Erismann et al. Health Res Policy Sys (2021) 19:29 https://doi.org/10.1186/s12961-020-00646-1 RESEARCH Open Access How to bring research evidence into policy? Synthesizing strategies of five research projects in low-and middle-income countries Séverine Erismann1,2*, Maria Amalia Pesantes3, David Beran4, Andrea Leuenberger1,2, Andrea Farnham1,2, Monica Berger Gonzalez de White1,2,5, Niklaus Daniel Labhardt1,2,6, Fabrizio Tediosi1,2, Patricia Akweongo7, August Kuwawenaruwa1,2,8, Jakob Zinsstag1,2, Fritz Brugger9, Claire Somerville10, Kaspar Wyss1,2 and Helen Prytherch1,2* Abstract Background: Addressing the uptake of research findings into policy-making is increasingly important for research- ers who ultimately seek to contribute to improved health outcomes. The aims of the Swiss Programme for Research on Global Issues for Development (r4d Programme) initiated by the Swiss National Science Foundation and the Swiss Agency for Development and Cooperation are to create and disseminate knowledge that supports policy changes in the context of the 2030 Agenda for Sustainable Development. This paper reports on five r4d research projects and shows how researchers engage with various stakeholders, including policy-makers, in order to assure uptake of the research results. Methods: Eleven in-depth interviews were conducted with principal investigators and their research partners from five r4d projects, using a semi-structured interview guide. The interviews explored the process of how stakeholders and policy-makers were engaged in the research project. Results: Three key strategies were identified as fostering research uptake into policies and practices: (S1) stakehold- ers directly engaged with and sought evidence from researchers; (S2) stakeholders were involved in the design and throughout the implementation of the research project; and (S3) stakeholders engaged in participatory and transdis- ciplinary research approaches to coproduce knowledge and inform policy. In the first strategy, research evidence was directly taken up by international stakeholders as they were actively seeking new evidence on a very specific topic to up-date international guidelines. In the second strategy, examples from two r4d projects show that collaboration with stakeholders from early on in the projects increased the likelihood of translating research into policy, but that the latter was more effective in a supportive and stable policy environment. The third strategy adopted by two other r4d projects demonstrates the benefits of promoting colearning as a way to address potential power dynamics and work- ing effectively across the local policy landscape through robust research partnerships. Conclusions: This paper provides insights into the different strategies that facilitate collaboration and communica- tion between stakeholders, including policy-makers, and researchers. However, it remains necessary to increase our understanding of the interests and motivations of the different actors involved in the process of influencing policy, *Correspondence: severine.erismann@swisstph.ch; helen. prytherch@swisstph.ch 1 Swiss Tropical and Public Health Institute, Basel, Switzerland Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http://creati veco mmons .org/public domai n/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Erismann et al. Health Res Policy Sys (2021) 19:29 Page 2 of 13 identify clear policy-influencing objectives and provide more institutional support to engage in this complex and time-intensive process. Keywords: Evidence-based policy-making, Research for development Background including policy-makers, from the onset of a research Increasingly, research funders are asking their grantees project, in order to identify strategies for evidence uptake to address the uptake of research findings into decision- and use. making processes and policy-making [1, 2]. This growing As part of the r4d Programme, several synthesis ini- trend is a response to a need for real-world and context- tiatives have been launched to disseminate the research sensitive evidence to respond to and address complex evidence from the r4d projects and increase its impact health systems and health service delivery bottlenecks (http://www.r4d.ch/r4d progr amme/synth esis). The aim faced by policy-makers, health practitioners, communi- of one of these synthesis initiatives is to support knowl- ties and other actors that require more than single inter- edge translation and exchange, as well as knowledge dif- ventions to induce large-scale change [3]. Moreover, fusion and dissemination among 15 r4d projects focusing there is growing pressure for applied and implementation on public health. More specifically, the aim is to facili- research to be relevant, demonstrate value for money tate the uptake of findings for the benefit of societies in and result in high-impact publications. The relevance of LMICs, especially with regards to social inclusion and ensuring the translation of research into practice is also gender equity in the drive towards universal health cov- reflected in growing support for research projects with erage (UHC) and the 2030 Agenda for Sustainable Devel- concrete requirements regarding the evaluation of their opment [6]. The present study and resulting article are impact of science on society [4]. part of this synthesis initiative. One example of the above is the Swiss Programme for In this article, we present—through five case stud- Research on Global Issues for Development (r4d Pro- ies—strategies to translate and bridge evidence emerging gramme) initiated by the Swiss National Science Founda- from research into policy-making and decision-making. tion (SNSF) and the Swiss Agency for Development and We rely on the experiences of five public health projects Cooperation (SDC) covering the period 2012–2022. The within the r4d research initiative. This paper describes r4d Programme is aimed at researchers in Switzerland these experiences, reports on the lessons learnt and out- and low-and middle-income countries (LMICs) conduct- lines important features and challenges of engaging in ing projects that specifically focus on poverty reduction this process using the researchers’ perspectives. This and the protection of public goods in developing coun- paper contributes to the body of literature on research tries. Its specific objectives are to create and disseminate translation by highlighting concrete examples and suc- knowledge that supports policy-making in the area of cessful strategies for the uptake of research evidence in global development and foster research on global issues policy formulation. in the context of the 2030 Agenda for Sustainable Devel- opment [5, 6]. Methods While the linkage of research to policy is strongly Invitations were sent out to researchers working on pro- encouraged by research funding agencies, the uptake of jects within the r4d Programme to share their experi- research evidence by policy-makers