The utilization of systematic review evidence in formulating India’s National Health Programme guidelines between 2007 and 2021

Abstract Evidence-informed policymaking integrates the best available evidence on programme outcomes to guide decisions at all stages of the policy process and its importance becomes more pronounced in resource-constrained settings. In this paper, we have reviewed the use of systematic review evidence in framing National Health Programme (NHP) guidelines in India. We searched official websites of the different NHPs, linked to the main website of the Ministry of Health and Family Welfare (MoHFW), in December 2020 and January 2021. NHP guideline documents with systematic review evidence were identified and information on the use of this evidence was extracted. We classified the identified systematic review evidence according to its use in the guideline documents and analysed the data to provide information on the different factors and patterns linked to the use of systematic review evidence in these documents. Systematic reviews were mostly visible in guideline documents addressing maternal and newborn health, communicable diseases and immunization. These systematic reviews were cited in the guidelines to justify the need for action, to justify recommendations for action and opportunities for local adaptation, and to highlight implementation challenges and justify implementation strategies. Guideline documents addressing implementation cited systematic reviews about the problems and policy options more often than citing systematic reviews about implementation. Systematic reviews were linked directly to support statements in few guideline documents, and sometimes the reviews were not appropriately cited. Most of the systematic reviews providing information on the nature and scale of the policy problem included Indian data. It was seen that since 2014, India has been increasingly using systematic review evidence for public health policymaking, particularly for some of its high-priority NHPs. This complements the increasing investment in research synthesis centres and procedures to support evidence-informed decision making, demonstrating the continued evolution of India’s evidence policy system.


