Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2014) 108, 606—608

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GLOBAL AFFAIRS

Why Evidence Based Approaches are urgently needed in Africa Frode Forland 1,3,∗, Eva Rehfuess 2, Paul Klatser 3, Patrick Kyamanywa 4, Harriet Mayanja-Kizza 5 1

Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Germany 3 KIT Biomedical Research, Amsterdam, the Netherlands 4 Dean School of Medicine and Pharmacy, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda 5 Dean School of Medicine, Makerere University, College of Health Sciences, School of Medicine, Kampala, Uganda 2

HIV/AIDS, malaria, tuberculosis and other infectious diseases are still major causes of mortality and morbidity in Sub-Saharan Africa (SSA). However, chronic noncommunicable diseases (NCDs) like ischemic heart disease and diabetes mellitus are also on the rise [1] (Lozano et al., 2012). This double burden is equally apparent when examining the leading risks to health, which are dominated by ‘‘traditional’’ risk factors, such as childhood underweight, household air pollution from solid fuel use and poor water, sanitation and hygiene, as well as ‘‘modern’’ life-style associated risk factors, such as physical inactivity and smoking [2] (Lim et al., 2012). Addressing this substantial burden requires a combination of effective curative, rehabilitative



Corresponding author: Frode Forland, MD, DPH, Program Head, Global Health Preparedness and AMR, Department of International Public Health, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, 0403 Oslo, Norway, Address: Marcus Thranes gt 2. Tlf: +47 21 07 84 23| Mob: +47 986 34 044. E-Mail: [email protected] (F. Forland).

http://dx.doi.org/10.1016/j.zefq.2014.10.025 1865-9217/

and preventative approaches that can feasibly be implemented in the African context. Evidence Based Medicine (EBM) has shown to be a very strong tool to guide policy formulation and implementation of preventive and curative interventions and research in Europe, North America and Australia. Few paradigm shifts have probably had a greater impact on priorities of health care delivery in the last two decades [3] (Hooker 1997). EBM is an essential component of effective and efficient health care. In Africa, where only a few can afford health insurance and the majority has to pay out of pocket at the point of care, the provision of effective health care becomes even more important. In addition, with inadequate funding towards addressing the non-communicable disease burden, it is even more critical that policies and interventions to mitigate these are effective and backed by contextualized evidence beyond expert opinion. As we move into the post2015 era of the Sustainable Development Goals, sub-Saharan Africa will need to refer to the evidence developed to consolidate the gains in Millennium Development Goals 4, 5, 6 and 7 while embarking on the growing challenges of the NCDs. By so doing, even greater gains can be realized.

Why Evidence Based Approaches are urgently needed in Africa In Europe close to a hundred organizations and institutions have been established to mainly carry out synthesis of research evidence, to develop systematic reviews, policy briefs, health technology assessments and guidelines for practice, thus serving as a source for guiding health interventions. [4] (Latham 2013). On the African continent, the growth of such institutions has been slow, and yet there is an urgent need for locally generated evidence to guide optimal delivery of health care and preventive interventions. African academic and health institutions must take to centre-stage in the synthesis and translation of the evidence to facilitate uptake by policy makers and practitioners. There have been a number of initiatives and projects to bring elements of EBM to the forefront of health care in many countries of Africa. Few, however, have taken on a systemic approach to strengthen health systems and to support the establishment of sustainable structures and institutions in African countries. To have a lasting impact we believe it is necessary to create strong networks between hubs of high quality EBM groups in Sub-Saharan Africa. The Collaboration for Evidence Based Healthcare in Africa (CEBHA), www.cebha.org where two major EBM institutions in South-Africa are members (South African Cochrane Center and Center for Evidence Based Health Care at Stellenbosch University) was established in 2010 to build the foundation of a network between EBM hubs in SSA. The network comprises universities, schools of public health and ministries of health in nine countries: Uganda, Ethiopia, Rwanda, Burundi, Tanzania, Kenya, Malawi, Zimbabwe and South Africa. This initiative was founded by the Royal Tropical Institute (KIT) in Amsterdam, the Netherlands, and supported by WHO and the Liverpool School of Tropical Medicine in the United Kingdom. In 2014 the Ludwig-Maximilians-University (LMU) of Munich, Germany joined as a partner together with the German Network for Evidence-Based Medicine. In doing so, it has emphasized the importance of global collaborative efforts in moving from individual-level focused health care to more populationlevel focused public health. There is a need for context-specific evidence for the health problems of Africa. When examining the systematic reviews of the Cochrane Collaboration, we find that few are dealing with neglected tropical diseases or the main challenges of health care organization and delivery in Low Income Countries (LICs). But there are exceptions. The Cochrane Center in South Africa has for more than 15 years supported researchers in many African countries and they have produced systematic reviews that have changed practice for diseases like tuberculosis and HIV/AIDS that probably have saved thousands of lives. Contextualizing evidence may relate to clinical factors such as late presentation of symptoms, co-infections and malnutrition, public health factors such as lack of preventive measures, different epidemiology and spread of infections, health systems factors such as lack of skilled health workers, lack of equipment and resources, and societal factors such as political instability, war and consequences of climate change. Many interventions recommended in high income countries can simply not be implemented in LICs because they are unaffordable, compounded by the lack of health insurance or resources in the public health systems. There is a need to define scopes for evidence reviews relevant for

