Evidence-informed decision-making for health policy and programmes Insights and best practices from successful country initiatives

Evidence-informed decision-making for health policy and programmes Insights and best practices from successful country initiatives

Evidence-informed decision-making for health policy and programmesii

Evidence-informed decision-making for health policy and

programmes: insights and best practices from successful

country initiatives

ISBN 978-92-4-003600-0 (electronic version)

ISBN 978-92-4-003601-7 (print version)

© World Health Organization 2021

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Insights and best practices from successful country initiativesiii

Contents

Foreword ........................................................................................................................... v

Acknowledgements .................................................................................................... vi

Executive summary ................................................................................................... viii

01. Scaling up knowledge translation capacity in Lebanon: The Knowledge to Policy (K2P) Centre’s evidence-informed COVID-19 rapid response service ................................................................... 1

02. A countrywide network of evidence centres. Strengthening knowledge translation throughout Brazil’s health system ............... 11

03. Retail regulation, advertising bans or increased taxation? Reducing the harmful use of alcohol in Moldova ................................. 21

04. The peril of broad-spectrum antibiotics: antimicrobial stewardship in long-term care facilities in Slovenia .......................... 29

05. From operational research to a One Health approach. The roadmap to eradicating Schistosomiasis in Indonesia ............ 39

06. Responding to antimalarial drug resistance in Uganda. Evidence use in updating the malaria treatment policy .................. 49

iv

Insights and best practices from successful country initiativesv

Foreword

Relevant, actionable evidence is the backbone of safe and effective health policies and programmes. In the hands of decision-makers and health actors, the right piece of evidence can make a true difference to patients’ health and well-being and strengthen health system performance and resilience. Through the Evidence-Informed Policy Network (EVIPNet), the World Health Organization (WHO) has been supporting countries in translating evidence into improved health policy and practice for more than 15 years and established successful knowledge translation platforms in over 50 countries.

For governments, investing in strong research to policy interfaces is of both high intrinsic and instrumental value. Leveraging the best available evidence for effective health policies and interventions increases accountability, participatory decision-making, and good governance, while improving national health outcomes and using resources optimally. At a global level, reinforcing the evidence to policy and impact nexus is a cornerstone of the WHO’s triple billion targets and the 2030 Agenda for Sustainable Development. The recently created Science Division is honing the Organization’s global leadership in evidence-informed policy- and decision-making, and is working to expand on EVIPNet’s global reach and continuing success.

As knowledge translation mechanisms around the world are increasingly recognized as key facilitators of effective health policy- and decision-making, the COVID-19 pandemic has again stressed the paramount importance of researchers, decision-makers, and health actors joining forces to put the latest research evidence into urgent life-saving action.

This publication shines a spotlight on what it takes to close research to policy gaps for pressing health issues across countries in five WHO Regions. Together, the case studies form both a testimony to WHO’s commitment to increased accountability and impact through effective health interventions, and a learning resource for researchers, health practitioners, and decision-makers.

Dr Soumya Swaminathan WHO Chief Scientist

Evidence-informed decision-making for health policy and programmesvi

Acknowledgements

The case studies featured in this publication were assembled from submissions of EVIPNet country champions, WHO Country and Regional Offices, and Member States. The editors would like to thank all authors for their invaluable contributions. Without their input and continuous feedback during the editing process, this publication would not have been possible.

Juliet Nabyonga-Orem (WHO Country Office, Zimbabwe); Ulysses Panisset (The Federal University of Minas Gerais, Brazil); Joseph Chukwudi Okeibunor, Bayo S. Fatunmbi (WHO Regional Office for Africa); Fadi El- Jardali, Racha Fadlallah (Knowledge to Policy (K2P) Center, American University of Beirut, Lebanon); Clara Abou Samra (Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Lebanon); Mehrnaz Kheirandish; Ahmad Mandil; Arash Rashidian (WHO Regional Office for the Eastern Mediterranean, Egypt); Marcela Ţîrdea (Ministry of Health; Labour and Social Protection of the Republic of Moldova); Angela Ciobanu (WHO Regional Office for Europe, Denmark); Maja Subelj (National Institute of Public Health; Slovenia); Polonca Truden-Dobrin (National Institute of Public Health; Slovenia); Marge Reinap (WHO Regional Office for Europe, Denmark); Aurelina Aguiar de Lima, Camile Giareta Sachetti, Daniela Fortunato Rêgo, Keitty Regina Cordeiro de Andrade, Roberta Borges Silva, Marina Melo Arruda Marinho, Virginia Kagure Wachira (Department of Science and Technology, Ministry of Health, Brazil); Laura Boeira (Veredas Institute, Brazil); Maritsa Carla de Bortoli, Tereza Toma, Sonia Venancio (Health Institute, Sao Paulo, Brazil); Sandra Maria do Valle Leone de Oliveira (University of Mato Grosso do Sul, Brazil); Ludovic Reveiz (WHO Regional Office for the Americas, United States of America), Jorge Otávio Maia Barreto (Fundação Oswaldo Cruz); Siswanto Siswanto, Tasnim Azim (WHO Regional Office for South-East Asia, India); Muhamad Faozan (National Institute of Health Research and Development Ministry of Health, Indonesia).

Insights and best practices from successful country initiativesvii

Reviewer: Ulysses Panisset (The Federal University of Minas Gerais, Brazil), Cristián Mansilla Aguilera (McMaster University, Canada)

Coordinating editors: Tanja Kuchenmüller, Samuel Sieber (WHO Evidence to Policy and Impact Unit, Research for Health, Science Division)

Evidence-informed decision-making for health policy and programmesviii

Executive summary

The Evidence to Policy and Impact Unit (ERP) within the Science Division and Research for Health Department strengthens the regular use of context-specific research evidence to catalyze the implementation of the World Health Organization’s 13th General Programme of Work, calling for heightened accountability, and prioritizing measurable outcomes and impact at country level to improve the lives of three billion people.

Evidence-informed decision-making and knowledge translation are two key concepts to the Evidence to Policy and Impact Unit’s work and the Organization’s mission. Evidence-informed decision-making aims to ensure that health policies and programs are informed by the best available research evidence, which is identified and appraised through systematic and transparent processes. Knowledge translation, in turn, emphasizes the synthesis and communication of reliable and relevant research results among the producers and users of research towards effective policy change and health interventions.

Building on successful knowledge translation mechanisms and a global Evidence-Informed Policy Network (EVIPNet) in more than 50 countries, all WHO Regional Offices were invited to share relevant case studies to document some of the facilitators of successful evidence-to-policy translation. The submissions from five WHO Regional Offices in Africa, the Americas, the Eastern Mediterranean, Europe and South-East Asia offer practical lessons on how to take evidence to action across a variety of health topics and through the decades – from a time before EVIPNet had been launched to the recent COVID-19 pandemic.

To respond to the COVID-19 pandemic in Lebanon, the Knowledge to Policy (K2P) Center at the American University of Beirut in early 2020 launched the COVID-19 Series Initiative to inform the pandemic response by harnessing the best available evidence and data, and making it accessible to policymakers, stakeholders and citizens in under thirty days.

In Brazil, the institutionalization of knowledge translation mechanisms in a network of decentralized evidence centres plays a key role in leveraging evidence-informed decision-making for public health policies at local, regional, and national levels. Bridging the

Insights and best practices from successful country initiativesix

country’s vast distances, these evidence centres recently helped improve municipal primary care, address pressing health issues in indigenous communities, and set up a rapid evidence summary series responding to the COVID-19 pandemic.

Tackling the harmful use of alcohol in the Republic of Moldova, a local team of the Evidence-informed Policy Network (EVIPNet) Europe developed and refined an evidence brief for policy, exploring three different regulatory instruments to reduce alcohol consumption with support from the Ministry of Health. The team’s work directly contributed to the Parliament of the Republic of Moldova introducing changes to the alcohol control legislation in September 2017.

In Slovenia, an evidence brief for policy paved the way for improving antimicrobial stewardship in long-term care facilities. The unnecessary use of antibiotics poses additional health risks for vulnerable patients and contributes to the impending global health crisis of increased antimicrobial resistance.

In the Central Sulawesi province of Indonesia, Schistosomiasis infections continue to affect villages and farming communities around Lake Lindu. To develop a comprehensive unified health approach towards eradicating the neglected tropical disease, in 2018 a national team of researchers and government authorities used operational research to shed light on the true scale of the health problem in the region, and held a dedicated policy forum to launch their evidence-driven roadmap.

In Uganda, where drug-resistant malaria parasites continue to pose major challenges to treatment and control strategies, health authorities with support from the WHO, successfully pioneered an evidence-informed decision-making approach to update the national malaria treatment policy. While closely working with clinicians, patients, and communities, policy-makers and implementing partners strongly relied on data on antimalarial resistance from sentinel sites across East Africa directly informing their policy process.

x

In Lebanon, a real-time evidence synthesis service for policy-makers, health authorities and the public supported the COVID-19 response, inlcuding with two publications discussing the efficacy, effectiveness, safety and health risks of different vaccine candidates and the roll-out of vaccination campaigns. Photo: WHO/Blink Media/Hannah Reyes Morales

01

Insights and best practices from successful country initiatives1

Scaling up knowledge translation capacity in Lebanon: The Knowledge to Policy (K2P) Centre’s evidence-informed COVID-19 rapid response service Fadi El Jardali, Racha Fadlallah, Clara Abou Samra (Knowledge to Policy (K2P) Centre, Faculty of Health Sciences, American University of Beirut, Lebanon) Mehrnaz Kheirandish, Ahmed Mandil, Arash Rashidian (WHO Regional Office for the Eastern Mediterranean, Egypt) Contributing to the mulisectoral emergency response to the COVID-19 health crisis in Lebanon, the Knowledge to Policy (K2P) Centre launched a real-time evidence synthesis service for policy-makers, health authorities and the public. The rapid responses, policy briefs and evidence summaries produced by the Centre facilitated evidence-informed decision-making in some key moments of Lebanon’s COVID-19 response.

COVID-19 response at the Rafik Hariri University Hospital in Beirut, the largest public hospital in the country in Lebanon. Photo: WHO/Rony Ziade

Evidence-informed decision-making for health policy and programmes2

Leveraging evidence in a complex health and economic crisis

From early 2020, the COVID-19 pandemic exerted tremendous strain on health-care systems around the world, while lockdowns and confinement measures heavily impeded global economic markets, international travel and social life.

In Lebanon, the pandemic hit in the middle of an ongoing, multifaceted economic and political crisis that was further exacerbated by a devastating explosion in Beirut Port, killing more than 200 people during August 2020 (1).

Despite strict lockdown measures, repeated spikes of COVID-19 infections and a large number of patients requiring intensive care threatened to overburden the country’s fragile health system. As a result of these shocks, more than half of the Lebanese population were estimated to be at risk of falling below the poverty line by mid-2020 (2).

The underlying health issue

• Lebanon was hit hard by recurring spikes of COVID-19 cases and overburdened hospitals in the middle of an ongoing economic and political crisis.

• The global effort to find effective COVID-19 treatments and vaccines led to new and sometimes conflicting evidence being published at a staggering pace, posing a challenge to authorities to base health and confinement measures on the latest recommendations.

• The WHO Regional Office for the Eastern Mediterranean has been supporting a network dedicated to building national knowledge translation capacities for health policy since 2015.