Introduction
Evidence-informed policymaking is an approach to policymaking that involves the use of systematic and transparent research evidence (Oxman et al., 2009a,b). Additionally, the use of views and opinions of stakeholders, policymakers, managers, experts and other groups providing information on contextual factors is an important component of this approach (Lomas, 2005). Evidence-informed policymaking provides clarity and gives information on the nature and extent of the problem, involves clear methods to find and assess research evidence available on policy options, and supports implementation (Oxman et al., 2009a,b).
This approach to policymaking often uses the evidence synthesized via 'systematic reviews' to answer policy relevant questions (Oxman et al., 2009b). As an evidence synthesis method, systematic reviews collate all the empirical evidence available to answer a pre-specified research question by using explicit, systematic and reproducible methods (Higgins et al., 2022). These reviews are summaries of the available research evidence that can be used to answer questions about 'what • Over the years, India has demonstrated a visible evolution in the evidence policy system that can be attributed to two key complementary components of the evidence system (1) development of systematic review generation centres, and (2) commitment to evidence-informed policy development. • The visibility of systematic reviews in Indian policy documents has been growing since 2014 with international support. Systematic reviews are most visible in policies addressing maternal and newborn health, communicable diseases and immunization. These systematic reviews are sometimes linked directly to support statements in policy documents and other times they appear in a list of additional readings towards the end of the document. • Systematic reviews are cited in Indian public health policy documents to: (1) justify the need for action; (2) identify key components, experiences, views, effects and costs of policy options to justify recommendations for action and highlight opportunities for local adaptation; and (3) highlight challenges and justify implementation strategies. • Indian data were mostly used in systematic reviews defining the policy problem rather than assessing different policy options emphasizing the need for methodologies that transfer global evidence about policy options to local settings. • This growing visibility of systematic reviews in policy documents reflects the earlier global enthusiasm for producing systematic reviews to address perinatal care and epidemiology, and the subsequent developments in systematic reviewing of health systems research and social science (e.g. professional education) more broadly.
works', additionally, systematic reviews can be used to provide an insight into the reasons for how and why a strategy works (e.g. a public health intervention) (Lavis et al., 2003). Another important aspect of evidence-informed policy is the translation of this systematically synthesized evidence into policy and practice. Over the years, many theoretical models for translating research evidence/knowledge to action have been introduced. Knowledge to action (KTA) models such as linear models (knowledge-push and demand-pull models), relational models and systems thinking models give information on how the research evidence can be translated to policy action and the different factors responsible for facilitating the same (Best and Holmes, 2010). Generally, the linear KTA models suggest a one-way approach of knowledge translation, where research evidence (generalizable across contexts), packaged as policy briefs, blogs, documentaries, is transferred from research producers to users and vice versa. In contrast, the relational model of KTA focuses on the importance of shared knowledge, building linkages or collaborations between researchers, decision makers and other stakeholders, for the effective translation of research evidence into policy and practice. This model also focuses on the importance of local-context evidence and its use in evidenceinformed policy. The systems thinking model builds on the linear and relational model of KTA and visualizes knowledge transfer from a complex system lens-focusing on building collaborations between organizational networks, leadership supporting organizational change, and effective communication between individuals and organizations (Best and Holmes, 2010). The systems thinking model of KTA also focuses on the different components of use of research evidence, such as creating access to specific research evidence and understanding or interpretation of the available evidence, useful for facilitating evidence-informed policy decisions (Langer et al., 2016). In India, the history of evidence for clinical decisions began in the 1990s when formal training on evidence-based medicine (EBM) was provided to the medical and nursing faculty of India, by the International Clinical Epidemiology Network (INCLEN) (Prasad, 2013). The importance of good processes for making policy decisions (rather than individual clinical decisions) was also recognized, specifically the value of considering relevant up-to-date knowledge and data, using analytical tools and widespread consultation for comparing policy options, followed by swift implementation (Agarwal and Somanathan, 2005). Yet, early adoption of evidence for clinical decisions in India had to overcome clinicians' lack of awareness, misinformation or misperceptions of the concept, the complexity of a multistep process, and its absence in the medical curriculum (Agarwal et al., 2008). There were similar barriers to developing standard treatment guidelines: limited understanding, time, enthusiasm and local expertise, and developing consensus between specialists and generalists to prepare guidelines; and when applying guidelines there were concerns about maintaining professional autonomy and treating patients as individuals and applying standards consistently across levels of health care (Sharma et al., 2015).
Evidence-informed decision-making was also recommended for policy because of its transparency, inclusiveness and independence, with attention paid to formal priority setting and resource allocation to avoid political or other competing interests (Bhaumik, 2014). Challenges such as the complexity of the healthcare sector, weaker primary health care, large and unregulated private sector, low spending on health and weak political accountability (Patel et al., 2015) are other likely impediments to the evolving health policymaking process in the country.
Nevertheless, evidence-informed policymaking has seen significant progress over the past few decades and, with systematic review methods now available to synthesize various types of studies, including the context of studies, the methodology is better suited to addressing challenging complex policy issues. Over the years, India has understood the importance of shared research knowledge and building linkages between researchers and decision makers, especially in health policy and systems research. As a result, in 2013 the Ministry of Health and Family Welfare (MoHFW) in India advocated the formation of a National Knowledge Platform to (1) enable knowledge sharing among researchers and policymakers, (2) enable capacity building in research, (3) facilitate research knowledge dissemination, and (4) support research initiatives in priority areas (Sriram et al., 2018). India has been working on achieving the above-mentioned objectives and during this journey has witnessed various milestones, such as establishing Cochrane South Asia, the Health Technology Assessment Board and other evidence synthesis centres, prioritizing evidence-informed policy making in the National Health Policy 2017 and creating task forces for adapting international evidence-based standard treatment guidelines to the Indian context (Mehndiratta et al., 2017). Additionally, the National Institution for Transforming India Aayog (previously the Planning Commission of India; also known as NITI Aayog) introduced evidence into its institutionalized strategic planning framework through researchers and policymakers collaborating to create policy-oriented research (Kattumuri, 2015). More information about the evidence informed policymaking (or EBM) milestones in India is given in Table 1.
With these structures and commitments in place, the question remains whether India has converted this progress and understanding of evidence synthesis into policy development? Evaluation and review of some of the clinical guidelines in the past suggest that India is in a transition phase of guideline development and the country requires more local capacity in evidence search and synthesis to increase the methodological quality and rigour of the clinical guidelines (Sonawane et al., 2015;Bhaumik et al., 2018).
Beyond clinical guidelines, the use of systematic review evidence has been prioritized for framing policies for one of the important components of public health in India, namely the National Health Programmes (NHPs). However, comprehensive information about this use is not available in one place. Although there is information available on the evaluation of some of the clinical guideline documents, there is a gap regarding information about the use of systematic reviews in other, non-clinical NHPs. In this paper, we have widened our scope beyond clinical guidelines to consider the use of systematic review evidence in the NHPs of India that are mentioned on the MoHFW website. Table 2 provides a list of the major NHPs in India that were considered in this paper [Ministry of Health and Family Welfare (MoHFW), not dated; National Health Portal of India, not dated]. Our analysis focuses on the patterns and trends associated with the use of evidence generated from systematic reviews in the Indian NHP policy or guideline documents, which will be useful in creating and revising the guideline documents in the future.

