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Background Midwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province. Methods A qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12. Results The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives’ living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges. Conclusion Midwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.

Background\ud National health research for development (R4D) platforms in lower income countries (LICs) are few. The Health Research Capacity Strengthening Initiative (HRCSI, 2008–2013) was a national systems-strengthening programme in Malawi involved in national priority setting, decision-making on funding, and health research actor mobilization.\ud \ud Methods\ud We adopted a retrospective mixed-methods evaluation approach, starting with information gleaned from reports (HRCSI and Malawian) and databases (HRCSI). A framework of a health research system (actors and components) guided report review and interview guide development. From a list of 173 individuals involved in HRCSI, 30 interviewees were selected within categories of stakeholders. Interviews were conducted face-to-face or via telephone/Skype over 1 month, documented with extensive notes. Analysis of emerging themes was iterative among co-evaluators, with synthesis according to the implementation stage.\ud \ud Results\ud Major HRCSI outputs included (1) National research priority-setting: through the production of themed background papers by Malawian health researchers and broad consultation, HRCSI led the development of a National Health Research Agenda (2012–2016), widely regarded as one of HRCSI’s foremost achievements. (2) Institutional research capacity: there was an overwhelming view that HRCSI had produced a step-change in the number of high calibre scientists in Malawi and in fostering research interest among young Malawians, providing support for around 56 MSc and PhD students, and over 400 undergraduate health-related projects. (3) Knowledge sharing: HRCSI supported research dissemination through national and institutional meetings by sponsoring attendance at conferences and through close relationships with individuals in the print media for disseminating information. (4) Sustainability: From 2011–2013, HRCSI significantly improved research systems, processes and leadership in Malawi, but further strengthening was needed for HRCSI to be effectively integrated into government structures and sustained long-term.\ud \ud Overall, HRCSI carried out many components relevant to a national health research system coordinating platform, and became competent at managing over half of 12 areas of performance for research councils. Debate about its location and challenges to sustainability remain open questions.\ud \ud Conclusions\ud More experimentation in the setting-up of national health R4D platforms to promote country ‘ownership’ is needed, accompanied by evaluation processes that facilitate learning and knowledge exchange of better practices among key actors in health R4D systems.

Background Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs. Methods We searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized. Results Few studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. Conclusions Research on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance. Electronic supplementary material The online version of this article (doi:10.1186/s12961-015-0001-3) contains supplementary material, which is available to authorized users.

Background: Health research capacity strengthening (RCS) projects are often complex and hard to evaluate. In\ud order to inform health RCS evaluation efforts, we aimed to describe and compare key characteristics of existing\ud health RCS evaluation frameworks: their process of development, purpose, target users, structure, content and\ud coverage of important evaluation issues. A secondary objective was to explore what use had been made of the\ud ESSENCE framework, which attempts to address one such issue: harmonising the evaluation requirements of\ud different funders.\ud \ud Methods: We identified and analysed health RCS evaluation frameworks published by seven funding agencies between 2004 and 2012, using a mixed methods approach involving structured qualitative analyses of documents, a stakeholder survey and consultations with key contacts in health RCS funding agencies.\ud \ud Results: The frameworks were intended for use predominantly by the organisations themselves, and most were oriented primarily towards funders’ internal organisational performance requirements. The frameworks made limited\ud reference to theories that specifically concern RCS. Generic devices, such as logical frameworks, were typically used to document activities, outputs and outcomes, but with little emphasis on exploring underlying assumptions or contextual constraints. Usage of the ESSENCE framework appeared limited.\ud \ud Conclusions: We believe that there is scope for improving frameworks through the incorporation of more accessible information about how to do evaluation in practice; greater involvement of stakeholders, following evaluation capacity building principles; greater emphasis on explaining underlying rationales of frameworks; and structuring frameworks so that they separate generic and project-specific aspects of health RCS evaluation. The third and fourth of these improvements might assist harmonisation.

