MOVERS, SHAKERS, AND GATEKEEPERS:

THE ROLE OF INTERMEDIARIES IN EVIDENCE-INFORMED DECISION MAKING

Nasreen Jessani, DrPH

Presentation for: Johns Hopkins Centre for AIDS Research

Implementation Science Scientific working group

13 April 2016

OVERVIEW • Evidence-informed decision making

• The focus on intermediaries/knowledge brokers

• Academic knowledge brokers in Kenya: A mixed methods study of relationships, characteristics and strategies

• Adapting the study to USA (and JHSPH)

• Relevance to CFAR

HOW ARE DECISIONS MADE?

WHAT INFLUENCES DECISIONS?

Political complexities

Party preferences

Other evidence Social, religious and cultural norms (acceptablity)

Relative benefit/harms of other options – cost, impact, equity, speed

etc…

Ecological impacts

Other actors – lobbyist, activists, media,

epistemic communities, stakeholders, funders

Operational practicality

EVIDENCE INFORMED DECISION MAKING •  “purposeful and systematic use of the best available

evidence to inform the assessment of various options and related decision making in practice, program development, and policy making (OAPN Canadian Centre of Excellence, 2010)

•  “a continuous interactive process involving the explicit,

conscientious and judicious consideration of the best available evidence to provide care” (Canadian Nurses Association, 2010).

•  policy should be informed by a wide breadth of evidence,

not just hard research. Key issues include the quality, credibility, relevance and the cost of the policy.

MODELS DEPICTING RESEARCH TO ACTION

GrahamID,LoganJ,HarrisonMB,etal.Lostinknowledgetranslation:timeforamap?JContinEducHealthProf2006;26:13–24.

Lavis,Lomas,Hamid,etal.“Assessingcountry-leveleffortstolinkresearchtoaction.”BulletinoftheWHO.August2006.p.622

BUT: -  transactional not relational -  Assumes homogeneity of actors

!

!!

CONTEXT'

CONTEXT'

Other'influences'

PUSH'FACTORS'!

PULL'FACTORS!"!!!

LINKAGE'AND'EXCHANGE'FACTORS!!

Academic!Institutions!

Unidimensional Gatekeepers Unskilled Outsource to specialists

ACADEMIC KNOWLEDGE BROKERS

Photo credit : http://bit.ly/1sHMceE Photo credit : http://bit.ly/1ruaULZ Photo credit : http://bit.ly/1rub5XB Photo credit : http://bit.ly/1plaeoN

Invisible Uniquely positioned

Skilled Credible

ACADEMIC KNOWLEDGE BROKERS

Picture credit: www.zizaza.com

Academic researchers Policymakers

Academic Knowledge Brokers: HYBRID/

BLENDED/EMBEDDED

Connected to policymakers as conduit to policy influence AND

Advisors to academic peers on evidence to policy

WHAT DID WE WANT TO LEARN?

Mapping the networks

Do academic knowledge brokers exist? An exploration of research-to-policy networks of faculty from six Schools of Public Health in Kenya

Understanding the brokers

The human capital of knowledge brokers: An analysis of attributes, capacities and skills of academic faculty at Kenyan schools of public health

Strategies for engagement

Navigating the academic and political environment: Strategies for engagement between public health faculty and policy makers in Kenya

HOW DID WE FIND OUT?

THE ACADEMIC CONTEXT IN KENYA KEY FACTS • 39 Universities

• 6 Schools of Public Health

‒ 5 with presence in Nairobi

• Revenues from non-governmental sources: 16.4% to

31.6% of total income

• Research not confined to traditional academic bodies

MAPPING THE NETWORKS DO ACADEMIC KNOWLEDGE BROKERS EXIST? AN EXPLORATION OF RESEARCH-TO-POLICY NETWORKS OF FACULTY FROM SIX SCHOOLS OF PUBLIC HEALTH IN KENYA

• 16 Ministries

• 6-10 Ministries per SPH (range of connections)