Methods
A study design of stand-alone document analysis was applied to answer the question of whether India's NHP guideline documents are explicitly informed by evidence syntheses. The methods followed recommendations from a qualitative systematic review of document analysis in health policy analysis studies in low-and middle-income countries (LMICs) (Kayesa and Shung-King, 2021) adopting clear inclusion criteria for documents, and clear procedures for identifying documents, coding them and extracting data; applying a clear analytical framework to analyse the role of systematic reviews cited in policy documents; and presenting the findings of each stage of the process from searching for documents to answering the research question.
A targeted search was conducted to identify the documents providing information about the use of systematic reviews in NHPs of India. Documents sought for analysis were the guideline documents produced by the NHPs in India (listed in Table 2) that cited systematic reviews. These were identified by searching official information sources or websites of the NHPs. Official websites of NHPs were searched for guidelines or policies that were based on systematic reviews i.e. the guideline documents that had cited systematic reviews with proper bibliographic information. The above-mentioned websites were accessed via the official website for the MoHFW, Government of India, as all the NHPs are linked to this ministry website. As the MoHFW is a central nodal ministry for health-related information or data in India, the NHPs mentioned on this website were considered in this document analysis. Searches were conducted in December 2020 and January 2021.
Documents available in the official government websites were screened at the time of searching, and information about any systematic review evidence used in framing of guidelines and policies, for that NHP, was extracted. We classified the systematic review evidence according to its role in the policymaking process. This was done by adapting the framework given by Lavis (2009) on the role and use of systematic reviews in the policymaking process. We used Lavis' framework and adapted it for classifying systematic reviews according to their role in the published policy documents (Figure 1). Specifically, we sought systematic reviews that informed three steps in developing policy. The first step is fulfilled by systematic reviews that provided information about the nature and scale of a policy problem and thereby justify its importance and the need for policy attention. These may be systematic reviews of observational or qualitative studies. The second step calls for systematic reviews that assess policy options in terms of effectiveness (from controlled trials), harm (from observational studies), cost-effectiveness (economic evaluations), and how or why interventions work, or not (often from mixed methods studies). The last step is implementation, which draws on systematic reviews of implementation barriers (from observational or qualitative studies) or effective solutions (from controlled trials).
More information is given in the Results section. This is a document analysis of NHP guideline documents, we did not perform a systematic review as our objective was not to synthesize data available from these documents, but to summarize the information available on use of systematic review evidence available from the NHP guideline documents. The National Programme for Family Planning was launched in India in 1952 and was integrated into the RMNCH + A in 2013. The objectives, strategies and activities of the family planning programme aim at achieving the family welfare goals and objectives [reducing crude birth rate (CBR), total fertility rate (TFR) and growth rate] stated in various policy documents such as the National Population Policy, National Health Policy and National Health Mission. The MoHFW launched RKSK in 2014 for improving sexual and reproductive health, nutrition, injuries and violence, non-communicable diseases, mental health and substance misuse among adolescents-male and female, rural and urban, married and unmarried, in and out-of-school adolescents with special focus on marginalized and underserved groups. The MoHFW launched the WIFS programme in 2012 to meet the challenge of high prevalence and incidence of anaemia amongst adolescent girls and boys by targeting school-going adolescent girls and boys in 6th to 12th class in government/government aided/municipal schools and out-of-school adolescent girls.