to establish new laws ences with the project. Based on the interest shown by and regulations or to improve policies to solve a prob- researchers, five projects were selected by the authors lem or enhance implementation effectiveness, especially to demonstrate the different approaches and strategies in LMICs, remains weak [2, 7]. This is often referred to used in the r4d projects with the aim to influence policy. as the gap between research and policy [8]. One of the Researchers were asked to share descriptions of the dif- factors that was identified with the dearth of research ferent approaches used in seeking to influence the uptake uptake in previous studies is a lack of evidence that is of research results by policy-makers. Each project repre- context sensitive, timely and relevant for policy-mak- sents a case study with emphasis on the main features of ers; other factors include difficulties in accessing exist- their translational approaches and the challenges, ena- ing evidence, challenges with correctly interpreting and blers and successes encountered. using existing evidence [7, 9] and also a lack of interest The different research–policy engagement strategies from policy-makers in the use and uptake of evidence were identified through data analysis of the interviews [10]. Using the SNSF r4d funding scheme, our aim is to conducted within the framework of the five r4d case show how researchers have engaged with stakeholders, studies and were inspired by the work conducted by E rismann et al. Health Res Policy Sys (2021) 19:29 Page 3 of 13 Uzochukwu and colleagues in Nigeria [2], who described involved using the content summary analysis method, four detailed strategies to support evidence-informed which consists of reducing the textual content and pre- policy-making: (1) policy-makers and stakeholders seek- serving only the essential content in order to produce a ing evidence from researchers; (2) involving stakeholders short text [14]. As several co-authors were interviewed, in designing objectives of a research project and through- they validated that their perspective was not misinter- out the research period; (3) facilitating policy-maker– preted or misrepresented. researcher engagement in optimizing ways of using research findings to influence policy and practice; (4) Results active dissemination of own research findings to relevant Three key strategies were identified for research uptake stakeholders and policy-makers (see Table 1). into policy and practice throughout the data collection In using the term stakeholder, we apply the following of this synthesis initiative: (S1) stakeholders directly definition by Brinkerhoff and Crosby [11]: “A stakeholder engaged with and sought evidence from researchers; (S2) is an individual or group that makes a difference or that stakeholders were involved in the design and through- can affect or be affected by the achievement of the organ- out the implementation of the research project; and (S3) ization’s objectives”. Hence, individual stakeholders can stakeholders engaged in participatory and transdiscipli- include politicians (heads of state and legislators), gov- nary research approaches to co-produce knowledge and ernment bureaucrats and technocrats from various sec- inform policy. The first two strategies (S1, S2) are in line tors (e.g. health), but also representatives of civil society with Uzochukwu and colleagues’ work [2], and the third organizations and support groups [12]. strategy (S3) is an additional category based on the expe- riences of researchers in r4d projects [2]. Each r4d pro- Data collection ject is described in more detail as a case study in one of Eleven in-depth interviews with principal investigators these three strategies (Table 2). and their research partners from five r4d projects were conducted by the first author, using a semi-structured S1: stakeholders directly engaged with and sought interview guide. The interview guide covered the fol- evidence from researchers lowing themes: (1) How were stakeholders involved in In this strategy, international stakeholders requested evi- the research project? (2) Was there uptake of research dence from the research team. This is a unique (and rare) evidence in national/international policies? (3) How strategy, as stated by Uzochukwu et  al. [2], and often were research results disseminated? (4) What were the involves a policy window of opportunity in which stake- challenges or obstacles encountered in disseminating holders, including policy-makers, are looking to solve a and translating evidence from research to policy? The particular problem, which coincides with the publishing interview duration was between 30 and 45  min. Seven of a scientific report or paper and the interests of these interviews were conducted with researchers based in same groups [15, 16]. Switzerland and four with researchers in LMICs. At least two interviews were conducted for each r4d case study. Improving the HIV care cascade in Lesotho: towards 90‑90‑90—a research collaboration Data management and analysis with the Ministry of Health of Lesotho Of the 11 interviews, nine were audio recorded and In this r4d project, the research team was approached notes taken. Audio files were transcribed verbatim by the by the International Aids Society (IAS) and the World same researcher. Two interviews were not recorded, but Health Organization (WHO) in Geneva, based on the detailed notes were taken during the interview. publication of their study protocol [17], introducing their A qualitative content analysis method was used in order innovative research approach of same-day antiretroviral to organize and structure both the manifest and latent therapy (ART) initiation in rural communities in Lesotho: content [13]. Aligned to overall study questions, essential content was identified by the first author, which involved “They [international stakeholders] were all keen of a process of generating a provisional list of themes of getting the results out and requested evidence of the interest that were based on the study objectives, includ- randomized controlled trials. We shared the results ing stakeholder involvement in the generation of research confidentially with WHO as soon as we had the questions, research process, generation of results and data and thereafter published the results in a jour- dissemination of research findings, as well as challenges nal with a wide reach. WHO as well as other inter- to research dissemination and policy uptake. In a next national guidelines and policy committees took up step, the transcripts were sorted and grouped by the first the recommendation of same-day ART initiation author according to the coding scheme for analysis. This and informed global guidelines” (Researcher 1). Erismann et al. Health Res Policy Sys (2021) 19:29 Page 4 of 13 Table 1 Framework strategies by Uzochukwu et al. [2] and strategies identified in the synthesis work Framework provided by Uzochukwu