Advancing the field of health systems research synthesis

Academic contributions to the development of evidence and policy systems: an EPPI Centre collective autoethnography

BACKGROUND

Evidence for policy systems emerging around the world combine the fields of research synthesis, evidence-informed policy and public engagement with research. We conducted this retrospective collective autoethnography to understand the role of academics in developing such systems.

METHODS

We constructed a timeline of EPPI Centre work and associated events since 1990. We employed: Transition Theory to reveal emerging and influential innovations; and Transformative Social Innovation theory to track their increasing depth, reach and embeddedness in research and policy organisations.

FINDINGS

The EPPI Centre, alongside other small research units, collaborated with national and international organisations at the research-policy interface to incubate, spread and embed new ways of working with evidence and policy. Sustainable change arising from research-policy interactions was less about uptake and embedding of innovations, but more about co-developing and tailoring innovations with organisations to suit their missions and structures for creating new knowledge or using knowledge for decisions. Both spreading and embedding innovation relied on mutual learning that both accommodated and challenged established assumptions and values of collaborating organisations as they adapted to closer ways of working. The incubation, spread and embedding of innovations have been iterative, with new ways of working inspiring further innovation as they spread and embedded. Institutionalising evidence for policy required change in both institutions generating evidence and institutions developing policy.

CONCLUSIONS

Key mechanisms for academic contributions to advancing evidence for policy were: contract research focusing attention at the research-policy interface; a willingness to work in unfamiliar fields; inclusive ways of working to move from conflict to consensus; and incentives and opportunities for reflection and consolidating learning.

Collaboration on evidence synthesis in Africa: a network study of growing research capacity

BACKGROUND

Evidence-based practice in medicine and social policy relies heavily on evidence synthesis. To translate evidence into practical guidelines for low- and middle-income countries, local expertise is essential. The objectives of this study are to assess the change in capacity for conducting evidence synthesis in Africa and to identify key African institutions for regional capacity-building. We take on a network perspective, considering that the position of an institution in the African evidence ecosystem is one constituent of its research capacity.

METHODS

We systematically identified 3548 evidence synthesis publications between 2008 and 2019 with at least one author in Africa from the Web of Science Core Collection. These articles involved 3769 institutions. Longitudinal institution-level collaboration network data were constructed based on co-authorship information. We used social network analysis to examine the institutions' connectivity and tendency for intra- and interregional collaboration. We also identified the degree- and betweenness-central African institutions and explored the structure and composition of their local network neighbourhoods.

RESULTS

The number of African institutions involved in evidence synthesis has increased substantially over the last decade, from 31 in 2008 to 521 in 2019, and so has the number of evidence synthesis publications with authors in Africa. African institutions in the evidence ecosystem have also become more connected during this period. Although the amount of intercontinental collaboration continues to exceed that of regional collaboration, the tendency for African institutions to collaborate with partners in Africa is increasing. We identified seven institutions-in South Africa, Egypt and Uganda-as central to the collaboration networks between 2008 and 2019, all of whom showed a tendency to collaborate across sectors.

CONCLUSION

The development of more regionally based network-building initiatives would help to foster communities of practice and inter-institutional collaboration, strengthening regional research capacity. Moreover, the analysis in this study adds depth beyond a simple bibliometric analysis and illustrates that network analysis could provide a useful tool to evaluate the effectiveness of capacity-building strategies and programmes in the future.

Researching, co-creating and testing innovations in paper-based health information systems (PHISICC) to support health workers' decision-making: protocol of a multi-country, transdisciplinary, mixed-methods research programme in three sub-Saharan countries

Background

Health information systems are crucial to provide data for decision-making and demand for data is constantly growing. However, the link between data and decisions is not always rational or linear and the management of data ends up overloading frontline health workers, which may compromise quality of healthcare delivery. Despite limited evidence, there is an increasing push for the digitalization of health information systems, which poses enormous challenges, particularly in remote, rural settings in low- and middle-income countries. Paper-based tools will continue to be used in combination with digital solutions and this calls for efforts to make them more responsive to local needs. Paper-based Health Information Systems in Comprehensive Care (PHISICC) is a transdisciplinary, multi-country research initiative to create and test innovative paper-based health information systems in three sub-Saharan African countries.