• Unique interplay between each SPH and government

• All SPHs connected to MOPHS and MOMS

• Some “Monopoly” relations

• Several overlapping or shared connections

INSTITUTIONAL RELATIONS

LegendAcademic Faculty Policymaker (various ministries) Academic Knowledge Broker Academic Faculty – externally influential Academic Faculty – internally trusted

WHOLE NETWORK: KENYATTA UNIVERSITY SPH

IDENTIFICATION OF KNOWLEDGE BROKERS

2

2

2

1

x

• 124 Academic faculty surveyed

• 5 Schools of Public Health with presence in the Capital

• 7 Knowledge Brokers Identified

• 4 Schools of Public Health with Knowledge Brokers

• Potential KBs across all 6 SPHs

Number of KBs in specific SPH

INDIVIDUAL ACADEMIC-POLICYMAKER NETWORKS RANGE IN SIZE, PREVALENCE, DEPTH AND BREADTH

Institution No. of respondents

No. of Policymakers by respondent

No. of unique contacts No. % Max. Avg.

No, Shared %.

PM relation Prevalence1

PM relation Depth3

PM relation Breadth2

22 43 36 16 72% 7 1.95 5 14%

15 34 27 12 80% 4 2.27 4 15%

29 49 27 16 55% 7 1.69 9 33%

24 21 16 13 52% 3 0.88 4 25%

17 17 15 7 41% 6 1.00 2 13%

17 40 31 12 71% 7 2.35 5 16%.

124 204 109 (unique) 76 61% n.a. n.a n.a. n.a. 1 Prevalence of academic-policymaker relations: absolute no. of faculty connected to >=1 policymaker; Proportion of same (Col 4/Col 2) 2 Breadth of academic-policymaker relations: maximum no. of PM contacts mentioned by any one faculty at the SPH; Avg no. of relations (Col 2/Col 1) 3 Depth of academic-policymaker relations: total no. of shared PM contacts in network; Proportion of relations shared (Col 6/Col 3)

CONCLUSION •  SNA is a useful tool to:

Map location and distribution of

•  academic expertise •  SPH connections to ministries (and others)

Enhance visibility of

•  existing KBS •  “potential” KBs

Identify

•  Unique connections •  Overlapping/ shared connections •  Gaps

UNDERSTANDING THE KBS THE HUMAN CAPITAL OF KNOWLEDGE BROKERS: AN ANALYSIS OF ATTRIBUTES, CAPACITIES AND SKILLS OF ACADEMIC FACULTY AT KENYAN SCHOOLS OF PUBLIC HEALTH

COMMON ATTRIBUTES AND CHARACTERISTICS OF KBS FALL UNDER 5 MAJOR CATEGORIES

Socio-demographics

Professional competence

Experiential knowledge

Interactive skills

Personal disposition

COMMON ATTRIBUTES AND CHARACTERISTICS OF KBS FALL UNDER 5 MAJOR CATEGORIES

Key elements

• >45yrs, majority male • PhD or equiv. degree

• >=1 foreign degree

• Academic position varied, history of admin responsibility

Socio-demographics

• Practical experience • Policy insights

Experiential knowledge

• Technical expertise • Relevant research focus

• Leadership experience

Professional competence

“be focused in an area of expertise because then you become visible.…and therefore to be sought after when there're issues that require policy engagement…regardless of who is in [office], or what the political structure is like”

-Leadership, KB, GLUK

“…the more senior one is, the greater will be the opportunity to engage in policymaking”

-Leadership, KB, GLUK

“ [Academics] have theory [but] when we deal with an outbreak, which requires more practical input….We have other organizations which are very good like the WHO, UNICEF, CDC”

-Policymaker, MOPHS

COMMON ATTRIBUTES AND CHARACTERISTICS OF KBS FALL UNDER 5 MAJOR CATEGORIES

Key elements

• Creation and maintenance of networks

• Communication skills, Interpersonal skills

Interactive skills

Personal disposition

• Social and moral conscience

• Determined and unrelenting

• Respectful, team player

“with presidents - both Moi and later Kibaki.… gave me the platform and confidence when I moved to the university that, I knew where to get certain support or help.”