• The WHO Country Office directly supported the COVID-19 Joint UN Plan, developed in line with the COVID-19 National Health Strategic Preparedness and Response Plan, providing leadership and strategic advice, needs estimates, capacity building and filling critical gaps.

The rapid spread of the novel coronavirus and its impact on morbidity and mortality triggered an unprecedented global research and development effort to find effective diagnostics, treatment, and vaccines, with new evidence becoming available nearly every day. This repeatedly led to outdated recommendations and uncertainty over the best available infection prevention and control options. At the same time, health authorities and political leaders found themselves under

Insights and best practices from successful country initiatives3

increasing pressure to make timely and evidence-informed decisions to respond adequately to the pandemic, balancing urgent health and infection control interventions against economic interests to lift confinement measures.

Since 2015, the WHO’s Regional Office for the Eastern Mediterranean has been supporting dedicated knowledge translation initiatives in several countries in the Region. Recognizing the importance of research evidence for health policy-making and to improve community health outcomes, WHO’s Regional Committee for the Eastern Mediterranean passed two resolutions in 2017 (3) and 2019 (4), calling upon Member States to build national institutional capacities and scale up dedicated mechanisms for evidence-informed policy-making as well as research and data to policy and practice translation (5).

One such mechanism is an evidence network hosted by the American University of Beirut in Lebanon since 2015, connecting independent academic research institutions to policy-makers and health system actors. At the core of this network is the K2P Centre, a WHO collaborating centre for evidence-informed policy-making and practice. Supporting the multisectoral response efforts, K2P’s novel rapid response service aimed to bridge the gap between science, policy and politics.

The K2P COVID-19 rapid response series included 20 tailored knowledge translation products. Photo: K2P

Evidence-informed decision-making for health policy and programmes4

A rapid response series putting available evidence in the hands of decision-makers

In mid-March 2020, the K2P Centre proactively launched the COVID-19 Series Initiative with a rapid response service to support policy-makers and national health authorities to take evidence-informed decisions during the pandemic. The service synthesized research evidence and data drawn from systematic reviews and single studies on high-priority topics upon requests from stakeholders and following the latest focus of the political agenda and public media attention, with a delivery time of 3 to 30 days depending on the urgency and scope of the topic.

To develop the rapid response products, the K2P Centre used a systematic and standardized process to prioritize topics, search and synthesize high-quality evidence, and tailor the collected information to the Lebanese context. The K2P Centre also collaborated and engaged with several decision-makers such as COVID-19 committee members and representatives from the Ministry of Public Health, as well as with healthcare professionals and experts such as epidemiologists and virologists to ensure high-quality deliverables and facilitate their dissemination to relevant stakeholders, policy-makers and the public.

Due to the quickly evolving events during the early phase of the COVID-19 pandemic, the rapid response series covered a wide array of topics. Thirty days after the first confirmed COVID-19 case had been reported in Lebanon, the K2P Centre released its first rapid response in late March, urging health actors to reinforce infection prevention and control at national, community and health-care system levels.(̂ 9) Based on a systematic search and review of 294 scientific publications and incorporating the latest recommendations from WHO and the Centres for Disease Control and Prevention (US CDC), the rapid response document detailed a cross-sectional road map for action in support of the Ministry of Public Health’s response strategy.

With COVID-19 case numbers continuing to increase in Lebanon throughout April 2020, another rapid response focused on the crucial role of local municipalities in supporting the government to translate national regulation into practical measures at the local community level (7).

“Knowledge translation platforms supporting evidence-informed policy-making are indispensable for strengthening the preparedness and response capacity of public health systems. It is strategic to continuously support these entities beyond the COVID-19 pandemic, offering a real-time response to different public health issues by utilizing the best available data and research evidence.” Fadi El Jardali, Knowledge to Policy (K2P) Centre

Insights and best practices from successful country initiatives5

Identifying relevant evidence using a systematic online search strategy on PubMed and taking stock of local laws and regulations, the final product assessed and recommended municipal initiatives such as distributing food and sterilization materials to families, educating communities on home quarantine and isolation, or disinfecting streets and meeting areas in towns. In line with the national response plan and

Key steps for evidence-informed decision-making

• A rapid response service summarizing and packaging research evidence and data drawn from systematic reviews and single studies including country reports for contextualization was launched in March 2020, to deliver tailored evidence to policy-makers, health authorities and the public within 3, 10 or 30 days.

• Priority health topics and policy issues were selected based on requests from policy-makers and health actors, as well as on the latest focus of the political agenda and public media attention.

• The rapid response service included rapid responses, briefing notes and evidence summaries in several languages, which were published on the K2P Centre’s public webpage as well as disseminated and shared with all relevant stakeholder organizations.

efforts from other actors, several of these recommendations were integrated into municipalities’ individual COVID-19 response strategies.

As government authorities entered discussions to end lockdown measures in Lebanon in late April, another rapid response synthesized available evidence and country experiences with easing confinement measures while safeguarding public health and responding to an increasing economic and social crisis (8).

In September, a three-part evidence series looked at the clinical features and transmission of COVID-19 in children, impact of school closures and strategies to safely reopen educational institutions (9,10,11).

With several COVID-19 vaccine candidates promising to effectively prevent severe illness in late 2020 and early 2021, the K2P Centre developed two publications discussing the efficacy, effectiveness, safety and health risks of different vaccine candidates and the roll-out of vaccination campaigns in Lebanon.(12,13)

Evidence-informed decision-making for health policy and programmes6

By early 2021, the K2P COVID-19 rapid response series included more than 20 tailored knowledge translation products, including rapid responses, evidence summaries and briefing notes.

Tailored evidence products for the COVID-19 response

Several recommendations identified by the COVID-19 rapid response series were discussed, consulted upon, and submitted to health authorities and partner organizations in Lebanon as well as in the wider Eastern Mediterranean Region, with support from WHO’s Regional Office for the Eastern Mediterranean.

The jointly developed evidence-informed roadmap for Lebanon’s COVID-19 response in March 2020, for example, was launched in a prime-time television interview and actively shared with parliamentarians, policy-makers and representatives of the COVID-19 national committee. The document later fed into the updated national response plan. Stricter social distancing measures were introduced in Lebanon shortly after, matching one of the key recommendations derived from the reviewed evidence.

The rapid response on strategies to exit lockdown measures, was consulted by several national COVID-19 committees, and supported the reopening process in Lebanon. Similarly, the synthesized evidence on COVID-19 vaccines helped authorities shape vaccination planning and were additionally used in support of the informational campaigns about vaccinations in communities and health-care facilities.

Another publication released in May explored how Lebanon and the Eastern Mediterranean Region could sharpen their agenda for digital health, build online platforms, machine learning and artificial intelligence technologies launched during the COVID-19 response (14). The presented evidence built the basis of a widely attended webinar series featuring local, regional and international experts on digital health. Furthermore, several years of active engagement of the WHO Country Office with academic partners and tobacco control experts led to a thematic press conference with the head of the parliamentary health committee in July 2020, where an evidence brief on tobacco control was referenced (15). Shortly after, waterpipe smoking was temporarily banned in restaurants during the peak of COVID-19 cases in Lebanon.

Insights and best practices from successful country initiatives7

In an article published in the British Medical Journal, the experience of running the COVID-19 rapid response series was discussed as a practical approach to further co-producing evidence among researchers and policy-makers, and reflected alongside similar experiences from Germany, Hong Kong and Pakistan (16).

Learning: driving factors and major challenges

• The K2P Centre’s established network and rich previous experience in promoting evidence-informed decision-making with national stakeholders and public audiences proved invaluable to building trust and credibility and provided critical linkages with key actors to launch the rapid response series.

• Keeping track and responding in a timely manner to rapidly changing evidence and priorities at the national level is essential to ensuring the relevance of evidence products and drive relevant policy change.

• Tailoring products to target audience was critical to ensure that messages were acted upon, and supported by further dissemination on social media, television channels, radio and newspapers (17).

• As reaching policy-makers amid lockdown measures was challenging, selected rapid response series documents were printed and sent to the offices of decision-makers, and individual meetings were held. Additional dissemination channels included social media platforms, targeted webinars, radio and TV interviews

• To ensure utilization of evidence in the policy-making process of Lebanon’s strongly polarized political landscape and across opposing political parties (18), the K2P Centre suggested measures for implementation at governance, financing and delivery levels informed by best-available evidence and available data. Remaining objective and politically neutral helped the K2P Centre to maintain its credibility and ensure transparency in generating evidence and recommendations.

• The pandemic presented new opportunities to further co-production of evidence among researchers, policy-makers, and other stakeholders as a way to support timely decision-making process.

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Evidence-informed decision-making for health policy and programmes10

A diabetes patient in Brazil receives insulin at a healthcare facility. In the municipality of Franco da Rocha, EVIPNet Brazil produced an evidence brief for policy to improve diabetic patients’ risk assessments. Photo: WHO/Eduardo Martino

02

Insights and best practices from successful country initiatives11

A countrywide network of evidence centres. Strengthening knowledge translation throughout Brazil’s health system Aurelina Aguiar de Lima, Camile Giareta Sachetti, Daniela Fortunato Rêgo, Keitty Regina Cordeiro de Andrade, Roberta Borges Silva, Marina Melo Arruda Marinho, Virginia Kagure Wachira (Department of Science and Technology, Ministry of Health, Brazil) Laura Boeira (Veredas Institute, Brazil), Maritsa Carla de Bortoli , Tereza Toma, Sonia Venancio (Health Institute, Sao Paulo, Brazil), Sandra Maria do Valle Leone de Oliveira (University of Mato Grosso do Sul, Brazil)

In Brazil, a network of evidence centres plays a key role in leveraging evidence-informed decision-making for public health policies at local, regional, and national levels. Bridging vast distances and a variety of different health issues, recent evidence centre initiatives span from improving municipal primary care to addressing health issues in indigenous communities and a rapid evidence summary series responding to the COVID-19 pandemic.

Patient waiting area at a diabetes centre in Bahia state, Brazil. High prevalence of type 2 diabetes is a health concern in several Brazilian states. Photo: WHO/Eduardo Martino

Evidence-informed decision-making for health policy and programmes12

Connecting evidence to local health issues in a complex health system

In Brazil’s large, universal and decentralized health system, designing evidence-informed health policies and effectively adapting healthcare programmes to local conditions pose a major challenge (19). Healthcare providers and policy-makers at federal, state and municipal levels jointly run the country’s healthcare system in 5 570 municipalities, many working with different managerial, technical, administrative and financial approaches and addressing a wide array of different health issues and social inequalities.

Since 2007, Brazil has been a member of the Evidence-informed Policy Network (EVIPNet) Americas, with the Department of Science and Technology of the Secretariat of Science, Technology, Innovation and Strategic Inputs at the Brazilian Ministry of Health coordinating national evidence-to-policy initiatives. For more than a decade, EVIPNet Brazil has been expanding its activities and reach, strengthening national capacity to produce evidence syntheses and carry out deliberative dialogues for improved public health policies and programmes.

A key driver of scaling evidence-informed decision-making across Brazil has been the implementation of integrated evidence centres, called Núcleos de Evidências (NEvs) in Portuguese. Located in universities or in regional and local health departments, these evidence centres provide technical support to translate research findings into tailored strategies that address local health issues and change relevant municipal, regional, and national public policies.