Methods/Design

The PHISICC initiative is being carried out in remote, rural settings in Côte d’Ivoire, Mozambique and Nigeria through partnership with ministries of health and research institutions. We began with research syntheses to acquire the most up-to-date knowledge on health information systems. These were coupled with fieldwork in the three countries to understand the current design, patterns and contexts of use, and healthcare worker perspectives. Frontline health workers, with designers and researchers, used co-creation methods to produce the new PHISICC tools. This suite of tools is being tested in the three countries in three cluster-randomized controlled trials. Throughout the project, we have engaged with a wide range of stakeholders and have maintained the highest scientific standards to ensure that results are relevant to the realities in the three countries.

Discussion

We have deployed a comprehensive research approach to ensure the robustness and future policy uptake of findings. Besides the innovative PHISICC paper-based tools, our process is in itself innovative. Rather than emphasizing the technical dimensions of data management, we focused instead on frontline health workers’ data use and decision-making. By tackling the whole scope of primary healthcare areas rather than a subset of them, we have developed an entirely new design and visual language for a suite of tools across healthcare areas. The initiative is being tested in remote, rural areas where the most vulnerable live.

Does an innovative paper-based health information system (PHISICC) improve data quality and use in primary healthcare? Protocol of a multicountry, cluster randomised controlled trial in sub-Saharan African rural settings

INTRODUCTION

Front-line health workers in remote health facilities are the first contact of the formal health sector and are confronted with life-saving decisions. Health information systems (HIS) support the collection and use of health related data. However, HIS focus on reporting and are unfit to support decisions. Since data tools are paper-based in most primary healthcare settings, we have produced an innovative Paper-based Health Information System in Comprehensive Care (PHISICC) using a human-centred design approach. We are carrying out a cluster randomised controlled trial in three African countries to assess the effects of PHISICC compared with the current systems.

METHODS AND ANALYSIS

Study areas are in rural zones of Côte d'Ivoire, Mozambique and Nigeria. Seventy health facilities in each country have been randomly allocated to using PHISICC tools or to continuing to use the regular HIS tools. We have randomly selected households in the catchment areas of each health facility to collect outcomes' data (household surveys have been carried out in two of the three countries and the end-line data collection is planned for mid-2021). Primary outcomes include data quality and use, coverage of health services and health workers satisfaction; secondary outcomes are additional data quality and use parameters, childhood mortality and additional health workers and clients experience with the system. Just prior to the implementation of the trial, we had to relocate the study site in Mozambique due to unforeseen logistical issues. The effects of the intervention will be estimated using regression models and accounting for clustering using random effects.

ETHICS AND DISSEMINATION

Ethics committees in Côte d'Ivoire, Mozambique and Nigeria approved the trials. We plan to disseminate our findings, data and research materials among researchers and policy-makers. We aim at having our findings included in systematic reviews on health systems interventions and future guidance development on HIS.

TRIAL REGISTRATION NUMBER

PACTR201904664660639; Pre-results.

Integrated community case management of childhood illness in low- and middle-income countries

BACKGROUND

The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012).

OBJECTIVES

To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison.

AUTHORS' CONCLUSIONS

iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.

Rapid response to crisis: Health system lessons from the active period of COVID-19

BACKGROUND

This paper outlines the need for a health systems approach and rapid response strategy for gathering information necessary for policy decisions during pandemics and similar crises. It suggests a new framework for assessing the phases of the pandemic.

METHOD

The paper draws its information and conclusions from a rapid synthesis and translation process (RSTP) of a series of webinars and online discussions from the Pandemic-Mental Health International Network (Pan-MHIN) - policy experts from across 16 locations in Australia, Denmark, Italy, Spain, Taiwan, the UK and the USA. While the initial focus of this research was on mental health, COVID-19 has raised much broader issues and questions for health planners.

RESULTS

We identified gaps affecting the capacity to respond effectively and quickly, including in relation to system indicators, the inadequacy of the prior classification of the phases of the pandemic, the absences of a healthcare ecosystem approach, and the quick shift to digital technologies. The strengths and weaknesses of COVID-19 responses across different systems, services, sites and countries been identified and compared, including both low and high impacted areas.

CONCLUSIONS

There is an urgent need for managerial epidemiology based on healthcare ecosystem research encompassing multidisciplinary teams, visualization tools and decision analytics for rapid response. Policy and healthcare context played a key role in the response to COVID-19. Its severity, the containment measures and the societal response varied greatly across sites and countries. Understanding this variation is vital to assess the impact of COVID-19 in specific areas such as ageing or mental health.

