Implementation of a Health Policy Advisory Committee as a Knowledge Translation Platform: The Nigeria Experience

Background In recent times, there has been a growing demand internationally for health policies to be based on reliable research evidence. Consequently, there is a need to strengthen institutions and mechanisms that can promote interactions among researchers, policy-makers and other stakeholders who can influence the uptake of research findings. The Health Policy Advisory Committee (HPAC) is one of such mechanisms that can serve as an excellent forum for the interaction of policy-makers and researchers. Therefore, the need to have a long term mechanism that allows for periodic interactions between researchers and policy-makers within the existing government system necessitated our implementation of a newly established HPAC in Ebonyi State Nigeria, as a Knowledge Translation (KT) platform. The key study objective was to enhance the capacity of the HPAC and equip its members with the skills/competence required for the committee to effectively promote evidence informed policy-making and function as a KT platform. Methods A series of capacity building programmes and KT activities were undertaken including: i) Capacity building of the HPAC using Evidence-to-Policy Network (EVIPNet) SUPPORT tools; ii) Capacity enhancement mentorship programme of the HPAC through a three-month executive training programme on health policy/health systems and KT in Ebonyi State University Abakaliki; iii) Production of a policy brief on strategies to improve the performance of the Government’s Free Maternal and Child Health Care Programme in Ebonyi State Nigeria; and iv) Hosting of a multi-stakeholders policy dialogue based on the produced policy brief on the Government’s Free Maternal and Child Health Care Programme. Results The study findings indicated a noteworthy improvement in knowledge of evidence-to-policy link among the HPAC members; the elimination of mutual mistrust between policy-makers and researchers; and an increase in the awareness of importance of HPAC in the Ministry of Health (MoH). Conclusion Findings from this study suggest that a HPAC can function as a KT platform and can introduce a new dimension towards facilitating evidence-to-policy link into the operation of the MoH, and can serve as an excellent platform to bridge the gap between research and policy.