et al. Description of the strategy by Uzochuwku Strategies identified in the r4d synthesis Differences encountered [2] et al. [2] work S1: Policy-makers and stakeholders seeking Stakeholders request evidence on implementa- S1: Stakeholders directly engaged with and In the research projects investigated, the funding evidence from researchers tion/scaling up. The research is either funded sought evidence from researchers scheme provided by the SNSF is common to all. by policy-makers and decision-makers or by Stakeholders, including policy-makers actively an external agency. Thus, the strategy is about sought evidence from researchers, but did not being responsive to opportunities created by initiate empirical research studies as suggested policy-makers calling for evidence in the framework provided by Uzochuwku et al. [2] S2: Involving stakeholders in designing objec- Stakeholders were involved in the designing S2: Stakeholders were involved in the design According to S2 as described by Uzochukwu et al. tives of a research project and throughout the of the research and throughout the project and throughout the implementation of the [2], policy-makers initiated empirical research research period period. The research questions and objectives research project studies. Similarly, we found stakeholders arose from these experiences of the MoH and involved in the design and implementation of involved stakeholders, such as the NHIS r4d research projects from early on, but it was not the policy-makers themselves initiating the research studies S3: Facilitating policy-maker–researcher This strategy focused on developing policy- – Among the participating r4d projects, we did not engagement in optimizing ways of using maker capacity to use research evidence for directly encounter this strategy of enhanc- research findings to influence policy and policy-making by, for example, enhancing ing policy-makers’ capacity to use research practice institutional capacity among senior and mid- evidence. However, in all the five r4d case dle level health managers within the MoH to studies studied, and hence as part of the three use research evidence to influence policy- identified strategies, initiatives for strengthen- making ing research capacity were undertaken to train national researchers and strengthen the asso- ciation with intstitutions directly involved S4: Active dissemination of own research They key concepts of knowledge transfer were S3: Stakeholders engaged in participatory and According to S4 by Uzochukwu et al. [2], findings to relevant stakeholders and policy- employed including research reports, peer transdisciplinary research approaches to co- researchers in researcher-initiated empirical makers reviewed papers, conference presentations produce knowledge and inform policy research studies actively disseminate their own and policy briefs findings We did not encounter this strategy as such among the r4d case studies, as all of the partici- pating resarchers were active in disseminating their research findings. Instead, our results showed that co-creation and transdisciplinary research approaches came close to this active knowledge transfer and even wents beyond dissemination to knowledge co-production by a range of stakeholders, which is why we have further elaborated this strategy MoH Ministry of Health, NHIS National Health Insurance Scheme, SNSF Swiss National Science Foundation E rismann et al. Health Res Policy Sys (2021) 19:29 Page 5 of 13 Table 2 R4d Programme case studies and strategies identified in the synthesis work Project name Geographic location Strategies identified in the synthesis Type of r4d projects’ policy Website work engagement according to the strategies identified Improving the HIV care cascade in Lesotho S1: stakeholders directly engaged with International stakeholders contacted the http://www.r4d.ch/modul es/thema tical Lesotho: towards 90-90-90—a research and sought evidence from researchers r4d research team based on the pub- ly-open-resear ch/hiv-care-casca de collaboration with the MoH lication of the research protocol and directly took up published research findings. As a result, same-day ART initiation was newly included in WHO guidelines. National stakeholders were also involved from the very beginning in the project design Health systems governance for an Ghana, Tanzania S2: stakeholders were involved in the National stakeholders involved since http://www.r4d.ch/modul es/publi c-healt inclusive and sustainable social health design and throughout the implemen- the beginning through an advisory h/healt h-syste ms-gover nance protection in Ghana and Tanzania tation of the research project function in country advisory boards. Participation in national workshops to identify research objectives and design the research project As a result of the evidence produced, policy documents were up-dated to improve identification of the poor to increase their enrollment, and tariffs were adjusted to reduce optional pay- ment plan by clients Health impact assessment for engaging Burkina Faso, Ghana, National stakeholders involved since the http://www.r4d.ch/modul es/publi c-healt natural resource extraction projects in Mozambique, Tanzania beginning through kick-off meet- h/health -impac t-assess ment sustainable development in producer ings—mining is a highly politicized regions (HIA4SD) environment in most countries). Evidence is still being produced and dissemination is part of second phase (starting in 2021) Intercultural transdisciplinary in Guate- Guatemala S3: stakeholders engaged in participa- Co-creative, participatory research http://www.r4d.ch/modul es/thema ticall y- mala and Peru: a North-South–South tory and transdisciplinary research approaches with involvement of open-resea rch/cultur ally -pertin ent-healt learning platform for culturally perti- approaches to co-produce knowledge stakeholders in designing objectives of h-provis ion nent public health provision systems and inform policy the research and throughout project for indigenous populations implementation Addressing the double burden of Nepal, Mozambique, Peru Each country had also a local advisory http://www.r4d.ch/modul es/publi c-healt disease: Improving health systems for board made up with people in deci- h/addres sing -doubl e-burde n-disea se non-communicable and neglected sion-making positions to plan research tropical diseases activities before project onset and to discuss ongoing research activities ART Antiretroviral therapy, HIA4SD health impact assessment for engaging natural resource extraction projects in sustainable development in producer regions Erismann et al. Health Res Policy Sys (2021) 19:29 Page 6 of 13 As a result, many HIV programmes in sub-Saharan Agency for Development and Cooperation) Health Pro- Africa as well as in the global north have adopted the motion and System Strengthening project and by the practice of offering rapid-start ART to persons who test SDC-supported