Rooted, resourced and connected: stakeholder perspectives on involvement in injury care policy and practice in Ghana, Pakistan, Rwanda, and South Africa - is consensus achievable?

BACKGROUND Strengthening health systems requires policy development that meets stakeholder needs and is informed by evidence. However, little is known about how to effectively engage stakeholders from diverse backgrounds in evidence uptake for policy or whether alignment can be achieved within and across different country contexts. This multi-country study, using injury care as a case study, aimed to: (1) ascertain the needs, preferences, and desires of stakeholders toward taking up evidence for policy; (2) understand if consensus is achievable within and across stakeholders; and (3) examine whether outcomes are shared across country contexts. METHODS The study was conducted in Ghana, Pakistan, Rwanda and South Africa, selecting one urban and one rural district in each country for broad representation. Stakeholder groups were: (1) communities and patients, (2) service providers, and (3) policymakers, with groups engaged separately to mitigate power imbalances. Workshops were structured using the nominal group technique to facilitate discussions and consensus-building. Data were collected through plenary sessions and voting, focusing on levels of involvement, mechanisms for involvement, and the barriers and facilitators to that involvement in developing evidence-based policy. In-depth interviews with policymakers were performed and thematically analysed. Finally, the research team synthesized findings across countries to identify consensus and differences. RESULTS A total of 297 stakeholders participated in the study: 240 through workshops and 57 in interviews. All stakeholder groups in all countries agreed that involvement in policy making was important. Consensus was achieved in each country in the levels at which stakeholders wanted to engage, with groups prioritizing local involvement. In Ghana and Rwanda, consensus was achieved on the mechanisms for policy engagement, specifically community engagement and advocacy. In Ghana and Pakistan, consensus was also reached on barriers and facilitators to policy involvement, primarily concerning resources and funding. CONCLUSION While involving diverse stakeholder groups in evidence-based policy development is a valuable goal, achieving consensus on levels, mechanisms, barriers, and facilitators for involvement is challenging and varies across contexts. Our work implies that deep engagement with stakeholders is required to ensure authentic and diverse involvement in policy and that solutions for involvement will differ across groups and contexts.