The underlying health issues

• Healthcare providers and policy-makers in Brazil face a wide array of health and social issues affecting the effective delivery of primary care programmes such as maternal and child health, non-communicable disease programmes, and nutrition in local municipalities and indigenous communities.

• Brazil’s health system is jointly run by national, regional, and local actors in 5 570 municipalities, each working with different technical, administrative and financial systems.

• Evidence centres (Núcleos de Evidências) provide specialized knowledge translation support and capacity building at local, regional, and national levels to tailor evidence-informed decision-making and public health policy processes to the regionally diverse needs.

Insights and best practices from successful country initiatives13

Within the scope of the Institutional Development Support Program of the Unified Health System (PROADI-SUS), the Ministry of Health hosts the executive secretariat of EVIPNet Brazil, and has since 2015 led three editions of a specialization course on evidence-informed decision-making processes in the management of health policies in partnership with the Hospital Sírio Libanês (HSL) (20). Targeting researchers, health managers, policy-makers, and civil society representatives in evidence centres, the course teaches practical skills to apply the SUPPORT-tools

(21) for evidence-informed health policy-making promoted by EVIPNet.

To strengthen the institutionalization and capacity building among members of the Núcleos de Evidências, EVIPNET Brazil adopted a multi-level collaborative configuration, regularly exchanging with evidence centres at national, state and municipality level, and supporting them through public grant calls for the application of evidence syntheses on high priority policy issues.

From improving primary care to tackling health issues in indigenous communities

Through the specialization course and EVIPNet Brazil’s public calls for applied evidence synthesis, several evidence centres all over Brazil successfully initiated knowledge translation and policy change processes.

Participants of the 2019 specialization course on evidence-informed decision-making in São Paulo, January 2019. Photo: Sociedade Beneficente de Senhoras, Hospital Sírio-Libanês (HSL)

Evidence-informed decision-making for health policy and programmes14

In Franco da Rocha, for example, a municipality in the metropolitan region of São Paulo, the Health Institute of São Paulo and the Franco da Rocha Health Department collaborated in 2014 to improve the local primary care system. The process started with diagnosing the local health system and reviewing municipal health priorities through data sourced from public information systems and field interviews. Based on this initial assessment, local health managers identified high maternal mortality rates, an increase in diabetes prevalence, and a high number of psychotropic medication prescriptions as the most pressing health issues.

On all three topics, the team produced dedicated evidence briefs for policy (22,23,24), and held three dedicated policy dialogues with health professionals, senior management of health facilities, researchers and local partners. The evidence-informed discussion of policy options and implementation considerations in the context of Franco da Rocha led to a series of workshops and discussion groups with healthcare professionals and medical staff, aiming to improve diabetic patients’ risk assessment, extend health professionals’ knowledge on reproductive and sexual health, and discuss mental health promotion strategies.

Key steps for evidence-informed decision-making

• EVIPNet Brazil supports the evidence centres (Núcleos de Evidências) across the country through training and regular grant calls for the application of evidence syntheses in local settings.

• In Franco da Rocha as well as the states of Maranhão and Tocantins, local evidence and community perspectives were sourced through field interviews and workshops to pinpoint the initial problem framing.

• Thematic evidence summaries and evidence briefs for policy on maternal health, diabetes care, psychotropic medication, iron deficiency and beriberi built the basis for respective policy dialogues with local stakeholders.

• To facilitate evidence-informed decision-making on health issues in Brazil’s indigenous communities in one region, the PROGRESS framework was used to put special attention on health equity.

In another of EVIPNet Brazil’s call for applied evidence synthesis, the Veredas Institute received a grant to develop evidence summaries and facilitate stakeholder dialogues on health priorities within the Brazilian indigenous population in 2017. The civil society organization’s original

Insights and best practices from successful country initiatives15

proposal focused on the high prevalence of iron deficiency among women and children, a major health issue identified through literature review and in consultation with representatives of an Indigenous Health District in the North of the country.

With several indigenous community groups living in different regions of Brazil, the first stage of the knowledge translation process, however, required validation of this problem framing with a larger group of stakeholders, including policymakers, healthcare professionals and indigenous leaders. Shortly after, the Secretary of Indigenous Health at the Ministry of Health put forward the equally pressing issue of beriberi-related deaths, a disease caused by vitamin B1 deficiency with high prevalence in three northern Brazilian states. The states of Maranhão and Tocantins were selected to pilot the evidence synthesis and deliberative dialogue processes, and a team from the Veredas Institute visited both states to organize a workshop on evidence-informed health policymaking for local partners and indigenous community leaders.

Multiple causes of iron deficiency and beriberi were identified during these dialogues, including food insecurity and flour-based nutrition, excessive alcohol-consumption, and poor sanitation resources in villages. The team then assessed individual views and perspectives of representatives of all 34 Indigenous Sanitary Districts in Brazil through an online survey. Based on the survey results, two evidence briefs were prioritized, discussing strategies on how to prevent and treat iron deficiency and eradicate beriberi among the indigenous population.

Both evidence summaries specifically addressed malnutrition as a major contributor to the problem, yet only limited evidence was available on implementing nutrition programmes in Brazilian indigenous populations. The Veredas Institute therefore repeated the two initial dialogue meetings with indigenous community representatives, discussing implementation barriers and facilitators, and ensuring policy options were sensitive to local beliefs, values and practices. Using the PROGRESS Framework (25), a method explicitly considering an inherently unfair difference in disease burden, the dialogues also focused on equity of implementation options across different indigenous communities.

“Setting-up evidence centers was instrumental in the institutional development of the Brazilian Unified Health System´s capacity in evidence-informed policy-making. We keep investing into regulatory improvements to further institutionalize these policy processes, introduce methodological standards, and build health managers’ skills in developing evidence-informed communication strategies.” Daniela Rêgo Department of Science and Technology, Brazilian Ministry of Health.

Evidence-informed decision-making for health policy and programmes16

Successful evidence synthesis and policy dialogues at multiple levels

In Franco da Rocha, the evidence syntheses and policy dialogues led to the development and implementation of new local guidelines on health-care provision and mental health. On the initiative of local and federal health actors, several additional evidence summaries have since been produced, tackling early childhood promotion, sickle cell disease, caesarean section rates, prescription errors, antimicrobial resistance, and emergency department overcrowding.

The evidence briefs on iron and vitamin deficiencies in indigenous communities in Maranhão and Tocantins states were used by the Ministry of Health’s Secretariat of Indigenous Health to adapt respective national policies and closely monitor the ongoing knowledge translation process. In both states, the policy dialogues also offered an opportunity to broadly raise awareness and rally support to address malnutrition and alcohol abuse with communities and local partners.

Illustrated pages from the product portfolio of the evidence production service to support decision-making, issued in 2020. Photo: Gabriel A. R. de Paula

Insights and best practices from successful country initiatives17

Across Brazil, fifteen Núcleos de Evidências have been launched since 2015 at municipal, regional and national levels, with members including health professionals, academics, university students, and civil servants in health departments. In a recent institutional assessment conducted by EVIPNet Brazil, all evidence centres demonstrated sound skills in acquiring and evaluating evidence for health policy-making, while a need for additional capacity building in adapting and applying evidence to local context was identified (26).

Learning: driving factors and major challenges

• Institutionalized evidence centres and targeted capacity building play a key role in expanding and maintaining knowledge translation capacity and evidence-informed decision-making throughout Brazil’s large and decentralized health system.

• Successful evidence syntheses and policy dialogues rely on ample communication space and feedback processes with health managers, allowing for a detailed understanding of their needs and implementation options.

• The systematic integration of evidence centres into policy processes, and, vice versa, institutionalizing regular demand from decision-makers for evidence in public health policy-making remain challenging.

• Lack of funding, as well as missing skills in applying evidence to different political and technical scenarios and effectively communicating research findings to recommend actions at the local level pose additional barriers to evidence-informed decision-making for improved health policies in Brazil.

More than 900 specialists from all regions of Brazil were trained in evidence-informed policymaking in the three editions of the specialization course organized by the Ministry of Health and the Hospital Sírio Libanês since 2015, and 49 evidence syntheses on local health issues were elaborated in the 2020 edition of the course alone.

Over the course of 2020, the Núcleo de Evidências established at the national Department of Science and Technology of the Ministry of Health produced 95 rapid evidence syntheses in response to the COVID-19 pandemic, as well as addressing different technical areas within the Ministry’s responsibility. In the same year, the centre issued guidelines for evidence synthesis for policy for researchers and members of other evidence centres, additionally standardizing network best practices (27).

Evidence-informed decision-making for health policy and programmes18

References

19. Brasil, Ministério da Saúde, Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Evidências científicas: informação para a gestão. [Scientific evidence: information for management.] Rev Saude Publica. 2009;43(2):1084–5 (in Portuguese) (https://www.scielo.br/j/rsp/a/gDNrZq9kDTVpKfg3qJ5nW5z/?lang=pt&format=pdf, accessed 4 August 2021).

20. Silvio Fernandes da Silva et al. Gestão de políticas de saúde informadas por evidências 2018�2020 [Evidence-informed health policy management 2018�2020]. São Paulo: Hospital Sírio-Libanês: Ministério da Saúde; 2018:4 (Projetos de Apoio ao SUS, 47) (in Portuguese).

21. Lavis JN, Oxman AD, Lewin S, Fretheim A. SUPPORT tools for evidence-informed health policymaking (STP). Health Res Policy Sys. 2009;7:I1 (2009) (https://doi.org/10.1186/1478-4505-7-S1-I1, accessed 4 August 2021).

22. Brasil Ministério da Saúde Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia. Síntese de evidências para políticas de saúde : controle da diabetes mellitus tipo 2 no município de Franco da Rocha [Evidence brief for policy: type two diabetes mellitus control in Franco da Rocha, Brazil]. Brasília: Ministério da Saúde; 2016 (in Portuguese) (https://pesquisa.bvsalud.org/evipnetbr/resources/repository-548, accessed 4 August 2021).

23. Brasil Ministério da Saúde Secretaria de Ciência, Tecnologia e Insumos Estratégicos Departamento de Ciência e Tecnologia, EVIPNet

Brasil. Reduzindo prescrições inapropriadas ou desnecessárias de antidepressivos. Uma síntese de evidências para a política de saúde [Reducing inappropriate or unnecessary prescriptions for antidepressants. A synthesis of evidence for health policy]. Brasília: Ministério da Saúde; 2016 (in Portuguese) (http://bvsms.saude.gov.br/bvs/publicacoes/sintese_evidencias_politicas_saude_antidepressivos.pdf, accessed 4 August 2021).

24. Brasil Ministério da Saúde Secretaria de Ciência, Tecnologia e Insumos Estratégicos Departamento de Ciência e Tecnologia, EVIPNet Brasil. Síntese de evidências para políticas de saúde: reduziindo a mortalliidade materna. [Evidence synthesis for health policies: reducing maternal mortality.]. Brasília: Ministério da Saúde; 2016 (in Portuguese) (http://bvsms.saude.gov.br/bvs/publicacoes/sintese_evidencias_politicas_mortalidade_materna.pdf, accessed 4 August 2021).

