Introduction
In his introduction to Dambisa Moyo's recent book Dead Aid: Why Aid Is Not Working and How There Is Another Way for Africa Niall Ferguson says that it seems problematic that so much of the public debate about Africa's problems should be conducted by non-Africans.1 We are very conscious of the incongruence of us - as white, relatively well-heeled citizens of one of the world's most secure countries discussing matters of which we can only ever be observers. Many of our colleagues from our Joanna Briggs Institute centres and groups in developing countries in Africa, Asia, Central Europe and South America are far better qualified to address this topic than us - so we plead, first of all, for forbearance as we, somewhat arrogantly, offer some thoughts on the realities of the evidence-based healthcare revolution in developing countries.
The realties of evidence-based healthcare in developing countries
The global burden of disease and illness is primarily situated in the developing world. Most developing countries struggle to establish and maintain functioning public health systems to promote health and get healthcare services and medicines to the sick. There are on average only 76 doctors per 100 000 in developing countries (compared with 253 per 100 000 in developed countries). The number of nurses in the developing countries is slightly higher at 85 per 100 000 (compared with 900+ per 100 000 in the USA). Because storage and distribution systems are often non-existent or poorly managed, significant losses of medicines occurs with the World Bank estimating that for every $100 spent by African governments on drugs, only $12 worth of medicines reaches patients. Developing countries also suffer from inadequate infrastructure - for example, communications systems, roads, transport, electricity, clean water supply - to support effective healthcare systems and health facilities are often located in urban areas, far away from rural populations most in need, or are not accessible to large numbers of the population via public transport.
Other fundamental economic, social and political issues in many developing nations impede access to healthcare services and medicines and healthcare services often take a back seat to defence spending. In some countries available health funds are left unspent because of bureaucratic mix-ups and mismanagement. Given these problems, it is clearly imperative that investments are made into those health interventions and activities that are the most feasible, appropriate, meaningful and effective in this unique and inimitable context.
Contrast this to the advanced economies - where the barriers to effective healthcare are much less evident and where policy makers, health services and health professionals have access to a dramatically increasing amount of evidence-based information and tools to support decision-making (although that does not mean that they are actually accessed and acted upon!!). Health systems and health professionals in the developing countries, because of the nature of the health workforce and the limitation of available interventions, have far greater information needs than those in the developed world, but have barely no access to appropriate evidence-based decision support or tools to apply evidence. This is in part a result of the paucity of evidence review work related to healthcare outside the high-tech environments in the advanced economies; and partly because of very poor connectivity to the Internet, where most of these resources are accessed.
The World Development Report, in analysing the risks and opportunities that the global information revolution presents for developing countries, concludes that access to financial, technical and healthcare knowledge is crucial to improving the health and living standards of the poor.2 It emphasises that when governments adopt policies to make the most of knowledge, they are better positioned to improve the lives of their citizens. It recommends that developing countries adopt policies to reduce the knowledge gaps separating them from rich countries. Similarly, the World Health Report states that the rapid sharing of information in order for countries to benefit from the most recent and most relevant experience elsewhere and adapting it to local circumstances is essential.3
In 2005 the World Health Assembly adopted Resolution WHA58.28 aimed at establishing an e-Health strategy for the World Health Organisation. In recognising the potential impact that advances in information and communication technologies could have on healthcare delivery for both low- and high-income countries, the resolution called for a long-term strategic plan for the development, implementation and evaluation of e-Health Services.4
There are already available very laudable programs that attempt to deliver information to the developing world. As most of you would know, the HINARI Programme (one of several programmes that endeavours to address the issue of access), set up by World Health Organisation together with major publishers, enables 108 developing countries to gain access to over 6400 biomedical and health journals. You will also be aware of HIFA 2015 (Health Information for All 2015), a campaign and knowledge network with more than 2700 members in 150 countries worldwide. These developments are a very good start to increasing access to reliable information but there are still debates to be had around the appropriateness of providing largely western-oriented evidence mainly via the Internet to inform healthcare delivery in developing countries.
