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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 resources1.
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.
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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
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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 instruments9.
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
Ministers 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.
http://hsc.usf.edu/CLASS/Gene/ebm.htm#Sourse#Soursehttp://hsc.usf.edu/CLASS/Gene/ebm.htm#Sourse#Sourse
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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 context-
based, with evidence defined with respect to a specific
decision-making context. This
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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 practical-
operational 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 decision7.
As the decision-making context shifts from the
individual-clinical level to the population-
policy 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, evidence-
based 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
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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
costeffective 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 Localities5.
''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
concept5
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
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for profit) and civil society. However, those partners are
performing in isolation due to ill
defined managerial systems for coordination and guidance5.
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 costeffectiveness. 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 evidence-
based 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
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Evidence based decision making Dr.Mustafa Salih
contextual factors are fixed, uncontrollable and cannot be
manipulated by decision-
makers (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 decisions
7.
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 decision-
making 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 population-
wide 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..
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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. Evidence-
based 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
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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 high-
quality 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
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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 population7.
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 process-
related 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 evidence7.
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
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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
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13 | P a g e
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 occursderives 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?
-
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-
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15 | P a g e
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 management-
related 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.
-
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 capacity8 .
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:
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17 | P a g e
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
-
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 countrys 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 non-
state 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
cases5.
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
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19 | P a g e
Table No1 Definition of priority policy questions by FMOH
directorates and
programmes
Defined policy questions No of Directorate
Yes 16 (76.1%)
No 5 (23.9%)
Total 21 (100%)
Table No 2 Availability of internet services for FMOH
directorates and
programmes 2003
Availability on internet services No of Directorate
Available all time 8 (38%)
Available some times 12 (57%)
Not available 1 (05%)
Total 21 (100%)
Table No 3 Utilization of internet services by FMOH directors
2003
Use of internet services No of Directors
Use daily on regular base 11 (52.3%)
Many times per weeks 7 (33.3%)
Some times 2 (9.5%)
Dont use 1 (4.7%)
Total 21 (100%)
Table No 4 main reasons of using internet services by FMOH
directors 2003
Use of internet services No of Directors
Search 20 (95.2%)
Communication 13 (61.9%)
Table No 5 knowledge about literature sources in the www by FMOH
directors
2003
Knowledge No of Directors
Good knowledge 13 (61.9%)
Little knowledge 5 (23.8%)
Dont know 3 (14.2%)
Total 21 (100%)
Table No 6 Conduction of research by FMOH directorates and
programmes 2003
Conduction of research No of Directorates
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Evidence based decision making Dr.Mustafa Salih
Yes 11 (52.3%)
No 10 (47.6%)
Total 21 (100%)
Table No 7 No of researches Conducted by FMOH directorates and
programmes
2002-2003
No of research No of Directorates
1-2 researches 5 (23.8%)
3-5 researches 3 (14.2%)
More than 5 researches 2 (9.5%)
No research conducted 11 (52.3%)
Total 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 No of Directorates
1-2 researches 3 (14.2%)
3-5 researches 3 (14.2%)
More than 5 researches 1 (4.7%)
No research conducted 14 (66.6%)
Total 21 (100%)
Table No 8 Receiving research reports from research institutes
outside FMOH by
