The importance of evidence-based practice in Africa

A Collaboration for Evidence Based Healthcare in Africa (CEBHA) has been established with partners from eight sub-Saharan African countries, Ethiopia, Uganda, Rwanda, Burundi, Tanzania, Malawi, Zimbabwe and South Africa. The aim of the Collaboration is to facilitate the provision of patient care based on evidence-informed decisions using context specific current best evidence; and to build capacity and sustainable structures of Evidence Based Healthcare in Africa.

We believe that access to equitable and effective healthcare should be a right for people in all countries. Irrespective of where one lives, the need for valid evidence determining the efficacy of healthcare interventions is essential. Where the unmet needs for health services are most prominent, it is essential to adopt practices that have proven to be beneficial and not harmful or ineffective to ensure scarce resources are not wasted. Incorporating Evidence-Based Health Care (EBHC) into the African context means setting priorities, developing evidence summaries and guidelines and implementing research findings relevant for African countries to support healthcare for all. Contextualising evidence relates to several issues, including the lack of evidence available for an African setting. The effectiveness of an intervention in Africa may be different from that found in studies elsewhere because of factors such as: later presentation, co-infections, malnutrition, higher levels of self-medication and use of traditional remedies, reduced level of resources, including human resources for basic healthcare, and political instability. In addition, effective interventions, as determined by many systematic reviews, may not be available or affordable in most African settings. This means that Africa needs valid and Africa-specific research and that authors of systematic reviews should take this into account by avoiding overgeneralisation when making conclusions.

EBHC extends the application of the principles of evidence-based medicine (EBM) as defined by Sackett et al,1 to all healthcare professionals. Evidence-based public health can be defined as ‘integration of the best available evidence with the knowledge and considered judgments from stakeholders and experts to benefit the needs of a population”.2 Judged by the number of publications, guidelines, textbooks and references made to the term EBM, few, if any, innovations have probably had a greater impact on healthcare over the last decades than the introduction of the methodologies and practice of EBM.3 “The Cochrane Collaboration is an enterprise that rivals the Human Genome project in its potential implications for modern medicine” wrote David Naylor in The Lancet.4 The application of evidence-based methods has become state of the art for clinical and public health decision making in most European countries, Australia and in the USA.

Up to now these innovations have not been widely utilised and implemented in African health systems5 and among the partners of the CEBHA, only South Africa has established centers for EBHC, the South African Cochrane Centre and the Centre for EBHC at Stellenbosch University. Capacity and organisational structures for the development and delivery of contextualised EBHC are lacking in most African countries, but several existing research initiatives and projects for EBHC and policy-making have been identified, among them SURE (Supporting the Use of Research Evidence for policy in African health systems) and REACH (Regional East African Community Health) which have developed tools for evidence-informed policy-making and shown ways of working together internationally.6 The Effective Health Care Research Consortium (http://www.evidence4health.org/) has developed evidence summaries relevant to infectious diseases in African contexts. However, for many prioritised areas of public health in low-income and middle-income countries, systematic reviews have not been carried out and there is a lack of contextualised research evidence.7 ,8 The highest rates of child mortality continue to be found in sub-Saharan Africa, where, in 2008, one in seven children died before their fifth birthday.9 Currently, maternal death rates are almost 200 times higher in sub-Saharan Africa than in high-income countries.10 ,11 Sub-Saharan Africa can increase its pace towards achieving health Millennium Development Goals only if efforts to prevent death and disability are tailored to local conditions and if choices of health interventions and policies are based on solid scientific evidence.12 At the same time there is a growing technical revolution occurring in Africa, which yields a vast array of opportunities. Internet access and the number of mobile telephones, many of which have internet access, have increased exponentially, with four  of five people in Africa now having access to mobile phones.13

Explorative workshop

In November 2011, CEBHA arranged a workshop with the partners in the Consortium (see acknowledgement) with the objective to explore the needs of the different countries and to set priorities for the collaboration. In addition, the Centre for  EBHC at Stellenbosch University systematically assessed training initiatives in the African region in 2011 by contacting medical schools, organisations, institutions and known experts in the field via email; and searching the internet for relevant training activities. In total, 40 EBHC training programmes were identified. These were presented by 8 universities and 10 other organisations, and 20 of them (50%) were offered in South Africa. The EBHC training programmes were offered to various healthcare professionals (students, doctors, nurses and others) and consisted of 3 postgraduate degrees; 9 modules within university degrees; 19 short courses (≤1 week) and 8 intensive courses (≥2 weeks). Of these, four were e-learning courses with no face-to-face lectures; and three consisted of both e-learning and face-to-face components. The results of this survey show that EBHC capacity development programmes are concentrated in South Africa and that there is a need to further expand training to other African countries (see online supplementary table S1, web only file).

Some of the main challenges regarding implementation of EBHC in Africa identified by the participants of the workshop include the lack of adequate information and communication technology equipment and human resources in health facilities. Health information systems are underdeveloped and there is a lack of coordinated structures for translation of health research findings into policy and practice. There is also a lack of understanding of the importance of EBHC among policy-makers and healthcare professionals and several guidelines lack background evidence. Medical research is underdeveloped and not yet integrated into the medical culture, limiting options for disseminating research findings. Additionally most African countries face problems with the provision of health workers in rural areas as they are often reluctant to work in these areas.

Establishment of CEBHA and strategies developed

To address these challenges and based on a needs assessment prepared by eight sub-Saharan African countries, supported by WHO, Liverpool School of Tropical Medicine and the Royal Tropical Institute in Amsterdam, the CEBHA has been established. The overall aim of this collaboration is to facilitate the attainment of the Millennium Development Goals 4, 5 and 6 (reducing child death rates, improving maternal health and combating HIV/AIDS, malaria and other serious diseases); and to encourage healthcare practice based on evidence-informed decisions, ultimately leading to equitable and effective healthcare for all. To achieve these goals a focus on reducing the burden of non-communicable diseases in Africa is also needed.

The following priorities for action were formulated in the 2011 workshop in Kampala:

• Building a sustainable collaboration for EBHC between researchers, policy-makers and clinicians—that will lead to the establishment of Centers for EBHC and satellite offices in at least eight African countries.

• Increasing the clinical and operational research to have more African-specific data integrated into the development of recommendations.

• Strengthening capacity in EBHC by training researchers, healthcare workers, policy-makers and librarians in finding, assessing and applying the best available evidence to improve health—that will lead to a sustainable training programme and key health personnel trained in EBHC.

• Developing and integrating courses in EBHC into the curriculum of the universities and schools of health education in Africa—to secure future knowledge uptake and transfer to the hospitals and primary health services.

• Establishing an African electronic library for health together with the WHO Evidence-Informed Policy Network (WHO–EVIPnet) and the HINARI (Access to Research in Health Programme) portal—that will provide free access to EBHC resources for all health personnel in Africa in a user friendly format.

• Conducting systematic reviews and encouraging development, adaption and implementation of guidelines relevant for the healthcare settings in African countries—that will create a resource base of African contextualised evidence.

• Developing strategies for dissemination and implementation of evidence at all levels of the healthcare system—that will facilitate the delivery of relevant knowledge at the right level of the healthcare system.

• Conducting research on dissemination and implementation strategies by using valid monitoring and evaluation indicators—that can continuously monitor the effect of the different strategies and allow for adjustments.

• Communicating and advocating EBHC to create links with other networks and projects—that will give strength and sustainability for the CEBHA in Africa.