Mapping the evolution of priorities for health systems evidence synthesis in a low-income country: A case study of Uganda from 2013 to 2023

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OBUKU, Robert APUNYO, Harriet NABUDEERE, Nelson K. SEWANKAMBO This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6017972/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract RATIONALE Resources for conducting health systems research are often limited and yet millions of research articles, systematic reviews, technical reports, and policy briefs are published annually with a significant proportion hardly read, let alone used for decision making. We aimed to identify health systems research priorities for evidence synthesis; assess the availability, evolution and alignment of this evidence with dynamic priorities; and contextualized our findings in Uganda’s health policies and systems. APPROACH This was a multiple methods study between 2013 and 2023, consisting of a mini–Delphi technique to identify health systems research priorities, an uncontrolled before–and–after assessment of availability of research evidence to support the identified priorities, and a qualitative documentary analysis of evolving health policies and systems in Uganda. MAIN FINDINGS Our findings highlighted financial arrangements as a resilient priority area for health system evidence synthesis in Uganda. Secondly, we found an abundance of existing evidence syntheses from the PDQ-Evidence database, in all the areas including health systems governance and human capital development. Third, we mapped the evolution of health systems priorities in Uganda together with the evidence in PDQ-Evidence over the past decade with the emergence of human capital development as a priority policy concern that received massive investment by the Ministry of Health, and indeed highest increase in researched evidence. The organizational realignment of Uganda’s Ministry of Health responded to the evolving health systems priorities in line with agenda 2030 of the sustainable development goals (SDG). CONCLUSIONS Our study findings suggest that access to evidence by decision makers remains an important challenge in bridging the “know–do–gap”. This calls for health systems researchers in Uganda to constantly engage decision makers about where and how to find relevant research evidence, and further refine their information needs. A key starting point is empowering the Uganda National Health Research Organization to provide an integrated knowledge translation platform for the health sector. BACKGROUND Resources for conducting health systems research are often limited (1,2). World over, millions of research articles, systematic reviews, technical reports, and policy briefs are published annually yet a significant proportion are hardly read, let alone used for decision making (3,4). This implies wastage of important resources in generating information that is either off the mark or simply inaccessible, which consequently gathers dust in shelves and libraries (5,6). Thus, efficiency gains are realized by identifying priority health systems problems that can be addressed through new research, be it primary studies or secondary syntheses (5,7). Stakeholder involvement in priority setting may enhance the relevance and use of research in decision–making (8–10), particularly in low resource settings such as sub–Saharan Africa. Systematic review findings report that engaging stakeholders establishes credibility, ensures transparency and accountability, and improves the relevance and quality of the research process as well as buy–in from the informed publics and policy actors (11). A stakeholder being any person or group with a vested interest in a particular clinical, public health or economic decision; and the evidence that supports that decision. Patients, economists who prepare social sector budgets, public health leaders at the ministry of health, or even Parliamentarians who allocate resources for social services, are examples of stakeholders in the health sector. Engaging stakeholders also helps to anticipate and manage controversy. However, the process of involving stakeholders in research is not without shortcomings (11). Indeed, literature on why, when, and how stakeholders should be engaged in the research process suggests that additional time and resource investments which tends to prolong research projects; selecting and finding the right people to achieve representativeness; reliability and consistency in participation by stakeholders; managing and supporting stakeholders are among the key challenges (11). For example, stakeholders often lack the technical know-how of the research process or content and as such require additional training or awareness. Sometimes stakeholders propose policy concerns that are broad and require further refining. We aimed to identify health systems research priorities for evidence synthesis by the Africa Centre for Systematic Reviews and Knowledge Translation at Makerere University. Secondly, we sought to assess the availability, evolution and alignment of this evidence with priorities over a decade, between 2013 and 2023. Thirdly, we aimed to contextualize our findings in Uganda’s dynamic health policies and systems taking into consideration relevance to stakeholders. METHODS Ethical considerations Our study received ethical and regulatory approval from the School of Medicine Research and Ethics Committee of Makerere University College of Health Sciences, the Uganda National Council for Science and Technology (SS3271) and Office of the President, Republic of Uganda (ADM/154/212/01). Uganda’s health systems context Uganda is a landlocked country in East Africa, with a population of 45 million in 2023 up from 35 million in 2013 and its GDP increased from approximately $ 800 to $ 1,000 United States Dollars in the same period (12,13). Uganda's health system is decentralized, characterized by health regions around regional referral hospitals, within which are district hospitals, and the basic complete unit being a health center level 4 at constituency level with a medical doctor, other medical staff, an operation theater and blood transfusion services (14,15). Medical services begin at health center levels 2 at the parish administrative unit and up to health center level 3 at the sub–county administrative unit. Community health workers constitute the village health teams and perform public health duties such as distribution of mosquito nets or mass immunization campaigns (16). The district health officer heads the district health team and reports to the chief administrative officer in the district for general duties or the director general health services at the ministry of health headquarters, in case of technical matters such as disease outbreaks (17). Design and description of the priority setting process This was a multiple methods study between 2013 and 2023, consisting of a mini–Delphi technique (18) to identify health systems research priorities, a uncontrolled before–and–after assessment (19) of availability of research evidence to support the identified priorities, and a qualitative documentary analysis (20). There were at least three priority setting exercises over this decade under review. In August 2013, we conducted the baseline cross–sectional study during a stakeholder dialogue using a mini–Delphi approach at Makerere University, Kampala, Uganda. We employed the Supporting Use of Research Evidence guide (SURE) for prioritizing topics for policy briefs ( http://global.evipnet.org/SURE-Guides/ ) (21). We presented participants with three background documents including priority topics for low– and middle–income countries written by the Norwegian Satellite of the Cochrane Effective Practice and Organization of Care (EPOC), https://epoc.cochrane.org/ ; and examples of research priority areas from the World Health Organization health systems pillars and the Millennium Development Goals 4 (child health), 5 (maternal health) and 6 (infectious and non-communicable diseases); and the Malawi National Health Research Agenda (22,23). The Principal of the College, Prof. Nelson Sewankambo, (NKS) delivered the keynote address highlighting the goals of the ‘Africa Centre’, which started its operations in March 2013. One of the researchers (HN) facilitated the participants to complete two group iterations using the mini–Delphi survey technique. We followed this by email reminders for further suggestions over two weeks, before analysis in 2013. In 2023, we complemented this survey with a retrospective documentary analysis, over the past10 year period from 2013. Briefly, we reviewed policy related strategic documents for Uganda’s health sector to assess the evolution and sustainability of these priorities in 2023. Study population, sampling, and sample size We purposively selected 54 individuals through identification and stakeholder mapping, with the aim of achieving diversity of views and engagement. Our map targeted the following stakeholders: Government techno–professionals, decision takers, and policy makers at the ministry of health; health service providers including health management organizations in public and private health sectors, from rural and urban areas; civil society constituting health consumer bodies and representatives of health professional associations; employer groups; development partners and health systems researchers. We also included invited participants of the first Africa Centre training on systematic reviews that was conducted by the Norwegian Satellite of Cochrane Effective Practice and Organization of Care (EPOC). Data collection, management, and synthesis First, we categorized the stakeholders into smaller groups in a brainstorming exercise. We then arranged for each group to present their findings before ranking them. Secondly, we requested the participants to make judgments and rank the policy concerns in need of research after assessing the following aspects: importance of the problem; availability of viable interventions; opportunity for change; important uncertainty about the health-systems issue; availability of relevant research and interest in deliberation on the problem. We conducted descriptive analysis of the frequencies after each round of ranking, giving equal weight to each assessment criteria. We computed the total score for each policy concern by which we ranked them, prior to the next round. Finally, we listed the top 10 ranked priority problems for health system research syntheses and their clusters, aligning these to the WHO pillars for health systems strengthening, that is leadership and governance, financing, human capital, health services delivery, access to medical products, vaccines and technologies and information use. As the initial assessment was done 10 years previously in 2013, we reviewed policy related strategic documents for Uganda’s health sector to assess the sustainability of these priorities in 2023. These were the Health Sector Development Plan 2015/2016–2019/2020 (24) and the Health Sector Strategic Plan 2020/2021–2024/2025 (25). We analyzed selected Annual Health Sector Performance Reports for 2014/2015 (26) as the baseline, then 2019/2020 (27) and 2022/2023 (28) for the end–line and mid–way the strategic plan periods respectively. After the analysis of the priority clusters, we conducted a feasibility scan of the PDQ–Evidence database ( https://www.pdq-evidence.org/ ) (29) to assess the extent