Evidence based decision making
Introduction
Health policy in the broadest sense can be defined as those actions of governm...
Evidence based decision making

Dr.Mustafa Salih

Rational
As health systems throughout the world decentralize, health pat...
Literature Review
Evidence-based health care policy
Consumers and providers mention several objectives of health care poli...
Evidence based decision making

Dr.Mustafa Salih

Evidence-based policy is not simply an extension of EBM: it is qualitati...
orientation suggests that temporal and contextual variation heavily influence the
determination of what constitutes eviden...
Evidence based decision making

Dr.Mustafa Salih

other sectors might be held responsible for providing the evidence relat...
for profit) and civil society. However, those partners are performing in isolation due to ill
defined managerial systems f...
Evidence based decision making

Dr.Mustafa Salih

contextual factors are fixed, uncontrollable and cannot be manipulated b...
The process can affect the introduction of evidence through the decision to employ
established evidence hierarchies and wh...
Evidence based decision making

Dr.Mustafa Salih

the areas of allied health, biological and physical sciences, humanities...
The second stage of the evidence utilization process is the interpretation of evidence
stage. This is where evidence that ...
Evidence based decision making

Dr.Mustafa Salih

context. The more clearly the external decision-making context is unders...
important role in determining how different evidentiary sources are weighted and
prioritised to justify a decision7.
Uses ...
Evidence based decision making

Dr.Mustafa Salih

Practice Guidelines
What is the best approach for patients with selected...
based problem-solving techniques for approaching and solving public health problems, or
in programs that focus predominant...
Evidence based decision making

Dr.Mustafa Salih

Although researchers have difficulty acknowledging it, the sources for t...
• Translation means to explain the decision context, so as to adapt the research
agenda and anticipate on the reactions of...
Evidence based decision making

Dr.Mustafa Salih

Sudan suffers from acute and complex health problems. The cycle of pover...
Table No1 Definition of priority policy questions by FMOH directorates and
programmes
Defined policy questions
Yes
No
Tota...
Evidence based decision making

Yes
No
Total

Dr.Mustafa Salih

11 (52.3%)
10 (47.6%)
21 (100%)

Table No 7 No of research...
Table No 10 Reasons of not Using research results for policy by FMOH directorates
and programmes 2003
Reason
No need to us...
Evidence based decision making

Dr.Mustafa Salih

International journal
Local periodical
Seminar
Other

17
13
16
1

Table ...
9. The evidence-based approach in health policy and health care delivery Social
Science & Medicine
Volume 51, Issue 6 , 15...
Evidence based decision making

Dr.Mustafa Salih

In 1927 the Stack Medical Research Laboratories (SMRL) were established ...
On account of outstanding contributions to tropical medicine and medical entomology
another two members of SMS were awarde...
Evidence based decision making

Dr.Mustafa Salih

1963 : Satti’s (Hasseeb’s successor) discovery of a new experimental hos...
thesis is a prerequisite for its award.
In 1991 the National Council for Research of the Ministry of Higher Education and
...
Evidence based decision making

Dr.Mustafa Salih

research including capacity building, organizational mechanisms, documen...
Research in charge of SMRL. Simultaneously with the start of Sudanese research leadership, some
outstanding developments t...
Evidence based decision making

Dr.Mustafa Salih

Finance, Training, Documentation and Information and Research Implementa...
4.2.1.General objective:
The main objective of this study is to critically assess the current health research situation an...
Evidence based decision making








Dr.Mustafa Salih

Functions.
Infrastructure and the working environment.
Per...
5.
6.
7.
8.
9.
10.
11.

2 x 26 states x 7 pd x $7 = 2,548
One statistician is needed part time for 2 months to analyze dat...
Evidence based decision making

Dr.Mustafa Salih
1,200

1,200

2,400

Admin Assistant/Accountant 1 x 24 pm x 100.0
$100
5,...
Budget Item

Amount in US$
Year 1 Year 2
Total
Personnel 18,808
Operating Expenses 29,514

8,520
10,680

27,328
40,194

RD...
Evidence based decision making

Dr.Mustafa Salih

use of research to identify and reduce health inequities, and the transl...
The Need for a New Concept
participating community or group. Yet, such outcomes may be difficult to
duplicate on a wider s...
Evidence based decision making

Dr.Mustafa Salih

issue of how to solve a particular problem. In fact, it may be helpful t...
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Evidence based decision making
Upcoming SlideShare
Loading in...5
×

Evidence based decision making

762

Published on

A document prepared by Dr. Mustafa Salih, the former director of the Directorate General of Health Policy, planning and research at the Federal ministry of Health in Sudan.

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
762
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
108
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Transcript of "Evidence based decision making"