Getting the appropriate information into the hands of those who determine health policy and who deliver healthcare is fundamental to improvements in healthcare delivery and health outcomes. Chinnock et al. assert that:
Wherever health care is provided and used, it is essential to know which interventions work, which do not work, and which are likely to be harmful. This is especially important in situations where health problems are severe and the scarcity of resources makes it vital that they are not wasted.5
Of course, in addition to knowing what does and does not work, and what is harmful, it is important to find out in ways that are ethically acceptable because the principles of respect for persons, beneficence and justice apply no less in developing countries than they do in the West.
HINARI and HIFA aside, much of the aid to lower-income countries focuses on development aid. Again, the recent increase in aid to the developing world is to be lauded - but Dambisa Moyo, a Zambian economist and author, has recently claimed that development aid '[horizontal ellipsis] does more harm than good in Africa' (i.e. aid given by governments and other agencies to support the economic, social and political development of developing countries as distinguished from humanitarian aid that aims at alleviating poverty in the long term, rather than alleviating suffering in the short term). Moyo's thesis focuses, of course, on the problems associated with financial development aid and the solutions she suggests are largely associated with Governments finding money for development through financial markets, both international and domestic. But it has some relevance here; as Paul Collier says in his review of Moyo's book:
I think that African societies need international help to overcome these problems; it is just that the help they need is not predominantly money.
So too, is the case with healthcare. Garner et al., for example, describe how new ideas and research findings are frequently seen by donors and policy-makers as 'magic bullets' that can be delivered through targeted programs to solve specific health problems (e.g. HIV/AIDS, Tuberculosis (TB), malaria).6 This is often referred to as a 'vertical' approach and critics claim that it neglects broader healthcare issues. A 'horizontal' approach focuses on local infrastructure and recognises the interdependence of national health systems. For example, working with health workers and health systems to establish point-of-care access to evidence-based decision support for delivering the care needed for a myriad of health issues that afflict poor populations (such as diarrhoea, respiratory tract infections, etc.) rather than a program that focuses on, for example, increasing immunisation rates or reducing the prevalence of malaria as discrete interventions/outcomes. Horizontal programs have objectives that explicitly address the inputs needed, the benefits resulting from these inputs and the need for local, collective action in achieving these benefits. Garner et al. suggest that there are already effective horizontal programs for implementing good practice in place in some developing countries and that:
In some, guidelines and standardised treatment manuals are better developed than in the West. Other guidelines are likely to become more evidence based over time.6
Over time is the telling point here - is it okay to hope that things will develop over time? Is our current focus on an evolutionary approach to evidence-based healthcare in the developing world the right one - or is there a need for a call to action - for a revolution? I would like to suggest the latter!!
A call to action
Given the enormous investment of aid to provide expertise, resources and leadership (such as overseas health professionals, training for health workers, food, sanitation, etc.) it is surprising that no innovative ways of drawing together an appropriate evidence base or, more importantly, of delivering appropriate (in both content and presentation) evidence-based guidance and distributing it are reported in the countries we work with.
It is our view - shared by many of our colleagues in the developing world, in the Joanna Briggs Institute and in the Joanna Briggs Foundation that there is a need to act decisively and quickly to bring about a dramatic change in ideas and practice (in other words, to initiate a revolution) that results in:
* The creation of an appropriate evidence base for the developing world
* The identification and use of appropriate technology for evidence transfer in the developing world
Creating an appropriate evidence base for the developing world
Chinnock et al. cogently argue that we are a long way away from seeing a comprehensive evidence base for the most pressing problems in healthcare in the developing world.5 They suggest that this is hampered by the focus of most systematic reviews on:
* Priority health conditions of the developed world
* Their impact in North America, Australasia and Western Europe
* High-tech and high-cost interventions
* Studies conducted in the developed world
They also suggest that there is relatively fewer, high-quality studies conducted in developing countries but, even when research has been conducted in these countries:
[horizontal ellipsis] it might not be published - or if it is published, it might not be in a journal that is indexed in the widely used bibliographic databases such as MEDLINE and EMBASE. Thus, despite the best efforts of many reviewers, relevant studies may easily be missed.5
Even if this were not the case - most systematic reviews and guidelines are not written and designed for the healthcare workforce typical to low-income countries because the bulk of care is delivered by auxiliary personnel.