25. O’Neill, J, Tabish H, Welch V, Petticrew M, Pottie K, Clarke M et al. Applying an equity lens to interventions: using progress ensures consideration of socially stratifying factors to illuminate inequities in health. J Clin Epidemiol. 2014;67(1):56–64.

26. de Oliveira SMDVL, Bento AL, Valdes G, de Oliveira STP, de Souza AS, Barreto JOM. Institucionalização das políticas informadas por evidências no Brasil [Institutionalizing evidence-based policies in Brazil Institucionalización de las políticas informadas por evidencia]. Rev Panam Salud Publica. 2020;44:e165. doi:10.26633/RPSP.2020.165 (in

Insights and best practices from successful country initiatives19

Portuguese) (https://iris.paho.org/bitstream/handle/10665.2/53138/v44e1652020.pdf, accessed 4 August 2021).

27. Brasil Ministério da Saúde Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde. Departamento de Ciência e Tecnologia. Diretriz metodológica : síntese de evidências para políticas [recurso eletrônico] [Methodological guideline: synthesis of evidence for policies].Brasília: Ministério da Saúde; 2020 (in ortuguese),(http://bvsms.saude.gov.br/bvs/publicacoes/diretriz_sintese_evidencias_politicas.pdf, accessed 4 August 2021).

Evidence-informed decision-making for health policy and programmes20

Following wide dissemination of an evidence brief for policy on the harmful use of Alcohol, the Parliament of the Republic of Moldova introduced changes to the alcohol control legislation. Photo: WHO/Sergey Volkov

03

Insights and best practices from successful country initiatives21

Retail regulation, advertising bans or increased taxation? Reducing the harmful use of alcohol in the Republic of Moldova Marcela Ţîrdea, Ministry of Health, Labour and Social Protection of the Republic of MoldovaAngela Ciobanu, World Health Organization Regional Office for Europe

In the Republic of Moldova, harmful use of alcohol is a major public health concern, not only among adults but also among children and adolescents. With support from the Ministry of Health, a local team of the Evidence-informed Policy Network (EVIPNet) Europe developed and refined an evidence brief for policy, exploring three different regulatory instruments to reduce alcohol consumption. The brief was presented to key stakeholders at two policy dialogues organized in 2016 and 2017, and directly supported changes to the alcohol control legislation introduced by the Moldovan Parliament in September 2017.

A kiosk selling alcohol, cigarettes, and other miscellaneous items in the Republic of Moldova. Harmful use of alcohol is a major public health concern in the country, including among the adolescent population. Photo: WHO/Tina Charlotte Kiaer

Evidence-informed decision-making for health policy and programmes22

The underlying health issue

• Harmful use of alcohol is a major contributor to the disease burden in the Republic of Moldova. • An alarming number of children and adolescents reported that they had easy access to alcoholic

beverages and drank regularly. • Alcoholic beverages are highly affordable and widely advertised in Moldova, and beer and wine were

exempt from regulations on alcoholic beverages until 2017.

“The evidence brief for policy allowed us to convincingly communicate evidence on the harmful use of alcohol in Moldova with other public authorities and civil society partners. It also helped us to convene key decision-makers for policy dialogues, which led to a change in legislation.”

Marcela Ţîrdea, Ministry of Health, Labour and Social Protection

Harmful use of alcohol: a pressing health issue with multiple policy options

Alcohol consumption levels in the Republic of Moldova are among the highest in the WHO European Region, reaching 12.3 L of pure alcohol per capita in 2015 (28). Nearly 70% of the population consumes wine, 19% drinks beer, 8% of the population aged 16–55 years reportedly consumes strong alcoholic beverages, and one in five alcohol consumers aged 18–69 years are episodic heavy drinkers (29,30).

Alcohol consumption rates among young people and adolescents are equally alarming, and nearly half of pupils in the eighth and ninth grades reported that they were able to access at least one alcoholic beverage easily (31). In 2014, 28% of children aged 11 years, 43% of children aged 13 years, 73% of children aged 15 years and 82% of adolescents aged 17 years had consumed alcohol at least once in their lifetime (32).

Alcohol contributes substantially to the disease burden in the Republic of Moldova. In 2010, 10% of deaths in the country were related to heavy alcohol consumption, a percentage more than double the global average. Countrywide, around 56% of deaths from liver cirrhosis, 9% of cancer deaths, 25% of deaths from cardiovascular disease and 51% of violent acts and unintentional injuries, including traffic accidents, are attributable to alcohol consumption (33,34).

,

The Republic of Moldova is a wine-producing country with a large and well-established alcohol-producing industry. Its representatives lobby to influence policy decision-making, particularly about the availability and affordability of alcoholic beverages. As a result, beer and wine were exempt from the regulations relating to the production and circulation of ethyl alcohol and alcoholic products until 2017 (35), allowing for restriction-free, round-the-clock retail sales in the country.

Insights and best practices from successful country initiatives23

Alcoholic beverages are also widely advertised in the Republic of Moldova, and existing legislation prohibits only the direct depiction of alcohol consumption, indirect advertising intended for minors, and advertising in institutions for children, educational institutions and medical facilities (36).

Compared to other countries in the WHO European Region, the esti-mated average retail prices of alcoholic beverages are among the lowest for spirits, in the mid-range for beer, and among the highest for wine (37).

From a multitude of evidence to three tangible policy recommendations

To tackle the pressing health issues caused by insufficient regulation and harmful use of alcoholic beverages, the Moldovan Ministry of Health in 2016 commissioned an evidence brief for policy (EBP) to support a draft law on alcohol control policies. To define the brief’s thematic focus, an open consultation process was held under the leadership of the deputy minister in charge of health-care services and the deputy minister in charge of public health.

With technical and capacity-building support from the Evidence-informed Policy Network (EVIPNet) Europe and its focal point in Moldova, a dedicated working group comprising representatives from the Ministry of Health, Labour and Social Protection, and the State University of Medicine and Pharmacy started developing the evidence brief.

The brief was designed to present three main policy options to tackle the harmful use of alcohol. Regulating retail sales of alcoholic beverages by limiting trading hours, establishing a retail licensing system, or increasing the minimum legal drinking age are known to limit alcohol consumption effectively, and offered a first policy option (38,39).

Key steps for evidence-informed decision-making

• Regulating retail pricing, limiting trading hours and raising legal buying age for alcoholic beverages, advertising bans, and increasing excise duties were identified as promising policy options.

• For each policy option, an in-depth review of the available evidence was conducted and the benefits, risks and barriers reflected in view of implementation in Moldova.

Evidence-informed decision-making for health policy and programmes24

Restricting or banning advertisements for alcoholic beverages was explored as a second option, which, however, often requires additional secondary preventative measures (40). Regulating excise taxation and pricing of alcoholic beverages offered a third policy option, which has proven to be cost–effective in several countries (41,42).

For each policy option, the working group conducted a review of both scientific works and the relevant grey literature, prioritizing recent publications and evidence focusing on the Republic of Moldova. Following EVIPNet’s framework for evidence briefs for policy, the reviewed evidence was then summarized to directly inform the health and regulatory problems at hand, framing the three policy options and exploring benefits, potential harm, costs and cost-effectiveness, equity, monitoring and evaluation strategies, as well as implementation considerations for each option in the Moldovan context.

For the policy option of limiting trading hours for alcoholic beverages, for example, one systematic review concluded that shortening hours for alcohol sales could significantly decrease the rate of violence and damage caused by excessive alcohol consumption, while another study suggested that illegal alcohol production could increase as a result. On advertising bans, one cross-sectional study established that stricter regulations on the marketing of alcoholic products are associated with a lower prevalence of hazardous alcohol consumption, yet similar legislation in Lithuania showed that such bans are effective only when they include systematic monitoring of the influence of the alcohol industry on legislation. Similarly, several studies identified price policy as a highly cost-effective control mechanism to decrease alcohol-related morbidity and mortality, while higher alcohol prices have reportedly also caused consumers to substitute products and led to alcohol smuggling.

The 2017 policy dialogue meeting led to changes in the alcohol control legislation. Photo: WHO Moldova Country Office

Insights and best practices from successful country initiatives25

A first version of the brief was finalized and presented as part of a national policy dialogue conducted in November 2016. The structured discussion of available evidence and possible policy options among national stakeholders led to refining of the problem definition, focusing on closing evidence gaps and improving legislation before tackling the implementation of regulatory alcohol control instruments. With mentoring from the Knowledge to Policy (K2P) Center in Lebanon, and in close collaboration with the WHO Secretariat of EVIPNet Europe, an amended policy brief (43) was prepared by the EBP team, and presented and discussed at a second policy dialogue meeting in August 2017.

During both policy dialogues, inputs from participating policy-makers, local public health authorities and civil society representatives, including youth organizations, provided valuable additional insights into improving and enforcing alcohol control regulation. A small survey from one region (44), for example, revealed that adolescents and teenagers have much easier access to purchasing alcoholic beverages than anticipated by national health authorities.

Learning: driving factors and major challenges

• A strong lack of reliable local evidence, modest experience with conducting policy dialogues and poor cooperation between policy-makers and the research community posed major systemic challenges during the development of the evidence brief.

• Industry lobbying caused interference in the public health policy-making process, with the criticism that the used evidence did not reflect the economic and health benefits of alcoholic beverages.

• Actively sharing and promoting the evidence brief among policy-makers and partners led to increased recognition of the problem, and improvement in health authorities’ reputation with partners in applying evidence-informed decision-making.

• Involving nongovernmental organizations in policy dialogues and disseminating the evidence brief influenced the opinion of policy-makers.

• Open access to relevant global evidence through the HINARI platform proved invaluable for countering the scarce availability of local evidence.

Evidence-informed decision-making for health policy and programmes26

Policy dialogues, changed legislation and high-level interest in alcohol control

Reflecting benefits alongside risks and the remaining evidence gaps, and highlighting implementation barriers next to possible mitigation strategies, the final evidence brief fostered dialogue among decision-makers and key stakeholders.

Supported by the policy dialogues and following wide dissemination of the evidence brief, the Parliament of the Republic of Moldova introduced changes to the alcohol control legislation in September 2017, legally recognizing beer as an alcoholic product and prohibiting any form of advertising of alcohol production, with the exception of grape wine. In 2019, excise taxation was increased on alcoholic beverages, including beer, and took effect from early 2020. Building on the experience and success of the brief and policy dialogues on the harmful use of alcohol, the EVIPNet team has since started to work on several new evidence briefs for policy, tackling other pressing public health challenges in the Republic of Moldova.

28. Global Information System on Alcohol and Health

(GISAH) [online database]. Geneva: Word Health

Organization; 2021 (https://www.who.int/data/gho/

data/themes/global-information-system-on-

alcohol-and-health, accessed 4 August 2021).

29. Ministry of Health, Labour and Social Protection.

KAP survey – knowledge, attitudes and practices

regarding alcohol consumption. Phase I, phase II and

phase III. Chișinău: Magenta Consulting; 2015.

30. Prevalence of noncommunicable disease risk factors

in the Republic of Moldova. STEPS 2013. Copenhagen:

WHO Regional Office for Europe; 2014 (https://www.

euro.who.int/__data/assets/pdf_file/0009/252774/

PREVALENCE-OF-NONCOMMUNICABLE-DISEASE-

RISK-FACTORS-IN-THE-REPUBLIC-OF-MOLDOVA-

STEPS-2013.pdf, accessed 4 August 2021).