development programme. HIV positive even outside a health facility. In this exam- These stakeholders were subsequently involved in ple, the policy window and direct stakeholder engage- steering the research, as captured by a researcher: ment was crucial for the effective translation and uptake of research evidence. “In Ghana, it was a balanced relationship. They Furthermore, by closely collaborating with national were involved since the very beginning of the pro- policy-makers, the research team advocated for the set- ject in articulating what the information gap at ting up of a research database and of knowledge man- policy level is, formulating the research questions agement units within the Ministry of Health (MoH) of and understanding the methods/what is feasible. In Lesotho, which have been successfully established. The Tanzania, where the policy landscape is more frag- members of the research project consortia have also initi- mented, it was very important to listen to the voices ated a national research symposium on a bi-annual basis, of several different stakeholders” (Researcher 2). which is chaired by the MoH with the aim of facilitating The stakeholder consultations in Ghana and Tanza- the dissemination and uptake of research findings. nia initially involved discussions on the relevance of the research plans to address the existing gaps in strength- S2: Stakeholders were involved in the design ening the social health protection scheme, the syner- and throughout the implementation of the research gies with other research initiatives and the feasibility of project implementing the proposed research. Later on in the In this strategy, policy uptake is facilitated through stake- project, the consultation process involved reviewing holder engagement from the beginning as well as during and discussing the focus of the research and the appro- the conduct of research activities, through participating priateness of the research aims in light of decisions and at workshops or functioning in the governance of the reforms that were under discussion by the government projects. Two r4d projects illustrate this strategy. but not in the public domain. This led to revision of the research questions as they would have become redun- Health system governance for an inclusive and sustainable dant when such reforms were made public, especially social health protection in Ghana and Tanzania in Ghana. These consultation processes were more for- This project established a Country Advisory Group mal in Ghana and more informal in Tanzania, but they (CAG) at the start that included representatives of the were very informative and had a tangible impact on the main stakeholders of the social health protection systems. research plans, which were revised according to the feed- The CAGs were involved in all phases of the project, from back received. However, the research teams were always the definition of the research plans to the dissemination independent in deciding on the research methodology of the results. The specific research questions addressed and in interpreting the results. The in-country dissemina- by the project emerged from the interactions with these tion of the results at the end of the first phase of the pro- main stakeholders, i.e. national policy-makers, healthcare ject informed the decisions to be made on the research providers and members of the social health protection plan for the second phase and provided the opportunity schemes (the NHIS and the Livelihood Empowerment to discuss policy implications based on the results of Against Poverty schemes in Ghana; and the National the first phase. Because of this close collaboration and Health Insurance Fund, the Community Health Funds engagement with stakeholders, the results of the stud- and the Tanzania Social Action Fund in Tanzania). Spe- ies were widely disseminated in Ghana. Two of the main cifically in Ghana, the following stakeholders played a findings of the project were particularly considered by major role in shaping the research plan: the Ministry of these stakeholders. According to the researcher: Gender Children and Social Protection (MGCSP), the “First, the study results showed that even though Ghana Health Service (Policy Planning and Monitor- people registered with the NHIS they continued to ing and Evaluation Division; Research and Develop- pay out of pocket for health services. The reasons for ment Division), the National Health Insurance Authority this were delays in reimbursement by NHIS, escalat- (NHIA) and the Associations of Private Health Care Pro- ing prices of drugs and medical products, low tar- viders. In Tanzania, a major role was played by the Minis- iffs, lack of trust between providers and NHIA and try of Health, Community, Development, Gender, Elderly inefficiencies. Secondly, the results showed that the and Children, the President’s Office—Regional Adminis- current system of targeting the poor is not working tration and Local Government, by representatives of civil properly, with more than half of people registered society organizations, such as Sikika, by the SDC (Swiss E rismann et al. Health Res Policy Sys (2021) 19:29 Page 7 of 13 in the NHIS as indigents being in the non-poor central importance in this project, as in most cases min- socio-economic groups. These results contributed to ing is a highly politicized topic. To promote the imme- inform decisions regarding the revision of the NHIA diate integration of research findings into policy, the reimbursement tariffs, and to improve the identifi- project is organized into two streams, namely an “impact cation of the poor to be exempted from paying the research stream” and a “governance stream”, that work NHIS premium, in collaboration with the MGCSP” in parallel. While the impact research stream is focused (Researcher 3). on evidence generation to support the uptake of health In Tanzania, research was conducted to assess the impact assessment (HIA) in Africa, the governance effects of the public private partnership, referred as the stream is focused on understanding the policy terrain Jazia Prime Vendor System (Jazia PVS), on improv- and consequently the pathways that need to be utilized to ing access to medicines in the Dodoma and Morogoro support translation of the evidence into policy and prac- regions in Tanzania. This is one of the reforms in the area tice. The second phase of the study is devoted to the dis- of supply chain management taking place in the country. semination of research findings into policy at the national Results showed that a number of accountability mecha- and local levels, including capacity-building activities for nisms (inventory and financial auditing, close monitoring national stakeholders. As the HIA4SD project examines of standard operating procedures) implemented in con- operational questions of relevance for guiding both pol- junction with Jazia PVS contributed positively to the per- icy-making and decision-making, team