This research was carried out at the sub-national level with emphasis on two States namely Enugu and Ebonyi, both of which are located in the Southeast geopolitical zone of Nigeria. The Southeastern geopolitical zone consists of five States viz Anambra, Enugu, Ebonyi, Abia, and Imo States. Enugu and Ebonyi States are the leading States in health policy and systems research in Nigeria.
Enugu State is also known as the coal city State and has 17 Local Government Areas. It has about 12 tertiary academic institutions and 4 tertiary health institutions. The economy of the state is public sector driven, making civil service the predominant occupation of its working population. Other major occupations in Enugu are farming and trading. The majority of Enugu people are of the Igbo ethnic group and the predominant religion is Christianity.
Ebonyi State is the youngest State in the Southeastern part of Nigeria. There are thirteen Local Government Areas (LGAs) in the state. There are also 6 tertiary academic institutions and 2 tertiary health institutions in the State. About 75% of the Ebonyi population are involved in agriculture and the crops grown in the state include yam, rice, cassava, maize, and many others .
The participants in this study were drawn from both states and included career policymakers (e.g. permanent secretaries, directors, heads of departments, programme managers)[12, 13], political/elected policymakers from health and related areas, parliamentarians, global health practitioners, representatives of professional associations, Non-Governmental Organization (NGO) representatives and HPSR researchers.
Study design and description
This was a before and after study embedded within the Health Systems Global (HSG) Africa regional network sub-national convening held on 4th August 2020 in Abakaliki, Ebonyi State. This convening study was organized by the Africa HSG regional network based on the Sixth Global HSG Symposium on Health Systems Research (HSR 2020) sub-theme (Engaging political forces) and the HSG Africa’s priority area (advocating for increased domestic funding for research). A total of five convenings were held in the African region of HSG.
The study was held using a workshop design consisting of pre-workshop, workshop, and post-workshop phases. The pre and post-workshop assessments collected quantitative data while qualitative data was collected using panel and breakout sessions. All the participants were invited to the workshop by invitation letters which were sent 2 weeks before the event. This was followed up with text message reminders three days, and a day before the event. The intervention was the capacity-building sessions and they were focused on the use of HPSR evidence in policymaking, funding processes and state of HPSR funding in Nigeria, innovative platforms, and strategic opportunities for advocacy on increased domestic funding for HPSR in Nigeria.
Sample size and selection of participants
A total of 26 purposively selected respondents participated in this study. This method of selecting policymakers and researchers for stakeholder events has been employed in previous studies.[13,14,15] The participants were selected based on the representativeness of the different stakeholders involved in HPSR in both States. The national guidelines on public gatherings not exceeding 30 persons in order to enforce physical distancing as part of the COVID-19 preventive measures influenced the sample size. Although the sample was limited to less than 30 persons, representatives of all the target stakeholder groups listed in the study participants’ subsection participated in the study.
Data collection methods and tools
Both quantitative and qualitative data were collected. The study instruments included a questionnaire and topic guide for group and panel discussions.
Quantitative data collection
A self-administered semi-structured questionnaire was used to collect information on knowledge and perception of respondents regarding HPSR funding. Semi-structured questionnaires have been used in previous studies among policymakers and researchers . The questionnaire was made up of 3 sections. Section A was used to collect information on the socio-demographic characteristics of the participants. Section B was used to assess the adequacy of knowledge and understanding of HPSR, HPSR funding and advocacy for HPSR funding using a total of 15 questions on a 5-point Likert scale. Each question had five options on a rating scale of 1–5 points and scored as follows: 1 point = grossly inadequate; 2 points = inadequate; 3 points = fairly adequate; 4 points = adequate and 5 points = very adequate. The third section (section C) was used to assess the respondent’s perception of HPSR funding in Nigeria. Nine questions on a 5-point Likert scale were used to measure perception. Every single question had five options with the lowest point as 1 and the highest point as 5. It was scored as 1 point = strongly agree; 2 points = disagree; 3 points = indifferent; 4 points = agree and 5 points = strongly agree. The hard-copy questionnaires were completed before and after the capacity building sessions. However, only the knowledge section was re-assessed after the capacity building sessions as the post-workshop assessment.
