We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (10 studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders.Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace well-being arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the well-being of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff well-being. This is the first systematic review of Schwartz Center Rounds (Rounds), a healthcare staff intervention from the USA that has spread rapidly through UK healthcare organisations.Additional scoping reviews of 11 interventions with similar aims to support the well-being of healthcare staff, enables a novel comparative analysis to key features of Schwartz Rounds.This paper compares other staff well-being interventions to Rounds, thereby resulting in a focus on key features of Rounds; we did not explicitly draw out key features of other interventions or compare them against each other.The use of scoping reviews for comparator interventions, and exclusion of evidence in populations other than healthcare staff means that some evidence may have been omitted.The heterogeneity of study designs and outcomes, and weak study designs, means that findings are summarised narratively rather than using meta-analysis.In this paper, we report the systematic review of evidence regarding Schwartz Center Rounds (Rounds) and conduct a comparative analysis of 11 interventions also broadly aimed at supporting healthcare staff with the emotional challenges of their work. In doing so, we define Rounds from the literature and discuss the future potential use of interventions to support staff with the emotional challenges of providing healthcare. Healthcare providers are among the largest employers in many countries worldwide. For example, the UK National Health Service (NHS) employs 1.5 million staff,Numerous publications have highlighted the high prevalence of psychological morbidity among healthcare staff in both clinical and non-clinical roles, and in many different countries worldwide.12–15Consequently, the well-being of healthcare staff is high on the agenda of healthcare organisations in the UK and worldwide.22What are the defining features of Schwartz Center Rounds, and what is their evidence base?What comparable interventions providing staff support/reflective space exist, what key features do they share with Schwartz Rounds and what is their evidence base in healthcare professionals?Schwartz Rounds are a rare example of an organisation-wide intervention that has seen rapid spread across healthcare organisations in the UK.Specifically, we aim to (i) identify key features of Rounds by synthesising published descriptions of Rounds to create a composite definition; (ii) systematically review and appraise all empirical evaluations of Rounds; (iii) identify comparative interventions, describe their key features and scope their evidence base and (iv) document similarities and differences between Rounds and comparative interventions.The review of Schwartz Rounds literature followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic literature review guidance where applicable.The search strategies for the systematic review of Rounds literature involved: (i) a traditional database search . As an example, the MEDLINE database search for Schwartz Rounds was: (Schwartz adj2 Round*).mp. , (ii) use of internet search engines and (iii) consultation with experts. Inclusion criteria included having a health professional sample  and empirically evaluating the intervention using qualitative and/or quantitative methods. The review excluded non-English language sources, unpublished dissertations/theses and any papers not accessible via the institution’s online library, Google Scholar or directly from the journal website. All records were pooled together into a bibliographic database. First, records were screened to exclude duplicate entries. Second, the title and abstract of remaining records was reviewed for eligibility. All database searches were conducted between 14 October 2014 and 5 February 2015, although searches for Schwartz Rounds evaluations and consultation with experts continued until September 2017.et al,et al.Standard data items were extracted to describe included papers  and the evaluation  using extraction sheets that were developed and piloted by all data extractors. In addition, items were developed that were specific to each intervention, for example, whether group or individual focused, size of group, length/number of sessions, content of sessions, whether facilitated or not (and if facilitated whether training/supervision was provided). Quality assessment of qualitative and quantitative primary studies was undertaken for each study using the tools developed by Jones Thematic analysis of the types of outcomes reported resulted in the identification of three categories relating to: a) self; b) others  or c) wider organisation . Findings are presented according to these three categories. Finally, the overall quality of the evidence base for each intervention is described based on the range in quality for individual studies.While the Schwartz Center for Compassionate Care, where Rounds originated, have a description of Schwartz Rounds on their website, this was found to omit key aspects of their design that we knew from scoping the literature to be important . Therefore, we constructed a ‘composite’ definition based on descriptions used in Rounds literature in order to determine the key features of Rounds for comparison with other interventions. For this process, we included all literature  providing it included a description of Rounds. Text describing Rounds  was extracted from published accounts. The text was analysed thematically by four team members independently , core concepts were discussed and agreed and a single definition was produced. The face validity of the definition was confirmed after review by study advisory and steering group members.The reviews of comparable interventions followed an interpretative scoping literature review methodology based on the framework outlined by Arksey and O’Malley.We aimed to identify interventions that support health professionals with the emotional challenges of delivering patient care. Initially, we identified aspects that were fundamental to Rounds, including providing an opportunity for reflection, disclosure and offering psychological safety; and these informed choices regarding potential comparative interventions. Included interventions needed to focus on psychological  well-being of staff; be person-directed (vs work directed) and provide primarily emotional rather than cognitive/clinical support . Although Rounds are a ‘group’  intervention, we chose not to limit comparative interventions by this characteristic, due to the importance of reflection and/or disclosure as a key potential mechanism in Rounds that is shared by other interventions that are not group-based. Potential comparative interventions were identified through published reviews of psychological/emotional support interventions for healthcare staffThe composite definition of Rounds was disaggregated into its individual descriptive features which were extracted into a table, together with the features that were ‘not’ part of Rounds. Further clarification was added for some descriptive features to ensure clarity of meaning . The description of each comparative intervention was then reviewed by the research team and assessed in relation to whether or not it also provided each of the key features of Rounds. The face validity of the comparison between Rounds and other interventions was confirmed with study advisory and steering groups .We actively involved patients through membership of the Project Steering Group (PSG), which included two patient public involvement (PPI) representatives  who had previously provided input to the original funding application. The PSG provided oversight to all aspects of the study, and alongside other group members our PPI representatives and Rounds staff members advised on design, inclusion of comparative interventions and commented on the findings.Forty-three documents/sources were included in the review of descriptions of Rounds , which a10.1136/bmjopen-2018-024254.supp1Supplementary file 1Twelve empirical evaluations of Rounds were included  arising Overall quality of the evidence-base was assessed to be low/moderate. Most studies had study designs prone to risk of bias , used non-validated questionnaires  and none of the quantitative evaluations had control group (non-attender) comparisons. Little information was provided on the samples/sampling frames in quantitative studies , nor were findings analysed or presented in relation to such factors. In two studies that did report the characteristics of their quantitative sample, most were female and of white ethnicity, and nurses predominated (but neither study reported the seniority of nurse).Electronic searches for the 11 comparative interventions yielded a total of 1725 papers, of which 146 were included  was in most cases widely heterogeneous (and/or lacked detail), and consequently synthesis of findings is problematic. Most of the quantitative evaluations across all interventions relied on weaker study designs , used non-probability sampling, had small samples likely to be underpowered and used non-validated outcomes measures. Many qualitative studies also lacked clear reporting of aspects of rigour . A summary of the evidence base for each intervention is provided in online 10.1136/bmjopen-2018-024254.supp3Supplementary file 3Most interventions presented evidence in relation to all three categories of outcomes , although evidence for resilience training, mindfulness-based stress reduction and reflective practice groups lacked inclusion of organisational outcomes. All of the interventions had evidence of positive benefits to self , and most provided some evidence of positive benefits to ‘others’. Impact on patients included fostering of better provider-service user relationships, communication with and/or attitudes towards patients and improved patient-centredness, knowledge of patients’ suffering and empathy. Impact on colleagues, included associations with better teamwork, peer support and knowledge/understanding of colleagues.At organisational level, there was evidence from some interventions of association with improved practice, for example, reductions in unnecessary prescriptions, increased uptake of psychosocial support , reduction in task and coordination errors and increased uptake of postfall huddles (after action reviews). Two interventions provided evidence of a positive impact on the workforce, including providing opportunities for mentoring and advice (action learning sets) and improved staff retention .In comparison to the other interventions, Rounds offer a unique organisation-wide ‘all-staff’ forum to share stories about the emotional impact of providing patient care . While mOther key aspects in which Rounds are distinct from the comparative interventions relate to what Rounds are intentionally ‘not’ meant to be. In particular, discussions within Rounds should not ‘problem solve’ in order to avoid focus on the clinical decision-making in a patient case, whereas problem solving/action planning are key features of many of the other interventions . Most of the comparative interventions also offered flexibility in format, compared with Rounds which require a contractual licence (with stipulated conditions) obtained via the Schwartz Center for Compassionate Care (USA) or Point of Care Foundation .Arguably the closest types of interventions to Rounds are Balint groups , and reflective practice groups . In particular, both are ongoing group programmes in which challenging/rewarding experiences about delivering patient care are shared and discussions are facilitated, and both provide the opportunity to give and/or receive peer support in safe and confidential environments. However, neither offers an organisation-wide opportunity for staff to attend, and both would have an expectation that members/attenders would contribute, whereas in Rounds attenders can choose to be silent listeners. Clinical supervision can also provide an opportunity to reflect on the emotional and ethical challenges of care without problem-solving/action planning, but unlike Rounds this usually occurs in a one-to-one situation, not group, and