-Leadership, KB, MUSOPH

“We had to get somebody who can lead this team, who is well known in the government circles, who knows politicians quite well, that is also quite conversant with the health situation in the country”

-Policymaker, PresOffice

“…sometimes you have these pushy characters who think they can push their way into Government... Present the good results and wait for change to happen in its own good time…It is a process...”

-Policymaker, MoLD

CONCLUSION

Unique combinations of sociodemographic attributes, professional competencies, experiential knowledge, interactive skills and personal disposition facilitate KB activities

Individual attributes, capacities and skills of KBs are not unique in and of themselves, but are advantageous when employed strategically and collectively.

Direct experience with policymaking arena enhances appreciation and navigation of political structures and processes. Leadership position facilitatory, not sufficient

Personal networks provide credibility, perceived power to influence, preferential political access

While some characteristics may be innate, others can be learned.

STRATEGIES TO ENGAGE NAVIGATING THE ACADEMIC AND POLITICAL ENVIRONMENT: STRATEGIES FOR ENGAGEMENT BETWEEN PUBLIC HEALTH FACULTY AND POLICY MAKERS IN KENYA

CURRENT STRATEGIES FOR FACULTY-POLICYMAKER ENGAGEMENT

Expert invitations

Deliberative dialogues

Initiated by National Level Government

Initiated by Schools of Public Health

Direct dissemination

Leveraging student

professionals

Honorary appointments

Mediated engagement

COMMON THREAD: RELATIONSHIPS

“the most important one is of course one on one connection. If you know somebody at a certain government department or ministry and they know me and they know my capabilities, they would be able to quickly pick a phone and say: ‘we are doing this. Can you join us on this and this day? We are starting to work on this”

-Leadership, KEMU

UNDERAPPRECIATED AND/OR UNDERUTILISED STRATEGIES FOR ENGAGEMENT

Initiated by Government OR Schools of Public Health

Face to face individual

interactions

Institutionalized Collaborations

Mediated engagement

Enhanced visibility

PROACTIVE IN-PERSON INTERACTIONS

• “Face to face..is practical and feasible, because if it is somebody outside of Nairobi, chances are that I may not do it. When there is face to face interaction, chances are that that network will stay for some time.”

Policymaker, MoLD

• “If they sit and say ‘Oh if the government wants our advice, let them come!’ that is not going to work really…just visit me …”

Policymaker, MOPHS

• “You see, its just a matter of writing a letter…to the officer and he responds and tells you ‘On this date we are ready for you. Come!”

Policymaker, MoMS

INSTITUTIONALIZED COLLABORATION

• “the clever universities have always tried to consult with the government, to find out about the relevancy of the programs that they are initiating at the university.”

Policymaker, MoPHS

•  “If dialogue had taken place between academicians, at the curricular development (stage) with the policy makers…then we would have produced medical officers who are …also capable of taking care of these facilities.”

Leadership, KEMU

•  “unless we collaborate…we’ll never make it, so that if a university comes up with a major project, you can now bring on board other experts from the sister universities”

Leadership, Knowledge Broker, KUSPH

MEDIATED ENGAGEMENT

• “When I do research, it doesn't mean I have to go to the ministry... I can also [ask] a colleague who is better placed as a communicator to go and present.”

Faculty member, Knowledge Broker, MUSOPH

• “When you don’t know [the policymaker], you create a medium to that person, you create a third party who will know them...”

Leadership, GLUK

• “if you have new research findings…put it in the newspapers. [Policymakers] don't read the journals, they may not attend the conferences…but they are going to read it in the papers”

Policymaker, MOPHS

ENHANCED VISIBILITY - ADVOCACY

• “Between 1990 to 1999 we [academics] kept on telling the government that AIDS is going to kill. But the President had not listened to us for a long time. Most of us had to go to the activists, from academia to activism for anybody to hear us.”

Leadership, GLUK

• “You might see me in the corridors and then I happen to bump into ‘so-and-so’ …someone might say, “You must be associated with so-and-so’ And I don’t want to be associated with anyone. I mean, you want to be as independent as you can be.”

Knowledge Broker, SPHUoN

• “don’t just stop at the PS…or your Minister, go out to other ministers, members of parliament - Make sure that they are also aware of this issue so that they can support you in it.”

