A case study from Botswana

Building capacities of elected national representatives to interpret and use evidence for health-related policy

decisions:

A case study from Botswana

Neil Andersson, Mokgweetsi Masisi, Lehana Thabane, Anne Cockcroft

Rationale

• Elected representatives make decisions and allocate funds

• They lack skills to interpret evidence on health-related topics

• It is possible to build such skills

Usually:

• Training for MPs covers mechanics and ethics of role

• Training in use of evidence targets technical officers

Can we bridge the gap?

The opportunity

• Debate about national HIV/AIDS policy in Botswana parliament in 2011

• Invited by government – to survey MPs about their needs for

evidence and training in its use– to provide training about evidence use

• Working with Office of President, National Assembly Office, NACA

The Botswana parliament

61 members

57 elected4 appointed

16 ministers

9 assistant ministers

The survey – October 2011

27 MPs completed short questionnaire 17 by telephone

10 face to face

As a parliamentarian do you feel you need more evidence, from research, about HIV and AIDS?

2

25

0 5 10 15 20 25 30

No Yes

CIET 2011

…receive evidence from reliable, unbiased sources?

4

12

11

0 2 4 6 8 10 12 14

DK No Yes

CIET 2011

…know enough about what to do about evidence?

11

16

0 5 10 15 20

No Yes

CIET 2011

…have had enough training in how to make the best use of evidence?

19

8

0 5 10 15 20

No Yes

CIET 2011

Do you think it could help your work if you felt better equipped to use evidence?

2

25

0 5 10 15 20 25 30

No Yes

CIET 2011

How would it help your work?

It would boost my confidence…decisions would be based on facts

We would have actual facts and knowledge to pass to our constituents

…help in effective policy making

We would discuss issues in a well-informed way

…could assist us to make positive changes

CIET 2011

What difficulties do you face in using evidence in your work as a parliamentarian?

…the use of jargon

…difficult wording and statistical data

…evidence from government agencies is outdated

…inexperienced research officers…lack of researchers for parliament

…technical terms are a challenge

…access to the information

CIET 2011

The training sessions

“Parliamentarians and evidence-based decision making”

Oct/Nov 20112 x ½ days

Nov 20122 x ½ days

Material Material

Some dropped, some added

Parliamentarians

Coverage

36 MPs 7 ministersDeputy speakerLeader of oppositionChair of HIV/AIDS cttee

Director HIV/AIDS MoHNACA personnel

Some of participants from 2011

Evidence for planning

• Evidence on impact, coverage and costs• Contrast (counterfactual evidence)• Describing evidence: population link• Value of different evidence sources:

contrast, ability to deal with other factors

The language of evidence

AnalysisAssociationInferenceInteractionContrastConfounder

Relative RiskRisk DifferenceGainsNumber needed to treat

AccuracyErrorBias

Randomised Controlled TrialRandomised Cluster Controlled TrialSystematic reviewMeta analysis

Statistical significanceP valueConfidence intervalStudy size

IncidencePrevalenceHyperendemic countriesBaseline measurementIngredients of a questionnaireUpward trajectory of costsConcomitant increase

Questions to ask about evidence

Discussed summaries of real, published evidence:

• Lacking or weak contrast

• Bias or confounding

• Different setting

• From small or single study

HIV prevention in Botswana

• Remaining 1.5% annual HIV incidence• About 14,000 new cases per year• Highest incidence in young women

• Calculating impact of prevention investment• Increased prevention investment needed• Current programmes not the answer

The Gizmo dashboard

What could you do in your constituency?

• MPs as exemplars, champions• Target poverty alleviation to young

women• Community discussions of “morality”• Sessions for school children• Involve traditional leaders

Measure impact on new cases

Evaluation of sessions2011 2012

Relevance of content 4.25 4.5

Level of content 4.15 4.3

Presentation 4.2 4.0

(Mean scores out of 5)

Would it work elsewhere?

• Timing was right (AIDS Policy debate)• Champion (minister is ADAPT fellow)• Botswana has functional parliament• Sought and incorporated perceived

needs of the MPs• Content direct and relevant