requires those being supervised to verbally contribute.Our work revealed a rich portfolio of available interventions to support staff with the emotional challenges of providing healthcare, each designed with different audiences and uses in mind. The evidence base regarding the effectiveness of these largely remains weak, and more should be done to examine these more systematically. The studies reviewed here show some evidence of impact at different levels, and future work should seek to unpick which interventions work best, under which conditions and for which participants. To our knowledge, this is the first comparative review of staff well-being interventions.Given the high rates of work-related stress and mental health issues among healthcare staff, it is not acceptable for employers not to act, despite the weak evidence base for most approaches and interventions currently. Some staff groups have clinical supervision, for example, as an integral part of their work , whereas most doctors and nurses do not, and such staff often have little or no support with the emotional, social and ethical challenges of their work. Non-clinical staff—who may have much contact with patients and the events they encounter—are even more neglected in relation to the impact of delivering patient care on them. Selection of interventions should be based on a strategic approach that incorporates needs assessment, implementation of interventions/approaches and policies and monitoring and review to determine the impact of these and refine/revise as necessary. There is a need for a range of approaches, not a one-size-fits-all and our work does not suggest an either/or approach for individual interventions. Rounds should not be seen as a replacement for or instead of clinical supervision (or other support/interventions), but could be offered to staff in addition. Organisation-wide interventions are important to tackle workplace environmental/cultural factors that impact on well-being; to change attitudes and cultural norms around staff needing support as well as changing conversations in organisations around empathy, compassion and the support required to deliver these. Involving all employees may improve coworker and supervisor support, which in turn can facilitate the development of a supportive workplace environment that reduces stress by improving attitudes and behaviours.26Schwartz Rounds were originally conceived to meet a very specific identified need in healthcare: to support healthcare providers to be compassionate to patients through giving them insight into their own thoughts, feelings and behaviours.26 79Workforce interventions are often complex in nature, with many components and aims. Their evaluation is thereby challenging, particularly with regard to attributing any changes to outcomes to the intervention as opposed to other causes within the organisation/system. The challenge of conducting a robust evaluations of organisation-wide interventions may be one explanation as to why such evidence is so sparse,26The focus of this review on the evidence within healthcare staff meant that wider evidence for some interventions, beyond healthcare, was not considered. Also, the scoping methods applied to the comparable interventions inevitably means that some relevant evidence may have been omitted, although systematic electronic searching and consultation with experts aimed to minimise this risk. The rapid uptake of Rounds in the UK and need to contextualise them within staff well-being interventions, informed the design of this review. It was thereby a review that compared other interventions with the key features of Rounds, and did not thereby compare the key features of all the other interventions with each other, apart from by describing and synthesising their origins and evidence base.Given the time and resources already committed to the interventions considered here, it is important to determine how best to identify the core features of effectiveness to optimise benefit for individual staff members and organisations as a whole. This work has now been undertaken for Schwartz Rounds using a realist-informed methodology that has identified the contextual factors that influence how and for whom Schwartz Rounds work, resulting in an organisational guide giving practical guidance and recommendations for organisations to maximise the effectiveness of Rounds in their organisations.


Psychiatric disorders could be evaluated in terms of behavioral activation and inhibition systems. Dysregulation of these systems may lead to development of manic or depressive episodes in patients with mood disorders. This study aimed to identify Behavioral Approach System (BAS) and Behavioral Inhibition System (BIS) hypersensitivity as the functional brain system behaviors in patients with major depressive disorder and bipolar mood disorder I, compared to healthy individuals.This case-control study was conducted in Razi Psychiatric Hospital, a mental health referral center in Northwest of Iran. The study consisted of two groups of patients, one with major depressive and the other with bipolar mood disorders and one healthy group. Each group had 40 patients (20 men and 20 women). The study data were collected through BIS and BAS questionnaire, Beck Depression Inventory (BDI-II), Young Mania Rating Scale (YMRS). The obtained data were analyzed by SPSS version 18.The findings showed a significant negative correlation between BIS, BAS and BAS subscales with the severity of depression and positive correlation with mania symptoms (P<0.05).BAS and BIS dysregulations may predispose people to mood disorder symptoms. BAS is hyperactive during manic phase and may predict the symptom severity of bipolar mood disorder. Patients with bipolar disorder had higher BAS, while those with MDD scored lower in BAS scales compared to healthy people.BAS-drive had the highest score in bipolar patients and the lowest score in MDD patients, but BAS-reward responsiveness was the highest in patients with bipolar disorder and lowest in those with depression.Bipolar patients scored higher in BAS-fun-seeking, BAS-drive and BAS-reward responsiveness, while patients with major depression had lower scores on BAS-FS, BAS-D, and BAS-RR subscales compared to the healthy individuals.Dysregulation of behavioral activation and inhibition systems may develop into manic or depressive episodes in patients with mood disorders. In this study, we tried to identify Behavioral Approach System (BAS) and Behavioral Inhibition System (BIS) hypersensitivity as the functional brain system behaviors in patients with major depressive disorder and bipolar mood disorder I compared to healthy individuals. The study consisted of two groups of patients; one with major depressive and the other with bipolar mood disorders as well as one healthy group. Each group had 20 men and 20 women. The study data were collected through BIS and BAS questionnaire, analyzed with Beck depression inventory, Young mania rating scale in SPSS.The findings showed a significant negative correlation between BIS, BAS and BAS subscales with the severity of depression and positive correlation with mania symptoms. BAS and BIS. Dysregulations may predispose people to mood disorder symptoms. BAS is hyperactive during manic phase and may predict the symptom severity of bipolar mood disorder.1.Currently, millions of people are affected by mental disorders worldwide. This problem results in huge economic and social costs due to the burden of disease itself and damage to the quality of life. Major Depressive Disorder (MDD) and Bipolar Mood Disorder (BMD) are serious mental illnesses which negatively impacts a variety of important life aspects. In this regard, the lifetime prevalence of depression and BMD are 17% and 3% in the general population that put them in the fourth and sixth highest ranks in the global disease list, respectively. In addition, after ischemic heart disease, depression is the second most prevalent mental condition. It is notable that based on the report of the World Health Organization, bipolar disorder has remained among the top 10 causes of years lived with disability worldwide .Biopsychological theory of personality was introduced by The systems are suggested to integrate biological and environmental factors with special focus on personality . They reWhereas activation of BIS is supposedly decrease the individual’s behavior toward stimuli such as threat, punishment, novelty, and frustrate non-reward cues, BAS increases one’s approach toward stimuli sensitive to reward and non-punishment. Gray and other researchers  proposedBIS governs anxiety and may control negative affectivity in response to cues of threat. Originally, Gray’s model was applied to anxiety, but Several studies have shown an association between bipolar disorder and depression as a spectrum . Other sAccording to this theory, symptoms of manic and depressive patients relate to neurotransmitters that underlie BIS and BAS, where mania results from an excessive dopamine-mediated responsiveness to rewards correlated with high BAS, while depression results from defective serotonin- and norepinephrine-mediated response to threats with low BIS. Also, most studies in cognitive neuroscience suggest that BIS scales, when measured with questionnaires, positively correlate with negative affects, while BAS scales positively correlate with positive affects . AdditioUnderstanding the role of personality underpinnings and behavioral brain system in mood disorders may help clinicians to predict the potential symptom development and establish preventive or treatment interventions. The major objective of the current study was to explore BAS and BIS implications in mood disorders. Moreover, we aimed to identify the potential biomarkers and experimental paradigms in the early intervention based on self-reported BIS and BAS functioning in individuals with mood disorders.2.2.1.In this case-control study, the subjects were recruited from Razi Psychiatric Hospital in Tabriz, Iran, from June 2013 to July 2014. We employed a simple random sampling method to recruit participants in two groups of patients, one with MDD (without psychotic features) and one with BMD I (with acute psychotic symptoms) based on DSM-IV-TR criteria. The third group consisted of healthy individuals without a history of psychiatric disorders. Twenty male and 20 female participants aged 18–65 years were recruited for each group. Those who did not fully complete the self-reported questionnaires were excluded from the study.The study was explained to the participants and a written informed consent was obtained from them. All people were recruited based on an individual code given by a psychiatrist. Both participants and the examiners were blind to the experimental design.2.2.2.2.1.The scales were of 4-point Likert-type questionnaires scored from 1 to 4 (1=Strongly disagree to 4=Strongly agree) consisting of 24 items, where items from the original BIS/BAS scales were modified based on Azari Language. To measure BIS, we included 7 items related to anticipation of punishment, while for measuring the BAS  we included five items about anticipation or occurrence of the reward, Reward Responsiveness (RR); four items about pursuit of desired goals for Drive (D); four items about desires, Fun-Seeking (FS) for new rewards and impulsive approach to potential.The internal consistency of the BIS subscales was determined based on 2.2.2.Revised Beck Depression Inventory is a screening self-reported instrument containing 21 items, which provides a highly reliable assessment regardless of the study population . Farsi v2.2.3.Young Mania Rating Scale is an 18-item questionnaire to measure the severity of manic symptoms such as irritability, disruptive and aggressive behavior, elevated mood, hyperactivity, impaired language and or thinking and other signs based on interpretation of scores from this scale. The scores were classified as the following: 0–9, without mania; 10–17, hypomania; 18–21, manic border; 22–35, mild to moderate mania; 36–53, moderate to severe mania; and finally, 54 or higher, severe mania. It has been standardized in Persian language .2.2.4.We used Structured Clinical Interview (SCID-I), as a tool for the diagnosis of disorders based on the Diagnostic and Statistical Manual of Mental Disorders (DSMIV), fourth