Table 2 Selected quotes

Policymaking is complicated, iterative and takes time

 “The thing with policy development is, you’ve got to engage with a lot of stakeholders, clinicians, management, local level academics, people in programmes, you’ve got to draw from all of that”. South Africa

 “But you need, to come together, all the parties, the community, health sector, and the decision makers, to understand and to have the same view on reasons why the coverage is low and to see together and adopt the same strategy and to look for the means, to adapt means to be used so as to address the issue at hand. The actors should be aware and try to have the understanding of the situation so as to adopt consensually the implementation strategies to deal with the problem at hand.” Cameroon

 “Theoretically, national government should be making policy through consistent engagement with provinces to ensure that policies are aligned with realities on the ground, but in practice there is room for improvement”. South Africa

 “…can take 2–3 months or a year and it depends on the person driving the policy in the province”. South Africa

Research is not the main driver of policy

 “research there, plays a major role and the things, I mean the kind of work that Cochrane does is very important because what you do is you bring together… the world of literature and you can make those kind of policy recommendations…”. South Africa

 “…at these meetings, evidence is not necessarily the major point or the major driver of a decision. It certainly plays a role, I suppose a massive role, but perhaps not the biggest”. South Africa

 “…One gets the impression that research is not a priority in the Ministry of Health…One year ago we thought there was a positive move, with the creation of the documentation centre…but the centre seems to be a stillbirth…nothing has really changed.” Cameroon

 “The expertise of the clinicians. They will have all the papers and the knowledge, it gets heavily tapped, especially in the HIV side, but there is a fair amount, in my impression, of opinion, you know, expert opinion, expert personal opinion that gets, makes its way up the chain”. South Africa

 “…In health there is something which I will call NGO dictatorship. One gets the impression that they are the ones who call the shots, they are the ones who take decisions…they would say, I want that such a policy be put in place and I will finance it… and this will happen even without they do paying due attention to not consider implementation implications…”. Cameroon

 “One gets the impression that nowadays, there are people at central level who have never been managers on the field, who do not know how a district health service works; yet they take decisions on how such operational levels should function…”. Cameroon

Buy-in from both managers and “coalface” implementers plays a role in policy

 “the basic principle would be to try and take note of the ground voices and if they strongly oppose a particular piece of policy then we know, it’s going to be impossible to implement anyway”. South Africa

 “…It is often difficult for the regional level to implement operational strategies decided at central level. For successful implementation, regions often adapt operational strategies developed at central level to conform to the local contextual issues including geography and availability of human resources”. Cameroon

 “so there would be a look at the ideal and then it becomes policy and then no resources are allocated to that policy and you have to implement and you have to report on something that you don’t have the skills or the resources or the tools or the mechanisms to do and it just frustrates everybody and it actually undermines the ability of government to do better”. South Africa

Research evidence is often unavailable, inaccessible, or not applicable or timeous

 “important thing, besides the length of it, the kind of layout, the kind of language, all of those things are very important. You’ve got to almost write it in plain English, not in the kind of jargon that full of statistical analysis and confidence limits and all of that.” South Africa

 “Our limitation however is that the research that happens from the point of design, towards the end point, very often is divorced from the services”. South Africa

 “Usually the way things happen in government is… things are supposed to happen like by yesterday” [but] “to generate the evidence usually takes a while”. South Africa

 “Sometimes we go to surf in the internet, there is many website, as you continue, you should have contradiction of information that you need, so you have the lot and you don’t know how to do, you have many negative and many positive and finally you don’t know which one is reliable.” Cameroon

 “…we are not able to download information from the Ministry of health online databases because there is limited internet access…”. Cameroon

 “…There is no library, though there is internet…We sometimes use personal documents collated by colleagues…some colleagues have personal documents…because obtaining documents online is very expensive…”. Cameroon

Good relationships and tailored methods of communicating evidence would potentially facilitate the adoption of evidence informed decision-making

 “There is no motivation, but I always say one needs a researcher to lean on. It is now more than 10 years that we have no formal links with the academic world…Even if one were to go to Yaoundé it is not evident that one would have access to big professors like you. I wonder how one can get access to researchers, through the Ministry of Health or through someone else who will hold one’s hand and introduce to the researchers?”. Cameroon

 “Researchers should not be remote; should be “imbedded” in services to understand context and formulate questions”. South Africa