Table 1 Cross-cutting themes for evidence uptake and related enablers and barriers identified from case studies

1. Leadership and political will

Creation of a culture of evidence use is determined to a great degree by the skills and priorities of managers and leaders within the MoH; in addition, centres or units that are specifically created to support/utilise HPSR need adequate leadership in order to be successful

Enablers:

● When leaders prioritise evidence generation and use, they can motivate other staff around them to do the same

● When leaders prioritise evidence, they can institutionalise processes for its generation and use by using political commitments to set up structures to support it

● When leaders prioritise evidence use, this can also attract additional resources to support those functions

Barriers:

● When leaders do not have strong agenda-setting and governance skills and appreciation for the research process themselves, they may not understand the value of evidence nor the time and resources required for staff to engage in these activities

● When leaders are focused on care delivery rather than evidence use, then that is where time and resources will be allocated instead

● When leaders are enmeshed in political processes or dynamics that are not focused on evidence (due to pace, corruption, conflict, etc.), then this can detract from overall evidence use

Illustrative examples (see Additional file for full descriptions):

• Ethiopia’s One Plan, One Budget, One Report

• Rwanda’s results-based financing and performance-based financing strategies

2. Incentives and resources

Evidence uptake requires funding and adequate support of staff; financial resources include support for training programmes, providing higher salaries for researchers, allocating more of the MoH’s budget towards research, dissemination and use; incentives can also include a desire to impress leadership, performance requirements and other accountability mechanisms

Enablers:

● Opportunities for training, networking with higher-level staff, traveling for work opportunities, and new responsibilities can be motivational to CSs; this is strongly linked with whether leadership prioritises HPSR and evidence use and therefore whether they direct resources towards it

● Salary top-ups meant to promote research activities can increase evidence generation among CSs (sometimes the first priority for these programmes is to counteract the low based salaries for CSs and the evidence generation is practically a secondary priority)

● Government policies requiring a certain percentage/amount of budget allocated towards research and international declarations and goals (e.g. the Algiers Declaration, World Health Assembly resolutions on health research, and the Bamako Call to Action on Research for Health) [20, 21]

● Strong connection with DPs, who want to see stronger evidence use in decision-making, can leverage international funding sources

● Sufficient resources to invest in building/strengthening entities that support health systems research such as rapid reviews mechanisms

Barriers:

● Inadequate resources (domestic resources, particularly in low- and middle-income as well as international) and/or resources earmarked for priorities that are not aligned to national strategy/needs; can result from reliance on DPs who do not prioritise (and thus do not fund) research activities

● Lack of career pathways and other incentives compared to clinical researchers and policy-makers

● Because of the time lag between the generation of evidence, uptake and related action, leaders are not always inclined to use their experience and authority

Illustrative examples (see Additional file for full descriptions):

• Rwanda’s increase in domestic resources and ‘district challenge fund’

• The Ethiopian Public Health Institute’s staffing evolution and opportunities

3. Infrastructure and access to health data

Infrastructure is a barrier to evidence uptake when appropriate processes and permissions are not present to enable access to needed information; this includes across agencies, ministries or partners

Enablers:

• Ability to share data between CSs and researchers and also between different agencies and sectors with government

• Data access, including real-time data, synthesised data, data from different agencies, having relevant documents and data in one place that is accessible to everyone

• Digitisation of datasets, reports and processes can greatly expedite the speed of access, analysis, dissemination (as long as supporting infrastructure such as electricity, internet, functional computers are present)

• Presence of a national statistics unit (not necessarily health specific) in multiple cases has also aided in data analysis and availability of digestible/usable results

Barriers:

● CSs not trained on how to use available databases

● Databases not functional due to other infrastructure limitations (electricity, internet, functional office spaces)

● Language barriers to being able to review and glean relevant information from scientific/international evidence

● Incoordination and miscommunication between data units and policy-makers

Illustrative examples (see Additional file for full descriptions):

• Chile’s integrated health technology assessment process

4. Designated structures and processes

Focused units, centres and other platforms that are institutionalised — not relying on individual relationships — can ensure accountability and sustainability of evidence-use demand; these structures can facilitate a coherent national research agenda or strategy

Enablers:

• National research agendas or policies established, often as part of a health systems reform processes

• Focused units/centre established that have resources (finances, staff, infrastructure) to support their mandates

• Local universities can be key players in these structures, when brought in strategically as partners and supported to understand and keep up with the pace of MoH evidence needs/decision-making processes

• Presence of tools and guidelines (international and national) for monitoring and evaluation planning can support these structures and processes

Barriers:

● Lack of focus on research/evidence use within MoH structure (make it challenging to strengthen a culture of evidence use)

● Legal or financial issues related to the autonomy/legitimacy of these structures

● Lack of designated positions and roles for CSs to engage in evidence generation/use

Illustrative examples (see Additional file for full descriptions):

• Mozambique’s Human Resources for Health National Directorate

• Lebanon’s Knowledge to Policy Center

5. Interaction and relationships

In order for effective evidence use to take place, multiple stakeholders are involved (researchers, CSs, donors, civil society and professional associations); these stakeholders need opportunities to interact with each other in order to share knowledge, understand priorities and build trusting and effective relationships

Enablers:

• Many stakeholders can contribute to this interaction in a constructive way, including beyond just CSs and researchers

• Pre-established policies or regular events (face-to-face, if possible) that bring researchers, CSs and policy-makers together with accountability of all parties; this includes national meetings or mandates that policy decisions must be backed by sufficient evidence

• International organisations or declarations/targets can help provide stability and another perspective during dialogues in order to break through political stalemates or ‘old’ patterns

Barriers:

• Building trusting and functional relationships among stakeholders takes time

• Lack of supportive infrastructure, including communication pathways, meeting spaces and leadership of these interactions can result in frustration and/or lack of results

Illustrative examples (see Additional file for full descriptions):

• Kyrgyzstan’s approach to responding to rising levels of cardiovascular disease

6. Capacity strengthening and engagement

Professional development opportunities for CSs to learn and apply skills for research as well as participate in policy activities; these can include in-service training, incentives, regular meetings to review evidence and determine recommendations, and strengthen relationships; all these increase the recognition and importance of evidence use in decision-making

Enablers:

• Training programmes that connect senior MoH staff with young professionals in conducting and translating research into policy; in addition, programmes that equip CSs with the skills needed to conduct, analyse and disseminate research should provide opportunities for CSs to participate in policy activities where they can advocate for the use of and apply evidence

• Opportunities for CSs to participate in policy activities where they interact with policy-makers and apply research skills

• Strong links with academic institutions, providing more avenues for capacity-building

Barriers:

• Non-existence of such programmes due to different MoH priorities or lack of leaders’ support

• CSs not knowing how to apply training in real policy-making

• Often, training programmes do not cover enough or the appropriate skills and knowledge for evidence use (in particular related to synthesis and dissemination) and therefore training incentives and programmes do not necessarily lead to more evidence use

• High turnover inhibits CSs from participating in trainings and applying skills

Illustrative examples (see Additional file for full descriptions):

• Sri Lanka’s Education, Training and Research Unit

• South Africa’s Health Economic Unit