Assessing the impact that research evidence has on policy is complex. It involves consideration of conceptual issues of what determines research impact and policy change. There are also a range of methodological issues relating to the question of attribution and the counter-factual. The dynamics of SRH, HIV and AIDS, like many policy arenas, are partly generic and partly issue- and context-specific. Against this background, this article reviews some of the main conceptualisations of research impact on policy, including generic determinants of research impact identified across a range of settings, as well as the specificities of SRH in particular. We find that there is scope for greater cross-fertilisation of concepts, models and experiences between public health researchers and political scientists working in international development and research impact evaluation. We identify aspects of the policy landscape and drivers of policy change commonly occurring across multiple sectors and studies to create a framework that researchers can use to examine the influences on research uptake in specific settings, in order to guide attempts to ensure uptake of their findings. This framework has the advantage that distinguishes between pre-existing factors influencing uptake and the ways in which researchers can actively influence the policy landscape and promote research uptake through their policy engagement actions and strategies. We apply this framework to examples from the case study papers in this supplement, with specific discussion about the dynamics of SRH policy processes in resource poor contexts. We conclude by highlighting the need for continued multi-sectoral work on understanding and measuring research uptake and for prospective approaches to receive greater attention from policy analysts.

Background Sexual and Reproductive Health (SRH) and HIV issues are often controversial and neglected, leading to challenges with engaging policy actors. Research evidence is complex, posing further challenges for ensuring that policy and practice are evidence-based. Many health researchers are adopting innovative approaches to engaging stakeholders in their research, yet these experiences are not often shared. This qualitative study focuses on the research communication and policy influencing objectives, strategies and experiences of four research consortia working on SRH, HIV and AIDS. Methods We carried out 22 in-depth interviews with researchers and communications specialists (research actors) from the four consortia and their partners, working in nine countries in sub-Saharan Africa and Asia. Using the ‘framework’ approach to qualitative data analysis, we identified factors that affect the interaction of research evidence with policy and practice. We used the ODI RAPID analytical framework to present these results, adapting this tool by incorporating the actions, strategies and positionality of research actors. Results The characteristics of researchers and their institutions, policy context, the multiplicity of actors, and the nature of the research evidence all play a role in policy influencing processes. Research actors perceived a trend towards increasingly intensive and varied communication approaches. Effective influencing strategies include making strategic alliances and coalitions and framing research evidence in ways that are most attractive to particular policy audiences. Tensions include the need to identify and avoid unnecessary communication or unintended impacts, challenges in assessing and attributing impact and the need for adequate resources and skills for communications work. Conclusions We contend that the adapted RAPID framework can serve as a tool for research actors to use in resolving these tensions, through facilitating a reflexive approach to considering their own combination of attributes, skills, networks and objectives and the ways these relate to policy contexts, actors and processes.

Background Despite substantial investment in health capacity building in developing countries, evaluations of capacity building effectiveness are scarce. By analysing projects in Africa that had successfully built sustainable capacity, we aimed to identify evidence that could indicate that capacity building was likely to be sustainable. Methods Four projects were selected as case studies using pre-determined criteria, including the achievement of sustainable capacity. By mapping the capacity building activities in each case study onto a framework previously used for evaluating health research capacity in Ghana, we were able to identify activities that were common to all projects. We used these activities to derive indicators which could be used in other projects to monitor progress towards building sustainable research capacity. Results Indicators of sustainable capacity building increased in complexity as projects matured and included - early engagement of stakeholders; explicit plans for scale up; strategies for influencing policies; quality assessments (awareness and experiential stages) - improved resources; institutionalisation of activities; innovation (expansion stage) - funding for core activities secured; management and decision-making led by southern partners (consolidation stage). Projects became sustainable after a median of 66 months. The main challenges to achieving sustainability were high turnover of staff and stakeholders, and difficulties in embedding new activities into existing systems, securing funding and influencing policy development. Conclusions Our indicators of sustainable capacity building need to be tested prospectively in a variety of projects to assess their usefulness. For each project the evidence required to show that indicators have been achieved should evolve with the project and they should be determined prospectively in collaboration with stakeholders.