31. National Centre for Health Management, EMCDDA.

Alcohol, drugs and tobacco use among students

in 8th and 9th grades, Republic of Moldova 2015.

Chișinău: Ministry of Health, Labour and Social

Protection of the Republic of Moldova; 2016 (http://

www.emcdda.europa.eu/attachements.cfm/

att_249296_EN_ENP%20ESPAD%20final%20report_

Moldova.pdf, accessed 4 August 2021).

32. Lesco G. Behavioral and social determinants of

adolescent health. Summary report of the Health

Behavior in School-aged Children (HBSC) study in

the Republic of Moldova. Chișinău: United Nations;

2015 (http://www.md.undp.org/content/dam/unct/

moldova/docs/pub/HBSC%20report%20Moldova%20

en.pdf, accessed 4 August 2021).

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Insights and best practices from successful country initiatives27

33. Shield KD, Rylett M, Rehm J. Public health successes

and missed opportunities. Trends in alcohol

consumption and attributable mortality in the WHO

European Region, 1990–2014. Copenhagen: WHO

Regional Office for Europe; 2016 (https://www.euro.

who.int/__data/assets/pdf_file/0018/319122/Public-

health-successes-and-missed-opportunities-

alcohol-mortality-19902014.pdf, accessed 4 August

2021.

34. IHME. GBD compare. Viz hub [online database].

Seattle (WA): Institute for Health Metrics and

Evaluation (http://vizhub.healthdata.org/gbd-

compare/, accessed 4 August 2021).

35. Article 3(2) of Law No. 1100-XIV of 30 June 2000. [On

the manufacture and circulation of ethyl alcohol and

alcoholic production] (https://www.legis.md/cautare/

getResults?doc_id=108521&lang=ro#, accessed 4

August 2021). (In Romanian)

36. According to Article 19(1) of Law No. 1227-XIII of

27 June 1997. [On advertising] (https://www.legis.

md/cautare/getResults?doc_id=109228&lang=ro;

accessed 4 August 2021). (In Romanian)

37. Tenth European status report on alcohol and health

2014. Pricing policies. Copenhagen: WHO Regional

Office for Europe; 2014 (http://www.euro.who.int/__

data/assets/pdf_file/0003/244902/Pricing-policies.

pdf, accessed 4 August 2021).

38. Sassi F, editor. Tackling harmful alcohol use:

economics and public health policy. Paris: OECD

Publishing; 2015 (https://www.oecd.org/health/

tackling-harmful-alcohol-use-9789264181069-en.

htm, accessed 4 August 2021).

39. Global status report on alcohol and

health 2014. Geneva: World Health

Organization; 2014 (http://apps.who.int/iris/

bitstream/10665/112736/1/9789240692763_eng.

pdf?ua=1, accessed 4 August 2021).

40. Siegfried N, Pienaar DC, Ataguba JE, Volmink J,

Kredo T, Jere M et al. Restricting or banning alcohol

advertising to reduce alcohol consumption in adults

and adolescents. Cochrane Database Syst Rev.

2014;(11):CD010704.

41. Anderson P, Chisholm D, Fuhr DC. Effectiveness and

cost-effectiveness of policies and programmes

to reduce the harm caused by alcohol. Lancet.

2009;373(9682):2234–2246 (https://www.ncbi.nlm.nih.

gov/pubmed/19560605, accessed 4 August 2021).

42. Cook WK, Bond J, Greenfield TK. Are alcohol

policies associated with alcohol consumption

in low and middle-income countries? Addiction.

2014;109(7):1081–90 (https://www.ncbi.nlm.nih.gov/

pmc/articles/ PMC4107632/, accessed 4 August 2021).

43. Evidence Brief for Policy. Informing amendments to

the alcohol control legislation directed at reducing

harmful use of alcohol in the Republic of Moldova.

Chisinau: WHO Regional Office for Europe, EVIPNet

Europe; 2019. (https://www.euro.who.int/en/countries/

republic-of-moldova/publications/evidence-brief-

for-policy-informing-amendments-to-the-alcohol-

control-legislation-directed-at-reducing-harmful-

use-of-alcohol-in-the-republic-of-moldova-2019,

accessed 4 August 2021).

44. Centrul de Sănătate Publică Orhei (2016). Cunoștințe,

atitudini și practice ale tinerilor din raionul Orhei

în ceea ce privește consumul de alcool, tutun și

droguri. Studiu de evaluare. [Knowledge, attitudes

and practices of young people in Orhei district

regarding the consumption of alcohol, tobacco and

drugs. Evaluation study] Chișinău, internal report. (In

Romanian) The report can be accessed at this link

https://ansp.md/publicatii/

Evidence-informed decision-making for health policy and programmes28

In many Slovene long-term care facilities like this retirement home, prescription of broad-spectrum antibiotics without appropriate diagnosis increases the risk of antimicrobial resistance. An evidence brief for policy (EBP) explored options to improve antimicrobial stewardship. Photo: Dusan Bozic

04

Insights and best practices from successful country initiatives29

The peril of broad-spectrum antibiotics: antimicrobial stewardship in long-term care facilities in Slovenia Maja Subelj and Polonca Truden-Dobrin, National Institute of Public Health, Slovenia

Physicians in Slovene retirement and nursing homes often prescribe broad-spectrum antibiotics without appropriate diagnosis or microbiological testing to treat residents presenting with health complications caused by infections. Used unnecessarily, these antibiotics pose additional health risks for vulnerable patients and contribute to increased antimicrobial resistance. A local team of the Evidence-informed Policy Network (EVIPNet) Europe worked with the Ministry of Health and key actors of the health sector to develop an evidence brief for policy (EBP) on improving antimicrobial stewardship in long-term care facilities.

In Slovenia, primary care physicians often prescribe antibiotics without using microbiological diagnostics, which can contribute to increased antimicrobial resistance. Photo: D Bozic.

Crucial infection prevention and control in Slovenia’s long-term care facilities

In Slovenia, more than 20 000 elderly people live in long-term care facilities such as retirement and nursing homes. Ninety-eight such facilities offer care and hospitality services across the country, and

Evidence-informed decision-making for health policy and programmes30

many larger structures are home to several hundred residents (A, 45). The large number of residents sharing an enclosed living environment and their frequent contact with family members, caregivers, staff and external health-care providers pose substantial challenges to infection prevention and control. Infections with resistant microorganisms and subsequent treatment complications are common, and vulnerable residents with frequent chronic diseases and weaker immune systems are particularly prone to high infection rates (46,47).

Recognizing and correctly diagnosing these infections is often complex. Not all patients present with specific symptoms, and laboratory testing capacities and specialized care are rarely available on site (48,49). As a result, primary care physicians often prescribe antibiotics without using microbiological diagnostics (59,51), and without indication, choice, dose or duration of therapy. This practice of empirical prescription leads to unnecessary use of antibiotics, can cause adverse drug events and contributes to increased antimicrobial resistance.

While the prevalence of antibiotic use in Slovenia’s long-term care facilities was reported at a relatively low 2.4% in 2016, most patients in long-term care facilities received combined amoxicillin and clavulanic acid and fluoroquinolones, two broad-spectrum antibiotics known to be associated with increased resistance patterns. Approximately one in five residents who received antibiotics were reportedly colonized with multidrug-resistant microorganisms, yet microbiology tests to determine the correct treatment were used only very rarely (54). One effective tool in the global fight against antimicrobial resistance are stewardship programmes promoting the responsible use of antimicrobials through evidence-based interventions at health-system or health-care facility level. These programmes often include training

The underlying health issue

• Due to high infection rates and suboptimal microbiological testing, empirical prescription of broadband-spectrum antibiotics is common in long-term care facilities in Slovenia, contributing to an increase in multidrug-resistant microorganisms.

• Antimicrobial stewardship programmes have proven effective in reducing unnecessary use of antibiotics and antimicrobial resistance, yet there is only limited local evidence on their feasibility and effectiveness in long-term care facilities.

A The largest care facility is home

to more than 800 residents, and

the national average is estimated

at 200 residents per facility.

Insights and best practices from successful country initiatives31

on diagnosing and treating patients with the right medication, limiting the availability of drugs to specific physicians, or introducing rapid microbial testing, measuring inflammatory markers and transitioning to computerized patient records for improved monitoring (53).

In Slovenia, several antimicrobial stewardship components have been successfully deployed in health clinics and hospitals. For implementation in long-term care facilities, health authorities, however, lacked detailed local evidence on the feasibility and effectiveness of these programmes in retirement and nursing homes.

Strategic partners and key components of effective antimicrobial stewardship

The Ministry of Health of Slovenia commissioned an evidence brief for policy in early 2017 to strengthen its capacity for evidence-informed policy-making on antimicrobial stewardship in long-term care facilities. In a first step, stakeholder mapping helped to identify relevant policy-makers, specialists in antimicrobial resistance and health system actors, including managers and service providers in long-term care facilities and representatives from professional associations.

An interdisciplinary working group was then formed, comprising representatives from the Ministry of Health, Health Insurance Institute of Slovenia, National Institute of Public Health, National Laboratory of Health, Environment and Food, and Institute for Microbiology and Immunology. The WHO Secretariat of EVIPNet Europe, in collaboration with colleagues from the Control of Antimicrobial Resistance Programme at the WHO Regional Office and the WHO Country Office, provided hands-on technical support, and a steering committee of high-level thematic experts advised on the inclusion of relevant evidence and implementation aspects. With guidance from the steering committee, the working group started to develop the brief by conducting a problem-framing and priority-setting exercise and drafting the problem definition using recent local research evidence.

A literature review covering global research findings and contextual evidence then allowed mapping the known causes and consequences of antimicrobial resistance in long-term care facilities as well as successful strategies to limit empirical prescription of antibiotics such as stewardship programmes. This review process focused on

“Evidence-informed policy-making is powerful because it builds the bridge from public health research to clinical practice. To be effective in Slovenia, we are working to make tools like the evidence brief for policy part of a permanent knowledge transfer platform.”

Maja Subelj National Institute of Public Health

Evidence-informed decision-making for health policy and programmes32

recently published evidence and interventions with the potential to scale up in Slovenia’s health- and social-care system, and prioritized research findings reflecting equity for people with physical and sensory disabilities, impaired cognitive function or limited mobility. The resulting evidence brief for policy (54) evolves around three main policy options with promising potential to tackle antibiotic prescribing practices in Slovene long-term care facilities.

Increased surveillance, monitoring and auditing of antibiotic use and antimicrobial resistance are key components of antimicrobial stewardship programmes globally and were identified as a first policy option. With most studies focusing on hospital-level care, only limited evidence was available on implementing surveillance strategies in long-term care facilities, where reports on resistance patterns are recommended to be shared with nursing staff, administration personnel and health-care professionals regularly (55). Furthermore, the available data from Slovene retirement and nursing homes merely provided an incomplete picture of the true scale of empirical antibiotic use (52),

In many stewardship programmes, dedicated guidelines and clinical pathways to improve the diagnosis and treatment of infections have successfully decreased inappropriate antibiotic prescribing. Yet most available evidence on this second policy intervention assesses guidelines and clinical pathways as part of multifaceted stewardship programmes, making it difficult to conclude on the effectiveness of specific components (56). The literature additionally suggests that guidelines should be developed jointly with health-care professionals so that they apply to their respective work environment, and include diagnostic criteria for common infections (55).