Background
Nigeria is among the increasing number of countries worldwide that are recognizing the importance of research evidence in the development of effective health policy that can strengthen the health systems (1,2). Numerous available scientific reports have indicated that evidence from research can enhance health policy process and development by informing decisions about policy content and direction (3)(4)(5)(6). However, there is widespread failure to implement health interventions that have been demonstrated to be costeffective by high-quality research in both high-and lowincome countries (7). The reason for this is not farfetched, and it is largely because getting research evidence into policy, also referred to as Knowledge Translation (KT), remains a daunting task and huge gaps still exist, especially in lowincome settings (8,9). KT is defined as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products and strengthen the system (10). According to Landry and colleagues (11), KT is about using research to inspire people to think and/ or act differently and the KT process is achieved through transmission and exchange of information and through extensive dialogue between the producers and users of the research. KT involves careful consideration of the experiences and information needs of stakeholders to improve the overall quality of research, and facilitate the application of research to practice and policy (11). The term "stakeholders" is used here to represent researchers, policy-makers, civil society organizations, Non-Governmental Organizations (NGOs), health professionals and media organizations. In Nigeria, the major challenge associated with evidence-to-policy link is the grossly deficient capacity among policy-makers in the use of evidence for policy-making (12). Some of the problem is attributed to the differences existing between those who do research and those who may be in a position to use it. Some of the differences that pertain include mutual mistrust, career paths and requirements, attitudes towards information among others. These differences persist largely due to the absence of opportunities to bring researchers, policy-makers and managers together to consider issues around the research to policy and practice interface (2). To address this challenge, there is a need to strengthen institutions and mechanisms that can more systematically promote interactions between researchers, policy-makers and other stakeholders who can influence the uptake of research findings (7). Stressing on the need to promote the interaction between researchers and policy-makers, Choi and colleagues (13) noted that it is desirable for scientists and policy-makers to communicate their knowledge effectively or run the risks of barriers in language and understanding. They further noted that more incentives and opportunities to collaborate will help scientists and policy-makers appreciate their different goals, career paths, attitudes towards information, and perception of time. One of the mechanisms that can serve as an excellent platform for the interaction of policy-makers and researchers is the Health Policy Advisory Committee (HPAC). The HPAC has been described as a forum for the government, development partners and other stakeholders (policy-makers, researchers, civil society organizations, funders, etc.), to discuss health policy and to advise on the implementation. The HPAC is thus a stakeholder coordination mechanism that provides a forum for information and experience sharing, and resolution of disagreements or conflicts among health sector stakeholders (14). The HPAC functions as a health coordination mechanism designed to standardize and develop a sector wide approach in the development of health policy and the strategies for implementation (15). Although the HPAC is operational in a number of high-income countries such as USA, New Zealand, and Israel, examples of such structures/ mechanisms are very few in the low-and middle-income countries, where the need for such structures/mechanisms is more acute, given their scare resources and rising demands (16)(17)(18)(19). As a health coordination mechanism, the HPAC identifies tasks that need to be undertaken through special assignments and approves terms of reference for the different assignment, the work plan, budget and other project expenditures for the health sector (14). Thus the HPAC has the potential of functioning as KT platform. One of the outstanding features of a KT platform is the promotion of evidence-informed policy-making. The process of utilizing evidence from research to make health policy is known as evidence-informed policy-making and is characterized by the systematic and transparent access to, and appraisal of, evidence as an input into policy-making (20). This is clearly what the low-and middle-income countries desperately need. In a review of organizations that support the use of research evidence, Mshinda from Tanzania noted that "If you are poor actually you need more evidence than if you are rich" (21). In the low-and middle-income countries where health systems are extremely weak, KT is imperative. This is because KT is a key factor in the promotion of not only evidence-informed policy-making but also health systems strengthening which are likely to produce better health outcomes. In evidence-informed policy-making and health systems strengthening, there is a shift away from opinionbased policies and practices to a more rigorous, rational approach that gathers, critically appraises, and uses highquality research evidence to inform health policy-making, professional practice, and systems operations (22). In this report we describe the establishment of a HPAC in Ebonyi State Nigeria, its role as a mechanism to bridge the divide between researchers and policy-makers and its implementation as a KT platform.

Study design
This study followed an implementation research framework. The goal of the study was to investigate the potential and feasibility of a HPAC serving as a KT platform. The study focused on the evaluation of the implementation of series of interventions (23,24). Qualitative methodology was used to determine the post-training perceptions and opinions of the members of the HPAC and understand how these related to their capacity and skill improvement regarding KT process (25). The process is described in further details below. Prior to the commencement of this study, the HPAC had never operated as a KT platform and the most of the members of the committee especially the policy-makers lacked any knowledge of KT and knowledge management in relation to "evidenceto-policy-to-action" process. Interviews of the members of the HPAC and group discussions among selected members of the HPAC were conducted before the commencement of the intervention and thereafter. The interviews and group discussions conducted before the intervention were done using an interview guide consisting of three questions as follows: i) what is the extent of your knowledge about KT?; ii) have you been involved in any KT initiative before now?; and iii) have you been involved in any training workshop on KT capacity enhancement before now? All individual interviews in this study were semi-structured and conducted by the lead researcher (CJU), while the group discussions were conducted by both CJU and AAE. The interviews and discussions were not tape-recorded but responses were written down. The intervention process consisted of series of training workshops and a three-month certificate programme on health policy and KT.