  1. 1. Evidence based decision making Introduction Health policy in the broadest sense can be defined as those actions of governments and other actors in the society that are aimed at improving the health of the populations. Ideally, there would be a cycle of policy formulation, implementation, and assessment. In the assessment of policy outcomes, scientific evidence should play an important role9. One of the dominant themes in health policy and planning today is the need for interventions to be based on sound evidence of effectiveness. Responsibility for ensuring that programs are consistent with the best available evidence must be shared between providers, policy makers and purchasers of services. Decision makers in health care are increasingly interested in using high-quality scientific evidence to support clinical and health policy choices. Reliable evidence is essential to improve health care quality and to support efficient use of limited resources 1. Public health officials and the communities they serve need to: identify priority health problems; formulate effective health policies; respond to public health emergencies; select, implement, and evaluate cost-effective interventions to prevent and control disease and injury; and allocate human and financial resources. Despite agreement that rational, data-based decisions will lead to improved health outcomes, many public health decisions appear to be made intuitively or politically2. However, Increased attention is being directed to the development of methods that can provide valid and reliable information about what works best in health care. Among the primary audiences for higher-quality evidence are clinical and health policy decision makers, including patients, physicians, payers, purchasers, health care administrators, and public health policymakers. Given the increasing advocacy for health in the political arena over the past decades, there is an increasing attempt towards transparency and rationalization of the decision making process in health policy. Consensus is growing on the interpretation of the role of both broad and specific health determinants, including health care provision, as well as on priority setting based on the burden of diseases9. Patients and physicians increasingly seek to combine their personal beliefs about health care choices with attention to high-quality evidence in making individual decisions about care. Medical professional societies produce guidelines to assist physicians and patients in making medical decisions The growth of medical information and continuing medical educational offerings in the past few years was huge. Ease of access and availability at any time are advantages of the World Wide Web. However, the quality of data in general practice clinical information systems varies enormously. Over the past two decades, national and international agencies have been systematically collecting a growing body of knowledge in support of health policy. Their documents typically address issues such as the general health status of the population and various subgroups, broad and specific health determinants, the occurrence of specific diseases and the use of health services9. |P age 1
  2. 2. Evidence based decision making Dr.Mustafa Salih Rational As health systems throughout the world decentralize, health patterns shift with aging populations, and resources available to the health sector continue to decrease, there is a continuing need to support evidenced-based public health policies and programs in countries and their communities. Building sustainable programs to strengthen the capacity in this arena is a delicate process and requires long-term, sustained efforts2. Public health research deals with the functioning of social systems and their impact on the health of populations: its outcomes are of interest only if they translate in policies. By definition, public health research has a vocation to be applicable research. Although there is a domain of increasing demand for research from decision makers, the relation between researchers and decision makers is complex made of unsatisfied expectations on both sides and misunderstanding. It needs to be better understood to be improved. We also need to improve the effectiveness of the link between research and decision-making. the Federal Ministry of Health in Sudan is in the process of undertaking a comprehensive health system reform that puts into consideration the recent local and international changes that affect the health system. These changes are political, social, economical and demographic. The ministry is embarking on preparing the updating of health policies, strategies, guidelines and regulations as well as rehabilitation and reconstruction of the health system– an aim requiring a solid information base and a comprehensive evidence based planning. A post-conflict health policy framework and a 25 years strategy for health have been developed, and a comprehensive health system study is being conducted at the meantime. It is time to take actions to promote the culture of evidence based health care in the Sudan to improve planning and decision making practices. To do this we need to evaluate the decision making behavior among health directors and policy makers including the process of decision making, the context, the introduction of information(evidence), interpretation and application of evidence. Objectives General Objective To assess the evidence based decision making in health care in Sudan, 2003 Specific objectives To define the sources of information and availability of evidence in the Federal Ministry of Health, Sudan 2003. To assess the use of evidence for policy making, planning and decision making by policy makers and health directors in the Federal Ministry of Health, Sudan 2003. To determine the information seeking behavior of policy makers and health directors in the Federal Ministry of Health, Sudan 2003. To study the link between researchers and policy makers, Sudan 2003
  3. 3. Literature Review Evidence-based health care policy Consumers and providers mention several objectives of health care policy in policy documents as universal access, comprehensive and uniform benefits, equitable financing, and value for money, public accountability and freedom of choice. When attempting to support health policy, it is important to understand how these objectives can be defined, operationalized and measured. This is by no means straightforward. Therefore, important obstacles to evidence-based health policy are clear understanding of policy objectives and the availability of relevant measurement instruments 9. David Sackett's definition of 'evidence based medicine' (EBM) is now well known and widely accepted. But the phrase 'evidence based health care' (EBHC) is rarely defined. Evidence based medicine is defined as "An approach to health care practice in which the clinician is aware of the evidence in support of his/her clinical practice, and the strength of that evidence." 6. Evidence-based decision-making is centered on the justification of decisions8. It is known as "The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." 7. In Canada, Prime Minister’s National Forum on Health in 1997 defined it as: “The systematic application of the best available evidence to the evaluation of options and to decision-making in clinical, management and policy settings.” "Evidence based health care takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information." 4 Several things follow from this definition: 1. 'Decisions that affect the care of patients' are taken by managers and health policy makers as well as by clinicians. EBHC is therefore just as relevant to managers and policy makers as it is to clinicians. 2. Many factors other than the results of randomized controlled trials contribute to decisions about the care of patients and may weigh heavily in both clinical and policy decisions (for instance, patient preferences and resources). This definition requires that valid, relevant evidence should be considered alongside other relevant factors in the decision making process. It does not assume that any one sort of evidence should necessarily be the determining factor in a decision. 3. Before information is used in a decision, an assessment should be made of the accuracy of the information and the applicability of the evidence to the decision in question; that is, information should be appraised. 4. 'Information' is deliberately left unspecified; there are many types of information that may be valid and relevant in particular circumstances. It is not wise to exclude any particular type of information as long as an appraisal is made of its validity and relevance and the information is given 'due weight' - neither more nor less. |P age 3
  4. 4. Evidence based decision making Dr.Mustafa Salih Evidence-based policy is not simply an extension of EBM: it is qualitatively different. As we move from EBM to evidence-based health policy, the decision-making context changes, shifting from the individual-clinical level to the population-policy level. Decisions are subject to greater public scrutiny and outcomes directly affect larger numbers of people, heightening the requirement for explicit justification. This shifting in decision-making context highlights our current conceptual deficiencies and the limited attention given to understanding the role that context plays in influencing evidence-based decisions. While proponents of EBM have recognized that scientific evidence, by itself, is not sufficient and needs to be integrated with other types of evidence, they still focus on the use of the `best' sources of evidence. This has led to the development of numerous hierarchies of evidence and classification criteria based largely on the sophistication of a study's design and its methodological rigor. Critics of EBM have countered that these evidence hierarchies lack their own evidence-base, imposing valuations and preferences that endeavor to constrain or limit the influence and impact of the full range of potential evidentiary sources on decision-making 7. The goal of evidence based decision making (EBDM) may not be for managers and policy makers to slavishly comply with every scrap of health services research, even assuming (somewhat unrealistically) that the research clearly resolves the informational uncertainty. This imperialistic view of the role of research in administrative and policy decisions seems destined for irrelevance. It is more likely to generate animosity than collaboration between researchers and decision makers. Rather, ‘successful’ EBDM may be no more than recognition of the research and an explanation of the way in which it was taken into account in the decision. If it was not used, why was it not used? Perhaps all that is being sought through evidence-based decision-making is a status for science in decisions that is at least equivalent to the current status of public or interest group opinion8. What constitutes evidence? This question is philosophical, rooted in epistemology and ontology theorizing how we relate to the world in terms of the creation, interpretation and evaluation of information and knowledge. This question is also practical, embedded in the fundamental process of decision-making, explicating support and justification for the decisions we make. The philosophical and practical aspects of evidence support two distinct orientations to what constitutes evidence, reflecting fundamentally different relationships between evidence and context. The first is a philosophical-normative orientation, while the second is a practical-operational orientation. Therefore, from a philosophical-normative orientation, what constitutes evidence is largely a function of the quality of the evidence, with the supposition being that higher quality evidence should lead, in turn, to higher quality decisions7. In contrast, the practical-operational orientation to what constitutes evidence is contextbased, with evidence defined with respect to a specific decision-making context. This
  5. 5. orientation suggests that temporal and contextual variation heavily influence the determination of what constitutes evidence. Evidence is not static, but rather, is characterized by its emergent and provisional nature, being inevitably incomplete and inconclusive. This orientation suggests that evidence is subjective, with different perspectives producing different explanations for the same decision outcome. Evidence may simply describe the state of knowledge at a particular time and place This practicaloperational orientation is more aligned with the decision-making sciences, focusing on how a multitude of factors contribute to a decision outcome. In contrast to the philosophical-normative orientation, the practical-operational orientation defines evidence less by its quality, and more by its relevance, applicability or generalisability to a specific context. This orientation suggests that evidence and context are mutually inclusive7 Evidence and health systems: Despite the public health community's agreement that rational decisions based on comprehensive analysis and good data will lead to improved health outcomes, policy makers, health officials, program managers, and community organizations seemingly make health-related decisions intuitively, based on empirical evidence. Some times decisions are made based on other considerations that include crises, current public opinion, political interests, or the concerns of organized interest groups2. Features of a health care system, including the degree of public and/or private financing and service delivery, and the degree of centralization or decentralization, potentially constrain or limit policy alternatives. The political attractiveness of a policy issue influences the degree of formal and informal support, while financial implications can constrain decision-makers and dictate evidentiary requirements to support a decision 7. As the decision-making context shifts from the individual-clinical level to the populationpolicy level, many questions arise: should what constitutes evidence change? Should the value attributed to different types of evidence change? Should we change how we make evidence-based decisions?7. Consensus is growing on the role of broad and specific health determinants, including health care, as well as on priority setting based on the burden of diseases and the opportunities to reduce such burden in a cost-effective way. With the increasing number of advocates for the enhancement of population health in the policy arenas, evidencebased approaches will provide the information and some of the tools to help with priority setting9. Evidence-based approaches are prominent on the national and international agendas for health policy and health research. It is unclear what the implications of this approach are for the production and distribution of health in populations, given the notion of multiple determinants in health. It is equally unclear what kind of barriers there are to the adoption of evidence-based approaches in health care practice. There will be a demand for intersectoral assessments, in spite of methodological constraints, especially in the area of health sector reform. Initiators of policy changes in |P age 5
