Swiss Centre for International Health
Swiss Tropical and Public Health Institute
University of Basel
Using evidence to improve health
systems: developing evidence-informed
guidance on health systems
Xavier Bosch-Capblanch
19th Cochrane Colloquium, Madrid 21st October 2011
Project: health systems guidance handbook
– WHO wanted to develop a handbook to produce health
systems guidance
– Team: Swiss TPH and NKCHS, assisted by a task
force
– Approach: adaptation of methods to produce clinical
guidelines
If imitation is the sincerest way of flattery, the clinicians who promoted
evidence-based medicine in the 90s should feel flattered
Yamey G, Feachem R. Evidence-based policymaking in global health – the payoffs and pitfalls. BMJ 2011.
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PICOT in ‘Google’
Francois Edouard Picot - Odalisque (1829)
(Stair Sainty Gallery, London)
http://www.mypicot.com/
Picots on a tatted insertion. The picots are the
small, oval-shaped loops arranged in threes at the
top of the tatted material.
Wikipedia
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PICOT in the field of public health
Streptococcus pneumoniae is one of the leading causes of
invasive disease, bacterial pneumonia and meningitis
among children in low-income countries.
Participants: healthy infants
Intervention: pneumococcal vaccine
Comparison: placebo or other vaccines
Outcomes: invasive disease, X-Ray penumonia
Time: follow up 24 months
Lucero MG et al. Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and X-ray defined pneumonia
in children less than two years of age. Cochrane Library.
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Research question
Health systems guidance
Participants
Timely
Intervention
Oriented towards policy
Comparison
Problem driven
Outcomes
Implementation
Time
Context
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Health system problems may be defined in different ways
Quality of care:
i) Self-reported outcome measures:
a. of health status and health–related quality of life
b. of patient satisfaction and experience with the process of care.
ii) Clinical behaviours (e.g., prescribing, referrals, treatments)
iii) Intermediate clinical and physiological indicators (e.g. blood pressure)
Scott A et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Library.
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Different definitions on quality of care
Donabedian 1990
Acceptability
Maxwell 1992
HSRG 1992
O'Leary 1992
Patient centeredness
Patient perspective
Accessibility
Accessibility
Acceptability
Legitimacy
Accessibility
Equity
Equity
Efficacy
Efficacy
Effectiveness
Effectiveness
Effectiveness
Effectiveness
Efficiency
Efficiency
Efficiency
Efficiency
Continuity /
coordination
Comprehensiveness
Relevance
HSRG: Health Services Research Group
Campbell SM et al. Soc Sci Med 2000
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Scope of problems and interventions
Types of interventions: Managerial supervision
Types of outcome measures: many (providers,
adherence, coverage…)
Bosch-Capblanch X et al. Managerial supervision to improve primary health care in low- and
middle-income countries. Cochrane Library.
Types of interventions: we included any type of
intervention that…
Types of outcome measures: consumer’s skills
for online health literacy
Car J et al. Interventions for enhancing consumers' online health literacy. Cochrane Library
Problems:
Interventions:
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Basic health system problems
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First step in policymaking process
Lavis JN. How Can We Support the Use of Systematic Reviews in
Policymaking? PLOS Medicine 2009.
Don de Savigny, Adam T. Health Systems Thinking. WHO
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What if before
starting doing what
ought to be done we
start doing what we
should have done?
Quino. Mafalda.
http://www.clubcultura.com/clubhumor/mafalda/f
rases/frase_felipe.htm
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Complexity of evidence
2. when the recommendation is against an
intervention and the 95% confidence interval
(or alternative estimate of precision) around
the pooled or best estimate of effect
a. the 95% confidence interval (or alternative estimate of
precision) around the pooled or best estimate of effect
includes no effect and the lower confidence limit
includes an effect that, if it were real, would represent
a harm that, given the benefits, would still be
unacceptable
GRADEProfiler help (3.6)
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It is beneficial to give routine malaria chemoprophylaxis in sickle cell disease
in areas where malaria is endemic.
Oniyangi O et al. Malaria chemoprophylaxis in sickle cell disease. Cochrane Library.
All trials demonstrate benefit in attenuating or reducing plasma viral load and/or
increasing CD4 counts.
Walson JL et al. Deworming helminth co-infected individuals for delaying HIV disease progression. Cochrane Library.
…these results indicate that routine surgery cannot be recommended unless
within the context of a large, well-conducted randomized controlled trial.
Jutte PC et al. Routine surgery in addition to chemotherapy for treating spinal tuberculosis. Cochrane Library.
Choice of therapy for second stage Gambiense HAT will continue to be determined
by what is locally available, but eflornithine and NECT are likely to replace
melarsoprol, with careful parasite resistance monitoring.
Lutke V et al. Chemotherapy for second-stage Human African trypanosomiasis. Cochrane Library.
Immunoglobulins seem to be effective for pre-exposure and post-exposure
prophylaxis of hepatitis A. However, caution is warranted for the positive
findings due to the limited number of trials, year of conductance, and risk of
bias..
Ping Liu J et al. Immunoglobulins for preventing hepatitis A. Cochrane Library.