Establishment of the Health Policy Advisory Committee (HPAC)
The HPAC was established in Ebonyi State South Eastern Nigeria in August 2011. The establishment of the HPAC was one of the products of the Alliance for Health Policy and Systems Research (AHPSR) of World Health Organization (WHO) funded study (Supporting National Processes for Evidence-Informed Policy in the Health Sector of Developing Countries) in Ebonyi State University Nigeria (http://www. who.int/alliance-hpsr/projects/ihrgebonyi_etpsnp/en/). The study focused on improvement of the skills of policy-makers in evidence-informed policy-making and the establishment of enabling environments and capacity for Health Policy and Systems Research (HPSR) for policy-makers, researchers and other stakeholders in the health sector. Following series of meetings between the policy-makers, other key stakeholders and researchers during the study implementation, there was a unanimous consensus for the establishment of a platform where policy-makers and researchers can permanently collaborate. Hence the study team initiated a proposal to the government for the establishment of the HPAC. Following the approval by the Health Ministry, the HPAC was inaugurated and became known as Ebonyi State Health Policy Advisory Committee (ESHPAC) and had its first meeting in August 2011 (26). The HPAC had 18 members including 9 directors from Ministry of Health (MoH), 5 senior researchers from the university, an NGO executive director, a director of public health in the local government service commission, the executive secretary of the AIDS control agency, and the State focal person of Millennium Development Goals (MDG). The committee meetings were scheduled at least once every quarter.

Description of the intervention i) A capacity enhancement training workshop on Knowledge Translation (KT)
A training workshop was held for the members of the HPAC on development and use of policy briefs, policy dialogues, and priority setting, based on the SUPPORT tools (http://www.health-policy-systems.com/supplements/7/S1). The workshop took place in May 2012. It was a one-day training workshop which commenced at 10 am and ended at 3 pm. A total of 14 out of the 18 members of the HPAC participated in the workshop. The workshop featured four training sessions which focused on the following: a) research evidence and its role in informing health policy decisions; b) the preparation and use of policy briefs to support evidenceinformed policy-making; c) how to organize and use policy dialogues to support evidence-informed policy-making; and d) how to set priorities for finding and using research evidence to support evidence-informed policy-making. All training sessions were facilitated by experts using PowerPoint presentations and handouts on each topic that were produced and distributed to all participants. All lectures were delivered in simplified, practical and easily comprehensible patterns, with little or no emphasis on complex mathematical or scientific computations/models for the benefit of non-specialists who constituted the majority of the participants. Question/ answer sessions, role play, demonstration, simulations, and presentations from participants were methods used during the workshops. Personal/private interactions also took place for individuals who desired more information either from the HPSR Study Team or from facilitators/resource persons. Key informant interviews were conducted with eight selected members of the HPAC at the end of the workshop using an interview guide, to obtain their impression about the training. The interview guide consisted of two questions as follows: i) how would you describe what you have benefited from this training on KT and its impact?; and ii) how would you describe your expectations from this KT training regarding evidence-to-policy link in Ebonyi State? Participants who were interviewed were those that remained consistent throughout the training (i.e. those that attended all the sessions of the training). Each interview lasted between 15-20 minutes.

ii) A three-month certificate course for Health Policy Advisory Committee (HPAC)
The members of the HPAC were enrolled into a three-month training/mentorship programme on Health Policy and Health Systems at the Ebonyi State University Abakaliki, Nigeria. This programme lasted from September 2012 to December 2012. The programme classes were held three days per week, from 2 pm to 5 pm each day. The aim of the programme was the enhancement of HPAC competence that is relevant to KT, these include: a) fostering research capacity; b) nurturing leadership development in the context of limited resources; c) enhancing capacity for evidence informed policy-making, health policy advocacy, demand creation, consensus building and negotiation; and d) health policy monitoring, evaluation and performance assessment. Ten topics were treated which covered the topical areas a to d listed above. All training sessions were facilitated by experts from Ebonyi State University and the teaching methods described section i above were also used. Key informant interviews were conducted with eight selected members of the HPAC using an interview guide at the end of the course to obtain their impression about the programme. The interview guide consisted of two questions as follows: i) how would you describe the impact of this course on your knowledge regarding health policy?; and ii) how is the knowledge so acquired relevant to your role in HPAC and the HPAC activities? Participants who were interviewed were those that remained consistent throughout the training (i.e. those that attended all the lectures sessions). Each interview lasted between 15-20 minutes and was conducted by the lead researcher.