  6. 6. Evidence based decision making Dr.Mustafa Salih other sectors might be held responsible for providing the evidence related to health. Due to limited possibilities for priority setting at the national health care policy level there is a shift of the responsibility for resource use from the central level to peripheral levels. Health care providers are encouraged to assume agency roles for both patients and society and asked to promote and deliver effective and efficient health care. Governments will have to set up the national framework to facilitate their organization and legal structure to enhance evidence-based health policy. Treatment guidelines supported by evidence on effectiveness and efficiency will be one essential element in this process. National health care policy-making is increasingly evidence-based. Many governments are supporting agencies for evidence-based health care. At the same time limitations to priority setting at the political level and insufficient availability of relevant evidence are apparent. The former can be seen in many health care systems where politicians tend to deviate from sound evidence-based advice in those cases, where they are asked to withhold certain treatment programs from patients. Public opinion then provides a stronger incentive when manipulated well by pressure groups. We expect a tendency to shift the responsibility for resource allocation in health care from the central level to peripheral levels, where health care providers are encouraged to assume agency roles for both patients and society and as such to promote and deliver cost–effective health care. In such settings, health policy deals with organizing the national framework to use available evidence on such divers areas as diagnostics (e.g. screening programmes), medical treatment, nursing, and care of patients to its full extent9. The government of Sudan adopted the federal system in 1994. Decentralization was introduced as a system of governance compatible with the needs of the multi-ethnic and multi-cultural society of Sudan. The country is divided into 26 states and 134 Localities 5. ''The system is founded upon a multi-tier government: federal, state and local governments. The federal level is concerned with policy making, planning, supervision & co-ordination. The state governments are empowered for planning, policy making and implementation at state level''5 Federal ministry of Health experienced marked reforms in its general directorates during the last year. Even though, its systems are still immature to withstand integration of programmes between different directorates. Both evidence based decision-making and collaboration needs to be promoted5 Sudan has 26 State Ministries of Health (SMoH), one in each State. The Federal Ministry of Health (FMoH) is responsible for the development of national health policies, strategic plans, monitoring and evaluation of health systems activities. The SMoH are mainly responsible for policy implementation, detailed health programming and project formulation. The implementation of the national health policy is undertaken through the district health system based on the primary health care concept 5 Health services are provided through different partners including in addition to federal & state ministries of health, armed forces, universities, private sector (both for profit and not
  7. 7. for profit) and civil society. However, those partners are performing in isolation due to ill defined managerial systems for coordination and guidance 5. The history of health research in the Sudan goes back to the end of nineteenth and the beginning of twentieth centuries, mainly in the areas of tropical diseases and public health ( at that time prominent and highly learned research and academic institutions were the sole protectors and guardians of research in the Sudan under the patronage of Sudan Government3. However, as in many developing countries research in Sudan is facing many obstacles not only in conducting research, but also in dissemination of research results to users and policy makers. The contribution of research in changing practice or policy formulation appears to be minimum or some times nil3 Evidence is used for priority setting , Economic evaluation and public health programmes assessment in terms of cost–effectiveness. The same holds true for many curative programmes with large financial consequences. Furthermore, it is important to assess possible discrepancies between the maximum possible outcome as observed in more or less controlled studies and health benefits as seen in actual practice. Health policy may benefit from the identification of the determinants of shortages in the process of health care9. Two decision-making contexts We broadly define the decision-making context to include all factors within an environment where a decision is made. A decision-making context is characterized by its complexity, comprising both the known and the unknown and the certain and the uncertain. However, we acknowledge that it is virtually impossible, and likely of limited utility, to fully account for all contextual factors that might have some potential influence or impact on a decision The internal decision-making context accounts for the environment in which a decision is made and includes factors such as the purpose for the decision-making activity, the role of participants in a decision-making process and the process employed to arrive at a decision outcome. Internal contextual factors can be manipulated and controlled, and explicitly reflect the contextual changes that occur as we move from EBM to evidencebased health policy. Perhaps the most critical internal contextual factor is related to the process of decision-making. Process includes both purpose, the `why', and participants, the `who', but really addresses the structures and mechanisms for `how' decisions are made7. The external decision-making context accounts for the environment in which a decision is applied and includes disease-specific, extra-jurisdictional and political factors. External |P age 7
  8. 8. Evidence based decision making Dr.Mustafa Salih contextual factors are fixed, uncontrollable and cannot be manipulated by decisionmakers (at least in the short-term), but clearly play a role in decision-making7. Disease-specific factors include the geographic, demographic and epidemiologic characteristics of a disease, each of which can impact on what constitutes evidence and how that evidence is utilized. Extra-jurisdictional factors refer to the relevant experiences of other jurisdictions that, while operating in different environments, can impact on what constitutes evidence and how evidence is utilized for a specific decision-making context. Both the internal and external decision-making contexts affect what constitutes evidence and how that evidence is utilized. While few would support decisions based solely on purpose, process or participants, not many would argue against the significant role that these internal contextual factors play in any decision. The external decision-making context can play both a contextual and an evidentiary role, in some situations providing constraints or limits for a decision, and in other situations providing an evidentiary basis for supporting or justifying a decision. The better we understand the context, the better our position to utilize high-quality evidence of all types improve7. While both evidence and context are fundamental to evidence-based decision-making, there will always be grey zones blurring a clearly definable relationship between evidence and context. Therefore it may be less critical how these fundamental components are defined, and rather more critical how the decision-making context impacts on how evidence is utilized in the development of evidence-based decisions7. Introduction of evidence The introduction of evidence stage refers to the means by which evidence is identified and the channels through which evidence is brought into the decision-making process. This stage addresses issues related to the availability and accessibility of evidence, including a range of evidence dissemination, transfer, diffusion and transmission activities. The introduction of evidence is based on both the perceived conception of evidence and the operationalisation of that conception of evidence, subject to both internal and external contextual factors. (7) The internal context can directly impact the introduction of evidence into a decisionmaking process. The purpose frames the problem, raising different questions. For example, the purpose could be to make a treatment decision for an individual patient, develop practice guidelines for clinicians, or develop recommendations for a populationwide program. As we move from the individual-clinical level to the population-policy level, the purpose progresses from a focus on efficacy and effectiveness to a focus on feasibility and implementation issues..
  9. 9. The process can affect the introduction of evidence through the decision to employ established evidence hierarchies and whether primary or secondary evidence reviews and searches will be conducted. The time and effort expended to access evidence and the extent of dissemination, transfer, diffusion and transmission activities can also affect what evidence is introduced. Decision-making participants can influence on the introduction of evidence by expressing personal values, interests, beliefs, or biases towards different evidentiary sources. As more decision-makers become involved in the decision-making process, participant variability increases. The role of interpersonal relationships, potential conflicts of interest, and individual responsibilities for identifying evidentiary sources, can also be critical. External contextual factors can indirectly affect the introduction of evidence by altering the internal decision-making context. For example, variation in service capacity among urban and rural areas may influence the purpose for, and/or the participants involved in, a decision-making process, thereby potentially affecting the introduction of evidence. Furthermore, external contextual factors can directly affect the introduction of evidence if some of these factors are formally incorporated into the evidence base at the outset of a decision-making process7. Identification of pririties: There are a number of sources from which high-priority questions could be identified. Virtually every clinical guideline, technology assessment, systematic review, and consensus report includes a section that lists specific clinical research priorities. These priorities deserve special attention because of the systematic and comprehensive method by which they have been generated. Finding the Evidence Over the last decade, an explosion in both the availability and accessibility of information was observed. With this, we have seen greater recognition of, and attention given to, the classic economic dilemma between the scarcity of resources and our potentially unlimited wants, raising difficult resource allocation, rationing and priority setting questions. Greater demand has been placed on decision-makers at all levels and in all fields to justify their decisions in response to this dilemma. Decisions are becoming more transparent, shifting from implicit to explicit methods of decision-making. Evidencebased decision-making has been proffered as a means to address this growing demand for explicitly justified decisions7. Literature Sources The biomedical literature is huge and growing daily with a wide range of paper journals, electronic publications, abstracts, posters and books available. There is no single source or electronic search that will yield all the required evidence. A search for evidence should begin with a ‘search strategy’. Electronic Databases MEDLINE encompasses information from Index Medicus, Index to Dental Literature, and International Nursing, as well as other sources of coverage in |P age 9