The third policy option looked at establishing continuing education programmes for medical personnel and providing health information on antimicrobial resistance for residents, patients and family members. Training physicians on the correct prescription of narrow- and broad-spectrum antibiotics, as well as on diagnosing specific conditions and differentiating viral from bacterial infections is known to facilitate the appropriate use of antibiotics (57,58). As physicians are often confronted with patients who are unaware of antimicrobial resistance and demand antibiotics unnecessarily, such training activities, however, also need to be accompanied by improved patient information campaigns (55).

Insights and best practices from successful country initiatives33

Multisectoral stakeholders participated at the policy dialogue meeting in 2018. Photo: WHO

For each of these policy options, the evidence brief for policy also discusses implementation considerations in long-term care facilities. The well-developed primary health care in Slovene retirement and nursing homes promised to deliver a head start for improved antimicrobial stewardship. Nonetheless, a need for additional financial and staffing resources was identified. Data gaps on local antibiotic use and antimicrobial resistance patterns, as well as a lack of technical knowledge and laboratory capacity to set up reliable surveillance systems, were identified as additional implementation barriers.

Key steps for evidence-informed decision-making

• Stakeholder mapping helped to identify relevant policy-makers, experts in antimicrobial resistance and health system actors to support the development of an evidence brief for policy.

• The evidence brief for policy synthesizes global and local evidence on three key components of successful antimicrobial stewardship programmes, including surveillance, monitoring and audit; diagnostic and treatment guidelines; and training for medical personnel paired with targeted information for residents and their caretakers.

• Each programme component was additionally assessed for feasibility in Slovene long-term care facilities through dialogues and individual consultation, exploring facilitators and implementation barriers with residents, medical personnel and within the wider health system.

Evidence-informed decision-making for health policy and programmes34

The final evidence brief for policy was presented and discussed at a policy dialogue meeting organized in November 2018. Participants included health policy-makers, representatives from long-term care facilities, infectious disease specialists and nursing care professionals, as well as insurance representatives and professional associations. The meeting offered a crucial forum for raising awareness on the issue of antimicrobial resistance in long-term care facilities and planned implementation of the outlined policy options.

Stepping stones to reducing antimicrobial resistance and improving antibiotic use

Building on the evidence brief and following the policy dialogue meeting, several antibiotic stewardship programme components were identified for implementation in Slovene long-term care facilities and incorporated into the 2019–2024 One Health National Action Plan and Strategy on Antimicrobial Resistance (59).The Action plan covers monitoring antimicrobial drug consumption and health-care-associated infections in elderly residents, updating recommendations for prescription of antibiotics, as well as recurring training sessions for physicians and health workers in long-term care facilities.

The evidence-informed decision-making and policy process towards tackling antimicrobial resistance in Slovene long-term care facilities additionally received much acclaim from regional and international health actors, policy-makers and researchers. The local EVIPNet team presented key evidence from the brief to the Standing Committee of the Regional Committee for Europe, and at the annual meeting of the European Union on joint action on antimicrobial resistance and health-care-associated infections. The brief was also used in a training and teaching session on evidence-informed policy-making at the Faculty of Medicine of the University of Ljubljana.

Addressing some of the identified implementation barriers such as staff shortages in long-term care facilities, the EVIPNet team organized another meeting in 2019 with partners and physicians working in long-term care, planning to develop new guidelines for antimicrobial management in institutional care for the elderly.

Insights and best practices from successful country initiatives35

In 2021, the evidence brief for policy on antibiotic prescribing in long-term care facilities for the elderly was included in a publication honouring achievements in public health on the occasion of Slovenia’s EU presidency (60).

Learning: driving factors and major challenges

• Early and continued involvement of stakeholders in the development of the evidence brief and the related policy dialogue secured their investment in the process and strengthened the cooperation between researchers and policy-makers.

• The direct participation of the Ministry of Health facilitated putting policy options on the political agenda, while support from WHO ensured a systematic and transparent process of evidence-informed decision-making and policy development.

• Missing local evidence from long-term care facilities, a common lack of experience with evidence-informed decision-making, and a fast-paced policy-making approach in Slovenia posed major challenges to the process of preparing the evidence brief for policy.

• Knowledge translation tools such as evidence briefs and policy dialogues are key to fully implementing important public health activities such as antimicrobial stewardship programmes in Slovenia and should be institutionalized to tackle other health issues as well

45. Point prevalence survey of healthcare-associated

infections and antimicrobial use in European

long-term care facilities. May–September 2010.

Stockholm: European Centre for Disease Prevention

and Control; 2010 (https://www.ecdc.europa.eu/

en/infectious-diseases-public-health/healthcare-

associated-infections-long-term-care-facilities-0,

accessed 4 August 2021).

46. Kotnik Kevorkijan B, Skok P, Saletinger R. Infections

in nursing homes for the elderly. In: Angeleski H,

Baklan Z, Beović B, editors. Pristop k starostniku z

okužbo F. [Approach to the elderly with an infection]

10. Bedjaničev simpozij/strokovno srečanje z učnimi

delavnicami, 29 –30 Maj 2015, Maribor, Slovenija

F10th Bedjanič’ [10. Symposium/expert meeting

with training workshops, 29–30 May 2015, Maribor,

Slovenia. Maribor: Maribor University Medical Centre;

137–47.] (In Slovenian)

47. Chesley LR. Infection control in long-term care

facilities. Curr Opin Infect Dis. 2014;27(4):363–9.

48. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M,

Enns EA, File TM Jr et al. Prevalence of inappropriate

antibiotic prescriptions among US ambulatory care

visits, 2010–2011. JAMA. 2016;315(17):1864–73.

49. Faulkner CM, Cox HL, Williamson JC. Unique aspects

of antimicrobial use in older adults. Clin Infect Dis.

2005;40:997–1004.

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50. Murray MT, Cohen B, Neu N, Hutcheon G, Simpser

E, Larson E et al. Infection prevention and control

practices in pediatric long-term care facilities. Am J

Infect Control. 2014;42(11):1233–4.

51. McClean P, Tunney M, Gilpin D, Parsons C, Hughes

C. Antimicrobial prescribing in residential homes. J

Antimicrob Chemother. 2012;67(7):1781–90.

52. Stepan D, Ušaj L, Petek Šter M, Galun MS, Smole H,

Beovic B et al. Antimicrobial prescribing in long-term

care facilities: a nationwide point-prevalence study,

Slovenia, 2016. Euro Surveill. 2018;23(46):1800100.

DOI: 10.2807/1560-7917.ES.2018.23.46.1800100

53. Davey P, Marwick CA, Scott CL, Charani E, McNeill

K, Brown E et al. Interventions to improve antibiotic

prescribing practices for hospital inpatients.

Cochrane Database Syst Rev. 2017;2(2):CD003543.

54. EVIPNet Europe, Evidence brief for policy. Antibiotic

prescribing in long-term care facilities for the elderly.

Copenhagen: WHO Regional Office for Europe;

2018 (EVIPNet Evidence Briefs for Policy Series

No. 3; http://www.euro.who.int/__data/assets/pdf_

file/0004/386419/evipnet-euro-sloveniano3-eng.

pdf?ua=1, accessed 4 August 2021).

55. Jump RLP, Gaur S, Katz MJ, Crnich CJ, Dumyati

G, Ashraf MS et al. Template for an antibiotic

stewardship policy for post-acute and long-term

care settings. J Am Med Dir Assoc. 2017;18(11):913–20.

56. Fleming A, Browne J, Byrne S. The effect of

interventions to reduce potentially inappropriate

antibiotic prescribing in long-term care facilities: a

systematic review of randomized controlled trials.

Drugs Aging 2013; 30(6):401–408.

57. Arnold SR, Strauss SE. Interventions to improve

antibiotic prescribing practices in ambulatory care.

Cochrane Database Syst Rev. 2005;19(4):CD003539.

58. Van der Velden AW, Pijpers EJ, Kuyvenhoven MM,

Tonkin-Crine SKG, Little P, Verheij TJM. Effectiveness

of physician-targeted interventions to improve

antibiotic use for respiratory tract infections. Br J of

Gen Pract. 2012;62(605):801–7.

59. Državna strategija “Eno zdravje” za obvladovanje

odpornosti mikrobov. [National Strategy “One

Health” for Microbial Resistance Management 2019–

2024.] Ljubljana: Ministry of Health; 26 September

2019 (https://www.gov.si/novice/nov-vlada-sprejela-

drzavno-strategijo-eno-zdravje-za-obvladovanje-

odpornosti-mikrobov-2019-2024-z-akcijskim-

nacrtom-za-obdobje-2019-2021/, accessed 4 August

2021). (In Slovenian)

60. Truden Dobrin P, Šubelj M, Beovic B. Evidence-

informed policy brief for prescribing antibiotics

to residents in long-term care facilities. In: Vracko

P, Kolar U (Eds.). Public Health Achievements in

Slovenia. Ljubljana: National Institute of Public

Health; 2021 (https://www.nijz.si/en/publikacije/

public-health-achievements-in-slovenia, accessed

29 October 2021).

Insights and best practices from successful country initiatives37

In Indonesia, operational research allowed to map out the habitat of snails infected with Schistosomiasis, and informed the national road map to eradicate the disease. Photo: NIHRD Indonesia

05

Insights and best practices from successful country initiatives39

From operational research to a One Health approach. The road map to eradicating Schistosomiasis in Indonesia Siswanto Siswanto (WHO South-East Asia Regional Office), Muhamad Faozan (National Institute of Health Research and Development Ministry of Health, Republic of Indonesia)

In the Central Sulawesi province of Indonesia, Schistosomiasis infections are endemic in villages and farming communities around Lake Lindu. In the marshlands between fields and watering channels, the parasitic flatworms causing the tropical disease reproduce in small tropical snails and threaten to infect human hosts who are exposed to the infested water. Building on operational research findings and a dedicated policy forum, the Indonesian National Institute of Health Research and Development (NIHRD) used an evidence-informed decision-making approach to develop a comprehensive road map to eradicating Schistosomiasis by 2025.

Searching for freshwater snails transmitting Schistosoma in the marshland next to farming fields in Central Sulawesi. Photo: NIHRD Indonesia

Evidence-informed decision-making for health policy and programmes40

Health concerns over parasitic flatworms and small freshwater snails

Schistosomiasis, a neglected tropical disease also known as bilharzia or snail fever, is endemic in tropical and sub-tropical areas around the world. The disease is caused by blood flukes called schistosomes, a type of parasitic flatworm infecting humans in larval form called cercaria when they are exposed to infested fresh water. Close to 240 million people are reportedly affected worldwide, and poor communities without access to safe sources of potable water and adequate sanitation facilities are particularly at risk (61).

Schistosomes reproduce in small tropical freshwater snails, before a large quantity of larvae is released into the water. The larvae can penetrate the skin of human hosts during routine activities such as farming, fishing or swimming in infested water. In the body, the larvae develop into microscopic adult flatworms living in the veins and draining the urinary tract and intestines. Typical symptoms of urogenital schistosomiasis include blood in the urine, fibrosis of the bladder and ureter, and kidney damage in more advanced stages. Intestinal schistosomiasis often causes abdominal pain, diarrhoea, and blood in the stool, and can lead to liver enlargement (61). The eggs of adult schistosomes are passed out of infected human hosts in faeces or urine and can again contaminate freshwater if adequate sanitation facilities are missing. Schistosomiasis is treatable with the anti-worm medication praziquantel, and transmission control measures include periodic, large-scale population treatment, vector control measures to decimate snails, and improving water and sanitation standards.