of already existing research evidence about the proposed priority topics. Also, we repeated the feasibility scan in PDQ–Evidence database in 2023, to assess the evolution of the availability of research evidence that would address Uganda’s health sector priorities since 2013. We searched for systematic reviews, scoping reviews, policy briefs or such related evidence briefs for policy in PDQ–Evidence database using Boolean logic (30). The specific search terms were: “health financing” OR “health insurance” OR “pay for performance” OR “performance–based funding” OR “results–based financing” OR “cost sharing”, for financial arrangements; “human resources” for human resources for health; “governance” OR “public-private partnership” OR “guidelines” OR “accreditation” OR “standards”; “community engagement” OR “community participation” OR “community involvement” OR “equity” OR “contracting” for governance arrangements. We also captured the primary studies to reflect the availability or scarcity of researched evidence to support health systems priorities of low– and middle–income countries where Uganda lies. The last search was conducted on 26th July 2023. RESULTS Participants of the stakeholder’s dialogue. There were 45 participants who responded and participated in the stakeholder dialogue of 2013, out of the 54 who were invited, giving a high response rate of 83%. Among the participants 14 were women (31%). Participants were from 25 different organizations including government ministries, departments, and agencies (MDAs), (n=4), non–governmental entities (n=6), health consumer groups (n=1) and research institutes (n=12). Majority (64%) of the participants were researchers from the 12 institutes predominantly Ugandan (53%). Other researchers from Tanzania, Kenya, Cameroon, and Botswana were invited to the dialogue as part of our inaugural pre–course workshop on evidence synthesis. This was the launch of the Africa Centre for Systematic Reviews and Knowledge Translation in August 2013; whose mission was to build capacity for evidence synthesis across sub–Saharan Africa. Priorities identified by the stakeholders in 2013. The stakeholders in 2013, identified 34 priority areas for health systems research evidence synthesis. These included shortage of or inadequate health financing models leading to catastrophic health expenditure; shortage of and poor remuneration for human resources for health; inefficient forecasting, procurement and stock outs of essential medicines and medical supplies; sub-optimal service delivery particularly in maternal and child health including not meeting immunization targets, as well as Tuberculosis (table 2). Further, stakeholders identified the role of politicians and the community in fostering health priorities and better health seeking behaviors. In the second level of synthesis, most priority health system problems were about three clusters: delivery arrangements (18, 53%); followed by financial (9, 26%) and organizational (6, 18%) arrangements. Importantly, financial arrangements dominated the top 10 priority questions (8, 80%), which highlighted health financing (health insurance), human capital (remuneration) and resource allocation (budgeting) as the resilient health systems issues (table 3). Priorities in Uganda’s strategic health policy documents from 2013 to 2023. Over the past decade, there were three health sector planning cycles in Uganda. The 2011 to 2015 period, from 2015 to 2020 and currently 2020 to 2025. This period reflects the transition from the Millennium Development Goals (MDG) to Sustainable Development Goals (SDG) in 2015 of which the midpoint is 2023 [24]. Our stakeholder engagement to identify health systems priorities was done in the eve of the MDG to SDG transition, during Uganda’s third health sector strategic and investment plan from the financial year 2010/2011 to 2014/2015 [32]. The theme of this plan was “promoting people’s health to enhance socio-economic development”. This plan focused on five pillars: service delivery, human resources, health infrastructure, medical products, and management support. Its strategic objectives were to scale up critical interventions, improve equity in access to primary healthcare, accelerate quality and safety of health services, improve operational and financial efficiency, and deepen health sector stewardship. As this plan was informed by the MDGs of 2000, it had a diseases priority model: prevention and control of communicable diseases (HIV, TB, Malaria), non–communicable diseases (diabetes, cardiovascular diseases and cancer) and maternal and child health conditions including sexual and reproductive health rights. In the post–2015 agenda, the next health sector development plan for financial years 2015/2016 until 2019/2020 [25] spelt out four strategic objectives to support the overall goal of universal health coverage (UHC). These were the production of a healthy human capital for wealth creation; addressing the key determinants of health; increasing financial risk protection of households and enhancing health sector competitiveness in the region and globally. A deeper analysis of these objectives highlighted the following areas of priority: Health promotion across the life course with specific focus on maternal and child health; provision of non-communicable disease (NCD) and infectious diseases prevention and control services focusing on HIV/AIDS, TB, and malaria. To address the key determinants of health, the Ministry of Health proposed strengthening intersectoral collaboration and partnerships with other MDAs, around safe water, environmental health, and sanitation; food and nutrition services; housing and urbanization; road safety; veterinary services; energy; gender and human rights. Under financial risk protection, the Ministry was to establish systems for revenue generation, risk pooling, and strategic purchasing of medical services, and improve financial and procurement management systems. Third, the current health sector strategic plan for financial year 2020/2021 until 2024/2025 (25) retained the 2030 target of UHC, and other strategic objectives of the previous plan through strengthening the health system within seven objectives. These were, enhancing the health sector governance, management and coordination; reinforcing human resources management and development; increasing access to nationally coordinated services for communicable and non-communicable diseases prevention and control; consolidating disease surveillance, epidemic control and disaster preparedness and response; ensuring availability of quality and safe medicines, vaccines and technologies; improving functionality and adequacy of health infrastructure; and logistics and accelerate health research, innovation and technology development. Evolution of priorities in Uganda’s strategic policy related documents and reports from the MDG into the SDG era from 2015 to 2023 A documentary synthesis of the strategic plans, aide memoires that spell out the annual re–prioritization list and annual health sector performance reports over this decade, underscored the unfinished business of the MDGs that were carried forward in Uganda’s strategic documents for the health sector in the post–2015 agenda of SDGs. Uganda’s unfinished MDG business entailed improving the effectiveness of social service delivery (31). Uganda’s MDG targets not achieved by the 2015 deadline were reduced maternal mortality ratio by three quarters; reduced under five-year old’s child mortality by two thirds and reversing the spread of HIV/AIDS. Importantly, even when the global targets of halting and reversing the incidence of malaria and TB, and universal access to antiretroviral therapy were met by Uganda, they were sustained in the priority list as going concerns in subsequent strategic documents (32). The SDG era ushered in the global UHC mantra, particularly considering national financial risk protection mechanisms (World Health Organization, 2015). Despite this high–level prioritization, Uganda’s desire to establish a national health insurance scheme evolved from the Bill of 2012 (34) that was modified into the Bill and Act of 2019 that was passed by the 10 th parliament of Uganda (35). However, this national health insurance scheme Act of 2019 was subsequently not assented to by the Uganda’s President due to limited consensus among stakeholders, especially manufacturers' lobby and diminished financial inclusion of 68% of Uganda’s rural population ( Personal communication with State House, Republic of Uganda ). Further, apart from the COVID–19 pandemic, there was an exponential increase in outbreaks of Ebola, yellow fever, rift valley fever, anthrax and Crimean Congo haemorrhagic fever in Uganda between 2013 and 2023 (36–39). Still, domestic financing of public health responses for these recurrent disease outbreaks in Uganda continued to be a donor affair (40,41). Thus, the desire to import a mixed health financing model remained an unrealized priority in Uganda’s development agenda. Notwithstanding Uganda’s health financing challenges, the country realized increased investment in human capital, medical technologies, and infrastructure as resilient priorities in the post–2015 SDG period. Specifically, in human capital development the government invested in training and hiring more medical workers and increased their salaries. For example, while medical schools increased from 4 to 14 over this decade (42,43), medical doctors employed by government hospitals increased from 536 to over 1,500 (44,45). Further, salaries of medical doctors increased from one million Uganda shillings (~$US400) to five million Uganda shillings (~$US1,500) per month [49, 50]. This investment in human capital was in tandem with the Government’s increased investment in physical infrastructure for specialized medical care, with major renovations and expansion of national and regional referral hospitals as well as construction of new major facilities over this decade, 2013–2023. For example, in the Kampala capital city metropolitan area alone, five new specialized national referral hospitals were constructed focusing on maternal and child health including infertility at the new Women’s hospitals at Mulago and another at Kawempe (46), adult health focusing on non-communicable diseases including renal dialysis at Kiruddu hospital, and accident and emergency at Naguru hospital (47). At the same time, the Uganda Cancer Institute was elevated into the East African Centre of Excellence in Oncology (48) and intensive care units were expanded in the regional and national referral hospitals from 55 beds (49,50) to 143 beds (Ministry of Health Uganda, 2022a). The latter was driven by the COVID–19 outbreak that necessitated establishing of medical oxygen facilities to 7 (52) from 2 (26) to support high dependency units and intensive care units countrywide. As before (34,53), the five–year strategic planning cycles coincided with the five–year electoral cycles signifying the importance of political regime transition in priority setting by making campaign promises to strengthen social services (54). For instance, promises uttered by presidential, parliamentary, and other local government political candidates highlighted the resilient priorities. Specifically, these were the promises to diversify health system financing through a national health insurance scheme that was never realized, salaries for medical workers were raised substantially, the