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Funded by the Public Health Agency of Canada | Affiliated with McMaster UniversityProduction of this presentation has been made possible through a financial contribution from the Public Health Agency of Canada. The views expressed here do not necessarily reflect the views of the Public Health Agency of Canada. .

Contextualizing Guidelines Workbook

Presenter:

Elizabeth AlvarezMD, MPH, CCFP, ABFM, PhD(c)

March 9, 2016 1:00 – 2:30 PM ET

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Contextualizing Guidelines Workbook

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Elizabeth Alvarez, MD, MPH, CCFP, ABFM, PhD(c)

Family MedicinePublic Health, AdministrationHealth Policy, Political StudiesVanier Canada Graduate Scholar

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CONTEXTUALIZING GUIDANCE WORKBOOKNCCMT WEBINAR MARCH 9, 2016

ELIZABETH ALVAREZ, MD, MPH, PHD(C)JOHN LAVIS, MD, MSC, PHD

KNOWLEDGE TRANSLATION

• Many terms – knowledge transfer, knowledge exchange, knowledge brokering

• “Knowledge transfer and exchange (KTE) is an interactive process involving the interchange of knowledge between research users and researcher producers” (Mitton et al, 2007)

BACKGROUND

• Fragmented and overburdened public health systems

• Unused / underutilized effective public health interventions

• Global, evidence-based guidance can be used to

strengthen public health systems (Bosch-Capblanch et al, 2012)

BACKGROUND

• Need to contextualize global guidance with national or local evidence and health system and political system assessments (Lavis et al, 2012)

• Clear direction from countries for need to have more support in implementing global guidance recommendations

• Countries requesting such support from WHO

• International forum on evidence-informed health policymaking in low and middle-income countries, Addis Ababa, Ethiopia, Aug 2012

CONTEXTUALIZING GUIDANCE WORKBOOK

A systematic, transparent, and user-friendly tool - a workbook to help develop national or subnational policy recommendations or policy decisions

Meshes global guidance and national or local evidence

Includes broader health system and broader political system factorshttp://optimizemnh.org/Annexes/Annex_8_Contextualizing_Workbook.pdf

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Poll Question #4

How familiar are you with the Contextualizing Guidelines Workbook?

A. I am not familiar with the Workbook.B. I have heard of the Workbook.C. I have used the Workbook.

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Health systems guidance contextualization framework

STEP 1 •Clarify the problem

STEP 2 •Frame the options

STEP 3 •Identify implementation considerations

STEP 4 •Consider the broader health system context

STEP 5 •Consider the broader political system context

STEP 6 •Refine the statement of the problem, options and implementation considerations in l ight of health system and political system factors

STEP 7 •Anticipate monitoring and evaluation needs

STEP 8 •Make policy recommendations or decisions

STEP 1 – CLARIFY THE PROBLEM 1) What is the problem?

a) a risk factor, disease or condition; b) the programmes, services or drugs currently being used to address a risk factor, disease, or condition; c) current health system arrangements, including delivery, financial and governance arrangements; or d) the current degree of implementation of an agreed upon course of action;

2) How did the problem come to attention, and has this process influenced the prospect of it being addressed, in addition to the guidance?;

3) What indicators can be used or collected to establish the magnitude of the problem and to measure progress in addressing it?;

4) What comparisons can be made to establish the magnitude of the problem and to measure progress in addressing it?;

5) How can the problem be framed (or described) in a way that will motivate different groups?

STEP 2 – FRAME THE OPTIONS 1) Has an appropriate set of options been identified to address the problem?;

2) What benefits are important to those who will be affected and which benefits are likely to be achieved with each option?;

3) What harms are important to those who will be affected, which harms are likely to arise with each option and how can these harms be mitigated?

4) What are the local costs of each option, and is there local evidence about their cost-effectiveness?;

5) What adaptations might be made to any given option and how might they alter its benefits, harms and costs?

6) Which stakeholder’s views and experiences might influence the acceptability of each option and its benefits, harms and costs?

STEP 3 – IDENTIFY IMPLEMENTATION CONSIDERATIONS

1) What are the potential barriers to the successful implementation of each option?;

2) What strategies should be considered in order to facilitate the necessary behavioural changes among healthcare recipients/citizens?;

3) What strategies should be considered in order to facilitate the necessary behavioural changes among healthcare professionals?;

4) What strategies should be considered in order to facilitate the necessary organizational changes?;

5) What strategies should be considered in order to facilitate the necessary system changes?

STEP 4 – CONSIDER THE BROADER HEALTH SYSTEM CONTEXT 1) How do delivery arrangements influence the

possibility of each option being adopted and implemented successfully?;

2) How do financial arrangements influence the possibility of each option being adopted and implemented successfully?;

3) How do governance arrangements influence the possibility of each option being adopted and implemented successfully?