members sought formance of Jazia PVS. Participants’ acceptability of Jazia to regularly engage with and inform the national stake- PVS was influenced by the increased availability of essen- holders. According to the researcher: tial medicines at the facilities, higher-order fulfilment “Strategies employed to influence policy vary accord- rates and timely delivery of the consignment [18–20]. ing to the country, but included regular stakeholder The findings from this study were disseminated dur- workshops, participation in a new national plat- ing the national meeting attended by various stakehold- form launched to discuss issues around mining in ers, including CAG members, government officials and Mozambique, development of policy briefs, strength- policy-makers. In addition, the findings were used to ened collaborations with national ministries of inform the national scale-up of the Jazia PVS interven- health, discussion of results and advocacy with pol- tion as the government of Tanzania decided to scale up icy makers, and conference presentation of findings” the Jazia PVS to all the 23 regions in 2018. Moreover, (Researcher 4). the results/manuscripts were published or submitted to peer-reviewed journals [18–20], enabling other countries In these two case examples, continuous stakeholder intending to adopt such innovate public–private partner- engagement was considered essential to translate and ships for improvement of the in-country pharmaceutical disseminate research evidence. Thus, beyond the stage supply chain to learn from Jazia PVS in Tanzania. of setting the objectives, contact with stakeholders was active and maintained on a regular basis through regu- lar exchanges with stakeholder groups during workshops Health impact assessment for engaging natural resource or meetings, which facilitated the dissemination and extraction projects in sustainable development in producer uptake of the research results. While the time and level regions (HIA4SD) of meaningful interaction varied across the countries and In this r4d project, stakeholders were involved from the workshops, all meetings were well attended by partici- outset through their participation in the project launch pants from varied levels of government, MoHs, nongov- meeting and in regular consortium meetings. The pro- ernmental organizations and private industry, prompting ject is a collaboration between the Swiss Tropical and spirited discussion and insight from these groups. All Public Health Institute (Swiss TPH), the Center for stakeholders were willing to attend these workshops as Development and Cooperation (NADEL) at the Swiss part of the scope of their professional duties. Federal Institute of Technology in Zurich/Switzerland and national research institutes, namely the Institut de S3: stakeholders engaged in participatory Recherches en Sciences de la Santé in Burkina Faso, the and transdisciplinary research approaches to co‑produce University of Health and Allied Sciences in Ghana, the knowledge and inform policy Centro de Investigação em Saúde de Manhiça in Mozam- In the two examples presented in this section, the bique and the Ifakara Health Institute in Tanzania [21]. research questions and approaches arose through com- The involvement of key stakeholders from the govern- munity and stakeholder participation in the research ment, civil society, private sector and research commu- and intervention design itself. The methodology adopted nity in an engaged dialogue from the beginning iss of allowed them to engage, design research, act, share and Erismann et al. Health Res Policy Sys (2021) 19:29 Page 8 of 13 sustain partnerships between the communities, the the study results and hence its dissemination, captured involved stakeholders and researchers [22]. These par- by the researchers as follows: ticipatory research approaches facilitated grassroot-level policy and practice changes which were not researcher “The main result was that they allowed a frank nor policy maker led, and that show promising discussion between Maya medical exponents in approaches for developing culturally aligned solutions human–animal health and Western medicine, [23]. Policy makers at both the regional and national lev- which allowed the patients and the animal hold- els were invited to be part of the participatory research ers to avoid the cognitive dissonance and so that approach: they were interviewed during the initial stage, the patients or the animal holders can choose freely then the research results were presented and discussed what they want. Cognitive dissonance exists if one with them; thereafter, we had several meetings to co- system dominates the other—or refutes the other” create potential interventions to address the identified (Researcher 7). problems, with the aim to directly engage in the research and intervention design itself in partnerships with the “After all stakeholders discussed the research evi- community stakeholders, including local leaders, and the dence produced jointly, an unprecedented process researchers. of collaboration between Government authorities and communities followed to develop three joint responses: a) education campaigns led by local Surveillance and response to zoonotic diseases in Maya teachers in tandem with the Ministry of Educa- communities of Guatemala: a case for OneHealth tion, b) communication strategies at regional levels The research was embedded in a collaboration between led by the Human and Animal Health authorities the Universidad del Valle in Guatemala, the MoH, the along with traditional Maya Ajilonel (medicine spe- Ministry of Animal Production and Health, the Maya cialists), and c) a policy framework for producing a Qéqchi’ Council of Elders, TIGO Telecommunications OneHealth approach led by Central Government Foundation and the community development councils. authorities” (Researcher 8). The objective of this r4d programme was to set up inte- The process of mutual learning throughout the project grated animal–human disease surveillance (OneHealth) produced a new level of awareness, facilitating cultur- in Maya communities in Guatemala. The research ally pertinent and socially robust responses that over- approach arose from a context of medical pluralism, came a historical tendency of unilateral policy making where communities have access to and use two different based solely on Western values and preferences. As the medical systems: (1) the modern Western medical system project implemented a new approach to monitoring ani- and (2) traditional Maya medicine [24]. mal and human populations, the involvement of regional Researchers and community members collaborated teams from the different ministries (Health, Livestock at all stages of the research process, including the plan- and Agriculture) throughout all the phases of methodo- ning stage. Even before the grant proposal was finalized, logical design, data collection, posterior data analysis and researchers met with