  10. 10. Evidence based decision making Dr.Mustafa Salih the areas of allied health, biological and physical sciences, humanities and information science as they relate to medicine and health care, communication disorders, population biology, and reproductive biology. MEDLINE contains bibliographic citations and author abstracts from over 4,000 journals published in the United States and in 70 foreign countries. It has 11 million records dating back to 1966. Abstracts are included for about 67% of the records. HealthInterNetwork The Health Internet work was created to bridge the "digital divide" in health, ensuring that relevant information - and the technologies to deliver it - are widely available and effectively used by health personnel: professionals, researchers and scientists, and policy makers. Launched by the Secretary General of the United Nations in September 2000 and led by the World Health Organization, the Health InterNetwork has brought together public and private partners under the principle of ensuring equitable access to health information. The core elements of the project are content, Internet connectivity and capacity building. Operational research Health services research and outcomes research have made important contributions toward the effective translation of clinical research discoveries to clinical practice and health policy. However, observational and other non-experimental methods may not provide sufficiently robust information regarding the comparative effectiveness of alternative clinical interventions, primarily because of their high susceptibility to selection bias and confounding. Operational research is the application of scientific method to the management of organised systems. It attempts to provide those who manage organised systems with an objective and quantitative basis for decision. It is normally carried out by teams of scientists or engineers, from a variety of disciplines, and often working with people involved in the organization and with detailed knowledge of it. The subject of operational research is the decisions that control the organization, with how managerial decisions could and should be made. clinical trials The production of high-quality clinical trials will increase significantly when health care decision makers decide to consistently base their decisions on highquality evidence. Research sponsors (public and private) will be motivated to provide the type of clinical research required by decision makers. Payers and purchasers can clearly indicate to the drug and device industry that favorable coverage and payment decisions will be expedited by reliable. In particular, manufacturers will be motivated to perform head-to-head comparative trials if these are required to justify payments higher than the existing less expensive alternatives. Physicians and medical professional organizations can also increase the degree to which care of individual patients and professional society clinical policy are guided by attention to reliable evidence. Interpretation of evidence
  11. 11. The second stage of the evidence utilization process is the interpretation of evidence stage. This is where evidence that has been introduced into a decision-making process is synthesized, evaluated and assessed on its quality and generalisability. During this stage there is recognition, appreciation and determination of the relevance, appropriateness, applicability, acceptability and utility of individual sources of evidence for supporting and justifying a decision7. The internal decision-making context directly affects the interpretation of evidence stage. The purpose for the decision-making process can set out the extent to which internal validity will be evaluated and assessed, in some cases commanding decision-makers to rely on external reviews, and, in other cases, engaging decision-makers to directly assess the quality of the evidence themselves. The purpose can also establish limits for assessing the external validity of the evidence. Consider two purposes: one to develop clinical practice guidelines and another to develop a population-wide program. The development of clinical practice guidelines often focuses on the assessment of the internal validity of the evidence, with the assessment of external validity deferred to the clinician who would be responsible for interpreting whether or not an individual patient's specific context appropriately fits within the constraints of the evidence. However, the purpose of developing a population-wide program would place a much greater focus on the interpretation of external validity, requiring careful scrutiny of how applicable the evidence would be to the entire range of individuals making up the target population 7. As in the introduction of evidence stage, the decision-making process can affect the interpretation of evidence based on the time and effort expended, the extent of dissemination, transfer, diffusion and transmission activities employed, and the intensity of the linkages between the research and decision-making communities. These processrelated factors greatly affect the degree to which the internal and external validity of the evidence can be evaluated and assessed. The use of evidence hierarchies also affects the interpretation of evidence by explicitly prioritising different types of evidence, with limited consideration for the particular quality of individual sources of evidence 7. Participants can affect the interpretation of evidence stage for many of the same reasons as they affect what is introduced as evidence. This includes factors such as which particular participants ultimately take on the responsibility for interpreting the evidence, the interrelationships among participants and personal conflicts of interest. Other critical factors include the participants' receptivity to the evidence, their cognitive and scientific skills, and the confirmation or challenges that the evidence presents to their existing beliefs, intuitions and assumptions. External contextual factors can affect the assessment of internal validity to the extent that the evidence threshold is extended and more external contextual factors are directly considered as evidence. Given the different levels of methodological sophistication or scientific rigor associated with this `evidence', the confidence in the interpretation of the quality of evidence can thereby be weakened. However external contextual factors, by their definition, are directly connected to the assessment of the external validity of evidence, and mark the most obvious and direct relationship between evidence and | P a g e 11
  12. 12. Evidence based decision making Dr.Mustafa Salih context. The more clearly the external decision-making context is understood, the more clearly the evidence is understood, resulting in improved interpretation of the generalisability of the evidence to a particular context in which a decision is to be applied. This reflects the growing recognition of the need to move beyond the usual focus on internal validity of evidentiary sources to improve methods for interpreting the external validity of evidence when making evidence-based decisions7. Application of evidence The final stage of the evidence utilisation process is the application of evidence. This is where evidence, that has been introduced and interpreted, is applied to support or justify a decision. While in the interpretation of evidence stage, individual sources of evidence are evaluated and assessed, in the application of evidence stage, collective sources of evidence are weighted, prioritised and/or transformed. This stage reflects the ultimate influence and impact that individual sources of evidence have on the decision outcome. However, the impact of evidence is distinguished from the use of evidence. Attention is given to subtle changes, partial usage and direct or indirect transformation between the evaluation and assessment of evidence and the weighting and prioritisation of evidence, with the key being the consistency of evidence utilisation between the interpretation and application stages. If there is inconsistency between these stages, what accounts for the transformation? As stated, it is necessary...to give an account that clarifies how the differing roles of evidence can be weighted at different contexts and levels of health care". Again, both internal and external contextual factors have an impact. The decision-making purpose (e.g. an individual-clinical treatment decision versus population-wide program development) can set out the level of demand and expectation for evidentiary support and justification of decision-making. The process can differ regarding the development of, or requirements for, consensus among decision-makers. As in the previous two stages, if a decision-making process employs an established evidence hierarchy, the application of evidence may reflect conformity to that evidence hierarchy, rather than incorporating less conventional evidentiary sources to support the decision. Decision-making participants can affect the application of evidence similar to their impact on the other stages, with personal factors, interpersonal relationships and individual and/or collective conflicts of interest, directly and indirectly affecting how evidence is applied to a decision. The external decision-making context also plays an important role in influencing the application of evidence. This often relates to the ideological compatibility, political saleability or economic feasibility of a potential evidence-based decision. For example, the existing political governance or the ruling ideology can affect the application of evidence at a population-policy level by making certain decisions unacceptable, necessitating a transformation from an unpopular interpretation of evidence to an application of evidence that is more politically or ideologically acceptable. The external decision-making context can also affect the prioritisation of evidence if, for example, a population has a strong rural component, whereby accessibility and equity issues play an
  13. 13. important role in determining how different evidentiary sources are weighted and prioritised to justify a decision7. Uses of Evidence in Decision Making (1) While the research and knowledge utilization literatures are often used and cited interchangeably, they differ from one another in one important way. Whereas research utilization has a more restricted focus on the use of scientifically produced research, knowledge utilization is broader in scope, including a range of other sources of data and information. This distinction is important when considering `evidence utilization' as it marks a progression from a rather narrow focus on the utilization of scientific research, to a broader focus on the utilization of knowledge, to an unrestrained focus on the utilization of scientifically and non-scientifically produced information and knowledge in support of a decision7. Several dimensions of utilization have been addressed, including the purposes for utilization, the utility, degree or extent of utilization, the ultimate impact of utilization, utilization in relation to beliefs and non-utilisation . It is not entirely clear what `utilization' actually means stated that "much of the ambiguity in the discussion of `research utilization'––the conflicting interpretations of its prevalence and the routes by which it occurs––derives from conceptual confusion". Almost two decades later, added, with respect to knowledge utilization, that "...it is essential that one be certain of what is meant by use, and that the concept can be operationalised in a fashion which realistically provides a basis for evaluation, accountability, and oversight"7. Many published epidemiologic studies report that particular findings should or could be used in setting priorities, planning, managing, and evaluating public health. Yet, it is often difficult to identify whether or how such information actually has been used by decision makers. Recommendations from epidemiologic investigations frequently are not implemented, and valid and compelling data that identify major risk factors for important public health problems go unheeded for decades before having any noticeable effect on health policy Increasing the use of evidence-based public health in the long-term, requires the creation of a data-use culture and a behavior change in those involved with the decision-making environment2. This pattern underscores the multifactorial and complex nature of decision making in public health, and documents that considerations other than data, such as political and philosophical issues (e.g., individual rights versus the effectiveness of regulations to protect communities), economic, social, ethical, and personal values, influence public health decisions 2 . Physician/Patient Decision Making : Of existing diagnostic or treatment alternatives, which makes the most sense for an individual patient? Choosing Plans or Physicians Which plan or physician is likely to provide high-quality care? | P a g e 13
  14. 14. Evidence based decision making Dr.Mustafa Salih Practice Guidelines What is the best approach for patients with selected conditions? Quality Measurement and Improvement How can evidence-based clinical performance be assessed? Do improvement programs result in enhanced clinical care? Product Purchasing and Formulary Selection How does this product compare with existing alternatives? Benefit and Coverage Decisions Should a new service be reimbursed and for which patients? Organizational and Management Decisions Does a hospitalist program decrease costs and improve outcomes? Program Financing and Priority Setting Which services represent the best value for additional investments? Product Approval Should this product be approved and, if so, for which indications? Factors affecting the use of data To develop interventions that would increase evidence-based public health, we first reviewed the literature to identify factors known to affect the use of data in decision making. We discovered several barriers, including the:  Probabilistic, observational, seemingly inconclusive nature of epidemiologic data (i.e., the quality of epidemiologic evidence)  Failure of decision makers to recognize epidemiologic questions that are relevant to policy issues  Failure of epidemiologists to analyze and frame issues in a policy context for decision makers  Failure of epidemiologists and other technical advisors to package and present data in an understandable and compelling format  Hesitancy of epidemiologists to aid in interpreting findings and to participate actively in the decision-making process  Poor incentive stemming from lack of decision-making authority  Failure of HISs to meet the needs of policy makers and program managers in terms of content, format, timeliness resulting from the non-participation of decision makers in system design or inadequately designed systems  Lack of trust in the accuracy of HIS data, resulting in decision makers discounting the information and Fear of social or economic consequences We also found that the type of training that public health professionals receive can influence the use of data in public health decisions Many decision makers, technical advisors, and researchers in the health sector have been trained in programs that emphasize either the use of the scientific method and rationally-
