Overall, the findings of this study show that TWGs are a key decision-making structure within the MoHP3, whose main mandate is to provide advice on health systems technical matters, make recommendations, give policy guidance, and develop policy documents. These findings are consistent with results from other studies (6, 11, 12). Since TWGs are expected to provide independent and evidence-based guidance to MoH in decision and policy making, integration of EIDM into TWGs is therefore crucial to ensure effective decision and policy making (18).
The findings further show that the TWG structure for the health sector in Malawi is well defined and has become more streamlined over the years; the official number of TWGs reduced to six from 14 in 2015, as presented in the functional review of TWGs report(12). Consequently, the number of sub-TWGs under each TWG is more controlled, ranging from 2 to 11 sub-TWGs, in contrast to over 39 sub-committees and task forces that existed in 2015. This has the potential to reduce duplication of activities and enhance efficiency in operations of TWGs. Nevertheless, there is still a challenge in coordination, collaboration and sharing of information across different TWGs. It is thus necessary to strengthen coordination and communication mechanisms at different levels. Previous studies done in other countries (6, 8, 19, 20)have stressed the importance for TWG to have a secretariat to coordinate its activities. A viable TWG structure with a secretariat and legally established TORs is essential for effective functioning of TWGs (9). In Malawi, the secretariat role for each TWG rests with the responsible MOH departments/programmes for the specific technical area, which was also the case in 2015 (12). Furthermore, in line with previous recommendations to establish a Partners and Coordination division within the Department of Planning and Policy Development (DPPD) to function as the HSWG secretariat (12), the DPPD has the responsibility to centrally manage and coordinate the overall HSWG/TWG structure. It is recommended that the MoHP should ensure that the DPPD is equipped with adequate personnel and infrastructure to strengthen coordination and collaboration across the different TWGs.
The study further established that TWGs for the health sector in Malawi operate based on clearly defined Terms of Reference (ToR) which was an improvement to the situation in 2015. The TORS indicate the need for TWGS to conduct research, identify and propose new areas of focus, thereby highlighting the importance of research evidence in setting priorities for the health sector. However, the TORS do not adequately promote systemic use of research evidence throughout decision-making processes in all TWGs. Rather, the role of research evidence is mainly emphasised within the Health Information TWG. It is therefore recommended that the TORs for each TWG should be updated to incorporate roles that explicitly promote Evidence-Informed decision-making within the TWGs.
In relation to the composition of the TWGs, this study revealed that membership for the health sector TWGs in Malawi was diverse and multi-disciplinary. Members included representatives from various MoHP departments, development partners, technical expertise from NGOs, civil society, academia, and research institutions. Availability of diverse and appropriate technical expertise in TWG has a huge influence on their functionality as it impacts the credibility of the recommendations made (4, 20). In addition, having researchers in TWGs provides reliability of research used to inform local solutions (9) and is therefore vital in promoting EIDM. Previous studies observed a lack of relevant expertise from groups in most advisory groups in LMICs (7). For some TWGs in Malawi, the required technical expertise was lacking in discussions due to delegation of the membership to junior personnel. Furthermore, membership is mostly through invitation from MoH which may be influenced by the nature of the existing relationships between MoH and the stakeholders, rather than technical expertise. Hence, there is a need to develop TWG membership selection guidelines to be used when nominating participants for TWGs in order to ensure the necessary range of expertise are included in the MoHP TWGs, as was done for NITAGs in various countries (9). Additionally, reputation and integrity of members is also an important aspect to consider in the selection process (19). In addition to strengthening the technical expertise in the TWGs, it is essential to strengthen the credibility of the decision-making process by ensuring rigour and transparency in the process as recommended by (21).