Qualitative data collection
A total of four group discussions were conducted. Two of the groups were focused on stakeholder mapping and power analysis while the other two groups discussed the strengths, weaknesses, opportunities, and threats (SWOT) analysis of domestic funding for HPSR in Nigeria. Writing materials (plain and cardboard sheets) and simplified, easy to understand templates for SWOT analyses (SWOT analysis box) and stakeholder power analysis (matrix and tables) were provided for the group work. Overall, the group discussions were used to better understand the importance of domestic funding to HPSR, sources of domestic funding, challenges, and consequences of lack of domestic funding for HPSR in Nigeria and advocacy strategies to improve domestic funding for HPSR in Nigeria.
The group discussion guide had 5–6 questions with probes and there were about 6–8 discussants per group. Each group discussion lasted about 35 min. To enable a participatory approach, ensure peer support, and minimize external interferences from the researchers, each group appointed a note-taker who wrote down salient points from the group discussions. Afterward, this was presented using flip charts by the group representative and critiqued by the other participants. An independent non-participatory note-taker was assigned to each group to write the responses of the participants.
The panel discussion was made up of about 6 panelists (commissioner for Donors and Grants, permanent secretaries and directors in the ministry of health, NGO representatives, HPSR researcher, and parliamentarian) and a moderator who anchored the discussions in a flexible manner. The themes discussed were: current state of health research and HPSR funding in Nigeria; research funding processes; influencing the budget-making process to increase HPSR funding and strategies for increasing domestic funding for HPSR in Nigeria. The panel discussion lasted for about one hour. Notes were taken by three note-takers to ensure that all the responses of the panelists were captured.
Capacity building session/intervention
The two capacity-building sessions were facilitated by a member of the research team who was skilled in HPSR and stakeholder engagement for use of evidence in policymaking. The topics covered were: a) overview of HPSR, the Nigerian health system, and health research funding b) identifying stakeholders and advocacy strategies for increased domestic funding for HPSR in Nigeria. PowerPoint presentations were used for the teaching sessions. All lectures were delivered in simplified, practical, and easily comprehensible patterns. Complex mathematical or scientific computations/models were avoided for the benefit of non-specialists who participated in the workshop. The participants were also provided with writing materials such as jotters, plain sheets, and pens. Questions and feedbacks were entertained at the end of each session. Each session lasted an average of one hour. The entire convening lasted from 10 a.m-3 p.m.
At the end of the capacity building sessions, the post-workshop assessment questionnaire was administered to the participants. The same questionnaire used at the pre-workshop survey was the same one used for post-workshop assessment. The aim of the post-workshop assessment was to evaluate the impact of the workshop on level of knowledge and understanding of respondents regarding HPSR funding in Nigeria.
Data analysis and management
Measurement of variables
The independent variables include socio-demographic and work characteristics such as: age, gender, organization, and designation/position.
The dependent variables were the knowledge and perception of HPSR funding in Nigeria.
To grade the knowledge and perception of HPSR funding, the Mean Neutral Rating (MNR) of the Likert scale responses was done using the methods developed at McMaster University Canada by Johnson and Lavis . For knowledge and understanding of HPSR funding, mean knowledge scores between 3.00 and 5.00 were categorized as good while values less than 3.00 were taken as poor knowledge. Mean perception scores between 3.00 and 5.00 were categorized as good while values less than 3.00 were taken as poor.
Quantitative data analysis was done using SPSS version 25. Frequencies, proportions, means, and standard deviations were computed. Results were presented using frequency tables.
Qualitative data analysis commenced with a review of hand-written notes from the group discussions to confirm the completeness of the information documented. Pre-conceived themes were generated from the discussion guide to develop a coding framework. The notes were then read to achieve familiarization and identify any themes that were not in the coding framework. The themes included in the final coding framework are as follows: (i) the importance of domestic HPSR funding, (ii) sources of HPSR funding, (iii) consequences of lack of domestic funding for HPSR, (iv) strategic stakeholders for increasing HPSR funding (v) strategies to improve domestic funding for HPSR in Nigeria, (v) strengths, weaknesses, opportunities, and threats to HPSR funding in Nigeria.