International experiments with different models of allocating funds to facilitate integrated care: a scoping review protocol

INTRODUCTION

Integrated care is viewed widely as a potential solution to some of the major challenges faced by health and social care systems, such as those posed by service duplication, fragmentation and poor care coordination, and associated impacts on the quality and cost of services. Fragmented models of allocating funds to and across sectors, programmes and providers are frequently cited as a major barrier to integration and countries have experimented with different models of allocating funds to enhance care coordination among service providers and to reduce ineffective care and avoid costly adverse events. This scoping review aims to assess published international experiences of different models of allocating funds to facilitate integration and the evidence on their impacts.

METHODS AND ANALYSIS

We will adopt a scoping review methodology due to the potentially vast and multidisciplinary nature of the literature on different models of allocating funds in health and social care systems, as well as the scarcity of existing knowledge syntheses. The framework developed by Arksey and O'Malley will be followed that entails six steps: (1) identifying the research question(s), (2) searching for relevant studies, (3) selecting studies, (4) charting the data, (5) collating, summarising and reporting the results and (6) and conducting consultation exercises. These steps will be conducted iteratively and reflexively, making adjustments and repetitions when appropriate to make sure the literature has been covered as comprehensively as possible. To ensure comprehensiveness of our literature review, we also search a wide range of sources.

ETHICS AND DISSEMINATION

An integrated knowledge translation strategy will be pursued by engaging our knowledge users through all stages of the review. We will organise two workshops or policy roundtables/policy dialogues in Alberta and British Columbia with participation of diverse knowledge users to discuss and interpret the findings of our review and to draw out policy opportunities and lessons that can be applied to the context of these two provinces.

Integrated mental health services in China: challenges and planning for the future

Eager to build an integrated community-based mental health system, in 2004 China started the '686 Programme', whose purpose was to integrate hospital and community services for patients with serious mental illness. In 2015, the National Mental Health Working Plan (2015-2020) proposed an ambitious strategy for implementing this project. The goal of this review is to assess potential opportunities for and barriers to successful implementation of a community-based mental health system that integrates hospital and community mental health services into the general healthcare system. We examine 7066 sources in both English and Chinese: the academic peer-reviewed literature, the grey literature on mental health policies, and documents from government and policymaking agencies. Although China has proposed a number of innovative programmes to address its mental health burden, several of these proposals have yet to be fully activated, particularly those that focus on integrated care. Integrating mental health services into China's general healthcare system holds great promise for increased access to and quality improvement in mental health services, as well as decreased stigma and more effective management of physical and mental health comorbidities. This article examines the challenges to integrating mental health services into China's general healthcare system, especially in the primary care sphere, including: accurately estimating mental health needs, integrating mental and physical healthcare, increasing workforce development and training, resolving interprofessional issues, financing and funding, developing an affordable and sustainable mental health system, and delivering care to specific subpopulations to meet the needs of China's diverse populace. As China's political commitment to expanding its mental health system is rapidly evolving, we offer suggestions for future directions in addressing China's mental health needs.

Policies supporting informal caregivers across Canada: a scoping review protocol

INTRODUCTION

As the population ages, governments worldwide have begun seeking ways to support informal caregiving. In this light, Canada is no exception, but despite the centrality of the informal care strategy in elder care, we know little about the intertwining and overlapping policies that have been implemented to support informal caregivers providing assistance to the elderly, and to fellow citizens with disabilities. This review aims to identify the diversity of Canadian national, provincial and territorial policies supporting informal caregivers. It seeks, from its generalist focus on all informal care, to draw out specific observations and lessons for the elder care policy environment.

METHODS AND ANALYSIS

Given the vast and multidisciplinary nature of the literature on informal care policy, as well as the paucity of existing knowledge syntheses, we will adopt a scoping review methodology. We will follow the framework developed by Arksey and O'Malley that entails six stages, including: (1) identifying the research question(s); (2) searching for relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarising and reporting the results; (6) and conducting consultation exercises. We will conduct these stages iteratively and reflexively, making adjustments and repetitions when appropriate to ensure we have covered the literature as comprehensively as possible. We will pursue an iterative integrated knowledge translation (iKT) strategy engaging our knowledge users through all stages of the review.

ETHICS AND DISSEMINATION

By adopting an iKT strategy we will ensure our knowledge users directly contribute to the project's policy relevant publications. Upon completion of the review, we will present the findings at academic conferences, publishing a research report, along with an academic peer-reviewed article. Our intent is to develop an online, free-access evidence repository that catalogues the full range of Canada's English language informal care support policies. Finally, the completed review will allow us to publish a series of policy briefs in collaboration with knowledge users illustrating how to promote and better implement informal care support policies. Our study has received ethics approval from the University of Calgary Conjoint Ethics Board.