national medical warehouse and blood transfusion services received increased budgets, as were several completed hospital infrastructures following these campaign promises during the post–2015 agenda. Ministry of Health organizational reforms re–aligned to new priorities Remarkably, in the post–2015 agenda, the Ministry of Health proposed organizational restructuring to align itself to fulfil Uganda’s evolving objectives under four directorates: curative services, public health, health governance and regulation, strategy policy and development, with 19 departments (see table 6). Initially there were 2 (two) directorates, 5 (five) departments, and 14 divisions. These were functionalized through the various Technical Working Groups reconstituted and reduced from 14 to 11 during this period. The reforms at Ministry of Health headquarters were followed by realigning the hospital staffing structure at all levels, national, regional and district referrals, and health centers. This elevated previous divisions into departments, such as Nursing, while new ones were created such as the institutional capacity building and human resource development, emergency medical services, integrated epidemiology and surveillance, laboratory and diagnostic services, with new openings for medical professional jobs at management level. Indeed, it is during this post–2015 agenda period that health center level 2 was abolished and transitioned to level 3, to enhance Universal Health Coverage. This coincided with the Parish Development Model (PDM) (55,56) introduced by the National Resistance Movement (NRM) to bring social services closer to the people, complete with medical doctors at health center level 3, down from health center level 4. Availability and evolution of evidence aligned to the identified health systems priorities between 2013 and 2023. A crucial aspect in this study was to assess whether researched evidence was available to support health systems priority interventions, in line with the priorities identified. We also assessed whether the interventions were aligned to the research evidence or vice versa, and the limitations of the availability of the researched evidence. We performed the feasibility scan of the researched evidence in PDQ–Evidence database (https://www.pdq-evidence.org/) in 2013 and again in 2023. The literature of any type was most abundant for healthcare financing with 1,226 articles including 196 systematic reviews and 23 broad syntheses, table 5. This was followed by literature on governance that had a cumulative 1,070 articles with 155 systematic reviews and 32 broad syntheses. Community engagement literature predominated the available evidence for health systems governance, with 556 articles of which 89 were systematic reviews and 18 were broad syntheses. Human resources for health, returned 744 articles including 152 systematic reviews and 40 broad syntheses. In terms of evolution of the available evidence on health systems interventions over the past decade (2013–2023), the highest proportional increase was about human resources for health (55%) including 129 systematic reviews and 33 broad syntheses. This was followed by literature on governance (43%) complete with 121 systematic reviews and 30 broad syntheses, driven by equity considerations in resource allocation (53%). While health financing returned the highest frequency of new literature in the past decade with 503 new articles including 130 systematic reviews and 15 broad syntheses, this proportion was the least at 35%. In this period, the Africa Centre for Systematic Reviews and Knowledge Translation was involved in the evidence supply-demand ecosystem in Uganda’s health sector, which informed our findings too (table 5). These included policy briefs about the national health insurance scheme law, performance–based funding, contracting out and community engagement amongst others. DISCUSSION Principal findings. Our study sought to identify priority concerns for health systems in resource constrained settings that required researched evidence to support policy proposals. Our findings highlighted financial arrangements as a resilient priority area for health system evidence synthesis in Uganda. Secondly, we found an abundance of existing evidence syntheses from the PDQ-Evidence database, in all the areas including health systems governance and human capital development. Third, we mapped the evolution of health systems priorities in Uganda together with the evidence in PDQ-Evidence over the past decade with the emergence of human capital development as a priority policy concern that received massive investment by the Ministry of Health, and indeed highest increase in researched evidence. Not least, we documented the organizational realignment of Uganda’s Ministry of Health to meet the evolving health systems priorities in line with agenda 2030 of the sustainable development goals (SDG). Findings in relation to existing evidence. Uganda’s priority health policy and systems agenda documented between 2008 and 2010 by the national health research organization have been sustained in our study, 15 years after (57). Indeed, the then top three resilient priority policy problems identified by Uganda’s ministry of health at that time were scaling up safe male medical circumcision for HIV/AIDS prevention after successful community clinical trials in Uganda (58), Kenya (59)and South Africa (60); introducing task shifting of healthcare professionals under human resources for health and developing a community health insurance strategy under innovative financing approaches (61). The respondents of this study perceived the lack of funding to health facilities, lack of drugs in government hospitals and not enough health personnel to provide medical services as the key challenges. In the same breadth, work by Ssengooba & colleagues identified health workforce, governance and service delivery as the top three priorities for universal health coverage (UHC) research in Uganda (62). The million–dollar question is, why have these health systems research priorities remained relevant, as depicted in our study of Uganda and indeed other agenda setting exercises in sub–Saharan Africa, despite massive investments in the health sector by both domestic and donor money? Perhaps this is a function of limited evidence on follow up strategies for research priorities in low–and middle–income countries, documented in a systematic review by McGregor and colleagues (63). Availability of researched evidence may be necessary but not sufficient to address priority health systems challenges in low-income countries. Despite being the most researched area by far, financing health systems remains an indomitable challenge in Uganda and similar low–income countries. Could this be a prominent reflection of the “know–do–gap”? (9,64,65) That all individuals access quality health services without suffering financial hardship is the cornerstone of UHC embedded in the Sustainable Development Goals (66,67). However, in a report by WHO tracking progress of UHC by 2017 (68), over a hundred million people were impoverished annually due to catastrophic health expenditures, spending 10% or more of household income on health seeking, especially in low-income countries. A similar report by WHO in 2022 (69) showed that over the past 20 years, out–of–pocket expenditure across most sub–Saharan African countries has increased. That catastrophic health expenditure affected 56% of 48 countries in sub–Saharan Africa, and in 66% of the countries catastrophic health expenditure was more than 25% of the household budgets. Over the same period in Uganda, catastrophic health expenditure declined from 41% (26) to 29% (financial year 2022/2023) (28), with only 4% of the population accessing private or some form of local community health insurance facilities up from 1% previously (70). Yet, efforts by the Ministry of Health to enact a national health insurance law were not successful over the last decade, from 2012 to 2022 (35). Clearly, the need for new evidence syntheses for innovative approaches on health financing at country level, perhaps locally contextualized evidence, may trigger governments of low–income countries such as Uganda to implement financial risk protection mechanisms such as pooling of risks and resources in countrywide insurance schemes. Given the chronic suboptimal health financing climate in sub–Saharan Africa (71), the need for innovative approaches to strengthen health systems governance based on synthesized evidence is even more urgent (72). Community involvement dominated literature on health systems governance, with substantial growth in the available evidence base in the past decade. Whether this literature informs community engagement strategies on health remains understudied. Noteworthy, the dynamic democratic evolution in sub–Saharan Africa provides for an increasingly central role of stronger health systems governance (73,74), that may bolster the other WHO pillars with leadership, strategic policy frameworks, oversight, and accountability (75) for which Uganda is beneficiary. Certainly, this has come with a growing demand from the informed citizenry for governments to demonstrate results from invested resources in public health, commonly packaged as promises during Uganda’s electoral cycles (53). Uganda’s community engagement strategy in policy formulation is prominent (76), through stakeholder meetings, with a proliferation of new policy documents diminished by the attendant challenge of limited policy action. Similarly, community participation in resources allocation is presumed to occur through its directly elected Parliament, where the people’s voice is represented. Within Uganda’s ministry of health, the people’s voice is heard through the health policy advisory committee (HPAC) and the various technical working groups, for which Uganda’s ministry of health underwent restructuring (77,78) Health systems can only function with health workers (79); improving health service coverage and realizing the right to the enjoyment of the highest attainable standard of health is dependent on their availability, accessibility, acceptability and quality (75). We documented human capital development as a resilient cornerstone priority that potentially would unlock far–reaching health systems reforms, if addressed holistically. Interestingly, human resources for health had the greatest increase in available research syntheses over the decade of our study period, suggesting increased availability of evidence informed solutions. This priority problem is in tandem with the estimated global shortfall of at least 10 million health workers by 2030 in line with SDGs (80,81), mostly in low–and lower–middle income countries for various reasons including: sustained under–investment in production of health workers, a mismatched skills mix, skewed within country rural–urban distribution, increasing ‘brain – drain’ to higher income countries, and the high–demand– unemployment conundrum co-existing with major unmet health needs. In the decade of our review, Uganda’s government circumvented these challenges by implementing evidence informed investments for human capital development through expanded medical schools from 3 to 10 (42), specialized medical skilling abroad, increased medical workers salaries, and restructured staffing norms at the ministry of health headquarters and health facility level, that provided new employment