National AIDS Control Programme (NACP) a
Launched in 1992 and since then it has been the major programme for control and management of HIV/AIDS in India. According to the need and strategies, the programme has been revised as NACP II (1999)

Integrated Disease Surveillance Programme (IDSP)
The programme was launched in 2004 for quick detection and response to outbreaks. This programme was initiated by the support of the World Bank fund that continued till 2012.

National Tuberculosis Elimination Programme (NTEP) a
Launched as the National Tuberculosis Programme ( (continued)

National Programme for Prevention and Management of Trauma and Burns injuries
Initially the programme was launched with two separate components of trauma care and burn injuries. In 2017, both the components of the National Programme for Prevention and Management of Trauma and Burn Injuries were merged as 'Territory Care Programmes'. D) Universal Immunization and Pulse Polio Programme 1. Universal Immunization Programme a The Universal Immunization Programme (UIP) programme was launched in 1985, with an objective of reducing mortality and morbidity due to the six vaccinepreventable diseases. Since then, the programme has seen changes according to the need and objectives and was added under the National Rural Health Mission in 2005. The Government of India declared 2012 as the 'year of intensification of routine immunization', and a commitment towards measles elimination by 2020, under the UIP.

Pulse Polio Programme
The programme was started in 2005, as a specific programme for polio control and elimination in addition to the UIP. Due to continued efforts and proper implementation, India reported the last case of polio in 2011 and was removed from the list of 'endemic to polio' countries in 2012. India was certified as wild poliovirus free in 2014.

National Programme for Prevention and Control of Fluorosis (NPPCF) 2. National Tobacco Control Programme
The NPPCF programme was launched in 2008-2009 and since then has been expanding in a phased manner. NPPCF addresses the problem of fluorosis due to high fluoride intake and works via the strategies of surveillance, capacity building, diagnosis, health education and management. For the prevention and control of tobacco use. a Programmes that used systematic review evidence. Source: The Ministry of Health and Family Welfare and National Health Mission (https://main.mohfw.gov.in/; https://nhm.gov.in).

Use of evidence to inform policy decisions in NHPs of India
Over the years, the NHPs of India have used a range of systematic review evidence to inform the various steps in framing guidelines and policies. In the section below, we have classified the identified systematic review evidence cited in the guideline documents of the NHPs as: (1) systematic reviews justifying the importance and need for action; (2) systematic reviews justifying recommendations for action, and opportunities for local adaptation; and (3) systematic reviews informing implementation. Detailed information on the identified evidence is given in Table 3.

Systematic review evidence for justifying recommendations for action, and opportunities for local adaptation
Sixteen published guideline documents from four NHPs [RMNCH + A, Universal Immunization Programme (UIP), NTEP and National AIDS Control Programme (NACP)] used systematic review evidence for justifying recommendations for action and opportunities for local adaptation. These 16 published guideline documents cited systematic reviews that provided information on the different programme and policy options applicable for the specific NHPs (Ministry of Health and Family Welfare, 2014a,b,c,d,e,f,g;2016a,b;2017c;2018a,b,c;2020b;; not dated). More information on the guideline document and the systematic review evidence used is given in Table 3.  2007; 2016c). As these guideline documents were used as training manuals for the medical officers, this evidence may have been cited to justify the guidance and motivate uptake.