edition. Reliability for the SCID has been shown to be strong. Also, the Farsi version of the tests achieved a high rate of agreement (kappa) for SCID used for the diagnostic decision and research approach.2.2.5.In this study, the patients’ age, gender, marital status, education, occupation, patient records, treatments and hospitalizations were collected and the relationship between BAS/BIS and MDD and BMD was explored.2.3.The sample size was estimated as 40 for each group  based on Alloy and colleagues  study da3.Initial analyses were conducted to calculate descriptive statistics. The results revealed a significant difference between the three groups in terms of BAS/BIS activity levels. Based on the regression model, BIS and BAS could predict depression with its related positive and negative intense impacts. They also could predict depressive episodes in three groups of the participants. BAS-RR subscale is a negative predictor for bipolar disorder and major depression, while in healthy participants, we did not find any significant relationship.BAS seems to be a significant predictor of mania symptoms’ intensity. The results obtained from the FS subscale in bipolar patients showed a significant predicting value but among individuals with major depression, we could not find any significant relationship. As shown in 4.Patients with bipolar disorder had higher BAS, while those with MDD scored lower in BAS scales compared to healthy people. Meanwhile, we noticed that the highest and lowest activity levels in the BAS-FS subscale were shown in BMD and MDD, respectively. These results are in line with the studies conducted by The negative correlation between BAS and MDD suggests that these individuals have deficits in controlling desires, goal-seeking behavior, and positive emotions. Therefore, anhedonia in depressed individuals is justified by a low activity level of BAS. We also found a positive correlation between BIS and depression which suggests that the patients with depression had sensitivity and hyperactivity in BIS leading to negative emotions. The results of some published works are in agreement with the current study , meanwhiOur findings suggest that BAS is hyperactive in bipolar disorder which supports the dysregulation in these patients. An inverse relationship between BAS, RR and depression suggests a BAS dysregulation in depressive patients. Depressed patients had lower responsiveness to reward and receive little reward as a motivation. While all patients scored higher on BIS in comparison with normal individuals, patients with BMD scored higher on BAS scales compared to patients suffering from depression. Our study had some limitations too. Small sample size, inability to discontinue medications, and self-reporting nature of BAS/BIS scales all constitute major limitations of this study. Dysregulations of BAS and BIS may predispose affected individuals to mood disorder symptoms. Our study findings emphasize the role of the behavioral brain systems as integrated models of biopsychological aspects in the occurrence and continuation of mood disorders. Any problems in these systems or related domains may predict the development of mood disorders.The study was conducted based on regional ethical guidelines. Informed consents were taken and all participants were free to leave the study whenever they would like to do.


Even within the fairly homogenous context of francophone Africa, among 18 options presented to experts on how to proceed toward universal health coverage (UHC), consensus was reached on only 1 with respect to effectiveness and another with respect to feasibility. The complexity and challenges of UHC as well as the weak evidence base likely contribute to this uncertainty. Even within the fairly homogenous context of francophone Africa, among 18 options presented to experts on how to proceed toward universal health coverage (UHC), consensus was reached on only 1 with respect to effectiveness and another with respect to feasibility. The complexity and challenges of UHC as well as the weak evidence base likely contribute to this uncertainty. Many countries rely on standard recipes for accelerating progress toward universal health coverage (UHC). With limited generalizable empirical evidence, expert confidence and consensus plays a major role in shaping country policy choices. This article presents an exploratory attempt conducted between April and September 2016 to measure confidence and consensus among a panel of global health experts in terms of the effectiveness and feasibility of a number of policy options commonly proposed for achieving UHC in low- and middle-income countries, such as fee exemptions for certain groups of people, ring-fenced domestic health budgets, and public-private partnerships. To ensure a relative homogeneity of contexts, we focused on French-speaking sub-Saharan Africa. We initially used the Delphi method to arrive at expert consensus, but since no consensus emerged after 2 rounds, we adjusted our approach to a statistical analysis of the results from our questionnaire by measuring the degree of consensus on each policy option through 100  minus the size of the interquartile range of the individual scores. Seventeen global health experts from various backgrounds, but with at least 20 years' experience in the broad region, participated in the 2 rounds of the study. The results provide an initial “mapping” of the opinions of a group of experts and suggest interesting lessons. For the 18 policy options proposed, consensus emerged only on strengthening the supply of quality primary health care services (judged as being effective with a confidence score of 79 and consensus score of 90), and on fee exemptions for the poorest (judged as being fairly easy to implement with a confidence score of 66 and consensus score of 85). For none of the 18 common policy options was there consensus on both potential effectiveness and feasibility, with very diverging opinions concerning 5 policy options. The lack of confidence and consensus within the panel seems to reflect the lack of consistent evidence on the proposed policy options. This suggests that experts' opinions should be framed within strengthened inclusive and “evidence-informed deliberative processes” where the trade-offs along the 3 dimensions of UHC—extending the population covered against health hazards, expanding the range of services and benefits covered, and reducing out-of-pocket expenditures—can be discussed in a transparent and contextualized setting. Le texte complet de l'article est aussi disponible en –,–During the past decade, universal health coverage (UHC) has progressively become global health's number one goal. Progress toward UHC is measured along 3 dimensions: (1) extending the population covered by a mechanism of financial protection against health hazards; (2) expanding the range of services and benefits covered; and (3) reducing out-of-pocket expenditure for the services and benefits that are provided.This article presents exploratory research attempting to measure global health experts' confidence in, and possible consensus on, the effectiveness and feasibility of a number of policy options commonly proposed for achieving UHC in low- and middle-income countries (LMICs). We first present our objectives and the methodological approach we used, and then draw general lessons from our results.This article attempts to measure global health experts' confidence in and consensus on the effectiveness and feasibility of policy options commonly proposed for achieving universal health coverage.Our research question emanated from the observation that many countries rely on standard recipes for accelerating progress toward UHC. We aimed to test the following hypothesis: only those policy options that are judged by a majority of experts to be both effective  and feasible  should be implemented in a vast range of contexts; the others would be used only in favorable, specific contexts. That is why we intended to assess the degree of confidence among a sample of global health experts on the potential effectiveness and feasibility of a set of common policy options, to allow us to move toward UHC in typical African contexts. To do so, we opted for the Delphi method with the hope that we could reach some degree of consensus on at least some policy options that countries could focus on or, alternatively, avoid.World Health Report 2010 on health systems financing,Based on the We designed a simple questionnaire comprising explanations about the research's purpose and 2 tables requiring respondents to rate the potential degree of “effectiveness” and “feasibility” of the policy options along a 5-point Likert scale. To limit variability of contexts and ensure coherence, we focused the study on typical contexts of French-speaking sub-Saharan African countries; and to limit ideological biases, we selected a number of global health experts working in various types of organizations  who had experience in this broad region. Experts were selected on an ad hoc basis to represent various profiles, but 2 inclusion criteria were that they had to have (1) at least 20 years' experience in supporting health reforms in LMICs in general, with substantive experience in francophone  Africa, and (2) a sufficiently generalist profile in order to be able to assess the effectiveness and feasibility of policies relative to the service provision and the financing dimensions of UHC.We intended to lead the survey across 2 panels: one composed of 15 experts originating from Europe and Northern America  (the Northern panel), and one composed of 16 experts from Northern, Western, and Central Africa  (the Southern panel). We contacted experts individually by email and proposed a discussion of the questionnaire through the use of Skype if they were willing to do so. The experts were blind to each other's scoring and did not interact during the survey. All participants were informed about the study's objectives and methods and consented freely to participate. Anonymity was guaranteed until the last step when we shared results in the aggregate with participating experts. We planned to pursue the Delphi process until a consensus was reached, and to also compare experts' responses with the available evidence on policy options. The 2 rounds of the study were conducted between April and September 2016.Unexpectedly, our research attempt confronted several issues. First, the participation rate was lower than expected. Of the 31 persons contacted, 23 participated in the first round  and 21 participated in the second round (10 Northern/11 Southern). However, we had to dismiss 4 respondents from the second round who had not participated in the first round, so only 17 experts completed the 2 survey rounds: 9 from Europe  and 8 from Northern, Western, and Central Africa . No substantial differences were observed between the 2 panels, so we merged them into a single panel in order to analyze the results. See in abstracto for each strategy considered in an isolated manner. As happens in the literature,,,Second, after the first round of the exercise, several experts mentioned the difficulty of granting a score Therefore, per the participants' request, we converted the initial questionnaire to include 2 sets of 2 questions for the second round. The first set of questions focused on confidence in the effectiveness of each policy option. These questions were broken down into 2 items and thus scored twice, once for its potential effectiveness as a stand-alone intervention, and once for its potential as part of a UHC reform package. The second set of questions focused on confidence in feasibility of each policy option. These questions were scored once for operational and technical feasibility, and once for political feasibility. Yet when asked to differentiate between stand-alone and part-of-package effectiveness, and between technical and political feasibility, the differences in scores were negligible. Consequently, we merged these when analyzing the results.Third, during the first round, experts gave a “moderate” response to the majority of policy options, thus not clearly positioning themselves in favor for or against proposed policy options. To allow for more clear-cut answers, we converted the Likert scale's results into a nominal scale from 0 to 100, and asked the second round's respondents to use the nominal scale to position themselves in the range between their previous response and the average response. However, during the second round, most policy options kept scoring in the “moderately effective” range, and no consensus emerged as we hoped would be possible.Therefore, we changed our analytical approach: since no consensus seemed to emerge through the use of the Delphi method, instead, we statistically analyzed the results from our 17 questionnaires. We measured the degree of consensus on each policy option through 100 minus the size of the interquartile range (IQR) of the individual scores, with 100 signifying total consensus.