openings. Nevertheless, a perennial challenge is the absorption of the new medical grandaunts in the public sector or through controlled emigration for mutual benefit, right from medical internship placements (82,83), for which new researched evidence may be informative. Implications for future research and next steps. The above observations pause new questions about the paradox of so much evidence available with so little done (84,85). First, why did key actors in Uganda’s health system, despite the abundance of synthesized evidence, recurrently prioritize human capital development or financing for further research? Was the availability of evidence necessary and sufficient to cause policy action in the Ugandan context? Or could it be that evidence required active feet beyond peer reviewed articles, policy briefs and dialogues? Were Ugandan researchers providing the relevant synthesis products to decision takers, through push or integrated efforts? (86) To what extent were Ugandan researchers creating demand for pull efforts from decision makers? (9,86) Perhaps these questions suggest that the ministry of health, development partners and health systems leaders in local governments could introduce an evidence checklist in its policy approval process, to enforce the use of researched evidence especially systematic reviews and evidence and gap maps. This will generate tailored demand by imploring policy formulators to find and apply researched evidence in the choice of interventions or dis-investment in ongoing policies. Strengths and limitations of identifying health systems research priorities in low-income countries including Uganda There were several strengths and important shortcomings of our study. First, this is the first synthesis of resilient health systems research priorities in a low–income country, over a decade. Secondly this study triangulates both methods and data from various sources, including a documentary analysis with validation from an open access health systems database, PDQ–Evidence. Third, this study maps the evolution of evidence and contextualizes its findings in Uganda’s evolving health systems over a decade transcending the post–2015 agenda of SDGs and UHC. There were also limitations namely empirical evidence from stakeholder views that were not captured; and the weak attribution of increased availability of researched evidence as identified in the PDQ-database, informing health sector reforms in Uganda’s health systems. CONCLUSIONS Our study findings suggest that access to evidence by decision makers remains an important challenge in bridging the “know–do–gap”. This calls for health systems researchers in Uganda to constantly engage decision makers about where and how to find relevant research evidence, and further refine their information needs. A key starting point is empowering the Uganda National Health Research Organization to provide an integrated knowledge translation platform for the health sector. Declarations Acknowledgements In memory of Dr. Harriet Nabudeere who was very instrumental in starting this work yet passed away before its fruition, during the COVID-19 outbreak. Dr. Marie Gloriose Ingabire of the International Development Research Centre, Ottawa, Canada (IDRC) for supporting the African Centre for Systematic Reviews and Knowledge Translation “The Africa Centre, MakCHS”, based at the College of Health Sciences, Makerere University. Funding declaration “The Africa Centre, MakCHS” was established in 2013 as an offshoot of my interest in evidence synthesis for policy via grant number 107237–001 held by Prof. Nelson Sewankambo, the Principal Investigator and my supervisor. Clinical Trial number Not applicable Ethics approval declaration Our study received ethical and regulatory approval from the School of Medicine Research and Ethics Committee of Makerere University College of Health Sciences, the Uganda National Council for Science and Technology (SS3271) and Office of the President, Republic of Uganda (ADM/154/212/01) . Data availability declaration No, I do not have any research data outside the submitted manuscript file. All the data available is provided in the tables in this manuscript and in the references for the documentary analysis, for example the Uganda Ministry of health Knowledge Portal: http://library.health.go.ug/ Author contributions Conception: EAO, HN, NKS | Data capture: EAO, HN, NKS, RA | Data synthesis: EAO, HN, NKS | Drafting manuscript: EAO, HN, NKS, RA | Accepting manuscript: EAO, NKS, RA Competing interest declaration No, I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. This manuscript arises from post-doctoral work of the lead author: E.A.O References Bredan A. Conducting publishable research under conditions of severely limited resources. Libyan Journal of Medicine. 2020;15(1). Knottnerus JA, Tugwell P. Prioritization of health care and research given limited and too limited resources. J Clin Epidemiol. 2017;86:1–2. Doemeland D, Trevino J. 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NRM Manifesto 2016-2021: steady progress: taking Uganda to modernity through jobs-creation & inclusive development [Internet]. 2016 [cited 2024 Jun 6]. Available from: https://www.yowerikmuseveni.com/sites/default/files/Manifesto.pdf Ministry of Local Government. Implementation Guidelines for Parish Development Model. Kampala: Ministry of Local Government [Internet]. Kampala; 2022 [cited 2024 Jun 8]. Available from: https://presidentialinitiatives.go.ug/parish-development-model/ Kyambadde KM. Uganda’s Parish Development Model: Factors to Prioritise to Guarantee Success in its Implementation. 2021; REACH-PI. Regional East African Community Health (REACH) Policy Initiative. Priority Health Policy & System Challenges (2008-2010) [Internet]. Kampala; 2010 [cited 2024 Jun 8]. Available from: http://repository.eac.int/bitstream/handle/11671/609/Report%20-%20Uganda%20Health%20Policy%20Priorities.pdf?sequence=1&isAllowed=y Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The lancet. 2007;369(9562):657–66. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The lancet. 2007;369(9562):643–56. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005;2(11):e298. Basaza R, Criel B, Van der Stuyft P. Low enrolment in Ugandan Community Health Insurance Schemes: underlying causes and policy implications. BMC Health Serv Res. 2007;7:1–12. Ssengooba F, Ssennyonjo A, Rutebemberwa E, Musila T, Namusoke Kiwanuka S, Kemari E, et al. Research for universal health coverage: setting priorities for policy and systems research in Uganda. Glob Health Action. 2021;14(1):1956752. McGregor S, Henderson KJ, Kaldor JM. How are health research priorities set in low and middle income countries? A systematic review of published reports. PLoS One. 2014;9(10):e108787. Bennett G, Jessani N. The knowledge translation toolkit: Bridging the know-do gap: A resource for researchers. IDRC; 2011. Hulme PE. Bridging the knowing–doing gap: know‐who, know‐what, know‐why, know‐how and know‐when. Vol. 51, Journal of Applied Ecology. Wiley Online Library; 2014. p. 1131–6. Vega J. Universal health coverage: the post-2015 development agenda. The Lancet. 2013;381(9862):179–80. Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91:602–11. World Health Organization, World Bank. Tracking universal health coverage: 2017 global monitoring report [Internet]. Geneva; 2017 [cited 2024 Jun 8]. Available from: https://documents1.worldbank.org/curated/en/640121513095868125/pdf/122029-WP-REVISED-PUBLIC.pdf World Health Organisation. 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Journal of Contemporary African Studies. 1999;17(1):5–28. Fallon KM. Democracy and the rise of women’s movements in Sub-Saharan Africa. JHU Press; 2008. World Health Organization. The world health report 2000: health systems: improving performance. World Health Organization; 2000. Ministry of Health Uganda. National Community Health Strategy (NCHS) for the period of 2021/22-2025/26. Kampala; 2022. Ministry of Health Uganda. Ministry Of Health Governance & Management Structures Implementation Guidelines 2013 [Internet]. Kampala; 2013 [cited 2024 Jun 8]. Available from: https://www.health.go.ug/docs/GMS.pdf Ministry of Health Uganda. Ministry Of Health Governance & Management Structures Implementation Guidelines 2022. 2022 [cited 2024 Jun 8]; Available from: https://www.health.go.ug/cause/ministry-of-health-governance-and-management-structures-implementation-guidelines-2022/ World Health Organization. Report on the first global forum on human resources for health [Internet]. World Health Organization; 2010 [cited 2024 Jun 8]. Available from: https://iris.who.int/bitstream/handle/10665/70834/WHO_H?sequence=1 Limb M. World will lack 18 million health workers by 2030 without adequate investment, warns UN. British Medical Journal Publishing Group; 2016. Boniol M, Kunjumen T, Nair TS, Siyam A, Campbell J, Diallo K. The global health workforce stock and distribution in 2020 and 2030: a threat to equity and ‘universal’health coverage? BMJ Glob Health. 2022;7(6):e009316. Ogei E, Lewis C. Medical Training in Uganda: A Critical but Neglected Part of the Healthcare System. Cureus. 2023;15(6). Zhao Y, Mbuthia D, Gathara D, Nzinga J, Tweheyo R, English M. ‘We were treated like we are nobody’: a mixed-methods study of medical doctors’ internship experiences in Kenya and Uganda. BMJ Glob Health. 2023;8(11):e013398. Lavis JN, Ross SE, Hurley JE. Examining the role of health services research in public policy making. Milbank Q. 2002;80(1):125–54. Shulock N. The paradox of policy analysis: If it is not used, why do we produce so much of it? J Policy Anal Manage. 1999;18(2):226–44. Lavis JN, Lomas J, Hamid M, Sewankambo NK. Assessing country-level efforts to link research to action. Bull World Health Organ. 2006;84(8):620–8. Tables Table 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files SUBMITTEDOBUKUE2024PriorityHSRDatatables20thJune2024.