"We develop medicines and other therapies which are based on very good research, but then we offer those therapies often in ways that are untested and have never been evaluated. So there is a natural progression from making sure that our treatments are evidence-based, to the next phase of ensuring that the way we offer those treatments to people is also evidence-based” said Professor Jimmy Volmink, Director of South African Cochrane Centre and Dean, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
Incidentally 22nd Cochrane Colloquium on “evidence-informed public health: challenges and opportunities” theme is being held in Hyderabad, India (21-26 September 2014) and will be followed by the 3rd Global Symposium on Health Systems Research on "science and practice of people-centred health systems" theme in Cape Town, South Africa (30 September – 3 October 2014). Whereas evidence-based medicine and public health remains a strong focus in Hyderabad, people-centred strong health systems will be the focus of the Cape Town meeting which begins next week.
Speaking to Citizen News Service (CNS) on how the medical fraternity responded to evidence-based approach, Prof Volmink said: “We have, over many years, challenged the healthcare community to base their decisions on best available evidence. Initially there was a lot of resistance from clinicians to adopting this approach. Default situation was that clinicians would very much be driven by strong opinions of powerful individuals. They would cherry pick whatever evidence they want to use and if it fits in what they want to promote they are happy to use it, but they are less happy in being systematic and comprehensive in their approach when looking at the evidence. I think that is the contribution of The Cochrane Collaboration over the years.”
But is evidence-based medical practice enough?
"Unless we offer these trusted treatments in ways that have proven to be most effective in local contexts, the impact will remain subdued. Also there is a risk of doing more harm than good if we roll out evidence-based medicines in ways that are irrelevant or ineffective or irrational - which makes it very important to know what will work and what will not!"
“I think we have been reasonably successful in the clinical community amongst health practitioners, doctors, and other clinicians. But there is more need for increased penetration of evidence-informed approaches in communities beyond medical and healthcare fraternity. We need to use the best available evidence to improve and strengthen health systems, in other words, the way healthcare is organized” said Prof Volmink.
But what should good health system look like?
Universal health coverage (UHC) has been gaining pitch in public health discourses over recent years. “We believe in the principle of UHC. People who need healthcare should have access to healthcare. But we do not know how best to do UHC” cautioned Prof Volmink. “How should UHC be done in different circumstances is a research question that should be answered. We need better research for implementation of healthcare and that, I think, is what the health systems conference in Cape Town is going to be about. Some of the principles of evidence-based approaches we have developed in the clinical environment may apply to health systems also. May be, the way we look at evidence in context of health systems is a little bit broader (for example, we may not use randomized controlled trials (RCTs) every time). But that does not mean that we cannot use evidence. We need to determine what is the best evidence that can be used in a systematic and conscientious way in context of health systems. That really will take us forward.”
'Some are more equal than others' propels inequity
The principle of equity is an absolute essential when it comes to health justice. “One of the critical problems of our times is the inequity between the ‘haves’ and the ‘have-nots’. Certainly there remains a problem of poverty in the world but in addition to that there is a problem of inequitable distribution of wealth and income in the society as a whole. At every stage of the social gradient there is a level of disadvantage that is associated with that” remarked Prof Volmink.
Health programmes not only need to remain evidence-based at all levels but also need to remain equally effective for all populations and contexts. Prof Volmink said: “When you offer your health interventions it needs to be tailored to people at different levels of social gradient so as to close the gap. If there is a healthcare for the rich and a healthcare for the poor, we often end up with healthcare for the poor being poor healthcare, versus the rich who have the rich healthcare. I like the UHC approach because it sets up a system for the country that everybody can access - one health system for everybody which applies common principles across the entire country. This way we ensure that the whole system works rather than just give poor health services to the poor. National health insurance system is a fundamental intervention to try and address the problem of inequity in the society.”
Evidence-based healthcare in Africa
South African Cochrane Centre has been supporting evidence-based medicine in 25 countries. But engagement varies from country to country. “In all the countries we are active, the interest in using evidence to inform policy and practice has grown exponentially over the last 16 years. The people we have trained in doing systematic reviews have often gone back to their countries in Africa to become champions for evidence based policy. They have not only taught other people to do systematic reviews but they are often involved with universities in trainings, often advise governments and ministries of health, and increasingly play an advocacy and advisory role within countries. This continued work by those we trained in different African countries is starting to raise awareness among policy makers on importance of using evidence, and very often policy makers are asking for evidence when they have to make an important decision.”
Do policy makers back their decisions with evidence?
Policy makers often ask for evidence to back important decisions they need to make. “They often approach us. In South Africa, alcoholism is a huge problem as our country is a wine producing country. What government would like to do is to ban all alcohol advertising. They are seeking evidence whether or not banning of advertising reduces alcohol consumption, particularly in the young people. We are in the process of summarizing and sharing evidence with the government” said Prof Volmink.
Evidence has also been used to push the government to change policies. “We have used evidence to fight against the decisions governments have made. In 2000 South African government went through a stage of HIV denialism – that AIDS is not caused by HIV and antiretroviral therapy (ART) is not helpful. Government wanted us to look whether ART was effective (government actually wanted an evidence that ART was harmful). We told the government that we are happy to look at harm but we will also look at the benefit. We did a very comprehensive review and our conclusion was that there may be some trivial and recoverable toxic effects like anaemia or so on, but on balance, the benefits far outweigh any harm that is associated with ART. So based upon our findings the recommendation was that antiretroviral therapy must be used. In South Africa that was one of the pieces of evidence that was used subsequently in a legal action that was taken against the government. Grassroots advocacy led by people also used this review. Eventually the policy changed. It was a collective effort by us, driven mainly by the civil society in pushing the agenda and we were very happy that we could be partners in that.”
When evidence questions policy
“Like anywhere in the world, governments and, to some extent, the medical community is very keen to use evidence when the evidence supports what they have already decided to do. When the evidence goes against of what they want to do, that is when it becomes really problematic. Success rate is variable when you are dealing with that kind of situation. Evidence alone does not swing things then, you have to work with many partners in order to put the kind of pressure on decision makers to do the right thing” said Prof Volmink.
But policy makers base their decisions on a range of factors which definitely should include evidence on what works (and what does not). “Evidence is not everything and policy makers have to take other factors into account. But they cannot ignore the evidence. That is not acceptable. I am guarded in my enthusiasm whether evidence changes policy, sometimes it does but sometimes it does not. It is the responsible thing for us to make sure that the decision makers are using the evidence” said Prof Volmink.
Shobha Shukla and Bobby Ramakant, Citizen News Service – CNS