  15. 15. based problem-solving techniques for approaching and solving public health problems, or in programs that focus predominantly on the use of management concepts and tools to address the organizational, human and financial resource, social, and political components of health policy and programs. Graduates of either type of program, however, often lack the full complement of scientific problem-solving and managementrelated skills needed to ensure that data are used effectively in the decision process. Moreover, neither type of program typically provides sufficient training in communications science, an understanding of which is critical in order for the graduate to be able to convey data, information, and messages effectively to target audiences for the purpose of advocating appropriate action. The Researcher-Decision Maker Relationship The role that participants in the policy-making process play in defining context is sometimes overlooked in the literature. Participants constitute a key factor that can impact both what constitutes evidence and how evidence is interpreted and applied. Participants can bring personal issues or relationships to the table that might not otherwise be addressed, altering the purpose and context for decision-making. Even proponents of EBM have acknowledged that "evidence does not make decisions, people do7. Increasingly more common is discussion of the linkages between the `two communities', researchers and decision-makers. The degree to which linkages exist could clearly have an effect at the introduction of evidence stage. Evidence-based health policy-makers face conflicts when attempting to apply the highest quality evidence possible to population-wide health policy decisions, while at the same time recognising that evidentiary thresholds may have to be relaxed to incorporate a broader range of evidentiary sources7 . Current ideas about evidence-based decision-making tend to focus exclusively on the direct interaction between researchers and decision makers. This appears to flow from the customer or client view of the relationship, minimizing the decision makers’ struggle with value uncertainty, and focusing on research as a product for delivery to the decision maker 8 . In the health system, it is not so simple: researchers and decision makers are rarely contained within the same organization. In addition, researchers span a continuum, historically clustered away from the mission-oriented or applied end. Decision makers are also heterogeneous, consisting of at least the three categories of policy makers, managers, and service professionals, and they rarely think in terms of “researchable questions”. There are few occasions when researchers convene with decision makers to interact directly, and few mediating mechanisms to indirectly bring their problems and solutions together8. | P a g e 15
  16. 16. Evidence based decision making Dr.Mustafa Salih Although researchers have difficulty acknowledging it, the sources for the evidence used by decision makers is rarely at the ‘scientific fact’ end of the continuum. ‘Stories’ based on personal experience, anecdote and myth form the basis of most communications with decision makers. Moving more to evidence based decision-making will involve tempering these anecdotes and stories from various interests with facts and evidence from research. The challenge for evidence-based decision-making is how to make sure that the ideas, best practices and interventions upon which decision makers act, and which they receive from knowledge purveyors, contain a more substantial component of evidence8. The links between each of these groups are, in fact, relationships between people and/or organizations. Improvement in evidence based decision-making will involve strengthening these relationships For instance, decision makers need to find more effective ways to organize and communicate their priorities and problems, while researchers and research funders must develop mechanisms to access information on these priorities and problems and turn them into research activity. Researchers need to learn how to simplify their findings and demonstrate their application to the health system in order to communicate better with decision makers and knowledge urveyors. The knowledge purveyors have to improve their ability to screen and appraise information — to sort the facts from the stories. Decision makers and their organizations need to improve their capacity to receive such appraised and screened information and to act upon it — developing ‘receptor capacity’8 . Getting ‘the evidence’, as represented by health services research, into decision-making involves multiple steps and is not only a matter of direct linkage between decision makers and researchers. Each of the steps involves improving relationships and communication across the four groups in the health sector, and that evidence-based decision-making is a ‘virtuous cycle’ and any weak link in the chain has the capacity to interrupt the optimal flow of research into decision making. In the shift from an individual-clinical to a population-policy level, the decision-making context becomes more uncertain, variable and complex. Because although decision makers are requesting more and more that researchers be their advisors, nevertheless this relation is complex, made of unsatisfied expectations on both sides and misundertsanding; Why do we need to improve the effectiveness of the link between research and decision making? • Because research has become a domain of increasing demand from decision makers; • Because, by definition, public health research has a vocation to be applicable research. • Public health research deals with the functionning of social systems and their impact on the health of populations: its outcomes are of interest only if they translate in policies From decision to research:
  17. 17. • Translation means to explain the decision context, so as to adapt the research agenda and anticipate on the reactions of different constituencies. From research to decision: • Translation means to explicit to the decision maker the way his or her demand has been transformed. Methodology Study design Descriptive cross sectional study to assess evidence based decision making in health, Sudan 2003. Study area Sudan is the largest country in Africa. It has an area of 2.5 million km2. It is characterized by a strategic geographical location, that links the Arab world to Sub Saharan Africa, and it shares its borders with 9 countries, where the Sudanese population and those of the neighbouring countries move freely across these borders. The environment ranges from damp rainy in the south, to desert in the northern areas. The population of the country is estimated at 32 million (projected from 1993 census). The population is unevenly distributed in the 26 States, the majority are concentrated in 6 States of the Central Region with a mean population density of 10 people per square kilometres, increasing to 50 at the agricultural areas. Natural disasters and the conflict resulted in high rates of rural-urban migration reaching 15%. The growth rate is 2.6%, indicating that the population doubles every 27 years | P a g e 17
  18. 18. Evidence based decision making Dr.Mustafa Salih Sudan suffers from acute and complex health problems. The cycle of poverty, malnutrition and loss of productivity exposes at risk populations to debilitating and serious diseases such as malaria, Tuberculosis (TB), malnutrition, diarrhoea, and Acute Respiratory Infections (ARI). The expansion of health facilities has not matched the growth in population over the years, and the war has destroyed many previously operating health facilities. Ineffective coverage is manifested in lack of infrastructure, inadequate drugs and medical equipment, and lack of skilled health personnel. Chronic conflict has stretched the country’s social service institutions including health, directly or indirectly. The war has a devastating effect on delivery of health care services, in a country already plagued with draught and epidemics. Lack of access to populations and the limited infrastructure has impeded the ability of the government, as well as the nonstate health actors to provide services and assistance. Communicable diseases dominate the health scene with high vulnerability to outbreaks. In addition, the double burden of diseases further creates a heavy load, to which the health system is not equipped to combat. Malaria is now considered endemic throughout the country and continues to feature as the major health problem in Sudan causing 7.5 – 8 million episode and 35,000 – 40,000 deaths per year. Diarrhoea and ARI prevalence rates are 28% and 17% among children under-five respectively, and diarrhoea prevalence reaches 40% in some States. The annual risk of infection for tuberculosis equals 1.8 %, and this indicates that for every 100,000 there are 90 infective cases 5. Health Research in Sudan Priority setting At least thirty priority research problems were identified in each state using the WHO selection criteria. Ten were epidemiological, ten biomedical and ten health system research problems. A National Health Research Conference was convened in September 2000. It endorsed the national priority health research problems according to rank and recommended capacity strengthening for health research, commitment to the priority research agenda, conduction of operational research and utilization of research results.(3) Study population Sample frame and sampling techniques Methods of data collection Results and discussions Results
  19. 19. Table No1 Definition of priority policy questions by FMOH directorates and programmes Defined policy questions Yes No Total No of Directorate 16 (76.1%) 5 (23.9%) 21 (100%) Table No 2 Availability of internet services for FMOH directorates and programmes 2003 Availability on internet services Available all time Available some times Not available Total No of Directorate 8 (38%) 12 (57%) 1 (05%) 21 (100%) Table No 3 Utilization of internet services by FMOH directors 2003 Use of internet services Use daily on regular base Many times per weeks Some times Don’t use Total No of Directors 11 (52.3%) 7 (33.3%) 2 (9.5%) 1 (4.7%) 21 (100%) Table No 4 main reasons of using internet services by FMOH directors 2003 Use of internet services Search Communication No of Directors 20 (95.2%) 13 (61.9%) Table No 5 knowledge about literature sources in the www by FMOH directors 2003 Knowledge Good knowledge Little knowledge Don’t know Total No of Directors 13 (61.9%) 5 (23.8%) 3 (14.2%) 21 (100%) Table No 6 Conduction of research by FMOH directorates and programmes 2003 Conduction of research No of Directorates | P a g e 19
  20. 20. Evidence based decision making Yes No Total Dr.Mustafa Salih 11 (52.3%) 10 (47.6%) 21 (100%) Table No 7 No of researches Conducted by FMOH directorates and programmes 2002-2003 No of research 1-2 researches 3-5 researches More than 5 researches No research conducted Total No of Directorates 5 (23.8%) 3 (14.2%) 2 (9.5%) 11 (52.3%) 21 (100%) Table No 7 No of researches Conducted by directorates and programmes in collaboration with research institutes outside FMOH 2002-2003 No of research 1-2 researches 3-5 researches More than 5 researches No research conducted Total No of Directorates 3 (14.2%) 3 (14.2%) 1 (4.7%) 14 (66.6%) 21 (100%) Table No 8 Receiving research reports from research institutes outside FMOH by directorates and programmes 2003 Receiving reports Regularly Sometimes Not receiving Total No of Directorates 1 (5%) 11 (52.3%) 8 (40%) 20 (100%) Table No 9 Use of research results for policy by FMOH directorates and programmes 2003 Use results for policy Yes No Total No of Directorates 13 (61.9%) 8 (38%) 21 (100%)
  21. 21. Table No 10 Reasons of not Using research results for policy by FMOH directorates and programmes 2003 Reason No need to use it Available information is not enough to build a decision Poor quality of available research Don’t know how to use it Others Total No of Directorates 0 (00%) 5 (62.5%) 0 (00%) 0 (00%) 3 (37.5%) 8 (100%) Table No 11 Type of research conducted by research institutes, Sudan 2003(n=21) Type Epidemiological research Health system Research Clinical research Basic research Different types No of institutes 4 (19%) 3 (14.2%) 9(42.8%) 5 (23.8%) 2 (9.5%) Table No 12 Areas of work of research institutes, Sudan 2003(n=21) Area of work Communicable diseases Non communicable diseases Health economics Bio medical research other No of institutes 3 8 1 2 6 Table No 13 Targeted audiences for research institutes, Sudan 2003(n=21) Targeted audience MOH Researchers Physicians Donors Others No of institutes 16 19 19 11 5 Table No 14 Methods of dissemination of research results by research institutes, Sudan 2003(n=21) Method of dissimination No of institutes | P a g e 11
  22. 22. Evidence based decision making Dr.Mustafa Salih International journal Local periodical Seminar Other 17 13 16 1 Table No 15 Sending research reports by research institutes to policy makers, Sudan 2003(n=21) Sending research reports Yes No Total No of institutes 16 5 21 1. S R. Tunis, B. Stryer, C. M. Clancy,"Increasing the Value of Clinical Research for Decision Making in Clinical and Health Policy" JAMA. 2003;290:1624-1632. Tunis SR Stryer DB, Clancy CM. 2. Pappaioanou M, Malison M, Wilkins K, Otto B, Goodman RA, Churchill RE, White M, Thacker SB ( Strengthening capacity in developing countries for evidence-based public health: the data for decision-making project.) , Social Science & Medicine Volume 57, Issue 10 , November 2003 , Pages 1925-1937 3. Mapping survey 4. (Dr Nicholas Hicks Department of Public Health and Health Policy Oxfordshire Health Authority) 5. strategy 5. Evidence Based Medicine Working Group at McMaster University, Canada 6. BMJ, 312:71-2,1996 7. Mark J. Dobrowa, Vivek Goelb and R. E. G. Upshurc Evidence-based health policy: context and utilisation Social Science & Medicine Volume 58, Issue 1 , January 2004, Pages 207-217 8. HEALTH SERVICES RESEARCH AND... Evidence-Based Decision-Making