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It is not possible to draw any conclusions about the effectiveness of strategies
to change organisational culture
Parmelli E et al. The effectiveness of strategies to change organisational culture to improve healthcare performance. Cochrane Library.
The findings suggest interventions relating to hospital nurse staffing models may
improve some patient outcomes… However, these findings should be treated
with extreme caution due to the limited evidence available from the research
conducted to date.
Butler M et al. Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Library.
There is a need to develop rigorous studies to evaluate the effects of social
franchising on access to and quality of health services in low- and middle-income
countries.
Perez Koehlmoos T et al. The effect of social franchising on access to and quality of health services in low- and middle-income countries. Cochrane
Library.
The findings of this review do not provide sufficient evidence to support or resist
a policy of altering the lengths of primary care physicians' consultations.
Wilson AD et al. Effects of interventions aimed at changing the length of primary care physicians' consultation. Cochrane Library.
There is insufficient evidence for the effectiveness of stress management training
interventions to reduce job stress and prevent burnout among healthcare workers
beyond the intervention period.
Va Wyk BE et al. Preventive staff-support interventions for health workers. Cochrane Library.
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Very diverse audience
IMMUNISATION PRACTICES ADVISORY COMMITTEE (TO WHO) - IPAC
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Associate Director of Surveillance and Epidemiology (Canada)
Medical Epidemiologist (Switzerland)
Medical doctor (Switzerland)
Professor of Engineering (USA)
Private Consultant (France)
Adjunct Professor Paediatrics (Jordan)
Maternal Child Health Programme Manager (Nigeria)
Emeritus Professor of Paediatrics (Sri Lanka)
Principal Fellow, Maternal and Child Health (Australia)
Private Consultant (France)
Centre for Data and Epidemiological Surveillance (Indonesia)
Immunization Team Leader (USA)
And observers from Global Health Initiatives, pharmaceutical industry, Non-Governmental
Organisations, Research Institutes…
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Annual governmental health budget =
(Tajikistan)
The tallest unsupported flagpole measures 165 m
(541 ft 4 in), and was erected by Trident Support
(USA). It was presented and measured in
Dushanbe, Tajikistan, on 24 May 2011. (Guiness
World Records)
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Barriers to the uptake of evidence
Evidence-related factors limiting the use of research evidence
– “Policy-free” evidence
– Undue focus on RCT
– Poor local applicability
– Lack of focus on social determinants for health
– Lack of complexity
‘External factors’ restricting the use of research evidence:
– Competing influences
– Resources constraints
– Stakeholders and public pressure
– Community views and local competition
Orton L et al. The use of research evidence in public health decision making process: systematic review. PLOS 2011.
Decision to introduce Hepatitis B vaccine at birth related to the death a
politician’s friend of liver cancer (IPAC meeting 2011).
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Adapted contents
Plain language summaires
The evidence was of low to very low quality and
the studies showed mixed results. Compared to
no supervision, some studies showed that
supervision had a small benefit on health worker
practices and knowledge, while other studies
showed no benefit or were inconclusive. We are
therefore uncertain about the effects of
supervision on the quality of primary healthcare
services.
Bosch-Capblanch X et al. Managerial supervision to improve primary health
care in low- and middle-income countries. Cochrane Library.
Thanks to Claire Glenton
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SUPPORT collaboration
Cochrane Consumers and
Communication Review Group
Centre for Health Communication and
Participation
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Structured contents
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Cosmetic issues
Thanks to Sarah Rosenbaum
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Implications
PICOTs for TOPICs
Can Cochrane reviews be made more appropriate for
decision making on health systems?
– a common taxonomy of HS TOPICs under the policymaking perspective
– a common taxonomy of PICOs questions under the research perspective
– inclusion of non-effectiveness evidence
– a common HS framework to align the approaches of Cochrane reviews on HS
interventions
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Contribution / acknowledgments
Project team
Xavier Bosch-Capblanch, Swiss TPH
Simon Lewin, NKCHS (Norway)
Kaspar Wyss, Swiss TPH
Lise Beck, Swiss TPH
Daniel Dröschel, Swiss TPH
Don de Savigny, Swiss TPH
Thanks to Paul Garner for reviewing this presentation
Taskforce members
Edgardo Abalos, CREP (Argentina);
Rifat Atun, GFATM
Fadi El-Jardali AU Beirut (Lebanon)
Timothy Evans, WHO
Abdul Ghaffar, AHPSR-WHO
Davina Ghersi, WHO
Lucy Gilson, UCT (South Africa)
Metin Gulmezoglu, WHO
Andy Haines (chair), LSHTM (UK)
John Lavis, McMaster U (Canada)
Regina Kulier, GRC-WHO
Sandy Oliver, IOE (UK)
Pierre Ongolo-Zogo, CDPBH (Cameroon)
Tikki Pang, WHO
Ulysses Panisset, WHO
John-Arne Røttingen, NKCHS (Norway)
Peter Tugwell, IPH (Canada)
Gunn Vist, NKCHS (Norway)
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Thanks for your attention
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