematic reviews of evidence . Often there is also little or no evidence regarding new or emergent technologies, which can present significant challenges for administrators feeling pressured by legislators, service providers, and consumers to expand coverage [2,6,16]. Because of lack of funding for research, there are hardly any research to produce evidence for policymaking. Even existing studies and systematic reviews that concerns health policy commonly lack features that would make them easier for government officials to evaluate. Most times the existing research is of poor quality or limited applicability and even when evidence is available, policymakers may have problems obtaining it .
The most prominent reason attributed to the limited usability of existing data which has also been indicated in some studies from other countries is that policymakers’ needs do not drive research [6,12,15]. Instead, much of the information is produced by service providers or product makers who both have a vested interest in the implications and provide answers to narrower, business questions. In addition, academic researchers generally follow their own interests when choosing what studies to conduct or tailor them to specific requests for grants. Similarly, the synthesis of existing research in the form of systematic reviews is driven by the researchers’ particular interests [1,18,19]. Also conflicts over fundamental political values concerning the proper role of government also can often limit the relevance of evidence to the decision-making process [12,20]. Another important factor is that of interest groups. Interest groups can greatly influence policymakers, often in ways that hinder evidence-informed decision making. Interest groups can inundate the policy setting with bad-quality evidence, champion poorly designed studies, and limit the critical analysis of information through the social relations they develop with officials .
Strategies to enhance evidence-informed health policymaking in Nigeria
Despite the challenges associated with evidence-informed health policymaking in Nigeria, they are not insurmountable. A number of strategies that can enhance evidence-informed policy making have been identified by the Alliance for Health Policy and system Research . These strategies have the potential of addressing the challenges in developing countries including Nigeria. The following are the strategies to enhance evidence-informed policy making:
1 . Enhance supply of policy-relevant research products: Improvement is brought about by strengthening priority-setting processes, particularly for health policy and systems research, and ensuring that funding follows identified priorities. Policy-makers, researchers and research funders need to commit to participating jointly in priority-setting processes and to abiding by the results.
2 . Enhance capacity of policy-making organizations to use evidence: Skills in using evidence may be improved through training and development programmes for policy-makers and other policy agents.
3 . Establish new organizational mechanisms to support use of evidence in policy: Cultivating organizations dedicated to supporting evidence use in policy can be very helpful. For example, the REACH initiative in East Africa aims to establish a new organization with a mandate to collate, summarize and package research evidence relevant to policy concerns and present this in a timely fashion to policy-makers . Such knowledge brokers are primarily intended to act as bridges between policy- and decision-makers on the one hand, and researchers on the other.
4 . Promote networking: Institutions for Health Policy can be established that can train students who would then go on to assume posts in health-related ministries and departments. This would enhance research-related capacities of government institutions and can facilitate academics’ access to policy processes.
5 . Establish norms and regulations regarding evidence use in policymaking: National governments can establish norms and regulations that support the development and use of research evidence. There is increasing recognition of how health system constraints impede progress in scaling-up service delivery, therefore support for evaluative and operational research should be part of the norm for funders of health systems.
The importance of capacity development among the policy makers and other stake holders in the Nigeria health sector can not be over stated. This is a major factor that has the potential of boosting the interest in the transfer and uptake of research evidence into policy and practice as it will positively influence governance and leadership, resources (human, material and financial), communication and quality of research. It is already a well established fact that skills training could help policymakers and their aides not only identify research evidence that has policy relevance but also distinguish research of high and low methodological quality. Targeted, evidence-based training of health professionals in charge of the health systems; national, regional, state and local officers of the health ministries; staff and consultants involved in public health issues within the health ministries; political/legal advisers on health related matters; and program/project managers under the health ministry, could provide a powerful means for influencing how research is used and how policy issues are framed in larger legislative and administrative settings in Nigeria.
It is of interest to note that the nature of the research to policy interface within Nigeria as in other low income countries is rapidly evolving. Consequently substantial use of novel approaches to respond to this evolution becomes imperative. Some of these approaches include: new methodological techniques in analyzing the research to policy; utilization of a conceptual framework of the interface that highlights the importance of particular entry points and appreciates essential developmental perspectives; choice of research topics with significant scope for innovation; and creative partnership formation to carry out the analysis. The challenge today is for Nigeria and other developing countries to forge ahead by demanding more good research (particularly empirical studies), producing it and then using it. Such empirical studies will be innovative as it would focus on policymaker’s perspective towards health research utilizing standard methods and a cross-sectional, multi-country approach. The research would represent a great opportunity to develop an empirical basis for understanding how policymakers and other stakeholders perceive research in Nigeria, and what value they ascribe to it in terms of their own decision making in the health sector. The gains would even be greater when the capacity of Health Systems is enhanced to conduct the research and this would most certainly improve evidence-informed health policymaking in Nigeria.