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Challenges in linking health research to policy   multi stakeholder response to ovc in ghana
 

Challenges in linking health research to policy multi stakeholder response to ovc in ghana

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    Challenges in linking health research to policy   multi stakeholder response to ovc in ghana Challenges in linking health research to policy multi stakeholder response to ovc in ghana Document Transcript

    • Gyapong et al. Health Research Policy and Systems 2011, 9(Suppl 1):S14http://www.biomedcentral.com/1478-4505/9/S1/S14 COMMENTARY Open AccessChallenges in linking health research to policy:a commentary on developing a multi-stakeholderresponse to orphans and vulnerable children inGhanaJohn Owusu Gyapong*, Richmond Ato Selby, Kwadwo Antwi AnakwahFrom Strengthening the research to policy and practice interface: Exploring strategies used by researchorganisations working on Sexual and Reproductive Health and HIV and AIDSLiverpool, UK. 18-19 May, 2009 Abstract The Research and Development Division (RDD) of the Ghana Health Service (GHS) has a remit to build research capacity and conduct policy relevant research. By being situated within the GHS, RDD has good access to directors and programme managers, within and beyond the Ministry of Health. This structure has been facilitating collaboration through research cycles for 20 years, from agenda setting to discussions on policy relevance. This approach has been applied to research activities within the Addressing the Balance of Burden in AIDS (ABBA) Research Programme Consortium to tackle the challenges facing HIV affected orphans and vulnerable children (OVCs). The government strategy on OVCs recommends they should be encouraged to live in their home communities rather than in institutions. We present lessons here on efforts to use research to build a response across different agencies to address the problems that communities and families face in caring for these children in their communities. This approach to building consensus on research priorities points to the value of collaboration and dialogue with multiple stakeholders as a means of fostering ownership of a research process and supporting the relevance of research to different groups. Our experience has shown that if the context within which researchers, policy makers and stakeholders work were better understood, the links between them were improved and research were communicated more effectively, then better policy making which links across different sectors may follow. At the same time, collaboration among these different stakeholders to ensure that research meets social needs, must also satisfy the requirements of scientific rigour.Introduction Ministry of Health; it was set up in 1990 to provide evi-In this paper we share our experience of researching dence for policy formulation and support for programmeorphans and vulnerable children (OVC) to illustrate how implementation because at that time academic researchthe Research and Development Division (RDD) in Ghana in Ghana was not perceived to be meeting the needs ofhas used an intersectoral approach to engagement with the health care delivery system. Since inception of theHIV policy actors. The Research and Development Divi- RDD the close involvement of policy makers and pro-sion has a unique position as a research agency being gramme persons in research has become more promi-located within the Ghana Health Service of the Ghana nent. The RDD has the following functions: • Undertaking research in support of programme* Correspondence: gyapong@4u.com.gh delivery and policy development and the commissioningResearch and Development Division, Ghana Health Service, P O Box MB-190,Accra, Ghana of research to appropriate institutions; © 2011 Gyapong et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
    • Gyapong et al. Health Research Policy and Systems 2011, 9(Suppl 1):S14 Page 2 of 5http://www.biomedcentral.com/1478-4505/9/S1/S14 • Assisting the Ghana Health Service in setting health support has therefore necessitated a collaborativepriorities through generation of new knowledge and sys- approach. The relevant agencies working with OVC aretematic review of existing information; the Department of Social Welfare, the Ministry for • Assisting the health sector in developing research Women and Children’s Affairs, and the Ministry of Man-proposals and conducting training in health systems power Youth and Employment. Evidence from Ghana hasresearch; suggested that OVC are best supported and cared for • Serving as a documentation centre for Health within their extended families, rather than institutions,Research; and this policy approach is therefore promoted (4). Addi- • Facilitating technical and ethical review of research tionally such an approach is generally more culturally The principles guiding the operations of the RDD- acceptable within the Ghanaian value system than institu-GHS are that the research agenda should be set through tional care for OVC. These departments encourage child-a consultative process; it should answer policy and pro- care within the community via a range of initiativesgramme questions and be relevant to the health sector relating to financial support, health and education targetedprogramme of work; human resource and infrastructure at HIV/AIDS OVC with additional support provided bydevelopment should be an integral component of any non-governmental organizations. The Ghana AIDS Com-research project to ensure capacity development; techni- mission is an intersectoral government body with the dutycal assistance for any collaborative research should be to coordinate, monitor and evaluate the national responsedemand driven; and the highest ethical standard should to