The Royal Tropical Institute isn't a name that you'd associate with Amsterdam, a city just about as far from the tropics as you could get. But it's here that a lot of significant work in healthcare in developing countries is initialized, as part of a broader official aim "to produce workable solutions to the challenges of sustainable development and international poverty reduction." In the case of healthcare in Africa, the important work the Institute does in Africa is conducted via the Collaboration for Evidence Based Healthcare in Africa.
The project manager for the Collaboration, Frode Forland, says the relationship between the Royal Tropical Institute and the Collaboration for Evidence Based Healthcare in Africa first came about through the work of a staff member based in Africa, specifically, "an initiative from Kimberly Boer, working as an epidemiologist for the Royal Tropical Institute in Rwanda and Harriet Mayanja-Kizza, Professor and Dean of Medical School Makerere University in Uganda." Forland says the Collaboration relies upon a series of networks between scientific institutions and experts in health education and research. He notes since its inception the Institute has established a "long track record of development assistance and health projects in Africa."
Forland says the Institute's role is to "facilitate a process where the tools, templates, and technologies of EBM can be exposed to the health needs of Africa." He says the collaboration represents a broad spectrum of African health and research institutions, including Universities and Health colleges from across Africa including: the National University of Rwanda; Kilimanjaro Christian Medical Center in Tanzania; South African Cochrane Centre and Centre for Evidence Based Healthcare at Stellenbosch University; National Public Health Institute at the National University of Burundi, Makerere University in Uganda; and Zimbabwe University. Collaborating partners also include the World Health Organization, Liverpool School of Tropical Medicine, and of course, the Royal Tropical Institute in Amsterdam. The Collaboration is a relatively recent initiative, with the partners holding their first Annual Meeting in Uganda in November of 2011.
Forland says as they are still short of funding, they have started small by offering training and "capacity building" for health industry workers and health librarians. He says several short courses have been arranged in countries like Uganda, Rwanda, Zimbabwe, and Ethiopia and says last year a Symposium on evidence-based healthcare was held in Uganda and had 80 attendees. This year, he says, there will be "Training of the Trainers workshop for librarians" in Ethiopia, while the Second Symposium for EBHC in Africa will be held in Rwanda. He says South Africa's Stellenbosch University has made great steps in integrating evidence-based healthcare into their undergraduate curricula and notes that information about its courses is shared among members of the Collaboration.
Forland says the Institute aims to integrate evidence-based treatment into African healthcare services, just as it has been utilized by Europe, and the Western world, at large. "In Europe there are more than 100 institutions primarily working on EBHC. Among the partners of the Collaboration for Evidence Based Healthcare in Africa, we have only localized such institutions in South Africa." He goes on to assert that "the role of the Royal Tropical Institute is to facilitate a process where the tools, templates, and technologies of EBM can be exposed to the health needs of Africa."
Specifically, Forland says the collaborating partners have set a number of objectives for the Collaboration for Evidence Based Healthcare in Africa. These include building "a sustainable collaboration for EBHC between researchers, policy makers, and clinicians," and more tangibly, establishing centers for evidence-based healthcare in eight or more countries. He says they also seek to improve their capacity to roll out EBHC measures through proper training of researchers, health workers, policy makers, and librarians and further integrating evidence-based healthcare into healthcare curriculum in Africa. Forland says "this will secure the knowledge uptake and transfer to the hospitals and primary health services in the future." Notably, he adds, the Collaboration also seeks to establish an "African Electronic Library for Health to provide free access to evidence-based resources for all health personnel in Africa."
In terms of the more tangible output of the Collaboration, they will conduct systematic reviews and develop specific healthcare guidelines which are specifically suited to African countries, in order to create what Forland calls a "resource base of African contextualized evidence." He states they will also develop strategies for the delivery of healthcare system, to "facilitate the deliverance of relevant knowledge at the right level of the healthcare system," further noting they will carry out research on "dissemination and implementation strategies by using valid monitoring and evaluation indicators" in order to make necessary adjustments to services where required. Forland insists that creating the right partnerships is a vital part of the Collaboration's efforts to advocate for evidence-based healthcare to "give strength and sustainability" to its program.
Understandably there are a range of fundamental challenges when trying to implement evidence-based healthcare in developing countries, such as those in Africa. Forland says that members of the Collaboration identified issues including: a shortage of proper decent equipment, a lack of well-trained personnel in health facilities, underdeveloped health information systems, reduced capacity for converting health research into policy, stagnating implementation of health policy changes, problems with rolling out rural healthcare measures, and "poor coordination in dissemination of research findings." He says there are also broader issues caused by a minimal knowledge of evidence-based healthcare including the implementation of guidelines that are not supported by evidence, as well as underdeveloped medical research. Significantly, he says a core challenge is ensuring evidence-based research is contextualized for an African setting and therefore "requires other managerial strategies due to cultural issues, different resistance patterns, lack of technical diagnostic and treatment options, and scarcity of educated health personnel." He also states that the way in which these services are rolled out needs to be adequate, citing there have to be "appropriate means of disseminating it in a local setting."
Although there are a number of well-known diseases associated with African settings, there are a number of neglected tropical diseases in Africa which are less appealing to big pharmaceutical companies. In these cases, Forland finds "low and middle income countries have to do research and develop diagnostic tests or treatment options themselves." Such cases involve diseases like Schistosomiasis, Onchocerciasis, Brucellosis, Dengue, and cholera.
According to Forland, the future looks promising for the Collaboration for Evidence Based Healthcare in Africa: "within a few years there will be at least one EBHC satellite office or resource in each of the partnering countries. The IT and Tele-technology revolution will ease the accessibility of updated evidence from a user friendly Electronic African Health Library open to all health workers in Africa." Significantly, he notes there will be more focus on selecting what systematic reviews to conduct in African countries and evidence from outside the continent will become increasingly contextualized for African settings. He says students will be better equipped for working in healthcare as they "will learn how to practice EBHC in their undergraduate education and national health policies and guidelines will be based on updated and best available evidence."
Although the work of the Collaboration for Evidence Based Healthcare in Africa is still in its infancy to some degree, Forland is proud of the work they have done already to run courses, instill people in influential healthcare positions, and to support existing organizations which provide evidence-based healthcare to the African populace. He says with assistance from the Cochrane Collaboration in South Africa, evidence-based healthcare has already made a difference to research into treatment for HIV, tuberculosis, and malaria, and "should attract resources and bring more countries up to the level of South Africa." Broadly, he takes comfort in the positive impact that the Collaboration has had on healthcare in Africa so far and the fantastic way in which different cultures have been able to work together toward shared goals.