“strengthen the supply of quality primary health care services” was consensually judged as being clearly effective by our panel (confidence score of 79 with a consensus rating of 90).Regarding potential effectiveness, only 8 policy options received a consensus rating of 80% or above, but 7 of them were in the “moderately effective” range (confidence scores between 48% and 60%), indicating “soft consensus” . Only thStrengthening the supply of primary health care services was the only policy option that the panel of experts agreed was effective for achieving UHC.“fee exemption for the poorest” was consensually judged as being fairly easy to implement by our panel . On the other hand, for 5 policy options, the consensus rating was below 70, indicating very diverging opinions among the experts.Regarding feasibility, the degree of consensus was even lower. Only 2 policy options received a consensus rating of 80 or above (performance-based payment of providers and fee exemption for the poorest), but one of them was judged moderately feasible (with a confidence score of 49), so that only the policy option To deepen our analysis, we attempted to compare responses from our panel of experts with the available evidence , in order to assess whether or not each corresponded with the other. We therefore opted to search for systematic evidence with regard to each of the 18 proposed policy options and completed the literature review with non-systematic evidence when needed.–,,–,,,Regarding the path toward UHC, overall, the existing literature concludes that the effect of UHC schemes on access, financial protection, and health status varies across contexts, UHC scheme design, and the implementation processes. In most countries and regions, a number of UHC schemes coexist although they demonstrate heterogeneity in terms of design and organization. Evidence on the impact of specific UHC design features on their intended outcomes is scarce and inconclusive, so that several pathways may be appropriate.Progressive expansion of a package of essential services for the whole population may be preferable to sequential extension of the share of the population covered with a full package, but no systematic evidence is available.lack of consistent evidence on the proposed policy options. Indeed, the literature is often scanty, inconclusive, and inconsistent, or may challenge the implementation of the proposed policy options. This is the case for:Fee exemptions: They are shown to entail many implementation challenges while robust evidence quantifying their impact remains scant.–Ring-fenced domestic budgets for health: The effectiveness of earmarking taxes or revenue for health appears to be mixed in terms of increasing overall funding, improving its stability, or increasing expenditure for the target program.,–Innovative financing mechanisms: These fall in various categories, but their potential impact on efficiency and equity depend on each country context.,Mandatory health insurance: A systematic review of the impact of state-subsidized or social health insurance schemes found no strong evidence of any impact on utilization, protection from financial risk, or health status.Performance-based financing: There is no consistent evidence of the effectiveness, efficiency, and equity of the approach, and there are indications of possible perverse effects on health care providers' behavior and weakening of health systems.–Public-private partnerships: Despite the scale and significance of the phenomenon, there is relatively limited conceptualization and in-depth empirical investigation of such partnerships. Evidence about their effect on clinical quality, coverage, equity, and cost-effectiveness is inadequate, and other challenges concern scalability and scope, indicating the limitations of such interventions as a basis for universal health coverage, though interventions can address focused problems on a restricted scale.,Purchaser-provider splits: No systematic review or coherent literature has been found on this matter, probably due to the extreme diversity in approaches.Performance-linked aid: Its alleged advantages are flawed theoretically and poorly backed by empirical research.–Regarding specific policy options, we found that the lack of confidence and consensus among our experts, with large inter-expert variability (ranging from 0 to 100 in the case of fee exemption for the poorest) and many policy options lying in the “woolly” consensus area, often matches the Despite the scale and significance of public-private partnerships, there is relatively limited conceptualization and in-depth empirical evidence of such partnerships.On the whole, the quality of the evidence is low and/or non-systematic. The panel's relative confidence in mandatory health insurance, purchaser-provider split, and the creation of a global fund for UHC contrasts with the lack of documented evidence for these options.can contribute positively to UHC. This is the case for:Community-based health insurance: There is systematic but weak evidence of a moderate effect with improved service utilization and financial protection by reducing out-of-pocket spending; yet, schemes serve only a limited section of the population.,Vouchers: A systematic review of the impact of vouchers on the use and quality of health care in developing countries found modest evidence that vouchers effectively target specific populations, but there is insufficient evidence to determine whether vouchers deliver health care efficiently. There is robust evidence that vouchers increase utilization, and modest evidence that vouchers improve quality,conditional cash transfers: Overall the evidence suggests that they are effective in increasing the use of preventive services and sometimes improving health status.Pooling/defragmentation: There is anecdotal evidence of a positive effect, even if experience suggests that once established, different pools are politically difficult to integrate or harmonize because integration involves the redistribution of resources across organized interest groups.,,,–Reduction of inefficiencies: There is non-systematic evidence of a positive effect,Strengthening primary health care: The experts on our panel were quite confident with regard to the potential of this policy option, which is also supported by existing evidence . This was done despite the fact that in 2014, the Independent Evaluation Group of the World Bank raised a flag by pointing out that the Bank had promoted results-based financing with insufficient empirical support on the soundness of the approach, even proclaiming that “… decisions were made to scale up regardless of weak, inconclusive, or incomplete pilot results.”Our study provides an initial “mapping” of the opinions of a group of experts, which offers interesting lessons. It shows that among a panel of 17 experienced global health experts coming from varied countries and backgrounds, None of the 18 common UHC policy options received sufficient consensus on both potential effectiveness and feasibility.Our findings suggest UHC policy options should be implemented only in favorable contexts, following a careful analysis and trade-off process.called for high-quality empirical evidence on reforms aimed at reaching UHC.importance of contextualized policy advice.When comparing our results with findings in the literature, we were struck by the lack of consistent, systematic evidence on the effectiveness of most policy options. Most worrying, even supposedly systematic evidence may not be entirely trusted when applied to complex issues. For instance, Coarasa et al. (2017) examined 2 systematic reviews of the literature on the quality of private-sector primary care in LMICs, published in the same journal within a year and reaching conflicting conclusions. They found that weaknesses in the underlying evidence, rather than the rigor of the reviews themselves, led to reasonable disagreements, and therefore ,We were also struck by the weak differentiation on the part of the experts between policy options that are isolated vs. part-of-package effectiveness on the one hand, and between technical vs. political feasibility on the other hand . We hypothesize that there is a disjunction between experts' professional rationality  and a rather heuristic appraisal when asked to judge a strategy. This has long been recognized,On this issue, Cairney and Oliver (2017) identify 2 important dilemmas for scientists and researchers—that we can extrapolate to advisers—contributing to an “evidence-policy gap.” First, effective actors combine evidence with manipulative emotional appeals to influence the policy agenda. Second, when adapting to multilevel policymaking, experts should not necessarily prioritize “evidence-based” policymaking above other governance principles such as the “coproduction” process of policy between local public bodies, interest groups, and service users, which may be based primarily on values. They conclude that successful engagement in evidence-based policymaking requires pragmatism, combining scientific evidence with governance principles, and persuasion to translate complex evidence into simple stories. To maximize the use of scientific evidence with regard to public health policy, experts should recognize the tendency of policy makers to base judgements on their beliefs and shortcuts based on their emotions and familiarity with information; be prepared to engage in long-term strategies to be able to influence policy; and, in both cases, decide how far they are willing to go to persuade policy makers to act and secure a hierarchy of evidence underpinning policy. These are value-driven and political, not just “evidence-based,” choices.Finally, we wondered why international organizations often continue to promote a number of strategies (“donor fads”), the effectiveness of which lack consistent evidence. Wane (2004) establishes both theoretically and empirically that the quality of aid is endogenous to the incentive system that prevails in the aid agency (career concerns) and the capacity and accountability of the recipient country to gauge the quality of aid. He shows that a mix of factors  leads to recipient governments accepting poorly designed projects to the detriment of their population.this exploratory study shows that global health experts' opinions on policy options with regard to achieving UHC diverge a great deal, they are often only moderately supportive or not in support of the standard UHC recipes prevalent in today's global health and development rhetoric, and that most policy options are not backed by systematic and coherent evidence. This conveys implications for the development community. Development agencies are understandably tempted to promote “magic bullet” approaches to UHC. Notably due to a culture of “pushing money” and low-capacity recipient governments,Despite the limitations pointed out above, and even when limiting the focus to the relatively homogeneous contexts of French-speaking sub-Saharan Africa, ,need to strengthen inclusive and “evidence-informed deliberative processes” enabling stakeholders to discuss the trade-offs along the 3 dimensions of UHC in a transparent way, to make the set of values and decision criteria used more explicit, and to take decisions in a coherent and contextualized way.–Therefore, there is clearly a need for a better understanding of the interactions between the multiple stakeholders—including not only the experts but also the domestic actors—their agendas, and their hierarchy of values. While progress toward UHC has taken various forms around the globe, a common feature emerging from experience is that adopting UHC is primarily a political rather than a technical issue.