  23. 23. 9. The evidence-based approach in health policy and health care delivery Social Science & Medicine Volume 51, Issue 6 , 15 September 2000 , Pages 859-869 Louis W. Niessen Els W. M. Grijseels and Frans F. H. Rutten , , Institute of Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Health Research in Sudan Since the beginning of the 20 th Century, health research has been a very important factor in the development of Sudan health services and in the shaping of health policy. The need for it was seen by the colonial administration as early as 1903 when the Welcome Tropical Research Laboratories (WTRL) were established as part of Gordon Memorial College (GMC). This was not only a significant development in the medical history of the country, but also an important one on a continent-wide basis. The revealing objectives of the WTRL and their multidisciplinary approach were the most appropriate way of successfully tackling the health problems of a vast country like the Sudan. Their contributions to health science in that era of pioneering health research were acknowledged by commemorating the name of their second director, A J Chalmers, in the Chalmers’ Medal of the Royal Society of Tropical Medicine and Hygiene (RSTMH). His most important contributions were in tropical diseases notably schistosomiasis. Chalmers in Khartoum confirmed Leipers discovery of the snail intermediate host in Ismailia in 1915. Christopherson in 1919 successfully treated the disease in Khartoum Civil Hospital using potassium antimony tartrate. These were probably the most significant contributions made to health science and research by two members of the Sudan Medical Service (SMS). A land mark in the history of medicine in the country was the establishment of the Kitchener School of Medicine (KSM) in 1924, as the first medical school in tropical Africa, to serve, in conjunction with WTRL, as a great civilizing factor in north-east Africa. | P a g e 13
  24. 24. Evidence based decision making Dr.Mustafa Salih In 1927 the Stack Medical Research Laboratories (SMRL) were established and formed the bacteriological wing of WTRL. The reorganization of the services dealing with scientific research in 1935 made the SMRL the official research organ of the SMS and the WTRL became the Wellcome Chemical Laboratories (WCL). By the late 1930s the research complex of the SMS had a tripartite structure: SMRL, WCL and the Entomological Laboratories. This reshaping of health research administration marked the beginning of a new epoch of health research in the Sudan, which reached its zenith in the 1940s. A series of officially directed applied research projects were designed around the public health problems of the country. These are: 1. Malaria control and Anopheles gambiae entomological survey in the Gezira. 2. The first Yellow fever serological survey in Africa (southern and western Sudan). 3. The first employment of the yellow fever 17D vaccine in an epidemic in Africa (Nuba Mountains epidemic). 4. Research on Kala-azar, cerebrospinal meningitis, enteric fever, smallpox, rabies, typhus fever, diphtheria and onchocerciasis. 5. The establishment of a vaccine institute in 1937 for the local production of smallpox, TAB, cholera and rabies vaccines. 6. Outstanding research on the transmission and chemotherapy of leishmaniasis Established phlebotomus orientalis as the vector and sodium antimony gluconate (pentostam) as a satisfactory therapeutic agent.
  25. 25. On account of outstanding contributions to tropical medicine and medical entomology another two members of SMS were awarded the Chalmers’ Medal of the RSTMH, Robert Kirk in 1943, and DJ Lewis in 1953 4.1.1.2 Post-Independence: The creation of a Sudanese Ministry of Health (MOH) in 1949 during the transitional period resulted in the Sudanization of senior posts and Robert Kirk was succeeded by MA Haseeb as Assistant Director for Research in charge of SMRL. Simultaneously with the start of Sudanese research leadership, some outstanding developments took place in health research. Both Hasseeb and Satti, the first nationals to pioneer research in the country, were awarded the Shousha Foundation Prize for outstanding contribution to medical education and research in the Sudan in 1963 and 1970, respectively: 1952 : A unified policy for the training of laboratory assistants in the North and South was designed and the School for Laboratory Assistants at SMRL became a WHO collaboration training centre. 1953 : The Sudan Medical Journal was launched as the official organ of Sudan Medical Association and a venue for research communication. The journal, however, has faced financial difficulties periodically. 1954 : The initiation of Sudanese Laboratory Technicians training. 1956 : WHO assistance to deal with major public health problems. 1960 : United States Naval Medical Research Unit Number Three (NAMRU3) started a five-year investigation to elucidate the epidemiology of visceral leishmaniasis. | P a g e 15
  26. 26. Evidence based decision making Dr.Mustafa Salih 1963 : Satti’s (Hasseeb’s successor) discovery of a new experimental host for leishmaniasis, the bush baby Galago senegalensis senegalensis. 1963 : Design of a concerted programme for postgraduate training of Sudanese researchers in Britain to cater for the broadening base of health research activities. 1963 : The Faculty of Medicine, University of Khartoum (U of K) started to grant postgraduate research degrees in the health sciences. 1970 : The inauguration of the National Public Health Laboratories incorporating SMRL, WCL, Entomological Laboratories together with accommodating the Departments of Pathology and Microbiology of the Faculty of Medicine, University of Khartoum. Further developments took place in the 1970s towards reorganization of health research and scientific research in the country: 1970 : The National Council for Research was established with five specialized research sub-councils: Agricultural, Animal Resources, Economic and Social, Industrial Research Center and Medical Research Council (MRC) 1971 : A Ministry of Higher Education and Research was created. 1972 : The MRC established the Institute for Tropical Medicine and the Hospital for Tropical Medicine. 1976 Gezira Faculty of Medicine and later Juba and other medical schools were established with new concepts of medical education 1978 : The Postgraduate Medical Studies Board in the Faculty of medicine, University of Khartoum awards post graduate clinical degrees. Research is considered as an integral component of the degree and a
  27. 27. thesis is a prerequisite for its award. In 1991 the National Council for Research of the Ministry of Higher Education and Research became the National Research Centre and the sub-councils were renamed, institutes. Within the health sector, the Institute for Tropical Medicine continued to exist. Link between evidence and decision Access to the online evidence base in general practice: a survey of the Northern and Yorkshire Region. Wilson P, Glanville J, Watt I. Health Info Libr J. 2003 Sep;20(3):172-8 AIMS: To assess the awareness and use of NHSnet within general practice. To investigate the presence of skills necessary to maximize the benefits of NHSnet connections. METHODS: Postal survey of general practice staff in the Northern and Yorkshire Region. RESULTS: At least one completed questionnaire was obtained from 65% of the general practices surveyed, and the individual response rate to the general practice survey was 44%. Ninety per cent of all respondents reported that their practice was connected to the NHSnet, with 59% of respondents reporting that they use NHSnet at least once a week. Although NHSnet was used to search for research information or guidance, all respondents in this survey still reported greater access to and use of paperbased information resources. Respondents indicated that they still needed further training on how to use NHSnet (42%), how to search the Internet (31%) and how to search electronic databases such as medline (49%). CONCLUSIONS: Since our 1999 survey, reported NHSnet connectivity has increased greatly, with a majority of respondents reporting that they use NHSnet at least once a week. Although encouraging, this level of usage suggests that using the Internet/NHSnet to find research has yet to become a core activity in general practice. display knowledge of the sources of relevant epidemiological and demographic data and its interpretation order to apply and underpin Khartoum MEMORANDUM OF UNDERSTANDING ON THE PROPOSED SITUATION ANALYSIS OF HEALTH RESEARCH IN THE SUDAN 1.INTRODUCTION: There is a gross imbalance in health research in developing countries including Sudan. This issue needs to address to find a possible solution for the existing inequities in opportunities and resources in health and health research . During the last decade Sudan has initiated a mechanism to develop health | P a g e 17
  28. 28. Evidence based decision making Dr.Mustafa Salih research including capacity building, organizational mechanisms, documentation and formulation of priorities. 2.HEALTH RESEARCH STRUCTURE AND DEVELOPMENT: 2.1 HISTORICAL PROSPECTIVE: 2.1.1. Pre-Independence: Since the beginning of the 20th Century, health research was a very important factor in the development of Sudan health services and in the shaping of health policy. The need for it was seen by the colonial administration as early as 1903 when the Welcome Tropical Research Laboratories (WTRL) were established as part of Gordon Memorial College (GMC). This was not only a significant development in the medical history of the country, but also an important one on a continent-wide basis. The revealing objectives of the WTRL and their multidisciplinary approach were the most appropriate way of successfully tackling the health problems of a vast country like the Sudan. Their contributions to health science in that era of pioneering health research were acknowledged by commemorating the name of their second director, A J Chalmers, in the Chalmers’ Medal of the Royal Society of Tropical Medicine and Hygiene (RSTMH). His most important contributions were in tropical diseases notably schistosomiasis. Chalmers in Khartoum confirmed Leipers discovery of the snail intermediate host in Ismailia in 1915. Christopherson in 1919 successfully treated the disease in Khartoum Civil Hospital using potassium antimony tartrate. These were probably the most significant contributions made to health science and research by two members of the Sudan Medical Service (SMS). A land mark in the history of medicine in the country was the establishment of the Kitchener School of Medicine (KSM) in 1924, as the first medical school in tropical Africa, to serve, in conjunction with WTRL, as a great civilizing factor in north-east Africa. In 1927 the Stack Medical Research Laboratories (SMRL) were established and formed the bacteriological wing of WTRL. The reorganization of the services dealing with scientific research in 1935 made the SMRL the official research organ of the SMS and the WTRL became the Wellcome Chemical Laboratories (WCL). By the late 1930s the research complex of the SMS had a tripartite structure: SMRL, WCL and the Entomological Laboratories. This reshaping of health research administration marked the beginning of a new epoch of health research in the Sudan, which reached its zenith in the 1940s. A series of officially directed applied research projects were designed around the public health problems of the country. These are: 1. Malaria control and Anopheles gambiae entomological survey in the Gezira. 2. The first Yellow fever serological survey in Africa (southern and western Sudan). 3. The first employment of the yellow fever 17D vaccine in an epidemic in Africa (Nuba Mountains epidemic). 4. Research on Kala-azar, cerebrospinal meningitis, enteric fever, smallpox, rabies, Typhus fever, diphtheria and onchocerciasis. 5. The establishment of a vaccine institute in 1937 for the local production of smallpox, TAB, cholera and rabies vaccines. 6. Outstanding research on the transmission and chemotherapy of leishmaniasis Established phlebotomus orientalis as the vector and sodium antimony gluconate (pentostam) as a satisfactory therapeutic agent. On account of outstanding contributions to tropical medicine and medical entomology another two members of SMS were awarded the Chalmers’ Medal of the RSTMH, Robert Kirk in 1943, and DJ Lewis in 1953 2.1.2 Post-Independence: The creation of a Sudanese Ministry of Health (MOH) in 1949 during the transitional period resulted in the Sudanization of senior posts and Robert Kirk was succeeded by MA Haseeb as Assistant Director for