The number of meetings held per year is one of the indicators of the functioning of advisory groups such as TWGs (22). This study revealed that the meetings across all MOH TWGs were irregular despite the recommended quarterly time frame. The frequency of the meetings depended on the availability of resources. These findings are consistent with a systematic review on the functionality of NITAGs in Africa (7) where the number of TWGs who met annually was low. Furthermore, it was observed (9) that TWGs with adequate funding were associated with regular meetings and their deliberations were most likely to inform decision making at high levels. Well planned and resourced meetings have a major effect in the functionality of TWGs as they drive the goals and objectives to discuss relevant health issues leading to recommendations. Specifically for low-income countries like Malawi, alternative ways of increasing the frequency of meetings should be explored. In this era of COVID 19 use of virtual platforms for meetings should be promoted to increase participation and ease financial constraints for TWGs without support. Physical TWG meetings would still be necessary, potentially held bi-annually, to provide opportunities for networking and relationship-building among stakeholders working in the sector which is essential for good coordination of activities. Additionally, meetings need to be pre- planned, and enough notice given to participants rather than scheduling or announcing them ad-hoc as previously recommended (19). This is particularly important in promoting EIDM as it may allow members to adequately prepare by reviewing, in advance, evidence that is useful to inform decisions. Regular meetings may be achieved by ensuring annual work plans have clear timelines for meetings and stakeholders identified to fund the meetings.
The use of research evidence in decision making was valued highly by decision makers within MOH. However, the extent to which research was used to inform decisions was perceived to vary, some TWGs were considered to use evidence fairly well and others very well. The barriers to use of evidence included lack of reliable mechanisms and capacity for generating, accessing, synthesizing, and using research. Other study findings show similar barriers (7, 20). In addition, uptake of recommendations based on evidence was affected by political interests and financial constraints. These findings resonate with Bell's (8) study on the effectiveness of TWGs in LMICs, where development of recommendations varied across groups and was hampered by lack of a systematic way to arrive at conclusions as noted in Uganda, Senegal, and Indonesia (9).
The study established variations in the capacity of TWGs to generate, synthesize and use research evidence, and this means that efforts to build technical capacity should further be strengthened. These results are consistent with findings of other studies(7–9, 13). Bell (9) further noted that time and publication languages were barriers to use of evidence by decision and policy makers including TWGs. In Malawi, initiatives to strengthen individual and institutional capacity in research synthesis and evidence use are being explored. However, tracking and monitoring of these initiatives is lacking. Perhaps targeted capacity building for motivated staff who can act as champions can be explored. To strengthen capacity within TWGs, other studies recommend visits to other NITAGs which can facilitate cross-learning, capacity building training and a repository to access relevant materials for TWGs (9).
Overall, there were perceived variations in relation to how TWGs functioned in Malawi and there was no common framework of assessment. Some scholars (20) expressed the need for a well-defined framework to assess the functionality of TWGs. Most published research on functionality has used data on meetings and self-assessment and fails to capture full TWGs effectiveness (9). The WHO-UNICEF Joint Reporting Form (JRF) has been extensively used as the analytical framework in most literature on National Immunisation Technical Advisory Groups (NITAGs) (10). The JRF is a standardised tool used to collect annual data for TWGs country performance. The form highlights six functionality indicators related to availability of TORs and a legislative basis, frequency of meetings, areas of expertise for members, distribution of documents prior to meetings and disclosure of conflict of interest (11). Despite the development of these tools to assess functionality of advisory groups, quality, especially from the JRF indicators in countries without financial support, was poor and NITAGs were not regularly monitored (11). In Malawi, to monitor and effectively strengthen functionality, MoH should consider adapting the WHO-UNICEF JRF for TWGs assessment. The tool can be used by the TWGs for self-assessment of their functionality annually to improve monitoring of their performance.
Inadequate funding emerged as a major challenge affecting functionality and sustainability of TWGs. Currently, funding is hugely dependent on donor aid. As observed by two global studies (7, 9) financial challenges noted in many African countries affect the functions and mandate of TWGs and their sustainability in the long run. This points to the need for the Malawi and other African governments to commit and support financial resources for the sustained functionality of TWGs.