Systematic review evidence used to inform implementation
How the use of systematic review evidence varied across national health programmes of India The section above classifies systematic review evidence according to its role in the published NHP guideline documents. In this section, we have elaborated more on the use of systematic review evidence by the NHPs of India. We found only six NHPs providing information about the use of systematic reviews in the guidelines (see Table 3). Additionally, not all the sub-themes or programmes, within these six programmes, provided information on systematic review use (see Table 2).
Systematic review evidence was mostly visible in guidelines or policies addressing maternal and newborn health  anti-retroviral therapy centres based on four symptoms (also known as the 4S complex) i.e. current cough of any duration, fever of any duration, weight loss or night sweats. This guideline is strengthened by the evidence from a meta-analysis (Getahun et al., 2011) reporting that the sensitivity of the 4S complex was 85%. Citation was directly linked to the statement in the main text Data sources: International; Author location: International (continued) for India These guidelines were based on evidence from already existing or new systematic reviews conducted by the guideline development team. Cochrane methodology was used for conducting the systematic reviews and the Cochrane South Asia network and Cochrane Infectious Disease group provided technical and methodological expertise for the same.
The guideline group considered evidence from a systematic review (Denkinger et al., 2014)  This strategy was based on evidence from a systematic review and metaanalysis (Morrison et al., 2008) that had provided information on the yield of TB among contacts and concluded that contact investigation is an important tool for improving early case detection and reducing transmission of TB in high-burden areas or countries.
Data sources: India + international; Author location: International (continued)

Contributors: Clinicians and scientists from
India and USA The rationale for using a lopinair-based regimen for children <3 years of age was supported by the two systematic reviews (references for these systematic reviews were not given in the bibliography of the report, therefore not cited here). These systematic reviews reported that a lopinair-based regimen was effective, and it had a low failure rate.  (Farrar et al., 2011) that supported the two-step screening approach for pregnant women at 11 to 14 weeks' gestation who were at a lower risk of being diagnosed with GDM as compared to the one-step approach. The safety and effectiveness of oral hypoglycaemic drugs recommending use of metformin for GDM management after 20 weeks of gestation in the guideline was based on a systematic review (Gui et al., 2013).  (Sandall et al., 2016).

Data sources: International; Author location: International
(continued) Indian clinicians This training manual has used evidence from systematic reviews to provide information about the efficacy and safety of TB prophylactic drugs, (Wilkinson et al., 1998) and the interactions between classical sexually transmitted diseases and HIV (Røttingen et al., 2001) Citations were directly linked to statements in the main text Contributors: Indian and international clinicians and scientists; WHO The document cited three systematic reviews: two defined the problem (Roest et al., 2010;DiMatteo et al., 2000) and the third assessed policy options (Lachat et al., 2013). There were no clear statements on the use of systematic review evidence for the development of the training manual.
Data sources: India + international; Author location: International 3. Implementation (RMNCH + A), communicable diseases and immunization. Most systematic reviews cited in the guideline documents provided information on assessing policy options and were used for justifying recommendations for actions and opportunities for local adaptation. Guideline or policy documents addressing implementation cited systematic reviews of epidemiology about the problems and policy options more often than systematic reviews about implementation. Only 9 of the 22 guideline documents (41%) consistently linked systematic reviews to the relevant statements in the document (Table 3). Other times they appear in a list of additional readings towards the end of the document.
Indigenization and local adaptation of the systematic review evidence is a vital component in policymaking. We found that for clinical programmes and policies, global systematic review evidence was used and cited in the Indian guidelines and many of these included Indian data. However, for some of the non-clinical guidelines, where the context may be particularly influential in how interventions work, the lack of Indian data is a concern. The INDEX-TB guidelines (Ministry of Health and Family Welfare, 2016b) considered the importance of using local evidence for guideline development. Indeed, the guideline development team acknowledged the absence of context-specific evidence and therefore downgraded the global evidence if it did not include Indian data. Generally, Indian data were mostly used in systematic reviews defining the extent of the policy problem rather than for assessing the different policy options.
Additionally, it was observed that none of the NHP guideline documents drew on synthesis of qualitative research that could justify recommendations for action and identify opportunities for local adaptation or inform implementation. Important global events and international funding paved the way for the creation of some of the NHPs and their use of systematic review evidence. The NACP was exceptionally early in citing systematic reviews in guideline documents. NACP I & II were initiated after World Bank funding in 1992 and 1999, long before systematic reviews were commonly used for policy (Ministry of Health and Family Welfare, 2010). Another early example was the 'Revised National Tuberculosis Control Programme' (National Health Portal of India, not dated), triggered by the declaration of tuberculosis (TB) as a global emergency, which included a training manual prepared in partnership with WHO and Centres for Disease Control in 2007 (Ministry of Health andFamily Welfare, 2007) that cited systematic review evidence by Wilkinson et al. (1998) and Røttingen et al. (2001) about the efficacy and safety of TB prophylactic drugs and the interactions between classical sexually transmitted diseases and HIV.
In contrast, most of the guideline documents citing systematic reviews were published after 2014, with major clusters in 2016 and 2017 (see Figure 2). For instance, the Reproductive and Child Health (RCH) I programme was launched in 1996 and revised as RCH II, at the time when the Bill and Melinda Gates Foundation funding for maternal and child health was announced in 2005 (PATH, 2005). However, guideline documents in this programme citing systematic reviews appeared as a cluster in 2014, with a higher frequency in 2017-2018. Two other programmes, NACP andNTEP [previously Revised National Tuberculosis Control Programme (RNTCP)], similarly demonstrated more recent use of systematic review evidence in most of their guideline documents when in 2017 they released their national strategic plans, respectively for AIDS control and TB elimination by 2025. More information about the important milestones and factors related to time that might have influenced the use of systematic reviews by the guideline documents is presented in Figure 2.
The growing visibility of systematic reviews in Indian guideline documents since 2014 coincided with the growth of evidence-informed medicine and evidence synthesis centres in the country (Table 1) and reflects the global trends for producing systematic reviews of health research, first addressing clinical practice in the area of perinatal care and epidemiology (cited in Indian policy documents from 2014), and subsequently health systems research such as continuity of care and screening programmes (cited in Indian policy documents from 2017).