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6017972","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":418362150,"identity":"67c5af71-a077-4a02-b300-47b1971151fc","order_by":0,"name":"Ekwaro A. OBUKU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYDACHjBpA8SMjQdI0ZIG0tJAkpbDYJI4Lfw8Zww/V1Sct1vbfhhoS41NNEEtkr09xpJnztxO3nYmEajlWFpuAyEtBud5N0g2tt1ONjsA1MLYcJiwFvvzvJt/NradSzY7/5BILQa8vduAthywM7tBrC0SZ85/s2w4k5xgdgNoSwIxfuHvSUu+2VBhZ292Pv3hgw81NoS1wEAiWGUCscpBwJ4UxaNgFIyCUTDCAADE8UfyOLJSQgAAAABJRU5ErkJggg==","orcid":"","institution":"Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University P.O. Box 7072, Kampala","correspondingAuthor":true,"prefix":"","firstName":"Ekwaro","middleName":"A.","lastName":"OBUKU","suffix":""},{"id":418362153,"identity":"d83da620-dae1-47e8-b45c-8d357a35c4bb","order_by":1,"name":"Robert APUNYO","email":"","orcid":"","institution":"Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University P.O. Box 7072, Kampala","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"APUNYO","suffix":""},{"id":418362154,"identity":"e983194b-16e1-422c-b63d-9c6ce03d63e5","order_by":2,"name":"Harriet NABUDEERE","email":"","orcid":"","institution":"Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University P.O. Box 7072, Kampala","correspondingAuthor":false,"prefix":"","firstName":"Harriet","middleName":"","lastName":"NABUDEERE","suffix":""},{"id":418362156,"identity":"5eea0ff9-37dd-4c28-831f-91dbff66a128","order_by":3,"name":"Nelson K. SEWANKAMBO","email":"","orcid":"","institution":"Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University P.O. Box 7072, Kampala","correspondingAuthor":false,"prefix":"","firstName":"Nelson","middleName":"K.","lastName":"SEWANKAMBO","suffix":""}],"badges":[],"createdAt":"2025-02-12 20:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6017972/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6017972/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87930290,"identity":"cc6f9be8-4b80-407f-ab20-a9a042a73372","added_by":"auto","created_at":"2025-07-30 13:32:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":751233,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6017972/v1/53611d21-8203-48cf-9764-0460641c3f36.pdf"},{"id":76858586,"identity":"2217ff1c-401b-4fe2-9ac1-6a9dd44ae377","added_by":"auto","created_at":"2025-02-21 13:19:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24331,"visible":true,"origin":"","legend":"","description":"","filename":"SUBMITTEDOBUKUE2024PriorityHSRDatatables20thJune2024.docx","url":"https://assets-eu.researchsquare.com/files/rs-6017972/v1/ae45397e66ec7a86d2a7306e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mapping the evolution of priorities for health systems evidence synthesis in a low-income country: A case study of Uganda from 2013 to 2023","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eResources for conducting health systems research are often limited (1,2). World over, millions of research articles, systematic reviews, technical reports, and policy briefs are published annually yet a significant proportion are hardly read, let alone used for decision making (3,4). This implies wastage of important resources in generating information that is either off the mark or simply inaccessible, which consequently gathers dust in shelves and libraries (5,6). Thus, efficiency gains are realized by identifying priority health systems problems that can be addressed through new research, be it primary studies or secondary syntheses (5,7).\u003c/p\u003e \u003cp\u003eStakeholder involvement in priority setting may enhance the relevance and use of research in decision\u0026ndash;making (8\u0026ndash;10), particularly in low resource settings such as sub\u0026ndash;Saharan Africa. Systematic review findings report that engaging stakeholders establishes credibility, ensures transparency and accountability, and improves the relevance and quality of the research process as well as buy\u0026ndash;in from the informed publics and policy actors (11). A stakeholder being any person or group with a vested interest in a particular clinical, public health or economic decision; and the evidence that supports that decision. Patients, economists who prepare social sector budgets, public health leaders at the ministry of health, or even Parliamentarians who allocate resources for social services, are examples of stakeholders in the health sector. Engaging stakeholders also helps to anticipate and manage controversy.\u003c/p\u003e \u003cp\u003eHowever, the process of involving stakeholders in research is not without shortcomings (11). Indeed, literature on why, when, and how stakeholders should be engaged in the research process suggests that additional time and resource investments which tends to prolong research projects; selecting and finding the right people to achieve representativeness; reliability and consistency in participation by stakeholders; managing and supporting stakeholders are among the key challenges (11). For example, stakeholders often lack the technical know-how of the research process or content and as such require additional training or awareness. Sometimes stakeholders propose policy concerns that are broad and require further refining.\u003c/p\u003e \u003cp\u003e We aimed to identify health systems research priorities for evidence synthesis by the Africa Centre for Systematic Reviews and Knowledge Translation at Makerere University. Secondly, we sought to assess the availability, evolution and alignment of this evidence with priorities over a decade, between 2013 and 2023. Thirdly, we aimed to contextualize our findings in Uganda\u0026rsquo;s dynamic health policies and systems taking into consideration relevance to stakeholders.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e Our study received ethical and regulatory approval from the School of Medicine Research and Ethics Committee of Makerere University College of Health Sciences, the Uganda National Council for Science and Technology (SS3271) and Office of the President, Republic of Uganda (ADM/154/212/01).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eUganda’s health systems context\u003c/h3\u003e\n\u003cp\u003eUganda is a landlocked country in East Africa, with a population of 45\u0026nbsp;million in 2023 up from 35\u0026nbsp;million in 2013 and its GDP increased from approximately \u003cspan\u003e$\u003c/span\u003e 800 to \u003cspan\u003e$\u003c/span\u003e1,000 United States Dollars in the same period (12,13). Uganda's health system is decentralized, characterized by health regions around regional referral hospitals, within which are district hospitals, and the basic complete unit being a health center level 4 at constituency level with a medical doctor, other medical staff, an operation theater and blood transfusion services (14,15).\u003c/p\u003e \u003cp\u003eMedical services begin at health center levels 2 at the parish administrative unit and up to health center level 3 at the sub\u0026ndash;county administrative unit. Community health workers constitute the village health teams and perform public health duties such as distribution of mosquito nets or mass immunization campaigns (16). The district health officer heads the district health team and reports to the chief administrative officer in the district for general duties or the director general health services at the ministry of health headquarters, in case of technical matters such as disease outbreaks (17).\u003c/p\u003e\n\u003ch3\u003eDesign and description of the priority setting process\u003c/h3\u003e\n\u003cp\u003eThis was a multiple methods study between 2013 and 2023, consisting of a mini\u0026ndash;Delphi technique (18) to identify health systems research priorities, a uncontrolled before\u0026ndash;and\u0026ndash;after assessment (19) of availability of research evidence to support the identified priorities, and a qualitative documentary analysis (20).\u003c/p\u003e \u003cp\u003eThere were at least three priority setting exercises over this decade under review. In August 2013, we conducted the baseline cross\u0026ndash;sectional study during a stakeholder dialogue using a mini\u0026ndash;Delphi approach at Makerere University, Kampala, Uganda. We employed the Supporting Use of Research Evidence guide (SURE) for prioritizing topics for policy briefs (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://global.evipnet.org/SURE-Guides/\u003c/span\u003e\u003cspan address=\"http://global.evipnet.org/SURE-Guides/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e (21). We presented participants with three background documents including priority topics for low\u0026ndash; and middle\u0026ndash;income countries written by the Norwegian Satellite of the Cochrane Effective Practice and Organization of Care (EPOC), \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://epoc.cochrane.org/\u003c/span\u003e\u003cspan address=\"https://epoc.cochrane.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; and examples of research priority areas from the World Health Organization health systems pillars and the Millennium Development Goals 4 (child health), 5 (maternal health) and 6 (infectious and non-communicable diseases); and the Malawi National Health Research Agenda (22,23).\u003c/p\u003e \u003cp\u003eThe Principal of the College, Prof. Nelson Sewankambo, (NKS) delivered the keynote address highlighting the goals of the \u0026lsquo;Africa Centre\u0026rsquo;, which started its operations in March 2013. One of the researchers (HN) facilitated the participants to complete two group iterations using the mini\u0026ndash;Delphi survey technique. We followed this by email reminders for further suggestions over two weeks, before analysis in 2013. In 2023, we complemented this survey with a retrospective documentary analysis, over the past10 year period from 2013. Briefly, we reviewed policy related strategic documents for Uganda\u0026rsquo;s health sector to assess the evolution and sustainability of these priorities in 2023.\u003c/p\u003e\n\u003ch3\u003eStudy population, sampling, and sample size\u003c/h3\u003e\n\u003cp\u003eWe purposively selected 54 individuals through identification and stakeholder mapping, with the aim of achieving diversity of views and engagement. Our map targeted the following stakeholders: Government techno\u0026ndash;professionals, decision takers, and policy makers at the ministry of health; health service providers including health management organizations in public and private health sectors, from rural and urban areas; civil society constituting health consumer bodies and representatives of health professional associations; employer groups; development partners and health systems researchers. We also included invited participants of the first Africa Centre training on systematic reviews that was conducted by the Norwegian Satellite of Cochrane Effective Practice and Organization of Care (EPOC).\u003c/p\u003e\n\u003ch3\u003eData collection, management, and synthesis\u003c/h3\u003e\n\u003cp\u003eFirst, we categorized the stakeholders into smaller groups in a brainstorming exercise. We then arranged for each group to present their findings before ranking them. Secondly, we requested the participants to make judgments and rank the policy concerns in need of research after assessing the following aspects: importance of the problem; availability of viable interventions; opportunity for change; important uncertainty about the health-systems issue; availability of relevant research and interest in deliberation on the problem.\u003c/p\u003e \u003cp\u003eWe conducted descriptive analysis of the frequencies after each round of ranking, giving equal weight to each assessment criteria. We computed the total score for each policy concern by which we ranked them, prior to the next round. Finally, we listed the top 10 ranked priority problems for health system research syntheses and their clusters, aligning these to the WHO pillars for health systems strengthening, that is leadership and governance, financing, human capital, health services delivery, access to medical products, vaccines and technologies and information use. As the initial assessment was done 10 years previously in 2013, we reviewed policy related strategic documents for Uganda\u0026rsquo;s health sector to assess the sustainability of these priorities in 2023. These were the Health Sector Development Plan 2015/2016\u0026ndash;2019/2020 (24) and the Health Sector Strategic Plan 2020/2021\u0026ndash;2024/2025 (25). We analyzed selected Annual Health Sector Performance Reports for 2014/2015 (26) as the baseline, then 2019/2020 (27) and 2022/2023 (28) for the end\u0026ndash;line and mid\u0026ndash;way the strategic plan periods respectively. After the analysis of the priority clusters, we conducted a feasibility scan of the PDQ\u0026ndash;Evidence database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.pdq-evidence.org/\u003c/span\u003e\u003cspan address=\"https://www.pdq-evidence.