  29. 29. Research in charge of SMRL. Simultaneously with the start of Sudanese research leadership, some outstanding developments took place in health research: 1952 1953 1954 1956 1960 1963 1963 1963 1970 : A unified policy for the training of laboratory assistants in the North and South was designed and the School for Laboratory Assistants at SMRL became a WHO collaboration training centre. : The Sudan Medical Journal was launched as the official organ of Sudan Medical Association and a venue for research communication. The journal, however, has faced financial difficulties periodically. : The initiation of Sudanese Laboratory Technicians training. : WHO assistance to deal with major public health problems. : United States Naval Medical Research Unit Number Three (NAMRU-3) started a five-year investigation to elucidate the epidemiology of visceral leishmaniasis. : Satti’s (Hasseeb’s successor) discovery of a new experimental host for leishmaniasis, the bush baby Galago senegalensis senegalensis. : Design of a concerted programme for postgraduate training of Sudanese researchers in Britain to cater for the broadening base of health research activities. : The Faculty of Medicine ,University of Khartoum (U of K) started to grant postgraduate research degrees in the health sciences. : The inauguration of the National Public Health Laboratories incorporating SMRL, WCL, Entomological Laboratories together with accommodating the Departments of Pathology and Microbiology of the Faculty of Medicine, University of Khartoum. Both Hasseeb and Satti, the first nationals to pioneer research in the country, were awarded the Shousha Foundation Prize for outstanding contribution to medical education and research in the Sudan in 1963 and 1970, respectively. Further developments took place in the 1970s towards reorganization of health research and scientific research in the country: 1970 : The National Council for Research was established with five specialized research sub-councils: Agricultural, Animal Resources, Economic and Social, Industrial Research Center and Medical Research Council (MRC) 1971 : A Ministry of Higher Education and Research was created. 1972 : The MRC formulated five priority research areas: Tropical diseases, childhood diseases, malnutrition, physiological norms and control of tuberculosis, and adopted a system of short- term project funding. 1972 : The MRC established the Institute for Tropical Medicine and the Hospital for Tropical Medicine. 1976 Gazira Faculty of Medicine and later Juba and other medical schools were established with new concepts of medical education 1978 : The Postgraduate Medical Studies Board in the Faculty of medicine, University of Khartoum awards post graduate clinical degrees. Research is considered as an integral component of the degree and a thesis is a prerequisite for the award of the degree. In 1991 the National Council for Research of the Ministry of Higher Education and Research became the National Research Centre and the sub-councils were renamed, institutes. Within the health sector, the Institute for Tropical Medicine continued to exist. 2.2. RECENT DEVELOPMENTS: RESUME OF CURRENT NATIONAL HEALTH RESEARCH STRUCTURE: 2.2.1. The Research Directorate: In 1998 the FMOH changed its Health System Research Unit established in 1996 to the Research Directorate (RD) to be responsible to the Under-Secretary. The RD has four units: Administration and | P a g e 19
  30. 30. Evidence based decision making Dr.Mustafa Salih Finance, Training, Documentation and Information and Research Implementation. Is guided by a multidisciplinary Research Council (RC). The Research Council, consist of all directorates of the FMOH, States MOH, medical schools, health institutions, individual researchers, health–related sectors, NGOs and the community, is charged with the objectives of laying down of the following:  General policy, work plans and follow-up of their implementation.  Principles of collaboration between all sectors involved in health research. To ensure maximal use of meager financial and manpower resources, the RC at its first meeting in January 2000 emphasized the importance of priority setting for health research. 2.2.3. Achievements of the RD to-date:       Preparation of the priority research agenda in the country. At least thirty priority research problems were identified in each state using the WHO selection criteria. Ten were epidemiological, ten biomedical and ten health system research problems. A National Health Research Conference was convened in September 2000, agreed upon the national priority health research problems according to rank and recommended capacity strengthening for health research, commitment to the priority research agenda, conduction of operational research and utilization of research results. A Data Base for Health Research was started in 2000 as a collaborative project to provide information about health related colleges, research institutes and health research units at the FMOH and in the states. Information on research institutions and health research abstracts since 1940 was collected. Still incomplete, the database now contains 3,000 abstracts available in electronic form (CD-ROM). A research manual for training in research methodology was published in English and Arabic, many training courses were conducted and the research methodology training was incorporated in the curricula of the paramedical schools. State Research Units were established for capacity strengthening in 8 states: Khartoum, Gezira, White Nile, Kassala, Red Sea, River Nile, North Kordofan and North Darfur. Seventeen Monthly Seminars for proposal review and presentation of research results were conducted on various topics. Recently a new Ministry of Science and Technology was created which implies an expected restructuring and strengthening of the organization of scientific research in the country. 3.MAJOR HEALTH RESEARCH INSTITUTIONS PROFILES: The names and addresses of the main health research organizations in the country, governmental and non-governmental, are depicted in the following table: 4. DESCRIPTION OF THE PROPOSED STUDY: 4.1. JUSTIFICATION: All health indicators show that endemic, communicable and infectious diseases are considered among major health problems in the Sudan. Sudan is characterized by diversity of health problems. These problems are further enhanced by the upheaval due to war displacement, famine, refugees and the changing pattern of diseases with the emergence of diseases of affluence particularly in major cities. All these need to be addressed through well-orchestrated health research mechanisms. Numerous lessons could be learnt from the review of the history of health research in the Sudan. It is hoped that, based on the outcome of this exercise, a strategy of health research will be formulated. 4.2.OBJECTIVES:
  31. 31. 4.2.1.General objective: The main objective of this study is to critically assess the current health research situation and to develop appropriate mechanism for enhancing and improving health research in the Sudan, to meet the following specific objectives: 4.2.2. Specific objectives: 1- To document the history of health research in Sudan. 2- To evaluate the health research management system, including mechanisms of collaboration between different research partners. 3- To identify and evaluate the charges and functions of institutions involved in the planning and implementation of health research. 4- To assess the documentation, publication, utilization and dissemination of the result of health research. 5- To find out the presence or absence of priority setting in health research at the institutional and national levels and how these priorities are derived. 6- To assess the mechanisms of research funding. 7- To evaluate the contribution and participation of the private sector and the community in health research. 8- To assess the training facilities and the work environment conductive to health research. 9- To investigate if health research covers the least developed and poor communities in the country. 12345678- 4.3. DESCRIPTION OF THE METHODOLOGY: 4.3.1 Study area:The study will be carried in the 26 states of the Sudan over a period of two years. 4.3.2. Study Design: Information will be obtained from a cross-section descriptive study. 4.3.3. Study Population: This is consists of the research institutions, policy makers, researchers, NGOs, health related sectors and the community. 4.3.4. Data collection Techniques: Techniques to be used for data collection includes the following: Structured Interviews. Self-administered questionnaires. Individual in-depth interviews. Focus group discussions. Secondary data sources. Observation using checklists. Content analysis of written materials. To realize the stated objectives, the following studies will be conducted: Study (1): Evaluation of the health research system at national leve, in terms of:        History of health research. Health research management system. Presence or absence of health research strategy. Mechanisms of collaboration. Funding, including contributions of the private sector and the community. Ethics in health research. Utilization of research results. Study (2): Evaluation of institutions involved in health research in terms of: | P a g e 31
  32. 32. Evidence based decision making        Dr.Mustafa Salih Functions. Infrastructure and the working environment. Personnel including the available training facilities. Priority setting at institutional level. Collaboration. Funding. Documentation, publications, Periodicals and utilization of research results.   Study 3: Review of the impact of the health research in terms of: The number and volume of the health research directed towards solving the health problems of the least developed and poor communities. Impact of health research on the health of these communities. 5. COORDINATION STEPS FOLLOWING SITUATION ANALYSIS: After the completion of the work and after analyzing the situation of health research in Sudan, a series of workshops will be undertaken. The workshops aim at discussing and evaluating the process and the future projections of health research. The target groups will be:   Policy-makers. Researchers   NGOs. Health - related sectors.  Beneficiaries 6. ESTIMATED BUDGET: US$100,000 is the estimated budget for the proposed situation analysis. Besides the expected grant of US$50,000, the Sudan FMOH will contribute a sum of US$20,000 in addition to other contributions in terms of providing office space for the project, means of transport for field work and salaries of the Research Directorate staff. These additional contributions are estimated to be US$30,000. The detailed budget is shown on Tables 1-3.The justification of this proposed budget is as follows: Budget Justification: 1. 2. PI: One PI will be needed half time to be responsible for execution of the project and guidance of the survey: 1 x 24 pm x $500 p/m = US$12,00 One Adm Assist/Accountant is needed full time for administrative and financial matters: 1 x 24 pm x $100 p/m =US$2,400 3. 4. 2 Field Supervisors are needed to oversee data collection part time, each for 13 states: 2 x 9 pd x 13 states x $25 = US$5,850 52 Data Collectors, 2 in each state to collect data part time:
  33. 33. 5. 6. 7. 8. 9. 10. 11. 2 x 26 states x 7 pd x $7 = 2,548 One statistician is needed part time for 2 months to analyze data: 1 x 2 pm x $120 = US$240 One Data Entry Person is needed full time for 9 months in year 1 to enter data: 1 x 9 pm x $100 = US$ 900 One Secretary is needed full time for the project life to do all secretarial work: 1 x 24 pm x $100 = 2,400 One driver is needed to do 11 round trips to 11 states with the Field Supervisors: 1 x 9 pd x 11 states x $10 = US$990 30 barrels of gasoline are needed to cover 11 round trips to 11 states: 30 barrels x $44 = US$1,320 Maintenance: A sum of US$3,000 is needed to maintain vehicles and equipment: Airlines Tickets: 14 tickets are needed for 14 round trips of field supervisors to 14 states: Lump sum for purchase of 14 Plane Tickets = US$11,064 12. Meetings: 8 quarterly progress meetings for the research team need to be conducted: 8 meetings x 10 persons x US$42 = US$3,360 13. Training: The cost of running one training course to cover 52 participants and 3 trainers Will be US$6,450: 2 participants x 26 states x 3 days x US$25 = US$5,850 3 trainers x US$200 = US$ 600 14. Workshops/Seminars: Three Ws/seminars for 50 participants each need to be conducted, one initially during the first quarter to launch project, the second during the fifth quarter for conveying preliminary results and the third during the last quarter for designing the future course of action: The cost of 3 workshops/seminars will be: 3 workshops x US$ 2,000 = US$6,000 15. Stationary: lump sum of US$3,500 will be needed for stationary and office supplies, US$2,000 in Year 1 and US$1,500 in year 2. 16. Desktop Computer and Printer: One desktop computer with one printer are needed: 17. 18. The cost will be US$1,500 Reports and Printing: 3 reports are needed to be prepared (in the 6th,7th & 8th ) costing US$4,000 Miscellaneous: A total sum of US$2,478 will be needed for miscellaneous items: US$1,300 in year 1 and US$1,178 in year 2. Budget Details BUDGET TABLES TABLE 1: PERSONNEL Amount in US$ Year 2 Total Category of personnel % of full Year 1 time on project Professional Scientific Staff Principal Investigator 1 x 12 pm x $1,000 50.0 6,000 6,000 12,000 | P a g e 33
  34. 34. Evidence based decision making Dr.Mustafa Salih 1,200 1,200 2,400 Admin Assistant/Accountant 1 x 24 pm x 100.0 $100 5,850 5,850 Field Supervisors: 2 x 9 pd x 13 states x 65.7 $25 2,548 Data Collectors (52): 2 x 26 states x 7 pd x 2.8 $7 2,548 Technical Staff 120 120 240 900 1,200 1,200 900 2,400 Statistician: 1 x 2 pm x $120 16.7 Data Entry Person: 1 x 9 pm x $100 45.0 100.0 Secretary 1 x 24 pm x $100 Other Staff 990 Driver: 1 x 9 pd x 11 states x $10 27.8 990 Total 18,808 8,520 27,328 TABLE 2: OPERATIONAL EXPENSES Budget Item Amount in US$ Year 1 Year 2 Total 1,320 1,320 Gasoline: 30 barrels x $44 Equipment Maintenance: 1,500 Airlines Tickets: 1 ticket x 14 states 11,064 1,680 1,500 1,680 3,000 11,064 3,360 4,000 6,450 6,000 1,500 3,500 Meetings: 10 persons x 8 meeting x $ 42 Training of Data Collectors: 2 particip. x 26 states x 3 days x $ 25 6,450 2,000 Workshops/Seminars: 3 workshops x $ 2,000 2,000 Stationary 1,500 1,500 Desktop Computer and Printer 2,000 2,000 4,000 29,514 10,680 40,194 Report and Printing: (8 quarterly + 1 annual + 1 final) x $ 400 Total TABLE 3: BUDGET SUMMARY (Table 1 + Table 2)