The underlying health issue

• In the marshlands around Lake Lindu in Indonesia, schistosomiasis infections remain a serious public health concern, causing intestinal symptoms such as abdominal pain, diarrhoea, blood in the stool, and liver damage when left untreated.

• The parasitic flatworms causing the disease infest small freshwater snails, before penetrating human hosts who are exposed to infested freshwater sources while farming, grazing, herding livestock, or fishing.

• Schistosomiasis control involves large-scale population treatment, snail control measures, and improving access to safe, potable water and sanitation facilities.

Insights and best practices from successful country initiatives41

While most schistosomiasis infections occur in sub-Saharan Africa, the Schistosoma japonicum species causing intestinal schistosomiasis is endemic in China, Indonesia and the Philippines, and has also been reported from Thailand (62). In Indonesia, Schistosoma japonicum are prevalent in the marshland regions around Lake Lindu in the Central Sulawesi province, where some 2 000 people are estimated to be infected, and a population of 40 056 people (63) remain at risk of contracting the disease.

The intermediate host of the parasite is a small tropical freshwater snail called Oncomelania Hupensis Linduensis, named after its habitat in the highlands and around Lake Lindu. Other than most congeneric snails infested by schistosomes, this species can neither survive in deep freshwater nor on dry land, but thrives in the humid marshland between water channels and farmland.

Despite only affecting a comparatively small part of the population, schistosomiasis remains a serious public health concern in Indonesia. In 2016, the Ministry of Health of Republic of Indonesia in collaboration with the Ministry of National Development Planning and the Central Sulawesi Provincial Government therefore commissioned the development of a road map to eradicate Schistosoma japonicum in Central Sulawesi.

Filling in local evidence-gaps and setting the policy agenda

Tasked with developing the road map to eradicate schistosomiasis, the National Institute of Health Research and Development (NIHRD) chose a public policy analysis and development approach, using problem structuring and deliberative dialogues to engage key stakeholders in designing evidence-informed solutions (64).

When analyzing the trends in the average prevalence of Schistosoma japonicum in humans in Central Sulawesi, the NIHRD team found that infections had been gradually declining since 2012 (65, 66). However, the parasites survive in snails and can also infest cattle, rats, and other wild mammals, making schistosomiasis nonetheless endemic in the region and a potential threat to infecting new human hosts. Reviewing additional evidence on Schistosoma japonicum eradication in Japan and repeatedly restructuring the initial problem definition with key

Evidence-informed decision-making for health policy and programmes42

stakeholders in the Central Sulawesi region, the team identified focusing interventions on snail habitats and better coordinating efforts of different government actors as major success factors for the planned road map.

As a first step, the NIHRD team set out to assess and influence the policy agenda with decision-makers in strategic branches of the national and provincial government. A personal meeting with the Minister of Health helped rally broad support for a high-level plenary meeting, involving Members of the Ministry of Health, the Ministry of Environment and Forestry in charge of Lake Lindu and the surrounding high lands, and the Ministry of National Development Planning responsible for resource allocation.

At the plenary meeting held in early 2016, NIHRD presented the declining trends of human infections with Schistosoma japonicum in Central Sulawesi, and reviewed lessons learned from eradicating schistosomiasis in Japan. Discussing the local trends and intervention strategies from other countries, the plenary meeting identified crucial evidence gaps regarding the exact location of snail habitats, their population density, and infection rates with larvae of Schistosoma japonicum.

The NIHRD’s Research and Development Center in Donggala District together with multi-sectoral partners in the province of Central Sulawesi consequently launched an operational research study mapping-out the habitat of Oncomelania Hupensis Linduensis snails

Parasitological analysis of freshwater snails in the laboratory at the Research and Development Center in Donggala District. Photo: NIHRD Indonesia

“Translating evidence into policy requires a client-oriented research approach. Knowledge producers and knowledge users need to work together from the beginning to formulate the research questions that have the potential to inform policy formulation, and can change the knowledge, attitude and actions of decision-makers and local partners alike.” Siswanto Siswanto Former Head of National Institute of Health Research and Development, Ministry of Health, Republic of Indonesia

Insights and best practices from successful country initiatives43

With support from the WHO Country Office in Indonesia, an expert on schistosomiasis eradication was brought in from China to support the team’s research and planning activities. In 2017, a small team from Indonesia visited a similar programme in China to gain hands-on experience for developing and implementing the planned road map.

The research team concluded its work by summarizing key findings in a dedicated study report, recommending a comprehensive environmental management approach with a strong focus on regional economic development to eradicate schistosomiasis in Central Sulawesi.

Key steps for evidence-informed decision-making

• The road map to eradicating schistosomiasis in Indonesia was developed using a public policy analysis and development approach, starting with problem structuring and setting the policy agenda in a high-level plenary meeting involving key government authorities.

• An operational research study mapped the habitats and infection rates of snails, and affected communities in Central Sulawesi, filling a crucial evidence gap.

• Lessons from successful schistosomiasis eradication interventions in China and Japan additionally informed the comprehensive environmental management approach identified as the most promising policy option.

• A multisectoral One Health approach emphasizing community participation was identified as the most promising approach to eradicating schistosomiasis in the province.

and affected communities. The study found snails inhabiting 31 infested areas and infection rates of 5.9% in Lindu highland, 26 infested areas and an infection rate of 1.9% in the Bada highlands, and 243 infested areas and infection rates of up to 5.4% in the adjacent Napu highlands (66). The findings also confirmed the snails’ preferred habitat to be near stagnant water channels, unmanaged marshland, small lagoons, and water springs. In flowing water and on dry land, the species is unable to survive and therefore easier to control.

Evidence-informed decision-making for health policy and programmes44

Taking the roadmap from concept to policy formulation

In the same year, NIHRD with support from the Ministries of Health, Environment and Forestry, and National Development Planning convened a national policy forum to finalize and launch the roadmap to eradicating schistosomiasis at central government level. The forum offered a strategic platform to obtain technical input, political support, and commitment for implementation across state, provincial, and district authorities, affected communities, and development partners. The direct involvement of the Ministry of National Development Planning was of particular importance for the new policy, securing funding to implement the roadmap over a five-year period.

The resulting Roadmap to Schistosomiasis Eradication 2018–2025 (67), built on three complementary intervention strategies, combining a comprehensive one-health approach with economic development support to farmers and local communities and affected by the disease.

In communities with high Schistosomiasis human infection rates, mass treatment using praziquantel remain the first response, while the new schistosomiasis control programme also includes systematic treatment of livestock. To support safer livestock management and avoid recurring infections, collective livestock pens help farmers to ensure their animals graze outside of areas where snail habitats were found. Regular molluscicides spraying is additionally used to eradicate

Minister of National Development Planning Bambang Brodjonegoro at the launch of the new roadmap . Photo: NIHRD

Insights and best practices from successful country initiatives45

the snails acting as intermediary hosts. These snail control measures are additionally supported by a comprehensive environmental management approach, facilitating better water irrigation, development of new water catchment areas, intensified management of rice fields, active promotion of fresh-water fish-farming, and management of idle land.

Following the policy forum, the road map was adopted as an official policy document and launched at the Office of Ministry of National Planning by official address from the Ministers of Health and National Development Planning. Several of the roadmap’s recommendations have since been adopted in communal regulations (68), and recent surveillance data suggests a decreasing trend in snail habitats in Central Sulawesi.

In several affected villages, NIHRD continues to collaborate with farmers and local communities advocating for safer farming and fishing practices, and has been inviting community representatives to the provincial laboratories to demonstrate and explain the risks of infested water sources.

Learning: driving factors and major challenges

• Convening state, provincial, and district authorities, affected communities, and development partners at a national policy forum provided a strategic platform to obtain political and financial support for the roadmap.

• Involving the Ministry of National Development Planning from the very beginning of the policy process helped secure crucial financing to implement the new roadmap over a five-year period.

• Designing a multisector one-health approach including a comprehensive environmental management component with developing programmes for farming communities helped frame the public health issue of schistosomiasis in a broader perspective and ensured buy-in from additional stakeholders.

• Strong involvement of affected farming communities in the operational research and policy process increased local ownership and continues to support implementation of the roadmap.

Evidence-informed decision-making for health policy and programmes46

61. World Health Organization Schistosomiasis: key

facts. In: World Health Organization [website].

(https://www.who.int/news-room/fact-sheets/detail/

schistosomiasis, accessed 4 August 2021).

62. Chitsulo L, Engels D, Montreso A, Savioli L. The

global status of schistosomiasis and its control.

Acta Tropica. 2000;77(1):41–51. https://doi.org/10.1016/

S0001-706X(00)00122-4, accessed 4 August 2021).

63. Indonesian Central Statistic Agency. Population

Survey Between National Cencus. 2015

64. Dunn WN. Public policy analysis: an integrated

approach. Routledge Taylor & Francis Group;

2018 (https://www.routledge.com/Public-Policy-

Analysis-An-Integrated-Approach/Dunn/p/

book/9781138743847, accessed 4 August 2021).

65. Anastasia H, Widjaja J, Nurwidayati A, et al.

[Evaluation of multi-sectoral schistosomiasis control

in 2018]. Buletin Penelitian Kesehatan. 2019;47(4):217–

26. https://doi.org/10.22435/bpk.v47i4.1861 (in

Indonesian).

66. Donggala Health R&D Division, National Institute

of Health Research and Development. Mapping of

Oncomelania HL habitat in Highland Bada, Napu and

Lindu. 2017.

67. Ministry of National Development Planning/National

Development Planning Agency. Roadmap Eradikasi

Schistosomiasis 2018–2025: Wujud Komitmen

Pemerintah Atasi Penyakit Demam Keong [The

roadmap to schistosomiasis eradication in Central

Sulawesi 2018–2025] 2018 (in Indonesian) (URL: https://

www.bappenas.go.id/id/berita-dan-siaran-pers/

roadmap-eradikasi-schistosomiasis-2018-2025-

wujud-komitmen-pemerintah-atasi-penyakit-

demam-keong/ (accessed 4 August 2021).

68. Kageroa Village. Kageroa Village Regulation No.

4/2019 on Schistosomiasis Control.

References

Insights and best practices from successful country initiatives47

Evidence-informed decision-making for health policy and programmes48

A lab technician working with malaria samples. In Uganda, and evidence-informed approach played a key role in updating the national treatment policy to tackle the diseases major health burden. Photo: WHO/R. Memba Paquete

06

Insights and best practices from successful country initiatives49

Responding to antimalarial drug resistance in Uganda. Evidence use in updating the malaria treatment policy Dr. Juliet Nabyonga-Orem, World Health Organization Regional Office for AfricaUlysses Panisset, The Federal University of Minas Gerais, Brazil

Malaria remains a major global health burden, with 229 million cases and 409 000 deaths estimated in 2019 alone. More than 90% of malaria infections occur in Africa, and six sub-Saharan countries together account for approximately half of all malaria deaths worldwide. One of these countries is Uganda, where malaria parasites have developed resistance to several first- and second line treatments in the past. Using data on antimalarial resistance from sentinel sites across East Africa, and working with clinicians, patients, and communities, Ugandan health authorities with support from the World Health Organization successfully updated the national malaria treatment policy.