Policymaker, MoLD

CONCLUSIONS

Academic faculty as well as policymakers utilize a variety of strategies for engagement – some more effective and utilised than others

The perceived responsibility for engagement continues to lie with academia. KBs appeared distinct amongst their peers

Delicate balance between leveraging personal individual relationships and establishing more sustained institutional partnerships.

Combination of deliberate and opportunistic strategies required.

Increased chance of uptake when tailored to policymaker preferences, responsive to current political requirements, and personalized.

RECOMMENDATION: INDIVIDUAL

•  Existing KBs should

•  nurture existing relations with policymakers as well as peers •  tailor strategies for policy engagement to the context and

audience

•  Non-KB faculty should

•  consult with existing KBs for support and advice

•  increase capacity to understand and navigate the policy environment

•  enhance tangible skills

•  SPH leadership should

•  recognize the value of intangible KB characteristics •  create opportunities for networking and learning

RECOMMENDATION: INSTITUTIONAL

•  SPHs should use SNA to understand competition, mobilise collective action, enhance their visibility and relevance

•  SPHs should not only passively support KB activities but also actively invest in individual KB endeavors

•  Recognize and leverage existing KBs, support emergence of potential KBs, and systematically recruit faculty with KB-specific characteristics

•  Institutionalize processes for sustained engagement to accelerate information flow

•  Invest in technological solutions to overcome barriers to communication and networking

RECOMMENDATION: NETWORK

•  Collaborate with other SPHs and academics for a unified voice

•  Build institutional relations with policymakers

•  Involve policymakers in SPH curricula design, research formulation

•  Leverage media as a key conduit for raising political profile of public health issues, spotlighting key researchers, gaining policymaker attention

ADAPTING THE KENYAN STUDY TO USA The influence of JHSPH faculty on public health decision-making: A mixed methods study exploring networks, relationships and engagement strategies

STUDY OBJECTIVES

•  Understand the network of relationships that faculty at JHSPH foster at the city, state, federal and international levels in order to contribute to public health decision-making.

Networks

• Explore how JHSPH faculty play a role in bringing evidence to bear on city, state, federal government and/or global level public health decision-making.

Strategies for evidence informed decision making

• Uncover the perceived attributes and capacities of SPH faculty (that make them effective) in bridging the evidence-to-policy divide.

Faculty attributes and capacities

•  Identify the organizational and environmental factors that facilitate or hinder JHSPH faculty engagement with decision makers

Proximal & distal determinants of engagement

RELEVANCE:

LINKS WITH APPROACH: •  Implementation research that uses SNA as well as qualitative

approaches to map as well as interrogate HIV/AIDS networks •  Eg: Latkin, C et al (1995): Using social network analysis to study

patterns of drug use among urban drug users at high risk for HIV/AIDS •  SNA: Network density and size of drug subnetworks were positively associated

with frequency of drug injection •  USING SNA TO IDENTIFY INTERMEDIARIES: are these subnetworks

linked by key brokers? Is there a strength in weak ties? Are there key people linking different networks – the movers and the shakers? Are there key people who can help break these links – the gatekeepers? Who are the influencers?

•  QUAL: Why is this case? How do these networks get built/maintained? What factors facilitate or hinder these relations? What is the relative contribution of the network structure to the patterns of drug use seen?

•  SO WHAT?: What kind of interventions could therefore mitigate the impact of this association? Who can be leveraged to assist with this?

LINKS WITH IMPACT: •  Implementation research with results that have policy and/

or practice implications so as to contribute to evidence-informed decision making

• Observational, experimental etc… •  Understanding the dynamics of disease transmission AND identifying

possible areas for intervention and control

•  Mapping influential peer/social networks AND identifying ways of affecting the structure of the network to mitigate (or enhance) such influence

•  Establishing key interventions amongst populations of interest and mapping the change of network structure over time as a result.

“You build a staircase of convincing people to change a policy…you don’t carry out the burden as if it’s yours of changing the policy. The burden has to be shared and that’s why networks and multiple approaches are so important to change policy”

-Leadership, GLUK

THANK YOU!