  35. 35. Budget Item Amount in US$ Year 1 Year 2 Total Personnel 18,808 Operating Expenses 29,514 8,520 10,680 27,328 40,194 RD staff + vehicles rent + office expenses 15000 Miscellaneous 1,300 15000 1,178 3000 2,478 Total 64,622 35,378 100,000 Introduction Research to Action and Policy: The Need for a New Concept Somsak Chunharas Bureau for Health Policy and Planning, Ministry of Health, Thailand Chair, COHRED Working Group on Research to Action and Policy Health research can have an impact on many different aspects of health development and at many different levels. It can create better understanding about the determinants of health, play a crucial role in the development and use of health technologies, and inform decisionmaking of various kinds which result in actions at an individual level or in health policies and programs at the population level. Researchers often adhere to the idea that the results of relevant and scientifically rigorous research will eventually find their way onto the desks and into the meeting rooms of policymakers and program planners. This is seldom the case and a problem that has itself generated a great deal of research. How can the link between research and action be strengthened? This question guided the work of the Council on Health Research for Development (COHRED) Working Group on Research to Action and Policy. Formed in 1998, the Working Group strove to better understand how to improve the linkage between research and action, and in particular, research and policy. It was hoped that such an understanding would identify capacity development needs to help countries in their efforts to make research an effective tool for health development. Case studies were carried out in five countries: Brazil, Burkina Faso, Indonesia, South Africa, and Uruguay. A combination of document analysis, interviews with researchers and decision-makers, and, in several cases, the case study authors’ personal experience in the research-policy process, were employed to document the use of research around a health problem or development effort. The case studies from Pakistan and Lithuania have not been conducted within the framework of the working group, but, as they cover similar issues, have been added to this publication as valuable additional examples and lessons. The Brazilian case study looked at governmental action to establish Hib and hepatitis B vaccine production capability in the country and the role of national research in this effort. The Burkina Faso case study examined the reasons why a long-standing research program advocating a “shared care” approach to improving the health of children has not been adopted by decision-makers. Similarly, the case study from Indonesia identified factors that constrained or supported the use of research in improving government policy with respect to a social safety net in the health sector. The Pakistan case study reported on the role that research has played in child health policy and programs in Pakistan – specifically, control of diarrheal disease (CDD), acute respiratory infection (ARI), and iodine deficiency disorders (IDD). The South African case study asked why, with the abundance of research studies being made available for policy development, so few of the results have contributed to policy, despite a seemingly receptive new political environment. The Lithuanian case study focused on the | P a g e 35
  36. 36. Evidence based decision making Dr.Mustafa Salih use of research to identify and reduce health inequities, and the translation of these research results into health policies. Lastly, the case study from Uruguay provides an historical overview of the relationship between research and action surrounding control programs for two diseases of national priority, Chagas disease and Foot and Mouth disease in animals. Each case, presented as a separate chapter of this report, offers valuable lessons about strengthening the link between research and policy. 2 The Need for a New Concept 1. Conceptual framework for an holistic approach to strengthening the research-policy link Previous attempts at improving the research-to-policy linkage have focused on the supplyside or research generation. But experience has taught that efforts must be directed at both the research generation and decision-making processes. A conceptual framework for an holistic approach to strengthening the linkage between research and policy, based on interactive learning through equal partnership, is presented in Figure 1. Identified are five components of the interface between research and policy: the process, the stakeholders, the mediators who help to link the two processes, the research products, and the larger context within which the decision-making and research processes take place. Lessons learned from the country case studies provide illustrations of the components of the framework. The Process: This encompasses the two inter-related processes of research generation and decision-making. It is important to pay attention to the process of how research is planned and executed, and also to the process whereby decisions are made. There are many steps in both processes that need to be linked, not just the initial steps of defining research questions and policy priorities and the later steps of disseminating results and implementing policies and programs. Linking the two processes may not mean simply inviting policymakers to participate in research planning. It may be equally useful for researchers to participate in the policy and program development process from which crucial research questions can be distilled. Lessons learned Neither researchers nor decision-makers should expect a one-way, linear, or one-for-one relationship between research and policy. There are several aspects to this lesson: • Decisions are not necessarily made based on a single study. The Uruguayan case study provides an example of how cumulative results of a number of research studies led to the development and refinement of Chagas disease and Foot and Mouth disease control programs. On the other hand, a single research study can have multiple policy implications – possibly for sectors other than health. • Research that is not immediately used or is rejected by a particular group of intended users may get picked up at a later point if the findings are still of relevance. Researchers should also be looking for new opportunities to make research results known or to be discussed by potential users. • No matter how relevant, timely, or scientifically rigorous its results, a research study still may not lead to action. Research created as a condition to external loans for development can pose a unique set of difficulties. In most instances, the loan condition provides for greater visibility of the research findings. On the other hand, it may create friction and resistance to adoption of research results by national decision-makers, depending on how the research projects were managed. Again, careful attention to the various stages of research planning and management is essential, especially when sensitivity among potential research users is anticipated. Action research at the community level is another way in which research can lead to action and have a significant impact on the health of the people in the 3
  37. 37. The Need for a New Concept participating community or group. Yet, such outcomes may be difficult to duplicate on a wider scale because most research projects require tremendous investments of time and human energy, which are difficult to generate or sustain on a broad basis. The Stakeholders: Stakeholders include the various groups of people who are concerned or affected by the issues being addressed by the process. Research will have a greater likelihood of being used in decision-making if the intended users are identified and become involved at various stages in the processes of research planning, management, and dissemination. All stakeholders need to be properly identified and involved. The results of research studies need to be communicated effectively to each group, bearing in mind their different roles, perceptions, and orientation to the issues. Lessons learned Supply-driven research, in particular that led by external research teams, may be perceived as being imposed on decision-makers. This was the case with the researcher-recommended shared care approach described in the Burkina Faso study. Although the research was of high quality and conducted by researchers with strong reputations, decision-makers asked themselves if “these ideas had been parachuted from Heidelberg.” Researchers may have been more successful in putting shared care on the agenda if greater ownership of the strategy could have been encouraged by more actively involving decision-makers in the early stages of the research process. Instead, efforts focused on disseminating results when the studies were complete. The case of child health research in South Africa shows a similar pattern: studies are based on the interests of the researchers, and, although addressing priority issues, study results may still be waiting to be used. Interaction with potential research users from the earliest stages of the research process may help to increase the chances of research results being used. Even when potential users have participated in formulating research questions or identifying priority concerns, the research-policy link may suffer. In the Burkina Faso case, several concerns about the feasibility of implementing shared care were identified for further research work, but the lack of continued involvement of the potential users and key stakeholders contributed to the failure to adopt the approach. While there is a need to improve researchers’ capacity, it is of equal, if not greater, importance to increase the receptivity of potential users to research. The success of research leading to action rests partly with good research results and good researchers. However, the potential users of research should also be carefully identified and efforts targeted at strengthening the demand for research. This may involve the policy formulation units or the policy advisors of key decision-makers, and not necessarily the decision-makers themselves. The media, who play a key role in communicating between researchers, decision-makers, and the public at large, is another important target group. Journalists and editors need to be more receptive to research work and knowledgeable about research results. 4 The Need for a New Concept The Products: The products refer to the research studies themselves and how they are linked to the decision-making process. In most cases, researchers are concerned about the quality of research, seeing it as the determining factor in whether or not it is used. The nature of the issues being addressed and the nature of the studies themselves, however, can also play a crucial role. Studies providing factual findings are viewed and used differently from those providing concrete recommendations and especially from studies trying to address the | P a g e 37
  38. 38. Evidence based decision making Dr.Mustafa Salih issue of how to solve a particular problem. In fact, it may be helpful to think of research products not only as final reports at the end of research projects, but as a series of different outputs within an ongoing integrated program which combines research and action. Sometimes several studies carried out within a program lead to a single decision. In turn, experience with decisions and actions can lead to the next series of studies. Lessons learned Too often the emphasis has been on forging links with users once the results have been obtained, and not earlier on in the process. A great deal of effort has gone into presenting research in an interesting and understandable manner. In fact, training courses and materials have been developed to help researchers become effective communicators. The use of media to help disseminate research findings and recommendations has also received much attention. While improving the research dissemination process is important, this strategy alone is not sufficient to guarantee use of research for action. Besides the format in which information is transmitted, the Burkina Faso case study showed that there is a need to ensure that the receiver is the appropriate person and is able to process the information. Therefore, time constraints for the reception of information have to be taken into account, as well as the fluctuation of key functions on the side of researchers and receivers of information. Research aimed at shaping policy should differentiate carefully between the research findings and the researchers’ recommendations. A failure to accept the recommendations should not be taken as an indicator that there is fault with the research itself. Instead, researchers should involve all those who may shape the eventual policy or course of action, in formulating recommendations based on study findings. Often researchers attempt to do this on their own, believing that they are more neutral to the situation and will not bias the recommendations. The Mediators: Mediators are perhaps the most crucial component of the framework. They are individuals or institutions who play an active role in fostering linkages between the research and policy processes, while making sure that all relevant stakeholders are involved. They could be organisations supporting research work. They could be researchers themselves. They could also be academic or civic groups that support evidence-based decision-making. National research coordinating bodies, such as the ENHR mechanism promoted by COHRED, can also play a mediating role to better foster research to policy linkages. International agencies too have an important contribution to make as intermediaries in linking knowledge and action. 5 The Need for a New Concept Lessons learned The influence of persons and institutions with the right attitudes, connections, and capabilities is crucial. The Uruguayan case study pointed to the role that certain committed scientists played, by virtue of their position or contacts within the Ministry of Health in influencing the development of the two disease control programs. Similarly, the recruitment of two leading scientists with entrepreneurial skills as well as technical and scientific proficiency led to the successful mobilisation of various stakeholders to bring together the requirements of the immunisation policy and vaccine research and development activity. The Brazilian case study also highlighted the important role played by institutions with the right mandate in the promotion and adoption of relevant research studies. The Context: Context refers to the environment surrounding the research and decisionmaking processes. International organisations and existing funding structures have a significant impact on research linkage to policy, as does the socioeconomic and political situation of the country. The prevailing nature of the decision-making process and the values and perceptions of the research community are important aspects of the environment that should also be

×