HIV/AIDS, it is also involved in resource mobilizationbe maintained. for HIV/AIDS OVC. The commission reports directly to Addressing the Balance of Burden in AIDS (ABBA) is a the office of the president and is therefore able to involveDFID funded project aiming to improve HIV/AIDS policy all sector of government.making in Africa http://www.abbarpc.org. It is a Research In 2007 the RDD hosted a set of consultative stake-Programme Consortium (RPC) consisting of collaborating holder meetings including policymakers, people livinginstitutions from Kenya, Malawi, South Africa, the United with HIV/AIDS, and orphanage managers at national andKingdom and Ghana. RDD is the Ghanaian partner of the regional levels. The aim of the meetings was to agree onABBA RPC. A central objective of the ABBA partnerships research priorities in the field of HIV and AIDS to takeis to influence poverty reduction and the achievement of forward within the ABBA research programme, which hasthe Millennium Development Goals by tackling and redu- the broad remit of understanding and addressing socialcing the causes of vulnerability through improving HIV/ issues related to HIV. Following a consensus building pro-AIDS policy-making. cess the discussions at the workshop highlighted gaps in One of the issues the Ghana team has addressed under understanding on OVCs in Ghana and in particular thethe ABBA RPC is developing appropriate responses to lack of knowledge and awareness of policy guidelines fororphaned and vulnerable children affected by HIV/AIDS. OVCs; the need to better identify OVCs in communitiesThis case-study illustrates the importance of an approach and consider changes to how interventions are implemen-which engages multiple official stakeholders in collaborat- ted; and build awareness of organisations and servicesing to facilitate the uptake of research evidence. Children provided for OVCs.affected by HIV in Ghana frequently live in poverty, are As a result of the consultative meetings the RDD under-stigmatized by society, have poor school attendance and fail took a research study (2008-10) to assess the state of HIVto receive the government protection and support they are affected OVC in households and orphanages. The studyentitled to. Ghana is believed to have approximately 17,500 questions arose from the consultative meetings, RDDchildren living with HIV infection [1]. The estimate of the developed the study design and stakeholders were able tonumber of AIDS orphans in Ghana is expected to double, comment on cultural sensitivities, ethics and communityincreasing from 132,000 in 2004 to 291,000 in 2015 [2]. entry. The objective was to describe the interventions thatTraditionally orphans in Ghana would be absorbed in to are available for children in different settings and to recog-extended families, the changing demographic profile and nise the differences and commonalities between thosethe projected orphan burden suggest this will become less OVCs living in households and orphanages receiving andfeasible and AIDS orphans will become increasingly vulner- not receiving formal support. The aim was to develop theable unless supportive interventions reach them effectively research project with all known stakeholders involved with[3]. Attempts have therefore been made by government OVC support and work with them to disseminate thebodies to improve the support services of OVCs, and to results so that a collaborative response could be developed.provide indirectly support via funding for associations RDD worked closely from the project’s inception withworking with People Living with HIV/AIDS (PLHA). multiple stakeholders. The stakeholders can be broadly Responsibility for HIV affected OVC lies across several classified into i) policy makers and practitioners, compris-government departments and designing a strategy for their ing the Ghana AIDS Commission (GAC), the National
    • Gyapong et al. Health Research Policy and Systems 2011, 9(Suppl 1):S14 Page 3 of 5http://www.biomedcentral.com/1478-4505/9/S1/S14AIDS Control Programme, the Department of Social Wel- Preliminary findings were presented to all stakeholdersfare (DSW) and the Ministry of Women and Children’s and given an opportunity to ask questions and input intoAffairs (MOWAC); ii) academia and researchers, predomi- the process. At this stage, the main dissemination was anantly research scientists working on HIV/AIDS; and iii) formality because the key stakeholders had been part ofthe community, usually represented by NGOs providing the process and were already aware of the key findings ofHIV/AIDS services at the community level and associa- the research project. The dissemination forum thereforetions of people living with AIDS. focuses more on the possible actionable points and who This was a mixed-method study of a purposively should do what rather than just telling the story of theselected non-randomized population. In-depth interviews results. This approach makes policy makers and endwere conducted with key personnel from 11 governmental users of research outcomes pay attention and becomeand non-governmental organizations which provide ser- more involved in the research process.vices for HIV and AIDS OVC in the Central region ofGhana. In-depth interviews were also conducted with 3 Discussioncaretakers of orphanages and 19 household heads that From the outset, RDD set the research agenda in colla-have HIV/AIDS OVC in their care [3]. Most of the in- boration with policy makers and stakeholders with whomdepth interviews were more like group discussions because contact was maintained through facilitative intersectoralthey required responses from different people in the discussions and forums up until the reporting stage. Theorphanages. Quantitative data on the socio-demographics setting of the research agenda took the form