607 African health needs and direct research questions based on the disease burden of Africa. EBM as a methodology has shown its potency both by ways of reliably summarizing current knowledge and by helping to define research needs. It is now state of the art to perform a systematic review of all high quality research for a given topic before embarking on new research. Access to equitable and effective health care should be a right for people irrespective of where they live. The need for valid evidence determining the efficacy and efficiency of health care and public health interventions is essential. Where the unmet needs for health services are most prominent, it is even more essential to apply practices that have proven to be beneficial and not harmful or ineffective to ensure scarce resources are not wasted. [5] (Chinnock 2005) Courses and conferences about EBM have been held in most CEBHA partnering countries and through the network many doctors, nurses, policy makers and librarians have been trained in the basic methodology of framing questions, searching for evidence, evaluating the evidence and understanding the challenges of implementation in a context-specific way. Evaluations of the training have shown great satisfaction with the content and that the courses have been highly relevant for all target groups. The roles of librarians to assist the health personnel in finding the evidence has been an area of focus, as librarians can play a key role in identifying and disseminating evidence. The following quotes from the evaluations reflect some of the views of participants of EBM workshops:

‘The course has equipped me with skills and new dimensions of looking at scientific papers and on how to integrate evidence in my clinical practice’. Clinician, Internal Medicine, Ethiopia ‘The training is crucial and timely as the field of medicine is becoming evidence based and up to date.’ Professor, Gynecology and Obstetrics, Ethiopia ‘I found the workshop exceptionally appropriate for me. One of which was having the privilege of sharing experiences and knowledge with fellow information professionals and librarians from other African countries’. Health librarian, Zimbabwe Several universities in different African countries offer short or long courses in EBM, but most continue to be concentrated in South Africa [6] (Forland 2012). The need to reach out to more African countries has been a motivation for the establishment of CEBHA. CEBHA has up to now been funded by the Royal Tropical Institute and the Elsevier Foundation. It has been hard to convince big funders of research and development agencies that building strong evidence-based health systems is a critical long-term investment that will pay off with respect to retention of health personnel and by getting more value for money through implementation of more cost-effective treatments, preventive interventions and health policies. It is thus particularly encouraging that the German Ministry of Education and Research last year announced a call for tender that asked for many of the core principles that CEBHA has been emphasizing: evidence-based interventions, translation of evidence into policy and practice and long-term networking and capacity building to strengthen

608 African health systems. CEBHA+ (where the plus reflects the increasing emphasis on public health as well as the network being expanded to include German partners) was pre-selected in the first round of this call and has received seed funding to develop a full proposal. The LMU in Germany is now leading this process, jointly with the long-term African coordination at Makerere University, Uganda supported by many partners in Africa and the KIT in Amsterdam. It is also encouraging to note that an African-born initiative to establish an African network under the ‘Guidelines International Network’ (GIN) www.g-i-n.net was discussed during this year’s Annual Meeting and Conference of GIN in Melbourne. The proposal was positively received by the GIN Board and ways of supporting such a network were discussed. Knowing that there has been a threefold increase in the aid going to the health sector in the last 15 years [7] (Dye et al., 2013), we believe it is of paramount importance that these investments are informed by robust evidence about what works and what does not work, and about how to optimize the impact of the investments. The burden of disease pattern should be monitored closely and serve as a guide for prioritization and distribution of aid, research should be initiated to fill critical knowledge gaps and the implementation of policy strategies should be analyzed carefully to gain new knowledge. Only by long-term investments in health systems, education, capacity building and research across sectors can SSA countries be expected to cope with the daily health challenges of their populations. This is also the only way to be prepared to meet extraordinary situations such as the

F. Forland et al. Ebola outbreak we have recently witnessed in West Africa. We encourage funders, policy makers and non-governmental organizations to adopt this perspective when investing in health in Africa. By strengthening vulnerable health systems in Sub Saharan Africa, where the EBM paradigm serves as a means of integration between research and policy and practice, long-term value for money can be expected.

References [1] Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K. al. e: Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012;380:2095—128. [2] Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012;380:2224—60. [3] Hooker RC. The rise and rise of evidence-based medicine. Lancet 1997;349:1329—30. [4] Latham J, Murajda L, Forland F, Jansen A. Capacities: practices and perceptions of evidence-based public health in Europe. Eurosurveillance 07 March 2013;18(10). [5] Chinnock P, Siegfried N, Clarke M. Is evidence-based medicine relevant to the developing world? PLoS Med 2005;2:e107. [6] Forland F, Rohwer AC, Klatser P, Boer K, Mayanja-Kizza H. Strengthening evidence-based healthcare in Africa. Evid Based Med 2013;18:204—6, http://dx.doi.org/10.1136/ eb-2012-101143. [7] Dye, Mertens, Hirnschall, et al. WHO and the future of disease control programmes. Lancet 2013;381:413—8.

Why Evidence Based Approaches are urgently needed in Africa.

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