National Policy Development for Cotrimoxazole Prophylaxis in Malawi, Uganda and Zambia: The Relationship between Context, Evidence and Links

"Several frameworks have been constructed to analyse the factors which influence and shape the uptake of evidence into policy processes in resource poor settings, yet empirical analyses of health policy making in these settings are relatively rare."

This paper explores national policymaking around cotrimoxazole (trimethoprim-sulfamethoxazole) preventive therapy (CPT) in developing countries as a case study for the application of a policy analysis lens to issues in health policy development on the national level. It is based on the contention that provision of cotrimoxazole as a prophylaxis is an inexpensive and highly efficacious preventative intervention in HIV-infected individuals, reducing both morbidity and mortality among adults and children with HIV/AIDS. However, according to the authors, evidence suggests that it has not been quickly or evenly scaled up in resource-poor settings.

Comparative analysis was conducted in Malawi, Uganda, and Zambia, using a case study approach. The authors applied the Research and Policy in Development (RAPID) framework developed by the Overseas Development Institute (ODI) and conducted a total of 47 in-depth interviews across the 3 countries to examine the influence of context (including the influence of donor agencies), evidence (both local and international), and the links between researchers, policymakers, and those seeking to influence the policy process.

Each area of analysis was found to have an influence on the creation of national policy on CPT in all 3 countries. In relation to context, the following were found to be influential: government structures and their focus, donor interest and involvement, healthcare infrastructure, and other uses of cotrimoxazole and related drugs in the country. In terms of the nature of the evidence, the authors found that how policymakers perceived the strength of evidence behind international recommendations was crucial (if evidence was considered weak, then the recommendations were rejected). Further, local operational research results seem to have been taken up more quickly, while randomised controlled trials were not necessarily translated into policy so swiftly. Finally, the links between different research and policy actors were of critical importance, with overlaps between researcher and policymaker networks crucial to facilitate knowledge transfer. Within these networks, in each country, the policy development process relied on a powerful policy entrepreneur who helped get CPT onto the policy agenda.

According to this article, the analysis underscores the importance of considering national-level variables in the explanation of the uptake of evidence into national policy settings and recognising how local policymakers interpret international evidence. Local priorities, the ways in which evidence were interpreted, and the nature of the links between policymakers and researchers could either drive or stall the policy process. Developing the understanding of these processes enables the explanation of the use (or non-use) of evidence in policymaking and potentially may help to shape future strategies to bridge the research-policy gaps and ultimately improve the uptake of evidence in decision making.

An excerpt from the report follows:

"The comparison of the country studies demonstrates how central a favourable healthcare context is to the adoption of research into policy. This is most visible in the case of the Malawi HIV Programme in 2002 and the Zambia HIV Programme in 2004/2005. In the former, the heavy emphasis on disease prevention through behaviour change, education and safe blood supplies left almost no room for a bio-medical approach, and a lack of interest in CPT (in contrast to the Malawi TB Programme which was searching for biomedical interventions). In Zambia (two years later), almost the reverse issue appeared, with a highly politicised bio-medical approach to HIV being dominated by a campaign to scale up ARVs [antiretrovirals], and the striking results of the research into CPT for HIV infected children were eclipsed. These policy processes show how an unfavourable policy context may make it difficult for policy development even when a sound evidence base upon which policy can be constructed exists.

...In all cases, the policy development process for CPT began either with attempts to collect national data (Malawi) or with the publication of the trials in Cote d'Ivoire and the subsequent WHO/UNAIDS [World Health Organization/Joint United Nations Programme on HIV/AIDS] provisional recommendations for Africa (Uganda and Zambia). The strength of evidence was crucial....Yet, this research also demonstrates clearly that while poor evidence may stall a policy process, even when powerful research evidence is available to policy makers, it does not necessarily get translated into policy: in our three countries, the only country to conduct randomized clinical trials took the longest amount of time to create national policy on CPT.

Finally, there appears to be a critical point when the policy implications of a piece of research evidence is contested (as was the case during the Malawian 2002 policy process), when a powerful policy entrepreneur, supported by policy champions can play a particularly important role in driving policy forward....Overall, the role of a policy entrepreneur was crucial in all cases, and, as an active agent, able to respond to and address barriers to policy development; providing additional evidence when questions were raised about the evidence base (particularly in Uganda and Malawi), making links between researcher and policy maker networks (most effectively in Malawi but also in Uganda and Zambia), and linking supportive policy champions with the evidence needed and the correct policy audience (in all three countries)."

This document is an output from a project funded by the Department for International Development (DFID) for the benefit of developing countries. The research was undertaken as part of Evidence for Action, an international research programme on HIV treatment and care systems.