Among the many barriers to evidence use in decision-making, weak capacity for evidence use has attracted a lot of focus in the last decade. The study aims to inform and enrich ongoing and future efforts to strengthen capacity for evidence use by presenting and discussing the experiences and lessons of a project implemented in Kenya and Malawi to strengthen individual and institutional capacity for evidence use within the ministries of health (MoHs).This paper draws on the internal and external evaluations of a 3-year project funded by the United Kingdom’s Department for International Development, the Strengthening Capacity to Use Research Evidence in Health Policy . To strengthen individual capacity, the project implemented a training and mentorship programme for 60 mid-level policy-makers in the two MoHs. To strengthen institutional capacity, the project conducted sustained advocacy with top leaders to strengthen structures that enable evidence-informed decision-making (EIDM), supported Kenya to develop research-for-health policies and priorities, supported Malawi to review the implementation of its health research agenda, developed EIDM guidelines for both MoHs, and supported bi-annual evidence dialogues to improve interactions and raise the profile of evidence. Internal evaluation included baseline and endline surveys (93 baseline and 92 endline interviews), 60 in-depth interviews, and intervention-specific evaluations . The external evaluation was implemented alongside project implementation, conducting three annual evaluations.The results show that training and mentorship programmes in EIDM were effective in improving competencies of civil servants. However, such programmes need to train a critical mass to be effective in enhancing EIDM practice at the MoHs. On strengthening institutional capacity for EIDM, while the project achieved some success, it did not realise long-lasting effects because of its limited time of implementation and limited focus on sustained political economy analysis, which meant that the intervention was negatively affected by frequently changing interests within the MoHs.Although training and mentorship are effective in improving EIDM competencies, they need to be incorporated in existing pre-service and in-service training programmes for sustainability. Strengthening institutional capacity for evidence use is complex and needs sustained political commitment and long-term investments. Although strong individual and institutional capacities are critical in enabling evidence-informed decision-making (EIDM), these remain weak in many developing countries for many reasons, including lack of EIDM training programmes for civil servants, and low priority and investments in strengthening institutional structures and mechanisms for enabling EIDM.Training and mentorship programmes in EIDM are effective in improving competencies of civil servants, but these need to be incorporated in existing pre-service and in-service training programmes to be sustainable and ensure the training of a critical mass.Strengthening institutional capacity for evidence use is complex and needs sustained political commitment and long-term investments.the ability of ‘individuals, institutions and societies’ to perform functions, solve problems, and set and achieve objectives in a sustainable manner” ) This paper discusses our experiences and lessons from one of the BCURE projects implemented in Kenya and Malawi to strengthen capacity for evidence use within the ministries of health (MoHs). The intervention implemented simultaneous activities to build technical skills at individual level, strengthen institutional policies and structures that enable evidence use, and cultivate a supportive political environment for enabling increased demand and use of evidence in health policy-making in Kenya and Malawi. This paper discusses fresh, context-specific lessons and insights in strengthening institutional and individual capacities in government agencies for evidence use in Kenya and Malawi. In this way, the paper enriches the emerging literature on strengthening institutions for evidence use. Although our BCURE intervention focused on both MoHs and parliaments, this paper focuses only on the experiences and lessons from the MoHs in the two countries.This paper draws primarily from the internal and external evaluation of our BCURE intervention, the Strengthening Capacity to Use Research Evidence in Health Policy  project. The SECURE Health project aimed to optimise individual and institutional capacity to use research in health sector decision-making in Kenya and Malawi.The intervention’s internal monitoring and evaluation comprised two components. The first was the baseline and endline assessments of capacity needs. The baseline and endline assessments were cross-sectional descriptive studies that used both quantitative and qualitative methods. Data were collected through semi-structured questionnaires completed in face-to-face interviews and in-depth interviews. With regards to sampling, the MoH Permanent/Principal Secretary and all heads of directorates (i.e. top-level policy-makers) in both MoHs were interviewed . In addition, we sampled at least 2–3 technical staff (i.e. mid-level policy-makers) from all divisions and units under the directorates . This was done to ensure representativeness of the data gathered. The selection of the 2–3 staff for interview was informed by this criterion – all division/unit heads were to be interviewed and they would then advise on two relevant staff from the division/unit who should also be interviewed. In cases where the division/unit heads were unavailable, we engaged the staff at the MoH research division/department to identify the relevant staff in the division/unit to be interviewed. We also purposively sampled and interviewed senior health researchers in either leadership positions in research institutions or those actively involved in the work of MoH policy task-forces or technical working groups. In-depth interviews with the researchers focused on understanding their experiences with supporting health research use and their perceptions of the status of institutional capacities for enabling EIDM.Table The semi-structured questionnaire was mainly used for the technical staff (mid-level policy-makers), whereas the in-depth interviews, which also used a semi-structured guide, were conducted for the top-level policy-makers and senior researchers. Whereas for the mid-level policy-makers, the focus of the interview was on assessing individual EIDM skills and practice  as well as institutional support mechanisms that enable or hinder EIDM practice, for the top-level policy-makers the focus was on institutional capacities  and their perception of the EIDM technical capacities among MoH staff. Quantitative data from the baseline and endline assessments were analysed using descriptive statistics, whereas qualitative data were analysed using a thematic framework where data were classified into themes and sub-themes.The second was implementation of activity-specific tools to assess activity effectiveness in contributing to the objectives of the intervention. These included the pre–post tests for the training workshops, feedback forms for the science-policy cafés, and documentation of effects of the various advocacy meetings conducted. The data that this paper has been drawn from reports of the project baseline and endline assessments, pre–post tests of training workshops, activity feedback forms and project progress reports that documented project outputs and changes in awareness, knowledge, attitudes and practices relating to EIDM.DFID commissioned external evaluation of the SECURE Health project that was implemented alongside project implementation . The evaluation used a realist approach and was conducted in three stages  see , 21, 22), 2221, 2Ethics review and approval for the project’s research component was provided by the Kenya Medical Research Institute (KEMRI)’s Scientific and Ethics Review Committee whereas, in Malawi, this was provided by the College of Medicine Research and Ethics Committee.The SECURE Health project aimed to optimise individual and institutional capacity to use research in health sector decision-making in Kenya and Malawi. The design of the project’s intervention, back in 2013, was informed by a synthesis framework that combined elements of the UNDP’s 2009 framework on capacity development  and the The intervention Table  was limiWhile the intervention was designed through consultations with MoH leadership in both countries before the capacity needs assessments above, the results of these needs assessments informed the refinement of the intervention and detailed design of specific intervention activities. The main barriers to evidence use revealed by the needs assessments in both countries included little interest in using research evidence among top-level decision-makers due to competing political and personal interests; inadequate technical skills among MoH staff to access, appraise, analyse, synthesise and apply research evidence; inadequate time to access and use research evidence due to competing demands; lack of a mechanism for accessing research evidence (no repository); weak institutional linkages with research institutions; poor data quality and an inefficient health information system; and inadequate funding to support the generation and use of research evidence in decision-making. Inadequate staffing as a barrier to evidence use was only mentioned in the Malawi MoH but not in the Kenya MoH. Given that results of the needs assessment did not differ greatly between the two countries, similar intervention activities were implemented in Kenya and Malawi. Table Recognising the complexity of policy-making in government institutions, and the need for capacity-building efforts to take these into consideration, the intervention was implemented in partnership with the MoHs in the two countries. This provided ownership of the intervention by the MoHs. The institutions involved in the design and implementation of the intervention with the MoHs included the African Institute for Development Policy, Family Health International 360, the Consortium for National Health Research (Kenya), Malawi College of Medicine, and the East, Central and Southern Africa Health Community. In Kenya, the intervention was embedded in the work-plan of the then newly formed Research and Development Division in the MoH whereas, in Malawi, the intervention was embedded in the work-plan of the Malawi Knowledge Translation Platform (KTP) coordinated by the MoH’s Research Department.The section summarises the EIDM landscape in the health sector in Kenya and Malawi as revealed by the capacity needs assessment conducted at the start of the intervention. At the national level in both Kenya and Malawi, there is no deliberate policy requiring evidence use or focused on promoting and enabling evidence use in decision-making in public policy and programming. There is some notable focus on the generation of research and data in both countries, but not