iii) Development of policy brief and hosting of a multistakeholder policy dialogue
The policy dialogue, which involved key stakeholders in the health sector, was held in July 2013. A total of 18 stakeholders participated in the dialogue and included some members of the HPAC, researchers, medical practitioners and a director of a NGO. The focus of the policy dialogue was on the government's health priority issue, Free Maternal Health Care Programme (FMHCP). The policy dialogue was based on the previously produced policy brief entitled: Improvement of Government's Free Maternal and Child Health Care Programme using Community-Based Participatory Interventions in Ebonyi State Nigeria (27). The policy brief was developed according to the guidelines described previously (28). The policy dialogue which involved key stakeholders in the health sector was held in July 2013 and was conducted as described by Lavis and colleagues (29). A policy dialogue guideline was provided for participants. The guideline included a description on how to evaluate the policy brief document in terms of content quality and relevance, as well as the policy issues presented, the magnitude of the problems to be addressed and how actionable the policy options recommended are. The policy dialogue was informed by discussion about the full range of factors that can inform how to approach a problem, possible options for addressing it, and key implementation considerations. The policy dialogue brought together many parties who could be involved in or affected by future decisions related to the issue. The policy dialogue aimed for fair representation among policy-makers, researchers and other stakeholders. The dialogue engaged a facilitator to assist with the deliberations and allowed for frank, off-the-record deliberations by following the Chatham House rule: "Participants are free to use the information received during the meeting, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed" (29). The dialogue lasted up to two hours and the participants made various inputs and suggestions on how the policy options can be better implemented. Key informant interviews were conducted with eight selected members of the HPAC at the end of the policy dialogue, to assess their impression about the programme. The interview guide consisted of two questions as follows: i) how would you describe your present knowledge about policy briefs and the impact of the policy dialogue on your relationship with other stakeholders?; and ii) how can the HPAC function be improved? Participants who were interviewed were those that had fully participated in the development of the policy brief and policy dialogue, as well as the two previous intervention activities above (i.e. workshop on KT and certificate course for HPAC). Each interview lasted between 15-20 minutes and was conducted by the lead researcher.

Data management and analysis
All the responses from the interview were noted. The responses were analyzed based on Giorgi's phenomenological approach (30), which was further described by Albert and colleagues (31). The analysis followed the following steps: i) going over all the textual data to gain an overall impression; ii) identifying all comments that appeared noteworthy to the research, extracting these meaning units; and iii) independent abstracting of the meaning units, followed by discussion and consensus. Data management and analysis were undertaken by CJU and AAE.

Results
An analysis of interviews demonstrated that following involvement with the HPAC and associated interventions, members of the HPAC reported improvements in their knowledge and understanding of what KT is and the practical steps necessary to carry out KT. The policy brief resulting from this study has been published (32). The feature of the policy brief included: i) statement of the issue/problem and a background of the problem; ii) description of the current situation of the Free Maternal and Child Health Care Programme; iii) policy options and implementation strategies for addressing the problem; and iv) justification of recommended policy options (32). The comments of the respondents are organized according to the two main themes below.

Knowledge and understanding of what KT is.
One of the members noted thus: "…the training has enabled me to understand better the evidence-to-policy process". This statement indicates improvement in the knowledge of KT process of this policy-maker. After the intervention, a leader of a NGO and is a member of the committee but who has never been involved in any KT activity previously stated thus: "…before this programme I never knew that the NGOs can play a tremendous role in the policy-making process but I now have come to understand that we in the NGOs are an indispensable stakeholders in the policy-making process…I have also gained enhanced understanding and skill on how to produce policy briefs and host a multi-stakeholder policy dialogues and other forms of stakeholder engagements…" Regarding the impact of the three-month certificate course for HPAC, two of the directors from the health ministry who are members of the HPAC expressed their opinions, the first person stated thus: "…the three-month training programme on Health Policy and Health Systems has enabled me to acquire the skill and capacity for health policy advocacy, consensus building and negotiation; and health policy monitoring…I am already using the capacity to promote evidence use in policy-making at the ministry of health…" The response of this policy-maker showed the extent the training had impacted on the individual capacity for evidenceto-policy process. The second policy-maker observed that the training has helped improved her understanding of KT and the "evidenceto-policy-to-action" process, she stated thus: One of the directors in the health ministry, who served on the HPAC, acknowledged that the training programme enabled them to be more proactive in promoting the use of evidence in policy-making and stated thus: "…since my participation in this programme I have been advocating for the use of reliable research evidence for any policy issue in my department… I am happy that I am now doing my work based on sound research evidence…" During the policy dialogue, the participants unanimously identified the need for the institution of a performance measurement mechanism for the HPAC and the initiation of a sustenance mechanism for the HPAC, to make it more independent to be able to carry out its evidence-to-policy advisory role.