Summary of findings
This paper focuses on the use of systematic review evidence in formulating public health policies for NHPs in India and the overall evolution of the evidence policy system in India. Our findings show that over the years, India has consistently invested in developing new centres for producing systematic reviews and capacity building in evidence synthesis. Additionally, since 2014, the visibility of evidence has increased in the Indian guideline documents, specifically for six NHPs i.e. NTEP, NACP, NVBDCP, NPCDCS, UIP and RMNCH + A. Overall, citing systematic reviews in guideline or policy documents appears to be a recent development, possibly influenced by international sources of funding. However, proper referencing of the systematic reviews in the guideline documents remains an area of concern because only 9 documents out of 22 guideline documents, identified from the above six NHPs, provided systematic review citations linked to statements in the text. Generally, the systematic review evidence cited in the guideline documents was international, and many of these systematic reviews included Indian data. Indian data were used by more systematic reviews providing information about the problem than those assessing policy options. The lack of Indian data in some systematic reviews providing information on non-clinical, context specific research questions is a concern.
Comparison with the wider literature Our findings show India's evolving system for evidenceinformed policy. This evolution can be attributed to the country's long-term investment in two key complementary components of the evidence system: (1) systematic review generation centres; and (2) commitment to evidence-informed policy development. Theoretical literature offers different models for how these key components work together to support KTA (Best and Holmes, 2010). The knowledge-push model of knowledge translation describes knowledge generated by researchers being packaged as systematic reviews, policy briefs, documentaries etc. for different stakeholders. India's growing commitment to this model is visible in the increasing number of centres committed to production and dissemination of systematic reviews (Table 1). The push model was further strengthened by formation of the Cochrane India Network in 2021, which includes in its objectives the synthesis of evidence for India and South Asia and dissemination of this evidence in local languages. However, there are still challenges encountered when using the global stock of systematic reviews because they contain limited data from India, so methods are needed to translate this global evidence for use in India.
The demand-pull model of knowledge translation focuses on research users demanding 'evidence' for specific policy questions from the researchers, so that the policy decision is evidence informed. Supporting this principle of the demandpull model of KTA is the growing commitment in India to developing evidence-informed guidance, expressed by guideline groups framing their questions and drawing on existing systematic reviews or commissioning new systematic reviews [e.g. INDEX-TB Guidelines (Ministry of Health and Family Welfare, 2016b)] or tailoring guidance from elsewhere for India (Kattumuri, 2015). The formation of the Health Technology Assessment in India (HTAIn) board strengthened the demand for evidence by the research users. Selected research institutions and researchers in the country produce evidence for the HTAIn board for specific policy questions framed by the HTAIn board (on demand of the decision makers) ( Table 1).
The relational model of KTA focuses on linkage exchange, collaboration and shared learning among different stakeholders. This model is apparent where policy makers, clinicians and researchers work together to develop policy documents (guideline documents mentioned in Table 3) (Table 3). Systematic reviews in progress were readily accessible when authors (Ministry of Health and Family Welfare, 2014b) or Cochrane editors (Ministry of Health and Family Welfare, 2016b) were members of the guideline group. The relational model is a good choice for knowledge translation when local or contextual knowledge is considered for adapting evidence-informed decisions. This was visible in the INDEX-TB guidelines (Ministry of Health and Family Welfare, 2016b). Evidence from global reviews were studied and downgraded by the guideline development team before framing policy documents for India.
Systems thinking models for KTA originally focused on how to solve policy problems with all the key stakeholders participating as active collaborators and their organizations investing time and resources in supporting organizational change (Best and Holmes, 2010). Systems thinking has also been applied to building an evidence and policy system itself, with evidence supporting three important components for strengthening use of evidence (Langer et al., 2016). The first essential component for use of research evidence is access to that evidence. India made an important step forward in 2017 when a new licensing agreement gave its students, practitioners, researchers and patients access to the systematic reviews for research addressing healthcare interventions through the Cochrane Library (Cochrane, 2017). The second essential component is decision-makers with skills to access and make sense of evidence (such as critical appraisal training programmes). India began such training programmes for clinicians with INCLEN in 1993 (Table 1). More recently, training in evidence use has reached hundreds of civil servants in India (Harvard Kennedy School, 2018). The third essential component is fostering changes to decision-making structures and processes. This is seen in India with the growth of systematic review centres from 2005 onwards and, in 2013, the MoHFW establishing a guideline task force to standardize evidence-based clinical management of diseases (Table 1). Development of the National Health Policy in 2017 (by the government of India) that prioritizes evidence use adds to this component. Sriram et al. (2018) described the enabling contextual factors and supporting interests, and the challenges in the form of complex evidence-to-policy processes and institutional arrangements that would allow both legitimacy and independence.
Global literature also provides information on the current state and evolution of evidence policy systems in other LMICs such as Uganda and Cameroon, where the climate for evidence-informed health policy system has improved over the years. As in India, this change can also be attributed to involvement of external agencies or donors, and over the years the policy documents of these two countries have also increased the usage of scientific evidence (Ongolo-Zogo et al., 2015). A similar study to evaluate the use of evidence in MNCH policy documents was conducted in Nigeria, which reported that the policy documents were prepared in consultation with various stakeholders and external partners. Also, the visibility of evidence in the documents increased post-2015 (Uneke et al., 2017). Studies from other LMICs such as Cambodia, Iran and Pakistan (with contexts similar to India), while explaining the environment, barriers and mechanism of evidence-informed health policymaking in these countries, recommend the increased evidence generation and building capacities of different stakeholders including policymakers to understand the use of evidence in policy (Haq et al., 2017;Liverani et al., 2018;Majdzadeh et al., 2022).
Greater visibility of Indian data in systematic reviews characterizing policy problems rather than considering policy options may indicate a lack of high-quality primary research assessing the effects of policy options in India (Goenka et al., 2019), or poor visibility in academic journals of research from India (SinGH, 2020) and other LMICs (Plancikova et al., 2021).
Additionally, our specific findings on use of systematic review evidence by the NHP guidelines concur with other global literature providing information on the use of systematic reviews in the guideline documents. As it was seen in our analysis that only 9 guideline documents (41%) consistently linked systematic reviews to the relevant statements in the document, similar results have been reported by related global literature. Limited or unsystematic focus on systematic reviews for guideline development is not unusual. A global survey found that few guidelines published in 2017 and 2018 based their recommendations on systematic reviews (32%) or systematic overviews (2%); notable exceptions were those prepared by the WHO and two high-income guideline producers (Lunny et al., 2021). Similar comparisons can be drawn on the use of qualitative synthesis by the guideline documents. While our findings reported that none of the Indian NHP guidelines included qualitative evidence, global literature indicates the use of qualitative synthesis by only 22% of guidelines (Lunny et al., 2021). This could be due to the low recognition and value attached to qualitative research in health systems research (Daniels et al., 2016) and underrepresentation of qualitative research in medical journals (Shuval et al., 2011). Lack of qualitative research in the guideline documents may also indicate a lack of awareness of the availability and value of qualitative synthesis, a methodology that has developed more recently than systematic reviews of the effects of policy options.