as much focus on the translation of the research and data, and its actual use in decision-making. In regard to research, the Kenya MoH has KEMRI, mandated to provide the research the MoH needs for decision-making. While the Malawi MoH has no dedicated research institute, it expects universities  to provide the research needed for decision-making. Both MoHs have the District Health Information System II, which provides data from a country’s healthcare system supposed to inform decisions. However, funding for research generation and District Health Information System II is largely left to development partners, with the governments only investing in the salaries of researchers at KEMRI and universities. Through the National Commission for Science, Technology and Innovation in Kenya and the National Council for Science and Technology in Malawi, the two governments provide some small grants for research, including health research.In 2012, the Malawi MoH established a KTP mandated to build capacity in evidence synthesis for health sector actors . Howeverguidelines for evidence-informed policy-making” as an institutional tool for promoting and enabling evidence use. Although the plan was to develop and launch guidelines in the first 2 years and use the final year of project implementation to assess their usefulness, this was not possible due to delays occasioned by the many stages of review and approval for the guidelines. The guidelines were only adopted and launched in the last 4 months of project implementation, leaving no time to track how they were used. The key indicators that we agreed on with the MoH leadership to use in assessing commitment to institutionalisation and use of the guidelines include extensive dissemination, incorporating the guidelines into the orientation programme for new staff and requiring the use of guidelines in the processes and procedures of developing and providing policy advice. In Kenya, the development of the EIDM guidelines stimulated the MoH to appreciate the need for guidelines for the policy development process, which the ministry developed.The programme supported the two MoHs to develop “In addition to the guidelines, the MoHs adopted the EIDM training curriculum developed and used in the intervention as their institutional tool for developing EIDM capacity. The adopted curriculum incorporated lessons learnt in using the EIDM curriculum in the Kenya and Malawi trainings. Since 2016, the Kenya MoH has worked with several partners  to use the curriculum to train its staff working at country levels.In order to define government’s research needs to guide the generation of responsive research, the intervention worked with the Kenya MoH to develop health research policy and priorities. The MoH led the development of the Research-for-Health Policy Framework and Priorities, with technical and financial inputs from our intervention. The process experienced notable delays that by the end of our intervention, the Research-for-Health Policy Framework and Priorities were fully developed, but yet to be adopted by the MoH pending health stakeholder review and approval. The draft policy outlines a comprehensive framework for, among others, improving and enabling the translation of health research for decision-making. It provides for the development of a knowledge management and translation framework that includes provisions for regular setting of priorities for research for health; the establishment of a functional knowledge-sharing mechanism comprising an online knowledge-sharing platform and regular conferences and dialogues for exchange of information and new research results; and the development of mechanisms for knowledge synthesis and exchange to inform policy and practice. The impact of this policy will be seen once the MoH adopts and implements it.In Malawi, the intervention undertook a mid-term review of the implementation of the National Health Research Agenda adopted by the MoH in 2011 to generate lessons for improving its implementation. The review revealed that, except for one objective, the Agenda was failing to achieve most of its objectives. The only objective where progress was being made was on enabling the generation of research that is responsive to the country’s health priorities identified by the Agenda. The poor performance of the Agenda was mainly attributed to the lack of a comprehensive implementation plan and committed resources for implementing it. The MoH discussed the results and recommendations of the review with stakeholders in order to generate support from other government agencies and development partners in implementing the Agenda. Although the endline survey did not show much change in the implementation of the Agenda, the impact of this review was not expected to be immediate and will likely be seen in years to come.The regular science-policy cafés were meant to provide a framework for strengthening interactions for policy-makers and researchers. Because the cafés were largely attended by different groups of researchers given the issue of focus, our endline survey did not find evidence that they improved relationships between researchers and policy-makers. However, endline results showed that the cafés were seen as one of the most effective activities implemented by the intervention because they facilitated critical discussions of evidence on urgent policy issues. Further, some of the evidence and recommendations provided by the cafés informed policy decisions in both Kenya and Malawi MoHs. In Kenya, the café on providing free-of-charge maternal health services informed the country’s policy shift on its funding mechanism for the free-of-charge maternity health services policy. In Malawi, the café on healthcare financing informed the MoH’s decision to retain its policy on user fee waivers for the provision of health services. The café on youth sexual and reproductive health and the role of sexuality education stimulated critical conversations between the MoH and Ministry of Education on providing comprehensive sexuality education in Malawi. Similarly, the recommendations from the café on bridging the health research-to-policy gap in Malawi stimulated efforts within the MoH and parliament to push for increased government funding for research, including health research. However, our hope to see the two MoHs institutionalise the cafés as formal platforms for sustained interactions between policy-makers and researchers was not realised by the end of the project.Regarding strengthening linkages at institutional level, the intervention stimulated closer working relations between the MoH and KEMRI in Kenya, and the MoH and the College of Medicine in Malawi. The interventions further provided ideas on how these institutions could work more collaboratively to promote the use of existing research evidence in policy and programming decisions. Although the benefits of these strengthened relationships were not immediately demonstrable in improving the use of research evidence, these may be seen in the future.In relation to improving structures for enabling EIDM, the project sought to stimulate the two MoHs to revive their defunct libraries, improve Internet connectivity and get subscribed to journal databases that are freely available such as the WHO’s Hinari Access to Research for Health Programme. Unfortunately, these efforts bore limited results. The process of getting connected to the WHO Hinari database was initiated by the Kenya MoH but was not completed by the end of the intervention. For the Malawi MoH, subscription to Hinari was not initiated as the Internet connectivity remained severely poor throughout intervention implementation.Having adequate financial and human resources is critical for enabling evidence use. Following the project’s high-level advocacy, the Kenya MoH introduced a budget line for the Research and Development unit in the 2015/2016 financial year to enable the unit to implement activities that facilitate evidence use in the ministry. For Malawi, the project did not stimulate any increases in funding for enabling evidence-informed policy-making mainly because, throughout the project period, the government of Malawi was operating entirely on an ‘austerity budget’, and so it was clear from the start of the project that it was going to be difficult for the government to increase or introduce budget lines aimed at enabling evidence-informed policy-making. Nevertheless, the intervention stimulated new thinking from other actors in the country, which has resulted in more funding from development partners through the MoH for EIDM .Regarding personnel, results of the baseline identified inadequate numbers of staff, and weak or lacking skills in EIDM as among the key barriers to evidence use. Therefore, while the training programme (discussed in the next section) aimed at building skills in EIDM for existing staff, our advocacy efforts hoped to stimulate recruitment of more staff to support EIDM work. In both countries, the ministries reported to have frozen new recruitments throughout the project period, and so the advocacy did not result in new recruitments. However, the Research unit in the Malawi MoH received two additional staff through transfers from other departments during the implementation of the project, increasing its staffing from two to four. In Kenya, the opposite occurred, where four of the existing staff in the Research unit left to join other divisions and one retired, leaving only one staff member by the end of the project.strong evidence that the training and mentorship activities had increased participants’ awareness, technical knowledge and or skills” .As seen in the table, the average ratings for research use skills among the Kenya MoH training participants improved from 2.65 before the training to 4.06 immediately after the training and 3.90 at endline. Similarly, among the Malawi MoH training participants, there was an improvement in the average ratings for research use skills from 2.68 before the training to 4.38 immediately after the training and 4.44 at endline. Besides assessing the change in perceived research use skills among trained staff, we also used the pre–post test survey to assess the EIDM knowledge acquired through the training. Results showed notable improvements in knowledge on various EIDM components, including the complexity of the policy-making process, the role and place of different types of research evidence in the policy-making process, barriers to evidence use and ways of overcoming these.An important aspect of the training programme’s follow-up support and mentorship was to support actual on-the-job application of skills, and the completion of policy briefs that learners started preparing during the 5-day initial training workshop over 12 months. On-the-job support proved difficult as trainees were very busy and either had very short turn-around times for activities that required the inputs of the trainers and so trainers were not able to support them, or learners were not forthcoming in seeking the support of trainers in real job tasks. As a result, most