of a nationalof households and the state (health, education and nutri- and regional dialogue which assembled various actorstion) of a sample of 137 OVC were also collected. involved in policy making and program implementation The government strategy has been to encourage HIV in the national response to HIV/AIDS. Beyond theaffected children to live within their extended families, agenda setting stage, contact with stakeholders was activehowever, no comprehensive database or tracking system and maintained through bi-monthly face-to-face andwas in place for HIV affected children, and there was lim- email updates on the process. The project concluded thatited understanding on the experiences and challenges to make an effective and sustainable shift towards thefaced by OVC and their carers in the home setting. A cash approach of keeping more OVC in households, structuresincentive system to encourage registration of OVC at a and mechanisms should be instituted to identify thesegovernment facility had been in place in order to identify children, their households and family members and pro-‘needy’ children, but was associated with fraudulent activ- vide them with the necessary support [3]ity and individual cases recorded in the database could not The research evidence was reported with recommen-be validated. In addition anecdotal evidence suggested that dations to refocus on an intersectoral collaborativepride prevented some families living in extreme poverty response including:from acknowledging they needed state support; the most 1. The DSW and MOWAC should identify and regis-frequent source of external support for households inter- ter community based OVCviewed in the study was through PLHA associations which 2. Registered children should be supported in acces-receive funding from the Ghana AIDS Commission, [3]. sing free health care and the Free Compulsory Universal The study found that all OVC in orphanages appeared Basic Education systemto have an advantage in terms of education, nutrition and 3. The Ghana AIDS Commission, MOWAC and otherhealth care over children living in the community because stakeholders should develop simple educational tools tothey could be easily targeted for support interventions. educate service providers and caregivers about the poli-Educational opportunities for those living in orphanages cies, support and social protection aimed at OVCwere good, with 100% of children attending school as Long-term engagement with stakeholders can be com-opposed to approximately 89% OVC living in households; plex and frustrating and this project faced several chal-however children from both groups tended to be behind lenges. There were differences in opinion with regardstheir age-peer group at school. OVCs in both households prioritization of issues for the research agenda, partly dueand orphanages showed that most were under weight, yet to the range of individuals participating in the process ofchildren in orphanages benefitted from free access to the developing the response. In the context of HIV in GhanaNational Health Insurance Scheme whereas children in we face the challenge that in some policy arenas evidencehouseholds tended to lack the funds for health insurance. from applied research is considered inferior to ‘hardThe study did not however collect data pertaining to child science’ by officials from biomedical backgrounds. It alsoaccess to anti-retroviral treatment. Limited data regarding became apparent that the potential for stakeholders to actchildren living in households who had been identified for on recommendations was limited by considerable resourcegovernment support suggested they did receive advantages constraints. Stakeholders recognised that recommenda-of free health and education services [3]. tions in the report would have a stronger chance of being
    • Gyapong et al. Health Research Policy and Systems 2011, 9(Suppl 1):S14 Page 4 of 5http://www.biomedcentral.com/1478-4505/9/S1/S14implemented if the government departments and organi- understanding of processes that support take up ofsations could work collaboratively and communities could research findings in relation to HIV and AIDS. First,be empowered to access services provided. continuous stakeholder engagement was essential for The position of the RDD as a research body within a the effective translation and dissemination of researchgovernment body (the Ghana Health Service) had impor- evidence. Second, the complexities of HIV in the com-tant implications for the scope of the research evidence munity context necessitated transactional, dynamicand the outcomes from the project. Not only has RDD approaches of applied research rather than a traditionalbeen able to criticise the establishment in a way that scientific linear approach. Third, despite involving allcould not have been possible from a non-governmental relevant sectors and policy actors in the research pro-organization, but it has also been able to use its network cess, translating research evidence into practice has notof links across the public sector to facilitate change. For yet been possible due to institutional resource con-example the Department of Social Welfare (DSW), the straints, however engagement with policy actors alloweddepartment with the greatest mandate to support OVCs these limitations to be identified and action taken towas powerless to undertake its responsibilities without rectify them. Fourth, intersectoral engagement was time-external intervention due to financial constraints. Prior consuming and labour-intensive, and effective dissemi-to the project there had been no links between RDD and nation to different professional cultures (academia, clini-the DSW, yet RDD was able to use its links to enlist cal practice, policy makers, and the community)advocates to lobby the Minister