Validity and usability testing of a health systems guidance appraisal tool, the AGREE-HS

Background

Health systems guidance (HSG) provides recommendations to address health systems challenges. No tools exist to inform HSG developers and users about the components of high quality HSG and to differentiate between HSG of varying quality. In response, we developed a tool to assist with the development, reporting and appraisal of HSG – the Appraisal of Guidelines for Research and Evaluation–Health Systems (AGREE-HS). This paper reports on the validity, usability and initial measurement properties of the AGREE-HS.

Methods

To establish face validity (Study 1), stakeholders completed a survey about the AGREE-HS and provided feedback on its content and structure. Revisions to the tool were made in response. To establish usability (Study 2), the revised tool was applied to 85 HSG documents and the appraisers provided feedback about their experiences via an online survey. An initial test of the revised tool’s measurement properties, including internal consistency, inter-rater reliability and criterion validity, was conducted. Additional revisions to the tool were made in response.

Results

In Study 1, the AGREE-HS Overview, User Manual, quality item content and structure, and overall assessment questions were rated favourably. Participants indicated that the AGREE-HS would be useful, feasible to use, and that they would apply it in their context. In Study 2, participants indicated that the quality items were easy to understand and apply, and the User Manual, usefulness and usability of the tool were rated favourably. Study 2 participants also indicated intentions to use the AGREE-HS.

Conclusions

The AGREE-HS comprises a User Manual, five quality items and two overall assessment questions. It is available at agreetrust.org.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0334-9) contains supplementary material, which is available to authorized users.

The SPARK Tool to prioritise questions for systematic reviews in health policy and systems research: development and initial validation

Background

Groups or institutions funding or conducting systematic reviews in health policy and systems research (HPSR) should prioritise topics according to the needs of policymakers and stakeholders. The aim of this study was to develop and validate a tool to prioritise questions for systematic reviews in HPSR.

Methods

We developed the tool following a four-step approach consisting of (1) the definition of the purpose and scope of tool, (2) item generation and reduction, (3) testing for content and face validity, (4) and pilot testing of the tool. The research team involved international experts in HPSR, systematic review methodology and tool development, led by the Center for Systematic Reviews on Health Policy and Systems Research (SPARK). We followed an inclusive approach in determining the final selection of items to allow customisation to the user’s needs.

Results

The purpose of the SPARK tool was to prioritise questions in HPSR in order to address them in systematic reviews. In the item generation and reduction phase, an extensive literature search yielded 40 relevant articles, which were reviewed by the research team to create a preliminary list of 19 candidate items for inclusion in the tool. As part of testing for content and face validity, input from international experts led to the refining, changing, merging and addition of new items, and to organisation of the tool into two modules. Following pilot testing, we finalised the tool, with 22 items organised in two modules – the first module including 13 items to be rated by policymakers and stakeholders, and the second including 9 items to be rated by systematic review teams. Users can customise the tool to their needs, by omitting items that may not be applicable to their settings. We also developed a user manual that provides guidance on how to use the SPARK tool, along with signaling questions.

Conclusion

We have developed and conducted initial validation of the SPARK tool to prioritise questions for systematic reviews in HPSR, along with a user manual. By aligning systematic review production to policy priorities, the tool will help support evidence-informed policymaking and reduce research waste. We invite others to contribute with additional real-life implementation of the tool.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-017-0242-4) contains supplementary material, which is available to authorized users.

eLearning for health system leadership and management capacity building: a protocol for a systematic review

INTRODUCTION

Health leadership and management capacity are essential for health system strengthening and for attaining universal health coverage by optimising the existing human, technological and financial resources. However, in health systems, health leadership and management training is not widely available. The use of information technology for education (ie, eLearning) could help address this training gap by enabling flexible, efficient and scalable health leadership and management training. We present a protocol for a systematic review on the effectiveness of eLearning for health leadership and management capacity building in improving health system outcomes.

METHODOLOGY AND ANALYSIS

We will follow the Cochrane Collaboration methodology. We will search for experimental studies focused on the use of any type of eLearning modality for health management and leadership capacity building in all types of health workforce cadres. The primary outcomes of interest will be health outcomes, financial risk protection and user satisfaction. In addition, secondary outcomes of interest include the attainment of health system objectives of improved equity, efficiency, effectiveness and responsiveness. We will search relevant databases of published and grey literature as well as clinical trials registries from 1990 onwards without language restrictions. Two review authors will screen references, extract data and perform risk of bias assessment independently. Contingent on the heterogeneity of the collated literature, we will perform either a meta-analysis or a narrative synthesis of the collated data.