of the follow-up focused on supporting learners to complete their policy briefs on issues they had identified as urgent for their units/divisions prior to the training. For Kenya, of the 34 staff, 12 completed and disseminated individual or group policy briefs, whereas for Malawi, out of 26 learners, 15 completed and disseminated individual policy briefs. For those who were unable to complete their policy briefs, the main reason cited was lack of time due to busy schedules.The development of policy briefs by trained staff provided a more objective way of gauging skills acquired by learners in the EIDM process. From our experience in both countries, except for a few briefs that were of good quality, most of the briefs developed were of average quality, pointing to the need for the technical officers to do more practice in order to improve the quality of briefs they develop. One of the MoH staff in Malawi shared her policy brief with a funding agency, which in turn provided funds to tackle the issue highlighted in the brief. Her brief advocated for the decentralisation of HIV testing to reduce results turnaround time through the use of point of care HIV diagnostic devises. Another learner in Kenya got his policy brief to inform the MoH policy/strategy on water and sanitation; his brief advocated for timely water safety surveillance highlighting the burden and cost of failing to do so.That training has helped me focus on evidence in my work. I attended the training when we were in the process of formulating the school health and nutrition policy. So that knowledge helped me very much in accessing the evidence on school health and nutrition that was reviewed for the policy.” Malawi MoH Staff, 2016.“The training enhanced my confidence that I can lead in the process of coming up with an evidence-informed policy. From the policy brief I prepared, we have put together a few technical people to finalise it and turn it into a concept note that we will later on develop into a policy.” Malawi MoH Staff, 2016.“The project has stimulated a new way of thinking in the staff involved. Now we need to make what the project has initiated a norm in the Ministry. We need to ensure that EIDP [evidence-informed decision-making and policy] is the norm.” Kenya Senior MoH Official, 2017.“The external evaluation found evidence that “a number of trainees were using their skills to inform policies or generate evidence products, and that BCURE had made an important contribution to this, alongside including donor-supported programmes providing an opportunity for evidence use”  ce use” .ce use” .In our internal evaluation, MoH staff in both countries identified their most severe barrier to evidence use at both baseline and endline as the lack of relevant research evidence and/or the lack of access to evidence. This is not surprising since the project’s efforts at institutional level to stimulate leaders into action to address persisting barriers to accessing research evidence were not very effective as already discussed. The fact that the intervention tried to address the ‘access to evidence’ barrier by getting the Kenya MoH connected to Hinari but failed shows the disconnect within the MoH in steering the intervention; the staff responsible for connecting MoH to Hinari were different from the staff facing the challenge of accessing evidence, and therefore the lack of urgency in completing this task reflected the low appreciation of common goals among staff at the MoH. Additionally, while the intervention strengthened links between the MoH and existing research institutions  through its activities, the benefits of these strengthened relationships were not immediate in improving access to research evidence, but may be seen in the future.We experienced challenges arising from the complex institutional structures and arrangements compounded by a web of power relations among individuals within these structures. In Kenya, for instance, the Research and Development unit was a Division at the start of the project in 2013, and this gave it a higher level in the hierarchy. Within 2 years, this had been demoted to a Unit, a decision occasioned largely by the exit of a top leader who valued research more than his successor.Co-implementing project with MoH staff exposed us to the slow processes, weak or lacking accountability structures, and inertia among MoH staff that often resulted in delays in implementing project activities. For instance, the process of getting the Kenya MoH subscribed to Hinari took a much longer period partly because the MoH staff responsible for this often did not do what was agreed upon, requiring a lot of follow-ups. Therefore, a process that appeared quite straight-forward, was not completed by the end of the project.Throughout the 3 years of implementing the project, there were numerous staff changes in the two MoHs. Such frequent staff transfers undermined project implementation, often leading to delays in activity implementation or low priority accorded to the project altogether by incoming staff.In order to attract the right and motivated MoH staff to benefit from the training, we advertised the training within MoH and required interested staff to apply for the training. Although we aimed to select 30 MoH staff for the training in each country, we received few applications to select from . To address this challenge, we engaged the MoH leadership to review the list of applications as well as devise other ways of identifying the right staff for the training. The MoH leadership in both countries asked heads of divisions to nominate relevant staff from their divisions for the training, which led to more applications. In Kenya, the MoH further revised the list of those who had applied, dropping some of them, who they argued were always attending trainings but failing to deliver in their work.The main complaint from MoH staff about the foundational 5-day EIDM training workshop was that it was ‘too intense’ and the time was not adequate. Although we considered offering the training in a series of modules over a month, we realised that we would face the challenge of getting different staff from the MoH depending on availability for different modules. As such, the option of a 5-day intense foundational workshop was made to ensure that all selected staff go through all the modules. It was also not possible to spread the training over periods longer than 1 week as staff would not be allowed to be away for such long periods.There was low participation in the one-on-one follow-up sessions and refresher workshops as well as slow progress towards completion of policy briefs. We engaged MoH leadership to support the process and require the completion of policy briefs. This strategy helped to get more learners actively involved in the mentorship process. We changed strategy to have learners work in groups to produce policy briefs, but this worked for some groups and not for others, and forced some learners to revert to working on individual briefs. We also increased the frequency of one-on-one contact with every learner from every 2 months to every 1 month to better understand the challenges they faced and provide timely feedback on draft policy briefs. This meant that we invested more personnel time than was budgeted for.There is increasing interest and investment in building capacity on the demand-side of evidence for enabling increased use of evidence in decision-making see , 20, 26), 2620, 2At an individual level, the training and mentorship for MoH staff increased the knowledge and skills in the use of evidence, which confirms results from other studies see , 27) on  on 27]) The question of sustainability of such a training programme is an important one, and which, because of the short-term nature of our intervention, was not addressed. While we made the EIDM training curriculum used by the programme available as open access for use by other actors, getting the EIDM training programme incorporated into existing pre-service and in-service training programmes for civil servants provides a more effective way to enable sustained capacity development for EIDM. Beyond the project period, the authors have continued to engage relevant training institutions in Kenya and Malawi to review and incorporate the EIDM training curriculum in their existing programmes.In relation to strengthening institutional capacity for evidence use, the intervention’s average results confirm the well-recognised fact that strengthening institutional capacity is most critical in capacity development efforts, but it is complex, has many dimensions, and requires sustained political commitment and investments over a long period of time , 12, 14.The guidelines for evidence use developed by the project and adopted by both MoHs provide an important tool for promoting and embedding EIDM in MoH processes if staff are trained on how to use them in their work . Hawkes The results of the science-policy cafés challenge the argument by other scholars see –31) that that31])Embedding the intervention in the Research division/department within the two MoHs was a critical success factor, confirming the findings of other scholars , 34. EveThe two MoHs’ over-reliance on funding from development partners for the health sector is an important factor that shapes EIDM practice. The average priority that the intervention received in both MoHs was partly because it was not a priority of many of the funders investing heavily in these two MoHs. This means that implementers of EIDM initiatives in future need to also sustain engagement with key funders for the MoHs so that these actors support the intervention in their conversations with the leadership of the MoHs and through additional funding.Overall, the results of the intervention confirm the important need for governments, funders and other development actors to take holistic and longer-term approaches to capacity development efforts for increased research use. Simultaneous and sustained efforts that address both ‘supply-side’ and ‘demand-side’ capacity challenges at individual, institutional and organisational levels could be more effective. Hawkes et al.  have proAmong the many barriers to evidence use, weak capacity for evidence use in policy and programme decisions has attracted much focus in the last decade , 8–12. I