Any endeavour to build an appropriate evidence base for the developing world requires significant education and support of researchers in these settings around the conduct of reviews of effect, but also of feasibility, appropriateness and meaningful specific to the needs of their unique context. The majority of current reviews deal with effectiveness. While useful, a broader view of what constitutes evidence for clinical decision-making in developing countries is essential.
Our first call for action (or revolutionary rallying cry) relates to producing systematic reviews and appropriate, usable evidence-based information for the developing world. The Institute is already working to establish evidence review centres and groups in developing countries (we currently have work programs in Burkino Faso, Botswana, Cameroon, Ethiopia, Fiji, Ghana, Kenya, Malawi, Myanmar, Nigeria, the Philippines, Rwanda, South Africa, Swaziland, Thailand, Tanzania and Uganda) and there is an overwhelming demand from our colleagues in these countries for action-oriented programs related to identifying the core evidence needs of first-line health professionals.
Identifying and using appropriate technology for evidence transfer
It is now well recognised that the dissemination of information derived from evidence reviews to key stakeholders at the point-of-decision-making/point-of-care is an essential prerequisite to changing practice. That is, getting the right information, to the right people, at the right time and in the right place. However, little has been done to ensure that this information is disseminated to health professionals and consumers in developing countries in a realistic and appropriate manner. We need a revolution in our thinking and practice related to the effective delivery of up-to-date information (i.e. updated at least annually) in localities where Internet connectivity is unavailable or unreliable and where the logistics of distributing written information is characteristically difficult to establish and maintain.
When one of us (Pearson) was practising in Papua New Guinea, the mainstay for survival as the most qualified, experienced health professional in an isolated community of with no access to other help other than via a two-way radio was the book by Maurice King.7 This fascinating book (Medical care in developing countries: a primer on the medicine of poverty and a symposium from Makerere, based on a conference assisted by WHO/UNICEF) is now well worn!! One fantastic feature (and there were many) was its focus on appropriate technology. In the 1960s and 1970s this was more about making drip stands, stretchers, delivery beds, etc. out of locally available material; these days, it has to relate to the communication of information. For the first-line health workers in the far-flung corners of the poorest countries of the world, the World Wide Web is simply not a communication option.
So, our second call for action (or revolutionary rallying cry) relates to, through working with the knowledge and creativity of people from developing countries, creating and delivering a comprehensive collection of evidence-based resources at the point-of-care.
The Institute has already developed a yet to be funded proposal to develop specific, relevant evidence-based resources and non-electronic modes of delivering evidence-based information in Africa in regions that include some of the poorest countries in the world where healthcare is delivered by auxiliary health personnel with limited resources and virtually no access to the best information on promoting health and treating the sick.
In collaboration with our African centres and groups, we are seeking to hold a major 10-day strategic planning program in Africa to bring together political leaders, policy-makers and health professionals from 12 African countries where Institute programs are progressing well (South Africa, Botswana, Ethiopian, Cameroon, Ghana, Kenya, Malawi, Nigeria, Rwanda, Tanzania, Uganda and Zimbabwe). The purpose is to initiate the development of a relevant evidence base to meet the needs of all levels of health workers for evidence-based decision support in Africa; to devise a sustainable strategy to ensure the resource is kept up-to-date; and that is freely available and accessible to all health professionals in the remotest of health outposts of each region.
Conclusion
It is time, we contend, for a revolution to develop an evidence base that addresses the requirements of the developing world. But the creation of an evidence base alone will not be sufficient to address these needs; getting this information into the hands of those who deliver healthcare is fundamental to improvements in healthcare delivery and health outcomes. Ensuring that healthcare professionals and workers have access to the best available evidence appropriate to the developing world to refer to in supporting their everyday decisions is, we contend, a critical objective for the evidence-based healthcare revolution!!
References