Strengths and limitations
To the best of our knowledge, this is a novel document analysis that comprehensively searched all official websites for the guidelines, and documents, to identify potential records to map the use of systematic review evidence for formulating NHPs under the MoHFW, Government of India. One of the prominent limitations of the paper is that the findings are based on available and documented information only. We did not involve any stakeholders or their feedback while searching and analysing the use of systematic reviews in formulating public health policies for NHPs in India. This might have limited our perceptions of the usefulness of systematic reviews for policy decisions and key contextual influences on evidence use for policymaking. Secondly, the search was restricted to the English language, this might have led to noninclusion of some potential records as India is a linguistically diverse country with each State of the country publishing their reports in regional languages/official language of the states. The authors have not attempted to search state-level or state-specific departments and ministry websites to identify recommendations, guidelines and any other potential records. Nevertheless, the state-specific guidelines are framed based on the national guidelines, therefore, we anticipate that we might not have missed important documents. Neither did we search specifically for citations of WHO guidance in Indian policy documents, which could inform policies indirectly with systematic review evidence.

Recommendations
This document analysis shows that India has used systematic review evidence for some of its high-priority programmes and is increasingly using evidence synthesis for developing guidelines. Through this paper we recommend increased visibility of evidence in all NHPs as is seen in NTEP, NACP, NVBDCP, NCPDCS, UIP and RMNCH + A. Furthermore, there were a few NHPs that mentioned the use of systematic reviews without proper citation. There is a possibility that these NHPs have used systematic reviews but have not documented it. Better citation practice would increase the visibility of science and model the use of evidence in policy development.
We found that Indian data were often included in systematic reviews cited in the guideline documents; more often providing evidence about the extent of policy problems than systematic reviews assessing policy options. This finding emphasizes the need for methodologies that transfer global evidence about policy options to local settings. This is required if international guideline development organizations (for example, the WHO), are to highlight or flag the local region-specific (specifically LMICs) considerations such as benefits, cost, context-specific considerations, while developing international guidelines for global public health related problems. Collaboration between international guidelines development organizations and regional or national institutions (e.g. with remits for India) could enhance transferability of evidence and provide contextual insights for transferring or adapting international guidelines to the Indian context.
Additionally, given the lack of qualitative systematic reviews informing the policy documents analysed, we recommend that policy development groups broaden their interest in systematic reviews to consider qualitative research that includes global evidence relevant to issues that are priorities for India. For instance, there are many systematic reviews of qualitative research which, together, offer in-depth understanding of contextual factors that influence women's choice and use of contraception (D'Souza et al., 2022). Similarly, a synthesis of qualitative evidence of recipient and provider views has shed light on implementation challenges encountered with rapid molecular tests for TB and TB drug resistance (Engel et al., 2022).

Conclusion
India is increasingly contributing to, and explicitly making use of, global efforts to systematically review health research to make policy decisions in health, mainly in the areas of perinatal health and communicable diseases. Over the years, India has successfully used systematic review evidence for some of its high-priority NHPs and has documented the same in national guidelines. Some documents supporting implementation of policy decisions also cite systematic reviews, although more to highlight the need for action and justify policy decisions than to guide implementation. The visibility of systematic review evidence and understanding about the use of evidence in NHPs will shape the future of guideline development and public health policy making in India.

Data availability
All data relevant to the study are included in the article. The dataset will be available on request from the corresponding author.

Funding
This research was funded by a research grant (number 1478) awarded the Scheme for Promotion of Academic and Research Collaboration (SPARC), Ministry of Human Resource Development, Government of India.