Noteworthy improvement in knowledge and understanding of evidence-to-policy link
Following the capacity enhancement processes undergone by the HPAC in this study, we observed a noteworthy improvement in the knowledge and capacity for evidenceinformed policy-making process and practice by the policy-makers involved in the HPAC. These individuals are carrying out strong advocacy on the review of the health policies that are not evidence-based in the MoH and are leading the promotion of evidence-informed policy-making in the ministry. The policy-makers in the HPAC are also currently actively utilizing the knowledge they have acquired in the course of the study. Most of them have noted that they now use scientific evidence in their presentations in the meetings of the MoH. This outcome was not unexpected. Dawad and Veenstra (33) had in their report observed that without adequate research and KT capacity enhancement, policy-makers will not have access to sound information on which to base decisions and the potential for shared learning will be lost. Furthermore they noted that policy-makers need to become skilled at translating information into appropriate action, to avoid forfeiting any progress made in developing and reforming the health system. The WHO also noted that capacity enhancement should involve both policy-makers and researchers since capacity strengthening is needed for both researchers to generate better evidence and for policy-makers and healthcare professionals to better use available evidence (34). Furthermore, Varkevisser and colleagues (35) observed in their study that capacity enhancement on Health Systems Research (HSR) of policy-makers and other stakeholders in the health sector increased the national expertise for operational health research, and strengthen decision-making in at all levels.

Elimination of mutual mistrust between policy-makers and researchers
The mutual mistrust existing between the researchers and policy-makers was addressed among the members of the HPAC. It was discovered that the constant contact between the policy-makers and the researchers helped to build trust and friendship. It is well established that a major factor that can bridge the gaps in evidence-to-policy process is sufficient contact between researchers and policy-makers (36). There is now a healthy collaboration and partnership between the policy-makers in the health ministry and the researchers of the University. This study has enabled us the researchers and the policy-makers to learn how to work with each other for the purpose of improving the operations of the health systems through evidence-informed policy-making. In a previous study conducted among policy-makers in Ebonyi State, participants in the focus group discussion were in consensus that collaboration between researchers and policy-makers was needful so as to build partnerships and also align researchers more specifically to operational problems inherent in the health systems from the policy-making perspective (1). We observed that there is a need for continuous training of the HPAC members to increase their knowledge on strategies to maintain partnership with each other. As the committee is made up of both researchers and policy-makers, such training will expose the researchers to the policy-making process and the policy-makers to research process. According to Choi and colleagues (13), scientists could become ''policy sensitive'' through training and participation in the policymaking process, while policy-makers could be exposed to science through training and participation in the research process so they can apply a ''science lens'' to policy-making. The benefit of this strategy is that it will enable the researchers and the policy-makers in the committee to know each other's strengths and weaknesses, as well as likes and dislikes and communicate their knowledge effectively to avoid the risks of barriers in language and understanding. This would promote communication among the policy-makers and researchers by creating a common language and which can help the policymaking process more effective (13,37,38).