The key role of surveillance in tackling antimalarial resistance

Malaria is a leading cause of morbidity and mortality in Uganda. The disease is highly endemic across the country, where nearly 14 million malaria cases and more than 5 000 related deaths were reported in 2019 alone (69). Virtually all malaria infections in Uganda are caused

A mother protecting her child against mosquitoes transmitting malaria in Uganda. Photo: WHO/Regional Office for Africa

Evidence-informed decision-making for health policy and programmes50

by plasmodium falciparum, the deadliest amongst parasites causing malaria in humans, which are transmitted through the bites of infected mosquitoes.

Antimalarial medicines can cure the disease, and are a mainstay of malaria control in African countries (70). Malaria parasites have however developed resistance to most antimalarial drugs, showing regionally varying resistance patterns that often correlate with the overuse of antimalarial drugs for prophylaxis and incomplete treatment of active infections (71). Resistance to commonly used antimalarial medication such as Chloroquine pose a major challenge to malaria control in endemic countries around the world.

The underlying health issue

• Parasitological drug resistance is a major barrier for effective malaria control and treatment in Uganda, where the disease is highly endemic and costs several thousand lives every year.

• Antimalarial resistance data from sentinel sites across the country indicated strong resistance against widely used first- and second-line treatments in the late 1990s, and again in the early 2000s.

In Uganda, strong parasitological resistance to Chloroquine was recorded in the late 1990s and early 2000s. Available data on antimalarial resistance together with an alarmingly high number of patients responding poorly to treatment led to a first change in Uganda’s malaria treatment policy, introducing a combination of Chloroquine and Sulfadoxine-Pyrimethamine as a first-line treatment

(72). Between 2001 and 2004, the efficacy of this combined treatment again declined significantly, indicating the development of new resistance. Ugandan health authorities therefore embarked on a second policy change process, adopting artemisinin-based combination therapy and quinine as the new first- and second-line treatments (73), which remain the recommended treatment options to date.

Insights and best practices from successful country initiatives51

From local treatment failure to a new national malaria treatment policy

Changing the malaria treatment policy to the current artemisinin-based combination therapies was a 25-month process, involving policy-makers, clinicians, researchers, technical partners and donors at both national and international levels. Data on the severity and spread of drug resistance in different regions of the country and in the wider East African context was sourced from the East Africa Network for Monitoring Antimalarial Treatment (EANMAT), a surveillance system set up in 1997 in Kenya, Rwanda, Tanzania and Uganda with support from WHO. Assembling data from sentinel sites representing all geographic areas and different epidemiological and ecological contexts in Uganda, EANMAT was a key initiative bringing together malaria researchers and health policy-makers, and a driving force in Uganda’s evidence-informed malaria policy process.

Mosquitos captured for testing and research purposes by in

Maniça, Mozambique. Photo: WHO/R. Memba Paquete

Even before the first malaria control policy was officially launched in June 2002, first drug efficacy studies on available treatments had indicated high and widespread resistance to Chloroquine and Sulfadoxine-Pyrimethamine. By early 2004, a multisite trial and a study amongst Ugandan children working with data from the sentinel sites across Uganda confirmed treatment failure rates ranging from 22% to as a high as 77%, (74,75), surpassing the WHO-recommended threshold of 25% and indicating the need for a change in antimalarial drug policy. Around the same time, WHO recommended artemisinin-based combination therapies as the new first-line treatment of choice in highly endemic countries with Chloroquine resistance (76).

Evidence-informed decision-making for health policy and programmes52

To initiate the adoption of artemisinin-based combination therapies in Uganda, a research committee was put in place by the Ministry of Health in January 2004, comprising malaria programme staff, national research actors, and technical partners including WHO, the Malaria Consortium, and UNICEF. The data from the local sentinel sites were interpreted by consulting a wide array of additional evidence, including international data on drug efficacy, WHO malaria control guidelines, evidence on cost effectiveness and implementation feasibility, behavioural change research, community reports and complaints, as well as observational evidence from health facilities in Uganda (77). All available evidence was then presented and discussed in the Malaria Case Management Technical Working Group, which synthesized key findings. An Interagency Coordination Committee provided additional oversight to the working group.

The Malaria Case Management Technical Working Group invited researchers, policy-makers, clinicians, donors, civil society organizations and district health managers to a national consultative stakeholder forum, facilitating a dialogue based on the synthesized evidence. The forum identified additional evidence gaps such as community acceptability and implementation feasibility for new health policy measures, and jointly set a research agenda for several additional studies on cost effectiveness and acceptability of new malaria treatments. Several technical and evidence briefs, research reports, and presentation materials were additionally produced by the working group to regularly update and exchange with decision-makers and partners (78).

Key steps for evidence-informed decision-making

• Data from local surveillance sentinel sites provided a reliable snapshot of antimalarial resistance in different regions of Uganda and neighbouring countries.

• A research committee and technical working group led the review and synthesis of local and global evidence with support from international partners.

• A national consultative stakeholder forum brought together policy-makers, researchers, health-care providers, and civil society organizations to identify evidence gaps and discuss implementation barriers.

• Once approved by the Ministry of Health, a policy implementation taskforce led the development and implementation of the final policy.

“Timely and reliable evidence is key to trigger action at health policy and practice levels. The routinely collected data on antimalarial resistance from sentinel sites facilitated planning and implementing evidence-informed and effective health programs, and successfully drove policy change in Uganda.”

Dr. Juliet Nabyonga-Orem WHO Africa Regional Office

Insights and best practices from successful country initiatives53

As a next step, the working group held a series of technical meetings involving key local and international malaria specialists and partners, discussing financial, logistical, and other challenges implicated by the policy change. One strategic consideration was whether the new treatments should be introduced only in regions where high resistance levels had been reported from sentinel sites, yet the logistical complexity of implementing a dual first-line treatment policy clearly favoured a nation-wide rollout. Another major hurdle was the substantially higher cost of artemisinin-based combination treatments over older treatments, which initially rendered the drugs unaffordable for several African countries. In April 2004, Uganda successfully submitted a grant proposal to the Global Fund for AIDS, Tuberculosis, and Malaria, securing the necessary funds for the new treatments for a five-year period from 2005 (79).

In June 2004, a brief outlining the proposed malaria treatment policy and synthesizing supporting evidence was presented to the senior management of the Ministry of Health Uganda, who approved and endorsed the document shortly after. Three months later, the Ministry of Health established a task force with several sub-committees to guide the planning steps for the countrywide update of the malaria treatment policy. One sub-committee, for example, developed new malaria treatment guidelines and training formats for health workers and community medicine distributors, while another issued a special handbook for parliamentarians and local leaders, aiming to facilitate evidence-informed discussion and rally broad support with constituents and affected communities (79). By September, the work of all sub-committees was discussed at a final joint meeting and summarized as a policy implementation plan. Relevant training and communication materials were ready for mass production shortly after.

Two decades of tackling malaria with an evidence-informed policy

Following the evidence-informed selection process of the best first- and second-line antimalarial medication and the extensive consultations in technical working groups and the national stakeholder forum, Uganda’s new malaria control and treatment policy was implemented and launched in several steps. In June 2005, the Uganda National Drug Authority officially registered Coartem as a new

Evidence-informed decision-making for health policy and programmes54

antimalarial medicine as a prescription drug, later reclassifying it to an over-the-counter medicine for use at community level and in home-based fever management. In early 2006, first shipments of the new artemisinin-based combination drugs arrived in Uganda, and in April of the same year, the new policy was officially launched at national level.

Supported by WHO and regional partnerships, Uganda went on to play a pioneer role in evidence-informed decision- and policy-making. Uganda’s experience with incorporating sentinel site data and evidence to improve its response to drug-resistant malaria was one of several initiatives favoring the Regional East African Community Health (REACH) Policy Initiative, a novel knowledge translation institutional mechanism developed in Kenya, Uganda, and the United Republic of Tanzania from 2001 to 2007. From 2005, the newly founded EVIPNet Africa collaborated on several major REACH initiatives, including the Supporting the Use of Research Evidence (SURE) project. An evidence brief for policy on artemisinin-based combination therapies for malaria (80) published in 2010 as part of a first series supported by EVIPNet

A laboratory technician works with sensitive samples of malaria parasites in a laboratory in Manhiça, Mozambique. Photo: WHO/R. Memba Paquete

Insights and best practices from successful country initiatives55

Africa country teams spearheaded the debate about a necessary change in the anti-malarial drugs policies of several East African countries.

Working closely with EVIPNet Africa, researchers at the College of Health Sciences at Makerere University piloted an innovative evidence rapid-response service in March 2010, the first of its kind in EVIPNet’s global network. The service assessed and synthesized evidence on several health issues in Uganda including on malaria treatment (81), and remains a reference for several low- and middle-income countries in Africa, Latin America and the Caribbean, and in the Eastern Mediterranean region (82), A study assessing the sustainability of knowledge translation mechanisms in Uganda commended the country’s successful history in evidence-informed health policy-making in 2018. The study also recommended establishing a dedicated operational unit as a knowledge translation platform to increase participation of the health workforce and ensure dedicated funding and continuous capacity building (83).

Learning: driving factors and major challenges

• The institutionalized setup of sentinel surveillance sites across the country proved invaluable to obtain continuous insight into local antimalarial resistance levels.

• Repeated consultative meetings under the leadership of the National Malaria Control Programme and support from WHO was instrumental to forge consensus on the best combination for treatments and preferred policy implementation option.

• Strategic partnerships for evidence-informed decision-making must be fostered right from the stage of developing the research agenda in order to promote uptake and implementation.

• A combination of tailored knowledge translation products including evidence briefs, research reports, presentation materials, and media briefings helped rally support along the policy change process.

• At the policy implementation stage, community leaders and medical practitioners were consulted to facilitate take up of the new treatment policy.

While Uganda’s malaria treatment policy has undergone several revisions in 2011 and 2018, the 2006 malaria treatment policy sustainably coined Uganda’s National Malaria Programme and the use of artemisinin-based combination drugs remains a recommended standard. Data from the sentinel sites continue to be used for

Evidence-informed decision-making for health policy and programmes56

monitoring the efficacy of antimalarial drugs and detect early signs of drug failure as part of regular therapeutic efficacy studies scheduled per the current Malaria Control and Elimination Policy.

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Evidence-informed decision-m

aking for health policy and programm

es

World Health Organization

Evidence to Policy and Impact Unit

Research for Health

Science Division

20, Avenue Appia

CH-1211 Geneva 27

Switzerland

Web: who.int/evidence

Email: evipnet@who.int

In the hands of decision-makers and health actors, the

right piece of evidence can improve patient care and

strengthen health system performance and resilience.

Through the Evidence-Informed Policy Network

(EVIPNet), the World Health Organization (WHO) has

been supporting countries in translating evidence into

improved health policy and practice for more than 15

years in over 50 countries.

This publication assembles case studies on evidence-

informed decision-making in Member States and

across EVIPNet’s global network. Featuring examples

from five WHO regions, the case studies demonstrate

how the best available evidence can be translated into

action and impact across a variety of health topics and

through the decades, highlighting crucial lessons

learned and recipes for success.