Table 3 The final list of EIPM barriers in knowledge utilization (PULL), presented separately for the systematic review and policy dialogue

A: The decision-making environment (macro-level and health sector)

Review

Policy dialogue

 Absence of long-term plans and directors' lack of commitment to such plans

*

 Organizational, social, and political pressure in decision-making and the dominance of pressure groups over scientific evidence in policy-making

*

 Lack of communication between different sectors of the MOHME in the development and implementation of health policies

*

 Short tenure of policy-makers and their rapid replacement

*

 Directors are not chosen based on meritocracy

*

 Time limitations in organizational decision-making

*

 Personal interpretations of enforceable laws

*

 Directors and policy-makers act based on their personal preferences

*

 Evidence is exploited to approve a predetermined mental framework

*

 Decision-makers' politicization

*

B: The health decision-making/policy-making process

 Lack of universality and institutionalization of the HTA process

*

 Absence of a specific criterion for prioritization and decision-making

*

 Policies and programmes are not evaluated, and improvement is not made based on evaluation

*

 No attention is paid to the contextualization of interventions

*

 Panels of experts are used instead of research, and the panels are not held properly

*

 Solutions are presented without complete and comprehensive data backup

*

C: Supportive processes and structures

 Lack of supervision, rules, and regulations regarding the development and implementation of guidelines

*

 Structural, financial, and legislative limitations in ordering the research needed

*

 Lack of processes that enforce the use of evidence in decision-making

*

 Lack of support of senior policy-makers (e.g. Parliament representatives) by scientific groups

*

 Shortage of skilled human resources for evidence utilization

*

D: Incentive system

 D1: Organizational and individual goals and values

  Absence of political support for evidence utilization in decision-making

*

  Policy-makers' inappropriate perceptions of the need for evidence utilization/ Decision-makers do not feel the need to utilize scientific evidence

*

  The health ministry's health decision-makers' preference to produce evidence themselves

*

  Giving priority to personal or organizational preferences over evidence

*

  Lack of health decision-makers' trust in the local research evidence

*

  Lack of commitment to evidence utilization in decision-making

*

  Policy-makers' inappropriate perceptions of the real outcomes of policy execution

*

  The perception of evidence utilization as a luxurious tool rather than strengthening and improving the health system

*

  Lack of decision-maker transparency and accountability

*

 D2: Individual capacities and capabilities

  Policy-makers' lack of awareness and skills in the analysis and rapid utilization of evidence

*

  Inappropriateness of individuals' skill and knowledge for policy-making and management; absence of strategic thinking among decision-makers

*

  Superficial and simplistic knowledge regarding issues, problems, and solutions

*

 D3: Performance evaluation and reward programmes

  Inappropriateness of indices for managers' performance evaluations (there's a quantitative approach, and the number of decisions is important); There is no criterion for evidence utilization in the managers' evaluation

*

*

  The supervision and evaluation system of decision-makers is not evidence-based

*

  The noncompetitive advantage of evidence utilization among policy-makers and managers and negative attitude towards policy-makers and managers who utilize evidence

*