We determined the range of normal spleen dimensions evaluated by ultrasonography (US) in children according to sex and age and the relationship between splenic measurements, auxological data and body proportions, in order to define splenomegaly parameters in support of the surgical mini-invasive approaches in pediatrics.We prospectively examined 317 caucasian children of both sexes. The patients were divided into three groups: 0–3 years; 4–10 years; 11–18 years. Sex, weight, height/length, body mass index (BMI), waist circumference and xipho-pubic distance were determined for each child. US spleen evaluation included longitudinal/antero-posterior/transverse diameters, transverse area and volume. Spleen volume/abdominal volume, longitudinal spleen diameter/longitudinal left kidney diameter and longitudinal spleen diameter/xipho-pubic distance ratios were also calculated.For caucasian subjects, in different age groups spleen volume, transverse area and diameter increased while the spleen/abdominal volume ratio decreased significantly (p<0.001). A significant (p<0.001) decrease in longitudinal spleen diameter/xipho-pubic distance ratio was noted between the 0–3 years group and both 4–10 and 11–18 years group. Age and auxological data, except BMI, showed a high correlation with spleen dimension (r≥0.8).The current concept of splenomegaly is not applicable in pediatric surgery. A dedicated classification of splenomegaly is needed for children and would improve the safety and feasibility of treatment. Laparoscopic splenectomy (LS) has gradually become the technique of choice for surgical removal of the spleen also in children –6. SplenUltrasonography (US) is an established safe, non-invasive, and reliable method to calculate splenic dimensions –15. In aUnfortunately, there is still no consensus on how to define splenomegaly in pediatric patients. Furthermore, the reference values for B-mode spleen ultrasound reported in the literature are controversial, with differences depending, at least in part, on the ethnic heterogeneity of studied pediatric populations that include subjects with different ethnic backgrounds, country of origin and residence. Racial differences and interfering genetic or infectious factors may influence spleen size –24. ConsAim of this study was to obtain normal percentile values in Caucasian children of both sexes, aged 0–18 years, and to evaluate the relationship between splenic measurements, chronological and auxological data, and body proportions.We prospectively examined 317 caucasian healthy children  referred to our department between May 2013 and June 2014 for preoperative day surgery workup. A complete auxological evaluation was also obtained before entering the study. The age range was from full-term newborns to 18 years. According to growth spurts, the children were divided into three groups: group 1: 0–3 years ; group 2: 4–10 years ; group 3: 11–18 years . Sex, weight, height/length, body mass index (BMI), waist circumference and xipho-pubic distance were obtained in each child.th percentile according to Cacciari for age≥2 years or to Gairdner’s and Pearson’s for age <2 years) or obese children (BMI>97th according to to Cacciari for age≥2 years) / 3600) / 3600) . The abdIn children older than two years, height, weight, and BMI were classified using Cacciari’s percentiles for the Italian population . In infaUS spleen evaluation was performed using an Esaote My Lab Twice ultrasound device for image acquisition, with a 3.5–5 MHz convex probe in children above 1 year of age and a up-to-10 MHz linear probe in younger children. All scans were obtained by a single expert sonographer.All patients were asked to lie down in a supine position or a lateral position when optimal scans were not achievable in the supine position. A water-based medium was applied to both the probe and the body area being scanned to ensure good transmission of the ultrasound beam.Optimal images for a complete spleen evaluation were obtained through sagittal, transverse, oblique and frontal scans and even though the intercostal space if necessary.From the obtained images, we measured: longitudinal diameter: between the highest superior-medial and the lower inferior-lateral points of the spleen; antero-posterior diameter: between the anterior and posterior surfaces; transverse diameter: between the hilum and the superior-lateral edge of the spleen; transverse area: delimited by the splenic external margin in the longitudinal scan. Spleen volume was calculated using the prolated ellipsoid formula (L x W x H x 0.523) . We alsoSpleen volume/abdominal volume, longitudinal spleen diameter/longitudinal left kidney diameter, antero-posterior spleen diameter/antero-posterior abdominal diameter and longitudinal spleen diameter/ xipho-pubic distance ratios were also calculated and included in the statistical analyses.th, median, and 75th percentiles if continuous. Both general (for comparison with adults) and pediatric non-parametric reference limits (2.5th—97.5th and 3rd– 97th percentiles) for spleen measures are reported. Moreover, model-based age specific reference intervals were computed [xriml user-written routine in Stata [th, 50th, 90th and 97th percentiles of the (log-transformed) variable were then plotted against age. Spleen measures were compared between age groups with the Kruskall Wallis test. Correlation between spleen measures and clinical characteristics were assessed with the Spearman correlation coefficient (R) and its 95% confidence interval (CI). To assess intra-operator agreement, the Lin’s concordance correlation coefficient (95%CI) [All statistical analyses were performed using STATA 13.1 statistical software . The level of significance was set at the two-tailed P-value <0.05. Data were described with counts, if categorical and with the mean, standard deviation, 25computed , with agin Stata . Log tra (95%CI)  and the  (95%CI)  were comClinical characteristics of the children enrolled in the study are reported in The intra-operator agreement for splenic diameters was excellent for all 3 diameters: longitudinal diameter: rho c = 0.984; 95%CI 0.951–0.995, difference -0.012 (0.301), 95% limits of agreement -0.602–0.579; antero-posterior diameter: rho c = 0.923; 95%CI 0.769–0.975, difference -0.051 (0.295), 95% limits of agreement -0.629–0.528; transverse diameter: rho c = 0.958, 95%CI 0.894–0.984, difference -0.089 (0.332), 95% limits of agreement -0.740–0.562.Considering that no significant differences in splenic measurements were noted between males and females, statistical analyses were performed by combining the data obtained by both sexes. For all measurements, a significant change according to age group was noted (p<0.001), particularly between the 0–3 and 4–10 years groups. Spleen volume, transverse area and diameters increased and spleen/abdominal volume ratio decreased with age. A decrease in longitudinal spleen diameter/ xipho-pubic distance ratio was noted between the 0–3 years group and the 4–10 and 11–18 years groups. Longitudinal spleen diameter/longitudinal left kidney diameter was greater in the 4–10 years group compared to the 0–3 and 11–18 years group.Correlations of the spleen dimensions with auxological data and body proportion are reported in Weight, height, body surface, age, waist circumference and xipho-pubic distance were highly correlated with spleen volume, transverse area, longitudinal and antero-posterior diameters. BMI showed the weakest correlation with all organ dimensions measured. No relevant correlation between clinical parameters and spleen volume/abdominal volume, antero-posterior spleen diameter/antero-posterior abdominal diameter, longitudinal spleen diameter/longitudinal left kidney diameter ratios was noted.Specific reference limits for each age from 0 to 18 years are shown as graphical outputs in We obtained a standard set of normal range splenic dimensions in caucasian children according to three age groups . A significant difference between the three age groups was found, particularly between the 0–3 and 4–10 year groups. While all measured spleen dimensions increased with age, though not linearly, their ratios to abdominal volume or kidney diameter appeared constant for the different ages. In addition to spleen length at the hilum, other dimensions were also considered for a more precise spleen size definition. No significant differences in splenic measurements between sexes was noted.The spleen is easily modified during lifespan due to several physiological and pathological conditions such as growth, infections, hematopoietic disorders, storage diseases, inflammatory conditions as well as splenic trauma. The assessment of organ size is an integral part of the evaluation and treatment of disease, particularly before splenectomy.Clinical examination is often inaccurate, especially in detecting small increases in size and several studies have documented that palpable cases do not necessarily indicate splenic enlargement –9. MoreoIn adults, splenomegaly is defined as a long axis exceeding 15 cm and massive splenomegaly as a long axis exceeding 20 cm ,34. OtheIn children, US is routinely used to evaluate the “true” size of abdominal organs because it offers numerous advantages: no radiation exposure, non-invasive technique, examination in real time, three-dimensional and independent of organ function –15. The Our data confirm that an increase in organ size is related to growth. Literature data on normal values of pediatric splenic dimensions are not univocal. The dishomogeneous ethnic distribution  of studied pediatric population, consisting prevalently of Nigerian, Indian, and USA children, may influence the variability of the estimation  and may limit the generalizability of the data –24.In addition to literature data ,12–14,43Contradictory findings on spleen measures and gender association have been previously reported. Some studies indicate a significant difference between males and female in spleen size –21. HoweA correlation between organ and abdomen dimensions  in relation to somatometric parameters would be helpful in defining a “normal “spleen” during growth and could be of paramount importance to define splenomegaly in children .A preoperative spleen size evaluation is crucial for surgeons when planning the feasibility of a LS approach in children, particularly when spleens are greater than 20 cm; these are considered to be “giant” sized spleens, and are difficult to remove laparoscopically in children, due to technical limitations.Our study showed that the spleen/abdominal volume ratio decreases with age. The spleen volume is relatively larger in infants and toddlers compared to older children. These data confirm the influence of anatomical factors and support the body proportion importance on technical limits during LS in the pediatric age, particularly in young children .LS is a well accepted approach for the treatment of multiple hematologic diseases. Standard surgical steps consist of trocar positioning, initial ligation of the splenic artery to reduce the spleen volume and avoid or reduce any possible bleeding upon spleen extraction. Several different less invasive techniques are available including the single port access splenectomy (SPAS) which reduces the surgery to one small incision; the reduced port access splenectomy (RPAS) which entails the use of fewer and smaller trocars, and the hand-assisted procedure ,47. The Laparoscopic techniques have been shown to offer several advantages over the traditional open technique, in particular: reduced hospital stay, faster return to unrestricted activities, and improved cosmetic results . HoweverKnowledge of spleen dimensions in relation to clinical data is mandatory to define splenomegaly in children. A dedicated pediatric splenomegaly classification would support the safety and feasibility of mini invasive approaches.