Background \ud The monitoring and evaluation of health research capacity strengthening (health RCS) \ud commonly involves documenting activities and outputs using indicators or metrics. We \ud sought to catalogue the types of indicators being used to evaluate health RCS and to assess \ud potential gaps in quality and coverage. \ud Methods \ud We purposively selected twelve evaluations to maximize diversity in health RCS, funders, \ud countries, and approaches to evaluation. We explored the quality of the indicators and \ud extracted them into a matrix across individual, institutional, and national/regional/network \ud levels, based on a matrix in the ESSENCE Planning, Monitoring and Evaluation framework. \ud We synthesized across potential impact pathways (activities to outputs to outcomes) and \ud iteratively checked our findings with key health RCS evaluation stakeholders. Results \ud Evaluations varied remarkably in the strengths of their evaluation designs. The validity of \ud indicators and potential biases were documented in a minority of reports. Indicators were \ud primarily of activities, outputs, or outcomes, with little on their inter-relationships. Individual \ud level indicators tended to be more quantitative, comparable, and attentive to equity \ud considerations. Institutional and national–international level indicators were extremely \ud diverse. Although linkage of activities through outputs to outcomes within evaluations was \ud limited, across the evaluations we were able to construct potential pathways of change and \ud assemble corresponding indicators. \ud Conclusions \ud Opportunities for improving health RCS evaluations include work on indicator measurement \ud properties and development of indicators which better encompass relationships with \ud knowledge users. Greater attention to evaluation design, prospective indicator measurement, \ud and systematic linkage of indicators in keeping with theories of change could provide more \ud robust evidence on outcomes of health RCS.

Background\ud Despite increasing investment in health research capacity strengthening efforts in low and middle income countries, published evidence to guide the systematic design and monitoring of such interventions is very limited. Systematic processes are important to underpin capacity strengthening interventions because they provide stepwise guidance and allow for continual improvement. Our objective here was to use evidence to inform the design of a replicable but flexible process to guide health research capacity strengthening that could be customized for different contexts, and to provide a framework for planning, collecting information, making decisions, and improving performance.\ud \ud Methods\ud We used peer-reviewed and grey literature to develop a five-step pathway for designing and evaluating health research capacity strengthening programmes, tested in a variety of contexts in Africa. The five steps are: i) defining the goal of the capacity strengthening effort, ii)describing the optimal capacity needed to achieve the goal, iii) determining the existing capacity gaps compared to the optimum, iv) devising an action plan to fill the gaps and associated indicators of change, and v) adapting the plan and indicators as the programme matures. Our paper describes three contrasting case studies of organisational research capacity strengthening to illustrate how our five-step approach works in practice.\ud \ud Results\ud Our five-step pathway starts with a clear goal and objectives, making explicit the capacity required to achieve the goal. Strategies for promoting sustainability are agreed with partners and incorporated from the outset. Our pathway for designing capacity strengthening programmes focuses not only on technical, managerial, and financial processes within organisations, but also on the individuals within organisations and the wider system within which organisations are coordinated, financed, and managed.\ud \ud Conclusions\ud Our five-step approach is flexible enough to generate and utilise ongoing learning. We have tested and critiqued our approach in a variety of organisational settings in the health sector in sub-Saharan Africa, but it needs to be applied and evaluated in other sectors and continents to determine the extent of transferability.

Background\ud Research institutions and donor organizations are giving growing attention to how research evidence is communicated to influence policy. In the area of sexual and reproductive health (SRH) and HIV there is less weight given to understanding how evidence is successfully translated into practice. Policy issues in SRH can be controversial, influenced by political factors and shaped by context such as religion, ethnicity, gender and sexuality.\ud \ud Methods\ud The case-studies presented in this paper analyse findings from SRH/HIV research programmes in sub-Saharan Africa: 1) Maternal syphilis screening in Ghana, 2) Legislative change for sexual violence survivors In Ghana, 3) Male circumcision policy in South Africa, and 4) Male circumcision policy in Tanzania. Our analysis draws on two frameworks, Sumner et al’s synthesis approach and Nutley’s research use continuum.\ud \ud Results\ud The analysis emphasises the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change – especially in SRH – where there are complex interactions between policy actors.\ud \ud Conclusion\ud Both frameworks demonstrate how policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximize research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural and practical.