ETHICS AND DISSEMINATION

The systematic review will aim to inform policy makers, investors, health professionals, technologists and educators about the existing evidence, potential gaps in literature and the impact of eLearning for health leadership and management capacity building on health system outcomes. We will disseminate the review findings by publishing it as a peer-reviewed journal manuscript and conference abstracts.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42017056998.

Quasi-experimental study designs series-paper 1: introduction: two historical lineages

OBJECTIVES

The objective of this study was to contrast the historical development of experiments and quasi-experiments and provide the motivation for a journal series on quasi-experimental designs in health research.

STUDY DESIGN AND SETTING

A short historical narrative, with concrete examples, and arguments based on an understanding of the practice of health research and evidence synthesis.

RESULTS

Health research has played a key role in developing today's gold standard for causal inference-the randomized controlled multiply blinded trial. Historically, allocation approaches developed from convenience and purposive allocation to alternate and, finally, to random allocation. This development was motivated both by concerns for manipulation in allocation as well as statistical and theoretical developments demonstrating the power of randomization in creating counterfactuals for causal inference. In contrast to the sequential development of experiments, quasi-experiments originated at very different points in time, from very different scientific perspectives, and with frequent and long interruptions in their methodological development. Health researchers have only recently started to recognize the value of quasi-experiments for generating novel insights on causal relationships.

CONCLUSION

While quasi-experiments are unlikely to replace experiments in generating the efficacy and safety evidence required for clinical guidelines and regulatory approval of medical technologies, quasi-experiments can play an important role in establishing the effectiveness of health care practice, programs, and policies. The papers in this series describe and discuss a range of important issues in utilizing quasi-experimental designs for primary research and quasi-experimental results for evidence synthesis.

Mapping the use of research to support strategies tackling maternal and child health inequities: evidence from six countries in Africa and Latin America

Background

Striving to foster collaboration among countries suffering from maternal and child health (MCH) inequities, the MASCOT project mapped and analyzed the use of research in strategies tackling them in 11 low- and middle-income countries. This article aims to present the way in which research influenced MCH policies and programs in six of these countries – three in Africa and three in Latin America.

Methods

Qualitative research using a thematic synthesis narrative process was used to identify and describe who is producing what kind of research, how research is funded, how inequities are approached by research and policies, the countries’ research capacities, and the type of evidence base that MCH policies and programs use. Four tools were designed for these purposes: an online survey for researchers, a semi-structured interview with decision makers, and two content analysis guides: one for policy and programs documents and one for scientific articles.

Results

Three modalities of research utilization were observed in the strategies tackling MCH inequities in the six included countries – instrumental, conceptual and symbolic. Instrumental utilization directly relates the formulation and contents of the strategies with research results, and is the least used within the analyzed policies and programs. Even though research is considered as an important input to support decision making and most of the analyzed countries count five or six relevant MCH research initiatives, in most cases, the actual impact of research is not clearly identifiable.

Conclusions

While MCH research is increasing in low- and middle-income countries, the impact of its outcomes on policy formulation is low. We did not identify a direct relationship between the nature of the financial support organizations and the kind of evidence utilization within the policy process. There is still a visible gap between researchers and policymakers regarding their different intentions to link evidence and decision making processes.

Quasi-experiments to establish causal effects of HIV care and treatment and to improve the cascade of care

PURPOSE OF REVIEW

Randomized, population-representative trials of clinical interventions are rare. Quasi-experiments have been used successfully to generate causal evidence on the cascade of HIV care in a broad range of real-world settings.

RECENT FINDINGS

Quasi-experiments exploit exogenous, or quasi-random, variation occurring naturally in the world or because of an administrative rule or policy change to estimate causal effects. Well designed quasi-experiments have greater internal validity than typical observational research designs. At the same time, quasi-experiments may also have potential for greater external validity than experiments and can be implemented when randomized clinical trials are infeasible or unethical. Quasi-experimental studies have established the causal effects of HIV testing and initiation of antiretroviral therapy on health, economic outcomes and sexual behaviors, as well as indirect effects on other community members. Recent quasi-experiments have evaluated specific interventions to improve patient performance in the cascade of care, providing causal evidence to optimize clinical management of HIV.

SUMMARY

Quasi-experiments have generated important data on the real-world impacts of HIV testing and treatment and on interventions to improve the cascade of care. With the growth in large-scale clinical and administrative data, quasi-experiments enable rigorous evaluation of policies implemented in real-world settings.