Increase in the awareness of importance of establishment of the Health Policy Advisory Committee (HPAC) and its Knowledge Translation (KT) potential
This study improved the awareness on the importance of the HPAC among key government officials and in the MoH. The process for the institutionalization of the committee at the MoH has commenced. The MoH is now giving consideration to the revised policy brief which resulted from the policy dialogue. Thus the HPAC has started operating as a KT platform, promoting the uptake of research evidence into the policy-making process in the State. By virtue of the composition of the Committee, its knowledge-base, deliberative dialogues, and its involvement in capacity strengthening activities it could also be said to function as a knowledge brokering forum. In a previous report it was noted that a KT platform is a logical continuation of knowledge brokering and as knowledge brokers, KT platforms are intermediaries between research and policy and their overall goals are to smooth the movement of research to the policy level; to connect the needs of the policy process with research and researchers; and to infuse public dialogue with an appreciation and understanding of research processes and research evidence (39). Bennett and Jessani (40) observed that KT relies upon key factors such as partnerships, collaborations, and personal contact between researchers and research-users. These factors are undoubtedly the bedrock of an efficient HPAC that is composed of researchers and policy-makers. Therefore by implementing the HPAC as a KT platform a new and interesting dimension has been introduced in the HPAC operation which could enhance its bridge building role between research and policy.

Institution of a performance measurement mechanism for the Health Policy Advisory Committee (HPAC)
We observed that there is need to develop a mechanism to measure the performance of the HPAC. An important and potentially contentious issue surrounding the use of advisory committees is how to judge their success (41). Therefore to ensure the success of the HPAC in Ebonyi State Nigeria, we plan to conduct a periodic collection and reporting of information regarding the performance of the Committee. The purpose of this is to enable the ESHPAC to periodically consider its operational process/strategies and see whether outcomes are in line with what was intended or should have been achieved by the Committee. In New Zealand the National Health Committee (NHC) which plays a policy advisory role continually keeps its performance under review, and refines and improves its processes accordingly. As part of its annual report, the NHC assesses the extent to which it has been effective in contributing to improved sector performance, value for money and fiscal sustainability (42). Drawing lessons from the suggestions of Lichiello (43), we plan to use the performance measurement exercise to achieve the following: i) compel the HPAC to reassess its programmes, goals and objectives; ii) give the HPAC an opportunity to step back and assess its capacity to undertake the policy advisory role; iii) give the HPAC an opportunity to create working arrangements with other groups, programs, departments, agencies, organizations, and stakeholders; iv) give the HPAC an opportunity to evaluate and define the types and levels of contribution it does or can make to achieving large, overarching public health goals; v) give the HPAC an opportunity to assess the quality or effectiveness of its work at the moment; and vi) enable the HPAC to track its progress over time and can give the Committee an opportunity to assess and improve on practices, processes, activities, and systems.

Strengths and limitations
This study draws its strength from the depth and variety of the interventions implemented which were designed to improve the capacity of the participants in the evidence informed policy-making process. Another area of strength is in the multi-disciplinary and multi-sectoral participant composition. This approach was necessitated by the need for all stakeholders to be part of the partnership mechanism to improve health policy-making process in low-income setting. In terms of limitations, this study applied qualitative methods which were exploratory, and may not have applied a very rigorous scientific process. Another major limitation was the technique used in the evaluation of the impact of the study. Only key informant interview involving only two questions was used which may not have been very adequate. The inclusion of quantitative survey could have improved the evaluation outcome. A more rigorous study design is advocated in future studies.

Conclusion
This is the first attempt to implement a newly established HPAC as a KT platform in Nigeria. This study highlights the importance of capacity building of policy actors on KT; the unexplored role of HPAC; the appropriateness of employed training approaches i.e. workshops and short course; the usefulness of a mainstream structure; the systematic engagement and structured dialogue between researches and policy-makers. The findings suggest that a HPAC can be implemented as a KT platform in a low-income setting, as can serve as a valuable platform to promote evidence-to-policy link. The lessons learned can aid in the design of a more complex study strategy that will fully elicit the unexplored KT potential of HPAC. conducted all group discussions. All authors participated in all training activities, contributed to drafting and revision of the manuscript.