the communities that, should the design of specific interventions for the local population funding come through, would be invited to participate in (transformation of scientific results into actions for pub- the research. According to the researchers: lic health improvement) was essential to ensuring that “The project was set up through a transdisciplinary the approach used secured the regional authorities’ com- process, with academic and non-academic actors— mitment to defining new policies for immediate applica- including national, local and traditional authori- tion in their territory. Accordingly, this also contributed ties—involved in the problem through a collabora- towards the development of a OneHealth national strat- tive design, analysis, dissemination and research egy for Guatemala in which ministries start to cooperate translation. It was a co-producing transformative to take up priority issues. process—transferring knowledge between academic and non-academic stakeholders in plenary sessions Addressing the double burden of disease: improving health and through group work. These meetings were held systems for non‑communicable and neglected tropical every year to continuously follow up the progress of diseases (Community Health System Innovation [COHESION]) the process” (Researcher 7). Together with three Swiss academic partners, this r4d The active engagement and collaboration by the com- project examined the challenges of a double burden of munity and stakeholders facilitated the acceptability of non-communicable and neglected tropical diseases at the primary healthcare level in vulnerable populations in Mozambique, Nepal and Peru. Community participation E rismann et al. Health Res Policy Sys (2021) 19:29 Page 9 of 13 and co-creation were key elements of the project’s These challenges are summarized and highlighted in approach. The work conducted in Peru illustrates this Table 3. approach: “At the beginning, the people who were involved Discussion were respondents, but then they became active par- Three key strategies identified for research uptake in ticipants. So it was this active engagement and the policy and practice are described in this paper, namely: changing of roles, giving feedback not just from the (S1) stakeholders directly engaged with and sought evi- research responses but also from being involved dence from researchers; (S2) stakeholders were involved in the process, which helped to design and cre- in the design and throughout the implementation of the ate interventions together with the research team” research project; and (S3) stakeholders engaged in partic- (Researcher 5). ipatory and transdisciplinary research approaches to co-produce knowledge and inform policy. These strategies This participatory approach to co-creation actively are in line with the overall objectives of the r4d projects, sought a diverse range of stakeholders, including com- which are to generate scientific knowledge and research- munity members, primary healthcare workers, and based solutions to reduce poverty and global risks in regional and national health authorities. The co-creation LMICs, and also to offer national and international stake- approach to participatory research enables context-spe- holders integrated approaches to solving problems [5]. In cific variation in methodological design, a critical ele- the course of our synthesis work, we found that several ment when studying three very different countries and lessons could be learned from the three strategies identi- health systems. Central to all aspects was a feedback loop fied for research uptake in policy and practice. whereby early findings were shared with research partici- pants for further elaboration and iteration. S1: raising awareness of planned research to attract As active co-creators of the research process, local stakeholder involvement communities developed high levels of trust in the The actual uptake of research findings in policy was most methodology and data, with the result that research- direct in the case of the first strategy (S1), in which IAS ers achieved deeper “buy-in” which in turn is known to and WHO stakeholders were wanting new knowledge enhance the uptake of findings by decision-makers [25] on HIV and same-day ART initiation, and were actively as communities in which research is being undertaken seeking new evidence on these specific topics. The find- play a central role in the decision-making process [26]. ings published in peer-reviewed journals were then taken up by these stakeholders to update international policies Challenges to research uptake in health policy identified and guidelines on rapid ART initiation [27]. This was also by r4d researchers found in other studies, highlighting the importance of the During the interviews, r4d researchers identified several timeliness and relevance of findings and the production challenges to research utilization and uptake into policy. of credible and trustworthy reports, among others, as Table 3 Challenges to research uptake in health policy identified by r4d researchers Challenge Relevant quote 1. Time investment, translation of research “Is it the role and responsibility of researchers? Do they have the skills and time to do it? It takes a long findings and the role of researchers time to synthesize multiple papers in one page” (Researcher 5) “It is difficult as it takes longer to do this translation. It is positive to engage with policy makers in a research project, but it takes much more work than what you would think in the beginning. Some- times it is challenging to engage with policy makers—research outputs take a long time; plus you may not have as many research results as you would like to” (Researcher 2) 2. Problem of scale and objectivity “You have to be very cautious in presenting findings to policy or decision-makers when they intend to use them. Findings in one small study do not necessarily make for generalities. One has to be very careful in translating findings to policy without first systematically reviewing a whole body of evidence. (Researcher 6) “What appears to be relevant in Peru might be very different to what is relevant in Nepal. It would be unethical to try to draw some similarities between them, or suggest policy changes on the basis of findings at these scales” (Researcher 6) 3. Frequent staff change at governmental level “There has been a lot of change in the team of the national health insurance authority; this makes it difficult to see how they are using the information” (Researcher 3) 4. Diverging interests and timelines “There is often a disconnect between data/science, research funders and policy makers interest” (Researcher 2) Erismann et al. Health Res Policy Sys (2021) 19:29 Page 10 of 13 key factors in promoting the use of research evidence in S3: co‑creation and equal partnerships policy [2, 28]. The third strategy with a strong participatory approach, such as that adopted by two r4d projects, OneHealth