directorates and programmes 2003
Receiving reports No of Directorates
Regularly 1 (5%)
Sometimes 11 (52.3%)
Not receiving 8 (40%)
Total 20 (100%)
Table No 9 Use of research results for policy by FMOH
directorates and
programmes 2003
Use results for policy No of Directorates
Yes 13 (61.9%)
No 8 (38%)
Total 21 (100%)
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11 | P a g e
Table No 10 Reasons of not Using research results for policy by
FMOH directorates
and programmes 2003
Reason No of Directorates
No need to use it 0 (00%)
Available information is not
enough to build a decision
5 (62.5%)
Poor quality of available research 0 (00%)
Dont know how to use it 0 (00%)
Others 3 (37.5%)
Total 8 (100%)
Table No 11 Type of research conducted by research institutes,
Sudan 2003(n=21)
Type No of institutes
Epidemiological research 4 (19%)
Health system Research 3 (14.2%)
Clinical research 9(42.8%)
Basic research 5 (23.8%)
Different types 2 (9.5%)
Table No 12 Areas of work of research institutes, Sudan
2003(n=21)
Area of work No of institutes
Communicable diseases 3
Non communicable diseases 8
Health economics 1
Bio medical research 2
other 6
Table No 13 Targeted audiences for research institutes, Sudan
2003(n=21)
Targeted audience No of institutes
MOH 16
Researchers 19
Physicians 19
Donors 11
Others 5
Table No 14 Methods of dissemination of research results by
research institutes,
Sudan 2003(n=21)
Method of dissimination No of institutes
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Evidence based decision making Dr.Mustafa Salih
International journal 17
Local periodical 13
Seminar 16
Other 1
Table No 15 Sending research reports by research institutes to
policy makers,
Sudan 2003(n=21)
Sending research reports No of institutes
Yes 16
No 5
Total 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
https://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=IssueURL&_tockey=%23TOC%235925%232003%23999429989%23452175%23FLA%23display%23Volume_57,_Issue_10,_Pages_1771-2012_(November_2003)%23tagged%23Volume%23first%3D57%23Issue%23first%3D10%23Pages%23first%3D1771%23last%3D2012%23date%23(November_2003)%23&_auth=y&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9cc541446b5af3e30a28070aced5db7bhttp://www.bmj.com/https://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):http:/www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-48V7W7S-1&_coverDate=01%2F31%2F2004&_alid=126978954&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5925&_sort=d&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9ad71bdef9260e021b04bdff859b17cf#affb#affbhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):http:/www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-48V7W7S-1&_coverDate=01%2F31%2F2004&_alid=126978954&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5925&_sort=d&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9ad71bdef9260e021b04bdff859b17cf#affc#affchttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=IssueURL&_tockey=%23TOC%235925%232004%23999419998%231%23FLA%23display%23Volume_58,_Issue_1,_Pages_1-221_(January_2004)%23tagged%23Volume%23first%3D58%23Issue%23first%3D1%23Pages%23first%3D1%23last%3D221%23date%23(January_2004)%23&_auth=y&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=432e31aa43914d756b4feb5f86f6d9de
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13 | P a g e
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 20th
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.
https://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=IssueURL&_tockey=%23TOC%235925%232000%23999489993%23197335%23FLA%23display%23Volume_51,_Issue_6,_Pages_787-989_(15_September_2000)%23tagged%23Volume%23first%3D51%23Issue%23first%3D6%23Pages%23first%3D787%23last%3D989%23date%23(15_September_2000)%23&_auth=y&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9edafa631120b0f959da184bb092678chttps://hin-sweb.who.int/http:/www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-40D5X4K-7&_user=977298&_coverDate=09%2F15%2F2000&_fmt=full&_orig=search&_qd=1&_cdi=5925&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=52bfa95df1d6371d462f14128d01da26&ref=full#m4.cor*#m4.cor*https://hin-sweb.who.int/spool/common_files/[email protected]
-
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.
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15 | P a g e
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
(NAMRU-
3) started a
five-year investigation to elucidate the epidemiology of
visceral
leishmaniasis.
-
Evidence based decision making Dr.Mustafa Salih
1963 : Sattis (Hasseebs 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
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17 | P a g e
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 paper-
based 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
-
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 20
th 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
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19 | P a g e
Research in charge of SMRL. Simultaneously with the start of
Sudanese research leadership, some
outstanding developments took place in health research:
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
(NAMRU-3) started a
five-year investigation to elucidate the epidemiology of
visceral leishmaniasis.
1963 : Sattis (Hasseebs 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.
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
-
Evidence based decision making Dr.Mustafa Salih
Finance, Training, Documentation and Information and Research
Implementation. Is guided by a multi-
disciplinary Research Council (RC). The Research Council,
consist of all directorates of the FMOH,
States MOH, medical schools, health institutions, individual
researchers, healthrelated 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:
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31 | P a g e
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
t