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e (29) to assess the extent of already existing research evidence about the proposed priority topics. Also, we repeated the feasibility scan in PDQ\u0026ndash;Evidence database in 2023, to assess the evolution of the availability of research evidence that would address Uganda\u0026rsquo;s health sector priorities since 2013.\u003c/p\u003e \u003cp\u003eWe searched for systematic reviews, scoping reviews, policy briefs or such related evidence briefs for policy in PDQ\u0026ndash;Evidence database using Boolean logic (30). The specific search terms were: \u0026ldquo;health financing\u0026rdquo; OR \u0026ldquo;health insurance\u0026rdquo; OR \u0026ldquo;pay for performance\u0026rdquo; OR \u0026ldquo;performance\u0026ndash;based funding\u0026rdquo; OR \u0026ldquo;results\u0026ndash;based financing\u0026rdquo; OR \u0026ldquo;cost sharing\u0026rdquo;, for financial arrangements; \u0026ldquo;human resources\u0026rdquo; for human resources for health; \u0026ldquo;governance\u0026rdquo; OR \u0026ldquo;public-private partnership\u0026rdquo; OR \u0026ldquo;guidelines\u0026rdquo; OR \u0026ldquo;accreditation\u0026rdquo; OR \u0026ldquo;standards\u0026rdquo;; \u0026ldquo;community engagement\u0026rdquo; OR \u0026ldquo;community participation\u0026rdquo; OR \u0026ldquo;community involvement\u0026rdquo; OR \u0026ldquo;equity\u0026rdquo; OR \u0026ldquo;contracting\u0026rdquo; for governance arrangements. We also captured the primary studies to reflect the availability or scarcity of researched evidence to support health systems priorities of low\u0026ndash; and middle\u0026ndash;income countries where Uganda lies. The last search was conducted on 26th July 2023.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eParticipants of the stakeholder\u0026rsquo;s dialogue.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 45 participants who responded and participated in the stakeholder dialogue of 2013, out of the 54 who were invited, giving a high response rate of 83%. Among the participants 14 were women (31%). Participants were from 25 different organizations including government ministries, departments, and agencies (MDAs), (n=4), non\u0026ndash;governmental entities (n=6), health consumer groups (n=1) and research institutes (n=12). Majority (64%) of the participants were researchers from the 12 institutes predominantly Ugandan (53%). Other researchers from Tanzania, Kenya, Cameroon, and Botswana were invited to the dialogue as part of our inaugural pre\u0026ndash;course workshop on evidence synthesis. This was the launch of the Africa Centre for Systematic Reviews and Knowledge Translation in August 2013; whose mission was to build capacity for evidence synthesis across sub\u0026ndash;Saharan Africa.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePriorities identified by the stakeholders in 2013.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe stakeholders in 2013, identified 34 priority areas for health systems research evidence synthesis. These included shortage of or inadequate health financing models leading to catastrophic health expenditure; shortage of and poor remuneration for human resources for health; inefficient forecasting, procurement and stock outs of essential medicines and medical supplies; sub-optimal service delivery particularly in maternal and child health including not meeting immunization targets, as well as Tuberculosis (table 2). Further, stakeholders identified the role of politicians and the community in fostering health priorities and better health seeking behaviors.\u003c/p\u003e\n\u003cp\u003eIn the second level of synthesis, most priority health system problems were about three clusters: delivery arrangements (18, 53%); followed by financial (9, 26%) and organizational (6, 18%) arrangements. Importantly, financial arrangements dominated the top 10 priority questions (8, 80%), which highlighted health financing (health insurance), human capital (remuneration) and resource allocation (budgeting) as the resilient health systems issues (table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePriorities in Uganda\u0026rsquo;s strategic health policy documents from 2013 to 2023.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver the past decade, there were three health sector planning cycles in Uganda. The 2011 to 2015 period, from 2015 to 2020 and currently 2020 to 2025. This period reflects the transition from the Millennium Development Goals (MDG) to Sustainable Development Goals (SDG) in 2015 of which the midpoint is 2023 [24]. Our stakeholder engagement to identify health systems priorities was done in the eve of the MDG to SDG transition, during Uganda\u0026rsquo;s third health sector strategic and investment plan from the financial year 2010/2011 to 2014/2015 [32]. The theme of this plan was \u0026ldquo;promoting people\u0026rsquo;s health to enhance socio-economic development\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis plan focused on five pillars: service delivery, human resources, health infrastructure, medical products, and management support. Its strategic objectives were to scale up critical interventions, improve equity in access to primary healthcare, accelerate quality and safety of health services, improve operational and financial efficiency, and deepen health sector stewardship. As this plan was informed by the MDGs of 2000, it had a diseases priority model: prevention and control of communicable diseases (HIV, TB, Malaria), non\u0026ndash;communicable diseases (diabetes, cardiovascular diseases and cancer) and maternal and child health conditions including sexual and reproductive health rights.\u003c/p\u003e\n\u003cp\u003eIn the post\u0026ndash;2015 agenda, the next health sector development plan for financial years 2015/2016 until 2019/2020 [25] spelt out four strategic objectives to support the overall goal of universal health coverage (UHC). These were the production of a healthy human capital for wealth creation; addressing the key determinants of health; increasing financial risk protection of households and enhancing health sector competitiveness in the region and globally. A deeper analysis of these objectives highlighted the following areas of priority: Health promotion across the life course with specific focus on maternal and child health; provision of non-communicable disease (NCD) and infectious diseases prevention and control services focusing on HIV/AIDS, TB, and malaria. To address the key determinants of health, the Ministry of Health proposed strengthening intersectoral collaboration and partnerships with other MDAs, around safe water, environmental health, and sanitation; food and nutrition services; housing and urbanization; road safety; veterinary services; energy; gender and human rights. Under financial risk protection, the Ministry was to establish systems for revenue generation, risk pooling, and strategic purchasing of medical services, and improve financial and procurement management systems.\u003c/p\u003e\n\u003cp\u003eThird, the current health sector strategic plan for financial year 2020/2021 until 2024/2025 (25) retained the 2030 target of UHC, and other strategic objectives of the previous plan through strengthening the health system within seven objectives. These were, enhancing the health sector governance, management and coordination; reinforcing human resources management and development; increasing access to nationally coordinated services for communicable and non-communicable diseases prevention and control; consolidating disease surveillance, epidemic control and disaster preparedness and response; ensuring availability of quality and safe medicines, vaccines and technologies; improving functionality and adequacy of health infrastructure; and logistics and accelerate health research, innovation and technology development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvolution of priorities in Uganda\u0026rsquo;s strategic policy related documents and reports from the MDG into the SDG era from 2015 to 2023\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA documentary synthesis of the strategic plans, aide memoires that spell out the annual re\u0026ndash;prioritization list and annual health sector performance reports over this decade, underscored the unfinished business of the MDGs that were carried forward in Uganda\u0026rsquo;s strategic documents for the health sector in the post\u0026ndash;2015 agenda of SDGs. Uganda\u0026rsquo;s unfinished MDG business entailed improving the effectiveness of social service delivery (31). Uganda\u0026rsquo;s MDG targets not achieved by the 2015 deadline were reduced maternal mortality ratio by three quarters; reduced under five-year old\u0026rsquo;s child mortality by two thirds and reversing the spread of HIV/AIDS. Importantly, even when the global targets of halting and reversing the incidence of malaria and TB, and universal access to antiretroviral therapy were met by Uganda, they were sustained in the priority list as going concerns in subsequent strategic documents (32).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe SDG era ushered in the global UHC mantra, particularly considering national financial risk protection mechanisms (World Health Organization, 2015). Despite this high\u0026ndash;level prioritization, Uganda\u0026rsquo;s desire to establish a national health insurance scheme evolved from the Bill of 2012 (34) that was modified into the Bill and Act of 2019 that was passed by the 10\u003csup\u003eth\u003c/sup\u003e parliament of Uganda (35). However, this national health insurance scheme Act of 2019 was subsequently not assented to by the Uganda\u0026rsquo;s President due to limited consensus among stakeholders, especially manufacturers\u0026apos; lobby and diminished financial inclusion of 68% of Uganda\u0026rsquo;s rural population (\u003cem\u003ePersonal communication with State House, Republic of Uganda\u003c/em\u003e). Further, apart from the COVID\u0026ndash;19 pandemic, there was an exponential increase in outbreaks of Ebola, yellow fever, rift valley fever, anthrax and Crimean Congo haemorrhagic fever in Uganda between 2013 and 2023 (36\u0026ndash;39). Still, domestic financing of public health responses for these recurrent disease outbreaks in Uganda continued to be a donor affair (40,41). Thus, the desire to import a mixed health financing model remained an unrealized priority in Uganda\u0026rsquo;s development agenda.\u003c/p\u003e\n\u003cp\u003eNotwithstanding Uganda\u0026rsquo;s health financing challenges, the country realized increased investment in human capital, medical technologies, and infrastructure as resilient priorities in the post\u0026ndash;2015 SDG period. Specifically, in human capital development the government invested in training and hiring more medical workers and increased their salaries. For example, while medical schools increased from 4 to 14 over this decade (42,43), medical doctors employed by government hospitals increased from 536 to over 1,500 (44,45). Further, salaries of medical doctors increased from one million Uganda shillings (~$US400) to five million Uganda shillings (~$US1,500) per month [49, 50]. This investment in human capital was in tandem with the Government\u0026rsquo;s increased investment in physical infrastructure for specialized medical care, with major renovations and expansion of national and regional referral hospitals as well as construction of new major facilities over this decade, 2013\u0026ndash;2023. For example, in the Kampala capital city metropolitan area alone, five new specialized national referral hospitals were constructed focusing on maternal and child health including infertility at the new Women\u0026rsquo;s hospitals at Mulago and another at Kawempe (46), adult health focusing on non-communicable diseases including renal dialysis at Kiruddu hospital, and accident and emergency at Naguru hospital (47). At the same time, the Uganda Cancer Institute was elevated into the East African Centre of Excellence in Oncology (48) and intensive care units were expanded in the regional and national referral hospitals from 55 beds (49,50) to 143 beds (Ministry of Health Uganda, 2022a). The latter was driven by the COVID\u0026ndash;19 outbreak that necessitated establishing of medical oxygen facilities to 7 (52) from 2 (26) to support high dependency units and intensive care units countrywide.