in S2: sustainable collaborations in a supportive policy Guatemala and COHESION, demonstrates benefits to environment with stakeholder engagement from early promoting co-learning as a way to minimize the impact on and throughout the research process of unequal power dynamics and to work effectively across With regards to the second strategy (S2), we found that the local policy landscape through equal partnerships. It constant collaboration with an advisory and steering also facilitates identifying solutions that are culturally group composed of diverse stakeholders, including pol- pertinent, socially more robust and implementable. icy-makers, from early on promotes the uptake and use The approaches of co-creation, equal participation of research evidence. In line with findings from other and stakeholder involvement used in the research pro- studies [2], the experiences encountered in the r4d pub- jects raise questions of ‘governance’, that is the way rules, lic health projects show that early involvement of stake- norms and actions are structured, sustained and regu- holders in the processes to identify the research problem lated by public and para-public actors to condition the and set the priorities facilitated the continuous exchange engagement and impact of public involvement activities of information that might ultimately influence policy. [32, 33]. Through stakeholder involvement in setting the The r4d project on social governance mechanisms in agenda and designing the research projects, as shown in Ghana highlight that the evidence produced influenced the case studies on social protection in Ghana and Tan- policy documents (identification of the poor and tar- zania and the HI4SD project, but particularly in the two iff adjustments), but that frequent changes government projects using a co-creation approach, the engagement of officials made it difficult to maintain a close relationship a range of stakeholders serves to make the health research between the researchers and the governmental agencies/ systems a participaant in the endeavor that then has the policy stakeholders. From this, we draw the conclusion capacity to promote changes in the healthcare system it that research approaches need to be more adaptive and aims to serve. By establishing a shared vision with a pub- flexible to be successful in an unsupportive or unstable lic involvement agenda and through the collaborative policy environment to ensure continuity in promoting efforts of various stakeholders, as we found particularly the dissemination and uptake of research evidence in in the co-creation approach, supportive health research policy-making. One possible manner to secure this trans- systems are established. This leads to greater public formation is for researchers to apply for additional fund- advancement through collaborative actions, thereby ing after the grant is finished. Other studies have also tackling the stated problems of the health systems [34]. come to this conclusion, thereby demonstrating the key role of a supportive and effective policy environment that Challenges includes some degree of independence in governance There were four key challenges mentioned by the and financing, strong links to stakeholders that facilitate respondents during the interviews to research uptake in trust and influence and also the capacity within the gov- policy making. The first was the necessary time invest- ernment workforce to process and apply policy advice ment by researchers to translate the result and develop developed by the research findings [29]. By involving policy advocacy products for the different audiences. stakeholders in the process of identifying research objec- This challenge is all the more difficult because research tives and designing the project, as seen particularly in the evidence and tangible products only become available r4d case studies on social health protection in Ghana and towards the end of a research project, leaving only a short Tanzania and the HI4SD, but also in the HIV care cascade window of opportunity for exchange and engagement. in Lesotho, the research approach responded to the need There seems to be a need for wider discussion on the role of locally led and demand-driven research in these coun- of researchers in influencing policy. The concerns raised tries, strengthening local research capacities and institu- included whether influencing policy is actually a role tions, but also investing in research that is aligned with for researchers and whether researchers have the right the national research priorities. As highlighted by other skills to be effective in persuasion or network formation authors, advantages of this “demand-driven” approach is [35]. Conversely, researchers may be in a good position that it tailors research questions to local needs, helps to to engage in the policy process if they enjoy finding solu- strengthen local individual and organizational capacities tions to complex problems while working with diverse and provides a realized stringent framework on which a and collaborative groups in partnerships [36, 37]. The research project should deliver outcomes [30, 31]. rationale for engaging in such a process needs to be clari- fied in advance: is the aim to frame an existing problem, or is it to simply measure the issues at stake and provide E rismann et al. Health Res Policy Sys (2021) 19:29 Page 11 of 13 sound evidence according to an existing frame? Regard- involved stakeholders better and improve their under- ing the the former, how far should researchers go to be standing of the policy world in practice, but also to build useful and influential in the policy process or to pre- diverse and longer-term networks [37, 44] and to iden- sent challenges faced by vulnerable populations [37]? tify policy problems and the appropriate stakeholders to While fully engaging in the policy process may be the work with [45, 46]. Engaging a diverse range of stakehold- best approach for researchers to achieve credibility and ers through co-designing the research is widely held to be impact, there may also be significant consequences, such practically the best way to guarantee the uptake and use as the risk of political interests undermining the method- of evidence in policy through a more dynamic research ological rigour of academic research (being considered as approach [47]. However, the development of networks academic ‘lightweight’ among one’s peer group) [38–41]. and contacts for collaboration, as well as the skills to do For researchers there is also considerable opportunity so, takes time and effort and is an ongoing process [48], costs because engaging in the policy-influencing process factors which need to be acknowledged more widely. is a time-consuming activity [35], with no clear guaran- Lastly, the fourth challenge related to research uptake tee of the impact of success [37]. It is therefore crucial was the diverging interests between researchers, research