STEP 5 – CONSIDER THE BROADER POLITICAL SYSTEM CONTEXT

1) Would current political institutions allow for or hinder each policy change?;

2) Which politically active group(s) might have an interest in (face concentrated or diffuse costs or benefits) and mobilize for or against each option?;

3) Does each option resonate with the beliefs and values of the government and the public? Is there any local research evidence on stakeholder’s views and experiences?;

4) Are there external factors which may press the issue forward or draw attention away from each option?

STEP 6 - REFINE THE STATEMENT OF THE PROBLEM, OPTIONS AND IMPLEMENTATION CONSIDERATIONS IN LIGHT OF HEALTH SYSTEM AND POLITICAL SYSTEM FACTORS

STEP 7 – ANTICIPATE MONITORING AND EVALUATION NEEDS

1) Is monitoring necessary?; Is monitoring already in place or are new systems necessary?

What are the costs of establishing a new system?

Are findings going to be useful for change? What actions would occur if monitoring reveals things are not going as planned?

2) What should be measured?; 3) Should an impact evaluation be conducted?; 4) How should the impact evaluation be done?

STEP 8 – MAKE POLICY RECOMMENDATIONS OR DECISIONS

1) If applicable, has the public been engaged in the policymaking process?

2) Is a policy brief being developed to collate all of the analyses captured in the workbook?

3) Is a policy dialogue being planned to support evidence-informed policymaking

EVALUATION OF THE WORKBOOK

• The process of using the workbook was studied in Peru and Uganda

•Overall, the findings reflect 3 changes in the process of developing evidence briefs:

1) A workbook, which was specific to contextualizing the OptimizeMNH guidance, was provided.

2) Two authors from Canada provided support throughout the process.

3) Each relevant recommendation from the OptimizeMNH guidance was worked through systematically for developing policy options for the evidence briefs, which according to country experts, is not how guidelines are typically used, and are instead used more generally as a reference.

+ Participants in both countries plan on using or are already using the workbook for other, unrelated, work.+ The workbook, which was specific for contextualizing the OptimizeMNH guidance, made the process faster and easier when compared with prior processes.+ The workbook was systematic, logical, and user-friendly. It served as a tool for developing evidence briefs but also as a checklist for evaluating the work. There was a concern raised, however, that because it is so systematic, it could also limit peoples’ thinking about the problem or how to address it.

+ Examples in the workbook were seen as helpful, however, there was disagreement over whether there was a need for more examples to help those in areas with limited data or those who were not trained in health policy and systems. + Country experts were helpful for both content and methods (i.e., evidence briefs).+ Outside support was helpful for building capacity and focusing attention on the work.+ The process of using the workbook helped find gaps in knowledge and in practice.+ The process of using the workbook helped evaluate the OptimizeMNH guidance and standardize thinking globally. Even though some of the comments made by participants reflected a sense of what the guidance and the workbook should be able to do, it is important to address the expectations of this work, as neither the guidance nor the workbook could address the specific contexts of each country or region (although consideration could be given to having WHO regional offices and country offices support the development of regional or national guidance) nor direct how the country should or could make necessary changes (e.g., ensure a law is passed to support the changes) nor replace the tacit knowledge of people at the country level.

ADVANTAGES OF USING THE WORKBOOK

CHALLENGES OF USING THE WORKBOOK

- The workbook was too long and complex. In general, everyone reviewing the workbook stated that it is too dense or tedious because of the amount of sections and questions asked in the workbook. However, when asked which sections could be left out to make it shorter, there were no specific areas mentioned.

- The workbook had areas of redundancy and overlap- The workbook had missing components: glossary of medical terms, advocacyAlso, although costs are addressed in the workbook they may need to come out more explicitly in the evidence brief since policymakers are very interested in cost.

- The language used in the workbook could be difficult for those without training in health policy and systems to understand. Also, English terms could be difficult for some to understand. This was not the case for those involved in these processes in Peru and Uganda because they had the appropriate training, but they felt others may have difficulty with the language. On the other hand, several interviewees felt the workbook was easy to understand and that the terms were described well.

NEXT STEPSRevise the workbook based on findings from evaluating the process of using the workbook in Peru and Uganda and from a critical interpretive synthesis of the literature to better define contextualization and contextual factors affecting policy development and implementation

REFERENCES

• Bosch-Capblanch X, Lavis JN, Lewin S, Atun R, Røttingen J-A, Dröschel D, et al. Guidance for Evidence-Informed Policies about Health Systems: Rationale for and Challenges of Guidance Development. PLoS Med. 2012 2012/03/06;9(3).

• Lavis JN, Røttingen J-A, Bosch-Capblanch X, Atun R, El-Jardali F, Gilson L, et al. Guidance for Evidence-Informed Policies about Health Systems: Linking Guidance Development to Policy Development. PLoS Med. 2012 2012/03/13;9(3).

• Mitton C, Adair C, McKenzie E, Patten S and Wayperry, B. Knowledge Transfer and Exchange: Review and Synthesis of the Literature. Milbank Quarterly 2007, 85(4): 729-768.

THANK YOU!!Questions??

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