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs before (34,53), the five\u0026ndash;year strategic planning cycles coincided with the five\u0026ndash;year electoral cycles signifying the importance of political regime transition in priority setting by making campaign promises to strengthen social services (54). For instance, promises uttered by presidential, parliamentary, and other local government political candidates highlighted the resilient priorities. Specifically, these were the promises to diversify health system financing through a national health insurance scheme that was never realized, salaries for medical workers were raised substantially, the national medical warehouse and blood transfusion services received increased budgets, as were several completed hospital infrastructures following these campaign promises during the post\u0026ndash;2015 agenda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMinistry of Health organizational reforms re\u0026ndash;aligned to new priorities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRemarkably, in the post\u0026ndash;2015 agenda, the Ministry of Health proposed organizational restructuring to align itself to fulfil Uganda\u0026rsquo;s evolving objectives under four directorates: curative services, public health, health governance and regulation, strategy policy and development, with 19 departments (see table 6). Initially there were 2 (two) directorates, 5 (five) departments, and 14 divisions. These were functionalized through the various Technical Working Groups reconstituted and reduced from 14 to 11 during this period.\u003c/p\u003e\n\u003cp\u003eThe reforms at Ministry of Health headquarters were followed by realigning the hospital staffing structure at all levels, national, regional and district referrals, and health centers. This elevated previous divisions into departments, such as Nursing, while new ones were created such as the institutional capacity building and human resource development, emergency medical services, integrated epidemiology and surveillance, laboratory and diagnostic services, with new openings for medical professional jobs at management level. Indeed, it is during this post\u0026ndash;2015 agenda period that health center level 2 was abolished and transitioned to level 3, to enhance Universal Health Coverage. This coincided with the Parish Development Model (PDM) (55,56) introduced by the National Resistance Movement (NRM) to bring social services closer to the people, complete with medical doctors at health center level 3, down from health center level 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability and evolution of evidence aligned to the identified health systems priorities between 2013 and 2023.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA crucial aspect in this study was to assess whether researched evidence was available to support health systems priority interventions, in line with the priorities identified. We also assessed whether the interventions were aligned to the research evidence or vice versa, and the limitations of the availability of the researched evidence. We performed the feasibility scan of the researched evidence in PDQ\u0026ndash;Evidence database (https://www.pdq-evidence.org/) in 2013 and again in 2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe literature of any type was most abundant for healthcare financing with 1,226 articles including 196 systematic reviews and 23 broad syntheses, table 5. This was followed by literature on governance that had a cumulative 1,070 articles with 155 systematic reviews and 32 broad syntheses. Community engagement literature predominated the available evidence for health systems governance, with 556 articles of which 89 were systematic reviews and 18 were broad syntheses. Human resources for health, returned 744 articles including 152 systematic reviews and 40 broad syntheses. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of evolution of the available evidence on health systems interventions over the past decade (2013\u0026ndash;2023), the highest proportional increase was about human resources for health (55%) including 129 systematic reviews and 33 broad syntheses. This was followed by literature on governance (43%) complete with 121 systematic reviews and 30 broad syntheses, driven by equity considerations in resource allocation (53%). While health financing returned the highest frequency of new literature in the past decade with 503 new articles including 130 systematic reviews and 15 broad syntheses, this proportion was the least at 35%.\u003c/p\u003e\n\u003cp\u003eIn this period, the Africa Centre for Systematic Reviews and Knowledge Translation was involved in the evidence supply-demand ecosystem in Uganda\u0026rsquo;s health sector, which informed our findings too (table 5). These included policy briefs about the national health insurance scheme law, performance\u0026ndash;based funding, contracting out and community engagement amongst others.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e \u003cb\u003ePrincipal findings.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur study sought to identify priority concerns for health systems in resource constrained settings that required researched evidence to support policy proposals. Our findings highlighted financial arrangements as a resilient priority area for health system evidence synthesis in Uganda. Secondly, we found an abundance of existing evidence syntheses from the PDQ-Evidence database, in all the areas including health systems governance and human capital development. Third, we mapped the evolution of health systems priorities in Uganda together with the evidence in PDQ-Evidence over the past decade with the emergence of human capital development as a priority policy concern that received massive investment by the Ministry of Health, and indeed highest increase in researched evidence. Not least, we documented the organizational realignment of Uganda\u0026rsquo;s Ministry of Health to meet the evolving health systems priorities in line with agenda 2030 of the sustainable development goals (SDG).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFindings in relation to existing evidence.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eUganda\u0026rsquo;s priority health policy and systems agenda documented between 2008 and 2010 by the national health research organization have been sustained in our study, 15 years after (57). Indeed, the then top three resilient priority policy problems identified by Uganda\u0026rsquo;s ministry of health at that time were scaling up safe male medical circumcision for HIV/AIDS prevention after successful community clinical trials in Uganda (58), Kenya (59)and South Africa (60); introducing task shifting of healthcare professionals under human resources for health and developing a community health insurance strategy under innovative financing approaches (61). The respondents of this study perceived the lack of funding to health facilities, lack of drugs in government hospitals and not enough health personnel to provide medical services as the key challenges.\u003c/p\u003e \u003cp\u003eIn the same breadth, work by Ssengooba \u0026amp; colleagues identified health workforce, governance and service delivery as the top three priorities for universal health coverage (UHC) research in Uganda (62). The million\u0026ndash;dollar question is, why have these health systems research priorities remained relevant, as depicted in our study of Uganda and indeed other agenda setting exercises in sub\u0026ndash;Saharan Africa, despite massive investments in the health sector by both domestic and donor money? Perhaps this is a function of limited evidence on follow up strategies for research priorities in low\u0026ndash;and middle\u0026ndash;income countries, documented in a systematic review by McGregor and colleagues (63).\u003c/p\u003e \u003cp\u003eAvailability of researched evidence may be necessary but not sufficient to address priority health systems challenges in low-income countries. Despite being the most researched area by far, financing health systems remains an indomitable challenge in Uganda and similar low\u0026ndash;income countries. Could this be a prominent reflection of the \u0026ldquo;know\u0026ndash;do\u0026ndash;gap\u0026rdquo;? (9,64,65) That all individuals access quality health services without suffering financial hardship is the cornerstone of UHC embedded in the Sustainable Development Goals (66,67). However, in a report by WHO tracking progress of UHC by 2017 (68), over a hundred million people were impoverished annually due to catastrophic health expenditures, spending 10% or more of household income on health seeking, especially in low-income countries. A similar report by WHO in 2022 (69) showed that over the past 20 years, out\u0026ndash;of\u0026ndash;pocket expenditure across most sub\u0026ndash;Saharan African countries has increased. That catastrophic health expenditure affected 56% of 48 countries in sub\u0026ndash;Saharan Africa, and in 66% of the countries catastrophic health expenditure was more than 25% of the household budgets. Over the same period in Uganda, catastrophic health expenditure declined from 41% (26) to 29% (financial year 2022/2023) (28), with only 4% of the population accessing private or some form of local community health insurance facilities up from 1% previously (70). Yet, efforts by the Ministry of Health to enact a national health insurance law were not successful over the last decade, from 2012 to 2022 (35). Clearly, the need for new evidence syntheses for innovative approaches on health financing at country level, perhaps locally contextualized evidence, may trigger governments of low\u0026ndash;income countries such as Uganda to implement financial risk protection mechanisms such as pooling of risks and resources in countrywide insurance schemes.\u003c/p\u003e \u003cp\u003eGiven the chronic suboptimal health financing climate in sub\u0026ndash;Saharan Africa (71), the need for innovative approaches to strengthen health systems governance based on synthesized evidence is even more urgent (72). Community involvement dominated literature on health systems governance, with substantial growth in the available evidence base in the past decade. Whether this literature informs community engagement strategies on health remains understudied. Noteworthy, the dynamic democratic evolution in sub\u0026ndash;Saharan Africa provides for an increasingly central role of stronger health systems governance (73,74), that may bolster the other WHO pillars with leadership, strategic policy frameworks, oversight, and accountability (75) for which Uganda is beneficiary. Certainly, this has come with a growing demand from the informed citizenry for governments to demonstrate results from invested resources in public health, commonly packaged as promises during Uganda\u0026rsquo;s electoral cycles (53). Uganda\u0026rsquo;s community engagement strategy in policy formulation is prominent (76), through stakeholder meetings, with a proliferation of new policy documents diminished by the attendant challenge of limited policy action. Similarly, community participation in resources allocation is presumed to occur through its directly elected Parliament, where the people\u0026rsquo;s voice is represented. Within Uganda\u0026rsquo;s ministry of health, the people\u0026rsquo;s voice is heard through the health policy advisory committee (HPAC) and the various technical working groups, for which Uganda\u0026rsquo;s ministry of health underwent restructuring (77,78)\u003c/p\u003e \u003cp\u003eHealth systems can only function with health workers (79); improving health service coverage and realizing the right to the enjoyment of the highest attainable standard of health is dependent on their availability, accessibility, acceptability and quality (75). We documented human capital development as a resilient cornerstone priority that potentially would unlock far\u0026ndash;reaching health systems reforms, if addressed holistically. Interestingly, human resources for health had the greatest increase in available research syntheses over the decade of our study period, suggesting increased availability of evidence informed solutions. This priority problem is in tandem with the estimated global shortfall of at least 10\u0026nbsp;million health workers by 2030 in line with SDGs (80,81), mostly in low\u0026ndash;and lower\u0026ndash;middle income countries for various reasons including: sustained under\u0026ndash;investment in production of health workers, a mismatched skills mix, skewed within country rural\u0026ndash;urban distribution, increasing \u0026lsquo;brain \u0026ndash; drain\u0026rsquo; to higher income countries, and the high\u0026ndash;demand\u0026ndash; unemployment conundrum co-existing with major unmet health needs. In the decade of our review, Uganda\u0026rsquo;s government circumvented these challenges by implementing evidence informed investments for human capital development through expanded medical schools from 3 to 10 (42), specialized medical skilling abroad, increased medical workers salaries, and restructured staffing norms at the ministry of health headquarters and health facility level, that provided new employment openings. Nevertheless, a perennial challenge is the absorption of the new medical grandaunts in the public sector or through controlled emigration for mutual benefit, right from medical internship placements (82,83), for which new researched evidence may be informative.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications for future research and next steps.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe above observations pause new questions about the paradox of so much evidence available with so little done (84,85). First, why did key actors in Uganda\u0026rsquo;s health system, despite the abundance of synthesized evidence, recurrently prioritize human capital development or financing for further research? Was the availability of evidence necessary and sufficient to cause policy action in the Ugandan context? Or could it be that evidence required active feet beyond peer reviewed articles, policy briefs and dialogues? Were Ugandan researchers providing the relevant synthesis products to decision takers, through push or integrated efforts? (86) To what extent were Ugandan researchers creating demand for pull efforts from decision makers? (9,86)\u003c/p\u003e \u003cp\u003ePerhaps these questions suggest that the ministry of health, development partners and health systems leaders in local governments could introduce an evidence checklist in its policy approval process, to enforce the use of researched evidence especially systematic reviews and evidence and gap maps. This will generate tailored demand by imploring policy formulators to find and apply researched evidence in the choice of interventions or dis-investment in ongoing policies.\u003c/p\u003e \u003cp\u003eStrengths and limitations of identifying health systems research priorities in low-income countries including Uganda\u003c/p\u003e \u003cp\u003eThere were several strengths and important shortcomings of our study. First, this is the first synthesis of resilient health systems research priorities in a low\u0026ndash;income country, over a decade. Secondly this study triangulates both methods and data from various sources, including a documentary analysis with validation from an open access health systems database, PDQ\u0026ndash;Evidence. Third, this study maps the evolution of evidence and contextualizes its findings in Uganda\u0026rsquo;s evolving health systems over a decade transcending the post\u0026ndash;2015 agenda of SDGs and UHC. There were also limitations namely empirical evidence from stakeholder views that were not captured; and the weak attribution of increased availability of researched evidence as identified in the PDQ-database, informing health sector reforms in Uganda\u0026rsquo;s health systems.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eOur study findings suggest that access to evidence by decision makers remains an important challenge in bridging the \u0026ldquo;know\u0026ndash;do\u0026ndash;gap\u0026rdquo;. This calls for health systems researchers in Uganda to constantly engage decision makers about where and how to find relevant research evidence, and further refine their information needs. A key starting point is empowering the Uganda National Health Research Organization to provide an integrated knowledge translation platform for the health sector.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn memory of Dr. Harriet Nabudeere who was very instrumental in starting this work yet passed away before its fruition, during the COVID-19 outbreak. Dr. Marie Gloriose Ingabire of the International Development Research Centre, Ottawa, Canada (IDRC) for supporting the African Centre for Systematic Reviews and Knowledge Translation \u0026ldquo;The Africa Centre, MakCHS\u0026rdquo;, based at the College of Health Sciences, Makerere University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The Africa Centre, MakCHS\u0026rdquo; was established in 2013 as an offshoot of my interest in evidence synthesis for policy via grant number 107237\u0026ndash;001 held by Prof. Nelson Sewankambo, the Principal Investigator and my supervisor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study received ethical and regulatory approval from the School of Medicine Research and Ethics Committee of Makerere University College of Health Sciences, the Uganda National Council for Science and Technology (SS3271) and Office of the President, Republic of Uganda (ADM/154/212/01)\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo, I do not have any research data outside the submitted manuscript file. All the data available is provided in the tables in this manuscript and in the references for the documentary analysis, for example the Uganda Ministry of health Knowledge Portal: http://library.health.go.ug/\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception: EAO, HN, NKS | Data capture: EAO, HN, NKS, RA | Data synthesis: EAO, HN, NKS | Drafting manuscript: EAO, HN, NKS, RA | Accepting manuscript: EAO, NKS, RA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo, I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. This manuscript arises from post-doctoral work of the lead author: E.A.O\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBredan A. 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Assessing country-level efforts to link research to action. Bull World Health Organ. 2006;84(8):620\u0026ndash;8.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6017972/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6017972/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eRATIONALE\u003c/p\u003e \u003cp\u003eResources for conducting health systems research are often limited and yet millions of research articles, systematic reviews, technical reports, and policy briefs are published annually with a significant proportion hardly read, let alone used for decision making. We aimed to identify health systems research priorities for evidence synthesis; assess the availability, evolution and alignment of this evidence with dynamic priorities; and contextualized our findings in Uganda\u0026rsquo;s health policies and systems.\u003c/p\u003e \u003cp\u003eAPPROACH\u003c/p\u003e \u003cp\u003eThis was a multiple methods study between 2013 and 2023, consisting of a mini\u0026ndash;Delphi technique to identify health systems research priorities, an uncontrolled before\u0026ndash;and\u0026ndash;after assessment of availability of research evidence to support the identified priorities, and a qualitative documentary analysis of evolving health policies and systems in Uganda.\u003c/p\u003e \u003cp\u003eMAIN FINDINGS\u003c/p\u003e \u003cp\u003eOur findings highlighted financial arrangements as a resilient priority area for health system evidence synthesis in Uganda. Secondly, we found an abundance of existing evidence syntheses from the PDQ-Evidence database, in all the areas including health systems governance and human capital development. Third, we mapped the evolution of health systems priorities in Uganda together with the evidence in PDQ-Evidence over the past decade with the emergence of human capital development as a priority policy concern that received massive investment by the Ministry of Health, and indeed highest increase in researched evidence. The organizational realignment of Uganda\u0026rsquo;s Ministry of Health responded to the evolving health systems priorities in line with agenda 2030 of the sustainable development goals (SDG).\u003c/p\u003e \u003cp\u003eCONCLUSIONS\u003c/p\u003e \u003cp\u003eOur study findings suggest that access to evidence by decision makers remains an important challenge in bridging the \u0026ldquo;know\u0026ndash;do\u0026ndash;gap\u0026rdquo;. This calls for health systems researchers in Uganda to constantly engage decision makers about where and how to find relevant research evidence, and further refine their information needs. A key starting point is empowering the Uganda National Health Research Organization to provide an integrated knowledge translation platform for the health sector.\u003c/p\u003e","manuscriptTitle":"Mapping the evolution of priorities for health systems evidence synthesis in a low-income country: A case study of Uganda from 2013 to 2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-21 13:19:30","doi":"10.21203/rs.3.rs-6017972/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5834a34e-5d25-461c-8283-e449403ec9ac","owner":[],"postedDate":"February 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-30T13:24:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-21 13:19:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6017972","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6017972","identity":"rs-6017972","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}