to consider the investment and overall time researchers funding bodies and stakeholders. Time was identified as may have to spend to engage [35], and how this time and a limiting factor from the perspective of the design of investment can be distributed between actual research the research project. Most research projects, including and the production of outreach products, such as policy the r4d projects, are funded for 3–4 years [5]. It takes a briefs, presentation of research findings as policy narra- considerable amount of time to generate new research tives [35] and the setting-up of alliances, building of net- results, and often these are more likely to be produced for works and exploitation of windows of opportunity for further use at the end of a project. If researchers should policy change [37]. engage more fully in the policy process to secure mean- The second challenge included the issue of scale and ingful impact, it is critical to discuss the extent to which objectivity, as most of the projects are not scaled or they have the skills, resources and institutional support national-level studies and thus are highly context spe- to do so [37], as well as how projects could be set up dif- cific. The difficulty to measure the contributions of a sin- ferently. This could be done either by the funders in pro- gle research project or study in terms of policy outcomes viding the necessary support that allows researchers to was also highlighted, particularly in view of the different have the means to impact policy, or by the researchers understandings among researchers and funders on the in the design of their project to take on board the dif- possible policy impacts of the research, which can range ferent strategies to influence evidence use and uptake. from guiding policy-makers to understand a situation or In moving forward, defining shared goals from the out- problem (awareness raising) to influencing a particular set between funders and the researchers might translate course of action by establishing new or revising existing to more achievable milestones in terms of which policy policies. This has also been emphasized in the Evidence issue, theme or process a research project aims to change Peter Principle [42], showing that single studies are often in order to effectively influence policy [49]. This would inappropriately used to make global policy statements for help to identify the resources and budget needed by the which they are not suitable. To make global policy state- funders in order for the researchers to engage with more ments, an assessment of the global evidence in systematic resources over a longer time span in this process. reviews is needed [42, 43]. The third challenge mentioned was the frequent Limitations changes in staff at the governmental level, which Interviews were limited to researchers of the r4d projects demanded continuous interactions between r4d and did not include local stakeholders. Therefore, the researchers and stakeholders, highlighting the need for synthesis work, including the analysis and results, reflects more adaptive and flexible research approaches. These solely the perspective of researchers. We are aware that should include a thorough analytical process prior to had we included a range of stakeholders, including pol- implementation in historical, sociopolitical and eco- icy-makers, in the sample, we would have potentially nomic aspects, power differentials and context; backward been able to identify additional factors relating to social, planning exercises to check assumptions; and conflict cultural and political barriers to the use and uptake of transformation and negotiation skills in order to be able research findings in politics and practice. However, con- to constantly adapt to changing contexts. In line with straints such as access to local stakeholders, language our research findings, when researchers make the time barriers and time zones drove our decision to focus on investment needed to engage in the policy-influencing researchers. A future synthesis effort would need to process, an opportunity is provided to getting know the include the other voices. Erismann et al. Health Res Policy Sys (2021) 19:29 Page 12 of 13 Conclusions Funding There is ever growing awareness of how critical it is The r4d synthesis initiative is implemented by the Swiss Tropical and Public Health Institute, which funded the costs of publishing this paper. to close the gap between policy-makers, practitioners and researchers. Using the researchers’ perspectives, Availability of data and materials in this article we give insight into three different strate- The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. gies that can facilitate this process, with the first strat- egy requiring proactive searching for the latest findings Ethics approval and consent to participate on the part of well-informed policy-makers, the second Not applicable. requiring researchers to take steps to ensure an active Consent for publication exchange of ideas and information with diverse stake- Not applicable. holders when designing the research project and ensur- Competing interests ing the latter’s involvement throughout; and the third The authors declare that they have no competing interests. using a transdisciplinary and/or co-creation approach to establish equal partnerships and trust among all Author details1 Swiss Tropical and Public Health Institute, Basel, Switzerland. 2 University involved stakeholders. of Basel, Basel, Switzerland. 3 CRONICAS Centre of Excellence in Chronic Dis- The five case studies reported here also show some of eases, Universidad Peruana Cayetano Heredia, Lima, Peru. 4 Division of Tropical the difficulties that prevail for research to be taken up and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland. 5 Centro de Estudios en Salud, Universidad del into policy and practice, despite everyone’s best inten- Valle de Guatemala, Guatemala, Guatemala. 6 Department of Infectious Dis- tions and efforts. Researchers may not always be best eases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland. 7 placed for communication, dissemination and advo- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana. 8 Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, Dar cacy work, all activities which are very time intensive or es Salaam, Tanzania. 9 Swiss Federal Institute of Technology Zurich, Zurich, become important only towards the end of a research Switzerland. 10 Gender Centre, Graduate Institute of International and Devel- project when clear and high-quality evidence is pro- opment Studies, Geneva, Switzerland. duced. Moreover, it takes a strong body of evidence, Received: 15 July 2020 Accepted: 15 October 2020 advocacy and coalition building with appropriate stake- holders to influence policy, and then a further major effort of resources to see policy followed through into practice. 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