for Social Welfare and required the adaptation of research evidence in order tothus empower the Department to carry out its work. The remain relevant to the diverse audiences. Specifically incase of OVC was put forward to the Minister as an exam- targeting the general population using national televisionple of the crises within the Department, following which as a channel of communication to stimulate and initiatemore resources were allocated to the department. fruitful discussions on the issue, it was imperative to Based on the research engagement, in 2010 a documen- adapt the research findings, in this case through the usetary film was commissioned by RDD with the intention of of the “docu-drama”. This model of adaptation ofdisseminating key findings to a wider audience and spread- research evidence better appealed to the target audience.ing awareness of the plight of OVCs using easily an under- Bringing together decision makers who can engagestandable format and language. This was a response to with one another and use research evidence in policystakeholders’ suggestion that dialogue and wider recogni- formulation is, in our experience, the most importanttion of the issues was necessary and social empowerment predictor for seeing the findings applied. The positional-was an important strategy. The film was a ‘docu-drama’ ity of the RDD (as a research organisation nested withinthat told the emotional story of an orphaned child living in the government infrastructure), meant that it was ablethe community, and featured interviews with high-ranking to make links between research and policy and bringgovernment officials. The message is exemplified in the together relevant government departments and research-statement from the film, “We must pull resources together, ers to ensure that research evidence is digested andwe must work in collaboration together, we must comple- responded to. HIV pushes us to think in new ways andment each other’s efforts, and once we are able to do that create broad partnerships between disciplines and gov-in harmony I think we stand a better chance to improve ernment departments. The effect of HIV on OVC, inupon the situation with our OVC” (Ruth Addison, Head of the case of Ghana, dictated that representatives fromProgrammes, Ministry or Women and Children’s Affairs). several sectors collaborated to create an impact thatThe RDD links to government were such that it could would not have been possible with a single institution;negotiate that the film was aired at low cost on primetime the existence of an autonomous institution embeddedtelevision across the three national networks over the within the government mechanism can create a vitalEaster holiday weekend. The public’s response to the docu- link between those sectors.mentary was striking, and prompted widespread discussionand demands for the government to act. As a response to Abbreviationsthe RDD research, the Ghana AIDS Commission expressed ABBA: Addressing the Balance of Burdens of HIV/AIDS; DFID: Department forcommitment to creating an index of OVC in Ghana to International Development; DSW: Department of Social Welfare; GAC: Ghanaassess what services are being delivered. The links facili- AIDS Commission; GHS: Ghana Health Service; MOWAC: Ministry of Women and Children Affairs; OVC: Orphans and Vulnerable Children; PLHA: Personstated by RDD in these examples highlight the potential of Living With HIV/AIDS; RDD: Research and Development Division; RPC:intersectoral working within HIV activities. Research Program Consortium AcknowledgementsConclusion This document is an output from a project funded by DFID for the benefitThe OVC research project has produced several trans- of developing countries. The views expressed are not necessarily those offerable lessons with which we can further our DFID. The research was undertaken with support from Addressing the
    • Gyapong et al. Health Research Policy and Systems 2011, 9(Suppl 1):S14 Page 5 of 5http://www.biomedcentral.com/1478-4505/9/S1/S14Balance of Burden of HIV/AIDS RPC, an international research programme onHIV treatment and care systems.We thank Olivia Tulloch, Sally Theobald and Hilary Standing for theircontributions to the development of this paper and comments on earlierdrafts.This article has been published as part of Health Research Policy and SystemsVolume 9 Supplement 1, 2011: Strengthening the research to policy andpractice interface: exploring strategies used by research organisationsworking on sexual and reproductive health and HIV/AIDS. The full contentsof the supplement are available online at http://www.health-policy-systems.com/supplements/9/S1.Authors’ contributionsJOG drafted the paper, RAS and KAA contributed to drafting and revisingthe manuscript. All authors read and approved the final manuscript.Competing interestsThis paper critically reflects on a research project in which the authors wereinvolved.Published: 16 June 2011References1. National AIDS Control Programme: HIV Sentinel Survey Reports. Ghana Health Service, Accra; 2003.2. Ghana Health Service: HIV/AIDS in Ghana: An Analysis Based on the Application of the AIDS Impact Model. Accra; 2004.3. Research and Development Division: Assessment of Interventions and the state of HIV and AIDS Orphans and Vulnerable Children. Ghana Health Service, Accra; 2010.4. Ghana AIDS Commission: National Report on the Progress of the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV And AIDS. Ghana Health Service, Accra; 2008. doi:10.1186/1478-4505-9-S1-S14 Cite this article as: Gyapong et al.: Challenges in linking health research to policy: a commentary on developing a multi-stakeholder response to orphans and vulnerable children in Ghana. Health Research Policy and Systems 2011 9(Suppl 1):S14. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit