title: Uptake of evidence in policy development: the case of user fees for health care in public health facilities in Uganda.
abstract: BACKGROUND
  Several countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. We explored the barriers and facilitating factors to uptake of evidence in the process of user fee abolition in Uganda and how the context and stakeholders involved shaped the uptake of evidence. This study builds on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitating factors for knowledge translation (KT). Application of the MRT to the case of abolition of user fees contributes to its refining.
  
  
  METHODS
  Employing a theory-driven inquiry and case study approach given the need for in-depth investigation, we reviewed documents and conducted interviews with 32 purposefully selected key informants. We assessed whether evidence was available, had or had not been considered in policy development and the reasons why and; assessed how the actors and the context shaped the uptake of evidence.
  
  
  RESULTS
  Symbolic, conceptual and instrumental uses of evidence were manifest. Different actors were influenced by different types of evidence. While technocrats in the ministry of health (MoH) relied on formal research, politicians relied on community complaints. The capacity of the MoH to lead the KT process was weak and the partnerships for KT were informal. The political window and alignment of the evidence with overall government discourse enhanced uptake of evidence. Stakeholders were divided, seemed to be polarized for various reasons and had varying levels of support and influence impacting the uptake of evidence.
  
  
  CONCLUSIONS
  Evidence will be taken up in policy development in instances where the MoH leads the KT process, there are partnerships for KT in place, and the overall government policy and the political situation can be expected to play a role. Different actors will be influenced by different types of evidence and their level of support and influence will impact the uptake of evidence. In addition, the extent to which a policy issue is contested and, whether stakeholders share similar opinions and preferences will impact the uptake of evidence.
authors.affiliation: WHO Regional Office for Africa, Health systems and services cluster, P.O Box 6, Brazaville, Congo. nabyongaj@who.int.
authors.forename: Juliet
authors.initials: J
authors.lastname: Nabyonga-Orem
authors.affiliation: Makerere University, School of Public Health, P.O. Box 7072, Kampala, Uganda. sengooba@musph.ac.ug.
authors.forename: Freddie
authors.initials: F
authors.lastname: Ssengooba
authors.affiliation: Regional East African Community Health (REACH) policy initiative, Uganda, College of Health Sciences, P.O. Box 7072, Kampala, Uganda. rmijumbi@chs.mak.ac.ug.
authors.forename: Rhona
authors.initials: R
authors.lastname: Mijumbi
authors.affiliation: Makerere University, School of Public Health, P.O. Box 7072, Kampala, Uganda. tashobyack@yahoo.co.uk.
authors.forename: Christine Kirunga
authors.initials: CK
authors.lastname: Tashobya
authors.affiliation: Institute of Tropical Medicine Antwerp-Belgium, Nationalestraat 155, 2000, Antwerp, Belgium. BMarchal@itg.be.
authors.forename: Bruno
authors.initials: B
authors.lastname: Marchal
authors.affiliation: Institute of Tropical Medicine Antwerp-Belgium, Nationalestraat 155, 2000, Antwerp, Belgium. Bcriel@itg.be.
authors.forename: Bart
authors.initials: B
authors.lastname: Criel
mesh_terms: D017954:Africa South of the Sahara; D055317:Evidence-Based Practice; D005249:Fees and Charges / Q000331:legislation & jurisprudence*; D006268:Health Facilities / Q000191:economics* / Q000331:legislation & jurisprudence*; D006291:Health Policy / Q000191:economics*; D006801:Humans; D011050:Policy Making; D014454:Uganda